Biomedical subjects

Peter John Wormald

Publications and source records attributed to Peter John Wormald.

17 recordsLinked to original sources

PubMed2006

Mechanical endonasal dacryocystorhinostomy with mucosal flaps.

Mechanical endonasal dacryocystorhinostomy (DCR) involves the creation of a large rhinostomy and the preservation of lacrimal and nasal mucosa. It replicates the main advantages of the external approach to DCR using minimally invasive techniques. A thorough knowledge of intranasal anatomy and the close collaboration of a multidisciplinary team are important when converting from the external to the endonasal approach.

Dacryocystorhinostomy↗

PubMed2006

Endoscopic assessment of the dacryocystorhinostomy ostium after endoscopic surgery.

OBJECTIVES: Dacryocystorhinostomy (DCR) is currently regarded as the treatment of choice for treatment of epiphora resulting from blockage at the level of the nasolacrimal duct. There has been debate on the effect of healing on the size of the DCR ostium after surgery. The aim of this study is to determine how the size of the surgically created lacrimal ostium changes over time. STUDY DESIGN: The authors conducted a prospective cohort study of unselected patients who underwent DCR from March 1999 to November 2004. METHODS: Thirty-eight patients who underwent intranasal DCR were analyzed. There were 14 males and 24 females with 11 patients undergoing bilateral DCR, resulting in 49 endoscopic intranasal DCRs being analyzed. The endoscopic findings of the size of the ostia were recorded at the time of surgery and at 4 weeks, 6 months, and 12 months after surgery. There were 33 DCRs reviewed at 12 months and 16 reviewed at 6 months who did not reattend for their 12-month appointment. Analysis of variance was used to compare the difference in the ostium sizes at the end of surgery and at 4 weeks, 6 months, and 12 months after surgery. RESULTS: The male to female ratio was 1:1.7 and the average age was 64.5 (standard deviation [SD]=17.8 years). The ostium measured 11.8 (STD=2.3, 95% confidence interval [CI]=11.1-12.5)x7.2 (SD=1.7; 95% CI=6.7-7.7) at the time of surgery and 10.1 (SD=2.3; 95% CI=9.3-10.9)x6.4 (SD=1.3; 95% CI=6.0-6.9) at 4 weeks, 9.8 (SD=2.5; 95% CI=9.0-10.6)x6.5 (SD=1.5; 95% CI=6.0-6.9) at 6 months, and 10.1 (SD=2.5; 95% CI=9.2-11.0)x6.6 (SD=1.6; 95% CI=6.0-7.1) at 12 months. Statistical analysis (analysis of variance) showed a significant shrinkage from surgery to 4 weeks but no statistical difference from 4 weeks to 6 or 12 months. CONCLUSION: The DCR ostium shrinks a small but significant amount in the first 4 weeks after surgery. Thereafter, the ostium size appears to be stable. We propose that the surgical technique used in which the nasal and lacrimal mucosa is approximated results in a first intention healing with minimal ostial granulation tissue and stenosis and minimal shrinkage of the postoperative DCR ostium.

Dacryocystorhinostomy↗

PubMed2005

Prevalence of pus in radiologically diseased sinuses in patients undergoing surgery for chronic rhinosinusitis.

OBJECTIVE: To establish the prevalence of pus in radiologically diseased sinuses in patients undergoing sinus surgery and to correlate this with the bacterial load in the sinuses. STUDY DESIGN AND SETTING: A prospective study performed on adult patients with the diagnosis of chronic sinusitis undergoing endoscopic sinus surgery at an Adelaide group of academic hospitals. In 45 consecutive and unselected patients, a radiologically diseased sinus was surgically opened, and a specially designed suction aspirator was placed into the sinus under endoscopic control. These aspirates were Gram stained and cultured to quantify the polymorphonuclear neutrophil count, bacterial flora, and bacterial colony count. The CT scans of all patients were graded by using the Lund-Mackay scoring system. RESULTS: A variety of bacteria, most commonly staphylococci, were cultured from a radiologically diseased sinus in 88% of patients. There was no correlation between the bacterial colony count and presence of pus, and only 11% of patients had microscopic evidence of inflammation in sinus aspirates. There was no correlation between the Lund-Mackay CT score and the presence of pus in the sinus. CONCLUSIONS: The majority of patients undergoing surgery for chronic sinusitis did not have a purulent exudate, and there was no correlation with the bacterial load. The usefulness of antibiotics in the treatment of chronic rhinosinusitis, in the absence of macroscopic pus, is questionable.

Adult↗

PubMed2004

Role of local immunoglobulin E production in the pathophysiology of noninvasive fungal sinusitis.

OBJECTIVES/HYPOTHESIS: Immunoglobulin (Ig)E-mediated hypersensitivity to fungi has been postulated to explain allergic fungal sinusitis (AFS). Not all patients suspected to have AFS demonstrate systemic evidence of allergy. Locally produced IgE might explain those patients with no systemic evidence of allergy but clinical features of AFS. The aim was to determine whether fungal-specific IgE could be demonstrated in sinus mucin in patients with eosinophilic mucin rhino-sinusitis. STUDY DESIGN: A prospective study was undertaken in a tertiary rhinology practice in Adelaide, South Australia. METHODS: : Eighty-six consecutive patients with nasal polyposis and thick, colored macroscopically "fungal-like" sinus mucin at time of surgery for chronic sinusitis were entered in the study. The sinus mucin was liquefied and underwent testing for fungal-specific IgE (Pharmacia UniCAP) and fungal culture. Serum fungal-specific and total IgE, eosinophil count, C-reactive protein (CRP), and eosinophilic cationic protein (ECP) were measured. RESULTS: Fifty-six (65%) patients were fungal culture positive, and 37% had a detectable fungal-specific IgE in sinus mucin. Data were available to classify 81 patients: AFS = 24 (30%), AFS-like = 6 (7%), nonallergic eosinophilic fungal sinusitis = 32 (40%), nonallergic, nonfungal eosinophilic sinusitis = 19 (23%). Patients with AFS were significantly more likely to have fungal-specific IgE in sinus mucin (17/24, 71%, P =.02). In all fungal culture-positive patients, positive mucin fungal-specific IgE was significantly associated with systemic fungal allergy (P =.005), but a raised total serum IgE was not. Six (19%) of the 32 patients with positive fungal cultures but negative serum fungal-specific IgE had a positive mucin fungal-specific IgE, suggesting that they may be reclassified as AFS. The mean ECP and total IgE were raised most significantly in the AFS subgroup. CONCLUSIONS: This is the first study to show that fungal-specific IgE may be demonstrated in sinus mucin. It was significantly associated with systemic fungal allergy and may play a role in a minority of fungal sinusitis patients in the absence of systemic fungal allergy.

Adult↗

PubMed2004

Efficacy of endoscopic sinus surgery for paranasal sinus mucocele including modified endoscopic Lothrop procedure for frontal sinus mucocele.

This study evaluated the efficacy of the modified endoscopic Lothrop procedure (MELP) for complicated frontal mucoceles and endoscopic marsupialization for other paranasal sinus mucoceles. It was a retrospective, consecutive case review of sinus mucoceles treated endoscopically by a single surgeon over a four-year period (1998-2002). There were 41 mucoceles in 28 patients, including 24 frontal, eight frontoethmoidal, three ethmoidal, five maxillary and one frontal mucocele. Twenty-one patients underwent the modified Lothrop procedure for frontal mucoceles, and seven underwent simple drainage and marsupialization for frontoethmoidal, ethmoidal and maxillary mucoceles. At median follow-up of 16 months, all patients had a patent mucocele opening. Patients treated by drainage and marsupialization did not have any complications or mucocele recurrence. All patients treated by the modified endoscopic Lothrop procedure had improvement in symptoms and signs. Four patients had minor complications including epistaxis and adhesions and five required further surgery. The average hospital in-patient stay was 2 +/- 1.4 days. Endoscopic techniques, including MELP are effective in the short term for the management of complex and simple paranasal sinus mucoceles. MELP has a useful place in the management of mucoceles with a significant bony partition from an adjacent sinus or nasal cavity. It is also indicated when the mucocele is associated with loss of lateral support in the sinus with risk of medial-wall collapse of the orbital contents obstructing drainage.

Adolescent↗

PubMed2004

The effect of nasal packing and prednisolone on mucosal healing and reciliation in a sheep model.

STATEMENT OF PROBLEMS: To determine whether topical prednisolone affected sinus mucosal healing in a sheep animal model. METHODS OF STUDY: A standardised sheep model with concurrent Oestrus ovus infection was utilised. Following full thickness nasal mucosal injuries, hyaluronic acid packs soaked with prednisolone were applied to one side of the nasal cavity, with hyaluronic acid packs without prednisolone, to the other. At four weekly intervals, for 16 weeks, mucosal biopsies were taken and analysed for epithelial thickness and length, for cilial height and percentage of ciliated mucosa and mucosal inflammation. RESULTS: Eighteen sheep were utilised, with each acting as its own control. At completion of the study there was no statistical difference between the control or treatment group for the percentage of mucosal epithelialisation (mean: 86.5% vs 92.2%), epithelial thickness (mean: 39.7 microns vs 39.3 microns or the percentage of epithelium ciliated (mean: 26.5% vs 30.8%). Furthermore prednisolone had no effect on mucosal inflammation with the control arm mean score of 3.44 (SD .022) and treatment arm mean of 3.77 (SD 0.21). CONCLUSION: Hyaluronic acid nasal packs soaked in prednisolone failed to improve the speed of mucosal healing or re-ciliation in the sheep model of eosinophilic rhinosinusitis.

Adjuvants, Immunologic↗

PubMed2003

Endoscopic removal of juvenile angiofibromas.

BACKGROUND: Angiofibromas have traditionally been removed through open procedures. All tumors in this consecutive series of patients were removed endoscopically. SETTING: Tertiary care hospital. MATERIALS AND METHODS: Seven consecutive patients presenting with an angiofibroma between 1994 and 2000 were included in the study. Tumor size varied with 1 stage 1, 2 stage IIa, 3 stage IIb, and 1 stage IIC according to the Radkowski et al classification. The surgical technique is presented. RESULTS: After an average of 3.75 years (SD, 1.9 years), there have been no tumor recurrences. CONCLUSION: Endoscopic removal of angiofibromas in the nasal cavity, with extension into the sinuses and pterygopalatine fossa and with limited extension into the infratemporal fossa, can be removed endoscopically with a good success rate.

Adolescent↗

PubMed2003

The agger nasi cell: the key to understanding the anatomy of the frontal recess.

The key to successful surgery in the frontal recess is a complete understanding of the anatomy. The frontal recess is behind the beak of the frontal bone between the lamina papyracea and superior portion of the middle turbinate. It is a hazardous and complex area with a range of anatomical configurations. This article describes the anatomy of the frontal recess as it relates to the agger nasi cell using this cell as the key around which the anatomy is built. The simplest anatomical configuration is explained first and this knowledge is built upon so that the more complex configurations can be better understood. The classification of frontal ethmoidal cells by Kuhn is incorporated into the anatomical description of the various configurations. The implication of each anatomical variation on the surgical approach to the frontal recess is discussed.

Ethmoid Sinus↗

PubMed2003

Salvage frontal sinus surgery: the endoscopic modified Lothrop procedure.

OBJECTIVES/HYPOTHESIS: Until recent years, the osteoplastic flap with frontal sinus obliteration has been the gold standard for recalcitrant frontal sinusitis. The present series evaluated the role of the endoscopic modified Lothrop procedure, which has recently been advocated as an alternative. STUDY DESIGN: Prospective non-randomized interventional case series. METHODS: The study prospectively assessed 83 consecutive patients who underwent endoscopic modified Lothrop procedure. The mean age was 52.4 years (SD = 13.6 y) with a male-to-female ratio of 3:1. Patients had a mean of six previous sinus surgical procedures with 17 patients having undergone previous frontal sinus obliteration with mucocele formation. Seventy-six patients (91%) had frontal pain or headache as their primary presenting symptom, with 72 having nasal discharge. There were 14 patients who presented with 17 complications of frontal sinus disease. There were eight erosions of the posterior table of the frontal sinus with extension of the mucocele intracranially, seven orbital complications, and one cerebrospinal fluid leak. Twenty-four patients (30%) had fungus cultured from their sinuses at the time of surgery. RESULTS: Six of the 83 patients (7%) developed frontal ostium stenosis resulting in a 93% primary success rate after an average follow-up of 21.9 months (SD = 6.1 mo). These patients all underwent a revision modified Lothrop procedure and had a patent frontal ostium at their last review. Twenty-one patients (25%) developed recurrent symptoms, which were managed medically. Of these 21 patients, 9 with previously diagnosed fungal sinusitis developed mucosal changes again in their frontal sinuses, but their ostia have remained patent. Four patients have had recurrent infections in the frontal sinuses, and three patients with aspirin-sensitive asthma and polyps have developed polyps again in their frontal sinuses. Five patients continued to have frontal pain without radiological evidence of further frontal disease. No patients required an osteoplastic flap procedure. CONCLUSION: The endoscopic Lothrop procedure is a successful short-term management option for recalcitrant and complicated frontal sinusitis caused by a wide range of diseases.

Chronic Disease↗

PubMed2003

Endoscopic removal of sinonasal inverted papilloma including endoscopic medial maxillectomy.

OBJECTIVES/HYPOTHESIS: Surgical excision is regarded as the treatment of choice for sinonasal inverted papilloma. Resection can be performed endoscopically or through an external approach. Debate exists about which approach to use. The study presents different endoscopic techniques for various tumor locations and reviews the results. STUDY DESIGN: A prospective study and an integrated literature review. METHODS: Seventeen consecutive patients with inverted papilloma who underwent endoscopic surgical excision, including medial maxillectomies and modified Lothrop procedures, were analyzed. Preoperative symptoms, computed tomography and magnetic resonance imaging findings, operative findings, tumor stage, and outcomes were recorded. RESULTS: Thirteen male and four female patients presented with inverted papilloma between December 1993 and October 2001. Nasal obstruction was the most common presenting symptom (50%). Sixty-five percent of tumors were either stage II or stage III. Endoscopic resection was the primary treatment in 14 patients. Of the three patients who were secondarily treated endoscopically, one had recurrence and was subsequently found to have focus of squamous cell carcinoma. The overall recurrence rate was 6% and the incidence of malignancy was 6% (1 of 17). Recurrence rate for primary resections was zero (0 of 14). Five patients underwent endoscopic medial maxillectomies, and one patient with frontal sinus inverted papilloma was successfully treated with a modified endoscopic Lothrop procedure. CONCLUSIONS: Endoscopic sinus surgery is a viable treatment alternative for sinonasal inverted papilloma. Recurrence rates for primary treatment are comparable to external approaches. Close follow-up of patients is mandatory because recurrence may be associated with malignancy.

Adult↗

PubMed2003

Modified endoscopic lothrop as a salvage for the failed osteoplastic flap with obliteration.

OBJECTIVE: To evaluate the effectiveness of the modified endoscopic Lothrop (MEL) procedure for the management of failed osteoplastic flap (OPF) with obliteration of the frontal sinuses. SETTING: Adelaide University Academic Hospital Complex. STUDY TYPE: Prospective case study of 16 patients presenting with symptoms after OPF with obliteration of the frontal sinuses. MATERIALS AND METHODS: Sixteen patients presented with symptoms of frontal sinus pain after having previously undergone OPF and fat obliteration of the frontal sinuses. All patients underwent computed tomography scanning; 13 underwent magnetic resonance imaging scanning, and 6 underwent a bone scan with technetium to exclude frontal osteitis. All patients underwent exploration of the frontal sinuses by way of the MEL procedure. RESULTS: Fifteen patients were found to have a frontal sinus mucocele, whereas one patient had no mucocele with only new bone and fibrous tissue found at the MEL procedure. Twelve of the 16 patients with mucoceles had resolution of their frontal headaches, with 15 having a patent and healthy communication between the mucocele and the nasal cavity. The one patient without a mucocele continues to have frontal pain. One patient underwent a successful MEL procedure but had persistent symptoms until a supraorbital ethmoid mucocele was removed at a revision procedure. Two other patients continued to have frontal headaches and pain despite a healthy ostium into the frontal sinus mucocele. CONCLUSIONS: MEL is a viable alternative to revision OPF for symptomatic patients who are shown to have a mucocele of the frontal sinuses.

Adult↗

PubMed2002

Powered endoscopic dacryocystorhinostomy.

OBJECTIVES: To describe powered endoscopic dacryocystorhinostomy (DCR) with full sac exposure and primary mucosal anastomosis and report perioperative and follow-up results achieved with this procedure. STUDY DESIGN: Prospective, nonrandomized cohort study. METHODS: Operative and postoperative data were prospectively collected on 36 unselected patients (15 men and 21 women; mean age, 62.4 y; range 14-91 y) who presented to a lacrimal clinic with epiphora and obstruction of the drainage of the nasolacrimal system and who consecutively underwent either primary or revision powered endoscopic DCR. A total of 47 procedures were performed; all were done by the same surgeon, who used a standardized surgical technique. Follow-up evaluations included symptom evaluation and endoscopic assessment of the newly created ostium with fluorescein testing at each postoperative visit. RESULTS: The only surgical complication was one case of orbital fat exposure. Forty-five of the 47 DCRs were patent after a mean follow-up of 11 months (standard deviation = 5 mo), yielding a success rate of 95.7%. Patency was assessed by endoscopic visualization of the ostium and fluorescein (initially placed on the conjunctiva) in the ostium. One of the 47 DCRs was a failure and one patient had O'Donaghue tubes in place with symptoms. Two patients with a patent ostium and positive results on fluorescein testing continued to have some symptoms. CONCLUSION: Powered endoscopic DCR with full sac exposure and primary mucosal apposition has a success rate comparable to that achieved with external DCR.

Adolescent↗

PubMed2002

The axillary flap approach to the frontal recess.

OBJECTIVES: To evaluate the access to the frontal recess using the axillary flap approach by identifying the frontal ostium during endoscopic sinus surgery. STUDY DESIGN: Prospective review of 64 consecutive patients (118 sides) undergoing axillary flap exposure of the frontal recess between November 1998 and July 1999. METHODS: Demographic data, identification of the frontal ostium, findings at surgery, use of nasal packing, the presence of postoperative symptoms, revision surgery, and the endoscopic appearance of the frontal recess were collected. The operative technique is presented. RESULTS: The frontal sinus ostium was identified in 96% of patients (104 of the 118 sides). Eight sides had Kuhn type 3 cells that required removal for clearance of the frontal ostium. Eighty-two percent of sides (97 sides) had endoscopically healed sinuses without symptoms after an average follow-up of 15.4 months. Six sides had middle meatal adhesions requiring division under local anesthetic. One patient has required revision surgery. CONCLUSION: The axillary flap approach to the frontal recess provides excellent access to the frontal recess and allows clearance of cells in the recess with identification of the frontal ostium in the vast majority of cases.

Adult↗

PubMedDate not supplied

Surgical techniques for the removal of frontal recess cells obstructing the frontal ostium.

BACKGROUND: Cells pneumatizing through the frontal ostium may vary in the degree of frontal sinus penetration. This series describes the use of the axillary flap technique and the endoscopic modified Lothrop procedure (EMLP) for the removal of cells that pneumatize to a varying degree through the frontal ostium into the frontal sinus. METHODS: Out of a total of 204 patients undergoing endoscopic sinus surgery, 31 patients had a cell on one side and 7 patients had bilateral obstructive cells resulting in 38 sides undergoing an axillary flap approach for the removal of the obstructing cell. In 13 patients, the obstructing cell was deemed inaccessible by conventional technique and these patients underwent an EMLP for removal of the obstructing cell. RESULTS: All patients who underwent both the axillary flap approach and the EMLP had a patent frontal ostium confirmed endoscopically at the last follow-up visit. However, 8 of the 38 sides (21%) that underwent the axillary flap procedure had residual minor symptoms with four patients (30%) who underwent an EMLP having a recurrence of minor symptoms CONCLUSION: The axillary flap and the EMLP can be used to remove successfully ethmoidal cells that have pneumatized through the frontal ostium.

Adult↗

PubMedDate not supplied

The incidence of complications after canine fossa puncture performed during endoscopic sinus surgery.

BACKGROUND: Patients with extensive disease affecting the maxillary sinus may require a canine fossa approach for complete removal of disease. This study was designed to determine the complications associated with this procedure. METHODS: We performed a retrospective study of 21 patients who had undergone a canine fossa puncture at an academic hospital complex in Adelaide, Australia. RESULTS: A total of 37 canine fossa punctures were made in 21 patients. Twenty-eight of the 37 (75.7%) sides in which a canine fossa puncture was performed experienced a complication. The most common complaint was of cheek swelling in 14 (38%) followed by facial pain in 12 (32%), facial numbness in 11 (30%), cheek pain in 10 (27%), dental numbness in 10 (27%), gingival complications in 9 (24%), and facial tingling in 6 (16%) of sides. Most complications (75.5%) resolved within the 1st month after surgery. Six patients (28.6%) had persistent complications with facial tingling in 3 patients (50%) followed by facial numbness and tingling in 1 patient (11%), facial numbness alone in 1 patient (8.3%), and facial pain in 1 patient (7.1%). CONCLUSION: Canine fossa antrostomy is a technique that provides additional access to the maxillary sinus. Surgeons need to be aware that, although minor, a significant number of patients will experience both transient and long-term complications.

Adult↗

PubMedDate not supplied

A prospective single-blind randomized controlled study of use of hyaluronic acid nasal packs in patients after endoscopic sinus surgery.

BACKGROUND: The aim of this study was to determine whether there was any benefit or detrimental consequences of placing a hyaluronic acid pack (Merogel) into the middle meatus after endoscopic sinus surgery (ESS). METHODS: A randomized controlled blinded study was performed in 42 patients with chronic sinusitis undergoing ESS. The patients were randomized to receive Merogel on one side and no packing on the other side. Patients were assessed at 2, 4, and 6-8 weeks after surgery and the presence of synechia, edema, and infection was noted with the observer blinded to the side that had received the Merogel. RESULTS: At 2 weeks the side packed with Merogel had 35% synechiae, 83% edema, and 30% mucopurulent discharge and on the control side the figures were similar with 22.5% synechiae, 83% edema, and 28% mucopurulent discharge. In both groups these figures improved over the observation period but percentages in the groups remained similar. At no time point was the difference between the packed and unpacked sides statistically significant for any of the measures when assessed with Fisher's exact test. CONCLUSION: Merogel nasal packing has no significant beneficial or detrimental effect in terms of synechia, edema, or infection when placed in the middle meatus after ESS.

Adjuvants, Immunologic↗

PubMedDate not supplied

Endoscopic vidian neurectomy.

BACKGROUND: Vidian neurectomy has in the past been advocated for the treatment of vasomotor rhinitis. With the recent better understanding of nasal and sinus anatomy, the surgical technique and outcomes of this procedure have been reassessed in this preliminary report. METHODS: A total of nine patients with symptoms of vasomotor rhinitis underwent 14 endoscopic vidian neurectomies between 1998 and 2001. All patients had negative screening for allergies on their serum or on skin-prick tests. The surgical technique for endoscopic vidian neurectomy is presented. The outcomes for the patients were retrospectively assessed with patients asked to score their pre- and postoperative symptoms rating these symptoms on a scale of 1-10 after a mean follow-up of 25 months (range, 21-36 months). RESULTS: On this retrospective analysis there was a significant improvement in the symptoms of rhinorrhea (p = 0.018) and nasal obstruction (p = 0.011). There was no significant difference between the pre- to postoperative symptoms for postnasal drip or sneezing. The most common minor adverse effect was dry eyes (35.7%) and nasal crusting (28.6%). CONCLUSION: Endoscopic vidian neurectomy improves the symptoms of nasal obstruction and rhinorrhea in patients with vasomotor rhinitis.

Adult↗