Several theories concern the pathogenesis of nasal polyps and chronic paranasal sinusitis, but the correlation of inflammatory cells between nasal polyps and chronic paranasal sinusitis mucosae has not been investigated. We studied inflammatory cells in 82 nasal polyps and ethmoid sinus mucosa and in 28 maxillary sinus mucosa in 53 patients with chronic paranasal sinusitis, grading the tissue density of eosinophils, lymphocytes/plasma cells, and neutrophils from 3+to-. Many neutrophils infiltrated only a few tissues, so we first studied predominant inflammatory cells by combining the positivity of eosinophils or lymphocytes/plasma cells. A statistically significant correlation was seen between nasal polyps and ethmoid sinuses and between ethmoid and maxillary sinuses. We then studied the correlation of positivity of eosinophils and lymphocytes/plasma cells. Eosinophils showed a high positive correlation among nasal polyps, ethmoid sinuses, and maxillary sinuses, as did that of lymphocytes/plasma cells, but not between nasal polyps and maxillary sinuses. Nasal polyps and ethmoid sinus mucosa in patients with asthma showed a higher positivity of eosinophils than in those without asthma. The positivity of lymphocytes/plasma cells showed no such difference. The positivity of eosinophils differed significantly between small and large nasal polyps. Our results thus suggest that (1) the same mechanism of inflammatory cell infiltration operates in nasal polyps and paranasal sinuses, (2) the presence of eosinophils may be related to the growth of nasal polyps and, (3) histologic nasal polyp biopsy may indicate the type of inflammatory cells predominant in chronic paranasal sinusitis, clarifying the course of medical management before and after surgery.

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To detect factors that may affect the prognosis of diplopia caused by orbital wall fractures, retrospectibely evaluated 82 cases were seen at the Saitama Medical School between January 1995 and July 1999. Of these, 44 (54%) reporting diplopia were divided into 2 groups. One in which diplopia lasted more than 1 month and one in which recovery occurred within 1 month. To study diplopia quantatively, the area within 15 degrees on the Hess chart was calculated and the ratio of area of affected side against that of normal side was obtained. Statistically, in patients in there low teens, cases with positive symptoms in the forced duction test and abnormalities in CT or MRI imaging tended to have a poor prognosis, indicating the need for early surgery. The absence of these factors suggested that a wait-and-see policy would produce a better prognosis.

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The Onodi (sphenoethmoid) cell, named after Onodi's report in 1903, has attracted attention in recent advances in CT and endoscopic sinus sugery. The paranasal sinus Anatomic Terminology Group in 1993 defined the Onodi cell as the most posterior ethmoid cell pneumatizing laterally and superiorly to the sphenoid sinus. Since the Onodi cell is intimately related to the optic nerve, this anatomic variant is considered clinically significant.The optic nerve is placed at risk during sinus surgery, and lesions of the Onodi cell may cause visual symptoms. Although the Onodi cell is generally accepted to occurs in about 10%, the reported incidence varies between 3.4% and 51%. We assessed the reliability of CT in detecting the Onodi cell to further understanding of this clinically relevant anatomic variation and the prevalence of affected Onodi cells.
We studied CT findings in 100 randomly chosen patients, evaluating 79 with both coronal and axial CT scanning and 21 with axial CT scanning alone. Using a cadaveric head containing a typical Onodi cell, we studied gross and CT findings. We found the Onodi cell in 23 patients (23%) including 4 with affected Onodi cells, i. e., 2 with cystic lesions (1 with visual disturbance) and 2 with sinusitis. In 6 patients (6%), coronal CT images showed features such as the Onodi cell. Axial CT scanning showed that confusing features in 5 cases corresponded to those of sphenoid sinuses divided into 2 by a transverse septum and to that of a posterior ethmoid cell invading under the sphenoid sinus in 1 case. In 10 patients (10%), we could not determine the presence of the Onodi cell due to ethmoid cell complexity ethmoid cell and limited CT resolution.
As suggested previously by correlative studies between CT and endoscopy, our results indicated that the Onodi cell is a more frequent anatomic variant than commonly appreciated, though CT is not always able to detect it. Serial axial CT imaging thus appears more useful than coronal CT imaging in detecting the Onodi cell. Pathological characteristics of Onodi cell lesions are required to be clarified in future studies.

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Endoscopic sinus surgery (ESS) offers many benefits to patients with extensive chronic sinusitis and nasal polyps. Olfaction disorder have been documented as the most uncontrollable complaint associated with ESS, and recognition of this finding suggests that the treatment of olfactory clefts is essential for dysosmia therapy. In this paper, endoscopic surgery procedures for inflammatory lesions in the olfactory cleft are described and postoperative findings are presented. From April 1, 1995, through March 31, 1999, the author operated on 60 patients (101 sides) with inflammatory lesions, such as polyps or polypous swellings, in the olfactory cleft. The average follow-up period was 338 days. The key points in the surgical technique are the cauterization of the edematous mucosa using high-frequency radiosurgical equipment (Surgitoron™), allowing both the middle and superior turbinate to remain unresected, and the opening of the sphenoethmoidal recess to insure sufficient space for the olfactory stream. In addition, endoscopic treatment during the follow-up period appears to be essential for successful treatment in cases of chronic sinusitis. The postoperative findings in the olfactory cleft at the time of final observation were evaluated according to three categories: patent, adhesion and obstruction due to recurrence. Eightyseven sides (86.1%) were patent, 5 sides (5.0%) exhibited adhesion, and 5 sides (5.0%) were obstructed. Olfaction was subjectively evaluated before and after surgery. Fifty patients (83.3%) did not experience dysosmia after surgery and 10 patients experienced no changes in olfaction.

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In the everyday examination of patients exhibiting a unilateral shadow in the maxillary sinus upon imaging, the differentiation of chronic sinusitis from other diseases, including malignant tumors, is extremely important.
A unilateral shadow in the maxillary sinus was detected on scout films and a subsequent CT examination of the sinus was performed in 108 patients who visited our department between January 1994 and December 1998.
Bone destruction was suspected after scout films were taken in 2 patients with malignant tumors. These 2 patients account for only a small percentage of the total patient population, but account for as much as 50% of the patients with malignant tumors.
In cases of malignant tumors, the CT images suggesting bone destruction agreed with operative findings. CT seems to be a useful tool for evaluating the condition of the bone.
When the density of scout films and CT images were compared, no significant difference was detected, suggesting that scout films can be used for the screening of malignant tumors. The density was (+++) in both the scout films and the CT images of the 2 patients with malignant tumors.
Finally, we present a flow chart for the diagnosis of unilateral maxillary sinus shadows that has been recently adopted as the basic protocol used in our department.

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B cells can be separated into at least two subsets, B-1 and B-2 cells, based on the expression of CD5 and CD45R/B220. B-1 cells are phenotypically and functionally distinct from conventional B cells (B-2 cells). B-1 cells predominate in the peritoneal and pleural cavities and in the lamina propria of the gut and play important roles in protective immunity as a major source of mucosal IgA. Although intestinal B-1 cells are well documented, the nature of B-1 cells in the upper respiratory tract remains unknown. In this study, we analyzed the characteristics of nasal B-1 cells at the single cell level. Mononuclear cells (MNCs) were isolated from the nasal passage (NP), nasal-associated lymphoid tissue (NALT), cervical lymph node (CLN), and spleen (SP) of normal mice. The frequency of B-1 and B-2 cells was analyzed by flow cytometry. B-1 and B-2 cells from the NP were purified, and isotype-specific antibody-producing cells were determined by enzyme-linked immunospot (ELISPOT) assay. To investigate antigen-specific immune responses in B-1 and B-2 cells, MNCs were isolated from the NP of orally cholera toxin (CT)-immunized mice and alterations after antigen exposure were analyzed using flow cytometry and a CT-specific ELISPOT assay. B-1 cells were predominant in the B cells found in the NP but accounted for only a few percent in the SP and were rare in NALT and the CLN. In addition, B-1 cells were the major producers of IgA in the NP. Interestingly, B-2 cells increased in the NP after immunization, and these B-2 cells produced larger amounts of CT-specific IgA than the B-1 cells. These results suggest that B-1 cells constitute a primitive immune system and play a role in the protective immunity that forms a first line of defense. Furthermore, B-2 cells can contribute to mucosal IgA responses via the common mucosal immune system. These findings suggest that two distinct lineages of IgA B cells developing from B-1 and B-2 cells are involved in the formation of the mucosal barrier in the upper respiratory tract.
NP: nasal passage NALT: nasal-associated lymphoid tissue CLN: cervical lymph node SP: spleen CMIS: common mucosal immune system CT: cholera toxin

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The primary function of the well-differentiated ciliated epithelium in the human paranasal sinuses is to eliminate microorganisms, debris, and foreign particles through the beating action of cilia. While factors regulating ciliary activity are not fully understood, we have demonstrated the expression of different nitric oxide synthase (NOS) isoforms in cultured human paranasal epithelial cells and have shown that ciliary activity in these cells is upregulated via an NO-dependent mechanisim. In this study, we studied the function of endogenously generated NO in signal transduction and discuss the role of NO synthesized by different isoforms with the ciliated cell. Cultured human paranasal sinus epithelium was incubated either with TNF-α (1ng/ml), dexamethazone (10^-6M), or nothing for 24 hours. Ciliary beat frequency (CBF) of ciliated cells in each group was measured photoelectrically at baseline and after the addition of 1mM each of L-arginine, L-NAME (a non specific NOS inhibitor), or S-ethylisothiourea (EIT, a specific inducible NOS inhibitor). The addition of L-arginine rapidly increased CBF in the untreated group (18.7%) and in the dexamethazone-treated group (21.5%), whereas the increase in the TNF-α-treated group was 9.2%, significantly lower than in the other 2 groups. The addition of EIT significantly increased CBF in the TNF-α-treated group (12.1%), but neither of the other 2 groups showed a significant change in CBF from the baseline. L-NAME rapidly decreased CBF by 17-21% within 5 minutes in all groups, decreases that were not statistically significant between groups. Immunocytochemical studies demonstrated constitutive endothelial NOS (eNOS) expression in all groups and strong iNOS reactivity in cells treated with TNF-α, indicating that NO generation by epithelial ciliated cells is mediated via different NOS isoforms and is constitutively involved in CBF regulation. We further surmise that NO modulates CBF in cultured sinus ciliated cells differently under conditions when iNOS expression is strongly augmented inside the cells.

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A clinical study was performed investigating 98 patients (110 sides) who underwent sinus surgery for post-operative maxillary cysts at our hospital between January 1985 and December 1999. The patients' mean age was 49.5 years, with a range of 23-73 years. Many of the patients had undergone their initial sinus operation for chronic sinusitis between the ages of 10 and 30 years. The mean period between the initial sinus operation and the surgery for post-operative maxillary cyst was 27.5 years. The length of time between the initial sinus operation and the post-operative maxillary cyst surgery was not significantly correlated with the age at the time of the initial sinus operation. The surgical methods used to remove the cysts consisted of Caldwell-Luc operations on 95 sides and endoscopic endonasal antrostomies on 15 sides. The frequency of endoscopic endonasal procedures has increased in recent years. We evaluated the postoperative CT findings in 15 patients (16 sides) who had undergone the removal of the entire cyst by a Caldwell-Luc procedure.
The postoperative sinus findings following the maxillary cyst surgeries were as follows: 4 reduced and obliterated maxillary cavities, 7 reduced maxillary cavities, 3 reduced maxillary cavities with areas of soft tissue density, and 2 recurrent cysts. These results suggest that removal of the entire cyst dose not always result in occlusion with healing by granulation.
The removal of the entire cyst may not be essential in surgery for post-operative maxillary cysts, but the wall of the cyst should be opened to the middle and/or inferior meatus as far as possible. We speculate that endoscopic endonasal procedures will be increasingly used in the future.

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We studied the relationship between eosinophil cationic protein (ECP) and epithelial cell injury and mucus hypersecretion in sinus mucosa permeated by active eosinophils. Only the existence of very slight cilia in the scanning electron microscopy of the nasal polyp surface with a high ECP concentration was seen and was being replaced by numerous mucus cells. Space existed intercellularly with partial deprivation. A high correlation was seen between nasal mucosa surface ECP concentration and albumin and fucose concentration, and with increasing ECP concentration indicating that it increased in both secretion of albumin from the blood and secretion from goblet cells. Cases of high ECP concentration thus involve both hypersecretion from goblet cells and blood and obvious epithelial cell injury, resulting in mucociliary function failure.

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Nitric oxide (NO) is produced by various cells within the respiratory tract. In healthy individuals, exhaled NO is mainly produced in the nasal airway. The most widely used technique for measuring NO in exhaled air is the chemiluminescence method. In the present study, exhaled NO was collected in a sampling bag placed over the mouth and nose, while nasal NO was sampled directly from the nasal cavity. Both exhaled and nasal NO levels were measured using a ML9841 chemiluminescence NO analyzer, which has a detection limit of 1 part per billion (ppb).
The purpose of this study was to determine whether ambient NO concentrations influence the levels of exhaled NO.
Subjects and Methods.
Twenty-six healthy volunteers were enrolled in the study. One volunteer was examined four times, cosequently twenty-nine samples of exhaled NO were obtained. Exhaled NO and nasal NO were measured after the subjects had inhaled either NO-free air or ambient room air.
Ambient NO was tested before each measurement of exhaled NO. Exhaled NO was then collected for 20 seconds in a sampling bag placed over the mouth and nose of the volunteer. The inspiration and expiration times were both 4 seconds. The recommended exhalation flow rate for oral and nasal breathing is 9L/min. Oral exhalation was measured using a resistance technique, which is the simplest and most effective method for preventing the contamination of exhaled air with nasal NO. Nasal cavity air was sampled every 20 seconds at a rate of 3.6L/min while the subjects held their breath.
Results.
Ambient NO concentrations ranged from 1.3 to 122ppb. Exhaled NO and nasal NO levels were higher when subjects inhaled ambient room air than when they inhaled NO-free air. In addition, significant correlations were observed between exhaled NO, nasal NO and ambient NO levels. Exhaled oral NO concentrations were significantly correlated with the ambient NO concentration (r=0.5982, p<0.001). Exhaled nasal NO concentrations (r=0.4928, p<0.01) and nasal NO concentrations (r=0.406, p<0.05) were also correlated with the ambient NO concentration.
Conclusions
Exhaled NO and nasal NO concentrations are influenced by the concentration of inhaled ambient NO. The dead space, which is the unventilated volume of the airway, was influenced by the ambient NO concentration. The dead space volume was about 15-19% of the ventilated volume. In our study, orally inhaled NO, which reflects the degree of contamination by ambient NO, was approximately 21.3%. The results of the present study suggest that inhaling ambient air containing a high concentration of NO effects the levels of exhaled NO. In usingexhaled NO tests to assess patients with airway inflamations, such as asthma, NO-free air should be inhaled in order to prevent contamination by ambient NO.

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Thirty-one patients with advanced paranasal sinus carcinomas received by “two-route” intra-arterial chemotherapy using cis-diamminedichloroplatinum (CDDP) and sodium thiosulfate (STS) to preserve the hard palate and the eye. In these patients, 100 or 150mg/m² of CDDP was administered weekly through each feeding artery of the tumor superselectively at a rate of 5mg/min. During the CDDP infusion, a dosage of STS that was two-hundred fold times larger than the CDDP dasage was injected through a catheter placed in the brachiocephic vein, introduced via the subclavian vein. The complete and partial response rates were 24/31 (77%) and 7/31 (22%), respectively. Twenty-six patients were treated through the femoral artery, eight patients were through the superficial temporal artery and three were through both the femoral and the superficial temporal arteries. The overall survival rate for untreated stage III and IV carcinomas was calculated by the Kaplan-Meier method to be 80%. Of the sixteen patients with orbital fat and/or musculature invasions, the orbital contents were preserved in 14 patients. CT-arteriography is a very efficient method for the visualization of feeding arteries into paranasal sinus cancers. Each weekly chemotherapy treatment was performed on schedule. This new method of chemotherapy appears to be very effective for advanced paranasal sinus carcinomas.

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