Nasolacrimal Duct Obstruction: An Unusual Presentation of Sarcoidosis.

Lacrimal drainage system disorders leading to epiphora are a common ophthalmologic complaint. When such a patient is identified, the ophthalmologist frequently collaborates with the otolaryngologist to perform a dacryocystorhinostomy (DCR). In rare cases, sinonasal sarcoidosis may lead to nasolacrimal duct obstruction (NLD) and dacryocystitis. A 48-year-old Caucasian female was referred to the Otolaryngology clinic for evaluation of a 6-month history of persistent right-sided nasal obstruction and epiphora. After physical examination and computerized tomography (CT) scan, she was diagnosed with right NLD with dacryocystitis. The patient underwent right endoscopic DCR. Pathology from the lacrimal bone and nasal tissue demonstrated noncaseating granulomas suggestive of sarcoidosis. Postoperative evaluation including lung CT scan confirmed systemic sarcoidosis. Nasolacrimal duct obstruction very rarely is the presenting symptom in patients with sarcoidosis. Imaging is necessary to rule out other causes of NLD, and histopathology is essential for diagnosis. Noncaseating granulomas are found along the nasal tissue and lacrimal sac, specifically in the subepithelial layer. Treatment consists of DCR, either endoscopic or external. Both approaches achieve long-lasting resolution of symptoms but may require revision from inflammation and scarring. There is no consensus on the use of intraoperative or postoperative steroids.

Breast Cancer Metastases to the Paranasal Sinuses Mimicking Inflammatory Sinus Disease.

INTRODUCTION: Breast cancer is one of the most common cancers in women. Metastatic disease is a leading cause of morbidity and mortality. It frequently metastasizes to bone, lungs, regional lymph nodes, liver and brain. Metastasis to the orbit and paranasal sinuses is uncommon. Patients presenting with sinus pain, nasal congestion, or visual disturbance can be misdiagnosed with an infectious process. METHODS: The authors describe 2 patients with metastatic breast cancer to the paranasal sinuses presenting with signs and symptoms of sinusitis and orbit pathology unresponsive to antibiotics. The authors discuss diagnostic strategy and perform a literature review. Both patients had biopsy-proven metastatic breast adenocarcinoma lesions, and subsequently underwent various treatment options. RESULTS: A literature review reveals that metastatic breast adenocarcinoma lesions to the paranasal sinuses are a rare entity that commonly denotes a very poor prognosis. These lesions can significantly affect one's quality of life, and can cause blurry vision, diplopia, proptosis, sinus pressure and pain, nasal congestion, mandibular misalignment or difficulty with mastication. However, early diagnosis and treatment of these lesions can lead to prolonged survival and improved quality of life. If the lesion is surgically resectable, endoscopic sinus surgery is generally considered to be the optimal treatment. However, radiotherapy, chemotherapy, and immunotherapy can potentially play a role in controlling the symptomatology. CONCLUSION: Metastatic lesions to the paranasal sinuses are a rare entity that should be considered in the appropriate clinical setting in order to expedite the proper treatment modality for improved morbidity and mortality.

Nasal cytology with emphasis on mast cells can improve the diagnosis and treatment of chronic rhinosinusitis.

OBJECTIVE: Chronic rhinosinusitis (CRS) involves inflammation of the nasal and para-nasal mucosa. Due to its heterogeneous nature, unknown pathogenesis, and high recurrence rate, effective treatment is difficult. Nasal cytology is presently not a part of the routine diagnosis or treatment decision for CRS. DATA SOURCES: A literature search was performed for published papers in English between January 1990 and June 2019 using MEDLINE. STUDY SELECTION: Terms used were chronic rhinosinusitis, eosinophils, etiology, immunopathology, inflammation, mast cells, nasal cytology, polyps, and treatment. Both reviews and original articles were collected and studied. RESULTS: There is no standard nasal fluid, mucus sampling, or staining techniques for identifying inflammatory cell types. Results were divergent from different countries. Moreover, the main focus of these papers on the cells in nasal washings was eosinophils, with infrequent mentioning of other cell types that may imply different etiology and pathology. The heterogeneous cell profile of CRS and the role of mast cells have been unappreciated due to the lack of specific immunohistochemical technique or study of its unique mediators. CONCLUSIONS: Nasal cytology could help distinguish the type and the activation state of inflammatory cells. Thus it can help in providing a clearer picture of CRS pathogenesis, identifying different patient groups, and developing effective treatments.

CO2-laser-assisted diverticulotomy remains an effective and safe method for treating Zenker diverticulum.

Our objectives were to review our experience with laser-assisted diverticulotomy (LAD) in the treatment of Zenker diverticulum (ZD) and compare our results with those in published literature on other endoscopic and surgical techniques. We conducted a retrospective chart review of 57 patients who underwent LAD treatment of ZD in a single tertiary care institution. Data on surgical complications, length of stay, and follow-up were collected. Age ranged from 56 to 89 years. Endoscopic exposure of the diverticulum was not possible in 2 patients. All 55 remaining patients who underwent LAD had significant symptom improvement. Three patients developed complications (5.5%); 2 had cervical emphysemas that were managed conservatively, and 1 experienced postoperative bleeding that required return to the operating room. Mean follow-up was 16 months. Two patients (3.6%) required revision surgery at 1 year postoperatively. There were no mortalities associated with the surgery. LAD remains a safe and effective method for treating ZD. The procedure permits short hospital stays and prompt return to normal oral intake. Results are like those of previously published reports on the endoscopic staple diverticulotomy technique.

Endoscopic Approach for Excision of Venous Malformation of the Orbital Apex.

INTRODUCTION: Venous malformation is a common tumor of the orbit, presenting with visual impairment and proptosis. These lesions can be excised via an external or transcranial approach, but recent advances in minimally invasive surgery have led to increased popularity of endoscopic approach. PATIENT: The authors report a 62-year-old female presenting with diplopia and proptosis, found to have a 1.7-cm venous malformation of the orbital apex. An endoscopic trans-nasal approach was undertaken for surgical resection. RESULTS: The tumor was successfully removed in a single specimen, without injury to the nearby orbital anatomy. The patient experienced resolution of her presenting symptoms 3 weeks after the procedure, with no adverse effects. A review of the literature demonstrates increasing reports of similar successful cases. CONCLUSION: A minimally invasive, endoscopic resection of orbital venous malformation is possible and provides a reasonably safe and effective approach. Further large-scale studies are needed to fully explore its outcomes relative to traditional approaches.

Surgical resection of sinonasal hemangiopericytoma involving anterior skull base: Case reports and literature review.

Hemangiopericytomas are soft tissue tumors composed of pericytic cells that are characterized by their "staghorn" vascular branching and their variable clinical presentation. Fifteen to 25% of all HPC occur in the head and neck, with only 5% found in the nose or paranasal sinuses. Sinonasal hemangiopericytoma (SNHPC) is considered distinct from its soft tissue counterpart - the former showing a more uniform cellular organization, has convincing pericytic differentiation and is associated with a far better prognosis. With less than 200 cases of SNHPC reported in the literature, only limited assumptions can be made about this rare tumor. The purpose of this article is to add to the growing body of literature on this disease. We report two new cases of SNHCP - both in female patients who presented with epistaxis and anosmia. Pulsatile vascular masses were visualized with nasal endoscopy - one in the left middle meatus and the second one near the cribriform plate. CT and MRI studies show enhancing masses in the left nasal cavities with thinning and erosion of the skull base. Diagnoses were confirmed by pathology which reported spindle cell neoplasm staining positively for VEGF, NSE, factor XIIIa, S-100 protein, and CD34, and negative for actin, desmin, CD31, and pankeratin, consistent with hemangiopericytoma. In one patient, embolization of the sphenopalatine and labial artery as well as pre-operative radiation therapy was performed before complete endoscopic resection was undertaken. The second patient had a tumor invading the skull base, so a craniofacial resection was performed. Both patients remained free of disease two years after surgery. Review of the literature and treatment options are discussed.

Schwannoma of the nasal cavity.

Schwannomas are benign peripheral nerve sheath tumors that occur throughout the body. They may present as either solitary or multiple masses. They rarely occur in the nasal cavity. The diagnosis is often made only after histologic examination. Because these lesions are radioresistant, the preferred treatment is complete surgical excision. We present a new case of a schwannoma of the nasal cavity.

Tracheoesophageal voice restoration following laryngotracheal separation procedure.

OBJECTIVES: Laryngeal dysfunction leading to incompetence and intractable aspiration can be a life-threatening problem. Laryngotracheal separation (LTS) can be used to prevent aspiration, but results in aphonia. The options for laryngeal speech following LTS are limited. METHODS: We performed tracheoesophageal puncture (TEP) and insertion of a Blom-Singer valve in 3 patients in an attempt to restore their voice after LTS for chronic aspiration. RESULTS: Two patients had intractable aspiration (5 and 14 years) after full-course radiotherapy for laryngeal cancer, and 1 patient had aspiration after a stroke. In the first patient TEP was done as a secondary procedure, and in the other 2 patients it was done at the time of the LTS. The TEP was successful in providing these patients with phonation ability after their LTS procedure. There was no morbidity from these procedures. CONCLUSIONS: Creation of a TEP after an LTS procedure is relatively simple and relatively safe, and allows for the control of aspiration while maintaining vocal function.

Paranasal sinus development: a radiographic study.

OBJECTIVE: To demonstrate the development of the paranasal sinuses in a pediatric population by computed tomography scans. STUDY DESIGN: Radiology records at a tertiary care institution were reviewed for the computed tomography scans of the face, orbit, or paranasal sinuses in patients aged 0 to 12 years. METHODS: Computed tomography scans were reviewed by a head and neck radiologist and otolaryngologist for the development of the frontal, maxillary, ethmoid, and sphenoid sinuses. The size of the pneumatized paranasal sinuses was measured in two planes and graded on a scale of 0 to 3. Ossification of the maxillary crest and vomer, obliteration of the foramen cecum, and development of agger nasi cells, Haller cells, and the superior turbinate were studied. Patients with syndromes, nasal stenosis, choanal atresia, or cystic fibrosis were excluded from the study. RESULTS: In all, 91 computed tomography scans in 66 patients were studied. Serial development could be followed in 16 patients who underwent repeat scans. Patients were divided into six age cohorts based on their age at the time of the scan: 0 to 3 months (10%), 3 to 12 months (13%), 1 to 3 years (13%), 3 to 5 years (20%), 5 to 8 years (29%), and 8 to 12 years (16%). Ethmoid sinuses were the first to fully develop, followed sequentially by maxillary, sphenoid, and frontal sinuses. Each sinus has a rapid rate of development during specified age cohorts. CONCLUSION: The results will aid the physician when correlating the clinical and radiographic findings of pediatric patients aged 0 to 12 years who are being evaluated for sinus disease and potential surgical intervention.

Sinonasal facial pain.

Evaluation of the paranasal sinuses and nasal cavity in patients with headache and or facial pain must include a thorough medical and social history, with close attention to the pattern and character of the pain, a thorough physical examination that includes a palpation and nasal endoscopy, and imaging studies such as CT scans and Magnetic Resonance Imaging. The physician must remember that every pain in the face is not caused by sinusitis.

Laser soft palate "stiffening": an alternative to uvulopalatopharyngoplasty.

BACKGROUND AND OBJECTIVE: Habitual snoring is best treated surgically, with uvulopalatophayngoplasty, but the standard "cutting" procedure poses potential morbidity. In this study, a new approach, stiffening of the soft palate with a low energy laser, was studied as a less invasive alternative. Study Design In an in vitro study, five fresh palates of canines were used to see acute thermal effect on the palatal tissue after laser treatment. The same laser irradiation was conducted in three living canines to observe a delayed response of the palate to the laser. MATERIALS AND METHODS: With the use of a non-contact 1.44 microm Nd:YAG laser at 0.1 J and 20 Hz, the mucosa on the marginal area of the soft palate was irradiated for 2-3 minutes. Following Outcome were Measured Acute shrinkage of the soft palate and thermal effect on the mucosa, and delayed stiffening and elevation of the palate after laser irradiation. RESULTS: There was immediate shrinkage of the palate of about 3.0 mm in the in vitro study. In the in vivo study, a delayed palatal stiffening with 6.0-7.0 mm elevated palatal arch was found at 5 weeks. There was no morbidity after the treatment. CONCLUSION: Laser stiffening of soft palate is simple, safe and effective for reduction of length and fluttering of the soft palate in the canine model. Clinical studies are warranted to evaluate its efficacy as an office treatment for snoring.