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Background: Besides sensorineural factors, conductive impediments likely contribute to olfactory losses in chronic rhinosinusitis (CRS) patients, yet no conclusive evidence exists. We aimed to examine possible conductive factors using computational fluid dynamics (CFD) models., Methods: A total of 29 CRS patients were assessed via odorant detection thresholds (ODTs), rhinomanometry (nasal resistance [NR]), acoustic rhinometry (minimum-cross-sectional area [MCA]) and computed tomography (CT) staging. CFD simulations of nasal airflow and odorant absorption to olfactory region were carried out based on individual CTs. Biopsies of olfactory epithelium (OE) were collected, cryosectioned, stained, and scored for erosion., Results: Significant correlations to ODTs were found for 3 variables: odor absorption in the olfactory region (r = -0.60, p < 0.01), MCA (r = -0.40, p < 0.05), and CT staging (r = 0.42, p < 0.05). However, significant findings were limited to ODTs of the highly soluble l-carvone. Multiple regression analysis revealed that these variables combined, with the addition of NR, can account for 65% of the total variance in ODTs. CT staging correlated significantly with OE erosion (r = 0.77, p < 0.01) and can replace the latter in the regression with comparable outcomes. Partial correlations suggest the contributions of both conductive and sensorineural variables are more prominent if adjusted for the effects of the other. Olfactory loss and inflammatory factors have strong bilateral involvement, whereas conductive factors are independent between sides. As validation, CFD-simulated NRs significantly correlated with rhinomanometrically assessed NRs (r = 0.60, p < 0.01)., Conclusion: Both conductive and sensorineural mechanisms can contribute to olfactory losses in CRS. CFD modeling provides critical guidance in understanding the role of conductive impediments in olfactory dysfunction in CRS., (© 2014 ARS-AAOA, LLC.)

Background: Chronic rhinosinusitis (CRS) is a complex heterogeneous inflammatory disease that affects the nasal cavity, but the pathological examination of the olfactory mucosa (OM) in this disease has been limited., Methods: Nasal biopsy specimens were obtained from 20 control subjects and 50 CRS patients in conjunction with clinical assessments. Histopathology of these nasal biopsy specimens was performed and immunohistochemistry was used to characterize nonneuronal, neuronal, and inflammatory cells in the OM. These OM characteristics were then evaluated to determine the degree to which pathological features may be related to smell loss in CRS., Results: Histopathological examination of control and CRS OM revealed changes in the normal pseudostratified olfactory epithelium (OE): intermixing of goblet cells, metaplasia to squamous-like cells, and erosion of the OE. Lower percentages of normal epithelium and olfactory sensory neurons were found in CRS OE compared with controls. Relative to other CRS patients, those with anosmia had the greatest amount of OE erosion, the highest density of eosinophils infiltrating the OE, and exhibited the most extensive abnormalities on CT and endoscopic examination, including being significantly more likely to exhibit nasal polyposis., Conclusion: Our results suggest that OM pathology observed in nasal biopsy specimens can assist in understanding the degree of epithelial change and sensorineural damage in CRS and the potential for olfactory loss.

Few studies have examined the induction of squamous metaplasia in human olfactory nasal tissue caused by tobacco use and the implications it may have for olfaction, particularly when there are pre-existing insults, such as chronic rhinosinusitis (CRS). Quantitative histopathological analyses were performed on Alcian blue- and H&E-stained sections of nasal biopsies taken from the upper aspect of the middle turbinate of CRS patients. Chronic rhinosinusitis patients who were current smokers had a predominance of squamous metaplasia in the olfactory sensory epithelium, whereas CRS patients who were nonsmokers and were not exposed to secondhand cigarette smoke had a prevalence of goblet cell hyperplasia. In spite of this difference, the groups did not differ significantly in olfactory threshold sensitivity. The impact of primary cigarette smoke on olfaction and a possible role of squamous metaplasia in preserving olfactory neurogenesis are discussed.

The impact of chronic rhinosinusitis (CRS) on the olfactory mucosa (OM) is dramatic. Cellular profiles and epithelial integrity in OM biopsies were evaluated using histological and immunohistochemical methods to define a strategy for future histological studies of CRS. We have examined nasal biopsies of 54 CRS patients (18-63 years old) and have defined specific histopathological patterns of the OM: normal pseudostratified, goblet cell hyperplasia, squamous metaplasia, and erosion. Goblet cell hyperplasia was most similar to a normal pseudostratified OM pattern but with goblet cells intermixed in the apical layers. Squamous metaplasia exhibited an absence of olfactory supporting cells and had olfactory sensory neurons that were morphologically abnormal. It is unknown if these neurons would be functional in this type of tissue transformation. The pattern of erosion exhibited a severe loss of epithelial layers and a higher prevalence of infiltrating inflammatory cells within the olfactory epithelium when compared to the other OM patterns. Although it is not known if the OM patterns we have noted correspond to specific stages or distinct pathways of the disease, the template proposed here can be used in further studies to understand how the histopathological progression of CRS relates to olfactory loss and the response to treatment.

Surgical orbital decompression is indicated for patients with compressive optic neuropathy, exposure keratopathy, an uncontrolled elevation of intraocular pressure, globe subluxation, and disfiguring proptosis secondary to Graves ophthalmopathy. Controversy exists, however, regarding the selection of surgical technique to achieve orbital decompression. We compared the results of our combined transnasal endoscopic and transconjunctival approach with those of our combined transnasal endoscopic and transantral approach to orbital decompression. We conducted a retrospective chart review of patients who had undergone medial- and inferior-wall orbital decompression from January 1994 through January 2004. During that time, 189 combined medial- and inferior-wall orbital decompressions were performed on 124 patients; 51 combined endoscopic and transantral decompressions were performed on 28 patients, and 138 combined endoscopic and transconjunctival decompressions were performed on 96 patients. Patient demographics and the degree of preoperative proptosis were statistically equal in the 2 groups. The incidence of optic neuropathy in the transantral group was significantly higher than the incidence in the entire group (p = 0.03), and the incidence of exposure keratopathy was significantly lower in the transantral group than in the entire group (p = 0.03). Postoperatively, the reduction in proptosis in the 2 groups was statistically equivalent, but the transconjunctival group had a significantly lower incidence of both infraorbital hypesthesia (p< 0.0001) and early rhinosinusitis (p = 0.008). Three cases of globe ptosis and 2 of infraorbital neuralgia occurred. No cases of visual loss, worsened optic neuropathy, diplopia in patients without preexisting diplopia, cerebrospinal fluid leak, significant epistaxis, or periorbital hematoma were noted. We conclude that combined endoscopic and transconjunctival orbital decompression offers equivalent efficacy with less postoperative infraorbital hypesthesia and early rhinosinusitis than does combined endoscopic and transantral orbital decompression.

Purpose: To compare the incidence of postoperative infraorbital (V2) hypesthesia and sinusitis between transantral/Caldwell-Luc and transconjunctival orbital decompression for thyroid-related orbitopathy., Methods: A retrospective review of all orbital decompressions from January 1994 to January 2001 performed by one surgeon was done. Seventy-eight patients (133 orbits) with thyroid-related orbitopathy underwent orbital decompression for compressive optic neuropathy, exposure keratopathy, or uncontrolled intraocular pressure. Main outcome measures were the presence of V2 hypesthesia and sinusitis determined at 3 postoperative evaluations (1 to 2 weeks, 1 to 3 months, 3 to 6 months)., Results: The incidence of V2 hypesthesia in the transconjunctival group declined from 29.2% (19/65) to 6.1% (4/65), whereas the incidence of V2 hypesthesia in the transantral/Caldwell-Luc group decreased from 68.2% (43/63) to 46% (29/63) over the postoperative course. The rate of sinusitis in the transconjunctival group stayed constant at 6.1% (4/65) at early and late postoperative visits, whereas the transantral group rate of sinusitis declined from 33.3% (21/63) to 9.5% (6/63)., Conclusions: Transconjunctival orbital decompression results in a statistically significant decrease of early and late postoperative infraorbital hypesthesia and early postoperative sinusitis when compared with the transantral approach.