Nasal and paranasal sinus surgery in children with cystic fibrosis

Cystic fibrosis (mucoviscidosis; fibrocystic disease of the pancreas) is an inherited autosomal recessive disorder that results in generalized dysfunction of exocrine glands. Chronic pansinusitis with nasal polyposis occurs frequently in this disease. Polypectomy and sinus drainage procedures are often required in those cases refractory to medical therapy. Recurrence of nasal polyps following removal is common. Controversy exists regarding the timing and extent of surgery. The management of 40 children with cystic fibrosis who underwent nasal polypectomy, intranasal ethmoidectomy, and Caldwell-Luc procedures to treat extensive sinusitis and nasal polyposis forms the basis for this report. Follow-up data indicate that fewer recurrences and longer symptom-free intervals result when intranasal ethmoidectomy and Caldwell-Luc procedures are combined with polypectomy.     

Nasal and paranasal sinus schwannomas

Although nearly half of all schwannomas involve the head and neck region, nasal and paranasal sinus presentations are quite rare in the literature. Two of the latter cases are presented in this report. In the first, the tumor originated from the nasal septum and was completely excised under local anesthesia. In the second, the schwannoma arose from the left frontal and anterior ethmoidal sinuses. This lesion was totally removed through a combined endoscopic intranasal and external frontoethmoidectomy approach. The patients have shown no tumor recurrence in 6 years and 18 months of follow-up, respectively. The extreme rarity of nasal and paranasal sinus schwannoma is the basis for discussion of these cases.     

鼻内镜鼻窦手术治疗儿童慢性鼻窦炎

目的探讨鼻内镜鼻窦手术治疗儿童慢性鼻窦炎的疗效。方法对36例66侧儿童慢性鼻窦炎患者行鼻内镜鼻窦手术。结果36例患儿治愈28例(77.78%),好转6例(16.67%),无效2例(5.56%),总有效率94.44%。结论在严格掌握适应证的情况下,鼻内镜鼻窦手术治疗儿童慢性鼻窦炎疗效确切,是治疗儿童慢性鼻窦炎的有效方法。     

Amoxicillin concentrations in nasal secretions of patients with acute uncomplicated sinusitis and in paranasal sinus mucosa of patients with chronic sinusitis

In this prospective randomized clinical study a total of 59 patients of both sexes (above 18 years of age) were enrolled. Thirty patients with acute sinusitis were randomly allocated to two treatment groups, one group receiving 1000 mg amoxicillin every 12h for 10 days and the other group receiving 500 mg amoxicillin every 8 h for 10 days. The median concentration of amoxicillin in nasal secretions was 2.34 µg/ml in the 12-h administration group and 1.95 µg/ml in the 8-h administration group. Median bioavailability of antibiotic at 8-24h did not show any statistical differences between the two treatment schemes [probability (Z) = 0.2]. Twenty-nine patients with chronic sinusitis were then randomly allocated to three groups, with patients receiving 1000 mg amoxicillin at 12, 8 or 6 h before nasal and/or sinus surgery was carried out. The mean amoxicillin concentrations in mucosal tissues removed intraoperatively ranged from 0.69 to 0.99 µ/g sample. Statistical evaluation by analysis of variance did not show any statistically significant differences among the three treatment groups [probability (F) = 0.1705]. In all cases of acute and chronic sinusitis, amoxicillin concentrations exceeded minimum inhibitory concentration values for pathogens common in sinusitis. Our results indicate that 1000 mg amoxicillin administered twice daily produces tissue concentrations high enough to be clinically effective in patients with either acute or chronic sinusitis.     

Nasal symptomatology,obstruction, and paranasal sinus opacity in patients with chronic obstructive pulmonary disease

Conclusion: Patients with chronic obstructive pulmonary disease (COPD) more frequently suffer from nasal symptoms as well as upper respiratory tract obstruction compared with the healthy population. Objective: The relationship between chronic rhinosinusitis and bronchial asthma has been studied in detail in the past. In recent years, a limited number of authors have also studied involvement of the nose and paranasal sinuses in patients with COPD. Methods: This was an observational cross-sectional study with subsequent prospective assessment; 42 patients with COPD were included. The control group consisted of 12 healthy subjects. All patients with a history of rhinitis or rhinosinusitis and patients with previous surgery of the nose and sinuses were excluded from the study. Clinical variables evaluated were nasal symptoms (SNAQ-11 questionnaire), nasal endoscopy, nasal patency (active rhinomanometry), and computed tomography of paranasal sinuses. Results: In the COPD group, there was a higher occurrence of nasal symptoms and pathological findings on nasal endoscopy compared with the control group. The overall nasal airflow was higher in the control group (compared with COPD patients) and the overall nasal resistance was higher in the COPD group (compared with controls). Pathological opacity of one or more sinuses was confirmed in 38% of COPD patients.     

Nasal and paranasal sinus manifestation of Rosai-Dorfman disease

Rosai-Dorfman disease is a rare, idiopathic, benign, histiocytic proliferation usually seen in younger patients. Most commonly neck lymph nodes are involved with a predominant infiltration of sinusoidal histiocytes. Nearly half of the patients have extranodal manifestation. Two cases of Rosai-Dorfman disease involving the nose and the paranasal sinuses are presented. The clinical presentation, radiographic findings, treatment and histological characteristics of the disease are discussed.     

Localization of T cells and subtypes in the paranasal sinus and turbinate mucosa in patients with chronic sinusitis

The aim of this study was to quantitate total T lymphocytes (total CD3+ cells) and T-lymphocyte subtypes (CD4+ [T helper] and CD8+ [T suppressor] cells) in patients with chronic sinusitis who were treated with functional endoscopic sinus surgery (FESS) and to investigate the pathophysiology of persistent inflammation in chronic sinusitis. This prospective study was conducted in study and control groups. The study group consisted of 32 patients (20 male, 12 female) with chronic sinusitis who underwent FESS. The control group consisted of 8 nonsinusitis patients (5 male, 3 female) who underwent septoplasty. Specimens from the study group were excised from five regions: the uncinate process, maxillary and ethmoid sinuses, and middle and inferior turbinates. The specimens were examined with x10 magnification by light microscopy, and the slides with a severe inflammatory process were included. Punch biopsy of the control group was taken from the inferior turbinate with patients' written approval. The surgical specimens from the study and control groups were examined with an immunohistochemical staining technique with monoclonal antibodies against CD3, CD4, and CD8 surface antigens of T lymphocytes. In every specimen, the numbers of CD3+, CD4+, and CD8+ cells were calculated in 3 to 4 high magnification field on light microscopy, and the mean number of these cells in the epithelium, subepithelial layer of the lamina propria, and deep paraglandular layer of the mucosa was determined. Statistical analysis by Kruskal-Wallis analysis of variance and the Mann-Whitney U test with Bonferroni correction revealed that the CD3 epithelial layer value of the inferior turbinate (p = .030) and the CD4 deep layer value of the middle turbinate (p = .048) were significantly higher than the corresponding values of the control group. In the epithelial (p = .018) and subepithelial (p = .012) layers of the uncinate process group, in the epithelial (p = .050) and subepithelial (p = .012) layers of the ethmoid sinus group, and in the subepithelial (p = .018) and deep paraglandular (p = .012) layers of the middle turbinate group, the difference between the CD4+ and CD8+ cell counts was found to be statistically significant by the Wilcoxon signed rank test. The number of CD4+ cells was higher than the number of CD8+ cells. In conclusion, T cells play a role in the pathophysiology of chronic sinusitis. CD4+ T helper cells, in particular, are predominant at the initiation and regulation of inflammation. The uncinate process, ethmoid sinus, and middle and inferior turbinates have the main roles by T cells and subtypes in the defense system in chronic sinusitis.     

Surgical management of chronic paranasal sinusitis

An attempt is being made to try to standardize an approach to surgical problems involving the paranasal sinuses, excluding malignancies. This is being done in conformity with a definition proposed by Ferris Smith in 1934 along with certain up-to-date modifications. There are five basic surgical operations commonly and effectively utilized in approaching these sinus problems. Three of these procedures, namely, the nasal antral window, the Caldwell-Luc, and the intranasal ethmoidectomy, are felt to be best utilized in the primary approach to the majority of inflammatory problems. The remaining two procedures, the fronto-ethmo-sphenoid sinusotomy and the osteoplastic frontal flap, are advocated primarily in approaching space occupying lesions, excluding polyps, and secondarily where attempts to manage the problem by the first three lesser surgical procedures have been unsuccessful. The merits, goals, and indications of all five procedures are discussed. In many instances two procedures may have equal effectiveness in handling a patient's particular problem, and the procedure of choice rests with the personal preference of the individual surgeon. At other times an inappropriate procedure may not benefit the patient while a properly selected operation could readily enable a cure. It is in this latter area of selecting the appropriate surgical procedure to attack a particular problem that a serious deficit now exists in the practice of otolaryngology. It is the further contention of this presentation that these five basic procedures can effectively handle the majority of chronically diseased paranasal sinusitis problems. It is unfortunate that the one procedure that is the most effective and the most physiological in handling the majority of the more difficult problems, namely, the intranasal ethmoidectomy, was allowed to fall into near disrepute by a historical misunderstanding.⁰     

Cytokine profile in paranasal effusions in patients with chronic sinusitis using the YAMIK sinus catheter with and without betamethasone

Recently, the YAMIK sinus catheter (YAMIK) has been reported to be a useful therapeutic device in the treatment of sinusitis. The present study was conducted to compare its delivery of either a normal saline (NS) or a betamethasone solution (0.4 mg/ml) into the paranasal sinuses of 25 patients (39 sides) with chronic sinusitis. The following parameters were evaluated: (1) subjective nasal clinical symptoms (nasal discharge, nasal obstruction, postnasal drip and headache), (2) X-ray photographs (ethmoid and maxillary sinuses) and (3) cytokine levels (IL-1, IL-8 and TNF-) by enzyme-linked immunosorbent assay. The total nasal symptom scores significantly decreased after the first therapy, and the total X-ray photograph scores significantly decreased after therapy with either NS or the betamethasone solution. In both NS and betamethasone patients, the levels of IL-1 and IL-8 had significantly decreased by the 3rd and 2nd weeks after therapy, respectively. In contrast, the TNF- level decreased after the first therapy with betamethasone solution and remained unchanged after therapy with NS. These findings suggest that evacuation of the pathological effusions in sinuses may exert a beneficial effect by reducing the levels of IL-1 and IL-8, and we speculate that removal of pathological effusions from the sinuses may provide treatment through different mechanisms than those that occur in treatment with betamethasone.     

Endoscopic sinus surgery in children with chronic sinusitis: a pilot study

This pilot study assessed the safety and preliminary data on the efficacy of endoscopic ethmoidectomy in children with chronic sinusitis. A total of 168 patients were evaluated for chronic sinusitis, and 31 were deemed appropriate candidates for ethmoidectomy. All patients were medical management failures. Twenty-six percent of the patients had asthma, 23% had some immune deficiency, 23% had allergies, and 2 patients (1%) had cystic fibrosis. All patients were followed for at least 1 year postoperatively. The only surgical complication was minor middle meatal scarring that developed in two patients. Overall, 71% of the patients were considered normal by their parents 1 year postoperatively. Of the 24 patients who did not have an underlying systemic disease (immune deficiency or cystic fibrosis) postoperatively, 80% were considered normal by their parents, 12% were improved but continued to have some symptoms, and 8% had unsatisfactory results. Seven children with underlying systemic disease had to undergo revision ethmoidectomy for persistent symptoms.     

The relationship between anatomic variations of paranasal sinuses and chronic sinusitis in children

CONCLUSIONS: Anatomical variations in the nose and paranasal sinuses are common in children. Due to the absence of a definitive relationship between anatomical variations and sinus disease, local, systemic or environmental factors appear to be more significant in pediatric sinusitis than the anatomic variations. OBJECTIVE: Chronic sinusitis is increasing in the pediatric population. Following the initial reports of functional endoscopic sinus surgery (FESS) for children, the majority of patients undergoing this procedure have experienced improved quality of life. Thus, we need to know the precise anatomy and anatomical variations of the nose, as well as the relationship between such anatomy and chronic sinusitis. PATIENTS AND METHODS: To determine the extent and distribution of disease, as well as associated anatomic abnormalities, computed tomography (CT) scans were performed on 113 children with persistent symptoms of sinusitis after failure of medical therapies. RESULTS: The maxillary sinus was the most commonly involved sinus, followed by the ethmoid, sphenoid, and frontal sinuses. There was no relationship between age and severity of sinusitis. Agger nasi cell was the most common anatomical variation, followed by septal deviation, Haller cell, concha bullosa, paradoxical middle turbinate, and Onodi cell. The prevalence of septal deviation increased with age. There was no significant relationship between the sinusitis and anatomic variations.     

The relationship between anatomic variations of paranasal sinuses and chronic sinusitis in children

Conclusions. Anatomical variations in the nose and paranasal sinuses are common in children. Due to the absence of a definitive relationship between anatomical variations and sinus disease, local, systemic or environmental factors appear to be more significant in pediatric sinusitis than the anatomic variations. Objective. Chronic sinusitis is increasing in the pediatric population. Following the initial reports of functional endoscopic sinus surgery (FESS) for children, the majority of patients undergoing this procedure have experienced improved quality of life. Thus, we need to know the precise anatomy and anatomical variations of the nose, as well as the relationship between such anatomy and chronic sinusitis. Patients and methods. To determine the extent and distribution of disease, as well as associated anatomic abnormalities, computed tomography (CT) scans were performed on 113 children with persistent symptoms of sinusitis after failure of medical therapies. Results. The maxillary sinus was the most commonly involved sinus, followed by the ethmoid, sphenoid, and frontal sinuses. There was no relationship between age and severity of sinusitis. Agger nasi cell was the most common anatomical variation, followed by septal deviation, Haller cell, concha bullosa, paradoxical middle turbinate, and Onodi cell. The prevalence of septal deviation increased with age. There was no significant relationship between the sinusitis and anatomic variations.     

Nasal polyps and sinusitis in children with cystic fibrosis

Eighteen children suffering from cystic fibrosis and nasal polyps were studied. Two patients presented with nasal polyps at two years of age; the remaining patients had an initial polypectomy at any age up to fifteen years (mean age of seven and a half years). There were no obvious correlations between the cultures of the sinus washouts and the corresponding sputum samples. Organisms were only grown from five of the fifteen wash outs and from nine of the sputum samples. The patients with severe polyposis were not obviously more atopic.     

Nasal endoscopy in chronic maxillary sinusitis

The role of the anterior ethmoids in the pathogenesis of chronic maxillary sinusitis is still a subject of controversy. Although the symptoms of maxillary sinusitis may be clinically dominant, many previous studies have showed that the origin of this disease was, in most cases, located within the anterior ethmoid region. This study included 100 Egyptian patients, suffering from chronic maxillary sinusitis (confirmed by maxillary sinoscopy), who were subjected to 'systematic nasal endoscopy'. It was found that all cases of chronic maxillary sinusitis were associated with anatomical variations and/or pathological abnormalities of 'the ostiomeatal area'. It is recommended, therefore, that during the diagnosis and treatment of chronic maxillary sinusitis, attention should be given to the region of the middle meatus and anterior ethmoid complex (or 'ostiomeatal area') for any anatomical variations and/or pathological abnormalities in order to avoid recurrence of maxillary sinusitis. This is the basis of the procedure of functional endoscopic sinus surgery.