American Journal of Rhinology & Allergy

Twenty-two Caucasians (16 male and 6 female) with chronic bilateral nasal obstruction due to hypertrophic inferior turbinates were followed up over a three-month period. They were assessed by clinical examination, as active anterior rhinometry, and acoustic rhinometry before and after topical decongestion, preoperatively and three months after surgery. All patients were treated by application of radiofrequency-volumetric-tissue reduction (RFVTR, or somnoplasty) to both inferior turbinates. Initial postoperative edematous response disappeared during the first week after RFVTR. Three months postoperatively 20 of 22 patients (91%) reported subjective improvement of nasal patency. The average cross-sectional area for both sides of the nasal cavity (measured at the head of the inferior turbinate (C-Notch) before decongestion) increased in 15 of 22 patients (68.2%). This means a significant improvement from 1.24 to 1.49 cm² for both sides of the nasal cavity (p = 0.0054). We conclude that RFVTR can safely reduce turbinate volume in a precise manner in patients with nasal obstruction due to hypertrophic inferior turbinates.

The InstaTrak system by Visualization Technologies, Inc. (Woburn, MA) has recently introduced attachments that can be utilized to localize the tip of the XPS Straightshot debrider (Xomed Industries, Jacksonville, FL) during image-guided surgery. The accuracy of these newer attachments has not been objectively tested in a clinical setting. Our primary objective was to compare the actual instrument (XPS debrider tip) location with its computer screen location in the coronal, sagittal, and axial views. This was considered to be the “accuracy” of the instrument being tested. We secondarily compared its accuracy with the accuracy of the 0° and 45° curved localizing aspirators in a prospective study. The manufacturer also recommends that the same headset used during scanning be utilized during surgery. A second objective therefore was to determine if a headset other than the one used during CT scanning could be used intraoperatively with an acceptable level of accuracy. Accuracy of the instruments between the patients’ own headset (used during CT scanning) and a generic or research headset (not used during scanning) was compared intraoperatively. The third and final objective was to determine if the same headset could be used repeatedly with an acceptable level of accuracy. Generic “research” headsets were therefore utilized for a total of five surgeries per headset and visual accuracy between the multiply utilized research headsets and the patients’ own headsets was recorded and compared. Anatomic localization accuracy was 1.06 mm for the XPS debrider, 0.89 mm for the 0° aspirator, and 1.05 mm for the 45 aspirator when the patients own headset was utilized. When the research (generic) headset was utilized the respective values were 0.69 mm for the debrider, 0.77 mm for the 0° aspirator, and 0.99 mm for the 45° aspirator. With multiple utilization of a single headset, there was no significant loss in accuracy. In conclusion, the accuracy of the newly marketed attachment for the debrider was found to be comparable to the standard aspirators. Accuracy remained acceptable when a headset other than the one used during CT scanning was used intraoperatively. No loss in accuracy was noted when a headset was utilized more than once.

Recently, the role of various cytokines in the pathogenesis of chronic rhinosinusitis has come under investigation. Various studies have reported increased levels of interleukin-3, interleukin-4, interleukin-5, interleukin-13, and granulocyte macrophage-colony stimulating factor in the sinonasal mucosa of patients with chronic rhinosinusitis. The present study investigated the levels of pro-inflammatory cytokines, including interleukin-1β (IL-1β), interleukin-5 (IL-5), interleukin-6 (IL-6), interleukin-8 (IL-8), and tumor necrosis factor-α (TNF-α), in the sinonasal mucosa of patients with chronic rhinosinusitis, and evaluated the response of these cytokines to oral corticosteroids. Chronic rhinosinusitis subjects (n = 15) and control subjects (n = 9) underwent nasal endoscopy and biopsy of the sinonasal mucosa. Chronic rhinosinusitis subjects were subsequently treated with a 10-day tapering dose of prednisone followed by a second sinonasal endoscopic exam and biopsy. Mucosal biopsy specimens were immunostained for IL-1β, IL-5, IL-6, IL-8, and TNF-α. In chronic rhinosinusitis subjects, mucosal levels of IL-1β, IL-6, IL-8, and TNF-α were significantly elevated when compared with control subjects, and levels of IL-5 demonstrated a strong trend toward elevation. In posttreatment chronic rhinosinusitis subjects, levels of IL-6 were significantly decreased when compared with pretreatment levels, and TNF-α levels demonstrated a significant trend toward reduction. These findings support the hypothesis that the inflammatory response in chronic rhinosinusitis is associated with elevated levels of pro-inflammatory cytokines, and suggest that oral corticosteroids may exert a beneficial effect by significantly reducing the levels of IL-6 and TNF-α.

Using the saccharin method, we performed tests of mucociliary function four times during pregnancy and once one month after delivery in 27 women. As the transport distance for saccharin varied from 37 to 65 mm, we used the transport speed for evaluation. Pregnancy rhinitis affects at least 20% of pregnancies. The mucociliary transport speed was higher in the group of women with pregnancy rhinitis, and was reduced during pregnancy in the group of women without that condition. We found no significant correlation between mucociliary transport speed and objectively registered nasal peak expiratory flow index. The pathophysiology of pregnancy rhinitis is not known, but is possibly multifactorial. The changes occurring in the nasal mucociliary transport system during normal pregnancy and in pregnancy rhinitis need further studies.

The application of endoscopic sinus surgery (ESS) for the management of paranasal sinus disease in patients with cystic fibrosis (CF) has been well described. Due to underlying medical issues such as acquired coagulopathies and advanced pulmonary, disease, perioperative morbidity is assumed to be higher in this group. The incidence and type of complications associated with CF patients undergoing ESS has not been previously described. We reviewed 52 consecutive endoscopic procedures in 41 patients with CF performed by a single surgeon over a 34-month period. This review focused on perioperative and postoperative complications. Additional clinical data gathered included estimated blood loss, length of procedure, coagulation laboratory studies, the presence of nasal polyposis, the use of nasal packing, pulmonary function status, and average hospitalization time. A total of six complications were identified-four immediate and two delayed. The perioperative or immediate complications included two cases of epistaxis, one case of periorbital ecchymosis, and one case of pulmonary hemorrhage. Delayed complications include one case of epistaxis and one case of intranasal scarring. In two of these six patients, length of hospitalization was prolonged for management of the associated complications. No study has specifically addressed complications of ESS in the CF patient. Our review demonstrates a complication rate of 11.5%, which compares favorably with the non-CF ESS complication rates of 0-17% reported in the literature. Critical to successful management of these patients is coordinated care delivered by the pediatrician or internist, the pulmonary specialist, the anesthesia team, and the otolaryngologist. In addition to a review of current literature, we discuss the overall management approach adopted at our institution and highlight elements thought to minimize morbidity.

Nasal and paranasal sinus manifestations are among the most common presentations of the acquired immunodeficiency syndrome (AIDS). Several studies cite that as many as 70% of patients with this disease have symptoms referable to the head and neck, including a 30% prevalence of sinusitis. Although the bacteriology of sinusitis in this population is largely considered comparable to that of immunocompetent patients, several opportunistic pathogens have been identified, particularly when T-cell counts are low. This report identifies Acanthamoeba as a potentially fatal cause of rhinosinusitis in immunosuppressed patients. The pathogenesis, diagnosis. and treatment of this rare entity will be discussed and the literature reviewed.

Endoscopic frontal sinus surgery, once the last frontier in the evolution of endoscopic sinus surgery. is considered difficult, risky to the patient. and likely to result in a high failure rate. We clarify the surgical anatomy for frontal sinus surgery that, based on a review of our data, provides safe and predictable access to the frontal sinus. We studied 200 consecutive patients with respect to indications, endoscopic and radiographic findings, results. and complications. The study will describe the technique in detail, including the following points: 1) computed tomography identification of the superior attachment of the uncinate process; 2) complete removal of the uncinate process, including its superior attachments, by using the microdebrider; 3) removal of the agger nasi cell, if present; and 4) verification of an open frontal sinus by a transillumination or image-guided system. Postoperative assessment of patients’ symptoms and the confirmation of a patent frontal sinus by office endoscopy and transillumination indicated a 90% patency for short-term follow-up (average 12.2 months). There were no major complications. Postoperative complications included frontal recess stenosis, polypoid mucosa occluding the frontal recess, and middle turbinate lateralization. All of these situations may lead to recurrence of infection and symptoms. In-depth understanding of anatomic variations of the uncinate process and precise surgical removal of its superior attachments provide surgical access to the frontal sinus that is based on the natural ostia and is, therefore, more likely to remain patent.

The human airway epithelium lines the respiratory tract from the nasal mucosa to the bronchioles. Electrolyte transport by these epithelia is crucial in maintaining the appropriate volume and salt composition of the airway surface fluid. When this epithelium becomes functionally impaired, the airways are more prone to respiratory infections. We studied the effect of six common topical agents that are commonly used to treat rhinorrhea and nasal inflammation on the transepithelial resistance, sodium, and chloride transport of primary cultures of human airway epithelia grown at the air-liquid interface. The pharmaceuticals fluticasone propionate, cromolyn sodium, ipratropium bromide, azelastine, oxymetazoline, and normal saline were used and the electrical function of the epithelia was studied in Ussing chambers. Azelastin and ipratropium bromide-treated epithelia were found to have a significant decrease in transepithelial resistance. Both normal saline and fluticasone propionate resulted in significant increases in amiloride-sensitive short circuit currents that reflect sodium transport Finally, normal saline resulted in a significant increase in bumetanide-sensitive short circuit current that reflects chloride transport across the epithelia. The data presented may explain a mechanism by which some topical pharmaceuticals help reduce rhinorrhea, and may point to some unwanted side effects of some pharmaceuticals on the electrolyte transport of the airway epithelia. In summary, several of the common topical nasal agents alter the electrolyte transport of the nasal airway epithelia. The in vivo significance of these findings is to be determined.

This study was designed to investigate subacute effects of long-term exposure of both healthy and chronically inflamed human respiratory mucosa to ozone. Functional and metabolic effects on ciliary beat frequency (CBF), release of interleukin 8 (IL-8), interleukin 4 (IL-4), and γ interferon (g-INF), as well as cellular viability and cytotoxicity, were monitored. Cell cultures of 60 specimens (healthy mucosa: n = 30, inflamed mucosa: n = 30) were exposed to synthetic air and to ozone-enriched synthetic air in different concentrations of WO, 500, and WOO μg/m³. Continuous expositions were performed using an air/liquid interface cell culture technique for a period of 4 weeks. CBF was monitored using video-interference contrast microscopy and cytokine release was quantified by enzyme immunoassays. Cellular viability and cytotoxicity were controlled by measuring lactate dehydrogenase activity, cytosolic activity of esterases, and by staining of nuclear DNA. Synthetic air had no influence on CBF during the 4 weeks of exposure. IL-8 release was continuously diminished in unaffected and in chronically inflamed mucosa. Within the first week of continuous exposure with any ozone concentration neither CBF nor release of IL-8 were affected in healthy or in inflamed mucosa. During the second and the following weeks of exposure CBF and the release of IL-8 were reduced in both tissues. Release of IL-4 or g-INF were not detectable at any time during the 4 weeks of ozone exposure. At higher ozone concentrations of 500 and 1000 μg/m³ there was an increase of cytotoxicity which was greater in chronically inflamed than in healthy mucosa. In conclusion, ozone had no measurable effect on those parameters measured in human upper respiratory epithelium after one week of in vitro exposure to different concentrations, but did after longer periods of exposure. Chronically inflamed mucosa had a tendency toward a higher susceptibility to intermediate and high concentrations of ozone that did not reach a level of statistical significance under the conditions used in this study.

Paragangliomas of the nasal cavity and paranasal sinuses are extremely rare. This study was conducted to investigate the biologic characteristics of these lesions on different molecular levels and to estimate their biologic behavior. Operative specimens of three patients who underwent surgery for a paraganglioma of the nasal cavity (one case) or paranasal sinuses (two cases) were investigated by routine histology, quantitative DNA analysis, and immunohistochemical assessment of proliferation markers (i.e., Proliferating Cell Nuclear Antigen, PCNA; Ki67-MIB-1), the expression of cell-surface antigens, which reflect the tumor-stroma interaction (i.e., CD 44 v0.4/5 and 6, CD 54, CD 106), oncogene products (nm-23; p53), and bcl-2 as a marker of apoptosis. Histologically, two tumors were paragangliomas of the adenomatous subtype, one lesion was classified as angiomatous. According to DNA analysis, aneuploid cells were detected in all tumors. Two of three paragangliomas were classified as a DNA type III pattern, implying a high percentage of aneuploid cells and an aggressive behavior. Immunohistochemically, paragangliomas of the nasal cavity showed increased scores for both proliferation markers tested, indicating a rapid growth pattern. According to the expression of cell-surface markers and oncogene products, these tumors displayed an aggressive behavior and an infiltrating growth pattern. The highest value for the parameters of quantitative DNA analysis and highest proliferation scores were found in a tumor of a patient who developed multiple tumor recurrences after radical excision of the Lesion with clear margins, and finally died of disease. In conclusion, paragangliomas of the nasal cavity and paranasal sinuses examined in this study should be regarded as suspicious concerning their biologic and clinical behavior. Radical excision, and in cases with highly aggressive biology, postoperative radiation therapy are recommended. Tumor biologic examinations can help to recognize high-risk patients for developing recurrences and possibly lesions with a malignant behavior and to enhance our understanding of the biology of these extremely rare tumors of the nasal cavity and paranasal sinuses.

Malignant fibrous histiocytomas are uncommon in the head and neck, the sinonasal tract being the most common location. This report describes 5 cases in this area: two in the nasal cavity, two in the maxillary sinus, and one in the frontal sinus. Four were primary cases and one was secondary to previous irradiation. All patients received surgical treatment, one of them with postoperative irradiation. All five patients experienced local recurrences and three also experienced distant metastases. Only one of these recurrences was successfully salvaged and the patient is alive and free of disease 3 years after resection. A summary of knowledge about the entity is reviewed.