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The Laryngoscope Feb 2022Dupilumab, a fully human monoclonal antibody that blocks the shared interleukin (IL)-4/IL-13 receptor component, significantly improved outcomes for patients with... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVES/HYPOTHESIS
Dupilumab, a fully human monoclonal antibody that blocks the shared interleukin (IL)-4/IL-13 receptor component, significantly improved outcomes for patients with chronic rhinosinusitis with nasal polyps (CRSwNP) in the SINUS-24 and SINUS-52 studies. This post hoc analysis evaluated dupilumab's effect on patient-reported symptoms and objective outcome measures using thresholds of clinically meaningful within-patient change from baseline.
METHODS
Patients with CRSwNP receiving subcutaneous dupilumab or placebo every 2 weeks in SINUS-24/SINUS-52 were analyzed. Patients recorded severity of nasal congestion (NC), loss of smell (LoS), and anterior/posterior rhinorrhea (each within range 0-3) daily. Total Symptom Score (TSS) was calculated as a composite severity score (0-9) for these symptoms. Objective measures included University of Pennsylvania Smell Identification Test (UPSIT; 0-40), nasal polyps score (NPS; 0-8), and Lund-Mackay computed tomography score (LMK-CT; 0-24). Thresholds of within-patient change in scores from baseline at weeks 24 and 52 considered clinically meaningful were ≥1.0 (NC, LoS), ≥3.0 (TSS), ≥8.0 (UPSIT), ≥1.0 (NPS), and ≥5.0 (LMK-CT).
RESULTS
A total of 724 and 303 patients were included in the week 24 and 52 analyses, respectively. Responder rates were significantly higher with dupilumab versus placebo at week 24 for NC (64% vs. 24%), LoS (63% vs. 14%), TSS (62% vs. 15%), UPSIT (54% vs. 6%), NPS (63% vs. 14%), and LMK-CT (59% vs. 3%); all P < .0001. Results were consistent at week 52.
CONCLUSION
Significantly greater proportions of dupilumab-treated patients with CRSwNP compared with placebo demonstrated clinically meaningful improvements in patient-reported sinonasal symptoms and objective outcomes.
LEVEL OF EVIDENCE
2 Laryngoscope, 132:259-264, 2022.
Topics: Adult; Aged; Antibodies, Monoclonal, Humanized; Chronic Disease; Double-Blind Method; Female; Humans; Male; Middle Aged; Nasal Polyps; Patient Reported Outcome Measures; Rhinitis; Sinusitis; Treatment Outcome
PubMed: 34817082
DOI: 10.1002/lary.29911 -
Annals of Maxillofacial Surgery 2019Timely, expeditious and appropriate management of Frontal bone fractures and associated Frontal Sinus (FS) injuries are both crucial as well as challenging. Treatment...
BACKGROUND
Timely, expeditious and appropriate management of Frontal bone fractures and associated Frontal Sinus (FS) injuries are both crucial as well as challenging. Treatment options vary considerably, depending upon the nature, extent and severity of these injuries as well as operator skill, expertise and experience. In cases of posterior table fractures of the Frontal Sinus, literature reports have in general, propounded direct visualization and exploration of the sinus via a bifrontal craniotomy, followed by sinus cranialization.
AIMS AND OBJECTIVES
To review the standard protocols of management of Frontal bone fractures and Frontal Sinus injuries. To assess the efficacy of a more conservative approach in the management of outer and inner table fractures of the FS.
MATERIALS AND METHODS
Contemporary and evolving management protocols and changing treatment paradigms of different types and severities of frontal bone fractures and frontal sinus injuries, have been presented in this case series. A useful Treatment Algorithm has been proposed to efficiently and effectively manage these injuries.
RESULTS
In the present case series, effective and satisfactory results could be achieved in cases of significantly displaced inner and outer table fractures of the Frontal sinus by a more conservative protocol comprising of open reduction and internal fixation carried out via the existing scar of injury, without having to resort to the more radical intracranial approach and sinus cranialization. Nevertheless, presence of complicating factors such as cerebrospinal fluid rhinorrhea, evidence of meningitis or the development of encephalomeningocoeles necessitated the standard protocol of sinus exploration and its cranialization or obliteration.
CONCLUSION
Management protocols of Frontal Sinus injuries vary, based on aspects such as the timing of presentation and intervention, degree of injury sustained, concomitant associated Craniomaxillofacial injuries present, presence of complicating factors or Secondary/Residual deformities & Functional debility, and need to be decided upon on a case to case basis.
PubMed: 31909005
DOI: 10.4103/ams.ams_151_19 -
Journal of Neurosurgery. Case Lessons Mar 2023Spontaneous rhinorrhea may be the initial manifestation of ecchordosis physaliphora (EP). There are currently 47 published cases of symptomatic EP, with spontaneous...
BACKGROUND
Spontaneous rhinorrhea may be the initial manifestation of ecchordosis physaliphora (EP). There are currently 47 published cases of symptomatic EP, with spontaneous rhinorrhea being one of the most prevalent symptoms. The authors report 1 case as a cause of cerebrospinal fluid (CSF) fistula.
OBSERVATIONS
A 46-year-old woman presented to the authors' clinic with meningitis secondary to nasal CSF leakage. The computed tomography (CT) scan indicated an imperceptibly thin/dehiscent focus along the posterior wall of the sphenoid air cell's midline. A tumor was identified during endoscopic endonasal CSF repair surgery. EP was diagnosed in the frozen and final pathology.
LESSONS
EP should be considered as a potential cause of spontaneous rhinorrhea. This initial clinical manifestation accounts for 35% of symptomatic EP cases. The prepontine and posterior sphenoid sinus wall appear to be the locations with the highest susceptibility. Surgical therapy of the fistula without excision of the lesion may result in insufficient issue resolution and recurrence.
PubMed: 37014027
DOI: 10.3171/CASE236 -
Clivus pathologies from diagnosis to surgical multidisciplinary treatment. Review of the literature.Acta Otorhinolaryngologica Italica :... Apr 2021
Review
Topics: Cranial Fossa, Posterior; Humans; Skull Base Neoplasms
PubMed: 34060519
DOI: 10.14639/0392-100X-suppl.1-41-2021-04 -
Iranian Journal of Otorhinolaryngology Jan 2021There are many fibrin-derived sealants used as topical haemostatic agents in many surgical procedures. Fibrin sealants are usually non-autologous derivatives or animal...
INTRODUCTION
There are many fibrin-derived sealants used as topical haemostatic agents in many surgical procedures. Fibrin sealants are usually non-autologous derivatives or animal derivatives, with the exception of Vivostat®, an autologous fibrin sealant derived from patients own blood.
MATERIALS AND METHODS
We present our experience on the use of Vivostat® in skull base closures in 20 patients operated at the Otorhinolaryngology Unit of the Hospital Ospedali Riuniti Villa Sofia - Cervello of Palermo. All postoperative patients were placed in an anti-trendeleburg position for 48 hours. After removal of the nasal swabs we did not find any rhinorrhea and we checked the tightness of the skull base defect with computed tomography.
RESULTS
On a total of the 20 patients (10 post-traumatic and 10 with iatrogenic leaks), 9 out of 10 post-traumatic cases had a leak in the border area between the anterior and posterior portion of the ethmoid, while 1 patient out of 10 post-traumatic cases had a leak at the level of the sella. In all 20 patients, we repaired skull base defects by fixing grafting materials with Vivostat®. We have not had any complications. Vivostat® is a useful product in skull base repair and safe for the patients.
CONCLUSION
Vivostat® has been used as a sealant on body tissues with greater elasticity and more resistant allowing better and safer wound repair, especially in skull base surgery. In particular, its immediate polymerisation is very useful for an evaluation of the mechanical sealants in the closure of the skull base cerebrospinal fluid leak.
PubMed: 33654684
DOI: 10.22038/ijorl.2020.42520.2385 -
World Neurosurgery Jun 2015To analyze outcomes after the management of mild (<1 mm) and moderately severe (>1 mm and <5 mm) breaches of the posterior wall of the frontal sinus with a goal of...
OBJECTIVE
To analyze outcomes after the management of mild (<1 mm) and moderately severe (>1 mm and <5 mm) breaches of the posterior wall of the frontal sinus with a goal of maintaining or restoring the functional status of the sinus.
METHODS
A retrospective analysis of prospectively accrued data was performed on patients with mild and moderately severe breaches of the posterior wall of their frontal sinus who were managed with the intent to preserve the frontal sinus. Data on presenting features, pathology, details on breaches of the posterior wall, management, outcome, and complications were collected from medical records and neuroimages.
RESULTS
Forty-two cases met inclusion criteria. Diagnostic categories included trauma in 34 cases, infection in 3, and other categories in another 5 cases. Five presented with cerebrospinal fluid rhinorrhea, and 26 had radiographic evidence of obstruction of a nasofrontal duct at time of presentation. Fifteen patients were managed without surgical intervention, and 27 underwent surgery. No complications occurred in the patients managed without surgery and 4 postoperative cerebrospinal leaks that were managed successfully with a period of drainage occurred in the surgical group. No patient developed meningitis or mucocele.
CONCLUSIONS
Many patients with mild to moderately severe breaches of the posterior wall of the frontal sinus can be managed safely and effectively by techniques that preserve the anatomy and function of the frontal sinus.
Topics: Adolescent; Adult; Aged; Cerebrospinal Fluid Rhinorrhea; Child; Craniocerebral Trauma; Female; Frontal Sinus; Frontal Sinusitis; Humans; Male; Middle Aged; Neurosurgical Procedures; Organ Sparing Treatments; Paranasal Sinus Neoplasms; Retrospective Studies; Severity of Illness Index
PubMed: 25527881
DOI: 10.1016/j.wneu.2014.12.023 -
Indian Journal of Otolaryngology and... Oct 2019Acquired nasopharyngeal stenosis after radiotherapy for NPC is rare. We report a case of bilateral choanal stenosis and nasopharygeal stenosis in patient treated with...
INTRODUCTION
Acquired nasopharyngeal stenosis after radiotherapy for NPC is rare. We report a case of bilateral choanal stenosis and nasopharygeal stenosis in patient treated with chemo radiotherapy for undifferentieted nasopharnygeal carcinoma.
CASE REPORT
A 68 years old man treated for undifferentiated nasopharyngeal carcinoma with chemo-radiotherapy 10 years before. He complained of complete nasal obstruction, rhinorrhea, anosmia, snoring and hearing loss. Clinical examination and imaging revealed bilateral choanal stenosis and nasopharyngeal stenosis. Patient underwent a transnasal endoscopic resection for scar tissue with stenting of posterior choanae. Restenosis was noted just after stent removal. Second endoscopic resection of stenosis was done, followed by application of mitomycin-C without stenting. Several months later, the patient has good airflow, a patent nasopharynx without reccurence of stenosis.
DISCUSSION
The use of topical mitomycin-C may prove useful in the treatment and prevention of subsequent restenosis and scar formation in larynx and tracheal. Mitomycin-C application has being shown useful in treating nasopharyngeal stenosis. It is safely used topically in various surgical sites without major side effect.
CONCLUSION
Nasopharyngeal stenosis is an unusual complication of radiotherapy that can be successfully treated with combine two modalities: surgical and mitomycin-C as an adjunct.
PubMed: 31741924
DOI: 10.1007/s12070-015-0954-0 -
Archivos Argentinos de Pediatria Aug 2022Choanal atresia is characterized by obliteration of the posterior nasal opening. It is the most common congenital anomaly of the nasal passages. It has an incidence of 1...
Choanal atresia is characterized by obliteration of the posterior nasal opening. It is the most common congenital anomaly of the nasal passages. It has an incidence of 1 in 5000 to 7000 newborns; predominantly female. It can occur in isolation or in association with other syndromes such as CHARGE (coloboma [C], cardiac malformations [H], choanal atresia [A], psychomotor and/or growth retardation [R], genital hypoplasia [G], atrial malformations and/or deafness [E]. Clinically presents nasal obstruction, cyanosis and respiratory distress from birth when bilateral, unilateral atresias are characterized by nasal ventilatory insufficiency and unilateral rhinorrhea, which may go unnoticed. Diagnosis is made by endoscopy and imaging tests. Treatment is surgical, with different techniques and approaches. A 7-year-old male patient is presented with unilateral atresia of the right choana with microendoscopic resolution, placement of an external tutor, with good resolution.
Topics: Child; Choanal Atresia; Coloboma; Endoscopy; Female; Humans; Infant, Newborn; Male; Nasal Obstruction; Nasopharynx
PubMed: 35900957
DOI: 10.5546/aap.2022.e171 -
Lin Chuang Er Bi Yan Hou Tou Jing Wai... Mar 2021To investigate the relationship between the pneumatization degree of paranasal sinuses and skull base and the incidence of spontaneous cerebrospinal fluid rhinorrhea...
To investigate the relationship between the pneumatization degree of paranasal sinuses and skull base and the incidence of spontaneous cerebrospinal fluid rhinorrhea (SCSFR). Date of 107 patients with SCSFR were reviewed retrospectively. Using CT scans, investigator evaluated the pneumatization degree of paranasal sinuses and skull base, and compared classifications of various imaging characteristics between SCSFR group(case group) and nasal septum deviation group(control group), including frontal cells, Onodi cell, lateral recess of sphenoid sinus (LRSS), pneumatization of anterior clinoid process and pneumatization of posterior clinoid process. One hundred and eight fistulas are found among 107 cases. The most common site of the fistulas is found in ethmoid sinus (38.89%), followed by olfactory cleft(37.04%), sphenoid sinus (21.30%) and frontal sinus (2.77%).The incidence of Onodi cell was significantly different between case and control group(²=4.755, <0.05), and the classification of Onodi cell has a linear effect on the occurrence of SCSFR (=3.345, <0.05), which suggests the increasing level of Onodi cell can increase the probability in occurrence of SCSFR. The incidence of type Ⅲ LRSS in the case group is significantly higher than in the control group(²=18.725, <0.05),a linear correlation is found between the classification of LRSS and the incidence of SCSFR (=3.578, <0.05).There was no significant difference in the incidence of frontal cells between the two groups(²=0.672, >0.05), nor was there a linear relationship between the classification of frontal cells and the incidence of SCSFR (=0.503, >0.05). Pneumatization of anterior clinoid process and posterior clinoid process were no significant difference between case and control (>0.05),nor were there linear relationships between their classifications and SCSFR (>0.05). The most common site of SCSFR is ethmoid sinus, followed by olfactory cleft,the hyperpneumatization of the LRSS and Onodi cell are closely related to its pathogenesis.
Topics: Cerebrospinal Fluid Rhinorrhea; Humans; Paranasal Sinuses; Retrospective Studies; Rhinorrhea; Skull Base; Sphenoid Sinus
PubMed: 33794612
DOI: 10.13201/j.issn.2096-7993.2021.03.013 -
Neurology India 2021Hypnic headache (HH) is a rare primary headache syndrome first described by Raskin in 1988. (Review)
Review
CONTEXT
Hypnic headache (HH) is a rare primary headache syndrome first described by Raskin in 1988.
AIM
To describe the occurrence of HH in Indian patients and compare its clinicoepidemiological features to those published in the literature and attempt to trace some of the evolving concepts regarding its etiology and clinical features since it was first described.
MATERIALS AND METHODS
Patients attending the neurology outpatient department of a tertiary referral teaching hospital from 01-05-2011 to 30-04-2016 who were identified to have HH as per ICHD 3 beta criteria were included in the study. A meticulous history of the headache and comorbidities, clinical examination, Epworth Sleepiness Scale, blood counts, blood biochemistry, magnetic resonance imaging (MRI) scans of the brain and polysomnography (in selected patients) were done and the results were compared to selected international literature.
RESULTS
A total of 11 patients with HH were identified during the study period, of which 8 (72.72%) were males and 3 (27.27%) were females. The age of the patients varied from a minimum of 53 years to a maximum of 78 years (Mean: 63.36, SD: 8.09). The frequency of attacks per month ranged from 5 to 46(Mean: 20.36, SD: 11.67). The duration of each headache episode ranged from a minimum of 30 minutes to a maximum of 4 hours (Mean: 1.93, SD: 1.23). The occurrence of the headaches was maximum during the time periods of 0.00-2.00am and 2.00-4.00am (38% and 36%, respectively). The pain was dull in a majority of patients, 7 (63.63%). Trigeminal autonomic features such as lacrimation, ptosis, or rhinorrhea were not recorded from our cohort. Motor activity was noted in 7 (63.63%) cases. Two (18.18%) patients had associated migraine headaches whereas 3 (27.27%) had associated tension-type headaches. None of the patients in our series had chronic obstructive pulmonary disease. Four (36.36%) patients had systemic hypertension and 1 patient (9.09%) had diabetes mellitus. Two (18.18%) patients had symptoms of obstructive sleep apnea syndrome. Three (27.27%) patients had symptoms of excessive daytime sleepiness according to the Epworth Sleepiness Scale. Blood examinations and MRI were normal in all patients, except for the findings of a few lacunar infarcts and nonspecific T2 weighted hyperintensities in 3 patients (27.27%).
CONCLUSION
Our study proves the existence of the newly described primary headache syndrome called HH in the Indian population. On comparing our results with the international literature, the similarities are much greater than the differences. MRI voxel-based morphometry to demonstrate the loss of gray matter in the posterior hypothalamus may prove to be a reliable test to diagnose primary HH in the future.
Topics: Female; Headache; Headache Disorders, Primary; Humans; Male; Middle Aged; Migraine Disorders; Pain; Polysomnography
PubMed: 34747799
DOI: 10.4103/0028-3886.329541