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Background: The objectives of the study were to compare the anatomical variants of maxillary and ethmoid sinus in CT PNS and diagnostic nasal endoscopy, to determine the incidence of variations of maxillary and ethmoid sinus and to determine the association of anatomical variations with extent of the disease.Methods: Patients with chronic rhinosinusitis attending the outpatient department of otorhinolaryngology, head and neck surgery (ENT-HNS) of KVG Medical College for a period of 12 months from December 2016 to November 2017. 100 consecutive patients with history of CRS subjected for nasal endoscopy and CT-PNS. Results: The majority of patients were females. Male to female ratio was 1:1.46. Headache and postnasal drip were the main symptoms (76%). Concha bullosa (42.4%) was most common anatomical variation, which was detected in 59(42.4%) patients on CT PNS and DNE. There was statistically significant correlation between right septal deviation and right maxillary sinusitis (pConclusions: By using diagnostic nasal endoscopy and CT PNS, anatomic variations can be easily identified and aid as a guide map during functional endoscopic sinus surgeries.

Acute sinusitis in children is a controversial issue in terms of its diagnostic criteria, classification and therapeutic management. A therapeutic delay can lead to complications if the cause is bacterial. Guidelines have been set, but they are not consensual in pediatrics. Complications of acute bacterial sinusitis are uncommon in children, but they can be extremely severe and cause high morbidity and mortality. Because of their rarity, they often are not identified early, exposing the patient to an unfavorable outcome. We report on a case of acute bacterial pan-sinusitis complicated with thrombophlebitis of the cavernous sinuses and meningitis in a 9-year-old child, in spite of early and adapted antibiotic therapy. The bacterial agent was Staphylococcus aureus, which had no resistance or toxin profile. The progression was favorable under intravenous antibiotic therapy and after bilateral sphenoidectomy. This case raises the question of the best therapy for acute bacterial sinusitis in pediatrics and the management of complications.

The usefulness of BG as a marker has been reported in patients with pulmonary aspergillosis. However, no data have demonstrated the behavior of BG in sino-orbital IA. We encountered a case of sino-orbital IA and demonstrated changes in the BG level, radiological images, and pathological features.A 63-year-old Japanese woman suffered from invasive sino-orbital aspergillosis. The serum BG level measured immediately before surgery was 37.2pg/mL (normal value3.4pg/mL). Endoscopic sinus surgery revealed some necrotic tissue extending from the ethmoid sinus to the orbit. The infiltrating Aspergillus was revealed in the pathological examination. The BG level decreased to the normal value. However, CT revealed a high-density area; this may indicate that an aspergillosis lesion remained slightly in the orbit.(1--3)-beta-d-Glucan (BG) is a useful marker for diagnosing Aspergillus and evaluating the therapeutic effect of the treatment administered.

Background Postoperative bleeding remains a major problem after endoscopic sinus surgery (ESS). Patients who continue to bleed after ESS are at risk of airway compromise from inhalation of blood clots or from aspiration of blood-stained vomitus. The aim of this study was to determine the in vivo efficacy of a novel gel on hemostasis after ESS in a sheep model of chronic rhinosinusitis. Methods Twenty-one sheep infested with Oestrus ovus underwent ESS with standardized mucosal injuries created at the anterior ethmoid region using a microdebrider. Immediately after injury a baseline bleeding time was taken using the Boezaart Surgical Field Grading Scale. Computer randomization was performed to either receive chitosan/dextran (CD) gel or no treatment (control). Boezaart bleeding scores were calculated for each side every 2 minutes. Each postoperative day videoendoscopy was performed to document crusting/CD gel dissolution. Results The CD gel side was significantly more hemostatic at 2, 4, and 6 minutes after injury. Average time to hemostasis was significantly better for the intervention side versus control side, 4.09 (±1.61) versus 6.57 (±2.20), respectively (p = 0.049). Complete hemostasis occurred by 6 minutes for all CD gel sides; however, control side bleeding was noted on three sides at 8 minutes and on one side at 10 minutes. There was no significant difference in crusts scores at days 1, 3, 7, and 14. Conclusion In the sheep model of ESS, CD gel significantly improved hemostasis compared with the control at 2, 4, and 6 minutes after mucosal injury.

Sinusitis has rarely been associated with short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) syndrome. We describe a case of symptomatic SUNCT syndrome caused by sinusitis, which showed typical features of SUNCT syndrome. The patient's symptoms completely resolved without recurrence after endoscopic sinus surgery followed by antibiotic treatment. We suggest that ipsilateral paranasal sinusitis accompanied by the spreading of inflammation through a dehiscence in the lamina papyracea could lead to the development of SUNCT syndrome.

The objective of this study was to describe and evaluate soft tissue and bone properties of nasal cavity and paranasal sinuses in ex vivo preparations for a safe robot-assisted endoscope movement during functional endoscopic sinus surgery (FESS). In a first experiment we measured forces exerted by the endoscope during FESS with a force/torque sensor. In a second experiment we used a purpose built device to exert forces on chosen tissue structures. The experiment was monitored by a custom software, which records force of the endoscope and the deformation and the breaking point of tissue. All tests were performed on five formalin fixed cadaver heads. In the first experiment we found that the average force during FESS is 2.21 N and the maximal force is 7.96 N. The force-way-ratio measurement shows highest elasticity for the ethmoidal bulla, followed by the lamina papyracea; however, they break at low forces (> or =6 N). Furthermore the carotid canal seems to have the lowest elasticity but it can tolerate forces up to 30 N. Based on these measurements force thresholds can be defined for robot-assisted endoscope guidance. All thresholds have to be assigned to subregions of the nasal cavity and paranasal sinuses.

Conclusions. The 23 patients with extensive sinonasal polyposis who had undergone partial resection of the middle turbinate during functional endoscopic sinus surgery (FESS) showed no differences in nasal airway resistance and in postoperative complication rate (1-year follow-up period) in comparison with the 25 patients who had FESS with middle turbinate preservation. Objective. The aim of the study was to investigate the outcomes of partial middle turbinectomy during FESS in patients with sinonasal polyposis. Patients and methods. A retrospective analysis of 48 consecutive patients who had undergone surgery for extended sinonasal polyposis was performed. Twenty-three patients underwent FESS with middle turbinate head resection; 25 patients underwent FESS with preservation of middle turbinate. We endoscopically scored polyposis extension and evaluated nasal airflow resistance (NAR) preoperatively and postoperatively. Results. We found an improvement of endoscopic score (high to low grade of polyposis extension) and a statistically significant reduction of NAR after both surgical techniques. There was no statistically significant difference in the mean NAR values before and after the two techniques.

We report a rare clinical presentation of breast carcinoma metastasis to the ethmoid sinuses, orbit and cavernous sinus in a 70-year-old lady with unsuspected breast carcinoma who presented with clinical features of acute ethmoiditis, orbital cellulitis and cavernous sinus thrombosis. The patient underwent endoscopic ethmoidectomy and histology of the necrotic tissue from the ethmoidal cells was positive for endovascular neoplastic emboli. Subsequent examination revealed a large mass in the left breast, tethered to the skin, which was histologically confirmed to be a carcinoma. The patient died 2 months post-diagnosis. To our knowledge, this is the third case manifesting with combined features of ethmoiditis, orbital cellulitis and cavernous sinus syndrome from an unsuspected breast carcinoma. This case highlights the importance of imaging and thorough physical examination when a dramatic clinical picture presents in the paranasal sinuses of an otherwise healthy individual. Such manifestation of breast carcinoma is difficult to diagnose, and therefore, a high index of suspicion should be maintained. Skull base metastases from breast carcinoma behave aggressively and if diagnosed early, treatment may prolong survival and improve quality of life.

Ethmomaxillary sinus is a variation of the posterior ethmoid cells. It is formed by the extension of the posterior ethmoid cells into the maxillary sinus and drains into superior nasal meatus. It is incidentally seen on paranasal sinus computerized tomography (CT) scans. Its prevalence has been reported as 0.7 and 2% in two studies. In this study, paranasal CT scans of 466 patients were investigated for the presence of ethmomaxillary sinus. The patients had paranasal CT with the preliminary diagnoses of septal deviation, chronic inflammatory paranasal sinus disease and nasal turbinate disorders. The ethmomaxillary sinus was present in nine of those patients (1.93%). It was septated in one of them. The CTs were further investigated for other anatomical variations and co-existent mucosal disease of the paranasal sinuses.

Allergic fungal sinusitis (AFS) is a form of paranasal nasal disease if not managed early often involves bone destruction and extension into the orbit and anterior skull base. We present our study of patients with AFS with intracranial, exdradural extension. This study includes our experience of 26 patients with the histological and immunological diagnosis of AFS based on findings of branching septate fungi interspersed with eosinophilic mucin and Charcot-Leyden crystals without fungal invasion of soft tissue, with intracranial extension. All had erosion of bone, which was observed on computerized tomography (CT) scans, extending intracranially and eight had disease that additionally involved the lamina papyracea. The average age of patients in this study was 25 years (range 9-46). There were 20 male and 6 female patients. All patients were immunocompetent. Skin test against aspergillin showed all patients had Type 1 hypersensitivity. All patients underwent transnasal and/or transmaxillary endoscopic approaches for debridement and eight underwent orbital decompression. No patient underwent craniotomy for removal of intracranial extradural disease. No patient had a cerebrospinal fluid leak. Postoperatively, all 26 were treated with a course of corticosteroids. The follow-up period ranged from 2 to 5 years. We conclude AFS is a unique form of fungal disease that might mimic anterior skull base and paranasal sinus tumors. Most cases can be successfully managed with transnasal and/or transmaxillary endoscopic techniques.

Mucormycosis is a potentially fatal, rapidly destructive, opportunistic infection often seen in immunocompromsied individuals and patients with diabetes mellitus. We describe two patients with rhino-orbital mucormycosis caused by Rhizopus oryzae who received posaconazole within 7 days of diagnosis and in whom cure was achieved in conjunction with extensive surgical resection of diseased tissue. Posaconazole was well-tolerated. Our experience indicates that this new extended-spectrum azole antifungal agent can be used early in the course of zygomycete infection with good results.

Aim To analyze the indications and outcomes of open neurosurgical approaches (ONA) and endoscopic transnasal approaches (ETA) in the surgical management of pediatric sinogenic subdural and epidural empyema. Material and methods Retrospective single-center study design within a tertiary care referral center setting. Children less than 18 years of age consecutively operated on between January 2012 and February 2014 for drainage of a sinogenic subdural empyema (SE) or epidural (EE) empyema were included. Main outcome measures: success of first surgical procedure, persistent symptoms and sequelae at the end of the follow-up period. Results Nine SE (53%) and 8 EE (47%) were observed. Neurological symptoms, especially seizures, were more frequent in the SE group. Perioperative pus samples were positive in 67% of the SE group and in 75% of the EE group. The most frequently isolated bacteria belonged to the Streptococcus anginosus group. CT or MR imaging showed that most empyema probably originated from the frontal sinus. However, two cases resulted from an ethmoiditis and one case from a Pott's puffy tumor, without any direct contact with the paranasal sinus. In cases of SE, the most effective surgical technique was ONA with craniotomy. Associated endoscopic sinus drainage was useful for the purpose of bacteriological diagnosis. In cases of EE, effectiveness was noted in both ONA and ETA techniques. In two cases of EE, the ETA procedure encompassed direct drainage of the empyema through the posterior wall of the frontal sinus (Draf III approach). The number of patients successfully treated after a single surgical procedure was higher in the EE group (p = 0.05). Regarding outcomes, no mortalities were observed. Persistent disorders at the end of the follow-up period, especially headaches, cognitive, concentration or schooling problems, tended to be more frequent in the SE group than in the EE group (67% vs 29%), and were more commonly observed in cases requiring several surgical procedures (75% vs 12.5%) (p = 0.05). Discussion Endoscopic sinus surgery plays a critical role in the surgical management of pediatric sinogenic SE and EE. In cases of small volume EE, the endoscopic approach associated with antibiotherapy may be sufficient to treat the infectious process.

Orbital cellulitis and subperiosteal abscess (SPA) are historically associated with poor outcomes. We seek to characterize current associations with abscess formation, surgical failure and vision loss.All cases of orbital cellulitis presenting to an affiliated hospital between April 2008 and 2013 were critically reviewed.Thirty patients met inclusion criteria. Average age was 28.7 ± 24.4. The male to female ratio was 2:1. Abscesses were identified in 56.7% of patients. Adults were less likely than children to present with abscesses (28.6% vs. 81.3%, p = 0.008). Of the other factors analyzed, only antibiotic use before admission (70.5% vs. 23.1%, p = 0.03) and maximum restriction (-2.5 ± 1.2 vs. -0.9 ± 0.7, p = 0.008) were associated with SPA. Temperature at presentation (37.9 ± 0.9 vs. 37.1 ± 0.4, p = 0.04), relative proptosis (5.8 ± 3.3 mm vs. 2.1 ± 1.1, p = 0.002) and abscess volume (4.3 ± 1.3 mm(3) vs. 0.7 ± 0.5 mm(3), p = 0.0004) were associated with progression to surgery. Reoperation was required in 26.7% of patients. Of these, two-thirds had combined superior/medial abscesses that re-accumulated after isolated endonasal surgery. Two of the 3 patients with profound vision loss had a dental etiology.Only young age, prior antibiotics and degree of restriction predicted the presence of an abscess. Re-accumulation was more common than anticipated, and drainage of superior/medial abscesses by endoscopic surgery alone had the strongest association with surgical failure. Patients with odontogenic abscesses must be treated with particular caution.

Les sinusites aspergillaires invasives sont des infections fongiques opportunistes rares, rapidement extensives de pronostic redoutable. Elles surviennent preferentiellement sur un terrain d'immunodepression. Leur presentation clinique et radiologique est peu specifique. Le diagnostic positif est oriente par l'imagerie mais sa confirmation est anatomopathologique et/ou mycologique. Seule une prise en charge medico-chirurgicale rapide et adequate permettra un meilleur pronostic chez les patients atteints de cette infection. Patient âge de 60 ans, suivi pour un diabete de type 2, a consulte pour des douleurs retro-orbitaires gauches avec œdeme palpebral homolateral et fievre evoluant depuis 7 jours. L'examen physique a trouve un œdeme palpebral, un ptosis et une rougeur oculaire. L'endoscopie nasale a objective une muqueuse congestive et necrosee. L'examen biologique a montre des valeurs glycemiques tres elevee. La TDM du massif facial a revele une sinusite ethmoido-maxillaire gauche avec epaississement des tissus mous palpebraux gauches et une infiltration de la graisse extra-conique. Plusieurs diagnostics ont ete evoques notamment un lymphome, une tuberculose ou une neoplasie solide. L'examen mycologique a confirme la presence de filaments myceliens d'Aspergillus fumigatus. Il a eu une ethmoidectomie gauche avec excision des lesions necrotiques par voie endonasale. Le traitement medical s'est base sur l'amphotericine B et l'insulinotherapie pour equilibrer son diabete. L'examen anatomopathologique a conclut a une necrose de la muqueuse nasale avec presence de nombreux filaments myceliens. L'evolution etait favorable avec un recul de 2 ans.

A 47-year-old woman with a history of bronchial asthma presented with progressive proptosis of the right eye and diplopia. Her right eye showed apparent exophthalmos, impaired movement, conjunctival hyperaemia and episcleritis. Laboratory analysis revealed an increased titre of MPO-ANCA (4.3 IU/mL) and hypereosinophilia (1900 cells/μL, 22.5% on white cell count). MRI showed significant swelling of the extraocular muscles of the right eye and right ethmoid sinusitis (figure 1). Since a biopsy of extraocular …

A 9 year old boy presented to the emergency department with a one day history of generalised swelling of the right eye, conjunctival oedema, and difficulty opening the eye (fig 1⇓). In the preceding two weeks he had experienced coryzal symptoms. Fig 1 Periorbital swelling of the right eye ### 1. What is the diagnosis? #### Short answer Periorbital (preseptal) or orbital (post-septal) cellulitis. #### Long answer The terminology used in the literature is often ambiguous, with the terms “periorbital” and “preseptal” cellulitis used interchangeably. Similarly, the terms “orbital” cellulitis and “post-septal” cellulitis are also used interchangeably. The orbital septum is a tough fibrous membrane that forms the scaffold for the eyelids. It also provides a barrier to infection between the superficial tissues of the face and the deep tissues within the orbits.1 2 Infection superficial to this layer (preseptal) is termed periorbital cellulitis, whereas infection deep to the orbital septum (post-septal) is termed orbital cellulitis. ### 2. What is the likely infective source? #### Short answer Infection of the paranasal sinuses (most commonly ethmoid sinusitis). Causative organisms tend to reflect the underlying involvement of sinus disease, with Streptococcus pneumoniae , Streptococcus pyogenes , Staphylococcus aureus , and Haemophilus species most commonly being cultured.3 #### Long answer Periorbital and orbital cellulitis can have a sinugenic or non-sinugenic cause. Given the history of coryzal symptoms, this patient’s infection probably originated from the paranasal sinuses (maxillary, ethmoid, frontal, or sphenoid sinusitis). Anatomically, the ethmoid sinuses lie directly medial to the orbits and are separated from the orbital cavities by a ‘paper thin’ layer of bone called the lamina papyracea. This makes the orbital cavities vulnerable to direct spread of infection from the nose.1 2 Non-sinugenic causes of infection are less common but …

L’accident vasculaire hemorragique et la meningite purulente constituent des urgences medicales chez la personne âgee. L’objectif est de rapporter un cas d’accident vasculaire hemorragique associe a une meningite purulente a Neisseria meningitides survenus chez une personne âgee. Il s’agit d’une patiente de 62 ans sans antecedent pathologique connu, a ete admise aux urgences medicales du CHU YO pour cephalees + vomissement et notion de perte brutale de connaissance. L’examen a son admission notait un syndrome infectieux, une conscience obnubilee sans deficit moteur, une raideur cervicale et une hypertension arterielle. La tomodensitometrie cerebrale avait objective une hemorragie meningee diffuse avec inondation du 4 eme ventricule responsable d’une hydrocephalie triventriculairesous jacente d’allure obstructive associee a des sinusites ethmoido-sphenoidales droites chroniques. Une ponction lombaire realisee avait montre un liquide cerebrospinal citrin dont l’analyse etait en faveur d’une meningite purulente a meningocoque. La glycemie etait elevee a 15,8 mmol/l et l’hemoglobine glyquee etait egale a 7,7%. L’evolution a ete favorable sous traitement a base de ceftriaxone et de Metformine. Devant un cas suspect de meningite chez une personne âgee, la ponction lombaire apres un TDM cerebral permet de poser le diagnostic et d’entreprendre rapidement une antibiotherapie indispensable pour la prevention des complications.

Summary Chronic rhinosinusitis microbiology studies show the presence of aerobe and anaerobe microorganisms, fungus and virus and their incidence vary according to each study. These studies guide us on choosing the most adequate antimicrobial agent to eliminate the infectious process, thus, helping in restoring rhinosinusal mucosa. Study design: Clinical prospective. Aim: This work aimed at studying the microbiology of the maxillary and/or ethmoid sinuses of patients with chronic rhinosinusitis and with indication of functional endoscopic sinus surgery. Materials and methods: During surgery, we collected secretion and/or fragments of maxillary and/or ethmoid sinus mucosa from 41 patients to perform Gram stain, fungus direct research, aerobe and anaerobe microorganism culture and fungus culture. Results: We identified the presence of aerobe microorganisms in 21 patients (51.2%), anaerobe microorganisms in 16 (39%) and fungus in 1 (2.4%). In the studied population, only 12 patients (29.2%) presented microorganisms considered pathogenic when analyzed together with the semi-quantitative leukocyte count. Staphylococcus coagulase-negative and Staphylococcus aureus were the most frequent microorganisms found, in 5 (12.18%) and in 4 (9.75%) patients respectively. Conclusion: This study reveals that Staphylococcus coagulase-negative and Staphylococcus aureus were the most frequent microorganisms isolated from patients with chronic rhinosinusitis.

Background. Sinogenic intracranial empyema (SIE) is an uncommon complication of sinusitis that can lead to devastating neurologic sequelae. Early recognition of the clinical findings is critical so that proper management can be instituted. Objective. To describe the symptoms, signs, and laboratory and imaging findings from one of the largest pediatric SIE case series reported. Methods. Descriptive study of a retrospective cohort of all children admitted to Primary Children's Medical Center with SIE between June 2000 and February 2004. Children were identified by a computerized search of Primary Children's Medical Center medical records using the terms “sinusitis” and “brain/subdural/epidural empyema.” Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) values of children with SIE were compared with a group of children with uncomplicated sinusitis cared for in the same health care system as outpatients. The medical records of the uncomplicated sinusitis group were not reviewed for any clinical or radiographic data other than CRP and ESR values. Results. Twelve children with SIE were identified. The median age of children with SIE was 11.5 years. Symptoms were usually present 10 days (median) before diagnosis and included headache (10), fever (11), nausea/vomiting (7), mental-status changes (5), and seizures (3). Physical findings included abnormal neurologic examination (9), Pott's puffy tumor (4), and orbital cellulitis (3). Using the Intermountain Health Care system's computerized database, 142 children with uncomplicated sinusitis treated as outpatients were identified. Children with SIE had markedly higher CRP levels (median: 10.05 mg/dL) and ESRs (median: 87 mm/hour) than those with uncomplicated sinusitis (median CRP: 0.7 mg/dL; median ESR: 6 mm/hour). Four children had hyperglycemia. Four children had a lumbar puncture at presentation, and the findings were normal for all of them. Craniofacial imaging included computed tomography (CT) and magnetic resonance imaging (MRI). SIE was not detected in 4 patients who had nonenhanced CT. Axial imaging alone was unable to demonstrate SIE in 1 child with sphenoid and ethmoid sinusitis, and coronal images were needed to demonstrate its presence and extent. The initial facial/orbital imaging studies in 2 patients with physical signs of complicated sinusitis (orbital cellulitis and Pott's puffy tumor) were not adequate to detect SIE. Using contrast-enhanced head CT or MRI, SIE was diagnosed in all 12 children. Conclusions. Children with sinusitis and any neurologic finding, signs of complicated sinusitis such as Pott's puffy tumor or orbital cellulitis, or persistent headache, fever, or nausea and vomiting after antibiotic therapy should have additional evaluation for SIE. Children with hyperglycemia or diabetes may be at increased risk for SIE. The ESR and CRP levels are markedly elevated in children with SIE and may be useful screening tools. MRI with gadolinium is the preferred method to diagnose SIE. If MRI is unavailable, a contrast-enhanced head CT with axial and coronal planes should be obtained. Nonenhanced CT alone lacks sensitivity, and a normal study may be falsely reassuring.

Background: It is necessary for the immune system in the nasal and paranasal sinus mucosa to possess appropriate responses to infective agents as well as allergic responses. Recently, the T helper (Th)1/Th2 paradigm has been proposed as a new concept to explain various immunologic phenomena. Objective: Toward the goal of better understanding chronic rhinosinusitis, we have tried to define the predominating helper T-cell subsets among patients with chronic rhinosinusitis through characterizing the expressed chemokine receptors by these cells to find out the relation between these chemokine receptors' expression and the underlying pathogenesis of chronic rhinosinusitis. Methods: Thirty patients with ethmoidal chronic rhinosinusitis were used in our study. Patients were divided into atopic and nonatopic groups according to their serum immunoglobulin (Ig)E levels. Samples from ethmoidal sinus mucosa were processed as follows: frozen sections were examined immunohistochemically for detection of CCR4, CCR5, and EG2 positive cells and the mRNA of CCR4, and CCR5 transcripts were then examined by real-time quantitative polymerase chain reaction (PCR). Results: By immunohistochemistry, atopic patients showed high expression of CCR4 and EG2 positive cells, whereas nonatopic patients showed high expression of CCR5 positive cells. The expression of CCR4 and CCR5 mRNA, detected by real-time quantitative PCR, supported the data obtained by immunohistochemistry. Conclusion: The present study suggests that eosinophil recruitment associated with Th2 cell infiltration is the main factor responsible for the pathology of atopic rhinosinusitis.

Summary Objective: To investigate whether the presence of pediatric middle turbinate pneumatization causes narrowing of the ostiomeatal complex (OMC) and is associated with the development of paranasal sinusitis. Methods: CT scans of 190 nasal sides of 95 children (1–15 years old) were analyzed for the presence of middle turbinate pneumatization and mucosal thickness in the paranasal sinus. Results: Middle turbinate pneumatization was detected in nine (4.6%) of the nasal cavities. Only one of these sides was in a patient younger than 10 years of age, while the other eight sides were in patients at least 13 years old. In six of those nine sides with pneumatization, paranasal sinusitis was also found. However, the images showed that in five sides the middle turbinate pneumatization itself did not obstruct the OMC. In addition, the mean ± standard deviation (S.D.) of the total score for the paranasal sinus opacification on the side which had the middle turbinate pneumatization was 5.67 ± 2.95. The corresponding value for the 76 sides without pneumatization was 5.29 ± 2.53, and the difference between these mean total scores was not statistically significant. However, in one side, the OMC was obstructed or narrowed due to the middle turbinate pneumatization, and an ethmoidal sinus pyocele formed on this side. Conclusion: A causal relationship was not found between middle turbinate pneumatization and the mechanism of development of paranasal sinusitis in children. However, in the event that the OMU becomes obstructed at some time, frequent cycles of improvement and aggravation of pediatric paranasal sinusitis may occur and lead to the development of a serious condition.

Orbital cellulitis and abscess are known complications of ethmoiditis in children, but they are very rare in the newborn. The authors report a case of orbital abscess caused by methicillin-resistant Staphylococcus aureus (MRSA) in a four-week-old neonate born four weeks prematurely.

Schizophyllum commune is a globally distributed basidiomycete fungus that is known as a rare cause of sinusitis, for which no prompt treatment has been established. We describe the first report of S. commune sinusitis following unrelated cord blood transplantation for acute lymphoblastic leukemia. Thirteen days after transplantation, a 23-year-old female developed maxillary and ethmoid sinusitis. The sinusitis was antimicrobial-resistant, and the sinus aspirate culture revealed white wooly mold, which was identified as S. commune by nucleotide sequencing. The patient was successfully treated with intravenous administration of liposomal amphotericin B for 2 months, followed by oral voriconazole. This report suggests the effectiveness of liposomal amphotericin B and voriconazole for S. commune infection in immunocompromised patients. Given the difficulty in distinguishing S. commune infection from aspergillosis by standard culture methods, the incidence of S. commune infection following allogeneic hematopoietic stem cell transplantation may be underestimated. Nucleotide sequencing may be useful in the diagnosis of S. commune infection.

A 37-year-old athletic black man consulted for headache, diplopia and photophobia. His symptoms had started 15 days earlier with fever, rhinorrhoea, tearing and right eye swelling associated with bilateral conjunctival hyperaemia, exophthalmos, decreased visual acuity and bilateral limitation of lateral gaze. Investigations in an African hospital showed hyperleucocytosis and increased erythrocyte sedimentation rate. MR brain scan showed ethmoidal sinusitis and bilateral orbital cellulitis. He received a 7-day course of intravenous ceftriaxone and vancomycin, together with intravenous corticosteroids. He was transferred to Switzerland for further management. On examination, there was right-sided exophthalmos, chemosis and conjunctival erythema, with bilaterally limited lateral gaze and decreased visual acuity (4/10 for each eye). Tests for HIV, diabetes mellitus, connective tissue diseases, antiphospholipid antibodies and other prothrombotic factors were negative. Cerebrospinal fluid (CSF) analysis showed increased protein and white cell count. Bacteriological analysis of blood, CSF and sinus biopsies was negative. A CT scan of head showed ethmoidosphenoidal sinusitis, bilateral orbital cellulitis with fluid collection in the right lateral rectus muscle and thrombosis in the left sigmoid sinus (figure 1). Figure 1 (A) Bone window axial CT slide showing mucosal thickening of ethmoid and sphenoid sinuses with collection and right eye proptosis. (B) A phlebo-CT slide showing a non-opacified left sigmoid sinus …

We report a case of intraoperative orbital haemorrhage as a complication of endoscopic sinus surgery performed under general anaesthesia. Initial unilateral complete visual loss occurred, but recovered due to accurate and early diagnosis combined with urgent surgical intervention. This patient’s case is reported to illustrate the importance of early recognition of clinical signs and how a stepwise approach to management can result in a favourable visual outcome. Moreover, the mechanisms and pathophysiology of visual loss due to orbital haemorrhage following endoscopic sinus surgery are discussed.

We present here the first case in the People's Republic of China of human disease caused by the fungus Arthrographis kalrae . The male patient had fungal panophthalmitis and invasive sinusitis involving the maxillary and ethmoid sinuses. He was an apparently healthy man before receiving trauma to his left eye. He complained of pain and loss of visual acuity in the injured eye, which displayed redness and edema and eventually discharged pus. His symptoms became more severe after he was treated with steroids and several antibacterial agents. A computed tomography scan of the left eye revealed that the maxillary and ethmoid sinuses were involved. A smear of purulent material from the left eye orbit revealed fungal elements, and cultures of the material grew a fungus. The isolate was identified as A. kalrae based on gross and microscopic morphologies, biochemical assays, and DNA sequence analysis. The patient received amphotericin B intravenously, itraconazole orally, and atomized allitridum by nebulizing allitridum therapy. The patient's wound healed following surgical intervention, but the patient lost the use of his left eye. This case should remind ophthalmologists and other clinicians to consider the possibility of infections being fungal when antibacterial agents have no effect and the patient's condition worsens.

Zygomycosis is an opportunistic fungal infection that is increasingly reported in hematological patients. We describe 2 cases of successfully treated rhino-cerebral zygomycosis and give an overview of 120 patients from the literature with underlying hematological or oncological disorders. These data document the improved survival in sinus (15/17 patients surviving) and cutaneous (6/9 patients surviving) disease. Hematological patients with pulmonary (9/30 patients surviving) or disseminated (4/38 patients surviving) zygomycosis still have a poor prognosis. The clinical course of sinus-orbital involvement (4/11 patients surviving) follows sinus-cerebral (2/3 patients surviving) or cerebral (3/6 patients surviving) disease. Besides deoxycholate amphotericin B (AmB) (24/62 patients surviving), patients seem to benefit from liposomal amphotericin B (L-AmB) (10/16 patients surviving) or sequential AmB/L-AmB treatment (6/8 patients surviving). Alternative treatment options lead only in a few patients to success.

Intracerebral hematoma after an intranasal ethmoidectomy has been rarely reported in the literature. This 56-year-old man presented with postoperative confusion. The cause is local injury.

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.

Objectives/Hypothesis Although the diagnosis of allergic fungal sinusitis is mainly based on characteristic histopathological findings, certain preoperative diagnostic criteria have been proposed. However, their usefulness in differentiating allergic fungal sinusitis from other sinus diseases is unknown. The objective of the study was to identify accurate preoperative diagnostic parameters for allergic fungal sinusitis. Study Design Prospective, comparative study. Methods Twenty consecutive cases of allergic fungal sinusitis were evaluated prospectively and compared with 16 cases of ethmoidal polyposis and 5 cases of invasive sinus aspergillosis, with regard to various clinical, radiological, and immunological parameters. All patients were categorized based on histopathological findings. Results Nasal polyps were seen in all 20 cases of allergic fungal sinusitis, all 16 cases of ethmoidal polyposis, and 2 of 5 cases of invasive sinus aspergillosis. Computed tomography (CT) scan hyper-attenuation was seen in all 20 cases of allergic fungal sinusitis but also in 2 (13%) cases of ethmoidal polyposis and 2 (40%) cases of invasive sinus aspergillosis. Serum levels of specific anti-Aspergillus immunoglobulin E were elevated in 14 (70%) cases of allergic fungal sinusitis, 2 (13%) cases of ethmoidal polyposis, and 3 (60%) cases of invasive sinus aspergillosis. The combination of all three (ie, nasal polyps, CT scan hyper-attenuation, and elevated titers of anti-Aspergillus immunoglobulin) was not found in any case of ethmoidal polyposis or invasive sinus aspergillosis. This triad demonstrated a sensitivity of 70% and a specificity of 100% for the preoperative diagnosis of allergic fungal sinusitis. Conclusions Nasal polyps, CT scan, and specific immunoglobulin E titers, when considered in combination, have a high preoperative diagnostic value in allergic fungal sinusitis. However, they should not be considered in isolation because considerable overlap occurs with invasive sinus aspergillosis and ethmoidal polyposis.

Purpose To report the first case of bilateral cavernous sinus thromboses and bilateral intraorbital abscesses secondary to Streptococcus milleri . Study design Single interventional case report. Intervention and testing The findings of the ophthalmic evaluation, radiographic imaging, medical and surgical intervention, specimen cultures, and clinical course were analyzed. Results A 17-year-old female had bilateral proptosis, decreased vision in the left eye, and altered mental status at presentation. An orbital compartment syndrome developed in the left eye and purulent material was present after lateral canthotomy, suggestive of an intraorbital abscess. Magnetic resonance imaging (MRI) scans revealed bilateral cavernous sinus thromboses, and subsequent computed tomographic (CT) scans revealed bilateral intraorbital abscesses in the setting of acute ethmoid and sphenoid sinusitis. Antibiotic treatment and surgical drainage of the orbital abscess and sinuses was performed, and specimen cultures revealed S. milleri . After surgery, the patient experienced hearing loss and a right internal capsule infarct, in addition to complete vision loss in the left eye. A second intraorbital abscess developed in the right eye and was drained surgically. The vision remained 20/20. Conclusions Streptococcus milleri is a virulent organism with a propensity to form abscesses in multiple areas of the body and should be considered as a possible etiologic agent in abscess formation of the orbit and cavernous sinus thrombosis.

Endoscopic ethmoidectomy is a delicate operation on the thin, honey-comb-like laminae of the ethmoidal sinuses. A high degree of precision is required to minimize disruption of the natural sinus mucociliary clearance system and to reduce the risk of orbital and skull base complications. It is therefore important that surgeons are aware of variation in the optical characteristics of the rod-lens telescopes produced by different manufacturers. A simple but precision endoscope goniometer was designed and manufactured. This was used to carry out a comparative study of the sinus telescopes in common use. The results showed significant variation in the view angle of the four brands of telescopes (Karl Storz, Olympus, Richards Smith & Nephew, and Richard Wolf) tested. Differences in the position of the horizon in the visual field, and different degrees of visuospatial distortion were evident. We also noted and measured the blind angle of telescopes, which, by virtue of a high degree of angulation, cannot view the horizon.

The authors report the case of na eighteen years old patient with a clinical picture of orbital abscess caused by ethmoid sinusitis. The decision for surgical intervention results from correlation between clinical findings and from the image diagnosis.

The supraorbital ethmoid (SOE) cell is an accessory ethmoid cell in the frontal area that extends into and pneumatizes superolaterally along the orbital plate of the frontal bone. The outflow pathway of the SOE cell can become obstructed, leading to an SOE mucocele. Given their lateral location, SOE lesions are traditionally treated through external approaches, although some authors have advocated treatment through standard endoscopic routes. We present a case of a large, supraorbital ethmoid mucocele treated with a novel modified hemi-Lothrop procedure (MHLP). This technique provides the benefit of an angulated approach to increase lateral visualization and bimanual, binostril instrumentation through a superior septectomy window.

Objectives The aim of the present prospective, randomized, double-blind, and placebo-controlled investigation (approved by the Ethical Committee of Padova University Hospital [Italy]) was to assess the effect of a nasal gel containing a combination of silver sucrose octasulfate and potassium sucrose octasulfate (Silsos gel® [SG]) in wound healing after endoscopic sinus surgery (ESS) for chronic rhinosinusitis in terms of: nasal symptoms (SNOT22), endoscopic appearance of the sinonasal mucosa (Lund–Kennedy score), nasal air flow (anterior active rhinomanometry), evidence of mucosal inflammatory processes (nasal cytology and histology), and microbiological growth. Methods Thirty-four patients with chronic rhinosinusitis were randomized on a 1:1 ratio to receive after ESS either SG or placebo (contained only the excipients [carbopol and propylene glycol] in the same concentrations as in SG). Results/conclusions Judging from the present prospective investigation on patients who underwent ESS for chronic rhinosinusitis, treatment with SG seems to enable a significantly faster improvement in specific symptoms (assessed on the validated SNOT22 scale) than placebo. Patients treated with SG also had a quicker improvement in the endoscopic appearance of their nasal mucosa after ESS than patients treated with placebo. These endoscopic improvements in the SG group were also confirmed at the long-term follow-up, while the same did not apply to the placebo-treated group.

We have carried out three-dimensional, computer-assisted, functional endoscopic sinus telesurgery. Surgeons at different locations up to 300 km apart could not only see and transfer video images but also transfer three-dimensional computer models and manipulate them in realtime during surgery. Two different approaches were used. In the first telesurgery procedure we used M-JPEG compression and transmitted the data using fibre optic connections (ATM OC-3) at a bandwidth of 155 Mbit/s. In the second telesurgery procedure video images were transmitted over four E1 digital lines, amounting to about 8 Mbit/s of bandwidth, with better compression standards, such as MPEG1 and 2. We found that MPEG2 video compression produced the best picture quality for the operating field and endoscopic cameras. For conferencing and consultation between two or more connected sites during the surgery, we used JPEG and MPEG1 video compression with audio. The main feature of our three-dimensional telesurgery was the use of three-dimensional modelling of the operative field. This is important for emergency surgical interventions. We do not advocate that inexperienced surgeons operate on patients, not even with the guidance of a remote surgeon. However, three-dimensional telesurgery may become very valuable for experienced surgeons in the future.

Background: Recurrent acute rhinosinusitis (RARS) being a low form chronic rhinosinusitis (CRS), is relatively under diagnosed many times because of lack of awareness regarding pattern of the disease presentation. Aim of the study is to evaluate the radiological significance of isolated ethmoid sinusitis in patients of RARS during the asymptomatic interval in between acute episodes of rhinosinusitis.Methods: Total 124 patients with history suggestive of RARS who had undergone computed tomography study of brain during April 2015 to October 2016 for indications other than sinonasal diseases, were evaluated for isolated ethmoid sinusitis in the department of Radiology. Patients having any inflammatory or expansile sinonasal masses were excluded.Results: Of total 124 patients of RARS aged from 18 to 70 years (mean age of 38.6 years), the study population included only seventy-two (58%) patients having isolated ethmoid sinus infections, were classified in to mild unilateral group I (46%) cases with grade I or II sinus infections and relatively severe bilateral group II (54%) cases having grade III or IV infections. Infective process involving two to three ethmoid cells each on either side is the most common variety encountered in 39% cases. Prevalence of infective process was fairly equal among all age groups. Statistical correlation between the severity of RARS in patients having group II variety of isolated ethmoid sinus infections was found highly significant.Conclusions: Isolated ethmoid sinus infections are commonly encountered CT findings in adult RARS patients while they are asymptomatic from acute episodes of rhinosinusitis.

Periorbital swelling is frequently encountered in ear, nose, and throat practices and, as it may be secondary to acute sinusitis, delayed diagnosis may lead to significant morbidity. We describe the case of a 24-year-old man with acute ethmoid-maxillary sinusitis and ipsilateral facial swelling particularly involving the periorbital area. We also discuss the workup that led to the formulation of an unusual diagnosis.

Nocardia Asteroides infection in a non-immunocompromised pediatric patient is extremely rare. We present a case of ethmoid sinusitis and orbital subperiosteal abscess caused by N. asteroides with a 20 year follow up and a review of the literature. N. asteroides was grown from intraoperative cultures for mycobacteria following surgical incision and drainage of the abscess. Postoperatively, the patient received a seven month course of trimethoprim-sulfamethozaxole and had no subsequent sequelae. Nocardia infections are common in immunocompromised patients. We present what we believe to be the first case of pediatric Nocardia sinusitis with 20-year follow up.

Proper knowledge of sinonasal configurations and anatomical structural variations is essential to perform safe endoscopic sinus surgery. Although common middle turbinate variations have been well described in literature, rare variations have not. The aims of this study are to revise the nomenclature of extra middle turbinate lamellas variations and suggest an easy classification system of these lamellas. A retrospective charts and medical records review was performed for consecutive cases that were diagnosed with extra lamella middle turbinate based on endoscopic and stander three-dimensional reconstruction computer tomography scan at a tertiary academic center. After extensive literature review, these lamellas were classified into four types depending on the presence or absence of uncinate process and their morphological configuration. Twenty-two subjects (mean age 35 years; 8 men and 14 women) were identified who had thirty extra middle turbinate lamellas. Nasal obstruction and discharge were the most common presenting symptoms. Accessory middle turbinate was the most common extra lamella been observed and bifid inferior turbinate was the least common. Ten patients (45 %) had an accompanied middle turbinate anatomical variations, 9 (41 %) had nasal septum deviation, 11 (50 %) had associated maxillary or ethmoid sinusitis and 5 (23 %) had hypoplastic maxillary sinus. Extra middle turbinate lamella is a rare type of middle turbinate anatomical variation that can be diagnosed by careful endoscopic examination and a precise computer tomography scan review. These lamellas may have a significant association with mucosa pathologies and are commonly seen with other common middle turbinate variations. Correct description and the use of common terminology can help to further evaluate the incidence of lamellas, their pathophysiological role, and to avoid any intraoperative landmark confusion.

Background: There are generally two methods to access the sphenoid sinus: either through the natural ostium {trans-sphenoethmoidalor via sphenoethmoidal recess), or by creating a second opening through the posterior ethmoids (trans-ethmoidal).This study psychophysically and subjectively evaluates the effect of the trans-sphenoethmoidal technique to the trans-ethmoidal technique for sphenoid sinusotomy on olfactory function. Methods: Prospective cohort analysis of 48 patients with comparable sinus disease underwent primary sphenoidotomy via transsphenoethmoidal(n = 24) versus trans-ethmiodal (n = 24) technique between September 2011 and February 2012. The patients had their olfaction measured psychophysically with "Sniffin' Sticks" and subjectively with a visual analogue scale (VAS) pre-operatively and at 5 weeks post-operatively. Results: Psychophysical scores from the Sniffin' sticks provide a Threshold, Discrimination and Identification (TDI) score out of 48.The TDI change (post-operative TDI score minus pre-operative score) as well as VAS change (post-operative VAS minus pre-operativeVAS) were analyzed using t-test analysis, which showed no significant difference between the two measurements. Conclusion: If the trans-sphenoethmoidal technique is done meticulously, patients have the same olfactory relief, psychophysically and subjectively, as those undergoing the trans-ethmoidal technique.

Objective Most asthmatics have been found to have rhinosinusitis (RS). Patients with ethmoid sinusitis, in particular, often suffer from an impaired sense of smell; this is clinically important and necessitates concurrent treatment for both asthma and RS. As a rational therapeutic strategy, we focused on a fine particle HFA-134abeclomethasone dipropionate (HFA-BDP) metered-dose inhaler. Because of its small size, the medication is still present in the exhaled breath after inhalation. Methods Five mild-to-moderate asthmatics with ethomoidpredominant sinusitis characterized by an impaired sense of smell and mild peripheral blood eosinophilia received a single-agent treatment with orally-inhaled HFA-BDP which was then exhaled through the nose. In addition, the stained small particles were created by an ultrasonic nebulizer and flow image of them during oral inhalation and nasal exhalation was evaluated by using nasal endoscopy. Results After treatment, the sense of smell was restored in all cases with a concomitant improvement in sinusitis as confirmed by computerized tomography. In addition, amelioration of peripheral blood eosinophilia as well as small airway obstruction as indicated by pulmonary function tests was observed. Macroscopical imaging revealed that small particles flow toward olfactory cleft during both the inhalation and exhalation phases. Conclusion We have presented 5 cases of asthmatic patients with RS treated with a concurrent single therapy, HFA-BDP exhaled through the nose (ETN). A clinical trial must be considered to establish this new therapeutic strategy based on the concept of "one airway, one disease."