Variation in labial shoulder geometry of metal ceramic crown preparations: a finite element analysis

BACKGROUND: The anatomic variation of the frontal sinus and frontal recess can create both a diagnostic and therapeutic challenge. Most cases of frontal sinus disease can now be treated by endoscopic approaches. For refractory cases or those with severe pathology, the microscopically controlled drainage (MCD) operation has at times been successful and spared the patient the morbidity of an external approach. The aim of this study was to evaluate microscopically controlled frontal sinus surgery in these difficult cases. MATERIAL AND METHODS: Prospective analysis was performed on the efficacy of MCD in patients for whom endoscopic sinus surgery had failed or in primary cases with severe pathology or unfavorable anatomy. The technique employs a self-retaining endonasal retractor and a diamond bur under microscopic visualization to remove solid bone (frontal spine) obstructing the sinus drainage and allow a wide opening of the frontal recess while causing minimal mucosal damage. Unilateral drainage (extended frontal sinus drainage operation), and in some cases bilateral drainage (median drainage procedure) is employed. RESULTS: With an average of 23 months of follow-up, over 90% of patients were either free of symptoms or substantially improved after the MCD procedure. Three patients required revision surgery (extend the opening into a median drainage procedure) for adequate relief of symptoms. CONCLUSIONS: The MCD procedure is highly successful in the treatment of frontal recess disease, particularly in those cases of severe pathology or difficult anatomy. It may be used in those cases refractory to standard endoscopic sinus surgery where an external approach and frontal sinus obliteration are contemplated. As with endoscopic sinus surgery, precise knowledge of the frontal recess and neighboring landmarks is critical, and adequate drainage with minimal mucosal disruption should be the goal.     

Pre- and postoperative imaging analysis for frontal sinus disease following conservative partial middle turbinate resection

The prudence of partial or complete middle turbinate resection during endoscopic sinus surgery (ESS) is controversial. The greatest concern regarding partial resection relates to the effect on the frontal recess and the development of frontal sinus disease. The purpose of this study was to radiographically evaluate the frontal sinus in patients who had undergone ESS with partial conservative middle turbinate resection. We reviewed the charts and operative records from 195 consecutive cases of ESS performed by a single surgeon (JFB) over a two-year period. Thirty-three of 117 patients who had undergone ESS with conservative partial middle turbinate resection without frontal recess exploration agreed to return for magnetic resonance imaging (MRI) of their sinuses. The preoperative computed tomography (CT) scans and postoperative MR images were reviewed and graded (1-3) by a single neuroradiologist. Significant frontal sinus disease (grades 2 and 3) was seen in 15 of 52 sides preoperatively (29%), and in 14 sides postoperatively (27%). During the postoperative MRI studies, only six frontal sinus sides demonstrated minimal mucosal thickening (grade 1) which had not been apparent on preoperative CT. This radiographic analysis suggests that conservative partial middle turbinate resection during ESS does not adversely affect the frontal sinus. We believe that the surgical technique employed when resecting the middle turbinate, and the avoidance of unnecessary dissection in the recess are both important factors in preventing the development of frontal sinus disease following ESS.     

Pediatric functional endoscopic sinus surgery: postoperative care

An effective postoperative care regimen is vital for a successful outcome. Children pose special postoperative challenges due to small anatomy, differences in underlying causes of sinus disease, and difficulties encountered with sinonasal cleansing and debridement. This article provides the clinician with a chronologic guide on how to manage the child after functional endoscopic sinus surgery.     

Frontal sinus surgery in children

Surgery for frontal sinusitis in children is unusual. When required, surgery for ostiomeatal disease or, in certain circumstances, frontal sinus trephination is usually all that is required. Nevertheless, for a few children, surgery of the nasofrontal recess and frontal sinus is required and can be very beneficial. A variety of surgical approaches to the frontal sinus are discussed. Functional endoscopic surgery based upon physiologic principles and the concept of reversible disease is emphasized.     

Sinonasal imaging

Recent changes in sinonasal imaging are a direct result of the development of functional endoscopic sinus surgery. Because of this technique, radiologists have noted an increased volume of sinus imaging, developed new imaging techniques, and are interpreting films in a different manner. This article covers the common variants seen on coronal computed tomography, discusses the complications of functional endoscopic sinus surgery, reviews the radiographic criteria for sinusitis, and addresses the role of computed tomography and magnetic resonance imaging in evaluating the sinonasal cavity.     

Endoscopic sinonasal surgery in the management of primary headaches

Primary headaches (migraine, cluster, tension-type) are common disorders thought to be unrelated to nasal and sinus abnormalities. We present data on 19 patients with refractory primary headaches in the absence of significant sinus symptoms. The majority of patients responded with decreased pain to office application of nasal anaesthesia. A high prevalence of sinonasal abnormalities was found on coronal CT scans. Seventy-nine per cent responded with either decreased pain severity or headache frequency after endoscopic sinonasal surgery. We discuss possible underlying mechanisms to explain these findings.     

Primary non-Hodgkin lymphoma of the sinonasal cavities: correlation of CT evaluation with clinical outcome

PURPOSE: To determine retrospectively the primary site of origin of sinonasal lymphomas with computed tomography (CT) and correlate the CT findings with histologic phenotype and clinical outcome. MATERIALS AND METHODS: In 24 patients with stage I and II non-Hodgkin lymphomas of the sinonasal cavities, the CT appearances and clinical data were reviewed retrospectively. RESULTS: The sites of primary tumor determined at CT were the nasal cavity in 13 patients, the ethmoidal sinus in three patients, and the maxillary sinus in eight patients. B-cell lymphomas were found mainly in the maxillary sinus, while T-cell lymphomas were found in the nasal cavity and ethmoidal sinus (P < .005). The 5-year survival rates in relation to the primary site of the tumor were 64% for the nasal cavity, 50% for the ethmoidal sinus, and 100% for the maxillary sinus (P = .26). CONCLUSION: Patients with B-cell primary lymphoma of the maxillary sinus tended to have a good prognosis in contrast to those with T-cell lymphomas that originated from midline structures. The primary site determined at CT appears to be correlated with the histologic phenotype and clinical outcome.     

Conservative approach to inflammatory nasofrontal duct disease

Endoscopic data reveal that mucosal disease frequently recurs following the surgical treatment of chronic diffuse hyperplastic frontal sinus and nasofrontal duct disease. However, this group of patients often remains asymptomatic. We present 40 patients who underwent endoscopic sinus surgery with a 4-year mean follow-up. Postoperative endoscopy revealed mucosal disease within the frontal recess in 39 of the 40 (97.5%) patients; however, only 3 of the 40 (7.5%) were symptomatic. Of these 3 patients, 1 underwent revision surgery. Historical information demonstrates the potential for significant nasofrontal duct stenosis associated with such revision surgery. On the basis of our initial results, endoscopic observation and medical therapy seem to be successful in controlling the symptoms associated with this disease process.     

Current indications and techniques in evaluating inflammatory disease and neoplasia of the sinonasal cavities

Imaging strategies of the sinonasal cavities have undergone extensive revision over the last 5-year period. The traditional imaging examination of the paranasal sinuses, plain film radiography, does reasonably well in diagnosing maxillary, frontal, and sphenoid sinusitis. However, it less reliable in depicting abnormalities in the ethmoid sinuses, the most common area first affected with inflammatory disease. Compared with sinus computed tomography (CT), plain films prove to be less specific and sensitive in depicting the extent of sinus abnormalities. One series plainly concluded that sinus radiographs were not reliable enough to be an integral part of the clinical decision process. The use of plain radiographs of the sinuses has clearly been reduced by medical cost-containment concerns, replacement by superior techniques, and by clear weaknesses of the modality. Although it is inexpensive and easily accessible, the low sensitivities and inaccuracies of plain film radiography have resulted in the current use of CT and high-field-strength (1.5 Tesla) magnetic resonance imaging (MRI). By using this cross-sectional imaging, we now visualize directly the pathologic conditions within the sinuses, as well as the normal anatomy. We discuss current use of diagnostic imaging in the evaluation of patients with nasosinusoidal complaints (most commonly resulting from acute and chronic inflammatory disease), with complications of sinonasal inflammatory disease, and with suspected/documented neoplasia. In addition to developing an imaging algorithm to provide the information affecting clinical decision making, we detail the specific imaging techniques necessary accurately to obtain that information. We also review the specific concerns about imaging patients in the intensive care unit and touch on several emerging imaging techniques. The imaging workup in pediatric patients and patients with congenital anomalies is beyond the scope of this review.     

Follicular adenocarcinoma of the thyroid in the maxillary sinus

No reports of metastatic thyroid carcinoma in the maxillary, ethmoid, or sphenoid sinuses can be found in the literature. A woman with severe posterior epistaxis was examined recently. She had undergone a partial lobectomy for a thyroid tumor 16 years previously. Hemorrhagic thyroid tissue was in the maxillary sinus. The results of subsequent examinations indicated thyroid deposits in the lung and spine. The patient received radioactive iodine, 100 MCi. Her lung and spine deposits lysed, and she experienced no further epistaxis. Thyroid carcinoma's ability to metastasize to a paranasal sinus is documented here. Epistaxis after a thyroidectomy for cancer now must be considered an unusual clinical manifestation of metastatic spread, unless otherwise proved. The differential diagnosis of epistaxis must now include thyroid carcinoma metastatic to the sinonasal tract.     

Retraction cholesteatoma of the sinus tympani

Posteromedial retraction of the tympanic membrane, between the oval window superiorly and the round window niche inferiorly, results in the formation of an epithelium-lined pocket within the sinus tympanic recess. Failure to recognize posterior invagination of the tympanic membrane intraoperatively leads to inadvertent tearing of the tympanomeatal flap at the level of the annulus with epithelial seeding of the middle ear and probably cholesteatoma recurrence. This article focuses on the clinical manifestations and radiographic findings suggestive of sinus tympanic epithelial retraction of the pars tensa and provides direct correlation between human cross-sectional temporal bone anatomy and otomicroscopy. The surgical management of these challenging lesions includes initial endaural access, external meatal bone removal posteromedial to the tympanic annulus and anterior to the vertical portion of the facial nerve, and middle ear ventilation after marsupialization of the epithelial retraction. Although early tympanic membrane retraction can be treated with a ventilation tube, deep epithelial pockets may require additional surgical treatment. A method for the management of sinus tympanic cholesteatomas is demonstrated.     

Hybrid verrucous squamous cell carcinoma of sinonasal tract: a case report

Verrucous carcinoma is a variant of squamous cell carcinoma and should be distinguished from benign papilloma and well-differentiated nonverrucous squamous cell carcinoma. It is rare tumor of the sinonasal tract. Occasionally, conventional squamous cell carcinomatous components may be seen in verrucous carcinoma. This entity is called a hybrid verrucous squamous cell carcinoma. We report a case of hybrid verrucous squamous cell carcinoma occurring in the nasal cavity and paranasal sinus of a 67-year-old male. The removed mass shows the typical feature of verrucous carcinoma, but focally conventional squamous cell carcinomatous area is also noted. The treatment of this case follows verrucous carcinoma, but close follow up is mandatory because it may potentially spread to regional lymph nodes in contrast to pure form of verrucous carcinoma.     

Effects of Recess on the Classroom Behavior of Children With and Without Attention-Deficit Hyperactivity Disorder.

The primary purpose of this study was to evaluate the effects of a traditional recess on the subsequent classroom behavior of children with a diagnosis of Attention-Deficit Hyperactivity Disorder (ADHD). In addition, the time of recess was matched to the behavior of the individual children diagnosed with ADHD based on prior assessment of their classroom behavior as a function of time of confinement in the classroom. All results were evaluated using single-case designs. Results showed that levels of inappropriate behavior were consistently higher on days when participants did not have recess, compared with days when they did have recess. Results also showed that the level of inappropriate behavior for all participants progressively increased over time on days when they did not have recess. However, this progressive increase did not occur on days when the participants had recess. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Comparisons of pulmonary and sinonasal lesions in patients with cystic fibrosis. Evaluation using computerized tomography

INTRODUCTION: Cystic fibrosis is a recessive genetic systemic exocrinopathy caused by a variety of mutations in the cystic fibrosis transmembrane conductance regulator gene (CFTR). The disease is characterized by alterations of the secretions, which become thickened and viscous. Both the paranasal sinuses and the lung parenchyma are involved in all cases. The aim of this study was to assess a correlation between the rhinosinusal and lung parenchyma changes in cystic fibrosis patients. MATERIAL AND METHODS: Eighteen patients (11 men and 7 women, age range: 8 to 22 years) were examined with chest HRCT and sinonasal low dose CT. Lung symptoms were found in all patients; 13 of them, also affected with rhinosinusal symptoms, had been examined with ENT and nasal endoscopy. The other 5 patients, without rhinosinusal symptoms and previously examined with ENT, were evaluated as control group. Chest CT was performed with the high-resolution technique, 2 mm slice thickness and 10 mm table feed. Rhinosinusal CT was performed with the low dose technique, acquiring contiguous 2-4 mm thickness coronal sections. The CT patterns were analyzed by two radiologists and scored as slight, medium and diffuse involvement of both districts. RESULTS: No statistically significant correlation between lung and sinonasal damage was found in our study. Parenchymal lung involvement appeared more severe than sinonasal involvement in 14/18 patients. The retention of secretions in the paranasal sinuses, even if limited, was demonstrated in all symptomatic and asymptomatic patients. CONCLUSIONS: The absence of correlation between pulmonary and sinonasal damage and more generally, the different severity of cystic fibrosis can be caused by different allele mutations of the cystic fibrosis transmembrane conductance regulator gene, the most frequent of which is Delta F-508.     

Invasive sinonasal disease due to Scopulariopsis candida: case report and review of scopulariopsosis

Sinonasal infection with fungi of the order Mucorales--termed mucormycosis or zygomycosis--is sometimes seen in immunosuppressed patients, including those with diabetic ketoacidosis and malignancy. We describe a case of invasive sinonasal infection with Scopulariopsis candida (not among the Mucorales organisms) in a 12-year-old girl who was being treated for non-Hodgkin's lymphoma. Only a few cases of invasive infection with Scopulariopsis species have been reported previously; five of six of these cases were associated with persistent or fatal disease. Our patient survived without undergoing radical surgical debridement and was treated with granulocyte colony-stimulating factor, amphotericin B, and itraconazole; chemotherapy was stopped. In vitro susceptibility testing of our patient's Scopulariopsis isolate showed that it was resistant to amphotericin B and that it was relatively susceptible to itraconazole and miconazole. The case described herein demonstrates the expanding spectrum of fungal organisms that may cause invasive sinonasal infection in immunocompromised hosts and the need for reliable antifungal susceptibility testing.     

Extranodal head and neck lymphomas in Guatemala: high frequency of Epstein-Barr virus-associated sinonasal lymphomas

Sinonasal lymphomas of T cell or natural killer cell (T/NK cell) phenotype represent a subset of extranodal head and neck lymphomas. T/NK cell sinonasal lymphomas have been described in diverse geographic settings, including China, Japan, Peru, Northern Europe, and North America. The frequency of these lymphomas is highly dependent on the geographic location in which they occur, their incidence being low in Europe and North America and relatively high in Asian countries and in Peru. Regardless of their geographic location, they are typically associated with the Epstein-Barr virus (EBV). Few studies have addressed the relative frequency of sinonasal lymphoma within the group of extranodal head and neck lymphomas. We investigated the anatomic distribution, immunophenotypical profile, and EBV status of 33 cases of extranodal head and neck lymphoma from patients in Guatemala. The anatomic distribution of these lymphomas is similar to that seen in Asian countries: 17 (52%) in the sinonasal area, five (15%) in the palate, and 11 (33%) in other locations. Fifteen (88%) of the 17 sinonasal lymphomas showed a T or null cell phenotype with a strong association with EBV by in situ hybridization. Most Guatemalan patients with these lymphomas were of Mayan descent. In Guatemala, the relative frequency of sinonasal lymphomas within the group of head and neck lymphomas is significantly higher than that reported for Western countries. In addition, the relative frequency of T/NK versus B cell sinonasal lymphomas is higher than that described in North America and similar to that observed in Asian countries and Peru.     

The radiographic evaluation of sinonasal tumors: an overview

It is axiomatic that advances in head and neck imaging improve our understanding of head and neck diseases. Dramatic improvements in radiologic imaging in recent years have, as a corollary, dramatically improved our understanding of sinonasal tumors. Older techniques such as plain film radiography and multidirectional tomography poorly delineate normal anatomy and pathologic changes in the craniofacial region. Modern imaging modalities depict sinonasal tumors and their metastases in detail, yielding information that allows treatment planning to proceed rationally. The radiologic examination is commonly employed as a precise "map" for implementation of therapy, and imaging studies are essential in the follow-up evaluation for tumor residual or recurrence. This article provides an overview of the current contributions made by head and neck radiology to the understanding and clinical management of sinonasal tumors.     

Lumbar facet joint arthrography with the posterior approach

Lumbar facet joint (LFJ) arthrography with intraarticular injections of long-acting steroids and local anesthetics is routinely used for therapeutic purposes in selected patients for relief of low back pain. The procedure may also be used for diagnostic reasons to establish the source of such pain. However, because direct access to the LFJ space is not always possible owing to degenerative changes such as osteophytes, another posterior approach has been proposed for LFJ arthrography. With the patient in the prone position, a spinal needle is inserted vertically into the inferior recess of an LFJ with fluoroscopic guidance and the patient under local anesthesia. To facilitate puncture, cushions are placed under the patient's abdomen to flatten normal lumbar lordosis, which enlarges the inferior recess of the LFJ. Use of cushions also results in a decrease in tissue thickness in the patient, thereby improving image quality and decreasing radiation exposure. LFJ arthrography can demonstrate the causative role of facet disease in abnormalities responsible for low back pain or sciatica and can be performed easily and rapidly with this direct posterior approach.     

Sinonasal undifferentiated carcinoma: a ray of hope

In 1987, we published a case series of a newly-described, highly malignant neoplasm, termed sinonasal undifferentiated carcinoma, in which treatment results were poor. In this updated study, we report the followup for the original three surviving patients and for six additional cases whose tumors were diagnosed between January 1987 and October 1991. These data suggest that the prognosis for patients with localized disease may be better than originally described.     

The sick sinus syndrome. What causes it?

The basic disorder in sinoatrial disease is a functional and/or anatomical defect in the sinus node and the atrium respectively. The clinical feature includes palpitations, angina pectoris, heart failure, giddiness and systemic emboli. Associated diseases are coronary heart disease, hypertension, diphtheria, myocarditis or rheumatic fever. Diagnosis is primarily made by clinical symptoms and conventional or long term ECG-monitoring. However, impaired sinus node function including sinusbradycardia, sinus arrest, sinoatrial block and the bradycardia-tachycardia syndrome cannot easily be assessed, when rhythm disturbances are occurring intermittently, as the recording of electrical activity of sinus node pacemaker cells is not available in man. Therefore methods of provocative atrial stimulation (rapid atrial stimulation, premature atrial stimulation) have been developed for (indirect) estimation of sinus node recovery time and sinoatrial conduction time. Treatment depends on symptoms. In most cases implantation of an electric pacemaker is mandatory since drug treatment usually is unsatisfactory. The natural history of the sinoatrial disease is imperfectly known but probably covers 5--10 years.