Conservative therapy using a vasoconstrictive agent is useful for mild lesions of the middle meatus and of the maxillary orifice. However, moderate or more severe lesions require surgical enlargement procedures. Nebulization therapy following enlargement surgery of the lesions allows aerosol into the maxillary sinus via the middle meatus and the maxillary orifice. Transitional concentrations of the antibacterial aerosol into the maxillary sinus reveal over MIC80 against main causative bacteria of sinusitis. We found that the ultrasonic-type nebulizer is more effective in the treatment of paranasal sinusitis than the jet-type by a comparative study of the transitional concentration of an antibacterial agent to the maxillary sinus. We conclude that minimally invasive surgery on the middle meatus followed with conservative nebulization therapy for the treatment of paranasal sinusitis leads to recovery from disease and is an effective alternative to hospitalized surgical treatment.
We have used a navigation system to identify location of cysts in paranasal surgery. Usually a navigation system is employed in neurosurgery via a neuronavigator, which allows the surgical site to be visualized in real time by CT or MRI images. By using this system, we can approach the surgical site more safely and accurately. The cyst location in nasal cavity must be identified. However, some cysts are difficult to identify by endoscopy only because they do not show a bulged cyst wall. We regard these cases as good indications for the navigation system. Our device, EVANS (TOMIKI Medical Instrument Corporation) has mechanical arm system. To date, we have used this system in six patients with paranasal cyst. All patients are confirmed post operative maxillary cysts. In all cases, we could navigate the cyst accurately, and open. To avoid risk areas in the nasal cavity, especially in revision surgery, we have used this system with an accuracy of about 2mm as a guide through the critical points of sinuses such as the orbital wall, ethomoid tegmen, and optic canal. Based on our experience, this navigation system has the potential to make operations more accurate and safely, and particulary in improving the surgeon's confidence in endoscopic paranasal cyst surgery.
The Onodi cell (sphenoethomoid cell) is the most posterior ethmoid cell pneumatizing laterally and superiorly to the sphenoid sinus. The optic nerve and the carotid artery can project into the cell's lumen. This anatomic variation is found in 8-14% of cases according to studies using CT in association with recent developments in endoscopic sinus surgery. Surgeons are cautioned to target the sphenoid sinus to avoid injuring the optic nerve and carotid artery when performing surgery in this area. The Onodi cell is recognized to be clinically important, however, pathological Onodi cell sinusitis has rarely been reported. We treated a 40-year-old man with Onodi cell sinusitis that caused severe headache and persistant low-grade fever. The patient underwent bilateral sinus operations at 12 years of age, and had no nasal symptoms since then. He was referred to us because of sinus abnormalities on MRI that were thought related to the headache. Antibacterial therapy with tosufloxacin tosilate for 12 days followed by clarithromycin for 6 weeks was not effective, subsequently, we performed external sphenoethomoidectomy. One of the posterior ethmoid cells was found to have formed a cavity with purulent effusion. The ethmoid sinus was exteriorized according to usual procedures, however, we were unable to reach the Onodi cell due to disorientation, which was the result of insufficient knowledge of the Onodi cell at the time, and our failure to spatially image the relationship between the Onodi cell and the posterior ethmoid cells as well as the sphenoid sinus by coronal CT images. Therefore, we devised a coronal CT scan for the subsequent operation so that the images contained an indicator that reached the sphenoid sinus through the nasal cavity. The Onodi cell was located by the external approach as indicated by the CT images, and found to be filled with purulent effusion. We exteriorized the Onodi cell into the nasal cavity, and removed the septal bone between the Onodi cell and the sphenoid sinus. We preserved the mucosal lining of both the Onodi cell and the sphenoid sinus because the mucosa did not appear severely inflamed. The headache and low-grade fever disappeared quickly after the operation, and CT images 3 months after the operation showed complete air space in the Onodi cell and extended into the lesser wing of the sphenoid. The present case provided us with an opportunity to consider the clinical significance of the Onodi cell. We emphasize that at least two-dimensional CT studies are essential for surgery in this region.
The localization of zinc in the nasal mucosa was investigated in normal rats using Timm's method under a transmission electron microscope. Changes in the localization were also studied after injection of dithizon, which is a chelating agent for zinc. A morphological study of the nasal mucosa was also performed under a transmission electron microscope in an animal model of rats with decreased serum zinc levels after receiving a zinc-deficient diet. Zinc was found mainly in secretory granules in the apical region of supporting cells located in the olfactory epithelium. Zinc in the secretory granules disappeared almost completely after an injection of dithizon. In some supporting cells in the low serum zinc animal model, deformity of microvilli and bulging of the cytoplasm into the surface of the nasal mucosa was noted. Morphological changes were negligible in olfactory cells and olfactory nerves. These results suggested that zinc is released from secretory granules into the surface of the nasal mucosa. Although the present study did not clarify whether zinc participates in olfaction, zinc may influence the solubility of odor molecules into the surface of the nasal mucosa and adhesiveness of odorants to the olfactory cell surface.
Seven patients with malignant melanoma of the nasal cavity and paranasal sinus were treated at Yokohama city University from August 1991 to July 1998. The sex distribution was 3 males and 4 famales, and their ages ranged from 40 to 74 years (mean: 57 years). The chief complaints were epistaxis and nasal obstruction. Generally, nasal examinations revealed black masses, and whitish or grayish nasal polyp-like masses were also observed in some cases. Histopathologicallt, the diagnosis of this tumor is very difficult, therefore immunohistochemical examination is useful for difinitive diagnosis. Theatment modalities for this tumor consisted of various combination therapies in-cluding surgery, radiotherapy, chemotherapy and immunotherapy. Combination chemotherapy consisting of dimethltriazeno imidazole carboxamide (DTIC, Dacarbazine), amino methyl pyrimidinyl chlorethy nitrosourea hydrochloride (AGNU), vincristine (VCR), and cisplatin (CDDP) were administered, whereas chemotherapy was not effective for these patients. Surgical treatment as an initial therapy was performed in 6 patients. In three of these, melanoma cells were located multifocally in both the nasal cavity and paranasal sinuses. On the basis of the characteristics, the surgical margin should be carefully determined for this tumor.
In this prospective study, we investigated changes to nasal airway patency in the immediate response to the topical nasal decongestant, tramazoline hydrochloride, in patients with various nasal diseases. The study was carried out on the following groups: the control group (n=15), the nasal allergy group against house dust mite (n=30), the chronic sinusitis group (n=25), and the laser cauterization group (n=12). The chronic sinusitis group was further subdivided into two groups whether visible nasal polyps existed in the nasal cavity. We employed acoustic rhinometry as an objective method, and the nasal cavity volume (NCV) and the minimum cross-sectional area (MCA) were calculated before and 10 minutes after nasal sprays. In untreated condition, the average NCV in the severe nasal allergy group was 6.63cm3, which was significantly lower than that in the control group (7.8cm3). Further analysis indicated that the reduced NCV in this group was mainly due to obstructive changes to the first 3cm area of the nasal cavity. No significant difference in the untreated NCV was observed in the other groups. Pharmacologic decongestion caused increased nasal patency by 56% from the baseline NCV values in the control group, 42% in the nasal allergy group, 26% in the sinusitis without nasal polyps group, 30% in the sinusitis with nasal polyps group, and 10% in the laser group. The reduction in responsiveness was statistically significant in the sinusitis groups (p<0.05) and in the laser group (p<0.01). Changes to the MCA also showed close correlation with those to the NCV detected in each group. On the other hand, the degree of changes to the cross-sectional area around the nasal valve region remained within 10% in all groups. The results presented in this study demonstrate that acoustic rhinometry is a valuable method for the objective assessment of nasal patency. The pharmacological effect of tramazoline seems to depend on the anatomical features of the nasal cavity, aging, and the pathological changes to the nasal mucosa as well as therapeutic effects against nose diseases.
Infant nasal problems are common for ENT clinicians. As their initial therapy usually involves broad spectrum antibiotics, it is often some cases require long-term antibiotic therapy. In treating pediatric patients, nasal hypertonic saline irrigation using a small spray bottle has been adopted. The effectiveness of this method was evaluated in 30 children age 5 years or younger, who had been treated for nasal problems. The patients' parents kept diaries about their children's nasal symptoms for 2 weeks during the period of irrigation therapy. The children's noses were inspected and the bacteriological examinations were done once a week. In more than 50% of the cases, both subjective and objective symptoms improved after the two weeks of the irrigation therapy. While the M. catarrhalis, H. influenzae and S. pneumoniae were detected as the main strains before treatment, in most cases pathogenic bacteria decreased or disappeared after the irrigation therapy in spite of using no antibiotics during the same period. Although 5 patients suffered from acute otitis media during this study, the results encourage the adoption of nasal irrigation as an additional therapy for infant nasal problems, and suggest a reduction of the amount of antibiotics.
Over the last 13 years, we have performed maxillary antral irrigation with excellent results using a Killian's cannula inserted through the middle nasal meatus in more than 2600 cases of sinusitis in children. We have encountered many cases of young children (3, 4 and 5 year-olds) who required maxillary antral irrigation and have found irrigation in these cases practicable and beneficial. We report a therapy for sinusitis in young children using maxillary antral irrigation as a main treatment. Our first choice of treatment for sinusitis in young children is a local treatment and administration of Cefditoren, Cefcapene and Cefdoxime because of the high detection rate of penicillin resistant Streptococcus pneumoniae as pathogenic bacteria in these cases. For intractable cases to this treatment, we administer Clarithromycin. When these drug therapies are not effective, maxillary antral irrigation is performed with good results. Owing to the application of Triple Therapy (irrigation and administration of a new macrolide and Azeptine), the recovery rate is increasing. Indications of maxillary antral irrigation for sinusitis in young children are as follows; 1) Intractable cases against preservative treatment. We treated 19 intractable cases and found the irrigation markedly effective. 2) Sinusitis with complications. (1) Acute sinusitis accompanied by headache or fever, in which the drug therapies are not effective. (2) Sinobronchitis and its subform such as cases accompanied by continuous coughing, sputum and nasal discharge. (3) Cases accompanied by intractable exudative otitis media. (4) Cases accompanied by intractable bronchial asthma with frequent attacks.