Middle Turbinate Research Articles

Nasal cast deposition for xylo- and oxymetazoline formulations using two different nasal pumps

Background: Allergic rhinitis, rhinosinusitis, and upper respiratory tract infections, including the common cold, are caused by inflammation of nasal cavity areas. A key symptom is nasal congestion, which can be relieved with nasal spray medications. A key goal in developing a nasal spray medication delivery device for the relief of nasal congestion is delivering a fine mist to the inflamed areas while providing user comfort and convenience. Methodology: Using a Koken nasal cast model, we studied the deposition patterns of 2 xylometazoline and 1 oxymetazoline for- mulations with 2 different nasal pumps, the currently marketed Freepod and the investigational laterally actuated device. Effects of nasal tip orientation and breathing were investigated. Additionally, the degree of xylometazoline and oxymetazoline dripping down the back of the cast was assessed. Results: The largest coverage overall was observed with the xylometazoline formulation with the laterally actuated pump and without breath simulation. The laterally actuated pump used at a 30° angle resulted in deposition to the inferior, middle, and superior turbinates of the nasal cast, with less variability than the Freepod. Drippage at the back of the cast was observed with the Freepod device but not with the laterally actuated device. Conclusions: Using a nasal cast model, the laterally actuated pump used at a 30° angle produced a full mist covering areas inflamed with the common cold, allergic rhinitis, and rhinosinusitis with no dripping at the back of the cast, an improvement compared with the Freepod pump. In vivo studies are needed to confirm nasal cast results.

Predictive Value of Eosinophil Cationic Protein in Nasal Secretions in Eosinophilic Chronic Rhinosinusitis.

To investigate the value of secretions Eosinophilic cationic protein (ECP) detection in the diagnosis of endotypes of Chronic rhinosinusitis (CRS) and its correlation with clinical symptoms, so as to provide guidance for the clinical application of EOS and ECP detection in secretions. Patients' nasal secretions and polyps (or middle turbinate for control) were collected and their EOS% and ECP levels were measured. Correlation analysis was performed for EOS% and ECP levels in secretions and tissues, respectively. The correlation between secretions EOS% and ECP and clinical symptom scores (symptomatic visual analog scale (VAS) scores, Lanza-kennedy scores from nasal endoscopy and Lund-Mackay scores from sinus CT) was further analyzed. Receiver operating characteristic curves were used to assess the predictive potential of EOS% and ECP in nasal secretions. Eosinophilic chronic rhinosinusitis (ECRS) patients had higher concentrations of ECP in nasal secretions than healthy subjects and NECRS (non-eosinophilic CRS) (p < 0.0001;0.0001); EOS% in nasal secretions was higher in ECRS than healthy subjects (p = 0.0055), but the differences between ECRS and NECRS were not statistically significant (p = 0.0999). Correlation analysis showed that tissue EOS% was correlated with ECP concentration and EOS% in nasal secretions (R = 0.5943;0.2815). There was a correlation between EOS% in secretions with a total LM score (R = 0.3131); ECP concentration in secretions with a total LK score (R = 0.3792). To diagnose ECRS, the highest area under the curve (0.8230) was determined for ECP in secretions; the highest area under the curve (0.6635) was determined for EOS% in secretions. Measurement of ECP in nasal secretions is useful for non-invasive diagnosis of ECRS. 3 Laryngoscope, 133:3304-3312, 2023.

Case Report: Case report: An unusual presentation of granulomatosis with polyangiitis

Aim: We are reporting a case of an unusual presentation of granulomatosis with polyangiitis (GPA) with liver involvement. Case presentation: A 45-year-old male patient presented with erythematous plaques on the face and bilateral nasal obstruction. On physical examination, the patient had a ring-shaped squamous plaque on the face. The laboratory findings revealed an accelerated erythrocyte sedimentation rate at 100 mm/h, an elevated C-reactive protein at 66 mg/L, hyper gamma globulinemia 16 g/L and an elevated alkaline phosphatase (twice the upper normal limit). The craniofacial and thoracoabdominal computed tomography (CT) -scans showed ethmoid and maxillary sinusitis, low facial bone density, multiple mediastinal and hilar lymphadenopathy, diffuse small pulmonary nodules, and hepatomegaly. A cutaneous lesion biopsy, the nasal mucosa, and the liver showed a chronic inflammatory granulomatosis process with necrosis. Serum anti-neutrophil cytoplasmic antibody (ANCA) against PR3 was positive. The clinical, biological, radiological, and histological findings substantiated the diagnosis of GPA. The patient received systemic steroids combined with cyclophosphamide pulses on days 1, 14 and 28 and then he was lost to follow-up. Two-years later, he presented with a cardiac failure and skin ulcer in the right lower limb. A nasal endoscopic exam showed nasal septum cartilage perforation with resorption of the middle and inferior nasal concha. Two weeks later, he developed a diffuse alveolar hemorrhage and was therefore transferred to the intensive care unit but died of respiratory failure 3 days later. Conclusion: Clinicians should be aware of GPA atypical clinical manifestations.

Revision Skull Base Reconstruction Using Combined Inferior and Middle Turbinate Flap After Nasoseptal Flap Failure

When patients with a history of skull base reconstruction where nasoseptal flap was used require revision surgery, selecting an appropriate flap may be challenging. We report here a successful experience of using combined inferior and middle turbinate flap for revision skull base reconstruction after a nasoseptal flap failure at 22 days postoperatively. A 63-year-old female complaining of right vision loss was referred for co-operation. The patient had undergone transsphenoidal approach (TSA) resection for a pituitary adenoma 20 years ago. Sella turcica MRI showed a recurrent pituitary adenoma of 3.5×5.3-cm in size in the sellar and suprasellar areas, extending to the right cavernous sinus. Endoscopic extended TSA with nasoseptal flap reconstruction was performed for the patient. Flap necrosis followed and flap failure progressed after 10 postoperative days. The patient then underwent a skull base reconstruction using a vascularized inferior turbinate flap and a contralateral middle turbinate flap. Postoperatively, the revision flaps successfully covered the skull base defect without complications.

Missed pituitary microadenoma during endoscopic transsphenoidal surgery for short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing with symptom relief: illustrative case.

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) is a rare headache disorder that has been associated with pituitary adenomas. Resection has been posited to be curative. A 60-year-old female presented with a 10-year history of SUNCT, which had been medically refractory. Sellar magnetic resonance imaging (MRI) showed a 2 × 2 mm nodule in the right anterolateral aspect of the pituitary. Endoscopic endonasal transsphenoidal resection of the pituitary microadenoma with neuronavigation was performed. The patient felt immediate relief from the headaches. Postoperative MRI showed persistence of the pituitary microadenoma and the resection tract to be inferomedial to the lesion. The right middle and partial superior turbinectomy site was close to the sphenopalatine foramen (SPF). The patient was discharged on postoperative day 1 and remained headache-free without any medications at the 4-month follow-up. Resection of pituitary lesions associated with SUNCT may not necessarily be the cause of SUNCT resolution. Manipulation of the middle and superior turbinate close to the SPF may lead to a pterygopalatine ganglion block. This may be the mechanism of cure for SUNCT in patients with related pituitary lesions who undergo endonasal resection.

Usefulness of the Three-step Simple Binostril Approach in Endoscopic Endonasal Transsphenoidal Surgery.

We describe a three-step, simple binostril approach to endoscopic endonasal transsphenoidal surgery in cases of sellar/parasellar lesions. In the first step, the mucosa of the lower third of the ethmoid bulla on the outside was coagulated with monopolar microdissection needle and opened to create space on the outside of the middle turbinate. The middle turbinate was moved outward using this space, and the natural ostium of the sphenoid sinus could be confirmed easily. In the second step, a less than 10 mm incision was made from the right natural ostium of the sphenoid sinus to the right nasal septal mucosa. The anterior wall of the sphenoid sinus was removed to free the sphenoid sinus. In the third step, the instrument was inserted through the left nostril using a hole connected to the natural ostium of the sphenoid sinus to reach the sellar floor via both nostrils. It took longer for the trainee than for the instructor to reach the sellar floor in the first four cases. However, there was no significant difference in the approach time after the fifth case. Approach-related postoperative complications were observed in 52 cases of sellar/parasellar lesions performed. This approach was considered to provide sufficient space and was simple and less burdensome to the patient.

Delayed post-traumatic intractable epistaxis due to pseudoaneurysms in concha bullosa: a case report

BackgroundDelayed post-traumatic bleeding at various sites is known due to vascular abnormalities related to structural changes in the vessel walls, in the form of pseudo aneurysms and arteriovenous malformations. Delayed epistaxis following facial trauma is a distinct entity that presents as recurrent episodes of bleeding from the nose. History of trauma is important to differentiate it from idiopathic intractable epistaxis, the management of which is less dramatic in the beginning in the form of endoscopy and electrocauterization. However, uncontrolled post-traumatic delayed epistaxis usually requires embolization. We report a rare case of intractable epistaxis associated with multiple pseudoaneurysms (PA), due to bleeding inside concha bullosa, where even embolization was unsuccessful.Case presentationA 25-year-old male patient presented to casualty and was referred to the Otorhinolaryngology department for recurrent profuse bleeding from left nasal cavity, where conservative measures like nasal packing, and electrocauterization did not help. Patient had a history of fall from height with facial bone fractures 1 month back. Angiography revealed blush with dilatation (pseudoaneurysms) in the nasal branches of internal maxillary arteries, ascending pharyngeal and labial arteries and embolization was done in the Interventional Radiology Department. Post-embolization, the patient again developed massive epistaxis. The patient was explored under general anaesthesia, to find out the site of bleed by nasal endoscopy. Collected blood was found in the left concha bullosa. Conchoplasty of the left middle turbinate was done with cauterization of bleeding vessels. The patient had no further epistaxis and was discharged in stable condition. He is asymptomatic for the last 6 months.ConclusionPost-traumatic pseudoaneurysms is a rare cause of delayed epistaxis following nasal trauma. Angiography helps in the localization of the source of bleeding inside nasal cavity and can identify pseudoaneurysmal dilatations of vessels. Our case highlights the importance of hidden bleeding points inside concha bullosa as a source of intractable epistaxis unresponsive to embolization.

Middle turbinate resection in FESS: Do or do not?

Middle turbinate resection in FESS: Do or do not? - IJOAS- Print ISSN No: - 2582-4147 Online ISSN No:- 2582-421X Article DOI No:- 10.18231/j.ijoas.2023.001, IP Journal of Otorhinolaryngology and Allied Science-J Otorhinolaryngol Allied Sci

Modelling the effects of post-FESS middle turbinate synechiae on sinonasal physiology: A computational fluid dynamics study

Objective(s)Chronic rhinosinusitis (CRS) is common and often requires surgical intervention. Surgical failure may lead to persistent symptoms and recalcitrant disease, often secondary to synechiae between the middle turbinate (MT) and lateral nasal wall. Synechiae prevention techniques have been extensively investigated, however evidence for the effect of synechiae on sinonasal physiology is lacking. We aimed to model the effects of MT synechiae on a post-functional endoscopic sinus surgery (FESS) sinonasal cavity using computational fluid dynamics (CFD). MethodsDICOM data from a CT-sinus of a healthy 25-year-old female was segmented to create a three-dimensional model. Virtual surgery was performed to simulate a “full-house” FESS procedure. Multiple models were created, each with a single unilateral virtual MT synechia of varying extent. CFD analysis was performed on each model and compared with a post-FESS control model without synechiae. Airflow velocity, humidity and mucosal surface and air temperature values were calculated. ResultsAll synechiae models demonstrated aberrant downstream sinonasal airflow. There was reduced ventilation of the ipsilateral frontal, ethmoid and sphenoid sinuses, with a concentrated central “jet” in the middle meatus region. Effects were proportionate to the size of synechiae. The impact on bulk inspired airflow was negligible. ConclusionPost-FESS synechiae between the MT and lateral nasal wall significantly disrupt local downstream sinus ventilation and nasal airflow. These findings may explain the persistent symptoms seen in post-FESS CRS patients with MT synechiae, reinforcing the importance of prevention and adhesiolysis. Larger cohort studies with multiple models of actual post-FESS patients with synechiae are required to validate these findings.

Two cases of concha bullosa in a contemporary Cypriot skeletal collection

Concha bullosa is the hypertrophy of the superior, middle, or inferior nasal conchae, most commonly referring to the pneumatisation of the middle conchae. It is considered to be the most common anatomical variant of the osteomeatal complex, rather than a pathological development. Though it is common, its aetiology is poorly understood. It is unclear whether sex or ethnicity impacts on the prevalence of concha bullosa, though some research suggests a correlation. Some researchers have argued that concha bullosa predisposes individuals to sinusitis, but the link is not consistent. In this paper, the authors present two new skeletal cases of bilateral concha bullosa identified in female individuals taken from the Cyprus Reference Research Collection (CRRC). This work aims to highlight the limitations associated with the palaeopathological diagnosis of inflammation and the interpretation of skeletal lesions that may be related to sinusitis or infection of the osteomeatal complex in archaeological bone, in relation to the presence of concha bullosa.

Clinical characteristics of nasal respiratory epithelial adenomatoid hamartoma

〓 Objectives: To analyze the pathological and clinical features of nasal respiratory epithelial adenomatoid hamartoma（REAH）, and summarize the diagnostic points, to improve the experience of diagnosis and treatment. Methods:The clinical data of 16 patients with REAH were analyzed retrospectively. The clinical manifestations, pathological features, imaging features, surgical treatment and prognosis were summarized. Results:16 cases of REAH were studied, 10 cases（62.50%） were associated with sinusitis, 1 case（6.25%） was associated with inverted papilloma, 1 case（6.25%） was associated with hemangioma. 5 cases（31.25%） had a history of nasal sinus surgery, including 1 case with 3 times of nasal sinus surgery, 1 case with 2 times of nasal sinus surgery, 3 cases with 1 time of nasal sinus surgery; 10 cases（62.50%） occurred in the bilateral olfactory cleft, 2 cases（12.50%） in the unilateral olfactory cleft, 3 cases（18.75%） in the unilateral middle turbinate, 1 case（6.25%） in the nasopharynx. All 16 patients were pathologically diagnosed as REAH. In the patients with lesions located in bilateral olfactory fissures, symmetrical widening of olfactory fissures and lateral displacement of middle turbinate were observed on preoperative sinus CT. The average width of bilateral olfactory fissures was （9.9±2.70） mm. The ratio of wide to narrow olfactory cleft was 1.21 ± 0.19. There was no significant difference in Lund-Mackay score between the two sides（P>0.05）. All patients underwent surgery under general anesthesia and nasal endoscopy. The follow-up period ranged from 1 to 66 months, and no recurrence occurred. Conclusion:Preoperative diagnosis of REAH is facilitated by the combination of clinical manifestations and endoscopic and imaging features. Endoscopic complete resection can achieve a good therapeutic effect.

Importance of S-point in the Management of Severe Epistaxis

Although severe epistaxis is uncommon, it is serious. The systematic endoscopic nasal examination is an essential step in identifying the bleeding point and aiding electrocauterization. Currently, the S-point, which is located in the superior part of the nasal septum behind the septal body and corresponding to the axilla of the middle concha, is identified in about 30% of cases with severe epistaxis. Cauterization of this point has an excellent rate of controlling the bleeding and preventing its recurrence. We aimed to highlight the significance of the S-point in the management of severe cases of epistaxis.

CT of Anatomic Variants of Sinonasal region and its correlation with symptoms of Rhinosinusitis

Background: Sinonasal region is subjected to wide anatomical variation. The paranasal sinuses (PNS) create a connection with nasal cavity. They are placed in close proximity to nose. The four paranasalsinuses ;maxillary, ethmoid, sphenoid, and frontal, are named after their coinciding bone. Computed Tomography (CT Scan )is important modality to describe the location of these paranasal sinuses. Aim: To ascertain the frequency of various anatomic variants of sinonasal region in population of Sahiwaland itsassociation with symptoms of rhinosinusitis. Methods: This descriptive cross sectional study was conducted in Sahiwal Teaching Hospital from 10th June 2022 – 10th December 2022, with collaboration of Radiology and otorhinolaryngeology Departments. 60 symptomatic subjects between 18-60 years of age, irrespective of gender with rhinosinusitiswere taken.They underwent CT Scan of paranasal sinuses. The findings of CT Scan related to nasal-septum, turbinates, uncinate process, ethmoid air-cells and other anatomical variants corresponded with symptoms of rhinosinusitis. The data was analyzed using SPSS version 23.0. Frequency, percentages and p-value of different variants were calculated. The p-value of ≤ 0.05 was considered as significant. Results: Our study showed 63.3% males and 36.7% females. The mean age of our subjects was 30.65 + 12.7 years. The most frequently seen anatomical variants in our population were nasal septum deviation (86.7%) followed by aggernasi cells (68.3%) and asymmetry of both sides of sphenoid sinuses (68.3%). The statically significant association was noted between concha bullosa of middle turbinate and nasal obstruction ( p-value 0.001) and between rhinorrhea and asymmetry of both sides of sphenoid sinus ( p-value 0.035) Practical Implications &amp; Conclusion: We concluded from our study that that however there is no significant association between rhinosinusitis and most of the anatomic variants of sinonasal region except concha bullosa of middle turbinate and asymmetry of both sides of sphenoid sinus. But to avoid operative complexities, a surgeon must be well aware of these diverse variants. Keywords: Anatomical variations, CT-scan, Rhinosinusitis

Feasibility of intranasal delivery of thin-film freeze-dried, mucoadhesive vaccine powders

Intranasal vaccination by directly applying a vaccine dry powder is appealing. However, a method that can be used to transform a vaccine from a liquid to a dry powder and a device that can be used to administer the powder to the desired region(s) of the nasal cavity are critical for successful intranasal vaccination. In the present study, using a model vaccine that contains liposomal monophosphoryl lipid A and QS-21 adjuvant (AdjLMQ) and ovalbumin (OVA) as a model antigen, it was shown that thin-film freeze-drying can be applied to convert the liquid vaccine containing sucrose at a sucrose to lipid ratio of 15:1 (w/w) into dry powders, in the presence or absence of carboxymethyl cellulose sodium salt (CMC) as a mucoadhesive agent. Ultimately, the thin-film freeze-dried AdjLMQ/OVA vaccine powder containing 1.9% (w/w) of CMC (i.e., TFF AdjLMQ/OVA/CMC1.9% powder) was selected for additional evaluation because the TFF AdjLMQ/OVA/CMC1.9% powder was mucoadhesive and maintained the integrity of the antigen and the physical properties of the vaccine. Compared to the TFF AdjLMQ/OVA powder that did not contain CMC, the TFF AdjLMQ/OVA/CMC1.9% powder had a lower moisture content and a higher glass transition temperature. In addition, the TFF AdjLMQ/OVA/CMC1.9% thin films were relatively thicker than the TFF AdjLMQ/OVA thin films without CMC. When sprayed with Aptar Pharma’s Unidose Powder Nasal Spray System (UDSP), the TFF AdjLMQ/OVA powder and the TFF AdjLMQ/OVA/CMC1.9% powder generated similar particle size distribution curves, spray patterns, and plume geometries. Importantly, after the TFF AdjLMQ/OVA/CMC1.9% powder was sprayed with the UDSP nasal device, the integrity of the OVA antigen and the AdjLMQ liposomes did not change. Finally, a Taguchi L4 orthogonal array was applied to identify the optimal parameters for using the UDSP device to deliver the TFF AdjLMQ/OVA/CMC1.9% powder to the middle and lower turbinate and the nasopharynx regions in both adult and child nasal replica casts. Results from this study showed that it is feasible to apply the thin-film freeze-drying technology to transform a nasal vaccine candidate from liquid to a dry powder and then use the UDSP nasal device to deliver the vaccine powder to the desired regions in the nasal cavity for intranasal vaccination.

Multi-layer reconstruction of skull base after endoscopic transnasal surgery for invasive pituitary adenomas.

To explore the efficacy of multi-layer skull base reconstruction after endoscopic transnasal surgery for invasive pituitary adenomas (IPAs). Skull base reconstruction for IPAs. This retrospective analysis involved 160 patients with IPAs who underwent operations from October 2018 to October 2020. All patients were diagnosed with IPAs by pituitary enhanced magnetic resonance imaging, and all tumours were confirmed to be Knosp grades 3a, 3b, or 4. The experimental group and the control group comprised 80 patients in each, and we used different methods to reconstruct the skull base in each group. The comparison indicators included cerebrospinal fluid leakage, sellar floor bone flap (or middle turbinate) shifting, delayed healing of the skull base reconstructed tissue, nasal discomfort, and epistaxis. We used the chi-square test, and p < 0.05 was considered statistically significant. In the experimental group, cerebrospinal fluid leakage occurred intraoperatively in 73 patients, two of whom had cerebrospinal fluid leakage postoperatively. Brain CT 12 months postoperatively showed no sellar floor bone flap (or middle turbinate) shifting. Endoscopic transnasal checks performed seven days after surgery showed that the skull base reconstructed tissue had healed in 74 patients and had failed to heal in six. However, endoscopic transnasal checks showed that all six of these patients' pedicled nasoseptal flaps had healed well by 14 days after surgery. Other sequelae comprised nasal discomfort in four patients, and epistaxis in four. In the control group, cerebrospinal fluid leakage occurred intraoperatively in 71 patients, 14 of whom had cerebrospinal fluid leakage postoperatively. Brain CT 12 months postoperatively showed floor bone flap (or middle turbinate) shifting in 12 patients. Endoscopic transnasal checks performed seven days after surgery showed that the skull base reconstructed tissue had healed in 65 patients. In 12 patients, pedicled nasoseptal flaps had healed well by 14 days after surgery, while the remaining three patients required reoperation. Other sequelae comprised nasal discomfort in five patients, and epistaxis in six. This new method of multi-layer skull base reconstruction could play an important role in endoscopic transnasal IPA surgery.

Quantitative study of Artemisia pollens deposition in the upper airways of children with adenoidal hypertrophy

Studies regarding the pollen transport and deposition in children nasal airways are still scarce, especially the regional deposition doses, which is difficult to provide guidance for precise application of pollen blockers and nasal administration. In addition, most previous investigations included only one child case, which lacked statistical significance. To this end, we used computational fluid particle dynamics (CFPD) modeling approach to calculate the deposition pattern of Artemisia pollen at various anatomical sites in the upper airway of 12 children with adenoid hypertrophy (AH), and analyzed the effects of respiratory flow rate and pollen density on the deposition distribution. Adult nasal airways from our previous study were included for data comparison. We found that nasal cavities of children with AH aged 4–6 years had a greater area/volume ratio than adults did, and the area and volume of the turbinate region were less than half that of adults. The physical diameter of Artemisia pollen was set to 21.0 μm, with a shape of ellipsoid. Its average density is 1080 kg/m3 in the humid state and 550 kg/m3 in the dry state. In resting state, children with AH had higher deposition rates of wet Artemisia pollen in the nasal septum and nasopharynx, and lower deposition rates in the nasal vestibule and middle turbinate compared with adults. Under exercising conditions, wet pollen was deposited mainly in the nasal vestibule and the anterior part of the nasal septum in children. Compared to wet pollen, the deposition rate of dry Artemisia pollen in resting state was approximately halved and the pollen entering the lower respiratory tract rose approximately 47-fold. The findings suggest that nasal cavities of children are not simply scaled-down version of adults. Notable differences in deposition hotspots and deposition patterns have been discovered between the two. The deposition hotspots shifted significantly forward as the respiratory flow rate increased. Dry Artemisia pollen has a low density and is more likely to enter the lower respiratory airways, which may put children at a higher risk of developing asthma.

Case Report: An unusual presentation of granulomatosis with polyangiitis

Aim: We are reporting a case of an unusual presentation of granulomatosis with polyangiitis (GPA) with liver involvement. Case presentation: A 45-year-old male patient presented with erythematous plaques on the face and bilateral nasal obstruction. On physical examination, the patient had a ring-shaped squamous plaque on the face. The laboratory findings revealed an accelerated erythrocyte sedimentation rate at 100 mm/h, an elevated C-reactive protein at 66 mg/L, hyper gamma globulinemia 16 g/L and an elevated alkaline phosphatase (twice the upper normal limit). The craniofacial and thoracoabdominal computed tomography (CT) -scans showed ethmoid and maxillary sinusitis, low facial bone density, multiple mediastinal and hilar lymphadenopathy, diffuse small pulmonary nodules, and hepatomegaly. A cutaneous lesion biopsy, the nasal mucosa, and the liver showed a chronic inflammatory granulomatosis process with necrosis. Serum anti-neutrophil cytoplasmic antibody (ANCA) against PR3 was positive. The clinical, biological, radiological, and histological findings substantiated the diagnosis of GPA. The patient received systemic steroids combined with cyclophosphamide pulses on days 1, 14 and 28 and then he was lost to follow-up. Two-years later, he presented with a cardiac failure and skin ulcer in the right lower limb. A nasal endoscopic exam showed nasal septum cartilage perforation with resorption of the middle and inferior nasal concha. Two weeks later, he developed a diffuse alveolar hemorrhage and was therefore transferred to the intensive care unit but died of respiratory failure 3 days later. Conclusion: Clinicians should be aware of GPA atypical clinical manifestations.

Middle Turbinate Pyocele, an Uncommon Differential for Nasal Mass: A Case report.

Mucoceles are respiratory epithelium-lined cystic lesions found in the paranasal sinuses. Pyocele occurs when a mucocele becomes infected. Mucoceles develop as a result of obstruction of the normal sinus drainage tract with superadded infection. Inflammatory mediators are secreted, which lead to bone resorption and expansion of the mucocele. Concha bullosa is one of the most common anatomical variations in the nasal cavity. It refers to an air-filled cavity within the middle turbinate. Obstruction of the concha bullosa can rarely lead to the formation of a mucocele which may be secondarily infected forming a mucopyocele. The mucocele of the middle turbinate may present as an uncommon cause of nasal obstruction, headache, and other nasal or ocular symptoms, which, if correctly diagnosed, can be completely reversed by endoscopic surgery.

Endoscopıc Anatomy of the Lacrımal Sac: A Cadaverıc Study.

To describe the anatomy of the lacrimal sac in relation to the lateral nasal wall by cadaver dissection, and to measure the distances of surgically important landmarks from relevant structures for safer and more efficient surgery. A total of 12 endoscopic dacryocystorhinostomy (DCR) were performed on both sides (right and left) of 6 fresh-frozen cadavers. The distances of the lacrimal sac to the posterior edge of the uncinate process, the frontal process of the maxilla, the maxillary ostium, the nasal vestibule, the middle turbinate attachment and the inferior turbinate were measured. In addition, the width and length of the lacrimal sac were measured. The mean width and length of the lacrimal sac were 5.6 mm and 11.1 mm, respectively. The lacrimal sac was located at 15.2 mm from the posterior edge of the uncinate process, at 35.5 mm from the nasal vestibule, at 13.5 mm from the maxillary ostium, at 12.2 mm from the frontal process of the maxilla, at 8.7 mm from the middle turbinate attachment, and at 7.3 mm from the inferior turbinate. This study provides additional measurements regarding the lacrimal sac and its relationships with nearby landmarks for use in endoscopic dacryocystorhinostomy. The distances of the lacrimal sac to the nasal vestibule, the uncinate process and the frontal process of the maxilla are not as reliable as the middle turbinate attachment for predicting the anatomic localization of the lacrimal sac during DCR.

Anatomical landmarks for localisation of the anterior ethmoidal artery: a combined radiological and cadaveric (endoscopic) study

PurposeThe anterior ethmoidal artery is a major surgical landmark that is susceptible to iatrogenic injury during surgery of the anterior ethmoidal sinus, frontal sinus, and skull base. The present study aimed to define the location of the anterior ethmoidal artery in relation to specific anatomical landmarks using radiological imaging and endoscopic dissection.MethodsEighty-six anterior ethmoidal arteries were assessed using computed tomography scans (bilateral analyses) and forty anterior ethmoidal arteries were assessed using cadaveric specimens (bilateral analyses). The skull base, anterior nasal spine, anterior axilla of the middle turbinate, and nasal axilla were morphometrically analysed to determine their reliability as anterior ethmoidal artery landmarks.ResultsDistances to the skull base, anterior nasal spine, and nasal axilla displayed statistically significant differences between sexes and sides (p < 0.05). All landmarks demonstrated excellent reliability as anatomical landmarks for the localisation of the anterior ethmoidal artery, radiologically and endoscopically (ICC values ranged from 0.94 to 0.99).ConclusionThe middle turbinate axilla was the most reliable landmark, due to the lack of statistically significant differences according to sex and laterality, and the high inter-rater agreement between measurements. Anatomical knowledge of variations and relationships observed in the present study can be applied to surgeries of the anterior ethmoidal sinus, frontal sinus, and skull base to improve localisation of the anterior ethmoidal artery, preoperatively and intraoperatively, and avoid iatrogenic injury of the vessel.