Acoustic rhinometry and paranasal sinuses: a systematic study in models, anatomic specimens, and in vivo

OBJECTIVE/HYPOTHESIS: Acoustic rhinometry (AR) evaluates the cross-sectional areas (CSA) of the nasal cavity through acoustic reflections. The aim of this study was to test whether the paranasal sinuses are a cause for the measurement of increased CSA in the posterior cavum of the nose. STUDY DESIGN:: Experimental study to evaluate the influence of paranasal sinus volume on AR measurements in two anatomic nose models, an anatomic specimen, and seven individuals. METHODS: The paranasal sinus volume was systematically reduced by filling of the maxillary sinus with saline. The paranasal sinus ostia were enlarged in the models and the anatomic specimen by infundibulotomy and supraturbinal fenestration, with AR repeated thereafter. RESULTS: No modification of the posterior area-distance curve was found in the models, the specimen, and the individuals after changing the volume of the maxillary sinus with unmodified anatomy of the paranasal sinus ostia. The apparent CSA measured in the posterior cavum after infundibulotomy and supraturbinate fenestration in the models and the specimen increased with the volume of the paranasal sinuses. CONCLUSION: Regular anatomy provided, AR reveals reproducible measurements that correspond with the actual CSA up to the ostia of the paranasal sinuses. Untypical large openings to the paranasal sinuses (e.g., after paranasal sinus surgery) appear to contribute to the inaccuracy of AR by overlapping paranasal sinus CSA with the posterior part of the area distance curve.     

Risk assessment in coronal computed tomography scans of the paranasal sinuses

Computed tomography (CT) is a prerequisite to planning and performing FESS procedures. No standards exist for assessing the risk to the anatomical structures in the proximity of the nose and sinuses associated with surgery. The aim is to assess the agreement of surgeons in identifying key areas related to the anterior skull base and the orbit on coronal CT scans. A cross-sectional study involving five otolaryngologists from three centres related the scans. Two scoring systems were used to rate each film; the Lund-MacKay system and a risk assessment system. The latter system was compiled and agreed upon by the authors. κ analysis was used for measurement of inter-observer agreement. A consecutive series of patients undergoing CT scanning in advance of paranasal sinus surgery formed the study population. Patients who had previous surgery, anterior skull base trauma or were suspected of malignant disease were excluded. Twenty-nine scans were reviewed. There was moderate agreement using the Lund-MacKay system (median value 0.5) values. The risk assessment system showed moderate agreement in two of 11 parameters (pneumatized ethmoid roof 0.58 and uncinate process variations 0.43), poor agreement on the other parameters assessed (range ?0.06–0.21). The difficulties encountered in judging vulnerability or anatomical structures on coronal CT of sinuses may relate to a lack of clear definitions of structures, subtle degree of variation or technical aspects of scanning.     

Efficacy of controlling rhinosinusitis on the prevention of complications in pituitary surgery with transsphenoidal approach

Objective

The microscopic transcolumellar transseptal transsphenoidal approach (TSA) is the one of the most widely used methods for the surgical treatment of sellar and parasellar lesions. But nasal and paranasal sinus inflammation is the relative contraindications of TSA. This study was performed to investigate the results of pre TSA treatment options according to the degree of nasal and paranasal sinus inflammation on the paranasal sinus computed tomography scan (PNS CT).

Methods

From January 2005 to September 2010, 145 consecutive patients underwent operation of pituitary lesions through the TSA. The preoperative CT images for these patients were reviewed, and 26 patients were identified with sinus opacification on PNS CT. We then analyzed presenting symptoms, physical and endoscopic examination, Lund–Mackay score on PNS CT and preoperative management of the sinus problem retrospectively.

Results

Twenty-six patients had sinus opacification on PNS CT. Eight patients had the symptoms of sinusitis corresponding to PNS CT finding, so they had therapeutic antibiotics, and had TSA after symptomatic improvement. Three patients had the symptoms of sinusitis and sinus opacification with mean Lund–Mackay score of 5.33, so they underwent endoscopic sinus surgery first, and they got TSA a few months after. One patient underwent endoscopic sinus surgery and TSA simultaneously. No patient had a serious complication including intracranial infection.

Conclusion

TSA is a relatively safe technique, but intracranial complication after surgery may be fatal. Therefore rigorous evaluation and management is mandatory. It is especially important to treat rhinosinusitis issues preoperatively. Our preliminary data may be helpful to evaluate and manage the paranasal sinus inflammation before TSA.     

Unilateral pathological lesions of paranasal sinuses removed by endoscopic surgery

Introduction

The aim of this study was to analyze the incidence and nature of unilateral pathological lesions of paranasal sinuses in patients who had endoscopic sinus surgery performed in ENT. Materials and methods: In the years 2006–2011 endoscopic sinus surgery for unilateral pathological lesions of paranasal sinuses was performed in 1847 patients (838 women and 1009 men). The enrollment of patients was based on the findings of otolaryngological clinical and subjective examinations, assessment of the paranasal sinuses on three-dimensional CT scans, and laboratory examinations. Based on the analysis of medical history data, including gender, age, the type of surgical procedure performed, and histopathological findings the cases were finally analyzed.

Results

Pathological lesions of the paranasal sinuses were localized on the left side in 132 (57%) patients, and on the right side in 100 (43%) patients. Of the 232 patients with unilateral pathological changes, 41.8% subjects underwent endoscopic sinus surgery for polypotic changes in the ethmoid and maxillary sinuses; 28.4% for the maxillary sinus; 10.8% for the ethmoid, maxillary and frontal sinuses; and 8.6% patients for all paranasal sinuses on one side. The number of operations of only one sinus was considerably lower: sphenoid sinus, 4.7%; ethmoid sinus, 2.2%; and frontal sinus, 1.7% patients. The histopathological analysis of unilateral pathological lesions removed by endoscopic surgery showed chronic paranasal sinusitis with polyps in 56.5% patients; chronic paranasal sinusitis in 22.8% patients; and maxillary sinus cyst was confirmed in 11.6% patients. In 5.1% patients inverted papilloma was diagnosed and in 2.2% patients the presence of osteoma was found.

Conclusions

Unilateral paranasal pathological lesions, leaving aside rather typical maxillary sinus cysts, require a particularly thorough pre-operative diagnosis and a precise histopathological assessment.     

增强MRI联合DWI序列对恶性肿瘤侵犯甲状软骨的诊断价值研究

目的探讨增强MRI联合DWI序列对喉癌和下咽癌患者的甲状软骨受累诊断价值,为制定合理的治疗方案及术中的具体处理提供重要的参考价值。方法选取自2013年1月~2014年12月在首都医科大学附属北京同仁医院头颈外科197例住院并行手术的原发喉癌及下咽癌患者,所有患者术前均行增强MRI检查,以组织病理学的结果作为金标准,计算增强MRI对喉癌和下咽癌患者的甲状软骨是否受累判断的敏感性、特异性、阳性预测值及阴性预测值,如果MRI判断为甲状软骨受累,还进一步判断肿瘤侵犯甲状软骨范围;影像学结果与病理对比分析并计算敏感性、特异性、阳性预测值及阴性预测值。所得数据并进行统计学分析。结果197例患者均行手术治疗,术后病理示63例患者（32.0%）甲状软骨受肿瘤侵及。MRI判断肿瘤侵犯甲状软骨与病理结果比较其敏感性、特异性、阳性预测值、阴性预测值分别为94%、87%、78%、97%。MRI判断肿瘤侵犯甲状软骨内板与病理结果比较其敏感性、特异性、阳性预测值、阴性预测值分别为90%、82%、61%、96%。MRI判断肿瘤侵犯甲状软骨外板与病理结果比较其敏感性、特异性、阳性预测值、阴性预测值分别为89%、84%、57%、97%。MRI对于甲状软骨内板和外板受累诊断结果的Kappa值分别为0.62和0.60。结论对于局部晚期喉癌或下咽癌是否侵犯甲状软骨的术前诊断中,可以采用常规序列联合SE EPI扩散加权成像弥散序列的MRI诊断。同时应用MRI对肿瘤侵犯甲状软骨范围进行诊断具有可行性。     

Acoustic rhinometry and paranasal cavities: a systematic study in box models

OBJECTIVE/HYPOTHESIS: Acoustic rhinometry (AR) is a well-established diagnostic tool in rhinology. The aim of the study was to test the hypothesis that the paranasal sinuses are a main cause for inaccuracy of AR in the posterior part of the nose. STUDY DESIGN: Experimental study to evaluate the influence of simulated paranasal sinus volume and of the contralateral side of the nose on AR measurements in "box models." METHODS: Models were measured with paranasal sinus volume simulated between 0 and 25 mL and with the junction between the models and the paranasal sinuses varying in length and diameter. RESULTS: Moderate but distinct modification of the posterior area-distance curve was found within the models after changing size of the paranasal sinuses and its junction to the cavity. The apparent cross-sectional area (CSA) measured in the posterior cavum decreased with the volume of the paranasal sinuses. This effect was limited by the length and the diameter of the paranasal junction, as well as by the concha. No influence of the contralateral side on AR measurements was seen. CONCLUSIONS: Acoustic rhinometry reveals reproducible measurements up to 4 cm from the nostril that correspond with the actual model CSA. Simulated paranasal sinuses appear to partially contribute to the inaccuracy in the posterior part of the area-distance curve.     

CT findings of aspergillosis in the paranasal sinuses

Summary The diagnosis of aspergillosis in the paranasal sinuses is preoperatively difficult to make in spite of the increasing number of reports showing its prevalence. However, because symptoms are usually non-diagnostic and infection is usually confined to a single sinus, X-ray findings are often suspect for possible neoplasm. We have studied six patients with aspergillosis, all of whom were suspected of having sinus tumors, but were otherwise healthy persons. Affected sinuses were examined by CT and the diagnosis of non-invasive aspergillosis was confirmed by operation. In this report, we have compared the CT and X-ray findings in our cases of aspergillosis. These findings indicate that CT is useful in the preoperative diagnosis of sinus aspergillosis.     

Parameters of nasal airway anatomy on magnetic resonance imaging correlate poorly with subjective symptoms of nasal patency

Forty-four patients undergoing magnetic resonance imaging (MRI) head scans for non-nasal disease were asked to complete a questionnaire immediately after the scan. Subjective patency was scored for each nasal airway, patients were also asked about other nasal symptoms, hay fever, upper respiratory tract infections, medication and any history of nasal surgery or trauma. The following measurements from MRI scans were made: the cross-sectional area of the nasal airway at the anterior end of the middle turbinate, the horizontal width of the inferior turbinate and maximum septal mucosal thickness. In addition the presence of any septal deviation and the thickness or the mucosa of the paranasal sinuses was assessed. Correlation between subjective airway patency and the anatomical parameters studied was generally very weak. However, patients with sinus mucosal thickening on MRI scanning had significantly lower subjective patency scores (left P= 0.003, right P= 0.029) for both nasal airways. Assessment of the nasal airway on MRI correlates poorly with symptoms of nasal obstruction. However, patients with sinus mucosal thickening ( > 5 mm) had significantly more symptoms of nasal obstruction on both sides.     

A stereological study on the correlation of inferior turbinate hypertrophy and paranasal sinus disease

The objective of this study is to investigate the correlation between inferior turbinate size and paranasal sinus opacification on computerized tomography (CT) scans. Paranasal sinus CT scans of a total of 185 patients (92 males, 93 females) were examined in terms of sinus opacification. Sizes of the inferior turbinates were measured using stereological method and these sizes in normal and opacified paranasal sinuses are compared using one-way analysis of variance. Scans of 185 patients (93 female, 92 male) aged between 12 and 84 (mean 37.85 ± 16.27) years were examined in this study. Sizes of the inferior turbinates were found to be increased significantly in case of opacification of ipsilateral maxillary and anterior ethmoid sinuses (p = 0.000 and p = 0.4, respectively) on both sides. On the other hand, such a relationship could not be demonstrated for sizes of inferior turbinates with opacified or non-opacified posterior ethmoid, frontal and sphenoid sinuses. In conclusion, the combination of CT and the Cavalieri principle can provide an unbiased, direct, and assumption-free estimate of the regions of interest. The presented method can be efficiently applied without any need for special software, additional equipment, or personnel than that required for routine CT in daily use. Paranasal sinus disease, especially the inflammatory diseases of maxillary and anterior ethmoid sinuses, must be carefully investigated in cases with inferior turbinate hypertrophy.     

鼻腔鼻窦腺样囊性癌放疗后诱发未分化多形性肉瘤1例报道

目的 总结鼻腔鼻窦腺样囊性癌放疗后诱发未分化多形性肉瘤(UPS)的诊疗经验.方法 回顾性分析1例鼻腔鼻窦腺样囊性癌术后4年放疗诱发未分化多形性肉瘤患者的临床资料,并结合文献进行分析.结果 患者于2015年1月行鼻侧切开上颌骨大部分切除术,术中完整切除肿瘤,术后病检结果提示为左侧上颌窦腺样囊性癌,术后规律行放化疗,201...     

Outcome of adenoidectomy versus adenoidectomy with maxillary sinus wash for chronic rhinosinusitis in children

OBJECTIVES: To compare postoperative outcomes of adenoidectomy versus adenoidectomy with maxillary sinus wash as surgical treatment of chronic rhinosinusitis (CRS) in children. STUDY DESIGN: A retrospective review of prospectively collected data. METHODS: Children who failed to respond to medical therapy for CRS and had an adenoidectomy alone (A) or an adenoidectomy with a maxillary sinus wash (wash/A) were reviewed. Outcome was assessed at least 12 months postoperatively. RESULTS: Sixty children who satisfied the inclusion criteria were reviewed. Thirty-two of the children had a sinus wash at the time of adenoidectomy. The age range was 3 to 13 years (mean, 6.3 years) and the mean computed tomography (CT) score was 6.1. The two surgical groups were comparable with regard to age, sex, presence of allergies, asthma, and smoking in the household. Twenty-eight (87.5%) of the 32 patients who underwent wash/A showed improvement of their symptoms after 12 months follow-up compared with 17 (60.7%) of 28 patients who underwent A (P = .017). Multivariable analysis using logistic regression analysis with age, sex, asthma, allergy, and CT score as covariables showed that the success of wash/A compared with adenoidectomy was higher (93% to 60%) for children with a high CT score compared to those with a lower CT score (P = .011). None of the other variables showed statistical significance. CONCLUSIONS: Children with more severe sinus disease as evidenced by a high CT score had a higher success rate if a maxillary sinus wash was performed at the time of adenoidectomy. Children with a low CT score did not have that benefit.     

The radiographic incidence of chronic sinus disease in the pediatric population

The otolaryngologist is frequently consulted for paranasal sinus disease which has been identified as an incidental finding on computed tomography (CT) in children. The significance of such a finding is difficult to interpret without prior knowledge of the actual incidence of chronic sinus mucosal hypertrophy in the general pediatric population. In this study of pediatric CT scans from busy otolaryngology and ophthalmology clinics, the radiographic incidence of sinus disease in the general pediatric population is estimated. One hundred forty-two CT scans of the orbits and temporal bones obtained over an 18-month period were reviewed. Fifty-eight (41%) scans showed some mucosal thickening or opacification in at least one sinus. When patients were stratified by age, or by the presence or absence of chronic otitis media or respiratory tract disease, exclusive of clinical sinusitis, there was no statistical difference between groups. The authors conclude that the asymptomatic child with an incidental paranasal sinus finding on CT scan need not be worked up further unless clinical symptoms and signs are elicited.     

Osteoma of the paranasal sinuses

Osteamas of the paranasal sinuses are rare, They often appear as a coincidental finding on X-ray in patients having radiographs for same other reasons. Tomographic evaluation is the mainstay surgical access and its subsequent follow up. We report a series of 20 cases of osteamas of the paranasal sinuses who underwent surgery for their symptoms. Wide exposure at surgery is necessary for complete or near complete removal. Tumour close to the dura, optic-nerve and internal carotid artery may be left Close and long period offollow-up is essential, especially when the tumour is partially left behind. In our experience, the rate of growth of tumour is very slow and a wait and watch policy can he adopted for very small tumours and those that are incompletely resected.     

鼻腔鼻窦骨化纤维瘤的螺旋CT诊断

目的探讨螺旋CT在鼻腔鼻窦骨化纤维瘤的诊断价值。方法回顾性研究本院行手术治疗并经病理确诊的鼻腔鼻窦骨化纤维瘤患者24例,分析其临床资料及螺旋CT影像学特征,探讨螺旋CT诊断程序。结果侵犯单个鼻窦的肿瘤12例,包括筛窦8例,上颌窦4例;其中6例伴有鼻腔侵犯。病变同时侵犯多个鼻窦和鼻腔者12例,包括上颌窦和筛实8例,筛窦和额窦4例。肿瘤的CT表现为鼻腔／鼻窦内单发类圆形或不规则形高密度肿块,部分区域可见低密度影,其周边显示完整的骨性包壳,呈膨胀性生长,周围组织受压变形但界限清晰。结论螺旋CT扫描是诊断鼻腔鼻炎骨化纤维瘤最常用和最有价值的影像学检查手段。     

A case of solitary fibrous tumour of the nose and paranasal sinuses

Solitary fibrous tumours (SFT), formerly known as benign fibrous mesothelioma, are rare mesenchymal spindle cell neoplasms, originally described in the pleura, but now found to arise in many other locations such as mediastinum, urogenital tract, face, nose, paranasal sinuses, orbit, meninges, ear, buccal mucosa, tongue, salivary gland etc. It was first described as a distinct neoplasm in 1931 by Klemperer and Rabin. On reviewing the literature, so far, 21 cases have been reported involving the nose and paranasal sinuses. A case of solitary fibrous tumour of the nose and paranasal sinuses is presented     

Unilateral opacification of the paranasal sinuses in CT or MRI: an indication of an uncommon histological finding

BACKGROUND: Clinical and radiological differentiation between subacute or chronic sinusitis and differential pathologies such as malignoma, inverted papilloma or mycosis can be very difficult. In some cases the CT- or MRI-scan shows a unilateral opacification of the paranasal sinuses. Which histological results can be found in patients with persisting sinusitis related problems and a unilateral opacification of the paranasal sinuses in the CT- or MRI-scan? There are only a few publications on this topic. PATIENTS: In a prospective study between June 1998 and November 1999 all patients who underwent surgery in our Department for subacute or chronic sinusitis problems were included into our study group if they had a unilateral opacification of the paranasal sinuses. Thereafter, the same neuroradiologist verified the unilateral radiological findings on CT or MRI, unaware of the clinical and histological findings. Cases with a pre-existing histological examination, previous operation or injury to the paranasal system were excluded from this study. Data on clinical symptoms, radiological and histological findings were analysed. RESULTS: 43 cases with unilateral opacified paranasal sinuses were diagnosed by means of CT or MRI. These were comprised of 24 males and 19 females with an average age of 43.6 years (range 6 to 88 years). The major findings of our study were as follows: Firstly unilateral opacification of the paranasal sinuses is often (19/43 cases or 43%) associated with diseases othe than simple chronic sinusitis (8 inverted papilloma, 5 malignoma, 3 mycoses and one brown tumor, one osteoidosteoma and one haemangioma). Secondly the incidence of significant pathology other than simple chronic sinusitis rises strikingly with increasing age of the patient. For instance pathologies other than simple chronic sinusitis were found in 14% (1/7) of cases in the under 16 years group, 27% (6/22) of cases in the 16-60 years group and in 86% (10/12) of cases in the over 60 years group. Concerning clinical signs of our patients with unilateral sinus opacity 7 of 11 patients (63%) with epistaxis and 3/5 with diplopia had histological findings other than simple chronic sinusitis. In contrast unilateral rhinorrhea, unilateral nasal congestion and cephalgia were not of predictive value. CONCLUSION: Unilateral opacification of paranasal sinuses in the CT or MRI is--especially at a higher age--an indice for a neoplasm or mycotic sinusitis and therefore an early histological diagnosis or operative treatment is always suggested.     

Ethmomaxillary sinus

Ethmomaxillary sinus is a variation of the posterior ethmoid cells. It is formed by the extension of the posterior ethmoid cells into the maxillary sinus and drains into superior nasal meatus. It is incidentally seen on paranasal sinus computerized tomography (CT) scans. Its prevalence has been reported as 0.7 and 2% in two studies. In this study, paranasal CT scans of 466 patients were investigated for the presence of ethmomaxillary sinus. The patients had paranasal CT with the preliminary diagnoses of septal deviation, chronic inflammatory paranasal sinus disease and nasal turbinate disorders. The ethmomaxillary sinus was present in nine of those patients (1.93%). It was septated in one of them. The CTs were further investigated for other anatomical variations and co-existent mucosal disease of the paranasal sinuses.     

Tuberculosis of paranasal sinuses

Nasal tuberculosis is very rare but much rarer is tuberculosis of paranasal sinuses. It involves especially the maxillary sinus and is usually unilateral. We report an unusual case of tuberculosis of frontal and maxillary sinus in a 68 years old male, who presented with a swelling above left medial canthus, with no other eye or nasal complaints. Clinical and radiological findings on our initial evaluation suggested that the patient had left frontal mucocoele with bilateral maxillary haziness. Diagnosis was established on FNAC report and subsequent Ziehl — Neelsen staining of nasal swabs and tuberculin skin test. Later chest x-ray examination was suggestive of pulmonary tuberculosis, which was the primary cause. Patient responded well to antituberculosis drug therapy.     

Surgical salvage after failed radiation for paranasal sinus malignancy

Objective: To comment on the role of surgical salvage following failed initial treatment for paranasal sinus malignancy. Design: A retrospective analysis of one hundred eighty patients treated at The Princess Margaret Hospital, Toronto, from 1976 to 1993. Materials and Methods: Thirty-four of 95 patients (36%) who failed initial treatment underwent surgical salvage. Initial therapy in this group was radiation only (n = 27) and combined therapy (n = 7). Patient, tumor, and surgical data were recorded. There were 23 T4, three T3, six T2, and two T1 carcinomas. Survival, recurrence rates, and the influence of a variety of variables on outcome were analyzed. Results: Two- and 5-year overall actuarial survival calculated from the date of diagnosis was 54% and 35%, respectively. Two- and 5-year overall actuarial survival calculated from the date of salvage surgery was 44% and 22%, respectively. Advanced age (P <.004), patients with T4 category disease (P <.04), and squamous cell carcinomas (P <.049) correlated with poorer outcome on univariate analysis. Local failure was the most common cause of death (n = 13; 65%). Conclusion: Salvage surgery has a limited role in the management of persistent or progressive disease following failure of initial treatment. Careful postradiation surveillance with endoscopic biopsy under general anesthesia and immediate surgical resection when appropriate may improve the salvage rate. Laryngoscope, 108:1618–1622, 1998     

Sinonasal organising haematoma – a little known entity

IntroductionSinonasal organising haematoma is a recently described, rare, benign inflammatory condition, which closely resembles malignancy in its clinical presentation.ObjectiveTo describe the clinical features of organising haematoma and to review the evolution of surgical options successfully used.MethodsA retrospective review of charts of all patients with a histopathological diagnosis of sinonasal organising haematoma was performed.ResultsSix (60%) of the 10 patients were male with a mean age of 47.4 years. All patients had unilateral disease with recurrent epistaxis as the presenting symptom. Maxillary sinus was the most commonly involved sinus. There was no history of trauma in any of the patients. Hypertension (80%) was the most commonly associated comorbidity. Contrast-enhanced CT scan of the paranasal sinuses showed heterogeneous sinus opacification with/without bone erosion. Histopathological examination was diagnostic. Complete endoscopic excision was done in all patients resulting in resolution of the disease.ConclusionAwareness of this relatively new clinical entity and its evaluation and treatment is important for otolaryngologists, maxillofacial surgeons and pathologists alike. Despite the clinical picture of malignancy, histopathological features of benign disease can safely dispel such a diagnosis.