Classification of frontal fossa fractures associated with cerebrospinal fluid rhinorrhea, pneumocephalus or meningitis. Indications and time for surgical treatment

The classification of anterior fossa fractures with their sequelae: cerebrospinal fluid (CSF) rhinorrhea, pneumocephalus, or meningitis is presented. This classification is based on five selection criteria which are discussed in this paper. This classification resulted in the table of indications for operative treatment, according to which the appropriate time for operation in urgent cases is immediately, in cases with absolute indication 5 to 6 days after the injury, in long-lasting CSF rhinorrhea or pneumocephalus 10 days after the onset, in intermittent or delayed rhinorrhea and/or pneumocephalus as soon as these signs occur, and in cases of meningitis soon after recovery. This study is based on the analysis of 52 consecutive surgically treated cases, collected from 1984 up to December 1989.     

Chronic mycoses of the paranasal sinuses--value of endonasal paranasal sinus surgery

BACKGROUND: Many host factors even in immunocompetent patients may have an influence on development of a fungal diseases within the paranasal sinuses. Fungal sinusitis can occur in an acute form or more often to a chronic type of the disease. These mainly relatively asymptomatic chronic forms and further divided into a chronic noninvasive, chronic allergic, and chronic invasive disease. Endonasal microsurgery has significantly changed the management of chronic fungal sinusitis and allows adequate removal of pathologic tissue even in advanced situations. The aim of this study was to analyze the efficacy of endonasal surgery in chronic fungal sinusitis. MATERIAL AND METHODS: In a retrospective study we assessed a group of 40 patients who had endonasal surgery for chronic fungal sinusitis. Patient records, CT and MRI scans, microbiology and histology as well as the postoperative clinical follow-up including endoscopic photo documentation were evaluated over a period of 5 years. All patients underwent endonasal surgery using endoscopic techniques. The microscopic was of additional help in a few cases with extended disease and multiple dehiscences of the skull base. RESULTS: Twenty-four patients had a chronic noninvasive of fungal sinusitis and 16 patients had a chronic invasive form. All these patients underwent endonasal surgery without external incision. The fungal disease was erradicated in 39 cases, and revision surgery was required in only one case in which involvement of the contralateral side was not initially detected. in two cases scar tissue in the middle meatus was later excised but without evidence of residual fungal disease. Only in 6 cases was antifungal chemotherapy required, where the disease had spread into surrounding tissue or the patient had severe symptoms. CONCLUSIONS: Endonasal microsurgical techniques are today the appropriate approach for managing chronic fungal sinus disease even in severe cases with radiologic evidence of expansion or invasion of surrounding tissue. Additional antifungal chemotherapy is only rarely indicated, specifically when the fungal disease invades surrounding tissue.     

A case of frontal sinus osteoma with unusual clinical course

This study was aimed at testing the hypothesis that different forms of fibronectin (FN), produced as a consequence of the alternative splicing of the precursor mRNA, play specific roles during follicular development. In particular, we analyzed the presence of the ED-I region, which is absent in the plasma form. Analysis of FN levels in follicular fluids corresponding to different stages of development of bovine follicles revealed marked changes in the concentrations of ED-I + FN whereas total FN levels remained relatively constant. A negative correlation (P < 0.001) was detected between ED-I + FN and estradiol levels. This steroid was without effect on the alternative splicing of FN in primary cultures of bovine granulosa cells. However, cAMP produced a marked decrease in the incorporation of the ED-I region. In contrast, transforming growth factor beta (TGF-beta) elicited both a stimulation on overall FN synthesis and an increase in the inclusion of ED-I. This effect was evident at the protein level (Western blots) and also in the mRNAs (Northern blots). A peptide corresponding to the ED-I region stimulated DNA synthesis in a bovine granulosa cell line (BGC-1) whereas the peptide corresponding to the flanking sequences was without effect. Data presented herein suggest a novel form of regulation by which changes in the primary structure of FN may mediate some of the effects of gonadotropin and intraovarian factors during follicular development.     

Mucocele of the sphenoid sinus presenting as spontaneous pneumocephalus

A 60 year old woman presented with headaches and a destructive lesion in the sella turcica. She refused treatment but returned seven years later with a spontaneous pneumocephalus and dementia. A mucocele of the sphenoid sinus was discovered. Her symptoms resolved after removal of the mucocele and obliteration of the sphenoid sinus.     

Pneumocephalus complicating osteoma of the frontal sinus

Osteomas of the paranasal sinuses are benign, often asymptomatic, tumors which progress very slowly. Endocranial development of an osteoma can breach the dura mata, allowing air to enter the cranium producing pneumocephalia which leads to severe neurological deficiencies. Pneumocephalia is an exceptional complication of osteoma. We found 40 cases reported in the literature. Brain CT scan easily gives the diagnosis. Surgical exeresis with closure of the breach gave very satisfactory results in our 2 cases.     

Complications of endonasal paranasal sinus surgery--diagnostic and therapeutic consequences

BACKGROUND: Functional endoscopic sinus surgery has been proven the therapeutic method of choice in surgical therapy of chronic sinusitis. On the other hand, endonasal sinus surgery may cause severe complications even when performed by a skilled surgeon. This is easily explained by the close vicinity of many functionally important structures to the operative site. CASE REPORTS: Three histories are reported that involve possible complications even in apparently simple cases. Diagnostic and therapeutic consequences are discussed. In a case previously diagnosed histologically as chronic unspecific sinusitis, an endonasal biopsy resulted in endocranial bleeding requiring neurosurgical intervention. Midline granuloma was found to be the correct diagnosis. Another patient was seen with a normal X-ray of the sinuses and solitary polypoid structure in his left nose. Polypectomy was planned and a CT scan was performed, which demonstrated a meningocele. Transfacial surgery was then performed to remove the meningocele. Another patient presented with a traumatic impression of the frontal sinus, and open reposition by transfacial surgery of the frontal and ethmoid sinus was planned. When CT scans revealed an uncovered optic nerve in the sphenoid sinus of the fractured side, we abandoned ethmodectomy and performed reposition of the frontal sinus as the only surgical procedure. RESULTS AND CONCLUSIONS: In this paper, we show typical complications of endonasal sinus surgery and strategies for avoiding them. If any complication occur, prompt treatment is required. Three groups of complications can be defined: perforation of frontobasal dura resulting in cerebrospinal fluid (CSF) fistula, severe bleeding, and orbital or optic nerve injury. When the surgeon discovers an intraoperative complication, possible consequences must be considered immediately to minimize side effects for the patient. A CSF fistula should be closed in the same procedure, and transfacial surgery may be necessary. Hemorrhage resulting from an ethmoidal artery may require frontoorbital surgery and ligation of this vessel. If retrobulbar hemorrhage caused by retraction of an ethmoid artery occurs, immediate intervention is necessary. Usually a transfacial approach, resection of the medial orbital wall and retrobulbar decompression are performed. In some cases lateral canthotomy may be the best way to drain haematoma and decompress the optic nerve. Subsequently, orbital revision and ligation of the retracted artery must be performed. Any delay can result in persistent visual loss. We conclude that the extranasal frontoorbital approach should be part of the residency training program in ENT departments. Any surgeon performing endonasal sinus surgery must be trained in transfacial emergency procedures, which should be part of anatomic preparations in teaching courses, thus avoiding severe damage in case of intraoperative complication.     

Clinical features and characteristics of paranasal sinus effusion in allergic sinusitis

Paraproteins or monoclonal proteins are the result of clonal B-cell or plasma cell proliferation of a malignant, premalignant or non-malignant nature. Monoclonal proteins may consist of intact immunoglobulin molecules or of heavy or light chains only. Depending on their rate of production and/or secretion they may accumulate in the serum and/or urine of patients. Their presence in the circulation may remain silent, as in monoclonal gammopathy of undetermined significance (MGUS), or may lead to clinical syndromes such as Hyperviscosity, Acrocyanosis, Cold hemagglutination, hemolysis and hemorrhagic manifestations. Their tissue deposition may be localized, with the kidney being the most frequent target as in Myeloma Cast Nephropathy or systemic, as in AL amyloidosis where heart, liver, nerves, tongue are usual targets, in addition to the kidneys.     

New methods of diagnosis and treatment of paranasal sinusitis with "IaMIK" sinus catheters

A new method for the diagnosis and treatment of PNS has been designed. The devices are named sinus-catheters YAMIK and consist of elongated flexible body with two inflatable vessels and three passages. Two of the passages have separate outlets into the vessel cavities and serve for their inflation. The third, working passage, opens on the body surface between the vessels and has an adaptor on the other end. Also a glass model of nasal sinuses has been developed. On the model YAMIK the procedure performs as follows: sinus catheter is inserted into the nasal cavity, the nostril and rhinopharynx are sealed off by inflating the vessels, a syringe is connected to the adaptor of the working passage. It creates controlled negative pressure in the nasal cavity, and this makes pathological secretion come out of the paranasal sinuses through their natural openings. After the evacuation of the pathological contents, medicine is introduced into the sinuses. This glass model is helpful in understanding the principle of YAMIK procedure which provides a good opportunity to evacuate pathological secretion from PNS through natural ostia and introduce medicine into the PNS.     

Spontaneous otogenic pneumocephalus. Case report and review of the literature

Pneumocephalus is commonly seen in clinical neurosurgical practice. Typical causes include trauma, tumor, and infection. Pneumocephalus may also occur iatrogenically at the time of intracranial surgery; it is not pathological and may be seen routinely on postoperative neuroimaging. Pneumocephalus is rarely encountered in the absence of the aforementioned entities. The authors report on an elderly woman in whom spontaneous intraventricular pneumocephalus occurred because of a congenital defect in the left tegmen tympani. Eustachian tube closure and middle ear exclusion were used to obliterate the fistulous connection. This case illustrates both an unusual cause and a unique treatment for spontaneous otogenic pneumocephalus.     

The management of massive pneumocephalus and cerebrospinal fluid rhinorrhoea as a consequence of biopsy in a patient with inverted papilloma

Nasal polypectomy is a common ENT operation. Cerebrospinal fluid (CSF) rhinorrhoea and pneumocephalus are rare complications. We present a patient who developed both these complications after biopsy of nasal polyps which subsequently proved to be an inverted papilloma. He had a defect in the ethmoid roof, which was repaired. Whilst endoscopic repair of CSF leak is increasing in popularity, in this patient because of his pathology and difficulty of access a more traditional lateral rhinotomy approach was made with a successful outcome. An overview of the management of these complications is presented.     

Value of B-image ultrasound in diagnosis of paranasal sinus diseases in comparison with computerized tomography

BACKGROUND: In diagnostic imaging of the paranasal sinuses, the A-mode technique is increasingly being substituted by B-mode ultrasonography. To assess the value of B-mode sonography we compared in a double-blind study computed tomography with our ultrasound findings. PATIENTS AND METHODS: Seventy-eight patients were examined by CT and subsequently by ultrasound, two-thirds before endonasal surgery and one-third for diagnosis of serious facial pain and swelling. RESULTS: Among 114 pathological maxillary sinus tomograms, 83 findings could also be diagnosed by ultrasound (sensitivity 72.8%). In the frontal sinuses only 12 of 52 of pathological findings could be detected (23.1%) and only 9 of 80 in the frontal ethmoid (11.3%). Except for circumscribed polyps and moderate general swelling of the mucosa, the detection rate by sonography was 97.4% for the maxillary sinuses, 31.5% for the frontal and 18% for the ethmoid sinuses. CONCLUSIONS: Ultrasound usually only demonstrates the presence of absence or unspecific findings. Differential diagnosis between tumors and sinusitis is generally difficult. The healthy individual is correctly assessed as healthy due to the total reflection of the air-filled healthy sinus. According to our findings ultrasound has a certain value in the diagnosis of maxillary sinuses. It can be used to obtain a preliminary diagnosis and as a screening method although a negative result never excludes a disease of the sinuses. As it does not involve radiation exposure, ultrasonography can be recommended as first step in diagnosis for children, pregnant women, and young women especially in acute sinusitis, because in acute sinusitis the maxillary sinuses are generally affected.     

Using a rotating suction debridement instrument with power generator in endonasal paranasal sinus surgery

Necrotizing fasciitis is rare in the orofacial region, with fewer than 20 cases reported in the literature. Extension of the disease process to involve the underlying bone has not been previously reported. A patient is presented in whom destruction of superficial skin and fascia, necrosis of a portion of the mandible, and involvement of the parotid gland complicated reconstruction.     

Coronal CT of the paranasal sinuses before and after functional endoscopic sinus surgery

Coronal CT of the paranasal sinuses and the ostiomeatal complex (OMC) was performed before and 12 months after bilateral functional endoscopic sinus surgery (FESS) in 30 patients with sinusitis and 12 patients with nasal polyposis. The extent of sinus mucosal thickening was graded, and the patency of the OMC was evaluated. After FESS, the percentage of open OMCs had increased from 42% to 83% in the sinusitis group, and from 8% to 45% in the polyposis group. There was only a small improvement in mucosal score in sinuses with opened OMC, so that the overall extent of sinus opacification before and after FESS was almost the same. Despite this, 91% of the patients reported clinical relief of symptoms. Preoperative coronal CT of the paranasal sinuses serves as an anatomical map for the surgeon, but there is no benefit of routine postoperative CT.     

Vibrometry of the vocal cords in healthy patients and in patients with nasal and paranasal sinus diseases]

The paper presents vibrometry data on resonance function of the vocal apparatus in healthy subjects and patients suffering from nasal and paranasal sinus diseases. It is shown that changes in the resonance function promote negative trends in development of dysphonia.     

Nursing of surgical closure of cerebrospinal rhinorrhea from sella turcica by the extranasal ethmoidal approach

The expression of estrogen receptor (ER) and progesterone receptor (PR) in 200 breast cancer specimens were imvestigated by monoclonal antibody with S-P staining to evaluate and standardize the criteria for positive staining. The results revealed that the incidence of ER and PR were 73.5% and 65.5% respectively. The authors concluded that the immunostaining could demonstrate in situ ER and PR, the results were stable, highly sensitive, consistent and comparable with the well established and recognized techniques home and abroad. The authors further pointed out that the crucial point of the staining is antigen retrieval and reported the optimal temperature and the time of sodium citrate buffer treatment. In this report, the criteria for positive staining were discussed intensively. The observations indicated that the percentage of the positive cells is more reliable, representative and practical than that of positive staining intensity index.