American Journal of Rhinology & Allergy

Cigarette smoke exposure is considered an important negative prognostic factor for chronic rhinosinusitis (CRS) patients. However, there is no clear mechanistic evidence implicating cigarette smoke exposure in the poor clinical evolution of the disease or in the maintenance of the inflammatory state characterizing CRS. This study aimed to evaluate the effects of cigarette smoke exposure on respiratory cilia differentiation.

Mouse nasal septal epithelium cultures grown at an air-liquid interface were used as a model of respiratory epithelium. After 5 days of cell growth, cultures were exposed to air on the apical surface. Additionally, cigarette smoke condensate (CSC; the particulate phase of tobacco smoke) or cigarette smoke extract (CSE; the volatile phase) were diluted in the basolateral compartment in different concentrations. After 15 days of continuous exposure, scanning electron microscopy and immunofluorescence for type IV tubulin were used to determine presence and maturation of cilia. Transepithelial resistance was also recorded to evaluate confluence and physiological barrier integrity.

CSC and CSE impair ciliogenesis in a dose-dependent manner with notable effects in concentrations higher than 30 μg/mL, yielding >70% nonciliation and shorter cilia compared with control. No statistical difference on transepithelial resistance was evident.

CSC and CSE exposure negatively impacts ciliogenesis of respiratory cells at concentrations not effecting transepithelial resistance. The impairment on ciliogenesis reduces the mucociliary clearance apparatus after injury and/or infection and may explain the poor response to therapy for CRS patients exposed to tobacco smoke.

The use of cytosine-phosphate-guanosine-oligodeoxynucleotides (CpG-ODNs) or immunostimulatory sequences (ISSs) in the treatment of airway diseases is gaining interest. Binding of the CpG-ODN ligand to Toll-like receptor 9 (TLR9) triggers a shift from a Th2- to a Th1-type response in the target tissue. In this study, we explored the potential use of CpG-ODN to dampen the predominantly Th2-driven chronic inflammatory state in our cohort of patients.

An in vitro explant model comprising of sinonasal tissue from patients with asthma (n = 12) and without asthma (n = 11) were stimulated with CpG-ODN or Staphylococcus aureus enterotoxin B (SEB) or CpG-ODN in combination with SEBfor 48 hours. Ten of the 12 asthma patients had nasal polyps. RNA was extracted for multiplex real-time reverse transcription polymerase chain reaction analysis and the 2^{−delta deltaC_T} method used to determine interleukin (IL)-5, p35 IL-12, interferon (IFN) gamma, and TLR9 expression levels.

CpG-ODN significantly reduced IL-5 mRNA expression in patients without asthma (p = 0.0379) but not in the asthma-associated group. SEB alone caused an increase in IL-5 levels that could be dampened when CpG-ODN was added in combination with SEB. Significant differences in mean IL-5 expression levels between the asthmatic and nonasthmatic categories were detected (Welch t-test; ^**p = 0.0041). Asthmatic and nonasthmatic patients present as two distinct categories as reflected by significant differences in their IL-5 response to CpG-ODN (F = 11.93; ^***p = 0.0008), SEB (F = 41.34; ^*p = 0.0476) and CpG-ODN with SEB (F = 13.2; ^*p = 0.0114). In contrast, no significant differences were observed in the expression levels of IL-12, IFN-gamma, and TLR9.

Localized application of CpG-ODN on its own or in combination with SEB may potentially reduce the expression of the proinflammatory cytokine IL-5 in nonasthmatic patients and may be further developed as an immunotherapeutic agent.

Heparanase (HPA) is known to be involved in tissue remodeling of various organs with inflammatory diseases. The aim of this study was to investigate the level of expression and the pattern of distribution of HPA in normal human sinus mucosa, inflammatory sinus mucosa, and nasal polyps to evaluate the possible effect of HPA on the tissue remodeling of chronic inflammatory sinus mucosa and nasal polyps.

Normal sinus mucosa was obtained from the ethmoid sinus during endoscopic reduction in 25 patients with blowout fractures. Inflammatory sinus mucosa and nasal polyps were obtained from 25 patients undergoing endoscopic sinus surgery for chronic sinusitis with nasal polyps. The levels of expression and the pattern of distribution of HPA were evaluated in normal human sinus mucosa, inflammatory sinus mucosa, and nasal polyps, using reverse transcriptase-polymerase chain reaction, immunohistochemical analysis, and Western blot analysis.

HPA mRNA and protein were detected in inflammatory sinus mucosa and nasal polyps but not in normal sinus mucosa. HPA was mainly localized in the vascular endothelium, epithelium, submucosal glands, and inflammatory cells of inflammatory sinus mucosa. In nasal polyps, inflammatory cells and vascular endothelium showed immunopositivity in the entire portion, whereas glands and epithelial cells did not show positivity.

Our results indicate that HPA is not constitutively expressed in normal sinus mucosa and is upregulated in chronic inflammatory sinus mucosa and nasal polyps, suggesting that HPA may play an important role in the tissue remodeling in chronic sinusitis.

Although it is well known that olfactory receptor neurons differentiated from stem cells have an unusual lifelong ability to continue neurogenesis, effective treatment of patients with sensorineural olfactory loss is still lacking. The purpose of this study was to determine whether intranasal prolactin (PRL) is an effective inducer of proliferation in the olfactory epithelium (OE).

The OE of mice treated with PRL for 6 consecutive days and of pregnant mice on gestation day (GD) 7 was investigated by immunohistochemical study using antibodies to bromodeoxyuridine.

The number of bromodeoxyuridine -labeled cells in the OE increased significantly in PRL-treated female mice and GD 7 mice (but not PRL-treated male mice) compared with controls.

Pregnancy may induce proliferation in the OE, and administration of intranasal PRL may have almost the same effect as pregnancy on the OE of female mice.

Olfactory dysfunction is deemed to be a significant contributor to poor quality of life (QOL). However, little is known about the relationship of olfactory testing to other measures of disease burden in patients with chronic rhinosinusitis (CRS). In this study, we examine the relationship of olfactory function to computed tomography (CT) scores, endoscopy scores, and QOL measures in patients with CRS.

A multi-institutional, cross-sectional analysis of 367 patients was performed. Several objective measures were collected: the Smell Identification Test, Lund-MacKay CT score, Lund-Kennedy endoscopy score, two validated disease-specific QOL instruments, the Rhinosinusitis Disability Index and the Chronic Sinusitis Survey, and a general health-related QOL instrument, the Medical Short Form-36. Analysis of variance was performed. Correlation coefficients were calculated.

Patients with olfactory dysfunction had significantly worse mean endoscopy scores (normosmics, 4.16 [± 3.97]; hyposmics, 6.26 [± 4.21]; anosmics, 9.61 [± 4.48]; p < 0.001) and significantly worse CT scores (normosmics, 9.11 [± 5.40]; hyposmics, 11.16 [± 5.96]; anosmics, 17.62 [± 5.37]; p < 0.001). Endoscopy scores were moderately correlated with olfactory scores (r = -0.46; 95% CI, -0.38, -0.54; p < 0.001). CT scores were moderately correlated with olfactory scores (r = -0.53; 95% CI, -0.45, -0.60; p < 0.001). Olfactory function was not correlated with disease-specific or general health-related QOL measures.

Although previous studies have suggested that olfactory impairment is associated with poor QOL, this study found no such correlation. In contrast, olfaction scores correlated well with other objective measures of CRS, namely, endoscopy and CT scores.

The effect of comorbid conditions such as asthma and atopy on the severity of chronic rhinosinusitis (CRS) and the presence of nasal polyps (NPs) remains an area of investigation. We sought to elucidate the relationship among these entities.

The study population included 106 consecutive patients who were referred to a multidisciplinary, university-based allergy and sinus clinic that underwent computed tomography (CT) scan, skin-prick testing, and had CRS. Data were analyzed to determine Lund-MacKay score (LMS), presence of NPs, asthma status, and sensitivity to seven classes of aeroallergens.

Skin tests were positive in 52 cases and negative in 54 cases. Although, there was no statistical relationship between LMS and atopic status in the entire group, among the asthmatic subgroup, mean LMS was greater in nonatopic asthmatic patients than in atopic asthmatic patients. Asthmatic patients had a higher LMS than nonasthmatic patients (p < 0.0001). Asthmatic patients were more likely than nonasthmatic patients to have NPs (57.6% versus 25%; p = 0.0015), regardless of atopic status. Mean LMS was higher in NP patients compared with nonpolyp patients (p < 0.0001), independent of atopic status. Mean LMS was not affected by sensitivity to any particular allergen, with the exception of cockroach-allergic patients who were more likely to have an LMS of >10 (p = 0.0236) and had more severe maxillary sinus involvement (p = 0.0391).

These data indicate a strong relationship between CRS severity, as measured by LMS, and chronic airway inflammatory diseases, asthma, and NPs. The association between LMS and atopic status appears weak. The present study suggests that CRS is an inflammatory disease that occurs independently of systemic IgE-mediated pathways.

The purpose of this study was to compare vectorial ion transport within murine trachea, murine nasal septa, and human sinonasal cultured epithelium. Our hypothesis is that murine septal epithelium, rather than trachea, will more closely mimic the electrophysiology properties of human sinonasal epithelium.

Epithelium from murine trachea, murine septa, and human sinonasal tissue were cultured at an air-liquid interface to confluence and full differentiation. A limited number of homozygous dF508 epithelia were also cultured. Monolayers were mounted in modified Ussing chambers to investigate pharmacologic manipulation of ion transport.

The change in forskolin-stimulated current (delta-I_SC, expressed as micro-A/cm²) in murine septal (n = 19; 16.84 ± 2.09) and human sinonasal (n = 18; 12.15 ± 1.93) cultures was significantly increased over murine tracheal cultures (n = 15; 6.75 ± 1.35; p = 0.035 and 0.0005, respectively). Forskolin-stimulated I_SC was inhibited by the specific cystic fibrosis transmembrane regulator (CFTR) inhibitor INH-172 (5 μM). No forskolin-stimulated I_SC was shown in cultures of dF508 homozygous murine septal epithelium (n = 3). Murine septal I_SC was largely inhibited by amiloride (12.03 ± 0.66), whereas human sinonasal cultures had a very limited response (0.70 ± 0.47; p < 0.0001). The contribution of CFTR to stimulated chloride current as measured by INH-172 was highly significantly different between all groups (murine septa, 19.51 ± 1.28; human sinonasal, 11.12 ± 1.58; murine trachea, 4.85 ± 0.49; p < 0.0001).

Human sinonasal and murine septal epithelial cultures represent a useful model for studying CFTR activity and may provide significant advantages over lower airway tissues for investigating upper and lower respiratory pathophysiology.

Nasal obstruction (NO) is a very common symptom, but its effect on nasal physiology has not been fully understood. We performed this study to determine the effect of severity of NO due to inferior turbinate hypertrophy on airflow pattern using the computational fluid dynamics simulations.

A three-dimensional nasal cavity model was constructed from the MRI scans of a healthy human subject. Nasal cavities corresponding to healthy, moderate, and severe NO was simulated by enlarging the inferior turbinate geometrically, which can be documented by approximately one-third reduction of the minimum cross-sectional area (1.453 cm² in the healthy nose) for the moderate (0.873 cm²) and two-thirds (0.527 cm²) for the severe obstruction.

Total negative pressure through the nasal cavity increased during the inspiratory phase by almost twofold (-19 Pa) and threefold (-33 Pa) for moderate and severe blockage, respectively, compared with the increase of total negative pressure of -10 Pa in a healthy nose. In cases of moderate and severe blockage, a higher velocity and shear stress was observed at the nasopharynx and dorsal region of the nasal cavity. Moreover, nasal valve function will not exist in severe NO because of the changes of airflow pattern at the original nasal valve location.

Impairment of nasal airflow and physiology is evidenced in NO caused by inferior turbinate hypertrophy. Data of this study may help in predicting the aerodynamic effects of surgical correction of the inferior turbinate hypertrophy.

Nitric oxide (NO) has a variety of effects on the pathophysiology of the nasal cavity and seems to play an important role in inflammation. It is increased in the common cold but decreased in acute and chronic rhinosinusitis (CRS). Exhaled NO increases after endoscopic sinus surgery in CRS. In our previous study we showed that NO metabolite (nitrate and nitrite) levels are increased in the sinus cavity of CRS patients. We hypothesized that NO metabolite levels are increased to normal in the nasal lavage of CRS patients after endoscopic sinus surgery and NO metabolites in the nasal lavage can be used as indicators of the disease status after surgery.

This study was performed on 52 patients with CRS who did not respond to medical therapy and who underwent surgery. NO metabolite levels were measured in nasal lavages of the patients before surgery and 2 months after surgery.

NO metabolite levels (mean ± SEM) were 18.11 ± 3.08 μmol/L and 35.97 ± 4.64 μmol/L in nasal lavages of patients before and after surgery, respectively. The levels of NO metabolites were increased significantly (p < 0.01) after surgery in nasal lavages and patients reported significant improvement based on the visual analog scoring after the operation.

NO metabolite levels were decreased in nasal lavages of CRS patients and were increased to normal levels after surgery along with improvement of the disease. NO metabolite levels may be used as an indicator for the follow-up of patients after endoscopic sinus surgery.

Cooling may induce nasal obstruction. In our previous study, we showed low temperature induced a rapid relaxation of isolated human nasal mucosa and it was independent of vasoconstriction. The aim of this study was to elucidate the mechanism responsible for such findings.

Nasal mucosa strips were prepared from inferior turbinate samples. Decellularization of human nasal mucosa was achieved by treatment with sodium dodecyl sulfate 0.1% for 15 hours at 37°C in a shaking water bath. Then, the effect of cooling (37-10°C) on the isometric tension change of decellularized nasal mucosa was evaluated. In addition, the presence of elastic fibers within the nasal mucosa was identified in both histological section and scanning electron microscope.

Results indicated cooling induced a relaxation response of isolated decellularized human nasal mucosa and it was similar to that of intact nasal mucosa. The elastic fibers formed in wavy lines and were distributed throughout the submucosal layer.

Cooling induced a similar relaxation response both in the absence or in the presence of cellular components in isolated human nasal mucosa, suggesting that this response is mediated by the abundant extracellular matrix.

Sternberg's (lateral craniopharyngeal) canal was originally described in anatomic studies as a membranous space in the lateral wall of the sphenoid sinus. The canal has been etiologically associated with lateral sphenoid sinus “spontaneous” cerebrospinal fluid (CSF) leaks. A patent Sternberg's canal has been reported in up to 4% of adults, and persistent vestiges have been reported in up to 30%. However, no modern studies analyzing high-resolution CT scans have been published.

A consecutive analysis of 1000 high-resolution CT scans of sphenoid bones was performed. Scans were analyzed for a lateral recess, bony defects, arachnoid pits, and holes possibly representing Sternberg's canal. Data were compared with a case series of lateral sphenoid CSF leaks.

Average patient age was 38.7 years (10-92 years). A sphenoid lateral recess was present in 35.3% (17.4% bilateral) of cases. Arachnoid pits were present on the floor of the middle cranial fossa in 23.4% of cases. Seven skull base defects were identified. Only one traveling medial to V2 resembled the description of Sternberg's canal. In contrast, a case series of 25 patients with lateral sphenoid sinus CSF leaks all had a lateral recess, defects, and arachnoid pits lateral to V2 (p < 0.00001).

Sternberg's canal as historically defined is not nearly as prevalent as previously reported. Furthermore, the presence of arachnoid pits in all sphenoid CSF leaks and the predominant leak location lateral to the sites of fusion of ossification centers suggests that the leaks are acquired. Contributing factors may include arachnoid pits/weaknesses in the skull base and intracranial hypertension.

Chronic rhinosinusitis (CRS) is basically an inflammatory disease of the mucosa and periosteum of the sinuses. The possibility of local osteitis can cause persistent mucosal inflammation and lead to failure of treatment. Bone scintigraphy is the gold standard procedure for detecting the bone involvement. This study was designed to evaluate whether single-photon emission computerized tomography (SPECT) findings predict severity of chronic sinusitis and subjective response to medical treatment. A prospective case control study was done.

Twenty-four patients with CRS were involved. SPECT findings for bone involvement and computed tomography-based staging (limited disease, stage 1; extensive disease, stages 2 and 3) were compared. These data were also analyzed in terms of subjective response to medical treatment and prognosis.

SPECT uptakes were positive in 79.2% (19/24) and negative in 20.8% (5/24) of the patients. SPECT was positive in 4/8 of the patients with limited disease and 15/16 of the patients with extensive disease. In subjective assessment of medical treatment 5/8 of the limited disease versus 1/16 the extensive disease patients had good response; whereas 5/5 of SPECT⁻ patients versus 1/19 of SPECT⁺ patients had good response.

Bone SPECT results were found to be correlated with the stage of CRS. Poorer subjective response was observed in patients with positive SPECT.

The nasal mucosa plays the main role as the entry and the exit of leprosy bacilli and the nasal involvement may precede the skin lesions by several years. Nasal biopsy has been used in research but its clinical application has not been described. We evaluated the contribution of the nasal biopsy for the diagnosis of leprosy and its correlation to skin biopsy and skin smear in untreated patients.

We evaluated changes in nasal biopsy in 227 leprosy patients. Patients were clinically classified and skin and nasal biopsies and skin smear were performed.

Nasal biopsy showed positivity in 100% of the lepromatous spectrum decreasing toward the tuberculoid (TT) pole. Patients with TT or indeterminate forms did not present any nasal alterations, showing that they are the true paucibacillary forms. Also, the nasal biopsies of two patients were the only exam to show positivity. The bacillary index of the nasal biopsy was strongly correlated to skin biopsy and slit-skin smear. Additionally, the agreement among the exams was good, revealing the reliability of the nasal biopsy in leprosy diagnosis.

The present study showed a rate of 48% of positivity in nasal biopsy of untreated patients, correlating well with skin biopsy and skin smear. Thus, the method in leprosy diagnosis and clinical form classification has shown great reliability.

Cerebrospinal fluid (CSF) leaks located within the frontal sinus can be difficult to repair effectively. Additional challenges arise from the need to simultaneously repair the leak or defect and to ensure the future patency of the sinus itself.

The cases of two patients who underwent surgical repair of CSF leaks and skull base defects located in difficult to access locations within their frontal sinuses were reviewed.

Two patients with CSF leaks in the frontal sinus underwent surgery to repair the leaks. The leaks were in the superomedial and superolateral locations within the sinus. One leak (in the superolateral location) was secondary to iatrogenic surgical trauma during craniotomy. The second leak (in the superomedial location) was secondary to congenital encephalocele. Surgical approach to ensure adequate exposure was via endoscopic modified Lothrop procedure. Successful repair was undertaken via underlay technique. At follow-up (27 and 7 months, respectively), frontal sinuses remained patent without evidence of CSF leak.

CSF leaks located in medial and lateral areas of the frontal sinus may be successfully repaired via endonasal approach with endoscopic modified Lothrop. Repair in this manner requires that attention be paid both to achieving a complete repair and to maintaining a patent sinus drainage pathway.

Endoscopic repair of skull base (SB) defects is successful in over 90% of cases. Certain factors may contribute to failure of SB repair techniques or need for secondary repair.

Five-year retrospective review of endoscopic SB defect repairs performed by a single surgeon.

Eighty-nine patients undergoing 110 procedures to repair 97 SB defects were evaluated. Etiology of defects included surgical/iatrogenic (64%), spontaneous (17%), traumatic (12%), congenital (6%), and idiopathic (1%). Defects occurred in the sella (41%), sphenoid sinus (18%), ethmoid roof (17%), olfactory cleft (16%), frontal sinus/recess (6%), and middle cranial fossa (2%). Sixty-three patients (71%) underwent primary SB defect repair and 26 patients underwent secondary repair (29%). In revision cases, mean number of prior repair attempts was 1.5 (range, 1-4). Factors potentially contributing to need for secondary SB defect repair included inability to localize SB defect (p =0 008), development of new SB defect, prior sinus or SB surgery (p < 0.001), prior craniotomy (p < 0.001), prior radiation therapy (p = 0.002), and intracranial infection (p = 0.023). SB defects were successfully closed in 83 patients overall (93%), with success achieved in 97% of primary patients and 85% of secondary patients. Of failures, 3 patients required craniotomy for defect closure, 2 patients underwent permanent cerebrospinal fluid (CSF) diversion, and 1 patient has persistent CSF rhinorrhea.

Although endoscopic repair of SB defect remains largely successful, certain factors should alert the surgeon to the potential for failure of repair or need for secondary SB defect repair.

Exposure of the petrous (C2) segment of the internal carotid artery (ICA; petrous carotid) is necessary to treat lesions that have spread from the intracranial space or adjacent sinonasal region. Recent advancements in endonasal-endoscopic approaches to the anterior skull base raise the possibility of extending these approaches beyond the sinonasal cavity. In this cadaveric study, we evaluate the feasibility and extent of exposure of the petrous carotid artery via a combined endoscopic endonasal approach.

Endoscopic dissection was performed in four formalin-fixed cadaver heads (eight sides). An endoscopic, endonasal, transmaxillary approach was used to identify the cervical and petrous carotid artery.

With the endoscopic endonasal, Caldwell-Luc approach, we could visualize the ventral petrous bone after dissecting the contents of the pterygopalatine fossa and infratemporal fossa. Careful dissection allowed exposure of the petrous carotid artery from the upper cervical carotid to the foramen lacerum.

In this cadaveric study using an endoscopic endonasal approach for exposure of the petrous carotid artery, combination with the transmaxillary-transpterygopalatine-transinfratemporal approaches permitted exposure of the ventral portion of the artery. The anatomy presented will assist experienced endoscopic skull base surgeons in the removal of lesions involving the ventral skull base.

Intractable posterior epistaxis sometimes requires intensive treatment, such as surgery or embolization. Maxillary artery ligation has been widely used for the treatment of intractable posterior epistaxis. It is highly effective, but significant complications may occur, including an oroantral fistula and damage to the infraorbital nerve. Embolization is less invasive and can be performed in poor surgical candidates. However, it has more serious complications, such as facial nerve paralysis and hemiplegia. This investigation evaluates the effectiveness and complications of endoscopic ligation of the sphenopalatine or maxillary artery for the treatment of intractable posterior epistaxis.

Between April 2003 and March 2007, 46 patients were hospitalized for the treatment of severe posterior epistaxis in our University Hospital. Thirty patients were successfully treated by anterior and/or posterior nasal packing, and five patients were treated by electrocoagulation. Endoscopic ligation was performed under general anesthesia in 11 patients (6 men and 5 women; age range, 50-80 years).

Eight patients underwent endoscopic ligation of the sphenopalatine artery, and three patients underwent endoscopic ligation of the maxillary artery through the middle meatus and posterior antral wall opening. There were no complications, and the patients’ postoperative courses were uneventful. Recurrent epistaxis occurred in one patient on oral anticoagulants 15 months after ligation of the sphenopalatine artery, and it was successfully treated by anterior nasal packing.

Endoscopic ligation of the sphenopalatine or maxillary artery is safer than arterial embolization and is less invasive than transantral ligation of the maxillary artery. This technique appears to be a simple and highly effective surgical treatment for patients with intractable posterior epistaxis.

The current otolaryngologic literature is lacking in basic science investigation regarding endoscopic anterior ethmoid artery (AEA) ligation as part of the armamentarium for epistaxis control. This investigation provides the anatomic rationale for endoscopic ligation of the AEA in the surgical treatment of epistaxis. In addition, it provides tools for identification of this vessel during routine endoscopic sinus surgery.

This descriptive cadaver study investigates the feasibility of endoscopic transnasal transethmoid dissection; anatomic description; and clip ligation within the periorbital space of 16 AEA specimens. A careful assessment for skull base penetration and disruption was performed.

All 16 anterior ethmoid arteries were readily identified and successfully clipped. The anatomy was carefully observed and described for each specimen, and no inadvertent skull base penetration occurred.

This study confirms that endoscopic ligation of the AEA is a safe and feasible technique for the control of epistaxis. Additionally, this anatomic knowledge is beneficial during routine endoscopic sinus surgery if AEA injury should occur. Further evaluation is necessary for clinical application of this technique in the treatment of epistaxis.

This article reviews our treatment results of sinonasal inverted papilloma (SNIP) over the past 18 years. A retrospective observational study was performed.

Fifty-six patients with SNIP seen between 1990 and 2008 with follow-up of >2 years were retrospectively analyzed.

Forty patients (71%) had primary endoscopic resection and 16 patients (29%) had endoscopic-assisted external approaches. Ten patients (18%) had small nasoethmoid residual disease resectable under local anesthesia in the outpatient department. Eight patients (14%) had recurrences requiring revision under general anesthesia, most of which were maxillary and frontal disease requiring additional external approaches. Comparing patients with and without a history of previous surgery (36% versus 64% of all patients), the former had a higher chance of requiring external approaches during the primary resection (45% versus 29%), a higher recurrence rate (45% versus 25%), and a higher chance of external approaches for revision (44% versus 22%). All the first recurrences were at the original tumor site. Eighty-nine percent of the first recurrences were diagnosed within the first 2 years postoperation.

Thirty-two percent of our patients had recurrence after their primary resection. Recurrences in the nasoethmoid area are usually small and resectable endoscopically under local anesthesia in the outpatient department whereas those inside the maxillary and frontal sinuses are likely to require additional external approaches under general anesthesia. A minimum of 2 years of follow-up is recommended for the preliminary report on the treatment results of this condition. Lifelong follow-up is recommended for possible late recurrences and metachronous multifocal disease.

Endoscopic management of sphenoid sinus disease has great potential for surgical complications. A variety of endoscopic surgical techniques have been described for entering the sphenoid sinus. The utility of these surgical techniques is based on the position of the superior turbinate attachment to the sphenoid face (Parson's ridge). We introduce a novel computerized tomography (CT) grading system for the attachment of the superior turbinate to the sphenoid face. Using this new grading system, we recommend a safer systematic approach for entry into the sphenoid sinus.

A grading based on the attachment of the superior turbinate to the sphenoid face at the level of the natural sphenoid ostium was developed. A total of 53 patients were enrolled. Types A, B, and C refer to the superior turbinate attachment at the medial, middle, or lateral third of the anterior sphenoid face, respectively, and type D refers to orbital attachment of the superior turbinate. The surgical approach used (superior turbinate intact [STI] or superior turbinate resection [STR]) was recorded and correlated to the type of superior turbinate attachment.

The overall incidence of the various superior turbinate attachments were 40% (41) for type A, 41% (42) for type B, 18% (19) for type C, and 1% (1) for type D. STR was used in 38 sides (44%) and STI was used in 48 sides (56%). Spearman correlation study showed that the closer the superior turbinate attachment was to the orbit the more likely STR was used as the choice of entry into the sphenoid (p < 0.001).

To perform a safe sphenoid entry it is pertinent to evaluate the superior turbinate attachment to the sphenoid face before making a decision on the method of entry.

Understanding paranasal sinus anatomy is crucial for successful outcomes in endoscopic sinus surgery (ESS). This study was designed to evaluate subjective and objective differences in ESS cadaver dissections among participants of varying experience levels in association with the use of image guidance and computer-aided technologies in a physician training cadaver dissection laboratory.

Participants in a 2-day cadaver dissection course completed daily predissection surveys evaluating subjective comfort with ESS. Pre- and postdissection computer tomography (CT) scans assessed completeness of dissection. Images were analyzed for maxillary antrostomy, frontal and sphenoid sinusotomy, residual ethmoid cells and partitions, and residual frontal recess cells.

Fifty-one sides were dissected. Participant comfort increased significantly from day 1 to 2 for overall ESS (p = 0.001) and for individual sinuses (p < 0.001 to p = 0.047). Participants with more years in practice had fewer unopened ethmoid cells (p = 0.015) and frontal recess cells (p = 0.014) on dissection day 1. Participants with increased comfort in ethmoid dissection had fewer retained ethmoid partitions on day 1 (p = 0.017). Observed differences on dissection day 1 for unopened ethmoid and frontal recess cells and retained ethmoid partitions were not present on day 2. No significant differences were found based on use of image guidance for any parameter.

Surgeons with increased comfort and more years in practice had more complete endoscopic cadaver dissections initially. Differences among participants diminished on dissection day 2, indicating the ability to review postdissection CT scans may improve surgeon comfort level and completeness of dissection.

The aim of this study was to reveal the efficacy of the “cross-stealing” technique in the repair of nasal septal perforation.

In a prospective clinical investigation, 10 patients with the complaints of crusting, bleeding, whistling, nasal obstruction, and pain and in whom septal perforation was detected underwent surgery by endonasal approach between April 2006 and January 2008. During surgery, the inferior-based mucoperichondrial flap was prepared on one side, the superior-based mucoperichondrial flap was prepared on the other side of the nasal septum, and they were passed to the opposite side through perforation. Interpositional graft was placed between flaps and sutured. Patients were followed for a minimum of 5 months before the evaluation of the results.

Complete closure was observed in 7 of 10 (70%) patients and partial closure was observed in 1 patient. In 2 patients perforation was not closed and its size remained unchanged.

The cross-stealing technique is advantageous in anterior-located septal perforations in that it can be performed endonasally and it is physiological. Because flaps are prepared in a vertical direction, it can be used only in small and middle-sized perforations, which restricts its use.

This study reviews the role of frontal sinus minitrephination in today's era of endoscopic sinus surgery. Retrospective chart review was performed of 163 patients undergoing a total of 149 bilateral and 39 unilateral frontal sinus minitrephinations.

Charts were reviewed for patient demographics and outcomes. Details obtained from the chart included type of surgery performed, reason for minitrephine placement, pathology, Lund score, complications, and endoscopic patency.

One hundred eighty-eight minitrephines were placed during 80 modified Lothrop and 108 frontal sinusotomies. Trephines were placed when there was difficulty finding the frontal recess, severe edema/polyps, obstructing frontal cells (type 3/type 4 frontoethmoidal cells and intersinus septum cell), and to aid the dissection and postoperative irrigation during the modified Lothrop. Twelve complications occurred with infection at the trephine site being the most common. Follow-up ranged from 2 to 122 months (average, 25.5 months) with 92% showing endoscopic patency at last visit.

Frontal sinus trephination is a safe useful procedure that can be extremely helpful in identifying the pathway to the frontal sinus. Fluorescein flushes through the trephine help guide the dissection in a modified Lothrop. Lastly, it may be used in the postoperative period to flush the sinus with saline and steroids to promote patency of the frontal sinus.

The incidence of nasolabial cysts is very low. Simple excision through a sublabial approach is the treatment of choice. The aim of this study was to evaluate the microdebrider as a tool in transnasal endoscopic marsupialization for nasolabial cysts and compare it with conventional instruments and a sublabial approach for cyst removal.

Retrospective chart review of 30 patients (31 cysts) with a mean age of 46.9 years received surgical treatments for nasolabial cysts. We performed three types of surgical procedures including the sublabial approach (10 cysts), conventional transnasal marsupialization (13 cysts), and microdebrider-assisted marsupialization (8 cysts).

Patients that received surgery with the sublabial approach experienced significant increases in operation time, blood loss, and hospitalized time compared with those treated with transnasal marsupialization. However, the number of postoperative stoma stenoses was higher for conventional transnasal marsupialization (two cases). No recurrences or other postoperative complications were found during the follow-up.

The transnasal marsupialization of nasolabial cysts has remarkable benefits compared with sublabial cyst excision during operation. Microdebriders can be used safely and effectively in endoscopic marsupialization without stoma stenosis.