Endoscopic neural blockade for rhinogenic headache and facial pain: 2011 update.

BACKGROUND: Over 45 million Americans suffer from recurrent headaches, and an estimated $11.9 million was spent on doctor's visits for rhinogenic pain last year. Sphenopalatine blocks have been described for various facial pain syndromes, but their use and the type of blockade agents remain controversial. The objective of this study was to demonstrate that endoscopic nerve blocks, using a mixture of bupivicaine and triamcinolone-40, injected into the anterior ethmoid or sphenopalatine regions, can be a relative safe and effective option for refractory pain. METHODS: The charts of all patients undergoing endoscopic neural blockade, in a private practice setting from 1998 to 2008 were retrospectively reviewed. A 1:1 mixture of 0.5% bupivicaine and triamcinolone acetonide injectable suspension was injected into the patients' anterior ethmoid or sphenopalatine neural distribution, or both, depending on the pain distribution. Charts were reviewed to assess outcomes and any adverse events from nerve blocks. RESULTS: A total of 882 nerve blocks were administered to 147 patients, over the course of 431 office visits. Four mild complications, 2 moderate complications, and no severe or permanent complications were noted. No permanent visual complications were observed. Of all the charts, 85% had documented effects of the nerve block at follow-up. Of those, 81.3% claimed improvement, 17.9% reported feeling the same, and 0.79% stated they had worse pain. CONCLUSION: Endoscopic neural blockade appears to be a relatively safe and viable option in the treatment of refractory headache and facial pain with a rhinogenic component.

Is surgical debridement and topical 5 fluorouracil the optimum treatment for woodworkers' adenocarcinoma of the ethmoid sinuses? A case-controlled study of a 20-year experience.

OBJECTIVES: Woodworkers' adenocarcinoma of the ethmoid sinuses is an extremely rare occupational malignancy with a locally aggressive course. Treatment with surgical exenteration and topical 5 fluorouracil (5FU) packs has become standard treatment over the last 10 years in this ENT unit. This study presents level 2 evidence that 5FU provides improved survival over previous management with primary radiotherapy and salvage craniofacial resection. DESIGN: Retrospective case series with historical control group. SETTING: District General Hospital. PARTICIPANTS: The records of 31 consecutive patients with the disease were analysed. Five patients died prior to treatment. One patient was treated with surgery alone and therefore excluded. Twenty-five patients were included in the analysis. Fourteen were treated with primary radiotherapy and 11 with surgery and topical 5FU. OUTCOME MEASURES: Disease free survival was measured using Kaplan-Meier survival analysis. RESULTS: Five-year disease free survival improved from 50% with primary radiotherapy to 86% with surgery and 5FU. This improvement is statistically significant (P = 0.03). CONCLUSION: Topical 5FU treatment improves survival of Woodworker's adenocarcinoma of the ethmoid sinuses. This finding may be useful in the treatment of other locally aggressive sinonasal malignancies.

[A new system for the classification of ethmoid polyposis. Effect of combined local and systemic steroid therapy]. / Ein neues System zur Einteilung der Siebbeinpolyposis. Einfluss einer kombinierten lokalen und systemischen Steroidtherapie.

BACKGROUND: Nasal polyps are a common disease with in the majority of cases unknown origin. Both the medical and surgical treatment of nasal polyps present a challenge in Otorhinolaryngology. METHODS: We developed a four-stage grading system for nasal polyps based on the endoscopic aspect of more than 300 patients. In a study of 37 patients, treated by systemically (Methylprednisolon 64 mg p.o., decreasing amounts for the first 11 days) and locally (Budesonid 400 micrograms intranasal) applied steroids for 90 days, this staging-system was tested. RESULTS: The mean stage of polyps decreased significantly (p < 0.01) from 2.8 at day 0 to 1.7 at day 7 and further to 1.2 and to 0.7 at day 28 and day 90 respectively. The mean nasal symptom score decreased equally from 1.14 on day 1 to 0.19 and to 0.14 on day 7 and day 28 respectively. To summarize, we observed a significant (p < 0.01) decrease in polyp stages of 75% respectively a significant (p < 0.01) reduction of symptom scores of 93%. CONCLUSIONS: Thus, we present a suitable new grading system for nasal polyps which we applied directly to assess the efficacy of combined local and systemic steroid therapy. It was shown that this treatment can reduce polyps and prevent their recurrence over the observed time.

Effect of intranasal treatment with capsaicin on the recurrence of polyps after polypectomy and ethmoidectomy.

The aim of this study was to evaluate the influence of five intranasal applications of capsaicin, performed after endoscopic polypectomy associated with partial middle turbinectomy and anterior ethmoidectomy, on the recurrence of nasal polyps and the intensity of nasal obstruction and rhinorrhea. Fifty-one patients (19 females, 32 males, mean age 43 years) suffering from nasal polyposis for more than 1 year were included in this double blind, randomized, placebo-controlled study. During post-surgical controls, local anaesthesia and vasoconstriction of the middle meatus area were performed in all patients with a cotton pellet soaked with lidocain and adrenaline. In 29 patients, the same type of cotton pellet soaked with capsaicin (3 x 10(-6) mol. dissolved in 70% ethanol) was left into the middle meatus of both nostrils for 20 min. As a control group, 22 patients, matched for age and sex, were treated with the capsaicin vehicle alone (70% ethanol). All patients studied received the intranasal treatment once a week for 5 weeks. Subjective evaluations of nasal airway resistance (NAR) and rhinorrhea were recorded by means of a visual analogue scale. Clinical staging of the nasal polyposis (graded from stage 0 = absence of polyp to stage 3 = polyps occupying the entire nasal cavity) was evaluated by the same ENT specialist (ZW) using a 0 degrees endoscope. All parameters were recorded for each patient 1 week before surgery, then once a month for 9 months. Patients treated by endoscopic surgery followed by intranasal capsaicin application, reported a marked reduction in their NAR compared with the pretreatment evaluation (p<0.001). In contrast, patients treated with the vehicle alone did not have any significant improvement of their subjective NAR. Subjective rhinorrhea was not modified by either treatment. Patients treated with capsaicin showed a significant smaller staging of their nasal polyposis compared with the control group (p<0.001). These observations suggest that endoscopic surgery followed by intranasal capsaicin application reduces polyps and nasal obstruction recurrence and could be an alternative treatment to expensive corticosteroids in developing countries.

Effect of a topical vasoconstrictor on computed tomography of paranasal sinus disease.

Apparent ethmoid inflammation which resolved with alternation of the nasal cycle or following application of topical vasoconstrictors has been observed with magnetic resonance imaging. A similar phenomenon might occur to a lesser degree with computed tomography (CT), leading to overdiagnosis of limited sinus disease. The degree to which ostiomeatal complex disease is reversible by topical vasoconstrictors was investigated. Ten patients with histories of chronic or recurrent sinusitis underwent coronal CT studies of the paranasal sinuses before and after the application of a topical vasoconstrictor. Mucosal volume or thickness measurements were obtained from the turbinates, infundibulum, ethmoidal cells, and antrum. Vasoconstrictor application markedly reduced turbinate size and appeared to reduce mucosal thickening in the ethmoidal infundibulum. Minimal mucosal changes identified in the paranasal sinuses by computed tomography were not reversed by vasoconstrictors and therefore are likely to be pathologic.

Cytotoxicity of human eosinophil granule major basic protein to human nasal sinus mucosa in vitro.

The toxic effects of the human eosinophil granule major basic protein (MBP), reduced and alkylated, were studied on human nasal mucosa in vitro. With a microscope coupled with a television monitor (magnification x 2500) and videotape recorder, we investigated the effects of MBP on the mucosa and the ciliary activity of single cells. In nasal mucosal specimens from normal individuals, MBP, 5 mumol/L and 10 mumol/L, significantly inhibited (p less than 0.01) ciliary activity by 4 and 1 hours of exposure, respectively. At these same MBP concentrations, the mucosal surface profiles were altered by 4 hours of exposure, and ciliostasis was 75% to 100% complete by 9 and 6 hours, respectively. In a mucosal specimen from a patient with nasal allergy, 1 mumol/L of MBP significantly inhibited (p less than 0.01) ciliary activity by 1 hour; alteration of the mucosal surface profile appeared by 3 hours of exposure, and ciliostasis was 75% to 100% by 13 hours. Similar alterations of the mucosal surface profile were observed with specimens from a second patient with allergies; in contrast, 1 mumol/L of MPB had no effect on specimens from a nonallergic patient. These results indicate that MBP damages human upper respiratory epithelium, causing ciliostasis and alteration of the epithelial surface at concentrations likely achieved in vivo. Furthermore, the mucosal specimens from two allergic patients were damaged by concentrations of MBP that had no effect on mucosal specimens from a normal individual.

Physiologic mucosal changes within the nose and ethmoid sinus: imaging of the nasal cycle by MRI.

Magnetic resonance studies frequently demonstrate increased T2-weighted signal in the nasal area. To further evaluate this phenomenon, several MRI examinations of the nasal cavity were performed within an 8- to 12-hour period. The study demonstrated that changes alternated from side to side and were interrupted by the administration of topical vasoconstriction, confirming imaging of the normal nasal cycle. Changes were also observed within the ethmoid sinuses. Signal intensity on T2-weighted images during the congested phase was similar to inflammatory mucosa. Occasionally, these changes make interpretation of the extent of pathology difficult in patients with sinus disease, and raise the possibility of inflammatory pathology in asymptomatic patients. Awareness of MRI imaging of nasal cycle should reduce the likelihood of diagnostic errors and provides another method for study of this physiologic phenomenon.

Osteolytic sinusitis and pneumomediastinum: deceptive otolaryngologic complications of cocaine abuse.

Recreational cocaine abuse via intranasal "snorting," "free-base" smoking, "body-packing," or intravenous injection can be lethal. Increasing illicit use of cocaine hydrochloride and the misuse of legal over-the-counter (OTC) nasal drugs are known causative agents of nasal septal perforation with loss of taste and smell. Although 2 to 3 mg/kg is the recommended maximum dose for topical anesthesia, cocaine snorters may use 1,000 mg or more daily on a "run." Furthermore, the newer route of smoking the extracted volatile "free-base" form of the adulterated street drug provides a plasma concentration producing the same physiological and subjective effects of intravenous cocaine. Presented are two cases exemplifying unusual complications of cocaine abuse: 1. total nasal septal bony and cartilaginous necrosis with resultant saddle-nose deformity and osteolytic sinusitis secondary to chronic intranasal "snorting" and 2. tracheobronchial rupture with pneumomediastinum secondary to smoking "free-base" cocaine.