Effectiveness of Functional Endoscopic Sinus Surgery in Surgical Management of Ethmoid Polyps

Background: Aim: To assess efficacy of functional endoscopic sinus surgery in surgical management of ethmoid polyps.Methods:One hundred twelve adult patients age ranged 18- 38 years of either gender with ethmoid polyps underwent FESS under general anesthesia. The extent of surgery was decided based on the findings in pre-operative CT scan of paranasal sinuses. Anterior ethmoidectomy, posterior ethmoidectomy, middle meatus antrostomy and clearance of frontal recess were performed in all the patients. Five functional criteria were evaluated as nasalobstruction , anosmia, rhinorrhea, post nasal drip, head ache and facial pain.Results:Pre- operative nasal obstruction percentage was 3.42 and post- operative ercentage was 2.10, Anosmia percentage was 2.14 and 1.15, Rhinorrhea percentage was 3.56 and 2.08 and ocular problem in 1 and synechia in 4 cases.Conclusions:Functional endoscopic sinus surgery found to be effective in management of ethmoid polyps and hence can be the treatment of choice.

326. Radiologic Findings of COVID-19 Associated Mucormycosis (CAM) from India

Background The unique feature of the second wave of the COVID -19 pandemic in India has been the alarming surge of acute invasive fungal infection among COVID -19 patients. The increased incidence of rhino-orbito-cerebral mucormycosis is a matter of concern, as this fulminant infection has high morbidity and mortality. Hence, it is imperative to understand it’s imaging features, for early diagnosis, staging and treatment. Methods We systematically reviewed 32 COVID-19 cases with imaging diagnosis of acute invasive fungal rhino-sinusitis or rhino-orbital-cerebral disease between March to May 2021. These patients underwent contrast MRI of the paranasal sinus, orbit and brain. Contrast enhanced CT chest and paranasal sinuses were done as needed. Results The age group ranged between 30 to 71 yrs with male preponderance. The most common predisposing factors were intravenous steroid therapy and supplemental oxygen. All cases were confirmed by fungal culture and most common was Mucor. The rhino-orbito-cerebral mucormycosis was staged as below In our study we found that the most common site in the nasal cavity was the middle turbinate /meatus and the earliest sign was non-enhancing / “black” turbinate. Premaxillary and retroantral fat necrosis was the earliest sign of soft tissue invasion. Spread via the sphenopalatine foramen and pterygopalatine fossa was more common than bony erosions. Orbital cellulitis and optic neuritis were the most common among stage 3 cases. Of patients with CNS involvement, the most common were cavernous sinus thrombosis and trigeminal neuritis. Two patients with pulmonary mucormycosis showed large necrotic cavitary lesions, giving the characteristic “bird’s nest” appearance. Figure 1. Black turbinate Contrast enhanced coronal T1 FS images of paranasal sinuses shows necrotic non-enhancing right superior and middle turbinates (*) Figure 2: Axial contrast enhanced T1 FS image showing necrotic non enhancing premaxillary (arrowhead) and retroantral fat (straight arrow) walled off by thin enhancing rim. Figure 3: Contrast enhanced axial T1 FS images of paranasal sinuses shows necrotic non-enhancing left middle meatus spreading along sphenopalatine foramen in to pterygopalatine fossa (arrow head) Conclusion The mortality rate was 20% in our study. In our short term follow up, 30 % of recovered patients had relapse on imaging due to incomplete clearance and partial antifungal treatment. High clinical suspicion and low imaging threshold are vital for early Mucormycosis detection in COVID-19 patients. Familiarity with early imaging signs is critical to prevent associated morbidity /mortality. Figure 4: Contrast enhanced coronal T1 FS and diffusion weighted images shows necrotic non-enhancing left middle meatus with left orbital cellulitis (*) and optic neuritis (white arrow) Figure 5. Bird’s nest Axial CT chest image in lung window shows necrotic right upper lobe cavity with internal septations and debris on a background of surrounding COVID-19 changes. Disclosures All Authors: No reported disclosures

CLINICAL AND RADIOLOGICAL FEATURES OF THE MAXILLARY SINUS IN PATIENTS AFTER REMOVAL OF FUNGAL BALL AND THEIR IMPACT ON THE FREQUENCY OF SUBANTRAL BONE AUGMENTATION COMPLICATIONS.

The mucoperiostitis and local osteitis are radiological symptoms of the fungal ball of the maxillary sinuses. The condition of the mucoperiosteum and the adjacent bone in the alveolar bay of the maxillary sinus predict the results of dental implantation and subantral augmentation. The endoscopic access to the sinus by the antrostomy in the middle meatus and infraturbinal have been used to avoid excessive tissue injury during the removal of the fungal ball. Aim: To assess the condition of the bone and mucoperiosteum of the maxillary sinus in patients with fungal ball after rhinosurgery by the antrostomy with additional osteoplastic infraturbinal access. Methods and materials: The data of 102 patients who underwent surgery for the fungal ball of the maxillary sinus were analyzed, and subsequently - subantral bone augmentation and dental implantation were performed. In patients of the first group (67 people) - endoscopic intervention was performed by antrostomy in the middle meatus, and in 2nd group (35 people) - additional osteoplastic infraturbinal access was used. Result: Computed tomography data were evaluated before endoscopic sinus surgery and before subantral augmentation. The frequency of signs and severity of osteitis according to Kannedy Osteitis Score, after the intervention did not change significantly, and was established as 0.90 ± 0.07 in patients of group №1 and 0.77 ± 0.08 – group №2. The total frequency of complications with subantral augmentation in the comparison groups was 17.91 ± 4.68% and 17.14 ± 6.37%, respectively. Symptoms of osteitis in patients with fungal ball of the maxillary sinus after endoscopic removal, in the first 4 - 6 months of observation tend to regress, but do not disappear. Conclusions: The incidence of osteitis in computed tomography in patients with maxillary sinuses fungal balls in 4.8 months after endoscopic removal tends to decrease and is 77.61 ± 5.09% when approach through the middle meatus and 74.29 ± 7, 39% in patients with combined infraturbinal approach. The use of additional infraturbinal approach in patients with a fungal ball does not adversely affect the results of subsequent subantral augmentation and dental implantation.

Unilateral Intervention in the Sinuses of Rabbits Induces Bilateral Inflammatory and Microbial Changes

BackgroundChronic rhinosinusitis (CRS) is a globally prevalent inflammatory condition of the paranasal sinuses which severely impairs patients’ quality of life. An animal model of unilateral sinusitis by transient sinus occlusion has been described previously in rabbits. The aim of this study was to characterise the sinusitis rabbit model by investigating temporal and bilateral changes in the bacterial community and mucosal inflammation.MethodsDevelopment of sinusitis was achieved by endoscopically placing Merocel®, a sterile nasal packing material, in the left middle meatus of six New Zealand white rabbits for four weeks. After a total period of 14 weeks, rabbits were assessed for sinusitis by endoscopic examination, magnetic resonance imaging (MRI) and histology. Swabs from the left and right middle meatus were obtained for bacterial community analysis at three time points (week 0, week 4, week 14) during the study.ResultsEndoscopic evaluation showed unilateral inflammation in all animals examined after the 4-week blocking period and at week 14. Notably, inflammatory changes were also seen in the contralateral sinus of all animals at week 4. MRI images demonstrated unilateral sinus opacification at week 4 in two rabbits, and partial unilateral sinus opacification at week 14 in one rabbit only. Histological analyses revealed substantial spatial heterogeneity of mucosal inflammation with inconsistent findings across all animals. No significant differences in mucosal inflammatory markers (such as goblet cell hyperplasia, epithelial denudation and oedema) could be identified between nostrils at week 14. The bacterial community in the rabbit sinuses was heavily dominated by Helicobacter at week 0 (baseline). At the end of the blocking period (week 4), bacterial alpha and beta diversity were significantly increased in both nostrils. The bacterial community composition at week 14 had primarily returned to baseline, reflecting the endoscopic and radiological results.ConclusionThis study reaffirmed the ability for development of sinusitis without inoculation of any pathogens in a rabbit model. We were able to demonstrate bilateral sinonasal mucosal inflammation, by inducing unilateral sinus blockage, which resulted in significant changes to the sinonasal bacterial community. These findings may explain some of the clinical observations seen in CRS and warrant further research to reveal potential implications for its therapeutic management.

Bilateral Schneiderian (sinonasal) papilloma: An uncommon rare entity

Sinonasal papilloma is a benign surface mucosal neoplasm with variable growth pattern and cytological features. It is a rare benign tumor with tendency to recur and also malignant transformation. The most common sites of inverting papillomata are lateral nasal wall and middle meatus and are usually unilateral. Rarely Bilateral disease can occur, which may be due to direct extension of the tumour, but can also occur as two distinct lesions. The etiology still remains unclear, eventhough the morphology and clinical behavior of this lesion has been well described. Here we report a case of recurrent bilateral nasal polyposis, histologically diagnosed as Inverted sinonasal papilloma, which is a rare entity.

Case report of a large rhinolith cast – A frequently missed diagnosis

Background: Rhinoliths are calcified or mineralized concretions that are deposited around a nucleus and are usually unilateral. They are rare with an estimated incidence of 1:10000 of all ENT outpatient cases. This may be an underestimation as many cases remain asymptomatic since the process may take years to develop. Case Report: We report a case of unilateral nasal obstruction since childhood in an adult male where the diagnosis remained obscured until thorough assessment was done. According to the anterior rhinoscopic and nasoendoscopic examination, there was an irregular bony mass occupying the left nasal cavity from the floor to the middle meatus. The diagnosis of rhinolith was confirmed by nasoendoscopy and non-contrast CT (NCCT) scan, and it was removed piecemeal from the nose. Conclusion: This case underlines the importance of a detailed clinical and endoscopic examination of the nose in adult cases with unilateral nasal obstruction. It also highlights the potential for misdiagnosis of such cases at the hands of general practitioners or physicians and the importance of early referral to an otolaryngologist in case of treatment failure by established protocols.

Demographic profile of subjects currently undergoing middle meatus antrostomy for maxillary sinusitis, in a tertiary care centre of Punjab: analysis of 64 subjects

Background: The demographic profile of patients with Maxillary sinusitis undergoing surgical intervention in the state of Punjab was analyzed. The emphasis was on the age, gender and clinical presentation in this prospective study. Methods: In this prospective study 64 patients with maxillary sinusitis, were randomly selected from the Rhinology clinics of Oto-rhino-laryngology services, Dayanand Medical College and Hospital, Ludhiana in a period of one and a half years (June 2008 to December 2009). All patients were taken up for Functional endoscopic sinus surgery with middle meatus antrostomy.Results: Only 7 (10.94%) patients, with maxillary sinusitis were in the pediatric age group. 40(62.5%) were males and 24 (37.5%) females. Males outnumbered females in the ratio of 1.67:1. Clinical findings were nasal polyp in 33 (51.56%), middle meatus discharge in 10 (15.63%) and septal deviation was seen in 36 (56.25%) patients. Polypoidal mass was seen in the posterior choana in 24 (37.5%) patients followed by discharge inferior to the Eustachian tube orifice in 7 (10.94%). Recurrence of polypoidal change or frank polyposis occurred in 7 patients (10.94%). Post nasal drip persisted in 15/49 cases, while 54 (84.38%) were completely relieved of their symptoms. Recurrence was noticed more commonly in the region of ethmoid air cells.Conclusions: Patients with maxillary sinusitis were seen in the broad age range from 11 to 66 years with a male predominance. Nasal blockage rather than cheek ache was the primary complaint followed by polyp in the middle meatus and post nasal drip inferior to the Eustachian tube.

Modelling effectiveness of PPE on aerosol exposure for healthcare workers during typical ENT procedures

BACKGROUND: Previous studies report environmental aerosolization with various endonasal procedures, but do not specifically measure intranasal levels of inhaled aerosolized particles in healthcare providers (HCP) performing such procedures. The purpose of this study is to measure the impact of various types of personal protective equipment (PPE) worn by HCP during a variety of office-based endonasal procedures. METHODOLOGY: Simulated sneeze and office-based procedures were performed in a test model and aerosol levels were quanti- fied in the middle meatus of a simulated HCP model wearing various forms of PPE by using a laser diode-based particle counter. Endoscopic exam, balloon sinus dilation, suction and irrigation, simulated tissue resection with a microdebrider, and routine debridement procedures were evaluated. The aerosol levels were evaluated with and without the use of PPE to assess HCP aerosol exposure. RESULTS: A simulated sneeze represents a worst-case aerosol generating event when compared to other common office-based procedures (approximately 1,000 times greater than baseline particle count). Common endoscopic procedures did not generate significantly greater particle counts above baseline. When compared to no mask, a surgical mask reduces particle counts experi- enced by HCP in the middle meatus by 69%, while an N95 mask significantly reduced particles by 93%. CONCLUSIONS: The levels of aerosols generated during common office-based procedures are consistent with the background aerosol levels measured at baseline. Masks are effective, with the N95 mask most effective at reducing HCP exposure to aerosols generated during a simulated sneeze.

Endoscopic removal of ectopic dentition in ethmoid sinus

A 66-year-old woman presented with a 6-month history of unilateral right nasal obstruction and rhinorrhoea not responding to medical therapy. She had a history of dental implantation for an unerupted tooth on the right side 3 years ago. Physical examination including flexible nasendoscopy demonstrated yellow debris in the right middle meatus. CT paranasal sinuses demonstrated a radiopaque lesion in the right anterior ethmoid sinus and resembled the unerupted tooth. The tooth was removed endoscopically from the right nasal cavity without complications. This case highlights the importance of eliciting an accurate dental history and considering ectopic dentition as a differential diagnosis in a patient with unilateral symptoms of sinusitis.