Radiology quiz case: eosinophilic granuloma.
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Eosinophilic Granuloma↗
Biomedical subjects
R A Lebowitz
Publications and source records attributed to R A Lebowitz.
Asymmetry of the ethmoid roof: analysis using coronal computed tomography.
OBJECTIVES/HYPOTHESIS: To determine the incidence and degree of asymmetry in the height and contour of the ethmoid roof. STUDY DESIGN: Retrospective review of direct coronal paranasal sinus computed tomography (CT) scans. METHODS: Retrospective review of 200 consecutive direct coronal sinus CT scans done at New York University Medical Center from July 25, 2000 to October 11, 2000. The height and contour of the fovea ethmoidalis were examined for symmetry between the right and left sides. When an asymmetry in the height of the fovea ethmoidalis existed, this difference was quantified. RESULTS: In 19 scans (9.5%), there was an asymmetry between the height of the fovea ethmoidalis on the right and left sides. Of these 19, 12 (63.2%) were lower on the right side, whereas 7 (36.8%) were lower on the left. Ninety-six patients (48.0%) demonstrated a contour asymmetry with "flattening" of the ethmoid roof on one side, 46 on the right and 50 on the left. One patient demonstrated both height and contour asymmetry. The fovea ethmoidalis on the remaining 86 scans (43.0%) was symmetric. CONCLUSIONS: In a patient population with sinus and nasal symptoms, the height and contour of the right and left fovea ethmoidalis were symmetric in less than 50% of individuals. The asymmetry was most often the result of a difference in contour with flattening of the fovea on one side. This underscores the importance of careful preoperative and intraoperative review of paranasal sinus CT scans in patients undergoing endoscopic sinus surgery.
Cephalometry↗
Initial report on postoperative healing after endoscopic sinus surgery with the microdebrider.
Synechiae formation is a frequent occurrence after endoscopic sinus surgery and may cause symptomatic sinus outflow tract obstruction. Various means are used to reduce the incidence of synechiae formation. These include meticulous operative technique, partial middle turbinate resection, middle meatus spacers or stents, and postoperative debridement. The microdebrider is a powered rotary shaving device that precisely resects tissue, minimizing inadvertent mucosal trauma and stripping. We present 40 cases of endoscopic sinus surgery performed with the microdebrider. Patients had at least a 5-month follow-up and demonstrated rapid mucosal healing, minimal crust formation, and a low incidence of synechiae formation. These initial data suggest that the microdebrider may be advantageous in surgery for chronic sinusitis.
Adult↗
Conservative approach to inflammatory nasofrontal duct disease.
Endoscopic data reveal that mucosal disease frequently recurs following the surgical treatment of chronic diffuse hyperplastic frontal sinus and nasofrontal duct disease. However, this group of patients often remains asymptomatic. We present 40 patients who underwent endoscopic sinus surgery with a 4-year mean follow-up. Postoperative endoscopy revealed mucosal disease within the frontal recess in 39 of the 40 (97.5%) patients; however, only 3 of the 40 (7.5%) were symptomatic. Of these 3 patients, 1 underwent revision surgery. Historical information demonstrates the potential for significant nasofrontal duct stenosis associated with such revision surgery. On the basis of our initial results, endoscopic observation and medical therapy seem to be successful in controlling the symptoms associated with this disease process.
Adolescent↗
Anosmia and chronic sinus disease.
Chronic sinus disease associated with progressive mucosal disease is often a cause for anosmia. Despite aggressive allergic, medical, and surgical intervention, long-term relief of anosmia has been difficult to document. Fifty patients sought treatment for subjective anosmia and symptoms of progressive sinusitis and underwent endoscopic sinus surgery. After surgery 52% maintained significant improvement in smell by subjective measures that correlated with objective olfactory University of Pennsylvania Small Identification test ("UPSIT") results. Of the remaining patients, some had intermittent improvement, but most remained hyposmic or anosmic despite clinically well-healed ethmoid surgical beds. Of the preoperative and postoperative historical, clinical, and radiological data analyzed, severity of the presenting sinus disease (defined as stage II In the Kennedy staging criteria or disease extending beyond the ethmoids on preoperative computed tomography scan) and persistent mucosal disease in the surgical bed are associated with persistent anosmia (p = 0.005).
Adult↗
Cerebrospinal fluid drainage in the management of CSF leak following acoustic neuroma surgery.
A retrospective analysis was performed on 174 patients operated on from 1992 to 1995 to evaluate the safety and efficacy of continuous lumbar cerebrospinal fluid drainage (CLCFD) in the management of cerebrospinal fluid (CSF) leaks following acoustic neuroma surgery. There was a 17% incidence of CSF leak. CLCFD stopped the leak in 87% of cases. There were no cases of meningitis associated with CLCFD. One deep vein thrombosis was treated without sequelae. It is concluded that CLCFD is safe and efficacious. The authors recommend that CLCFD be implemented immediately when indicated, foregoing a trial of conservative therapy. Indications and precautions are discussed.
Cerebrospinal Fluid↗
Role of the agger nasi cell in chronic frontal sinusitis.
Agger nasi cells contribute to nasofrontal duct (NFD) obstruction and chronic frontal sinus disease. To investigate this relationship, we conducted a review of the surgical outcome and computed tomographic imaging in 26 patients with chronic frontal sinusitis. Coronal and sagittal images were used to delineate the anatomic variability and mucosal disease in the NFD and frontal sinus region. Data from coronal and sagittal images were compared. The results were also correlated with the outcome of frontal sinus surgery in patients with a clinical history of chronic frontal sinus disease. Our data suggest that agger nasi cell pneumatization with narrowing of the frontal sinus outflow tract is a significant cause of persistent frontoethmoid pain and chronic frontal sinusitis. Sagittal reformatted images are more capable than coronal images of demonstrating agger nasi cell encroachment on the NFD, as well as NFD mucosal disease. Endoscopic frontal sinusotomy is an effective treatment for chronic frontal sinus disease.
Adult↗
Safe and effective infundibulotomy technique.
The ostiomeatal complex has been identified as an important anatomic region in the pathogenesis of sinusitis. Functional endoscopic techniques rely on removal of mucosal disease from this site to improve drainage and aeration. Structural variations and the use of a sharp blade to create the infundibulotomy can result in inadvertent injury to the orbit. To avoid orbital penetration we perform the infundibulotomy with a curved, blunt dental elevator and displace the uncinate with its medial and lateral mucosa toward the middle turbinate. This stretches the infundibulum to reveal the maxillary ostium at its depth. The remaining mucosal attachments of the uncinate process are then incised under direct vision, and the complex is resected, creating an initial wide antrostomy. This technique has avoided orbital penetration in 700 cases in patients with early or late stages of mucosal disease.
Endoscopy↗
Autologous fibrin glue in the prevention of cerebrospinal fluid leak following acoustic neuroma surgery.
Postoperative cerebrospinal fluid (CSF) leak is a serious complication of acoustic neuroma surgery. The authors retrospectively reviewed the charts of 492 patients who underwent acoustic neuroma surgery to determine the efficacy of fibrin glue in preventing postoperative CSF leak. Thirteen of 92 patients (14%) undergoing retrosigmoid/transmeatal surgery experienced CSF leak when fibrin glue was used; 29 of 199 patients (15%) when it was not used. Nineteen of 85 patients (22%) experienced CSF leak when fibrin glue was used following translabyrinthine surgery; 23 of 116 patients (20%) when it was not used. No decrease was noted in the incidence of CSF leak following acoustic neuroma surgery with the use of autologous fibrin glue.
Cerebrospinal Fluid Otorrhea↗
The role of flexible bronchoscopy in children with AIDS: an update of the New York University experience.
The clinical courses of children with acquired immunodeficiency syndrome (AIDS) who underwent diagnostic flexible bronchoscopy at Bellevue Hospital from 1987-1992 were reviewed to determine the value of the procedure in patient management. Twenty-eight children (age 13 days to 12 years) underwent 31 bronchoscopies for indications including respiratory distress, fever and abnormal chest radiograph. Procedures were well tolerated. Complications were limited to transient hypoxia and epistaxis. Although 58% of bronchoscopies yielded a diagnosis (Pneumocystis carinii, Streptococcus viridans, Pseudomonas aeruginosa, Cytomegalovirus, atypical mycobacterium, giant cell pneumonia, and mechanical obstruction), empiric medical therapy was altered in only 16% of cases. Bronchoscopic diagnoses are correlated with Centers for Disease Control (CDC) classification, immune status, treatment and outcome.
AIDS-Related Opportunistic Infections↗
Preoperative sagittal CT evaluation of the frontal recess.
Endoscopic surgical approaches for chronic frontal sinusitis require the reestablishment of adequate frontal sinus ventilation and drainage for relief of symptoms. After the resection of anterior ethmoid mucosal disease and cellular structure, the anterior to posterior depth of the nasofrontal beak to the base of skull at the insertion of the ethmoidal bulla (frontal sinus ostium) often represents a critical margin for functional success. However, little information concerning this dimension is available. Depending on intraoperative surgical judgment of this distance, extended endoscopic surgical procedures involving additional bone resection may be indicated. These approaches may be hazardous due to the proximity of the cranial cavity and orbit. In addition, secondary stenosis can result from the subsequent inflammatory response. Improved CT imaging, high resolution sagittal reformatting, and computer workstations provide the ability to obtain direct preoperative measurements of the frontal recess. We used a paramedian sagittal section and recorded the maximal anterior to posterior depth from the nasofrontal beak to the base of skull at the insertion of the ethmoidal bulla in 20 patients, 31 sides, undergoing primary endoscopic frontoethmoidectomy. In addition, we found a positive correlation between this distance and agger nasi air cell size measured in the same 31 sides.
Chronic Disease↗
The bacteriology of chronic rhinosinusitis: results using a novel culture device.
The bacteriology of chronic rhinosinusitis is an area of great interest among rhinologists. Numerous studies have reported culture results implicating a variety of aerobic and anaerobic organisms in the etiology of this disease process. Sampling is generally accomplished through the nasal cavity, creating the potential for contamination with resident nasal flora. In some reports, strict anaerobic techniques have not been used, possibly accounting for the failure to recover these fastidious organisms. In an attempt to clarify the microbiology of chronic rhinosinusitis, we used a novel culture and transport system in 50 patients undergoing endoscopic sinus surgery. The Accu-CulShure (MLA Systems, Pleasantville, NY, USA) is a self-contained polyethylene culture swab and transport device, capable of collecting a representative sample from the sinus without contamination, and preserving the quality of the material during transport. Our aerobic and anaerobic culture results, as well as pertinent patient data, are presented. The Accu-CulShure device may permit standardization of culture techniques for future studies, and allow for more accurate determination of the microbiology of chronic rhinosinusitis.
Adolescent↗
Middle turbinate resection: issues and controversies.
Diversity of opinion continues to exist among otolaryngologists regarding the potential benefits of preservation or resection of the middle turbinate during endoscopic ethmoidectomy. Rhinologists in favor of middle turbinate preservation cite the potential loss of olfactory function as well as diminished humidification and filtration of inspired air following its resection. In addition, the middle turbinate remnant could lateralize, causing frontal recess obstruction and frontal sinusitis. In general, it is accepted that a diseased or flail middle turbinate should be resected during ethmoidectomy to create a marsupialized surgical bed. However, in the case of a structurally sound middle turbinate, indications for resection vary significantly. We are reporting on 100 primary endoscopic ethmoidectomies for chronic rhinosinusitis followed for at least 2 years. Of these 100 sides, 50 included conservative partial middle turbinectomy and 50 were performed with middle turbinate preservation. The postoperative clinical and endoscopic findings revealed no difference in the incidence of frontal sinusitis or frontal recess stenosis between groups. We compared additional data and present our technique of conservative middle turbinate resection, which preserves a portion of this structure as an important anatomic landmark.
Adolescent↗
Chronic sinusitis complicating sinus lift surgery.
Sinusitis has been reported as a complication of sinus lift surgery with antral bone augmentation. The procedure involves the creation of a submucoperiosteal pocket in the floor of the maxillary sinus for placement of a graft consisting of autogenous, allogenic, or alloplastic material. This can result in inadvertent tearing of the mucoperiosteal flap with extrusion of graft material into the antrum. Obstruction of the sinus outflow tract by mucosal edema and particulate graft material may result in sinusitis. We will discuss the clinical presentation and management of 14 cases of chronic sinusitis following sinus lift surgery with alloplastic hydroxyapatite (HA) augmentation of the maxillary antrum.
Adult↗
Histopathologic evaluation of the ethmoid bone in chronic sinusitis.
Chronic rhinosinusitis (CRS) is defined as a condition lasting for a period greater than 12 weeks, and manifested by an inflammatory response involving the mucous membranes of the nasal cavity and paranasal sinuses, fluids within these cavities, and/or the underlying bone. The mucosal changes that occur in CRS have been well described, and include edema, decreased number of ciliated cells, and goblet cell hyperplasia. However, the changes that may occur in the underlying ethmoid bone have only recently been investigated. We evaluated decalcified ethmoid bone specimens from 20 patients undergoing endoscopic sinus surgery for CRS. Our analysis revealed histopathologic changes consistent with varying grades of bone remodeling. Polarized light microscopy demonstrated changes in the extracellular matrix, such as bone resorption and neoosteogenesis. Preoperative clinical data and CT staging were recorded on all patients and correlated with the histopathologic findings. These findings suggest that CRS may be associated with osteitis of the underlying ethmoid bone.
Bone Remodeling↗
An analysis of sites of disease in revision endoscopic sinus surgery.
Revision endoscopic sinus surgery is performed when symptoms associated with sinusitis persist after sinus surgery and despite continued medical therapy. The causes of treatment failure are varied and may include systemic, mucosal, and anatomic factors associated with persistent inflammatory disease. The purpose of this retrospective review was to define the sites of recurrent or persistent sinonasal disease in patients undergoing revision endoscopic sinus surgery. This data was based on our preoperative CT scan and nasal endoscopy, as well as intraoperative findings. This study includes an evaluation of the most recent sinus surgery in a group of 153 patients and 265 operated sides. The frequency and distribution of regional anatomic sites of disease is presented and discussed.
Endoscopy↗
Antral augmentation, osseointegration, and sinusitis: the otolaryngologist's perspective.
Osseointegrated dental implants are a widely used method of replacing lost or missing teeth. Resorption of the alveolar ridge of the edentulous posterior maxilla may necessitate augmentation before osseointegration to provide adequate bone for implant fixation. This can be accomplished through an intraoral approach to the maxillary sinus, with elevation of the mucosa of the sinus floor creating a pocket for graft placement. Disruption of the intact sinus mucosa may result in sinusitis, graft infection, or extrusion with secondary formation of an oroantral communication. To treat these patients effectively, the otolaryngologist must be aware of the techniques of sinus augmentation and osseointegration as well as the etiology of associated complications. We will discuss the management of four patients with significant sinus complications, and evaluate the otolaryngologist's role in the preoperative and postoperative care of these patients.
Adult↗
Primary amyloidosis presenting as a nasopharyngeal mass.
Amyloid is defined as a pathologic proteinaceous substance which, when deposited between the cells of tissues and organs, leads to various clinical conditions. Immunohistochemistry has allowed for better classification and understanding of the pathophysiology of amyloidosis. In the upper aerodigestive tract, amyloidosis is a rare condition occurring most frequently in the larynx. We present the case of a 42-year-old woman with complete nasal obstruction due to primary nasopharyngeal amyloidosis. This represents the first reported case of primary nasopharyngeal amyloidosis containing both the lambda and kappa immunoglobulin light chains. The clinical and radiologic findings, as well as the management of primary amyloidosis of the upper aerodigestive tract, will be discussed. A review of the literature pertaining to nasal and nasopharyngeal amyloidosis will be presented.
Adult↗