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Background Nonsteroidal anti‐inflammatory drug (NSAID) exacerbated respiratory disease (N‐ERD) is a triad with asthma, chronic rhinosinusitis with nasal polyps, and NSAID intolerance. Uncontrolled N‐ERD forms a major public health problem due to frequent and difficult‐to‐treat exacerbations and/or requiring putatively frequent endoscopic sinus surgeries (ESS). Our aim was to study factors affecting control of N‐ERD. Methods Retrospective patient record data (patient characteristics, prior sinus surgeries, follow‐up data in 2020) from 167 N‐ERD patients undergoing consultation at three tertiary hospitals from 2001 to 2017 was used. Outcome measurements reflecting uncontrolled N‐ERD were revision ESS, corticosteroids/biological therapy, and antibiotic courses during 2016–2020. Associations were analyzed by using nonparametric tests, Cox's proportional hazard, and binary logistic regression models. Results Nasal polyp eosinophilia increased the risk of revision surgery during the follow‐up (adjusted hazard ratio [aHR] 3.21, confidence interval 1.23–8.38). Also baseline oral corticosteroids (OCS; HR, 1.73, 1.04–2.89) and baseline surgery without total ethmoidectomy increased the risk of revision ESS (HR, 2.17, 1.07–4.42) in unadjusted models. In addition, both baseline OCS (adjusted odds ratio [aOR] 2.78, 1.23–6.26) and a history of ≥4 previous ESS (aOR, 2.15, 0.98–4.70) were associated with the use of OCS/biological therapy during the follow‐up, but not with high number of antibiotics. Conclusions Nasal polyp eosinophilia, baseline OCS, and a history of recurrent ESS predict uncontrolled N‐ERD. These factors might be clinically useful in risk‐estimation of uncontrolled disease and for organizing follow‐ups. Prospective cohort studies with larger sample size are needed to further study the factors affecting the upper airway control of N‐ERD., The patient record data of 167 patients with NSAID‐exacerbated respiratory disease was analyzed to study factors affecting the disease control. Nasal polyp eosinophilia increased the risk of revision surgery, and baseline oral corticosteroids and a history of four or more endoscopic sinus surgeries were associated with poor disease control during the follow‐up.

Human sinonasal anatomy varies widely between patients, challenging surgeons operating in the sinuses. Ethmoid sinus anatomy is so variable it has been referred to as a labyrinth. Accordingly, reliable, consistent anatomic landmarks aid surgeons operating in this region. The goal of this investigation was to explore our observations and hypothesis that the ethmoidal bulla and the uncinate process are not entirely separate structures but rather attach, and the attachment could potentially provide a landmark for surgeons performing ethmoid and frontal recess surgery. Ethmoid sinus anatomy was studied in 57 sinonasal complexes through a variety of methods including gross anatomic dissection, endoscopic dissection and 3D CT stereoscopic imaging. The uncinate process and ethmoidal bulla were noted to fuse at the superior aspect of the hiatus semilunaris in 57/57 cases, forming a genu-like feature in the anterior ethmoid. This consistent anatomic feature related closely to the frontal sinus drainage pathway, which drained medial to it in 44/57 (77%) cases. The anterior ethmoidal "genu" appears to be an excellent anatomic feature that surgeons can use during ethmoid and frontal recess surgery. High resolution 3D stereoscopic CT scan is capable of demonstrating sinonasal anatomy in a detailed fashion previously only achieved by cadaveric dissection. This technology can potentially allow for a virtual dissection of a patient's anatomy prior to surgery and could improve minimally invasive procedures and reduce complications. Clin. Anat. 32:534-540, 2019. © 2019 Wiley Periodicals, Inc.

Background Anosmia has an estimated prevalence of 5% of the general population. Outside of inflammatory causes, therapeutic options are limited despite research advances. Bypassing peripheral neuronal damage through central stimulation is a potential therapeutic option that has shown success in other sensory systems, most notably with hearing. We performed a pilot study to determine the feasibility of inducing smell through artificial electrical stimulation of the olfactory bulbs in humans. Methods Subjects with a history of sinus surgery, including total ethmoidectomy, with intact ability to smell were enrolled. The ability to smell was confirmed with a 40-item smell identification test. Awake subjects underwent nasal endoscopy and either a monopolar or bipolar electrode was positioned at 3 areas along the lateral lamella of the cribriform plate within the ethmoid sinus cavity. A graded stimulation current of 1-20 mA at 3.17 Hz was administered while cortical evoked potential (CEP) recordings were collected. Subjective responses of perceived smell along with reports of discomfort were recorded. Subjects with artificially induced smell underwent repeat stimulation after medically induced anosmia. Results Five subjects (age, 43-72 years) were enrolled. Three subjects reported smell perception smell with electrical stimulation. This was reproducible after inducing anosmia, but CEP recordings could not provide objective support. All subjects tolerated the study with minimal discomfort. Conclusion This is the first report of induced smell through transethmoid electrical stimulation of the olfactory bulb. These results provide a proof of concept for efforts in development of an olfactory implant system.

BACKGROUND Surgical skill development outside the operating room aims to improve technique and subsequent patient safety. The purpose of this study was to evaluate the correlation between technical and cognitive skills with cadaveric endoscopic sinus surgery (ESS) performance and change in ESS performance before and after implementation of a dedicated ESS simulation-based and knowledge-based curriculum. METHODS A before-after study design was implemented among 10 medical students and 10 junior otolaryngology residents. Participants completed a knowledge-based, multiple-choice ESS pretest and watched an ESS prosection video. Participants performed 9 tasks on a previously validated low-cost, low-technology, nonbiologic sinus surgery task trainer followed by cadaveric maxillary antrostomy and anterior ethmoidectomy. Participants then completed a simulation-based and knowledge-based ESS curriculum followed by a repeat cadaveric maxillary antrostomy and anterior ethmoidectomy. Performance was graded with a 5-point global rating scale (GRS) and a 5-point ESS-specific checklist. RESULTS We observed a stronger correlation between the multiple-choice, knowledge-based, ESS pretest scores and cadaveric ESS GRS score (r = 0.73) than between task trainer performance and cadaveric ESS GRS score (r = 0.43). We also noted a significant increase in precurriculum vs postcurriculum mean ± standard deviation (SD) cadaveric ESS checklist scores for both medical students (1.18 ± 0.25 vs 2.58 ± 0.57; p = 0.0002) and residents (2.09 ± 0.78 vs 2.88 ± 0.54; p = 0.023). The greatest improvements for residents were in performance of uncinectomy, enlargement of maxillary os, and identification of the bulla. CONCLUSION These findings provide evidence supporting the use of ESS training curricula outside the operating room.

Objectives To determine a paradigm for evaluating and managing maxillary sinus conditions before dental implantation via preoperative sinonasal assessment. Study Design Prospective cohort study. Methods Eighty-four patients who underwent dental implantation with or without sinus augmentation were included. Maxillary sinus conditions were classified into groups 1 to 6 according to cone-beam computed tomography (CT) findings: 1) nonspecific findings, 2) solitary polyp or cyst, 3) mucosal thickening, 4) air–fluid level or fluid accumulation, 5) near-total opacification of the maxillary or other paranasal sinus, and 6) calcification spots in the maxillary sinus. Dental implantation with or without sinus augmentation was suggested with postoperative sinus observation (groups 1–3), after medication for acute sinusitis (group 4), and after comprehensive treatment of chronic or fungal sinusitis (groups 5–6). Intraoperative and postoperative sinus-related complications were recorded. Results Two patients (groups 1 and 3) developed acute rhinosinusitis after sinus augmentation; both recovered completely with medical treatment. Schneiderian membrane perforation occurred during sinus lift surgery in six patients (group 1): five recovered after conservative medical therapy and close observation, whereas one required endoscopic sinus surgery and recovered well. No chronic rhinosinusitis developed after dental implantation. Conclusion Craniofacial CT is crucial for pre-dental implantation sinonasal evaluation. The risk of dental implant-related chronic rhinosinusitis is low for patients with cysts, polyps, or mucosal thickening in the maxillary sinus. However, preventive endoscopic sinus surgery is recommended for patients with incurable chronic rhinosinusitis, fungal sinusitis, and large polyps or cysts. Level of Evidence 4. Laryngoscope, 2017

BACKGROUND Topical solutions to the sinus cavity are primarily administered via a transnasal route with inherent limitations of distribution. Here we describe an alternate method of sinus access via lacrimal sinus diversion using a novel lacrimal diversion device (LDD). METHODS A cadaveric study was performed using 12 disarticulated fresh heads. The LDD was implanted in 23 sides meeting insertion criteria. Time to placement was recorded and patency was assessed via nasal endoscopy. Methylene blue was administered via the LDD and 16 sides underwent surgical ethmoidectomy to assess distribution of mucosal staining. Four cadavers underwent computed tomography (CT) imaging to demonstrate stent position. RESULTS Mean time of placement was 3.66 ± 2.37 minutes (mean ± standard deviation [SD]). Patency rate was 100%. Six sides (37.5%) had anterior ethmoid staining, 6 sides (37.5%) had posterior ethmoid staining, and the remaining 4 sides (25%) had mixed anterior and posterior ethmoid staining. Stents placed optimally resulted in anterior ethmoid staining without complication. Malpositioned stents resulted in posterior ethmoid staining and some inadvertent ethmoid vertical lamella trauma in 2 instances. CONCLUSION Sinus irrigation can be delivered to the ethmoid sinuses directly via a lacrimal diversion stent. Technique modification or image guidance may be helpful in ensuring optimal placement.

Background Postoperative wound healing after endoscopic sinus surgery (ESS) in patients with chronic rhinosinusitis (CRS) is an important factor in procedural success. Local steroids and separation of opposing mucosa are commonly implemented to optimize healing. A bioabsorbable, fluticasone propionate (FP)-eluting implant, SinuBand FP, was assessed for its safety and efficacy when used in patients with CRS and nasal polyps, who were indicated for ESS including bilateral anterior and posterior ethmoidectomy. Methods A first-in-human, randomized, partially double-blind, single-tertiary-referral-center, controlled trial enrolling 30 patients receiving 2 of 3 treatments (1 per sinus, intrapatient control): SinuBand FP, SinuBand (without FP), or standard nasal pack (Merocel®). Primary outcome measures were local safety, ocular safety (intraocular pressure [IOP], lens opacity), and 24-hour urine cortisol. Secondary measures (evaluated by independent review of postoperative video endoscopies) were ethmoid inflammation, polyp score, adhesion formation, and Lund-Kennedy score. Patient-reported outcomes of postoperative pain, nasal congestion, and nasal discharge were collected. Results Of 30 enrolled patients (used for safety analysis), 27 patients completed the trial. SinuBand FP showed local safety, ocular safety, and no significant change in 24-hour urine cortisol. SinuBand FP showed a trend to do better concerning inflammation. Concerning polyp score SinuBand FP did significantly better compared to Merocel (p = 0.03). No significance compared to SinuBand without corticosteroids (p = 0.97). Adhesions were comparable across treatments. Patient reported pain was nominally lower in the SinuBand group. Conclusion SinuBand FP was well tolerated and showed evidence of efficacy. A larger study is needed to further evaluate and confirm the benefits of SinuBand FP.

Objectives The relationship between a particular surgical technique in endoscopic sinus surgery (ESS) and airflow changes in the post-operative olfactory region has not been assessed. The present study aimed to compare olfactory airflow after ESS between conventional ethmoidectomy and ethmoidectomy with superior meatus enlargement, using virtual ESS and computational fluid dynamics (CFD) analysis. Study Design Prospective computational study. Materials and Methods Nasal computed tomography images of four adult subjects were used to generate models of the nasal airway. The original preoperative model was digitally edited as virtual ESS by performing uncinectomy, ethmoidectomy, antrostomy, and frontal sinusotomy. The following two post-operative models were prepared: conventional ethmoidectomy with normal superior meatus (ESS model) and ethmoidectomy with superior meatus enlargement (ESS-SM model). The calculated three-dimensional nasal geometries were confirmed using virtual endoscopy to ensure that they corresponded to the post-operative anatomy observed in the clinical setting. Steady-state, laminar, inspiratory airflow was simulated, and the velocity, streamline, and mass flow rate in the olfactory region were compared among the preoperative and two postoperative models. Results The mean velocity in the olfactory region, number of streamlines bound to the olfactory region, and mass flow rate were higher in the ESS-SM model than in the other models. Conclusion We successfully used an innovative approach involving virtual ESS, virtual endoscopy, and CFD to assess postoperative outcomes after ESS. It is hypothesized that the increased airflow to the olfactory fossa achieved with ESS-SM may lead to improved olfactory function; however, further studies are required. Level of Evidence N/A.

Background The retroantral ethmoid cell (RAEC) is defined as a posterior ethmoid cell that pneumatizes inferolaterally behind the posterior wall of the maxillary sinus. The RAEC can present a challenge to otolaryngologists during endoscopic ethmoidectomy due to its concealed location. It is also encountered during the endoscopic transpterygoid approach to the skull base, which requires dissection behind the posterior wall of the maxillary sinus. Because the RAEC is not described in the literature, this study aims to better characterize this anatomic variant. Methods This is a retrospective review of 58 consecutive patients who underwent revision functional endoscopic sinus surgery (FESS) within a 2-year period at a tertiary referral center. Sinus computed tomography (CT) scans for this cohort (116 sides total) were reviewed independently by 3 authors to determine the incidence of the RAEC and the degree of surgical dissection during prior surgery. Results Of the 116 sides included in the study, RAEC was identified in 19 (16%). Furthermore, 14 of 19 (74%) cells were diseased with evidence mucosal thickening or neo-osteogenesis. Of the 12 sides with RAEC that had evidence of previous posterior ethmoidectomy, 4 (33%) cells were not opened, 6 (50%) were partially opened, and only 2 (17%) were completely opened. Conclusion This study demonstrates the relatively high prevalence of the RAEC in our patient population. The majority of RAECs showed both evidence of disease and that they were not completely opened during previous surgery. Recognition of this anatomic entity may allow for more thorough ethmoidectomy.

Background In medically refractory chronic frontal sinusitis, ethmoidectomy without instrumentation of the frontal ostium may resolve frontal disease. Our aim was to determine the efficacy of ethmoidectomy alone for the treatment of chronic frontal sinusitis. Methods Adults with chronic rhinosinusitis prospectively enrolled in a multicenter study who demonstrated frontal sinusitis on computed tomography were divided into 2 groups: (1) endoscopic sinus surgery (ESS) incorporating ethmoidectomy, but excluding frontal sinusotomy; and (2) ESS incorporating frontal sinusotomy. The primary outcome was improvement in 22-item Sino-Nasal Outcome Test (SNOT-22) scores. Secondary outcomes included endoscopic scores and use of corticosteroids and antibiotics. Results A total of 196 cases undergoing frontal sinusotomy and 30 cases treated with ethmoidectomy without frontal sinusotomy were analyzed and were comparable demographically. The prevalence of nasal polyps, previous ESS, asthma, and aspirin intolerance was more common in the frontal sinusotomy group (p < 0.050). Preoperative endoscopy and computed tomography scores were higher in the frontal sinusotomy group (p ≤ 0.001). Postoperatively, both groups showed comparable SNOT-22 scores with worse endoscopy scores in the frontal sinusotomy group (p = 0.038). Postoperative improvement in SNOT-22 total and subdomain scores was comparable between groups. Nasal endoscopy scores improved to a greater degree in the frontal sinusotomy group (p = 0.023). Duration of postoperative topical steroid use was higher in the frontal sinusotomy group (p = 0.007). Revision surgery was needed in 2.6% of frontal sinusotomy patients and 0% of patients without frontal sinusotomy. Conclusion The treatment of chronic frontal sinusitis through ethmoidectomy is a potential alternative to frontal sinusotomy achieving similar quality of life (QOL) improvements in patients manifesting less severe sinus disease.

Background Long-term use of systemic glucocorticoid therapy has been associated with hypothalamic-pituitary-adrenal axis suppression and other systemic adverse events. This pharmacokinetic study evaluated the systemic safety and performance of a bioabsorbable sinus implant that gradually releases 1350 μg of mometasone furoate directly to the sinus mucosa. Methods A prospective, single-center study treating 5 adult patients with recurrent polyposis after bilateral total ethmoidectomy. Each patient received 2 steroid-releasing implants in-office under local/topical anesthesia. Plasma concentrations of mometasone furoate and cortisol were determined before placement and through 30-day follow-up, which also included endoscopic grading and patient-reported outcomes. Results Five patients (mean age 46.2 ± 9.2 standard deviation [SD] years; 60% male) underwent successful placement in all 10 ethmoid sinuses. There were no serious adverse events. The plasma concentrations of mometasone furoate were generally below the lower limit of quantification (LLOQ) of the assay (30 pg/mL). Cortisol concentrations at follow-up ranged from 3.9 to 5.7 mg/dL compared to 4.7 mg/dL at baseline. At 1 month, there was a significant improvement in bilateral polyp grade (p = 0.037), nasal obstruction score (p = 0.002), and 22-item Sino-Nasal Outcome Test (SNOT-22) (p = 0.010) compared to baseline. Conclusion The reported 100% placement success, negligible systemic exposure to mometasone furoate released over time, lack of adrenal suppression, and the absence of serious adverse events suggest that the implant provides a valid and safe option for the in-office treatment of recurrent polyposis. Randomized, controlled, blinded clinical studies are underway to provide further evidence of safety and efficacy.

Kapossiform hemangioendothelioma (KHE) of the paranasal sins (PNS) is a rare cause of recurrent epistaxis. To date, only two cases of PNS KHE have been reported in the literature, both occurring in the pediatric population. The case presented here appears to be the first case of PNS KHE occurring in an adult. A 46-year-old white female presented with progressively worsening unilateral recurrent epistaxis. Diagnostic histopathology confirmed it to be KHE. After a detailed workup, the tumor was completely excised en bloc (medial maxillectomy; anterior and posterior ethmoidectomy) via a lateral-rhinotomy approach. Complete excision of the tumor with clear margins offers the best results. Laryngoscope, 124:2103–2106, 2014

Background The purpose of this study was to describe the incidence of the middle ethmoidal artery and its anatomical nuances via an endoscopic endonasal approach. Methods A cadaveric study was performed on 22 adult specimens. First, a frontal sinusotomy and ethmoidectomy were performed via an endoscopic endonasal approach in order to fully expose the anterior skull base. Subsequently, the lamina papyracea and the bone of the canals covering the ethmoidal neurovascular bundles were removed to identify the anterior, middle, and posterior ethmoidal arteries. Presence, laterality, and location of the middle ethmoidal artery were recorded. Results A total of 14 middle ethmoidal arteries were identified (10 right and 4 left), among 44 sides (22 specimens), accounting for an incidence of 31.8%. Bilateral middle ethmoidal arteries were found in 3 of 22 specimens (14%). Endonasal endoscopy features of the middle ethmoidal artery were noted. Conclusion This is the first study assessing the anatomical features of the middle ethmoidal arteries from an endonasal endoscopic perspective. The findings of this research have clinical significance in guiding surgeries that involve the medial orbital wall, intractable epistaxis, and anterior skull base pathologies, as well as endoscopic endonasal surgeries.

Background Ethmoid sinus osteomas are uncommon, benign, osteogenic tumors. The purpose of this retrospective study was to describe their usual clinical presentation and to discuss their surgical management. Methods The medical records of 25 patients treated for ethmoid osteoma between March 2001 and December 2010 were retrospectively reviewed. Results The average tumor size was 18.5 ± 14 mm. Only 3 patients were asymptomatic, 14 had a history of frontal sinusitis (complicated with orbital cellulitis in 4 cases), and 4 patients presented with diplopia. An endoscopic approach was performed in 19 cases, a coronal approach in 4 cases, and a combined approach (endoscopic + coronal) in 2 cases. No recurrence was reported. Conclusion Ethmoid sinus osteoma can be asymptomatic and detected incidentally on CT scans, but often causes frontal sinusitis and orbital complications. The endoscopic approach offers the possibility of safe removal with cosmetic advantages compared to coronal approach.

Background: Differentiating between posterior ethmoid and sphenoid sinuses can be difficult endoscopically. Anatomic relationships should guide surgery, irrespective of the ability to verify them with image guidance. The authors sought to verify an anatomic landmark found to be useful during endoscopic sinus surgery: the ability to see the sphenoid floor with a 0-degree nasal endoscope. Methods: The angle formed by a nasal endoscope placed at the sphenoid ostium and the mucosa of the sphenoid floor was measured in 93 consecutive sphenoid sinuses radiologically. Angles of view of 3 common endoscopes were directly measured and compared to the radiologic measurements. Results: The angle to the most inferior aerated portion of the sphenoid sinus averaged 113.6 degrees with a range of 77 to 145 degrees. The angle of view of the 3 endoscopes was found to be 38.1 degrees, 46.7 degrees, and 44.4 degrees. With these angles of view, the most inferior aerated portion of 100% of the radiologically assessed sinuses could not be seen with these endoscopes. Conclusion: Inability to see the mucosa of the floor of the sphenoid sinus with a 0-degree nasal endoscope appears to be a reliable finding. Individual variations that may affect this finding such as hypoplasia or severe mucosal edema should be identified preoperatively on imaging. In their absence, the inability to see the floor of an entered sinus with a 0-degree nasal endoscope provides another reliable clue to the position of the sphenoid sinus during endoscopic sinus surgery. © 2011 ARS-AAOA, LLC.

Objectives/Hypothesis: Transantral endoscopic balloon dilatation (TABD) was recently introduced for the management of limited mild maxillary and ethmoid disease. An expanded approach by inserting surgical tools into the antrum via a second port, directed toward the maxillary ostium, ethmoid infundibulum, and posterior ethmoids will allow for the treatment of moderate disease as well. Study Design: Retrospective data review. Methods: A study including all TABD procedures performed between January and December 2009 was performed. Sublabial approach with two working channels, one for the endoscope and a second port for balloon dilatation or other surgical instrumentation, was devised. Both channels were created via mini-trephine aimed toward the osteo-meatal complex (OMC) with different angulations. The same approach was used for transantral posterior ethmoidectomy (TAPE). Data collected included demographics, Sino-Nasal Outcome Test (SNOT) scores, Lund-Mackay score, and complications. Results: Thirty-five patients with 64 dilated sinuses and 10 TAPE procedures were enrolled. All SNOT scores showed statistically significant improvement decreasing from 1.77 to 0.83. Complication rate was minimal. Only a small number of procedures were converted to standard endoscopic septoplasty (ESS) owing to severity of OMC disease. TAPE proved to be a minimally invasive procedure. Conclusions: Two trocars inserted through the canine fossa can achieve a successful result in moderate antral disease for TABD and allow TAPE to be performed, thus creating a bridge between mild disease and one requiring standard full ESS. The minimally invasive approach proved to be particularly useful.

Objectives: to describe three-dimension (3-D) tomosynthesis and cone beam computed tomography (CBCT) as an intraoperative imaging system to guide both sinus and skull-base surgery in a cadaveric model. Methods: five cadaveric heads underwent baseline CBCT imaging. Surgical targets were resected from each head (uncinectomy, ethmoidectomy, medial maxillectomy, pituitary gland resection, and clivus ablation). Intraoperative imaging was provided so that for a given task, the acquisition arc (theta(tot) = 20 degrees, 45 degrees, 60 degrees, 90 degrees, 178 degrees) of the tomosynthesis scan was fixed. Different heads and tasks were allocated different acquisition angles. There was no limit to the number of scans that could be requested. Residual target was highlighted with 3-D visualization software. Result: the larger the image acquisition angle, the better the image. Only CBCT (theta(tot) approximately 178 degrees) provided nearly isotropic 3-D spatial resolution and soft-tissue visibility in all three views. The volume of residual tissue remaining and the volume of adjacent-normal tissue that was resected were calculated as a function of tomosynthesis angle. For the easier surgical tasks (uncinectomy, ethmoidectomy) the residual tissue was not related to the tomosynthesis angle. However, for the difficult ablative tasks, the image quality became more important and tomosynthesis angle was related to the residual tissue. Conclusions: we describe an intraoperative imaging platform that can deliver near-real-time images of the target and related structures with low radiation dose. Tomosynthesis scanning angles higher than 60 degrees provided quantifiable benefits to the surgeon and facilitated total target ablation while helping to spare surrounding structures.

The maxillary sinus is universally described as a pyramidal-shaped cavity in the maxilla. Hypoplasia, which can occur unilaterally or bilaterally, is graded by the authors by the degree of failure of descent below the nasal floor in achieving its position adjacent to the posterior dentition in the adult. Unlike early studies using plain X-rays, which considered pneumatization into the zygomatic recess and dental alveolus as criteria, the authors have adopted the above-cited parameters based on computed tomography (CT) imaging, which reveals that even when smaller the sinus retains a pyramidal configuration, although truncated. Rarely, the sinus is excessively pneumatized in the nonpathologic state. Review of the literature failed to reveal a comprehensive study of the conditions that alter maxillary sinus volume and configuration. Based on a retrospective review of 6,000 high resolution CT scans of the paranasal sinuses, the types and relative incidences of these conditions have been determined, and a classification system proposed. The mixed-sex sample group (= 2,540) was comprised of nonpediatric (adolescent and adult) and was of a polyethnic composition. Results showed that enlargement of the sinus is uncommonly encountered, and is produced by air (pneumocele) and mucus (mucocele) entrapment, or by benign tumors which have arisen in the sinus or adjacent maxilla and have grown intracavitarily, with the sinus walls expanding and remodeling to accommodate them. Reduction in size and volume is more frequent. Heredo-familial syndromic conditions reduce sinus size by impaired facial growth centers, or obliteration by dense osteosclerosis. Irradiation for neoplastic disease in the pediatric population similarly, directly effect growth centers, or impairs pituitary function. Another iatrogenic cause, direct surgical intervention (Caldwell-Luc procedure) almost universally alters sinus volume and shape by osteoneogenesis. Midfacial fractures involving the sinus also produce distortion by sclerosis as well as by malpositioning of bone fragments. The principal systemic disorders, sickle cell anemia and osteopetrosis, which diffusely effect medullary bone, do so either through compensatory marrow proliferation or sclerotic new bone formation, thus serving to produce maxillary enlargement and sinus obliteration. The greatest source of maxillary sinus distortion and destruction are neoplasms. Malignant sinonasal and oral cavity tumors produce bony erosion of the sinus walls, whereas benign odontogenic cysts remain external to the sinuses and compress it as they enlarge. Most odontogenic tumors produce external compression and remodeling. Fibro-osseous disorders similarly produce size and shape distortions by external impingement. Although diverse developmental and pathological conditions influence maxillary sinus morphology, there is a limited range of biologic response.

An anatomic and endoscopic study of 48 cadaveric heads (96 sphenoid sinuses) was undertaken to describe the anatomy of the sphenoid sinus in Asians. Sellar type of sphenoid sinus is the most common, present in 53 out of 96 sides (55%). Forty-five of the 48 heads had a dominant sphenoid cavity, of which 11 contained vital structures from both sides of the sphenoid sinus. The incidence of accessory septae, carotid artery, optic nerve, maxillary nerve, and vidian nerve bulges were 70.8%, 67.7%, 69.8%, 61.5%, and 64.6%, respectively. There is a significantly higher number of overriding ethmoid sinuses in Asian cadavers (46/96 sides) compared to western studies (P < 0.0005). Seven (15%) of these 46 sides were also Onodi positive. The rest of the overriding ethmoid cells were Onodi negative. Surgeons should be aware of the significantly higher number of overriding posterior ethmoid cells in Asian populations during functional endoscopic sinus surgery (FESS). The optic nerve is at risk during FESS surgery if the sphenoid sinus is sought behind the deepest point of these posterior ethmoid cells. These overriding posterior ethmoid cells may also confuse the unwary surgeon that he has entered the sphenoid sinus where in fact he is still operating in the posterior ethmoid cells. Clin. Anat. 20:745–750, 2007. © 2007 Wiley-Liss, Inc.

Background. Epistaxis is very common during childhood. It occurs primarily in boys and is usually self-limiting. Trauma and nose picking are among the most common causes. In general, epistaxis can be easily treated with anterior nasal packing or electrocoagulation. Methods. We report a case of an 8-year-old girl with severe unilateral epistaxis. Results. The bleeding originated from a kaposiform heman- gioendothelioma arising in the left nasal cavity and ethmoid sinus. The feeding vessels originating from the maxillary artery were first embolized. The tumor was then surgically removed through a combined external ethmoidectomy and endonasal approach. The postoperative course was uneventful. MRI at 6 months after surgery showed no tumor recurrence. Conclusions. We report a previously undescribed cause of epistaxis in children, namely, a kaposiform hemangioendothe- lioma. To our knowledge, this is the first such case in the English- language literature. The differential diagnosis of severe unilateral nasal bleeding among the pediatric population should include the possibility of a kaposiform hemangioendothelioma. V C 2006

Objectives/Hypothesis The goal of our study is to identify the number of Endoscopic Sinus Surgery (ESS) cases required to obtain competency in ESS, using a previously validated assessment tool. Study Design Prospective observational study. Methods Seventeen residents from Johns Hopkins Otolaryngology–Head & Neck Surgery residency program were evaluated as they performed endoscopic sinus surgery in the operating room. Global and checklist parts of the ESS instrument were used for assessment purposes. Items on the tool were grouped into three different milestones for analysis of data (Milestone 1 = Maxillary Antrostomy + Anterior Ethmoidectomy, Milestone 2 = Posterior Ethmoidectomy + Sphenoidostomy, Milestone 3 = Frontal Sinusotomy). Residents were deemed competent if they achieved a minimum score of 3 on a 5-point Likert scale on each step of the surgery. Results A total of 73 evaluations were completed for 17 residents (Postgraduate Level 2–5) by eight evaluators between 2009 and 2011. A 60% probability of achieving competency in performance of all milestones of ESS is obtained with performing 42 ESS procedures and the probability is increased to a 100% with performance of 55 endoscopic sinus surgery procedures. On average it took residents 23 cases to become competent in performance of maxillary antrostomy and anterior ethmoidectomy. Conclusions Our results suggest that it requires 42 ESS procedures to attain a 60% probability of competency in ESS. These results have implications for otolaryngology residency programs when developing curriculum and benchmarks for the training residents. Laryngoscope, 123:2932–2934, 2013

Objective: To demonstrate the potentials and limitations of three different endoscopic procedures employed for treatment of inverted papilloma (IP) of the sinonasal tract. Study Design: Retrospective analysis of a cohort of patients treated at two University hospitals. Methods: From January 1992 to June 2000, 47 patients with IP underwent endoscopic resection. Preoperative workup included multiple biopsies of the lesion and imaging evaluation by computed tomography or magnetic resonance imaging. Massive skull base erosion, intradural or intraorbital extension, extensive involvement of the frontal sinus, abundant scar tissue caused by previous surgery, or the concomitant presence of squamous cell carcinoma were considered absolute contraindications for a purely endoscopic approach. Three types of resection were used: ethmoidectomy with wide antrostomy and sphenoidotomy (type 1) for IPs confined to the middle meatus, medial maxillectomy with ethmoidectomy and sphenoidotomy (type 2) for IPs partially invading the maxillary sinus, and a Sturmann-Canfield operation (type 3) for IPs involving the mucosa of the alveolar recess or of the anterolateral corner of the maxillary sinus. All patients were followed by periodic endoscopic evaluations. Results: Type 1, 2, and 3 resections were performed in 26, 15, and 6 patients, respectively. No recurrences were observed after a mean follow-up of 55 (range 30–132) months. One patient, who underwent a type 2 resection, developed a stenosis of the lacrimal pathways requiring endoscopic dacryocystorhinostomy. Conclusions: Our experience confirms that endoscopic surgery is an effective and safe method of treatment for most IPs. The availability of different endoscopic techniques allows the entity of the dissection to be modulated in relation to the extent of disease. Strict application of selection criteria, meticulous use of subperiosteal dissection in the involved areas, and regular follow-up evaluation are key elements for success.

Objectives/Hypothesis Powered dissection is increasingly used in endoscopic sinus surgery. Although it has certain clear advantages over conventional instrumentation, powered dissection also presents special liabilities. The objectives of the report are to highlight the special dangers of powered instrumentation near the orbit, to suggest techniques that might minimize these risks, and to review the management of orbital injuries. Study Design Case series. Methods A retrospective review was performed of patients who were referred to our institution with orbital injury complicating endoscopic sinus surgery in which powered instrumentation had been used. Patient demographics, status as revision or primary surgery, degree of intraoperative blood loss, indications for surgery, intraoperative findings, the complication sustained, time of recognition of the complication, immediate and delayed treatment, and clinical course were obtained from the clinical records. Results Three patients had medial rectus muscle injuries. In addition to the medial rectus injury, one patient also had blindness, probably from an orbital hemorrhage. One patient underwent orbital exploration in an unsuccessful attempt to reattach the ends of the medial rectus muscle. One patient had continuing diplopia, but declined orbital exploration or strabismus surgery. Conclusions Intraoperative orbital complications that might be of minor consequence with conventional instrumentation can have dramatic sequelae when powered dissection is used. Special care must be exercised in using powered instrumentation.

Objective We investigated the surgical anatomy of the sphenopalatine artery. First, the location of the sphenopalatine foramen on the lateral nasal wall and the pattern of the main branches of the sphenopalatine artery from the sphenopalatine artery were studied. Second, the course of the posterior lateral nasal artery with respect to the posterior wall of the maxillary sinus, the perpendicular plate of the palatine bone, and the pattern of distribution of its branches on the fontanelle was determined. Third, the distribution pattern on the inferior turbinate was analyzed. Study Design Fifty midsagittal sections of randomly selected Korean adult cadaver heads with intact sphenoid sinus and surrounding structures were used in the study. Methods The mucosa on the sphenopalatine foramen and its surrounding mucosa were removed with a microscissors, a fine forceps, and a pick to expose the sphenopalatine artery under an operating microscope (original magnification ×6). Results The feeding vessels of the superior turbinate were from the septal artery in 36 cases (72%). The feeding vessels to the middle turbinate branch originated from the proximal portion of the posterior lateral nasal artery just after exiting the sphenopalatine foramen in 44 cases (88%). Some portion of the posterior lateral nasal artery ran anterior to the posterior wall of the maxillary sinus in 38%. The major feeding arteries to the fontanelle were from the inferior turbinate branch in 25 cases (50%). In most cases, the inferior turbinate branch was the end artery of the posterior lateral nasal artery (98%). Conclusions The study provides detailed information concerning the sphenopalatine artery, which we hope will help explain the arterial bleeding that may occur during ethmoidectomy, middle meatal antrostomy, conchotomy, and endoscopic ligation of the sphenopalatine artery.

Objective/Hypothesis: The role of endoscopic sinus surgery for treating chronic maxillary sinusitis is well established. The purpose of the study is to determine the efficacy of endoscopic sinus surgery in the treatment of maxillary sinus inflammatory disease that includes mucoceles, retention cysts, and antrochoanal polyps. Study Design: This is a retrospective review of 32 consecutive patients who underwent endoscopic sinus surgery for mucoceles (n = 21), retention cysts (n = 5), or antrochoanal polyps (n = 6). Methods: The medical records were reviewed for patient demographics, presenting symptoms, and type of operation. Surgical outcome was determined by resolution of symptoms, recurrence of disease, and need for revision or additional surgery. Results: Ethmoidectomy with middle meatal antrostomy was performed in all patients; 28 patients had additional middle turbinectomy. Postoperative follow-up ranged from 6 months to 4 years. The operation resulted in resolution of symptoms and a patent antrostomy on long-term follow-up in all cases of mucoceles. No case required revision surgery. On the other hand, the disease recurred in three patients (60%) with retention cysts and three patients (50%) with antrochoanal polyps despite patent antrostomies. The recurrences occurred 3 to 6 months after the surgery. The recurrent cases of antrochoanal polyps required Caldwell Luc procedures. The three failures in cases of retention cysts were successfully managed with repeated office endoscopic marsupialization through a patent antrostomy. Conclusions: Endoscopic sinus surgery is an effective treatment for mucoceles, with favorable long-term outcome. Maxillary retention cysts commonly recur after endoscopic sinus surgery. However, the recurrence can be managed in the office through a patent antrostomy. Endoscopic sinus surgery may be offered as initial surgical treatment for antrochoanal polyps, but a Caldwell Luc operation may be needed for recurrent disease.

Objectives/Hypothesis The aim of this study is to evaluate an endoscopic sinus surgical simulator (ESS) as a training device and to introduce a methodology to assess its impact on actual operating room performance. Study Design Prospective evaluation of the endoscopic sinus surgical simulator as a trainer. Methods Ten junior and senior ear, nose and throat residents served as subjects, some of whom had prior training with the simulator. The evaluation team collected several measures, which were analyzed for a statistical correlation, including simulator scores, operating room performance rating, ratings of videotaped operating room procedures, and surgical competency rating. Results These findings suggest the ESS simulator positively affects initial operating room performance across all measures as judged by senior surgeons rating anonymous videotapes of those procedures. The two simulation-trained residents were rated consistently better than the other two residents across all measures. These differences approached statistical significance for two items: anterior ethmoidectomy (P = .06;P

Objectives:Assess the safety and efficacy of a drug-eluting catheter to be inserted into the ethmoid sinuses during endoscopic sinus surgery to elute triamcinolone in patients with CRSwP (nasosinusal polyposis).Methods:Prospective, randomized, controlled, double-blind, clinical trial using intrapatient control design. The study enrolled 40 patients with CRSwP undergoing endoscopic sinus surgery. In every case, after polypectomy was done to expose the ethmoid bulla, a drug-eluting catheter to elute triamcinolone (0.3 mL) was randomly applied to one nasal fossa, whereas the other was treated by conventional total ethmoidectomy. Outcome measures were visual analogue scales, Rhinosinusitis Disability Index, endoscopy, and olfactometry assessment at baseline, 3, 6, and 12 months. Safety assessments included ocular examinations at baseline and 30 days. All CT imaging was done after more than 12 months of follow-up.Results:After randomization was performed, unilateral devices were successfully placed in all pati...

Objective: To assess the safety and efficacy of Sepragel sinus, a hylan B gel (cross-linked hyaluronic acid molecule), when used as a postoperative dressing after endoscopic sinus surgery as a facilitator of healing and a preventative for scarring and stenosis. Study Design: Ten patients undergoing bilateral endoscopic ethmoidectomy in an outpatient specialty hospital operating room underwent complete filling of a randomly selected right or left ethmoidectomy cavity with Sepragel sinus. Outcome measures were synechiae, middle meatal stenosis, mucosal status, mucosal regeneration, transparency of Sepragel sinus, and subjective pain and congestion. Results: Sepragel sinus significantly improved all outcome measures by week 2 and remained statistically significant for reduction of synechiae and stenosis. Conclusion: Sepragel sinus is useful as a space-occupying gel stent to separate sinus mucosal surfaces. The data strongly support the superiority of Sepragel sinus over no treatment in the control of postethmoidectomy synechiae and middle meatal stenosis, as well as early improvement in mucosal healing and postoperative pain. Significance: Because of its biocompatibility, lack of inflammatory response, transparency, and ability to fill any complex volume, Sepragel sinus offers distinct advantages over currently used stenting materials. (Otolaryngol Head Neck Surg 2001;125:603-8.)

Objective: Endoscopically or microscopically controlled paranasal sinus surgery currently represents the state of the art. For anatomic reasons the ostium of the frontal sinus and the frontal sinus itself are difficult to observe. Flexible endoscopes are often difficult to implement and do not provide enough light intensity to visualize all parts of the frontal sinus. Materials and Methods: A specially curved rigid endoscope with a working channel of 1.5 mm that allows passage into the frontal sinus has been developed to manage this problem. The system was used on 15 patients during paranasal sinus surgery to evaluate possible indications and its clinical usefulness. Results: The endoscope could be introduced into the frontal sinus after an ethmoidectomy had been performed in all of the patients. The anatomy of the sinus could be visualized with sufficient light intensity in 14 patients. The shadowing of the frontal sinus seen in CT was not due to polyps of the mucosa of the frontal sinus in all cases, but rather due to secretion with otherwise normal mucosa. In the cases with polyps, it was necessary to irrigate with saline solution to prevent the buoyant polyps from collapsing over the endoscope. The following specific indications for this endoscopic version were established during this first test: intraoperative and postoperative control of the frontal sinus, clinical evaluation of tumor growth into the frontal sinus, biopsies within the frontal sinus, and evaluation of fractures. Conclusion: The new device provides further insight within the field. (Otolaryngol Head Neck Surg 2001;125:613-6.)

To investigate the role of gelatinases in nasal polyposis, a common and disabling airway disease characterized by chronic inflammation and tissue remodelling, matrix metalloproteinase-2 (MMP-2) and MMP-9 expression was investigated in the nasal polyps (NP) of 24 patients undergoing ethmoidectomy and compared with 15 control nasal mucosal (CM) samples obtained from snorers during turbinectomy. Tissue samples were either frozen for enzymatic analysis or paraffin wax-embedded for immunohistochemistry. Zymography and quantitative image analysis showed that MMP-9 active forms were significantly increased (p

Objective To determine the efficacy of computed tomographic image-guided endoscopic surgery in the hands of inexperienced surgeons. Study Design Four second-year otolaryngology residents, with no prior experience performing ethmoidectomies, performed endoscopic sinus surgery (ESS) on formalin-fixed human cadaveric specimens with and without the aid of computer-assisted surgery (CAS). Methods Each resident was asked to identify critical sinus, orbital, and skull base structures while performing a total ethmoidectomy and multiple sinusotomies. Their surgical accuracy (percentage of correctly identified structures), total operative time, and incidence of major complications were recorded for each side. A total of 16 sides were evaluated (8 with and 8 without CAS). Statistical significance between groups was determined by means of Pearson's χ2 analysis. Results Statistical analysis showed a significant difference (P = .001) in the mean accuracy of identifying critical anatomical landmarks between the CAS (97%) and non-CAS (76.8%) groups. Although not statistically significant, operative time appeared to be longer in the group using CAS (average of 67 vs. 80 min). Three major intracranial complications were documented only in the group not using CAS. Conclusions Although, unquestionably, a thorough knowledge of the anatomy remains essential for performing ESS, CAS improves surgical accuracy and reduces the risk of major intracranial or intraorbital complications for residents. In additional, our data suggest that this technology may enhance surgical efficiency and improve the learning curve by reducing operative time (below one's normal baseline) while maintaining a greater than 90% accuracy in identifying critical anatomical landmarks.

Inadequate bone height in the lateral part of the maxilla forms a contra-indication for implant surgery. This condition can be treated with an internal augmentation of the maxillary sinus floor. This sinus floor elevation, formerly called sinus lifting, consists of a surgical procedure in which a top hinge door in the lateral maxillary sinus wall is prepared and internally rotated to a horizontal position. The new elevated sinus floor, together with the inner maxillary mucosa, will create a space that can be filled with graft material. Sinus lift procedures depend greatly on fragile structures and anatomical variations. The variety of anatomical modalities in shape of the inner aspect of the maxillary sinus defines the surgical approach. Conditions such as sinus floor convolutions, sinus septum, transient mucosa swelling and narrow sinus may form a (usually relative) contra-indication for sinus floor elevation. Absolute contra-indications are maxillary sinus diseases (tumors) and destructive former sinus surgery (like the Caldwell-Luc operation). The lateral sinus wall is usually a thin bone plate, which is easily penetrated with rotating or sharp instruments. The fragile Schneiderian membrane plays an important role for the containment of the bonegraft. The surgical procedure of preparing the trap door and luxating it, together with the preparation of the sinus mucosa, may cause a mucosa tear. Usually, when these perforations are not too large, they will fold together when turning the trap door inward and upward, or they can be glued with a fibrin sealant, or they can be covered with a resorbable membrane. If the perforation is too large, a cortico-spongious block graft can be considered. However, in most cases the sinus floor elevation will be deleted. Perforations may also occur due to irregularities in the sinus floor or even due to immediate contact of sinus mucosa with oral mucosa. Obstruction of the antro-nasal foramen is, due to its high location, not a likely complication, nor is the occurrence of severe haemorrhages since the trap door is in the periphery of the supplying vessels. Apart from these two aspects, a number of anatomical considerations are described in connection with sinus floor elevation.

Objective: To describe the clinical presentation of maxillary sinus mucoceles, understand their pathogenesis, and determine the long-term efficacy of the endoscopic surgical treatment. Study Design: Retrospective review. Methods: Thirteen consecutive patients who presented with maxillary sinus muco(pyo) celes were studied. Subjects with history of preceding sinus/nasal surgery or facial trauma were excluded. The presenting signs and symptoms, radiological findings, and surgical management were reviewed. Results: There were six women and seven men with an age range of 31 to 71 years. Two patients had environmental allergies. Nine patients complained of cheek pressure or pain, six of nasal obstruction, and eight of nasal drainage. On endoscopic nasal examination, the medial wall of maxillary sinus was bulging with prolapsed middle meatal mucosa in 10; drainage was seen in 7, but none had polyps. The sinus involvement was limited to the maxillary sinus and the ipsilateral ethmoid on computed tomographic studies in 10 cases. Patients were treated with endoscopic ethmoidectomy, middle meatal antrostomy, and marsupialization of the mucocele. Intraoperative cultures grew organisms in five patients. Postoperative follow-up ranged between 10 and 66 months. Two patients required lysis of adhesions in the middle meatus, and one, revision antrostomy. All patients had a patent middle meatal antrostomy and healthy maxillary sinus mucosa at latest follow-up. The presenting symptoms resolved or improved in 12 cases. Conclusions : The etiology of maxillary sinus mucoceles is not well understood. Mechanical obstruction or allergy or both do not seem to play an important role. An infectious origin is also not supported by the above data. Endoscopic sinus surgery is a reliable therapeutic measure with a favorable long-term outcome.

Objective/Hypothesis: The introduction of optical aids for endonasal sinus surgery has not produced the expected drop in the rate of serious intraoperative complications. Study Design/Methods:1. Retrospectively, consecutive procedures of different surgeons were analyzed in regard to major complications (periorbital injury, orbital lesion, dural injury, endocranial lesion, damage to the internal carotid artery). The chronological distribution was transformed into a personal learning curve. 2. From our own experience and as surveyors, we analyzed the experiences of surgeons having encountered severe complications and compared them with the above-mentioned learning curve. Result: In total, 1,500 operations carried out by five surgeons with 16 serious complications were assessed. For the learning curve, the following stages were defined. stage I: greatest risk of complication, with dural injury (1st to 30th operation); stage II, slighter risk of complication, with frequent periorbital injuries (31st to 180th operation); and stage III, least risk, corresponding to an experienced surgeon. Serious complications occur most frequently among experienced surgeons. Conclusion: The beginner enjoys the most effective type of assistance, in the form of personal guidance of an experienced surgeon who is constantly present during the first 30 operations, and who should then be readily available during the next 70 operative procedures. The use of multimedia software appears to be helpful, though its actual value still remains to be determined. The experienced surgeon in particular must be willing to exercise repeated self-criticism to keep his or her rate of complications to a minimum.

Removal of the soft tissue lesions from the maxillary sinus is sometimes difficult and time consuming in endoscopic sinus surgery. Failure of endoscopic removal may necessitate combination of canine fossa approach and endoscopic approach. Our new instrument, 'Derevator', is designed for easy removal of the pathological soft tissue lesions from the maxillary sinus through middle meatal antrostomy. Derevators are available for both adults and children. Suction-tipped ones are also available.

Objective: To characterize the anatomy of the sinus lateralis and enable a more accurate and safe approach to endoscopic ethmoidectomy, Study Design : An anatomic study of 33 cadaver heads providing a prospective evaluation of 50 ethmoid sinuses. The sinus lateralis, in particular, was thoroughly examined and typical variations were classified into four categories. A technique using the sinus lateralis as a critical landmark is described which allows calculated removal of anterior ethmoid cells in a posterior-to-anterior direction, avoiding inadvertent entry into the posterior ethmoid. Prospective evaluation of this technique in 12 pediatric patients found it to be safe and particularly useful for neophyte endoscopic surgeons. Methods: Endoscopic examination of 50 cadaver sinuses using 0-, 30-, and 70-degree, 4-mm telescopes to dissect the anterior ethmoid. The characteristics of each sinus lateralis were documented. To confirm the endoscopic findings, we grossly examined each specimen. Results: Four different categories of sinus lateralis formation were identified: type I (n = 22), posterosuperior extension to skull base; type II (n =15), posterior extension to sphenoid face; type III (n = 8), abrupt termination posterior to ethmoid bulla; and type IV (n = 5), extension into posterior ethmoid through dehiscent basal lamella. Conclusions: The sinus lateralis is a consistent feature of the anterior ethmoid. Type I and II patterns are most conducive to the aforementioned technique. Type III is the most difficult to identify endoscopically, whereas type IV is most apt to encourage an unplanned posterior ethmoidectomy. Regardless of the chosen ethmoidectomy technique, careful assessment of the sinus lateralis should enable more accurate and safe removal of ethmoid disease with reduced complications.

W hereas foreign bodies of the nose are relatively common, foreign bodies of the paranasal sinuses occur infrequently. They may present in a delayed fashion, frequently with symptoms of chronic inflammation, and necessitate careful removal because of their relationship to vital structures. 1 We present a case of chronic sinusitis caused by a sphenoid and ethmoid sinus foreign body of 16 years’ duration and its endoscopic removal.

The maxillary sinus is an uncommon site for mucoceles within the paranasal sinuses. In this study nine patients with maxillary sinus mucoceles are presented. Six of these patients were treated by open approaches, and three were treated by endoscopic drainage alone. For uncomplicated maxillary sinus mucoceles, endoscopic drainage appears to be a reasonable approach, whereas for more complicated cases extending outside the sinus, open approaches may be required.

Objectives:1) Explore developments in endoscopic techniques and their application in the management of Sinonasal Inverted Papilloma (SNIP). 2) Describe 0% recurrence rates with aggressive endoscopic resection of complex SNIP.Methods:Retrospective single-center patient cohort analysis of twenty-one cases of SNIP treated by endoscopic resection at Charing Cross Hospital from December 2002 to September 2012. Pre-operative assessment included tomography or magnetic resonance imaging and biopsies. The origin and extent of the tumor determined the surgical strategy, and a combination of antrostomy, ethmoidectomy, sphenoidotomy, and endoscopic medial maxillectomy (EMM) with the assistance of angled instrumentation were performed. Sub-periosteal dissection followed by diamond burr drilling of the underlying bone were performed in all cases. All patients were followed up by regular endoscopic surveillance.Results:The study group consisted of 12 (57%) male and 9 (43%) female patients with a mean age of 59 years. El...

Objectives:Orbital cellulitis occurs primarily following sinusitis. This infection resides posterior to the orbital septum with inherent risk to the eye, cavernous sinus, meninges, and brain. Fortunately, complications remain rare due to the advent of antibiotics. Surgical drainage through orbitotomy or ethmoidectomy may occur. We aim to characterize the demographic stratification, surgical treatment variation, and cost and resource use related to orbital cellulitis over time.Methods:We queried the Kid Inpatient Database for 2003, 2006, and 2009, identifying all cases of International Classification of Disease, ninth revision, clinical modification (ICD-9-CM) codes 376.01, orbital cellulitis. Census data were used to calculate incidence. We used Statistical Analysis Software for our analysis. This study used a publically available, de-identified database allowing exemption from the Institutional Review Board.Results:From 2003 to 2009, the incidence remained stable (3.2 to 2.8/100000 population). Males mad...

Objectives:Describe the endoscopic anatomy of medial and inferior orbital walls and present 5 illustrative clinical cases.Methods:Two vessel-injected cadavers (4 sides) were dissected through endoscopic endonasal transethmoid-sphenoid-maxillary approach.Results:Total ethmoidectomy and maxillary antrostomy were performed. Maxillary sinus roof was removed until reaching the infraorbital canal laterally. Anterior and posterior ethmoidal arteries were identified. Lamina papyracea was removed. Transnasal and transethmoidal sphenoidotomies were made. Periorbita was incised along medial and inferior orbital walls. Cavernous carotid artery was exposed and medialized to show oculomotor (CNIII), trochlear (CNIV), ophthalmic (CNV1), maxillary (CNV2), and abducent (CNVI) nerves in cavernous sinus. In superolateral wall of sphenoid sinus, the optocarotid recess was visualized as well as the optic nerve (CNII) and ophthalmic artery (OphA) entering the orbit. Anteriorly, the annulus tendineus of Zinn (ATZ) was found and...

Recurrent sinus barotrauma is an uncommon condition but it may terminate the career of an aviator. Sinus barotrauma occurs almost exclusively on descent and probably results from occlusion of the sinus ostia through a combination of mucosal disease and anatomical abnormalities. Traditional methods of treating sinus barotrauma have achieved mixed results so we have employed functional endoscopic sinus surgery (FESS) since 1990. The presentation and outcome of 39 patients with recurrent sinus barotrauma managed by FESS have been reviewed. Ninety-five per cent were able to resume their full flying duties without further treatment or recurrence of sinus barotrauma. Passing a postoperative decompression testing is a reliable indicator of an aviators's fitness to fly after FESS.

Background and objectives: Most studies on outcome after endoscopic sinus surgery (ESS) include patients with varying degrees of disease severity. Recurrence rates cited by those studies may not apply to the subset of patients with severe polyposis. Our aim is to provide reference information for recurrence rates and need for revision surgery in patients with severe disease. Study design, patients, and methods: Review of patients with severe polyposis with a minimum Lund-McKay score of 16 and with a Kennedy computed tomography stage 3 or 4. Data collection included demographics, presence of asthma or documented allergy, history of previous surgery, extent of surgery, preoperative and postoperative management, recurrence rates, revision surgery rates, and follow-up. Results: One hundred and eighteen records were reviewed. Fifty-nine (50%) patients had asthma, and 93 (79%) had documented allergy. All patients required extensive bilateral nasal polypectomy, complete anterior and posterior ethmoidectomy, and maxillary sinusotomy. One hundred (85%) also had frontal or sphenoid sinusotomy. Follow-up ranged from 12 to 168 (median 40) months. Seventy-one (60%) developed recurrent polyposis. Fifty-five (47%) were advised to undergo revision surgery, and 32 (27%) underwent surgery. History of previous sinus surgery or asthma predicted higher recurrence (P

Persistent frontal sinusitis traditionally has been treated with external procedures such as osteoplastic frontal sinus obliteration or the Lynch procedure. Currently, functional endoscopic sinus surgery can be used in most cases to remove disease from the frontal recess, the most frequent site of frontal sinus obstruction, thereby relieving the sinusitis. In some cases, however, frontal recess exploration has failed to relieve the obstruction of the frontal sinus, necessitating an osteoplastic frontal sinus obliteration. We present our experience with a transnasal modification of the Lothrop procedure. The Lothrop procedure, first described in 1914, uses a combined external and transnasal approach to resect the median frontal sinus floor, superior nasal septum, and intersinus septum to drain the frontal sinus. This procedure was largely abandoned and forgotten by modern otolaryngologists. However, with the advent of the computed tomography scan and endoscopic techniques, we sought to reassess the basic tenant of the Lothrop procedure (i.e., wide median frontal sinus drainage). An anatomic study of cadaver heads was performed to quantify the surprisingly large potential opening and to better understand the pertinent anatomy. This procedure was performed on 10 patients, with no resulting complications and no failure to maintain patency of the frontal sinus drainage throughout the follow-up period (mean, 7 months). We are encouraged by our initial favorable results and intend to use the procedure in the future as needs arise.

A retrospective review of all cases of inverted papilloma at the University of Michigan from 1975 to 1992 revealed 51 cases of inverted papilloma. Of these, 14 (27%) had an associated squamous cell carcinoma (SCC). Eight (16%) were metachronous and 6 (11%) were synchronous. At a mean follow-up of 53 months, the disease-free survival of patients with carcinoma limited to the nasal cavity and paranasal sinuses was 57% (4/7) compared to 14% (1/7) of those patients presenting with disease extending beyond the nasal cavity and paranasal sinuses. The data also support the lateral rhinotomy approach with medial maxillectomy and ethmoidectomy as a minimum procedure followed by postoperative radiation therapy. The mean interval between the diagnosis of inverted papilloma and development of SCC was 63 months (range, 6 months to 13 years). Therefore, long-term follow-up with clinical examination and computed tomography (CT) scan is indicated for all patients with inverted papilloma.

Objective: 1) Describe the rare case of an adolescent with a concha bullosa mucopyocele presenting as a nasal mass. 2) Review the existing literature discussing mucopyocele of a concha bullosa.Method: Case report of a 14-year old girl presenting to the emergency department with localized right-side facial pain, pressure, and headaches. The patient had no rhinorrhea, was afebrile, and had a normal white blood cell count and c-reactive protein.Results: Sinus CT showed a right-side intranasal mass with destruction of middle turbinate bone. MRI revealed post-obstructive fluid throughout the maxillary, ethmoid, and frontal sinuses. The patient was taken to the operating room for biopsy of the presumed mass and drainage of the sinuses. A large, bulging middle turbinate was found on nasal endoscopy and incision into the turbinate revealed a purulent concha bullosa. The concha bullosa was opened and unilateral maxillary antrostomy and anterior ethmoidectomy performed. Literature discussing concha bullosa mucopyoc...

Objective: Functional endoscopic sinus surgery (FESS) provides symptomatic relief of sinus disease in patients with CF (cystic fibrosis), but it is unclear whether it has beneficial effects on lung disease in this population. This study assessed the effect of FESS on the respiratory status of adult CF patients.Method: We performed a retrospective chart review at a tertiary medical center encompassing 32 adult CF patients who underwent 45 operative cases. Outcome measures were the effect of FESS on the rate of decline in lung function, intravenous antibiotic use, and hospitalization for pulmonary exacerbation.Results: FESS was performed in 32 patients encompassing maxillary antrostomy, ethmoidectomy, frontal sinusotomy, sphenoidectomy, and polypectomy. The rate of decline in FEV1 and FVC were not significantly different in the 12 months before and after FESS. FESS did not reduce days hospitalized or days on intravenous antibiotics for a respiratory exacerbation in the pre- vs postoperative period. Limiting...