Light intensity distribution in images from rigid endoscopes used in minimal access sinus surgery.

OBJECTIVES/HYPOTHESIS: To investigate the pattern of intensity levels in images generated by the two most commonly used rigid endoscopes angulations in sinus surgery: 0° and 30°. METHODS: An enclosed light box containing an optical square grid, under endoscope illumination set just below saturation level, was used for measuring light distribution levels across test images. Endoscopes with 0° and 30° angulations were tested at 10 mm from the grid, typical for sinus surgery. The grid was set perpendicular to the axis of the shaft of the endoscope. The grayscale light intensity (GLI) levels (0 = black, 255 = white) in each of the grid squares were quantified from the digitized images. RESULTS: Light intensity was highly non-uniform for both endoscopes. The brightest area of the field of view was at the center for the 0° endoscope and at about 20% of the image diameter proximally from the center for the 30° endoscope. For the 0° endoscope with a maximum value of about 230 GLI (90% of white saturation) at the center the minimum value was about 100 GLI at the periphery. The 30° endoscope with a similar maximum GLI value of 226 had a minimum of under 50 GLI at the most distant periphery, too dark for clear grid line definition. CONCLUSION: There are wide variations in light intensity across the image circle and much reduced illumination of the field edge. Surgeons should be aware of this fact so that accommodation can be made when surgical manipulation is performed away from the center of the endoscope field. This is especially relevant in angled cavities such as the frontal sinus recess, where the degree of angulation necessitates "edge of field" surgery.

Review Global seroprevalence of legionellosis - a systematic review and meta-analysis.

Legionella is a ubiquitous pathogen yet the global occurrence of legionellosis is poorly understood. To address this deficit, this paper summarises the available evidence on the seroprevalence of Legionella antibodies and explores factors that may influence seroprevalence estimates. Through a systematic review, a total of 3979 studies were identified with seroprevalence results published after 1 January 1990. We tabulated findings by World Health Organization (WHO) region, location, study period and design, composition of study population(s) for all ages in terms of exposure, sex, detection methods, IFA titre, Legionella species measured, and present seroprevalence point estimates and 95% confidence intervals. Sampled populations were classified according to income, WHO region, gender, age, occupation and publication date. We conducted a meta-analysis on these subgroups using Comprehensive Meta-Analysis 3.0 software. Heterogeneity across studies was evaluated by the Q test in conjunction with I2 statistics. Publication bias was evaluated via funnel plot and Egger's test. Fifty-seven studies met our inclusion criteria, giving an overall estimate of seroprevalence for Legionella of 13.7% (95% CI 11.3-16.5), but with substantial heterogeneity across studies.

Unique case of inverted papilloma of septum with nasopharyngeal carcinoma: Is it a metachronous tumour?

Inverted papilloma is a rare and benign tumour. It affects the nasal cavity and paranasal sinuses, has a high rate of recurrence and is associated with malignant transformation. Only few cases of a poorly differentiated carcinoma arising from inverted papilloma have been reported, none of which in the nasopharynx. We report a case of a 37-year-old female, who presented originally in 2012 with inverted papilloma of the nasal septum which was surgically resected. Nasopharyngeal biopsy from 2014 was reported as carcinoma in situ and treated with local endoscopic resection. Three years later she presented with a solitary lesion of the right Eustachian tube opening, confirmed as invasive poorly differentiated carcinoma. Imaging revealed T4 N2b M0 malignancy with skull base and prevertebral space invasion, likely extension into right temporal lobe and malignant adenopathy. Although rare, malignant transformation of inverted papilloma in unusual places should be considered during workup and monitoring of patients.

Risk Factors for Development of Hypocalcemia in Patients With Cancer Treated With Bone-Modifying Agents.

BACKGROUND: This retrospective analysis describes the prevalence of and risk factors associated with the development of hypocalcemia in patients with cancer receiving bone-modifying agents (BMAs) as supportive care. PATIENTS AND METHODS: Patients with cancer treated with an intravenous or subcutaneous BMA, including pamidronate, zoledronic acid, or denosumab, at a tertiary care/safety net hospital in 2005 through 2015 were included in this retrospective review. We reviewed the medical records for predictive clinical and laboratory parameters and for patient outcomes. RESULTS: A total of 835 patients with cancer received at least one dose of a BMA during the specified time frame; 205 patients (25%) developed hypocalcemia of CTCAE grade ≥1 within 8 weeks of BMA initiation, 18 of whom (8.8%) had grade ≥3, and 3 patients died as a result. Multivariate analysis showed that patients with hematologic malignancy (odds ratio [OR], 1.956; P=.025), bone metastases (OR, 2.443; P=.017), inpatient status (OR, 2.592; P<.001), and deficient baseline vitamin D levels (OR, 2.546; P<.023) were more likely to develop hypocalcemia. Hypercalcemia before BMA administration (OR, 0.474; P=.032) was protective. CONCLUSIONS: Certain patient populations, including those with hematologic malignancies and/or bone metastases, warrant closer monitoring of calcium levels while receiving BMAs because of the high rate of hypocalcemia. Low pretreatment vitamin D levels are associated with the development of hypocalcemia. These data support close monitoring of calcium levels in patients with cancer receiving BMAs, in addition to adequate repletion of vitamin D before initiation of BMAs when possible.

Intermittent Dosing of Dabrafenib and Trametinib in Metastatic BRAFV600E Mutated Papillary Thyroid Cancer: Two Case Reports.

BACKGROUND: A multi-institutional, randomized phase II trial of continuous dosing of dabrafenib with or without trametinib is ongoing in metastatic thyroid cancer. Preclinical evidence and emerging clinical experience in other cancers support evaluating intermittent dosing of these two agents to achieve more durable response, while being better tolerated and more cost effective. PATIENTS: Two consecutive patients with symptomatic, metastatic radioactive iodine-resistant BRAFV600E mutated papillary thyroid cancer and poor performance status were treated initially with dabrafenib 150 mg twice daily plus trametinib 2 mg once daily, first in continuous daily dosing, then in a five-week-on and three-week-off schedule. RESULTS: Both patients showed rapid clinical improvement upon starting the regimen. They also noted improved tolerance of treatment upon transitioning to the intermittent dosing schedule. They continue to show evidence of antitumor activity 27 and 18 months respectively from the start of treatment and 15 and 13 months respectively from the start of the first break using intermittent dosing. CONCLUSIONS: Achieving durable palliation in these consecutive patients supports evaluating the intermittent dosing schedule of dabrafenib and trametinib in BRAFV600E mutated papillary thyroid cancer. Results of the ongoing phase 3 trial of continuous daily dosing and a subsequent trial of intermittent dosing, as is being tested in other cancers, will be needed to confirm that an intermittent dosing strategy in thyroid cancer can forestall resistant disease, improve tolerability, and decrease the cost of care.

Automatic glare removal in endoscopic imaging.

BACKGROUND: Glare from surgical instruments and tissue surfaces often occurs during endoscopic procedures and can be disturbing to the operator. The brightness level of the light source can be reduced, but at the expense of overall image clarity, so alternative solutions are needed for removing glare. Digital image-processing methods offer the opportunity to lessen or eliminate glare by reducing the intensity of the affected parts of the image. This study investigated a new automated method for glare reduction that uses two different intensity thresholds as a basis for applying glare reduction processes and it also reduces unpleasant artifacts at the glare region boundaries. METHODS: The new glare-reduction method was compared with a previous method. Three variants of each method, each with different color biases in the glare regions, were applied to a 20-s surgical recording containing substantial amounts of glare. The six versions and the original recording were evaluated subjectively by a group of 10 experienced surgeons using a paired-comparisons method, in which each version was compared for preference with all the other versions. RESULTS: The new double-threshold intensity-subtraction method scored significantly higher than the previously developed glare-reduction method (p < 0.05). It also scored higher than the original (unprocessed) version, but not significantly. The color bias was important, with combinations of pink and grey performing better than yellow tints. CONCLUSIONS: The findings show the new method to be a significant improvement in automatic glare reduction compared with earlier methods. The method is not computationally demanding, so it can in the future be evaluated clinically in high-definition endoscopic imaging systems and developed further in this environment.

Measurement of osteotomy force during endoscopic sinus surgery.

Greater understanding of the surgeon's task and skills are required to improve surgical technique and the effectiveness of training. Currently, neither the objective measurement of osteotomy forces during endoscopic sinus surgery (ESS) nor the validity of the properties of cadaver materials, are well documented. Measurement was performed of peak axial osteotomy force during ESS. A comparison was made of results with previously published cadaver data to validate the force properties of cadaver models. A prospective, consecutive cohort of 25 patients was compared with data from 15 cadaver heads. A modified Storz sinus curette measured osteotomy force from uncinate, bulla ethmoidalis, and ground lamella. Independent variables were osteotomy site, age, gender, indication for surgery, and side. Corresponding cadaver data were analyzed for the independent variables of osteotomy site, side, and gender and then compared with the live patient data. Mean osteotomy force in live patients was 9.6 N (95% CI, 8.9-10.4 N). Mean osteotomy force in the cadaver heads was 6.4 N (95% CI, 5.7-7.0 N). Ethmoid osteotomy of live patients required 3.2 N (95% CI, 2.1-4.3 N) more force than the cadaver heads (p = 0.0001). This relationship was statistically significant at the bulla ethmoidalis (p = 0.002) and the ground lamella (p = 0.0001) but not at the uncinate (p = 0.068). Osteotomy in female live subjects required 1.6 N (95% CI, 0.1-3.1 N) more force than male live subjects (p = 0.03). Cadaver tissue may underestimate the mean osteotomy force required in osteotomy of living ethmoid sinus lamellae by a factor of 1.5 times. Caution may be required in extrapolating force estimates from cadaver tissue to those required in living patients.

Surgical instrument force exerted during endoscopic sinus surgery: differences within the ethmoid sinus complex.

BACKGROUND: Endoscopic sinus surgery (ESS) has been the most important technical advance in surgical rhinology in the last 25 years. The technique is now used beyond its initial sinus confines but knowledge of the forces required to perform ESS is limited. Greater understanding of these forces will lead to improved surgical training and safety. The aim of this study was to quantify the magnitude of the forces exerted during punch osteotomy of the bony lamella of the paranasal sinuses and surrounding bony structures during ESS. METHODS: Fifteen formalin-fixed cadaveric heads underwent simulated ESS. Peak axial forces were measured using a pair of modified Blakesley forceps. Measurements were recorded during osteotomy of the paranasal sinus complex, skull base, and crests of the optic nerve and internal carotid artery. Statistical comparison between the mean forces was performed. RESULTS: A mean force of 6.06 N was required to breach the lamellae of the ethmoid sinus complex. This was significantly less than the mean force required to breach the skull base, excluding the olfactory cleft (17.80 N; p < 0.0001), crests of the optic nerve (15.43 N; p < 0.001), and internal carotid artery (13.15 N; p < 0.001). There was no significant difference between the ethmoid lamella and the lamina papyracea (6.13; p = 0.67). CONCLUSION: Significantly greater force was required to breach the skull base and other safety critical areas encountered in ESS, than the bony lamellae of the ethmoid sinus complex. Although this result is reassuring, in vivo studies are now required to validate this relationship in the operative patient.

A systematic review of outcomes after dacryocystorhinostomy in adults.

BACKGROUND: This study was designed to systematically review the clinical outcomes of dacryocystorhinostomy (DCR) surgery. Data sources included PubMed for English language literature from January 1966 to December 2008 combined with a manual review of citations within article bibliographies. METHODS: Citations acquired from the targeted search were filtered independently by two researchers. Relevant articles were reviewed to obtain information including interventions and outcome measures. The surgical techniques were categorized into external DCR (EX-DCR), endonasal laser-assisted DCR (LA-DCR), and nonlaser endoscopic endonasal DCR techniques (EN-DCR). Articles were then assigned level-of-evidence grades as defined by the Oxford Center for Evidence-Based Medicine. RESULTS: A total of 73 studies that fulfilled the inclusion criteria were analyzed. Of these, 68 were graded as level 4, 11 were graded as level 3b, and 1 was graded at level 2b evidence. A total of 4800 patients were pooled, from which 4921 DCRs were performed. All studies reported success during the follow-up period, although the outcome measures used were not consistent in the studies. Success varied between 65 and 100% after EX-DCR compared with EN-DCR, which varied from 84 to 94%. The success rate of LA-DCR varied widely between 47 and 100%. There was low evidence base to support the use of silicone stent to improve surgical success. Most studies did not show significantly improved outcomes with an antimetabolite. The overall intra- and postoperative complication rates were 1.0 and 6%, respectively. CONCLUSION: DCR is an effective and safe method for the treatment of nasolacrimal obstruction. Meta-analysis of outcomes was not feasible because of the heterogenous patient groups and outcome measures used. Nonetheless, the literature provides considerable levels 3 and 4 evidence to support DCR surgery in adults. Outcomes after EN-DCR and EX-DCR were comparable. The failure rate for LA-DCR was higher.

Outcomes following surgical decompression for dysthyroid orbitopathy (Graves' disease).

PURPOSE OF REVIEW: Graves' disease is a multiorgan autoimmune disease of complex pathophysiology that primarily affects the thyroid gland and orbit. The ophthalmic manifestations of Graves' disease may vary from mild proptosis which causes minimal cosmetic embarrassment to subluxation of the globe, exposure keratitis, corneal abrasion and even blindness. This article focuses on outcomes following orbital decompression. RECENT FINDINGS: Surgical techniques have evolved with improved understanding of sinonasal anatomy and being technology-driven with the use of the fiberoptic endoscope and image guidance. The most common surgical outcome reported in the literature is reduction in proptosis, followed by visual acuity and intraocular pressure. Quality-of-life assessments are not routinely measured. SUMMARY: There are a myriad of surgical techniques currently in practice which underscores the fact that no single technique is clearly superior to another. Endoscopic decompression results in a mean reduction of 3.50 mm and is associated with a low complication rate. Nevertheless, the literature suggests that the best techniques are likely to be multiwall approaches such as combined medial and lateral wall decompression. Management of dysthyroid ophthalmopathy is clearly multidisciplinary. Future studies should consider a minimum data set for reporting outcome measures which should include a quality of life tool.

The effect of functional endoscopic sinus surgery on nasal spray distribution to the middle meatus in patients with rhinosinusitis.

BACKGROUND: Because the principle behind functional endoscopic sinus surgery (FESS) recognizes the middle meatus as essential for the control of the disease, the effect of the operation in the distribution of drugs in the same area should be of similar importance. This study was designed to clarify whether nasal drug delivery is improved in patients after FESS. The study involved a prospective assessment within subject comparison. The subjects were 20 adult (>18 years old) patients on the waiting list for FESS. It was conducted within two teaching hospitals in the East of Scotland. METHODS: A novel method was used, positioning a neurosurgical patty in the middle meatus and assessing blue dye nasal spray absorption on a 4-point scale. RESULTS: A significant improvement was observed in the distribution of the indicator in the middle meatus postoperatively. Seventy percent of the patients showed improvement in the drug distribution after FESS. The median result for absorption score was 2 preoperatively (<50%) and 3 postoperatively (>50%). The difference was statistically significant (p<0.001). CONCLUSION: The distribution of nasal drugs is improved in the middle meatus after FESS. This can have important clinical applications that can benefit patients in otolaryngology as well as other disciplines.

Surgical techniques for the treatment of nasal valve collapse: a systematic review.

OBJECTIVES/HYPOTHESIS: To critically evaluate the surgical treatment strategies for nasal valve collapse. METHODS: A systematic review of studies to treat nasal valve collapse, using surgical methods, from 1970 to 2008. A search of EBM reviews, MEDLINE, and EMBASE was performed using the following search terms: "nasal valve collapse" AND "alar collapse," "nasal valve insufficiency," "alar insufficiency," and "functional rhinoplasty." The following outcome measures were sought: subjective symptom relief, cosmetic outcome, and objective measurements of nasal airway patency. The following were inclusion criteria: at least 10 patients in each study, stated aim to improve airway obstruction, and a minimum of 1 month follow-up for every patient. RESULTS: Our search identified 98 papers, which were then retrieved and analyzed. Of these, 43 met the inclusion criteria. No randomized controlled trials exist; one trial presented level IIIb evidence, but all other studies were classed as level IV. Seven authors present objective measurements of nasal airflow or cross-sectional area, and four authors present validated outcome measures. CONCLUSIONS: A variety of focussed surgical techniques are described to deal with nasal valve collapse. We could find no randomized controlled trials on nasal valve surgery. Research in nasal valve surgery is frequently driven by technical description of surgical technique rather than the establishment of evidence of long-term patient benefit. Although our understanding of the role of the nasal valve in the pathophysiology of nasal obstruction has improved vastly, the myriad of surgical techniques described perhaps reflects our uncertainty in choice of technique and in degree of patient benefit.

A systematic review of outcomes following surgical decompression for dysthyroid orbitopathy.

OBJECTIVES: To systematically review and compare the surgical outcomes of orbital decompression for dysthyroid orbitopathy. METHODS: Data sources used were PubMed, EMBASE, and Cochrane search for English-language literature from January 1990 to April 2008, combined with manual review of citations within article bibliographies. Citations acquired from the targeted search were filtered independently by two researchers. Relevant articles were reviewed to obtain information including interventions and outcome measures. Articles were then assigned level-of-evidence grades as defined by the Oxford Centre for Evidence-Based Medicine. RESULTS: A total of 516 citations were generated from which 135 abstracts were regarded as potentially relevant. After other relevant articles identified from the bibliography and duplicate articles excluded, 56 studies were available for analysis. Fifty studies were identified as level 4 and six as level 3 evidence. A total of 2,315 patients were pooled, from which 4,176 orbits were decompressed. Fifteen different surgical techniques were broadly identified. The most common surgical indication was cosmesis. Decompression by combined transpalpebral-endoscopic technique resulted in the highest average reduction in postoperative proptosis. The largest improvement in visual acuity was after coronal approach orbital decompression. The overall complication rate was 9.3%. The most significant complications were vision loss and cerebral vascular accident. The highest complication rate was associated with combined endoscopic and transpalpebral decompression. CONCLUSIONS: There are myriad techniques in practice for decompressing the orbit, but no one technique has yet to achieve consistently good outcome and low complication rates. The reporting of outcomes should conform to a minimum dataset. Laryngoscope, 2009.

Rapidly expanding maxillary pneumosinus dilatans.

Maxillary pneumosinus dilatans is a rare and difficult to diagnose condition at its outset. The natural history of a case where a computer tomography (CT) scan was performed 6 months prior diagnosis raises the possibity that pneumosisnus dilatans and sinus pneumocoele may be a continuum of the same diease process. The classification and aetiology are discussed.

A comparison of aesthetic proportions between the healthy Caucasian nose and the aesthetic ideal.

BACKGROUND AND OBJECTIVE: The aim of septorhinoplasty is to create a nose that is aesthetically pleasing to the patient and to maintain nasal function. Although a small number of population cohort studies have been performed on the ethnic nose, little is known of the aesthetics standards of nasal proportions in the general Caucasian population. The aim of this study was to establish parameters of the average nose in the healthy population and to compare them with those of the aesthetic ideals. MATERIAL AND METHODS: Ethical approval was obtained to recruit a cohort of staff and students from the medical school. Two photographs were taken: anterior and right lateral. The following measurements were made: intercanthal width, alar width, length of the nose (nasion-pronasion length), naso-labial angle, nasal tip projection, naso-facial angle and naso-frontal angle. These parameters were compared with published aesthetic ideals. RESULTS AND CONCLUSION: Aesthetic nasal proportions of 50 healthy Caucasians were examined from a cohort of 57 volunteers. Results showed that the average nose did not conform to neo-classical facial canons. The alar width (average 3.6 cm) was significantly wider than the intercanthal width (average 3.0 cm, p<0.05). The nasal width-length ratio was also greater suggesting that the cohort average was shorter and wider than the aesthetic ideal. The Baum ratio was 2.5:1, indicating that the average nasal tip was more projected that the aesthetic ideal (2.8:1). The naso-frontal and naso-facial angles are both more obtuse, and in profile the average nose overall appeared more prominent, as a result of the reduced forehead projection. The only parameter where there appeared to be consistency between the average and the ideal nose was the naso-labial angle. This study shows that many aesthetic parameters from a cohort of healthy subjects differ from the widely used aesthetic standards. Rhinoplasty surgeons should, therefore, give thought to the frame of reference used when discussing aesthetic objectives with their patients.

Aesthetic proportions of the nasal aperture in 3 different racial groups of men.

OBJECTIVE: To define baseline aesthetic dimensions of the nasal aperture in 3 different racial groups. METHODS: Healthy volunteers from 3 different racial groups (15 white, 15 Chinese, and 15 Indian men) were enrolled in the study at the Department of Otolaryngology, University of Dundee, Dundee, Scotland. Those with a history of nasal or facial surgery or trauma were excluded from the study. Images were obtained and stored in a digital format. The dimensions of nasal aperture were defined by the length of the columella at the narrowest point, the width of the columella at the narrowest point, the length of the nasal aperture at the maximum length, the width of the nasal aperture at the maximum width, and the width of the alar cartilage base. RESULTS: There was no significant difference in the length or the width of the columella for the 3 racial groups. There was no significant difference in the length of the nasal aperture between the Chinese and the white groups. The nasal aperture was longer in the Indian group compared with the other 2 groups (P<.002). The nasal aperture at the maximum width was narrower in the Chinese group compared with the other groups (P<.002); there was no significant difference between the white and Indian groups. The nasal alar width was slightly narrower at the alar base in the Chinese group compared with other racial groups (P<.001). CONCLUSIONS: The aesthetic dimensions of the nasal aperture differ between racial groups. The nasal aperture and the alar base were narrower in the Chinese group, and the nasal aperture was longer in the Indian group. The aesthetic surgeon should ideally have an understanding of these ethnic variations.

An unusual foreign body in the oesophagus. The body packer syndrome.

We report a case of drug smuggling by internal concealment of heroin in the oesophagus. We review the literature and discuss presentation and management highlighting the need to maintain an awareness of "body packer syndrome" in the differential diagnosis of ingested foreign bodies.