Invasive Fungal Sinusitis in Post COVID-19 Patients: A New Clinical Entity.

OBJECTIVES: Occurrence of invasive fungal respiratory superinfections in patients with COVID-19 has gained increasing attention in the latest studies. Yet, description of acute invasive fungal sinusitis with its management in those patients is still scarce. This study aims to describe this recently increasing clinical entity in relation to COVID-19 patients. STUDY DESIGN: Longitudinal prospective study. METHODS: Prospective longitudinal study included patients diagnosed with acute invasive fungal rhinosinusitis after a recent COVID-19 infection. Antifungal agents given included amphotericin B, voriconazole, and/or posaconazole. Surgical treatment was restricted to patients with PCR negative results for COVID-19. Endoscopic, open, and combined approaches were utilized to eradicate infection. Follow-up for survived patients was maintained regularly for the first postoperative month. RESULTS: A total of 36 patients with a mean age of 52.92 ± 11.30 years old were included. Most common associated disease was diabetes mellitus (27.8%). Mycological analysis revealed infection with Mucor and Aspergillus species in 77.8% and 30.6% of patients, respectively. Sino-nasal, orbital, cerebral, and palatine involvement was found in 100%, 80.6%, 27.8%, and 33.3% of patients, respectively. The most common reported symptoms and signs are facial pain (75%), facial numbness (66.7%), ophthalmoplegia, and visual loss (63.9%). All patients were treated simultaneously by surgical debridement with antifungal medications except for two patients with PCR-positive swab for COVID-19. These two patients received antifungal therapy alone. Overall survival rate was 63.89% (23/36). CONCLUSION: Clinical suspicion of acute invasive fungal sinusitis among COVID-19 patients and early management with antifungal therapy and surgical debridement is essential for better outcomes and higher survival. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2652-2658, 2021.

Leukocyte- and platelet-rich fibrin: a new graft material in endoscopic repair of spontaneous CSF leaks.

BACKGROUND: Spontaneous CSF leak is a challenging condition, with frequent recurrences following attempted surgical closure. The selection of graft materials depends on the experience of the operating surgeon. Leukocyte- and platelet-rich fibrin (L-PRF) is a second-generation platelet concentrate that has currently invaded every surgical specialty. To our knowledge, no previous reports about the use of L-PRF in repair of CSF leak were published. The study was conducted to assess the potential role of L-PRF in spontaneous CSF leaks repair. METHODS: This prospective controlled study was conducted on 40 patients who were randomly divided into 2 groups: In group A, L-PRF was used in addition to another layer, while patients in group B underwent multilayer repair using traditional graft materials. RESULTS: Preoperative HRCT scan showed bony dehiscence (n = 30) and opacity in a nearby sinus (n = 9). MRI findings varied between empty sella in 28 patients, and meningocele in 19 patients. Mean preoperatively measured CSF pressure was 26.6 cm H2O. Cribriform plate was identified as the commonest site of leaks. Multiple skull defects were detected in 2 cases. Failure of repair was found in 3 patients (15%) of group B and 1 patient (5%) of group A, this difference was statistically insignificant (P value = 0.28). Significance correlation between recurrence of CSF leak and elevated intracranial pressure was observed (P value; 0.04). CONCLUSION: L-PRF was found to be a good adjunct material in endoscopic spontaneous CSF leaks repair. It helps in decreasing the number of layers needed for defect closure.

Endoscopic enucleation of large jaw cysts: Promising outcomes.

OBJECTIVE: To describe the endoscopic approach for management of large jaw cysts and assess the feasibility of endoscopic enucleation as well as analyze its outcome on a wide scale at Mansoura University Hospital MUH. METHODS: This prospective cohort study was done on 23 consecutive cases presenting with different types of large jaw cysts in the period from January 2013 to July 2016 at ENT Department, Mansoura University Hospital. All patients, (16 maxillary & 7 mandibular) cysts, were managed endoscopically. Follow up ranged from 6 to 48 months. RESULTS: All patients showed complete resolution of their symptoms postoperatively except for 2 maxillary case who didn't undergo an antrostomy and 1 mandibular indicated a second look. CONCLUSION: Large jaw cysts lie at the border line of management options. Resection of the affected segment is a radical option but the most deforming. On the other hand, conservative procedures are prolonged and not definitive. To our knowledge this is the first case series of endoscopic enucleation of large maxillary and mandibular cysts, highlighting its advantages in variable types.

Endoscopic bilateral congenital choanal atresia repair of 112 cases, evolving concept and technical experience.

OBJECTIVE: This study aims to present 18 years' experience with endoscopic treatment of bilateral congenital choanal atresia as regard to management concept, surgical technique, results, pitfalls, and complications. PATIENTS AND METHODS: A retrospective study including 112 cases of bilateral congenital choanal atresia, treated at Mansoura University Hospital endoscopically in the period from January 1998 to March 2015. As far as we know, this is the largest study group on transnasal endoscopic choanal atresia repair in literature. RESULTS: One hundred and twelve infants (87 females, 25 males) were included in the study. Age at operation ranged between 1 day and 28 days (8.75 days in average), and body weight average was 2.76kg. All patients were diagnosed at birth except 3 infants. In this study, 85 cases were mixed atresia, 25 cases were bony atresia, and only two cases were membranous. In all cases, obliterated choana bone and vomer bone was removed, lateral wall drilling was used in 33 cases. Follow up ranged between 6 months and 18 years (95.6 months in average). The most common complication was restenosis, occurred in 42% (47 cases). Second-look procedure was done in 68 cases. The need for second-look evaluation with stent group was 74.5% (62 out of 83 infants), whereas in non-stent group was 20.6% (6 out of 29 infants). CONCLUSION: Endoscopic repair of bilateral choanal atresia is a safe, effective technique with minimal complication. Usage of 30 degree sinuscope permits better visualization and higher accessibility for the surgical instruments. Surgically formed wide single neochoana with removal of all intervening tissue surroundings, and good follow up permit higher success rate without stenting. Advanced learning curve permits tailoring the perfect surgery with minimal tissue injury and better outcome. Post-operative choanal dilatation using esophageal dilators under endoscopic examination decrease the need for stenting and second-look evaluation.

Endoscopic management of spontaneous CSF rhinorrhea with septal graft and middle turbinate rotational flap technique: a review of 31 cases.

Spontaneous cerebrospinal fluid (CSF) rhinorrhea poses a major challenge to rhinologists. Much controversy attends its cause, pathophysiology, management, and prognosis. It has been suggested that endoscopic placement of a septal graft with a middle turbinate rotational flap may represent the ideal approach to closing skull base defects. We conducted a retrospective chart review to compile the results of this approach in 31 patients with spontaneous CSF rhinorrhea-22 women and 9 men, aged 18 to 67 years (mean 38.5 ± 8.96) at diagnosis. After one surgery, success had been achieved in 27 of these patients (87.1%). The remaining 4 patients underwent a second surgery, and 2 of them experienced a successful closure. In the remaining 2 patients, a third surgery was still unsuccessful, and they were referred to the neurosurgical team for a shunt procedure. Thus, the overall success rate with the septal graft and a middle turbinate rotational flap was 93.5% (29/31). Septal grafts and middle turbinate flaps are easy to harvest and easy to place. Accurate localization of the defect, meticulous surgical technique, and cerebral dehydrating measures may improve outcomes. Further study of spontaneous CSF rhinorrhea to better evaluate its pathophysiology and prognostic factors is warranted.

Single flap with three pedicles, bone paté and split-thickness skin graft for immediate mastoid obliteration after canal wall down mastoidectomy.

Our objective was to evaluate single flap with three pedicles, bone paté and split-thickness skin graft for mastoid cavity obliteration after canal wall down mastoidectomy done for chronic suppurative otitis media and its efficacy in producing a small and dry mastoid cavity. Over a period of 7 years (2003-2010), 100 consecutive procedures in 100 patients with chronic suppurative otitis media were performed at the Mansoura University Hospital (Egypt) with a minimum follow-up of 12 months (range 12-72 months). All patients had canal wall down mastoidectomy with simultaneous tympanoplasty. Anteriorly, inferiorly and superiorly pedicled periosteal flap, which was covered by split-thickness skin graft, was used in conjunction with autologous bone paté to obliterate the mastoid cavity. Postoperative evaluation was done based on certain criteria and grading system from 0 to 3. Grade 0 is considered perfect, grade 3 represents failure and grade 1 and 2 are adequate but not perfect. The summation of grade "0" (perfect dry) and grade "1" (adequate dry) was 88, 95, 97.23 and 98.44% after follow-up periods of 12, 24, 36 and 48 months, and 100% after 60 and 72 months. Periosteal flap based on three pedicles (anterior, inferior and superior) covering the bone paté is simple, perfect and adequate for obliteration of mastoid cavity after canal wall down mastoidectomy. Split-thickness skin graft is important to hasten the epithelialization that helps to obtain a dry cavity. The use of local tissues saves costs and avoids complications from the synthetic materials.

Endoscopic cauterization of the sphenopalatine artery in pediatric intractable posterior epistaxis.

OBJECTIVE: To evaluate the rule of endoscopic sphenopalatine artery cauterization in posterior intractable epistaxis in pediatric age group as regard technical difficulty, efficacy, and safety in children. STUDY DESIGN: Retrospective study. PATIENTS AND METHODS: From March 2008 to February 2011, 7 children (4 male, 3 female) with idiopathic intractable posterior epistaxis, patients' age ranged from 8 to 14 years (10.7 average). All patients underwent preoperative laboratory investigations to exclude bleeding or coagulation disorders and CT paranasal sinus. All patients underwent endoscopic sphenopalatine artery cauterization (7 procedures for 7 patients, 5 were in the right side and 2 were in the left side). RESULTS: postoperative evaluation showed no recurrence for epistaxis during the post operative follow up period. Also, no complications were found. The average follow up period was 17.8 months. CONCLUSIONS: Endoscopic cauterization of sphenopalatine artery in pediatric age group was effective and safe technique providing that the surgeon has a good experience regarding pediatric endoscopic sinonasal anatomy. Minimal endoscopic technique in this age group is important to avoid unnecessary operative and postoperative complications. Avoid excessive cauterization to lateral nasal wall in this technique is crucial to avoid unexpected nerve injury or tissue necrosis.

Choanal adenoid in adults with persistent nasal symptoms: endoscopic management to avoid misdiagnosis and unsuccessful surgeries.

Our objective was to confirm the necessity of nasal endoscopy in the diagnosis and treatment of choanal adenoid in adult patients with persistent bilateral nasal obstruction and recurrent nasal infections that may lead to repeated unsuccessful medical and surgical procedures. We present a series of 64 adult patients (18-37 years: 40 males, 24 females). All patients had persistent bilateral nasal obstruction and recurrent nasal infections. There was history of repeated medical and surgical unsuccessful procedures. Choanal adenoid was confirmed by nasal endoscopy and CT scanning. Absence of adenoid tissues in the nasopharynx was confirmed in all cases. Surgical removal of choanal adenoids was undertaken in all cases endoscopically. Some other surgical procedures like straightening of a deviated septum or reduction of a hypertrophied turbinate were undertaken in some indicated cases. Most of the cases experienced complete relief from obstruction and return of a patent nasal airway, and improvement of associated complaints such as dry mouth and persistent cough. A thorough review of this phenomenon and its clinical relevance, and methods of diagnosis and management are presented. We recommend a thorough nasal endoscopy as a routine in cases of persistent nasal obstruction even in the presence of an apparent cause of obstruction.

Endoscopic repair of bilateral congenital choanal atresia.

OBJECTIVE: The literature about endoscopic repair of bilateral choanal atresia is scarce. The advantages and difficulties encountered with this technique are discussed. STUDY DESIGN: Prospective case series in a tertiary care center. METHODS: Nine infants with bilateral choanal atresia underwent transnasal endoscopic repair. On computed tomography scans, six had mixed atresia and three had bony atresia. Extra-long burrs, ear curettes, and dissectors all have been used with 4- and 2-mm, 0 degrees telescopes. The neochoana has been stented for 5 to 8 weeks. All cases were examined with the endoscope on removal of the stent; any granulation or polyps were removed at that time. RESULTS: Five cases remained patent after removal of stenting. Two patients required revision surgery because of repeat stenosis; one case remained patent and the other had repeat stenosis on one side. One infant died because of unrelated medical problems that occurred later. In one case the atretic tissue was thick, and the procedure was stopped because of bleeding; the infant died in the postoperative period after resuscitation. CONCLUSION: Careful review of the computed tomography scan and experience with endoscopic nasal surgery makes the transnasal endoscopic treatment a safe and effective approach for managing bilateral choanal atresia.