The frontal sinus unobliteration procedure.

Although intranasal frontal sinusotomy can now be performed for most cases of chronic frontal sinusitis, the osteoplastic frontal sinus procedure with obliteration, unfortunately, still is considered by many to be the standard for chronic frontal sinusitis against that which other frontal sinus procedures are judged. Unobliterating the previously obliterated sinus is indicated for patients with evidence of frontal sinus pathology on CT or MR images and for patients with chronic symptoms with equivocal radiologic results. The reopened frontal sinus can be reventilated and remucosalized, or reobliterated with the placement of a new fat graft. Complete or partial auto-obliteration by new bone formation or fibrosis is another possible endpoint that can result when unobliteration is attempted.

Cost analysis of computer-aided endoscopic sinus surgery.

Functional endoscopic sinus surgery' (FESS) is a common otolaryngologic procedure, with over 250,000 operations performed annually. Computerized surgical navigation systems are available to assist the rhinologic surgeon in the complex dissection required for FESS. Our objective was to determine whether this system provided quantifiable benefits in FESS. We retrospectively reviewed 203 patients with chronic sinusitis who underwent endoscopic sinus surgery, and divided them into two groups based on whether or not computerized surgical navigation was used. There was no statistically significant difference between the two groups in terms of surgery duration, extent of surgery, percent of complementary procedures, percent of supplementary procedures, complexity of surgery, and percent revision surgery. Computer-assisted surgery (CAS) was 6.7% more expensive than sinus surgery without computerized surgical navigation (p = 0.01). However, the intangible benefits of CAS may outweigh the added expense. (American

Recurrence of the acute HIV syndrome after interruption of antiretroviral therapy in a patient with chronic HIV infection: A case report.

BACKGROUND: Clinical and virologic consequences of temporary interruption of HIV therapy are incompletely understood. OBJECTIVE: To describe a febrile illness that was consistent with the acute HIV syndrome and occurred after interruption of antiretroviral therapy. DESIGN: Case report. SETTING: University clinic. PATIENT: HIV-infected man. MEASUREMENTS: Plasma viral load, lymphocyte subsets, diagnostic evaluation (including cultures and serologic tests), and analysis of lymph node tissue. RESULTS: The patient began antiretroviral therapy 3 months after initial HIV exposure and had sustained viral suppression, except during a brief scheduled treatment interruption. One hundred sixty-nine days after resuming therapy, the patient discontinued it again immediately following an influenza vaccination. Eleven days later, he presented with a febrile mononucleosis-like syndrome associated with dramatic shifts in plasma HIV RNA level (<50 to >1 000 000 copies/mL) and CD4 cell count (0.743 x 10(9) cells/L to 0.086 x 10(9) cells/L). Evaluation for alternative causes of fever was unrevealing. Symptoms resolved rapidly with resumption of HIV therapy. CONCLUSION: Therapeutic interruption may be associated with profound viral rebound and recurrence of the acute HIV syndrome.

Initial increase in blood CD4(+) lymphocytes after HIV antiretroviral therapy reflects redistribution from lymphoid tissues.

Previous studies proposed a dynamic, steady-state relationship between HIV-mediated cell killing and T-cell proliferation, whereby highly active antiretroviral therapy (HAART) blocks viral replication and tips the balance toward CD4(+) cell repopulation. In this report, we have analyzed blood and lymph node tissues obtained concurrently from HIV-infected patients before and after initiation of HAART. Activated T cells were significantly more frequent in lymph node tissue compared with blood at both time points. Ten weeks after HAART, the absolute number of lymphocytes per excised lymph node decreased, whereas the number of lymphocytes in the blood tended to increase. The relative proportions of lymphoid subsets were not significantly changed in tissue or blood by HAART. The expression levels of mRNA for several proinflammatory cytokines (IFN-gamma, IL-1beta, IL-6, and macrophage inflammatory protein-1alpha) were lower after HAART. After therapy, the expression of VCAM-1 and ICAM-1 -- adhesion molecules known to mediate lymphocyte sequestration in lymphoid tissue -- was also dramatically reduced. These data provide evidence suggesting that initial increases in blood CD4(+) cell counts on HAART are due to redistribution and that this redistribution is mediated by resolution of the immune activation that had sequestered T cells within lymphoid tissues.

Constant mean viral copy number per infected cell in tissues regardless of high, low, or undetectable plasma HIV RNA.

Quantitative analysis of the relationship between virus expression and disease outcome has been critical for understanding HIV-1 pathogenesis. Yet the amount of viral RNA contained within an HIV-expressing cell and the relationship between the number of virus-producing cells and plasma virus load has not been established or reflected in models of viral dynamics. We report here a novel strategy for the coordinated analysis of virus expression in lymph node specimens. The results obtained for patients with a broad range of plasma viral loads before and after antiretroviral therapy reveal a constant mean viral (v)RNA copy number (3.6 log10 copies) per infected cell, regardless of plasma virus load or treatment status. In addition, there was a significant but nonlinear direct correlation between the frequency of vRNA+ lymph node cells and plasma vRNA. As predicted from this relationship, residual cells expressing this same mean copy number are detectable (frequency <2/10(6) cells) in tissues of treated patients who have plasma vRNA levels below the current detectable threshold (<50 copies/ml). These data suggest that fully replication-active cells are responsible for sustaining viremia after initiation of potent antiretroviral therapy and that plasma virus titers correlate, albeit in a nonlinear fashion, with the number of virus-expressing cells in lymphoid tissue.

Endoscopic resection of fibro-osseous lesions of the paranasal sinuses.

Fibro-osseous tumors, including osteomas, ossifying fibromas, and fibrous dysplasia, are not uncommon benign lesions arising in the paranasal sinuses. Conventional wisdom advocates resection when these lesions are symptomatic, or when they exhibit rapid growth. Traditionally, resection has been performed via a variety of open approaches. With the advent of sinonasal endoscopy in the mid 1980s, and subsequent advances in technology and surgical techniques, endoscopic management of some of these lesions is now feasible. To date, a search of the literature reveals only three case reports of osteomas resected with endoscopic guidance. We present a series of 10 symptomatic fibro-osseous lesions (nine osteomas and one fibrous dysplasia) occurring in nine patients in which endoscopic techniques were used. Nine ethmoid and frontal recess osteomas were resected transnasally and one sphenoid sinus fibrous dysplasia was resected using a transseptal transsphenoidal approach with endoscopic visualization. There were two anticipated CSF leaks, which were recognized and repaired at the time of surgery. There were no other complications and no tumor recurrence. All patients noted improvement in preoperative symptoms. We discuss patient selection, operative techniques and strategies, and the advantages and disadvantages of the endoscopic approach in the management of paranasal sinus fibro-osseous lesions.

Endoscopic resection of fibro-osseous lesions of the paranasal sinuses.

Fibro-osseous tumors, including osteomas, ossifying fibromas, and fibrous dysplasia, are not uncommon benign lesions arising in the paranasal sinuses. Conventional wisdom advocates resection when these lesions are symptomatic, or when they exhibit rapid growth. Traditionally, resection has been performed via a variety of open approaches. With the advent of sinonasal endoscopy in the mid 1980s, and subsequent advances in technology and surgical techniques, endoscopic management of some of these lesions is now feasible. To date, a search of the literature reveals only three case reports of osteomas resected with endoscopic guidance. We present a series of 10 symptomatic fibro-osseous lesions (nine osteomas and one fibrous dysplasia) occurring in nine patients in which endoscopic techniques were used. Seven ethmoid and frontal recess osteomas were resected transnasally and one sphenoid sinus fibrous dysplasia was resected using a transseptal transsphenoidal approach with the assistance of direct endoscopic visualization. There were two anticipated CSF leaks that were recognized and repaired at the time of surgery. There were no other complications and no tumor recurrence. All patients noted improvement in preoperative symptoms. We discuss patient selection, operative techniques and strategies, and the advantages and disadvantages of the endoscopic approach in the management of paranasal sinus fibro-osseous lesions.

Endoscopic sinus surgery in the management of mucormycosis.

This is a report of the use of endoscopic sinus surgery in the management of three patients diagnosed with rhino-orbital or rhino-orbito-cerebral mucormycosis. A retrospective review was performed of the clinical examinations and imaging studies of three patients who underwent endoscopic sinus surgery as part of their therapy for mucormycosis. In addition to endoscopic surgery, all patients had aggressive control of underlying risk factors (diabetes mellitus, immunosuppression) and prolonged intravenous amphotericin B therapy. All three patients survived and avoided orbital exenteration. In selected patients with rhino-orbito-cerebral mucormycosis, endoscopic techniques can play a valuable role in diagnosis and management.

Image-guided transnasal endoscopic surgery of the paranasal sinuses and anterior skull base.

Image-guided surgery represents a new technology with applicability to patients undergoing functional endoscopic sinus surgery for medically refractory rhinosinusitis. It also shows promise in helping to safely expand minimally invasive transnasal endoscopic techniques for nonrhinosinusitis diagnoses of the paranasal sinuses, orbits, and anterior skull base. This report discusses the application of the InstaTrak, a commercially available image-guided surgical navigation system, in 109 consecutive operations. The device was useful for localization to within less than 3 mm in 106 (98%) cases. In the remaining three (2%) surgeries where the perceived accuracy was not within 3 mm, the device was not used. The acquisition of radiographic data, operating room set-up, intraoperative localization and complications, and indications for surgical navigation will be discussed.

Cerebrospinal fluid fistula: detection with MR cisternography.

PURPOSE: Our goal was to assess the role of MR cisternography in the examination of patients with suspected CSF rhinorrhea. METHODS: MR cisternography was performed as a heavily T2-weighted fast spin-echo study with fat suppression and video reversal of the images in 37 patients over a 3-year interval. Twenty-four of the patients subsequently had exploratory surgery for fistula. Statistical analysis of the surgical results was compared with the findings at MR cisternography. RESULTS: MR cisternography showed significant correlation with surgical findings, with sensitivity, specificity, and accuracy of 0.87, 0.57, and 0.78, respectively. CONCLUSION: MR cisternography proved to be an accurate diagnostic imaging technique in the evaluation of suspected CSF rhinorrhea.

Angiographic embolization for epistaxis: a review of 114 cases.

Angiography with selective embolization has become an accepted method of treating posterior epistaxis that is not controlled with conservative measures. The authors reviewed 112 cases of patients who had received selective angiographic embolization for refractory epistaxis from January 1990 to December 1995. There were 114 embolizations over this 5-year period. The immediate success rate was 93%, with long-term success achieved in 88% of patients. The overall complication rate was 17%, with the long-term morbidity rate less than 1%. Selective angiographic embolization is a safe and effective method that should be considered in the treatment of refractory epistaxis.

Physiologic effects of an external nasal dilator.

An external nasal dilator (Breathe Right, CNS, Inc., Bloomington, MN) has become popular with athletes. The dilator is an adhesive band with a central elastic strip. When applied across the nasal valve, the device theoretically increases nasal valve area. We used acoustic rhinometry (Hood Laboratories, Pembroke, MA) to measure the cross-sectional area at the nasal valve with and without the device in 53 athletes. Thirty athletes were exercised on a cycle ergometer with and without the device while measuring physiologic parameters, including oxygen consumption (VO2), heart rate, and respiratory rate. The study was conducted in a randomized, double-blind, placebo-controlled manner. At rest, the external nasal dilator was found to significantly increase nasal valve area in all demographic groups measured. The device was also found to significantly decrease submaximal exercise perceived exertion, heart rate, ventilation, and VO2 when compared with placebo.

Magnetic resonance cisternography and thin coronal computerized tomography in the evaluation of cerebrospinal fluid rhinorrhea.

In recent years cerebrospinal fluid (CSF) rhinorrhea has been managed successfully with transnasal endoscopic techniques. The most important and often most difficult step is the precise localization of the fistula. Computerized tomographic and radionuclide cisternography are two commonly used techniques for preoperative identification of the CSF fistula when it cannot be seen clearly with nasal endoscopy. Each of these requires a lumbar puncture, and the intrathecal placement of contrast material has been associated with transient neurotoxicities. Magnetic resonance cisternography (MRC) is a noncontrast study that does not require a lumbar puncture and has been used recently in the diagnosis of spontaneous and traumatic CSF leaks. Magnetic resonance cisternography utilizes a fast spin-echo sequence with fat suppression and video image reversal that highlights CSF. This allows precise localization of the fistula in both coronal and sagittal planes. Thin section coronal computed tomography (TCCT) is another noninvasive technique that can be helpful in localizing CSF leaks. The technique of MRC and TCCT and the results of 16 CSF leaks in 15 patients are reported. There was good correlation between MRC, TCCT, and intraoperative findings. Magnetic resonance cisternography and thin coronal computerized tomography appear to be accurate and complementary, noninvasive radiographic studies that should be considered in the evaluation CSF rhinorrhea.

Endoscopic surgery of the frontal sinus.

Endoscopic intranasal frontal sinusotomy represents a relatively new technique for approaching disease in the frontal sinus. As with all "new" techniques, it has not withstood the scrutiny of time. It does represent, however, a significant alternative to external obliterative procedures for the frontal sinus. The frontal sinus can be visualized with office nasal endoscopy, and the difficult evaluation of the obliterated cavity can be avoided. With an in-depth understanding of frontal sinus anatomy and the application of advanced endoscopic techniques, the frontal sinus surgeon may achieve satisfying results while producing minimal morbidity.

Radiation exposure in paranasal sinus imaging.

Plain films of the paranasal sinus were the imaging technique most frequently used before the advent of computed tomography. With improved resolution, computed tomography imaging has become the standard for evaluating patients with disease of the paranasal sinuses. With the widespread availability of computed tomography scanning, patients are likely to undergo multiple examinations during the treatment of their disease. Concern has been raised over the radiation exposure to the patient, in particular, with regard to radiation-induced cataracts. The purpose of this study is to measure the radiation dose associated with a variety of techniques for imaging the paranasal sinuses. A cadaveric specimen with thermoluminescent dosimeters placed over the orbits was used to measure radiation exposure during plain-film imaging, limited computed tomography, standard axial and coronal computed tomography, thin-cut axial computed tomography, and thin-cut coronal computed tomography. The measured dose in all these techniques is less than 4% of the acute dose associated with cataract formation.

Spontaneous rupture of the stomach in an adult.

We have reported a case of spontaneous rupture of the stomach in an adult. Immediate onset of severe upper abdominal pain after overindulgence in food and drink along with radiographic evidence of pneumoperitoneum and the clinical findings of massive abdominal distention, epigastric tenderness, shock, and occasionally subcutaneous emphysema should suggest the possibility of gastric rupture. The treatment is simple, but mortality is high when surgical intervention is not rapid.