Introduction: Unilateral sinus shadows can be observed in various diseases, including chronic sinusitis, odontogenic maxillary sinusitis, paranasal mycosis, and naso-sinus tumor. Because the appropriate treatment varies for each disease, the preoperative differential diagnosis is important and is usually made by computed tomography (CT). Here we review our surgical cases presenting unilateral sinus shadows to determine the accuracy of preoperative diagnoses used to guide initial treatment planning and to assess the frequency and characteristics of unilateral sinusitis based on CT findings, such as bone destruction, the density of soft tissue shadows, bone hypertrophy and the presence or absence of a deflected septum.
Methods: The records of 72 patients who were found to have unilateral sinus shadows on CT and underwent surgery between January 2012 and April 2014 were reviewed.
Results and Discussion: The postoperative diagnosis was chronic sinusitis in 25 (34.7%) patients, odontogenic maxillary sinusitis in 14 (19.4%), paranasal mycosis in 9 (12.5%), papilloma of the nasal and paranasal sinuses in 7 (9.7%), maxillary carcinoma in 4 (5.6%), radicular cyst in 4 (5.6%) patients, and other in 9 (12.5%) patients. Soft tissue shadows with heterogeneous CT values were observed in 21 (84.0%) of the patients with chronic sinusitis, 12 (85.7%) of the patients with odontogenic maxillary sinusitis, and 9 (100%) of the patients with paranasal mycosis. CT revealed bone hypertrophy in 20 of the 25 (80.0%) patients with chronic sinusitis, 8 of the 14 (57.1%) patients with odontogenic maxillary sinusitis, and all 9 (100%) of the patients with paranasal mycosis. As the appropriate treatment varies for each disease, the preoperative differential diagnosis should be made based on each patient’s medical history, complaints, and CT findings. We determined the frequency of several diseases associated with unilateral sinusitis based on CT findings.
Bisphosphonates are frequently used for the treatment of bone metastases, multiple myeloma, osteoporosis, and other bony diseases. Recent reports have described bisphosphonate-related osteonecrosis of the jaw (BRONJ) as a potentially serious complication related to the long-term use of these drugs despite their various benefits. An 86-year-old osteoporotic woman suffered from right cheek pain, nasal discharge, and discharge from the maxillary gingiva. She was diagnosed as having BRONJ with right sinusitis on the basis of exposed, necrotic bone in the right maxillary region, current bisphosphonate use, and no history of radiation therapy to the jaw. After 2.5 months of treatment with antibiotic therapy and discontinuation of bisphosphonate administration, a right subperiosteal orbital abscess appeared. We performed sequestrectomy, and endoscopic sinus surgery with drainage of the right subperiosteal orbital abscess. After surgery, the patient was doing well.
After dacryocystorhinostomy (DCR), a silicon tube is generally inserted into the superior and inferior puncta and then passed through the canaliculi to the opened lacrimal sac. Instead, we insert a T-sheet into the opened sac after DCR. In this method, an incision is made on the ridge of the nose, and a flap is elevated. A DCR diamond burr is used to remove the bone and expose the lacrimal sac and the nasolacrimal duct surface. Then, a vertical incision is made in this region. Next, a T-sheet is made from a Penrose drain tube. The horizontal part of the T-sheet is inserted into the sac and is left in the sac for 2 to 4 weeks. Twenty sacs in 17 cases have been subjected to the above method in the past 14 years. Two cases required further surgical procedures, and the success rate was 90%. Physicians who are familiar with endoscopic sinus surgery can easily perform the reported procedure.
Isolated sphenoid sinus disease (ISSD) is relatively rare. A retrospective analysis of 38 cases is reported. The study population included 21 males and 17 females with a median age of 64.0 years (range, 12–85 years). There were 14 patients with inflammatory disease, 11 with cystic disease, 8 with fungal sinusitis, and 5 with tumors.
There are several surgical approaches that can be used to treat ISSD, including the trans-ethmoid, trans-nasal, and trans-septal approaches. Among our cases, 18, 14, and 6 were treated via the trans-nasal, trans-septal, and trans-ethmoid approach, respectively. The superior turbinate was resected in 27 cases (70.3%), and 16 patients (42.1%) underwent ethmoidectomy. No significant difference in the frequency of recurrence was detected between the trans-septal approach and the other approaches. None of the patients treated with simple sphenoidectomy or sphenoidectomy with partial ethmoidectomy suffered recurrence, which suggests that ethmoidectomy is not essential for treating ISSD.
Thin-sliced computed tomography revealed Onodi cells in 9 cases. Bleeding from the posterior septal branches of the sphenopalatine artery (SPA) occurred in 4 cases without Onodi cells. However, no episodes of such bleeding occurred in the patients with Onodi cells. This indicates that in cases of ISSD without Onodi cells, surgeons should be aware of bleeding from the posterior septal branches of the SPA.
Invasive fungal sinusitis of the sphenoid sinus can cause serious symptoms due to involvement of surrounding structures such as the skull base and cavernous sinus, and may be fatal. Thus, early diagnosis and appropriate treatment are crucial for this disease. We report a case of invasive fungal sinusitis of the sphenoid sinus in which abducens nerve paralysis developed. An 81-year-old man with diplopia was referred by an ophthalmologist due to MRI findings indicating possible sphenoid mycosis. The patient had no symptoms other than diplopia. A CT scan showed soft tissue density with calcification in the right sphenoid sinus and a bone defect in the posterior wall of the sphenoid sinus, which corresponded to the abducens nerve tract on the clivus. In serum, the β-D glucan level was not elevated, but aspergillus antigen was elevated. Invasive fungal sinusitis was diagnosed based on the CT and biochemical findings. The patient underwent endoscopic sinus surgery on the day of examination, followed by intravenous administration of an azole-based antifungal agent, VRCZ. The postoperative clinical course was uneventful, with complete neurological recovery of the abducens nerve and improvement of the aspergillus antigen level in serum. Measurement of the aspergillus antigen level in serum was useful in early diagnosis and for evaluation of the therapeutic effect.
A congenital nasolacrimal duct cyst (CNDC) is generally formed due to nasolacrimal duct obstruction during fetal development. Nasolacrimal duct obstruction leads to cystic enlargement of the duct resulting in the formation of an intranasal mass on the inferior meatus. Depending on the site and size, CNDC causes varying degrees of respiratory impairment. We report a male neonate with CNDC. The CNDC was surgically resected using an intranasal endoscopic approach. He presented with respiratory impairment just after birth and was treated with continuous positive airway pressure. An intranasal mass was located on the left inferior meatus. Computed tomography and magnetic resonance imaging showed an enlarged lacrimal sac and a nasolacrimal duct with the mass on the inferior meatus. Because his respiratory impairment became progressively more severe, an intranasal endoscopic marsupialization was performed with a microdebrider to improve his obstructed nasal respiration. Under general anesthesia, direct visualization of the left nasal cavity was performed using a straight telescope with an outside diameter of 2.7mm.
Endoscopic observation and iodine injection excluded the presence of right nasolacrimal duct cysts. Before marsupialization, the patency of the nasolacrimal duct was confirmed by iodine injection into the lacrimal punctum. The procedure with the microdebrider was carefully performed to prevent injury to the surrounding tissue. Nasal packing to prevent bleeding was not necessary. Although his respiratory state was not fully restored postoperatively, his obstructed nasal respiration was relieved, and no instances of recurrence or complications were noted. Nasal endoscopic marsupialization with a microdebrider represents a safe and effective method for the treatment of CNDC.
Objectives: Chronic rhinosinusitis (CRS) is one of the diseases that is most frequently associated with olfactory disorders. Conversely, few patients with allergic rhinitis (AR) complain of olfactory disorders. This study aimed to compare the olfactory disorders that occur in patients with AR and CRS.
Methods: Two hundred and thirty-nine patients with AR or CRS, who underwent primary bilateral inferior turbinate surgery (ITS) or endoscopic sinus surgery (ESS) whose olfactory acuity was evaluated at our department between March 2012 and April 2015, were enrolled. The patients aged from 20 to 49 y.o. were classified into three groups: i) 35 AR patients who underwent bilateral ITS (group ITS), ii) 35 CRS patients without eosinophilia (Eo≤5%) who underwent ESS (group ESS without Eo); and iii) 36 CRS patients with eosinophilia (Eo>5%) who underwent ESS (group ESS with Eo). The patients’ chief complaints, olfactory visual analog scale (VAS) scores, the severity of their olfactory disorders according to their mean recognition thresholds which were assessed with a T&T olfactometer, and their reactions to intravenously injected prosultiamine at the preoperative stage were retrospectively analyzed in both groups.
Results: None of the patients in the group ITS complained of olfactory disorders, whereas 37% (26/71) of the patients in the two ESS groups complained of them. The mean olfactory VAS score of the group ITS (71%) was significantly better than that of the two ESS groups (≈45%) (p<0.01). In the group ITS, the severity of the patients’ olfactory disorders (according to their mean recognition thresholds) was classified as normosmia in 16 (45%) patients, mild disorder in 15 (43%) patients, moderate disorder in 2 (6%) patients, severe hyposmia in 1 (3%) patients, and anosmia in 1 (3%) patients. The mean T&T recognition threshold (1.5 ± 1.2) of the group ITS was significantly milder than that of group ESS without Eo (3.4 ± 1.9) and group ESS with Eo (3.8 ± 2.0) (p<0.001). No significant correlation was detected between the VAS score and the mean recognition threshold in group ITS (rs = −0.322), whereas these differences in both two ESS groups were significant (p<0.001). As for the intravenous olfaction test, all (29/29) of the patients in the group ITS responded to prosultiamine, whereas 4.6% (3/65) of the two ESS groups did not respond.
Conclusion: This study demonstrated that patients with AR suffer from olfactory dysfunction, even if they do not complain of olfactory disorders. Although the frequency and severity of the olfactory disorders seen in patients with AR are lower and milder, respectively, than those seen in patients with CRS, it is important to accurately evaluate olfactory disorder in patients with AR.