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Postoperative bleeding and adhesion formation are the two most common complications after endoscopic sinus surgery (ESS). Continued bleeding risks airway compromise from the inhalation of blood clots and from the aspiration of blood-stained vomitus. Additionally, adhesion formation is the most common reason for patients requiring revision surgery. This study aimed to determine the efficacy of a novel chitosan/dextran (CD) gel on hemostasis and wound healing after ESS. A randomized controlled trial was performed involving 40 patients undergoing ESS for chronic rhinosinusitis. Immediately after surgery a baseline Boezaart Surgical Field Grading Scale was taken. Computer randomization was performed with one side receiving CD gel and the other side receiving no treatment (control). Boezaart bleeding scores were then calculated for each side every 2 minutes. Patient's endoscopic features of wound healing were assessed at 2, 6, and 12 weeks after surgery. CD gel achieved rapid hemostasis with the mean time to hemostasis at 2 minutes (95% CI, 2-4 minutes) compared with 10 minutes (95% CI, > or =6 minutes) for the control (p < 0.001). There were significantly less adhesions at all time points with CD gel versus control: 2 versus 18 at 2 weeks (p < 0.001), 3 versus 16 at 6 weeks (p < 0.001), and 2 versus 12 at 3 months (p < 0.001). There was no significant difference between CD gel and control with respect to crusting, mucosal edema, infection, or granulation tissue formation. CD gel is rapidly hemostatic immediately after ESS and prevents adhesion formation, addressing two of the most common complications of sinus surgery.

Objectives: We compared anesthesia with sevoflurane–remifentanil hydrochloride (SR) to total intravenous anesthesia with propofol–remifentanil hydrochloride (PR) in patients undergoing endoscopic sinus surgery for chronic rhinosinusitis in terms of sinonasal mucosal blood flow, the surgical field visualization score, and blood loss. Methods: We performed a double-blinded prospective study at a tertiary care center in 23 adults scheduled to undergo endoscopic sinus surgery for chronic rhinosinusitis. The patients were randomized to receive SR or PR. The sinonasal mucosal blood flow was measured by optical rhinometry. The surgical field visualization score was based on the Boezaart scale. Results: The groups had similar clinical characteristics. During the 60- to 90-minute and 90- to 120-minute operative time windows, the blood flow was significantly greater in the PR group than in the SR group (p = 0.04 and p = 0.03, respectively). The amounts of blood loss in the PR and SR groups were 152.9 ± 161.3 mL and 355.9 ± 393.4 mL, respectively (p = 0.12). The median ratios of the surgical field visualization score to the number of sinuses operated on in the PR and SR groups were 2.1 and 1.8, respectively (p = 0.52). Conclusions: The intraoperative blood flow, as determined by optical rhinometry, was significantly greater with anesthesia with PR than with anesthesia with SR, 1 hour into the procedure; however, this difference did not translate into differences in the amounts of operative blood loss or in the surgical field visualization scores.

Endoscopic sinus surgery is a widely used technique in otolaryngologic practice. To avoid complications, the locations of important anatomical structures, such as the anterior ethmoid artery (AEA), should be determined preoperatively. We want to evaluate the effect of ethmoid cavity pneumatization on the location of the AEA and to determine consistent landmark(s) for locating the AEA. 524 consecutive patients undergoing sinus CT scans between February and October 2012 were reviewed retrospectively. After the exclusion criteria were applied, 150 CT scans (300 sides) were selected for the study. A statistically significant positive correlation was found between ethmoid pneumatization and the distance of the AEA to the attachment of the inferior turbinate to the lateral nasal wall (Spearman’s rho = 0.305; p  < 0.001). Likewise, a statistically significant positive correlation was found between ethmoid pneumatization and the distance between the AEA and the frontonasal junction (Spearman’s rho = 0.219; p  < 0.001). We found that the artery was located mostly between the second and third lamellae [ n 211 (71 %) cases]. There was no statistically significant correlation between ethmoid pneumatization and AEA location in terms of the lamellae. Increased ethmoid volume increases the distance of the AEA from the frontonasal junction and the lateral attachment of the inferior turbinate. However, increased pneumatization of the ethmoid cavity did not affect AEA localization in terms of the lamellae. Based on our findings, we suggest that using the lamellae to locate the AEA is reliable.

Exposure of the petrous (C2) segment of the internal carotid artery (ICA; petrous carotid) is necessary to treat lesions that have spread from the intracranial space or adjacent sinonasal region. Recent advancements in endonasal-endoscopic approaches to the anterior skull base raise the possibility of extending these approaches beyond the sinonasal cavity. In this cadaveric study, we evaluate the feasibility and extent of exposure of the petrous carotid artery via a combined endoscopic endonasal approach. Endoscopic dissection was performed in four formalin-fixed cadaver heads (eight sides). An endoscopic, endonasal, transmaxillary approach was used to identify the cervical and petrous carotid artery. With the endoscopic endonasal, Caldwell-Luc approach, we could visualize the ventral petrous bone after dissecting the contents of the pterygopalatine fossa and infratemporal fossa. Careful dissection allowed exposure of the petrous carotid artery from the upper cervical carotid to the foramen lacerum. In this cadaveric study using an endoscopic endonasal approach for exposure of the petrous carotid artery, combination with the transmaxillary-transpterygopalatine-transinfratemporal approaches permitted exposure of the ventral portion of the artery. The anatomy presented will assist experienced endoscopic skull base surgeons in the removal of lesions involving the ventral skull base.

Chronic sinusitis is a common condition that is frequently refractory to medical and surgical intervention. It has not been well defined as to which patient subgroups benefit from surgical intervention and which do not. Our purpose is to determine whether the presence of certain inflammatory cell types is predictive of postoperative outcome in sinus surgery for chronic sinusitis. We performed a retrospective chart review of 75 patients who underwent endoscopic sinus surgery or polypectomy between 1994 and 1996. Of these patients, 15 met inclusion criteria for chronic sinusitis, asthma requiring inhaled steroids, and 1 year preoperative and postoperative management by the allergist or otolaryngologist at Northwestern Medical Faculty Foundation. Ten of these 15 patients had a complete set of data allowing immunohistochemical analysis. Sections of sinus tissue obtained at surgery were hematoxylin and eosin stained and evaluated for the presence of lymphocytes, plasma cells, eosinophils, and macrophages. Immunostains for T lymphocytes, B lymphocytes, and macrophages were performed also. The total number of antibiotic courses patients received were enumerated into 6-month blocks for 1 year preoperatively and 1 year postoperatively as markers of disease activity. Postoperatively, four patients improved, three patients worsened, and three patients remained unchanged, as defined by the number of antibiotic courses required 1 year postoperatively compared with 1 year preoperatively. We found no difference in the magnitude or specific type of inflammatory cells present at the time of surgery between the groups. However, when the difference between the preoperative versus postoperative antibiotic courses was compared between patients who improved versus patients who did not improve, the improved group required markedly fewer courses relative to the nonimproved group (p < 0.009). Neither total magnitude of inflammation nor specific inflammatory cell types correlated with surgical outcome in this group. The patients who did not improve postoperatively had a statistically significantly lower number of preoperative antibiotics than the patients who improved. These findings suggest that patients with less severe disease may be less likely to benefit from sinus surgery.

We examined the management options used for epistaxis of varying severity in patients with hereditary hemorrhagic telangiectasia (HHT) to develop a treatment algorithm. Fifty patients with HHT were studied from 1991 to 1997 to consider various treatment options and their relative efficacy. There were 28 females and 22 men; their ages ranged from 15 to 85. Follow-up ranged from 6 months to 6 years. A wide variety of treatments had been used (including various forms of cautery, septal surgery, topical and systemic hormones, antifibrinolytic therapy, arterial ligation, laser therapy, and closure of the nostrils). Treatments used during the follow-up period were argon laser therapy (40), systemic estrogen or progesterone (17), septodermoplasty (12), or closure of the nostrils (14). Patients were divided into those with mild to moderate disease (requiring one or no blood transfusions during the course of their illness) and those with severe disease (requiring more than one blood transfusion). Using this broad categorization, those with mild to moderate disease did well with sequential argon laser therapy with or without the adjunct of septodermoplasty or hormone therapy. Those with severe disease did not find argon laser therapy beneficial but found their epistaxis completely stopped with closure of the nasal cavities. Based on these findings, a simple treatment algorithm defines the optimum treatment options for epistaxis in this difficult-to-treat group of patients.

Background: Amino-acid transporters are necessary for the tumour cell growth and survival, and have a crucial role in the development and invasiveness of cancer cells. But, it remains unclear about the prognostic significance of L-type amino-acid transporter 1 (LAT1), system ASC amino-acid transporter-2 (ASCT2), and xCT expression in patients with tongue cancer. We conducted the clinicopathological study to investigate the protein expression of these amino-acid transporters in tongue cancer. Methods: Eighty-five patients with surgically resected tongue cancer were evaluated. Tumour sections were stained by immunohistochemistry for LAT1, ASCT2, xCT, 4F2hc/CD98hc (4F2hc), Ki-67, and microvessel density (MVD) determined by CD34, and p53. Results: L-type amino-acid transporter 1 and 4F2hc were highly expressed in 61% (52 out of 85) and 45% (38 out of 47), respectively. ASC amino-acid transporter-2 and xCT were positively expressed in 59% (50 out of 85) and 21% (18 out of 85), respectively. The expression of both LAT1 and ASCT2 was significantly associated with disease staging, lymph-node metastasis, lymphatic permeation, 4F2hc expression and cell proliferation (Ki-67). xCT expression indicated a significant association with advanced stage and tumour factor. By univariate analysis, disease staging, lymphatic permeation, vascular invasion, LAT1, ASCT2, 4F2hc, and Ki-67 had a significant relationship with overall survival. Multivariate analysis confirmed that LAT1 was an independent prognostic factor for predicting poor prognosis. Conclusions: L-type amino-acid transporter 1 and ASCT2 can serve as a significant prognostic factor for predicting worse outcome after surgical treatment and may have an important role in the development and aggressiveness of tongue cancer.

To investigate the characteristics of the laryngeal mucosal microvascular network in suspected laryngeal cancer patients, using narrow band imaging, and to evaluate the value of narrow band imaging endoscopy in the early diagnosis of laryngeal precancerous and cancerous lesions. Eighty-five consecutive patients with suspected precancerous or cancerous laryngeal lesions were enrolled in the study. Endoscopic narrow band imaging findings were classified into five types (I to V) according to the features of the mucosal intraepithelial papillary capillary loops assessed. A total of 104 lesions (45 malignancies and 59 nonmalignancies) was detected under white light and narrow band imaging modes. The sensitivity and specificity of narrow band imaging in detecting malignant lesions were 88.9 and 93.2 per cent, respectively. The intraepithelial papillary capillary loop classification, as determined by narrow band imaging, was closely associated with the laryngeal lesions' histological findings. Type I to IV lesions were considered nonmalignant and type V lesions malignant. For type Va lesions, the sensitivity and specificity of narrow band imaging in detecting severe dysplasia or carcinoma in situ were 100 and 79.5 per cent, respectively. In patients with type Vb and Vc lesions, the sensitivity and specificity of narrow band imaging in detecting invasive carcinoma were 83.8 and 100 per cent, respectively. Narrow band imaging is a promising approach enabling in vivo differentiation of nonmalignant from malignant laryngeal lesions by evaluating the morphology of mucosal capillaries. These results suggest endoscopic narrow band imaging may be useful in the early detection of laryngeal cancer and precancerous lesions.

Background It has been reported that the morphology and volume of the maxillary sinus (MS), which is the largest paranasal sinus, have an impact on the success of surgical procedures that are to be performed in the MS region. The aim of this study was to evaluate the effect of sphenopalatine foramen (SPF) and alveolar antral arterial canal (AAAC) diameters and posterior dentition status (PDS) on maxillary sinus volume (MSV). Methods The study included cone beam computed tomography (CBCT) images of patients over 20 years of age with no impacted teeth in the MS, and in whom the entire MS margins, AAAC, and SPF were clearly visible. Only images without metal or motion artefacts and with adequate clarity were selected. In this study, a total of 90 patients’ CBCT images, 47 males and 43 females, with a mean age of 47.10 years, were evaluated. AAAC diameter was measured on the coronal section, and SPF diameter was measured on the axial section of CBCT. MSV was measured on axial sections with 3D DOCTOR software. Results The mean MSV was 14.02 cm 3 , 14.47 cm 3 in dentate patients, and 13.21 cm 3 in edentulous patients. The mean MSV was found to be 24.99 cm 3 in the female group and 30.84 cm 3 in the male group. Statistical analysis revealed that the mean MSV and AAAC diameter were higher in males ( p  = 0.000). While the mean MSV was higher in the dentate group, this disparity did not demonstrate statistical significance ( p  = 0.126). A weak negative correlation was identified between MSV and SPF diameter ( p  = 0.004, r = -214). Conclusions In the present study, CBCT evaluation revealed that a negative correlation was found between MSV and SPF, and a positive correlation between SPF and AAAC, while no significant relationship was observed between MSV and AAAC. It is recommended that the sample size be increased in future studies to evaluate the possible statistical relationship between MSV and AAAC. The AAAC diameter was larger in patients with edentulous PDS, suggesting increased caution is needed during sinus elevation in such cases. MSV was higher in males, indicating its potential use in sex determination in forensic sciences.