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Background Chronic rhinosinusitis with nasal polyposis (CRSwNP) is associated with substantial sinus opacification. In a phase 2a study (NCT01920893), dupilumab, a fully human anti-IL-4RI± monoclonal antibody, improved outcomes in CRSwNP refractory to intranasal corticosteroids. We evaluated dupilumab’s effect on sinus opacification in relation to effects on nasal polyp burden, symptoms, and health-related quality of life (HRQoL) in patients with CRSwNP. Methodology 16-week randomized, double-blind, placebo-controlled, parallel-group study in 60 adults with CRSwNP. Patients received weekly subcutaneous dupilumab 300-mg or placebo and daily mometasone furoate nasal spray. Sinus opacification was assessed using standard and Zinreich-modified Lundâ€"Mackay (zLMK) scoring. Correlation was assessed between zLMK score and CRSwNP endpoints, including nasal polyp score (NPS), SNOT-22, daily symptom scores, and UPSIT smell-test score. Results Baseline characteristics were similar across treatment groups. Mean plus/minus SD baseline LMK scores of 18.7 plus/minus 5.5 (placebo) and 18.6 plus/minus 5.0 (dupilumab) indicated severe disease with extensive opacification involving all sinuses. Baseline LMK and LMK scores correlated with NPS severity and loss of sense of smell (daily symptoms; SNOT-22 smell/taste; loss of sense of smell [UPSIT]). At Week 16, dupilumab-treated patients had significantly improved sinus opacification measured by LMK in all individual sinuses vs placebo. Dupilumab also showed similar efficacy with zLMK, with only small differences from LMK, and correlated with SNOT22 smell/taste. The most common adverse events were nasopharyngitis, injection-site reactions, and headache. Conclusions In patients with CRSwNP, baseline LMK showed extensive sinus opacification and correlated with symptoms, HRQoL, and hyposmia. Dupilumab treatment reduces opacification across all sinuses and related symptoms in patients with CRSwNP.

The purpose of this article is to identify and define the appropriate imaging techniques in the evaluation of post-functional endoscopic surgery (FESS) complications. Although most complications encountered during FESS are identified readily during surgery, some are less conspicuous and require postoperative imaging. As illustrated in this article, these include cerebrospinal fluid leak, vascular injury, brain injury, orbital injury, and infectious complications of the brain and meninges. Some of the common anatomic variants of the paranasal sinuses are identified, and how these may predispose to surgical complications is discussed.

PRESENTATION An 88-year-old woman’s startling ophthalmologic symptoms were initially attributed to infection during an outpatient examination. When treatment offered no improvement, she presented to Johns Hopkins Hospital, where she reported progressive left eye swelling of 2 weeks duration. Seven years earlier, she had undergone mastectomy, chemotherapy, and radiation for breast cancer. Her medical history was also significant for a prior stroke, hypertension, and dementia. Initially, the patient noticed the onset of left-eye redness and swelling; she commented that her eye gradually “popped out.” An outside ophthalmology evaluation resulted in a diagnosis of conjunctivitis, and she was prescribed a regimen of tobramycin/dexamethasone ophthalmic suspension and moxifloxacin ophthalmic solution. Yet, her symptoms persisted. Two days prior to her presentation at the hospital, her son noticed ipsilateral cheek swelling. Given the progression of symptoms and her profoundly compromised appearance, the patient and her son sought further evaluation at the hospital. She did not have fever, chills, sweats, headaches, nausea, or vomiting. In addition, she denied having ocular pain, discharge, or visual compromise. She was admitted to the Osler Medical Service.

Three-dimensional (3D) visualizations of volumetric data from CT have gained widespread clinical acceptance and are an important method for evaluating complex anatomy and pathology. Recently, cinematic rendering (CR), a new 3D visualization methodology, has become available. CR utilizes a lighting model that allows for the production of photorealistic images from isotropic voxel data. Given how new this technique is, studies to evaluate its clinical utility and any potential advantages or disadvantages relative to other 3D methods such as volume rendering have yet to be published. In this pictorial review, we provide examples of normal calvarial, maxillofacial, and skull base anatomy and pathological conditions that highlight the potential for CR images to aid in patient evaluation and treatment planning. The highly detailed images and nuanced shadowing that are intrinsic to CR are well suited to the display of the complex anatomy in this region of the body. We look forward to studies with CR that will ascertain the ultimate value of this methodology to evaluate calvarium, maxillofacial, and skull base morphology as well as other complex anatomic structures.

Magnetic Resonance Imaging (MRI) offers great potential for planning, guiding, monitoring and controlling interventions. MR arthrography (MRAr) is the imaging gold standard for assessing small ligament and fibrocartilage injury in joints. In contemporary practice, MRAr consists of two consecutive sessions: (1) an interventional session where a needle is driven to the joint space and MR contrast is injected under fluoroscopy or CT guidance; and (2) a diagnostic MRI imaging session to visualize the distribution of contrast inside the joint space and evaluate the condition of the joint. Our approach to MRAr is to eliminate the separate radiologically guided needle insertion and contrast injection procedure by performing those tasks on conventional high-field closed MRI scanners. We propose a 2D augmented reality image overlay device to guide needle insertion procedures. This approach makes diagnostic high-field magnets available for interventions without a complex and expensive engineering entourage. In preclinical trials, needle insertions have been performed in the joints of porcine and human cadavers using MR image overlay guidance; in all cases, insertions successfully reached the joint space on the first attempt.

Imaging of sinonasal structures has evolved from standard radiographs to the much more complicated and informative techniques used today. The plain radiograph was useful when the surgical techniques practiced were primarily aimed at the maxillary and frontal sinuses. With a better understanding of the mucociliary clearance of the nasal cavity and the paranasal sinuses, the surgical technique was shifted to the ethmoid sinuses and became more focal, thus needing a better understanding and display of the intricate morphology of the nasal cavity and paranasal sinuses. Polytomography was a step above plain radiographs and was first used in the display of the regional anatomy for the development of functional endoscopic sinus surgery. Polytomography was quickly replaced by computed tomography, as this imaging technique provides a much more detailed view of the sinonasal architecture than does polytomography. Magnetic resonance imaging has also shown usefulness in imaging this morphological area, as it provides better soft tissue resolution, but it does not allow good visualization of bony structures. Newer computer systems with software capable of reconstructing the digitized information into a 3-dimensional display further enhance our understanding of the regional morphology and afford an improved means of correlating the imaging and endoscopic information. Furthermore, stereotactic navigation systems allow surgeons the ability to visualize the endoscope-instrument tip position, as instruments are actively being used during surgery, on the computed tomographic and/or magnetic resonance images. There is a persistent trend toward reducing the size of the imaging equipment to render it more mobile (computed tomography) and adapt it for operating room use.

For the theoretic advantages of 3T units to translate to improved diagnostic quality, careful attention must be paid to optimization of pulse sequences and development of clinically feasible imaging protocols. RARE sequences continue to be the choice for routine clinical imaging of the head and neck; although exquisite T2W images are afforded, T1W imaging is problematic. Short ETLT1W RARE imaging seems to be a good compromise.

We present a 2D image overlay device to assist needle placement on computed tomography (CT) scanners.The system consists of a flat display and a semitransparent mirror mounted on the gantry. When the physician looks at the patient through the mirror, the CT image appears to be floating inside the body with correct size and position as if the physician had 2D 'X-ray vision'. The physician draws the optimal path on the CT image. The composite image is rendered on the display and thus reflected in the mirror. The reflected image is used to guide the physician in the procedure. In this article, we describe the design and various embodiments of the 2D image overlay system, followed by the results of phantom and cadaver experiments in multiple clinical applications.Multiple skeletal targets were successfully accessed with one insertion attempt. Generally, successful access was recorded on liver targets when a clear path opened, but the number of attempts and accuracy showed variability because of occasional lack of access. Soft tissue deformation further reduced the accuracy and consistency in comparison to skeletal targets.The system demonstrated strong potential for reducing faulty needle insertion attempts, thereby reducing X-ray dose and patient discomfort.

Objectives: to develop consensus definitions for rhinosinusitis and outline strategies useful in clinical trials

Patients with superior canal dehiscence (SCD) syndrome experience vertigo and oscillopsia with loud sounds and/or stimuli that result in changes in middle ear or intracranial pressure. Findings on temporal bone CT were analyzed to determine if a developmental abnormality is associated with the syndrome.Temporal bone CT scans [0.5 mm collimation and projections into the superior semicircular canal (SC) plane] were used to compare the bone overlying the SC in patients with SCD syndrome (20 unilateral, 7 bilateral) and in 88 patients without SCD syndrome who had undergone temporal bone CT for evaluation of other otologic disorders (controls).The thickness of bone overlying the SC in the controls measured 0.67 +/- 0.38 mm (mean +/- SD). For individual control subjects. the thickness of bone on one side was correlated with that on the other side (r = 0.43; p0.0001). The thickness of bone overlying the SC on the intact side in patients with unilateral dehiscence measured 0.31 +/- 0.23 mm, and was thinner than that noted in the controls (p0.0001).These findings support the notion that there is a developmental abnormality underlying SCD syndrome. When dehiscence is found on one side, the contralateral side is likely to be thin.

Background Mometasone furoate nasal spray (MFNS) 400 μg, twice daily, as adjunctive treatment with oral antibiotic significantly improved symptoms of recurrent rhinosinusitis. Objective To evaluate the effectiveness and safety of MFNS 200 μg, twice daily, and 400 μg, twice daily, compared with placebo as adjunctive treatment with oral antibiotic for acute rhinosinusitis. Methods In this multicenter, double-blind, placebo-controlled study, 967 outpatients with computed tomographic scan-confirmed moderate to severe rhinosinusitis received amoxicillin/clavulanate potassium (Augmentin, GlaxoSmithKline, Research Triangle Park, NC) 875 mg, twice daily, for 21 days with adjunctive twice daily MFNS 200 μg, MFNS 400 μg, or placebo nasal spray. Patients recorded scores of six rhinosinusitis symptoms and any adverse events twice daily. Pre- and postcosyntropin–stimulation plasma cortisol levels were measured in a subset of patients at selected study sites. Results Treatment with MFNS 200 μg or 400 μg, twice daily, produced significantly greater improvements in total symptoms score (primary efficacy variable) day 1 to day 15 average (50% and 51%, respectively) than placebo (44%, P ≤0.017). Both doses of MFNS produced significant total symptoms score improvement over placebo by day 4, and maintained efficacy over the entire 21-day study. Relief of individual symptoms showed a similar pattern. Both doses of MFNS were well tolerated, and adverse events were similar to that of placebo. Cosyntropin stimulation showed no evidence of hypothalamic-pituitary-adrenal axis suppression. Conclusions As adjunctive therapy to oral antibiotic treatment, MFNS at doses of 200 μg or 400 μg, twice daily, was well tolerated and significantly more effective in reducing the symptoms of rhinosinusitis than antibiotic therapy alone.

To evaluate the dimensions of specific white matter tracts in the brainstems (region of brain thought to be least affected) of children with holoprosencephaly by using diffusion tensor magnetic resonance (MR) imaging and to correlate these abnormalities with forebrain malformation severity and neurologic deficit severity.Thirteen patients with holoprosencephaly underwent diffusion tensor MR imaging, with which white matter color maps were generated. Type of holoprosencephaly was correlated with presence or absence of specific brainstem white matter tracts. Furthermore, patient rank based on cortico-ponto-spinal tract (CPST) and middle cerebellar peduncle (MCP) dimensions was correlated with holoprosencephaly type and neurodevelopmental score by using Spearman rank correlation analysis.Two patients had alobar holoprosencephaly, five had the semilobar type, one had the lobar type, and one had the middle-hemisphere-variant type. Four patients were excluded from analysis. In the two patients with alobar holoprosencephaly, the CPSTs were absent bilaterally. In all of the remaining patients except one, who had semilobar holoprosencephaly in which the CPSTs could not be identified at the level of the medulla oblongata, all tracts were present bilaterally. Holoprosencephaly type and neurodevelopmental score correlated strongly with CPST and MCP dimensions (P.01) over and above the effect of age.In vivo identification of brainstem white matter tract abnormalities in patients with holoprosencephaly can be achieved by performing diffusion tensor MR imaging.

Background: Intranasal glucocorticoids are effective in the treatment of allergic rhinitis. Their effectiveness as an anti-inflammatory adjunct in the treatment of acute recurrent sinusitis has not been adequately established in a controlled clinical study. Objective: The purpose of this study was to test the hypothesis that intranasal corticosteroid treatment produces additional relief in the treatment of acute sinusitis with oral antibiotics. Methods: Patients who were 12 years old and older with a history of recurrent sinusitis were treated while experiencing a new episode of acute sinusitis, which was diagnosed by symptoms and confirmed by computed tomography scan of the paranasal sinuses. Patients were treated for 21 days with amoxicillin clavulanate potassium and randomized to receive concurrent mometasone furoate nasal spray (MFNS; Nasonex [400 μg, twice daily]; n=200 patients) or placebo spray (twice daily; n=207 patients). Symptom scores for headache, facial pain, congestion, purulent rhinorrhea, postnasal drip, and cough were recorded at baseline and throughout treatment. Results: Baseline symptom scores showed a moderate level of symptom severity comparable in both groups. Patient-recorded twice daily symptom scores showed that adjunctive treatment with MFNS caused a significantly greater decrease in total symptom score (primary efficacy variable) and in individual scores of inflammatory symptoms associated with the obstruction process (headache, congestion, and facial pain) compared with placebo. Symptoms associated with the secretory processes were improved to a lesser degree. Therapy-related local adverse events were not significantly different between groups. Conclusion: The addition of intranasal corticosteroid, MFNS 400 μg twice daily, to antibiotics significantly reduces symptoms of acute sinusitis compared with antibiotic treatment alone. (J Allergy Clin Immunol 2000;106:630-7.)

Purpose: To create criteria for detecting dural ectasia on MR or CT images in adult Marfan patients. Methods: Images were analyzed using a workstation. Parameters that predicted dural ectasia were included in our criteria. Results: Major criteria include: (1) width of dural sac below L5 > width above L4; (2) anterior sacral meningocele. Minor criteria include: (1) L5 nerve root sleeve diameter > 6.5 mm and (2) S1 scalloping > 3.5. Dural ectasia exists if 1 major or 2 minor criteria are present. Conclusion: MR and CT diagnose dural ectasia with high specificity and sensitivity. Our criteria accurately diagnose dural ectasia in adult Marfan patients.

Standard radiographs are suboptimal in the display of the regional morphology in the nasal cavity and paranasal sinuses, especially the ethmoid sinus. The preferred radiographic modality for the evaluation of the nasal cavity and paranasal sinuses is computed tomography (CT). Coronal CT imaging perpendicular to the bony palate affords the best display of the ostiomeatal channels and facilitates the surgeon's perception of this regional morphology because it most closely resembles the endoscopic view. The purpose of this article is to familiarize the reader with the regional anatomy of the nasal cavity and paranasal sinuses, specifically the 14 anatomic structures the examiner must understand and systematically check in the evaluation of this morphologic area. A description of the most commonly found anatomic variations that influence the patency of the ostiomeatal channels as well as specific relationships between the paranasal sinuses, the orbits, and the intracranial compartment are also detailed. Although less helpful in the display of paranasal sinus chronic inflammatory disease, magnetic resonance imaging is beneficial in the diagnosis of fungal disease, neoplastic disease, and the display of inflammatory extension into the intracranial and intraorbital compartments.

In patients with sinonasal disease, recognition of anatomic landmarks may be difficult. The ISG Viewing Wand is an intraoperative navigational device that allows the surgeon to correlate the anatomy of the patient with a computerized display of the reformatted image of preoperative computed tomographic or magnetic resonance scans. We have found the ISG Viewing Wand to be a valuable tool for surgery of the paranasal sinuses. Representative cases are presented that illustrate the application of this device. An intraoperative navigational device enhances the surgeon's ability to safely identify anatomic structures.

OBJECTIVE : A frameless stereotactic system (the Viewing Wand ; Elekta Instruments, Atlanta, GA) has been developed for use with preoperative computed tomography, magnetic resonance imaging, and positron emission tomography as an adjunct for surgical planning and intraoperative navigation. This clinical study was designed to evaluate the safety, efficacy, and accuracy of the Viewing Wand in a variety of intracranial procedures. METHODS : We used this system in 250 patients undergoing a wide range of neurosurgical procedures from July 1990 to July 1994, to assess its clinical usefulness and safety. In a subset of 45 neurosurgical patients studied between March 1993 and March 1994, a battery of objective accuracy measurements was obtained before and during surgery. RESULTS : In this series, there were no instances of adverse outcomes attributable to the use of this system. A comparison of two alternative patient-image registration techniques established that the fiducial-fit method was slightly more accurate than the surface-fit method (geometric means = 2.51 and 3.03 mm, respectively). The clinical accuracy achieved with magnetic resonance imaging was nearly equivalent to that with computed tomography. CONCLUSIONS : On the basis of this clinical series, recommendations are made regarding preoperative scanning parameters, registration techniques, and methods for reestablishing registration if needed during the course of surgery. The primary clinical benefits of the wand in this series were improved intraoperative navigation and surgical safety. For most cases, the wand was also useful in planning the location and size of the scalp incision, craniotomy, or corticotomy, as well as the extent of surgical resection.

Imaging Quiz Case 1 Phillip A. Pollice, MD; Nasir I. Bhatti, MD; John K. Niparko, MD; Baltimore, Md A 37-year-oldwoman with mental retardation of unknown origin, seizures, hypothyroidism, chondromalacia, gastrointestinal dysmotility, and chronic anemia was referred for evaluation of progressive unilateral hearing loss and intermittent vertigo. In March 1992, her audiogram revealed a mild symmetrical sensorineural hearing loss: speech reception threshold (SRT), 25 dB in both ears; speech discrimination score (SDS), 90% in both ears. One year later, she began to complain of episodic dizziness. Electronystagmography revealed a significant right-sided weakness on caloric testing and no evidence of spontaneous, gaze, or positional nystagmus; the left side was normal. By March 1995, the patient's episodes of dizziness had increased in severity and frequency, often lasting hours, and were associated with nausea and vomiting. Her hearing loss had progressed on the right side. The audiogram revealed that she had an SRT of 70 dB and an SDS of 85% in the right ear and an SRT of 30 dB

Nearly all patients with cystic fibrosis (CF) have abnormal findings on plain paranasal sinus radiographs. To establish this relationship more accurately, 58 CF patients with nasal symptoms were evaluated with paranasal sinus computed tomography (CT). Bilateral medial displacement of the lateral nasal wall in the middle meatus and uncinate process demineralization were seen in 43 patients (74%). Three patients (5%) had unilateral displacement and uncinate demineralization. Ten patients had maxillary sinus opacification, two patients (3.5%) had unremarkable paranasal sinuses on CT, and another patient (2%) had normal findings on one side. Although the vast majority of CF patients do have paranasal sinus abnormalities, we found on CT scan a progression of abnormalities that range from normal sinuses to pansinus disease, and in 74%, bilateral medial displacement of the lateral nasal wall and uncinate process demineralization.

Computer-assisted image guidance during endoscopic sinus surgery allows for safer and more thorough sinus surgery. We have previously reviewed our experience with the ISG Intraoperative Viewing Wand system. This article describes our current technique and indications for use of the system. Several new technological advances, including the development of a curved operative probe for use in the frontal recess, as well as the introduction of a free-hand infrared localizer, are also described.

This article details the imaging modalities available for patients being considered for functional endoscopic sinus surgery. The pertinent radiologic anatomy is reviewed with an emphasis on normal variations. Imaging appearances of inflammatory sinus disease as well as postoperative appearances, including complications, are presented.

Program Description: The miniseminar provides an open forum for interactive discussion of management options and the decision rationale involved in sinus and skull base cases of varying complexity. A case presentation format is utilized with case presentations from each of the panelists. Questions regarding differential diagnosis, evaluation, imaging, and treatment are posed to the audience in multiple choice format. The responses provided by the audience response system are then discussed and expanded upon by the panelists in an interactive discussion. In general, cases are selected that might be encountered by either a general otolaryngologist or a subspecialty rhinologist, but which have important decision and management dilemmas. Each panelist has been chosen because of their depth of knowledge in the field and because of the clarity of their presentations. Particular emphasis is placed on the decision making process and on frontal sinus disease, revision surgery, and fungal sinusitis, as well as the ...

Diagnostic imaging plays an essential role in the evaluation of disease processes that affect the upper airway. Imaging allows for the localization and characterization of various conditions that are often occult on physical examination. Plain radiography maintains a limited role in airway evaluation, whereas advanced imaging modalities, including computed tomography and magnetic resonance imaging, have emerged as indispensable tools in patient evaluation. Common disease entities affecting the upper airway in the adult population, including trauma, infectious/inflammatory diseases, and neoplastic diseases, as well as other common pathologic conditions are reviewed in this article.

Magnetic resonance images (MRI) of the brain from 75 homosexual men were reviewed to evaluate the frequency and severity of incidental sinus disease associated with human immunodeficiency virus (HIV). All scans had been performed for reasons other than a history of sinus disease. The opacification of each sinus cavity was scored such that 0 = normal, 1 =25%, 2 = 25% to 75%, and 3 =75% opacification. Subjects were then stratified by clinical status into four groups: HIV-, HIV+ without HIV-related symptoms, AIDS-related complex (ARC), or AIDS. Grade 1 mucosal thickening was present in 52% to 55% of HIV- and HIV+ subjects alike. Moderate disease (grade 2 or 3) was seen in seven of 52 HIV+ subjects, but none of the 23 HIV- controls. The incidence of maxillary sinus thickening was 69% in men with AIDS, compared to 30% in HIV- men (chi 2 = 4.1, p0.05). Mean maxillary sinus scores were 1.25 +/- 0.29 in those with AIDS compared to 0.43 +/- 0.15 in HIV- men (f = 5.11, p0.05). Our results suggest that maxillary sinus disease is more common and more severe in patients who have AIDS.

To correctly interpret imaging studies, it is essential to understand the anatomy of the lateral nasal wall and its relationship to adjacent structures. The lateral nasal wall contains three bulbous projections: the superior, middle and inferior turbinates (conchae). The turbinates divide the nasal cavity into three distinct air passages: the superior, middle and inferior meati. The superior meatus drains the posterior ethmoid air cells and, more posteriorly, the sphenoid sinus (via the sphenoethmoidal recess). The middle meatus receives drainage from the frontal sinus (via the frontal recess), the maxillary sinus (via the maxillary ostium and subsequently the ethmoidal infundibulum) and the anterior ethmoid air cells (via the ethmoid cell ostia). The inferior meatus receives drainage from the nasolacrimal duct [1–15].

• We present three patients in whom the diagnosis of intranasal meningoencephalocele was made by magnetic resonance imaging. The initial clinical evaluation and computed tomographic examinations of these patients failed to distinguish between chronic inflammation and intranasal meningoencephalocele. Although both computed tomography and magnetic resonance imaging are used to distinguish between normal, inflammatory, and neoplastic tissue in the nasal cavity and paranasal sinuses, limitations do exist and these are the focus of our communication. A clear understanding of the efficacy of these radiographic modalities will enhance surgical planning and can preclude severe complications. ( Arch Otolaryngol Head Neck Surg. 1992;118:1253-1256)

A patient presented with a frontal sinus mucopyocele and an epidural space infection secondary to an obstructing frontoethmoidal osteoma. Preoperative diagnosis was facilitated by both computerized tomography and magnetic resonance imaging. His treatment involved both open and endoscopic surgical techniques of accomplishing sinus and epidural space drainage and osteoma removal. The clinical entity of paranasal sinus osteomas is discussed, with emphasis on diagnosis, associated complications, and decisions regarding surgical management.

OBJECTIVEThe purpose of this study was to determine the applicability, safety, and normal parameters of a xenon-enhanced CT technique to quantify maxillary sinus ventilation.PATIENTS AND METHODSNine healthy subjects inhaled a xenon-oxygen-air mixture through their noses while repeated CT scans were performed through the same section of their sinuses. Images were obtained every 1 to 3 minutes and analyzed to measure the density of the gas in the maxillary sinus as a function of time.RESULTSIndividual nasal cavity time constants ranged from 0.5 to 18 minutes. Studies performed after decongestion showed poorer sinus ventilation.CONCLUSIONSThe xenon-CT washin/washout technique is safe, effective, and gives representative data.

Since the introduction of functional endoscopic sinus surgery (FESS) in the United States in 1985, the information gained from imaging has proved imperative in understanding regional morphology and guidance of surgical procedures. More than 20 years later, the importance of imaging continues to be the anatomic detail afforded by this technology, the roadmap it provides in planning the surgery, and the morphologic detail it provides in recurrent disease. The latest development in CT technology, cone beam CT instrumentation, may change the way imaging of the nasal cavity and paranasal sinuses is performed in the future. These topics are discussed in this article.

Background: Sinusitis and rhinitis are associated with uncontrolled asthma. There are no simple, validated tools to screen for these diseases. The objective of this study was to assess instruments to assist in the diagnosis of chronic sinonasal disease. Methods: Participants without acute sinonasal symptoms underwent an extensive evaluation. The results were submitted to an expert panel that used the Delphi method to achieve consensus. Using the consensus diagnosis of the panel, we determined the sensitivity and specificity of test procedures to diagnose chronic sinonasal disease. We determined the reproducibility of the most sensitive and specific instrument in a separate cohort. Results: Fifty-nine participants were evaluated, and the expert panel reached consensus for all (42 participants with chronic sinonasal disease, 17 participants without chronic sinonasal disease). A six-item questionnaire based on the frequency of nasal symptoms was the most sensitive tool used to diagnose sinonasal disease (minimum specificity, 0.90). Reproducibility testing in a separate cohort of 63 participants (41 chronic sinonasal disease with asthma, 22 chronic sinonasal disease without asthma) showed a concordance correlation coefficient of 0.91 (95% CI, 0.85 to 0.94) when this questionnaire was limited to five items (ie, excluding a question on smell). This five-item questionnaire had a sensitivity of 0.90 (95% CI, 0.77 to 0.97), a specificity of 0.94 (95% CI, 0.71 to 1.00), and an area under the receiver operating characteristic curve of 0.97 (95% CI, 0.93 to 1.0). Sinus CT scans and nasal endoscopy lacked sensitivity for use in the diagnosis of chronic sinonasal disease. Conclusions: We have developed a sensitive, specific, and reproducible instrument to screen for chronic sinonasal disease. Validation studies of this five-item questionnaire are needed, including in patients with asthma. (CHEST 2009; 136:1324–1332) Abbreviations: AUC area under the curve; ROC receiver operating characteristic; SNQ sinonasal questionnaire

The atelectatic maxillary sinus is a distinct anatomic variant. It may be identified in a symptomatic patient complaining of recurrent acute or chronic sinusitis or may be found incidentally, presenting as an asymptomatic opacified sinus. Recognition of the disorder is important. Lateral displacement of the posterior fontanelle may lead to the erroneous radiographic diagnosis of an air fluid level. At surgery, the infundibular atelectasis associated with the disorder may give rise to inadvertent orbital entry as the uncinate process is incised. Surgery may be further complicated by lateral displacement of the medial maxillary sinus wall, reducing access to the sinus by the transnasal approach. Although the atelectatic sinus may be identified at any age, its occurrence in childhood and the typical concurrence of sinus hypoplasia suggests sinus hypoventilation from an early age. The characteristic findings of the atelectatic maxillary sinus are presented and its surgery discussed.

The choice radiographic modality for the evaluation of the nasal cavity and paranasal sinuses is computed x-ray tomography (CT). Coronal CT imaging affords optimal display of the osteomeatal channels and facilitates the surgeon's perception of regional morphology. The object of this communication is to outline the parameters we feel will optimize the CT examination and to describe the regional anatomy as displayed primarily in the coronal plane. Magnetic resonance imaging, although less optimal for the display of chronic inflammatory disease, is felt to be beneficial in identifying fungal disease and diagnosing neoplastic disease.

A better understanding of the pathogenesis of chronic sinus disease has led to an increased performance of endonasal sphenoethmoid surgery. Approaching the sphenoid sinus via this route mandates that the surgeon be aware of the anomalies which may be encountered in this region, if injury to the related neurovascular structures is to be avoided. This study was therefore undertaken to evaluate a critical anatomic variation, the incidence of bony dehiscence over the carotid artery. Following cadaver sphenoethmoidectomy, the lateral wall of the sphenoid sinus was examined endoscopically and gently palpated in 188 sphenoid sinuses. An apparent dehiscence of bone was found over the carotid artery in 41 sinuses (22%), a significantly higher incidence than reported in other studies. In 3 specimens the carotid artery was exposed in the posterior ethmoid sinus. The study highlights the importance of considering this anatomic variation and of careful evaluation of the patient's computed tomographic scan, before this kind of surgery is attempted. Management of injury to the internal carotid artery in this area is also discussed.

A new technique for visualization of the lacrimal drainage system uses computed tomography after topical application of 0.6 ml of water-soluble contrast medium to the conjunctival surface. The safety of the contrast medium was tested by slit lamp examination of eight rabbit eyes and four monkey eyes. Because no adverse affects were observed in the eyes of experimental animals, post traumatic, neoplastic and inflammatory conditions affecting the lacrimal drainage system in man were assessed with this technique, and excellent lacrimal system visualization was obtained.

Radiologic imaging is an essential part of the presurgical evaluation of patients with sinusitis and of the monitoring of difficult-to-treat,recurrent, and postsurgical disease. In patients with noninflammatory sinus pathology and those who "baffle" clinical diagnosis, ima-ging is extremely helpful in differentiating the various pathological entities and determining the extent of disease. Computerized tomography (CT), when deemed clinically necessary, is the current modality of choice to evaluate sinusitis. CT's ability to display bone,mucosa, and air makes it a perfect tool for imaging of the paranasal sinuses. The fine bony architecture of the nasal cavity and the para-nasal sinus drainage pathways are depicted accurately with CT examination.

Magnetic Resonance Imaging (MRI) has unmatched potential for planning, guiding, monitoring and controlling interventions. MR arthrography (MRA) is the imaging gold standard to assess small ligament and fibrocartilage injury in joints. In contemporary practice, MRA consists of two consecutive sessions: 1) an interventional session where a needle is driven to the joint space and gadolinium contrast is injected under fluoroscopy or CT guidance. 2) A diagnostic MRI imaging session to visualize the distribution of contrast inside the joint space and evaluate the condition of the joint. Our approach to MRA is to eliminate the separate radiologically guided needle insertion and contrast injection procedure by performing those tasks on conventional high-field closed MRI scanners. We propose a 2D augmented reality image overlay device to guide needle insertion procedures. This approach makes diagnostic high-field magnets available for interventions without a complex and expensive engineering entourage.