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A Pott's Puffy Tumour (PPT) is a rare clinical entity, which, traditionally has been described as an acute abscess with periosteitis secondary to osteomyelitis of the external table of the frontal bone of the skull, complicating an acute frontal sinusitis. The aim of this article is to present a case of progressively evolving PPT, which emerged during the course of a common rhinitis, in a patient who, thirty years previously, had undergone a reconstruction of the frontal sinus involving osteosynthesis. The patient was treated with antibiotic therapy coupled with external access surgery using the Cairn Unterberger approach. This allowed the drainage of pus, the removal of infected osteosynthetic material and a complete debridement of osteomyelitic bone from the affected area. Frontal sinus obliteration was undertaken using methyl methacrylate, preferable in this case to hydroxyapatite, due to the direct communication with the neighbouring sinus cavities and the presence of defective bone in the superior orbit. A review of literature available on Medline up to January 2008 reveals that this is the third published case of PPT complicating a frontal reconstruction.

Topic: Olfactory dysfunction may be assessed in the clinic with psychophysical testing and electrophysiological recording. Chemosensory event-related potentials (CSERPs) constitute an objective method to assess chemosensory function. Olfactory and trigeminal stimuli activate chemoreceptors from the olfactory neuroepithelium and from the nasal mucosa to evoke an electrophysiological response respectively called olfactory (OERPs) and trigeminal ERPs (TERPs). The purpose of this study is to assess the usefulness and feasibility of these diagnostic tools in the rhinology clinic and to correlate these results to the olfactory disorder aetiology., Materials and Methods: This study encompasses a cohort of 229 patients with a complaint of olfactory dysfunction from different origins. Orthonasal (Sniffing stick test with the treshold-discrimination-identification score: maximal score 48) and retronasal olfactory (maximal score 20) testing as well as CSERPs both after olfactory and trigeminal stimuli have been routinely performed. Olfactory dysfunction aetiologies were as follows: congenital (Cong.), chronic rhinosinusitis (CRS), idiopathic (Idiop.), post-medication (PM), neurologic (Neuro.), post-traumatic (PT) and post-infection (PI)., Results: Mean orthonasal and retronasal scores were respectively: 11.8 and 10.1 for Cong., 18.5 and 13.1 for CRS, 15.6 and 10.4 for Idiop., 15.3 and 10.2 for PM, 17 and 10.6 for Neuro., 15 and 9.9 for PT and 18.3 and 12 for PI. Correlations between orthonasal and retronasal scores were present for all subgroups except congenital and chronic rhinosinusitis subgroups. Orthonasal and retronasal scores were different (p < 0.05) when comparing CRS vs Cong., CRS vs PT and PT vs PI. Technical problems (olfactometer or olfactory stimulation, EEG amplifier,...) and patients discomfort (anxiety, stress,...) did not allow to draw any conclusion in 2 patients. Three patients after olfactory stimulus and 6 patients after trigeminal stimulus demonstrated too much eye blinking or muscular artifacts that did not allow us to perform electrophysiological analysis and averaging as 60% of artifact-free recording was not achieved. Olfactory ERPs were recorded in 28% of the patients and trigeminal ERPs were obtained in almost every patient (95%). There was no statistical difference between each subgroup regarding the presence or absence of OERPs., Conclusions: Psychophysical olfactory testing is a useful method to assess olfactory function in patients with olfactory loss and may help us to obtain a semi-objective and a basal evaluation of the olfactory performances. Feasibility and usefulness of CSERPs are also underlined in this study with only a limited number of patients who did not complete the examination. Psychophysical testing gives different results according to the aetiology of the olfactory disorder, which was not the case for electrophysiological recording. Olfactory acuity assessment should be based on psychophysical and CSERPs evaluation in a clinical setting.

Juvenile angiofibroma (JNA) is a rare benign but locally aggressive tumour of the nasopharynx that primarily occurs in adolescent males. We report a series of 6 consecutive cases operated by exclusive endoscopic approach between from March 1996 and June 2003. All were male. The mean age was 17.2 years old (range: 11-23 years). The tumour involved the nasopharynx in all the cases (6/6), the sphenoid sinus (3/6) and the medial part of the pterygopalatine fossa (4/6). According to Radkowski's classification (Table 1), one patient was stage Ia, one was stage Ib and four patients were stage IIb. The mean duration of the surgery was 2 hours. The mean intraoperative blood loss was 575 ml despite a preoperative hyperselective embolization. The mean follow-up after the first operation was 67 months. All patients but one were free of disease. One patient had a recurrence in the nasopharynx and sphenoid sinuses requiring a successful revision procedure 3 years after the primary surgery. Another patient presented with a 5 mm non-symptomatic nodule in the pterygopalatine fossa, regressing on MRI during the 4 years following the surgery. In conclusion, endoscopic resection of JNA is a difficult but effective operation in experienced hands. Based upon the recent international literature, endonasal surgery combined with a preoperative embolization of the arterial supply is indicated for small and middle size JNAs but also for large tumours extended to the pterygopalatine fossa and medial aspect of the infratemporal fossa. Minimal intracranial extension is not an absolute contraindication if there is no clinical or radiological involvement of the cavernous sinus. A tridimentional guiding system can be of some help in large tumours.

Upper airway patency is essential during sleep in order to avoid sleep-related breathing disorders (SRBD). Nasal obstruction may have a negative impact on sleep quality and must be considered to be a co-factor in the pathophysiology of SRBD. In this paper we will discuss the relation between nasal physiology at night and sleep quality and the possible mechanisms between nasal obstruction and obstructive sleep apnea-hypopnea syndrome (OSAS). We will review the effect of the relief of nasal obstruction (with nasal dilators, medication and/or surgery) on SRBD. Also an algorithm on the management of OSAS patients when nasal surgery is indicated will be proposed.

Objectives: To establish the feasibility of the paraseptal approach to the sella and to demonstrate the superiority of the endoscopic over the microscopic vision during pituitary surgery., Study Design: Prospective monocentric study., Methods: Nine consecutive patients with a pituitary tumour were operated since November 2002. The surgical procedure consisted of a paraseptal approach of the sella with use of a rigid endoscope. Pre- and postoperative (3 months after surgery) symptoms, Magnetic Resonance Imaging (MRI) findings, endocrine and ophthalmic assessment, and intraoperative findings were recorded., Results: One patient presented a CSF leak with a successful peroperative repair. Regarding symptom resolution, headache disappeared during the early postoperative period in case of pituitary apoplexy. All cases of preoperative hemianopsia and diplopia but one improved significantly. Two patients recovered preoperative deficient hormonal functions and six patients did not require substitution therapy any more. No nasal packing was needed except in one case. Considering the healing course, the mucosa repair inside the sphenoid sinus was quicker with Surgicel removal at week 4. Postoperative MRI demonstrated a residual parasellar nodule in 3 out of 6 cases of macroadenoma. Only one required radiation therapy. These results are commented through comparison with the transseptal approach and with surgery exclusively using the microscope., Conclusions: The paraseptal transsphenoidal approach to the sella turcica using the telescope is at least as effective as the conventional transseptal approach using the operating microscope only. It provides a wide access to the pituitary fossa and an optimal vision of the critical areas. The absence of postoperative nasal packing improves significantly the comfort of the patient during the first postoperative hours.

Objectives: Several factors may influence the results of bacteriological studies in chronic rhinosinusitis. We investigated the potential role of nasal cavity disinfection in the bacteriology of the bulla ethmoidalis in patients suffering from chronic sinusitis., Material and Methods: Bacteriology of the bulla ethmoidalis was studied in 176 consecutive adult patients presenting a chronic sinusitis refractory to standard medical treatment who underwent functional endoscopic sinus surgery. Two different techniques were used: (A) a technique with nasal vestibule and facial disinfection with chlorhexedin (N = 89 patients and 165 samples) vs. (B) a technique with facial, nasal vestibule and nasal cavity disinfection with a povidone-iodine solution followed by a cleansing of the nasal cavity (N = 87 patients and 166 samples)., Results: Culture rate was 89.6% (183 bacterial isolates) for technique (A) vs 76.5% (164 bacterial isolates) for technique (B) (p < 0.001). Major bacteria encountered in the (A) group and in the (B) group were respectively: Coagulase Negative Staphylococcus: 77 vs 40 isolates (p < 0.001); Coagulase positive Staphylococcus: 44 vs 30 isolates (p = 0.061); Streptococcus pneumoniae: 4 vs 5 isolates; Others: Streptococcus sp.: 12 vs 16 isolates; Haemophilus influenzae: 8 vs 6 isolates; Enterobacteriacea: 33 vs 53 isolates (p = 0.013) and others Gram Negative Bacilli: 3 vs 7 isolates., Conclusions: The standard (A) technique to study the bacteriology of the bulla ethmoidalis in patients with chronic sinusitis yielded a higher percentage of positive culture and of bacterial isolates than a more advanced (B) technique. This is mainly due to the higher percentage of contaminant bacteria such as Coagulase Negative Staphylococcus recovered with the standard technique. Enterobacteriacea and others Gram Negative Bacilli were more often encountered into the bulla ethmoidalis with the technique where disinfection of the nasal cavity was performed.

Solid-cast forming actinomycotic canaliculitis is an uncommon cause of unilateral chronic red eye resistant to conventional topical medical therapy. The authors report the history of a 62-year old woman who was complaining of mucopurulent discharge from the right lower canaliculus for a period of 12 months. Culture yielded a few colonies of Actinomyces. Magnetic resonance imaging showed a dilation of the right lower canaliculus. The signal was hypointense and heterogeneous on both T1 and T2 weighted sequences. Surgery enabled removal of several solid yellowish casts and resulted in resolution of the disease. Histopathologic examination confirmed the presence of dense, basophilic conglomerates of filamentous organisms. Because rhinologists have more and more opportunities to perform surgery of the lachrymal pathway they need to be informed about this clinical entity.

Objectives: To evaluate the outcomes of the surgical correction of unilateral choanal atresia using a transnasal approach., Patients and Method: Over a 36-months period (from 1999 to 2001), seven children underwent endoscopic endonasal repair of an unilateral choanal atresia using the microdebrider (powered instrumentation). At the end of the procedure, topical application of Mitomycin-C was performed. No postoperative nasal stenting was inserted. Clinical characteristics of these patients, CT scan examination, complications of the procedure and outcomes were analysed and compared to historical cases treated in the same institution from 1990 to 1998., Results: Seven patients (2 M/5F) (age 6 to 46 months) presented with primary unilateral choanal atresia and were operated during the period from 1999 to 2001. All the patients were symptomatic before surgical correction. No patients showed other facial anomaly. Of the 7 patients procedures, 6 (85.7%) remained patent (follow-up range 12 to 36 months). Mean surgical repair per patient before obtaining patent choana was 1.14. One patient required surgical transnasal revision nine months after the initial procedure with a patent choanal after this second procedure (follow-up 9 months). Minor turbinoseptal synechiae diagnosed 6 months after the surgical correction occurred in one patient and was the only postoperative complication. When compared to historical cases of unilateral choanal atresia (19 patients from 1990 to 1998) repaired without endoscopic control and without Mitomycin-C, it was shown that this current method provided better results; mean surgical repair per patient; 1.14 vs 1.89 and 85.7% of patent choanae at twelve months vs 47.3%., Conclusion: An endoscopic endonasal approach without postoperative stenting, using the microdebrider seems to us the treatment of choice for unilateral choanal atresia. The exact role of the topical application of Mitomycin-C needs to be further investigated.

Objective: To study the microbiology of the bulla ethmoidalis of patients who suffered from chronic sinusitis., Design: A prospective study performed at the Saint-Luc universitary clinic (University of Louvain) from June 1999 to December 2000., Material and Methods: Seventy seven patients underwent functional endoscopic endonasal surgery during this period for chronic sinusitis refractory to standard medical treatment. All the patients presented symptoms for more than 3 months. After Povidone-Iodine disinfection, samples were taken into the bulla ethmoidalis after its opening with an endoscopic endonasal control. Samples were transferred to the microbiology laboratory using a thioglycolate medium for aerobic and anaerobic cultures., Results: One hundred forty eight samples were studied. Culture rate was 73.6%. Thirty nine samples remained sterile. In the 109 culture positive specimens, 135 bacterial isolates were recovered. The main results are: Staphylococcus coagulase negative: 31, Staphylococcus aureus: 22, Streptococcus sp: 20, other Gram positive Cocci: 5, Haemophilus influenzae: 4, non-fermentative Gram negative bacilli: 6, Enterobacteriaceae: 45, anaerobic bacteria: 2., Conclusion: Enterobacteriaceae or enteric gram negative bacilli were frequently encountered in the bulla ethmoidalis of patients suffering from chronic sinusitis. This report suggests that endoscopically guided culture obtained from the ethmoid sinus may accurate our understanding of the microbiology of chronic ethmoidal sinusitis and underline the importance of Enterobacteriaceae in this disease.

Congenital nasal pyriform aperture stenosis (CNPAS) is recognized as a cause of nasal airway obstruction in the newborn. The nasal pyriform aperture is narrowed by a bony overgrowth of the nasal process of the maxilla. The CNPAS may occur as an isolated congenital defect or in combination with other abnormalities. Three cases of CNPAS are reported with special attention to the clinical presentation and to the management recommendation prior to surgery. Surgical repair was performed for all these three highly symptomatic patients using a sublabial approach for drilling the nasal process in order to obtain a wider nasal vestibular patency. All of them were equipped with bilateral nasal stenting.

A case of disseminated invasive fusarial infection (DFI) with sinus involvement in a patient with acute myeloblastic leukaemia is reported. Amphotericin B with rifampin were administrated and wide radical sinus surgery was performed. Nevertheless, the patient died six weeks later. The four principal forms of fusarial infections in humans are discussed: toxicosis, allergic fungal sinusitis, locally invasive infection, and disseminated invasive infection. Prognosis of DFI in the immunocompromised host is usually poor, and treatment is difficult. Profound and prolonged neutropaenia appears to be the major predisposing factor. The literature on infections caused by Fusarium species in immunocompromised hosts is reviewed, especially those where the sinuses were involved.

We compared the efficacy and safety of 5 mg cetirizine (CTZ), 120 mg pseudoephedrine retard (PER) and their combination (COM), given twice daily for three weeks, for the treatment of perennial allergic rhinitis. Two hundred and ten evaluable patients (97 males and 113 females) were included in the study and randomly allocated to one of three treatment groups, each of 70 patients. Nasal obstruction, sneezing, rhinorrhoea, nasal and ocular pruritus were scored each day throughout the study by patients using a symptom scale ranging from 0 (no symptom) to 3 (severe). The mean proportion of days without symptoms was higher in the COM group (11.8%) than in the CTZ (6.8%) and PER (5.1%) groups, but the differences were not statistically significant. The mean percentage of days when symptoms were absent or at most mild was significantly higher in the COM group (64.8%) than in either CTZ (45.5%; p = 0.003) or PER groups (40.6%; p = 0.0001). In addition, evaluation of symptoms by investigators and their global evaluation at the end of treatment showed statistically significant differences in favour of COM compared, to both CTZ and PER. The most frequent adverse events were somnolence in the CTZ and COM groups (8.6% and 12.9%, respectively) while insomnia was most frequent in the PER group. No clinically significant abnormalities were found in haematological or biochemical tests. These results indicate that the combined treatment was more effective than and as well tolerated as treatment with each individual agent.

Dacryocystorhinostomy (DCR) allows an obstructed lachrymal drainage system to be drained into the nasal fossa. Since the development of endonasal microsurgical techniques, the endonasal approach presents itself as an alternative choice to the conventional external approach. It is far less traumatic, yet as efficacious as the conventional approach, and avoids the need for a skin incision and the disruption of the medial canthal structures. Twenty-six patients suffering from lachrymal system obstruction underwent 28 endonasal dacryocystorhinostomies under microscopical (n = 25) or endoscopic control (n = 3). Pre-operative assessment included clinical symptoms (sac swelling, purulent secretions, epiphora) and outflow obstruction on X-rays (conventional dacryocystography and/or subtraction macrodacryocystography). Post-operatively, 23 DCR were free of symptoms. Two presented occasional epiphora and three were unsuccessful. The presence of pre-operative purulent secretions was significantly correlated with post-operative success and with lachrymal sac patency, which is also confirmed by X-ray examination (p<0.001). Thus in cases of purulent secretion with epiphora, X-ray examination is redundant and may be avoided. On the contrary, when epiphora is an isolated symptom, X-rays must be performed in order to determine where the obstruction is located and to provide information on lachrymal sac morphology.

A double-blind, four-centre study was carried out in 66 children to compare the clinical efficacy and safety of N-acetyl-aspartyl-glutamic acid (NAAGA) and disodium cromoglycate (DSCG) nasal sprays. At similar dosage conditions (one puff per nostril, four times daily, for 3 weeks), no significant differences between the treatments were discernible in the primary efficacy parameters (scores, patients' and physicians' opinion). Both products induced statistically significant improvements in the nasal, ocular and total scores, but not in the respiratory (breathing) score. The hay-fever symptoms improved clinically in > 50% of the children after only two weeks with both treatments. The exact figures depended on the parameters considered. Thirteen out of 25 patients (52%) in the NAAGA group found the efficacy "good" or "excellent" at the end of the treatment period; the corresponding opinion in the DSCG group was expressed by 10 out of 24 patients (41.7%). Of the 28 patients that used the rescue medication, 12 (42.8%) were from the NAAGA group and 16 (57.1%) from the DSCG group. One patient on NAAGA treatment reported side effects, i.e. pruritus in the nose and sneezing.