Rhinology

Endoscopic view of nasopharyngeal scarring

January 19, 2015     Joseph P. Mirante, MD, FACS; Dewey A. Christmas, MD; Eiji Yanagisawa, MD, FACS
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A finding of fibrous or scar tissue in the nasopharynx usually indicates previous trauma or surgery in the area. The most common iatrogenic cause is adenoidectomy.

An uncommon cause of allergic fungal sinusitis: <i>Rhizopus oryzae</i>

January 19, 2015     Marie Devars du Mayne, MD; Maxime Gratacap, MD; David Malinvaud, MD, PhD; Frederic Grenouillet, PhD; Pierre Bonfils, MD, PhD
article

Abstract

We report what we believe is the first case of allergic fungal rhinosinusitis (AFRS) caused by the fungus Rhizopus oryzae. Our patient was a 32-year-old woman who presented with unilateral nasal polyps and chronic nasal dysfunction. Computed tomography of the sinuses detected left-sided pansinusitis and bone erosion. T2-weighted magnetic resonance imaging demonstrated a signal void that suggested the presence of a fungal infection. The patient underwent unilateral ethmoidectomy. Histologic examination of the diseased tissue identified allergic mucin with 70% eosinophils and no fungal hyphae. Mycologic culture detected R oryzae. After a short period of improvement, the patient experienced a recurrence, which was confirmed by radiology. A second surgery was performed, and the same fungal hyphae were found in the mucus and on culture, which led us to suspect AFRS. Since no IgE test for R oryzae was available, we developed a specific immunologic assay that confirmed the presence of specific IgG, which identified a high degree of immunologic reaction against our homemade R oryzae antigens. With a long course of systemic antifungal treatment, the patient's symptoms resolved and no recurrence was noted at 5 years of follow-up.

Iatrogenic fracture of the superomedial orbital rim during frontal trephine irrigation

December 19, 2014     Douglas Angel, MD; Rebecca Zener, MD; Brian W. Rotenberg, MD, MPH, FRCSC
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Frontal sinus trephination (FST) has numerous applications in the treatment of acute and chronic sinus disease. This procedure involves making an incision at the medial aspect of the supraorbital rim and then drilling the sinus's anterior table. Placement of a frontal trephine allows for irrigation of the frontal recess in order to evacuate the frontal sinus in a minimally invasive manner. Orbital injury is a rare complication of FST. We present a case of previously unreported orbital compartment syndrome secondary to iatrogenic fracture of the superomedial orbital rim as a complication of frontal trephine irrigation. We also review the literature on the applications of FST and its associated complications, and we discuss orbital compartment syndrome as a complication of sinus surgery.

Cutaneous malignant melanoma metastatic to the sphenoid sinus

December 19, 2014     Silviu Albu, MD; Opincariu Iulian, MD; Sorin Necula, MD
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While metastases to the paranasal sinuses are unusual, metastases to the sphenoid sinus are exceedingly rare, especially metastases of a cutaneous melanoma to the mucosa. We report the case of a 38-year-old man who presented with a solitary sphenoid sinus metastasis that had spread from a cutaneous malignant melanoma. The metastasis was removed via a wide, endoscopically assisted sphenoidotomy. The patient was further treated with external radiotherapy, and at 8 months of follow-up he was free of disease. However, he experienced a recurrence at 3 years that proved to be fatal. We review the pathogenesis and histopathology of sinus metastases, and we discuss the imaging features that characterize melanoma metastatic to the upper respiratory tract. While complete cure of patients with a sphenoid sinus metastasis has not been reported, significant palliation with radiation therapy is possible in many patients. Therefore, patients with sphenoid sinus symptoms suggestive of a sphenoid sinus malignancy should be vigorously evaluated for the possibility of a primary malignancy as well as a metastasis to the sinus.

Necrotizing sialometaplasia of the nasopharynx with parapharyngeal extension: Case report and brief review of the literature

December 19, 2014     Sanjeev Kumar, MS, MRCS, DOHNS; Asad Qayyum, FRCS, AFRCS, DLO; Nazir Bhat, MS, FRCS(ORL-HNS)
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We report a rare case of necrotizing sialometaplasia of the right lateral nasopharynx with extension into the right parapharyngeal space in a 39-year-old man. Since this is a self-limiting condition, the patient began to improve spontaneously over the next few weeks, and he experienced a complete recovery. Necrotizing sialometaplasia is an uncommon condition that is known to involve the palate; nasopharyngeal involvement is very rare, and to the best of our knowledge, extension into the parapharyngeal area has not been previously reported in the English-language literature. This condition poses a diagnostic dilemma because it closely mimics a malignancy, and failure to recognize it can result in unnecessary investigations and extensive surgery. We also review the literature on necrotizing sialometaplasia of the oropharyngeal area.

Sinus transillumination, then and now

December 19, 2014     Dewey A. Christmas, MD; Joseph P. Mirante, MD, FACS; Eiji Yanagisawa, MD, FACS
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In recent years, a new use has been found for transillumination in sinus surgical procedures involving balloon dilation. In these procedures, it is used to identify a sinus and to confirm that the balloon has entered the sinus correctly.

Cerebrospinal fluid leaks following septoplasty

December 19, 2014     Naren N. Venkatesan, MD; Douglas E. Mattox, MD; John M. Del Gaudio, MD
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We conducted a retrospective review to identify the characteristics of cerebrospinal fluid (CSF) leak in patients who had undergone septoplasty and in selected patients who had experienced a spontaneous CSF leak. CSF leak is a known but infrequently reported complication of septoplasty; to the best of our knowledge, only 4 cases have been previously published in the literature. A review of our institution's database revealed 3 cases of postseptoplasty CSF leak. We reviewed all the available data to look for any commonalities among these 7 cases. In addition, we reviewed 6 cases of spontaneous CSF leak selected from our database for the same purpose. For all patients, we noted the side of the cribriform plate defect, its size and, for the postseptoplasty cases, the interval between the septoplasty and the leak repair. Overall, we found that leaks were much more common on the right side than on the left. The sizes of the leaks in the 2 postseptoplasty groups were comparable (mean: 14.0 x 6.4 mm). The interval between septoplasty and leak repair ranged from 2.5 to 20 years in our cases and from 3 days to 22 weeks in the previously published cases. All 3 of the postseptoplasty patients in our database presented with clear rhinorrhea. Two of the 3 patients had meningitis; 1 of these 2 also had pneumocephalus. Of the 6 cases of spontaneous CSF leaks, 4 occurred on the right and 2 on the left; the average size of the defect was 5.8 mm in the greatest dimension. The finding that cribriform plate defects after septoplasty were typically right-sided likely reflects the prevalence of left-sided surgical approaches. Also, the fact that the defects were larger in the postseptoplasty cases than in the spontaneous cases is likely attributable to the torque effect toward the thin skull base that occurs when the perpendicular plate is twisted during septoplasty.

Sinonasal tract mucosal melanoma

October 17, 2014     Lester D.R. Thompson, MD
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Patients with obstructive symptoms, multiple sites of involvement, tumors of 3 cm or larger, an undifferentiated tumor on histology, a high mitotic count, and an elevated stage are more likely to have a poor prognosis.

Mucormycosis (Mucor fungus ball) of the maxillary sinus

October 17, 2014     Hang Sun Cho, MD; Hoon Shik Yang, MD, PhD; Kyung Soo Kim, MD, PhD
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Abstract

A fungus ball is an extramucosal fungal proliferation that completely fills one or more paranasal sinuses and usually occurs as a unilateral infection. It is mainly caused by Aspergillus spp in an immunocompetent host, but some cases of paranasal fungal balls reportedly have been caused by Mucor spp. A Mucor fungus ball is usually found in the maxillary sinus and/or the sphenoid sinus and may be black in color. Patients with mucormycosis, or a Mucor fungal ball infection, usually present with facial pain or headache. On computed tomography, there are no pathognomonic findings that are conclusive for a diagnosis of mucormycosis. In this article we report a case of mucormycosis in a 56-year-old woman and provide a comprehensive review of the literature on the “Mucor fungus ball.” To the best of our knowledge, 5 case reports (8 patients) have been published in which the fungus ball was thought to be caused by Mucor spp.

An unusual case of acute periorbital swelling

October 17, 2014     Sara Torretta, MD; Alessandra Brevi, MD; Davide Pagani, MD; Lorenzo Pignataro, MD
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Abstract

Periorbital swelling is frequently encountered in ear, nose, and throat practices and, as it may be secondary to acute sinusitis, delayed diagnosis may lead to significant morbidity. We describe the case of a 24-year-old man with acute ethmoid-maxillary sinusitis and ipsilateral facial swelling particularly involving the periorbital area. We also discuss the workup that led to the formulation of an unusual diagnosis.

Endoscopic view of an ostium in a concha bullosa of the superior turbinate

October 17, 2014     Eiji Yanagisawa, MD, FACS; Dewey A. Christmas, MD; Joseph P. Mirante, MD, FACS
article

A specific outflow tract or ostium of the superior turbinate, as was seen in this case, has been infrequently described or imaged.

Distal nasolacrimal duct showing the valve of Hasner

October 17, 2014     Joseph P. Mirante, MD, FACS; Dewey A. Christmas, MD; Eiji Yanagisawa, MD, FACS
article

Recognition of the location of the nasolacrimal duct opening is important to prevent its damage while performing an intranasal inferior meatal antrostomy or creating a window transantrally in the inferior meatal wall during a Caldwell-Luc procedure.

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