Faculty Bibliography

BACKGROUND: Anatomic and mucosal obstruction of the frontal sinus outflow tract (FSOT) can result in frontal sinusitis often associated with frontal headache. Thorough evaluation of symptomatic patients requires axial and coronal computerized tomographic (CT) scans of the paranasal sinuses (PNS). With the advent of multichannel multidetector CT scanning, the availability of high-quality sagittal images has become increasingly widespread. However, the utility of these images in the assessment of FSOT patency has not yet been established. METHODS: A retrospective review of coronal and sagittal images from 25 PNS CT scans (50 sides) were randomized, blinded, and independently evaluated by two neuroradiologists. FSOT obstruction by agger nasi cells, the ethmoid bulla, and mucosal disease was assessed. A degree of confidence was rendered for each of these findings. The results were then compared against a consensus diagnosis, which was rendered based upon simultaneous reading of the coronal and sagittal images. Generalized estimating equations were used to assess the difference between sagittal and coronal images in terms of reader confidence and diagnostic concordance with the consensus. RESULTS: Review of sagittal images had a higher degree of concordance with the consensus than did coronal images, and was highest for mucosal disease. Both readers were more confident in rendering a diagnosis based upon the sagittal images. CONCLUSION: Sagittal reformatted CT images of the PNS are helpful in the radiologic evaluation of the FSOT. Experienced neuroradiologists had a higher degree of confidence in the diagnosis of the obstruction of the FSOT using sagittal reformatted images

The use of an intracoperative navigation device improves surgical accuracy, helps identify anatomic landmarks, and minimizes the risk of complications during surgery of the paranasal sinuses and skull base. Despite the benefits of image guidance, its use is limited by the headset, which precludes external surgical access. We report the successful use of a cranial pin placed into the outer table of the calvarium during surgery. This pin eliminates the need for a headset and permits unencumbered external surgical access. We describe a case that used a combined endoscopic and osteoplastic flap approach to the frontal sinus with this cranial pin system. There were no complications associated with placing the pin. The patient reported only minimal postoperative discomfort related to the temporal scalp incision. The cranial pin combines the benefits of surgical navigation with external surgical access to the paranasal sinuses and skull base. (C) 2004 Elsevier Inc. All rights reserved

OBJECTIVES/HYPOTHESIS: Allergic fungal sinusitis and the role of fungi in the pathogenesis of chronic rhinosinusitis are topics of interest and controversy in rhinology. The classification of chronic rhinosinusitis as either a bacterial infection or an allergic (eosinophilic) reaction to fungi has significant implications for treatment of this disease process. We designed a study to determine whether standard isolation techniques, as employed in a university hospital mycology laboratory, could isolate and identify fungi in the intraoperative specimens from patients undergoing functional endoscopic sinus surgery for chronic rhinosinusitis. STUDY DESIGN: Forty-five random patients with a diagnosis of chronic rhinosinusitis by clinical and computed tomography criteria underwent endoscopic sinus surgery during 2001, performed by two senior surgeons (J.B.J., R.A.L.). Specimens of mucin, sinus secretions, and/or tissue were obtained intraoperatively and sent to the New York University Medical Center (New York, NY) mycology laboratory for isolation and identification of fungi. METHODS: Specimens were treated with Sputolysin and chloramphenicol; plated on Sabouraud, ChromAgar/Candida, Mycosel, and Niger seed agar plates; and incubated at 30 degrees C (or 37 degrees C) for up to 1 month. RESULTS: We were able to demonstrate the presence of fungi in 56% of intraoperative specimens obtained from patients undergoing surgery for chronic rhinosinusitis. CONCLUSIONS: Using a standard hospital mycology laboratory protocol, which is relatively inexpensive and readily available, fungus can be isolated from a majority of patients undergoing functional endoscopic sinus surgery for chronic rhinosinusitis. Educational statement: Discuss the possible role of fungus in chronic rhinosinusitis and evaluate the efficacy of documenting the presence of fungus in a routine fashion to encourage clinically relevant directed treatments.)

OBJECTIVES/HYPOTHESIS: To determine the incidence and degree of asymmetry in the height and contour of the ethmoid roof. STUDY DESIGN: Retrospective review of direct coronal paranasal sinus computed tomography (CT) scans. METHODS: Retrospective review of 200 consecutive direct coronal sinus CT scans done at New York University Medical Center from July 25, 2000 to October 11, 2000. The height and contour of the fovea ethmoidalis were examined for symmetry between the right and left sides. When an asymmetry in the height of the fovea ethmoidalis existed, this difference was quantified. RESULTS: In 19 scans (9.5%), there was an asymmetry between the height of the fovea ethmoidalis on the right and left sides. Of these 19, 12 (63.2%) were lower on the right side, whereas 7 (36.8%) were lower on the left. Ninety-six patients (48.0%) demonstrated a contour asymmetry with 'flattening' of the ethmoid roof on one side, 46 on the right and 50 on the left. One patient demonstrated both height and contour asymmetry. The fovea ethmoidalis on the remaining 86 scans (43.0%) was symmetric. CONCLUSIONS: In a patient population with sinus and nasal symptoms, the height and contour of the right and left fovea ethmoidalis were symmetric in less than 50% of individuals. The asymmetry was most often the result of a difference in contour with flattening of the fovea on one side. This underscores the importance of careful preoperative and intraoperative review of paranasal sinus CT scans in patients undergoing endoscopic sinus surgery

Sinusitis has been reported as a complication of sinus lift surgery with antral bone augmentation. The procedure involves the creation of a submucoperiosteal pocket in the floor of the maxillary sinus for placement of a graft consisting of autogenous, allogenic, or alloplastic material. This can result in inadvertent tearing of the mucoperiosteal flap with extrusion of graft material into the antrum. Obstruction of the sinus outflow tract by mucosal edema and particulate graft material may result in sinusitis. We will discuss the clinical presentation and management of 14 cases of chronic sinusitis following sinus lift surgery with alloplastic hydroxyapatite (HA) augmentation of the maxillary antrum

Chronic rhinosinusitis (CRS) is defined as a condition lasting for a period greater than 12 weeks, and manifested by an inflammatory response involving the mucous membranes of the nasal cavity and paranasal sinuses, fluids within these cavities, and/or the underlying bone. The mucosal changes that occur in CRS have been well described, and include edema, decreased number of ciliated cells, and goblet cell hyperplasia. However, the changes that may occur in the underlying ethmoid bone have only recently been investigated. We evaluated decalcified ethmoid bone specimens from 20 patients undergoing endoscopic sinus surgery for CRS. Our analysis revealed histopathologic changes consistent with varying grades of bone remodeling. Polarized light microscopy demonstrated changes in the extracellular matrix, such as bone resorption and neoosteogenesis. Preoperative clinical data and CT staging were recorded on all patients and correlated with the histopathologic findings. These findings suggest that CRS may be associated with osteitis of the underlying ethmoid bone

Diversity of opinion continues to exist among otolaryngologists regarding the potential benefits of preservation or resection of the middle turbinate during endoscopic ethmoidectomy. Rhinologists in favor of middle turbinate preservation cite the potential loss of olfactory function as well as diminished humidification and filtration of inspired air following its resection. In addition, the middle turbinate remnant could lateralize, causing frontal recess obstruction and frontal sinusitis. In general, it is accepted that a diseased or flail middle turbinate should be resected during ethmoidectomy to create a marsupialized surgical bed. However, in the case of a structurally sound middle turbinate, indications for resection vary significantly. We are reporting on 100 primary endoscopic ethmoidectomies for chronic rhinosinusitis followed for at least 2 years. Of these 100 sides, 50 included conservative partial middle turbinectomy and 50 were performed with middle turbinate preservation. The postoperative clinical and endoscopic findings revealed no difference in the incidence of frontal sinusitis or frontal recess stenosis between groups. We compared additional data and present our technique of conservative middle turbinate resection, which preserves a portion of this structure as an important anatomic landmark

The bacteriology of chronic rhinosinusitis is an area of great interest among rhinologists. Numerous studies have reported culture results implicating a variety of aerobic and anaerobic organisms in the etiology of this disease process. Sampling is generally accomplished through the nasal cavity, creating the potential for contamination with resident nasal flora. In some reports, strict anaerobic techniques have not been used, possibly accounting for the failure to recover these fastidious organisms. In an attempt to clarify the microbiology of chronic rhinosinusitis, we used a novel culture and transport system in 50 patients undergoing endoscopic sinus surgery. The Accu-CulShure (MLA Systems, Pleasantville, NY, USA) is a self-contained polyethylene culture swab and transport device, capable of collecting a representative sample from the sinus without contamination, and preserving the quality of the material during transport. Our aerobic and anaerobic culture results, as well as pertinent patient data, are presented. The Accu-CulShure device may permit standardization of culture techniques for future studies, and allow for more accurate determination of the microbiology of chronic rhinosinusitis