Otolaryngology–Head and Neck Surgery

Surgical approaches to the inner ear with hearing preservation have valuable implications for neurotologic surgery. In a previous study in guinea pigs, we demonstrated that click-evoked auditory brain stem responses (ABRs) were preserved after transection and plugging of 1 or more semicircular canals but were lost after entering the vestibule (Smouha EE, et al. Otolaryngol Head Neck Surg 1996;114:777–784). A limitation of that study was that click-evoked ABR might not represent the function of the entire cochlea. In this study we used tone-burst ABR to determine thresholds across a broad range of frequencies (2 to 24 kHz) before and after surgical entry into the labyrinth at the lateral semicircular canal, ampulla, and vestibule. Serial measurements were made, and a sham surgery group was used as a control. The results obtained with tone-burst ABR generally agreed with those previously obtained with click stimuli. Tone-burst ABR thresholds were similar across most frequencies tested. Transection of the lateral semicircular canal resulted in preservation of ABR thresholds. Ampullectomy had a variable effect on ABR thresholds. Vestibulotomy usually resulted in substantial hearing loss. We conclude that hearing can be preserved across a range of frequencies after selective surgery of the inner ear. Surgical entry into the membranous labyrinth near the vestibule is the critical factor contributing to hearing loss after partial labyrinthectomy.

Current methods to assess voice outcomes in patients with unilateral vocal cord paralysis (UVCP) are limited by expense, reliability, or lack of a true patient-relevant focus. The purpose of this study was to develop and validate a patient-based, disease-specific instrument, the Voice Outcome Survey (VOS), that is brief, reliable, and sensitive to real clinical change in patients with UVCP. Fifty-six consecutive patients with uncompensated UVCP and without complicating comorbid illness received the VOS, the Medical Outcome Study Short Form 36-Item Health Survey (SF-36), and a voice laboratory analysis before and 6 months after type I thyroplasty. Overall, reliability of the VOS was excellent (r = 0.87, P< 0.0001). The VOS index was significantly (P < 0.05) correlated to subscales of the SF-36 including social functioning (SF) (r = 0.56) and physical role functioning (r = 0.35), as well as changes in objective voice measures such as phonation time (r = 0.51) and average intensity (r = 0.44). The VOS index was the most sensitive measure to clinical change after surgery (standardized response means: VOS, 1.92; phonation time, 0.68; SF, 0.58; physical role functioning, 0.53; intensity, 0.51). The VOS is a brief, valid, reliable, and highly sensitive measure of disease-specific health status in patients with UVCP.

The cause of hearing loss in children is often difficult to identify. We evaluated a cohort of 114 children (47 boys, 67 girls) referred with newly diagnosed hearing loss (non–otitis media) to identify factors predictive of etiology and type of hearing loss. Clinical (history and physical examination), laboratory, and radiographic data were collected. One hundred children (87.7%) had sensorineural hearing loss, and 14 (12.3%) had conductive or mixed hearing loss. The cause of hearing loss was identified in 54 children (48%). Patients with isolated aural atresia (n = 7) or with a known diagnosis of congenital cytomegalovirus infection (n = 21) were excluded from further data analysis. We conducted statistical analysis to identify factors predictive of the cause and type of hearing loss. Clinical factors that aided in identifying a cause included abnormal physical examination findings (p= 0.001) and craniofacial anomalies (p = 0.006). Computed tomography of the temporal bones was the only diagnostic test predictive of cause (p < 0.001). Factors predictive of the type of hearing loss detected (sensorineural vs. conductive or mixed) were abnormal physical examination findings (p = 0.01) and craniofacial anomalies (p = 0.004). An exhaustive laboratory or radiographic workup did not prove beneficial in identifying the etiology of hearing loss in our series.

The clinical usefulness of posturography is unknown, despite its costing more than $500 per test in some areas of the United States, including Boston. We cross-sectionally and prospectively studied blinded vestibulo-ocular and vestibulospinal tests from 29 stable patients with chronic vestibular hypofunction; 22 patients were affected bilaterally (BVH), and 7 were affected unilaterally (UVH). Vestibulo-ocular function was assessed by electronystagmo-graphic caloric stimulation and sinusoidal vertical axis rotation gains at 0.05 Hz. Vestibulospinal function was assessed by moving-platform and visual-surround posturography sensory organization tests (SOTs), paced and free gait in a gait laboratory, and clinical tests of timed gait and standing. Posturography SOT moving-platform tests 4 through 6, designed to assess vestibular function, correlated significantly (r≤ 0.72, P ≥ 0.01) with vestibulo-ocular tests in 5 of 6 comparisons among BVH patients. Posturography SOT results, however, correlated poorly with other vestibulospinal measures: correlations were statistically significant for only 7 of 18 comparisons with clinical balance and gait function (r ≤ 0.69, P ≥ 0.01) and with 2 of 12 comparisons for gait laboratory dynamic stability measures (r ≤ 0.55, P ≥ 0.01) among the BVH patients. When both the platform and visual surround moved (SOT 6), however, correlations were statistically significant with static standing clinical measures (r = 0.51 to 0.69, P < 0.01) and with whole-body maximum moment arm during paced gait (r= 0.55, P< 0.01). Posturography scores for the UVH patients did not significantly correlate with any vestibulo-ocular or other vestibulospinal measures. These data indicate that among patients with BVH posturography SOT scores relate at best modestly with accepted measures of vestibulo-ocular function, less well with clinical measures of balance control, and poorly with dynamic gait-performance measures. We conclude that posturography SOT does not assess vestibulospinal function.

Horizontal canal nerves of 3-, 6-, 9-, and 12-month-diabetic rats were compared with those of age-matched controls. The myelin sheaths of the horizontal canal nerves in diabetic rats were thinner than those of age-matched controls (mean ± SD 0.63 ± 0.04 mm [n = 16] vs. 0.71 ± 0.05 mm [n = 9]; p< 0.0001, one-tailed t test). Regression analysis revealed that myelin sheath thickness did not correlate with severity of diabetes, but myelin thinning did occur as a function of the duration of diabetes (p < 0.05, regression ANOVA). The progression of myelin thinning over time is consistent with the possibility of an accelerated decline in vestibular function with age in diabetic patients. That myelin thinning did not correlate with the severity of diabetes suggests that this thinning is not directly related to the aging effects attributed to nonenzymatic glycosylation of myelin proteins. Multivariate analysis revealed a significant difference between diabetic and control groups when fiber diameter and intrasheath diameter were considered together (p < 0.008, canonical discriminant-function analysis). Diabetic and control groups did not differ significantly in total nerve fiber counts. In the diabetic group, however, nerve fiber counts were higher in animals with higher blood glucose levels (p< 0.02, linear-regression ANOVA; r 2 = 0.49). The finding of higher nerve fiber counts in more severely diabetic rats is consistent with an earlier transmission electron microscopic finding of false myelinated nerve fiber profiles in micrographs from more severely diabetic rats. These false profiles are believed to represent phagocytosis-like Schwann cell reactions against their own myelin, triggered by excess myelin glycosylation.

The management of long-segment tracheal stenosis remains an unsolved clinical problem that has significant implications for the survival of some patients and the quality of life of others. However, recent advances in microvascular tissue transfer may allow tracheal transplantation to be used as a treatment option. Studies in dogs have demonstrated that the reanastomosis of the cranial thyroid artery (CTA) after the transplantation of a short segment of trachea sustains cartilage viability. However, the distal perfusion zone of the CTA within the canine trachea has not been described. Hence it is unclear what length of trachea can be safely harvested, with use of the CTA as the donor artery, without risking ischemia of the distal trachea. This study determined the perfusion territory of the CTA by use of latex or dye infusion via the thyroid branches of the CTA. Findings in five perfusion-fixed cadaver mongrel dogs (8 to 12 kg) were studied. In each dog, both common carotid arteries were dissected and the CTAs identified. The right CTA was ligated and the left common carotid artery was ligated cranial to the CTA. The left common carotid artery was perfused for 10 minutes under 100 mm Hg pressure with black india ink/saline solution (20:1000 ml) or with blue latex solution. Perfusion territories were determined by grossly and microscopically measuring the region of stain in the endolaryngeal and endotracheal airways. The results demonstrated that up to 18 ipsilateral rings of the canine trachea are perfused after injection of dye under physiologic pressure into the CTA. Contralateral staining was also noted, but to a lesser degree. These results suggest that the canine CTA may perfuse, on average, a 16- to 17-ring tracheal segment.

For more than 50 years, the Mohs technique has offered both the highest cure rate for skin cancers and the maximum preservation of surrounding normal tissue. Mohs skin cancer excision is traditionally performed by a Mohs dermatologist, followed by a secondary repair by a head and neck or plastic surgeon. This study comprises a review of 300 cases involving single-procedure Mohs therapy with immediate one-anesthetic reconstruction. The data reviewed include types of reconstructions, cosmetic results, complications, and recurrence rates. In addition to offering the psychologic and quality advantages of immediate closure, the procedure allows patients to return to work sooner. With changes in technique ranging from the chemosurgery of the 1930s to the fresh-tissue methods of the 1970s, single-procedure Mohs is the logical next step in the evolution of Mohs surgery.

Microscopic evaluation of all adult tonsillar specimens has been considered essential despite the low incidence of unsuspected pathologic conditions. We evaluate whether routine histologic examination of clinically benign adult tonsillar specimens is indicated. We retrospectively reviewed pathology results from all tonsillectomies performed on patients ages 18 years or older at our institution from 1989 through 1996. Three groups were created on the basis of indications for tonsillectomy: (1) routine tonsillectomies for benign disease, (2) asymmetric tonsils, and (3) search for unknown primary lesions. Demographic data and pathologic findings in each group were analyzed. In 1280 tonsillectomies performed for benign disease there were no malignancies (0%) and 32 cases (2.50%) with clinically unsuspected benign pathologic conditions. In 31 cases of tonsillar asymmetry, two cases with malignant lymphoma (6.5%) and three cases with benign pathology (9.7%) were identified. In nine patients with squamous cell carcinoma metastatic to the neck, two occult primary lesions were identified in the ipsilateral tonsil. Our results suggest that histologic evaluation of adult tonsils removed for benign disease may be clinically unnecessary. The elimination of microscopic examination of tonsils removed from patients whose clinical presentation is entirely consistent with benign disease poses minimal risk of missing clinically significant pathologic conditions. Substantial costs for negative examinations may be avoided.

This study evaluates our complications arising directly or indirectly from placement or management of percutaneous endoscopic gastrostomy (PEG) tubes and provides recommendations for avoidance of complications. Seventy-one patients received PEG tube placement by otolaryngologists between January 1991 and May 1997. Records were reviewed for diagnoses, combined procedures, and complications. Addressing potential causes of complications prompted modification of our technique of PEG tube placement and management. Twenty-three patients received PEG for dysphagia/aspiration unrelated to neoplasia, 11 received PEG with staging endoscopy, 11 received PEG after treatment for head and neck neoplasm, and 26 received PEG at the time of primary resection. Major complications included retained PEG hub and delayed colon abscess ultimately resulting in death. Minor complications included skin abscesses, cellulitis, and early and late vasovagal response with PEG tube removal. An airway emergency, on attempted oral airway intubation, resulted in an aborted PEG attempt and constituted another complication outside the 4 groups stated above. The major complication was not found within a literature review. We have modified our management for avoidance of this complication. We believe the causes of the minor complications have been identified, and with additional modifications in our technique, we have not had any similar complications recently. The recommended techniques are discussed in detail.

Papillary carcinoma of the thyroid is the most common thyroid cancer. At the time of clinical presentation, most papillary carcinomas are still confined to the thyroid gland, and appropriate surgical treatment achieves a 95% 5-year survival rate. Certain carcinomas, however, behave in a much more aggressive fashion. Because specific therapies do not exist, for those tumors that have escaped local control, patients with disseminated disease have little or no chance of permanent cure or long-term survival. Cyclin D1, a protein that plays a critical role in the control of the cell cycle, has been shown to be overexpressed in a variety of human neo-plasias and may serve as a prognostic parameter of disease progression. To explore the role played by cyclin D1 in the pathogenesis of thyroid papillary carcinoma, we have quantitated, by computerized image analysis, the immunohistochemical expression of cyclin D1 in formalin-fixed, paraffin-embedded tissue from 35 conventional papillary carcinomas of the thyroid and correlated the results with established clinicopathologic parameters and available survival data.

Gastroesophageal reflux (GER) into the laryngopharynx causes or contributes significantly to a variety of upper respiratory problems in children. The pH probe, laryngeal examinations, and bron-choalveolar lavage results for children with subglottic stenosis, recurrent croup, apnea, chronic cough, laryngomalacia, recurrent choanal stenosis, vocal fold nodules, and chronic sinusitis/otitis/bronchitis were reviewed in an effort to quantify the role of GER in each of these disorders. This review suggests that GER plays a causative role in subglottic stenosis, recurrent croup, apnea, and chronic cough. It is an important inflammatory cofactor in laryngoma-lacia and possibly in true vocal cord nodules and problematic recurrent choanal stenosis. GER is also an important inflammatory cofactor in chronic sinusitis/otitis/bronchitis but may be the result of chronic illness in the older patients.

The existence of a long learning curve for endo-scopic sinus surgery has been proposed as a reason for rigorous and extensive training to prepare physicians to perform this surgery. In this article, the author—who participated in this type of training program—examines his experience over a 5-year period to assess the effect of rigorous training on the learning curve for endoscopic sinus surgery. Beginning with the first day of practice after training, 5 years with 393 cases were evaluated for complications and the need for revision surgery. The results were analyzed in 100-case groups. The results show no difference in major and serious complications or revision surgery rates. However, a statistically significant difference in the minor-complication rate, specifically frontal-sinus stenosis, was found from the first half to the second half of the experience. These findings show that, with rigorous training of the physician, the learning curve can largely be completed during residency training, allowing the new practitioner to perform endoscopic sinus surgery safely and with good results.

We determined the safety, feasibility, and efficacy of a treatment regimen consisting of maxillary sinus aspiration and irrigation with or without adenoidectomy, followed by culture-directed intravenous antibiotics and oral prophylaxis, for children with chronic rhinosinusitis refractory to oral antimicrobial therapy. Twenty-seven children (age 1–12 years, mean 6.7 years) with symptomatic (mean duration 16 months) and computed tomography-proven sinus disease, which persisted despite at least 1 month of oral antibiotics, were treated. Twenty-four patients (89%) had complete resolution of their presenting symptoms after intravenous therapy; in 3 (11%), intravenous therapy failed and endoscopic sinus surgery was required. Follow-up data were available for 26 of the children (96%); 23 of them had initial complete resolution. At last follow-up (mean 282 days, range 26–1095 days), 10 of these 23 patients (44%) remained asymptomatic, and 13 (57%) had had at least one other episode of sinusitis (mean 1.0, range 1–3) treated with oral antibiotics, with resolution. Treatment-related complications included superficial thrombophlebitis (7%), diarrhea (7%), intravenous catheter guide-wire kink requiring venotomy (4%), and serum sickness–like syndrome (4%). These preliminary results suggest that this treatment plan is relatively safe and feasible and that it may be a reasonable alternative to endoscopic sinus surgery in children with chronic rhinosinusitis unresponsive to orally administered antimicrobial therapy.

Epidemiologic and clinical trials have suggested that exposure to ozone increases airway hyperre-sponsiveness and inflammatory response to inhaled nasal allergen challenge in allergic asthmatic subjects. Previous studies have demonstrated an increased late-phase response to nasal allergen challenge; however, the early-phase response is unknown. We sought to characterize the early-phase response by measuring mast-cell inflammatory mediators and cellular influx at time points immediately following ozone exposure and subsequent allergen challenge. A cohort of mild, asymptomatic dust mite–sensitive asthmatic subjects was identified. Each subject underwent two separate exposures to both 0.4 ppm ozone and clean air in a randomized manner. Nasal lavage was performed before and after each exposure. Nasal allergen was then administered to a defined clinical end point, followed by nasal lavage. Differential cell counts and mast-cell products were identified in each lavage specimen. The mast-cell mediators tryptase and prostaglandin D₂ were analyzed, as was a marker of epithelial cell permeability, albumin. Although allergen produced an increase in early-onset mediator release (mast cell–derived), no enhancement was noted after exposure to ozone. Neutrophil and eosinophil inflammatory mediators were not increased after ozone exposure or enhanced after allergen exposure, although ozone did enhance eosinophilic influx after exposure to allergen. Ozone exposure does not promote early-phase–response mediator release or enhance the response to allergen challenge in the nasal airways of extrinsic asthmatic subjects. Ozone, however, may promote an inflammatory cell influx, which helps induce a more significant late-phase response in this population.

Food allergies are an important cause of morbidity in the pediatric population. We used a questionnaire to assess the value of in vitro testing in evaluating children for food allergy. The patient population was divided into two groups: those who tested positive (Class I or greater) for food allergy (combined food/inhalant allergy or food allergy alone) and those who tested negative for food allergy (inhalant only or negative test). Although we recognize that a significant proportion of food allergies may not be IgE-mediated, for the purposes of this study we considered a patient food allergy–positive if in vitro testing was positive and food allergy–negative if testing was negative. Thirty-eight of 77 patients tested (49%) were positive for food allergies. Those with food allergies did not have pre-treatment scores significantly different from those of patients negative for food allergies (55 vs. 65, p = 0.11). Similarly, we detected no statistically significant difference between the symptom-improvement scores of the two groups (37 vs. 40, p = 0.57). We conclude that in vitro testing for food allergies is warranted in children with allergic symptoms, for several reasons: The prevalence of IgE-mediated food allergy in children may be higher than previously thought, and children with food allergies experience the same severity of symptoms as those without. It must be remembered that in vitro testing only detects IgE levels, and therefore a negative test does not mean that the patient does not have food allergies. However, when positive, in vitro testing gives the physician the opportunity to modify the treatment plan, helping avoid time-consuming and demanding oral food challenges. Our questionnaire also showed that food allergy and non–food allergy patients had similar pretreatment and posttreatment symptom scores.

Acoustic rhinometry is an appropriate method for detecting and recording the nasal cycle in normal subjects in terms of the cross-sectional areas and volume of the nasal cavity. In this study, we tried to detect and to define the nasal cycle in normal subjects so that we might develop a reliable and reproducible technique to be used in conjunction with studies on the physiology and pathology of nasal disease. We used normal volunteer adult subjects and performed bilateral acoustic rhinometry measurements every 15 minutes over 4 hours, along with the use of a visual analog scale for assessment of the subjective feeling of congestion (or patency) just before each acoustic rhinometry measurement. Volume and cross-sectional area changes were observed along with subjective patency-score changes in each subject. The subjective feeling of patency was not related to the volume and cross-sectional area changes measured simultaneously. The technique of recording the nasal cycle with acoustic rhinometry in nasal research is presented.

OBJECTIVE: To evaluate the prevalence of obstructive sleep apnea in a large population of children with achondroplasia and to evaluate the effectiveness of adenoidectomy and/or tonsillectomy as treatment.

METHODS: Retrospective review of 95 children with achondroplasia.

RESULTS: Thirty-six patients (38%) had clinical evidence of obstructive sleep apnea. Thirty-four patients underwent surgery, with more than 1 procedure required in 10 children (29%). Adenotonsil-lectomy was the initial procedure for 22 of 34 patients, and further therapy was required in only 18% of this group. Adenoidectomy was the initial procedure for 10 of 34, with 90% requiring further surgery for recurrent obstructive sleep apnea. Tonsillectomy alone was performed in 2 patients: 1 was effectively treated and 1 later required adenoidectomy. Endotracheal intubation was accomplished in all patients without complication; 53% required a smaller endotracheal tube than would be predicted by their age. Eight postoperative complications were recorded.

CONCLUSIONS: Obstructive sleep apnea is very common in children with achondroplasia. Surgery is effective, but recurrent symptoms are common, particularly when the initial procedure is adenoidectomy. The complication rate is higher than that observed in a general pediatric population but is readily managed with standard therapy. Anesthesia can be given safely to these patients with special consideration for limited neck extension and appropriate endotracheal tube size.

Small quantities of botulinum toxin (BTX) are useful in the treatment of certain movement disorders, such as laryngeal spasmodic dysphonia, blepharo-spasm, and cervical dystonia. However, the corrective paralytic effects of BTX are only temporary, in part because of the formation of remodeled neuro-muscular junctions. Here, we questioned whether various factors within and near the neuromuscular junction could contribute to the remodeling seen after BTX treatment. BTX was injected subcutaneously in the region of the levator auris longus muscle. At 1-week intervals, levator auris longus muscles were removed and examined histochemically. As previously described, BTX treatment results in a progressive elongation of end plates. The neural cell adhesion molecule was not associated with the elongated end plates but was associated with the BTX-induced nerve sprouts after long intervals (3 to 4 weeks). Similarly, after BTX, laminin-1 (composed of α1, β1, and γ1 chains) reactivity was associated with the nerve sprouts, but not with the end plates. Laminin β2 reactivity at the end plate dispersed somewhat within 1 week but remained diffusely associated with the elongating end plates for up to 5 weeks. Together these results suggest that neural cell adhesion molecule and laminins may participate in the sprouting observed after BTX treatment and that alterations in laminin β2 expression may participate in initial loss of contacts.

Vestibular schwannomas have been noted to have increased frequency and aggressivity in female patients, suggesting a possible role of estrogen. This study evaluated the effects of estrogen and tamoxifen on the growth of human vestibular schwannoma tissue implanted in subcutaneous pockets of nude mice. Animals were implanted with 1 of 3 human vestibular schwannomas and observed for 28 days. Mice were then separated into 3 treatment groups: controls, estrogen (receiving 1.7 mg of 17B-estradiol), and estrogen + tamoxifen (receiving 1.7 mg of 17B-estradiol + 10 mg of tamoxifen), and treated for 28 days. Mice treated with estrogen showed increased growth that was statistically significant (P < 0.05) when compared with that of both the controls and the animals treated with estrogen + tamoxifen. Controls and animals treated with estrogen + tamoxifen showed a general trend of decreased volume during the treatment period. These early results support the hypothesis that estrogen modulates the growth of vestibular schwannomas in the nude mouse model and that these effects can be blocked by tamoxifen administration.

The annual frequency of Bell's palsy in 16 consecutive years was investigated in a 465,000-person health area in Madrid, Spain. The annual incidence of Bell's palsy per 100,000 population was found to be 24.1. The male-to-female ratio was 46:54. Seasonal difference in the incidence was noted in our series with fewer cases during summer. According to these results, the illness in Spain seems to have a similar incidence to that in Western countries. In addition to this, Bell's palsy does not have an infectious epidemiologic pattern in our country, but its frequency decreases in warm weather.

Flap necrosis is still a significant complication in all types of flap surgery. The effect of parenteral pentoxifylline and nitroglycerin in improving survival of ischemic skin flaps was tested in Wistar rats. In the control group (n = 15) the mean viable length of the flaps was calculated to be 6.160 ± 0.936, and non-necrotic flap area was found to be 1859.1 ± 269.3. In the group treated with pentoxifylline and nitro-glycerin (n = 15), the mean viable length of the flap was calculated to be 6.907 ± 0.617, and the mean nonnecrotic flap area was found to be 2078.5 ± 172.7. In this study results showed that the use of parenteral pentoxifylline and topical nitroglycerin is effective on skin flap survival.

Medialization laryngoplasty was performed in 25 patients between 1993 and 1997. The underlying pathology resulting in glottal incompetence was vocal cord paralysis in 22 patients and vocal cord bowing in 3 patients. Two types of implants were used: self-carved Proplast in 19 patients and prefabricated hydroxyapatite prostheses in 6 patients. Preoperative and postoperative results were compared in terms of dysphagia, vocal quality as graded by three experienced voice specialists, and computer measurements of the glottal gap. All patients showed improvement both subjectively and on the objective measurements used. Swallowing returned to normal in all patients who had isolated recurrent laryngeal nerve paralysis. The voice improved in all patients but was rarely judged as entirely normal.

As a result of increasing use of bone marrow transplantation and new cytotoxic chemotherapy, more patients have become susceptible to sinus disease caused by unusual organisms. Sinusitis caused by fungi and gram-negative bacteria can be difficult to treat, may lead to severe complications, and should be managed promptly in the bone marrow transplant patient. Here we present the results of 41 cultures of the paranasal sinuses obtained from 18 bone marrow transplant patients in whom sinusitis developed. The most common agents were gram-negative bacteria (56.7%), followed by gram-positive bacteria (26.7%) and fungi (16.6%). In 13 samples the cultures were negative. Nasal cultures were performed ipsilateral to the sinus drained in 28 cases. Concordance was obtained in only 5 (17.8%) samples. The antibiogram of the isolated agents from the maxillary sinuses in this series revealed that the most efficient antibiotics were those that covered gram-negative bacteria. Treatment was usually prolonged in these patients, and different antibiotics were necessary to clear infections from the sinuses. In conclusion, treating sinusitis in bone marrow transplant patients may be challenging. Considerations about the microbiology and antibiogram susceptibilities of this specific population should be kept in mind when dealing with such cases.

Subperiosteal abscess of the orbit is not a rare entity. Its source is typically ethmoid sinusitis, with direct or hematogenous spread through the lamina papyracea. The treatment usually involves confirmation of the diagnosis through CT imaging, intravenous antibiotics, and either internal or external surgical drainage. We report a case of acute ethmoid sinusitis with periorbital abscess from a unique source—fibrous dysplasia of the middle turbinate—and discuss the therapy and management dilemmas of this unusual problem.