American Journal of Rhinology & Allergy

Since its original description in the early 1980s, our understanding of allergic fungal sinusitis (AFS) has continued to evolve. The goal of this research was to characterize the typical AFS patient and describe a treatment protocol using endoscopic sinus surgery, high-dose itraconazole, low-dose bursts of oral corticosteroids, and topical corticosteroids.

A 12-year retrospective chart review was conducted to extract demographic and management data on 139 patients meeting the AFS criteria of atopy, characteristic radiographic findings, eosinophilic mucin, nasal polyposis, and a positive fungal culture or stain.

The typical AFS patient presented at 42.8 years of age, was female, and had 3.5 positive fungal cultures over an average of 31.4 months of follow-up. Although 69 patients (50.3%) experienced recurrence, reoperation was required in only 17 (20.5%) of 83 patients initially managed by our protocol. There were no serious adverse effects attributed to itraconazole over the 36,000 doses prescribed.

The use of itraconazole, short-burst low-dose oral corticosteroids, topical corticosteroids, and endoscopic surgery is a safe and clinically effective regimen in the management of AFS. Our clinical experience suggests medical management of recurrent AFS with itraconazole may avoid revision surgery.

Nasal endoscopy allows the collection of middle meatus secretion samples and is an alternative method for determining microorganisms in rhinosinusitis. This study assessed endoscopically collected middle meatus secretions in patients with chronic rhinosinusitis (CRS) and compared those findings with ipsilateral maxillary sinus aspirates and microbiological data of healthy individuals.

Middle meatus samples were collected from 114 CRS patients for aerobic, anaerobic, and fungal cultures; maxillary sinus secretions were collected from 13 of these patients. Twenty-three healthy volunteers served as controls.

Aerobes were isolated in 86% of CRS patients, anaerobes were isolated in 8% of CRS patients, and fungi were isolated in 11% of CRS patients; the most frequent microorganisms were Staphylococcus aureus (36%), coagulase-negative Staphylococcus (20%), and Streptococcus pneumoniae (17%). Middle meatus and maxillary sinus cultures presented the same pathogens in 80% of cases. In healthy individuals, coagulase-negative Staphylococcus (56%), S. aureus (39%), and S. pneumoniae (9%) were the most frequent isolates.

The culture of endoscopically collected middle meatus secretions is effective in identifying microorganisms in CRS patients.

Controversy persists regarding the use of minimally invasive sinus techniques (MIST) to treat chronic sinusitis primarily because of an absence of comparative outcome data.

In this prospective study of 85 patients with chronic sinusitis treated surgically with MIST, the long-term postoperative outcome was assessed using the duration-based Chronic Sinusitis Survey (CSS) quality of life instrument. Patient age ranged from 4 to 81 years old (mean age, 42 ± 16.7 years). Forty-three subjects were male patients and 42 were female patients. Mean follow-up time was 23.8 ± 2.2 months.

At follow-up, there was a 124.0% improvement in the mean CSS symptom score (p < 0.00001), a 30.1% improvement in the mean CSS medication score (p < 0.00001), and a 62.0% improvement in the mean CSS total score (p < 0.00001). An overall improvement was found in 78.8% of patients; 12.9% of patients were worse and 8.2% of patients were unchanged. Thirty-four patients (40.0%) had postsurgical CSS total scores within the normative interquartile range obtained in healthy controls. Twenty-six of these patients had postsurgical scores that actually surpassed the mean normative CSS total score. Before follow-up evaluation, 5 of the 85 patients (5.9%) had revision surgery after the initial procedure. All had revision MIST procedures and all were found to have an overall improvement at the time of follow-up.

We conclude that MIST significantly improves the outcome in patients with chronic sinusitis and should strongly be considered as the initial surgical option for such patients.

To review the personal experience of a single surgeon over a 31 year period.

A retrospective analysis of 7447 rhinoplasties performed by a single surgeon from 1969 to 2000. Ninety-five surgeries performed at educational courses were excluded from this series.

During the many years of performing rhinoplasties, cartilage splitting, delivery, and external approach are among the most common techniques. In the first decade, 62% were cartilage splitting, 33% delivery, and 3% external. In the second decade, 13% were cartilage splitting, 58% delivery, and 26% external. In the third decade, 11% were cartilage splitting, 52% delivery, and 36% external.

Over a three-decade period, the techniques of the author have been influenced by national trends, training, and patient outcomes.

The aim of this study was to delineate patient symptoms and economic burdens of chronic rhinosinusitis (CRS).

Adult patients with CRS were assessed prospectively with a survey instrument. Symptom scores for major and minor symptoms of CRS, medication use, physician visits for CRS, and work days missed were determined. Cost analyses were conducted.

Three hundred twenty-two patients were studied prospectively (mean age, 42.3 years). Nasal obstruction and facial congestion were the most common and severe major symptoms, and headache and fatigue were the most common and severe minor symptoms. Patients received an average of 2.7 antibiotic courses and used nasal steroids and prescription antihistamines 18.3 and 16.3 weeks, respectively, in a 12-month period. Mean medical resource costs were $921 per patient-year. CRS caused an average of 4.8 days of missed work per 12-month period. The overall yearly economic cost of CRS was $1539 per patient.

Nasal and facial symptoms prevail over systemic and oropharyngeal symptoms in CRS. Significant medical resource expenditures and global economic costs accompany CRS.

Cocaine-induced lesions may cause extensive destruction of the osteocartilaginous structures of the nose, sinuses, and palate that mimics the clinical picture of other diseases.

From January 1991 to September 2001 25 patients with cocaine-induced midline destructive lesions were observed at the Department of Otorhinolaryngology of the University of Brescia. The diagnosis was based on physical and endoscopic evaluation, routine blood and urine analysis, radiological findings, and repeated biopsies of the nasal mucosa. Serum was analyzed by the antineutrophilic cytoplasmic antibody (ANCA) test using indirect immunofluorescence and by enzyme-linked immunosorbent assay for antibodies against proteinase 3 and myeloperoxidase.

Septal perforation was present in all 25 patients, 16 of which (68%) also had partial destruction of the inferior turbinate. Hard palate reabsorption was observed in only six patients (24%); in two of these patients, the lesion also extended to the soft palate. Fourteen patients (56%) were positive by the immunofluorescence test (nine patients had a P-ANCA and five patients a C-ANCA pattern). Four patients (16%) with the P-ANCA pattern and all patients with the C-ANCA pattern also tested positive for anti–proteinase 3 antibodies.

Any sinonasal inflammation involving the midline that persists or remains refractory to treatment may be the first manifestation of potentially lethal drug addiction. Cocaine abuse should be considered in the differential diagnosis of destructive lesions of the nasal cavity even in the presence of a positive ANCA test.

Rhinophyma is a benign inflammatory growth of the nose. It usually involves the caudal one-third of the nose in men. It not only affects the patient's appearance, but also can have profound functional implications. Many difficult treatment methods have been advocated, often with acceptable success. Because there appears to be no distinct advantages in the different therapeutic modalities, no one modality is universally endorsed.

We performed a retrospective review of patients from 1990–2001 who underwent treatment of their rhinophyma at Louisiana State University, Health Science Center and Overton Brooks Veteran's Hospital in Shreveport, LA. The tumescent anesthesia, Weck blade excision and argon beam coagulator technique (TWA) was used on 51 patients.

Patients undergoing this technique have operating times no greater than ten minutes. The average blood loss was less than 5cc. No surgical complications were noted.

The TWA technique yields good cosmetic results and is cost-effective.

The optimal form of nasal packing after endoscopic sinus surgery (ESS) still has not been established. Although wide variations exist among sinus surgeons, the goals are adequate hemostasis, rapid healing, and patient comfort. Preliminary studies indicated that FloSeal (FS), a novel absorbable hemostatic paste used as a nasal pack, was associated with minimal postoperative discomfort and effective hemostasis. This study was designed to evaluate the effects of this agent on mucosal healing in ESS.

Twenty consecutive patients underwent bilateral ESS. For each patient, one ethmoid cavity was randomized to receive FS and the other received thrombin-soaked gelatin foam. The extent of granulation tissue and adhesion formation was evaluated at 6–8 weeks after surgery.

No significant differences were observed between the FS and the thrombin-soaked gelatin foam groups with respect to the preoperative Lund-Mackay score, extent of surgery performed, or need for additional nasal packing. However, the FS group showed clear trends toward increased granulation tissue (p = 0.007) and adhesion (p = 0.006) formation.

Conclusion: Absorbable hemostatic agents are associated with a high degree of patient comfort and provide hemostasis comparable with traditional techniques. Different materials may induce differential patterns of mucosal healing, potentially affecting the ultimate result of ESS.

Stenosis of the nasolacrimal drainage system is a relatively frequent complication of acute or chronic inflammation, trauma, tumor, or congenital malformation. Symptoms include epiphora, intermittent purulent secretion, and swelling of the nasolacrimal sac. The principle of dacryocystorhinostomy (DCR) is to create an artificial opening of the lacrimal sac into the nasal cavity. This can be done via an external as well as an endonasal route.

In this retrospective study, we examined 74 microscopic endonasal DCRs, which were performed on 70 patients between 1990 and 2000. All of the 74 DCR operations had no major complications intraoperatively.

Sixty DCR procedures (81.1%) were successful after a mean follow-up time of 3.18 years. This success rate is lower than those rates reported in the literature for the external approach, which range between 85 and 99%, although follow-up times were shorter in most of these studies.

Advantages of the endonasal approach such as saving the medial palpebral ligament, the lacrimal pump mechanism, and the horizontal apparatus are obvious. If necessary, additional management of sinus, septal, and conchal disease can be performed simultaneously. Our results reveal that the microscopic endonasal approach is a safe and reliable procedure in the management of postsaccular or saccular nasolacrimal duct obstruction and is an alternative to the traditional external route.

Refractory posterior epistaxis is a challenge for otolaryngologists. Most algorithms for managing this condition ultimately call for interrupting the arterial blood supply to the nasal mucosa. Traditionally, this was accomplished either by transantral arterial ligation or by arteriographic-guided embolization. More recently, the endonasal endoscopic approach has also been described. Because the primary blood supply to the posterior nasal cavity is derived from the terminal branches of the sphenopalatine and the posterior nasal arteries, we conducted this anatomic study to examine and describe the anatomic relationship of these two arteries as they exit the pterygopalatine fossa and enter the nasal cavity.

We performed endoscopic dissections of this anatomic region in nine fresh and one formalin-preserved cadaver specimens. A total of 19 sides were examined.

In 3 of 19 specimens (16%), the sphenopalatine artery branched from the sphenopalatine artery within the sphenopalatine canal, allowing the two arteries to exit together. In 8 of the 19 specimens (42%), the sphenopalatine artery exited much more posteriorly, yet from within a shared posteriorly elongated sphenopalatine foramen. In the remaining eight specimens (42%), the sphenopalatine artery exited through a distinct foramen directly posterior to the larger sphenopalatine foramen.

Understanding this anatomic relationship is important in performing endoscopic arterial ligation. If the sphenopalatine artery is not specifically identified and ligated, an important component of the posterior nasal circulation will not be addressed adequately by this surgical approach.