Nasal septal deformities in chronic rhinosinusitis patients: clinical and radiological aspects.

Septal deformities are very frequent in patients suffering from chronic rhinosinusitis (CRS). The question is whether or not some types of septal deformities are involved more frequently in this process or not. The authors observed the incidence of particular types of septal deformities in a group of CRS patients using Mladina classification. The same has been done with a control group that consisted of healthy volunteers. In the literature, type 7 has been found very frequently, i.e. in nearly 30% of all CRS cases. Herein, type 7 was mostly composed of types 3 and 5. Type 3 can be accurately recognised on axial MSCT scans, while type 5 can be accurately recognised on coronal views. Concomitant septal surgery at the time of endoscopic sinus surgery is recommended.

Blindness after reduction of facial fractures.

Blindness in patients suffering maxillofacial trauma is usually caused by optic nerve or optic canal injuries. It is, however, an uncommon complication of facial trauma, with a reported incidence of only 2 to 5 percent. Blindness may also follow surgical repair of facial fractures. Many mechanisms, such as intraoperative direct nerve injury, retinal arteriolar occlusion associated with orbital edema, or delayed presentation of indirect optic nerve injury sustained at the time of the initial trauma, have been implicated in causing this blindness. In this article, four cases of visual loss after surgical repair of facial trauma are reported. In a review of the University of Maryland Shock Trauma experience with facial trauma over 11 years, we discovered that 2987 of the 29,474 admitted patients (10.1 percent) sustained facial fractures, and that 1338 of these fractures (44.8 percent) involved one or both of the orbits. One thousand two hundred forty of these patients underwent operative repair of their facial fractures. Three patients experienced postoperative complications that resulted in blindness, a total incidence of only 0.242 percent. Postoperative ophthalmic complications seem to be primarily mediated by indirect injury to the optic nerve and its surrounding structures. The most frequent cause of postoperative visual loss is an increase in intraorbital pressure in the optic canal. When our data were added to the summarized cases, blindness was attributable to intraorbital hemorrhage in 13 of 27 cases (48 percent). In addition, 5 cases in our review attribute the visual loss to unspecified mechanisms of increased intraorbital pressure, bringing the total cases of visual loss caused by intraorbital pressure or hemorrhage to 18 of 27 cases, or 67 percent. Within the restricted confines of the optic canal, even small changes in pressure potentially may cause ischemic optic nerve injury.

Blindness as a complication of Le Fort osteotomies: role of atypical fracture patterns and distortion of the optic canal.

Blindness in patients suffering maxillofacial trauma is usually caused by optic nerve or optic canal injuries. It is, however, an uncommon complication of facial trauma, with a reported incidence of only 3 to 5 percent. This incidence drops dramatically when fractures are performed in the controlled situation of orthognathic surgery. Given the rarity of ophthalmic complications after traumatic Le Fort I injuries, it is not surprising that few cases have been reported after orthognathic surgery. In this article, three cases of visual loss or skull base injury after elective Le Fort I osteotomy are described. All of these cases were presumably straightforward surgically and were performed by experienced surgeons. The literature is reviewed and the pathomechanics of each injury are experimentally explored in a cadaver model. To determine the presence of increased pressure on the optic nerve, optic canal deformation, or fractures extending to the skull base, two separate experiments were devised. In the first experiment, a pressure transduction system was used to document any significant forces that may be directly transmitted to the contents of the optic canal during pterygomaxillary separation. Then tested was the hypothesis that a stepped or tapered osteotomy will allow for a more predictable pterygomaxillary fracture. One of five cadaver specimens in group 1 demonstrated a transient increase in the right optic canal pressure during down-fracture of the maxilla. This change was less than 10 mmHg, and its duration was less than 5 seconds. The canal pressure returned to baseline with the completion of the fracture. In group 2, there was no documented pressure change with either osteotomy technique. Of note, in group 2, all specimens undergoing standard Le Fort osteotomy demonstrated uncontrolled propagation of the fracture lines superiorly in the pterygoid bones. The uncontrolled and unpredictable nature of pterygomaxillary disjunction may result in the extension of fractures to the skull base or the generation of deforming forces to the optic canal may compress or injure the optic nerve and its circulation. It is proposed that a stepped or tapered osteotomy will generate a more controlled pterygomaxillary separation during orthognathic surgery and may reduce the risk of devastating ophthalmologic complications.

Sound- and/or pressure-induced vertigo due to bone dehiscence of the superior semicircular canal.

OBJECTIVES: To present symptoms, patterns of nystagmus, and computed tomographic scan identification of patients with sound- and/or pressure-induced vertigo due to dehiscence of bone overlying the superior semicircular canal. To describe anatomical findings and outcome in 2 patients undergoing plugging of the superior semicircular canal for treatment of these symptoms. DESIGN AND SETTING: Prospective study of a case series in a tertiary care referral center. PATIENTS AND RESULTS: Eight patients with vertigo, oscillopsia, and/or disequilibrium related to sound, changes in middle ear pressure, and/or changes in intracranial pressure were identified in a 2-year period. Seven of these patients also had vertical-torsional eye movements induced by these sound and/or pressure stimuli. The direction of the evoked eye movements could be explained by excitation or inhibition of the superior semicircular canal in the affected ear. Computed tomographic scans of the temporal bones identified dehiscence of bone overlying the affected superior semicircular canal in each case. Disabling disequilibrium in 2 patients prompted plugging of the dehiscent superior canal through a middle cranial fossa approach. Symptoms were improved in each case. One patient developed recurrent symptoms requiring an additional plugging procedure and developed sensorineural hearing loss several days after this second procedure. CONCLUSIONS: We have identified patients with a syndrome of vestibular symptoms induced by sound in an ear or by changes in middle ear or intracranial pressure. These patients can also experience chronic disequilibrium. Eye movements in the plane parallel to that of the superior semicircular canal were evoked by stimuli that have the potential to cause ampullofugal or ampullopetal deflection of this canal's cupula in the presence of a dehiscence of bone overlying the canal. The existence of such deshiscences was confirmed with computed tomographic scans of the temporal bones. Surgical plugging of the affected canal may be beneficial in patients with disabling symptoms.

Advantages and disadvantages of three-dimensional computed tomography intraoperative localization for functional endoscopic sinus surgery.

Intraoperative three-dimensional computed tomography (3-D-CT) localization has been available for use during functional endoscopic sinus surgery (FESS) for several years, although relatively few otolaryngologists operate in conjunction with this technology. Proponents of intraoperative localization believe that operating with stereotaxis enhances surgical precision and reduces complications. A 1-year review was conducted at the University of Pennsylvania from January 1994 through January 1995. During this period 5% of sinus operations were performed in conjunction with intraoperative localization. The advantages and disadvantages of using intraoperative localization were evaluated for each case. Also examined were type and indication for surgery, anesthesia used, added time, and cost. Overall, intraoperative localization was found to be helpful when anatomy was distorted or obscured. However, selecting patients who may have benefited from localization was often not possible using preoperative data. Ideally, localization should be available for all FESS. Criteria are outlined which will need to be met prior to localization becoming a significant aspect of FESS.

Imaging of inflammatory sinus disease.

Sinusitis, especially as it relates to allergies, is one of the most commonly overlooked and misunderstood diseases in clinical practice. This article explores the radiographic appearance and anatomic characteristics that must be considered in the diagnosis and treatment of sinusitis. CT scans and MR imaging also are discussed in relation to the diagnosis of this disease.

Sinusitis in HIV-infected patients: a clinical and radiographic review.

PURPOSE: To describe the clinical, radiographic, and laboratory features of sinus disease in human immunodeficiency virus (HIV)-infected individuals. PATIENTS: Seventy-two patients with a history of sinusitis identified from 1,461 consecutive admissions (667 patients) to the HIV ward at The Johns Hopkins Hospital. METHODS: Retrospective chart review. SETTING: The Johns Hopkins Hospital. RESULTS: Sinusitis was identified in 72 HIV-infected patients, predominantly individuals with a CD4 cell count of less than 200/mm3. A history of respiratory infections such as bacterial pneumonia, bronchitis, and otitis media was common. Although nasal congestion and postnasal drainage were found in the majority of patients, symptoms of sinusitis were often nonspecific and the diagnosis was incidental in 28 patients (33%). Magnetic resonance imaging or computed tomography was significantly more sensitive than plain radiography (p less than 0.001) in defining the extent of the disease, particularly with posterior sinus involvement, which occurred in the majority of the patients. The number of radiologically abnormal sinuses correlated inversely with the CD4 count. Although the majority of patients responded at least partially to antibiotic therapy, only 15% had complete resolution of clinical symptoms. Fifty-eight percent of patients had clinical and/or radiographic evidence of recurrent/persistent sinus infection, and chronicity correlated with a CD4 count less than 200/mm3 (p less than 0.001). CONCLUSIONS: Sinusitis in HIV-infected patients is common, severe, and difficult to treat. Patients with CD4 counts less than 200/mm3 are prone to disease involving multiple sinuses that responds incompletely to antibiotic therapy, often resulting in chronic sinusitis. Unlike the immunocompetent host, the majority of the HIV-infected patients with advanced immunodeficiency develop posterior sinus disease.

Neonatal diagnosis of a presacral mass in the presence of congenital anal stenosis and partial sacral agenesis.

The simultaneous presentation of clinically symptomatic anal anomalies and roentgenographically demonstrated sacral dysgenesis should alert the pediatric surgeon to investigate for the presence of a presacral malformation. We report on such a case to illustrate a new radiographic technique that facilitates diagnosis and management of complex congenital malformations. A 1-day-old white boy presented with anal stenosis, a scimitar-shaped sacrum, and large anterior and posterior meningoceles. In addition, a distinct presacral tumor--a teratoma--was identified. These malformations were identified utilizing metrizamide myelography and three-dimensional reconstruction computed tomography (CT) scanning. The meningoceles and a tethered cord were successfully corrected utilizing a posterior approach. A diverting colostomy was performed and subsequently taken down. Two years postoperatively, the patient continues to do well. This case demonstrates that this triad of anomalies (presacral mass, sacral dysgenesis, and anorectal malformation), once considered, can be safely detected with modern radiologic techniques and can be expeditiously corrected during infancy before further deterioration occurs.

Patency of the internal jugular vein after functional neck dissection.

The objective of this study was to determine the immediate patency rate for internal jugular veins preserved in functional neck dissections. Thirteen patients had contrast-enhanced CT scans 2 to 4 weeks postoperatively. Ten veins were patent and had a diameter comparable to that seen on the preoperative scan; one vein was narrowed but patent; two were occluded. Probable factors associated with occlusion include trauma of the vessel and extrinsic compression of the vein by the skin or myocutaneous flaps.

Percutaneous trephine bone biopsy of the thoracic spine.

The authors performed six consecutive percutaneous trephine biopsies of the thoracic spine under local anesthesia, using computed tomography to localize lesions and guide needle placement. The details of the technique are illustrated. Complications were not found. The authors conclude that closed large needle biopsy of the thoracic spine can be performed safely with the aid of computed tomography.