What is the evidence for the use of mucosal flaps in Draf III procedures?

PURPOSE OF REVIEW: Recent literature has described the use of mucosal grafts or transplants to reduce the rate of frontal ostium restenosis after the endoscopic-modified Lothrop procedure. This article presents a review of the literature on the rates of revision and restenosis related to Draf III procedures, factors implicated in the causation of restenosis and the evidence to support the role of mucosal grafts in reducing restenosis rates. RECENT FINDINGS: Compared to historic data and to the meta-analysis data by Anderson and Sindwani, results from three case series examining the use of mucosal flaps after endoscopic-modified Lothrop procedure look extremely promising compared to a baseline average stenosis rate of 19% and revision rate of 14% quoted in the literature. SUMMARY: Although the concept appears sound in principle and the limited series published show potential reduction in revision rates, there is inadequate evidence to state conclusively that this technique will improve the results of Draf III procedures in all surgical hands.

Use of topical nasal therapies in the management of chronic rhinosinusitis.

OBJECTIVES/HYPOTHESIS: To determine whether the use of topical nasal therapies with saline alone and in combination with antibiotics, antifungals, or corticosteroids is effective in the treatment of patients with chronic rhinosinusitis (CRS). DATA SOURCES: A systematic literature search was performed utilizing the MEDLINE database (1966 to May 2012), EMBASE database (1980 to May 2012), and the Cochrane Central Register of Controlled Trials. REVIEW METHODS: Electronic databases were searched by three otolaryngologists. Studies on five major categories of topical nasal therapies searched included saline (hypotonic, isotonic and hypertonic); topical antibiotics, topical steroids, and topical antifungals were obtained. Randomized controlled trials and meta-analyses of randomized controlled trials were included. RESULTS: Sixteen randomized controlled trials were identified examining topical saline (hypertonic or isotonic) in CRS patients. Two randomized controlled trials were found studying the effect of topical antibiotics in patients with CRS. Four randomized controlled trials were identified studying topical antifungal treatment for CRS. Twenty-five randomized controlled trials were found studying topical steroids in CRS patients. CONCLUSION: A high aggregate quality of evidence supports the effectiveness of saline irrigations in treating CRS. There is insufficient evidence to support a clear benefit of topical antibiotics in patients with chronic rhinosinusitis. Topical antifungal therapies have not been shown to be significantly different in efficacy than saline controls on CRS outcomes. Topical steroids are beneficial in the treatment of CRS with nasal polyps, but have not been shown to be effective in CRS without nasal polyps.

Planum, tubercular, sellar and clival defects.

Transsphenoidal and extended transsphenoidal approaches have provided improved surgical access to numerous intradural and extradural tumors from the retrosellar area to the craniovertebral junction. The evolution in reconstruction of planum, tubercular and clival skull base defects has progressed from the use of free tissue grafts alone to the use of free tissue grafts in combination with vascularized flaps. Sellar floor reconstruction is usually necessary only if intraoperative CSF leaks, prolapse of the suprasellar cistern, or bleeding from the medial aspect of the cavernous sinus occur. In patients with intraoperative CSF leak, accurate packing of the sella in the area of the arachnoid membrane tear, with or without packing of the sphenoid sinus, is performed. An increasing armamentarium of local and regional tissue flaps have reduced postoperative CSF leak rates to less than 5%. Future refinements in skull base reconstruction techniques will allow better management of patients at high risk for a postoperative CSF leak, especially those who have been previously irradiated and/or require revision surgery.

Mometasone implant for chronic rhinosinusitis.

The Propel mometasone-eluting stent (Intersect ENT, Palo Alto, CA) is the first Food and Drug Administration-approved device for delivering steroid medication into the ethmoid cavity following surgery. The implant is composed of a biodegradable polymer in a lattice pattern that expands in a spring-like fashion to conform to the walls of a dissected ethmoid cavity and contains a total of 370 µg of mometasone furoate designed for gradual release over 30 days. The purpose of this article is to review the mode of action and the evidence supporting the efficacy of this novel technology. Three recently published clinical trials have demonstrated that the mometasone-eluting stent produced statistically significant reductions in inflammation, polyp formation, and postoperative adhesions. In addition, the implant has been found to significantly reduce the need for postoperative administration of oral steroids and to decrease the frequency of postoperative lysis of adhesions. Minimal adverse effects were reported in these trials and included infection, crusting, and granulation tissue formation. Although the placement of steroid-impregnated packing, stents, sponges, and gels has previously been used in the postoperative sinus cavities, the Propel mometasone-eluting stent introduces a new mechanism for localized and controlled delivery of topical therapy directly to the nasal mucosa for chronic rhinosinusitis.

Nasal irrigation with or without drugs: the evidence.

PURPOSE OF REVIEW: To review the recent literature of nasal irrigations with or without drugs, including delivery systems, nasal saline, antibiotics, antifungals, steroids, surfactants, and interleukin (IL)-5 modulators, for the treatment of chronic rhinosinusitis (CRS). RECENT FINDINGS: As antibiotic resistance increases in CRS, culture-directed, rather than empiric, topical antibiotics are increasingly critical in optimal treatment. Topical irrigation with mupirocin significantly reduces Staphylococcus aureus biofilm mass in vitro. Surfactants and humanized anti-IL-5 monoclonal antibody are novel therapies demonstrating promising results in CRS. SUMMARY: Physiologic saline irrigation is beneficial in the treatment of symptoms of CRS. Low-level evidence supports the effectiveness of topical antibiotics in the treatment of CRS. The use of topical antifungals is not supported by the majority of studies. Intranasal steroids are beneficial in the treatment of CRS with nasal polyposis. There is insufficient evidence to demonstrate a clear overall benefit for topical steroids in CRS without nasal polyposis.

In vitro expression and characterization of MYH9 mutant alleles linked to hereditary hearing loss.

OBJECTIVE: To assess whether MYH9 mutant alleles linked to hereditary hearing loss induce disruption of cellular functions and associated phenotype following transient expression within cultured human cell lines. STUDY DESIGN: Dominantly inherited MYH9 mutant alleles, MYH9(R702C) and MYH9(R705H), were integrated within eukaryotic expression vector and then transfected into cultured human cell lines for transient expression and analysis. The transfected cells were assessed for transgene-induced alterations of the cellular phenotype, including NMHC-IIA-dependent cell shape, actin cytoskeleton integrity, and inhibition of cytokinesis. SETTING: Laboratories of Molecular Otology and Molecular Genetics at the New York University School of Medicine. SUBJECTS AND METHODS: HeLa and MDA-MB-231 cultured cell lines were transiently transfected with an expression vector carrying a wild type or mutant MYH9 alleles, linked to nonsyndromic and syndromic hearing loss. Expression of exogenous transgene product was detected with antibodies directed toward its N-terminal HA tag, and transfection efficiency was greater than 95 percent. Host cells were characterized for cell shape, integrity of actin-myosin cytoskeleton, and nuclear status before and after transfections via immunofluorescence. RESULTS: MDA-MB-231 cells transfected with MYH9(R705H) but not MYH9(R702C) were found to have a greater than two-fold increase in cells with filopodia and a ten-fold increase in proportion of cells with multiple nuclei, indicating inhibition of cytokinesis, relative to the control cells transfected with wild type MYH9. Actin cytoskeleton configuration within MDA-MB-231 cells was unaffected by expression of MYH9(R702C) or MYH9(R705H). Unlike MDA-MB-231 cells, HeLa cells were refractory to MYH9(R705H) and MYH9(R702C). CONCLUSIONS: MYH9(R705H)-induced altered phenotype of the MDA-MB-231 cell line supports the pathogenicity of the mutation and represents a suitable assay system for identification and characterization of its dysfunction.