Arrested pneumatization: witness of paranasal sinuses development?

OBJECTIVES

Recent radiological studies have demonstrated that formation of the sphenoid sinus is preceded by a phase of fatty transformation of the bone marrow, and then by a phase of fat involution prior to the appearance of an aerated cavity and that this process can sometimes be interrupted, resulting in the persistence of images of arrested pneumatisation. The objective of the study was to confirm the existence of arrested pneumatisation in the sphenoid bone, and to investigate the presence of similar images in the maxilla, frontal and ethmoid bones.

MATERIAL AND METHODS

In this single-centre, retrospective study, 207 CT scans with no signs of mucosal opacity or sinus retention performed for assessment of septorhinoplasty or chronic nasal dysfunction were reviewed according to Welker's criteria to detect images of arrested pneumatisation.

RESULTS

Twenty-two patients presented 30 images suggestive of arrested pneumatisation of the maxilla (13/30), sphenoid (10/30) and frontal (7/30) bones. No images of arrested pneumatisation were observed in the ethmoid bone.

CONCLUSIONS

The results of this study question the classical mechanisms of formation of the paranasal sinuses. According to the hypothesis of postnatal bone cavitation resulting from bone marrow involution and centripetal gas production, paranasal sinuses would constitute distinct organs that develop independently of the ethmoidal olfactory organ, which is formed from the embryonic cartilaginous olfactory capsule.

Septorhinoplasty by disarticulation: early assessment of a new technique for morphological correction of crooked noses

OBJECTIVE

This study was aimed to assess the early morphological results of a new septorhinoplasty technique based on disarticulation (SRD) between bony and cartilaginous nose structures.

METHODOLOGY

A retrospective, multi-judge, blind comparison of pre- and post-operative photographs displayed on Google documents was designed. A nasal morphology analysis grid based on 10 items was fulfilled independently by 6 judges to assess pre- and post-operatively, two times with a 15 day interval, the severity of each deformity by a score between 0 and 2. The sum of all deformities in a single patient produced the individual global score of nasal deformity, which was set between 0 and 20 for each patient. Pre- and post-operative individual global scores were compared using Student`s t test on paired samples. Percentages of post-operative improvement and deterioration were calculated for each item.

RESULTS

Thirty-five SRD were analyzed. Before surgery, 80% of noses were humped and 86% were crooked; three months after surgery, 64% of noses had a rectilinear nasal crest on profile and 57% on facial view. The mean global score of deformities drop- ped from 11.1 before surgery to 5.8 after surgery, an improvement of 47% . Improvement rates of 82% and 74.3% were obtained, respectively, for hump profiles and orbitonasal lines.

DISCUSSION

The early morphological results of SRD allow to propose this technique as a possible solution to correct crooked noses with humps.

The Reference Level of Serum S-100B Protein for Poor Prognosis in Patients with Intracranial Extracerebral Hematoma

BACKGROUND

S-100B protein, blood-brain barrier permeability marker, is one of a few biochemical indicators useful in the evaluation of traumatic brain injury. Our aim was to correlate serum concentration of S-100B with clinical condition and CT head scan findings as well as to estimate the level of the protein significant for clinical outcome prediction.

METHODS

The cohort of 41 subjects underwent clinical examination by the neurosurgeon, consciousness was evaluated with Glasgow Coma Scale (GCS). Diagnosis was established on the basis of CT head scans. Venous blood samples were collected before surgery. Serum concentration of S-100B protein was estimated using electrochemiluminesce immunoassays (ECLIA) on Cobas 6000 Analyzer (Roche Diagnostics). Clinical outcome was measured applying Glasgow Outcome Scale (GOS). Finally, data were analyzed with Statistica, v. 8.0 (StatSoft, Inc. 2007).

RESULTS

The average S-100B concentration was 0.95 ± 1.75 μg/L. Statistical analysis revealed significant correlation between S-100B and GCS, GOS and dimers-D concentration (p<0.001, Spearman correlation test). There were statistically significant differences in the S-100B concentration depending on the presence of brain oedema (1.29±2.02 vs. 0.06±0.03; p<0.01, Mann-Whitney test) or contusion foci (1.37±1.77 vs. 0.72±1.92; p<0.01) in CT scans. The S-100B concentration of 0.288 μg/L was determined as a cut-off point for unfavorable clinical outcome prediction (ROC, p<0.001).

CONCLUSIONS

Association between serum S-100B concentration and clinical, radiological or laboratory findings prove its usefulness as a diagnostic marker for assessment of brain trauma severity. The concentration of the protein >0.288 μg/L is associated with poor prognosis.

Validation of a self-questionnaire for assessing the control of allergic rhinitis

BACKGROUND

Allergic rhinitis affects the lives of patients for whom discomfort is, in most cases, significantly improved by pharmacological treatment.

OBJECTIVE

To develop and validate a self-assessment global score for allergic rhinitis control (five items scored from 1 to 5 assessing the rhinitis over the 2 previous weeks).

METHODS

Study of acceptability, reliability, validity and sensitivity to change during a prospective observational study in 902 patients selected by 411 general practitioners or allergists.

RESULTS

The score correlated significantly to the clinical picture and to the impact of the rhinitis on social and sports activities at inclusion (P<0.0001). A significant improvement in the score was observed after 15 days of treatment: 14.9 ± 4.0 at inclusion and 21.5 ± 2.9 at re-evaluation after 15 days of treatment (P<0.0001). Using receiver operating characteristics curve, a score of 20 was the cut-off for poor vs. well-controlled rhinitis; a score strictly higher than 20 (best being 25) had a sensitivity of 67%, a specificity of 82%, a negative predictive value of 32% and a positive predictive value of 95%.

CONCLUSION AND CLINICAL RELEVANCE

The self-assessment score for allergic rhinitis control appeared to be sensitive to change and correlated to the clinical expression of rhinitis and also to its involvement with treatment. These results suggest that this self-completion questionnaire could be used in daily practice at each consultation to determine, in a standardized manner, the level of control of the allergic rhinitis of an individual patient.

Pathology of tumours originating in the olfactory cleft

PROBLEMS/OBJECTIVE: This study describes the variety of tumours originating in the olfactory cleft which have been treated with endonasal endoscopic surgery.

METHODOLOGY

The study is a retrospective review covering a seven-year period (2004-2010) of the medical records of all patients in whom a tumour originating in the olfactory cleft was excised (72 patients: 63 men and 9 women; age: average of 61 years; range, 19 to 90 years).

RESULTS

The most common tumours in the series were adenocarcinoma (43 [60%] patients), inverted papilloma (7 [10%] patients), respiratory epithelial adematoid hamartoma (6 [8%] patients) and olfactory neuroblastoma (5 [7%] patients).

CONCLUSIONS

The olfactory cleft can be identified as a new surgical field for endonasal endoscopic surgery. This anatomic region is amenable to endoscopic evaluation and the excision of tumours. Exenteration of the olfactory cleft appears to be a key technique for removing adenocarcinoma and can be extended to exenteration of the olfactory groove in cases with intracranial extension. Partial exenteration of the olfactory cleft would seem to be a suitable way of removing benign tumours like inverted papilloma or respiratory epithelial adematoid hamartoma.

CT assessment of woodworkers' nasal adenocarcinomas confirms the origin in the olfactory cleft

BACKGROUND AND PURPOSE

Endoscopic endonasal surgery let us observe that woodworkers' nasal adenocarcinomas originate in the olfactory cleft. Our aim was the identification of CT imaging features that corroborate the olfactory cleft as the site of origin for woodworkers' adenocarcinoma.

MATERIALS AND METHODS

We designed a retrospective study to compare CT scans of 27 unilateral olfactory cleft adenocarcinomas with 30 cases of nasosinusal polyposis (NSP) and 33 healthy sinus controls. Enlargement of the olfactory cleft, lateralization of the ethmoidal turbinate wall, and contralateral bulging of the nasal septum were measured on coronal scans passing through crista galli and posterior half of both ocular globes. Comparisons have been performed by using analysis of variance and the Bonferroni procedure.

RESULTS

The nasal septum was significantly bulging across the midline in adenocarcinoma (4.6 +/- 3 mm; range, -0.1-13.7 mm) compared with NSP (0.7 +/- 1 mm; range, -2.1-2.3 mm) or healthy sinus controls (0.5 +/- 1 mm; range, -1.2-2 mm) (P < .001). The olfactory cleft was significantly wider in adenocarcinoma (15.1 +/- 4.5 mm; range, 8.6-25.7 mm) than in NSP (3.6 +/- 0.4 mm; range, 2.8-4.6 mm) or healthy sinus controls (3.3 +/- 0.7 mm; range, 1.4-4.6 mm). The ethmoidal labyrinth width was significantly smaller on the pathologic side in adenocarcinoma (7.2 +/- 2.7 mm; range, 3.2-14.2 mm) than in the control groups (P < .001). Whereas the angle between the conchal lamina and vertical midline was close to zero degrees in NSP (0.03 +/- 2.25 degrees ; range, -5 degrees -3 degrees ) and healthy sinus controls (0.45 +/- 2.13 degrees , range, -5 degrees -5 degrees ), it reached 39.76 +/- 13.83 degrees (P < .001) in adenocarcinoma.

CONCLUSIONS

Radiologists should suspect nasal adenocarcinoma on sinus CT scans showing a unilateral expanding opacity of the olfactory cavity.

Long-term study of fluticasone propionate aqueous nasal spray in acute and maintenance therapy of nasal polyposis

BACKGROUND

Topical steroids are first-line medication to control nasal polyposis (NP), a disease with long-term clinical course.

OBJECTIVE

The aim of this study was to evaluate the efficacy and safety of fluticasone propionate aqueous nasal spray (FPANS) 200 microg twice a day (bd) after 1 month of treatment, and to compare FPANS 200 microg bd and FPANS 200 microg once a day (od) in maintenance and long-term treatment.

METHODS

Double-blind, placebo-controlled, 8-month study with three treatment periods (1-month acute period followed with 1-month maintenance period and 6-month follow-up period) was carried out. Group 1 received FPANS 200 microg bd, during acute, maintenance and follow-up periods, Group 2 received FPANS 200 microg bd during acute period and FPANS 200 microg od during maintenance and follow-up periods, and Group 3 received placebo during acute and maintenance periods and FPANS 200 microg bd during follow-up period. Endpoints were change from baseline in clinic peak nasal inspiratory flow (PNIF), domiciliary evening PNIF, intensity of symptoms and polyposis grade.

RESULTS

After acute period and maintenance periods, FPANS 200 microg bd was significantly more effective than placebo on all endpoints and more effective than FPANS 200 microg od after 1-month maintenance period on clinic PNIF, evening PNIF, obstruction, percentage of days with no sense of smell and percentage of nights with no disturbances. The two doses were similar on other endpoints. After the 6-month follow-up period, there was no difference between the two doses of FPANS at all efficacy endpoints. The safety profile of FPANS did not highlight any new or unanticipated adverse events.

CONCLUSION

The study demonstrated the efficacy of FPANS 200 microg bd in acute treatment and FPANS 200 microg od as a sufficient dose to maintain a long-term efficacy in the treatment for NP.

[Woodworker's nasal adenocarcinoma revealed by anosmia]

OBJECTIVES

The aim of this article is to report two cases illustrating the origin of woodworkers' adenocarcinoma in the olfactory cleft and to discuss screening, prevention, and surgical approaches.

MATERIAL AND METHOD

Retrospective study of the charts of two cases of adenocarcinoma of the olfactory cleft revealed by a loss of the sense of smell.

RESULTS

Of 30 consecutive cases of woodworkers' adenocarcinoma of the olfactory cleft observed during the last 3 years, the two cases revealed by anosmia were diagnosed as small tumors located in one olfactory cleft.

CONCLUSION

In light of these two cases, we discuss anosmia in the diagnostic screening of this tumor and its consequences in the olfactory cleft: flexible endoscopic examination of the olfactory cleft seems preferable to rigid endoscope examination of the middle meatus at screening; endoscopic resection of the olfactory cleft seems preferable to resection through external approaches; and nasal lavages seem preferable to the Proetz technique for preventive sinus lavage. The new knowledge on adenocarcinoma of the olfactory cleft should be familiar to occupational health physicians, general practitioners, and otorhinolaryngologists because of its practical consequences for screening, diagnosis, prevention, and surgical treatment.

[Advantages of the L-menthol test in assessing chronic nasal obstruction]

OBJECTIVES

In normal and anosmic patients, l-menthol inhalation is responsible for the subjective sensation of increased nasal permeability, related to a stimulation of the internal nasal nerve (branch of trigeminal nerve) endings connected with cold pressor receptors. At present, routine assessment of nasal obstruction does not include the l-menthol test. The aim of this case report was to show the advantages of this test in chronic nasal obstruction evaluation.

MATERIAL AND METHODS

The example of a patient with a medical history of facial trauma and anosmia for sequela is reported. This patient complained of chronic nasal obstruction that persisted despite several septorhinoplasties and that conflicted with clinical examination and rhinomanometry data.

RESULTS

An l-menthol test did not induce any mint smell recognition, any improvement of nasal permeability sensation, or any freshness sensation.

CONCLUSION

The authors suggest that the nasal obstruction sensation could result, in this case, from post-trauma anesthesia of the trigeminal nerve, particularly its internal nasal nerve branch. The l-menthol test could be a predictive test that may prevent recurrent functional failures of surgical treatment proposed for nasal obstruction.

[Willebrand factor deficiency and septorhinoplasty]

INTRODUCTION

Willebrand disease can be diagnosed late, sometimes only when hemorrhage complicates surgery. French guidelines do not recommend investigation before surgery when no personal or familial hemorrhagic diathesis is reported.

OBJECTIVE

To consider the advantages of Willebrand factor dosage before septorhinoplasty.

METHOD

Three cases of septorhinoplasty and Willebrand factor deficiency complicated with hemorrhage compromising the functional result are reported. The routine tests (platelet count, bleeding time, and activated partial thromboplastin time) and Willebrand factor dosage were done before or after surgery.

RESULTS

In the three cases, no personal or familiar hemorrhagic diathesis was found. For two cases, a hemorrhage occurred during surgery. One of them had prolonged and repeated nose bleedings after surgery. In this case, iterative packings damaged the result of surgery and a new rhinoplasty had to be done. In one case, a prolonged activated partial thromboplastin time before surgery revealed a Willebrand factor deficiency, leading to prophylactic treatment (desmopressin) of bleeding.

CONCLUSION

The cases described suggest that systematic dosage of Willebrand factor before septorhinoplasty could be advantageous and that functional prognosis can be impaired by uncontrolled epistaxis.