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Objective Silent sinus syndrome (SSS) and chronic maxillary atelectasis (CMA) are unusual conditions having subtle symptoms with a possible progressive evolution. They are particularly infrequent in the pediatric population. Our objective was to review our experience with pediatric patients having SSS or CMA, and to review all cases involving patients under 14 years of age reported in the literature. Methods A retrospective review of 6 patients diagnosed with SSS or CMA surgically treated from 2001 to 2014 was carried out. All cases reported in literature were reviewed. Results All patients underwent functional endoscopic sinus surgery with an improvement in symptoms after surgery. Diplopia disappeared in two patients who presented with it and enophthalmos improved in all five patients presenting with it. Only one patient out of four presenting with headache had a persistence of the symptoms which were, however, milder than they had been preoperatively. Endoscopic examination demonstrated a reventilated maxillary sinus in all cases. A radiological examination at follow-up was performed in 5 cases and demonstrated a reexpansion of the maxillary sinus as compared to the contralateral side in all patients except one. None of the patients required an orbital floor reconstruction. Eleven similar cases reported in the literature were analyzed and compared. Conclusion Endoscopic uncinectomy and middle meatal antrostomy should be the treatment of choice for these conditions in patients presenting with enophthalmos and/or hypoglobus and symptoms related to it. Orbital floor reconstruction should be performed as a delayed procedure only in selected cases. Chronic maxillary atelectasis or SSS should be considered as a possible cause of persistent headache of unknown origin in pediatric patients.

Background Meningocele and meningoencephalocele of the lateral wall of the sphenoidal sinus (LWSS) are rare lesions, crossing the borders of multiple disciplines such as ear-nose-throat, maxillofacial, and neurologic surgery. We reviewed our surgical experience to analyze the role of the endoscopic endonasal approach and consider these pathologies from different perspectives. Methods All consecutive cases of meningocele and meningoencephalocele of LWSS operated through an endoscopic endonasal approach from 1998 to 2015 in our institutions were collected. Medical history, focusing on previous episodes of cerebrospinal fluid leak, meningitis or seizures, was considered. The outcome was assessed considering the medical condition and the postoperative neuroimaging. Results The series includes 23 patients (7 male, 16 female). Mean age was 52 years (26–73 years). Eleven cases were meningoencephaloceles and 12 meningoceles. A clear cerebrospinal fluid leak occurred on in 19 patients and was associated with meningitis in 3. Two were presenting a history of epilepsy. No complications were observed, but 1 case presented seizures on waking. At follow-up (mean 84 months, 4–167) each patient is in good clinical condition with no further episodes of leaking or seizures. Conclusions Endoscopic endonasal surgery is a safe and effective approach for meningocele and meningoencephalocele of LWSS; it allows resection of herniated tissue and repair of the osteodural defect. The favorable clinical outcome and the possible effectiveness on seizures lead us to support this approach as first minimally invasive treatment also in presence of epilepsy, as a first low risk epilepsy surgical procedure.

Objective The purposes of this study were to report our experience with endoscopic treatment of choanal atresia (CA), to illustrate our surgical technique and analyse the different factors that may affect outcomes. Material and methods A retrospective review was performed of patients affected by congenital CA and treated between June 1996 and November 2013 at three referral centres which follow a uniform policy. Results Eighty-four patients with CA (55 unilateral and 29 bilateral), aged between one day and 76 years (mean, 13 years) were included. Associated malformations were present in 28 patients. The overall success rate was 93%, with 96.3% and 86.2% success rates for unilateral and bilateral CA respectively. Six patients (7%) required revision surgery for early symptomatic restenosis. Statistical analysis revealed that outcomes were not influenced by sex, previous surgeries, unilateral versus bilateral atresia or associated anomalies. However, age seemed to be a prognostic risk factor for patients under one year-old. Conclusion The endoscopic endonasal approach is safe and effective, with a very high success rate and low morbidity. The removal of the vomer and the use of mucoperiosteal flaps are the main keys to avoiding postoperative stenosis. The use of stents or Mitomycin C is therefore not mandatory.

Objective: Postoperative infection is a potentially dramatic consequence in endoscopic endonasal surgery. The aim of this study is to assess the efficacy of our intraoperative antibiotic prophylaxis, analyzing the risk factors of postoperative meningitis in our series. Methods: Each endoscopic endonasal procedure performed since 1998 in patients with no preoperative infections and a follow-up longer than 30 days have been included and retrospectively reviewed. Antibiotic protocol consisted in single antibiotic administration of ampicillin/sulbactam 3 g or cefazolin 2 g on induction, no postoperative administrations have been performed after 2005. All cases of CSF leak, meningitis, and systemic infection were recorded. Results: Two thousand thirty-two procedures matched the inclusion criteria (median age 50; range: 1-89, male/female ratio: 1:1.12). Intraoperative CSF leak occurred in 32.8% of the cases and postoperative CSF leak in 3.4%. The rate of meningitis was 0.69%, other systemic infections were observed in 0.44% of cases. Meningitis was statistically associated with intra- and postoperative CSF leak (p

Objective Pediatric periorbital cellulitis represents a common disease complicating a nasal infection. Methods A ten–year retrospective review of fifty-seven children admitted to our institution with the diagnosis of periorbital cellulitis as a complication of sinus infections was carried out. Results The age varied from one month to eleven years (mean 3.9 years). Thirty-five were males (62%), while twenty-two were females (38%). Nine out of fifty-seven (15.8%) presented exophthalmos associated with eyelid erythema and edema, while the rest suffered mainly from eyelid erythema and edema. Twenty-two patients complaining of exophthalmos or not responding to medical therapy within 48 h were assessed with a computed tomography scan (38.6%). A subperiosteal orbital abscess was detected in nine cases and these patients underwent surgical drainage (15,8%). Recurrence of orbital infection occurred in three cases (5.3%). Conclusions Medical management is the main treatment for both preseptal and postseptal orbital cellulitis. Nevertheless, there is no universally accepted guideline for the treatment of subperiosteal abscesses and each case should be treated accordingly. Urgent surgical drainage should be considered in cases not responding to adequate medical management, or those cases presenting visual deterioration.

The endoscopic bidimensional vision offered by the endoscope during endoscopic sinus surgery involves difficulty in visualizing surgical field depth which makes it difficult to learn this surgical technique and makes it necessary for the endoscopic surgeon to mentally create a three-dimensional (3D) picture of the paranasal sinuses anatomy. In particular, frontal recess surgery requires good knowledge of its anatomic position, also since it is necessary to use angled endoscopes, which distort the view, and angular instruments which are difficult to use. Purpose of this project is to offer to the endoscopic surgeon a detailed 3D model of the nose and paranasal sinuses with particular attention to the frontal recess. A 3D reconstruction of the frontal recess and its related structures, starting from computer tomography scans of the human skull, was realized using a professional 3D graphics software. A detailed reconstruction of the main structures which contribute to form the frontal recess was obtained. Particular attention was paid when reproducing the agger nasi cells, uncinate process, ethmoidal bulla, anterior ethmoidal cells, frontoethmoidal cells and their anatomic variants. This is the first experience reported in literature regarding this new technique of iconographic didactics applied to endoscopic sinus surgery. It represents a new frontier, which surpasses and integrates the previous didactic techniques to help the surgeon to mentally create a 3D image of the paranasal sinuses.

We thank Basant Kumar Misra and Milind V. Kitrtane for their commentary on our article entitled “Meningocele and meningoencephalocele of the lateral wall of sphenoidal sinus: the role of the endoscopic endonasal surgery

Objectives. Epistaxis is one of the most common otorhinolaryngologic emergencies representing more than 12% of conditions managed at the Ear, Nose and Throat (ENT) Emergency Consulting Room of our Otorhinolaryngologic Unit each year. The elevated frequency of this pathology makes it necessary to adopt the most effective and least expensive therapeutic strategy available. The aim of this study was to compare the efficacy, costs and morbidity of nasal packing (NP), which is the mainstay of treatment for anterior epistaxis in our ENT Emergency Consulting Room versus submucosal infiltrations of lauromacrogol (LA). Methods. A retrospective study was designed from August 2012 to April 2013 involving 53 patients suffering from anterior epistaxis. Anterior NP was used in 27 patients versus 26 patients undergoing 27 procedures performed with submucosal infiltrations of LA (or polidocanol). Outcomes for each treatment were evaluated. Patients in group 1 were treated with LA 400 injection next to the bleeding point: 0.5- to 1-mL single or multiple infiltrations with a 27-gauge needle. The whitening of the nasal mucosa around the bleeding point during infiltration was considered a marker of correct procedure in order to achieve the best results. Bilateral treatment was also performed at the same time. Patients in group 2 were treated with standard NP. Results. Bleeding recurrence was higher in the NP group even if it was not statistically significant (P=0.2935). However, the LA infiltrations were better tolerated with lower morbidity and costs as compared to NP. No complications were observed in either group. Conclusion. LA infiltrations were shown to be a viable alternative in anterior epistaxis treatment. They are safe, easy to use with good efficacy and have a low cost.

Sir, we read with great interest the recent article by Asimakopoulos et Al. entitled “Ultrasonographic assessment of tonsillar volume in children”1. The study has been well planned and we would like to appreciate the effort made by the Authors to shed light on this topic. However there are few points regarding the methodology with which we have some reservations and would like to highlight these through your prestigious journal . First, the clinical utility of tonsillar volume as a predictor of OSAS severity has not been clearly demonstrated despite its widespread use. The etiologies of pediatric OSAS are diverse. Tonsil size is not the sole factor and this could explain why tonsillectomy is not 100 % curative2. Because the tonsils are larger relative to the airway size a better way to assess tonsil size clinically is to evaluate the tonsils within a more 3-dimensional/volumetric framework to capture the impact of the tonsils on the upper airway. Second, since in the paper by Asimakopoulos et Al indication for tonsillectomy was recurrent tonsillitis in about 70% of the patients, it could be hasty to conclude that “Preoperative ultrasound assessment of tonsillar anatomy and size may be an additional and suitable, objective method in the development of a risk stratification system in children with obstructive sleep apnoea undergoing tonsillar surgery”. Certainly, as supposed by the Authors, tonsillar ultrasound may have a role to assess for tonsillar asymmetry and potentially prevent patients from undergoing unnecessary diagnostic tonsillectomies. Finally, even if assessment of tonsils size is an effective screening tool for the clinical diagnosis of paediatric OSA , the true effect of tonsils volume on sleep disordered breathing requires further exploration. Particularly, in the case of a child who may be at higher risk for complications during surgery only a PSG may have real value in firmly establishing the risk of postoperative respiratory compromise potentially needing for ICU overnight observation3.