Sinus transillumination, then and now

December 19, 2014     Dewey A. Christmas, MD; Joseph P. Mirante, MD, FACS; Eiji Yanagisawa, MD, FACS

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.

Cutaneous malignant melanoma metastatic to the sphenoid sinus

December 19, 2014     Silviu Albu, MD; Opincariu Iulian, MD; Sorin Necula, MD

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.

Cerebrospinal fluid leaks following septoplasty

December 19, 2014     Naren N. Venkatesan, MD; Douglas E. Mattox, MD; John M. Del Gaudio, MD

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.

An unusual case of acute periorbital swelling

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


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.

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


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.

Sinonasal tract mucosal melanoma

October 17, 2014     Lester D.R. Thompson, MD

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.

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

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

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.

A rare occurrence of a fungus ball in the sphenoethmoid recess

October 17, 2014     Jae-Hoon Lee, MD; Ha-Min Jeong, MD

A fungus ball usually appears as a calcification within the sinus, suggesting the presence of a foreign body.

Pedunculated cavernous hemangioma originating in the olfactory cleft

September 17, 2014     Kaiming Su, MD, PhD; Weitian Zhang, MD, PhD; Haibo Shi, MD, PhD; Shankai Yin, MD, PhD


Sinonasal cavernous hemangioma is a rare condition that usually affects the lateral wall of the nasal cavity. We report the case of a 77-year-old man who presented with severe epistaxis, nasal congestion, and olfactory dysfunction. Endoscopic examination of the nasal cavity revealed the presence of a red-blue tumor that had almost completely filled the nasopharynx. Preoperatively, it was difficult to distinguish this lesion from a juvenile nasopharyngeal angiofibroma. During endoscopic surgery, the tumor was found to originate in the left olfactory cleft, and it had a long peduncle that contained blood vessels. Postoperative histopathologic examination indicated that the mass was a cavernous hemangioma. To the best of our knowledge, this is the first case of an olfactory cleft cavernous hemangioma and the first case of olfactory cleft disease associated with a cavernous hemangioma to be reported in the English-language literature.

Comparative study of intranasal septal splints and nasal packs in patients undergoing nasal septal surgery

September 17, 2014     Raman Wadhera, MS; Naushad Zafar, MS; Sat Paul Gulati, MS; Vijay Kalra, MS; Anju Ghai, MD


We conducted a prospective, comparative, interventional study to evaluate the role of intranasal septal splints and to compare the results of this type of support with those of conventional nasal packing. Our study population was made up of 60 patients, aged 18 to 50 years, who had undergone septoplasty for the treatment of a symptomatic deviation of the nasal septum at our tertiary care referral hospital. These patients were randomly divided into two groups according to the type of nasal support they would receive: 30 patients (25 men and 5 women, mean age: 23.3 yr) received bilateral intranasal septal splints and the other 30 (26 men and 4 women, mean age: 22.4 yr) underwent anterior nasal packing. Outcomes parameters included postoperative pain and a number of other variables. At 24 and 48 hours postoperatively, the splint group had significantly lower mean pain scores (p < 0.05). At 48 hours, the splint group experienced significantly fewer instances of nasal bleeding (p < 0.01), swelling over the face and nose (p < 0.01), watering of the eyes (p < 0.01), nasal discharge (p = 0.028), nasal obstruction (p < 0.001), and feeding difficulty (p = 0.028). Likewise, mean pain scores during splint or pack removal were significantly lower in the splint group (p < 0.01). At the 6-week follow-up, only 2 patients (6.7%) in the splint group exhibited a residual deformity, compared with 8 patients (26.7%) in the packing group (p = 0.038). Finally, no patient in the splint group had an intranasal adhesion at follow-up, while 4 (13.3%) in the packing group did (p < 0.05). We conclude that intranasal septal splints result in less postoperative pain without increasing postoperative complications, and thus they can be used as an effective alternative to nasal packing after septoplasty.

Focal hyperostosis of an intranasal inverted papilloma observed on computed tomography

September 17, 2014     Jae-Hoon Lee, MD; Ha-Min Jeong, MD

Precise preoperative identification of the tumor origin is as important as detecting the extent of tumor invasion.

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