Coblation for epistaxis management in patients with hereditary haemorrhagic telangiectasia: a multicentre case series.

OBJECTIVE: To propose radiofrequency coblation as a potential treatment modality for mild to moderate epistaxis in patients with hereditary haemorrhagic telangiectasia. METHOD: Case reports and review of the world literature concerning coblation and other treatment modalities for epistaxis in patients with hereditary haemorrhagic telangiectasia. RESULTS: Effective epistaxis control was achieved in four out of five cases of hereditary haemorrhagic telangiectasia. In the fifth case, we struggled to achieve haemostasis due to disease severity. CONCLUSION: Radiofrequency coblation is a novel technique, which was found to be a safe, effective, quick and well tolerated treatment option for epistaxis management in patients with hereditary haemorrhagic telangiectasia.

Endoscopic resection of intracranial dermoid cysts.

INTRODUCTION: Nasal dermoid cysts are congenital lesions which are often diagnosed in infancy or childhood. However, a small number present in adulthood, and some extend intracranially. Traditional treatment for the intracranial portion of these cysts includes frontal craniotomy. CASE REPORTS: Two intracranial dermoid cysts were resected via a transnasal endoscopic approach, using 70° nasal endoscopy for complete visualisation and intracranial tumour removal. We describe our technique for the procedure itself and for reconstruction of the skull base defect. DISCUSSION AND CONCLUSION: The endoscopic transnasal skull base approach is an excellent alternative to a traditional frontal craniotomy, to achieve complete resection of intracranial dermoid cysts.

Frontal recess cells: a rare cause of frontal sinus pneumocoele.

BACKGROUND AND AIMS: A pneumocoele is a pathologically expanding, air-containing paranasal sinus. Pneumocoeles are uncommon entities, with very few cases reported in the literature. The most plausible aetiological theory is that of a one-way valve effect allowing air into the sinus under increased pressure without pressure equilibration. METHODS: Review of a frontal sinus pneumocoele caused by a type III frontal cell and intersinus septal cell. RESULTS: We present a patient with chronic sinusitis who developed a pneumocoele of her left frontal sinus with erosion into her orbit. This patient was a habitual, chronic nose-blower with a large type III frontal cell adjacent to an intersinus septal cell. CONCLUSION: We propose the new theory that, in our patient, such cells formed a one-way valve, causing air-trapping and pathological expansion of the frontal sinus. To our knowledge, there are no previously published cases that establish an association between large frontal cells and expansion of a pneumocoele.

Real-time computed tomography image update for endoscopic skull base surgery.

INTRODUCTION: The development of computer-aided systems for endoscopic sinus surgery has enabled surgical navigation through diseased or surgically altered sinus anatomy with increased confidence. However, conventional computer-aided systems do not provide intra-operative updated computed tomography imaging. We describe the technical aspects of the xCAT, a new intra-operative mobile volume computed tomography scanner. TECHNICAL REPORT: A patient with a malignant melanoma unwittingly removed at another hospital underwent surgery for removal of the lateral nasal wall and directed biopsies, in an attempt to identify the site of tumour origin. The procedure was performed with the GE InstaTrak 3500 Plus computer-aided system, updated with intra-operative computed tomography images. Intra-operative, updated images were integrated successfully into the InstaTrak system, and these images were consistent with the observed endoscopic anatomy. CONCLUSION: The xCAT intra-operative mobile volume computed tomography scanner is a technological advancement that can assist the endoscopic sinus surgeon when performing complex rhinological and skull base procedures.

Endoscopic repair of frontal sinus cerebrospinal fluid leaks.

OBJECTIVE: To describe endoscopic management of frontal sinus cerebrospinal fluid (CSF) leaks. STUDY DESIGN: Retrospective. METHODS: We reviewed all frontal sinus CSF leaks treated using an endoscopic approach at our institutions from 1998 to 2003. CSF leaks originated immediately adjacent to or within the frontal recess or frontal sinus proper for inclusion in the study. Data collected included demographics, presenting signs and symptoms, site and size of skull-base defect, surgical approach, repair technique, and clinical follow up. RESULTS: Seven frontal sinus CSF leaks in six patients were repaired endoscopically. Average age of presentation was 45 years (range 25-65 years). Aetiology was idiopathic (three), congenital (one), accidental trauma (one), and surgical trauma (two). All patients presented with CSF rhinorrhea; two patients presented with meningitis. Four defects originated in the frontal recess, while two others involved the posterior table and frontal sinus outflow tract. Four patients had associated encephaloceles. We performed endoscopic repair in all six patients with one patient requiring an adjuvant osteoplastic flap without obliteration. All repairs were successful at the first attempt with a mean follow up of 13 months. All frontal sinuses remained patent on both post-operative endoscopic and radiographic exam. CONCLUSIONS: Endoscopic repair of frontal sinus CSF leaks and encephaloceles can be an effective method if meticulous attention is directed toward preservation of the frontal sinus outflow tract, thus avoiding an osteoplastic flap and obliteration. The major limiting factor for an endoscopic approach is extreme extension superiorly or laterally within the posterior table beyond the reach of current instrumentation.

Meniere's disease.

Meniere's disease is an idiopathic disorder of the inner ear characterized by the syndrome of endolymphatic hydrops, episodic vertigo, fluctuating hearing loss, tinnitus, and aural fullness. People with this disorder may be severely disabled. Medical therapy exists in the form of diuretics and dietary restriction of salt to minimize the fluid pressure in the labyrinth and cochlea. Treatment of allergies with desensitization and steroids has also shown to be effective in selected patients. Surgical therapies exist in two categories, conservative and ablative. Endolymphatic sac decompression with or without shunt placement remains highly effective and we feel that it should be the first line surgical therapy for patients who fail medical therapy. Ablative therapies include labyrinthectomy (medical or surgical) and vestibular neurectomy. Both of these procedures control the episodic vertigo by destroying vestibular function in the affected ear and should be reserved for patients who have persistent vertigo in spite of more conservative treatments.

PH20: a novel tumor marker for laryngeal cancer.

OBJECTIVE: To determine whether levels of PH-20, a hyaluronidase similar to that found in human sperm, are elevated in laryngeal cancer tissue. DESIGN: In this case-control study. reverse transcription polymerase chain reaction was used to measure levels of PH-20 messenger RNA in tissue taken from laryngectomy specimens. SETTING: A university medical center. PATIENTS: We compared tissue samples taken from 11 patients with laryngeal cancer, and from 2 metastatic lymph nodes, with samples of normal, healthy laryngeal tissue and prostate cancer tissue (positive control). MAIN OUTCOME MEASURE: PH-20 complementary DNA expression as quantified by densitometric analysis. RESULTS: Expression of PH-20 was significantly higher in nonirradiated laryngeal cancer specimens than in normal laryngeal tissue (P<.01). Metastatic lymph nodes also had higher levels of PH-20 expression than did primary laryngeal cancer tissue (P = .11) and normal laryngeal tissue (P<.01). Irradiated laryngeal cancer specimens had PH-20 levels comparable to normal. CONCLUSIONS: We report the first data on PH-20 expression in laryngeal cancer tissue. PH-20 expression is significantly elevated in primary laryngeal cancer tissue and seems to be even higher in metastatic lesions compared with normal laryngeal tissue. PH-20 may be a useful tumor marker and prognostic tool for laryngeal cancer.

Ethylcarbamoyl protection for cysteine in the preparation of peptide-conjugate immunogens.

During the solid-phase synthesis of over 100 peptides, we have observed that the ethylcarbamoyl group is useful for the side chain protection of cysteine in peptides containing a single cysteine residue. The ethylcarbamoyl group is stable to the conditions of acidolytic cleavage, purification and long term storage. Brief treatment of peptides containing an S-ethylcarbamoyl-cysteine residue with aqueous sodium hydroxide gives the deprotected cysteine peptide that can be coupled to carrier molecules such as proteins to give immunogen conjugates.

Enhancement of beta-propiolactone tumorigenesis in mouse skin by pretreatment with the anti-inflammatory steroid fluocinolone acetonide.

Using a two-step carcinogenesis protocol, SENCAR mice were initiated with 25 micrograms 7,12-dimethylbenz[a] anthracene (DMBA) and were then treated twice weekly with either (a) 0.5 mg beta-propiolactone (BPL) or (b) 1 microgram fluocinolone acetonide (FA) followed in 30 min by 0.5 mg BPL. The tumor incidence for the group receiving FA prior to BPL was significantly greater than for BPL alone (P less than 0.0005). Under these experimental conditions, BPL alone showed neither promoting activity nor complete carcinogenic activity. These results were not anticipated, but the reasons for their occurrence are being explored.