Management of intra-operative cerebrospinal fluid leak in transnasal transsphenoidal pituitary microsurgery: use of post-operative lumbar drain and sellar reconstruction without fat packing.

BACKGROUND: This study aims at describing primary reconstruction of sella turcica using lyophilized dura graft and fibrin glue without fat packing of the sphenoid sinus, together with postoperative lumbar drain in the management of intraoperative cerebrospinal fluid (CSF) leak. METHOD: Records of 127 consecutive patients undergoing 129 transnasal transsphenoidal procedures were reviewed retrospectively with respect to intra- and post-operative CSF leak and lumbar drain use. One hundred and ten patients had adenomas (60 secreting adenomas, 48 non-functioning), 10 Rathke's cleft cysts and 9 miscellaneous lesions. FINDINGS: Intra-operative leak was detected in 43 (33.3%) of 129 procedures: 38 (34.5%) of 110 adenoma related procedures and 5 (26.3%) of 19 non-adenomas. Among adenomas, leak occurred in 35 (41.2%) of 85 patients with suprasellar extension (SSE) and in 3 (12%) of 25 without SSE (p = 0.007). Lumbar drain was used in 61 cases (47.3%): in 34 it was inserted immediately before and in 27 at the end of procedure. In 24 of 34 patients (70.6%) with pre-operative drain (all adenomas), saline infusion was used to mobilize SSE. Only 2 patients (1.6%) developed post-operative leak, requiring an endoscopic procedure with fascia and muscle obliteration of the sphenoid sinus. CONCLUSIONS: Meticulous duroplasty and routine postoperative lumbar drain has shown satisfactory results in dealing with intra-operative CSF leaks. It compares favorably with other techniques and obviates the need for fat harvesting. In patients with SSE, where leak occurs more frequently, we recommend inserting the lumbar drain before the procedure. As an adjunctive benefit, this allows for the saline-infusion method to mobilize the SSE without producing the venous engorgement of the Valsalva maneuver.

Rathke's cleft cyst presenting as sphenoid sinusitis.

Rathke's cleft cysts are developmental abnormalities of the craniopharyngeal duct composed of retained stratified ciliated cuboidal cells of the respiratory type. Incidentally found in the pars intermedia in 13% to 33% of routine autopsies, they are discovered in growing numbers on CT and MRI scans. From 1991 to 1999, 9 cases of Rathke's cleft cysts were encountered by the senior authors, 4 of which were treated surgically (3 by using a transsphenoidal approach and one by using a transcranial subfrontal approach). Of the 3 patients treated with a transsphenoidal approach, 2 presented with symptoms mimicking sphenoid sinusitis and were initially referred for otolaryngologic evaluation. The clinical, pathologic, and radiologic features, as well as management and follow-up of those 2 patients, are reviewed. There has been only one previous case report of Rathke's cleft cysts presenting as sinusitis. Nevertheless, the otolaryngologist should be aware of this condition because it may present with other significant symptomatic extracranial extensions.

Clinical manifestations of sinonasal pathology during pregnancy.

OBJECTIVE: Pregnancy may confer a number of conditions related to the head and neck. The objective of this study was to evaluate the clinical manifestations of sinonasal pathology that occur during pregnancy. METHODS: Thirty-three pregnant patients were evaluated for the occurrence of rhinorrhea, congestion, epistaxis, or acute sinusitis during the first trimester of pregnancy, controlling with 28 women of child-bearing age. A visual analogue scale was used to grade the severity of each symptom. Statistical analysis was carried out to assess for significant differences in the prevalence and severity of symptomatology between cases and controls. RESULTS: Compared to the control group, there was no statistically significant difference in the prevalence of congestion, epistaxis, rhinorrhea, or acute sinusitis. There was no statistically significant difference in the severity of any presenting symptom between pregnant and control group patients. CONCLUSION: Pregnancy is not associated with an increased prevalence or severity of nasal symptomatology during early pregnancy. The influence of hormonal changes on nasal physiology during pregnancy is discussed with a view toward safe management.

Effects of passive smoking on odour identification in children.

BACKGROUND AND OBJECTIVE: The effect of passive smoking on odour identification in children has rarely been reported. This study assessed the ability of such young subjects to identify a variety of odours. METHODS: The study population consisted of 20 children, 10 who were exposed to passive smoke at home and 10 with nonsmoking parents. Ten odourants were tested: vinegar, ammonia, peppermint, roses, bleach, vanilla, cough drops, turpentine, licorice, and mothballs. Each child was presented with five test trays containing all 10 odourants in random order. RESULTS: Of the total of 500 odours presented, the control group correctly identified 396 (79%) and the study group identified 356 (71%) (p < .005). The study group tended to misidentify 4 of the 10 odourants tested, namely, vanilla, roses, mothballs, and cough drops-56 of 200 (28%), compared with 96 of 200 (48%) in the control group. This was a highly significant finding (p < .0005). CONCLUSION: This work demonstrated that children exposed to passive smoke have difficulty identifying odours in comparison with children raised in relatively smoke-free environments. The identification of four odourants, vanilla, roses, mothballs, and cough drops, was particularly diminished in this study group.

Analysis of human papillomavirus in schneiderian papillomas as compared to chronic sinusitis and normal nasal mucosa.

Schneiderian papillomas (SPs) are tumours arising from the surface epithelium (schneiderian epithelium) of the nasal cavity and paranasal sinuses. Evidence points toward a viral etiology, specifically human papillomavirus (HPV). Although substantial data indicate HPV as a likely etiology, little is known about the role of HPV in benign nasal pathologies or in normal nasal mucosa. The objective of this study was to characterize the relationship between HPV and SP, chronic sinusitis (CS), and normal nasal mucosa. A case-control study was undertaken, matching patients with SP to patients with CS. Patients with normal nasal mucosa served as a control group. All patients had their tissues analyzed for the presence of various HPV subtypes using line blot assay. A total of 168 patients were identified (74 SP, 74 CS, 20 control). Of these, 70 (41.7%) had detectable deoxyribonucleic acid and 9 of 70 (12.9%) had detectable HPV of subtypes 6, 11, and 16. None had detectable HPV type 18. Significant differences were detected in the presence of HPV in the CS, SP, and control groups, as well as in the presence of low- versus high-risk subtypes among investigation and control groups. Significant differences exist in HPV infectivity among SP, benign nasal pathologies such as CS, and normal nasal mucosa. Human papillomavirus plays an important role, at least in part, in the development of SP, with types 6, 11, and 16 being more pivotal than other types. Line blot assay is a useful technique in identifying HPV in SP.

Connections of the facial and vestibular nerves: an anatomic study.

The facial and vestibulocochlear nerves emanate from the brain stem and then run parallel to each other within the internal auditory canal prior to their more peripheral distribution. Although anatomic connections between the facial and cochlear nerves have been described, reports outlining facial-vestibular anastomoses are few and may be found primarily in the non-English literature. The present study documents the existence of vestibulofacial neural connections as part of an anatomic dissection of 17 fresh human temporal bones.

Local synthesis of epsilon germline gene transcripts, IL-4, and IL-13 in allergic nasal mucosa after ex vivo allergen exposure.

BACKGROUND: The production of epsilon germline gene transcripts (Iepsilon(+)/Cepsilon(+) RNA) precedes class switch recombination to IgE and is induced by IL-4 and/or IL-13. Although Iepsilon and Cepsilon RNA(+) B cells have been identified within nasal tissue after in vivo allergen exposure, suggesting local germline transcription, whether these were resident or infiltrating B lymphocytes was not clear. OBJECTIVE: We sought to examine whether B cells resident to the nasal mucosa undergo epsilon germline transcription. METHODS: Nasal mucosal biopsy specimens were obtained from asymptomatic patients with seasonal allergic rhinitis and exposed to allergen ex vivo. Using immunocytochemistry, B lymphocytes were enumerated; with in situ hybridization, the number of cells expressing Iepsilon, Cepsilon, IL-4, and IL-13 messenger (m)RNA(+) cells was examined. RESULTS: Tissue cultured in medium containing specific allergen exhibited significantly more Iepsilon and Cepsilon RNA(+) cells compared with medium alone (P <.05). IL-4 and IL-13 mRNA synthesis also resulted from ex vivo allergen exposure; there were significantly more cells expressing transcripts for these cytokines within allergic nasal mucosal tissue cultured with allergen than medium alone (P <.05). Within allergen-stimulated tissue obtained from allergic patients, 30% of total B cells were Iepsilon RNA(+), and the majority of IL-4 and IL-13 mRNA(+) cells were T cells (68% and 44%, respectively) and mast cells (32% and 19%, respectively). CONCLUSION: These results demonstrate that the nasal mucosa is a site of epsilon germline gene transcription and suggest that local T cell and mast cell production of IL-4 and IL-13 may regulate this event.

Septal deviation and chronic sinus disease.

The introduction of computerized tomography in the identification of sinonasal pathology and associated anatomic variants has contributed to a greater understanding of the factors leading to ostiomeatal complex (OMC) obstruction and chronic sinus disease. The OMC and paranasal sinus regions were prospectively evaluated in 150 consecutive patients as a function of the degree of nasal septal deviation and compared with matched controls. These data were correlated with paranasal sinus disease, lateral nasal wall findings, and middle turbinate abnormalities. An increased incidence and severity of bilateral chronic sinus disease was present with increasing septal deviations (p < 0.05). Similarly, patients with increasing nasal septum deviations were noted to have a higher incidence of OMC obstruction (p < 0.05). Ostiomeatal complex obstruction in the direction of septal angulation was associated with nasal septal deformity; however, contralateral OMC obstruction was associated with middle turbinate and lateral nasal wall abnormalities (p < 0.05). The evaluation of the degree of septal angulation has helped better understand the factors contributing to chronic sinus disease and OMC obstruction.

Outcome analysis of endoscopic sinus surgery for chronic sinusitis in patients having Samter's triad.

A study was conducted to assess outcome analysis in acetylsalicylic acid (ASA) triad patients after endoscopic sinus surgery (ESS). The control group consisted of patients with chronic sinusitis, with or without asthma, who had also undergone ESS. The study group contained 18 patients with the classic triad who were compared with 22 controls. The study was conducted in retrospective fashion highlighting clinical presentation, radiologic evaluation, surgical findings, and recurrence rate of nasal polyps. Although both groups had a relatively similar age of onset of symptoms, the symptomatic picture was different in the two groups. Radiologic evaluation of the nose and paranasal sinuses revealed more extensive involvement of the sinuses in ASA triad patients. Furthermore, ASA triad patients underwent a greater number of repeat operations. This review suggests that ASA triad patients respond less well to surgical intervention and that other treatment modalities should perhaps be explored.

In vivo expression of signal transducer and activator of transcription factor 6 (STAT6) in nasal mucosa from atopic allergic rhinitis: effect of topical corticosteroids.

BACKGROUND: The allergen-induced late nasal response is associated with a high local expression of interleukin (IL) -4, a TH2-type cytokine implicated in immunoglobulin (Ig) E production, tissue eosinophilia and other events considered to be relevant to allergic inflammation. Interaction of IL-4 with its receptor activates at least two distinct signalling pathways that culminate in the transcription of specific target genes. One pathway involves the activation of a transcription factor termed signal transducer and activator of transcription factor 6 (STAT6). OBJECTIVE: To investigate the expression of STAT6 in the allergen-induced late nasal response and to examine the effect of local steroid treatment on STAT6 expression. METHODS: Inferior turbinate biopsies were obtained from subjects with allergic rhinitis out of the allergen season. Subjects were then randomized into topical steroid- (n = 6) and placebo-treated (n = 6) groups in a double-blind fashion. After a 6-week treatment period, a second nasal biopsy was performed 24 h after local challenge with allergen. STAT6 immunoreactivity was examined in biopsy specimens by immunocytochemistry using a specific monoclonal antibody. Numbers of inflammatory cells (CD3+ T cells and MBP+ eosinophils) and IL-4 mRNA+ cells were investigated by immunocytochemistry and in situ hybridization, respectively. RESULTS: STAT6 immunoreactivity was detected in all biopsies studied and localized predominantly to inflammatory tissue of the nasal mucosa. After allergen challenge, expression of STAT6 was markedly increased in placebo-treated patients (P < 0.01). By confocal microscopy, STAT6 was localized to the cytoplasm and the nucleus of positively-staining cells. The allergen-induced increase in STAT6 immunoreactive cells was not observed in the steroid-treated patients. The change in STAT6 immunoreactivity after allergen challenge correlated significantly with the change in numbers IL-4 mRNA+ cells (r = 0.74, P = 0.006) and CD3+ T cells (r = 0.76, P = 0. 004), but not MBP+ eosinophils. CONCLUSION: This study provides the first evidence of increased STAT6 expression in vivo in human allergic inflammation. The results support a role for STAT6 and IL-4 in the pathogenesis of late nasal response and show that decreases in STAT6 expression parallel the reduction in IL-4 expression that occurs with topical steroid treatment.

Unique characteristics of malignant schneiderian papilloma.

PURPOSE: To ascertain the characteristics unique to malignant schneiderian papilloma (MSP). METHODS: A case-control study of all schneiderian papilloma (SP) patients treated between 1978 and 1997 was conducted. Comparison was made between patients with MSP and patients with benign SP (BSP). RESULTS: A diagnosis of SP was made in 72 patients. Malignant changes, all of them the inverted papilloma subtype, were found in 8 of these patients. Three were diagnosed carcinoma in situ, and 5 were defined as invasive squamous cell carcinoma. At presentation, the MSP patients had significantly larger tumor spread into the ethmoid and sphenoid sinuses. The recurrence rate was significantly lower in SP patients treated with extensive surgical procedures. An association was found between the presence of malignant lesions and positive smoking history, subjective awareness of a nasal mass, and ethmoid and sphenoid sinus involvement. Also, histologic multicentricity was a feature more often seen in MSP than BSP and was a significant correlate with malignancy. CONCLUSION: The physician evaluating a patient with SP should be aware of the features described and of their possible association with a malignant lesion.

Expression of interleukin (IL)-12 (p40) and IL-12 (beta 2) receptors in allergic rhinitis and chronic sinusitis.

BACKGROUND: Interleukin (IL)-12 is a relatively new and structurally distinct TH1-associated cytokine produced by B cells and macrophages, which may play a suppressive role in the development of allergic sinonasal mucosal responses. OBJECTIVE: We investigated the expression of IL-12 (inducible p40 subunit) and its receptor (IL-12R beta2 subunit) in tissue biopsies of naturally exposed patients with allergy-associated (ACS) and nonallergy-associated chronic sinusitis (NCS) and compared it with controls. We also examined IL-12 and IL-12R expression in biopsies from a ragweed allergen challenge model. In the allergen challenge model, the effect of pretreatment with topical corticosteroids on IL-12 and IL-12R expression was assessed. METHODS: To detect IL-12 and IL-12R mRNA, we employed the technique of in situ hybridization using digoxigenin-labelled riboprobes. RESULTS: In both ACS and NCS subjects there was decreased expression of IL-12 as compared with control (P < 0.05). IL-12R (beta2) expression was decreased in ACS subjects as compared with control (P < 0.05), however, there was no significant difference found between NCS subjects and control. In the allergen challenge subjects, there was a significant decrease in IL-12 expression following challenge (P < 0.05). This effect was abrogated by pretreatment of the subjects with topical corticosteroids. However, IL-12R (beta2) expression showed no change following allergen challenge while pretreatment with topical corticosteroids resulted in increased expression of the (beta2) receptor after allergen challenge (P < 0.05). CONCLUSION: Our data suggest that IL-12 plays a role in the in vivo suppression of the allergic inflammatory response and that the control of this suppression may be exerted largely via the IL-12 (beta2) receptor.

Endoscopic repair of cerebrospinal fluid rhinorrhea: is it the treatment of choice?

Between 1991 and 1998, 12 patients with cerebrospinal fluid rhinorrhea were operated on using the intranasal endoscopic approach. The procedure was successful in 10 cases. The endoscopic approach failed in two patients who had larger bony defects and herniating meningoencephaloceles. This paper analyzes the case material with respect to the etiology and site of leakage. The value of computed tomography and magnetic resonance imaging for preoperative localization of the leak is discussed. The technique of underlay fascia graft is described and discussion ensues regarding potential pitfalls that may lead to failure of leak closure.

Monocyte chemotactic proteins in allergen-induced inflammation in the nasal mucosa: effect of topical corticosteroids.

BACKGROUND: Human allergen-induced rhinitis is associated with the recruitment and activation of inflammatory cells, particularly eosinophils and CD4(+) T cells, in the nasal mucosa. Chemokines are inflammatory mediators capable of attracting specific inflammatory cell populations. Monocyte chemotactic proteins (MCPs), a subfamily of CC chemokines, have been shown to induce chemotactic activity particularly in eosinophils, T cells, and monocytes under in vitro assay conditions. OBJECTIVE: To assess the contribution of MCPs in the recruitment of inflammatory cells in vivo, we investigated the allergen-induced late response in subjects with allergic rhinitis. METHODS: Patients were randomized to receive a 6-week treatment with either topical corticosteroid (n = 6) or a matched placebo (n = 6). Nasal inferior turbinate biopsy specimens were obtained from all subjects before and during allergen-induced late responses. By using immunocytochemistry, tissue sections were examined for the presence of MCP-1, MCP-3, and MCP-4 and for the phenotype of infiltrating cells within the nasal mucosa. In addition, double sequential immunocytochemistry was used to confirm the phenotype of MCP-immunoreactive positive cells. Furthermore, the effect of topical corticosteroids on the expression of MCPs and on the cellular infiltrate was also examined. RESULTS: MCP-1, MCP-3, and MCP-4 were expressed in all the baseline samples, with prominent staining observed within the nasal epithelium. Biopsy specimens taken after challenge exhibited significant upregulation in the expression of MCP-3 and MCP-4 (P <.001). On the other hand, this increase in response to allergen was reduced in patients pretreated with topical corticosteroids. Colocalization experiments revealed that the majority of MCP+ cells in the subepithelium were macrophages, followed by T cells and eosinophils. CONCLUSION: Our results demonstrate that allergen-induced rhinitis is associated with an increased expression of MCP-3 and MCP-4, which may be closely related to the influx of inflammatory cells and may thus contribute to the pathogenesis of allergic rhinitis.

Th-2 type cytokine receptors in allergic rhinitis and in response to topical steroids.

OBJECTIVES: Th-2 type cytokine production (Interleukin-4 [IL-4] and interleukin-5 [IL5]) has been demonstrated to play a significant role in the pathophysiology of allergic rhinitis (AR), and the treatment of AR with topical corticosteroids has been shown to reduce the expression of Th-2 type cytokines in vivo. However, the contribution and expression of Th-2 type cytokine receptors in AR and their response to corticosteroid treatment remain to be clarified. Objectives of the current study are 1. To examine the expression of the cytokine IL-4 and IL-5 receptors (IL-4R and IL-5R) in a nasal allergen challenge model and to contrast this with the expression of the receptor for the Th-1 type cytokine, interferon-gamma receptor (IFN-gammaR), and 2. to examine the effects of pretreatment with topical corticosteroid before allergen challenge on the expression of these same receptors. STUDY DESIGN: Randomized prospective study involving 14 ragweed-allergic subjects evenly divided between placebo and corticosteroid pretreatment. METHODS: Immunocytochemistry (alkaline phosphatase-antialkaline phosphatase labeling [APAAP] technique) was used to stain nasal biopsy specimens before and after allergen challenge. Antibodies used included anti-CD3, CD4, CD8, major basic protein (MBP), IL-4R, IL-5R, and IFN-gammaR. RESULTS: Following allergen challenge, we observed a significant increase in the Th-2 type cytokine receptors (IL-4R and IL-5R; P<.05), as well as a significant decrease in the expression of the Th-1 type cytokine receptor (IFN-gammaR; P<.05). Pretreatment with topical corticosteroids before nasal allergen challenge resulted in decreased expression of IL-4R (P<.05) and IL-5R (P<.05) and increased expression of IFN-gammaR (P<.05). Further, IL-4R and IL-5R expression correlated with eosinophil infiltration in the tissues. CONCLUSIONS: We have demonstrated that in AR, cytokine receptors for IL-4, IL-5, and IFN-gamma follow a similar pattern to their ligands. In addition, pretreatment with topical corticosteroids was shown to alter the cytokine receptor expression pattern from a Th-2 profile more toward a Th-1 profile.