American Journal of Rhinology & Allergy

The formation of postoperative adhesions is perhaps the most frequent complication of endoscopic sinus surgery: These incidents may vary from trivial, small strands of scar to serious obstructive situations that mandate further surgery. This study is a retrospective analysis of 970 endoscopic ethmoidectomies performed in 535 patients over a 5-year period and followed by a single surgeon. Postoperative follow-up ranged from 6 to 70 months. The overall incidence of postoperative adhesions of all types was 10.5% and involving 102 cases. Of these, 40 cases (4.1%) of the total required subsequent revision surgery due to obstructive scarring. Further analysis is presented, showing the effects of various surgical techniques on the development of adhesions. The incidence of postsurgical lateral adhesion of the middle turbinate was reduced in this series in procedures that incorporated partial middle turbinate resection.

The “Hummer” microdebrider is a powered rotary shaving device with continuous suction. Its use in functional endoscopic sinus (FES) surgery allows precise and delicate removal of diseased tissue. Traditional FES instruments frequently cause trauma to non-diseased mucosa or inadvertently strip mucous membranes, both of which are counter to the functional concepts. The “Hummer” facilitates preservation of mucosa and vital structures, such as the middle turbinate, by resecting diseased, obstructive tissue with very limited blood loss. Simultaneous continuous suction at the operative site is a marked benefit of this instrument, which helps overcome the well-recognized problem of blood pooling that increases the potential for operative morbidity. Polypectomies are performed in a more precise manner with very little blood loss so that visibility is usually unimpaired, even in patients with cystic fibrosis. The instrument is applicable to most FES cases and is the authors’ preferred technique, even for small pediatric patients. Accelerated healing and reduced synechiae were observed in these patients.

Traditionally sinusitis has been classified as acute or chronic based on the duration of patient symptoms, and treatment has been based on empiric principles, as the bacteriologic spectrum is felt to be understood, and culturing of nasal secretions has been frowned upon in the past. In this investigation, endoscopically guided cultures were obtained and analyzed from patients, with chronic sinusitis referred to a rhinologic surgeon for evaluation. Often sinusitis was “recalcitrant” to Standard medical and/or surgical therapy. Ninety-eight cultures were obtained from 47 patients with chronic sinusitis who had pathologic sinus secretions noted during the study period. Gram negative enteric bacteria were noted in 47/134 (34.1%) total isolates, a particularly high frequency. Organisms isolated included Pseudomonas aeruginosa, Klebsiella pneumonia, Proteus mirabilis, and Enterobacter aerogenes. The results are significant as gram negative bacteria have been previously reported only infrequently as a cause of sinusitis. Data from this study suggest that endoscopically guided cultures may be helpful in directing medical therapy, especially in longstanding cases of chronic sinusitis that has been “recalcitrant” to traditional medical and surgical therapy. In these patients a shift in the bacterial spectrum to include gram negative organisms, not typically associated with sinusitis, may occur. Empiric selection of standard antimicrobial therapy for chronic sinusitis may not address these bacteria. Classifying sinus disease solely on symptom duration is an oversimplification, and the bacterial spectrum of sinusitis may not be as limited as previous studies suggest. Possible pathophysiologic mechanisms for the shift in the bacterial spectrum and poor response to treatment are discussed.

This is one of the first human studies of maxillary sinus mucociliary activity using human serum albumin labelled with 99m-technetium (^99mTc-HSA) as a tracer in patients suffering from recurrent or chronic maxillary sinusitis. The tracer was injected into both maxillary sinuses through small sinus irrigation catheters. Nasal endoscopy and computed tomography were performed in all patients shortly before the injection. The clearance rates of four case report patients with different endoscopic and radiographic findings showed great individual variation. The technique proved to have viability for clinical use when evaluating sinusitis treatment options and results.

The success of outcomes research for sinus disease will depend in part on the utilization of a computed tomography (CT) staging system that meets rigorous statistical criteria. Such a staging system must demonstrate an even distribution of population by scale, a high inter-rater and intra-rater agreement, and a low percentage of unclassifiable scans. Four proposed sinus CT classification systems were evaluated for these parameters. Each system was used by four masked raters to rate 42 consecutive preoperative CT scans on two separate occasions. One of these systems is based on the site of disease rather than the degree of sinus opacification and gives a clear definition of sinus disease (2 mm or greater of mucosal thickening). This system had the highest inter-rater agreement (κ = 0.61, range = 0.38 to 0.61) and the lowest percentage of unclassifiable scans (0.6%, range = 0.6 to 14.2%). The statistical attributes of this particular sinus CT staging system support its use for outcomes research in sinus disease.

Acoustic reflections have been used in adult humans to determine nasal cavity dimensions in terms of cross-sectional areas as a function of the distance from the nostril (J. Appl. Physiol., 66:295–303, 1989). In order to measure nasal cavity dimensions in guinea pigs, we modified equipment for use in humans by decreasing sound tube dimensions, increasing sampling frequency, and applying a special nosepiece. We measured 5 guinea pigs (Duncan Hartley strain, 500 g) on two days, before and after instillation of epinephrine and histamine in one nostril. In the control measurements, the minimum cross-sectional area of a nasal cavity was 1.1 mm² (SD = 0.3 mm²), and the volume from the nostril to 20 mm into the nasal cavity was 60 mm³ (SD = 19 mm³). There was a tendency (P < 0.10) for epinephrine to increase minimum cross-sectional area on the treated side and volumes on both sides. Histamine decreased volume on both sides (P < 0.05), but not uniformly between animals. Measurements in a tube with 2 mm internal diameter (area 3.1 mm²) underestimated true area by approximately 30%. The method, therefore, at its present state of development, measures changes in dimensions rather than absolute values. It is concluded that the acoustic reflections technique may be a useful alternative to other, more invasive methods to assess nasal cavity dimensions in guinea pigs, but further studies are necessary to improve and validate the method.

The present study was undertaken to determine whether a modification to commercially available acoustic rhinometry (AR) instrumentation might allow equipment designed for use in adults to accurately determine the nasal cavity configuration of infants and children. The standard wave tube was replaced with a version having a narrow (0.312 cm²) internal diameter. After calibration, this device was used to generate nasal area curves for the nasal cavity of a full term infant cadaver. Direct volume measurements and area measurements of polyvinylsiloxane nasal casts of the same specimen were used to evaluate the accuracy of the acoustic method. AR correlated well with nasal cast data (r = 0.88) for total nasal cavity area. The acoustic method underestimated the total area at the nasal valve by only 1.8 mm² (22.1 mm² vs. 23.9 mm²) and overestimated choanal area by 10 mm² (56.9 mm² vs 46.9 mm²) compared to data derived from polyvinylsiloxane nasal casts. In addition, AR measured total nasal volume to within 5.2% percent of the value obtained by direct measurement. This is the first report that AR can produce useful nasal area information in infants, and it suggests that the device has utility both in airway research and as a nasal patency screening tool in the pediatric population.

The increasing popularity of fiberoptic endonasal sinus surgery has led some to state that a Caldwell-Luc procedure should be performed only to manage tumors involving the maxillary sinus and epistaxis, a procedure that requires exposure of the pterygopalatine fossa for vessel ligation. However, a modern version of the Caldwell-Luc procedure should be considered in instances where failure of endoscopically-controlled endonasal sinus surgery (coupled with appropriate medical management) occurs because of the presence of severely or diffusely diseased or damaged mucosa. This approach is also suggested for suspected fungal sinusitis extensively involving the antrum, for all reoperations for isolated antral disease in which the ostiomeatal complex and ethmoids are clear, and for closure of oro-antral fistulas associated with marked inferior antral mucosal disease.

Granulocytic sarcoma (GS) is a solid form of leukemia. It may occur before, simultaneous with, or after the onset of systemic leukemia. More than 400 cases of GS are reported in the literature. However, only six cases involve the nasal cavity, none of which take origin from the nasal septum. In this paper, we report the first case of granulocytic sarcoma to occur on the nasal septum in a patient with chronic myelomonocytic leukemia. In addition, we review the currently accepted modalities for the diagnosis and treatment of these tumors.

Azelastine, a phthalazinone derivative, is a chemically novel antiallergy compound that inhibits inflammatory responses in the upper and lower airway. Previous clinical trials demonstrated the effectiveness of azelastine in the treatment of allergic rhinitis. The objective of this double-blind trial was to further evaluate the efficacy and safety of oral azelastine compared with placebo in patients with perennial allergic rhinitis. A total of 192 patients (between 13 and 60 years of age) who satisfied a minimum symptom score during a single-blind placebo evaluation period were randomized to receive one of three treatments: 2 mg of azelastine b.i.d., 1.34 mg of clemastine fumarate b.i.d., or placebo b.i.d. for a 4-week double-blind treatment period. In the primary efficacy analysis, rhinitis symptoms were analyzed as a Total Symptom Complex severity score (nose blows, runny nose, sneezes, stuffy nose, itchy nose, and itchy eyes/ears/throat). After 2 and 4 weeks of therapy, the azelastine group had greater mean percent improvements than the placebo group in the Total Symptom Complex severity scores. The overall and endpoint improvements for the azelastine group were statistically significant (P ≤ .026) versus placebo. Improvements in individual rhinitis symptoms for the azelastine group were superior to placebo for nose blows, runny nose, sneezes, itchy nose, and itchy eyes/ears/throat. Azelastine was well tolerated. Clemastine was also significantly more effective than placebo and was well tolerated. The results support oral azelastine's safety and effectiveness in the treatment of perennial allergic rhinitis.