Bilateral Sinus Research Articles

Pembrolizumab-Induced Nasal Polyposis: The First Reported Case

The last decade has seen the emergence of immune checkpoint inhibitors for the treatment of a wide variety of cancer types. While these medications are generally speaking well tolerated, the full long-term side effect profiles of these medications have not been fully elucidated. We describe a case of chronic rhinosinusitis with nasal polyposis induced treatment with pembrolizumab, the first reported case. We present the case of a 48-year-old man with a background history of stage IV non-small cell lung cancer with bone metastases. He was commenced on pembrolizumab and over the course of the subsequent 5 years he developed significant nasal polyps bilaterally, and was commenced on medical therapy. Sinus CT scan demonstrated bilateral total opacification of all his sinuses and nasal cavity. He subsequently underwent bilateral functional endoscopic sinus surgery. He remains symptom-free and at his last clinical follow-up visit 1 year later. There are limited case reports of nasal polyposis occurring in patients receiving immune checkpoint inhibitors, with only one case requiring surgery. We describe the first case of severe nasal polyps due to pembrolizumab and successfully treated with polypectomy. From our review, there were no cases that required a cessation of therapy.

Application of expanding bilateral sphenoid sinus plasty in the treatment of sphenoid sinus diseases.

Expanding bilateral sphenoid sinus plasty is an essential technique for the treatment of sphenoid sinus diseases, such as refractory sphenoid sinusitis, sphenoid sinus cyst, fungal sphenoid sinusitis, sphenoid sinus carcinoma and sphenoid sinus chordoma. The present study evaluated the potential application of expanding bilateral sphenoid sinus plasty in the treatment of sphenoid sinus diseases. A retrospective medical record review of 42 patients treated with the expanding bilateral sphenoid sinus plasty from December 2012 to December 2018 was performed in a tertiary-care university hospital. A follow-up of the surgical effects and complications was performed. Of the 42 patients, the symptoms were relieved after operation in all except preoperative hyposmia in 2 and impaired vision in one with no obvious improvement. No complications such as nasal bleeding, olfactory hypofunction and perforation of nasal septum occurred. Follow-up data revealed good mucosal epithelization in all patients within a mean time of 8.6 weeks. Endoscopic sinus reexamination demonstrated that the sphenoid sinus orifice was well opened, and no cases of sphenoid sinus orifice closure were observed. Expanding bilateral sphenoid sinus plasty, with advantages of clearly exposed surgical field, full opening of the sinus cavity, high surgical safety, short epithelialization time and intuitionistic postoperative follow-up, demonstrated great promise for greater use in the treatment of sphenoid sinus diseases in the future.

Sinonasal and ear manifestations of Erdheim-Chester disease.

To calculate the prevalence of sinonasal and ear involvement in an Erdheim-Chester disease (ECD) population, to describe the different ear, nose and throat (ENT) manifestations and to study the association between ENT involvement, other organ involvement, and BRAF mutations. We led a retrospective monocentric study in the national referral center for ECD. One hundred and sixty-two patients with ECD and ENT data were included between January 1, 1980 and December 31, 2020. Ear and nose clinical and radiological findings were noted. We described and studied the prevalence of ENT involvement in ECD population. The association between sinonasal and ear involvement, other organ involvement, and BRAF mutations was calculated. The prevalence of ENT manifestations is around 45%. No clinical rhinologic or otologic signs were specific to ECD. Sinus imaging was abnormal in 70% of cases. A bilateral maxillary sinus frame osteosclerosis was highly specific of ECD. Associations were found between the sinus MRI imaging type and BRAF status, central nervous system involvement, cerebellum involvement and xanthelasma. Sinonasal or ear involvement is frequent in ECD and has specific imaging features for sinuses. Trial registration: #2011-A00447-34.

The Radiological Spectrum of Rhino-Oculo-Cerebral Mucormycosis.

Aim We aim to study the spectrum of imaging findings in patients with rhino-oculo-cerebral mucormycosis(ROCM). Materials and methods This retrospective descriptive study was performed in histopathologically confirmed cases of rhino-oculo-cerebral mucormycosis in a tertiary care center in Bihar, India. The case records of patients with radiological, cultural, and histological evidence of acute invasive ROCM were retrospectively evaluated for relevant radiological and clinical data between May 2021 and June 2022. Results The radiological evaluation included computed tomography (CT) and magnetic resonance imaging(MRI) scans done on 52 patients. The patient's average age was 48 years. The ethmoid sinus was involved in 51 (98%)cases and the maxillary sinus in 50 (96%) cases. Bilateral sinus involvement(45, 86%) was the most common, followed by pansinus involvement (27, 52%). The orbit was involved in 39 (75%) cases, the face in 25 (47%) cases, and retroantral fat stranding in 24 (46%) cases. Mucosal thickening (91%) was the most common pattern of involvement, followed by complete opacification (77%). Osseous involvement was seen in 17 of 44 patients who had CT scans, and the majority of patients had extrasinus extension with intact bone. MRI revealed variable T2SI, with T2 hyperintensity being the most common pattern. Heterogeneous enhancement in post-contrast imaging was the most common. Conclusion ROCM is alife-threatening invasive fungal infection, especially in an immunocompromised state. ROCMis characterized by a variety of imaging abnormalities on CT and MRI, although nonspecific. Imaging aids in suspicion or early diagnosis in appropriate clinical contexts, particularly in an immunocompromised state, and in determining the degree of involvement and complications.Early detection of ROCM and its complications enables proper treatment, which can lowerthe cost of care, morbidity, and mortality.

Inflammatory Sinonasal Polyposis-Causing Globe Perforation-With Response to Dupilumab Therapy.

A 75-year-old male patient with asthma presented with left eye vision loss for 1 year and progressive nasal obstruction, anosmia, and purulent eyelid and nasal discharge for several months. There was no light perception vision with an afferent pupillary defect in the left eye. Examination demonstrated nasal dorsum widening, sino-cutaneous fistulae, bilateral proptosis, and left eye chemosis with corneal keratinization in the setting of prior perforation (Fig. 1A). Nasal endoscopy showed severe, bilateral polyposis (Fig. 1B). MRI revealed an extensive sinonasal process with left globe disfigurement and severe, postobstructive, sinus mucocele formation (Fig. 2, top). The patient underwent bilateral functional endoscopic sinus surgery. Intraoperatively extensive sinonasal polyposis and inspissated mucinous debris were encountered. Histopathology demonstrated nasal polyps with dense eosinophilic infiltration and cultures grew polymicrobial bacteria. He underwent left eye evisceration, left lower eyelid ectropion repair, and second-stage sinus surgery. Postoperatively, there were improvements in pain, breathing, and smell. Nasal endoscopy displayed improved sinus patency, although with rapid polyp recurrence. Given concern for mucocele formation and potential impact on the right eye, bimonthly subcutaneous dupilumab was initiated. Following 5 doses, there was dramatic improvement, with symptom resolution, nasal bridge narrowing, sinonasal polyposis reduction, and fistulae closure (Fig. 1C). Subsequent CT showed dramatic polyposis involution and sinus clearing (Fig. 2, bottom). Severe chronic sinusitis with polyposis may exert mass effect on local structures including the brain, optic nerves, and globes. Among patients with severe, refractory, or recurrent polyposis, subcutaneous dupilumab may provide a dramatic clinical response.FIG. 1FIG. 2

Radiological findings of mucormycosis rhinosinusitis among Indian COVID-19 patients during the pandemic second wave

BackgroundSinonasal mucormycosis is a quickly progressing and lethal fungal disease which showed an increased incidence in COVID-19 patients in the Indian population during the second wave of the pandemic. The objective of this study was to study the various sinus areas affected and the imaging findings of the disease.MethodsThe imaging records of patients with sinonasal mucormycosis during the second wave of the COVID-19 pandemic were reviewed and analysed for whom computed tomography (CT) and/or magnetic resonance imaging (MRI) images had been performed.ResultsOf the 65 patients, 6.1% had single sinus involvement, and 93.9% had multiple sinus involvement, and out of latter, 91.8% had bilateral sinuses affected by the disease process. A total of 49.2% patients with sinus involvement had erosions of the sinus walls. A total of 35.4% patients had only sinonasal mucormycosis, 38.5% patients had rhino-orbital mucormycosis, 4.6% patients had rhino-cerebral mucormycosis and 16.9% patients had rhino-orbitocerebral mucormycosis. The pterygopalatine fossa was affected in 26.2% patients. A total of 9.2% patients had cavernous sinus thrombosis. A total of 12% of the cases had infarction in the cerebral hemispheres.ConclusionIn a setting of sinonasal mucormycosis, especially in the immuno-compromised and with those infected with COVID-19, cross-sectional imaging can assess the presence and extent of the disease and helps plan its medical and surgical management.

Common Drainage Pathway From Bilateral Frontal Sinuses: Lessons From 2 Cases

Primary pneumatization of the frontal bone occurs in the first year of life, but further pneumatization continues until 18 years of age. Elongation of the ethmoidal infundibulum and frontal recess, or upwards migration of the anterior ethmoidal cells has been proposed as a mechanism of frontal sinus development. The frontal sinus drainage pathway is displaced in the anterior or posterior direction depending on the pneumatization pattern of the frontoethmoidal cells. Also, frontal sinuses can be connected to the infundibulum or directly to the middle meatus depending on the superior attachment pattern of the uncinate process. Bilateral frontal sinuses are separated by their bony septum, and thus have their own drainage pathways. Contrary to this general rule, we experienced two cases of frontal sinuses that were connected to each other, showing a single drainage pathway from both frontal sinuses. We report these two cases along with a literature review.

Rapidly Resolving Orbital Pseudotumor in Systemic Lupus Erythematosus

Rapidly Resolving Orbital Pseudotumor in Systemic Lupus Erythematosus

Usefulness of post-operative endoscopic score for optimal treatment selection in recurrent eosinophilic chronic rhinosinusitis.

This study retrospectively analysed post-operative endoscopic scores to determine the optimal post-operative treatment in patients with eosinophilic chronic rhinosinusitis undergoing functional endoscopic sinus surgery. In total, 339 adults who underwent initial bilateral functional endoscopic sinus surgery for eosinophilic chronic rhinosinusitis were enrolled. Patients were divided into group A, which required no additional post-operative treatment; group B, which required local/systemic steroids post-operatively; and group C, which further required dupilumab and/or revision surgery. Sixty-five per cent of patients could be treated with initial functional endoscopic sinus surgery (group A). Post-operative steroids were required in 35 per cent of patients with a post-operative endoscopic score of 30 per cent (group B). Further advanced treatments with dupilumab and/or revision functional endoscopic sinus surgery were required in 10 per cent of patients with a post-operative endoscopic score of 65 per cent (group C). The post functional endoscopic sinus surgery endoscopic score can be used as an index to determine treatment at the time of eosinophilic chronic rhinosinusitis recurrence.

Bilateral petrosal sinus sampling - a 15-year experience from a tertiary hospital

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Abstract #1401779: Rare Case of Functional Gonadotroph Adenoma

Of all pituitary adenomas, approximately 25-35% are clinically nonfunctioning or "silent" and of those approximately 70-90% are gonadotropin adenomas making them the most common nonfunctional pituitary macroadenoma. However, it is important to know that gonadotropin adenomas can be functional and that gonadotropin excess can result in clinical symptoms and lab abnormalities. This case demonstrates an example of a functional gonadotropin pituitary adenoma overproducing FSH resulting in high-normal testosterone level in addition to compressive symptoms of the optic chiasm. 57-year-old African-American male with pre-diabetes mellitus and gout (only home meds are allopurinoL 300 MG once daily and indomethacin 50 MG three times daily) presented for evaluation of vision loss and large sellar mass on MRI. Vision loss first noted January 2022 along with occasional headaches for 3-4 months (no headaches prior). Patient eventually saw a neuro-ophthalmologist for visual field testing demonstrating left field deficits concerning for optic nerve compression. He then underwent orbital MRI which demonstrated a large sellar mass extending into bilateral cavernous sinus and effacing and displacing the optic chiasm. During visit, patient admitted to fatigue, constipation, polyuria, and nocturia. He denied‌ breast tenderness, nipple discharge, weight change, temp intolerance, skin/hair change, palpitations, tremors, increase hand/foot size, teeth spacing change, worse glycemic control, hypertension, joint pain, acne, hirsutism, striae, clotting disorders, fractures, decreased libido, or erectile dysfunction. He had no known allergies. Blood pressure109/83 | Pulse 101 | Ht 5' 10" (1.778 m) | Wt 88.2 kg (194 lb 7.1 oz) | SpO2 97% | BMI 27.90 kg/m2. Physical exam: Visual fields intact to confrontation but with some patchy deficits in the left eye only. No other notable findings. Subsequent labs demonstrated appropriate cortisol 11.8 ng/dL with normal ACTH of 17 pg/mL, normal IGF-1 of 95 ng/mL, normal TSH of 1.6 uIU/mL with normal free T4 of 0.8 ng/dL. However, prolactin was mildly elevated at 36.5 ng/mL (presumably from stalk effect given size of tumor) and FSH was impressively elevated at 70.3 mIU/mL with a normal LH of 6.5 mIU/mL and a high-normal total testosterone level of 890 ng/dL which was highly suggestive an FSH-producing functional gonadotropin adenoma. It is important to realize the efficacy of surgical resection of functional non-prolactinoma pituitary tumors, especially when the optic chiasm is involved. Patient underwent transsphenoidal resection of pituitary adenoma and indeed pathology revealed a gonadotroph adenoma with SF1 and alpha subunit. He reported slightly improved vision in left eye and had some residual occasional headaches. Awaiting post-operative labs but anticipate normalization of prolactin and FSH and a likely decrease in testosterone level. Awaiting post-operative visual field testing to demonstrate objective improvement. These should be available by the time of the conference.

Atypical clinical features of post COVID-19 mucormycosis: A case series.

This case series aims to evaluate patients affected with post COVID-19 mucormycosis from clinical presentation to surgical and pharmacological treatment to improve the disease prognosis. This case series was conducted at a specialized surgery hospital in Baghdad Medical City for over 10 months. Fifteen cases who had mild to severe COVID-19 infections followed by symptoms similar to aggressive periodontitis, such as mobility and bone resorption around the multiple maxillary teeth, were included in this case series. All patients did not receive COVID-19 vaccination; seven had a history of diabetes mellitus type 2, another five patients had a history of diabetes-like syndrome during the COVID-19 infection, and the remaining three patients had no history of any systemic diseases. No intracranial involvement was seen in all patients, and bilateral sinus involvement was seen in three patients. Being highly suspicious of all patients affected with COVID-19 is highly recommended to avoid the complications of the late diagnosis of mucormycosis. In addition, our knowledge and methods in diagnosing and treating classical mucormycosis should be modified regarding post COVID-19 mucormycosis.

Do Nasal Anatomical Variations Affect the Maxillary Sinus? A CBCT Volumetric Analysis

Objective: This study aimed to determine the effect of the concha bullosa (CB) and the nasal septum deviation (NSD) on the volume of the maxillary sinuses using ITK-SNAP (http://www.itksnap.org/ download/snap/). Methods: A total of 70 CBCT scans were analyzed. Three groups were evaluated; control (absence of CB), unilateral CB, and bilateral CB. Moreover, scans were classified according to the NSD into control (no deviation), mild, moderate, and severe NSD deviation. The volume of each maxillary sinus was calculated using the ITKSNAP. Intra-observer reliability analysis was performed by paired-sample t-test. Analysis of variance ANOVA and t-test were used to compare the mean bilateral maxillary sinus volumes. Results: Intra-observer reliability for the maxillary sinus volume exhibited no significant difference for both sides (p > 0.05). The mean volume of the right and left maxillary sinuses were 12.98±4.90 cm3 and 13.18±4.99 cm3 , respectively. No significant difference between the volumes of both sides (p > 0.05) was found. The results showed no significant differences between the CB or NSD groups on both sides (p > 0.05). Conclusion: The two anatomical variations have no effect on the maxillary sinus volume. The open-source software ITK-SNAP is a valuable tool for volumetric analysis.

Clinical and patient-centered outcomes following rehabilitation of atrophic edentulous maxilla using six implants placed simultaneously with bilateral maxillary sinus augmentation: A retrospective case series

ObjectivesTo evaluate treatment success, patient satisfaction, and oral health-related quality of life (OHRQoL) after rehabilitation of atrophic edentulous maxilla (AEM) with six implants placed simultaneously with bilateral maxillary sinus floor augmentation (MSFA). Materials and methodsThe selected patients were fully edentulous with atrophic maxillary posterior residual ridges and rehabilitated with six implants placed simultaneously with bilateral MSFA and immediate All-on-4 provisional fixed prosthesis (PFP). After 7–12 months of implant surgery, all patients have received an All-on-6 definitive fixed prosthesis (DFP). After at least one year of function with DFP, clinical and radiographic examinations were performed. Patient satisfaction was assessed through a visual analog scale (VAS). The OHRQoL before treatment (T0), during provisional (T1), and after definitive prosthesis (T2) was evaluated using OHI-14. Results20 maxillary edentulous patients were rehabilitated with 120 implants, 20 immediate All-on-4 PFP, and 20 All-on-6 DFP. Of those, 12 patients have passed at least a year follow-up after DFP insertion and were eligible to be included in the assessment of treatment success. After a mean of 20 (12–36) months follow-up, the implant and prosthesis survival rates were 100%. The success rate at the implant level was 98.6%. The mean marginal bone loss (MBL) was 0.09 ± 0.06 mm. No prosthetic or postoperative complications, and the mean general satisfaction was (91.75 ± 7.06). There was a significant improvement in all OHIP-14 domains during the final All-on-6 prosthesis (T2) (P < 0.01). ConclusionsRehabilitation of atrophic edentulous maxilla using six implants with simultaneous bilateral MSFA and immediate All-on-4 PFP is a successful treatment approach associated with minimal postoperative complications and significant improvement in OHRQoL.

Lemierre syndrome associated Cavernous Sinus Thrombosis and Development of Internal Carotid Artery Narrowing: A Case Report and Review of Literature (P2-5.005)

<h3>Objective:</h3> To report a case of Lemierre syndrome complicated by cavernous sinus thrombosis (CST) and bilateral internal carotid artery (ICA) stenosis without cerebral infarction in a young woman and summarize the literature on Lemierre syndrome with arterial involvement. <h3>Background:</h3> Lemierre syndrome is a complication of oropharyngeal infection characterized by thrombosis of the internal jugular vein (IJV) with septic thrombophlebitis followed by bacteremia and septic emboli dissemination to distal organs, but arterial involvement is extremely rare. <h3>Design/Methods:</h3> A 24-year-old previously healthy woman presented to the hospital with one week of progressive jaw pain and neck swelling after recent tooth extraction. Physical examination showed left ptosis without other neurologic deficits. Computer tomography (CT) of the neck found multiple anterior neck abscesses. The patient underwent emergent incision and drainage of abscess at the left lateral pharyngeal, left masticator, and bilateral sublingual space. Vascular imaging revealed findings of non-occlusive thrombus in the left IJV, bilateral cavernous sinus thrombosis (CST), and septic emboli in bilateral apical lungs, consistent with Lemierre syndrome. Neuroimaging showed no cerebral infarction even though a digital subtraction angiogram (DSA) demonstrated bilateral ICA severe stenosis (&gt;70%) in both extracranial and intracranial segments. Cultures of abscess samples proved positive for <i>Candida albicans</i> and <i>Streptococcus constellatus</i>. The patient received treatment with full-coverage antibiotics and anticoagulation therapy resulting in an excellent outcome. <h3>Results:</h3> A literature search yielded 29 cases of Lemierre syndrome with arterial complications, which manifested as ICA occlusion or stenosis, or mycotic aneurysm development. Despite variable clinical symptoms, most patients developed CST and were all treated with antibiotics. Anticoagulation therapy is controversial given scarce and inconsistent evidence. <h3>Conclusions:</h3> The presented case and literature review emphasize the variability of the clinical course of Lemierre syndrome. Septic CST can be a rare cause of ICA occlusion, stenosis, or pseudoaneurysms because of arteritis, and thus expedited workup is necessary. <b>Disclosure:</b> Dr. Zhou has nothing to disclose. Dr. Malik has nothing to disclose.

Headache, vision changes and cranial nerve palsy after head trauma.

A 43-year-old female was brought to the hospital after a ground level fall and her Glasgow Coma Scale was 15. Non-contrast head computed tomography (CT) scan showed small bilateral subdural hematomas, left traumatic subarachnoid hemorrhage, left occipital bone and left longitudinal temporal bone fractures. She was managed conservatively. Interval repeat non-contrast head CT scans showed resolution of the hemorrhage. Two and a half months later she presented to the hospital with headaches, intermittent diplopia, blurry vision and a right lateral gaze palsy. Non-contrast head CT scan showed mild hyperattenuation in the cavernous sinus. Subsequently, a CT angiogram of the head was obtained that showed opacification of the bilateral cavernous sinus and distention of the orbital veins (Figure 1A,B). Evaluation with diagnostic cerebral angiogram showed direct bilateral carotid-cavernous fistulas (CCFs) (Figures 2 and 3). She underwent staged embolization of the CCFs. Direct CCF is the abnormal connection between the internal carotid artery and the cavernous sinus.1, 2 CCFs can present with the classic triad of chemosis, pulsatile proptosis and ocular bruit.3, 4 Other symptoms include orbital pain, abducens nerve palsy, deterioration of visual acuity and ophthalmoplegia.4, 5 Causes of CCF formation are traumatic, iatrogenic, connective tissue disorders and spontaneous.2, 6-9 Traumatic CCFs formation occurs in up to 1.25% of patients with traumatic brain injury or facial and skull base fractures.10, 11 Bilateral CCF formation is rare after trauma and symptoms develop in a delayed fashion.10-15 Treatment options include conservative management, open surgery, endovascular procedures and radiosurgery.16-18

Volumetric evaluations of the maxillary sinus before and post regenerative surgery.

The purpose of this study was to investigate possible differences in the filling of the various recesses of the maxillary sinus after the procedure of sinus floor elevation in relation with the initial volume of the same and if the sinus volume can influence long-term graft dimensions, by using cone beam computed tomography (CBCT) as diagnostic analysis device. This study included 32 sinuses corresponding to 16 patients referred for bilateral maxillary sinus augmentation procedures needing to increase the volume of the surgical site with the porcine cortical bone for dental implant placement in the posterior maxilla. The sinuses were analyzed by preoperative and postoperative (15 days and 6 months after sinus surgery) cone beam computed tomography. No statistically significant relations were observed between initial sinus dimensions and the entity of the contraction of the graft between T1 (15 days after surgery) and T2 (180 days after surgery). The behavior was the same either for the large sinus (> 15.65 cm3) and for the small one (< 15.65 cm3). Instead, about the filling of the various sinus recesses, a linear regression model was used to explain the difference between the mean preoperative and postoperative surgical spaces; in most of the samples, the filling of the anterior recess was ~15% of the total volume of the graft, i.e., the minor one among the main recesses. Our findings suggest that: (1) in the procedure of sinus floor augmentation by a lateral approach with deproteinized porcine bone there are no relations between the initial dimensions of the sinus and the long-term dimensional changes of the graft, and (2) that, among the main recesses of the sinus, the anterior one is generally the less filled.

OWN EXPERIENCES IN THE APPLICATION OF INTRAOPERATIVE 3D SPATIAL IMAGING IN THE ENDOSCOPIC SURGERY OF THE PARANASAL SINUSES

Introduction: Intraoperative spatial imaging using a high-resolution 3D camera is a state-ofthe-art technique applied to endoscopic paranasal sinus surgery. It enables better visualization of the surgical site, improves depth perception and facilitates tissue identification. All 3D endoscopy capabilities are still under review. The purpose of this study is to compare analogous endoscopic surgeries performed with 3D technique and those performed with traditional 2D technique based on the analysis of length of surgery, blood loss, occurrence of intraoperative complications and hospital stay time. Material: The material included 346 patients who underwent endoscopic paranasal sinus surgery with unilateral or bilateral sinus opening. In case of 152 patients, corrective surgery of the nasal septum was additionally performed. The patients were divided into two groups (2D group and 3D group) comprising 173 patients each, who underwent paranasal sinus opening using 2D and 3D endoscopic visualization. Each group was divided into four subgroups: the first were patients after bilateral paranasal sinus surgery (PSS), the second were patients after bilateral endoscopic paranasal sinus surgery and nasal septal correction surgery (PSS+NS), the third were patients after unilateral paranasal sinus surgery (UPSS), and the fourth group was patients after unilateral endoscopic paranasal sinus surgery and nasal septum correction surgery (UPSS+NS). Methods: The surgery was carried out using a TipCam 3D endoscope from Storz (Germany), 18 mm in length, 4 mm in diameter, with 30° optics, with an integrated camera capable of transmitting 3D images, as well as classic 2D endoscopes, 16 mm in length, 4 mm in diameter and 30° optics, along with a video track and instrument set. Patients underwent unilateral or bilateral endoscopic surgery with opening of the maxillary sinuses, frontal sinuses, anterior and posterior ethmoid as well as corrective surgery of the nasal septum. Patients underwent unilateral or bilateral endoscopic surgery with opening of the maxillary sinuses, frontal sinuses, anterior and posterior ethmoid as well as corrective surgery of the nasal septum. Results: The length of surgery were as follows in the 2D group: 2D/PSS+NS group — 107 min. (±22); 2D/PSS group — 95 min (±24); 2D/UPSS+NS group — 68 min (±21); 2D/UPSS group — 53 min (±14); The length of surgery in the 3D group: 3D/PSS+NS group — 91 min. (±17); 3D/PSS group — 83 min (±20); 3D/UPSS+NS group — 69 min (±15); 2D/UPSS group — 49 min (±10); Among the complications were early and late postoperative bleeding, eyelid or orbital hematomas, and eyelid edema. There were 17 complications in the 2D group (9.82%), and 7 complications in the 3D group (4.05%). Conclusions: It was found that 3D endoscopic surgeries significantly reduced the length of surgery, especially in serious bilateral paranasal sinus surgeries. and influenced a decrease in perioperative complications. 3D endoscopic surgeries had no significant effect on the amount of blood loss and the length of the patient’s stay at the Clinic.

Machine learning models for differential diagnosis of Cushing's disease and ectopic ACTH secretion syndrome.

Using machine learning (ML) to explore the noninvasive differential diagnosis of Cushing's disease (CD) and ectopic corticotropin (ACTH) secretion (EAS) model is the next hot research topic. This study was to develop and evaluate ML models for differentially diagnosing CD and EAS in ACTH-dependent Cushing's syndrome (CS). Two hundred sixty-four CD and forty-seven EAS were randomly divided into training and validation and test datasets. We applied 8 ML algorithms to select the most suitable model. The diagnostic performance of the optimal model and bilateral petrosal sinus sampling (BIPSS) were compared in the same cohort. Eleven adopted variables included age, gender, BMI, duration of disease, morning cortisol, serum ACTH, 24-h UFC, serum potassium, HDDST, LDDST, and MRI. After model selection, the Random Forest (RF) model had the most extraordinary diagnostic performance, with a ROC AUC of 0.976 ± 0.03, a sensitivity of 98.9% ± 4.4%, and a specificity of 87.9% ± 3.0%. The serum potassium, MRI, and serum ACTH were the top three most important features in the RF model. In the validation dataset, the RF model had an AUC of 0.932, a sensitivity of 95.0%, and a specificity of 71.4%. In the complete dataset, the ROC AUC of the RF model was 0.984 (95% CI 0.950-0.993), which was significantly higher than HDDST and LDDST (both p < 0.001). There was no significant statistical difference in the comparison of ROC AUC between the RF model and BIPSS (baseline ROC AUC 0.988 95% CI 0.983-1.000, after stimulation ROC AUC 0.992 95% CI 0.983-1.000). This diagnostic model was shared as an open-access website. A machine learning-based model could be a practical noninvasive approach to distinguishing CD and EAS. The diagnostic performance might be close to BIPSS.

Abstract Number ‐ 93: Endovascular thrombectomy for cerebral venous sinus thrombosis using the Penumbra Indigo Aspiration System

Introduction Cerebral venous sinus thrombosis (CVST) is an uncommon cause of stroke that can be difficult to treat. Endovascular thrombectomy techniques have evolved over time, but evidence behind the efficacy and safety of these techniques for CVST is still lacking. The Penumbra Indigo® Aspiration System (Penumbra, Inc., Alameda, California, USA) is designed to remove emboli from the peripheral arteries and veins and can potentially restore blood flow in cases of limb ischemia and venous thrombosis. We report our initial experience in the treatment of CVST using the Penumbra Indigo® Aspiration System. Methods A 35‐year‐old African American male with no major past medical history presented to the hospital with altered mental status. Computed tomography (CT) showed multiple areas of venous infarction. CT vessel imaging revealed extensive dural venous sinus thrombosis involving the superior sagittal sinus (SSS), torcula, left transverse sinus, right paramedian transverse sinus with partial filling defects in the left sigmoid sinus and distal right transverse sinus with a matched defect in the left paramedian anterior frontal lobe corresponding to the area of evolving infarct. Continuous low‐dose heparin infusion was started. Cerebral angiogram revealed evidence of extremely slow perfusion to the brain with no significant drainage through the dural sinuses with complete occlusion of the distal portion of the SSS and bilateral transverse sinuses. Furthermore, angiogram of the right internal jugular (IJ) vein displayed complete occlusion of the bilateral transverse sinuses. Results An Aristotle® 24, 200‐cm Guidewire (Scientia Vascular, Salt Lake City, Utah, USA) was inserted into a 160‐cm‐long Zoom 35™ catheter (Medtronic, Minneapolis, Minnesota, USA), and this system was then advanced within the CAT12 aspiration catheter within a right IJ 12 French Sheath under fluoroscopic guidance across the occlusion to the superior sagittal sinus, Multiple aspiration attempts were then performed. The CAT 12 Aspiration was performed in the SSS and bilateral transverse sinuses. Afterwards, CAT8 and then CAT7 were then advanced into the thrombus more proximally in the SSS and multiple aspiration attempts were performed in the SSS with the aid of the separator device. There was evidence of partial recanalization of the SSS with significant improved flow of bilateral sigmoid sinuses and bilateral transverse sinuses. A decision was made to stop the intervention. There were no complications related to these procedures. Conclusions The Penumbra Indigo® Aspiration System has been used in various arterial and venous systems but this is the first report to demonstrate its technical feasibility in thrombectomy for CVST. Further feasibility studies are necessary to inform its applicability in CVST.