Sinusotomy

Abstract: Objectives/Hypothesis: Herein we present our experience in the management of fungus ball (FB) of the paranasal sinuses. Preoperative imaging strategy and findings, surgical technique, and pathologic and microbiologic results are discussed. Study Design: Retrospective chart review of patients with FB of the paranasal sinuses who underwent endoscopic surgery at the Department of Otorhinolaryngology of the University of Brescia, Italy. Methods: From January 1990 to December 2006, 160 patients with sinonasal fungus ball were treated with a purely endoscopic approach. All patients underwent preoperative computed tomography (CT) and/or magnetic resonance (MR) imaging; an endo-oral dental x-ray or orthopantomography and odontological evaluation were also performed in patients with maxillary sinus localization. All removed material was sent for pathologic and microbiologic evaluation. All patients were prospectively followed with endoscopic control every 2 months during the first postoperative year and subsequently every 6 months. Results: The patient cohort included 118 females and 42 males, with an age from 19 to 85 years (mean, 52.7 years). FB was located in the maxillary sinus in 135 (84.4%) patients; in two cases both sinuses were affected. Sphenoid and ethmoid involvement was observed in 23 (14.4%) and 1 (0.6%) patients, respectively. Simultaneous ethmoid and sphenoid involvement was found in one (0.6%) case. In all patients complete removal of fungal debris was obtained through wide sinusotomy. No recurrence was observed. Conclusions: Endoscopic surgery is a safe and effective treatment for paranasal sinuses FB. A proper imaging study by MR and/or CT can address diagnosis, which is based upon detection of fungal hyphae at histology. Laryngoscope, 2009

Abstract: IT is evident that ocular hypertension in glaucoma is usually due to an increased resistance to the outflow of the intra-ocular fluid. In about two-thirds of all patients there is no visible obstacle to the outflow in the anterior chamber angle (so-called wide-angle glaucoma); these pathological changes in the intramural pathways, starting from the trabecular meshwork, are usually held responsible for the circulatory disturbance. Some authors consider the trabecular zone as the site actually affected (Teng, Katzin, and Chi, 1957; Speakman, 1961). Grant (1958) pointed out that this area-accounted for about 75 per cent. of the normal resistance to outflow, but this is not necessarily the site of the pathological process. There are sound arguments in favour of the theory that the outflow is affected in the region of the intrascleral collectors between Schlemm's canal and the anterior ciliary veins (Duke-Elder, 1955; Dvorak-Theobald and Kirk, 1956). Each theory is probably valid in certain cases. The results of histochemical studies carried out in our clinic on fifty scleral specimens obtained during glaucoma surgery confirm the existence of pathological changes in early wide-angle glaucoma. This particularly applies to abnormal mucopolysaccharide distribution. Similar data have already appeared in the literature (Unger, 1963; Larina, 1966). It should be noted, however, that different layers of the sclera are not equally affected. Whatever its nature, the process usually spreads within the sclera \"sandwich-wise\", affecting some strata and leaving others apparently undamaged, full-thickness involvement being exceptional. The middle layers are most commonly affected, the deep ones less frequently, and the superficial areas very rarely. This supports the hypothesis that the outflow is sometimes obstructed in the trabecular meshwork, and sometimes (more often) in the intrascleral collectors; in other words the obstruction may be either distal or proximal to Schlemm's canal. One may thus speak of an \"intrascleral\" and a \"trabecular\" form of glaucoma. These considerations seem to justify a new approach to the surgery of glaucoma, confining the intervention to a very limited region where the outflow is obstructed. Glaucoma may thus be classed into four main types: angular (iris-block), trabecular, intrascleral, and hypersecretional. The methods of surgical management applicable to this pathogenicallyoriented system have been described elsewhere (Krasnov, 1965), and this paper deals with only one of the operations which is in practice the most important.

Abstract: Background Although opioids are widely used as analgesics in general anaesthesia, they have unpleasant side-effects and can delay postoperative recovery Acupuncture and related techniques are effective for acute and chronic pain, and reduces some side-effects We assessed the effect of transcutaneous electric acupoint stimulation (TEAS) on intra-operative remifentanil consumption and the incidences of anaesthesia-related side-effects Methods Sixty patients undergoing sinusotomy were randomly assigned to TEAS or control group TEAS consisted of 30 min of stimulation (6–9 mA, 2/10 Hz) on the Hegu (LI4), Neiguan (PC6), and Zusanli (ST36) before anaesthesia The patients in the control group had the electrodes applied, but received no stimulation Bispectral index was used to monitor the depth of anaesthesia Perioperative haemodynamics were recorded, and peripheral blood samples were collected to measure the levels of mediators of surgical stress The primary end point was intraoperative remifentanil consumption and the secondary endpoints were recovery quality and anaesthesia-related side-effects Results Patients in the TEAS group required 39% less remifentanil during surgery than controls [00907 ( sd 0026) μg kg−1 min−1 vs 0051 (0018) μg kg−1 min−1] There were no differences in intra-operative haemodynamics or surgical stress between groups However, the time to extubation and recall in the control group was 168 (68) min and 230 (50) min, respectively, significantly longer than that in the TEAS group (P Conclusion The use of TEAS significantly reduced intra-operative remifentanil consumption and alleviated postoperative side-effects in patients undergoing sinusotomy Clinical trial registration The trial was registered at clinicaltrialsgov (NCT01700855)

Abstract: Objective Whether instillation into the maxillary sinus of topical budesonide affected the immune response and improved allergic patients with chronic rhinosinusitis that had persistence of symptoms despite appropriate surgical intervention was assessed. Study Design Double-blind placebo-controlled. Methods Twenty-six patients with allergy to house dust mites who had previously had surgery and who had persistent symptoms of disabling rhinorrhea or pressure-pain resistant to oral antibiotics and intranasal corticosteroids were recruited. During the double-blind study, patients instilled 256 μg budesonide daily or placebo through an intubation device (maxillary antrum sinusotomy tube) into one of the maxillary sinuses for 3 weeks before clinical assessment and a second biopsy. Results We found an improvement in the symptom scores in 11 of the 13 patients who received budesonide; we also found a decrease in CD-3 (P = .02) and eosinophils (P = .002), and a decrease in the density of cells expressing interleukin-4 (P = .0001) and interleukin-5 messenger RNA (P = .006) after treatment. Conclusion Topical budesonide delivered through a maxillary antrum sinusotomy tube can control chronic rhinosinusitis that persists after surgery.