Reducing nasal morbidity after skull base reconstruction with the nasoseptal flap: free middle turbinate mucosal grafts.

OBJECTIVES/HYPOTHESIS: The nasoseptal flap provides hearty vascularized tissue for reconstruction of expanded endonasal approaches (EEA); however, it produces donor site morbidity due to exposed cartilage. Mucosalization of the septum requires 12 weeks, multiple debridements, and frequent saline rinses. This study addresses the reduction of nasal morbidity by grafting middle turbinate mucosa onto the exposed septum. STUDY DESIGN: Small prospective study with retrospective analysis of a larger cohort. METHODS: Fifteen patients undergoing EEA of the ventral skull base were prospectively enrolled. In seven cases, the sacrificed middle turbinate mucosa was harvested and placed as a free mucosal graft on the septal cartilage. In eight controls, middle turbinate grafting was not performed due to tumor involvement. Septal mucosalization and crusting of all patients was quantified at follow-up appointments. An additional 46 patients were retrospectively identified who received middle turbinate grating on their exposed septal cartilage, and mucosalization rates were determined from clinical records. RESULTS: Three weeks after initial operation, the mucosalization rate was 70% versus 5% in the graft and nongraft groups, respectively. At postoperative week 6, the mucosalization and crusting were 97% and 5% for the graft group versus 60% and 85% for the nongraft group. Mucosalization rates in the retrospective graft series agreed with the prospective series. CONCLUSIONS: Despite donor site morbidity, the nasoseptal flap is becoming the standard of care for skull base reconstruction due to its reliability in reestablishing a barrier between the subarachnoid space and the sinonasal tract. It is possible to dramatically increase the rate of septal mucosalization and decrease crusting by using a middle turbinate free mucosal graft.

A controlled laboratory and clinical evaluation of a three-dimensional endoscope for endonasal sinus and skull base surgery.

BACKGROUND: One criticism of current video systems for endoscopic surgery is that two-dimensional (2D) images lack depth perception and may impair surgical dissection. To objectively measure the efficacy of 3D endoscopy, we designed a training model with specific tasks to show potential differences between 2D and 3D endoscopy. Its clinical value was then evaluated during endoscopic sinus and skull base surgical cases. METHODS: Fifteen subjects were grouped according to endoscopic experience: novices and nonnovices. A training model was constructed to include five tasks: incision manipulation; ring transfer; nerve hook; distance estimation, visual only; and distance estimation, visual and tactile. Each participant was assessed with both a standard 2D endoscope and a 3D endoscope. The clinical value of a 3D endoscope (Visionsense, Ltd., Petach Tikva, Israel) was then examined in four endoscopic sinus cases and four skull base cases. RESULTS: Of the subjects, six (40%) were novices. Overall, the errors committed during any one task were not significantly different between systems. Novices trended toward more success during the nerve hook task using the 3D system. With size cueing versus visualization alone, distance estimation was significantly more accurate. Novices tended to prefer the 3D system and experienced surgeons disliked the initial learning curve. Advantages were particularly noticed during skull base surgery; subjectively improved depth perception was beneficial during vascular dissection. CONCLUSION: Three-dimensional endoscopy may improve depth perception and performance for novices. The 3D endoscope is a safe and feasible tool for endoscopic sinus and skull base surgery; it is promising for improving microneurosurgical dissection precision transnasally.

Sphenoid "drill-out" for chronic sphenoid rhinosinusitis.

BACKGROUND: Chronic sphenoid rhinosinusitis (CSR) refractory to both medical management and 1 or more sphenoidotomies is a difficult entity to treat. In contrast to the surgical hierarchy that exists for the frontal sinus, there is no systematic approach for addressing persistent disease in the sphenoid. Sphenoid marsupialization has been advocated as a method of addressing recurrent sphenoid sinusitis. OBJECTIVE: We present a new technique called the sphenoid drill-out, which we place between traditional sphenoidotomy and sphenoid marsupialization in the surgical hierarchy for management of CSR. METHODS: We performed a retrospective review on all patients undergoing sphenoidotomy between 2005 and 2009. We studied demographics, procedure type, diagnoses, comorbidities, efficacy, revision rate, and endoscopic outcomes using Lund-Kennedy scores. RESULTS: A total of 10 patients underwent sphenoid drill-out for CSR. Average follow up was 17 months. Patients had an average of 5 prior sinus surgeries with 2.6 prior sphenoidotomies. One patient required a revision drill-out procedure. The mean preoperative and postoperative Lund-Kennedy scores were 6.67 and 1.78, which was a statistically significant difference. CONCLUSION: The sphenoid drill-out procedure is safe and effective for the management of recalcitrant CSR. It should be considered as an intermediate procedure between sphenoidotomy and sphenoid marsupialization.

High-resolution ultrasound in the evaluation of pediatric recurrent respiratory papillomatosis.

OBJECTIVES: To characterize the ultrasonographic appearance of laryngeal papillomatosis and to compare ultrasound with direct laryngoscopy and bronchoscopy, the criterion standard, for airway evaluation. DESIGN: Prospective, nonrandomized analysis of preoperative and postoperative airway ultrasound images. SETTING: Tertiary, university-based medical center. PARTICIPANTS: Eight patients (4 females and 4 males) with recurrent respiratory papillomatosis, with a mean age of 10.25 years and a mean of 14 surgical papilloma resections (range, 3-35). INTERVENTION: The patients underwent planned papilloma resections with ultrasound evaluation before formal endoscopic resection. Preresection ultrasound images of respiratory papillomas were evaluated. MAIN OUTCOME MEASURES: The ultrasonographic appearance of respiratory papillomas and pediatric airway anatomy. RESULTS: Respiratory papillomas appeared as discrete, hyperechoic lesions on the relatively hypoechoic background of the true vocal folds. CONCLUSIONS: Recurrent respiratory papillomas have a characteristic ultrasonographic appearance that seems to correlate with endoscopic findings. It seems that this modality holds promise for identifying pedunculated papillomas. Although direct laryngoscopy and bronchoscopy are the criterion standard, airway ultrasound may have a role in the early diagnosis of, surveillance of, and operative planning for recurrent respiratory papillomatosis. To our knowledge, this is the first study to describe the ultrasonographic appearance of papillomas and the first comparison of ultrasonographic and endoscopic airway images. This modality merits further study, and further investigation is ongoing.

Cytokine amplification by respiratory syncytial virus infection in human nasal epithelial cells.

OBJECTIVES: Respiratory syncytial virus (RSV) is an important cause of upper respiratory infections and is known to play a causal role in the pathogenesis of rhinitis, sinusitis, acute otitis media, and pneumonia. RSV appears to prime the respiratory tract to secondary inciting events, such as bacterial or antigen challenges. To study the proinflammatory priming effects of RSV infection, cytokine expression was measured in well-differentiated human nasal epithelial cells (WD-NE) after RSV infection alone or after subsequent tumor necrosis factor (TNF)-alpha stimulation. STUDY DESIGN: In vitro investigation. METHODS: Human nasal epithelial cells were obtained from surgical specimens and allowed to differentiate in air-liquid interface cultures until ciliation and mucus production were evident. Two experimental paradigms were used. First, accumulation of cytokines in the media was measured by real-time, quantitative reverse-transcriptase polymerase chain reaction (RT-PCR) and enzyme-linked immunosorbent assay after RSV infection alone. In the second set of experiments, cytokines were also measured after TNF-alpha stimulation in both RSV-infected and uninfected cultures. RESULTS: RSV infection of WD-NE resulted in significant accumulations of interleukin (IL)-6, IL-8, and RANTES when compared with findings in control samples. Real-time, quantitative RT-PCR demonstrated significant increases in IL-8 gene expression following RSV infection when compared to controls. Secondary TNF-alpha stimulation following well-established (i.e., 72 h) RSV infection induced marked increases in IL-6, IL-8, and RANTES when compared with both RSV infection alone and TNF-alpha stimulation alone. CONCLUSIONS: These findings suggest that RSV infection primes nasal epithelial cells to secondary proinflammatory challenge, resulting in a hyperimmune response. RSV-induced priming of a hyperimmune response may be important in the pathogenesis of sinusitis, acute otitis media, and pneumonia.