Effects of functional endoscopic sinus surgery on maxillary sinus mucosa

Schneiderian Membrane Regeneration After Lateral Bony Window Repositioning in Modified Endoscopic-Assisted Maxillary Sinus Surgery: Transmission Electron Microscopy Evaluation

Mandibular reconstruction is one of the most complex procedures concerning the patient’s postoperative facial shape and occlusion condition. In this study, the authors integrated mixed reality, three-dimensional (3D) printing, and robotic-assisted navigation technology to complete the mandibular reconstruction in a novel and more accurate way. Mixed reality can visualize the significant anatomical structures of the operative area, but only be used in simulated operation by now. Three-dimensional printing surgical guide plate makes it easy to separate tissue, while imprecision often occurs due to the potential of displacement and deformation. In recent years, most robotic-assisted navigation surgery technology can only achieve precise position by 2D view on the screen but not realistic 3D navigation. in this study, the integrated 3 technologies were used in mandibular reconstruction. Preoperative imaging examination was performed, and the data were imported into the digital workstation before operation. First, the original data was edited and optimized to reconstruct the digital model and formulate the surgical plan. Then MR was used to output the visualized project and matched the 3D reconstruction model in reality. The 3D plate was printed for surgical guidance. Last, robotic-assisted navigation was used to guide and position the vascularized fibula autograft and the immediate dental implantation. In conclusion, the authors integrated the 3 technologies and constructed a new digital surgical procedure to improve surgical accuracy and simplify the procedure comparing with traditional surgery.

Changes in the Sphenoid Bone Encountered During the Endoscopic Endonasal Transsphenoidal Approach

OBJECTIVES

We estimated volume changes in the posterior bony wall of the sphenoid sinus, as well as alterations in nasal function (including olfactory function and subjective symptoms), after sphenoid mucosal repositioning using the endoscopic endonasal transsphenoidal approach (EETSA).

METHODS

During 2010 and 2021, 13 patients underwent sphenoid mucosal repositioning during EETSA, while 24 patients (the control group) did not. Pre- and postoperative paranasal sinus computed tomography and the Mimics program were used to evaluate three-dimensional changes in the posterior wall of the sphenoid sinus. All patients underwent the Connecticut Chemosensory Clinical Research Center (CCCRC) test, the Cross-Cultural Smell Identification Test (CCSIT), Nasal Obstruction Symptoms Evaluation (NOSE), the Sino-Nasal Outcome Test-20 (SNOT-20), and visual analog scale (VAS) evaluation.

RESULTS

The increase in the volume of the posterior wall of the sphenoid sinus after surgery was objectively smaller in the sphenoid mucosal repositioning group than in the control group (P = .046). However, this did not affect olfactory function (as revealed by the CCCRC test or the CCSIT) or subjective symptoms (as revealed by the NOSE, SNOT-20, and VAS scores) (all P > .05).

CONCLUSION

Surgical closure via sphenoid mucosal repositioning during EETSA reduces the volume of the posterior wall of the sphenoid sinus and facilitates re-operation. We suggest that sphenoid mucosal repositioning is appropriate during EETSA.

LEVEL OF EVIDENCE

4 Laryngoscope, 2022.

Mucociliary Transport Function and Damage of Ciliated Epithelium

The influence of epithelial damage on mucociliary transport was studied in relation to the amount of mucus. The mucosal epithelium of mucus-depleted frog palate was dissected and mounted on a plastic plate. Mechanical damages were created on the frog mucosa by pressing a different thickness of boards (2, 3, 5, and 8 mm). Two different amounts of frog mucus (7.9 L [small amount of mucus {S-mucus}]) and 51.0 L [large amount of mucus {L-mucus}])were applied on the frog mucosa with and without mucosal damage. There was no difference in mucociliary transport rate (MTR) on undamaged frog mucosa between S-mucus and L-mucus. However, on the damaged mucosa, MTR of S-mucus was significantly decreased compared with that of L-mucus. Moreover, capability of mucus transportation across the mucosal damage was significantly lower in S-mucus than in L-mucus. Results indicate that the larger the mucus amount becomes, the more the mucus travels the damaged epithelium. Moreover, MTR of L-mucus was decreased with increasing the degree of epithelial damage. This study indicates that the degree of loss of cilia is an important factor of mucociliary deceleration. (American Journal of Rhinology 16, 215–219, 2002)

Evaluation of Ultrastructural Changes in Paranasal Sinus Mucosa after Functional Endoscopic Sinus Surgery in Patients with Chronic Rhinosinusitis

The purpose of this study was to compare the preoperative and postoperative ultrastructural changes of paranasal sinus mucosa in patients treated with functional endoscopic sinus surgery for chronic rhinosinusitis. Twelve patients undergoing functional endoscopic sinus surgery for the treatment of chronic rhinosinusitis were involved. The ethmoid sinus mucosa was sampled during the operation and ∼6 months after the operation. The ciliated epithelium of sinus mucosa was evaluated with transmission electron microscopy. The samples were taken at the Otolaryngology Department of Istanbul University School of Medicine. Electron microscopic study was performed at the Histology and Embryology Department of the same University. Preoperatively, ciliated epithelial cells of the sinus mucosa of the patients showed degenerated ultrastructure with decreased number of cilia, cytoplasmic protrusions, cisternal dilatations of endoplasmic reticulum, and mitochondrial swellings. Remnants of degenerated cells and cellular separations at cell junctions were evident in the diseased epithelium. Goblet cells were frequent along the epithelial lining. Postoperatively, normal architecture and ultrastructure of the ciliated epithelium was restored. These observations showed that unlike other surgical operations, paranasal sinus mucosa can regenerate and the ciliated epithelium can return to normal after functional endoscopic sinus surgery.

The Healing Effects of Autologous Mucosal Grafts in Experimentally Injured Rabbit Maxillary Sinuses

OBJECTIVES

Healing processes of the nose and paranasal sinuses are quite complex, and poorly understood. In this study, we aimed to compare the effect of mucosal autologous grafts on the degenerated rabbit maxillary sinus mucosa with spontaneous wound healing. It is hypothesized that mucosal grafts will enhance ciliogenesis and improve the morphology of regenerated cilia.

METHODS

Ten female New Zealand rabbits were included in the study. They underwent external maxillary sinus surgery through a transcutaneous approach. A total of 20 maxillary sinuses were randomly divided into 2 groups: 'spontaneous healing group' and 'autologous graft group.' The animals were sacrificed at the 14th day after the surgery. Scanning electron microscope (SEM), and light microscope were used for the evaluation.

RESULTS

Cellular composition of the graft group is better than the spontaneous healing group. The graft group had larger areas covered with ciliary epithelium than the spontaneous healing group, and the mean length of the cilias were also longer. Additionally, there were wider cilia with abnormal morphology areas in the spontaneous healing group.

CONCLUSION

In our opinion, covering of the denuded areas with a graft improves re-epithelization, and may prevent the early complications after sinus surgeries.

Comparison of maxillary sinus specimens removed during Caldwell-Luc procedures and traditional maxillary sinus antrostomies

The cases of 80 patients who underwent Caldwell-Luc surgery for the treatment of chronic rhinosinusitis between 2002 and 2007 at Vanderbilt University Medical Center's Department of Otolaryngology were reviewed. Data on demographics, comorbidities, details of surgery, surgical pathology, and histology were collected. These data were compared with those of 40 patients who underwent standard functional endoscopic sinus surgery in 2007. Statistically significant differences were found in terms of mean patient age, sex, mean number of sinuses surgically addressed, number of prior surgeries, and tissue eosinophil counts. Microscopic examination revealed the presence of "necrotic bone" in 2 Caldwell-Luc specimens, and "necrotic debris" in 2 other Caldwell-Luc specimens. No similar finding was seen in the control group. Caldwell-Luc is a surgery of last resort for patients who fail aggressive interventions for maxillary sinus disease. The mucosal lining of this small group of patients appears to be different from that of patients who respond favorably to functional endoscopic sinus surgery.

Effect of passive smoking on ciliary regeneration of nasal mucosa after functional endoscopic sinus surgery in children

HYPOTHESIS AND BACKGROUND

Passive smoking in the paediatric age group is associated with an increased frequency of a number of childhood respiratory disorders. However, its effect on ciliary regeneration after functional endoscopic sinus surgery for chronic sinusitis has not previously been reported.

MATERIAL AND METHODS

We conducted a prospective, nonrandomised cohort study on 38 paediatric patients with chronic sinusitis. We compared two patient groups--passive smokers and those not subjected to passive smoking--as regards ciliary regeneration after functional endoscopic sinus surgery, using objective methodology.

RESULTS AND CONCLUSION

We found passive smoking to have a negative impact on sinus cilia regeneration following functional endoscopic sinus surgery.

Functional study of nasal mucosa in endoscopic sinus surgery and its correlation to electron microscopy of cilia

The effect of functional endoscopic sinus surgery (FESS) was evaluated in 20 patients with chronic sinusitis. The physiological function of sinus mucosa and its mucociliary transport mechanism was assessed pre and post operatively in patients undergoing FESS by performing Saccharin clearance test. The effect of functional sinus surgery on nasal mucosa was evaluated using scanning electron microscopy and study of the ultrastructure of cilia in pre and post operative patients and correlation with histopathological examination. The mucociliary transport mechanism of the sinus mucosa improved 6 weeks following surgery. Histopathologically there was evidence of improvement in the ciliary population and decrease in inflammation, ulceration, fibrosis, vascular congestion, edema, squamous cell metaplasia, basement membrane thickening and polyp formation in comparison to the diseased mucosa sampled preoperatively. Scanning electron microscopic examination revealed considerable increase in the ciliary area as well as the orientation of cilia. Subjective improvement 6 weeks following surgery was confirmed by decrease in saccharin test time. This study revealed that FESS is an effective surgical procedure in chronic sinusitis and improves the overall function of the sinuses.

Histological evaluation of maxillary sinus mucosa after functional endoscopic sinus surgery

BACKGROUND

This study was performed to evaluate the histological changes of the maxillary sinus mucosa of patients with chronic rhinosinusitis (CRS) after functional endoscopic sinus surgery (FESS).

METHODS

In a cohort study, biopsy specimens were collected from the maxillary sinus of patients submitted for FESS. One year after surgery, patients were clinically reassessed. Patients showing recurrence of disease (group 1) required a revision surgery, through which a second biopsy specimen was collected. Patients showing a favorable clinical response (group 2) were submitted to an outpatient maxillary biopsy through the previous opened middle meatus antrostomy. Biopsy material from four cadavers was used as control. The histological and electron microscope findings were analyzed.

RESULTS

At the initial surgery, patients presented many histopathological alterations, such as an inflammatory process infiltrating the submucosa, atypical respiratory epithelium with an important increase in goblet cells, metaplasia, or mixed epithelium. Group 1 patients persisted with the same alterations 1 year later, but ciliary dysmorphy was more accentuated. Group 2 patients presented a predominantly pseudostratified epithelium, but some areas contained an increased number of goblet cells and a reduction in the number of ciliated cells.

CONCLUSION

Recovery of the maxillary sinus mucosa of patients with CRS, observed by electron and light microscopy, was incomplete 1 year after endoscopic surgery, even in nonsymptomatic patients; nevertheless, these alterations were more important in symptomatic patients than in asymptomatic patients.

Quantitative analysis of uvular muscles in cases of simple snoring and obstructive sleep apnea: an image analysis study

Studies on the histopathological changes of the palatine muscles in cases of obstructive sleep apnea (OSA) and simple snoring are controversial, while some authors confirm the presence of muscle hypertrophy and increase in total muscle bulk (obstructive theory), others deny this confirming the presence of muscle atrophy and decrease in the muscle bulk (neurogenic theory), but all these studies depended on subjective observer dependent methods to calculate the muscle bulk. We are carrying a unique study to calculate the muscle bulk in uvular specimens in ten cases of OSA comparing it to ten cases with simple snoring and controls using digital computer dependent software (image analysis). Cases of OSA are associated with definite increase in the total muscle bulk of the palatine muscles when compared to cases of simple snoring and controls. Uvular muscular hypertrophy and the obstructive theory seem to explain the pathophysiology of OSA.

Inflammatory mechanisms and remodeling in chronic rhinosinusitis and nasal polyps

Chronic rhinosinusitis (CRS) is presently classified into two subgroups: CRS without and CRS with nasal polyps. A variety of inflammatory mediators, including cytokines and chemokines, as well as adhesion molecules and matrix metalloproteinases, are upregulated in both subgroups of CRS; remodeling is also observed in both. However, there are also characteristic differences. Whereas CRS without nasal polyps has more neutrophilic infiltration, in CRS with nasal polyps (especially when associated with allergy/asthma) eosinophil infiltration is strikingly increased. Although several features of remodeling (eg, squamous metaplasia, basement membrane thickening, collagen deposition, hyperplasia of mucous glands, and goblet cells) are features seen in both subgroups of CRS, epithelial shedding as observed in asthma is not seen in either subgroup. Furthermore, pseudocyst formation seen in CRS with nasal polyps is not seen in CRS without nasal polyps.

Endoscopic radical antrectomy: a permanent replacement for the Caldwell-Luc operation

INTRODUCTION

Chronic inflammation of sinus mucosa is a multifactorial condition which sometimes results in irreversible pathological mucosal changes.

AIMS

To evaluate the efficacy of endoscopic radical antrectomy in treating chronic, hyperplastic, eosinophilic sinusitis, and to compare this procedure with classical endoscopic middle meatal antrostomy.

MATERIALS AND METHODS

A randomised, controlled trial with parallel design was conducted between July 2000 and December 2004, including 119 patients who fulfilled the clinical, radiological and histopathological criteria for chronic, hyperplastic, eosinophilic sinusitis. Patients were randomly allocated to two treatment groups: classical endoscopic middle meatal antrostomy and endoscopic radical antrectomy. The main outcome measures were recorded in each subgroup at the time of the patient's last clinic visit. In each subgroup, these included subjective improvement and evaluation of the endoscopic appearance of the maxillary sinus.

RESULTS

Thirty-two per cent of patients in the endoscopic middle meatal antrostomy group were considered surgical failures, compared with 14.5 per cent of the endoscopic radical antrectomy group. This was statistically significant (p = 0.023). Unhealthy maxillary sinuses were significantly more prevalent in the endoscopic middle meatal antrostomy group (p = 0.029).

CONCLUSIONS

In those patients fulfilling the criteria suggestive of chronic, irreversible sinonasal pathology, primary endoscopic radical antrectomy was significantly better than endoscopic middle meatal antrostomy, based on subjective and objective findings.

Retinoic acid improves ciliogenesis after surgery of the maxillary sinus in rabbits

OBJECTIVES/HYPOTHESIS

Retinoids have been shown to be important cofactors in regulating the differentiation and proliferation of ciliated epithelial cells of the respiratory tract. In particular, retinoic acid has been shown to enhance the regeneration of paranasal sinus mucosa. The objective of this study is to use scanning electron microscopy techniques to evaluate the effect of topical retinoic acid on mucosal wound healing in a rabbit model of maxillary sinus surgery. It is hypothesized that the application of topical retinoic acid will enhance ciliogenesis and improve the morphology of regenerated cilia compared with controls.

STUDY DESIGN

Prospective multi-arm controlled animal trial.

METHODS

Eighteen New Zealand white rabbits underwent surgical opening of the maxillary sinuses through a midline incision. The rabbits were divided among four experimental groups: 1) mucosal stripping alone (stripped control), 2) stripping followed by topical application of an inert aqueous gel, 3) stripping followed by application of 0.01% retinoic acid in aqueous gel, and 4) no mucosal stripping and no topical treatment (nonstripped control). After 14 days, the medial wall of the maxillary sinus was harvested and examined by scanning electron microscopy at x2,000 and x5,000 magnification. The micrographs were then rated by a blinded review panel for ciliary density, orientation, and morphology.

RESULTS

Mean scores for ciliary density, orientation, and morphology were all significantly higher for the retinoic acid treatment group compared with both the inert aqueous gel treatment group and the stripped control group (P=.004-.03 for all comparisons, Student's t test). Mean scores for the retinoic acid treatment group were numerically lower than the nonstripped control group but did not approach statistical significance for any parameter (P=.23-.31).

CONCLUSIONS

In a rabbit model of maxillary sinus surgery, topically delivered retinoic acid enhances ciliogenesis. Qualitative assessment of ciliary density, orientation, and morphology shows improved healing in retinoic acid treated sinuses compared with both untreated control sinuses and aqueous gel treated sinuses.

Mucosal healing and mucociliary transport change after endoscopic sinus surgery in children with chronic maxillary sinusitis

OBJECTIVES

The aim of the study was to evaluate the effects of endoscopic sinus surgery for chronic maxillary sinusitis in children by investigating ultrastructure element changes in the sinus mucosa and nasal mucociliary clearance before and after operation.

METHODS

Twenty-five children with chronic maxillary sinusitis scheduled to undergo functional endoscopic sinus surgery and another five controls were enrolled. A saccharin transit test was performed before and after the operation for each subject. Forty specimens of diseased maxillary sinus mucosa were classified into edematous and polypoid types, with 20 specimens in each type. The mucosal specimens were taken from the superolateral wall of each maxillary sinus during surgery and at post-operative follow-up when the mucosal recovery had begun and the symptoms had subsided. The specimens were examined with a scanning electron microscope.

RESULTS

A significant increase in number of the submucosal gland openings (GO) was noted for the sinusitis group, of both edematous and polypoid types. In post-operative cases, the number of gland openings decreased, however, it remained higher than for the control group. The number of goblet cells (GC) decreased in the sinusitis cases, and significant difference was not demonstrated compared to postoperative and control groups. After endoscopic sinus surgery, the cilia in both types of antral mucosa were significantly regenerated compared to preoperative variants. Significant differences in postoperative saccharin transit time were demonstrated for both types of antral mucosa compared to the preoperative values.

CONCLUSION

After endoscopic sinus surgery for chronic pediatric sinusitis, the antral mucosa recovered and mucociliary clearance improved for both types of antral mucosa, with improved ventilation and drainage demonstrated for our patients. Based on our specimens, the edematous mucosa appear to regenerate sooner than the polypoid variant, with close post-operative follow-up for more than 2 and 4 months for the edematous and polypoid types of antral mucosa, respectively, necessary to prevent sinusitis relapse.

Clinical implications of the immunomodulatory effects of macrolides on sinusitis

This article reviews the treatment of chronic sinusitis with macrolides. Chronic sinusitis is often the result of bacterial infections that lead to chronic inflammation with thickening of the sinus mucosa and hypersecretion of mucus. In addition to their anti-infective properties, some macrolides possess immunomodulatory effects. These macrolides have been used successfully to treat diffuse panbronchiolitis, a progressive inflammatory lung disease, and may be useful for treatment of asthma, chronic bronchitis, chronic sinusitis, cystic fibrosis, and bronchiectasis. The clinical benefits of macrolides in patients with chronic sinusitis include decreased nasal secretions and postnasal drip, with improvement in nasal obstruction. In vivo and in vitro studies show that some macrolides affect neutrophil chemotaxis and infiltration, inflammatory cytokine production, mucus production, and the transportability of airway secretions. These findings indicate that macrolides are promising agents for treating chronic inflammation of the airways.

Estudo histológico e ultra-estrutural da mucosa do seio maxilar em pacientes com rinossinusite crônica e polipose nasossinusal

Na rinossinusite crônica, a inflamação da mucosa nasossinusal provoca alterações qualitativas e quantitativas do epitélio respiratório que recobre toda a cavidade nasossinusal, levando à manutenção do quadro inflamatório. FORMA DE ESTUDO: Caso-controle. MATERIAL E MÉTODO: Foram avaliados histopatologicamente dez pacientes com rinossinusite crônica (RC) e polipose nasossinusal (PN) por meio da história clínica e alérgica, estudo microbiológico, microscopia óptica, eletrônica de transmissão e varredura. RESULTADO: A diminuição do número de células colunares ciliadas, o aumento das células caliciformes, a diminuição do número de cílios por célula afetada e a metaplasia escamosa foram alterações freqüentemente encontradas nos casos de rinossinusite, explicando a persistência do quadro pela destruição no epitélio e quebra do sistema mucociliar.

Maxillary sinusitis as an indicator of respiratory health in past populations

Chronic infectious respiratory disease in a past human population is investigated through the quantification of maxillary sinusitis among Iroquoian horticulturists. Three hundred forty-eight right and left maxillae of a Southern Ontario Iroquoian skeletal sample, Uxbridge Ossuary, ca. AD 1440, were examined for evidence of chronic infection (minimum number of individuals = 207: 114 adults, 22 adolescents, 38 juveniles and 33 infants). Modern clinical criteria were applied to differentiate lesions of respiratory and dental origin. Osseous lesions of the maxillary sinuses were observed in 50% of the individuals examined. These lesions are morphologically consistent with nonspecific lesions observed in other past populations that have been attributed to the presence of pathogens. The prevalence of maxillary sinusitis increases with age. Osseous changes suggestive of maxillary sinusitis of respiratory origin are at a maximum prevalence in juveniles and adolescents. In adults, infection of dental origin becomes a confounding factor in the identification of sinusitis of respiratory origin. Fifteenth century Iroquoians were experiencing high airborne pathogen levels and poor indoor air quality. The prevalence of maxillary sinusitis and the exploration of the origin of tissue injury may contribute to our reconstruction of the quality of life and the respiratory health status of past human populations.