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Objectives: To describe potential mechanisms by which pepsin induces inflammation in refractive chronic rhinosinusitis (CRS). Our hypothesis was that pepsin induces mitochondrial damage and cytokine expression in human nasal epithelial cells (HNEpC) in vitro.Methods: Western blot was used to detect pepsin in sinus lavages from patients with CRS and controls. The HNEpC cells were treated with pepsin (pH 7; 0.1 mg/mL) for 1 or 16 hours and routine electron microscopy (EM) and MTT assay were performed. Cytokine ELISA was performed on media collected from HNEpC cells 16 hours following a 1-hour pepsin treatment.Results: Pepsin was detected in sinus lavages from 4 out of 6 CRS patients and 0 out of 3 controls. The EM showed mitochondrial damage in pepsin-treated HNEpC cells but not in control cells. The MTT assay demonstrated reduced mitochondrial activity in pepsin-treated HNEpC cells compared to controls (P< .001). Pepsin increased IL-1A (P= .003) and IL-6 (P= .04) expression in HNEpC cells.Conclusions: Pepsin in sinus lavages from patients with CRS is consistent with previous studies. This study reveals the damaging effect of pepsin on mitochondria in nasal epithelial cells in vitro. Cytokines previously associated with CRS were elevated following pepsin treatment of HNEpC cells in vitro. These results demonstrate mechanisms by which pepsin may potentiate CRS.

IMPORTANCE Epistaxis is the most common otolaryngologic emergency in the United States. Most cases are controlled with first-line measures, but intractable epistaxis can be a challenging clinical problem requiring posterior nasal packing and surgical or endovascular intervention. Bleeding from nasal telangiectasias is well known in hereditary hemorrhagic telangiectasia, but there are no reports in the literature of recurrent epistaxis due to isolated telangiectasias not associated with systemic disease. This report describes a series of cases in which intractable epistaxis due to isolated primary telangiectasias was effectively controlled with bipolar electrosurgery. OBSERVATIONS We describe a patient with intractable epistaxis that had failed management with posterior packing and embolization. We also report a series of 16 cases of epistaxis, 6 of which were intractable, in adults without hereditary hemorrhagic telangiectasia who received treatment between 2009 and 2012. These cases reveal a common pattern of bleeding from telangiectasias on the anterior septum (8 cases [42%]), nasal sidewall (3 [16%]), inferior meatus (2 [10%]), posterior septum (2 [10%]), nasal floor (2 [10%]), middle turbinate (1 [5%]), and inferior turbinate (1 [5%]). CONCLUSIONS AND RELEVANCE Telangiectasias not associated with systemic disease are a previously unreported source of significant nasal bleeding that, when identified endoscopically, can be treated successfully with bipolar electrosurgery rather than with more invasive and costly surgical and endovascular measures.

Trephination of the frontal sinus has been used for more than a century to address acute infections of the frontal sinus. There are many levels at which the sinus can be entered. This article describes the options and indications for the various approaches to trephination of the frontal sinus. [Copyright &y& Elsevier]

The external medial maxillectomy has long been used to manage benign and malignant tumors of the lateral nasal wall. Although many advocate for an endoscopic approach to these tumors, there are still tumors that may lend themselves to an external medial maxillectomy. This article describes the authors'' technique for performing an external medial maxillectomy. [Copyright &y& Elsevier]

Background Patients commonly present with complaints of postnasal drainage (PND) without objective evidence to support a sinonasal or infectious etiology. PND has been attributed to extra-esophageal reflux (EER), and an empiric trial of antireflux medication often is used to treat PND and associated symptoms. This study was performed to (1) evaluate the relationship between symptoms of EER and PND and (2) assess the efficacy of proton pump inhibitors (PPIs) in the management of PND.Methods Patients with a chief complaint of PND without objective evidence of sinonasal inflammatory disease were enrolled in a prospective, double-blinded, randomized placebo-controlled trial using rabeprazole, 20 mg, orally twice daily or placebo for 90 days. Subjects completed two-site 24-hour pharyngeal pH probe monitoring before treatment. Outcome measures included pre- and posttreatment visual analog scales for PND symptoms, reflux symptom index, and reflux finding score (RFS).Results Forty-seven patients were enrolled (mean age, 55 years)—21 patients in the PPI group and 26 in the placebo group. Fifty-six percent of subjects had pH probe confirmed EER using a cutoff of pH < 5.0. Baseline symptom measures between subjects with and without EER were not different. Compared with placebo, subjects receiving rabeprazole reported significant reduction in PND frequency (p = 0.0180), hoarseness (p = 0.0164), and chronic cough (p = 0.0204). The RFS decreased slightly in the placebo group (p = 0.1490) whereas it increased slightly in the PPI group (p = 0.5235). This difference between groups was significant (p = 0.0272).Conclusion Although 50% of subjects had evidence of EER, there was no difference in baseline symptoms between subjects with and without. Our findings support the potential benefit of PPI therapy for reducing PND frequency, hoarseness, and chronic cough, and confirm a placebo effect for other laryngopharyngeal reflux symptoms. The effect on laryngeal findings is mixed and patients may experience symptomatic improvement before changes in laryngoscopic appearance.

The autonomic nervous system has been implicated in the pathophysiology of chronic upper airway inflammatory disease for decades. We discuss the most recent literature with regard to autonomic nervous system dysfunction and chronic upper airway disease.

The purpose of this review is to discuss endoscopic management of cerebrospinal fluid leaks and to highlight recent advances in both outcomes and technique.

Purpose:Sex has been demonstrated to affect outcome in many diseases. Our current aim is to investigate the relationship between sex and outcomes of endoscopic sinus surgery (ESS) in patients with chronic rhinosinusitis (CRS).

Purpose:To assess objective and quality of life (QOL) outcomes before and after endoscopic sinus surgery (ESS) in patients with chronic rhinosinusitis (CRS) and to determine preoperative factors that predict surgical outcome in these patients.

Background Endoscopic sinus surgeons are commonly faced with the management of patients with persistent maxillary sinusitis despite previous Caldwell–Luc surgery. Given the potential for altered mucociliary clearance in the post-Caldwell–Luc maxillary sinus, the optimal approach for surgical revision has not been well characterized. The objective of this study was to review our experience in endoscopic versus repeat Caldwell–Luc approaches in patients who have failed Caldwell–Luc surgery for chronic maxillary sinusitis.Methods Retrospective chart review was performed on patients who had a history of a Caldwell–Luc procedure and who then underwent a surgical revision for persistent maxillary sinusitis at the Oregon Health and Science University and Medical College of Wisconsin between 1983 and 2002.Results Sixty-eight patients were identified, with a total of 156 revision procedures performed on 103 maxillary sinuses. Fifty-three percent of the sinuses underwent endoscopic maxillary antrostomy as the first surgical revision, while 47% underwent a revision Caldwell–Luc procedure. Sixty-seven percent of the sinuses in the revision endoscopic group had clinical resolution with a single surgical revision, and 60% of the sinuses in the revision Caldwell–Luc group had clinical improvement with one surgical revision (p = 0.46). The endoscopic group averaged 1.3 ± 0.5 revision procedures per sinus to achieve clinical resolution, and the revision Caldwell–Luc group averaged 1.7 ± 1.0 revision procedures per sinus (p = 0.3). Mean follow-up was 25 months.Conclusion Endoscopic revision of the maxillary sinus yields comparable outcomes to repeat Caldwell–Luc procedure in patients with a history of previous failed Caldwell–Luc surgery. Endoscopic revision surgery is a viable alternative for surgical rehabilitation of the post-Caldwell–Luc maxillary sinus.

Background Patients commonly present with complaints of postnasal drainage (PND). This study reports the pharyngeal pH probe findings in patients without rhinitis/rhinosinusitis who present with complaints of PND.Methods This is a prospective study of patients presenting with PND but no historical or endoscopic evidence of rhinitis/rhinosinusitis. Twenty-four-hour pharyngeal pH probe studies were done on 32 consecutive patients and compared with historical controls.Results There were a total of 32 patients with PND (mean age, 54 years) and 51 controls (mean age, 49 years). The proportion of patients with positive pH probe studies was higher in PND (28.1%) versus controls (17.6%) but did not reach statistical significance (p = 0.27). However, when comparing the mean number of pharyngeal acid exposure events, patients with PND had significantly more events (1.6) than controls (0.3; p < 0.002). In addition, the mean acid exposure time was significantly higher in PND (0.18%) versus controls (0.01%; p < 0.004).Conclusion The proportion of patients with PND displaying positive pharyngeal 24 pH probe studies is not significantly greater than controls. However, patients with PND do exhibit a statistically greater degree of pharyngeal acid exposure as compared with controls. Additional research is required to delineate the role of pharyngeal reflux in patients with PND.

Background The increased experience with the endoscopic approach to sinonasal inflammatory disease has resulted in the increased use of endoscopes to manage many different sinonasal pathologies.Methods A chart review of patients with sinonasal tumors treated with primary endoscopic management, from January, 1993 to November, 2003 was performed.Results Forty patients were identified (26 men and 14 women). The mean age was 53.2 years, and the mean follow-up was 31.1 months. For benign tumors, 24 patients were identified with a mean age of 50.7 years, a mean follow-up of 17.5 months, and a recurrence rate of 4.2%. For malignant tumors, 16 patients were identified, with a mean age of 57.3 years, a mean follow-up of 51.5 months, and a recurrence rate of 31.3%. The overall survival rate was 87.5%.Conclusion Endoscopic surgical excision of selective sinonasal tumors may be an effective therapeutic modality. In some cases, adjuvant external procedures may be required based on tumor location.

Introduction:The management of cerebrospinal fluid (CSF) rhinorrhea has evolved in recent years. The purpose of this comprehensive retrospective study is to assess issues related to the management of skull base defects associated with CSF rhinorrhea involving the nose and paranasal sinuses.

Background Discordance has been reported between patient symptoms and objective measures of disease in chronic sinusitis, such as radiographic evaluation. The objective of this study was to evaluate the association between presurgical objective studies and presurgical quality of life (QOL). This work was designed as a cross-sectional study of 90 consecutive patients presenting to a tertiary rhinology practice for surgical management of sinonasal disease.Methods QOL assessment was performed using disease-specific instruments (Chronic Sinusitis Survey and Rhinosinusitis Disability Index). Computed tomography (CT) scans were scored according to the Lund-Mackay CT scoring system and endoscopy evaluation was scored by the system proposed by Lund and Kennedy.Results Ninety surgical candidates were enrolled and included in the analysis. Correlation between the QOL total scores and subscale scores was excellent (r = 0.39; p = 0.0001) as was the correlation between CT and endoscopy scores (r = 0.59; p = 0.0001). In contrast, correlation between QOL and objective measures was poor. These results were not significantly influenced by subgroup analysis by diagnosis, comorbidity, and other patient factors.Conclusion Preoperative objective measures of CRS disease show little, if any, correlation with disease-specific QOL measures in surgical candidates. It is likely that CT and endoscopy are measuring a different aspect of CRS disease than the QOL measures. In addition, it is possible that preoperative QOL, either alone or in combination with CT and endoscopy, may prove important in selecting patients most likely to benefit from surgery.

Because of the complex issues surrounding frontal sinus fractures, we evaluate alternative management strategies for frontal sinus fractures involving the frontal sinus outflow tract. In this article, we describe issues related to frontal sinus fracture management, alternative strategies with illustrative case reports, and a discussion of our rationale.

ObjectiveTo determine the outcome of Nissen fundoplication surgery for the treatment of patients with chronic extraesophageal manifestations of reflux (EER).

Background The aim of this study was to examine the long-term outcomes of the modified endoscopic Lothrop procedure for the management of the most severe forms of recalcitrant chronic frontal sinusitis.Methods This case series evaluated 13 consecutive cases of the modified endoscopic Lothrop procedure for chronic frontal sinusitis from April 1996 to December 1999. Patent communication to the frontal sinus was evaluated by postoperative endoscopic exam. Postoperative patient symptomatology and medication requirements were assessed during clinic evaluation and by standardized telephone questionnaire.Results At a mean follow-up period of 34.5 months, a 77% patency rate was obtained, with 2 of the 13 patients requiring an osteoplastic flap with obliteration. Telephone questionnaire results indicate improved symptoms and decreased medication requirements in the majority of patients who maintained patency.Conclusions These results show that the modified endoscopic Lothrop procedure provides a good alternative to the osteoplastic flap with obliteration for patients with the most severe forms of chronic frontal sinusitis. Initially, high patency rates decline with longer-term follow-up, and severe forms of chronic rhinosinusitis continue to significantly impact patient-perceived quality of life in some patients. The modified endoscopic Lothrop procedure should be reserved for patients who have failed more conservative endoscopic approaches to the frontal recess.

ObjectivesTo evaluate alternative management strategies for anterior table frontal sinus fractures involving the frontal sinus outflow tract.

ObjectiveWe reviewed the 15‐year experience of our institution (Medical College of Wisconsin, Milwaukee, WI) in managing sinonasal inverting papilloma, examining trends in diagnosis and treatment.

Sarcoidosis is a chronic granulomatous disease of unclear etiology with a propensity to involve the lower respiratory tract, but may also involve the upper respiratory tract. Histologically. it is characterized by non-caseating granulomas of various organ systems. Although nasal and sinus involvement is uncommon, patients with sarcoidosis presenting with nasal and sinus complaints may have sinonasal sarcoidosis or simply rhinosinusitis. We reviewed the cases of six patients with pulmonary sarcoidosis who developed chronic sinonasal disease. All six patients had intranasal findings consistent with sinonasal sarcoidosis. but only four had histologic evidence of sinonasal sarcoidosis. These four patients continue to require extensive therapy including topical steroids. systemic steroids, intralesional steroid injections. and nasal irrigations. We conclude that patients with histologically proven sinonasal sarcoidosis present a significant therapeutic challenge because their symptoms and physical findings are often persistent despite aggressive medical and surgical therapy. Their recalcitrant sinonasal disease is thought to result from the destruction of cilia and mucus-producing glands by the granulomatous process.

Endoscopic sinus surgery has become a frequently performed procedure for minimally invasive surgical management of sinonasal inflammatory and neoplastic disease as well as skull base defects. The development of image guidance systems is a further extension of the trend toward minimally invasive approaches to surgical head and neck problems. Computer-guided endoscopic sinus surgery allows the surgeon to localize the instrument within the sinonasal cavity through the use of computerized tracking systems. Such a system provides a real-time video display of instrument location on a preoperative CT scan. The use of computer-guided endoscopic sinus surgery is especially helpful in identifying spaces within the sinonasal cavity when the normal anatomic landmarks have been distorted by previous surgery or disease processes. This paper reviews the role of computer-guided endoscopic sinus surgery in the management of surgical sinonasal problems.

The surgical management of chronic frontal sinusitis continues to evolve. There is no single surgical approach that will lead to successful resolution of disease and symptoms in all cases, and many options must be considered. These options generally attempt to restore drainage and ventilation to the sinus or to obliterate the sinus. When chronic frontal sinusitis fails to respond to maximum medical management, surgical treatment should proceed in a logical progression from simple to more radical procedures. Advanced imaging techniques can offer critical information in this area of highly variable and complex anatomy. Most endoscopic procedures directed at the frontal recess are performed in patients who have previously undergone sinus surgery. In these patients, it is not uncommon to find anatomic variants that predispose the patient to frontal sinus disease as well as scarring and osteoneogenesis. When attempts to restore drainage and ventilation fail, osteoplastic flap with obliteration remains the time-honored treatment even though it is associated with substantial surgical morbidity and renders the otolaryngologist less able to evaluate the frontal sinus endoscopically or radiographically.

ObjectivesTo review our experience and evaluate the utility of computer‐aided surgery for frontal sinus and frontal recess disease.

ObjectiveTo demonstrate the utility of quantitative neurological laboratory testing of autonomic nervous system dysfunction and to apply this methodology to further study the relation of chronic vasomotor (nonallergic) rhinitis to the autonomic nervous system.

Hypoplastic maxillary sinus is a relatively rare clinical problem that has a variable presentation. The purpose of this article is to review the recent literature with regard to evaluation and treatment.

Gastroesophageal reflux has been implicated in many disorders affecting the upper airway over the past three decades. This article reviews the recent literature regarding the relationship of chronic rhinosinusitis to gastroesophageal reflux.

&lt;it>Objectives&lt;/it>: The aim of the study was to analyse the susceptibility of unique and non-duplicate aerobic and anaerobic isolates from surgical patients to a novel des-F(6)-quinolone (garenoxacin) and other selected antimicrobial agents. &lt;it>Methods&lt;/it>: Eleven hundred and eighty-five aerobic and anaerobic isolates from general, vascular, cardiothoracic and otolaryngologic surgical patients were tested for susceptibility to garenoxacin and seven other antibiotics (ciprofloxacin, moxifloxacin, levofloxacin, piperacillin&sol;tazobactam, imipenem, clindamycin and metronidazole) using the referenced microbroth and agar-dilution method. &lt;it>Results&lt;/it>: Garenoxacin exhibited greater antimicrobial activity than comparator quinolones such as ciprofloxacin, levofloxacin and other antimicrobials when tested against selected Gram-positive organisms. The &lt;it>in vitro&lt;/it> aerobic and anaerobic activity of garenoxacin was similar to that of moxifloxacin. All fluoroquinolones tested were effective against most Gram-negative facultative anaerobes including &lt;it>Escherichia coli&lt;/it>. Garenoxacin and moxifloxacin demonstrated similar &lt;it>in vitro&lt;/it> antimicrobial activity against selected anaerobic Gram-positive and Gram-negative anaerobic bacteria such as members of the &lt;it>Bacteroides fragilis&lt;/it> group. Overall, the &lt;it>in vitro&lt;/it> activity of the advanced spectrum quinolones against anaerobic surgical isolates compared favourably with selected comparator agents, metronidazole, imipenem and piperacillin&sol;tazobactam. &lt;it>Conclusions&lt;/it>: These findings suggest that 82.4% of aerobic surgical isolates were susceptible to a concentration of garenoxacin ≤1.0 mg&sol;L, whereas 84.5% of the anaerobic isolates were susceptible to a garenoxacin concentration ≤1.0 mg&sol;L. Garenoxacin may be a valuable surgical anti-infective for treatment of serious head and neck, soft tissue, intra-abdominal and diabetic foot infections.