Modified sphenoidotomy for isolated sphenoid sinus disease: A series of 117 cases

BACKGROUND

The atresia rate of sphenoid ostium after endoscopic sphenoidotomy for isolated sphenoid disease is 9.4%-10.2%.

AIMS

To reduce sphenoid sinus ostium atresia rate after sphenoidotomy surgery.

MATERIALS AND METHODS

The data of patients with isolated sphenoid sinus disease at our hospital between 2015 and 2022 were retrospectively analyzed. The age, gender, disease course, pathology, postoperative follow-up time, anatomy data of sphenoid sinus and postoperative sinus ostium atresia rate were compared between the two groups of patients with traditional sphenoidotomy and modified sphenoidotomy.

RESULTS

A total of 117 patients with isolated sphenoid sinus disease underwent endoscopic sphenoidotomy. There were 76 cases in the traditional sphenoidotomy group, fungus ball in 59.2% of patients, the postoperative sinus ostium atresia rate was 14.5%. There were 41 cases in the modified sphenoidotomy group, fungus ball in 53.6% of patients, and 0 case of sinus ostium atresia. Statistical analysis showed significant differences in postoperative sinus ostium atresia rate. There was no significant difference in age, pathology, postoperative follow-up time, anatomy data of sphenoid, and other data.

CONCLUSIONS AND SIGNIFICANCE

The modified endoscopic sphenoidotomy may reduce the rate of postoperative sinus ostium atresia.

Treatment of inferior turbinate hypertrophy by plasma turbinate reduction with onepointthreeside way

OBJECTIVES

Nasal congestion is often the main symptom of the patients with non-allergic rhinitis, who have inferior turbinate hypertrophy if getting poor treatment effect. Plasma treatment for inferior turbinate hypertrophy can effectively improve nasal obstruction. Generally, plasma treatment with multiple puncture sites, makes patients intraoperative painful and postoperative bleeding, which let patients often fear of surgery. Postoperative nasal adhesion or lower turbinate scar and other complications sometimes happened, and some patients still feel nasal obstruction due to severe mucosal damage and scar formation. We innovatively used one-point-three-side plasma turbinate volume reduction in the treatment of inferior turbinate hypertrophy, in order to reduce complication, improve symptoms, and enhance curative effect.

METHODS

A total of 111 patients with non-allergic rhinitis with complete data due to hypertrophy of inferior turbinate and poor drug treatment from Nov. 2011 to Oct. 2019. The hypertrophic inferior turbinate of patients with non-allergic rhinitis was ablated by plasma turbinate volume reduction, and the symptom scores of patients were evaluated by visual analog scales (VAS) before surgery, 1 week, 1 month, 3 months, and 6 months after surgery. The intraoperative pain was scored by VAS. The pathological morphology of nasal mucosa was observed before and after operation in some patients.

RESULTS

The nasal obstruction score of the patients was significantly lower at 1 week, 1 month, 3 months and 6 months after the operation (all P<0.05). The distribution of submucosal blood vessels and glands was improved by postoperative pathological observation.

CONCLUSIONS

Plasma turbinate volume reduction with one-point-three-side is effective with minimally invasion, and less complication, which is worthy of clinical promotion.

The role of structured reporting and structured operation planning in functional endoscopic sinus surgery

Computed tomography (CT) scans represent the gold standard in the planning of functional endoscopic sinus surgeries (FESS). Yet, radiologists and otolaryngologists have different perspectives on these scans. In general, residents often struggle with aspects involved in both reporting and operation planning. The aim of this study was to compare the completeness of structured reports (SR) of preoperative CT images and structured operation planning (SOP) to conventional reports (CR) and conventional operation planning (COP) to potentially improve future treatment decisions on an individual level. In total, 30 preoperative CT scans obtained for surgical planning of patients scheduled for FESS were evaluated using SR and CR by radiology residents. Subsequently, otolaryngology residents performed a COP using free texts and a SOP using a specific template. All radiology reports and operation plannings were evaluated by two experienced FESS surgeons regarding their completeness for surgical planning. User satisfaction of otolaryngology residents was assessed by using visual analogue scales. Overall radiology report completeness was significantly higher using SRs regarding surgically important structures compared to CRs (84.4 vs. 22.0%, p<0.001). SOPs produced significantly higher completeness ratings (97% vs. 39.4%, p<0.001) regarding pathologies and anatomical variances. Moreover, time efficiency was not significantly impaired by implementation of SR (148 s vs. 160 s, p = 0.61) and user satisfaction was significantly higher for SOP (VAS 8.1 vs. 4.1, p<0.001). Implementation of SR and SOP results in a significantly increased completeness of radiology reports and operation planning for FESS. Consequently, the combination of both facilitates surgical planning and may decrease potential risks during FESS.

Paranasal sinus disease could be a reason for unsuccessful immunotherapy of inhalant allergy in children

PURPOSE

The aim of this study was to evaluate the role of paranasal sinuses condition assessed in computed tomography on inhalant allergen desensitization effects.

MATERIALS & METHODS

Retrospective analysis of medical records of children undergoing allergen immunotherapy in outpatient otolaryngology clinic of University Children Hospital in Lublin was performed. Control group consisted of children who underwent allergen immunotherapy and obtained satisfying effects; study group consisted of children who did not experience significant improvement after desensitization therapy.

RESULTS

Computed tomography of nose cavity and paranasal sinuses exposed numerous pathologic changes affecting both, control and study group. Blockage of ostiomeatal complex was twice more common in children who did not respond adequately to desensitization therapy. In our study group, radiological findings suggesting rhinosinusitis were found in 73% of patients, while retention cysts in maxillary sinuses were discovered in 27% of patients.

CONCLUSIONS

Pathological findings in paranasal sinuses in computed tomography may arise from uncontrolled allergic rhinitis. If chirurgical management is indicated, allergen immunotherapy should be postponed until total recovery from operational procedure and repeated.

Giant follicular cyst with maxillary sinus and pterygomaxillary space extension

BACKGROUND

Dentigerous, follicular, cysts are developmental odontogenic cysts of reduced adamantine epithelium origin, associated with an impacted tooth. They are the second most frequent cystic pathology after inflammatory cysts. Although the frequency of dentigerous cysts associated with upper third molars is far lower than the mandibular ones, their complications are nothing but ordinary. Most of the times asymptomatic, being discovered during routine x-ray examinations, maxillary follicular cysts can grow to important size, altering the position of adjacent teeth, producing osteolysis of the nearby bone structures, as well as infectious complications, antral and orbital pathology.

CASE REPORT

The present manuscript describes the clinical, radiological, pathological and therapeutical aspects of a giant follicular cyst with antral and pterygomaxillary extension, associated with an impacted upper third molar.

CONCLUSION

The most efficient treatment of maxillary follicular cysts consists in the surgical removal of the lesion along with the involved tooth. Complete excision is mandatory to prevent recurrence. Extension into adjacent structures might complicate the surgery Preoperative evaluation and rigorous planning are essential, especially in large-sized lesions. Pathological examination is outmost importance in order to exclude aggressive transformations.

KEY WORDS

Dentigerous follicular cyst, Maxillary sinus extension, Pterygomaxillary space.

Onodi cell mucocele causing isolated trochlear nerve palsy: A case report

RATIONALE

Acquired vertical diplopia is commonly observed in trochlear nerve palsy, often resulting from blunt head trauma or vascular problems. It is rarely caused by tumorous conditions or space occupying lesion. We report the first case of Onodi cell mucocele causing isolated trochlear nerve palsy.

PATIENT CONCERNS

A 62-year-old male noticed a double vision which worsened when looking down. On ophthalmologic examinations, the patient showed no abnormalities in visual acuity, intraocular pressure, and no swelling in optic disc. In ocular motility test, he was notable for 10° left hypertropia in primary position, 6° in right head tilt position, 14° in left head tilt position and this was aggravated in right and down gaze. Ostiomeatal complex CT depicted an expansile soft tissue density completely filling the left Onodi cell.

DIAGNOSES

He was diagnosed with a trochlear nerve palsy caused by an isolated mucocele in the left Onodi cell.

INTERVENTIONS

Three days after presentation, he underwent endoscopic sinus surgery for marsupialization of the mucocele in the left Onodi cell.

OUTCOMES

The mucocele was completely removed through the endoscopic endonasal approach. Within 4 months after surgery, his 4th nerve palsy had gradually and completely improved.

LESSONS

Onodi cell mucoceles that cause trochlear nerve palsy are extremely rare. Timely surgical decompression is essential to achieve optimal recovery of the neural function. Combined trochlear nerve palsy should be evaluated when Onodi cell mucocele involves the orbital apex from above.

[IgG4 related disease with exclusive sinonasal involvement: A case report and literature review]

IgG4 related disease (igG4-RD) is a pathological process which integrates a large number of diseases of unknown pathogenesis, considered as being exclusive to many different organs. Diagnosis is established through histological, radiological and serological criteria. Treatment is based on long term corticosteroids; rituximab being used only in refractory cases. It is unusual for this entity to be found exclusively in the head and neck, without systemic involvement; there are only a few reported cases to date. We present a case of a nasosinusal IgG4-RD orbital tumor with paranasal sinus involvement. The accurate diagnosis made early onset corticosteroid treatment possible and the patient is currently asymptomatic.

Evaluation of Health or Pathology of Bilateral Maxillary Sinuses in Patients Referred for Cone Beam Computed Tomography Using a Low-Dose Protocol

The aim of this study was to evaluate the health or pathology of bilateral maxillary sinuses using cone beam computed tomography (CBCT) with a low-dose protocol, and to analyze potential influencing factors. The study included only CBCT scans with complete visualization of bilateral maxillary sinuses. The scans were taken using a medium to large field of view and a low-dose protocol, as indicated by the manufacturer. CBCT images were analyzed with regard to the morphology of the sinus membrane and surrounding bone twice by one observer. Influencing factors such as age, sex, or status of the remaining dentition in the posterior maxilla, including periodontal and endodontic parameters, were evaluated. The study included 134 CBCT scans (268 maxillary sinuses). Using a low-dose protocol, intraobserver reliability of the measurements was almost perfect (kappa value range 0.875 to 1). More than half the sinuses evaluated (63.1%) did not show visible morphologic changes. The most frequently identified pathologic appearance was a flat, shallow thickening of the sinus membrane of > 2 mm (47 positive findings [17.5%]). Only 15 (5.6%) sinuses were associated with teeth with endodontic treatment and/or pathology, and 10 (3.7%) with teeth exhibiting periodontal pathology. CBCT scans with a low-dose protocol can be recommended as a feasible adjunctive tool to evaluate health or pathology of the maxillary sinuses prior to surgical interventions such as sinus floor augmentation. Of all morphologic changes seen, only a small portion of the cases were considered to need further medical diagnosis/treatment.

[Orbital cavity tumor with macular folds]

A 40-year-old patient presented with an orbital tumor of the right eye accompanied by visual impairment and macular folds. The diagnosis of mucocele was made through clinical and radiological investigations. The excision of the mucocele was performed immediately. As early as 8 weeks after the operation, an obvious increase in visual acuity was noticed. At this time, the macular folds were no longer detectable.

Aneurysmal Bone Cyst of the Maxillary Sinus with USP6 Rearrangement: Case Report of a Rare Entity and Review of the Literature

Aneurysmal bone cysts (ABCs) are benign lesions which most frequently occur in the long bones of pediatric patients. Long thought to be reactive, recent molecular advances have demonstrated that the majority of primary ABCs harbor rearrangements of the USP6 gene, confirming their neoplastic nature. Secondary ABCs arising from other lesions do not demonstrate this recurrent genetic anomaly. ABCs rarely occur in the craniofacial bones, and sinonasal ABCs are exceedingly rare. We report a case of a primary ABC arising the maxillary sinus of a 14-year-old female, which was found to harbor USP6 rearrangement. We describe the clinical, radiologic, and pathologic features of this case, and review the current literature on craniofacial ABCs. Careful histologic evaluation and genetic studies are warranted in order to confirm the rare occurrence of a primary sinonasal ABC.

Ghost cell odontogenic carcinoma with suspected cholesterol granuloma of the maxillary sinus in a patient treated with combined modality therapy: A case report and the review of literature

RATIONALE

Ghost cell odontogenic carcinoma (GCOC) is a rare malignant odontogenic tumor with aggressive growth characteristics.

PATIENT CONCERNS

A 41-year-old Chinese male visited our hospital in 2013, with a 4-month history of bloody purulent rhinorrhea with a peculiar smell in the right nasal cavity.

DIAGNOSES

The patient suffered from recurrent GCOC with suspected cholesterol granuloma of the maxillary sinus. The patient was incorrectly diagnosed with a calcifying epithelial odontogenic tumor at his first recurrence. Physical examination, radiological examination, and histopathology were used to identify GCOC.

INTERVENTIONS

Considering the recurrence of GCOC and poor effects of single surgery, postoperative adjuvant chemotherapy and concurrent chemoradiotherapy were performed after radical surgical excision.

OUTCOMES

So far, no significant evidence has suggested recurrence or metastasis after a long-term follow-up.

LESSONS

We advocate wide surgery with clean margins at the first accurate diagnosis. Combined modality therapy could be taken for the recurrent GCOC. We expect to provide a new treatment strategy to prevent the growth of this neoplasm.

Isolated orbital mucoceles in the absence of obstructive sinus disease

Orbital surgeons are quite familiar with the diagnosis and management of paranasal sinus mucoceles due their frequent involvement of the orbit. These benign masses form and expand following sinus outflow obstruction secondary to various causes including trauma, inflammation and malignancy, amongst others. The authors present two cases of isolated orbital mucoceles without associated sinus outflow obstruction. There were notably no connections between the paranasal sinuses and the lesions. The mucoceles were diagnosed following orbitotomies and excisional biopsies with confirmatory histopathology. These rare orbital lesions should be considered when evaluating cystic orbital lesions, and the orbital surgeon should be familiar with the proposed pathophysiology and treatment recommendations.

Correlation of frontal sinus recess anatomy with ethnicity, gender, and pathology

PURPOSE

Research on frontal sinus cells has been conflicting regarding relationship between frontal sinus cells and frontal sinus disease. There are no published studies regarding gender differences in frontal sinus disease. No comparisons between African Americans and Caucasians and frontal sinus disease have been published. This study attempts to define the above relationships as well as the relationship between number and types of cells and disease.

METHODS

A retrospective chart review was performed on sinus CT scans done from 2003 to 2011 at an academic medical center. Exclusion criteria included previous frontal sinus surgery, sinus malignancy, obvious trauma, congenital anomalies, and poor quality of scan. Number and type of frontal cells were recorded for 602 scans. Statistical analysis performed demographic comparisons and compared number and types of cells to evidence of disease.

RESULTS

Males were more likely than females to have frontal sinus disease. Patients with Type 3 and Type 4 cells were more likely to have disease. No significant ethnic related differences in disease were found using a multivariate logistic regression model. Total number of cells did not significantly affect likelihood of disease.

CONCLUSIONS

This is one of the largest collections of data on frontal sinus cells as predictors of frontal sinus disease. These results suggest that gender and certain types of cells affect likelihood of disease. This study is the first to demonstrate a lack of difference in disease in African Americans and Caucasians. These results are significant regarding gender, race, number and type of cells as predictors of disease.

[Significance of differential diagnosis for sinonasal mass by CT value]

OBJECTIVE

To explore whether CT value is useful in identifying different disease in tumors of rhinosinus parenchyma.
 Methods: The data of preoperation noncontrast CT in 277 patients were retrospectively reviewed. The final diagnosis and classification were based on the result of surgical histopathological examination. The CT value range for different classification was calculated and was compared. All patients were re-diagnosed according to CT value range combined with pathological results by the same doctor team. The diagnosis rates according to CT value range were compared.
 Results: The CT value was (25.3±3.5) Hu in nasal polyp, (7.9±3.5) Hu in serous cyst, (42.2±4.7) Hu in mucocele, (40.7±5.3) Hu in papilloma, (112.3±10.9) Hu in fungus ball, (41.7±4.8) Hu in hemangioma, (51.2±9.9) Hu in malignant melanoma, and (47.1±9.9) Hu in squamous carcinoma. The CT value in nasal polyp is significantly higher than that in serous cyst, which was significantly lower than that in mucocele, papilloma, fungus ball, hemangioma, malignant melanoma and squamous carcinoma (all P<0.05); the CT value in serous cyst was significantly lower than that in other classification diseases (all P<0.05); the CT value in fungus ball was significantly higher than that in other classification diseases (all P<0.05); there was no significant difference in CT value among mucocele, papilloma, hemangioma, malignant melanoma, squamous carcinoma (all P﹥0.05). The diagnosis rate was elevated (from 71.1% to 92.4%) according to CT value range, with significant difference (χ2=42.150, P<0.01).
 Conclusion: CT value in nasal polyp, serous cyst, fungus ball is different from other diseases, and the 3 diseases can be distinguished only by CT value range; the CT value in mucocele, papilloma, hemangioma, malignant melanoma and squamous carcinoma is similar, and their differential diagnosis should combine with imaging data and other clinical characters. The diagnosis rates can be improved when the CT value range is taken into account.

[Imploding antrum syndrome: three cases with different management approaches]

BACKGROUND

Silent sinus or imploding antrum syndrome is a very rare condition, consisting of a usually asymptomatic spontaneous collapse of the sinus walls and floor of the orbit. It is associated with negative pressures, and when this occurs, it presents with manifestations such as enophthalmos, hypoglobus, and tilt flow orbital floor. As its incidence is very low, it is frequently missed as a diagnosis, and in fact there are currently fewer than 150 cases reported in the literature.

CLINICAL CASES

Three patients have been identified in our practice over a period of two years, with different symptoms that influenced the decision of the treatment modality, which were: watch and wait, endoscopic sinus surgery, or endoscopic sinus surgery plus orbitoplasty.

CONCLUSIONS

Despite being a rare entity, it stills catches the attention of the ENT, OMF surgery and Ophthalmologist. The diagnosis is mainly radiological, due to the late clinical manifestations and symptomatology. The treatment should be individualised and based on the symptoms and the individual decision of each patient, firstly by Functional Endoscopic sinus surgery, and once sinus permeability is restored, it may require augmentation surgery of the orbital floor, either with autologous bone implant, titanium or other material. It is important to be aware of this pathology, to know and to suspect it, avoiding misdiagnosis.

Mulberry hypertrophy and accompanying sinonasal pathologies: A review of 68 cases

Mulberry hypertrophy occasionally coexists with sinonasal pathologies. There are very few reports in the literature on this clinical entity. We conducted a retrospective study to draw attention to this condition in the context of accompanying sinonasal pathologies. Our study group was made up of 68 patients-51 males and 17 females, aged 13 to 57 years (mean: 34.9)-who had been diagnosed with mulberry hypertrophy and at least one accompanying sinonasal pathology. All patients had a long-standing chronic discharge. Forty-nine of these patients (72.1%) had unilateral mulberry hypertrophy. The most common concomitant pathologies were chronic rhinosinusitis and ostiomeatal complex disease; others included septal deviation, nasal polyposis, allergic rhinitis, and concha bullosa. Thirty-six patients (52.9%) with varying degrees of choanal/nasal obstruction were operated on with endoscopic excision to treat the mulberry hypertrophy. In all, most patients underwent some sort of surgery to treat either the mulberry hypertrophy or the accompanying sinonasal pathology. Based on our findings, we suggest a clinical staging system to serve as a way to standardize management and guide future basic and clinical research.

The difference in anatomical and invasive characteristics between primary and secondary paranasal sinus mucoceles

Objective

To evaluate the difference in anatomical and invasive characteristics of primary and secondary paranasal sinus mucoceles.

Study Design

A retrospective chart review at a tertiary academic center.

Results

During a 10-year period, 57 and 109 patients with primary and secondary mucoceles were enrolled, respectively. Thirty-five (61.4%) of primary and 26 (23.9%) of secondary mucoceles had intraorbital extension (IOE), while seven (12.3%) of primary and two (1.8%) of secondary mucoceles had intracranial extension (ICE). In comparison of tendency for IOE or ICE between primary and secondary mucoceles in each sinus, only primary maxillary mucoceles were shown to have a significantly higher probability of IOE than secondary maxillary mucoceles. Among primary mucoceles, ethmoid mucoceles had a significantly greater capability to cause IOE while maxillary mucoceles had the least. Among secondary mucoceles, frontal and ethmoid mucoceles had a greater ability to cause IOE while maxillary mucoceles had the least. As for ICE, sphenoid mucoceles had a greater potential in both groups.

Conclusions

Primary mucoceles seem to have a greater potential to cause IOE and ICE than secondary mucoceles. In both groups, ethmoid mucoceles have a higher potential of IOE, while sphenoid mucoceles have a greater tendency to cause ICE.

Gene Expression Analysis in Sinonasal Polyposis before and after Oral Corticosteroids: A Preliminary Investigation

OBJECTIVE: To characterize gene expression in sinonasal polyps and to gain insight into change in expression after oral corticosteroid treatment.

STUDY DESIGN AND METHODS: Nasal polyps were obtained before and after oral corticosteroid treatment and gene expression was analyzed with a focused gene array technique.

RESULTS: Pretreated sinonasal polyps demonstrated high gene expression for chemokine and leukotriene receptor genes (CCR2, CCR5, CX3CL1, and LTB4R) in all patients. After treatment, the global effects of corticosteroids were evident on gene expression.

CONCLUSIONS: Gene array techniques hold promise as a research method in sinonasal polyposis. The potential benefits, as well as the potential challenges, in using these research methods will be discussed.

Unilateral Opacification of Paranasal Sinus CT Scans

Objectives

The aim of study was to describe the histopathology in patients with unilateral sinus opacification and to identify variables that may predict neoplastic pathology.

Study Design

A retrospective review of paranasal sinus CT scans performed between 2000 and 2003 was conducted to identify patients with unilateral sinus opacification.

Results

Twenty-eight of 1118 CT scans showed unilateral sinus opacification. Twelve patients had neoplastic disease, 13 had inflammatory disease. Nasal discharge was more common in inflammatory than neoplastic disease (P = 0.009). A polyp or mass lesion was more common on nasendoscopy in neoplastic than inflammatory disease (P = 0.01). Bony erosion was only identified in malignant disease.

Conclusion

A wide variety of pathologies present with unilateral sinus opacification on CT scanning. In our series, neoplastic disease was more associated with a visible polyp or mass lesion and less with nasal discharge. Bony erosion on CT scan was only seen in malignant disease. Histologic confirmation remains obligatory for diagnosis.

Partial Removal of Orbital Tumor in Rosai-Dorfman Disease

BACKGROUND

Rosai-Dorfman disease is a rare idiopathic histiocytic proliferation disorder that typically presents with painless cervical lymphadenopathy. We report our experience with the management of a case of Rosai-Dorfman disease with compressive optic neuropathy.

CASE

Rosai-Dorfman disease involving the bilateral orbital and paranasal sinuses was diagnosed in a 14-year-old boy. Diagnosis was based on the characteristic histopathologic features of sinus histiocytosis, composed of large, round S-100 protein-positive histiocytes with striking emperipolesis. The boy received chemotherapy to resolve the bilateral proptosis and compressive optic neuropathy in the right eye, but this treatment failed. Orbital debulking surgery using the Lynch approach was performed.

OBSERVATIONS

Corneal exposure was resolved and visual acuity recovered from 14/20 to 20/20 after partial removal of the tumor mass. There were no complications after surgery. During the 22 months of follow-up, orbital tumor masses redeveloped to cause lagophthalmos again, but did not cause visual impairment.

CONCLUSIONS

Rosai-Dorfman disease is a rare disorder, especially in Asia. The disease is usually chronic with spontaneous remission and is refractory to treatment. Partial removal of tumor masses is a workable way to improve visual acuity and correct corneal exposure. Before carrying out this procedure, we discussed with the parents of the patient the potential complications that might follow surgery and secured their permission before proceeding further.

[Two rare case report of maxillary sinus foreign body]

The maxillary sinus is the largest paranasal sinuses. Foreign bodies of nosal sinus can caused by car accidents, firearm attacks, or iatrogeniccause. We reported two rare cases of foreign body of pulp needle and loach. The clinical manifestations might include facial numbness, facial paresthesia, swelling, nasal congestion, facial pain, eye discomfort, limited mouth opening and relapse and etc. Both CT scan and the medical history were helpful in diagnosis. Functional endoscopic surgery would be the first choice of treatment.

Mixed radiopaque and radiolucent lesion of the maxillary sinus: a radiographic challenge

This article describes 3 patients, each of whom presented with an asymptomatic mixed radiopaque and radiolucent lesion of the maxillary sinus associated with a nonvital tooth. Based on the radiographic findings, a diagnosis of a collapsed (ruptured) radicular cyst was rendered in each case. A tissue biopsy was performed in 1 case, and the results supported the diagnosis. The radiographic and histopathological features, etiology, pathophysiology, and radiographic differential diagnosis of this condition are discussed.

Computed Tomography in the Evaluation of Pathological Lesions of Paranasal Sinuses

BACKGROUND

Computed tomography is now the modality of choice for imaging paranasal sinuses and along with Functional Endoscopic Sinus Surgery has empowered the modern rhinologist to treat patients more effectively. This study aims to evaluate anatomical variation in paranasal sinuses; compare computed tomography with histopathological and surgical findings and establish its diagnostic value.

METHODS

A hospital based observational study including all patients referred from the department of Ear, Nose and Throat for computed tomography scan of paranasal sinus to the department of radiology and imaging of Trubhuvan University Teaching Hospital from August 2011 to July 2012. Both axial and coronal sections were evaluated and findings were correlated with surgical findings and histopathology.

RESULTS

A total of 44 patients were included in the study. The most common clinical diagnosis was sinonasal polyposis and chronic rhinosinusitis. Most common anatomical variation was deviated nasal septum (68.2%) followed by choncha bullosa(27%). In most cases more than one sinus was involved. Maxillary sinus was involved in 90.9% followed by ethmoid sinus in 81.8%. Inflammatory pathology was seen in 35 (79.5%) patients with sinonasal polyposis pattern being the most common pattern of involvement. Findings of computed tomography were similar to surgical findings in 84.6% cases. The sensitivity and specificity of computed tomography was fairly good except for fungal rhinosinusitis.

CONCLUSIONS

CT scan should be performed preoperatively in order to guide the surgeon for Functional Endoscopic Sinus Surgery or other surgical procedures.

Isolated Xanthoma Of The Sphenoid Sinus: A Rare Presentation

OBJECTIVE

To present the first case in the English literature of a sphenoid xanthoma.

METHODS

Case Report

DISCUSSION

A 36 year-old Hispanic female with past medical history of Hashimoto's hypothyroidism and family history of hyperlipidemia that presented with a 1-year history of sporadic left sided epistaxis. A paranasal sinus Computed Tomography (CT) was performed revealing a soft tissue lesion infiltrating the left sphenoid sinus. Patient underwent endoscopic sinus sphenoidotomy with intraoperative findings of a yellow-tan, friable soft tissue mass filling the left sphenoid sinus. Biopsies were taken which exhibited histologically findings consistent with a xanthoma.

CONCLUSION

In a patient with hyperlipidemia isolated lesions on paransasal sinuses can be related to xanthoma formation.

[Diagnosis and treatment of nasal sinus mucoceles invaded the skull base and orbit]

OBJECTIVE

To review the clinical manifestations and management of nasal sinus mucoceles invaded the skull base and orbit.

METHOD

Medical records for 30 patients of paranasal sinus mucoceles invaded the skull base and orbit were reviewed retrospectively. CT and MRI were important tools for diagnosing nasal sinus mucocele. The patients received endoscopic surgery to remove mucocele, some of them were operated auxiliary incision. Steroid therapies were given after the operations and routine examination with endoscopy were carried out during follow-up.

RESULT

All cases were successfully performed surgery without complications after the surgeries, or the majority of symptoms. However, vision recovery was observed only in some patients. Recovery of vision depended on the timing of surgery and severity of initial visual loss. Delay treatment can seriously compromise the recovery of vision impairment. Moreover, the patients without light perception before surgery had poor visual recovery even when optic nerve decompressions were performed.

CONCLUSION

Endoscopic surgery has effect on nasal sinus mucocele with visual loss. Because visual recovery depends on prompt diagnosis and surgical intervention,a good understanding of the disease and prompt imaging studies are important.

A case of respiratory epithelial adenomatoid hamartoma

We report a case of a 50-year-old man diagnosed with a unilateral nasal mass found to be a respiratory epithelial adenomatoid hamartoma (REAH) upon pathologic examination.REAH is a recently described pathologic entity that can present with nasal obstruction, congestion, rhinorrhoea,epistaxis, hyposmia, and headaches. It is a rare lesion of nasal and paranasal sinuses, but should be considered in the differential diagnosis because it is a benign lesion and complete surgical resection is curative.

Large, expansile odontogenic cyst with bilateral maxillary sinus involvement

Residual cysts are common odontogenic lesions of the tooth-bearing areas of the jaws. A case of an unusually large residual cyst that crosses the maxillary midline and occupies portions of the maxillary sinuses is being reported. Investigations included a panoramic radiograph, CT scan and a biopsy. The differential diagnoses were common odontogenic lesions, including cysts and benign tumors. The value of advanced imaging modalities is stressed when determining the presence and extent of lesions in complex structures such as the maxilla. The need to visualize the entire lesion beyond what may be seen on intraoral views, as well as panoramic radiographs, is discussed.

Central giant cell reparative granuloma of the ethmoids with bilateral proptosis and intracranial extension

Central giant cell reparative granuloma is an infrequent, benign, proliferating lesion affecting the maxilla, mandible and, rarely, cranial bones. A 16-year-old girl presented with a 6-month history of recurrent nasal bleeding, a mass in the nose, difficulty in nasal breathing, a change in voice, and bilateral proptosis. Radiologically, an extensive ethmoidal mass was seen. Histologic examination revealed a central giant cell reparative granuloma. After endoscopic removal, the patient was symptom-free at the 12-month follow-up. The clinical picture of central giant cell reparative granuloma of the ethmoids is discussed, along with the differential diagnosis, histologic evaluation, appearance on computed tomography, and endoscopic management of this lesion.

Isolated nasal amyloidosis: a case report

Amyloidosis is a rare condition characterized by the deposition of abnormal protein filaments into the extracellular tissue. Only 16 cases of true primary idiopathic amyloidosis localized in the nose and the paranasal sinuses have previously been reported. We present a case of localized amyloidosis involving the sinonasal cavities and the nose in a 53-year-old woman. Our patient was operated on as a typical case of chronic rhinosinusitis with polyps, but after 2 years, the patient came back with severe symptoms of nasal obstruction and pain in the frontal and maxillary regions with proptosis of both eyes. Magnetic resonance imaging revealed sinonasal-intraorbital masses. Primary amyloidosis (AL type) was confirmed by tissue biopsy. A systemic workup for additional amyloid deposits revealed no evidence of other diseases. Extended surgery produced a symptomatic improvement.

Staphylococcus aureus cavernous sinus thrombosis mimicking complicated fungal sinusitis

Septic cavernous sinus thrombosis is a rare and potentially life-threatening complication of infections involving the paranasal sinuses or the middle one-third of the face. We report a challenging case of cavernous sinus thrombosis to familiarize otolaryngologists with its clinical features, diagnosis, and management. The patient was a 45-year-old diabetic woman whose signs and symptoms mimicked those of complicated fungal sinusitis. She presented with fever, nausea without vomiting, frontal headache, bilateral ptosis and swelling, double vision, a partial loss of visual acuity in the left eye, and restricted lateral ocular movements. Her Snellen visual acuity had been reduced to 8/10 on the right and 6/10 on the left. Radiologic investigation revealed cavernous sinus extension of sphenoid sinusitis and a fungus-ball appearance in the sphenoid sinus. On the second day of her admission, the patient's vision was further reduced to 6/10 on the right and 2/10 on the left. She then underwent urgent bilateral anterior and posterior ethmoidectomy and sphenoidectomy. At postoperative follow-up, her vision had stabilized at 10/10 bilaterally. At 2 months after discharge, she exhibited no evidence of abducens nerve palsy, and her ocular function had returned to normal. The diagnosis of cavernous sinus thrombosis requires a high index of suspicion and confirmation by imaging. The favorable outcome in our case was attributable to early diagnosis, prompt initiation of appropriate intravenous antibiotic therapy, and surgical drainage by the skillful surgical team.

[Silent sinus syndrome--two cases report]

INTRODUCTION

Silent Sinus Syndrome (SSS) is a rare pathology, characterized by retraction of the maxillary sinus walls, leading to enophthalmos, sometimes diplopia and midfacial depression. It is usually not associated with sinonasal symptoms. Sinus ventilation and drainage stops its progression, but usually cannot reverse the process. This empiric treatment supports the Hypoventilation Theory that would explain the pathogenesis of this disorder.

MATERIALS & METHODS

We describe two cases of SSS. A 65 year-old-man complaining of enophthalmos with an insidious onset whose CT-Scan confirmed SSS. After he was submitted to drainage surgery, the ocular asymmetry showed slight improvement. The second case describes a 34 year-old-woman with a sudden onset enophthalmos associated with diplopia, in only 5 days. She didn't have nasal or sinus related symptoms. CT-scan revealed SSS due to maxillary and ethmoidal sinus. Early endoscopic surgery enabled reversal of enophthalmos and correction of diplopia.

Rhinocerebral mucormycosis--a case report

BACKGROUND

Rhinocerebral mucormycosis (RCM) is a rare, fulminating opportunistic fungal infection caused by a fungus of order Mucorales. These fungi are ubiquitus, subsisting on decaying vegetation and diverse organic material. Although fungi and spores of Mucorales show minimal intrinsic pathogenicity towards normal person, they can initiate aggressive and fulminating infection in immunocompromised host. Since RCM occurs infrequently, it may pose a diagnostic and therapeutic dilemma for those who are not familiar with its clinical presentation.

CASE REPORT

We present a patient with classical presentation of RCM involving paranasal sinuses, orbit, and cranial base who was treated by combination of aggressive surgical and medical therapy.

DISCUSSION

The purpose of this paper is to draw attention to the clinical presentation and pathogenesis of RCM and to emphasize need for high index of suspicion in diagnosis and treatment.

Wegener's granulomatosis of the paranasal sinuses with orbital and central nervous system involvement-diagnostic imaging

Wegener's granulomatosis (WG) is a systemic vasculitis that can affect any organic system, but primarily involves the upper and lower respiratory tracts and the kidneys. WG relatively frequently affects the nervous system (in 30-50%), usually in the form of peripheral or cranial neuropathy. Involvement of the brain is reported in a very small percentage of patients (2%-8%). Three major mechanisms have been described as the cause of central nervous system (CNS) disease in WG: contiguous invasion of granuloma from extracranial sites, remote intracranial granuloma and CNS vasculitis. CNS involvement caused by contiguous invasion of granuloma from extracranial sites is the rarest. We report the case of a 37-year-old man with WG, manifested as a pulmonary and paranasal sinuses disease, with orbital and CNS involvement, caused by contiguous invasion from the paranasal sinuses. In this report, the rich spectrum of findings achieved by computed tomography and magnetic resonance are demonstrated. The importance of computed tomography in bony destruction PNS findings, and the importance of MR imaging in evaluation of the direct intracranial spread from nasal, paranasal and orbital disease are also emphasized.

Implants placed simultaneously with maxillary sinus floor augmentations in the presence of antral pseudocysts: a case report

An antral pseudocyst on the maxillary sinus has previously been a contraindication for sinus augmentation. The authors report the case of a patient with an antral pseudocyst (16.7 mm × 27.6 mm) in his left sinus, who was referred for dental implant treatment. The surgical plan was to perform the sinus augmentation after removing the cyst whilest simultaneously placing implants. During the operation the cyst could not be found in the left sinus. The sinus augmentation was carried out successfully without sinus membrane perforation and the implants were placed according to plan. Three mouths later, the cyst was still present and good osseointegration of the implants was achieved. After the implants had been in place for a year, a CT scan showed that the cyst had decreased in size. The authors conclude that it is may not be necessary to remove a sinus cyst before sinus augmentation or during the sinus augmentation operation if the patient does not have any symptoms and the cyst is not large. In cases with large lesions or an unclear diagnosis, further evaluation is needed before surgical intervention.

A case of respiratory epithelial adenomatoid hamartoma of the sinonasal tract

Respiratory epithelial adenomatoid hamartoma is a rare, non-neoplastic tumour characterised by an abnormal mixture of tissues that are indigenous to the region. REAH are shiny, polypoid, exophytic masses with a rubbery to firm texture. They may arise and co-exist in the setting of inflammatory polyps. We present a case of a 49-year-old patient who was referred to the department with a clinical diagnosis of chronic nasal sinusitis. Results of post-op histopathological examination show a mild change of the respiratory epithelium requiring, among others, differentiation from inverted papilloma and adenoid carcinoma.

[Exophthalmos arising from paranasal sinuses]

INTRODUCTION

Proptosis due to intraorbital process is frequent and secondary to various aetiologies. Its findings in ENT practice is the sign of a serious complication. The purpose of this study is to review a series of patients who presented an exophtalmy.

MATERIAL AND METHODS

We conducted a retrospective analysis of 15 patients with exophthalmos complicating a rhinosinusal benign disease, diagnosed and treated in our department between January 2003 and December 2010. As their management is different, we excluded all cases of orbital cellulitis.

RESULTS

Average age of presentation was 38 years, without sex predominance. Exophthalmos was unilateral, non axial and irreductible in all cases. The average duration of symptoms installation was 18 months. The most common aetiology was fronto-ethmoidal osteomas (9 cases), followed by fronto-ethmoidal mucoceles (5 cases) and spheno-orbito-frontal fibrous dysplasia (1 case). The functional prognosis of the affected eye depended on the aetiology and the degree of ocular injury.

CONCLUSION

In our experience, sinusal causes of exophthalmos comprise osteomas and ethmoidal mucoceles. Medical history, clinical and radiological data as provide the diagnostic. In case of benign tumours, surgery is the curative treatment.

Comparison of clinical characteristics between primary and secondary paranasal mucoceles

PURPOSE

Paranasal sinus mucocele is a benign, expansile mass which can occur as a result of trauma or spontaneous obstruction of a sinus tract. The purpose of this study was to describe and compare the clinical characteristics of primary mucoceles occurring in patients with no previous sinus surgery history or known cause of mucoceles and secondary mucoceles resulting as a complication following endoscopic sinus surgery or the Caldwell-Luc operation.

MATERIALS AND METHODS

We performed a retrospective chart review of 33 cases of primary mucoceles and 60 cases of secondary mucoceles which were diagnosed and surgically corrected between 1996 and 2008.

RESULTS

The most common presenting symptoms in primary mucoceles were nasal obstruction (19.4%) and rhinorrhea (17.7%). In secondary mucoceles, the most common symptoms were cheek pain (31.7%) and nasal obstruction (18.3%). The most common origins of primary mucoceles were the ethmoid sinus (45.5%) and the maxillary sinus (18.2%). In secondary mucoceles, the maxillary sinus was the most common site (86%), followed by the ethmoid sinus (7.1%). All patients with secondary mucoceles had a history of sinus surgery.

CONCLUSION

The maxillary sinus was the most common site of secondary mucoceles while the ethmoid sinus was the most common origin of primary mucoceles. Cases of secondary mucoceles that occurred following sinus endoscopic surgery developed more frequently in the ethmoid sinus than in those following the Caldwell-Luc procedure, therefore, we suggest that the incidence of maxillary sinus mucoceles in the Asian population would decrease as the rate of endoscopic sinus surgery increases.

Current concepts in topical therapy for chronic sinonasal disease

INTRODUCTION

There has been an explosion in the understanding of the mechanisms of chronic sinonasal inflammation. Multiple approaches to control and modify the inflammatory reaction in chronic rhinosinusitis have led to many new agents being introduced topically to the sinonasal cavities. This article aims to provide an evidence-based approach to the science behind topical management of sinonasal disease.

METHODS

The literature on delivery device, position, surgical state, and pharmaceutical and mechanical concepts of topical therapy to the paranasal sinuses is reviewed.

RESULTS

High-volume irrigation under positive pressure and in head-down positions is important for effective delivery and mechanical action of topical solutions. Unoperated paranasal sinuses appear to receive very limited topical therapy. Enhanced steroid therapy and surfactants appear to be the most promising pharmaceutical approaches. Future novel therapies may include enhancers of the innate immune system. The effect of antibiotic additives is difficult to establish as this might be treating a disease-modifying state rather than the underlying pathology.

CONCLUSIONS

Topical therapies, applied after surgery, are likely to represent the mainstay of future management for chronic inflammatory rhinosinusitis.

Serial cytokine levels during wound healing in rabbit maxillary sinus mucosa

CONCLUSION

Collagen deposition was increased in regenerative rabbit maxillary mucosa, and the elevated collagen deposition during wound healing was associated with increased interleukin (IL)-6 and IL-8, and decreased IL-10.

OBJECTIVES

To observe the natural progression of wound healing in rabbit maxillary sinus mucosa and to detect the expression of relevant cytokines.

METHODS

A rabbit wound-healing model was established in the maxillary sinus. At different times after injury, the sizes of maxillary ostia were recorded, and histological changes in the sinus mucosa were examined by means of hematoxylin and eosin (H&E) and Masson trichrome staining. Enzyme-linked immunosorbent assay (ELISA) was used to detect the concentrations of IL-6, IL-8, IL-10, and collagen types I and III.

RESULTS

A large amount of immature spindled collagen deposition was observed in the basal lamina and lamina propria of regenerative mucosa. IL-6 was increased significantly in regenerative mucosa after injury, especially at 14 days post wounding when compared with normal mucosa. IL-8 was also increased significantly in regenerative mucosa; however, IL-10 was decreased significantly when compared with normal mucosa. IL-6 and IL-8 showed a significant correlation with the expression level of collagen type I.

Idiopathic sclerosing orbital inflammation with intranasal extension

INTRODUCTION

To report a case of idiopathic orbital sclerosing inflammation (ISOI) with intranasal extension.

MATERIAL AND METHODS

The patient presented with a 6-month history of epiphora, upper eyelid swelling, ptosis and mild orbital pain. Ophthalmologic examination, CT, MRI and biopsy with surgical debulking were performed.

RESULTS

MRI revealed a homogeneously enhancing diffuse right orbital mass in the inferonasal quadrant of the orbit, which extended to the nasal cavity up to inferior nasal concha, maxillary and ethmoid sinuses. Histological analysis showed dense collagenous tissue with sparse infiltration of mixed inflammatory cells. Inmunohistochemical analysis confirmed polyclonality. The diagnosis of idiopathic sclerosing orbital inflammation was made and 80 mg/day of oral prednisolone was prescribed. At last follow up, one year later, there was no clinical evidence of recurrent orbital disease.

CONCLUSION

ISOI can present with extraorbital extension. Corticosteroids are a reasonable first-line treatment, until the pathogenesis is better understood.