Clinical implications of serum galactomannan measurement in patients with acute invasive fungal rhinosinusitis

BACKGROUND

Acute invasive fungal rhinosinusitis (AIFR) is an aggressive opportunistic infection with a high mortality rate. Recently, non-invasive techniques have been introduced for diagnosis of invasive fungal disease. The purpose of this study is to evaluate the diagnostic significance of serum galactomannan measurement in patients with AIFR.

METHODOLOGY

We conducted a retrospective case-control study of 28 patients with AIFR and 36 fungus ball (FB) patients. We evaluated clinical, laboratory, and pathologic findings along with disease course.

RESULTS

In 28 patients with AIFR, there were 21 cases of invasive aspergillosis (IA) and 7 cases of invasive mucormycosis (IM). The control group was comprised of 36 patients with FB. The three-group analysis showed a statistically significant difference among the groups. At the cut-off value of 0.48, the sensitivity and specificity were 71.4% and 93.0%, respectively. Comparison of mean serum galactomannan levels in 5 non-survivors and 9 survivors at initial measurement showed no significant difference, but that became significantly different 1 week later. Statistical analysis showed that the levels of serum galactomannan decreased significantly according to the measurement-point in within survivor-group analysis. The difference in between survivor-groups analysis was also significant.

CONCLUSION

Serum galactomannan measurement seems useful for early diagnosis and discrimination of fungal species in patients with AIFR. In addition, clinical outcomes may be related to the levels and patterns of serum galactomannan, especially in IA. The appropriate measurement of galactomannan might be helpful in treating the patients at high risk for AIFR.

Clinical implications of serum galactomannan measurement in patients with acute invasive fungal rhinosinusitis

BACKGROUND

Acute invasive fungal rhinosinusitis (AIFR) is an aggressive opportunistic infection with a high mortality rate. Recently, non-invasive techniques have been introduced for diagnosis of invasive fungal disease. The purpose of this study is to evaluate the diagnostic significance of serum galactomannan measurement in patients with AIFR.

METHODOLOGY

We conducted a retrospective case-control study of 28 patients with AIFR and 36 fungus ball (FB) patients. We evaluated clinical, laboratory, and pathologic findings along with disease course.

RESULTS

In 28 patients with AIFR, there were 21 cases of invasive aspergillosis (IA) and 7 cases of invasive mucormycosis (IM). The control group was comprised of 36 patients with FB. The three-group analysis showed a statistically significant difference among the groups. At the cut-off value of 0.48, the sensitivity and specificity were 71.4% and 93.0%, respectively. Comparison of mean serum galactomannan levels in 5 non-survivors and 9 survivors at initial measurement showed no significant difference, but that became significantly different 1 week later. Statistical analysis showed that the levels of serum galactomannan decreased significantly according to the measurement-point in within survivor-group analysis. The difference in between survivor-groups analysis was also significant.

CONCLUSION

Serum galactomannan measurement seems useful for early diagnosis and discrimination of fungal species in patients with AIFR. In addition, clinical outcomes may be related to the levels and patterns of serum galactomannan, especially in IA. The appropriate measurement of galactomannan might be helpful in treating the patients at high risk for AIFR.

Extraocular muscle injury during endoscopic sinus surgery: a series of 10 cases at a single center

BACKGROUND

Extraocular muscle (EOM) injury is a rare but serious complication of endoscopic sinus surgery (ESS). The aim of this study is to describe the clinical characteristics and course of EOM injury occurring during ESS.

DESIGN

Retrospective case series.

METHODS

Medical records and CT images of patients who suffered from EOM injury after ESS between 2006 and 2012 were retrospectively reviewed. Patient demographics, endoscopic anatomy, type of surgery (primary or revision), predisposing risk factors, site and extent of injury on CT imaging, and associated complications were evaluated. In addition, data regarding ophthalmologic management and clinical outcomes were collected.

RESULTS

Ten patients with EOM injuries after ESS were included in this study. One patient was undergoing revision ESS. All patients sustained medial rectus muscle injury and one patient suffered concurrent ipsilateral inferior rectus muscle injury. A microdebrider was used in nine cases. Right-sided injury (90% of patients) was more prevalent than left-sided injury, and 70% of injured medial rectus muscles were completely transected. After subsequent strabismus surgery, 8/9 patients regained binocular single vision in primary gaze despite residual diplopia in some gaze positions.

CONCLUSION

Although proper ophthalmologic surgery after EOM injury may improve deviation in the primary gaze position, none of the patients regained normal EOM movement. Therefore, prevention of this complication through adequate surgical technique and precautions is important.

Evaluation of inferior turbinate outfracture outcomes using computed tomography

BACKGROUND

Outfracture of the inferior turbinate (IT) presents numerous advantages, but it is generally believed that the lateralized IT will resume its original position. The purpose of this study was to evaluate the outcome of IT outfracture objectively using computed tomography (CT).

METHODOLOGY

Fifteen patients who underwent bilateral IT outfracture for the removal of pituitary adenomas by the endonasal approach were enrolled. The angles between the lateral wall of the nasal cavity (NC) and IT on both sides were measured from CT scans before and at least 6 months after operation. In addition, we evaluated the effects of variables including age, thickness of IT attachment site and width of the nasal floor, on the angles.

RESULTS

Regardless of the side where a Hardy retractor was placed, the angle between the lateral wall of the NC and IT decreased significantly within 6 months after the outfracture compared to preoperative values on both sides. Other variables showed no significant correlations with the angle between the IT and the lateral wall of the NC.

CONCLUSION

The outfracture procedure effectively lateralized the IT and it maintained that position for at least 6 months after the operation.

Predictive capabilities of serum eosinophil cationic protein, percentage of eosinophils and total immunoglobulin E in allergic rhinitis without bronchial asthma

This study identified cut-off values for allergy markers for use in the diagnosis of allergic rhinitis in the absence of other allergic diseases. Total immunoglobulin E (IgE), eosinophil cationic protein (ECP) and the numbers of eosinophils were measured in serum samples from 442 patients with typical symptoms of allergic rhinitis. A definite diagnosis was made on the basis of the presence of specific IgE levels. Cut-off values with a maximal discrimination to diagnose allergic rhinitis were found to be 98.7 IU/ml, 24.7 μg/ml and 4.0% for total IgE, ECP and eosinophils, respectively. Sensitivity, specificity and odds ratio for these values were 75.2%, 69.7% and 6.93, respectively, for total IgE, 55.7%, 74.4% and 3.70 for ECP, and 57.5%, 72.0% and 3.47 for eosinophils. A composite score representing positive results for all three markers had a positive predictive value of 85.3%, with an odds ratio of 8.55. It was concluded that total serum IgE, ECP and eosinophil percentage are strong predictors of allergic rhinitis and the determination of cut-off values for these markers can aid in the diagnosis of allergic rhinitis in the clinical setting.

Sinonasal inverted papilloma: value of convoluted cerebriform pattern on MR imaging

BACKGROUND AND PURPOSE

A convoluted cerebriform pattern (CCP) has been reported as a valuable MR imaging feature of inverted papilloma (IP). The purpose of this study was to validate the usefulness of CCP for distinguishing IP from various malignant sinonasal tumors in a relatively large number of patients.

MATERIALS AND METHODS

We retrospectively reviewed MR images of 30 patients with IP and 128 patients with various malignant sinonasal tumors proved on histologic examination and compared the prevalence of a CCP between the 2 groups. In 8 patients with IP concomitant with squamous cell carcinoma, we also tried to find the MR features to help suggest coexistent malignancy.

RESULTS

A CCP was demonstrated in all 30 (100%) of the IPs and 17 (13%) of the 128 malignant sinonasal tumors on MR imaging. There was a significant statistical difference in the prevalence of a CCP between IP and malignant sinonasal tumors with the overall sensitivity, specificity, positive predictive value, negative predictive value, and accuracy 100%, 87%, 64%, 100%, and 89%, respectively. Of 8 IPs concomitant with squamous cell carcinoma, a focal loss of a CCP was demonstrated in 4 tumors, 3 of which also showed aggressive bone destruction with extrasinonasal extension on MR images.

CONCLUSION

Although a CCP is a reliable MR imaging feature of sinonasal IPs, it can also be seen in various malignant sinonasal tumors. A focal loss of a CCP might be a clue to the diagnosis of IPs concomitant with malignancy.

Sinonasal organized hematoma: CT and MR imaging findings

BACKGROUND AND PURPOSE

Sinonasal organized hematoma (OH) is an uncommon, nonneoplastic benign condition that can be locally aggressive. The purpose of this work was to characterize the CT and MR imaging findings of sinonasal OH.

MATERIALS AND METHODS

CT (n = 11) and MR (n = 10) images of 12 patients (9 men and 3 women; mean age, 41 years; range, 12-76 years) with pathologically proved sinonasal OH were retrospectively reviewed. Particular attention was put on the location, shape, size, extent, internal architecture, and enhancement pattern of the lesion and associated sinus wall change.

RESULTS

The lesions were seen as an expansile (n = 9) or nonexpansile (n = 3) mass, ranging in size from 2.2 to 6.0 cm (mean, 4.2 cm), primarily involving the maxillary sinus (n = 11) or nasal cavity (n = 1) unilaterally. The ipsilateral nasal cavity was also involved in 9 of 11 maxillary sinus lesions. Smooth sinus wall erosion other than the medial maxillary sinus wall was noted in 8 lesions. The internal architecture was best displayed on T2-weighted MR images on which all of the lesions were seen as a mixture of marked heterogeneous hypointensity and isointensity, surrounded by a hypointense peripheral rim, reflecting histologic heterogeneity of the lesion composed of hemorrhage, fibrosis, and neovascularization. Marked irregular nodular, papillary, or frondlike enhancement at the areas of neovascularization was also a typical finding seen in all of the lesions.

CONCLUSION

An expansile soft tissue mass, smooth sinus wall erosion, marked heterogeneous signal intensity with a hypointense peripheral rim on T2-weighted MR images, and marked irregular nodular, papillary, or frondlike enhancement are characteristic CT and MR imaging findings of sinonasal OH.

Comparison of surgical conditions during propofol or sevoflurane anaesthesia for endoscopic sinus surgery

BACKGROUND

Endoscopic sinus surgery (ESS) is often affected by intra-nasal bleeding, which can be influenced by various anaesthetics and preoperative conditions. This study compared the surgical condition and the amount of intra-nasal bleeding between patients given sevoflurane/remifentanil (SR) and propofol/remifentanil (PR) anaesthesia.

METHODS

ASA I or II patients undergoing ESS were randomly assigned to group SR (n=20) or group PR (n=20). The extent of the preoperative surgical lesion was classified as high (> 12) and low Lund-Mackay (LM) (< or = 12) scores according to the computed tomography findings. The amount of intraoperative blood loss was calculated from the patients' haemoglobin (Hb) and the amount of blood in the suction canister. The surgeons rated the visibility of the surgical field on a numeric rating scale (NRS).

RESULTS

In the high-LM score patients, the median (1st/3rd quartiles) blood loss for the SR and PR groups was 135 (121/222) and 19 (8/71) ml h(-1), respectively (P<0.01), and the mean (SD) of NRS was 5.8 (2.3) and 2.3 (1.0), respectively (P<0.05). However, in patients with low-LM score, both blood loss and NRS scores were not different between groups SR and PR.

CONCLUSIONS

In the high-LM score patients, PR anaesthesia results in less blood loss and a better surgical conditions for ESS than SR anaesthesia.

Focal hyperostosis on CT of sinonasal inverted papilloma as a predictor of tumor origin

BACKGROUND AND PURPOSE

To evaluate the CT characteristics of focal hyperostosis in patients with sinonasal inverted papilloma and to correlate these characteristics with the detection of the origins of tumors.

MATERIALS AND METHODS

Paranasal sinus and nasal cavity CT images of 76 patients were reviewed retrospectively to detect areas within which there was focal hyperostosis. We correlated the sites on the CT scans within which there was focal hyperostosis with the origin of the tumors described in the corresponding patient's medical records. We also evaluated the CT features of focal hyperostosis according to the origin of tumors.

RESULT

Surgical evaluation of 55 lesions with focal hyperostosis in CT images revealed that 49 of these lesions coincided with the actual origin of tumor. The CT-based determination of the locations of the areas of focal hyperostosis corresponded to the actual tumor origin in 89.1% of cases. Especially in cases with focal hyperostosis within the frontal, maxillary, sphenoid, and posterior ethmoid sinuses, areas of focal hyperostosis corresponded to the origin of tumor without exception. In the evaluation of the CT features of focal hyperostosis, 2 patterns of localized bone thickening were noted. Plaquelike bone thickening was seen mainly when focal hyperostosis involved the lateral wall of the nasal cavity. On the other hand, cone-shaped bone thickening was seen only in the walls of the paranasal sinuses or the bony septum.

CONCLUSIONS

A high correlation between the origin of the inverted papilloma and focal hyperostosis on CT might facilitate preoperative prediction of tumor origin by radiologists and rhinologists.

Rhinosinusitis in transplant patients

The control of perioperative infection has become more important to increase the success rate of organ transplantation. Thorough examination for occult infection prior to transplantation, careful postoperative monitoring and prompt treatment of infections are required. We reviewed the medical records of 278 patients who received organ transplantation over 4 years and analysed the clinical course of rhinosinusitis during the pre- and post-transplantation period. Thirty-two (11.5%) patients had rhinosinusitis. Nineteen were detected during preoperative examination and 13 were postoperative. Sinus surgery was performed in nine patients before organ transplantation. Ten out of 13 patients who had rhinosinusitis detected after transplantation required sinus surgery and three patients had invasive fungal infections. In the immunocompromised host, the clinical presentation of rhinosinusitis may be subtle, but the subsequent clinical course may be fulminant or even fatal. If the transplant recipient has unexplained fever or any nasal symptom, thorough evaluation with a high index of suspicion and prompt management are required.

Computed tomography anatomy of the anterior ethmoid canal

The roof of the anterior ethmoid swings up anteriorly from its more or less horizontal course at the point where the anterior ethmoid canal (AEC) is situated. The AEC is an important structure in endoscopic sinus surgery since its injury results in bleeding into the nasal cavity and may result in intraorbital bleeding. We therefore investigated the location of this canal and the anatomic characteristics of the area surrounding the canal using coronal computed tomography (CT) of the paranasal sinuses. One hundred sides of 50 paranasal coronal CT images in patients with sinusitis were analyzed to assess the location of the AEC, the shape of the superolateral wall of the ethmoid sinus anterior and posterior to the AEC, and pneumatization of the roof of the anterior ethmoid sinus. The AEC is situated in the second quarter of the roof of the ethmoid sinus. The superolateral wall anterior to the AEC demonstrated an acute angle in 99% of sides, while the superolateral wall posterior to the AEC showed an obtuse angle in 87% of sides. The ethmoid cell anterior to the AEC pneumatized posteriorly over the AEC in 26% of sides. We conclude that coronal CT confirmation of the anatomic characteristics of the AEC, and the area surrounding the canal, is invaluable for preoperative planning for endoscopic sinus surgery.

Effect of endoscopic sinus surgery on asthmatic patients with chronic rhinosinusitis

There have been several reports on the effectiveness of endoscopic sinus surgery (ESS) in asthmatic patients with chronic rhinosinusitis. Whether ESS has a positive effect on the clinical course of asthma still remains controversial. There have been several subjective evaluations but few objective results. We performed a study to evaluate the effectiveness of ESS in 19 patients with asthma who underwent ESS for rhinosinusitis. The use of antiasthma medication and postoperative asthma symptoms was analyzed. Objective changes of pulmonary function tests were evaluated. There was a significant improvement in diurnal and nocturnal asthma symptoms. Improvements in asthma medication scores were also confirmed, and individual asthma symptoms (dyspnea, cough, wheezing, and sputum production) improved significantly. Despite a reduction in use of antiasthma medication after ESS, the parameters of the pulmonary function tests did not change. Both subjectively and objectively, it seems that ESS, when used to treat asthmatic patients with chronic rhinosinusitis, can play a significant role in the clinical improvement of asthma.

Diagnostic accuracy in sinus fungus balls: CT scan and operative findings

A fungus ball may be characterized by its radiologic and operative gross findings. Computed tomography (CT) revealed a rim of soft tissue attenuation of variable thickening along the bony walls of the isolated paranasal sinus, or mottled hyperdense foci of variable size. A small amount of friable muddy mass surrounded by purulent secretions or dirty brown clay-like materials provide highly pathognomonic findings. However, these characteristics may induce clinical misdiagnosis. During the last four years we experienced 11 cases of chronic paranasal sinusitis in which pathologic examination failed to confirm fungal hyphae, despite clinical suspicion of a fungus ball based on operative or CT findings. During the same period, we also experienced another 52 patients who were diagnosed with fungus ball at pathologic examination. To evaluate the diagnostic accuracy of CT scans and operative gross findings in sinus fungus balls, we reviewed the medical records of these 63 patients and also reviewed CT scans and operative records of another 1127 patients who received endoscopic sinus surgery for chronic rhinosinusitis. The sensitivity of CT evaluation was 62%, and specificity was 99%. The false-positive and false-negative rate were 22% and 2%, respectively. With regard to operative findings, such as clay-like inspissated mucus, the sensitivity, specificity, and predictive value positive rate were 100%, 99%, and 83%, respectively. To make a diagnosis of fungus ball, a high index of suspicion is necessary and a pathologic confirmation is mandatory.

Mucus circulation between accessory ostium and natural ostium of maxillary sinus

We report a case of one asymptomatic 28-year-old male with mucus circulation between the natural ostium and the accessory ostium of the maxillary sinus. Computerized tomography (CT) revealed a recirculating mucus ring between the two ostia of the maxillary sinus.

Estrogen protects against 3-methylindole-induced olfactory loss

Olfactory dysfunction is among the first signs of Alzheimer's disease (AD). Since estrogen therapy may mitigate the cognitive symptoms of AD, we determined whether 17beta-estradiol (E2) alters the olfactory discrimination performance of female rats exposed to the olfactotoxicant 3-methylindole (3-MI). Twelve ovariectomized rats received daily injections of E2 (1 mg/kg i.p.) in corn oil and 10 received daily injections of corn oil alone. Sensory testing occurred on a near-daily basis throughout a 10-week test period, midway in which a single injection of 3-MI was administered (300 mg/kg i.p.). On each pre- and post-3-MI test day, the rats were required to perform a series of successively more difficult odor discrimination tasks until one was reached where <80% performance was attained. The tasks were between the odor of a 10-4 v/v concentration of ethyl acetate (EA) and the odor of each of six different concentrations of butanol added to the EA (10-4, 10-4.5, 10-5.0, 10-5.5, 10-6.0, 10-6.5 v/v). Following 3-MI treatment, the performance of the E2-treated rats was found to be superior to that of the oil-treated rats and to return more quickly to the pre-3 MI baseline, suggesting that high doses of E2 mitigate 3-MI-induced smell loss in rats. Additional work is needed to determine the physiologic basis of this phenomenon.

Acoustic rhinometry in the study of the acute nasal allergic response

Acoustic rhinometry is a recently developed method for the objective assessment of nasal patency. In this study, acoustic rhinometry was used to measure changes in nasal cavity dimensions in the immediate response to nasal allergen challenge in eight pollen-sensitive subjects. Acoustic rhinometric changes were compared with subjective symptoms, as well as histamine in nasal secretions, cytology of nasal mucosal scrapings, and changes in olfactory function. A significantly greater decrease in nasal airway caliber occurred following allergen challenge as compared to buffer diluent challenge in the same individuals (70% +/- 7% versus 22% +/- 5%). During an allergic response, a strong correlation was found between the minimum cross-sectional area and the volume of the nasal cavity measured by acoustic rhinometry (r = .9). However, no correlation was observed between nasal airway caliber and concomitant subjective congestion reported by the subjects. A modest decrease in olfactory function was seen following allergen challenge (3.1 +/- 1.4 fewer odors identified correctly out of 20; p = .08). However, the alterations of olfactory function did not correlate with changes in nasal patency. The results presented in this study demonstrate that acoustic rhinometry has great potential as a reproducible method for the objective assessment of nasal obstruction occurring in nasal allergen challenge studies.