Endoscopic Sinus Surgery

The intimate anatomical relationship between the orbit and the paranasal sinuses places the orbit and its contents at risk of harm from primary pathologic processes of the sinuses. In the absence of ophthalmic signs or symptoms, ophthalmologists are not routinely involved in the management of patients with sinus disease. Occasionally, some patients may develop ophthalmic complaints after surgical intervention. The orbit, optic nerve, extraocular muscles, and lacrimal drainage system are susceptible to injury during endoscopic sinus surgery. The risk of injury is related to the skill of the sinus surgeon, history of previous surgery, extent and severity of disease, and anatomic variation. Furthermore, recent advances in endoscopic sinus surgery, in particular the use of powered cutting instruments, has resulted in a novel mechanism of injury to the ocular structures.

Absorbable hemostatic agents are commonly used after endoscopic sinus surgery (ESS). MPH (microporous polysaccharide hemospheres) is a novel hemostatic powder that is rapidly absorbed. The goal of this study was to examine the effects of MPH on bleeding after ESS. Randomized, controlled, single-blinded. Tertiary university hospital. Patients undergoing bilateral (symmetric) ESS for CRS by the same surgeon were randomized to unilateral treatment with MPH at surgical conclusion. The untreated opposite side served as a control. All patients received standard postoperative management. Patients completed symptom diaries using visual analog scales (VAS, scored out of 100) at baseline and through postoperative day (POD) 30. Outcomes including bleeding, pain, obstruction, and nasal discharge were recorded separately for left and right sides. Forty patients (19 men, 21 women) with an average age of 48.3 years were included. There were no complications, and all patients were discharged home the same day. The mean bleeding score on POD one for MPH-treated sides was 22.5 vs 39.0 for untreated controls (mean reduction 16.5, P < 0.0001, 95% CI -23.2 to -9.7). The scores for bleeding at baseline and at all other post-treatment days were not significantly different (P > 0.05). There were no other significant differences between MPH-treated and control sides in any other variables measured. The use of MPH after ESS results in significantly less bleeding in the early postoperative period with no increase in pain, obstruction, or nasal discharge. Patients treated with MPH follow a normal postoperative recovery otherwise.

This study compared the pharmacokinetics of azithromycin (AZI) following administration of extendedrelease (ER) and immediate-release (IR) formulations in plasma and sinus mucosa in patients with chronic rhinosinusitis. Patients (n = 71) were randomised 1:1 to receive a single dose of AZI-ER 2 g or up to three doses of AZI-IR 500 mg daily. Paired plasma and sinus tissue samples were taken during endoscopic sinus surgery at 2-168 h (four patients per time point) after the first dose. Samples were measured by a validated liquid chromatography/mass spectrometry assay. Pharmacokinetics were determined using composite concentration-time profiles. Comparison between formulations showed that within the first 24 h, the AZI area under the plasma concentration-time curve (AUC 24 ) for ER was 5.2-and 7.0-fold higher than IR in plasma and sinus tissue, respectively. Comparison between matrices showed that the AUC 24 and AUC 168 in sinus tissue were 28.2-and 62.2-fold higher than in plasma for the ER formulation, whilst the AUC 24 in sinus tissue was 21.1-fold higher than in plasma for IR formulation. These results indicated that AZI has good penetration into sinus tissue regardless of formulation; however, dosing of AZI-ER (2 g) increased AZI exposure within the first 24 h compared with the Day 1 dose of 500 mg IR regimen.

OVERVIEW ''Few issues in health care spark as much ire and angst as medical malpractice litigation.'' 1 The current malpractice climate in the United States has fueled much debate and emotion on the part of attorneys as well as physicians. Physicians may feel pressure, real or perceived, to order additional testing or take additional steps to document for fear of litigation, adding to the cost of health care delivery.

Endoscopic sinus surgery (ESS) is effective in improving the symptoms of chronic rhinosinusitis and thus in ameliorating the quality of life of patients suffering from this common disease. However, one important drawback to this type of surgery remains the potential for serious complications. This is inevitably because of the proximity of critical anatomic structures such as the orbit, the internal carotid arteries, the skull base, dura, and brain.

The intimate anatomical relationship between the orbit and the paranasal sinuses places the orbit and its contents at risk of harm from primary pathologic processes of the sinuses. In the absence of ophthalmic signs or symptoms, ophthalmologists are not routinely involved in the management of patients with sinus disease. Occasionally, some patients may develop ophthalmic complaints after surgical intervention. The orbit, optic nerve, extraocular muscles, and lacrimal drainage system are susceptible to injury during endoscopic sinus surgery. The risk of injury is related to the skill of the sinus surgeon, history of previous surgery, extent and severity of disease, and anatomic variation. Furthermore, recent advances in endoscopic sinus surgery, in particular the use of powered cutting instruments, has resulted in a novel mechanism of injury to the ocular structures.

Assess paranasal sinus distribution of topical solutions following endoscopic sinus surgery (ESS) using various delivery devices. Experimental prospective study. Ten cadaver sinus systems were irrigated with Gastroview before surgery, after ESS, and after medial maxillectomy. Delivery was via pressurized spray (NasaMist), neti pot (NasaFlo), and squeeze bottle (Sinus Rinse). Scans were performed before and after each delivery with a portable CT machine (Xoran xCAT), and blinded assessments were made for distribution to individual sinuses. Total sinus distribution was greater post-ESS (P < 0.001). Additional distribution was gained with medial maxillectomy (P = 0.02). Influence of delivery device on distribution was significantly higher with neti pot > squeeze bottle > pressurized spray (P < 0.001). Frontal sinus penetration was greatest after surgery (P = 0.001). ESS greatly enhances the delivery of nasal solutions, regardless of delivery device. Pressurized spray soluti...

Purpose: The proximity of the paranasal sinuses to the orbit puts the anterior visual pathways at risk during sinus surgery. Although the ophthalmic complications of sinus surgery are well known to the otolaryngologist, they are rarely encountered in clinical practice. Several recommendations will help the surgeon performing intranasal sinus surgery. Materials and Methods: To study the incidence of orbital complications of intranasal ethmoid surgery, a retrospective review of 372 cases, most of them bilateral, was performed. Results: Our series of 372 patients who underwent endoscopic sinus surgery showed five orbital complications. Conclusion: Several recommendations may help the surgeon to avoide any ophthalmic complication. When orbital wall dehiscence is suspected, either by CT scan or at surgery, especially in a previously operated case, extreme care should be taken not to penetrate the periorbita. If orbital fat protrudes into the operative field, it should not be pulled or twisted in an attempt to remove it. The surgeon should seek the cooperation of the anesthesiologist working the case. A knowledge of the variable anatomy is essential to avoid iatrogenic injury. The surgeon should be aware of the different complications for early recognition and management.

Current research has only reinforced the belief that chronic rhinosinusitis is a multifactorial and idiosyncratic disease process. Most basic science research on the topic focuses on delineating the many proposed contributing factors and attempting to establish therapeutic targets. In patients whose symptoms do not respond to medical therapy, endoscopic sinus surgery may be offered. Several surgical techniques have been proposed, and it would appear that certain techniques are ideal for certain situations. Recent clinical research has focused on the introduction of new technology and new techniques. Additionally, investigators have looked for ways to optimize current techniques and to determine which patient populations may expect to benefit from which types of interventions.

Purpose of Review The advent of endoscopic sinus surgery (ESS) has enabled the development of minimally invasive surgical procedures in Rhinology. However, proficiency with ESS techniques can still be hampered by poorly controlled bleeding limiting visibility of the surgical field (VSF). This can lead to increased operating time and, more importantly, increased risk of major and minor complications. To optimize the VSF and mitigate the risk of complications, many strategies have been explored. Recent Findings This is a narrative review of the relative risks and benefits of pre-and intra-operative interventions aimed at optimizing intraoperative conditions during ESS. The value of these interventions is determined based on their impact on intraoperative blood loss, time of surgery, and the VSF, and weighed against their adverse event profile. Summary This review provides a comprehensive overview of the evidence relating to the safety and efficacy of interventions used to improve intraoperative conditions during ESS.

Chronic rhinosinusitis endoscopic surgery requires an accurate evaluation of diseases and paranasal sinus anatomic variations. This study aims to show the main anatomical variations in the ostiomeatal complex and paranasal sinuses which are usually depicted by computed tomography (CT). CT scans obtained 2 mm thickness in axial and coronal plane from a series of 200 patients with chronic sinusitis were examined to determine the prevalence of anatomic variants. Anatomical variations determined were supraorbital recess in 6%, concha bullosa in 30%, sphenomaxillary plate in 17%, infra-orbital ethmoid cells (Haller's cells) in 6%, spheno-ethmoid cells (Onodi's cells) in 12%, pneumatization of the anterior clinoid process in 6%, carotid artery bulging into the sphenoid sinus in 8%, pneumatization of the uncinate process in 2%, paradoxical curvature of the middle turbinate in 3% and septal deviation in 36%. Level difference between the ethmoid roof and nasal vault was an average of 8 mm in right side and 9.5 mm in left side. Awareness of these different variations will help the rhinologic surgeon in his orientation during endoscopic surgical procedures.

Objectives: Evaluate causes of surgical failure at time of revision endoscopic sinus surgery. Study Design: Prospective review of 682 cases that had endoscopic sinus surgery performed between 1991 and 1995. Methods: In all cases, variables of age, sex, asthma, allergy, computed tomography stage, associated procedures, complications, and operative findings were collected. Those cases that had a failure after a previous endoscopic sinus procedure and not an intranasal procedure or an external procedure were evaluated. Results: Fifty-two patients (7.6%) were identified. The age range was 24 to 70 years. The most common cause of failure was residual air cells and adhesions in the ethmoid area (30.7%), followed by maxillary sinus ostium stenosis in 27%, frontal sinus ostium stenosis in 25%, and a separate maxillary sinus ostium stenosis in 15% of the cases. Conclusion: Review of surgical causes of failure in endoscopic sinus surgery patients revealed that residual air cells and stenotic maxillary or frontal sinus ostium were the most common causes of failures.

A pneumatized superior turbinate is a rare cause of headache. Nasal endoscopy alone, does not provide us with adequate information for this inaccessible area of the superior nasal cavity. A coronal computed tomography (CT) must be obtained to confirm the diagnosis. We present a 40-year-old female with migraine-type headache and nasal obstruction. Nasal endoscopy revealed a mild septal deviation, a right middle concha bullosa and a paradoxically curved middle turbinate on the left side. Coronal CT-scan showed also the presence of a superior concha bullosa on the left, which was in close contact with the nasal septum. The patient underwent septoplasty and bilateral endoscopic sinus surgery, including partial removal of both the pneumatized middle turbinates in conjunction with gentle lateralization and resection of the lower half of the left superior turbinate. Prompt relief from headache and nasal symptoms was obtained. Pneumatized superior concha causing migrainous headache is a rar...

Endoscopic surgery of the posterior ethmoid and sphenoid sinuses can present the operator with a considerable challenge. Although endoscopic training and physician experience have increased significantly in the past decade, surgical complications such as optic nerve trauma and cerebrospinal fluid leak still occur. Surgeons reporting such complications cite a lack of orientation within the dissection field as a primary cause. Because endoscopic sinus surgery is now being performed more routinely, surgical strategies designed to reduce the risk of complications are more important than ever. An anatomic landmark that could reliably orient the dissection within the posterior ethmoids and guide the surgeon to the sphenoid sinus could reduce the possibility of such adverse outcomes. In our experience identification of the superior meatus and superior turbinate provides a reliable landmark within the dissection field that can ensure surgical orientation to the operator. This technique allows safe, reliable dissection of the posterior ethmoids and an efficient approach to the sphenoid sinus, especially in patients undergoing revision surgery. In this article our technique for the identification and definition of the superior meatus and superior turbinate is presented, and the advantages of using this landmark in sinus surgery are discussed. In our experience identification of the superior meatus, superior turbinate, posterior skull base, and medial orbital wall defines a parallelogram-shaped box, which delineates the sphenoid face. This box provides the necessary orientation to guide the surgeon's entrance into the sphenoid sinus through the posterior ethmoid sinus (as Messerklinger described). Techniques for identifying the superior turbinate and meatus and for entering the sphenoid are detailed.

Nasal polyposis are common presentations in patients of chronic rhinosinusitis and are considered to be associated with more severe forms of disease with poor treatment outcome. The presentation and treatment outcome after endoscopic sinus surgery in patients of chronic rhinosinusitis and nasal polyposis have been analysed in this study. A prospective analysis of 90 patients of chronic rhinosinusitis who were classified into two groups depending on presence and absence of nasal polyps was performed in the study. The two groups were evaluated using subjective (patient complaints) and objective (computed tomography scan and endoscopy scores) criteria. Preoperative data were compared with data obtained 12 months post endoscopic sinus surgery. The study included 38 patients of chronic rhinosinusitis and 52 patients of nasal polyps. The patients of nasal polyp group presented with increased severity of symptoms of nasal blockage, nasal discharge and reduced sense of smell as compared to the chronic rhinosinusitis group who had significantly higher presentation of headache and facial pain. The preoperative CT scan revealed significantly higher bilateral disease with increased involvement of multiple sinuses in nasal polyp group. Post endoscopic sinus surgery both the groups showed significant improvement in their symptoms with the nasal polyp group demonstrating reduction in improvement on 1 year follow up. In our study we have found the patients with chronic rhinosinusitis and nasal polyp have varied severity of symptoms with the nasal polyp group having higher nasal symptoms and increased severity as compared to chronic rhinosinusitis group. Though the universal rationale of management by adequate drainage and ventilation of sinus is similar in both groups, there is a reduction in both objective and subjective scores during 1 year follow up in the nasal polyp group.

TECHNICAL FIELD - This application relates to the field of coatings that prevent fogging on solid surfaces without altering the characteristics of the covered surface. The coatings may be used on devices and equipment for sports and recreation, the medical field, military and industrial safety
applications. Such devices and equipment include windows and mirrors of automobiles, motorcycles, boats, airplanes, and trains. In industrial and instrumentation application: protective windows, domes, and lenses of gauges, dials, meters. In medical applications: intraocular lenses, endoscopic/laparoscopic lenses, protective eyewear, contact lenses for visual correction, medical implants, surfaces, and medical and surgical tools.
BACKGROUND
The problem of condensation with fogging: Hydrophobic versus hydrophilic surfaces. Protective eyewear, glasses, sunglasses, swimming goggles, diving goggles, helmet visors, windshields, intraocular lenses, medical scopes, and high-precision instrumentation are just several applications where visual distortion due to fogging with condensation poses a problem.
Control of fogging due to condensation on polymer and glass surfaces has seen development, testing and patenting of solutions for a broad spectrum of optical, vision, visor, goggle and lens materials, including optical glasses, borosilicate glass, polycarbonates, tinted thin film coatings, and other polymers for athletic visor and vision-wear. These can require optimization of the robustness and resiliency to create permanent anti-fog coatings, and optimization of adhesion on polycarbonates and surfaces with difficult geometries such as very high curvature. Therefore, anti-fog technologies and their applications have to be conceived and optimized by
adapting to a broad range of specifications for use, use duration, etc., and require working directly with a variety of end users to create such adaptability. End users for anti-fog technology include, but were not limited to: surgeons, professional athletes, recreational users, professional safety users, fire-workers, emergency personnel, biohazard handlers, medical and surgical personnel, and instrumentation dials and domes manufacturers.
Control of fogging should be tested using the specific conditions of condensation experienced by each group end users, such as body or outdoor temperatures, and water vapor pressures and various fluids present during use, such as bodily fluids, sweat, blood, skin oils and human tears or fluids produced from machinery. U.S. patent application Ser. No. No. 13/674,307 (hereinafter '307 application) describes an emulsion that physically changes the surface topography so that condensation behavior can be controlled. The result in the '307 application is a hydrophilic surface that manipulates water droplets so that the water droplets form a thin translucent film on the hydrophilic surface. The'307 application describes a  wet anti-fog technology, where the emulsion is applied when the
surface requires an antifogging coating and should not be dried on the surface. When the emulsion of the '307 application is dried, the polymers come out of the solution and precipitate so that the coated surface is no longer optically transparent and fails to maintain optical quality.
Specifically, the emulsion described in the '307 application is optimized for temporary application and for ease of application. The emulsion described in the '307 application was designed for medical applications, including but not limited to vitro-retinal surgery as well as endoscopic and laparoscopic procedures and surgeries. Thus the emulsion described in the '307
application does not permanently coat the surfaces with anti-fog technology. Accordingly, there is need for a dry permanent anti-fog technology that manipulates water so the water droplets form a thin translucent film on a surface rather than produce fogging on the surface while maintaining optical quality. First, the invention consists of permanent anti-fog coatings, including but not limited to their materials components, composition, adaptive formulation and several methods of fabrication.
The permanent anti-fog is referred to as “FogKnox™”. It includes but is not limited to very high quality optical transmission films that are distortion-free, and exhibit a very high degree of transparency. FogKnox™ includes but is not limited to dry, permanent and very highly uniform optical anti-fog coatings, which can be delivered in wet (fluid) or solid from. Both wet and solid form preserve and improve instantaneously visualization on edges of lenses, dials and surfaces and wide-angle lens. Only after drying is the anti-fog a permanent, non-removable solid film. In a separate embodiment, the anti-fog coatings can be made removable for applications where
lenses and devices on which they are applied need to be resurfaced, called KnoxFog™. The antifoam coatings can also be made semi-permanent, so it can be scrubbed, thus removable by scrubbing, detergent washing and/or sonication, for medical applications, and are then called
VitreOx™. Second, the invention includes, for all above mentioned anti-fog coatings, their method of application in large scale, medium scale or small scale manufacturing, via several possible coating processes, adaptive compositions, adjustments of physical properties and surface
preparation procedures, which are disclosed as the second part of the invention. Third, all the above coatings can also be applied on existing, already manufactured optical devices, tools, dials, goggles, vials, bottles and scopes, via the third element of the invention, specific delivery device and its cartridge of anti-fog coatings materials. The delivery device
includes a coating delivery and element to allow for quick drying element attachment to the metered delivery automated mechanism to apply the coating in a few seconds, and let it dry within minutes.

One of the most common nasal pathologies to present to an otolaryngologist is polyposis. Two well-recognized forms occur, the common antrochoanal polyp and the rare sphenochoanal polyp. Differentiation between the two is necessary for proper management by endoscopic sinus surgery.

Brodawczak odwrócony (papilloma inversum) jest rzadkim, ∏agodnym guzem pochodzenia na-b∏onkowego, który wykazuje miejscowo agresywny wzrost. Stanowi 0,5-4,0% wszystkich pierwotnych guzów nosa. Guz ten po raz pierwszy opisa∏ Ward w roku 1854, a rok póêniej Billroth [1]. Kramer i Som wykazali odmiennoÊci patologii brodawczaka odwróconego w porównaniu z polipami o charakterze zapalnym, natomiast Ringertz odkry∏ sk∏onnoÊç guza do odwróconego wrastania w pod-∏o˝e [2]. Brodawczak odwrócony wyrasta z pozosta-∏oÊci wyst´pujàcej w okresie embrionalnym b∏ony Schneidera, która oddziela b∏on´ Êluzowà nosa od b∏ony zatok przynosowych. Obraz histologiczny wykazuje proliferacj´ oraz endofityczne wrastanie pokrywajàcego zmian´ pogrubia∏ego nab∏onka p∏askiego typu nowotworowego w g∏àb podÊcieliska, w postaci palczastych wypustek, nie przechodzàc jednak poprzez b∏on´ podstawnà. B∏ona podstawna jest prawid∏owej gruboÊci, nie ma cech hialinizacji, wyraênie odró˝nia si´ od tkanki ∏àcznej pod∏o˝a. W nacieku zapalnym brak eozynofilów i obrz´ku podÊcieliska [3, 4].

Endoscopic sinus surgery (ESS) is a method used with success in the treatment of chronic inflammatory paranasal sinus diseases. Between February 1991 and June 1995 the Messerklinger technique for ESS was used in 415 patients who had been pre-operatively evaluated in detail according to the staging system used in our clinic. Average post-operative follow-up was 23 months. Our general success rate was found to be 86.3% upon evaluating the subjective improvements in the patients’ symptoms in the post-operative period. The major and minor complication rates in our series were 0.24 and 20.24%, respectively.

Twenty-seven men and 54 women (19-91 years old; mean 49.4 years) were considered. Seventy-three patients had a single sinus affected, but eight presented multiple localisations. Maxillary was the most involved sinus followed by sphenoidal and ethmoidal. Moulds have been isolated in 28/81 cases. Histology showed fungal colonisation but not invasion in all cases. Tomography showed bone erosion in 33.3% of patients. All have been treated only by functional endoscopic sinus surgery. Seventyseven of 81 patients have been cured. Four of 81 patients needed another surgical treatment. Follow up was between 6 and 132 months (average: 63 months). Fungus ball is a sinusal pathology caused by mycetes like Aspergillus spp. Histology confirms the fungal aethiology excluding tissue invasion. Mycological culture consented to identify the pathogenic mould in 34.5% of cases. Actually functional endoscopic sinus surgery is the gold standard for treatment of this pathology, and antifungal therapy is unnecessary.

The invention consists of three parts made to work together to ensure safe, fast and effective deployment to the end users, which include but are not limited to surgeons and doctors in emergency and operating rooms, occupational hazards equipment goggles, visors and shields, defensive protective armors and high impact vision wear, high performance athletic equipment, and avionics surfaces. The three parts are the anti-fog coating materials composition, their methods of preparation and processing in large, medium or small scale manufacturing, and a single unit delivery device with the coating materials to apply on any existing surface, lens, scope, tools or dials, as a wet or quickly drying coating.

T he development of endoscopic techniques for a variety of sinonasal disorders has paralleled advances in technology and instrumentation including angled endoscopes, multi-chip cameras, and image guidance. Despite the progressive technological innovations in modern endoscopic surgery, the visualization that is currently used remains 2-dimensional (2D). This is associated with significant limitations, notably a lack of depth perception. Although visual and haptic cues allow for a surgeon to understand the spatial relationships of the various structures, current visualization technology fails to provide the 3-dimensional (3D) perspective that is available in open and microscopic surgery. The development of a miniature stereoscopic camera and its adaptation to rigid endoscopes allows for performance of 3D endoscopic sinus surgery. It is hypothesized that incorporation of 3D visualization may enhance the spatial resolution required in advanced endoscopic approaches with a theoretical potential to improve outcomes.

Deep neck abscesses are life-threatening conditions, in early stages preferably treated by intravenous antibiotic therapy; in advanced stages, surgical drainage is mandatory. We report two cases of retro-parapharyngeal abscess with prevalent retronasopharyngeal extension in two men aged 60 and 82, both of whom underwent transnasal endoscopic drainage. The main surgical steps were incision of the posterior pharyngeal mucosal wall, widening of the incision, drainage of purulent collection and careful dissection and removal of the necrotic tissue. The first patient, with an abscess associated with chronic otitis media and presenting hypoglossal nerve palsy, quickly recovered from pharyngodinia, otalgia and trismus. Twenty-six months after surgery, he is symptom-free, with hemitongue atrophy due to denervation as the only residual sign. The second patient, affected by skull base osteomyelitis secondary to malignant external otitis, after a first successful drainage, underwent a second endoscopic procedure for the reoccurrence of an abscess in the contralateral retroparapharyngeal space. Twelve months after the first surgery, the patient reported an improvement of symptoms, except for persistent dysphonia related to vagal nerve palsy. At follow-up MR, another abscess was detected in the left retro-parapharyngeal space. In selected cases of abscess, transnasal endoscopic drainage may be an effective alternative to external approaches. Minimal morbidity, the absence of cervical or palatal scars and a short hospitalization time can be considered as important advantages in comparison to external approaches. Patients with abscess secondary to skull base osteomyelitis require close imaging surveillance because of the difficulty of definitive control of the disease.

BACKGROUND AND PURPOSE: Defects at the skull base leading to spontaneous CSF rhinorrhea are rare lesions. The purpose of our study was to correlate CT and MR findings regarding the location and content of CSF leaks in 27 patients with endoscopic sinus surgery observations.

To determine the necessity of nasal packing or hemostatic agents or both following endoscopic sinus surgery. Retrospective review of cases in a tertiary care sinus practice at an academic medical center. Records of 165 patients undergoing 169 endoscopic sinus surgeries were reviewed to determine the presence of adjunctive nasal procedures, the use of nasal packing or hemostatic agents or both, blood loss during surgery, and the incidence of bleeding complications following surgery. The median estimated blood loss during surgery was 50.0 mL (range, 5-1000 mL). In four surgeries (2.4%) hemostatic agents were placed in the nose at the conclusion of surgery, 19 (11.2%) had packing, and 147 (87.0%) had no material left in the nose. No patients had bleeding complications postoperatively. There was a significant decrease in the use of packing or hemostatic agents or both over time. Placement of nasal packing or other hemostatic agents or both within the nasal cavity is not necessary in the majority of endoscopic sinus surgeries. The risks, costs, and discomforts associated with these interventions can often be avoided.

To develop a standardized in vitro model for evaluating efficacy of the microdebriders and to assess whether differences in efficacy exist among available microdebriders. Microdebriders combine suction of tissue with amputation by a hollow rotating cutter. Several models are available, and they are increasingly popular in endoscopic sinus surgery. Seven microdebriders were tested by using a standardized soft tissue model (standard fresh raw oysters excluding muscle) and a firm tissue model (standard fresh raw oyster muscle). Efficacy was measured in grams of tissue aspirated per minute. Models to simulate lamina papyracea (eggshell) and dura (egg sac) were also tested with each microdebrider. Statistically significant differences in soft tissue aspiration were found between most microdebriders ranging from the Xomed (Jacksonville, FL) Straight Shot/4.0-mm blade (147 g/min); the ESSential Shaver (Smith & Nephew, Memphis, TN)/4.0-mm blade (99 g/min), the Linvatec (Largo, FL)/4.2-mm blade and Dyonics (Burscheid, Germany)/3.5-mm blade and Wizard Plus/4.0-mm blade (range 43 to 46 g/min), followed by the Hummer II (Stryker, Santa Clara, CA) 4.0-mm blade (22.5 g/min), and finally the Xomed Wizard Plus/3.5-mm blade at 16 g/min. The Xomed Straight Shot/4.0 blade was statistically superior to all other microdebriders in efficiency of aspiration in the firm tissue model. All microdebriders were able to abrade a "bony" spicule and intact "dura," whereas none could abrade intact "bone." Significant differences exist among the various microdebriders in this standardized model of efficiency of aspiration. Additional clinical factors including cost, safety, ease of use, and adaptability should also be considered in the choice of a microdebrider.

Nasal packings can aid in control of postoperative bleeding and healing following functional endoscopic sinus surgery (FESS), but traditional non-resorbable stents have several inherent drawbacks. We performed a randomized, controlled, multicenter clinical trial to assess eYcacy of resorbable nasal packing in patients undergoing FESS for chronic rhinosinusitis. A total of 66 patients for 88 nasal cavities were randomized to receive either hyaluronan resorbable packing (MeroGel ® ) or standard non-resorbable nasal dressing after FESS. All underwent preoperative rhinoscopy, CT of sinuses, and, after surgery, were reassessed by rhinoscopy at 2, 4, and 12 weeks in blinded fashion. A total of 44 nasal cavities (MeroGel ® -group) received resorbable packing, whereas the remaining 44 were packed with non-resorbable nasal dressing. At follow-up endoscopic visit, the presence of nasal synechia was evaluated as primary outcome. Moreover, the tolerability and surgical handling properties of MeroGel ® and its comfort were assessed by surgeons and patients. Preoperative severity of rhinosinusitis was similar in both groups. No signiWcant adverse events were observed in all patients. Follow-up endoscopy showed a lower proportion of nasal adhesions in MeroGel ® -group at both 4 (P = 0.041) and 12 weeks (P < 0.001). Moreover, an improvement of other endoscopic nasal Wndings such as re-epithelialization, presence of granulation tissue, and appearance of nasal mucosa of nasal cavities after FESS was observed in the MeroGel ®group. Tolerability and surgical handling properties of MeroGel ® were positively rated by clinicians and the overall patient judged comfort of MeroGel ® was favorable. In conclusion, MeroGel ® can be considered a valid alternative to standard non-resorbable nasal dressings. It is safe, wellaccepted, well-tolerated, and has signiWcant advantage of being resorbable. Moreover, it may favor improved healing in patients undergoing FESS and reduce formation of adhesions.

Middle turbinate squeeze syndrome (MTSS) refers to sino-nasal headache due to intense contact between the middle turbinate and the nasal septum and/or between middle turbinate and other structures in the lateral nasal wall. This study was intended to evaluate the efficacy of precise endoscopic surgical treatment of MTSS. This is a prospective study of 126 patients with refractory cephalgia due to endoscopically confirmed MTSS who underwent functional endoscopic naso-sinus surgery (FENS) wherein the contact points and ostio-meatal complex obstruction were endoscopically relieved. 91% of cases reported improvement/ resolution of headache and 95% of cases had relieved contact points as documented endoscopically. This surgery was also found to facilitate resolution of sinus disease, both radiologically (in 64% of cases) and endoscopically (in 94% of cases). Cephalgia caused by MTSS can be effectively treated by an ultra-conservative endoscopic approach.

Rhinitis and sinusitis are among the most common medical conditions and are frequently associated. In Western societies an estimated 10% to 25% of the population have allergic rhinitis, with 30 to 60 million persons being affected annually in the United States. It is estimated that sinusitis affects 31 million patients annually in the United States. Both rhinitis and sinusitis can significantly decrease quality of life, aggravate comorbid conditions, and require significant direct medical expenditures. Both conditions also create even greater indirect costs to society by causing lost work and school days and reduced workplace productivity and school learning. Management of allergic rhinitis involves avoidance, many pharmacologic options, and, in appropriately selected patients, allergen immunotherapy. Various types of nonallergic rhinitis are treated with avoidance measures and a more limited repertoire of medications. For purposes of this review, sinusitis and rhinosinusitis are synonymous terms. An acute upper respiratory illness of less than approximately 7 days' duration is most commonly caused by viral illness (viral rhinosinusitis), whereas acute bacterial sinusitis becomes more likely beyond 7 to 10 days. Although the mainstay of management of acute bacterial sinusitis is antibiotics, treatment of chronic sinusitis is less straightforward because only some chronic sinusitis cases have an infectious basis. Chronic rhinosinusitis (CRS) has been subdivided into 3 types, namely CRS without nasal polyps, CRS with nasal polyps, and allergic fungal rhinosinusitis. Depending on the type of CRS present, a variety of medical and surgical approaches might be required.

Objective/Hypothesis: The role of endoscopic sinus surgery for treating chronic maxillary sinusitis is well established. The purpose of the study is to determine the efficacy of endoscopic sinus surgery in the treatment of maxillary sinus inflammatory disease that includes mucoceles, retention cysts, and antrochoanal polyps. Study Design: This is a retrospective review of 32 consecutive patients who underwent endoscopic sinus surgery for mucoceles (n ‫؍‬ 21), retention cysts (n ‫؍‬ 5), or antrochoanal polyps (n ‫؍‬ 6). Methods: The medical records were reviewed for patient demographics, presenting symptoms, and type of operation. Surgical outcome was determined by resolution of symptoms, recurrence of disease, and need for revision or additional surgery. Results: Ethmoidectomy with middle meatal antrostomy was performed in all patients; 28 patients had additional middle turbinectomy. Postoperative follow-up ranged from 6 months to 4 years. The operation resulted in resolution of symptoms and a patent antrostomy on long-term follow-up in all cases of mucoceles. No case required revision surgery. On the other hand, the disease recurred in three patients (60%) with retention cysts and three patients (50%) with antrochoanal polyps despite patent antrostomies. The recurrences occurred 3 to 6 months after the surgery. The recurrent cases of antrochoanal polyps required Caldwell Luc procedures. The three failures in cases of retention cysts were successfully managed with repeated office endoscopic marsupialization through a patent antrostomy. Conclusions: Endoscopic sinus surgery is an effective treatment for mucoceles, with favorable long-term outcome. Maxillary retention cysts commonly recur after endoscopic sinus surgery. However, the recurrence can be managed in the office through a patent antrostomy. Endoscopic sinus sur-gery may be offered as initial surgical treatment for antrochoanal polyps, but a Caldwell Luc operation may be needed for recurrent disease.

Controversy surrounds the appropriate surgical approach and the appropriate medical therapy for Allergic Fungal Sinusitis. The present prospective study aims to assess the impact of these factors on the treatment outcome of Allergic Fungal Sinusitis. In the present study 34 cases with AFS were randomized into one of 3 methods of post operative therapy i.e. systemic itraconazole (group A, n=11), topical steroids (group B, n=12) and nasal alkaline douches only (group C, n=11). Outcome was assessed at 6 months postoperative by the Kupferberg grading system for assessment of nasal and sinus mucosa. Grade '3' mucosal disease was defined as recurrence.

Inverted papilloma (IP) of the nasal cavity and paranasal sinuses is an uncommon pathology, especially in the pediatric population. We present a pediatric case of recurrent IP in the left nasal cavity. The physical examination of a 9-year-old girl revealed a polypoid mass filling the middle meatus in the left nasal cavity. Purulent secretion and adenoid vegetation obstructing the choanea were also noted. Coronal and axial maxillo-facial computed tomography demonstrated a mass in the nasal cavity, enlarging the left middle meatus. We discussed the imaging findings and treatment of IP and concluded that it should have been included in the differential diagnosis of nasal mass lesions in the pediatric population.

The effect of intravenous tranexamic acid on blood loss and surgical field quality during endoscopic sinus surgery: a placebo-controlled clinical trial ☆,☆☆ Abstract Study Objectives: To evaluate the effects of intravenous (IV) tranexamic acid on blood loss and surgical field quality during functional endoscopic sinus surgery (FESS). Design: Randomized, double-blinded, controlled trial. Setting: Operating room and postoperative recovery area of a university-affiliated hospital. Patients: 84 consecutive, adult, ASA physical status 1 and 2 patients undergoing FESS. Interventions: Patients were randomized to receive either IV tranexamic acid 10 mg/kg (TA group) or sterile water 0.1 mL/kg (placebo group) as a bolus dose immediately after induction of anesthesia. Measurements: Amount of blood loss and bleeding and satisfaction scores were obtained from the surgeon. Main Results: Blood loss in the TA group was 184 ± 64 mL and in the placebo group, 312 ± 75 mL on average (P b 0.01). The median (range) bleeding score in the TA group was significantly lower than the placebo group [2 (1-3) vs 2.5 (2-4); P b 0.0001]. The surgeon was more satisfied with the surgical field in the TA group than the placebo group [median score: 4 (3-5) vs 3 (1-5), P b 0.001]. Conclusion: Intravenous tranexamic acid effectively reduces bleeding and improves the surgical field during FESS.

Controversy surrounds the appropriate surgical approach and the appropriate medical therapy for Allergic Fungal Sinusitis. The present prospective study aims to assess the impact of these factors on the treatment outcome of Allergic Fungal Sinusitis. In the present study 34 cases with AFS were randomized into one of 3 methods of post operative therapy i.e. systemic itraconazole (group A, n=11), topical steroids (group B, n=12) and nasal alkaline douches only (group C, n=11). Outcome was assessed at 6 months postoperative by the Kupferberg grading system for assessment of nasal and sinus mucosa. Grade '3' mucosal disease was defined as recurrence.

Establish the feasibility of a predictive validity study in sinus surgery simulation training and demonstrate the effectiveness of the Endoscopic Sinus Surgery Simulator (ES3) as a training device. Prospective, multi-institutional controlled trial. Four tertiary academic centers with accredited otolaryngology-head and neck surgery residency programs. Twelve ES3-trained novice residents were compared with 13 control novice residents. Subjects were assessed on the performance of basic sinus surgery tasks. Their first in vivo procedure was video recorded and submitted to a blinded panel of independent experts after the panel established a minimum inter-rater reliability of 80 percent. The recordings were reviewed by using a standardized computer-assisted method and customized metrics. Results were analyzed with the Mann-Whitney U test. Internal rater consistency was verified with Pearson moment correlation. Completion time was significantly shorter in the experimental group (injection ...

Purpose: The objective of this study is to evaluate the effect of the hemostatic agent, FloSeal (FS), on bleeding and healing after functional endoscopic sinus surgery. Methods: We performed randomized, double-blinded, controlled study at a tertiary care center. Patient nasal sides were randomized to FS or control. After completion of sinus surgery, FS was placed in the appropriate nasal cavities followed by saline-soaked neuropatties in both nasal cavities. Control sides received saline-soaked neuropatties alone, without FS. Results: Forty-five patients were enrolled. Mean time to cessation of bleeding in recovery was 16.4 and 30.8 minutes for the FS-and control-treated sides, respectively ( P = .028). Patients maintained diaries for 7 days postoperatively and reported similar durations of bleeding at home, but indicated less discomfort on the FS-treated side. Postoperative endoscopic examinations revealed significantly less crusting in FS-treated nasal cavities at 1 week, but significant difference at 1 and 3 months. There were no differences in postoperative scarring or middle turbinate lateralization. Conclusions: Use of FS after functional endoscopic sinus surgery resulted in less bleeding, immediately postoperatively, and less discomfort, and did not increase the incidence of crusting or scarring compared with control. D

Acute lymphoblastic leukemia (ALL) is a hemopoietic malignancy of the bone marrow that rarely invades the sinonasal area. If infiltration of paranasal sinuses occurs, it may lead to rhinosinusitis and orbital complications that need aggressive treatment. In this report, a 26-year-old male patient who had a history of ALL and had one relapse, suffered from rapid progression of right periorbital pain and exophthalmos, which usually presented in patients with orbital complications of sinusitis. A sinus computed tomography showed right maxillary and ethmoid sinus opacification with orbital bone destruction. Urgent endoscopic sinus surgery (ESS) was performed for orbital decompression and histopathologic diagnosis. Pathology revealed lymphoblast infiltration and inflammation of respiratory mucosa. Subsequent bone marrow aspiration cytology confirmed the diagnosis of a second relapse of ALL. Obstructive causes of sinusitis should be evaluated in patients with ALL. ESS has proven to be effective in obtaining tissue for histopathologic diagnosis, and in treating patients with sinusitis with orbital complications. (Chang Gung Med J 2004;27:924-9)

In this study, we have pointed out the effectiveness of the endoscopic approach for the treatment of three children affected by mucoceles. Two patients complained of visual disturbances while one complained of persistent bitemporal headache. None of these cases was affected by cystic fibrosis. The endoscopic treatment consisted mainly of drainage and marsupialization of the mucocele. These young patients were free of any recurrence and symptoms at 36, 30, and 16 months of follow-up, respectively.