American Journal of Rhinology & Allergy

Chronic rhinosinusitis (CRS) and nasal polyposis (NP) are histopathologically characterized by different gross morphological aspects. Transforming growth factor (TGF) β1 plays an important role in tissue remodeling, which is poorly understood in chronic diseases of the sinuses.

The expression of TGF-β1 was analyzed by enzyme-linked immunosorbent assay, quantitative reverse-transcription polymerase chain reaction, and immunohistochemistry in nasal tissue from controls (n = 6), CRS (n = 19), or NP (n = 19).

CRS presented significantly higher concentrations of TGF-β1 at protein (p = 0.0008) and mRNA levels (p = 0.025) when compared with NP samples. In CRS, TGF-β1⁺ staining of the extracellular matrix was found abundantly and related to fibrosis. In contrast, no TGF-β1 staining was found in the pseudocyst areas in NP.

CRS was histologically characterized by fibrosis, which was reflected by a significantly higher expression of TGF-β1 at RNA and protein levels when compared with NP. We show that TGF-β1 expression is related to fibrosis, differentiating CRS without polyps from NP.

The etiology of chronic sinusitis with nasal polyposis (CS/NP) remains enigmatic. Frequently, Staphylococcus aureus is present in the nose of CS/NP patients, although the significance is unclear. Recent reports have suggested the hypothesis that these bacteria may secrete exotoxins triggering the inflammatory mucosal changes seen in CS/NP. This mechanism of immunopathology has been established in other diseases associated with Staphylococcus colonization and exotoxin secretion such as atopic dermatitis. In atopic dermatitis, the exotoxins incite a local superantigen response in which clonal T-cell activation and massive cytokine release occur in the affected skin. Second, these exotoxins can act as traditional allergens, stimulating a typical immunoglobulin E (IgE) response in the serum, which has been correlated with disease severity. This study is designed to begin the assessment of the hypothesis that a similar mechanism takes place in CS/NP.

Serum was drawn from patients with CS/NP undergoing endoscopic sinus surgery as well as 13 atopic and nonatopic control subjects without sinusitis. IgE levels to S. aureus exotoxins A (SEA), SE exotoxins B (SEB), and toxic shock syndrome toxin 1 were measured using enzyme-linked immunosorbent assay. Tissue eosinophilia and the presence of lymphocytes on hemotoxylin and eosin-stained sections of polyps were scored by a blinded pathologist and correlated to presence of toxin IgE in the serum.

Staphylococcal exotoxin (SE)-specific IgE was found in the serum of 5/10 (50%) of the patients with CS/NP. In contrast, 0/13 control patients had IgE to the exotoxins (p = 0.031). Polyp eosinophil, lymphocyte, and mononuclear cell counts were compared in IgE exotoxin-positive and -negative subjects. A trend toward increased eosinophil counts in patients with SE IgE (SE IgE⁺) was present, but not statistically significant.

These results indicate that a high percentage of CS/NP patients show a systemic IgE response to S. aureus exotoxins in comparison with controls without CS/NP. Although these results are consistent with the actions of Staphylococcus toxins in other diseases, additional work is necessary to establish a local superantigen response in the nasal mucosa of CS/NP patients. (American Journal of Rhinology 18, 273–278, 2004)

Frontal sinus obliteration (FSO) traditionally has represented the final stage in the algorithm for difficult to manage frontal sinus disease. In addition, FSO has been used in selected cases of frontal sinus trauma. However, this procedure has been associated with failure in 5–10% of cases. Advances in surgical instrumentation and image-guided surgical navigation have permitted endoscopic management of these failures.

Eleven patients presenting with failure of a previously performed FSO were managed endoscopically with the assistance of image-guided surgical navigation.

Initial frontal sinus pathology included chronic inflammatory disease in six patients and frontal sinus trauma in two patients. Two patients underwent obliteration after neurosurgical frontal craniotomy and one patient underwent obliteration after curettage of a frontal sinus ossifying fibroma. Frontal sinuses were obliterated with fat in eight cases, bone chips in two cases, and bone cement in one case. The mean time interval to FSO failure was 11.1 years (range, 4 months–35 years). The etiology of failure included mucocele in eight patients, chronic frontal sinusitis in two patients, and Pott's puffy tumor in one patient. All 11 patients were managed endoscopically, of which 3 patients underwent a trans-septal frontal sinusotomy. Two patients required revision endoscopic surgery, but all were patent at last follow-up (mean, 14.8 months).

Endoscopic management of failed FSO may be performed safely. These approaches are viable alternatives to open revision procedures in the management of failed FSO. (American Journal of Rhinology 18, 279–284, 2004)

The aim of this study was to present a new technique for frontal sinus template creation used in osteoplastic flap surgery, obviating the need for the traditional 6-ft Caldwell radiograph.

Seventeen human cadaver skulls were studied prospectively. Using digital addition algorithms of sequential coronal computed tomography (CT) images of the frontal sinus to create a composite image, an image is printed to 1 cm = 1 cm scale. A frontal sinus template was created using this processed image and compared with a control 6-ft Caldwell radiograph.

The mean variance between corresponding vertical points on the templates was 0.71 mm (95% confidence interval, 0.56–0.87 mm). The mean variance between horizontal points was 1.11 mm (95% confidence interval, 0.97–1.28 mm). The mean difference in width was 2.46 mm. The plain film templates were always wider than the CT-generated templates.

The CT-generated frontal sinus templates are virtually identical to the Caldwell radiograph-derived templates. They may obviate the need for additional imaging and minimize the potential errors commonly associated with 6-ft Caldwell templates. (American Journal of Rhinology 18, 285–290, 2004)

Benzalkonium chloride (BAC) is added to nasal preparations to prevent microbial contamination. Adverse effects of BAC on human nasal mucosa should be evaluated.

The ciliotoxicity of BAC was assessed in isolated human nasal epithelia from 15 donors. The effects of nasal BAC 0.05% (4 X 200 μL/day for 8 days) on nasal saccharin transport time, inflammatory cells and cytokine levels in nasal secretions, and nasal symptom scores were assessed in a randomized, double-blind crossover trial in 16 healthy volunteers.

In vitro, BAC was ciliotoxic (p < 0.0001). In vivo, BAC did not alter saccharin transport time in healthy individuals (p > 0.8). No BAC-associated proinflammatory effects were observed. The staining index for myeloperoxidase was 4.8% in the placebo period and 6.3% (p = 0.42) in the BAC period. Also, nasal secretion levels of cytokines and the neuropeptide substance P revealed no BAC-associated differences. Concentrations for interleukin (IL)-6 in the placebo period were 41.5 pg/mL (0.9–91.7 pg/mL) and in the BAC period were 17.6 pg/mL (3.2–65.9 pg/mL; p = 0.46), and concentrations for substance P were 119 pg/mL (58–293 pg/mL) and 131 pg/mL (80–330 pg/mL; p = 0.31), respectively. Immediately after application, BAC caused nasal irritation (p = 0.001), a burning sensation (p = 0.0003), and hypersecretion (p = 0.006). Moreover, BAC caused a persistent sensation of nasal irritation (p < 0.01).

BAC in concentrations used in nasal preparations is ciliotoxic. In healthy individuals, the ciliotoxic effect of BAC is neutralized, probably by components of nasal secretions. No BAC-related proinflammatory effects have been observed. At higher doses than normally used therapeutically, BAC caused significant nasal irritation. (American Journal of Rhinology 18, 291–299, 2004)

Scoring systems exist to standardize the recording of nasal endoscopy findings. The extent to which two surgeons will agree on the findings of nasal endoscopy in adults currently is unknown, although a study in children showed high rates of agreement between two observers. We studied the interobserver agreement of adult nasal endoscopy scored with the system proposed by Lund and Mackay. Method: A consecutive series of otolaryngology patients attending with a variety of nasal complaints were recruited. All were examined with a 0^o 4-mm endoscope by two surgeons on the same clinic visit. Each independently recorded their findings using the Lund and Mackay scoring system. Neither surgeon was aware of the other's findings.

Thirty patients were studied (16 women and 14 men). Because the endoscopic findings were recorded separately for each side of the nose, each surgeon made 60 observations. Interrater agreement was calculated as Cohen's κ, and suggested moderate agreement for edema (κ = 0.45), good agreement for crusting (κ = 0.62), and very good agreement for polyp (κ = 0.93) and discharge (κ = 0.84).

Two independent observers agree on the findings of nasal endoscopy in a high proportion of cases. Nasal endoscopy is a reliable tool, especially when a scoring system such as that of Lund and Mackay is used. (American Journal of Rhinology 18, 301–303, 2004)

Computed tomography and magnetic resonance imaging (MRI) are the techniques of choice for pretreatment staging in neoplasms of the sinonasal tract. In inverted papilloma (IP), the information provided by computed tomography regarding characterization of the lesion is rather nonspecific. The present retrospective study was performed in the attempt to identify distinguishing features of IP on MRI.

MRI examinations of 23 patients affected by IP (16 primary and 7 recurrent) and 23 patients affected by malignant tumors (MT; 12 adenocarcinomas, 9 squamous cell carcinomas, and 2 neuroendocrine carcinomas) of the sinonasal tract were evaluated. IP arose from the lateral nasal wall in 17 cases, the maxillary sinus in 5 cases, and the nasal septum in 1 case. The signal intensity of IP and MT was compared with muscles on spin-echo (SE) T2 and SE T1 images; contrast enhancement was compared with nasal septum mucosa. Possible specific MRI patterns in the two groups of patients were investigated. Bone involvement was graduated as remodeling or erosion (focal, ≤15 mm; intermediate, >15 mm and ≤30 mm; extended, >30 mm). The size of the lesions was assessed by measuring the greatest diameter on MRI. Parametric statistics in the form of Student's t-test or chi-squared test was used for data comparison.

IP showed a columnar pattern in all 23 cases by enhanced SE T1 images and in 16 of 23 lesions (>20 mm in diameter) by SE T2. This pattern was observed in only 1 of the 23 MTs; pathological examination of that specimen showed multiple foci of IP associated with squamous cell carcinoma. Bone remodeling was observed in 19 of 23 IPs, which in four patients was associated with focal (two cases) or intermediate (two cases) erosion. In MT, remodeling was present, which was always combined with focal (2 cases) or extended (21 cases) erosion. A strong correlation was found between the pattern of bone changes and histology (p = 0.00001). Bone alterations did not correlate with the size of the IP. The mean size of the IPs was significantly less than that of MT (33.9 ± 15.7 mm versus 59 ± 16 mm; p = 0.0003).

A columnar pattern is a reliable MRI indicator of IP and reflects its histological architecture (positive predictive value of 95.8%). The combination of this finding with the absence of extended bone erosion allows for the confident discrimination of IPs from MTs. (American Journal of Rhinology 18, 305–310, 2004)

Synechia and stenosis formation after endoscopic sinus surgery (ESS) represents a potential source of surgical failure. Mitomycin C (MMC) has been used successfully in other fields to decrease postoperative scar formation. We hypothesize that the topical application of MMC reduces the incidence of stenosis and synechia formation after ESS.

This study is a randomized, controlled, single-blinded study based in a tertiary care teaching hospital. After routine ESS, a pledget soaked in MMC (0.5%) was randomly placed into the middle meatus of one nasal cavity for 5 minutes and a pledget soaked in saline was placed in the contralateral side in each patient. A blinded observer followed the patients for any evidence of stenosis or synechia formation. The medical records of enrolled patients were reviewed for demographics, diagnosis, prior surgery, type of sinus surgery, complications, incidence of stenosis/synechia, and need for further procedures.

Twenty-nine patients were included in the final analysis. The mean follow-up period was 15 months (range, 3–32 months). There were no complications in this series. Eight patients experienced 10 episodes of synechia formation and one patient experienced 1 episode of synechia formation and 1 episode of stenosis of the maxillary sinus ostium. Seven of the 12 episodes of synechia/stenosis occurred on the side of the MMC application and the remaining 5 episodes occurred on the side opposite to the MMC application. This difference was not statistically significant.

The topical application of MMC did not decrease the incidence of stenosis and synechia formation after ESS. (American Journal of Rhinology 18, 311–314, 2004)

More than 600 million units of nasal decongestants are sold worldwide annually. The cytotoxic and ciliary toxic potential of decongestants, as well as the preservatives of these products, in particular benzalkonium chloride (BKC), is well established. Recently, a beneficial effect of dexpanthenol on the tolerability of the ά-sympathomimetic xylometazoline and BKC has been described; however, it was unclear if this effect, resulting in significantly higher cell counts in a cytotoxicity study and an increase in ciliary beat frequency in a ciliary toxicity study was of protective or therapeutic nature. The objective of this study was (a) to evaluate whether dexpanthenol would be a useful additive to nasal decongestants to counter the cytotoxic and ciliary toxic effects of the active ingredient and the preservative and (b) to find out whether this beneficial effect is of protective or therapeutic nature.

Systematic cytotoxic in vitro tests were performed. After exposure to xylometazoline (0.1%), the effect of dexpanthenol (5%) and BKC (0.01%) was determined by placebo-controlled assessment of cell growth in a human amniotic cell line.

Dexpanthenol significantly reduces the toxic effects of xylometazoline regarding cell growth (p < 0.001) when applied in advance. When BKC is eliminated from the nasal sprays, a further significant increase of cell growth was found (p < 0.001). When dexpanthenol is therapeutically applied after xylometazoline, effects on cell growth are only one-half of those of the protective approach.

The additive application of dexpanthenol (5%) given before nasal decongestants or preserved nasal sprays is able to improve the tolerability of these substances and to counteract the toxic effects. (American Journal of Rhinology 18, 315–320, 2004)

Controversy exists about the optimal management of subperiosteal orbital abscesses (SPOAs) in pediatric patients. Some otolaryngologists advocate immediate surgical drainage while others recommend medical management initially and reserve surgery for nonresponders. We hypothesized that patients who can be managed without surgery have identifiable features on presentation that may aid in predicting their response to medical therapy.

A retrospective chart review was performed on all patients ≤18 years of age who were admitted to the University of Iowa between 1984 and 2001 with findings consistent with an SPOA on computed tomography imaging. Patients were divided into two groups: group I received medical treatment only while group II underwent surgical drainage of the abscess. Presenting features were compared between the two groups.

Forty-two patients were identified with 17 group I patients and 25 group II patients. All patients had resolution of their SPOA and favorable outcomes. The following variables attained significance: group I patients were younger than group II patients (5.1 years versus 11 years; p < 0.0001), had less restriction of ocular motility (—1.0 versus —2.3), and were hospitalized for fewer days (6.5 days versus 9.6 days; p = 0.011). The following clinical variables did not vary significantly between the groups: gender, side of abscess, temperature, total white blood cell count, neutrophil count, chemosis, visual acuity, and proptosis. Culture results predominantly showed growth of anaerobic organisms (7/23). With increasing age, there was an increase in the number of organisms cultured (p = 0.005).

A subset of patients with SPOAs can be managed medically. These patients tend to be younger and present with minimal restriction of ocular motility. (American Journal of Rhinology 18, 321–327, 2004)

As medical costs increase, less expensive alternatives to standard diagnostic tests are sought to reduce the economic burden placed on society. One alternative is using limited, non-consecutive cut computed tomography (CT) scans for the evaluation of sinonasal disease. This study evaluates the cost-effectiveness of using limited CT scans instead of full sequence CT scans in the diagnosis and management of rhinosinusitis.

A Medline search was performed to obtain data for the sensitivity and specificity of limited CT scans, the prevalence of abnormal CT scans, and recommendations on using limited CT scans for operative management. A standard cost-effectiveness analysis, including a sensitivity analysis, was performed using a hypothetical population of patients with sinus complaints who failed prior appropriate medical therapy.

At baseline, the limited CT scan was found to be less cost-effective than the full CT scan, costing $217.13 more per correct diagnosis. The sensitivity analysis demonstrated that changes in the prevalence of abnormal CT scans and the percentage of surgeons who would operate using a limited scan had the greatest impact on cost, whereas changes in the price of the full CT or limited CT scan had the least effect.

This study finds the use of limited CT scans to be economically unsound as a method to reduce costs in the defined population. Published literature recommends obtaining a full CT scan before operative management. Basing intervention on limited CT scans increases the possibility of erroneous diagnoses leading to either excessive or inadequate treatment of patients. (American Journal of Rhinology 18, 329–334, 2004)

The goal of this study was to examine safety and efficacy of transarterial embolization for the treatment of idiopathic posterior epistaxis.

A retrospective chart review was conducted to characterize the underlying conditions of eighty-one consecutive patients for whom complete records were available presenting with posterior epistaxis, the associated risk factors for patients with idiopathic posterior epistaxis, and the success rate of embolization in this patient population.

One hundred consecutive patients undergoing embolization for epistaxis were identified and 81 patients were included in the analysis. Nineteen patients did not have sufficient and retrievable medical records to be included in the study. Idiopathic posterior epistaxis was the most common underlying etiology of patients with refractory posterior epistaxis (34%). Hypertension, vascular disease, and diabetes were frequently detected comorbid diseases. Patients were equally as likely to be hypertensive as normotensive at the time of presentation (45 and 55%, respectively). Most patients (83%) had failed at least one prior treatment modality. Few patients had a recurrence of epistaxis within 72 hours (three patients [12%]) or had an adverse effect associated with embolization (three patients [12%]).

Embolization for the treatment of posterior epistaxis is a safe and effective treatment modality.