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Antibiotics, steroids, and combination therapy in chronic rhinosinusitis without nasal polyps in adults

June 28, 2018  |  Yuan F. Liu, MD; Clare M. Richardson, MD; Stewart H. Bernard, MD; Christopher A. Church, MD; Kristin A. Seiberling, MD


Despite a lack of robust data regarding their efficacy, oral antibiotics and steroids remain two of the most common treatments for chronic rhinosinusitis without nasal polyps (CRSsNP). We sought to objectively compare the efficacy of antibiotics and steroids, independently and in combination, for the initial treatment of CRSsNP. To that end, we conducted a retrospective chart review of 100 patients-51 men and 49 women, age 20 to 85 years (mean: 50)-who were treated for CRSsNP from January 2010 through January 2015. Of this group, 17 patients were treated with an antibiotic only, 28 with a steroid only, and 55 with both agents. All patients underwent computed tomography (CT) before and after treatment, and we compared the three groups' pre- and post-treatment Lund-Mackay CT scores, symptom scores, and rates of surgery. The average time between the pre- and post-treatment visits was 4.4 weeks. The mean Lund-Mackay CT score for the entire study population was significantly lower after treatment than at baseline (6.3 vs. 9.1; p < 0.001); however, there were no significant differences among the three groups in either pre- or post-treatment scores. Symptom scores were significantly better in the combination therapy group than in the two monotherapy groups (p < 0.001). In all, 40 of the 100 patients underwent surgery; the difference in surgery rates among the three groups was not statistically significant (p = 0.884). Surgery was performed on 9 of the 52 (17.3%) patients who either were followed for at least 1 year or who had had surgery within the first year postoperatively; again, there were no significant differences among the three groups (p = 0.578). We conclude that although the Lund-Mackay CT scores decreased significantly in the antibiotic, steroid, and combination therapy groups, no one regimen was superior to any other for treating CRSsNP in our study.

Hemifacial spasm secondary to middle ear cholesteatoma

June 28, 2018  |  Maheep Sohal, MD; Nicholas Karter, MD; Marc Eisen, MD, PhD


Hemifacial spasm is a peripheral myoclonus of the VIIth cranial nerve that is characterized by paroxysmal contraction of the muscles of facial expression. It exists in both primary and secondary forms. In rare cases, hemifacial spasm is caused by middle ear pathology. We describe the case of a 90-year-old man with recurrent cholesteatoma and tympanic segment fallopian canal dehiscence manifesting as right-sided hemifacial spasm. His history was significant for a right-sided tympanomastoidectomy for cholesteatoma 6 years earlier. Computed tomographic angiography performed to look for vascular compression of the facial nerve demonstrated a right middle ear opacification. Middle ear exploration revealed a completely dehiscent tympanic segment with cholesteatoma abutting the facial nerve. The overlying keratin debris and matrix were carefully dissected off, and facial nerve function was preserved. The final diagnosis was hemifacial spasm. During 14 months of postoperative follow-up, the patient experienced no further facial spasm.

Balloon eustachian tuboplasty and the tragedy of the commons

June 28, 2018  |  Brian J. McKinnon, MD, MBA, MPH, FACS

An inverted papilloma arising from the middle turbinate and extending to the maxillary sinus ostium

June 28, 2018  |  Jae Hoon Lee, MD

Inverted papillomas have been reported to have a high propensity for recurrence, and they are associated with squamous cell carcinoma.

Low-grade sinonasal sarcoma with neural and myogenic features

June 28, 2018  |  Neil G. Hockstein, MD; Peter E. Dross, MD; Shoheb Farooqui, MD; Ian N. Wilhelm, MD

The distinction between bony destruction versus erosion is important because they suggest different pathologic entities.

Intradermal nevus of external auditory canal revisited

June 28, 2018  |  Pei-Hsuan Wu, MD; Hsin-Chien Chen, MD, PhD

Intradermal nevus, a subtype of melanocytic nevus, occurs relatively rarely in the external auditory canal.

Laryngeal chondrosarcoma

June 28, 2018  |  Norman J. Chan, MD; Christopher Fundakowski, MD; Ahmed M.S. Soliman, MD

About 80% of laryngeal chondrosarcomas have calcifications that can be seen on CT, but MRI can help to determine extralaryngeal extension.

The incidence of revision adenoidectomy: A comparison of four surgical techniques over a 10-year period

June 28, 2018  |  Nipun Bhandari, MPH; Debra M. Don, MD; Jeffrey A. Koempel, MD, MBA


Approximately 130,000 adenoidectomies are performed each year in the United States. Few studies have examined adenoid regrowth and the incidence of revision surgery or have compared four different surgical instruments commonly used for adenoid surgery within the same institution. This study aimed to determine the incidence of revision adenoidectomy after the use of microdebrider, Coblation, suction cautery, and curette instruments over a 10-year period at a single major tertiary children's center in the United States. A retrospective chart review was performed for all patients who underwent primary and/or revision adenoidectomy at the Children's Hospital Los Angeles (CHLA) between August 2004 and August 2014. During the 10-year study period, a microdebrider was used in 212 cases, Coblation in 382, suction cautery in 1,926, and curette in 3,139 adenoidectomies. The percentages of revision adenoidectomy were 1.42% (3 patients) for microdebrider, 0.79% (3 patients) for Coblation, 0.36% (7 patients) for suction cautery, and 0.03% (1 patient) for curette. The cumulative incidence of revision adenoidectomy for initial surgeries performed at CHLA was 0.2% for the 10-year study period. Pearson chi-square analysis showed statistically significant differences between the surgical techniques (p < 0.0001). In conclusion, regrowth of adenoid tissue requiring revision surgery occurs very infrequently irrespective of the instrument used for the primary procedure, and the most common indication for revision adenoidectomy is to improve eustachian tube dysfunction rather than nasal obstruction due to adenoid hypertrophy.

Histopathologic evaluation of Ecballium elaterium applied to nasal mucosa in a rat rhinosinusitis model

June 28, 2018  |  Can Mehmet Eti, MD; Yusuf Vayisoglu, MD; Berkan Kardas, MD; Rabia Bozdogan Arpaci, MD; Elif Sahin Horasan, MD; Arzu Kanik, PhD; Neslihan Eti, MD; Serap Yalin, BScPhm; Derya Umit Talas, MD


This study aimed to evaluate the antimicrobial effects of the medicinal plant Ecballium elaterium, which is topically applied as a traditional medicine for the treatment of rhinosinusitis. Pure and extract forms of E elaterium were applied to the nasal cavity of rats for the treatment of Streptococcus-pneumoniae -induced rhinosinusitis. The nasal mucosa, soft palate, and trachea of the rats were harvested in the first hour, third day, and third week for histopathologic evaluation. This experiment revealed the anti-inflammatory effects of E elaterium and showed that it reduced fibrosis. The anti-inflammatory effect of all forms of E elaterium was found to reach its maximum level on the third day, decreasing by the third week. We also observed that the pure form of E elaterium caused severe epithelium loss in the first hour after application. The mechanism of the anti-inflammatory effect of different levels of extract forms needs to be further analyzed with different doses and duration of treatment.

Endoscopic surgery for primary sinonasal malignancies: Treatment outcomes and prognostic factors

June 28, 2018  |  Yan Huang, MD; Qian-hui Qiu, MD, PhD; Shui-xing Zhang, MD, PhD


We retrospectively reviewed the cases of 85 patients with primary sinonasal malignancies who had undergone endoscopic surgery with curative intent achieved by “regional resection.” Our goal was to assess the efficacy of endoscopic surgical treatment vis-à-vis traditional open surgery. Kaplan-Meier data analysis revealed that the 1-, 3-, and 5-year disease-specific survival rates were 82, 60, and 49%, respectively. Multivariate Cox model survival analysis revealed that male sex, certain pathologic types of cancer (i.e., undifferentiated carcinoma, olfactory neuroblastoma, and rhabdomyosarcoma), and T3/T4 category negatively impacted survival (adjusted hazard ratios: 3.601, 0.012, 0.287, 0.068, and 0.339, respectively; p < 0.05 for all). We also performed a separate analysis of 47 patients who had category T3 or T4 cancer to determine if the type of surgical approach is a prognostic factor. For this, we identified 20 new patients who had undergone open resection, and we compared them to 27 of our endoscopically treated patients who had similar clinical characteristics. We found that the type of surgical approach did not appear to be a prognostic factor (p > 0.10), although those patients who had undergone endoscopic resection had significantly shorter hospital stays (p < 0.001). We conclude that patients with primary sinonasal malignancies who are treated with endoscopic surgery have acceptable survival rates and therefore endoscopic surgery is justified in the hands of highly experienced surgeons in selected cases.