Image guided dilation of sinus ostium in revision sinus surgery

PURPOSE

Assess if a rigid, image-guided balloon could be used effectively and safely in revision sinus surgery.

MATERIALS AND METHODS

A prospective, non-randomized, single-arm, multicenter study to assess the safety and device performance of the NuVent™ EM Balloon Sinus Dilation System. Adults with CRS in need of revision sinus surgery were enrolled for balloon sinus dilation of a frontal, sphenoid, or maxillary sinus. The primary device performance endpoint was the ability of the device to (1) navigate to; and (2) dilate tissue in subjects with scarred, granulated, or previously surgically-altered tissue (revision). Safety outcomes included the assessment of any operative adverse events (AEs) directly attributable to the device or for which direct cause could not be determined. A follow-up endoscopy was conducted at 14 days post-treatment for assessment of any AEs. Performance outcomes included the surgeon's ability to reach the target sinus (es) and dilate the ostia. Endoscopic photos were captured for each treated sinus pre- and post-dilation.

RESULTS

At 6 US clinical sites, 51 subjects were enrolled; 1 subject withdrew before treatment due to a cardiac complication from anesthesia. 121 sinuses were treated in 50 subjects. The device performed as expected in 100 % of the 121 treated sinuses, with investigators able to navigate to the treatment area and dilate the sinus ostium without difficulty. Ten AEs were seen in 9 subjects, with 0 related to the device.

CONCLUSION

The targeted frontal, maxillary or sphenoid sinus ostium were safely dilated in every revision subject treated, with no AEs directly attributed to the device.

Acoustic Rhinometry Predicts Tolerance of Nasal Continuous Positive Airway Pressure: A Pilot Study

Background

Nasal continuous positive airway pressure (nCPAP) is usually the first-line intervention for obstructive sleep apnea, but up to 50% of patients are unable to tolerate therapy because of discomfort–-usually nasal complaints. No factors have been definitively correlated with nCPAP tolerance, although nasal cross-sectional area has been correlated with the level of CPAP pressure, and nasal surgery improves nCPAP compliance. This study examined the relationship between nasal cross-sectional area and nCPAP tolerance.

Methods

We performed acoustic rhinometry on 34 obstructive sleep apnea patients at the time of the initial sleep study. Patients titrated to nCPAP were interviewed 18 months after starting therapy to determine CPAP tolerance. Demographic, polysomnographic, and nasal cross-sectional area data were compared between CPAP-tolerant and -intolerant patients.

Results

Between 13 tolerant and 12 intolerant patients, there were no significant differences in age, gender, body mass index, CPAP level, respiratory disturbance index, or subjective nasal obstruction. Cross-sectional area at the inferior turbinate differed significantly between the two groups (p = 0.03). This remained significant after multivariate analysis for possibly confounding variables. A cross-sectional area cutoff of 0.6 cm2 at the head of the inferior turbinate carried a sensitivity of 75% and specificity of 77% for CPAP intolerance in this patient group.

Conclusion

Nasal airway obstruction correlated with CPAP tolerance, supporting an important role for the nose in CPAP, and providing a physiological basis for improved CPAP compliance after nasal surgery. Objective nasal evaluation, but not the subjective report of nasal obstruction, may be helpful in the management of these patients.

Endoscopic Sinus Surgery for Ostiomeatal Disease

The advent of endoscopic sinus instrumentation and high-resolution computed tomographic (CT) scanning enables otolaryngologists to delineate precisely the anatomy of the middle meatus. We have utilized a staging system for chronic sinusitis based on endoscopic and CT criteria. This system provides a means of evaluating and standardizing the surgical approach and provides a basis for institutional comparison. In this system Stage I disease includes patients with a history of recurrent sinusitis and anatomic findings which narrow and impinge upon the ostiomeatal complex. We are reporting on 25 patients with Stage I disease who underwent surgical treatment for ostiomeatal complex disease. The endoscopic and CT findings will be presented, as well as follow-up defining control of symptomatology.

Utility of Sagittal Reformatted Computerized Tomographic Images in the Evaluation of the Frontal Sinus Outflow Tract

Background

Anatomic and mucosal obstruction of the frontal sinus outflow tract (FSOT) can result in frontal sinusitis often associated with frontal headache. Thorough evaluation of symptomatic patients requires axial and coronal computerized tomographic (CT) scans of the paranasal sinuses (PNS). With the advent of multichannel multidetector CT scanning, the availability of high-quality sagittal images has become increasingly widespread. However, the utility of these images in the assessment of FSOT patency has not yet been established.

Methods

A retrospective review of coronal and sagittal images from 25 PNS CT scans (50 sides) were randomized, blinded, and independently evaluated by two neuroradiologists. FSOT obstruction by agger nasi cells, the ethmoid bulla, and mucosal disease was assessed. A degree of confidence was rendered for each of these findings. The results were then compared against a consensus diagnosis, which was rendered based upon simultaneous reading of the coronal and sagittal images. Generalized estimating equations were used to assess the difference between sagittal and coronal images in terms of reader confidence and diagnostic concordance with the consensus.

Results

Review of sagittal images had a higher degree of concordance with the consensus than did coronal images, and was highest for mucosal disease. Both readers were more confident in rendering a diagnosis based upon the sagittal images.

Conclusion

Sagittal reformatted CT images of the PNS are helpful in the radiologic evaluation of the FSOT. Experienced neuroradiologists had a higher degree of confidence in the diagnosis of the obstruction of the FSOT using sagittal reformatted images.

Nasal Obstruction and Sleep-Disordered Breathing: A Study Using Acoustic Rhinometry

Background

The relationship between nasal airway function and sleep-disordered breathing (SDB) remains unclear. Although correction of nasal obstruction can significantly improve nighttime breathing in some patients, nasal obstruction may not play a role in all cases of SDB. An effective method of stratifying these patients is needed. Acoustic rhinometry (AR) is a reliable, noninvasive method of measuring the dimensions of the nasal airway.

Methods

In 44 patients, we performed acoustic rhinometric measurements of nasal airway cross-sectional area, followed by hospital-based polysomnography and nasal continuous positive airway pressure (nCPAP) level titration. We compared anatomic nasal obstruction to perceived nasal obstruction, as well as respiratory distress index and nCPAP titration level, using the Pearson correlation and multiple linear regression analysis within body mass index groups.

Results

Perceived nasal obstruction correlated significantly with objective anatomic obstruction as measured by AR (r = 0.45, p < 0.01). For certain subgroup analyses inpatients with a body mass index below 25, AR measurements correlated significantly with both nCPAP titration pressure (r = 0.85, p < 0.01) and respiratory distress index (r = 0.67, p = 0.03).

Conclusion

Nasal airway function may be a significant component of SDB in some patients, perhaps playing a larger role in patients who are not overweight. The best responders to nasal surgery for SDB may be nonoverweight patients with nasal obstruction. AR along with nasal examination may be helpful in the evaluation and treatment of the SDB patient.

Rhinomanometric and Clinical Evaluation of Triamcinolone Acetonide and Beclomethasone Dipropionate in Rhinitis

A prospective randomized study comparing the effectiveness of triamcinolone acetonide and beclomethasone dipropionate nasal sprays in the treatment of allergic or vasomotor rhinitis was conducted at New York University Medical Center. Both medications were used at their recommended dosages. Fifty patients were evaluated during a 2-month treatment period. Nasal air flow and resistance were quantified by anterior active rhinomanometry using the Rhinotest microprocessor rhinomanometer. The patients’ subjective complaints were graded on a standard questionnaire. Both steroid inhalants were highly effective in relieving local symptomatology and the subjective improvement in nasal obstruction correlated with rhinomanometric assessment of the nasal airway. Triamcinolone acetonide used once daily represents an alternative to the twice daily beclomethasone dipropionate nasal steroid spray currently available for the treatment of rhinitis.

Evolution in Visualization for Sinus and Skull Base Surgery: From Headlight to Endoscope

Rhinoscopy became a formal field of study in the mid-nineteenth century as improvements in nasal specula were made and the potent vasoconstrictive effects of cocaine on the intranasal tissues were discovered. Since then, a multitude of advances in visualization and illumination have been made. The advent of the Storz-Hopkins endoscope in the mid-twentieth century represents a culmination of efforts spanning nearly 2 centuries, and illumination has evolved concomitantly. The future of endoscopic sinus surgery may integrate developing technologies, such as 3-dimensional endoscopy, augmented reality navigation systems, and robotic endoscope holders.

Measurement of mycotoxins in patients with chronic rhinosinusitis

Mycotoxins are toxic secondary metabolites produced by a variety of fungi including Aspergillus, Alternaria, and Penicillium species. The presence of mycotoxins in sinonasal tissue and secretions and any possible link to chronic rhinosinusitis (CRS) or other diseases of the head and neck have not been reported. The authors performed an exploratory study to determine the presence and levels of mycotoxins in the sinonasal tissue and secretions of 18 subjects undergoing endoscopic sinus surgery for CRS. Using commercial enzyme-linked immunosorbent assay kits, samples were analyzed for the following mycotoxins: aflatoxin, deoxynivalenol, zearalenone, ochratoxin, and fumonisin. All specimens were negative for aflatoxin, deoxynivalenol, zearalenone, and fumonisin. Four (22%) of 18 specimens were positive for ochratoxin. The clinical significance of this finding remains to be determined.

Effects of acetazolamide on infantile nystagmus syndrome waveforms: comparisons to contact lenses and convergence in a well-studied subject

AIM

To determine if acetazolamide, an effective treatment for certain inherited channelopathies, has therapeutic effects on infantile nystagmus syndrome (INS) in a well-studied subject, compare them to other therapies in the same subject and to tenotomy and reattachment (T&R) in other subjects.

METHODS

Eye-movement data were taken using a high-speed digital video recording system. Nystagmus waveforms were analyzed by applying an eXpanded Nystagmus Acuity Function (NAFX) at different gaze angles and determining the Longest Foveation Domain (LFD).

RESULTS

Acetazolamide improved foveation by both a 59.7% increase in the peak value of the NAFX function (from 0.395 to 0.580) and a 70% broadening of the NAFX vs Gaze Angle curve (the LFD increased from 20° to 34°). The resulting U-shaped improvement in the percent NAFX vs Gaze Angle curve, varied from ~60% near the NAFX peak to over 1000% laterally. The therapeutic improvements in NAFX from acetazolamide (similar to T&R) were intermediate between those of soft contact lenses and convergence, the latter was best; for LFD improvements, acetazolamide and contact lenses were equivalent and less effective than convergence. Computer simulations suggested that damping the central oscillation driving INS was insufficient to produce the foveation improvements and increased NAFX values.

CONCLUSION

Acetazolamide resulted in improved-foveation INS waveforms over a broadened range of gaze angles, probably acting at more than one site. This raises the question of whether hereditary INS involves an inherited channelopathy, and whether other agents with known effects on ion channels should be investigated as therapy for this condition.

Scanning electron microscope study of early lichen synthesis

In the early stages of cellular interaction between the symbionts of Lecidea albocaerulescens, the phycobiont produced an extracellular sheath which bound to it hyphae of the mycobiont. Such a sheath may be a means by which the symbionts recognize each other. Hyphae of the mycobiont formed flattened appressoria as they grew over the algal cells and in this way secured the autotrophic population necessary for the development of a lichen thallus.

From virtual reality to the operating room: the endoscopic sinus surgery simulator experiment

OBJECTIVE

Establish the feasibility of a predictive validity study in sinus surgery simulation training and demonstrate the effectiveness of the Endoscopic Sinus Surgery Simulator (ES3) as a training device.

STUDY DESIGN

Prospective, multi-institutional controlled trial.

SETTING

Four tertiary academic centers with accredited otolaryngology-head and neck surgery residency programs.

SUBJECTS

Twelve ES3-trained novice residents were compared with 13 control novice residents.

METHODS

Subjects were assessed on the performance of basic sinus surgery tasks. Their first in vivo procedure was video recorded and submitted to a blinded panel of independent experts after the panel established a minimum inter-rater reliability of 80 percent. The recordings were reviewed by using a standardized computer-assisted method and customized metrics. Results were analyzed with the Mann-Whitney U test. Internal rater consistency was verified with Pearson moment correlation.

RESULTS

Completion time was significantly shorter in the experimental group (injection P = 0.003, dissection P < 0.001), which, according to the rater panel, also demonstrated higher confidence (P = 0.009), demonstrated skill during instrument manipulation (P = 0.011), and made fewer technical mistakes during the injection task (P = 0.048) compared with the control group. The raters' post hoc internal consistency was deemed adequate (r > 0.5 between serial measurements).

CONCLUSION

The validity of the ES3 as an effective surgical trainer was verified in multiple instances, including those not depending on subjective rater evaluations. The ES3 is one of the few virtual reality simulators with a comprehensive validation record. Advanced simulation technologies need more rapid implementation in otolaryngology training, as they present noteworthy potential for high-quality surgical education while meeting the necessity of patient safety.

REM-associated nasal obstruction: a study with acoustic rhinometry during sleep

OBJECTIVE

Obstructive sleep apnea events are more common in REM sleep, although there is no relationship between sleep phase and pharyngeal airway status. We studied the patency of the nasal airway during REM and non-REM sleep with the use of acoustic rhinometry.

METHODS

Serial acoustic rhinometric assessment of nasal cross-sectional area was performed in 10 subjects, before sleep and during REM and non-REM sleep. All measurements were standardized to a decongested baseline with mean congestion factor (MCF).

RESULTS

MCF in the seated position was 10.6% (+/-3.7) and increased with supine positioning to 16.2% (+/-2.3). In REM sleep, MCF was highest, at 22.3% (+/-1.7). In non-REM sleep, MCF was lowest, at 2.3% (+/-3.1). All interstage comparisons were statistically significant on repeated measures ANOVA (P < 0.05).

CONCLUSION

REM sleep is characterized by significant nasal congestion; non-REM sleep, by profound decongestion. This phenomenon may be attributable to REM-dependent variation in cerebral blood flow that affects nasal congestion via the internal carotid system. REM-induced nasal congestion, an indirect effect of augmented cerebral perfusion, may contribute to the higher frequency of obstructive events in REM sleep.

Superior Turbinate Pneumatization in Patients with Chronic Rhinosinusitis: Prevalence on Paranasal Sinus CT

With the availability of high-resolution computed tomography (CT), a great deal of attention has been paid to the anatomy of the paranasal sinuses. But while investigators have focused on the osteomeatal complex and its relation to chronic rhinosinusitis, there has been little discussion of the superior turbinate. Although a few anatomic studies have tried to quantify pneumatization of the superior turbinate, the prevalence of this finding on radiography is not well addressed in the literature. We prospectively studied 100 consecutively presenting patients who underwent coronal CT of the paranasal sinuses (200 sides) for the evaluation of symptoms of chronic rhinosinusitis at an academic tertiary referral center to determine the prevalence of pneumatization of the superior turbinate. We found evidence of pneumatization in 44 of the 200 sides, for a prevalence of 22%. In all, pneumatized superior turbinates were found in 27 patients (27%)—bilaterally in 17 (17%) and unilaterally in 10 (10%).

Superior turbinate pneumatization in patients with chronic rhinosinusitis: prevalence on paranasal sinus CT

With the availability of high-resolution computed tomography (CT), a great deal of attention has been paid to the anatomy of the paranasal sinuses. But while investigators have focused on the osteomeatal complex and its relation to chronic rhinosinusitis, there has been little discussion of the superior turbinate. Although a few anatomic studies have tried to quantify pneumatization of the superior turbinate, the prevalence of this finding on radiography is not well addressed in the literature. We prospectively studied 100 consecutively presenting patients who underwent coronal CT of the paranasal sinuses (200 sides) for the evaluation of symptoms of chronic rhinosinusitis at an academic tertiary referral center to determine the prevalence of pneumatization of the superior turbinate. We found evidence of pneumatization in 44 of the 200 sides, for a prevalence of 22%. In all, pneumatized superior turbinates were found in 27 patients (27%)-bilaterally in 17 (17%) and unilaterally in 10 (10%).

Construct Validity of the Endoscopic Sinus Surgery Simulator

OBJECTIVES

To establish discriminant validity of the endoscopic sinus surgery simulator (ES3) (Lockheed Martin, Akron, Ohio) between various health care provider experience levels and to define benchmarking criteria for skills assessment.

DESIGN

Prospective multi-institutional comparison study.

SETTING

University-based tertiary care institution.

PARTICIPANTS

Ten expert otolaryngologists, 14 otolaryngology residents, and 10 medical students.

INTERVENTIONS

Subjects completed the ES3's virtual reality curriculum (10 novice mode, 10 intermediate mode, and 3 advanced mode trials). Performance scores were recorded on each trial. Performance differences were analyzed using analysis of variance for repeated measures (experience level as between-subjects factor).

MAIN OUTCOME MEASURES

Simulator performance scores, accuracy, time to completion, and hazard disruption.

RESULTS

The novice mode accurately distinguished the 3 groups, particularly at the onset of training (mean scores: senior otolaryngologists, 66.0; residents, 42.7; students, 18.3; for the paired comparisons between groups 1 and 2 and groups 1 and 3, P = .04 and .03, respectively). Subjects were not distinguished beyond trial 5. The intermediate mode only discriminated students from other subjects (P = .008). The advanced mode did not show performance differences between groups. Scores on the novice mode predicted those on the intermediate mode, which predicted advanced mode scores (r = 0.687), but no relationship was found between novice and advanced scores. All groups performed equally well and with comparable consistency at the outset of training. Expert scores were used to define benchmark criteria of optimal performance.

CONCLUSIONS

This study completes the construct validity assessment of the ES3 by demonstrating its discriminant capabilities. It establishes expert surgeon benchmark performance criteria and shows that the ES3 can train novice subjects to attain those. The refined analysis of trial performance scores could serve educational and skills assessment purposes. Current studies are evaluating the transfer of surgical skills acquired on the ES3 to the operating room (predictive validity).

The sub-clinical see-saw nystagmus embedded in infantile nystagmus

A transient, decompensated vertical phoria in an individual with infantile nystagmus syndrome (INS) resulted in two images that oscillated vertically-a diplopic oscillopsia. Ocular motor studies during the vertical oscillopsia recreated by vertical prisms, led to the identification of a sub-clinical see-saw nystagmus (SSN), present under the prism-induced diplopic condition. Retrospective analysis of ocular motor recordings made prior to the above episode of vertical diplopia revealed the presence of that same sub-clinical SSN. The SSN had not been detected previously despite extensive observations and recordings of this subject's pendular IN over a period of forty years. Three- dimensional search-coil data from fourteen additional INS subjects (with pendular and jerk waveforms) confirmed the existence of sub-clinical SSN embedded within the clinically detectable horizontal-torsional IN in seven of the fifteen and a sub-clinical, conjugate, vertical component in the remaining eight. Unlike the clinically visible SSN found in achiasma, the cause of this sub-clinical SSN is hypothesized to be due to a failure of the forces of the oblique muscles (responsible for the torsional component of the IN) to balance out the associated forces of the vertical recti; the net result is a small, sub-clinical SSN. Thus, so-called "horizontal" IN is actually a horizontal-torsional oscillation with a secondary, sub-clinical SSN or conjugate vertical component. The suppression of oscillopsia by efference copy in INS appears to be accomplished for each eye individually, even in a binocular individual. However, failure to fuse the two images results in oscillopsia of one of them.

Acoustic rhinometry predicts tolerance of nasal continuous positive airway pressure: a pilot study

BACKGROUND

Nasal continuous positive airway pressure (nCPAP) is usually the first-line intervention for obstructive sleep apnea, but up to 50% of patients are unable to tolerate therapy because of discomfort-usually nasal complaints. No factors have been definitively correlated with nCPAP tolerance, although nasal cross-sectional area has been correlated with the level of CPAP pressure, and nasal surgery improves nCPAP compliance. This study examined the relationship between nasal cross-sectional area and nCPAP tolerance.

METHODS

We performed acoustic rhinometry on 34 obstructive sleep apnea patients at the time of the initial sleep study. Patients titrated to nCPAP were interviewed 18 months after starting therapy to determine CPAP tolerance. Demographic, polysomnographic, and nasal cross-sectional area data were compared between CPAP-tolerant and -intolerant patients.

RESULTS

Between 13 tolerant and 12 intolerant patients, there were no significant differences in age, gender, body mass index, CPAP level, respiratory disturbance index, or subjective nasal obstruction. Cross-sectional area at the inferior turbinate differed significantly between the two groups (p = 0.03). This remained significant after multivariate analysis for possibly confounding variables. A cross-sectional area cutoff of 0.6 cm2 at the head of the inferior turbinate carried a sensitivity of 75% and specificity of 77% for CPAP intolerance in this patient group.

CONCLUSION

Nasal airway obstruction correlated with CPAP tolerance, supporting an important role for the nose in CPAP, and providing a physiological basis for improved CPAP compliance after nasal surgery. Objective nasal evaluation, but not the subjective report of nasal obstruction, may be helpful in the management of these patients.

Tenotomy does not affect saccadic velocities: support for the "small-signal" gain hypothesis

We investigated the effects of four-muscle tenotomy on saccadic characteristics in infantile nystagmus syndrome (INS) and acquired pendular nystagmus (APN). Eye movements of 10 subjects with INS and one with APN were recorded using infrared reflection, magnetic search coil, or high-speed digital video. The expanded nystagmus acuity function (NAFX) quantified tenotomy-induced foveation changes in the INS. Saccadic characteristics and peak-to-peak nystagmus amplitudes were measured. Novel statistical tests were performed on the saccadic data. Six out of the 10 INS subjects showed no changes in saccadic duration, peak velocity, acceleration, or trajectory. In the other four, the differences were less than in peak-to-peak amplitudes (from 14.6% to 39.5%) and NAFX (from 22.2% to 162.4%). The APN subject also showed no changes despite a 50% decrease in peak-to-peak amplitude and a 34% increase in NAFX. The "small-signal" changes (peak-to-peak nystagmus amplitude and NAFX) were found to far exceed any "large-signal" changes (saccadic). Tenotomy successfully reduced INS and APN, enabling higher visual acuity without adversely affecting saccadic characteristics. These findings support the peripheral, small-signal gain reduction (via proprioceptive tension control) hypothesis. Current linear plant models, limited to normal steady-state muscle tension levels, cannot explain the effects of the tenotomy.

Accuracy and cost analysis of image-guided sinus surgery

The use of image guidance in FESS has become widespread over the past several years. Numerous studies involving large numbers of patients illustrate the accuracy of these systems. In addition, case reports concerning patients who have extensive sinonasal neoplasms or distorted anatomy serve to demonstrate the usefulness of IGS. Studies by Metson et al [22] and Fried et al [23] have also investigated the surgeons' opinions of IGS. The vast majority of sinus surgeons have been pleased with the systems' ease of use and accuracy. Increased confidence in precisely localizing anatomical structures was the primary benefit. The major drawback to using image-guided systems was the increased operative time. Despite this, almost all surgeons who were questioned reported that they expect to increase their use of IGS in the future. By giving the surgeon real-time localization of surgical instruments, IGS could result in safer and more thorough surgery. This effect could have major implications for difficult surgeries in which distorted anatomy or extensive disease might otherwise result in incomplete eradication of the disease process. Studies examining these issues are necessary before a final conclusion can be drawn as to whether the accuracy achieved with current systems is truly beneficial and the cost is worth incurring.

Utility of sagittal reformatted computerized tomographic images in the evaluation of the frontal sinus outflow tract

BACKGROUND

Anatomic and mucosal obstruction of the frontal sinus outflow tract (FSOT) can result in frontal sinusitis often associated with frontal headache. Thorough evaluation of symptomatic patients requires axial and coronal computerized tomographic (CT) scans of the paranasal sinuses (PNS). With the advent of multichannel multidetector CT scanning, the availability of high-quality sagittal images has become increasingly widespread. However, the utility of these images in the assessment of FSOT patency has not yet been established.

METHODS

A retrospective review of coronal and sagittal images from 25 PNS CT scans (50 sides) were randomized, blinded, and independently evaluated by two neuroradiologists. FSOT obstruction by agger nasi cells, the ethmoid bulla, and mucosal disease was assessed. A degree of confidence was rendered for each of these findings. The results were then compared against a consensus diagnosis, which was rendered based upon simultaneous reading of the coronal and sagittal images. Generalized estimating equations were used to assess the difference between sagittal and coronal images in terms of reader confidence and diagnostic concordance with the consensus.

RESULTS

Review of sagittal images had a higher degree of concordance with the consensus than did coronal images, and was highest for mucosal disease. Both readers were more confident in rendering a diagnosis based upon the sagittal images.

CONCLUSION

Sagittal reformatted CT images of the PNS are helpful in the radiologic evaluation of the FSOT. Experienced neuroradiologists had a higher degree of confidence in the diagnosis of the obstruction of the FSOT using sagittal reformatted images.

Nasal obstruction and sleep-disordered breathing: a study using acoustic rhinometry

BACKGROUND

The relationship between nasal airway function and sleep-disordered breathing (SDB) remains unclear. Although correction of nasal obstruction can significantly improve nighttime breathing in some patients, nasal obstruction may not play a role in all cases of SDB. An effective method of stratifying these patients is needed. Acoustic rhinometry (AR) is a reliable, noninvasive method of measuring the dimensions of the nasal airway.

METHODS

In 44 patients, we performed acoustic rhinometric measurements of nasal airway cross-sectional area, followed by hospital-based polysomnography and nasal continuous positive airway pressure (nCPAP) level titration. We compared anatomic nasal obstruction to perceived nasal obstruction, as well as respiratory distress index and nCPAP titration level, using the Pearson correlation and multiple linear regression analysis within body mass index groups.

RESULTS

Perceived nasal obstruction correlated significantly with objective anatomic obstruction as measured by AR (r = 0.45, p < 0.01). For certain subgroup analyses in patients with a body mass index below 25, AR measurements correlated significantly with both nCPAP titration pressure (r = 0.85, p < 0.01) and respiratory distress index (r = 0.67, p = 0,03).

CONCLUSION

Nasal airway function may be a significant component of SDB in some patients, perhaps playing a larger role in patients who are not overweight. The best responders to nasal surgery for SDB may be nonoverweight patients with nasal obstruction. AR along with nasal examination may be helpful in the evaluation and treatment of the SDB patient.

Isolation of fungi by standard laboratory methods in patients with chronic rhinosinusitis

OBJECTIVES/HYPOTHESIS

Allergic fungal sinusitis and the role of fungi in the pathogenesis of chronic rhinosinusitis are topics of interest and controversy in rhinology. The classification of chronic rhinosinusitis as either a bacterial infection or an allergic (eosinophilic) reaction to fungi has significant implications for treatment of this disease process. We designed a study to determine whether standard isolation techniques, as employed in a university hospital mycology laboratory, could isolate and identify fungi in the intraoperative specimens from patients undergoing functional endoscopic sinus surgery for chronic rhinosinusitis.

STUDY DESIGN

Forty-five random patients with a diagnosis of chronic rhinosinusitis by clinical and computed tomography criteria underwent endoscopic sinus surgery during 2001, performed by two senior surgeons (J.B.J., R.A.L.). Specimens of mucin, sinus secretions, and/or tissue were obtained intraoperatively and sent to the New York University Medical Center (New York, NY) mycology laboratory for isolation and identification of fungi.

METHODS

Specimens were treated with Sputolysin and chloramphenicol; plated on Sabouraud, ChromAgar/Candida, Mycosel, and Niger seed agar plates; and incubated at 30 degrees C (or 37 degrees C) for up to 1 month.

RESULTS

We were able to demonstrate the presence of fungi in 56% of intraoperative specimens obtained from patients undergoing surgery for chronic rhinosinusitis.

CONCLUSIONS

Using a standard hospital mycology laboratory protocol, which is relatively inexpensive and readily available, fungus can be isolated from a majority of patients undergoing functional endoscopic sinus surgery for chronic rhinosinusitis. Educational statement: Discuss the possible role of fungus in chronic rhinosinusitis and evaluate the efficacy of documenting the presence of fungus in a routine fashion to encourage clinically relevant directed treatments.)

An expanded nystagmus acuity function: intra- and intersubject prediction of best-corrected visual acuity

The Nystagmus Acuity Function (NAF) provides an objective measurement of the foveation characteristics of nystagmus waveforms and an assessment of potential visual acuity for subjects with congenital (CN) or latent/manifest latent (LMLN) nystagmus. It is based on the subjects' ability to maintain fixation within a physiologically based 'foveation window' of +/- 0.5 degrees and +/- 4.0 degrees/s. However, some subjects are incapable of controlling fixation well enough to remain within this window with duration sufficient for good foveation. To obtain a measure of the CN waveforms of these individuals, we are proposing an eXpanded Nystagmus Acuity Function (NAFX) that relaxes either the position limit, the velocity limit, or both. Data used in this study comes from 11 human subjects with CN (10 idiopathic and 1 with achiasma) and a Belgian sheepdog with achiasma. Visual acuity was tested with a standard Snellen chart and eye movements recorded with infrared oculography or scleral search coil. For the NAFX to be useful, it must not only be applicable for subjects who cannot maintain fixation within the standard limits of the NAF, but also must yield results equivalent to those obtained with the NAF when testing subjects who are capable of maintaining good fixation control. For the latter subjects, the amount of time when position and velocity fell within the expanded limits was measured, the standard deviations of the position and velocity during these times were calculated, and a tau-surface for the exponential function was generated to guarantee the equivalence between the NAF and the NAFX. We developed an automated NAFX equivalent to the original NAF. We demonstrated that equivalence in 10 subjects and the use of the NAFX on two additional (1 human and 1 canine) subjects who were incapable of maintaining fixation within the standard position and velocity limits. We demonstrated the effects of surgery and related the results to visual acuity. We found the results to be comparable to those seen when applying the NAF to subjects who had good fixation control. The NAFX can be determined for CN and LMLN subjects with poor control of fixation by extending the standard NAF position and/or velocity limits for foveation. The resulting function can be used along with the longest foveation domain (derived from the NAFX to measure breadth of a high-NAFX region) to identify the gaze or convergence angles with the best waveform and to predict the best-possible visual acuity that could be achieved with the reduction of their nystagmus.

The torsional component of "horizontal" congenital nystagmus

OBJECTIVES

To study the relationship between the major horizontal and minor torsional components of congenital nystagmus to elucidate the diagnostic importance, effects on vision, and pathogenetic implications of the torsional components.

METHODS

We recorded the eye movements of 13 subjects with congenital nystagmus using a three-dimensional magnetic search coil technique over a 15-year period. The subjects fixated on stationary targets straight ahead and along the horizontal and vertical meridians. Six of the 10 subjects with horizontal congenital nystagmus were asymptomatic; the remaining 4 (plus two with a vertical component to their congenital nystagmus) had adult-onset symptoms. An additional subject without symptoms had a vertical congenital nystagmus component plus seesaw nystagmus; one of the symptomatic subjects also had seesaw nystagmus.

RESULTS

In all 13 subjects, the horizontal and torsional cycles were phase-locked, and positive horizontal (rightward), vertical (upward, if any), and torsional (clockwise) motion coincided in 10 subjects. That is, rightward horizontal eye rotation coincided with clockwise curvilinear motion (rightward and downward) of the upper pole of each eye. During the horizontal foveation periods, torsional motion was also of low velocity. In 2 of 13 subjects, the torsional waveforms differed from those in the horizontal plane; in others, the direction or the variation with gaze angle differed from that predicted by Listing. In each of the 13 subjects, the torsional components ranged from 8.16% to 94.42% (median, 32.94%) of the peak-to-peak magnitudes of the congenital nystagmus. In most cases, the measured torsion was far greater than that predicted by Listing's law for a worst-case analysis (range, 0.69-11.83%; median, 4.91%). The torsional components of the two subjects with seesaw nystagmus were 60.48% and 264.02%.

CONCLUSIONS

The manner in which the horizontal and torsional components of "horizontal" congenital nystagmus were phase-locked made clinical detection of the torsional component difficult. Most "horizontal" congenital nystagmus is actually horizontal-torsional congenital nystagmus. Visual acuity during horizontal foveation periods is not significantly diminished by torsional motion. In only one subject did the torsional component of the congenital nystagmus have an amplitude equivalent to Listing torsion; in the other 12 subjects, torsion exceeded our estimate of what Listing's law would predict. The torsional components of the seesaw nystagmus in two subjects also greatly exceeded the torsion predicted by Listing torsion. The most parsimonious explanation for our data is that the cyclic torsion in congenital nystagmus was generated centrally and not a result of Listing torsion, mechanical crosstalk, or normal or abnormal extraocular-muscle (plant) dynamics. Further measurements are needed to confirm this hypothesis.

Asymmetry of the ethmoid roof: analysis using coronal computed tomography

OBJECTIVES/HYPOTHESIS

To determine the incidence and degree of asymmetry in the height and contour of the ethmoid roof.

STUDY DESIGN

Retrospective review of direct coronal paranasal sinus computed tomography (CT) scans.

METHODS

Retrospective review of 200 consecutive direct coronal sinus CT scans done at New York University Medical Center from July 25, 2000 to October 11, 2000. The height and contour of the fovea ethmoidalis were examined for symmetry between the right and left sides. When an asymmetry in the height of the fovea ethmoidalis existed, this difference was quantified.

RESULTS

In 19 scans (9.5%), there was an asymmetry between the height of the fovea ethmoidalis on the right and left sides. Of these 19, 12 (63.2%) were lower on the right side, whereas 7 (36.8%) were lower on the left. Ninety-six patients (48.0%) demonstrated a contour asymmetry with "flattening" of the ethmoid roof on one side, 46 on the right and 50 on the left. One patient demonstrated both height and contour asymmetry. The fovea ethmoidalis on the remaining 86 scans (43.0%) was symmetric.

CONCLUSIONS

In a patient population with sinus and nasal symptoms, the height and contour of the right and left fovea ethmoidalis were symmetric in less than 50% of individuals. The asymmetry was most often the result of a difference in contour with flattening of the fovea on one side. This underscores the importance of careful preoperative and intraoperative review of paranasal sinus CT scans in patients undergoing endoscopic sinus surgery.

A normal ocular motor system model that simulates the dual-mode fast phases of latent/manifest latent nystagmus

The fast phases of latent/manifest latent nystagmus (LMLN) may either cause the target image to fall within (foveating) or outside (defoveating) the foveal area. We previously verified that both types are generated by the same mechanism as voluntary saccades and propose a hypothetical, dual-mode mechanism (computer model) for LMLN that utilizes normal ocular-motor control functions. Fixation data recorded during the past 30 years from 97 subjects with LMLN using both infrared and magnetic search coil oculography were used as a basis for our simulations. The MATLAB/Simulink software was used to construct a robust, modular, ocular motor system model, capable of simulating LMLN. Fast-phase amplitude versus both peak velocity and duration of simulated saccades were equivalent to those of saccades in normal subjects. Based on our LMLN studies, we constructed a hypothetical model in which the slow-phase velocity acted to trigger the change between foveating and defoveating LMLN fast phases. Foveating fast phases were generated during lower slow-phase velocities whereas defoveating fast phases occurred during higher slow-phase velocities. The bidirectional model simulated Alexander's law behavior under all viewing and fixation conditions. Our ocular-motor model accurately simulates LMLN patient ocular motility data and provides a hypothetical explanation for the conditions that result in both foveating and defoveating fast phases. As is the case for normal physiological saccades, the position error determined the saccadic amplitudes for foveating fast phases. However, the final slow-phase velocity determined the amplitudes of defoveating fast phases. In addition, we suggest that individuals with LMLN use their fixation subsystem to further decrease the slow-phase velocity as the target image approaches the foveal center.

Histopathologic evaluation of the ethmoid bone in chronic sinusitis

Chronic rhinosinusitis (CRS) is defined as a condition lasting for a period greater than 12 weeks, and manifested by an inflammatory response involving the mucous membranes of the nasal cavity and paranasal sinuses, fluids within these cavities, and/or the underlying bone. The mucosal changes that occur in CRS have been well described, and include edema, decreased number of ciliated cells, and goblet cell hyperplasia. However, the changes that may occur in the underlying ethmoid bone have only recently been investigated. We evaluated decalcified ethmoid bone specimens from 20 patients undergoing endoscopic sinus surgery for CRS. Our analysis revealed histopathologic changes consistent with varying grades of bone remodeling. Polarized light microscopy demonstrated changes in the extracellular matrix, such as bone resorption and neoosteogenesis. Preoperative clinical data and CT staging were recorded on all patients and correlated with the histopathologic findings. These findings suggest that CRS may be associated with osteitis of the underlying ethmoid bone.

Chronic sinusitis complicating sinus lift surgery

Sinusitis has been reported as a complication of sinus lift surgery with antral bone augmentation. The procedure involves the creation of a submucoperiosteal pocket in the floor of the maxillary sinus for placement of a graft consisting of autogenous, allogenic, or alloplastic material. This can result in inadvertent tearing of the mucoperiosteal flap with extrusion of graft material into the antrum. Obstruction of the sinus outflow tract by mucosal edema and particulate graft material may result in sinusitis. We will discuss the clinical presentation and management of 14 cases of chronic sinusitis following sinus lift surgery with alloplastic hydroxyapatite (HA) augmentation of the maxillary antrum.

Middle turbinate resection: issues and controversies

Diversity of opinion continues to exist among otolaryngologists regarding the potential benefits of preservation or resection of the middle turbinate during endoscopic ethmoidectomy. Rhinologists in favor of middle turbinate preservation cite the potential loss of olfactory function as well as diminished humidification and filtration of inspired air following its resection. In addition, the middle turbinate remnant could lateralize, causing frontal recess obstruction and frontal sinusitis. In general, it is accepted that a diseased or flail middle turbinate should be resected during ethmoidectomy to create a marsupialized surgical bed. However, in the case of a structurally sound middle turbinate, indications for resection vary significantly. We are reporting on 100 primary endoscopic ethmoidectomies for chronic rhinosinusitis followed for at least 2 years. Of these 100 sides, 50 included conservative partial middle turbinectomy and 50 were performed with middle turbinate preservation. The postoperative clinical and endoscopic findings revealed no difference in the incidence of frontal sinusitis or frontal recess stenosis between groups. We compared additional data and present our technique of conservative middle turbinate resection, which preserves a portion of this structure as an important anatomic landmark.

The bacteriology of chronic rhinosinusitis: results using a novel culture device

The bacteriology of chronic rhinosinusitis is an area of great interest among rhinologists. Numerous studies have reported culture results implicating a variety of aerobic and anaerobic organisms in the etiology of this disease process. Sampling is generally accomplished through the nasal cavity, creating the potential for contamination with resident nasal flora. In some reports, strict anaerobic techniques have not been used, possibly accounting for the failure to recover these fastidious organisms. In an attempt to clarify the microbiology of chronic rhinosinusitis, we used a novel culture and transport system in 50 patients undergoing endoscopic sinus surgery. The Accu-CulShure (MLA Systems, Pleasantville, NY, USA) is a self-contained polyethylene culture swab and transport device, capable of collecting a representative sample from the sinus without contamination, and preserving the quality of the material during transport. Our aerobic and anaerobic culture results, as well as pertinent patient data, are presented. The Accu-CulShure device may permit standardization of culture techniques for future studies, and allow for more accurate determination of the microbiology of chronic rhinosinusitis.

Preoperative sagittal CT evaluation of the frontal recess

Endoscopic surgical approaches for chronic frontal sinusitis require the reestablishment of adequate frontal sinus ventilation and drainage for relief of symptoms. After the resection of anterior ethmoid mucosal disease and cellular structure, the anterior to posterior depth of the nasofrontal beak to the base of skull at the insertion of the ethmoidal bulla (frontal sinus ostium) often represents a critical margin for functional success. However, little information concerning this dimension is available. Depending on intraoperative surgical judgment of this distance, extended endoscopic surgical procedures involving additional bone resection may be indicated. These approaches may be hazardous due to the proximity of the cranial cavity and orbit. In addition, secondary stenosis can result from the subsequent inflammatory response. Improved CT imaging, high resolution sagittal reformatting, and computer workstations provide the ability to obtain direct preoperative measurements of the frontal recess. We used a paramedian sagittal section and recorded the maximal anterior to posterior depth from the nasofrontal beak to the base of skull at the insertion of the ethmoidal bulla in 20 patients, 31 sides, undergoing primary endoscopic frontoethmoidectomy. In addition, we found a positive correlation between this distance and agger nasi air cell size measured in the same 31 sides.

Latent and congenital nystagmus in Down syndrome

OBJECTIVES

Although nystagmus has been reported in Down syndrome (DS), it has been poorly characterized, because most investigators have relied on clinical observations rather than on eye movement recordings. This study was conducted to investigate nystagmus in DS, using quantitative measurements of eye movements.

METHODS

Ocular motility and visual functions were examined in 26 unselected adults with DS and compared with those in an age-matched group of 35 subjects with other causes of mental retardation. The eye movements of those with clinically evident nystagmus were recorded with the infrared technique. We also recorded the eye movements of a child with DS and nystagmus.

RESULTS

Nystagmus was identified in six (23%) adults with DS and in none in the control group. All six patients showed latent/manifest latent nystagmus (LMLN), prominent with the covering of one eye, and esodeviations of 10 to 30 prism diopters. Eye movement recordings confirmed LMLN with its exponentially decaying waveform. Frequencies ranged from 2 to 5 Hz and amplitudes from 5 degrees to 20 degrees. While attempting to fixate straight ahead in the absence of visual cues, three subjects exhibited shifts in the mean eye position. In contrast with the findings in adults, the only child with DS examined had both congenital nystagmus and LMLN waveforms.

CONCLUSIONS

The predominant type of nystagmus in the study subjects with DS is LMLN. The high prevalence of LMLN may reflect abnormal integration of visuospatial information that is typical of DS. The concurrent presence of congenital nystagmus in a child but only LMLN in the adults with DS raises the possibility of age-related waveform changes or could reflect sample variation.

A new surgery for congenital nystagmus: effects of tenotomy on an achiasmatic canine and the role of extraocular proprioception

PURPOSE

Human eye-movement recordings have documented that surgical treatment of congenital nystagmus (CN) also produces a broadening of the null zone and changes in foveation that allow increased acuity. We used the achiasmatic Belgian sheepdog, a spontaneously occurring animal model of human CN and see-saw nystagmus (SSN), to test the hypothesis that changes induced by surgical interruption of the extraocular muscle afference without a change in muscle-length tension could damp both oscillations.

METHODS

An achiasmatic dog with CN and SSN underwent videotaping and infrared oculography in a sling apparatus and head restraints before and after all extraocular muscles (stage 1: 4 horizontal rectus muscles and stage 2 [4 months later]: 4 vertical rectus muscles and 4 oblique muscles) were surgically tenotomized and immediately reattached at their original insertions.

RESULTS

The dog had immediate and persistent visible, behavioral, and oculographic changes after each stage of this new procedure. These included damped CN and SSN, increased ability to maintain fixation, and increased periods of maintaining the target image on the area centralis over a broad range of gaze angles.

CONCLUSIONS

Severing and reattaching the tendons of the extraocular muscles affect some as-yet-unknown combination of central nervous system processes producing the above results. This new procedure may prove effective in patients with CN with either no null, a null at primary position, or a time-varying null (due to asymmetric, (a)periodic, alternating nystagmus). We infer from our results in an achiasmatic dog that tenotomy is the probable cause of the damping documented in human CN after Anderson-Kestenbaum procedures and should also damp CN and SSN in achiasma in humans. It may also prove useful in acquired nystagmus to reduce oscillopsia. The success of tenotomy in damping nystagmus in this animal suggests that the proprioceptive feedback loop has a more important role in ocular-motor control than has been appreciated. Finally, we propose a modified bimedial recession procedure, on the basis of the damping effects of tenotomy.

Primary amyloidosis presenting as a nasopharyngeal mass

Amyloid is defined as a pathologic proteinaceous substance which, when deposited between the cells of tissues and organs, leads to various clinical conditions. Immunohistochemistry has allowed for better classification and understanding of the pathophysiology of amyloidosis. In the upper aerodigestive tract, amyloidosis is a rare condition occurring most frequently in the larynx. We present the case of a 42-year-old woman with complete nasal obstruction due to primary nasopharyngeal amyloidosis. This represents the first reported case of primary nasopharyngeal amyloidosis containing both the lambda and kappa immunoglobulin light chains. The clinical and radiologic findings, as well as the management of primary amyloidosis of the upper aerodigestive tract, will be discussed. A review of the literature pertaining to nasal and nasopharyngeal amyloidosis will be presented.

Antral augmentation, osseointegration, and sinusitis: the otolaryngologist's perspective

Osseointegrated dental implants are a widely used method of replacing lost or missing teeth. Resorption of the alveolar ridge of the edentulous posterior maxilla may necessitate augmentation before osseointegration to provide adequate bone for implant fixation. This can be accomplished through an intraoral approach to the maxillary sinus, with elevation of the mucosa of the sinus floor creating a pocket for graft placement. Disruption of the intact sinus mucosa may result in sinusitis, graft infection, or extrusion with secondary formation of an oroantral communication. To treat these patients effectively, the otolaryngologist must be aware of the techniques of sinus augmentation and osseointegration as well as the etiology of associated complications. We will discuss the management of four patients with significant sinus complications, and evaluate the otolaryngologist's role in the preoperative and postoperative care of these patients.

Characteristics of foveating and defoveating fast phases in latent nystagmus

PURPOSE

Under certain conditions, the fast phases of latent/manifest latent nystagmus (LMLN) can defoveate the target of interest instead of foveating it, as was thought to be their only function. LMLN fast phases in the waveforms from four subjects were studied with the goals of better understanding their characteristics and determining what triggers both foveating and defoveating fast phases.

METHODS

Eye movement records were made using both the scleral search coil and infrared methods. Relationships of fast-phase sizes with slow-phase positions and velocities before and after fast phases were analyzed, as were relationships of saccade size with peak velocity and duration. RESULTS. The data showed that LMLN with defoveating fast phases occurred in the presence of higher slow-phase velocities. Also, larger saccade sizes corresponded to larger presaccadic and postsaccadic slow-phase velocities. The peak velocities and durations of LMLN fast phases were in the same ranges as normal saccades.

CONCLUSIONS

Defoveating fast phases with decreasing-velocity slow phases may be the result of the addition of saccadic pulses to linear slow phases. Mechanisms are suggested to explain the switch from foveating to defoveating fast phases in LMLN.

Conservative approach to inflammatory nasofrontal duct disease

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

Initial report on postoperative healing after endoscopic sinus surgery with the microdebrider

Synechiae formation is a frequent occurrence after endoscopic sinus surgery and may cause symptomatic sinus outflow tract obstruction. Various means are used to reduce the incidence of synechiae formation. These include meticulous operative technique, partial middle turbinate resection, middle meatus spacers or stents, and postoperative debridement. The microdebrider is a powered rotary shaving device that precisely resects tissue, minimizing inadvertent mucosal trauma and stripping. We present 40 cases of endoscopic sinus surgery performed with the microdebrider. Patients had at least a 5-month follow-up and demonstrated rapid mucosal healing, minimal crust formation, and a low incidence of synechiae formation. These initial data suggest that the microdebrider may be advantageous in surgery for chronic sinusitis.

The congenital and see-saw nystagmus in the prototypical achiasma of canines: comparison to the human achiasmatic prototype

We applied new methods for canine eye-movement recording to the study of achiasmatic mutant Belgian Sheepdogs, documenting their nystagmus waveforms and comparing them to humans with either congenital nystagmus (CN) alone or in conjunction with achiasma. A sling apparatus with head restraints and infrared reflection with either earth- or head-mounted sensors were used. Data were digitized for later evaluation. The horizontal nystagmus (1-6 Hz) was similar to that of human CN. Uniocular and disconjugate nystagmus and saccades were recorded. See-saw nystagmus (SSN), not normally seen with human CN, was present in all mutants (0.5-6 Hz) and in the one human achiasmat studied thus far. This pedigree is an animal model of CN and the SSN caused by achiasma or uniocular decussation. Given the finding of SSN in all mutant dogs and in a human, achiasma may be sufficient for the development of congenital SSN and, in human infants, SSN should alert the clinician to the possibility of either achiasma or uniocular decussation. Finally, the interplay of conjugacy and disconjugacy suggests independent ocular motor control of each eye with variable yoking in the dog.

Pendular nystagmus in patients with peroxisomal assembly disorder

BACKGROUND

Pendular nystagmus commonly occurs in congenital and acquired disorders of myelin.

OBJECTIVE

To characterize the nystagmus in 3 siblings with an infantile form of an autosomal recessive peroxisomal assembly disorder causing leukodystrophy.

DESIGN

We examined visual function and measured eye movements using infrared oculography. We noted changes in eye speed and frequency before and after the administration of gabapentin to 1 patient.

RESULTS

All 3 siblings showed optic atrophy and pendular nystagmus that was predominantly horizontal, at a frequency of 3 to 6 Hz, with phase shifts of 45 degrees to 80 degrees between the oscillations of each eye. Gabapentin administered to 1 child caused a modest improvement of vision and the reduction of the velocity and frequency of oscillations in the eye with worse nystagmus.

CONCLUSION

The pendular nystagmus in these patients was due to their leukodystrophy and may have a similar pathogenesis to the oscillations seen in other disorders affecting central myelin.

Assessment of distress associated with tinnitus

This paper focuses upon the quality of the Dutch translation of the STSS (Subjective Tinnitus Severity Scale), a scale which assesses the severity of tinnitus and the related distress. Research has been done on the psychometric qualities of this scale, its relationship with loudness-matching procedures and several psychological variables. Data presented on 104 tinnitus patients demonstrated the reliability of the STSS with a coefficient alpha of 0.71. Factor analysis revealed four factors: emotional distress, intrusiveness, annoyance and cognitive distress. With regard to the validity, significant correlations of a moderate degree were found with several unitary subjective scales measuring the same construct (rs = 0.50, p < 0.001 and rs = 0.43, p < 0.01). Correlational research demonstrated that the STSS is independent of the loudness of tinnitus as measured by matching procedures (rs = 0.00). In contrast, significant correlations of a moderate magnitude were found with anxiety (rs = 0.33, p < 0.001) and depression (rs = 0.31, and rs = 0.35, p < 0.001).

100 years of frontal sinus surgery

The surgical treatment of chronic inflammatory frontal sinus disease over the past century has varied between intranasal and external procedures. There has been constant modification of these techniques; however, a single approach that will lead to relief of symptoms, eradication of disease with preservation of function, and a minimum of deformity has not yet been attained. The functional theory of sinus disease, the evolution of endoscopic techniques, and data provided by the computed tomography scan have renewed our interest in the anatomy of the lateral nasal wall and endonasal surgery. Extensive literature exists concerning the results of ethmoid, maxillary, and sphenoid endoscopic surgery. However, detailed information is not available on the treatment of inflammatory frontal sinusitis. The author presents the results of a retrospective analysis of a series of 101 patients with inflammatory frontal sinusitis who underwent endoscopic surgery that included the frontoethmoid complex. Results for improvement of symptoms as well as endoscopic findings are presented. Relief of symptoms was significant but did not correlate with postoperative endoscopic findings in patients with hyperplastic and polypoid sinusitis. Patients with anterior ethmoid cell encroachment on the frontal sinus outflow tract had a positive correlation between improvement of symptoms and postoperative endoscopic findings. Frontal recess stenosis was associated with a poor outcome. Anatomic obstruction of the frontonasal duct is most consistent with the functional theory of sinusitis.

An analysis of sites of disease in revision endoscopic sinus surgery

Revision endoscopic sinus surgery is performed when symptoms associated with sinusitis persist after sinus surgery and despite continued medical therapy. The causes of treatment failure are varied and may include systemic, mucosal, and anatomic factors associated with persistent inflammatory disease. The purpose of this retrospective review was to define the sites of recurrent or persistent sinonasal disease in patients undergoing revision endoscopic sinus surgery. This data was based on our preoperative CT scan and nasal endoscopy, as well as intraoperative findings. This study includes an evaluation of the most recent sinus surgery in a group of 153 patients and 265 operated sides. The frequency and distribution of regional anatomic sites of disease is presented and discussed.