Giant frontal sinus osteoma and its potential consequences: illustrative case

BACKGROUND Osteomas of the paranasal sinuses are benign, slow-growing bone tumors that can cause a variety of clinical features depending on their size and location. Most osteomas are asymptomatic and located in the frontal sinus. In rare cases, they may grow to extend into the cranial or orbital cavities, resulting in atypical presentations. The authors presented an aggressive case of a frontoethmoidal sinus osteoma with intracranial extension of an inflammatory sinonasal polyp. OBSERVATIONS A 30-year-old man with a history of chronic sinusitis presented to the hospital after three episodes of loss of consciousness, chronic worsening of headache, and decreased sense of smell. Rhinoscopic examination showed mucosal polyps arising from the infundibulum and the superior meatus. Computed tomography showed a fibro-osseous mass in the left frontal sinus. Subsequent brain magnetic resonance imaging with and without contrast revealed a large, septated intracranial left frontal lesion approximately 6.5 cm in diameter that was compressing the underlying brain parenchyma. LESSONS Intracranial extension of frontal sinus osteomas can have dire neurological implications. Early detection of lesions obstructing the paranasal sinuses outlet could prevent intracranial extension of the disease. The surgical approach to such tumors may be endonasal, open cranial, or a combination of both.

Accessory maxillary sinus ostia in superior meatus: a retrospective study and its clinical application

Objectives: To investigate the incidence of accessory maxillary sinus ostia in superior meatus in patients with clinical and radiological signs of maxillary sinusitis and the association with the development of chronic rhinosinusitis. Design: Retrospective study Setting: Tertiary care hospital Participant: 159 patients examined with paranasal sinus computed tomography scans Main outcome measures: We retrospectively evaluated patients who visited the outpatient department at an academic medical facility between January and April 2020 with a clinical diagnosis of chronic rhinosinusitis. Paranasal sinus axial and coronal computed tomography scans were evaluated for accessory maxillary sinus ostia in superior meatus and confirmed by reconstructed three-dimensional simulation images. The demographic information and incidence of accessory ostia in superior meatus were assessed. The Lund–Mackay score was used to rate chronic rhinosinusitis severity. Analysis of variance was performed to correlate the severity of chronic rhinosinusitis with presenting accessory ostia in superior meatus. Results: Of 159 patients (81 males; 78 females), 41.5% had accessory maxillary sinus ostia in superior meatus. Of these, two-thirds were bilateral and one-third was unilateral. The severity of rhinosinusitis was not correlated with having accessory maxillary sinus ostia in superior meatus, but the presence of accessory ostia was significantly associated with less severe chronic rhinosinusitis (P < 0.001). Conclusions: Accessory maxillary sinus ostia in superior meatus are significantly associated with less severe chronic rhinosinusitis and most cases are bilateral.

Nasal polyps and rhinosinusitis

Rhinosinusitis is defined as inflammation of one or more of the paranasal sinuses and affects approximately 12% of the population. Acute rhinosinusitis is defined as symptoms that last < 12 weeks, and chronic rhinosinusitis (CRS) is defined as symptoms that last > 12 weeks. CRS is divided into three groups: CRS with nasal polyps (CRSwNP), CRS without nasal polyps (CRSsNP), and allergic fungal rhinosinusitis. Nasal polyps are inflammatory outgrowths of paranasal sinus mucosa caused by chronic mucosal inflammation and are present in 20% of patients with CRS. Nasal polyps typically present with nasal congestion, nasal obstruction, and anosmia or hyposmia, and occur more frequently in patients with persistent asthma, aspirin-exacerbated respiratory disease (AERD), CRS, and cystic fibrosis. The sinus cavities are lined with pseudostratified ciliated columnar epithelial cells interspersed with mucous goblet cells. Cilia continuously sweep the mucous toward the ostial openings and are important in maintaining the proper environment of the sinus cavities. The frontal, maxillary, and anterior ethmoid sinuses drain into the ostiomeatal unit of the middle meatus. The posterior ethmoid sinuses and superior sphenoid sinuses drain into the sphenoethmoid recess of the superior meatus. Most acute sinus infections are caused by viruses, and, therefore, it is not surprising that the majority of patients improve within 2 weeks without antibiotic treatment. A bacterial infection should be considered if symptoms worsen or fail to improve within 7‐10 days. Combining an intranasal corticosteroid with an antibiotic reduces symptoms more effectively than antibiotics alone. Topical nasal steroids are the treatment of choice for nasal polyps. They significantly decrease polyp size, nasal congestion, and rhinorrhea, and increase nasal airflow. Short courses of oral steroids may be needed to reduce polyp size, followed by maintenance therapy with topical steroids. Surgery is reserved for patients in which polyps cause severe obstruction or recurrent sinusitis and for patients for whom medical therapy has failed. Aspirin desensitization may decrease the requirement for polypectomies and sinus surgery in patients with AERD.

Post-operative course prediction during endoscopic sinus surgery in patients with chronic rhinosinusitis

Objective:This study aimed to analyse findings of functional endoscopic sinus surgery to estimate the post-operative course of patients with chronic rhinosinusitis.Methods:From 2007 to 2015, 291 adult patients with bilateral chronic rhinosinusitis, divided into eosinophilic chronic rhinosinusitis (n= 210) and non-eosinophilic chronic rhinosinusitis (n= 81) groups, who underwent primary functional endoscopic sinus surgery were enrolled. Functional endoscopic sinus surgery findings, scored as operating score, were analysed in relation to pre-operative olfactory recognition threshold and sinonasal computed tomography imaging score, as well as post-operative endoscopic appearance.Results:Operating scores in eosinophilic chronic rhinosinusitis were significantly worse than those in non-eosinophilic chronic rhinosinusitis. The anterior ethmoid sinus and superior meatus were predominantly inflamed. Operating score significantly correlated with pre-operative olfaction recognition threshold, computed tomography score and pre-operative endoscopic appearance score. In eosinophilic chronic rhinosinusitis, higher operating scores were related to post-operative deterioration of endoscopic appearance score.Conclusion:The operating score reflects the course following functional endoscopic sinus surgery. Patients with more severe operative findings require longer post-operative treatment.

A safe way to find the posterior ethmoidal cells: navigation with cottonoid

BACKGROUND. Functional endoscopic sinus surgery (FESS) is a reliable option in the treatment of sinus pathology, but the presence of the anatomical variant and difficult cases like massive polyposis or revision FESS can generate some problems to surgeons. MATERIAL AND METHODS. After performing an unciformectomy, a partial anterior ethmoidectomy and maxillary ostium antrostomy, we slide a cottonoid back to the basal lamella of the middle turbinate with a Cottle dissector and introduce it in the superior meatus. After that, we return to the middle meatus and proceed to open the basal lamella finding the cottonoid placed there previously. RESULTS. An easy technique, safe and reproducible, that allows us to advance in our dissection, avoiding damaging important structures. CONCLUSION. In this paper we present a safe way to approach the posterior ethmoidal cells complex in the classic way through the basal lamella of the middle turbinate, under the guidance of a cottonoid, a safe and easy maneuver to do this procedure in the beginning of our formation or in complex cases.

Anatomicosurgical References for Endoscopic Localization of Sphenopalatine Foramen: A Cadaveric Study

ABSTRACT Introduction In patients with posterior epistaxis, generally the source of bleeding is branches of sphenopalatine artery (SPA), which enter the nasal cavity through the sphenopalatine foramen (SPF). Cases of intractable massive bleeding may require endonasal endoscopic occlusion of these vessels. Materials and methods A total of 32 hemisections of formalinfixed cadaveric heads were used. The anatomic variations of SPF, its distance from anatomical landmarks, and angle of elevation of endoscope were studied so as to facilitate accurate localization of the foramen and endoscopic arterial ligation. Results The SPF was generally single; however, multiple exits in the form of accessory foramina were found in 36.75% hemisections. The transition of superior and middle meatuses was the most common location of SPF, followed by the superior meatus, and middle meatus was the least common site. The accessory foramina were commonly present in the superior meatus. Ethmoid crest was distinctly visible in all but two cases. In majority of the cases, the SPF was located within a range of 55 to 65 mm from the anterior nasal spine (ANS); 60 to 70 mm from piriform aperture, 50 to 60 mm from limen nasi, 20.1 to 25 mm vertically above the floor of nasal cavity, and 8 to 15 mm from the inferior turbinate (IT). The angulation of SPF from the floor of nasal cavity was 20 to 30°. Conclusion Exploration of lateral nasal wall (LNW) up to middle meatus would minimize the risk of missing any arterial branch, and the data of distance from the anatomical references would assist in more precise localization of SPF during endoscopic ligation or cauterization of the branches of the SPA. How to cite this article Aggarwal A, Gupta T, Sahni D, Gupta A. Anatomicosurgical References for Endoscopic Localization of Sphenopalatine Foramen: A Cadaveric Study. Clin Rhinol An Int J 2016;9(3):109-114.