A highly specific recurrent pleomorphic adenoma of the nasal septum.

A 90-year-old woman presented with the sudden onset of visual loss. She previously underwent surgery to treat a right septal pleomorphic adenoma (PA) at 77 years old. She initially presented to our hospital with severe nasal obstruction at 83 years old. A large tumor occupied the bilateral nasal cavities and, thus, surgery was performed using midfacial degloving and an endoscopic endonasal combined approach. A 60×45×43 mm tumor was completely removed; however, a small area of the tumor capsule was damaged. Six years after surgery, PA recurred in the posterior midline portion of the nasal cavity. Imaging examinations revealed a 48×42×45 mm mass, which compressed the bilateral optic canal, thereby causing severe visual loss. The recurrent tumor was endoscopically removed, and vision recovered after surgery. The lack of malignant transformation was pathologically confirmed throughout this period. The present case had several highly specific features: she was very elderly, the tumor was very large, and visual dysfunction was caused by nasal PA. We described surgical procedures in detail and considered the specific findings of the present case. En bloc resection with a sufficient margin was considered to be important in the present case because recurrence may be caused by incomplete excision.

Preference evaluation and perceived sensory comparison of fluticasone furoate and mometasone furoate intranasal sprays in allergic rhinitis.

OBJECTIVE: Intranasal corticosteroid sprays (INCSs) are commonly used for therapy of allergic rhinitis (AR). Adherence to regular use of INCSs is influenced by patient perception and preferences of products. The study objective was to compare perceived sensory attributes of fluticasone furoate nasal spray (FFNS) and mometasone furoate nasal spray (MFNS) in AR patients. METHODS: In a multicenter, randomized, crossover, prospective study, 40 seasonal AR patients were administered both FFNS and MFNS for 2 weeks each in a crossover fashion, for a total of 4 weeks. Patients completed questionnaires for each product regarding perceived sensory attributes at the end of each two-week period of product administration. RESULTS: FFNS was significantly preferred over MFNS. Significantly, fewer subjects perceived a bitter taste (p=0.01), medication running down their throat (p=0.033), and medication running out of their nose (p=0.002) with FFNS. MFNS was more frequently reported to induce nasal irritation (p=0.012), sneezing (p=0.017), and rhinorrhea (p=0.007) compared to FFNS. Interestingly, these findings were markedly observed in females. Medicine dripping out of the nose and nasal shooting were the most common problems reported for MFNS with a higher proportion of subjects who felt moderate-to-severe discomfort. Overall, 52.5% of patients expressed a preference for FFNS compared with 22.5% for MFNS. CONCLUSION: Several perceived sensory attributes of FFNS were rated significantly superior to MFNS. FFNS may contribute to enhanced treatment outcomes in AR patients due to improved treatment adherence.

Retrieval of ruptured medial rectus muscle with an endoscopic endonasal orbital approach. A case report and indication for surgical technique.

INTRODUCTION: Rupture of the extraocular muscle is extremely rare, and a traumatic event is especially uncommon. Although retrieval of an injured MRM is usually performed by an anterior approach by an ophthalmologist, missing muscles in the orbital retrobulbar space are sometimes difficult to identify. This is the first report to demonstrate direct muscle to muscle anastomosis by an endoscopic endonasal orbital approach by a single otolaryngologist. CASE REPORT: A 67-year-old man presented with left medial rectus muscle (MRM) rupture due to a traffic accident 4 months after injury. The MRM was completely ruptured, and the muscle was repaired by an endoscopic endonasal orbital approach. After surgery, his eye abduction was improved in the primary position, and adduction ability was markedly restored on right gaze without diplopia. CONCLUSIONS: Our endonasal endoscopic approach provides excellent access to the MRM in the orbital retrobulbar space and avoids a facial scar. We could suture both ends of the muscle together by an endonasal endoscopic approach and could obtain a good result without any complications.

Evaluation of adenotonsillectomy and tonsillectomy for pediatric obstructive sleep apnea by rhinomanometry and the OSA-18 questionnaire.

CONCLUSION: Nasal resistance and the OSA-18 score were useful for evaluating surgical treatments. The sleep disturbance score may also be useful for predicting the severity of obstructive sleep apnea (OSA) in children. OBJECTIVE: We evaluated the effect of surgery on children with OSA using polysomnography (PSG) parameters, nasal resistance, and the OSA-18 questionnaire, and also investigated the cut-off OSA-18 score to screen for pediatric OSA. METHODS: This was a retrospective study in which PSG parameters and nasal resistance were measured using a rhinomanometer and the OSA-18 score was obtained from the OSA-18 questionnaire before and after surgery in 45 children with OSA. RESULTS: The mean age of the 45 patients was 5.7 ± 2.0 years. The mean value of the obstructive apnea hypopnea index (O-AHI) improved from 16.2 ± 14.3/h before surgery to 1.1 ± 1.7/h after surgery, the mean nasal resistance improved from 0.44 ± 0.19 to 0.32 ± 0.10 Pa/cm(3)/s, and the mean OSA-18 score improved from 61.1 ± 13.7 to 30.4 ± 5.8, and all these improvements were significant. The O-AHI value was lower than 1/h after surgery in 64.4% of patients (29/45). The O-AHI value was significantly correlated with the sleep disturbance score (r = 0.352, p = 0.018). When the cut-off OSA-18 score for screening was set at 40, sensitivity was 100%.

Usefulness of nasal packing with silver-containing carboxy methylated cellulose in endonasal sinus surgery.

OBJECTIVE: Silver-containing carboxymethylcellulose fiber dressing (Aquacel®-Ag) has been used to treat burns and ulcers with a large amount of exudate. The aim of this investigation was to confirm whether Aquacel®-Ag has beneficial effects when it is used as nasal packing. METHODS: We included 44 patients who underwent bilateral endoscopic sinus surgery due to chronic rhino-sinusitis. Beschitin-F® or Aquacel®-Ag was packed postoperatively into the bilateral middle meatus. Patient's comfort was recorded using a VAS, as well as wound healing, postoperative bleeding and local infection. Postoperative-specific organisms were also evaluated from the removed packing materials located in the middle meatus when they were removed on the 4th day after surgery. RESULTS: The scores for nasal obstruction and pain were not statistically different in each group. Postoperative bacteriologic studies indicated marked differences. Coagulase-negative staphylococci were predominant and potential pathogens were recovered in a few cases in the Aquacel®-Ag group. In contrast, potential pathogens, including Streptococcus pneumonia, Haemophilus influenza, and Gram-negative rods, were predominant in the Beschitin-F® group. CONCLUSION: The results indicate that Aquacel®-Ag might contribute to hemostasis, wound healing, and patient comfort after endonasal surgery, similar to Beschitin-F®. Additionally, it may have advantages concerning the prevention of postoperative infection.

Obstructive sleep apnea in Asian primary school children.

PURPOSE: The objectives of this study were to examine the prevalence of obstructive sleep apnea (OSA) in primary school children, relationships between OSA and tonsillar hypertrophy, adenoid, and patency of the nasal cavity, and the effects of the tonsillar hypertrophy and adenoid on the nasal patency. METHODS: An examination of the palatine tonsils and anterior rhinoscopy, completion of a questionnaire survey, a measurement of nasal resistance, an examination for sleep apnea at home using portable polysomnography device, and radiography of pharyngeal tonsil were performed in 152 primary school children. RESULTS: The obstructive apnea hypopnea index (O-AHI) increased with enlargements in the palatine tonsils. The adenoidal nasopharyngeal ratio (A/N ratio) decreased with advances in grade. A significant difference was observed in the O-AHI between those with and without adenoid. The median value of the O-AHI increased with advances in grade. The nasal resistance was significantly higher in the group with adenoid compared as in the group without. It was also higher in the nasal disease group with OSA than in the group without. Full polysomnography(PSG) was recommended in 16 (10.5%) of 152 who underwent the examination using the portable polysomnography device, and of the eight who underwent PSG, six (75%) were confirmed to have OSA, while its prevalence in all subjects was estimated as 7.9%. CONCLUSIONS: Disturbances in nasal respiration as well as tonsillar hypertrophy and adenoid were found to be a risk factor of OSA in primary school children.

A massive adenoid cystic carcinoma of nasal septum progressed into the skull base.

BACKGROUND: Adenoid cystic carcinoma (ACC) is a malignant tumor commonly occurring in the major salivary glands. ACC of the nasal septum is exceeding rare. METHODS: The case of a 42-year-old woman with ACC of the nasal septum is presented. Her chief complaint was nasal obstruction and dysosmia for two month. CT and MRI demonstrated a massive mass occupying the nasal septum infiltrating the palate, vomeronasal, anterior skull base, and dura mater. Combined anterior cranial surgery, endoscopic intranasal surgery, and transpalatal surgery were selected due to the size and location of the tumor. A negative surgical margin was achieved without cosmetic deformity or functional disorder. RESULTS: She had postoperative radiotherapy with no recurrence or distant metastasis during the follow-up period. CONCLUSION: The tumor location and the perineural spread pattern should be considered to determine the treatment plan for septum ACC. Post operative radiation is now generally recommended. ACC has a high incidence of local recurrence and distant metastasis rate; therefore, long-term follow-up is necessary.

Efficacy of intranasal steroid spray (mometasone furoate) on treatment of patients with seasonal allergic rhinitis: comparison with oral corticosteroids.

OBJECTIVE: Intranasal corticosteroids are effective for allergic rhinitis and broadly used in daily clinical practice. Systemic oral corticosteroids are also known to be effective for treatment of allergic rhinitis. These topical and systemic corticosteroids are both effective formulations for allergic rhinitis, and both drugs have some side effects. When treatment formulations for allergic rhinitis are selected based on side effects, topical corticosteroids are more commonly selected than systemic steroids. Systemic corticosteroids, on the other hand, have traditionally been believed to have higher and more instantaneous therapeutic effects than those of topical corticosteroids. However, there have been few reports of direct comparisons between topical corticosteroid and systemic corticosteroid efficacy. The purpose of this study was to evaluate the subjective outcomes of nasal symptom management using topical intranasal corticosteroid therapy or systemic oral corticosteroid therapy in patients with seasonal allergic rhinitis. We compared the efficacy of mometasone furoate nasal spray (MFNS) to betamethasone oral tablets (BOT) for the treatment of patients with seasonal allergic rhinitis. METHODS: In an open label study, patients with seasonal allergic rhinitis who had intermediate-to-severe symptoms and who visited the hospital without prior treatment were allocated to 1 of 3 treatment groups (noncorticosteroid group, topical corticosteroid group, and oral corticosteroid group). Evaluation was conducted using allergy diaries that consisted of patient questionnaires. The Japanese Rhinoconjunctivitis Quality of Life Questionnaire (JRQLQ) was used in this study. RESULTS: Compared to only loratazine nonsteroid therapy, both MFNS 200µg once daily and BOT 0.25mg twice daily significantly reduced the total and individual symptom scores for sneezing, nasal obstruction, watery nasal discharge, and nasal itching (P<0.05). Scores for itching of the eyes were reduced slightly more in the MFNS group than in the noncorticosteriod treatment group, but the difference was not significant. CONCLUSION: MFNS and BOT have virtually equivalent effects on nasal symptoms in patients with seasonal allergies. Our study was the first direct comparison between an intranasal corticosteroid spray and a systemic oral corticosteroid for seasonal allergic rhinitis. No significant differences were found in the therapeutic effects of the topical and systemic corticosteroids tested, suggesting that topical corticosteroids are expected to sufficiently improve nasal symptoms without administration of oral corticosteroids. Treatment with intranasal corticosteroid spray is more strongly recommended than treatment with systemic corticoid steroids, due to the side effects associated with each treatment.

Blindness caused by septic superior ophthalmic vein thrombosis in a Lemierre Syndrome variant.

A 65-year-old man presented with right facial cellulitis and right blindness. Enhanced CT and MRI showed right facial cellulitis involved with pterigopalatine fossa. Additionally, orbital cellulitis, superior ophthalmic vein thrombosis, and pulmonary multiple nodules were observed. (18)F-FDG PET/CT supported these findings. He was diagnosed with septic superior ophthalmic vein thrombosis accompanied with Lemierre Syndrome variant and was treated mainly by the administration of intravenous antibiotics. His symptoms and image findings improved after a few days of treatment, but the right visual loss has not recovered. Since septic superior ophthalmic vein thrombosis and Lemierre Syndrome both have life-threatening potential, early diagnosis and appropriate treatment are important and may contribute to reduce the incidence of severe complications. Septic superior ophthalmic vein thrombosis accompanied with Lemierre Syndrome is exceeding rare, and this case is the first report of blindness in Lemierre Syndrome. A literature review and discussion of septic superior ophthalmic vein thrombosis and Lemierre Syndrome are included.

Evaluation of adult Pott's puffy tumor: our five cases and 27 literature cases.

OBJECTIVES/HYPOTHESIS: Pott's puffy tumor (PPT) is defined as one or more subperiosteal abscesses of the frontal bone based on osteomyelitis. PPT is observed predominantly in the adolescent age group and rarely in adults. Some parameters affecting prognosis and an appropriate surgical approach for antecedent frontal sinusitis have not been elucidated due to the rarity of patients with adult PPT. STUDY DESIGN: Retrospective patient record and literature study. METHODS: Five patients from our cohort and 27 patients identified in a literature search formed the study group. RESULTS: The incidence rate of intracranial complications was lower than in previous reports at 29.0%. There was no correlation between the incidence rate of intracranial complications and each patient's parameters. It was indicated that the department first consulted by the patients was possibly related to the initial diagnosis and the incidence rate of intracranial complications. CONCLUSIONS: Although the incidence rate of major complications is lower than in children and later than in earlier published adult cases, patients are still at high risk of serious intracranial complications. Early diagnosis and adequate treatment may contribute to reducing the incidence rate.

Indications and limitations of endoscopic endonasal orbitotomy for orbital lesion.

BACKGROUND: Endoscopic endonasal surgical techniques have developed tremendously in the last 20 years. Endoscopic techniques have been applied to the treatment of cranial base lesions, pituitary tumors, orbital lesions, pterygopalatine fossa lesions, infratemporal fossa lesions, posterior cranial fossa lesions, and clival lesions. In some reports, endoscopic endonasal transparanasal orbitotomies have been indicated for lesions localized to the medial and inferomedial parts of the orbit. The aim of this article was to present the technique of endoscopic endonasal orbitotomy (EEO) for orbital extraperiosteal and intraperiosteal lesions, as well as its indications and limitations. METHODS: We present cases of 4 patients who underwent EEO for typical extraperiosteal and intraperiosteal orbital lesions. We examined the indications and limitations in each case. RESULTS: All 4 orbital lesions were completely removed by EEO with no major complications. CONCLUSIONS: The EEO procedure, which does not require a skin incision, is a minimally invasive surgery used for treating orbital retrobulbar lesions. It leads to excellent cosmetic results with little bleeding. In the future, we need to determine its operative indications, safety, and dangers. It is necessary for us to further improve this surgical technique to allow for the generalization of the procedure.

Nasal resistance in Japanese elementary schoolchildren: determination of normal value.

CONCLUSION: Rhinomanometry is a useful method for evaluating nasal airway patency in schoolchildren, and we could confirm the validity of the results it produces. OBJECTIVE: Our purpose was to assess the validity nasal resistance measurements produced using anterior active rhinomanometry by comparing the results with those of our previous study and to determine a normal value of the nasal resistance. METHODS: Nasal resistance was measured by rhinomanometry in 852 children using the active anterior method. RESULTS: Mean nasal resistance was 0.45 ± 0.70 Pa/cm(3)/s. Nasal diseases were noted in 358 (42%) children, and nasal condition was normal (the normal group) in 494 (58%) children. Nasal resistance was 0.57 ± 1.05 Pa/cm(3)/s in the nasal disease group and 0.35 ± 0.16 Pa/cm(3)/s in the normal group, showing that resistance was significantly higher in the nasal disease group. In the normal nasal groups, nasal resistance tended to be lower in the children in higher grades (first grade, 0.44 ± 0.17 Pa/cm(3)/s; second grade, 0.37 ± 0.11 Pa/cm(3)/s; third grade, 0.36 ± 0.23 Pa/cm(3)/s; fourth grade, 0.36 ± 0.14 Pa/cm(3)/s; fifth grade, 0.30 ± 0.08 Pa/cm(3)/s; sixth grade, 0.29 ± 0.11 Pa/cm(3)/s), and taller groups (<120 cm, 0.43 ± 0.16 Pa/cm(3)/s; 120-130 cm, 0.37 ± 0.19 Pa/cm(3)/s; 130-140 cm, 0.34 ± 0.12 Pa/cm(3)/s; >140 cm, 0.28 ± 0.09 Pa/cm(3)/s). Results similar to those seen in our previous study were obtained in each group.

Intraosseous cavernous hemangioma of the middle turbinate.

Hemangiomas mostly arise from the soft tissues, and intraosseous hemangiomas are uncommon. They usually occur in the vertebra and skull bones, and intraosseous hemangioma of the nasal cavity is exceedingly rare. We describe a 56-year-old woman who was referred to our hospital with a tumor in her right nasal cavity, without subjective symptoms such as epistaxis. The tumor was located at the front end of the right middle turbinate. Enhanced computed tomography demonstrated a 3 cm×2cm expansive bony tumor replacing the bottom of the right middle turbinate with some partial enhancement effects. The characteristic honeycomb appearance was observed. The tumor and right middle turbinate were excised en bloc by the endoscopic endonasal approach. No complications or severe bleeding occurred during the peri-operative period. Histological examination showed endothelium-lined blood-filled vascular spaces within the bony trabeculae, which suggested the typical pattern of intraosseous cavernous hemangioma. To the best of our knowledge, this is the first case report of intraosseous cavernous hemangioma of the middle turbinate in the English literature.

Measurement of nasal resistance by rhinomanometry in 892 Japanese elementary school children.

OBJECTIVE: The normal value of nasal resistance in adults has been reported (0.25 Pa/cm³/s), but that in children has not. In this study, we measured nasal resistance in Japanese school children by employing rhinomanometry. METHODS: An otolaryngologist examined 939 Japanese school children with regard to the presence or absence of nasal diseases and tonsil size. Nasal resistance was measured by rhinomanometry employing the active anterior method in 892 children. A questionnaire concerning the condition during sleep, such as the presence or absence of snoring and sleep apnea syndrome, was performed. RESULTS: The mean nasal resistance was 0.43 ± 0.50 Pa/cm³/s: 0.46 ± 0.65 and 0.39 ± 0.22 Pa/cm³/s in boys and girls, respectively. Of the 892 children, Grade 3 and 4 tonsil hypertrophy was noted in 84 (9%), but the presence of tonsil hypertrophy did not influence nasal resistance. Nasal diseases were noted in 335 children (38%) and the nasal condition was normal (the normal group) in 557 (62%). Nasal resistance was 0.56 ± 0.75 Pa/cm³/s in the nasal disease group and 0.36 ± 0.21 Pa/cm³/s in the normal group, showing that the resistance was significantly higher in the nasal disease group. The resistance tended to decrease as the school grade increased. In the normal group, 290 children (33%) experienced no problem regarding the upper airway, such as snoring and sleep apnea syndrome, based on a questionnaire, and nasal resistance was 0.35 ± 0.17 Pa/cm³/s. CONCLUSION: This normal nasal resistance value may be adopted for the objective evaluation of nasal obstruction and effects of treatment in pediatric nasal diseases.

Functional optical hemodynamic imaging of the olfactory cortex in normosmia subjects and dysosmia subjects.

CONCLUSION: These activated areas may be related to the orbitofrontal cortex, corresponding to olfactory cortices. This study shows that multichannel near-infrared spectroscopy (NIRS) enables the evaluation of brain activity of normosmia subjects and dysosmia subjects by olfactory stimulation. OBJECTIVE: Objective olfactory testing is not common. NIRS has beenused before to study functional activations in various areas of the brain, but we wanted to investigate the difference in brain olfactory activity in normosmia subjects and dysosmia subjects using multi-channel NIRS (MNIRS). SUBJECTS AND METHODS: This study was conducted on eight normosmia subjects and five dysosmia subjects. We employed a 22-channel near-infrared spectroscopy device with eight light incident fibers and seven light detector fibers, each with an inter-optode distance of 2.5 cm on the frontal head. Isovaleric acid was used as the odor stimulant. We measured the change in oxyhemoglobin concentrations [oxyHb], deoxyhemoglobin concentrations [deoxyHb], and total hemoglobin concentrations [totalHb] from pre-baseline values. Furthermore, we divided the frontal cortex into four areas (right upper, left upper, right lower, left lower) and measured the activity in each area. Then, the changes in [oxyHb], [deoxyHb], and [totalHb] of normosmia subjects and dysosmia subjects were compared in each area. RESULTS: In all normosmia subjects, isovaleric acid caused remarkable changes, especially in the lower areas of the frontal cortex. However, in all dysosmia subjects, isovaleric acid caused no changes.

IL-16 variability and modulation by antiallergic drugs in a murine experimental allergic rhinitis model.

BACKGROUND: Interleukin-16 (IL-16) is a cytokine that induces selective migration of CD4+ cells and participates in inflammatory diseases including allergic rhinitis. Histamine and prostaglandin D(2) are important chemical mediators of allergic inflammation, and antiallergic drugs are commonly used for the treatment of allergic rhinitis. It remains unknown whether treatment with the drugs affects IL-16. OBJECTIVE: We evaluated the variability of IL-16 and the effects of the antiallergic drugs fexofenadine (40 mg/kg/day) and ramatroban (30 mg/kg/day) on IL-16 in an OVA-sensitized BALB/c murine experimental allergic rhinitis model. METHODS: We measured the expression level of IL-16 protein in the mouse nasal septal mucosa by immunohistochemistry, and the serum level of IL-16 by ELISA. Several other parameters associated with allergic rhinitis (nasal symptoms, OVA-specific IgE, eosinophil and T cell infiltration) were also measured. RESULTS: Local and systemic expressions of IL-16 were significantly increased in OVA-sensitized mice when compared to the nonsensitized group. Fexofenadine and ramatroban significantly inhibited the following OVA-induced allergic features when compared to the nontreated sensitized group: sneezing, nasal rubbing, eosinophil infiltration, IL-16 expressions in nasal tissue, and serum IL-16 level. Serum OVA-specific IgE and local T cell infiltration were reduced, but they did not reach significant values. CONCLUSIONS: These results suggest that IL-16 was both systemically and locally upregulated in the murine allergic rhinitis model and that IL-16 changed in parallel to allergic state by treatment with the drugs.

Computed tomographic evaluation of anatomic relationship between the paranasal structures and orbital contents for endoscopic endonasal transethmoidal approach to the orbit.

OBJECTIVE: Some recent reports have described the endoscopic endonasal removal of orbital tumors. However, the surgical anatomy for an endoscopic endonasal approach has not yet been clearly described. The first aim of this study is to examine the anatomic relationship between the paranasal and orbital structures with the use of computed tomographic imaging and to find useful landmarks for a transethmoidal approach to the orbital retrobulbar space. The second aim is to determine a procedure to minimize the possibility of bleeding via the endonasal transethmoidal approach. METHODS: One hundred axial and coronal computed tomographic scans obtained between January 2004 and December 2005 were evaluated. RESULTS: The third lamella was located posteriorly to the posterior end of the eyeball on all axial computed tomographic scans, thus indicating that it may be a useful landmark for the localization of the retrobulbar space. There was a large variation in the relationship among the inferior and medial rectus muscles and the ethmoid-maxillary plate regarding their location. These results demonstrate that the route into the orbit via the ethmoid-maxillary plate gains no access to the medial side of the medial rectus muscle, the region with abundant blood vessels. CONCLUSION: These results suggest that the third lamella and ethmoid-maxillary plate are the most important anatomic landmarks for an endoscopic endonasal transethmoidal approach to the orbital retrobulbar space.

Functional optical hemodynamic imaging of the olfactory cortex.

OBJECTIVE: We used multichannel near-infrared spectroscopy (MNIRS) to monitor the activity of the frontal cortex as mirrored by hemodynamic responses subjected to olfactory stimulation. The aim of this study was to clarify the functional brain imaging of olfactory activity. STUDY DESIGN: Prospective study. METHODS: This study was conducted on eight healthy subjects aged from 22 to 39 years (4 men and 4 women; mean age, 28.8 yr). We used a 22-channel near-infrared spectroscopy device with eight light-incident fibers and seven detector fibers, each with an interoptode distance of 2.5 cm on the frontal region. Olfactory stimulation consisted of five repetitions, each lasting 5 seconds and followed by a 55 seconds rest period. Isovaleric acid was used as odor stimulation, and saline was used as a control. We measured the changes in concentrations of oxyhemoglobin [oxyHb], deoxyhemoglobin [deoxyHb], and total hemoglobin [totalHb] from prebaseline values. Furthermore, we divided the frontal cortex into four areas (right upper, left upper, right lower, left lower) and investigated the activity in each area. RESULTS: Isovaleric acid caused changes, especially in the lower area, but saline caused no changes. [oxyHb] and [totalHb] increased after odor stimulation, but [deoxyHb] did not change. These active areas may be related to the orbitofrontal cortex, corresponding to olfactory cortices. CONCLUSION: This study has shown that MNIRS enables evaluation of changes in hemodynamics related to brain activity by olfactory stimulation.

Removal of an orbital apex hemangioma using an endoscopic transethmoidal approach: technical note.

OBJECTIVE: The posterior orbit contains a number of important and vulnerable structures, including the optic nerve, the ophthalmic artery and vein, and the ocular muscles and their motor nerves, which makes surgical access to the lesion in this region quite difficult. Transfrontal, transfrontal-ethmoidal, and transmaxillary procedures have the disadvantage of possible injuries to a number of nontumor structures, whereas an endoscopic transethmoidal approach is a minimally invasive surgery for the retrobulbar lesions. Retrobulbar cavernous hemangioma was successfully removed by a transethmoidal approach. METHODS: Tumor removal was performed in a patient with an intraconal cavernous hemangioma of approximately 15 mm in diameter. By a transethmoidal approach, the medial-inferior part of the orbit, as well as the apex of the orbit, were clearly visualized after endonasal ethmoidectomy. After the removal of the medial orbital bone, the orbital periosteum was incised and elevated. By elevating the orbital fat, the tumor could be identified separately from the orbital contents. RESULTS: Cavernous hemangioma at the orbital apex was removed without complications. CONCLUSION: An endoscopic transethmoidal approach, which requires no skin incision, is a minimally invasive surgery for retrobulbar orbital tumor, leading to excellent cosmetic results with less bleeding.