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Biomedical subjects

Raj Sindwani

Publications and source records attributed to Raj Sindwani.

17 recordsLinked to original sources
PubMed2006

Endoscopic orbital and optic nerve decompression.

The endoscopic transnasal approach is well suited for decompression of both the orbit and optic canal. High-resolution nasal endoscopes provide excellent visualization for bone removal along the orbital apex and skull base. Endoscopic orbital decompression has proved to be safe and effective for the treatment of patients with Graves' orbitopathy; however, the indications and outcomes for endoscopic decompression of the optic nerve remain controversial.

Decompression, Surgical↗
PubMed2006

Anatomy of the orbit, lacrimal apparatus, and lateral nasal wall.

Endoscopic approaches to the orbit take advantage of key anatomic relationships that arise from the fact that the sinonasal tract and orbit are contiguous structures separated by thin bone. For the most part, the orbit is surrounded by air-containing sinuses for much of the length of three of its four borders. Thus, a thorough understanding of both sinonasal and orbital anatomy is essential for safe and efficacious surgery in this complex region. The structural features of the lateral nasal wall and medial orbit are highlighted, and relevant aspects of orbital, lacrimal, and paranasal sinus anatomy are reviewed.

Humans↗
PubMed2006

Endoscopic dacryocystorhinostomy and conjunctivodacryocystorhinostomy.

Intranasal approaches to the correction of lacrimal outflow obstruction initially were described more than 100 years ago, but they have gained renewed popularity with the recent development of the field of endoscopic sinus surgery. Endoscopic dacryocystorhinostomy (EDCR) surgery may be considered in many patients who have lacrimal outflow obstruction. It may be particularly advantageous in patients who have concomitant sinonasal disease, patients with a history of radiation therapy, pediatric patients, and in revision procedures. Advantages of the endoscopic technique include excellent visualization, the ability to evaluate the location and size of the rhinostomy site thoroughly, and the avoidance of a facial scar. Recent studies suggest that the success rates of EDCR are comparable to those achieved through traditional external dacryocystorhinostomy.

Conjunctiva↗
PubMed2006

Patient expectations and recovery following endoscopic sinus surgery.

OBJECTIVES: Studies examining the early postoperative period after endoscopic sinus surgery (ESS) are lacking. The objectives were to determine patient expectations of recovery following ESS and compare these expectations to actual outcomes. STUDY DESIGN: A prospective study. An 11-item survey regarding recovery from anesthesia and sinonasal outcomes was administered after ESS over postoperative days (POD) #1, #7, and #14. Preoperative surveys established baseline levels and explored patient expectations of POD #1 outcomes. RESULTS: Forty-six patients participated. Individual expectations generally did not correlate with POD #1 outcomes. Sinonasal symptoms, narcotic usage, and activity level (P < 0.05) demonstrated significant improvement over the postoperative period. Within one week, 75% of patients returned to work. By POD #14, nasal obstruction, discharge, fatigue, and overall health (P < 0.05) had improved over preoperative levels. Patients undergoing concomitant septoplasty had a more difficult postoperative course. CONCLUSION: Patient expectations of ESS vary widely, although this surgery is generally well tolerated with a brief recovery period. EBM RATING: C-4.

Activities of Daily Living↗
PubMed2006

Impact of duty hour restrictions on otolaryngology training: divergent resident and faculty perspectives.

OBJECTIVES: In 2003, the Accreditation Council for Graduate Medical Education (ACGME) passed a controversial mandate limiting resident work hours. We sought to examine the impact of these restrictions on otolaryngology programs and to explore faculty and resident perspectives. METHODS: Faculty and residents of all 102 ACGME-accredited otolaryngology residency programs were invited to participate in an anonymous online survey. RESULTS: The study population consisted of 460 respondents: 275 residents and 185 faculty (including 41 program directors) representing 57 otolaryngology programs. Sixty-five percent of programs implemented at least one change specifically to comply with duty-hour restrictions. Strategies included tracking work hours electronically (35.7%), utilization of "home call" (33.1%), and hiring additional healthcare professionals (23.1%). When asked if the restrictions have had a negative effect on patient care, 61% of respondents said no, but a surprising 33% said yes. Sixty-nine percent of faculty felt that the restrictions have actually had a negative effect on resident training compared with only 31% of residents (P<.001). Thirty-nine percent of participants felt resident workload was excessive before the restrictions. Opinions on whether duty-hour limits had fostered improvements in resident education, research, or examination scores varied, but most agreed that resident mental health had improved (67%). CONCLUSIONS: Otolaryngology programs have successfully restricted resident duty hours through significant infrastructural changes. Of concern, the majority of residents surveyed appeared to be in favor of the ACGME restrictions, whereas most program directors and faculty were opposed. Further studies are needed to establish whether limited work hours will enhance or hinder the residency training experience.

Adult↗
PubMed2006

Massive enlargement of the nasolacrimal canal causing epiphora and chronic maxillary sinusitis.

OBJECTIVES: Enlargement of the nasolacrimal canal (NLC) is a rare anatomic variant. We present the first report of a massively dilated NLC causing epiphora and chronic sinusitis. METHODS: The authors conducted a literature review and case report. RESULTS: A 65-year-old man with refractory sinonasal symptoms and a remote history of a dacryocystorhinostomy was found to have a massively dilated, air-filled NLC. Using a combined endoscopic transnasal and endoscope-assisted Caldwell-Luc approach, the posterolateral wall of the NLC was removed. The patient's symptoms were improved 10 months postoperatively. CONCLUSIONS: Symptoms suggestive of nasolacrimal dysfunction should prompt a search for potential sinonasal pathology.

Aged↗
PubMed2006

Frontal sinus cranialization using the pericranial flap: an added layer of protection.

OBJECTIVES: Extensive fractures involving the anterior and posterior tables of the frontal sinus are treated by frontal sinus cranialization. During this procedure, the disrupted posterior wall of the frontal sinus is removed, the sinus mucosa is drilled away, and the brain and dura are permitted to rest against the repaired anterior wall and sinus floor. Conventionally, the area originally occupied by the frontal sinus is left as dead space or filled with free adipose tissue. We describe a method of cranialization using a pericranial flap and report our experience with this technique. STUDY DESIGN: Retrospective study. METHODS: The medical records of patients who underwent frontal sinus cranialization using the pericranial flap at our institution were reviewed. Demographics, indications for cranialization, complications, and perioperative outcomes were examined. RESULTS: A total of 19 patients underwent (bilateral) frontal sinus cranialization with the pericranial flap between 2000 and 2005. Indications included extensive frontal sinus fractures involving the posterior table (78.9%), mucocele (10.5%), arteriovenous malformation (5.3%), and frontal bone osteomyelitis (5.3%). There were no intraoperative complications. A postoperative cerebrospinal fluid leak occurred in one patient with extensive skull base injuries. This was repaired endoscopically. Follow-up ranged from 9 to 55 months. CONCLUSIONS: The pericranial flap is easily harvested and versatile. Using this vascularized tissue during cranialization affords added protection by providing an extra barrier between the intracranial cavity and the frontal bone and sinonasal tract. This technique is inexpensive, safe, and effective and should be considered when cranialization of the frontal sinus is performed.

Adult↗
PubMed2005

Image-guided frontal sinus surgery.

Most patients with inflammatory frontal sinus disease that is un-responsive to medical therapy can be surgically managed with conventional endoscopic techniques; image-guidance technology is not usually necessary.However, in more advanced cases or for revision surgery, a surgical navigation system can be extremely beneficial in preoperative planning and intraoperative localization of complex frontal sinus outflow anatomy. For patients who have failed endoscopic approaches, external procedures, such as frontal sinus obliteration, can also be enhanced through the application of image guidance. Navigation technology has the potential to improve the efficacy and safety of frontal sinus surgery; however, its use is no substitution for proper surgical training and technique.

Frontal Sinus↗
PubMed2005

The next generation of navigational technology.

Registration for image guidance has become significantly simplified and will continue to improve in accuracy. Unparalleled visualization of target tissues has been made possible through advances in imaging technologies,some of which have been modified to be employed directly in the operating room. With the advent of functional imaging techniques, the promise of functional rather than structural imaging suggests potentially fascinating interventions based on functional disturbances in tissue. Given the aggressive nature of the technology industry, some of the issues in surgical navigation discussed in this article have probably already been resolved and may be on their way to market. Undoubtedly, other points will also soon be addressed in novel and imaginative ways. As a result, the authors hope, the practice of rhinology will continue to evolve to improve the standard of care for patients. The future of many therapeutic interventions seems to be tied to the information infrastructure provided by information-guided therapy. Only through the innovative use of information-guided technology will further minimization of risks and maximization of benefit be achieved.

Endoscopy↗
PubMed2005

Endoscopic frontal sinus obliteration: a new technique for the treatment of chronic frontal sinusitis.

OBJECTIVES: Patients who fail endoscopic drainage procedures for chronic frontal sinusitis often require obliteration of the frontal sinus with abdominal fat. The purpose of this study was to evaluate an endoscopic technique for frontal sinus obliteration. STUDY DESIGN AND SETTING: Retrospective case-control. Thirty-five patients underwent frontal sinus obliteration using either an endoscopic (n=10) or conventional osteoplastic flap (n=25) technique from 1994 to 2004 at an academic medical center. RESULTS: Patients undergoing endoscopic obliteration had less blood loss (P = 0.006), decreased operative time (P = 0.016), and a shorter hospital stay (P = 0.003) compared to osteoplastic control subjects. All 3 surgical complications occurred in the control group. No patients required additional surgery for frontal sinusitis. CONCLUSIONS: The endoscopic approach to frontal sinus obliteration appears to reduce patient morbidity and should be considered in the surgical management of advanced frontal sinus disease. SIGNIFICANCE: This is the first report of a minimally-invasive technique for frontal sinus obliteration.

Adult↗
PubMed2005

The maxillary line: anatomic characterization and clinical utility of an important surgical landmark.

OBJECTIVES: The maxillary line is a mucosal projection along the lateral nasal wall that serves as a landmark for endoscopic sinus and orbital procedures. The anatomic relations of this structure are not well described. We sought to define the anatomy of the maxillary line and explore its clinical utility. STUDY DESIGN: Cadaver dissection/case series. METHODS: Twenty-five cadaveric nasal specimens were dissected. Extranasal and intranasal measurements of structures including the lacrimal crests, sac and duct, the suture line between the maxillary and lacrimal bones, and the maxillary sinus ostium were taken. The mid-point of the maxillary line, termed the "M point," was used for reference. The distance from the nasal sill to the M point was measured in 30 consecutive clinic patients. RESULTS: The maxillary line corresponded intranasally to the junction of the uncinate and maxilla and extranasally to the suture line between the lacrimal bone and maxilla within the lacrimal fossa. This suture was approximately half way between the anterior and posterior crests. Axially, the plane of the M point corresponded to the superior margin of the maxillary sinus ostium posteriorly (average 10 mm) and was just inferior to the lacrimal sac-duct junction anteriorly. In live subjects, the M point was approximately 3.9 cm from the nasal sill in women and 4.8 cm in men. CONCLUSION: Understanding the conserved relationships of the maxillary line and M point with adjacent nasal and orbital structures will ensure the complete removal of the uncinate process during uncinectomy and promote safe and ample exposure of the lacrimal sac during endoscopic dacryocystorhinostomy.

Cadaver↗
PubMed2004

Impact of image guidance on complications during osteoplastic frontal sinus surgery.

OBJECTIVES: To evaluate the impact of image-guidance technology on intraoperative complications during frontal sinus obliteration surgery. STUDY DESIGN AND SETTING: Retrospective case control. Twenty-four patients underwent frontal sinus obliteration with image-guidance technology (n = 15) or conventional instrumentation (n = 9) between 1992 and 2003. The image-guidance system was used to delineate the frontal sinus perimeter and direct cuts through the frontal bone. RESULTS: Intraoperative complications occurred in none of the patients in the image-guidance group and in 3 patients in the control group (P = 0.042). Adverse events included dural tear with CSF leak in 2 patients and exposure of orbital fat in 1 patient. The incidence of postoperative complications was similar between groups (P = 0.326). No patients required revision surgery. Mean follow-up was 5.2 years. CONCLUSIONS: The use of surgical navigation during frontal sinus obliteration appears to improve intraoperative safety. SIGNIFICANCE: This is the first report to document a reduction in the rate of intraoperative complications when image guidance is utilized for frontal sinus surgery.

Case-Control Studies↗
PubMed2004

Endoscopic surgery for frontal sinusitis--a graduated approach.

Contemporary surgical treatment of patients with frontal sinusitis is based on a graduated approach determined by the patient's history and the extent of disease present. Most patients with inflammatory disease of the frontal sinus respond well to an anterior ethmoidectomy and clearing of agger nasi cells encroaching upon the frontal recess. In more advanced cases, a frontal sinusotomy with enlargement of the ostium may be performed to facilitate frontal sinus drainage and ventilation. For patients in whom conventional endoscopic techniques have not been successful, the floor of the frontal sinus is removed with a drill, usually with the assistance of image-guidance technology. Frontal sinus obliteration is reserved for patients with advanced disease for whom endoscopic management has been unsuccessful. Although patients with refractory frontal sinusitis can present a therapeutic challenge, proper surgical management usually results in successful control of symptoms and overall improvement in quality of life.

Drainage↗
PubMed2003

Myospherulosis following sinus surgery: pathological curiosity or important clinical entity?

OBJECTIVES/HYPOTHESIS: Myospherulosis is a foreign body reaction to lipid material used on nasal packing at the conclusion of sinus surgery. This reaction has been associated with postoperative adhesion formation. The purpose of the study was to determine whether the occurrence of myospherulosis has an adverse effect on clinical outcome following sinus surgery. STUDY DESIGN: Case-control study at an academic medical center. METHODS: Thirty-two cases of myospherulosis were identified in 28 patients (4 with bilateral disease) who underwent sinus surgery between 1989 and 1999. Cases were staged according to histological and radiological grading systems. Clinical outcome was compared with a control group of 28 patients who had similar surgery during the same time period. RESULTS: Patients with myospherulosis were found to have a significantly higher likelihood of developing postoperative adhesions compared with control subjects (50% vs. 18%, respectively [P =.023]). Histological stage, based on the extent of lipid vacuoles and spherules (erythrocyte remnants) present in the surgical specimen, was found to correlate with disease severity based on preoperative sinus computed tomography staging (P =.009). Patients with myospherulosis tended to have a shorter interval between their last two surgeries than did control subjects (2.2 +/- 2.1 vs. 4.5 +/- 7.1 y, respectively [P =.086]). Patient age, sex, comorbid conditions, CT stage, and number of previous operations were not predictive for the occurrence of myospherulosis. CONCLUSIONS: Patients who develop myospherulosis from lipid-based packing material used during sinus surgery are more likely to form postoperative adhesions. These adhesions appear to be clinically relevant and may hasten the need for revision surgery.

Adult↗
PubMed2003

Role of endoscopic septoplasty in the treatment of atypical facial pain.

BACKGROUND: An endoscopically performed septoplasty enables correction of deformities under superior visualization with limited tissue trauma and offers marked teaching advantages. OBJECTIVE: To investigate the role of endoscopic septoplasty in the treatment of atypical facial pain caused by septal contact points. In addition to describing the technique, we also intended to outline favourable selection criteria for patients who may benefit from this procedure. METHOD: Thirteen patients with unilateral facial pain and septal contact points with lateral nasal wall structures who met our inclusion criteria were selected for endoscopic septoplasty. RESULTS: The follow-up period ranged from 7 to 20 months postoperatively. There were no intraoperative or postoperative complications. Seven of 13 (54%) patients were "completely cured" of their facial pain and another 5 patients (38.5%) were "significantly improved." Only one patient did not improve following surgery. CONCLUSIONS: Endoscopic septoplasty is a useful approach for dealing with some septal abnormalities and can be very effective in the treatment of atypical facial pain in the appropriately selected patient.

Adult↗
PubMed2003

Perioperative management of the sinus patient: a Canadian perspective.

OBJECTIVE: To survey the current practices and opinions of Canadian otolaryngologists with regard to the perioperative management of the sinus patient and to explore practice variations and examine the preferred methods of experts. DESIGN: A mailed survey was designed and sent to all members of the Canadian Society of Otolaryngology-Head and Neck Surgery who practice in Canada. The multiple-choice questionnaire addressed issues including diagnostic evaluation; routine preoperative, intraoperative, and postoperative methods; and practice demographics. RESULTS: A total of 242 questionnaires were returned, for an overall response rate of 72%. Preoperatively, the majority of surgeons obtained a computed tomographic scan (70%) and administered inhaled steroids (83%). Half of those surveyed performed endoscopic sinus surgery (ESS) using the image on the video monitor, and close to 70% routinely used postoperative nasal packing. There were significant variations in practice habits between the general respondents and a subgroup of self-defined "experts" in the field, defined as those who spent greater than 40% of their clinical time managing sinonasal disease. Analysis uncovered that the experts were statistically more likely to use preoperative systemic steroids (p = .008), use the video monitor (p = .045), and perform surgery under neuroleptic anaesthesia (p = .045). As a group, they were also less likely to routinely use postoperative place nasal packing (p = .004). CONCLUSIONS: Considerable variations in clinical practices were identified among Canadian surgeons. Continued efforts aimed at diminishing these variations through the establishment of evidence-based practice guidelines will assist in standardizing the care of these patients.

Adult↗