Geographic variation in allergic fungal rhinosinusitis.

Allergic fungal rhinosinusitis (AFRS) has a worldwide distribution. This survey of 20 otolaryngologic practices throughout the United States confirmed a variation in the frequency of AFRS relative to endoscopic sinus procedures performed for all other diagnoses. The highest incidence occurred in Memphis, Tennessee at 23%, with three other southern practices reporting a frequency of at least 10%. In the northern locations the frequency ranged from 0 to 4%. No correlation with mould counts was demonstrated, possibly because of incomplete mould data relative to most of the surgical locations.

Lasers in endonasal surgery.

The laser has played a valuable primary and adjunctive role in the management of nasal and sinus disorders. When using the laser there must be appropriate knowledge about safety, instrumentation, and types of pathologic conditions in which the laser is effective. The laser is effective for turbinate dysfunction of various causes. Its coagulating, cutting, and vaporization ability make it useful in managing intranasal vascular disorders such as hereditary hemorrhagic telangiectasia and hemangioma. There is some promise in using the laser for nasal polyposis with eosinophilia.

Osteomyelitis of the orbit.

Although rare, orbital osteomyelitis secondary to sinusitis can be devastating. Early, aggressive ophthalmologic surgical intervention, as well as otorhinolaryngologic co-management, is necessary to obtain the best outcomes. We present two cases of orbital osteomyelitis. One patient remained infected with Pseudomonas meningitis even after extensive sinus and orbital surgery, rapidly declined, and is now deceased. The other patient, after multiple sinus procedures and a medial orbitotomy, was placed on hyperbaric oxygen and is still undergoing treatment.

Low back and cervical spine disorders.

Neck and back pain are common work-related complaints. The natural history of these symptoms favors rapid recovery. Medical management of workers with these complaints relies on carefully managing this natural history, while attempting to minimize the resulting disability. Medical advice should focus on decreasing patients' fears and encouraging a rapid return to function (including work) as acute pain symptoms improve. Interventions should be as limited as possible and promote self care. Patients with radicular symptoms may require additional interventions but, there, too, the natural history is favorable. Surgery may be necessary in a small percentage of patients with catastrophic and severe neurologic symptoms or persistent, severe pain. Chronic neck and back pain symptoms are commonly encountered. Medical and reversible causes of pain should be sought in such patients. When none is found, interventions aimed at maximizing back and neck function and improving tolerance for physical activities may be beneficial in returning these workers to productive lifestyles.

Complications of endoscopic sinus surgery: analysis of 2108 patients--incidence and prevention.

The incidence of complications of endoscopic sinus surgery (ESS) in a combined experience with 2108 total patients is compared to complications in 11 other series of patients (2583 total) who underwent ESS and 6 series of patients (2110 total) who underwent traditional endonasal sinus surgery. The incidence of major perioperative complications was 0.85%, with cerebrospinal fluid (CSF) leak being the most common. The most common minor complications of ESS were those related to orbital penetration and middle turbinate adhesions; minor complications occurred in 6.9% of the 2108 patients. There were no statistically significant differences in the overall incidences of major complications between this series and the other two groups. Recommendations are made for the prevention of complications during ESS.

Facial nerve morbidity following parotid surgery for benign disease: the Cleveland Clinic Foundation experience.

Standard surgical management for benign tumors of the parotid gland requires either superficial, subtotal, or total parotidectomy with preservation of the facial nerve. Although this approach is effective in minimizing recurrence, the resultant facial nerve morbidity is seldom addressed. Two hundred fifty-six consecutive patients who underwent parotid surgery for benign neoplasia at this institution in the past 15 years are reviewed, with attention to postoperative facial nerve function. Immediate dysfunction was frequently encountered (46.1%), but permanent dysfunction was uncommon (3.9%). The incidence of long-term dysfunction may be higher in revision cases and when an extended (total or subtotal) parotidectomy is performed.

Factors influencing survival in ethmoid sinus cancer.

Nineteen patients with primary ethmoid sinus malignancies were treated at the Cleveland (Ohio) Clinic Foundation between 1976 and 1989. Pathologic diagnoses included adenocarcinoma (eight), sarcoma (four), squamous cell carcinoma (three), mucoepidermoid carcinoma (two), adenoid cystic carcinoma (one), and undifferentiated carcinoma (one). All patients underwent surgical resection: 13 had craniofacial resection, four had craniofacial resection/orbital exenteration, one had radical ethmoidectomy/maxillectomy/orbital exenteration, and one had transantral ethmoidectomy. Twelve patients had combined treatment with radiation therapy. Ten patients were alive with no evidence of disease. A trend toward improved prognosis is associated with negative surgical margins. Preservation of the globe was not associated with local recurrence at this site. A poor prognosis was noted with involvement of the dura, brain, nasopharynx, or sphenoid sinus.

Otorhinolaryngologic causes of headache.

Pain around the face and neck is common. This pain may be referred from a different area. Because patients usually present with pain and discomfort in a specific location such as the ear, nose, face, throat, or neck, this article discusses separately the innervation of each region and the most frequent causes of pain in each of these areas.

The use of surface tension measurements in the design of antibody-based product formulations.

Many proteins in aqueous solution are susceptible to interfacial denaturation and precipitation during mechanical agitation. With the large number of protein parenteral products currently in research or clinical testing, it is important not only to understand this denaturation process but also to develop effective methods for stabilizing the products. Surfactants, such as Polysorbate 80 or sodium dodecyl sulfate (SDS), are frequently used to stabilize parenteral products. While it is a commonly accepted technique, little has been published about the precipitation and stabilization processes in general. We describe the stabilization of antibody products in solution by preferential adsorption of a water-soluble, non-ionic surfactant at the air-liquid interface. Data are presented from antibody and immunotoxin solution shake studies and surface tension measurements to support the utility of surface tension measurements in formulation design.

The potassium--titanyl phosphate laser for treatment of turbinate dysfunction.

Patients with nasal turbinate dysfunction most often are seen by the physician with such symptoms as watery nasal secretions, nasal obstruction, congestion, facial pressure, or pain. There will often have been multiple attempts to manage the problem medically and symptomatically with antihistamines, decongestants, antibiotics, nasal cromolyn, and topical or systemic steroid therapy. Some patients will have undergone numerous attempts at surgical therapy, most often with cryosurgery or cauterization. The cause of the symptoms of turbinate dysfunction for most of these patients is either vasomotor rhinitis, allergic rhinitis, or polypoid hypertrophic turbinates. A visible-wavelength laser with a wavelength of 532 nm, the potassium-titanyl phosphate laser has been used with nasal endoscopes to perform laser photocoagulation of the nasal turbinates. A description of the technique and early results have been previously reported. This article reports good long-term results with the technique.

Carotid body tumors.

The surgical management of carotid body tumors requires identification and preservation of neural and vascular structures without compromising resection of the neoplasm. Fifteen patients were examined and treated for carotid body tumors at the Cleveland (Ohio) Clinic Foundation from 1979 through 1987. The benchmark of diagnosis is bilateral carotid angiography. When neural structures are free of tumor, meticulous dissection facilitates their preservation. Large tumor size increases risk for arterial resection necessitating reconstruction. The use of a vascular shunt minimizes the risk of cerebral ischemia. Postoperative intravenous digital subtraction angiography allows for evaluation of arterial repair. A retrospective review of 15 carotid body tumor resections performed in 14 patients revealed no evidence of tumor recurrence, no mortality associated with surgical intervention, no postoperative cerebrovascular accident, and limited morbidity associated with unavoidable sacrifice of neural elements.

Inverted papillomas and associated squamous cell carcinomas.

Inverted papillomas of the nose and paranasal sinuses are found to be associated with squamous cell carcinomas in a small percentage of cases. The records of forty-six patients treated for inverted papillomas in these areas over a 10-year period were reviewed. Eleven patients (24%) were found to have squamous cell carcinoma, and one carcinoma in situ, in relationship to the inverted papillomas. This is a much higher percentage than generally reported. Four of these patients were found to have inverted papillomas coincidentally in surgical specimens resected for squamous cell carcinoma. Patients with squamous cell carcinoma were found to be in older age groups, were more likely to manifest epistaxis than the more common unilateral nasal obstructive symptoms, and had less time between the onset of symptoms and presentation than those with inverted papillomas alone. The clinical presentation, treatment, and outcome of inverted papillomas and squamous cell carcinomas in association with inverted papillomas are discussed.

Upper airway obstruction due to tonsillar lymphadenopathy in human immunodeficiency virus infection.

Head and neck manifestations of human immunodeficiency virus (HIV) infection are common and include diffuse cervical lymphadenopathy, cutaneous and mucosal Kaposi's sarcoma, mucosal herpes simplex infection, upper aerodigestivetractcandidiasis, and parotidlymphadenopathy and cysts. Recurrent otitis media and chronic sinusitis have been noted in the pediatric HIV population. We describe a patient with HIV-associated tonsillar and adenoid lymphadenopathy and upper airway obstruction. Pathologic analysis of the tonsillar tissue revealed severe lymphofollicular hyperplasia similar to that of other lymphoid tissue in HIV infection. The importance of symptomatic treatment of the airway obstruction is stressed.

The office diagnosis of nasal and sinus disorders using rigid nasal endoscopy.

Functional nasal endoscopic surgery has become increasingly popular because of the development of fiberoptic ridge nasal endoscopes. These same nasal endoscopes play an important role in the office diagnosis of nasal and sinus disorders. While not all physicians or medical institutions can afford the cost of nasal endoscopes for nasal sinus surgery, the cost of an office examination set is reasonable and the patient benefits are great. One hundred and fifty consecutive patients with nasal and/or sinus complaints and normal anterior rhinoscopic nasal speculum and posterior rhinoscopic nasopharyngeal examinations were each examined with rigid fiberoptic nasal endoscopy by two physicians to confirm each findings. Nasal endoscopy revealed fifty-eight (38.7%) patients with nasal pathology who had not been seen with traditional anterior and posterior rhinoscopic examination. The pathology found included obstructed natural maxillary sinus ostia and several pathologic disorders in the middle meatus, such as polyps and "synechiae". Many of these patients had seen several physicians and exhibited frustrating longstanding symptoms, some of which included postnasal catarrh, postnasal drainage, headache, facial pain, "sinus", pressure, and congestion. Nasal endoscopy can find nasal and sinus pathology that might easily be missed with routine speculum and nasopharyngeal examination. For patients with unexplained nasal sinus symptoms, the general otolaryngologist might consider rigid nasal endoscopic office examination as part of the routine office examination.

Functional endoscopic sinus surgery: evaluation, surgery, and follow-up of 250 patients.

Although much has been written about the surgical technique of functional endoscopic sinus surgery, little has appeared about its long-term results. Two hundred fifty patients underwent endoscopic nasal office evaluations and subsequent functional endoscopic sinus surgery (42 unilateral + 208 bilateral = 458 procedures) for nasal polyposis and chronic sinusitis from January 1986 to June 1988. Immediate postoperative data indicated that 8.3% developed minor complications and 0.7% developed major complications. Two hundred twenty-one patients were available for long-term follow-up at 12 to 42 months (mean = 17 months) with success rates of 89.7% for relief of sinonasal polyposis and 80.2% for relief of chronic sinusitis.

Nonsquamous cell malignancies of the paranasal sinuses.

Nonsquamous cell malignancies represent half of paranasal sinus cancers. Since 1975, 103 patients have been treated at The Cleveland Clinic Foundation for sinus malignancies. Forty-nine patients had nonsquamous cell malignancies: 12 (25%) sarcoma, 10 (20%) adenoid cystic carcinoma, 9 (18%) adenocarcinoma, 9 (18%) lymphoma, and 9 (18%) miscellaneous tumors. Ten patients presented with T1 or T2 disease at the primary site, 16 with T3, and 23 with T4. Ten patients had primary ethmoid malignancies; the remainder of the tumors originated in the maxillary sinus. Five patients had evidence of regional or distant metastases at presentation. Twelve patients were free of disease after initial management. Three patients with recurrent disease were salvaged with additional therapy. Two patients died of complications in the immediate postoperative period. Patients with less extensive primary lesions have an improved prognosis. Survival was similar for the different histologic diagnoses.

Three-dimensional surface rendering of nasal anatomy from computed tomographic data.

This article investigates the potential of using three-dimensional surface-rendered computed tomographic reconstructions for demonstrating normal and pathologic intranasal anatomy. Three-dimensional surface renderings of the intranasal structures were generated in 38 patients from coronal high-resolution computed tomographic images. Because of the complex anatomy, three-dimensional images were believed to be useful for surgical planning. There may be a correlation between the appearance of the uncinate process and severity of inflammatory sinus disease.