Endonasal endoscopic resection of ossifying fibroma involving the ethmoid sinus, orbit and anterior skull base: case report and literature review.

Ossifying fibroma is a benign fibro-osseous tumour that rarely involves the ethmoid sinuses and orbit. It is classified as a benign fibroosseous lesion, a term that is synonymous with a variety of lesions reported in the literature. Recurrence rate with deleterious effects in cases of extramandibular ossifying fibroma is the impetus for open en bloc resection of the tumour. Continuously evolving techniques in endonasal endoscopic sinus surgery has rendered resection of large benign sinonasal and cephalonasal tumours possible. The authors report a case of ossifying fibroma involving the ethmoid sinus, orbit and anterior skull base in a 65-year-old previously healthy woman completely resected by endonasal endoscopic sinus surgery. The patient was free from postoperative complications and was dismissed from hospital on the sixth postoperative day. At present, the patient is disease-free at a regular five-year postoperative follow-up. Endonasal endoscopic resection of sinonasal ossifying fibromas is an excellent therapeutic option when performed by a surgeon experienced in endoscopic sinonasal surgery. The advantages of an endonasal endoscopic approach include direct visualization, enhanced visibility and magnification resulting in decreased intraoperative and postoperative morbidity. Aesthetic outcome is excellent in the absence of facial scars.

Could nasal septal deformities type 5 and 6 be a predictive factor of the indi- vidual genetic predilection for the onset of an acute coronary syndrome?.

OBJECTIVES: the possible impact of nasal septal deformities (SD) on cardiac pathology has not been well studied, despite growing evidence among data showing that upper air-way obstruction has a negative effect on cardiac function in general and a "deviated nasal septum" being considered one of the most frequent factors responsible for impaired nasal breathing. METHODS: a retrospective, case-control, double-blind study was performed on 249 patients who survived an acute coronary syndrome (ACS) attack. All patients underwent coronary angiography and were divided into coronary angiography positive (123 pts) and coronary angiography negative (126 pts) groups. The quality of nasal breathing was not considered in this study, but morphological aspects of the nasal septum (nasal septal deformities) were observed by anterior native rhinoscopy and endoscopic examination of the nose following the application of superficial anaesthesia. Mladina classification of nasal septal deformities was used. RESULTS: there was a statistically significant difference between coronary angiography negative and positive patients in Mladina type 1 to Mladina type 7 groups (p=0.000, X²=54.605). The incidence of nasal SD types 5 and 6 was higher in the group of ACS patients with the positive coronary angiography, whereas general distribution of the particular types of nasal septal deformities as they appear in the general population was found in the coronary angiography negative group. CONCLUSION: the fact that types 5 and 6 are inherited deformities and not related to trauma against the nose suggests the possible genetic predisposition for the onset of ACS with positive coronary angiography.

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.

An animal model for endoscopic endonasal surgery and dacryocystorhinostomy training: uses and limitations of the lamb's head.

OBJECTIVES: Structured training in endoscopic sinus surgery is essential, considering the serious potential complications. We have developed a detailed endoscopic endonasal surgery training programme, using a lamb's head model. This study aimed to assess the possibilities of using such a model for endoscopic dacryocystorhinostomy training. MATERIALS AND METHODS: Dacryocystography was performed on lamb's head models, which were then meticulously dissected, both macroscopically and endoscopically, to assess the nasolacrimal system. RESULTS: Dacryocystography showed the absence of a lacrimal sac in all the lamb's heads dissected. This result was confirmed by dissection. CONCLUSION: Lamb's heads are excellent models with which to teach endoscopic sinus surgery techniques. However, this study clearly demonstrated the absence of a lacrimal sac in all such models dissected. Thus, this animal model is inappropriate for endoscopic dacryocystorhinostomy training.

A biofilm exists on healthy mucosa of the paranasal sinuses: a prospectively performed, blinded, scanning electron microscope study.

OBJECTIVES: Based on our hypothesis that biofilm is nothing else but normal, otherwise abundantly colonised mucosal mucous blanket, the aim of this study was to check out whether bacterial biofilm exists exclusively at the diseased mucosal surfaces or at healthy mucosa of paranasal sinuses as well. DESIGN: Prospective and blinded. SETTING: Tertiary academic hospital. PARTICIPANTS: The patients suffering from the diseases not related to the chronic inflammation of the paranasal sinuses. Mucosal tissue samples from healthy sphenoid sinuses were taken from 48 patients who underwent pituitary gland surgery and from ethmoidal sinuses mucosa of the 17 patients who underwent endonasal endoscopic orbital decompression because of Graves' disease. MAIN OUTCOME MEASURES: The samples were submitted blindly along with similar samples from patients with chronic rhinosinusitis to two scanning electron microscope experts. In all samples the looked for the main signs of biofilm presence of: the 'towers', rod-shaped bacteria and water channels. RESULTS: Signs of biofilm presence were found in 45 out of 48 pituitary gland surgery patients (94%) and in all of 17 EEOD patients (100%). CONCLUSIONS: Our study showed the presence of the biofilm at the surface of the healthy mucosa of the paranasal sinuses. This suggests that perhaps so called bacterial biofilm is nothing else but regular respiratory mucosal blanket, a part of the mucociliary system itself, containing a great number of bacteria.

International Consensus on Nasal Polyposis 2002-2004.

Seventeen well-known experts in rhinosinusology from various countries tried to achieve consensus on the etiology, conservative approach and surgical approach to nasal polyposis. A Digi-Vote electronic system was used for an immediate computer analysis of expert answers to 23 questions related to the problem of nasal polyposis.

Cervical necrotizing fasciitis: sources and outcomes.

BACKGROUND: Abscesses of the peritonsillar region are among the most common deep abscesses of the head and neck. However, cervical necrotizing fasciitis (CNF) associated with a peritonsillar abscess is an extremely rare condition, with only 12 well-documented cases described. PATIENTS: We reviewed and compared all 12 cases of CNF arising from peritonsillar abscesses, including our own case. CNF that developed after peritonsillar abscesses was also compared with that developing predominantly after odontogenic infection. RESULTS: The overall mortality was higher in the group with peritonsillar abscesses (33% vs 25%). CONCLUSION: It is probable that of all cases of CNF, that arising from peritonsillar abscess has the worst prognosis.

Comparison of topically applied 0.2% glyceryl trinitrate ointment, incision and excision in the treatment of perianal thrombosis.

BACKGROUND AND AIMS: Topically applied 0.2% glyceryl trinitrate ointment to the anal region, incision and excision were compared in the treatment of perianal thrombosis, in order to establish which method is the best in terms of pain relief, number of recurrences and the appearance of anal skin tags. PATIENTS AND METHODS: A total of 150 patients were randomly divided into three groups of 50, each group being treated by one of the above-mentioned methods. The results of the treatment were evaluated during the first 4 days, after one month and after one year. RESULTS: A statistically significant reduction of pain was achieved by excision if compared with incision or conservative treatment with glyceryl trinitrate (p<0.001), and by conservative treatment with glyceryl trinitrate if compared with incision (p<0.01 on the 4th day of follow-up. Comparison of patients treated by the three different methods did not reveal any significant difference between these methods after one month (p>0.05). After one year the number of recurrences was significantly reduced after excision if compared with incision (p<0.05) or conservative treatment with glyceryl trinitrate (p<0.05). The number of patients without symptoms was significantly greater after excision if compared with incision or conservative treatment with glyceryl trinitrate (p<0.001). The number of patients with anal skin tags was significantly reduced in patients treated by excision if compared with incision (p<0.001) or glyceryl trinitrate treatment (p<0.001). CONCLUSION: Excision is a significantly better method of treatment of perianal thrombosis than incision or topically applied 0.2% glyceryl trinitrate ointment.

Endonasal endoscopic dacryocystorhinostomy in a four-month-old infant.

The authors present a case of endonasal endoscopic dacryocystorhinostomy in a 4-month-old girl suffering from remarkable epiphora, persistent bulging and recurrent abscesses in the medial canthal region of the left eye. All conservative therapeutic attempts failed. Several external incisions were performed in order to solve the acute phases of the inflamed lacrimal sac. The procedure was performed by means of otologic microsurgical instruments under endoscopic control. No silicone stent was used. Ten months after surgery, the girl is doing very well.

Necrotizing fasciitis after peritonsillar abscess in an immunocompetent patient.

Cervical necrotizing fasciitis (CNF) is a rapidly progressive, severe bacterial infection of the fascial planes of the head and neck. Group A beta haemolytic Streptococcus spp. (GABHS), Staphylococcus spp., or obligatory anaerobic bacteria are the most common causative pathogens. The disease usually results from a dental source or facial trauma. Extensive fascial necrosis and severe systemic toxicity are common manifestations of CNF. Review of the literature reveals only seven such cases, with four successful outcomes. The authors present the case of a 50-year-old immunocompetent female with CNF arising from a peritonsillar abscess. Intravenous immunoglobulins in conjunction with surgery and antibiotics were used successfully. The authors also suggest the importance of the early diagnosis, aggressive surgical debridement, broad-spectrum antibiotics, and possible usefulness of the intravenous immunoglobulins in the treatment of CNF, especially when the disease is associated with toxic shock syndrome.

Influence of nasal fontanel receptors on the regulation of tracheobronchal vagal tone.

AIM: To test the hypothesis according that the receptors located in the nasal fontanels influence the regulation of the tracheobronchial tree vagus tone. METHODS: Changes in respiratory parameters (forced expiratory volume in the first second- FEV1 and total resistance- Rt) occurring consequentially to light mechanical nasal stimulation were determined in healthy volunteer, non-smokers using spirometric and body plethysmographic measurements. The parameters were measured before and at 15 and 60 min after mechanical stimulation with cotton pledge. RESULTS: In subjects in whom the middle nasal meatus was stimulated by a cotton pledge soaked in saline, FEV1 decreased (p=0.01) and Rt increased (p=0.03). In subjects in whom the middle nasal meatus was stimulated by a cotton pledge soaked in 5% cocaine solution, no change was observed. In the control group of subjects, in whom the inferior nasal concha was stimulated by a cotton pledge soaked in saline, only a statistically significant decrease for FEV1 (p=0.04) was found. CONCLUSION: There is a reflex communication between the nasal fontanel receptors and lungs, which is regulating the tracheobronchial vagal tone and resistance in lung airways. Further studies of this important physiologic relation are needed.

Congenital bony fixation of the malleus.

Bony fixation of the malleus seems to be one of the most controversial clinical entities among various congenital disorders of the auditory ossicles. According to various theories, it could be caused by trauma, chronic infection of the ear, otosclerosis or even development failures in the tympanic cavity itself. Histological analysis of 1,108 temporal bones showing a normal middle ear structure was performed. All bones were cut in serial sections of 20 microns. Audiograms and the data on ear trauma or chronic infection were analysed from case histories belonging to each bony specimen. Bony fixation of the malleus was found in 14 cases. It was almost always unilateral. The most frequent site of the fixation was the lateral epitympanal wall. The forms of fixation differed from a thin bony lamella to a solid bony bridge. The mallear ligaments were not involved in any case. No relationship to chronic ear infection, ear trauma or otosclerosis was found. Only a slight conductive hearing impairment up to 20 dB was recorded in 6 out of 14 cases. The most probable predisposing anatomical factors for the onset of the bony fixation of the malleus and the most recent preoperative diagnostic possibilities are discussed.

"Cross-stealing" technique for septal perforation closure.

The authors described a technique for the surgical repair of anterior septal perforations of medium size (up to 2 cm). This technique is based on two mucoperichondral (mucoperiosteal) flaps, one from each side of the septum. Four patients have been treated in this way, resulting in permanent and complete closure in three of them. In one patient the perforation has been significantly reduced and positioned much more posteriorly. The main advantage of this technique is a mutual overlapping of the raw flap surfaces which prevents drying-out and decay of the flaps. This technique proves to be rather simple to perform and has not shown any evidence of disturbed nasal physiology in a long-term follow-up period.

The nose in children with unilateral cleft lip and palate.

Surgeons and orthodontists are still challenged to achieve 'better' noses for children with a unilateral cleft or lip, alveoulus and palate (UCLP). Various aspects are discussed: infant anatomy and later changes, developmental mechanics, cleft syndrome in animals with surgically produced facial clefts, untreated patients with congenital clefts, the radical primary correction of the UCLP nose, the unsolved problems in secondary rhinoplasty and suggestions for scientific communication.

A-mode diagnostic ultrasound of maxillary sinuses: possibilities and limitations.

The diagnostic possibilities and limitations of A-mode ultrasound of maxillary sinus diseases are presented. A group of 219 subjects suffering from various sinus diseases was examined. All cases were analyzed in parallel by means of X-rays, sinoscopy and ultrasonography. The investigated group was divided into seven subgroups, according to clinical entity (polypoid degeneration, polyps, cysts, et cetera). The comparison of the three techniques was made for each clinical entity. Some divergent findings that can be reached by these techniques were explained from the clinical point of view as well. The ultrasound A-mode technique plays a complementary role in the diagnostic process of maxillary sinus diseases. The main advantages of ultrasound technique are its harmlessness and non-invasivity.