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Journal of Asthma and Allergy 2022Chronic rhinosinusitis (CRS) is defined as the inflammation of nose and paranasal sinuses, affecting the patients' quality of life and productivity. Chronic... (Review)
Review
Chronic rhinosinusitis (CRS) is defined as the inflammation of nose and paranasal sinuses, affecting the patients' quality of life and productivity. Chronic rhinosinusitis with nasal polyps (CRSwNP) is a principal clinical entity confirmed by the existence of chronic sinonasal inflammation and is characterized by anterior or posterior rhinorrhea, nasal congestion, hyposmia and/or facial pressure or facial pain. Several epidemiologic studies have revealed wide variations in the incidence of CRS among regions globally ranging from 4.6% to 12%. The Gulf countries are also witnessing an unprecedented burden of CRSwNP. According to the current clinical guidelines, glucocorticosteroids and antibiotics are the principal pharmacotherapeutic approaches. Endoscopic sinus surgery is recommended for those who have failed maximal pharmacotherapy. Recently, biologics are considered as an alternative best approach due to the complications associated with medical therapy and surgery. However, precise data on the clinical position of biologic agents in the management of CRSwNP in the Gulf region is not available. The present review article addresses the current diagnostic and management approaches for CRSwNP and also emphasizes the role of emerging biologics in the current treatment strategies for CRSwNP in the Gulf region. Further, a consensus protocol was convened to rationalize the guideline recommendations, strategize the best practices with biologics, and develop clinical practice guidelines for all primary-care specialists in the Gulf region. The consensus-based report will be a useful reference tool for primary-care physicians in primary-healthcare settings, regarding the appropriate time for the initiation of biological treatment in the Gulf region.
PubMed: 35018101
DOI: 10.2147/JAA.S321017 -
Neurology International Sep 2023Ecchordosis physaliphora (EP) is a benign notochordal remnant, which is often an incidental finding; however, it can rarely present with neurological symptoms. We... (Review)
Review
Ecchordosis physaliphora (EP) is a benign notochordal remnant, which is often an incidental finding; however, it can rarely present with neurological symptoms. We performed a systematic review of the literature for cases of symptomatic EP published in PubMed, Web of Science and Embase from January 1982 to May 2023. This is the largest review to date and revealed 60 cases including ours. Headache (55%) and CSF rhinorrhea (32%) were the most frequent clinical manifestations. The majority of symptomatic EP lesions were located in the prepontine region (77%) and required surgical resection (75%). EP should be considered in patients with neurologic symptoms in the setting of prepontine or posterior sphenoid sinus lesions. While symptomatic patients often require surgical intervention, rare cases may respond to oral corticosteroids.
PubMed: 37873832
DOI: 10.3390/neurolint15040075 -
Indian Journal of Otolaryngology and... Apr 2023Spontaneous or post-traumatic CSF (cerebrospinal-fluid) rhinorrhea occurs when there is a skull-base defect. In our study, we tried endoscopic approach, exclusively as...
Spontaneous or post-traumatic CSF (cerebrospinal-fluid) rhinorrhea occurs when there is a skull-base defect. In our study, we tried endoscopic approach, exclusively as surgical modality. To study feasibility of trans-nasal endoscopic approach for repair of skull-base defects and success rates at each anatomical subsite, with complications. Patients, who underwent endoscopic repair of CSF rhinorrhea between 2016 and 2019 were recruited into study. Details of investigative work-up, aetiology, surgery done, site of leak, number of surgical procedures done, post-operative complications and their management, success rate for each anatomical sub-site, was retrieved retrospectively and analyzed. All patients were initially managed with conservative measures before taking up for surgery. Eighteen-patients (male-11, female-7, mean age-40.3 years) with CSF rhinorrhea {spontaneous-5(27.7%), traumatic-13(62.3%)} were found. Sites of leak were cribriform-plate (CP), fovea-ethmoidalis (FE) and posterior-table of frontal-sinus (FS) in 8(44.4%), 5(27.7%) and 5(27.7%) respectively. Twelve (66.6%) patients had no postoperative complications. No patients with defects in CP had post-operative complication. Two (11.1%) patients with FS defect had meningitis, one (5.5%) patient with FS defect developed pneumocephalus. One (5.5%) patient developed frontal sinusitis at end of 4-months. Two (11.1%) patients, each with defects in FE and FS needed a revision repair on postoperative day 0 and 90-till date, none of the patients have any delayed procedure related complications or recurrences. Endoscopic repair of CSF leaks is the norm of the current day due to its minimally invasive nature. However, endoscopic repair of leaks through the frontal sinus were challenging and was associated with a high rate of complications.
PubMed: 37206806
DOI: 10.1007/s12070-022-03272-1 -
The Laryngoscope Aug 2020To assess the efficacy and safety of cryoablation of the posterior nasal nerve (PNN) for treatment of chronic rhinitis. (Clinical Trial)
Clinical Trial
OBJECTIVE
To assess the efficacy and safety of cryoablation of the posterior nasal nerve (PNN) for treatment of chronic rhinitis.
METHODS
This was a prospective single-arm trial of 98 adult patients at six U.S. centers with chronic allergic and nonallergic rhinitis. PNN cryoablation was performed in-office under local anesthesia using a handheld device. Patients discontinued use of intranasal ipratropium 3 days prior to treatment and throughout the study period. Reflective Total Nasal Symptom Score (rTNSS) was measured at pretreatment baseline and posttreatment at 1 month, 3 months, 6 months, and 9 months. The Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) was completed at pretreatment and 3 months posttreatment. Adverse effects and postprocedure medication usage were recorded.
RESULTS
Ninety-eight procedures (100%) were successfully completed. rTNSS significantly improved over pretreatment baseline (6.1 ± 1.9) at 1 month (2.9 ± 1.9, P < 0.001), 3 months (3.0 ± 2.3, P < 0.001), 6 months (3.0 ± 2.1, P < 0.001), and 9 months (3.0 ± 2.4, P < 0.001) postprocedure. Nasal congestion and rhinorrhea subscores improved significantly at all time points (P < 0.001). Both allergic and nonallergic rhinitis subcohorts showed improvement (P < 0.001), with a comparable degree of improvement between groups. RQLQ significantly improved over pretreatment baseline (3.0 ± 1.0) at 3 months (1.5 ± 1.0, P < 0.001), and all RQLQ subdomains demonstrated improvement. Of 54 patients using intranasal medication at baseline, 19 (35.2%) were able to discontinue use. Twenty-nine adverse effects were reported, including headache, epistaxis, and sinusitis.
CONCLUSION
Cryoablation of the PNN for chronic rhinitis is safe and can result in relief of nasal symptoms and improvements in quality of life.
LEVEL OF EVIDENCE
4 Laryngoscope, 130: 1877-1884, 2020.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anesthesia, Local; Chronic Disease; Cryosurgery; Female; Humans; Male; Middle Aged; Prospective Studies; Quality of Life; Rhinitis; Surveys and Questionnaires; United States
PubMed: 31566744
DOI: 10.1002/lary.28301 -
OTO Open 2021To determine the safety and efficacy of temperature-controlled radiofrequency (RF) neurolysis of the posterior nasal nerve (PNN) area for the treatment of chronic...
OBJECTIVE
To determine the safety and efficacy of temperature-controlled radiofrequency (RF) neurolysis of the posterior nasal nerve (PNN) area for the treatment of chronic rhinitis.
STUDY DESIGN
A multicenter, prospective, single-blinded, randomized controlled trial, in which the control arm underwent a sham procedure.
SETTING
Sixteen otolaryngology centers.
METHODS
Patients with 24-hour reflective Total Nasal Symptom Score (rTNSS) ≥6, including moderate to severe rhinorrhea and mild to severe congestion, were randomized 2:1 to active treatment of the posterior nasal nerve area with a temperature-controlled RF device or a sham procedure, with no RF energy delivery. The stylus was applied bilaterally to nonoverlapping areas of the posterior middle meatus and posterior inferior turbinate in each nostril in the region of the PNN. The primary endpoint was responder rate at 3 months, where a response was defined as ≥30% improvement (decrease) in rTNSS from baseline.
RESULTS
Patients had a mean baseline rTNSS of 8.3 (95% CI, 7.9-8.7) and 8.2 (95% CI, 7.6-8.8) ( = .797) in the active treatment (n = 77) and sham control (n = 39) arms, respectively. At 3 months, responder rate was significantly higher in the active treatment arm: 67.5% (95% CI, 55.9%-77.8%) vs 41.0% (95% CI, 25.6%-57.9%) ( = .009). The active treatment arm had a significantly greater decrease in rTNSS (mean, -3.6 [95% CI, -4.2 to -3.0] vs -2.2 [95% CI, -3.2 to -1.3]) ( = .013). Three adverse events related to the device/procedure were reported, and all resolved.
CONCLUSION
This randomized controlled trial showed temperature-controlled neurolysis of the PNN area is free from significant adverse events and superior to a sham procedure in decreasing the symptom burden of chronic rhinitis.
PubMed: 34527852
DOI: 10.1177/2473974X211041124 -
Gland Surgery Oct 2020Pituitary adenomas (PAs) are tumors that arise from the cells of the anterior pituitary gland. PAs are the most common tumors to occur in the sella area and the third...
BACKGROUND
Pituitary adenomas (PAs) are tumors that arise from the cells of the anterior pituitary gland. PAs are the most common tumors to occur in the sella area and the third most common intracranial neoplasm in surgery. Due to developments such as microscopy and neuroendoscopy, the curative effect of PA surgery continues to improve. However, postoperative complications may still occur. PA surgery can result in iatrogenic trauma, which is a primary cause of cerebrospinal fluid (CSF) rhinorrhea. PA surgery can affect the posterior pituitary gland, causing decreased antidiuretic hormone secretion and increased urine output, which can lead to hyponatremia. The nasal cavity and sphenoid sinuses may also be damaged during PA surgery, causing the sphenoethmoidal recess to be blocked. This increases the risk of infection. The purpose of this study was to analyze quality of life in PA patients post-resection, and to provide references for the development of early targeted risk assessment programs and intervention measures.
METHODS
We selected patients who underwent neuroendoscopic transnasal PA resection at the Affiliated Hospital of Nantong University between January 2017 and October 2019. These patients' hospital records were retrospectively obtained, including details of any postoperative complications. The patients were followed up by telephone 12 weeks following discharge, and we used the EuroQol 5 Dimensions (EQ-5D) health scale to assess the patients' quality of life.
RESULTS
At follow-up 3 months after discharge, 68 people (41.72%) had experienced at least one common complication, including 7 cases of infection (4.29%), 56 cases of hypopituitarism (34.36%), 18 cases of CSF rhinorrhea (11.04%), 28 cases of diabetes insipidus (17.18%), and 25 cases of hyponatremia (15.34%). Patients that experienced complications reported having more serious problems on the dimensions of the EQ-5D descriptive system (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) than patients without complications. The scores of patients with complications on the EQ-5D visual analog scale (EQ-VAS) were lower than that of patients without complications.
CONCLUSIONS
Postoperative complications are negatively associated with quality of life in PA patients. Actively preventing common complications could therefore improve these patients' quality of life and reduce their burden of disease.
PubMed: 33224827
DOI: 10.21037/gs-20-690 -
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