Biomedical subjects
Publications and source records attributed to James A Stankiewicz.
CAS can be useful in orbital surgery. It can help to identify various structures, although it is certainly not necessary, nor is it a replacement for knowledge of the orbit's anatomy and its relationship to surrounding structures.
OBJECTIVE: To evaluate the incidence of occult pathology in routine, uncomplicated endoscopic sinus surgery, and to suggest guidelines for when to send specimens for histopathologic exam. STUDY DESIGN AND SETTING: Retrospective analysis of case records of 790 patients who underwent 868 endoscopic sinus surgeries at a tertiary care center from 1986 to 2003. Indications were chronic sinusitis, recurrent acute sinusitis, nasal polyposis, or combinations of these diagnoses. All cases were considered routine and did not involve preoperative suspicion of neoplasm or other complicating factors. Charts were reviewed for surgical indication, patient age, laterality of disease, history of prior sinus surgery, intraoperative suspicion of tumor, and final histopathology. RESULTS: In 868 cases of endoscopic sinus surgery, occult neoplasm was diagnosed in 2 patients (0.23%). In one patient, the initial surgery cured the lesion. Final histopathology of the remaining 866 (99.8%) specimens was consistent with inflammation and/or nasal polyposis. In 121 cases of unilateral sinusitis, none was positive for neoplasm. In 277 cases involving bilateral nasal polyposis and 13 involving unilateral polyposis, no neoplasms were found. Intraoperative suspicion of neoplasm occurred in 12 cases, with all specimens read as consistent with sinusitis and/or polyposis. CONCLUSIONS: Histopathologic review of every specimen obtained in routine sinus surgery for sinusitis and/or nasal polyposis is not indicated. Submission of specimen is indicated in routine cases when: 1) there is intraoperative suspicion of tumor, 2) unilateral nasal polyposis is present, 3) unilateral sinus opacification is present, and 4) additional diagnostic information is needed (eg, presence of eosinophils, fungal forms, etc.). SIGNIFICANCE: Establishes a safe and reasonable standard of care, with potential cost savings and medico-legal ramifications.
PURPOSE OF REVIEW: Little is published regarding variations of skull-base anatomy and their relevance to the performance of endoscopic sinus surgery. Several catastrophic complications have occurred in patients with low-lying skull-base variation. This review's purpose is to make the reader aware of skull-base variation, their recognition, and a surgical plan for sinus surgery in these patients. RECENT FINDINGS: Only a few papers are available for review discussing variations of the low-skull base. Recent findings in reviewing multiple CT scan indicate several variations of the skull. It has also been noted that there are variations of thickening in the skull (ie, lateral ethmoid, thicker bone, more medial, thinner bone). Several case reports have surfaced reflecting how a low-lying skull-base can play a role in brain-related complications. These figures are reviewed. SUMMARY: A knowledge of orbital and skull-base variations preoperatively can help plan the surgical procedure and avoid major complication. The preoperative CT scan is the key to preoperative knowledge. The use of special techniques to aid in localization of a low-lying skull-base including image computer guidance is recommended.
PURPOSE OF REVIEW: This review is designed to update the reader on the current state of nasal endoscopy in the control of epistaxis. Recent articles are reviewed and demonstrate recent developments and results. RECENT FINDINGS: The use of endoscopy for control of anterior and posterior epistaxis is beneficial, with less morbidity then external procedures or Caldwell Luc approaches. Postoperative endoscopic sinus surgery epistaxis is easily treated with endoscopic visualization. Epistaxis secondary to tumors can be controlled via an endoscopic approach. Patients with Osler-Weber-Rendu disease (hereditary hemorrhagic telangiectasia) can have more selective laser control of telangiectasia using endoscopic technique. Endoscopic septodermoplasty is straight-forward and avoids external incisions. Following a protocol for control of hemorrhage from an injured carotid artery during endoscopic sinus surgery, patients can survive with good function. SUMMARY: Endoscopic visualization and techniques are the state of the art for surgical control of epistaxis. Alternatives are embolization or external/Caldwell-Luc approaches.
Tinnitus is tolerated by most patients, but in others it is enough of a problem that they seek medical attention. Results of treatment have been mixed. On occasion, a patient is so distressed by tinnitus that he or she is incapacitated and seeks help in an emergency department. We describe what we believe is the first reported case of recurrent incapacitating tinnitus secondary to inner ear tertiary syphilis in which a patient successfully responded to emergency treatment with intravenous lidocaine.
The definition of chronic rhinosinusitis globally applies to any patient who has nasal and/or sinus inflammatory disease for a period of more than 3 months, provided the patient has particular signs and symptoms. However, to treat chronic rhinosinusitis appropriately, specific etiologies must be diagnostically ruled in or out. Chronic rhinosinusitis can be complex, because there are several factors involved in its causation. Endoscopy and imaging can play a role in helping to lead to a more specific diagnosis, allowing more targeted treatment.
OBJECTIVE: While reported results utilizing the osteoplastic flap procedure are very good, some patients fail the surgery due to recurrent or persistent frontal sinus disease. This study was performed to evaluate the utility of the endoscopic modified Lothrop sinus surgery for osteoplastic flap failure. STUDY DESIGN AND SETTING: A retrospective chart analysis and telephone survey of 10 patients from outside our institution for whom an osteoplastic flap with fat obliteration failed were salvaged using a computerized endoscopic modified Lothrop procedure. RESULTS: The main complaints were headache/pressure and recurrent infection. The usual pathology was chronic sinusitis and/or mucocele. The frontal recess and floor of the frontal sinus were the most common areas of persistent disease. Symptomatic clinical improvement was noted in more than 90% of patients. CONCLUSION: Salvage endoscopic modified Lothrop sinus surgery is recommended for a limited number of traditional osteoplastic flap failures. Computerized surgical navigation may help avoid complications in situations with abnormal anatomy and previous dissection. SIGNIFICANCE: The endoscopic modified Lothrop procedure should be considered to salvage failed osteoplastic flap sinus obliteration.
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Explore the source record for details and available documents.
OBJECTIVE: The goal of the present study was to identify levels of leukotrienes released by leukocytes and nasal polyps from aspirin-sensitive patients (ASPs) and non-aspirin-sensitive patients (NASPs) after exposure to various concentrations of aspirin. Eosinophil expressions of apoptosis regulators were also compared. STUDY DESIGN AND SETTING: Leukotriene release from nasal polyps and leukocytes of ASPs and NASPs was measured after exposure to differing concentrations of aspirin. Eosinophils were analyzed for Fas and Fas ligand receptors using flow cytometry. RESULTS: NASPs showed increased leukotriene release from nasal polyps on increased aspirin exposure. Polyps from ASPs did not show any change. ASPs showed greater leukotriene release from blood on increasing aspirin exposure compared with NASPs. Flow cytometric analysis showed eosinophils in the peripheral blood of ASPs have decreased Fas expression compared with those of NASPs. CONCLUSIONS: This study showed differences in leukotriene release and eosinophil apoptosis between ASPs and NASPs. SIGNIFICANCE: These findings suggest a role of leukotrienes and eosinophils in aspirin sensitivity mechanisms in blood.
OBJECTIVE: Traditional assessments of the microbial flora associated with acute bacterial rhinosinusitis have relied on maxillary sinus punctures (taps) and culture. These taps are now considered the gold standard for obtaining cultures and are used as the method of identifying bacterial pathogens in antimicrobial trials. Maxillary sinus taps are limited by discomfort to the patients and technical concerns. Because of these factors, the standard of performing taps has limited antibiotic trials and microbial surveillance. Alternatives to maxillary sinus taps have been explored. STUDY DESIGN: We conducted a retrospective, systematic review of the literature from 1950 to 2000 of articles comparing culture techniques in the nose and paranasal sinuses for acute bacterial rhinosinusitis. RESULTS: Nasal cultures have poor correlation to maxillary sinus cultures, whereas there is 60% to 85% concordance between endoscopically guided middle meatal cultures and maxillary sinus cultures. These studies, however, are all limited by small sample sizes and therefore are inadequate to make any concrete recommendations regarding the relative role of endoscopically guided middle meatal cultures as a formal method of pathogen identification in acute bacterial rhinosinusitis. CONCLUSION: A formal prospective study with sufficient sample size to assess the concordance between the microbial flora of the maxillary sinus punctures and middle meatal cultures in acute rhinosinusitis is recommended.
OBJECTIVES: Although endoscopy has been shown by a few authors to be a valuable tool for the diagnosis of chronic rhinosinusitis, its true role in the evaluation of the patient with chronic rhinosinusitis has not been elucidated. The current definition of chronic rhinosinusitis is a symptom-based definition, and objective testing such as endoscopy or computed tomography (CT) is not included. However, the current treatment paradigm for chronic rhinosinusitis is dependent on the definition for diagnosis. Patients are treated with 4 weeks of antibiotics and decongestant/antihistamines/steroids based on the definition. This study aims to evaluate in a prospective fashion the place of endoscopy in the diagnosis of chronic rhinosinusitis. STUDY DESIGN: A group of 78 patients meeting the definition of chronic rhinosinusitis were subjected to same-day endoscopy and CT scanning. RESULTS: Seventeen (22%) of 78 patients had positive endoscopic and CT results. There were 20 (26%) of 78 patients with negative endoscopic and positive CT results. Six (8%) patients had positive endoscopic and negative CT results, and 35 (45%) had negative endoscopic and negative CT results. Overall, 37 (47%) patients had positive CT results, and 41 (53%) patients had negative CT results. Endoscopy showing the presence of purulence, nasal polyps, or watery congested mucosa correlated well with CT results. Negative endoscopy correlated with CT results in 65% of patients. CONCLUSION: The use of endoscopy to corroborate the diagnosis in nonpolypoid or nonpurulent rhinosinusitis in previously unoperated patients is questioned. Patients who meet the subjective definition of chronic rhinosinusitis should have a high degree of sensitivity and specificity with endoscopy or CT. The fact this is not the case questions the accuracy of the definition and the treatment paradigm. SIGNIFICANCE: According to this study, positive endoscopic results correlated well with CT, and negative endoscopic results correlated in 71% of patients with negative CT results.
OBJECTIVE: To evaluate the efficacy hydroxyapatite cement as an alternative to autologous fat in the obliteration of the frontal sinus after trauma or chronic suppuration. METHODS: Single institution, nonrandomized, prospective analysis of patients treated in an academic, tertiary care center. Patients were followed with physical examinations and were monitored for recurrent infections, which would have necessitated removal of the implant. Follow-up radiographs were obtained at 12 months. Standard surgical techniques were used to obliterate the frontal sinus with the addition of the placement of a vascularized pericardial flap along the frontal sinus floor. RESULTS: Eleven patients underwent hydroxyapatite frontal sinus obliteration. There were 2 women and 9 men in the series with age ranges from 33 to 82 years (mean, 48 y). Three patients underwent obliteration for trauma and 8 for chronic infections with or without mucopyocele. The mean follow-up is 27 months (range, 3.3-37 mo). No patient has developed clinical or radiographic evidence of recurrent frontal sinusitis and at this point no implants have been removed. Nine of 11 patients (91%) report complete resolution of all symptoms. CONCLUSION: Hydroxyapatite cement had demonstrated efficacy in full-thickness reconstruction of frontal sinus defects. The pericranial flap may provide a barrier to prevent infection of the implant in the face of acute ethmoid sinusitis. Hydroxyapatite cement offers the advantages of no donor site morbidity and the potential for complete osseointegration.
The intimate anatomical relationship between the orbit and the paranasal sinuses places the orbit and its contents at risk of harm from primary pathologic processes of the sinuses. In the absence of ophthalmic signs or symptoms, ophthalmologists are not routinely involved in the management of patients with sinus disease. Occasionally, some patients may develop ophthalmic complaints after surgical intervention. The orbit, optic nerve, extraocular muscles, and lacrimal drainage system are susceptible to injury during endoscopic sinus surgery. The risk of injury is related to the skill of the sinus surgeon, history of previous surgery, extent and severity of disease, and anatomic variation. Furthermore, recent advances in endoscopic sinus surgery, in particular the use of powered cutting instruments, has resulted in a novel mechanism of injury to the ocular structures.
BACKGROUND: The current definition of chronic rhinosinusitis is a symptom-based definition with minimal reliance on objective information. Based on this definition, patients are diagnosed and treatedl with medical therapy. A computed tomography (CT) scan is obtained only if the patient is not improved after medical therapy. No study is available evaluating in an evidence-based manner the accuracy of the current definition and its impact on diagnosis and treatment. METHODS: This study represents 78 patients evaluated in a prospective fashion who met the subjective criteria for the definition of chronic rhinosinusitis. All patients underwent a complete history with a questionnaire evaluating symptom severity, a physical exam including anterior rhinoscopy and endoscopy, and a CT scan obtained on the day of their initial visit. Objective CT scan findings were compared with the subjective findings and related to the ultimate diagnosis of chronic sinusitis. RESULTS: Only 37/78 (47%) had a positive (+) CT scan, indicating demonstrable sinusitis. There also was no real diffrence in symptom severity between patients with positive (+) and negative (-) CT scanning. CONCLUSION: The current symptom-based definition of chronic sinusitis poorly predicts whether a patient truly has chronic sinusitis and needs reevaluation.
BACKGROUND: Hydroxyapatite cement (HAC) was first introduced in the 1980s as a new method for bone replacement. However, it has not been recommended for use in areas exposed to air. Despite this, surgeries have been performed using HAC to close nasal/sinus cerebrospinal fluid (CSF) leaks or in the treatment of encephaloceles. METHODS: This study retrospectively documented four patients in whom HAC was used for closure of ethmoid and sphenoid sinus CSF leaks. RESULTS: This study showed that exposed hydroxyapatite could be extremely problematic resulting in scarring, chronic granulation, infection, and prolonged healing. Oftentimes, revision surgery was necessary to help control the reaction to hydroxyapatite. CONCLUSION: Because of the frequent complications occurring with use of hydroxyapatite in the paranasal sinuses, its use should be limited to selected individuals in whom difficulty in achieving closure of the CFS leak could be anticipated and in whom adequate tissue coverage could be provided.
BACKGROUND: The present treatment regimen for a diagnosis of chronic rhinosinusitis involves a prolonged course of antibiotic therapy along with other adjunctive therapy. The decision to start treatment is made after diagnosis of chronic rhinosinusitis, which is based on subjective symptoms. The working hypothesis of this study is that the diagnosis based on subjective symptoms is inaccurate, leading to inappropriate antibiotic therapy and unnecessary health care expense. METHODS: One hundred patients were evaluated prospectively to determine which patients qualified for this study. Seventy-eight patients satisfied current criteria for a diagnosis of rhinosinusitis. RESULTS: Fifty-three percent (41 patients) of the 78 patients did not have a diagnosis of chronic sinusitis based on same-day computed tomography (CT) scanning. A charge analysis comparing treatment after diagnosis with medical therapy alone and CT scan for failures versus CT scanning with medical treatment for positive scans was performed. Although the most economical method of treatment was initiating medical therapy, it was also the least sensitive and specific in that 52% of patients didn't require the treatment. Endoscopy and/or CT screening with medical therapy were much better at appropriate diagnosis and targeted therapy but charge analysis indicated a much higher cost. CONCLUSION: Presently, the current subjective diagnostic paradigm for chronic rhinosinusitis is most cost-effective but least accurate. Objective evaluations (endoscopy and CT scanning) to aid in diagnosis are more accurate but more costly. Where cost constraints are important, careful considerations of alternatives are important.
BACKGROUND: Knowledge of anatomy including variations observed with endoscopy or computerized tomography scan is vital to the performance of safe endoscopic sinus surgery. The lower-than-normal skull base/cribriform plate is an anatomic variation, which if not noted preoperatively, can lead to entrance into the brain causing major injury. METHODS: Four case studies of chronic rhinosinusitis are reviewed in which either the whole anterior skull base or the cribriform plate is lower than usual and major complications occurred. RESULTS: All four cases had unilateral or bilateral entrance into the skull base/cribriform plate of the brain in the biopsy specimen, postoperative cerebrospinal fluid leak, and/or brain hemorrhage. One patient died from the injury, three patients had marked neurological sequelae. The low skull base and its meaning for the surgeon is discussed at length. CONCLUSION: The preoperative anatomy as determined by endoscopy and computerized tomography scanning has to be identified. Variations or abnormalities should be noted and taken into consideration for preoperative and operative planning. Failure to note skull base or cribriform anatomy variations may lead to brain entrance, injury, and death.