Rhinology

Septic arthritis: A unique complication of nasal septal abscess

March 2, 2015     Steven M. Olsen, MD; Cody A. Koch, MD, PhD; Dale C. Ekbom, MD
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Abstract

Nasal septal abscesses (NSAs) occur between the muco-perichondrium and the nasal septum. They most often arise when an untreated septal hematoma becomes infected. The most commonly reported sequela is a loss of septal cartilage support, which can result in a nasal deformity. Other sequelae include potentially life-threatening conditions such as meningitis, cavernous sinus thrombosis, brain abscess, and subarachnoid empyema. We report the case of a 17-year-old boy who developed an NSA after he had been struck in the face with a basketball. He presented to his primary care physician 5 days after the injury and again the next day, but his condition was not correctly diagnosed. Finally, 7 days after his injury, he presented to an emergency department with more serious symptoms, and he was correctly diagnosed with NSA. He was admitted to the intensive care unit, and he remained hospitalized for 6 days. Among the abscess sequelae he experienced was septic arthritis, which has heretofore not been reported as a complication of NSA. He responded well to appropriate treatment, although he lost a considerable amount of septal cartilage. He was discharged home on intravenous antibiotic therapy, and his condition improved. Reconstruction of the nasal septum will likely need to be pursued in the future.

Basaloid squamous cell carcinoma of the sinonasal tract with metastasis to the liver: A case report and literature review

February 2, 2015     Boon Ping Toe, FRCR(Lond); Norlisah Ramli, FRCR(Lond); Sze Yin Lam, MRad(Mal); Kum Thong Wong, FRCPath(Lond); Narayanan Prepageran, FRCS(Edin)
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Abstract

Basaloid squamous cell carcinoma (BSCC) is a rare subtype of squamous cell carcinoma. To date, only 95 cases of sinonasal BSCC have been reported in the English-language literature, and they account for 5% of all cases of head and neck BSCC. We describe what we believe is only the second reported case of a sinonasal tract BSCC that metastasized to the liver. The patient was a 36-year-old woman who presented with right-sided nasal obstruction and a foul-smelling discharge. Clinical examination and imaging identified a large lobulated enhancing mass in the right nasal cavity. Following excision of the mass, the patient was scheduled for radiotherapy. However, before it could be administered, follow-up imaging detected a metastasis to the liver and lung, and the patient was switched to chemotherapy. Initially, she responded well clinically, but at 5 months postoperatively, a follow-up CT showed an increasing metastatic presence in the liver and bone. The patient died of her disease 1 year after surgery.

Effects of nasal saline lavage on pediatric sinusitis symptoms and disease-specific quality of life: A case series of 10 patients

February 2, 2015     Sandra Y. Lin, MD; Katherine M. Baugher, DO; David J. Brown, MD; Stacey L. Ishman, MD
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Abstract

We conducted a prospective study to assess (1) the effects of daily nasal irrigation in children with chronic sinonasal symptoms and (2) the impact that treatment had on disease-specific quality of life as assessed by a validated instrument, the five-item Sinus and Nasal Quality of Life Survey (SN-5), and by an overall nasal quality-of-life (NQL) score based on a 10-point faces scale. Our patient population was made up of 10 children-7 girls and 3 boys, aged 3 to 9 years (mean: 6.1)-who had presented with symptoms of chronic rhinosinusitis for more than 3 months and who had not responded to previous medical management. Patients were administered nasal saline lavage daily for 1 month. These patients and/or their caregivers completed an SN-5 questionnaire upon entry into the study and at the completion of treatment. At study's end, a comparison of pre- and post-treatment scores with paired Student t tests showed that the mean total SN-5 score improved significantly over baseline, falling 45% from 21.4 to 11.7 (p = 0.0002). Moreover, significant overall improvement was seen in each of the five subcategories of the SN-5 survey (p = 0.0009 to 0.038). The NQL scores also improved significantly from 4.7 to 7.7 (p = 0.0034). Compliance with nasal lavage was generally good among the 10 patients, as 8 of them used at least 75% of the recommended quantity of saline at least once a day. During a follow-up period that ranged from 2 to 23 months (mean: 10.4), only 1 patient required an adenoidectomy for symptom control. The results of this pilot study suggest that nasal saline lavage may significantly alleviate chronic sinonasal symptoms and improve disease-specific quality of life in children with symptoms of chronic rhinosinusitis.

Primary thyroid-like papillary adenocarcinoma of the nasal septum: A case report

February 2, 2015     Kerem Ozturk, MD; Rasit Midilli, MD; Ali Veral, MD; Yesim Ertan, MD; Bulent Karci, MD
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Abstract

Primary thyroid-like papillary adenocarcinomas are extremely rare neoplasms that generally originate in the nasopharynx. We report the case of a 24-year-old woman who was diagnosed with a thyroid-like papillary adenocarcinoma that originated in the nasal septum. The tumor was surgically removed, and the patient showed no evidence of local recurrence during 4 years of follow-up.

Palliative endoscopic surgery for sinonasal metastases: A case report and literature review

February 2, 2015     Jason M. Roberts, MD; Christopher Brook, MD; Steven Parnes, MD
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Abstract

Cancer metastatic to the paranasal sinuses often presents with ophthalmologic and facial deformities, as well as sinonasal complaints. These diminutive tumors are difficult to effectively treat, often leading to poor quality of life. Although breast cancer is a common cancer affecting more than 150,000 women each year,1 rarely is metastatic breast cancer found within the sinuses. We report our palliative treatment approach and outcomes of a 40-year-old patient with breast cancer metastatic to the paranasal sinuses. While providing a better understanding of this tumor's metastasis through a review of the literature, our report describes the role of palliative surgery for metastases to the paranasal sinuses.

Endoscopic view of a medial ethmoid drainage pathway into the middle meatus

February 2, 2015     Dewey A. Christmas, MD; Joseph P. Mirante, MD, FACS; Eiji Yanagisawa, MD, FACS
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The ostium of the ethmoid bulla is often found in the hiatus semilunaris superior, but that it can also be found in the anterior or lateral wall of the bulla, the ethmoid infundibulum, the hiatus semilunaris inferior, or the retrobullar recess.

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: Rhizopus oryzae

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

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.

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.

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.

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