Sinus Drainage Pathway Research Articles

Balloon Sinuplasty Versus Surgical Management of Chronic Rhinosinusitis

The first US Food and Drug Administration-approved dilating balloon catheter system for obstructed paranasal sinus drainage pathways was introduced in September 2005. It was discussed as an alternative treatment option for traditional endoscopic sinus surgery for those suffering from chronic rhinosinusitis. Widespread patient interest has ensued, although controversy regarding application of this device continues. Many otolaryngologists have been trained to use the device, and more than 88,000 patients have had surgery using this device. Like similar dilating catheters used in other specialties to relieve obstruction, it is a minimally invasive tool for mucosal-sparing dilation of sinus ostia or sinus outflow tracts. Although studies have been completed that demonstrate feasibility, safety, and long-term patency of dilated sinuses, the evolving indications for its use remain controversial. Referring physicians and patients can expect a range of opinions on the role of these devices in the treatment of rhinosinusitis for the foreseeable future.

粘液線毛系からみた上気道疾患

Mucociliary transport so critical in nasal, paranasal sinus, and middle ear physiology is impaired in chronic sinsusitis and otitis media by factors such as increased mucus viscoelasticity, decreased ciliary area, and primary or secondary ciliary immotility. We reviewed the pathophysiology of primary ciliary dyskinesia, otitis media with effusion, chronic sinusitis, and allergic rhinitis in terms of mucociliary transport. Subjects with primary ciliary dyskinesia may experience recurrent middle ear infection, chronic airway infection, predominantly lower-lobe bronchiectasis, male sterility, or situs inversus. Primary ciliary dyskinesia is sometimes difficult to diagnose in cases without situs inversus. Nasal nitric oxide concentration in such patients decreases, although why is unclear. Mutations may involve dynein arm intermediate chain 1 (DNAI1) or dynein arm heavy chain 5 (DNAH5). Mucociliary clearance decreases more in those with otitis media with effusion than in those without, due in part to increased middle ear effusion viscosity. Prognosis is poor in subjects with viscous effusion, which is difficult to clear from the middle ear via the mucociliary system. An understanding of anatomic paranasal sinus variations is thus extremely important in chronic sinusitis when endoscopic sinus surgery is attempted, although recent advances in computed tomography (CT) have enabled paranasal sinus drainage pathways to be delineated more clearly than ever before.

Correlation of Computed Tomographic Findings and Intraoperative Findings in Patients with Chronic Sinusitis

ABSTRACT Objective Chronic sinusitis affects more than 30 million people each year worldwide. Computed tomography (CT) has become a standard diagnostic tool in the evaluation of paranasal sinuses (PNS), but medical literature lacks studies correlating preoperative CT and intraoperative findings of functional endoscopic sinus surgery (FESS). The aim of our study was to evaluate ostiomeatal unit on multidetector CT (MDCT) and correlate findings of MDCT with intraoperative findings during FESS in patients with chronic sinusitis and hence check for its usefulness during surgery. Study design Prospective clinical study. Materials and methods Forty-nine patients with chronic sinusitis who visited the Lok Nayak Hospital, Delhi, India, between October 2010 and February 2012 were included in the study. All such patients underwent preoperative CT scan of PNS before surgery, i.e., FESS with or without septoplasty under general anesthesia. Results Maxillary sinus was found to be the most common sinus involved in chronic sinusitis. Preoperative CT findings correlated well with intraoperative findings for all sinuses except left maxillary sinus. Conclusion Multiplanar CT of nose and PNS helps to deli­neate the anatomy of nose and PNS, and drainage pathways of sinuses preoperatively. Therefore, the operating surgeon should be well versed with it. Progress of endoscopic sinus surgery can be partially attributed to revolution in imaging modalities. How to cite this article Tandon S, Rathore PK, Raj A, Prakash A, Wadhwa V. Correlation of Computed Tomographic Findings and Intraoperative Findings in Patients with Chronic Sinusitis. Clin Rhinol An Int J 2017;10(2):78-85.

Three-dimensional reconstruction based on computed tomography images of the frontal sinus drainage pathway

This study aimed to investigate the utility of three-dimensional reconstructions of paranasal sinus computed tomography data in depicting the anatomy of the frontal sinus drainage pathway. Twenty-nine patients underwent imaging of the sinuses for various clinical indications. Variations in frontal sinus recess anatomy were determined from 0.75-mm thick coronal, axial and sagittal computed tomography images. Three-dimensional, reformatted images were generated from manually segmented volumes of interest. Observations were made on the variation and usefulness of these reconstructions. Three-dimensional, reformatted images of segmented volumes aided delineation of the spatial relationships of the frontal sinus, frontal sinus drainage pathway, infundibular and meatal direction of drainage, agger nasi cells, ethmoid bulla cells, supraorbital cells, and suprabullar cells. Three-dimensional, reformatted images of frontonasal anatomy enable improved understanding of the frontal sinus drainage pathway anatomy and of the spatial relationships between ethmoid air cells in this region. Such images may provide a useful adjunct to surgical planning and education.

Management of Frontoethmoidal Cells in Frontal Recess Surgery

Frontal recess surgery is the most demanding and technically challenging part of endoscopic sinus surgery. The complexity of the anatomy and proximity with the skull base, the orbit, and the anterior ethmoidal artery often make the endoscopic approach to the frontal sinus drainage pathway difficult and increase the possibility of complications. The basic key structures to the frontal recess are the agger nasi cell and the superior fusion of the uncinate process. Above the agger nasi, the four categories of frontoethmoidal cells contribute to the complexity of the anterior wall of the frontal recess, and the bulla ethmoidalis, the suprabullar cells, and frontal bulla cells may also narrow the frontal sinus outflow. The supraorbital cells are often associated with low position of the anterior ethmoidal artery. Finally, the intersinus septal cells displace the frontal sinus drainage pathway posterolaterally, draining anteriorly into one or both middle meatuses. Clear understanding of the three-dimensional anatomy of the area is of upmost importance for a successful surgical approach. Thorough preoperative study of the CT scan with graphical reconstruction, as described in the literature, is the best way to achieve this. The concept will be presented with examples of various pathologies and anatomical configurations. The aid of frontal mini trephination and the use of image guidance will be outlined. Finally, the balloon dilatation of the frontal drainage pathway will be discussed, with reference to possible indications and contraindications.

Endoscopic Endonasal Repair of Difficult-To-Access Cerebrospinal Fluid Leaks of the Frontal Sinus

Cerebrospinal fluid (CSF) leaks located within the frontal sinus can be difficult to repair effectively. Additional challenges arise from the need to simultaneously repair the leak or defect and to ensure the future patency of the sinus itself. The cases of two patients who underwent surgical repair of CSF leaks and skull base defects located in difficult to access locations within their frontal sinuses were reviewed. Two patients with CSF leaks in the frontal sinus underwent surgery to repair the leaks. The leaks were in the superomedial and superolateral locations within the sinus. One leak (in the superolateral location) was secondary to iatrogenic surgical trauma during craniotomy. The second leak (in the superomedial location) was secondary to congenital encephalocele. Surgical approach to ensure adequate exposure was via endoscopic modified Lothrop procedure. Successful repair was undertaken via underlay technique. At follow-up (27 and 7 months, respectively), frontal sinuses remained patent without evidence of CSF leak. CSF leaks located in medial and lateral areas of the frontal sinus may be successfully repaired via endonasal approach with endoscopic modified Lothrop. Repair in this manner requires that attention be paid both to achieving a complete repair and to maintaining a patent sinus drainage pathway.

Paranasal Sinus Mucoceles : Surgical Management In A Nigerian Tertiary Health Institution.

Objective: To study and review the surgical management of the mucoceles of the paranasal sinuses in a Nigerian tertiary health institution . Materials and Methods: This is a retrospective study of surgical management of all cases of mucoceles of the paranasal sinuses at the Usmanu Danfodiyo University Teaching Hospital Sokoto from Jan.2000 to Dec. 2005 who were seen by both departments of Otorhinolaryngology and Ophthalmology. Results: A total number of 2242 patients were seen who had rhinosinusitis during the period. Seventy five patients(3.3%) underwent surgeries for rhinosinusitis out of which 10(13.3%) were cases of mucoceles from chronic rhinosinusitis. Nine were males and one female (male: female ratio 9:1). Their ages ranged from nine to 45 years with an average age of 25.8 years.Facial asymmetry from cystic swelling with non axial proptosis was the commonest clinical presentation. Duration of symptoms varied from three to 15 years with an average symptom duration of 6.8 years. Frontal sinus, five cases (50%) followed by ethmoidal sinus, four cases (40%) and sphenoidal sinus, one case (16.7%) were the paranasal sinuses involved. There was no intracranial extension. Chronic rhinosinusitis was the only identifiable remote predisposing factor. External sinus surgeries (fronto-ethmoidectomy, and sphenoidectomy through different transfacial approaches) along with reconstruction of sinus drainage pathway were carried out with no complication or recurrence post-operatively. Conclusion: Mucoceles of the paranasal sinuses require appropriate surgical technique for adequate exposure and drainage in order to avoid recurrence. Keywords: Mucoceles, Paranasal sinus, Rhinosinusitis Nigerian Journal of Plastic Surgery Vol. 3 (2) 2007: pp. 47-53

Endoscopic management of the inverted papilloma with attachment to the frontal sinus drainage pathway

Conclusion. Extensive inverted papilloma (Krouse T3 lesions) with attachment to the frontal sinus drainage pathway can be treated successfully using an endoscopic approach. Objectives. The endoscopic management of inverted papilloma (IP) has gained in popularity over the last 15 years. However, the appropriate management of lesions involving the frontal sinus and its drainage pathway still has to be determined. Patients and methods. We performed a retrospective review of the results for patients with IP in the Otolaryngology, Head and Neck Surgery Department, Beijing Tongren Hospital from 2004 to 2007 to identify those patients with lesions involving the frontal sinus and its drainage pathway. By their appearance on nasal endoscopic examination and by computed tomography scanning, the tumors were defined using the Krouse staging system. Sinus endoscopy was used to screen for disease after endoscopic resection and the clinical outcomes were analyzed. Results. A total of nine patients (eight males and one female) were identified in which IP involved the frontal sinus and its drainage pathway. Preoperative and postoperative pathological examinations revealed IP as the diagnosis. All tumors were defined as T3 lesions. Four cases with lateral wall of frontal recess tumor attachment underwent an endoscopic Draf IIA frontal sinusotomy. Three cases with either lateral and posterior walls of frontal recess and frontal infundibulum attachment, or medial and posterior walls of frontal recess and frontal infundibulum attachment underwent a Draf IIB procedure. Two cases with posterior wall of frontal recess and frontal infundibulum attachment, or medial, lateral, and posterior walls of frontal recess and frontal infundibulum attachment underwent a Draf III procedure. All patients remain disease-free after an average follow-up period of 15 months.

Medical management in functional endoscopic sinus surgery failures.

Functional endoscopic sinus surgery has a high rate of success, ranging from 75 to 95% improvement in symptoms for patients who have medically refractory chronic rhinosinusitis. However, symptom improvement does not necessarily correlate with disease resolution, and even asymptomatic patients may require long-term medical management and endoscopic surveillance if late recurrence is to be avoided. The 5 to 25% percent of patients who continue to have symptoms create a challenge for the rhinologist. Correct diagnosis is the hallmark of successful treatment of this recidivistic population, carried out through history, nasal endoscopy, and radiologic (computed tomography) studies. Particularly in patients with a primary complaint of headache or facial pain, the initial preoperative diagnosis should also be revisited, particularly before further surgical intervention is considered. Once a proper diagnosis is made, management is multifaceted, including topical and systemic medications, and mechanical improvements in the sinus drainage pathways, either through treatments in the office or revision surgery. Therefore, we strongly recommend that chronic rhinosinusitis be viewed as a medical disease in which surgery plays a therapeutic role. Frequently, persistent inflammation slowly settles down over time with appropriate medical management.