American Journal of Rhinology & Allergy

Of 15 patients with primary unilateral antrochoanal polyps (ACPs), we noticed that all ACPs except one extended through the accessory ostium of the maxillary sinus projected posterior along the nasal cavity. We observed no structural changes in ostiomeatal area on a coronal computed tomography scan.

We classified 15 patients with ACP into three stages according to the coronal computed tomography findings of (i) status of the accessory ostium of the maxillary sinus and (ii) level of extension to the nasopharynx. The extent of inflammation in the computed tomography and histologic aspects were also evaluated according to such stages.

In three patients, ACPs did not extend to the nasopharynx (stage I). Among the other ACPs reaching the nasopharynx, complete occlusion of the opening (stage II) was noted in seven patients, and partial occlusion of the opening (stage III) was noted in five patients. The extent of ipsilateral, as well as bilateral, inflammation in the imaxillary sinus in stages I and II was greater than that in stage III. More severe inflammatory cell infiltration was observed in stage II in histologic examination.

We hypothesize that stage I may correspond to an early stage, stage II to full-blown disorder, and stage III to a regression stage. When the exit site of an ACP is the accessory ostium, this opening should be connected to the natural ostium of the maxillary sinus to prevent a possible recirculation phenomenon.

Wound healing is a highly coordinated process involving clot formation, inflammatory reaction, immune response, and, finally, tissue remodeling and maturation. Only few data regarding the specific healing of the nasal or sinusal mucosa are available.

After a short summary of the general principles of wound healing, the most important data regarding in vitro or in vivo models of wound healing of the nasal and paranasal mucosa are discussed. Attention is paid to clinical application.

First observations regarding the specific regulation of epithelial regeneration by growth factors have underlined the complex relationship between extracellular matrix and epithelium during the repair process. However, only poor and aspecific correlations can be described between endoscopically and histomorphologically defined postoperative phases.

There is a paucity of knowledge about the healing of the nasal respiratory mucosa after endoscopic sinus surgery (ESS). Nasal packs often are placed after ESS in an attempt to reduce adhesions but the effect of these packs on the healing of the nasal mucosa is not known.

A standardized normal animal model (the sheep) was used to examine the healing of the nasal epithelium after ESS. A full-thickness wound was created in the nasal mucosa and either packed with a dissolvable hyaluronic acid–based pack or left unpacked to serve as control. The wounded areas were biopsied at 28, 56, 84, and 112 days postinjury and epithelialization, and cilial regeneration was assessed by light microscopy and scanning electron microscopy.

The wounds with the dissolvable hyaluronic acid–based packs showed no differences in reepithelialization up to 84 days postwounding. However, a significant increase in reepithelialization was observed on day 84 in packed wounds compared with unpacked controls, indicating an increased rate of healing at that time point. In addition, there was a significant increase in the epithelial height in the packed wounds on day 28, indicating that packing was affecting the epithelial maturity of the mucosa. No significant difference was observed in cilial regeneration between the packed and control wounds.

Application of the hyaluronic acid–based nasal packs to wounds after ESS may improve reepithelialization of the nasal mucosa but appears to have minimal effect on reciliation at the time points studied in normal-healing wounds.

To assess with computerized tomography (CT) the association of unilateral inverted papilloma (IP) and contralateral sinus inflammation.

Retrospective analysis of CT findings in a sample of patients with unilateral IP, a sample with other unilateral sinonasal tumors, and normal controls.

Sixteen patients with unilateral IP comprised the study population. Nine patients with other unilateral sinonasal tumors (five with squamous papilloma, two with squamous cell carcinoma, and one each with adenocarcinoma and large cell carcinoma) were used as a comparison population. Patients undergoing maxillofacial CT for nontraumatic orbital conditions comprised the control sample (n = 12 sides). Each patient's preoperative CT scan was evaluated with a modified Lund-Mackay scoring system. The scores for the sides opposite the IPs were compared with the sides contralateral to other sinonasal tumors as well as to normal controls.

Analysis of all three samples’ contralateral sides simultaneously using analysis of variance revealed a difference (p = 0.010). The contralateral sinus scores in IPs tended to be higher than the sides opposite the other sinonasal tumors (mean, 2.66 ± 1.07 versus 1.18 ± 0.76; p = 0.06). These in turn were higher than the normal controls (mean, 0.75 ± 0.48; p < 0.02).

Unilateral IPs are associated with contralateral inflammation as detected by CT. This degree of contralateral inflammation is greater than that seen in other sinonasal tumors. The etiology of this association is unclear. A recent histological review suggested IP is an inflammatory polyp and not a true papilloma. Our data further suggest inflammation may be involved in the pathogenesis of IP. Further work is needed to better understand the pathophysiology and behavior of IP and to define its relationship to sinus inflammation.

To review the safety and efficacy of endoscopic drainage of subperiosteal orbital abscesses (SPOAs) secondary to sinusitis and to evaluate risk factors that may be associated with failure.

Retrospective chart review. Methods: All patients admitted to the University of the Virginia Health System with a diagnosis of SPOA between 1992 and 1999 were reviewed.

Seven of the 10 SPOAs identified, each located medially, resolved without complication after endoscopic drainage. The remaining three patients required a second drainage. One patient had an inferiorly located SPOA, which recurred laterally after endoscopic drainage. A second pediatric patient, who did not undergo a routine second-look procedure, developed middle turbinate lateralization and synechiae, which led to recurrent SPOAs. A third patient with a significant history of sinusitis was found to have an ethmoid sinus mucocele extending into the medial and posterior orbit. All patients eventually resolved their symptoms.

Endoscopic drainage of medial SPOAs appears to be safe and effective. However, several risk factors must be recognized when present. Management of these risk factors is discussed.

The gold standard for surgical treatment of chronic frontal sinusitis has been the osteoplastic flap with obliteration. In an attempt to preserve the frontal sinus, we have been performing the endoscopic modified Lothrop or frontal drill-out.

Retrospective chart review.

We performed the modified Lothrop on 54 patients between 1993 and 1998. The modified Lothrop was successful (no revision surgeries and only an occasional need for antibiotics) after one procedure in 68% (30/44) of patients followed up for ≥1 year. Six patients underwent successful revision, bringing the overall success rate to 82% (36/44). Eight patients (18%) eventually underwent osteoplastic flap with obliteration, three of those after attempted revision. Mean follow-up was 40 months with failures occurring a mean of 12 months after initial Lothrop. Overall complication rate was 11%.

The modified Lothrop is a technically challenging operation that provides an acceptable alternative to the osteoplastic flap with obliteration.

Although masses in the pterygomaxillary space are uncommon, they frequently present diagnostic challenges when they occur. If a tissue biopsy is required for pathological analysis, the relative inaccessibility of this region can make the surgical approach more extensive and technically difficult than seems justified. In this study, we describe a series of four cases in which a transnasal endoscopic technique was used to biopsy masses of the pterygomaxillary space.

The four patients described in this report had lesions of the pterygomaxillary space that were detected radiographically. The surgical approach involved an endoscopic uncinectomy and a wide maxillary antrostomy to provide maximum exposure of the posterior maxillary sinus wall. Careful opening of the bone and underlying periosteum provided ready access to the pterygomaxillary space in an atraumatic fashion. Biopsy specimens were taken under direct endoscopic visualization using traditional biopsy forceps.

In each case, satisfactory exposure of the mass was achieved and diagnostic biopsy specimens were obtained. There were no adverse sequelae related to the procedure. One patient was returned to the operating room 2 weeks later for a repeat biopsy so that additional diagnostic studies could be performed. This was obtained easily through the previous antrostomy and posterior maxillary wall opening.

The transnasal endoscopic approach to the pterygomaxillary space is a safe, relatively noninvasive technique that can be performed by otolaryngologists trained in endoscopic sinus surgery. This procedure allows adequate exposure of the pterygomaxillary space for biopsy while avoiding the morbidity of an open surgical approach. (American Journal of Rhinology 16, 109–112, 2002)

The use of multiplanar reconstructed computed tomography (CT) images of frontal recess and sinuses was assessed with regard to depiction and understanding of anatomy and effect on surgical approach.

Three otorhinolaryngologists and one radiologist read CT scans of 43 patients referred for routine paranasal sinus scans. Spiral (helical) CT scans were obtained and coronal and parasagittal reconstructions were imaged. Three hundred forty-two readings were analyzed. The scans were assessed in the coronal plane and then in the parasagittal plane. The images were assessed for (i) Bent and Kuhn classification of frontal ethmoidal sinus air cells, (ii) size of frontal sinus ostium (assessed as unsure, normal, small, or large), (iii) use of parasagittal scans regarding additional understanding of the anatomy with particular reference as to how the agger nasi cell and frontal ethmoidal cells were arranged in a three-dimensional space, and (iv) if the parasagittal scan and subsequent three-dimensional picture created altered the surgical approach. The first two criteria were assessed in the coronal plane and then in the parasagittal plane.

There was no statistically significant difference between the Bent and Kuhn classification of frontoethmoidal cells on coronal and reconstructed parasagittal images (t-test; p < 0.05). The parasagittal scans were significantly better than the coronal scans for identifying and assessing the size of the frontal sinus ostium (p > 0.001; chi-square test). Assuming an intraobserver change rate (repeat error) of 10% on CT scan observations, an exact binomial test was performed on S-PLUS, which showed that there was a significant (p < 0.001) proportion of observers who changed their rating after looking at the parasagittal scan. There also was significant improvement in observers’ abilities to identify and classify the size of the frontal ostium as reflected by the number of observers who changed from being unsure on the coronal scans to sure on the parasagittal scans. Observers felt that the parasagittal scans improved their three-dimensional understanding of the anatomy of the frontal recess by 58% on a 10-point Lickert scale. In 55% of these observations, the surgical plan was altered by a mean of 70.2% on a 10-point Lickert scale based on additional information obtained by viewing the parasagittal scans.

The three-dimensional understanding of the frontal recess is improved greatly by using both coronal and parasagittal reconstructed images as compared with coronal images alone. This had important implications on the planning of the surgery in the frontal recess.

Impairment of sinus ostial function is considered an important factor in the pathophysiology of sinus disease. The use of the decongestants such as α2-agonists is thought to improve sinus ostial function. Previous studies have shown an effect of α2-agonists on maxillary sinus ostial function only when administered in nasal bellows, but not as a nasal spray or nasal drops. The effect of decongestants on ventilation of the frontal and posterior ethmoidal and sphenoidal sinuses has not been studied to date.

In this study, the 133-xenon washout method was used to determine ventilation for all paranasal sinuses before and after administration of oxymetazoline as nasal drops in eight subjects and from nasal bellows in nine healthy subjects.

No significant effect of oxymetazoline on sinus ventilation was seen in either group.

The results indicate that α2-agonists do not have any effect on sinus ventilation in healthy subjects. However, one cannot exclude that decongestants improve sinus ventilation in patients suffering from sinus disease and this requires further studies.