Adenoidectomy: Anatomical Versus Clinical Success

Endoscopic adenoidectomy with powered instruments,a challenge in resource-constraint developing countries, has been on the rise. To evaluate conventional curettage as compared to endoscopic assisted adenoidectomy in the successful management of adenoid enlargement. A randomized controlled double-blinded study among children undergoing adenoidectomywas done. Primary outcomes were assessed by pre- and postoperative evaluation with a symptoms questionnaire and fiberoptic nasal endoscopy. There were 71 children aged 3-15 years, majority having grade III adenoids. Conventional adenoidectomy was done by the surgeon who was blinded to preoperative adenoid status. Patients were randomized to two groups, 35in conventional curettage where no further on-table intervention was done. Check endoscopyof the remaining 36 patients, formingthe second group, revealed residual grade III adenoidsin 5.6%. They underwentcompletion adenoidectomyendoscopically. By the 12th postoperative week, nasal endoscopy noted that 39.3% had grade I/II and 8.8% had grade I in the conventional and endoscopic groups respectively. Thoughstatistically significant, all pre-op symptoms settled except sleep-related ones which persisted in both groups (25% versus 14.7) with no complications in either group. Relief of all symptoms other than sleep-related ones, was achieved despite residual adenoids being up to grade II in both conventional and endoscopic group. This suggests non-obstructive causes in a subset of these patients. Conventional adenoid curettage is comparable to endoscopic adenoidectomy by cold method among children aged three and above. Complete adenoidclearance for achieving 'anatomical success' appears not to be necessary for 'clinical success'.

Novel targets and therapies for keloid

Keloids are the result of aberrant tissue scarring typically occurring in injured skin, and are caused by the overgrowth of granulation tissue or collagen type III during the healing process. There is a genetic component, thus a predisposition can be genetically transmitted. Keloids are difficult to treat because of their postexcisional recurrence, and they have an impact on patient quality of life due to psychological distress caused by cosmetic concerns and functional disability. Treatment ranges from classic corticosteroid therapy to multimodal approaches such as injections, cryotherapy, laser, radiation, radiofrequency ablation and extracorporeal shockwave therapy. Recent discoveries into the pathogenesis of keloid have enabled clinicians to expand the therapeutic options for treatment. The aim of this paper was to review the literature, clarify the general concept of keloid development, and assess emerging treatment options such as stem cell therapy, mitomycin C, bleomycin, interferon, botulinum toxin type A, calcium channel blockers, angiotensin-converting enzyme inhibitors and fat grafting, and the evolutionary advancement towards epigenetic modifications and gene therapy.

CSF Rhinorrhea After Endonasal Intervention to the Skull Base (CRANIAL) - Part 2: Impact of COVID-19

BACKGROUND

During the coronavirus disease 2019 (COVID-19) pandemic, concerns have been raised regarding the increased risk of perioperative mortality for patients with COVID-19, and the transmission risk to healthcare workers, especially during endonasal neurosurgical operations. The Pituitary Society has produced recommendations to guide management during this era. We sought to assess contemporary neurosurgical practice and the effects of COVID-19.

METHODS

A multicenter prospective observational cohort study was conducted at 12 tertiary neurosurgical units (United Kingdom and Ireland). Data were collected from March 23 to July 31, 2020, inclusive. The data points collected included patient demographics, preoperative COVID-19 test results, operative modifications, and 30-day COVID-19 infection rates.

RESULTS

A total of 124 patients were included. Of the 124 patients, 116 (94%) had undergone COVID-19 testing preoperatively (transsphenoidal approach, 97 of 105 [92%]; expanded endoscopic endonasal approach, 19 of 19 [100%]). One patient (1 of 116 [0.9%]) had tested positive for COVID-19 preoperatively, requiring a delay in surgery until the infection had been confirmed as resolved. Other than transient diabetes insipidus, no other complications were reported for this patient. All operating room staff had worn at least level 2 personal protective equipment. Adaptations to surgical techniques included minimizing drilling, draping modifications, and the use of a nasal iodine wash. At 30 days postoperatively, no evidence of COVID-19 infection (symptoms or positive formal testing results) were found in our cohort and no mortality had occurred.

CONCLUSIONS

Preoperative screening protocols and operative modifications have facilitated endonasal neurosurgery during the COVID-19 pandemic, with the Pituitary Society guidelines followed for most of these operations. We found no evidence of COVID-19 infection in our cohort and no mortality, supporting the use of risk mitigation strategies to continue endonasal neurosurgery in subsequent pandemic waves.

A Rare Case of Fungal Rhinosinusitis Caused by Scedosporium apiopermum

Fungal rhinosinusitis (FRS) is inflammation of the paranasal sinus mucosa due to fungal infections, which can be invasive or non-invasive. The occurrence of a sphenoid mucocele with a fungal ball is rare. We report a case of sphenoid sinus mucocele with a fungal ball caused by Scedosporium apiopermum in a 32-year-old female who presented to the Emergency Department with persistent headache not relieved on medications. The radiological images showed a mucocele with clival osteomyelitis. Urgent endoscopic examination and debridement was undertaken which demonstrated a mucocele with fungal ball. Microbiological examination confirmed it to be Scedosporium apiopermum.

Endonasal surgery in the coronavirus era - Birmingham experience

BACKGROUND

The World Health Organization declared coronavirus disease 2019 a pandemic on 11th March 2020. There is concern regarding performing endonasal surgical procedures because of a high viral load in the nasopharynx. This paper describes our experience in conducting emergency and urgent endonasal operations during the peak of the coronavirus disease 2019 pandemic in the UK.

OBJECTIVES

To show the outcome of endonasal surgery during the peak of the coronavirus disease 2019 pandemic and to assess the post-operative rate of nosocomial coronavirus disease 2019 infection.

METHODS

A retrospective cohort study was conducted of all patients who underwent high priority endoscopic nasal surgery or anterior skull base surgery between 23rd March and 15th June 2020 at University Hospitals Birmingham NHS Trust.

RESULTS

Twenty-four patients underwent endonasal surgery during the study period, 12 were males and 12 were females. There was no coronavirus-related morbidity in any patient.

CONCLUSION

This observational study found that it is possible to safely undertake urgent endonasal surgery; the nosocomial risk of coronavirus disease 2019 can be mitigated with appropriate peri-operative precautions.

Lipid profile in leukemia and Hodgkin's disease

A number of epidemiologic studies has been published in recent years showing an increase risk of death from cancer in subjects with low plasma cholesterol levels. Although several authors proposed that hypocholesterolemia is predisposing factor for cancer development, no causative relation has been established so far and that it may be that low plasma cholesterol is secondary to malignant disease. Hence, the present study was undertaken to examine the lipid profile in children patients with leukemia and Hodgkin's disease in comparison with age matched controls. The study included 52 normal healthy controls and 105 patients with leukemia and Hodgkin's disease. Lipid profile included serum cholesterol, HDL & LDL cholesterol and triglycerides. Serum cholesterol, HDL & LDL cholesterol were found to be inversely associated with incidence of cancer, whereas triglycerides were significantly elevated in cancer patients. The inverse association between cancer and serum cholesterol may reflect a physiological response to early undiagnosed stages of cancer.

Revelation on the potency of α(1) -blockers - parallel blockade of angiotensin II receptor: a new finding

CONTEXT

The problem of hypertension has gained enormous proportions in the past decade. Multifactorial etiology and complex pathophysiology of the disease has rendered the treatment of the disease a hard task. Sympathetic nervous system and the renin-angiotensin-aldosterone system are primary contributors of blood pressure homeostasis.

OBJECTIVE

Structural similarities were identified among AT(1) and α(1)-antagonists, initiating a speculation that α(1)-antagonists could possibly block the AT(1) receptor and vice-versa.

METHODS

To corroborate this speculation, we screened prototypical α(1)-antagonists such as prazosin, doxazosin, and terazosin for antagonism of angiotensin II on rat aortic strips. We also examined the AT(1) antagonists losartan, valsartan, and olmesartan for their possible antagonistic effect, on contractions of rat aortic strips induced by phenylephrine.

RESULTS

To our astonishment, we found that prazosin and its analogs which have been reported to have α(1)-antagonistic activity only, were able to shift concentration response curves of angiotensin II.

CONCLUSION

Our findings suggest that the potent antihypertensive effect of prazosin-type α(1)-antagonists is not purely due to α(1)-receptor blocking activity of these compounds but also due to blockade of AT(1) receptors. This finding may lead to the development of more potent dual inhibitors which would prove to be of immense value in the control of the scourge of hypertension.

Clinical significance of lipid profile in cancer patients

In the present study, we have examined lipid profile in normal healthy age matched control and patients with various malignancies. Analysis of data revealed that total lipids, cholesterol and HDL cholesterol levels are inversely associated with incidence of cancer where as triglycerides levels were significantly elevated in cancer patients. Electrophoretic separation of lipoproteins revealed a significant decrease in the mean values of alpha fraction in patients with malignancy when compared with the corresponding control group. The other fractions beta and pre-beta did not show any change in the mean values in patients with cancer as compared to the normal corresponding control group.