Extratemporal facial nerve branching patterns: systematic review of 1497 cases.

OBJECTIVE: The aim of this systematic review was to analyse the complex anatomy of the extratemporal portion of the facial nerve with an accurate description of the branching patterns based on the Davis classification. METHOD: Medline, ScienceDirect and the Cochrane Library databases as well as other sources were searched by two independent reviewers. RESULTS: Analysis of 21 studies with a total of 1497 cases showed that type III is the most common branching pattern accounting for 26.8 per cent of cases. The type I pattern, previously considered as the normal anatomy in most textbooks, was the fourth most common branching pattern at 16.3 per cent. The majority of specimens (96.4 per cent) were found to have a bifurcated main trunk, and only 3.2 per cent were found with a trifurcated main trunk. CONCLUSION: Surgeons should be aware of anatomical variations in the course of the facial nerve. An early identification of the branching pattern during surgery reduces the risk for iatrogenic facial nerve injury.

Treatment strategies for inverted papillomas with intracranial or intraorbital involvement.

OBJECTIVE: Sinonasal inverted papillomas are challenging benign tumours of the nasal cavity because of their high recurrence rates and the lifetime malignant transformation risk of 10 per cent as well as their locally aggressive behaviour. This study aimed to describe treatment strategies for inverted papillomas with intracranial or intraorbital involvement. METHOD: This was a prospective case series study of 18 patients with inverted papilloma with intracranial or intraorbital involvement. Patient demographic data, imaging, pathology, surgical technique and recurrences were recorded prospectively over a period of seven years. RESULTS: A total of 83 per cent of the patients in this study had been previously operated on, consisting of 8 cases with intracranial involvement, 1 case with intraorbital involvement and 9 with both. During follow up with a medium of 37 months (range, 13-115 months) there were two recurrences. CONCLUSION: It was postulated that intracranial or intraorbital involvement observed in this series was the result of multiple revisions. However, using accurate imaging protocols and the pedicle-oriented approach for tumour excision, complete tumour removal was achieved in most cases with minimal post-operative complications.

Ecchordosis physaliphora: a cautionary tale.

BACKGROUND: Ecchordosis physaliphora is a congenital, benign lesion originating from notochordal remnants along the craniospinal axis, most frequently located at the level of the clivus and sacrum. Sometimes ecchordosis physaliphora is difficult to recognise and treat, with a total of twenty-six cases described in the literature. METHODS: This study reports on three cases of previously undiagnosed ecchordosis physaliphora presenting with cerebrospinal fluid rhinorrhoea and meningitis. CONCLUSION: Endoscopic transclival or transsphenoid surgery including three-layer (fat, fascia and nasoseptal flap) reconstruction was used in all cases with complete resolution of the symptoms.

Social Factors in the Development of Chronic Rhinosinusitis: a Systematic Review.

PURPOSE OF REVIEW: In an era where prevention is paramount, understanding social factors for chronic rhinosinusitis (CRS) may facilitate preventive interventions that mitigate risk factors associated with the initiation or progression of the disease. RECENT FINDINGS: Both passive and active smoking are clearly and unequivocally associated with both the incidence and the severity of rhinosinusitis, while there an increasing body of evidence linking social deprivation and low socioeconomic status with rhinosinusitis and its complications. However, overall, only a handful of studies were longitudinal, while the available studies suffer from lack of standardized definitions of rhinosinusitis. In this systematic review, we assessed the available evidence linking CRS with social factors, such as socioeconomic status and class, educational status, family status, living and working location and conditions, and use of toxins or recreational drugs as well as exercise and diet. Thirty studies from 1995 onwards fulfilled our inclusion criteria and were used for this review. Social deprivation and low socioeconomic level seem to be directly associated with rhinosinusitis, as there are pollutants in living or working environment. A clear and direct association between smoking (both active and passive) and rhinosinusitis was also shown. However, the link between rhinosinusitis and education level, and exercise and diet, if any, seems to be more complex.

Endoscopic treatment of inverted papilloma attached in the frontal sinus/recess.

BACKGROUND: Inverted papilloma (IP) is a benign sinonasal tumour for which endoscopic surgery, with complete removal of the underlying and surrounding mucoperiosteum at the attachment site followed by drilling and/or coagulation of this area, is the treatment of choice. This can be challenging in the frontal sinus. OBJECTIVES: To report on the outcome of treatment for IPs involving the frontal sinus. To propose the possible use of topical 5-fluorouracil 5% (5-FU) in the postoperative management of challenging IPs. METHODS: This is a retrospective cohort evaluation of patients with IPs attached in the frontal sinus or in the frontal recess and growing into the frontal sinus. Data on primary or revision surgery, uni- or bilaterality, attachment site, surgical procedure, 5-FU usage, recurrence and follow-up are provided. The end points are disease-free follow-up in months and recurrence. RESULTS: Twenty cases, including fifteen revision cases, were retrieved over a period of ten years. All cases were treated endoscopically. Two cases recurred (10%) and the intervention was repeated. In eight cases, 5-FU was applied at the end of surgery. None of these cases recurred. The mean follow-up after the last intervention was 42 months (standard deviation (SD) 22.1). CONCLUSION: IP involving the frontal sinus is a surgical challenge that can be successfully addressed endoscopically. The topical application of 5-FU could have a place in postoperative treatment when it is difficult to be absolutely sure that all diseased mucoperichondrium or mucoperiosteum at the attachment site(s) has been completely removed.

Is chronic rhinosinusitis related to allergic rhinitis in adults and children? Applying epidemiological guidelines for causation.

The relationship between allergic rhinitis and chronic rhinosinusitis has been assessed in a number of observational and experimental studies. In this review, we attempt their synthesis and evaluation using the modified Bradford Hill guidelines for causation. Although there is no proof of causation, especially in the pediatric literature, an evaluation of underlying allergies is recommended at least as an initial measure of symptoms relief.

Surgery of the external nasal valve: the correlation between subjective and objective measurements.

OBJECTIVES/HYPOTHESIS: Minimum cross-sectional area of the nasal passage on CT (CT-MCA) is an objective computerised determination of the minimum cross-sectional area of the nasal passage on CT. CT-MCA was evaluated before and after surgery on the external nasal valve using the 'lateral crus pull-up' procedure (LCPU). The outcomes of CT-MCA were compared with other currently available objective tests for nasal valve patency. STUDY DESIGN: Prospective cohort study. METHODS: This study included 34 patients undergoing surgery on the external nasal valve with the use of the LCPU technique. CT-MCA was performed before and after surgery and compared with the subjective perception of nasal passage using the Nasal Obstruction Symptom Evaluation (NOSE) scale and with objective tests such as acoustic rhinometry (A-MCA), rhinomanometry (NAR) and peak nasal inspiratory flow (PNIF). RESULTS: This study showed a significant correlation between CT-MCA and the NOSE scale, PNIF and NAR. Paired-samples t-tests showed significant improvement after surgery on CT-MCA, PNIF and the NOSE scale. Multiple linear regression analysis showed that PNIF, CT-MCA and NAR were significantly associated with the NOSE scale. CONCLUSION: CT-MCA and PNIF were both significantly correlated and associated with the patient's subjective perception of nasal passage. The surgical procedure, the 'lateral crus pull-up', showed a significant improvement in the postoperative result both subjectively and objectively.

SCUAD and chronic rhinosinusitis. Reinforcing hypothesis driven research in difficult cases.

BACKGROUND: Our objective is to present recent research findings on recalcitrant chronic rhinosinusitis (CRS) in relation to "Severe Chronic Upper Airway Disease" (SCUAD). METHODOLOGY: Literature review using Medline and Em base databases (search terms 'chronic rhinosinusitis'; "chronic sinusitis" or"Severe Chronic Upper Airway Disease") limited to articles published in the English language. RESULTS: Complex pathophysiological mechanisms characterize various forms of chronic rhinitis and rhinosinusitis (CRS), where inflammation persists in spite of adequate medical treatment. In these cases, a multifactorial etiology often underlies the development of sino-nasal inflammation. The interaction between chronic upper and lower airway inflammation via neurogenic and systemic pathways may complicate the therapy of these patients, and lead to insufficient symptom control. CONCLUSION: The recently introduced definition of"Severe Chronic Upper Airway Disease" (SCUAD) increases awareness of those patients with persistent inflammation and symptoms despite guideline-driven pharmacologic treatment. The concept of SCUAD may prove helpful in directing research towards clarifying the definition, diagnosis and pathophysiology of rhinitis and rhinosinusitis,their limits and overlap. In this review, a hypothesis on SCUAD immunopathology is also presented.

Role of tranexamic acid in endoscopic sinus surgery - a systematic review and meta-analysis.

BACKGROUND: The role of tranexamic acid in patients undergoing endoscopic sinus surgery (ESS) is not clearly defined. The aim of our study is to systematically review the existing evidence on the role of tranexamic acid in patients undergoing ESS. METHODOLOGY: Systematic search of MEDLINE (1950 - 2013), EMBASE (1980 - 2013), metaRegister, Cochrane Library and ISI conference proceedings was carried out. RESULTS: Five randomised controlled trials with 192 patients receiving tranexamic acid and 196 controls were included. Meta-analysis demonstrated that mean estimated blood loss was significantly lower, and surgical field quality was significantly better in tranexamic acid group. There was no significant difference in mean operative time between the two groups. No significant adverse effects were noted in either of the groups. CONCLUSION: Intra-operative use of local and systemic tranexamic acid in ESS, results in significantly reduced estimated blood loss and improved surgical field quality. There is no statistically significant difference seen in operative time and incidence of side effects. Well-conducted larger RCTs using validated objective outcome measures and reporting on minor and major complications are required.

Long-term results of functional endoscopic sinus surgery in children with chronic rhinosinusitis with nasal polyps.

BACKGROUND: Chronic rhinosinusitis with nasal polyps (CRSwNP) is rare in children and has a major impact on Quality of Life (QoL). Functional endoscopic sinus surgery (FESS) has proven to be an effective treatment, but it is still unclear what long-term outcomes are in children with CRSwNP. The objective of this study was to assess long-term results of FESS in children with CRSwNP. METHODOLOGY: We performed a combined prospective and retrospective study. A QoL questionnaire was send to all children with CRSwNP who received FESS between the year 2000-2010. Almost half of these children also filled in this questionnaire preoperatively. RESULTS: Forty-four Children underwent FESS. From 18 patients, we also prospectively collected preoperative QoL questionnaires. The mean follow-up period was 4.0 years (+- 2.9). The mean age at surgery was 13 years (+-2.9). Of these children, 9 had CF and 10 children asthma. R-SOM scores showed a significant improvement both in general symptoms as well as several different domains when comparing pre- and postoperative questionnaires. Only 5 of 44 patients needed a subsequent intervention. In children with CF this was 3 of 9. CONCLUSION: This study demonstrates that long-term results of FESS in children with CRSwNP are good. QoL has improved significantly, especially in nasal symptoms, showing that FESS is a good treatment in children with CRSwNP. Furthermore, even children with CF show good results.

Quality of life in extended endonasal approaches for skull base tumours.

OBJECTIVE: To assess the quality of life (QOL) impact of extended endonasal approaches and nasoseptal flap reconstruction for benign skull base tumours METHODS: A random sample of 110 patients undergoing either limited endonasal transphenoidal hypophysectomy or extended endonasal approaches (trans-cribriform, trans-sellar, trans-tuberculum, trans-pterygoid) for the removal of benign skull base tumours were asked to complete Rhinosinusitis Outcome Measure (RSOM-31) questionnaire. RESULTS: A total of 91 patients returned the completed questionnaire. All patients in the limited approach group had pituitary adenomas, while patients in the extended group had a variety of tumours including adenomas with suprasellar or cavernous extension, chordomas, meningiomas, craniopharyngiomas and dermoids. Median time to completion of questionnaire was 1104 days in the limited group and 142 days in the extended approaches group. Although smell and headache were significantly worse in the group undergoing reconstruction with Haddad flap, there was no significant difference in overall, nasal, general, emotional or sleep quality of life between the two groups. Both smell and headache showed significant improvement with time. In linear regression, the single most important factor independently associated with overall worse RSOM-31 total scores was the presence of secreting adenomas. CONCLUSION: The use of nasoseptal flap appears to have a limited negative impact in nasal quality of life, mainly related to heada- che and reduced smell, both of which tend to improve with time. Hormone-secreting tumours have the most important adverse effect in quality of life extending in general, emotional, sleep and overall wellbeing, as reflected in RSOM 31 subscales.

The microdebrider, a step forward or an expensive gadget?

BACKGROUND: Although the use of the microdebrider (shaver) is well known in endoscopic sinus surgery (FESS), there is lack of evidence from comparative studies focussing on the difference in operating time, intra-operative blood loss and user-friendliness between the microdebrider and traditional operating techniques. In this study we compared the use of the microdebrider to conventional instruments in FESS in these areas. METHODS: A prospective randomised double blind controlled trial in 60 patients with chronic rhinosinusitis with nasal polyposis (CRSwNP) undergoing bilateral FESS. Each subject received FESS using only traditional instruments (Blakseley forceps) on one side and the other side with the additional use of the microdebrider, this way serving as their own control. The primary outcome was operation time, intra-operative blood loss and user friendliness and secondly safety and postoperative healing with a follow-up period at different time points up to three months postoperative. RESULTS: We found a 37% longer operating time when operating without a microdebrider. This difference was highly significant. The microdebrider scored significantly higher on every different parameter of user friendliness, except on the preparation of the instrument needed before surgery. For estimated blood loss during surgery we found no differences. Also there was no significant difference in postoperative healing at any point of time. CONCLUSIONS: This study demonstrates that operating patient with CRSwNP with the microdebrider is efficient and that the microdebrider at the same time is safe and easy to use.

Long-term low-dose antibiotics in recalcitrant chronic rhinosinusitis: a retrospective analysis.

INTRODUCTION: In recalcitrant Chronic RhinoSinusitis (CRS) treatment with intranasal corticosteroids, short-term antibiotics and even sinus surgery is frequently insufficient. Long-term low-dose administration of antibiotics has been suggested as a treatment option in these patients. We analysed the outpatient clinic population treated with different long-term low-dose antibiotics at the AMC Amsterdam. PATIENTS AND METHODS: Eligible patients, who were treated with trimethoprim-sulfamethoxazole or macrolides, were retrospectively identified from our outpatient clinic in 2009. The two main outcome measures were sinonasal complaints and nasal endoscopic findings. A 5-point grading scale was used to score the results compared with the pre-treatment situation. This was measured at several time-points during, and after the antibiotic course, and at the end of the follow-up term. RESULTS: Seventy-six patients were included, 53 per cent had asthma and all of them had undergone sinus surgery. Seventy-eight per cent showed improvement of the symptoms, and 84 per cent demonstrated improvement of the sinonasal mucosa at the end of the course. No significant difference was found between the trimethoprim-sulfamethoxazole and macrolide group. DISCUSSION: Long-term low-dose treatment with antibiotics seems to improve CRS symptoms and the appearance of the sinonasal mucosa on nasal endoscopy. However, at this stage, strong conclusions are immature because no placebo-group has been included. Despite increasing use of long-term low-dose treatment of recalcitrant CRS in referral centres, hard clinical evidence is lacking. More research is urgently required.

Complications of acute rhinosinusitis in The Netherlands.

BACKGROUND: Despite the evidence demonstrating that antibiotics are of little benefit in acute rhinosinusitis (ARS), GPs continue to prescribe them, possibly in an attempt to prevent potentially dangerous complications. In this study, we present epidemiological data about the incidence, course and severity of such complications in the Netherlands. METHODS: This retrospective cohort study included all patients hospitalized in The Netherlands in 2004 with a complication of ARS. Records were made of the symptoms of ARS and the complication, demographics, medical history, medical treatment preceding hospitalization, diagnostic techniques, therapeutic management, course and outcome. RESULTS: Forty-seven patients with 48 complications (16 intracranial and 32 orbital) were included. In the intracranial group (mean age 35.9 years), six patients had been treated with oral antibiotics prior to hospitalization. While hospitalized, all patients were treated with intravenous antibiotics and 15 underwent surgery. Eight patients recovered fully after treatment, three patients had residual symptoms and three patients died (missing data: 2). Of the 31 patients with orbital complications (mean age 17.4 years), 14 received oral antibiotics before admission. While hospitalized, all patients were treated with intravenous antibiotics and 13 underwent surgery. Twenty-seven patients recovered fully and two had residual symptoms (missing data: 2). CONCLUSIONS: Severe ARS complications occur in an otherwise healthy population in an estimated 1:12,000 paediatric and 1:32,000 adult cases in the Netherlands. Our study suggests that antibiotic treatment of ARS in general practice does not play a role in preventing complications.

Lack of efficacy of long-term, low-dose azithromycin in chronic rhinosinusitis: a randomized controlled trial.

BACKGROUND: In persistent chronic rhinosinusitis (CRS), conventional treatment is often insufficient. Long-term, low-dose administration of macrolides has been suggested as a treatment option. The MACS (Macrolides in chronic rhinosinusitis) study is a randomized placebo-controlled trial evaluating the efficacy of azithromycin (AZM) in CRS. METHODS: We describe a group of patients with recalcitrant CRS with and without nasal polyps unresponsive to optimal medical and (in 92% also) surgical treatment. Patients were treated with AZM or placebo. AZM was given for 3 days at 500 mg during the first week, followed by 500 mg per week for the next 11 weeks. Patients were monitored until 3 months post-therapy. The assessments included Sino-Nasal Outcome Test-22 (SNOT-22), a Patient Response Rating Scale, Visual Analogue Scale (VAS), Short Form-36 (SF-36), rigid nasal endoscopy, peak nasal inspiratory flow (PNIF), Sniffin' Sticks smell tests and endoscopically guided middle meatus cultures. RESULTS: Sixty patients with a median age of 49 years were included. Fifty per cent had asthma and 58% had undergone revision sinus surgery. In the SNOT-22, Patient Response Rating Scale, VAS scores and SF-36, no significant difference between the AZM and the placebo groups was demonstrated. Nasal endoscopic findings, PNIF results, smell tests and microbiology showed no relevant significant differences between the groups either. CONCLUSION: At the investigated dose of AZM over 3 months, no significant benefit was found over placebo. Possible reasons could be disease severity in the investigated group, under-dosage of AZM and under-powering of the study. Therefore, more research is urgently required.

Long-term quality-of-life outcomes in children undergoing adenotonsillectomy for obstructive sleep apnoea: a longitudinal study.

OBJECTIVES: To assess a cohort of patients who underwent adenotonsillectomy for obstructive sleep apnoea, 4 years after surgery for evidence of continued and long-term improvement in quality of life. We also sought to compare our results to Child Health Questionnaire scores obtained from our previous study. We also compared our data with a healthy UK children population from normative data available. DESIGN: Longitudinal study. SETTINGS: University Hospital Tertiary Referral Centre. PARTICIPANTS: A 4-year follow-up study of 37 children who underwent adenotonsillectomy for obstructive sleep apnoea confirmed on polysomnography. There were 19 boys and 18 girls from our initial cohort. The primary caregiver completed the validated Child Health Questionnaire Parental Form version-28, 4 years after initial surgery. Our control group consist of 221 healthy children aged 6-18 that were included as 'normal' controls in a study looking at children with juvenile arthritis. The children were defined as healthy by a physician and/or after declaration by the parent. MAIN OUTCOME MEASURE: Child Health Questionnaire Parental Form version-28 scores. RESULTS: A total of 33 patients (89%) from our initial cohort were contacted. The mean age was 10.6 (median, 11; range, 5-16). When compared with results obtained 3 months postoperatively, the mean scores were higher in five domains and were statistically significant in three subscales (Role Limitations P < 0.00001; Bodily Pain P < 0.002; and Global Health P < 0.02). There was a significant deterioration in Behaviour subscale (P < 0.0007) in spite of surgery. Compared with controls, 4-year follow-up scores were higher in five domains with the Global Health domain (P < 0.0004) being statistically significant. When the 4-year follow-up scores were compared with preoperative values, these were higher in all 13 domains with statistically significant improvements in nine domains, indicating that improvements had persisted 4 years after surgery. At 4 years, however, the means scores in many domains remain lower when compared with controls. CONCLUSION: Quality-of-life data are an important measure when deciding on a specific clinical intervention. In the short term, quality-of-life measures have been shown to improve after adenotonsillectomy for obstructive sleep apnoea. Our study demonstrates that the benefits of surgery are still persistent and the children continue to improve in the long term.

Osteitic bone in recalcitrant chronic rhinosinusitis.

INTRODUCTION: There is increasing interest in the underlying bone of the paranasal sinuses as an important player in recalcitrant Chronic Rhinosinusitis. Close inspection of CT scans often reveals areas of increased bone density and irregular thickening of the sinus walls. This osteitic bone could at least partly explain, why inflammation of the mucosa persists. METHODS: We searched PubMed for all relevant studies, using the following text words: chronic rhinosinusitis, sinusitis, bone, osteitis, osteomyelitis, histology, and treatment. Cited references of retrieved articles were also examined. RESULTS: Background, available data, potential diagnostic options, treatment implications, and suggestions for future research are discussed. CONCLUSION: Osteitis is associated with CRS, however its role in the pathogenic process is not well defined. More research is needed.

Long terms results of Draf type III (modified endoscopic Lothrop) frontal sinus drainage procedure in 122 patients: a single centre experience.

OBJECTIVES: To assess the effectiveness and factors associated with restenosis after Draf type III (Endoscopic Modified Lothrop) frontal sinus drainage procedure. DESIGN: Retrospective analysis of prospectively collected data. PATIENTS: A hundred and twenty two consecutive patients undergoing Draf III procedure for recalcitrant chronic frontal rhinosinusitis (CRS) (71%), frontal sinus mucocoele (15%), benign frontal sinus tumours (9%) and cystic fibrosis with severe CRS (5%) were followed up for an average of 33 months. OUTCOME MEASURES: Symptom burden (Visual Analogue Scale and Rhinosinusitis Outcome Measure), patency of neo-ostium and revision surgery. RESULTS: At the end of follow up, ninety percent of patients had a patent neo-ostium, while 88% were either clinically better or completely asymptomatic. Thirty-nine patients required endoscopic revision surgery and 9 eventually underwent frontal sinus obliteration. Sixty percent of revision operations were performed during the first two years. RSOM showed a significant improvement in both general and nasal symptoms while on a VAS, headache improved significantly. The only factor weakly associated with re-stenosis was the presence of allergy. There were no major complications during any of the procedures. CONCLUSION: Draf III Procedure is safe and effective for patients who have failed conventional frontal sinus procedures and a valid alternative to frontal sinus obliteration. Although the revision rate may appear to be quite significant, it can often be performed as an outpatient procedure and needs to be balanced against the reduced morbidity and the ease of follow-up.