Organized Hematoma of the Sphenoid Sinus With Acute Blindness: Insight Into Pathogenesis of Disease.

Sinonasal organized hematomas (OHs) are rare lesions that primarily localize to the maxillary sinus. The rate of growth of these masses has not been described in the literature. We present a case of a 59-year-old gentleman with polyostotic fibrous dysplasia who presented with acute loss of vision in the left eye from an expanding OH of the sphenoid sinusitis. After expanded endonasal, transpterygoid approach and debulking, patient experienced significant vision improvement. Close follow-up imaging preoperatively allowed radiologic documentation of the rate of OH growth and this is presented in detail.

Intracranial complications of pediatric rhinosinusitis: Identifying risk factors and interventions affecting length of hospitalization.

OBJECTIVE: To identify risk factors and interventions affecting length of hospitalization (LOH) and clinical outcome in children with intracranial complications of rhinosinusitis. METHODS: Retrospective chart review of 12 children hospitalized at 2 academic medical centers for intracranial complications of rhinosinusitis over the past 5 years. RESULTS: 12 patients were identified with an average age at presentation of 13 years old. 92% were male and 75% were African American. The most common presenting symptoms were fever and headache. Localizing neurological symptoms including hemiparesis and aphasia, in addition to seizures occurred in 33% of patients and increased LOH significantly (33 versus 15 days, p = 0.03). Epidural (EA) and subdural abscesses (SA) were the most common intracranial complications. 58% of patients were initially treated with a combination of open neurosurgical (ON) intervention and endoscopic sinus surgery (ESS) and LOH was significantly shorter for these patients compared to those treated otherwise (14 versus 31 days, p = 0.02). Streptococcus species were the most common group of bacteria identified in 75% of cases, with S. anginosus accounting for 42% of cases. The overall average LOH was 21 days with 92% of patients having complete resolution of symptoms by time of discharge. CONCLUSIONS: Treatment of intracranial complications of acute rhinosinusitis can have favorable outcomes after appropriate surgical management. Localizing neurologic symptoms and seizures portend longer hospital stay and recovery time. Shorter hospital stay was seen in those undergoing early combined ON and ESS interventions.

Causes of dacryocystorhinostomy failure: External versus endoscopic approach.

OBJECTIVES: To compare the causes of failure between external and endoscopic dacryocystorhinostomy (DCR) techniques for the treatment of lacrimal obstruction. STUDY DESIGN: A retrospective cohort study. METHODS: The study population consisted of 53 consecutive patients who underwent revision endoscopic DCR from 2002 to 2013 for lacrimal duct obstruction. Identified causes of previous DCR failure were compared between patients whose initial surgery was performed through an external versus an endoscopic approach. RESULTS: Reasons for surgical failure after external (n = 21) versus endoscopic (n = 32) DCR included cicatricial closure of the internal lacrimal ostium (52.4 versus 53.1%; p = 0.96), inadequate removal of bone overlying the lacrimal sac (23.8 versus 9.4%; p = 0.15), sump syndrome (9.5 versus 9.4%; p = 0.99), and intranasal adhesions (65 versus 37.5%; p = 0.05). Adhesions that involved the middle turbinate were a particularly impactful cause of failure when the DCR was performed through an external versus the endoscopic approach (57.1 versus 28.1%; p = 0.04). Septoplasty was more likely to be needed at the time of revision surgery if the initial procedure was performed externally (71.1 versus 15.6%; p = 0.02). Surgical success rates for revision DCR were comparable between the groups (75.0% external versus 73.3% endoscopic; p = 0.90), with a mean follow-up of 12.7 months. CONCLUSION: DCR failure associated with intranasal adhesions was more likely to occur when the surgery was performed through an external rather than an endoscopic approach. Endoscopic instrumentation allowed for identification and correction of intranasal pathology at the time of DCR, including an enlarged middle turbinate or a deviated septum, which may improve surgical outcome.

Surgical Management of Severe Epistaxis.

Many patients with severe epistaxis benefit from endoscopic intervention for control of bleeding. Critical maneuvers to improve endoscopic visualization during surgery include head-of-bed elevation, application of topical vasoconstrictors, and local injection of vasonstrictors. Controlled, hypotensive anesthesia may also decrease intraoperative blood loss and improve visualization during surgery. Intractable posterior epistaxis can be controlled with high rates of success with endoscopic sphenopalatine artery ligation. Although less common, intractable anterior epistaxis may be controlled by anterior ethmoid artery ligation once this artery is identified as the primary source. Less common sources of severe epistaxis are also discussed in this article.

Comparative techniques of medial rectus muscle retraction for endoscopic exposure of the medial intraconal space.

OBJECTIVE: The medial rectus muscle (MRM) is the medial boundary to the intraconal space of the orbit, and retraction of the MRM is oftentimes necessary for endoscopic removal of intraconal tumors, e.g., orbital hemangioma. We evaluated each of the reported methods of MRM retraction for endoscopic orbital surgery and quantified the degree of intraconal exposure conferred by each method. METHODS: Eight orbits from four cadaver heads were dissected. In each orbit, medial orbital decompression was performed and the MRM was retracted by using four previously described techniques: (1) external MRM retraction at the globe insertion point by using vessel loop (external group), (2) transseptal MRM retraction by using vessel loop (transseptal group), (3) transchoanal retraction of the MRM by using vessel loop (choanal group), and (4) transseptal four-handed technique by using double ball retraction by a second surgeon (transseptal double ball group). The length, height, and area of exposure of the medial intraconal space were quantified and compared. RESULTS: The average ± standard deviation (SD) anterior-posterior exposures for the external group, transseptal group, and transseptal double ball group were 17.51 ± 3.39 mm, 16.59 ± 4.16 mm, and 18.0 ± 15.25 mm, respectively. The choanal group provided significantly less exposure (12.39 ± 3.44 mm, p = 0.049) than the other groups. The average ± SD vertical exposures for the transseptal group, choanal group, and transseptal double ball group were 12.53 ± 4.38 mm, 13.05 ± 5.86 mm, and 13.57 ± 3.74 mm, respectively. The external group provided significantly less exposure (4.51 ± 1.56 mm, p = 0.0072) than the other groups. The transseptal and transseptal double ball groups provided the greatest total access by surface area (58.88 ± 26.96 mm(2) and 62.94 ± 34.74 mm(2), respectively) compared with the external and choanal groups (34.82 ± 23.37 mm(2) and 43.10 ± 23.68 mm(2), respectively). Although the transseptal trajectory of MRM retraction was optimal, the difference in total area of exposure between the static vessel loop retraction and the dynamic, four-handed technique with double ball instrument retraction was not significant. Of note, the exposure provided by the choanal technique required the surgeon to work both above and below the muscle. CONCLUSION: Retraction of the MRM toward the choanae provided the least length of exposure, and external retraction exposed the least height and total area. Transseptal MRM retraction was most favorable and provided the largest endoscopic corridor to the medial intraconal space. A four-handed approach for endoscopic intraconal surgery of the orbit may offer advantages in dynamic adjustments in retraction.

A Rare Finding of Schwannoma of the Vidian Canal: A Case Report.

Background Schwannomas of the vidian canal are an extremely rare type of intracranial tumor that can have variable clinical presentations including headache, facial pain, facial muscle paralysis, decreased lacrimation, or nasal dryness. We present an atypical case of an incidentally identified asymptomatic vidian canal schwannoma. Case Description A 49-year-old woman with a history of multiple sclerosis presented for routine surveillance magnetic resonance imaging that detected an ovoid mass originating in the vidian canal. Given the unusual location of the lesion, an endoscopic endonasal biopsy was performed and confirmed the diagnosis of a vidian canal schwannoma, for which the patient chose to receive fractionated radiation therapy. Conclusion When a vidian canal tumor is identified, endoscopic endonasal biopsy can be used to confirm the diagnosis before pursuing either surgical or radiotherapy treatment. In particular, fractionated radiation therapy offers a radiobiologically safe means of delivering radiation when there is concern for late radiation-related side effects following treatment completion.

Human papillomavirus infection and biomarkers in sinonasal inverted papillomas: clinical significance and molecular mechanisms.

BACKGROUND: The role of human papillomavirus (HPV) in sinonasal inverted papillomas (IPs) is controversial. Determining the prevalence of HPV infection and its impact on the molecular biology of these tumors is critical to characterizing its role in the pathogenesis of IPs. METHODS: A total of 112 paraffin-embedded IPs from 90 patients were studied. A tissue microarray was constructed and stained for p16, p53, epidermal growth factor receptor (EGFR), and cyclin D1. HPV presence and types were determined using PGMY 09/11 primers and integration using HPV 11 detection of integrated papillomavirus sequences by ligation-mediated polymerase chain reaction (DIPS-PCR). RESULTS: HPV was detected in 11 of 90 (12%) patients. HPV 11 was found in 9 samples. HPV 6 and HPV 27 were found in 1 sample each. EGFR staining proportion was higher in HPV-positive IPs vs HPV-negative specimens (56.2% vs 23.6%; p = 0.009). Differences in p16, p53, and cyclin D1 staining were not significant. HPV-positive lesions tend to progress to malignancy (p = 0.064). Three samples were analyzed for integration. Viral integration was found in both malignant tumors but not in the precursor IP. CONCLUSION: Degradation of p53 and p16/cyclin D1 dysregulation are not important mechanisms in low-risk HPV-related IP. The low prevalence of HPV in this series indicates it is not a main etiological factor for IPs; however, when present, low-risk HPV may contribute to the biology of IPs through an increase of EGFR expression and a predisposition for malignant progression by integration into the cellular genome.

Volumetric analysis of chronic maxillary atelectasis.

BACKGROUND: The relationship between orbit and maxillary sinus volumes in patients with chronic maxillary atelectasis (CMA), commonly known as silent sinus syndrome if enophthalmos is present, is poorly understood. METHODS: A retrospective review of 22 patients who underwent endoscopic sinus surgery (ESS) for CMA from 2005 to 2013 was performed. Computed tomography (CT) images were analyzed using OsiriX 5.8.2 software for volumetric analysis of the orbit and maxillary sinus at presentation and after surgical treatment with ESS. RESULTS: Pretreatment mean orbit volumes on the diseased side (DS) and the contralateral side (CS) were 29.22 and 26.50 mL, respectively (p < 0.001); mean sinus volumes on the DS and CS were 8.51 and 17.20 mL, respectively (p < 0.001); and pretreatment mean midorbit heights (MOHs) on the DS and CS were 3.39 cm and 3.07 cm, respectively (p < 0.001). The percent decrease in sinus volume on the DS compared to that on the CS did not correlate significantly with the percent orbit-volume increase. Enophthalmos was present in nine (41%) patients, and diplopia was present in three (14%) patients. The measured degree of increased orbit volume and decreased sinus volume secondary to CMA did not significantly predict the presence of enophthalmos at presentation. Seven patients underwent sinus CT more than 6 months after ESS. In these patients, orbit volume on the DS decreased from 29.67 to 27.52 mL (p = 0.005), and sinus volume on the DS increased from 9.78 to 11.84 mL (p = 0.08). CONCLUSIONS: Volumetric analysis is a powerful and novel method for objectively demonstrating the degree of orbit expansion and maxillary sinus contraction seen with CMA. Spontaneous maxillary sinus expansion and a decrease in orbit volume can occur after ESS, but post-ESS volumes do not return to the normal volume of the CS.

Comparison of second-echelon treatments for Ménière's disease.

IMPORTANCE: To compare the efficacy of treatments commonly offered to patients with Ménière's disease who fail conservative medical therapy including diuretics and a sodium-restricted diet. OBJECTIVES: This study compared three second-echelon treatments: the Meniett device, endolymphatic sac decompression, and intratympanic gentamicin injections to determine their comparative effectiveness and capacity to mitigate against the necessity of a surgical labyrinthectomy. DESIGN, SETTING, AND PARTICIPANTS: Retrospective observational study at an academic tertiary care center. Patients with Ménière's disease who failed primary medical management were evaluated after treatment with a Meniett device (n=20), endolymphatic sac decompression (n=23) or intratympanic gentamicin injections (n=17). Cases were included if auditory and vertigo control data were available before and a minimum of two years after treatment, in patients without previous otologic surgery or intratympanic injections. Average age ranged from 54 to 75 years. INTERVENTIONS: Use of the Meniett device, endolymphatic sac shunt decompression surgery or intratympanic gentamicin injections using variable doses and injection schedules. MAIN OUTCOMES AND MEASURES: Proportion of patients with vertigo control and hearing preservation by a modified version of the AAO-HNS criteria after second-echelon treatment, thus not requiring definitive labyrinthectomy. RESULTS: Despite endolymphatic sac surgery demonstrating a longer duration (61 months) prior to labyrinthectomy, no differences were found between the 3 treatment options in terms of patients going on to definitive labyrinthectomy or in the number of months of symptom relief following treatment. There was also no difference in residual auditory perception across the 3 groups. CONCLUSIONS AND RELEVANCE: No significant therapeutic differences were found between the studied second-echelon treatments for symptom relief of Ménière's disease.

Sinonasal inverted papilloma: prognostic factors with emphasis on resection margins.

Objective We review our institution's experience with the treatment of inverted papilloma (IP) with emphasis on the implications of surgical margins for disease control. Design Retrospective chart review of patients with IP treated at the University of Michigan from 1996 to 2011. Setting Tertiary care center. Participants Patients undergoing surgical resection with curative intent for IP. Main Outcome Measures Overall survival, disease-specific survival, and locoregional control were used as main outcome measures. Results We studied 129 patients including 19 with carcinoma arising from IP. Disease-free rates at 2, 3, and 5 years were 79.7%, 77.9%, and 61%, respectively. Overall, 10 of 18 recurrences were detected > 2 years from follow-up, with recurrences detected up to 8 years from surgery. For benign disease, obtaining tissue margins outside of the primary specimen for margin control did not affect disease control rates. Conclusion IP is a disease that requires significant follow-up periods beyond 2 years. For IP without carcinogenesis, acquiring margins outside of the tumor specimen did not appear to affect disease control rates in this study. No clear predictors of malignancy were seen in this study, which highlights the need for further research to predict this phenomenon.

Lesions of the petrous ridge: metastatic pituitary carcinoma with discussion of differential diagnosis.

OBJECTIVE: To discuss the differential diagnosis of petrous ridge lesions based on a rare case of metastatic pituitary carcinoma. PATIENT: A 41-year-old man with a past medical history of pituitary adenoma and hypopituitarism presented with imbalance and vertigo. Imaging showed a mass eroding the left posterior petrous face. INTERVENTION: Transtemporal, transmastoid approach for complete resection of tumor. MAIN OUTCOME MEASURES: Surgical pathology and imaging studies. RESULTS: Surgical pathology revealed metastatic pituitary carcinoma. The patient has been followed at our institution for 28 months postoperatively without evidence of recurrence. CONCLUSION: Lesions of the petrous ridge are rare. The wide differential diagnosis includes endolympatic sac tumor, meningioma, jugulotympanic paraganglioma, myeloma, and metastasis. The clinician must take into account unique imaging features on CT and MRI, and final diagnosis often requires pathologic analysis.

Epidermal growth factor receptor, p16, cyclin D1, and p53 staining patterns for inverted papilloma.

BACKGROUND: The aim of this study was better characterize the staining patterns of inverted papilloma (IP) with and without carcinoma by performing immunohistochemistry for p16, epidermal growth factor receptor (EGFR), p53, and cyclin D1 antibodies in a large patient cohort. METHODS: A total of 162 IP specimens were collected from 147 patients treated at the University of Michigan between 1996 and 2011. Twenty-two specimens contained carcinoma. Tumor was extracted for construction of 2 tissue microarrays and stained for p16, EGFR, p53, and cyclin D1. Tumor staining intensity and percentage staining were scored. RESULTS: Benign disease was positive for p16 in 64%, EGFR in 50%, p53 in 30%, and cyclin D1 in 76%. IP with carcinomatous degeneration was positive for p16 in 14%, EGFR in 71%, p53 in 62%, and cyclin D1 in 76%. The differences in staining positivity between benign and malignant disease reached significance for p16 and p53 only. Mean percentage staining by tumor surface area for IP and IP with carcinoma was 12% vs 7% for p16 (no statistical significance [NS]), 20% vs 34% for EGFR (NS), 4% vs 24% for p53 (p < 0.001), and 17% vs 21% for cyclin D1 (NS). CONCLUSION: Important characteristic staining pattern for IP with and without carcinoma are highlighted in this study. Unlike recent trends in human papilloma virus (HPV)-related head and neck malignancies, low expression of p16 is a marker for malignancy in this series. Positive staining for p53 correlates with the development of carcinoma in IP.

Use of advanced imaging technology and endoscopy for chronic rhinosinusitis varies by physician specialty.

BACKGROUND: Patients with chronic rhinosinusitis are cared for by multiple specialties. Endoscopy and imaging are important diagnostic tools. However, because physicians vary in their access to imaging and endoscopy, testing may vary across specialties. The purpose of this study is to characterize differences in use of imaging and endoscopy between physician specialties. METHODS: Using data from the National Ambulatory Medical Care Survey, we identified adult visits with primary, secondary, and tertiary diagnoses of chronic rhinosinusitis from 2005 through 2008. We measured rates of advanced radiographic imaging (CT, MRI, and PET) and office procedures. Logistic regression models were used to assess the bivariate and independent effects of patient, physician, and practice-level factors on use of advanced imaging and office procedures. RESULTS: There were nearly 51 million visits for diagnoses coded as chronic rhinosinusitis, representing an average of 12.7 million visits annually. Primary care providers saw the majority of these patients. Otolaryngologists used advanced radiographic imaging at a rate higher than primary care physicians per outpatient visit (16.0% versus 1.93%; p < 0.001). Office procedures, performed almost exclusively (99.2%) by otolaryngologists, were performed at 24.5% of otolaryngology visits. Private insurance was significantly associated with a lower use of advanced radiographic imaging (odds ratio, 0.54; 95% CI, 0.31-0.94) among otolaryngology visits, but no patient or provider-level variables were associated with office procedure use. CONCLUSION: Radiographic imaging and office procedures are used at a higher rate per outpatient visit by otolaryngologists than by primary care providers. Additional studies are needed to identify and characterize factors that contribute to these different rates of use.

Climate change and its impact on allergic rhinitis and other allergic respiratory diseases.

PURPOSE OF REVIEW: To discuss current evidence of global climate change and its implications for allergic rhinitis and other allergic respiratory diseases. RECENT FINDINGS: Global climate change is evidenced by increasing average earth temperature, increasing anthropogenic greenhouse gas levels, and elevated pollen levels. Pollutants of interest include carbon dioxide (CO2), ozone (O3), and nitrous oxide (NO2) because they can enhance the allergic response and lead to increased symptoms of allergic respiratory diseases. Heightened CO2 levels stimulate pollen production via photosynthesis and increased growth in multiple plant species investigated. Although worsened air quality appears to increase prevalence of allergic rhinitis, the effects of increased temperature are less certain. The findings of increased aeroallergen levels likely contribute to increases in presentation of allergic diseases, although more healthcare impact studies are necessary. SUMMARY: Although recent literature indicates and strongly supports changes in temperature, pollution levels, and aeroallergen levels, more longitudinal epidemiologic surveillance of allergic diseases in relation to climate change as well as pathophysiologic studies on changing aeroallergen effects on allergic diseases are needed.

Canal switch after canalith repositioning procedure for benign paroxysmal positional vertigo.

Canal switch is a complication following canalith repositioning procedure (CRP) for posterior canal benign paroxysmal positional vertigo (BPPV). Instead of being returned to the utricle, the loose otoconia migrate into the superior or horizontal semicircular canal. Patients remain symptomatic, and treatment can be ineffective unless the switch is recognized and additional repositioning maneuvers directed toward the appropriate semicircular canal are performed. This report provides the first videographic documentation of canal switch involving conversion of unilateral posterior semicircular canal BPPV to geotropic horizontal canalithiasis.

RhoC expression and head and neck cancer metastasis.

RhoC protein, a known marker of metastases in aggressive breast cancers and melanoma, has also been found to be overexpressed in certain head and neck cancers, thus we investigated the correlation between RhoC expression and the metastatic behavior of head and neck squamous cell carcinoma. Selective inhibition of RhoC expression was achieved using lentiviral small hairpin RNA (shRNA) transduced and tracked with green fluorescent protein to achieve 70% to 80% RhoC inhibition. Fluorescence microscopy of the RhoC knockdown stable clones showed strong green fluorescence in the majority of cells, signifying a high efficiency of transduction. Importantly, quantitative real-time PCR showed no significant decrease in the mRNA expression levels of other members of the Ras superfamily. Cell motility and invasion were markedly diminished in RhoC-depleted cell lines as compared with control transduced lines. H&E staining of lung tissue obtained from severe combined immunodeficiency mice, which had been implanted with RhoC knockdown cells, showed a marked decrease in lung metastasis and inflammation of the blood vessels. The cultured lung tissue showed a significant decrease in cell growth in mice implanted with RhoC-depleted cell lines as compared with shRNA-scrambled sequence control lines. Microscopic studies of CD31 expression revealed substantial quantitative and qualitative differences in the primary tumor microvessel density as compared with parental and shRNA-scrambled controls. This study is the first of its kind to establish the involvement of RhoC specifically in head and neck metastasis. These findings suggest that RhoC warrants further investigation to delineate its robustness as a novel potentially therapeutic target.

Analysis of cervical esophagogastric anastomotic leaks after transhiatal esophagectomy: risk factors, presentation, and detection.

BACKGROUND: Transhiatal esophagectomy with cervical esophagogastric anastomosis is a common approach in patients requiring esophagectomy. Factors for developing cervical esophagogastric anastomosis leaks (CEGAL), their presentation, and the value of a routine postoperative screening barium swallow in detecting CEGALs and other complications were analyzed. METHODS: This single-institution retrospective study used medical records and an esophagectomy database to assess results in 1,133 patients who underwent transhiatal esophagectomy and a cervical esophagogastric anastomosis, 241 for benign disease and 892 for cancer, between January 1996 and December 2006. RESULTS: Esophagectomy patients who experienced CEGALs included 127 (14.2%) with cancer and 23 (9.5%) with benign disease. Logistic regression analysis identified increasing number of preoperative comorbidities (p < 0.001), active smoking history (p = 0.044), and postoperative arrhythmia (p = 0.002) as risk factors for CEGALs, and a side-to-side stapled cervical esophagogastric anastomosis compared with a manually sewn one as protective (p < 0.001). For cancer patients, higher pathologic stage disease (p = 0.050) was a risk factor for CEGALs. For patients with benign disease, a higher number of prior esophagogastric operations (p = 0.007) is a risk factor for CEGALs. Of the 90.7% of CEGALs that occurred on or before postoperative day 10, cervical wound drainage (63.3%) was the most common presenting symptom. Screening barium swallow identified postoperative complications and influenced outcome in 39 patients (3.8%). CONCLUSIONS: Higher number of preoperative comorbidities, advanced pathologic stage, postoperative arrhythmia, an increased number of prior esophagogastric surgeries, and active smoking history are risk factors for developing CEGAL, and a side-to-side stapled cervical esophagogastric anastomosis is protective. Screening barium swallow identifies few postoperative complications, but provides quality control.