The nasal floor pedicled flap: a novel technique for use in skull base reconstruction.
Daraei Pedram,Oyesiku Nelson M,Patel Zara M
International forum of allergy & rhinology
BACKGROUND:Skull base reconstruction can be accomplished using various donor sites. Vascularized tissue, commonly the nasoseptal flap, is the most effective option for large defects or high flow leaks. In cases where the septum cannot be used, a mucoperiosteal flap from the nasal floor, pedicled from the sphenopalatine artery, is a viable option without reported outcomes. The aim of this work was to describe this flap and to report successful outcomes in a cohort of patients. METHODS:Retrospective chart review of patients seen by the senior author from 2011 to 2013 requiring skull base reconstruction for defects with cerebrospinal fluid leak. RESULTS:A total of 108 patients underwent endoscopic skull base reconstruction. Ten patients had reconstruction with use of a pedicled nasal floor flap. Mean age was 53.3 years. Defects involved the ethmoid roof in 5 patients, sellar floor in 2, clivus in 2, and planum sphenoidale in 1. Reasons why the septal flap could not be used were intentional sacrifice due to disease involvement, sacrifice for proper exposure, or previous septal perforation. Mean length of follow-up was 10.2 (range, 4 to 25) months. No patient developed cerebrospinal fluid leaks postoperatively. CONCLUSION:Nasal floor pedicled flaps are an effective alternative to nasoseptal flaps for reconstruction of the skull base, and have not been previously described in the literature. Outcomes are promising in our small cohort of patients. If the septum must be sacrificed, attention should be paid to the nasal floor, which provides a large mucoperiosteal flap that can be consistently exposed and elevated by the experienced surgeon.
The Impact of Middle Turbinate Concha Bullosa on the Severity of Inferior Turbinate Hypertrophy in Patients with a Deviated Nasal Septum.
Tomblinson C M,Cheng M-R,Lal D,Hoxworth J M
AJNR. American journal of neuroradiology
BACKGROUND AND PURPOSE:Inferior turbinate hypertrophy and concha bullosa often occur opposite the direction of nasal septal deviation. The objective of this retrospective study was to determine whether a concha bullosa impacts inferior turbinate hypertrophy in patients who have nasal septal deviation. MATERIALS AND METHODS:The electronic medical record was used to identify sinus CT scans exhibiting nasal septal deviation for 100 adult subjects without and 100 subjects with unilateral middle turbinate concha bullosa. Exclusion criteria included previous sinonasal surgery, tumor, sinusitis, septal perforation, and craniofacial trauma. Nasal septal deviation was characterized in the coronal plane by distance from the midline (severity) and height from the nasal floor. Measurement differences between sides for inferior turbinate width (overall and bone), medial mucosa, and distance to the lateral nasal wall were calculated as inferior turbinate hypertrophy indicators. RESULTS:The cohorts with and without concha bullosa were similarly matched for age, sex, and nasal septal deviation severity, though nasal septal deviation height was greater in the cohort with concha bullosa than in the cohort without concha bullosa (19.1 ± 4.3 mm versus 13.5 ± 4.1 mm, P < .001). Compensatory inferior turbinate hypertrophy was significantly greater in the cohort without concha bullosa than in the cohort with it as measured by side-to-side differences in turbinate overall width, bone width, and distance to the lateral nasal wall (P < .01), but not the medial mucosa. Multiple linear regression analyses found nasal septal deviation severity and height to be significant predictors of inferior turbinate hypertrophy with positive and negative relationships, respectively (P < .001). CONCLUSIONS:Inferior turbinate hypertrophy is directly proportional to nasal septal deviation severity and inversely proportional to nasal septal deviation height. The effect of a concha bullosa on inferior turbinate hypertrophy is primarily mediated through influence on septal morphology, because the nasal septal deviation apex tends to be positioned more superior from the nasal floor in these patients.
The CREST syndrome variant of scleroderma in a mother-daughter pair.
Mund D J,Greenwald R A
The Journal of rheumatology
The CREST syndrome variant of scleroderma was discovered in a 48 year old woman whose mother, age 70, also had CREST syndrome characterized by extensive skin involvement. HLA typing of the two patients, as well as the two asymptomatic daughters of the proband, revealed the A11-Bw22 haplotype. Review of the family relationships revealed two first cousin marriages. This is the fifth case report of vertical transmission of PSS or its variants, and the first report of this HLA type in such patients. An unusual feature of the illness in the mother was a large perforation of the nasal septum of the type usually associated with Wegener's disease.
Anatomical aspects of sinus floor elevations.
van den Bergh J P,ten Bruggenkate C M,Disch F J,Tuinzing D B
Clinical oral implants research
Inadequate bone height in the lateral part of the maxilla forms a contra-indication for implant surgery. This condition can be treated with an internal augmentation of the maxillary sinus floor. This sinus floor elevation, formerly called sinus lifting, consists of a surgical procedure in which a top hinge door in the lateral maxillary sinus wall is prepared and internally rotated to a horizontal position. The new elevated sinus floor, together with the inner maxillary mucosa, will create a space that can be filled with graft material. Sinus lift procedures depend greatly on fragile structures and anatomical variations. The variety of anatomical modalities in shape of the inner aspect of the maxillary sinus defines the surgical approach. Conditions such as sinus floor convolutions, sinus septum, transient mucosa swelling and narrow sinus may form a (usually relative) contra-indication for sinus floor elevation. Absolute contra-indications are maxillary sinus diseases (tumors) and destructive former sinus surgery (like the Caldwell-Luc operation). The lateral sinus wall is usually a thin bone plate, which is easily penetrated with rotating or sharp instruments. The fragile Schneiderian membrane plays an important role for the containment of the bonegraft. The surgical procedure of preparing the trap door and luxating it, together with the preparation of the sinus mucosa, may cause a mucosa tear. Usually, when these perforations are not too large, they will fold together when turning the trap door inward and upward, or they can be glued with a fibrin sealant, or they can be covered with a resorbable membrane. If the perforation is too large, a cortico-spongious block graft can be considered. However, in most cases the sinus floor elevation will be deleted. Perforations may also occur due to irregularities in the sinus floor or even due to immediate contact of sinus mucosa with oral mucosa. Obstruction of the antro-nasal foramen is, due to its high location, not a likely complication, nor is the occurrence of severe haemorrhages since the trap door is in the periphery of the supplying vessels. Apart from these two aspects, a number of anatomical considerations are described in connection with sinus floor elevation.
The cocaine user: the potential problem patient for rhinoplasty.
Slavin S A,Goldwyn R M
Plastic and reconstructive surgery
The current popularity of cocaine use poses special hazards for the patient and the plastic surgeon during rhinoplasty. It is incumbent upon the surgeon to inquire preoperatively about possible recreational use of cocaine. As the preferred site of cocaine administration, the nasal septal mucosa is exposed to both the intense vasoconstrictive action of cocaine and the irritative effects of numerous contaminating additives. Pathologic changes in the septal mucosa should be recognized by preoperative rhinoscopy and evaluated by biopsy. In this series of 13 patients, fewer than half were properly identified as cocaine users during the preoperative consultation. Preoperative rhinoscopic findings varied from grossly unremarkable septal mucosa to visible perforation and microscopic evidence of granulomas, inflammation, and necrosis. Surgical complications consisted of localized septal collapse, delayed mucosal healing, and inadequate correction of septal deflection. Submucous resection and septoplasty should be avoided in patients with a known history of intranasal cocaine application. Although rhinoplasty can be safely performed in selected patients with a history of cocaine use, it may be extremely limited, unfeasible, or hazardous in those with significant mucosal and cartilaginous impairment as well as in those patients who refuse or are unable to relinquish the drug.
[Chronic chromate intoxication with renal tubular damage--report of a case].
Lin J L
Journal of the Formosan Medical Association = Taiwan yi zhi
A 46-year-old male chromium plating worker visited our hospital due to rhinorrhea, sneezing and cough with blood-tinged sputum for more than 10 years. He also had skin ulceration and chronic dermatitis on both hands Medical therapy was inefficient. Physical examinations revealed nasal septum perforation, severe inflammation of the nasopharynx cavity, and eczema of both hands. Laboratory investigations showed significant tubule proteinuria, enzymuria, hypercalciuria, etc. It is evident that renal tube damage was present in this patient. The blood chromium level was 25 ng/mL, and the 24-hour urine chromium excretion level was 2.8 mg/day. A pulmonary function test showed reduced functional residual capacity (FRC), which may be due to either long-term smoking or chromate acid exposure. To our knowledge this is the first case of renal tubal damage induced by chronic chromate intoxication Taiwan. Further evaluation of the occupational safety and health of chromium plating workers is needed on this island.
Skin reactions to inhaled corticosteroids.
Corticosteroids intended for inhalation into the lungs or into the nose have been used since the 1970s. Only 2 attempts to assess contact allergy attributable to inhaled corticosteroids in patients with asthma and/or rhinitis have been made, and only 1 single case of contact allergy attributable to budesonide and tixocortol pivalate was found. However, several case reports of allergic mucosal and skin symptoms caused by corticosteroids applied locally to the mucosa have been published. Local adverse effects from nasal corticosteroids have ranged from nasal congestion, pruritus, burning, and soreness to perforation of the nasal septum. Inhalation of corticosteroids into the lungs has been reported to cause pruritus, dryness, erythema and oedema of the mouth, a dry cough and odynophagia. Systemic signs reported from the use of nasal corticosteroids and inhalation of corticosteroids into the lungs have been eczematous lesions, particularly on the face, sometimes with spreading to the trunk and flexures. Urticaria has also been noted.
Perforation of the Hard Palate Due to Tuberculosis.
Sarojini P A,Basheer A M,Gopalakrisnan Nair T V,Pasha M H
Indian journal of dermatology, venereology and leprology
A case of tuberculosis affecting the skin and nasal septum and 10 years later involving the hard palate causing perforation is reported.
Self-induced ethmoidectomy from rhinotillexomania.
Caruso R D,Sherry R G,Rosenbaum A E,Joy S E,Chang J K,Sanford D M
AJNR. American journal of neuroradiology
A 53-year-old woman with a long history of compulsive nose picking (rhinotillexomania) presented with a large, self-inflicted nasal septal perforation and right-sided penetration of the ethmoidal sinus, or "ethmoidectomy."
A risk-benefit assessment of intranasal triamcinolone acetonide in allergic rhinitis.
Gawchik S M,Saccar C L
The efficacy of intranasal triamcinolone acetonide in seasonal and allergic rhinitis has been evaluated in clinical trials and has been compared with antihistamines and other intranasal corticosteroids. Intranasal corticosteroids are either as equally effective as or more effective than comparative drugs. Intranasal corticosteroids are particularly useful as they decrease membrane permeability and inhibit both early and late phase reactions to allergens. They minimise the nasal secretory response and reduce the sensitivity of local nasal irritant receptors. A potential benefit of topical application is the flushing action of the nasal mucosa, which may reduce allergens and secretions. In addition to seasonal and perennial rhinitis, intranasal corticosteroids have additional benefits when used to reduce inflammation in the treatment of sinusitis and may help in decreasing secondary rhinovirus infections. Furthermore, suboptimal control of asthma can be avoided by treatment of allergic rhinitis with intranasal corticosteroids. In clinical trials, common adverse effects for triamcinolone acetonide include sneezing, dry, mucosa, nasal irritation, sinus discomfort, throat discomfort, epistaxis and headache. Posterior subcapsular cataract formation has not been seen with triamcinolone acetonide. Recent literature evaluating systemic absorption of intranasal corticosteroids have shown surprising results where significant absorption has occurred with intranasal budesonide and fluticasone propionate. Growth and hypothalamic pituitary axis (HPA) function studies have been reviewed, with some intranasal corticosteroids showing changes with continual use. A retrospective study in children receiving daily triamcinolone acetonide for 12 months showed no effect on height and bodyweight. Triamcinolone acetonide at standard dosages (110 or 220microg once or twice a day) does not appear to suppress adrenal gland function and is effective in relieving most symptoms of allergic rhinitis. The International Consensus Conference Proceedings on Rhinitis now currently recommends the use of intranasal corticosteroids as first line therapy, since they have been found to be well tolerated and effective with minimal adverse effects and, specifically, no cognitive impairment. The recommended maximum dose of aqueous triamcinolone acetonide in adults and children is 220microg once a day. The aerosol form may be recommended in children between 7 and 12 years old, up to 440microg once a day or in divided doses. Duration of allergy treatment is generally for the length of each allergy season. If symptoms are perennial, then a reduction of dosage is made to the lowest effective dose with monitoring every 3 months for risk and benefit assessment. Complications to watch for include bleeding, and possible septal perforation and nasal candidiasis, although these are rare.
Tuberculosis caused by Mycobacterium africanum associated with involvement of the upper and lower respiratory tract, skin, and mucosa.
Baril L,Caumes E,Truffot-Pernot C,Bricaire F,Grosset J,Gentilini M
Clinical infectious diseases : an official publication of the Infectious Diseases Society of America
Cutaneous tuberculosis is rarely seen in industrialized countries and is usually caused by Mycobacterium tuberculosis. We report a case of cutaneous tuberculosis with bilateral nodular scleritis, nasal sinus invasion, and nasal septum perforation (confirmed by computed tomography scans of the sinuses), associated with pulmonary infiltrates and mediastinal adenopathy, in an African woman. Mycobacterium africanum was recovered from the sputum after 8 weeks of culture in Löwenstein-Jensen medium. To our knowledge, this is the first description of M. africanum associated with cutaneous tuberculosis and nasal sinus invasion.
Nasal myiasis in leprosy leading to unusual tissue destruction.
Thami G P,Baruah M C,Sharmce S C,Behera N K
The Journal of dermatology
Nasal mucosal involvement is a constant feature in lepromatous leprosy (1). Granulomatous infiltration of nasal mucosa and consequent sensory loss may result in atrophic rhinitis and or painless ulceration, which is usually asymptomatic except for later complications of epistaxis, septal perforation, inflammation, and/or myiasis in long neglected patients. An unusual destruction of nasal architecture mimicking cancrum oris caused by myiasis in lepromatous leprosy is described for its rarity.
Extended transsphenoidal approach for pituitary adenomas invading the anterior cranial base, cavernous sinus, and clivus: a single-center experience with 126 consecutive cases.
Zhao Bing,Wei Yu-Kui,Li Gui-Lin,Li Yong-Ning,Yao Yong,Kang Jun,Ma Wen-Bin,Yang Yi,Wang Ren-Zhi
Journal of neurosurgery
OBJECT:The standard transsphenoidal approach has been successfully used to resect most pituitary adenomas. However, as a result of the limited exposure provided by this procedure, complete surgical removal of pituitary adenomas with parasellar or retrosellar extension remains problematic. By additional bone removal of the cranial base, the extended transsphenoidal approach provides better exposure to the parasellar and clival region compared with the standard approach. The authors describe their surgical experience with the extended transsphenoidal approach to remove pituitary adenomas invading the anterior cranial base, cavernous sinus (CS), and clivus. METHODS:Retrospective analysis was performed in 126 patients with pituitary adenomas that were surgically treated via the extended transsphenoidal approach between September 1999 and March 2008. There were 55 male and 71 female patients with a mean age of 43.4 years (range 12-75 years). There were 82 cases of macroadenoma and 44 cases of giant adenoma. RESULTS:Gross-total resection was achieved in 78 patients (61.9%), subtotal resection in 43 (34.1%), and partial resection in 5 (4%). Postoperative complications included transient cerebrospinal rhinorrhea (7 cases), incomplete cranial nerve palsy (5), panhypopituitarism (5), internal carotid artery injury (2), monocular blindness (2), permanent diabetes insipidus (1), and perforation of the nasal septum (2). No intraoperative or postoperative death was observed. CONCLUSIONS:The extended transsphenoidal approach provides excellent exposure to pituitary adenomas invading the anterior cranial base, CS, and clivus. This approach enhances the degree of tumor resection and keeps postoperative complications relatively low. However, radical resection of tumors that are firm, highly invasive to the CS, or invading multidirectionally remains a big challenge. This procedure not only allows better visualization of the tumor and the neurovascular structures but also provides significant working space under the microscope, which facilitates intraoperative manipulation. Preoperative imaging studies and new techniques such as the neuronavigation system and the endoscope improve the efficacy and safety of tumor resection.
Catastrophic manifestation of the antiphospholipid syndrome.
Schaar C G,Ronday K H,Boets E P,van der Lubbe P A,Breedveld F C
The Journal of rheumatology
We describe a young woman who displayed the "malignant" variant of the antiphospholipid syndrome (APS), also known as the "catastrophic APS." Renal insufficiency, retinopathy, cerebral infarcts, bone marrow necrosis, skin ulcers, and nasal septum perforation were the result of widespread thrombotic microangiopathy. She recovered during high intensity anticoagulation.
Acute upper gastrointestinal haemorrhage and colitis: an unusual presentation of Wegener's granulomatosis.
Steele C,Bohra S,Broe P,Murray F E
European journal of gastroenterology & hepatology
Wegener's granulomatosis is a rare necrotizing vasculitis usually affecting the respiratory tract and kidneys. The aetiology is unknown and it usually occurs in patients over the age of 40. Involvement of the gastrointestinal tract in Wegener's granulomatosis is relatively rare and usually occurs long after the onset of initial symptoms. Acute colitis as a presenting feature of Wegener's granulomatosis is very rare with only a few reports in the literature. We describe a young woman who presented initially to hospital with gastrointestinal features and then developed a severe colitis and severe gastrointestinal haemorrhage. This preceded the development of respiratory tract features with severe pulmonary haemorrhage, haemoptysis and the development of rapidly progressive renal failure and nasal septal perforation. Following treatment with intravenous steroids and cyclophosphamide, gastrointestinal symptoms and signs improved dramatically, as did her pulmonary disease. She still remains dialysis dependent, due to end-stage renal disease secondary to glomerulonephritis.
Cutaneous and paranasal aspergillosis in an immunocompetent patient.
Khatri M L,Stefanato C M,Benghazeil M,Shafi M,Kubba A,Bhawan J
International journal of dermatology
A 26-year-old Libyan woman presented with asymptomatic nodulo-ulcerative skin lesions present for 1 year. Three years prior to presentation, she had experienced a nasal discharge followed by the development of a nodule in the nasal cavity and a plaque on the hard palate. These lesions had gradually increased in size and ulcerated, resulting in perforation of the nasal septum and palate. Two years later, the patient noticed the appearance of skin lesions: a nodule on the right thumb and numerous nodulo-ulcerative lesions on the extremities. General physical examination was normal with no significant lymphadenopathy. Examination of the oral cavity revealed perforation of the distal nasal septum, with a perforated nodular plaque involving the entire palate, associated with subluxation of the upper incisors (Fig. 1a). On skin examination, multiple firm nodules and nodulo-ulcerative lesions with a central eschar and raised margins were observed. The lesions ranged in size from 0.5 to 5 cm and were distributed on the right hand and fingers, left upper arm (Fig. 1b), left calf, and right thigh. Routine laboratory investigations (liver function tests, serum calcium, electrolytes, lipid profile, urine and stool culture studies) were normal. Immunoelectrophoresis disclosed normal levels of immunoglobulins IgG, IgA, and IgM. Serologic studies for human immunodeficiency virus (HIV) and syphilis, and a tuberculin test, were all negative. A Giemsa-stained tissue smear was negative for Leishmania tropica organisms. Radiological studies disclosed a slight haziness of the maxillary sinuses with perforation of the nasal septum. A chest X-ray was normal. Histopathologic examination of biopsies taken from both the palate and from ulcerated and nonulcerated skin lesions was performed, and all showed similar findings. The biopsy of a nonulcerated skin lesion showed pseudoepitheliomatous epidermal hyperplasia with neutrophilic microabscesses (Fig. 2a). A dermal diffuse and nodular granulomatous mixed infiltrate of lymphocytes, histiocytes, giant cells, numerous eosinophils, and neutrophilic microabscesses was seen in all tissues examined. Septate hyphae were present both within giant cells and free in the dermis (Fig. 2b). The hyphae were branching at a 45 degrees angle and were positive on periodic acid-Schiff and Grocott methenamine silver stains (Fig. 2c). Fungal culture studies of material taken from an ulcerated skin lesion grew Aspergillus flavus. Blood cultures were negative for Aspergillus sp. or other microorganisms. The patient was treated with intravenous amphotericin B, but the medication was discontinued due to her intolerance to the drug. She was subsequently lost to follow-up.
Nasal cocaine abuse presenting as a central facial destructive granuloma.
Sittel C,Eckel H E
European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery
We describe a 36-year-old patient with an aggressive, midline intranasal and naso- and oropharyngeal destructive process. For months the patient denied heavy abuse of nasal cocaine, but finally admitted it. Necrosis and atrophy of the inferior and middle nasal turbinates bilaterally, prominent naso and oropharyngeal ulcers, nasal septal as well as hard palate perforation were observed clinically. Repeated biopsies revealed focal areas of chronic inflammation and necrosis, but there was no evidence of vasculitis or granuloma formation. Since serum was slightly positive for antineutrophil cytoplasmic antibody, the initial diagnosis was Wegener's granulomatosis. In the United States there have been a few reports on a new cocaine-associated syndrome presenting as an aggressive, midline, intranasal and intrapharyngeal destructive process mimicking limited Wegener's granulomatosis and midline reticulosis. We report the first such case in Europe and offer guidelines for the diagnostic work-up of such cases.
Mucocutaneous leishmaniasis masquerading as Wegener granulomatosis.
Brahn Ernest,Pegues David A,Yao Qingping,Craft Noah
Journal of clinical rheumatology : practical reports on rheumatic & musculoskeletal diseases
A 43-year-old Brazilian female presented in 2001 with nasal stuffiness and sinusitis. A biopsy was consistent with limited Wegener's granulomatosis although antineutrophil cytoplasmic antibodies were negative. Her nasal inflammation progressed despite trials of prednisone, methotrexate, and azathioprine. A septal perforation developed and a repeat biopsy showed granulomatous inflammation. In 2006 the patient was referred to Division of Rheumatology, University of California, Los Angeles. The nose was grossly erythematous and a magnetic resonance imaging revealed nasal destruction and sinusitis. Palatine biopsies showed chronic inflammation. Cyclophosphamide at 150 mg/d resulted in markedly improved mucocutaneous lesions. The patient developed a leg and arm rash in 2007. A skin biopsy was positive for Leishmania braziliensis. The cyclophosphamide was discontinued and amphotericin B was initiated with transient benefit. Remission was achieved with pentavalent antimony. Despite multiple nasopharyngeal biopsies, for a 6-year span, mucocutaneous leishmaniasis masqueraded as Wegener's granulomatosis. Cyclophosphamide not only resulted in clinical improvement, due to reduced inflammatory response, but also allowed widespread cutaneous dissemination.
Safety and tolerability profiles of intranasal antihistamines and intranasal corticosteroids in the treatment of allergic rhinitis.
Salib Rami Jean,Howarth Peter Hugo
Intranasal corticosteroids and intranasal antihistamines are efficacious topical therapies in the treatment of allergic rhinitis. This review addresses their relative roles in the management of this disease, focusing on their safety and tolerability profiles. The intranasal route of administration delivers drug directly to the target organ, thereby minimising the potential for the systemic adverse effects that may be evident with oral therapy. Furthermore, the topical route of delivery enables the use of lower doses of medication. Such therapies, predominantly available as aqueous formulations following the ban of chlorofluorocarbon propellants, have minimal local adverse effects. Intranasal application of therapy can induce sneezing in the hyper-reactive nose, and transient local irritation has been described with certain formulations. Intranasal administration of corticosteroids is associated with minor nose bleeding in a small proportion of recipients. This effect has been attributed to the vasoconstrictor activity of the corticosteroid molecules, and is considered to account for the very rare occurrence of nasal septal perforation. Nasal biopsy studies do not show any detrimental structural effects within the nasal mucosa with long-term administration of intranasal corticosteroids. Much attention has focused on the systemic safety of intranasal application. When administered at standard recommended therapeutic dosage, the intranasal antihistamines do not cause significant sedation or impairment of psychomotor function, effects that would be evident when these agents are administered orally at a therapeutically relevant dosage. The systemic bioavailability of intranasal corticosteroids varies from <1% to up to 40-50% and influences the risk of systemic adverse effects. Because the dose delivered topically is small, this is not a major consideration, and extensive studies have not identified significant effects on the hypothalamic-pituitary-adrenal axis with continued treatment. A small effect on growth has been reported in one study in children receiving a standard dosage over 1 year, however. This has not been found in prospective studies with the intranasal corticosteroids that have low systemic bioavailability and therefore the judicious choice of intranasal formulation, particularly if there is concurrent corticosteroid inhalation for asthma, is prudent. There is no evidence that such considerations are relevant to shorter-term use, such as in intermittent or seasonal disease. Intranasal therapy, which represents a major mode of drug delivery in allergic rhinitis, thus has a very favourable benefit/risk ratio and is the preferred route of administration for corticosteroids in the treatment of this disease, as well as an important option for antihistaminic therapy, particularly if rapid symptom relief is required.
A boy with consecutive development of SLE and Wegener granulomatosis.
Erdoğan Ozlem,Oner Ayşe,Demircin Gülay,Bülbül Mehmet,Memiş Leyla,Uner Ciğdem,Kiper Nural
Pediatric nephrology (Berlin, Germany)
An 11-year-old boy with consecutive development of systemic lupus erythematosus (SLE) and Wegener granulomatosis (WG) is presented. He was first admitted to the hospital with the findings of SLE, including crescentic glomerulonephritis, Coombs' test-positive hemolytic anemia, hypocomplementemia, antinuclear antibody (ANA) positivity, and elevated levels of anti-double-stranded (ds) DNA antibodies. He was treated successfully with steroids, cyclophosphamide, and peritoneal dialysis. One month after his discharge he developed an apparent viral infection. Three weeks afterwards he was readmitted with the findings of lower respiratory tract involvement, maxillary sinusitis, nasal septum perforation, p- and c-antineutrophil cytoplasmic antibody (ANCA) positivity, but normal complement, ANA, and anti-ds DNA levels, suggesting the diagnosis of WG. He did not respond to anti-infectious and immunosuppressive treatment, and he died of Pseudomonas sepsis.
Nasal cocaine abuse causing an aggressive midline intranasal and pharyngeal destructive process mimicking midline reticulosis and limited Wegener's granulomatosis.
Daggett R B,Haghighi P,Terkeltaub R A
The Journal of rheumatology
We describe a 36-year-old white man with an aggressive, midline intranasal and naso and oropharyngeal destructive process temporally associated with heavy (3 g/week) abuse of nasal cocaine. Necrosis and atrophy of the inferior and middle nasal turbinates bilaterally, prominent naso and oropharyngeal ulcers, and nasal septal perforation were observed clinically. Biopsies of a necrotic posterior oropharyngeal ulcer revealed focal areas of chronic inflammation and necrosis, but there was no evidence of vasculitis or granuloma formation. Serum was negative for antineutrophil cytoplasmic antibody. The oropharyngeal ulcer improved with abstinence from cocaine. Nasal septal perforation is a well recognized complication of nasal cocaine insufflation. Our case illustrates that a more aggressive midline intranasal and intrapharyngeal destructive process mimicking limited Wegener's granulomatosis and midline reticulosis can be associated with nasal cocaine abuse.
Chronic invasive fungal sinusitis associated with intranasal drug use.
Pekala Kelly R,Clavenna Matthew J,Shockley Ross,Weiss Vivian L,Turner Justin H
Chronic invasive fungal sinusitis (CIFS) is a rare but potentially aggressive form of invasive fungal disease that occurs in immunocompetent patients. We report a case of CIFS in an otherwise healthy young adult associated with intranasal illicit drug abuse. The patient presented with nonhealing nasal septal and palatal perforations. Biopsy demonstrated invasive Aspergillus flavus requiring surgical debridement and extended intravenous antifungal therapy. Tissue necrosis and ulceration related to intranasal drug use should be recognized as a potential risk factor for invasive fungal sinusitis.
Clinical associations of renal involvement in ANCA-associated vasculitis.
Kronbichler Andreas,Shin Jae Il,Lee Keum Hwa,Nakagomi Daiki,Quintana Luis F,Busch Martin,Craven Anthea,Luqmani Raashid A,Merkel Peter A,Mayer Gert,Jayne David R W,Watts Richard A
OBJECTIVE:Renal involvement in anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitis is associated with significant morbidity and higher mortality rates. This study examined clinical manifestations associated with renal involvement in ANCA-associated vasculitis within a large, international cross-sectional cohort. METHODS:Univariate and multivariate analyses were performed to identify clinical factors associated with renal disease, which was defined as i) a serum-creatinine >30% above normal and a fall in creatinine-clearance >25%; or ii) haematuria attributable to active vasculitis. RESULTS:The study cohort include 1230 patients from 31 countries; 723 (58.8%) presented with renal involvement: microscopic polyangiitis (82.2%), granulomatosis with polyangiitis (58.6%), and eosinophilic granulomatosis with polyangiitis (26.4%). The following clinical and laboratory factors were more common among patients with renal disease: age (OR 1.01, 95% CI 1.01-1.02), fever (OR 1.97, 95% CI 1.35-2.88), fatigue (OR 1.55, 95% CI 1.14-2.10), weight loss (OR 1.62, 95% CI 1.23-2.12), polyarthritis (OR 1.39, 95% CI 1.02-1.89), petechiae/purpura (OR 1.47, 95% CI 1.06-2.05), pulmonary haemorrhage (OR 5.23, 95% CI 1.39-19.63), gastrointestinal symptoms (OR 2.19, 95% CI 1.34-3.58), seizures (OR 3.42, 95% CI 1.26-9.30), lower serum albumin (OR 2.42, 95% CI 1.64-3.57), higher CRP (OR 2.06, 95% CI 1.04-4.06), low serum C3 at baseline (OR 3.86, 95% CI 1.30-11.53), myeloperoxidase- (OR 7.97, 95% CI 2.74-23.20) and proteinase 3-ANCA (OR 3.40, 95% CI 1.22-9.50). The following clinical factors were less common among patients with renal disease: mononeuritis multiplex (OR 0.63, 95% CI 0.41-0.98), proptosis/exophthalmos (OR 0.19, 95% CI 0.06-0.59), nasal polyps (OR 0.32, 95% CI 0.19-0.55), septal defect/perforation (OR 0.29, 95% CI 0.14-0.60), respiratory distress/pulmonary fibrosis/asthma (OR 0.08, 95% CI 0.04-0.19), and wheeze/obstructive airway disease (OR 0.29, 95% CI 0.16-0.52). CONCLUSION:In this large international study, several clinical and laboratory factors were identified as associated with renal involvement in ANCA-associated vasculitis.
Osteolytic sinusitis and pneumomediastinum: deceptive otolaryngologic complications of cocaine abuse.
Schweitzer V G
Recreational cocaine abuse via intranasal "snorting," "free-base" smoking, "body-packing," or intravenous injection can be lethal. Increasing illicit use of cocaine hydrochloride and the misuse of legal over-the-counter (OTC) nasal drugs are known causative agents of nasal septal perforation with loss of taste and smell. Although 2 to 3 mg/kg is the recommended maximum dose for topical anesthesia, cocaine snorters may use 1,000 mg or more daily on a "run." Furthermore, the newer route of smoking the extracted volatile "free-base" form of the adulterated street drug provides a plasma concentration producing the same physiological and subjective effects of intravenous cocaine. Presented are two cases exemplifying unusual complications of cocaine abuse: 1. total nasal septal bony and cartilaginous necrosis with resultant saddle-nose deformity and osteolytic sinusitis secondary to chronic intranasal "snorting" and 2. tracheobronchial rupture with pneumomediastinum secondary to smoking "free-base" cocaine.
Overexpression of tumor vascular endothelial growth factor A may portend an increased likelihood of progression in a phase II trial of bevacizumab and erlotinib in resistant ovarian cancer.
Chambers Setsuko K,Clouser Mary C,Baker Amanda F,Roe Denise J,Cui Haiyan,Brewer Molly A,Hatch Kenneth D,Gordon Michael S,Janicek Mike F,Isaacs Jeffrey D,Gordon Alan N,Nagle Raymond B,Wright Heather M,Cohen Janice L,Alberts David S
Clinical cancer research : an official journal of the American Association for Cancer Research
PURPOSE:This phase II trial evaluated bevacizumab plus erlotinib in platinum-resistant ovarian cancer; exploratory biomarker analyses, including that of tumor vascular endothelial growth factor A (VEGF-A), were also done. EXPERIMENTAL DESIGN:Forty heavily pretreated patients received erlotinib (150 mg/d orally) and bevacizumab (10 mg/kg i.v.) every 2 weeks until disease progression. Primary end points were objective response rate and response duration; secondary end points included progression-free survival (PFS), toxicity, and correlations between angiogenic protein levels, toxicity, and efficacy. RESULTS:Grade 3 toxicities included skin rash (n = 6), diarrhea (n = 5), fatigue (n = 4), and hypertension (n = 3). Grade 4 toxicities were myocardial infarction (n = 1) and nasal septal perforation (n = 1). Only one grade 3 fistula and one grade 2 bowel perforation were observed. Nine (23.1%) of 39 evaluable patients had a response (median duration, 36.1+ weeks; one complete response), and 10 (25.6%) patients achieved stable disease, for a disease control rate of 49%. Median PFS was 4 months, and 6-month PFS was 30.8%. Biomarker analyses identified an association between tumor cell VEGF-A expression and progression (P = 0.03); for every 100-unit increase in the VEGF-A score, there was a 3.7-fold increase in the odds of progression (95% confidence interval, 1.1-16.6). CONCLUSIONS:Bevacizumab plus erlotinib in heavily pretreated ovarian cancer patients was clinically active and well tolerated. Erlotinib did not seem to contribute to efficacy. Our study raises the intriguing possibility that high levels of tumor cell VEGF-A, capable of both autocrine and paracrine interactions, are associated with resistance to bevacizumab, emphasizing the complexity of the tumor microenvironment.
Nasal surgery complications.
Teichgraeber J F,Riley W B,Parks D H
Plastic and reconstructive surgery
This study examines the incidence of serious complications in nasal surgery and discusses the diagnosis and management of these complications. The authors review 259 consecutive cases performed between January 1, 1983, and August 31, 1988. One-hundred and ninety-five patients had septorhinoplasties, 29 had septoplasties, and 35 had rhinoplasties. Thirteen of these cases involved serious complications as follows: hemorrhage (5), perforation (4), infections (3), and pneumocephalus (1). All the patients with these serious complications had associated septal and/or turbinate surgery. The diagnosis and management of these complications will be discussed. In this small series of nasal surgery patients, the incidence of serious complications was 5.0 percent, with no fatalities reported. The higher incidence of serious complications occurred when associated septal and/or turbinate surgery was required. Awareness of these complications is essential because of the increasing number of patients presenting to plastic surgeons for nasal surgery in whom associated septal and/or turbinate surgery is necessary.
Banks Taylor A,Gada Satyen M
Allergy and asthma proceedings
A case of atrophic rhinitis complicated by nasal septum perforation is presented, followed by a discussion of the clinical characteristics, pathophysiology, diagnosis, and management of this disease process. Clinical pearls and pitfalls are emphasized for the use of the practicing allergist and fellow in-training. The diagnosis of atrophic rhinitis is guided by a careful clinical history and evaluation to exclude other possible etiologies for the patient's symptoms and physical findings. Because atrophic rhinitis is a poorly understood process, it is surrounded by considerable contention in the literature and its management is not well defined. Atrophic rhinitis often carries significant morbidity and is best addressed by a multidisciplinary approach.
Nasal extranodal NK/T-cell lymphoma presenting as a perforating palatal ulcer: a diagnostic challenge.
Patel Vidula,Mahajan Sunanda,Kharkar Vidya,Khopkar Uday
Indian journal of dermatology, venereology and leprology
A 40-year-old man presented with chronic nasal stuffiness and bloodstained discharge of 3 years' duration, along with a non-healing palatal ulcer since 2 months. Examination revealed a perforation in the midline on the hard palate and a superficial ulcer on the soft palate. Histopathology and immunohistochemistry suggested a diagnosis of extranodal nasal/nasal-type T-cell lymphoma. The patient was started on multiagent chemotherapy in the form of cyclophosphamide, doxorubicin, vincristine and prednisolone but succumbed after two cycles. Only one case of nasal T cell lymphoma presenting as nasal septal perforation, oronasal fistula and a concomitant palatal ulcer has been described. We report this case of a perforating palatal ulcer as a rare presentation of nasal lymphoma.
Cocaine-induced midline destructive lesions - an autoimmune disease?
Trimarchi M,Bussi M,Sinico R A,Meroni Pierluigi,Specks U
In Europe it is estimated that around 13million of adults (15-64years) have used cocaine at least once in their lifetime. The most frequently used route of administration for the drug is intranasal inhalation, or "snorting", and thus the adverse effects of cocaine on the nasal tract are very common. Habitual nasal insufflations of cocaine may cause mucosal lesions, and if cocaine use becomes chronic and compulsive, progressive damage of the mucosa and perichondrium leads to ischemic necrosis of septal cartilage and perforation of the nasal septum. Occasionally, cocaine-induced lesions cause extensive destruction of the osteocartilaginous structures of nose, sinuses and palate that can mimic other diseases such as tumors, infections, and immunological diseases. Thorough diagnostic workup, including endoscopic, radiologic, histopathologic and serologic testing is imperative to arrive at the proper diagnosis and to initiate appropriate local and systemic treatment. Positive antineutrophil cytoplasmic antibody (ANCA) test results may be found in an unexpectedly large proportion of patients with CIMDL. In several instances their lesions are clinically indistinguishable from granulomatosis with polyangiitis (Wegener's) limited to the upper respiratory tract. CIMDL seem to be the result of a necrotizing inflammatory tissue response triggered by cocaine abuse in a subset of patients predisposed to produce ANCA, particularly those reacting with HNE. The presence of these HNE-ANCA seems to promote or define the disease phenotype. CIMDL do not respond well to immunosuppressive therapy. Only the consistent removal of persistent stimuli of autoantibody production (cocaine, bacterial superinfections) can halt the disease process, prevent the progression of the lesions and promise success of surgical repair procedures.
Intranasal steroids and septum perforation--an overlooked complication? A description of the course of events and a discussion of the causes.
Cervin A,Andersson M
The use of intranasal steroids for the treatment of allergic and vasomotor rhinitis has doubled during the past 5 years. The number of reported cases of nasal septum perforation has increased correspondingly. The mechanism behind this is unknown, and steroid-induced septum perforation is rarely described in the literature. In order to describe the course of events and to form an idea of the extent of the problem, we have reviewed the cases reported at our clinic and compiled reports on side-effects from the Swedish Medical Products Agency. In our department we found 32 patients with septum perforation (21 women and 11 men). The most common risk factor for septum perforation was steroid treatment, 11 cases (10 women, 1 man, average age 33 years, range 19-49 years). The information obtained from the Swedish Medical Products Agency showed that 38 cases of steroid induced septum perforation had been reported during the past 10 years. The number of side-effects per million Defined Daily Dose (DDD) was averaged to 0.21. The risk of perforation is greatest during the first 12 months of treatment and the majority of cases involves young women. We conclude that septum perforation due to nasal sprays are underreported in Sweden and that perforations are most likely to appear in young females during their first months of medication.
Trans-septal suturing technique in septoplasty: a systematic review and meta-analysis.
Certal V,Silva H,Santos T,Correia A,Carvalho C
STATEMENT OF THE PROBLEM:Trans-septal suturing techniques are routinely used to obviate the need for packing after septoplasty surgery. This study aimed to systematically assess the evidence for the efficacy and safety of suturing techniques after septoplasty. METHODS:A MEDLINE, Scopus, Cochrane Library, and ProQuest Dissertations & Thesis Database search, followed by extensive hand-searching for the identification of relevant studies. No time and language limitations were applied. Only prospective randomized controlled trials (RCTs) comparing trans-septal suturing techniques following septoplasty with conventional packing were included. For each outcome, risk difference and 95% confidence intervals (CIs) were calculated. Tests for heterogeneity and tests for publication bias were applied. RESULTS:Eight RCTs with 869 patients were included in the review. Postoperative pain and headache were significantly lower in the non-packing group. Conventional packing and trans-septal suturing technique appear to be equivalent with regard to postoperative haemorrhage risk, mucosal adhesions, septal perforation, septal haematoma and local infection. CONCLUSIONS:The evidence for the advantage of suturing techniques over conventional packing in septoplasty is now robust, and the use of suturing techniques as a first line intervention is becoming advisable.
Otolaryngology Concerns for Illicit and Prescription Drug Use.
Gonik Nathan J,Bluth Martin H
Clinics in laboratory medicine
Concern for illicit and restricted drug use in otolaryngology is similar to other surgical specialties with a few notable exceptions. Many illicit drugs are consumed transnasally. Repeated nasal exposure to stimulants or narcotics can cause local tissue destruction that can present as chronic rhinosinusitis or nasoseptal perforation. Further, the Food and Drug Administration has taken a stance against codeine for pediatric patients undergoing adenotonsillectomy. They have identified an increased risk of death postoperatively with these medications. Because codeine has been the most commonly prescribed narcotic, this has shifted the standard practice.
An unusual cause of nasal septum perforation.
Umaria N,Chavda S V,Pahor A L
The Journal of laryngology and otology
We present a case where the use of magnetically held earring clips in the nose led to an unfortunate series of events resulting in perforation of the nasal septum.
Cocaine induced midline destructive lesions.
Trimarchi M,Bertazzoni G,Bussi M
PURPOSE:Review of the literature concerning cocaine induced midline destructive lesions (CIMDL). METHODS:We reviewed the English literature regarding CIMDL involving the nose and its surrounding structures. The review is based on a search of the US National Library of Medicine (PubMed) online database from January 1st, 1982 to March 31st, 2013. RESULTS:CIMDL is a pathology that mimics systemic diseases with positive anti-neutrophil cytoplasmic antibodies (ANCA). The prevalence of CIMDL is considered to be about 4.8% among cocaine users. Clinical manifestations include hyposmia, facial pain, crusting, ulcers, nasal septal perforation, palatal perforation, sinus wall destruction, orbital erosion and damage of the anterior skull base. The presence of ANCA directed against human neutrophil elastase (HNE) is the most distinguishing feature of CIMDL. Toxicological tests, indirect immunofluorescence microscopy, antigen specific solid assay testing, histopathological analysis, apoptosis assay and MRI imaging concur in the clinical identification of CIMDL. The pathogenesis of CIMDL is poorly understood and implicates inflammatory, infective, proapoptotic and autoimmune mechanisms. CONCLUSION:CIMDL must be readily recognized by clinicians to provide appropriate treatment. Immunosuppressive therapy has no role in the treatment of CIMDL. Only abstinence can interrupt the progression of the disease.
Progressive Perforation of the Nasal Septum Due to : A Case of Mucosal Leishmaniasis in a Traveler.
Harrison Nicole,Walochnik Julia,Ramsebner Reinhard,Veletzky Luzia,Lagler Heimo,Ramharter Michael
The American journal of tropical medicine and hygiene
This report describes a case of mucosal leishmaniasis caused by with destructive perforation of the nasal septum illustrating the diagnostic challenges of a rare clinical presentation of infection in a traveler. The atypical presentation may have been associated with the use of cortisone as a potential trigger for the progressive destruction of the nasal septum.
Fulminant Wegener's granulomatosis: a case report.
Dinić Miroslav Z,Sekulović Lidija Kandolf,Zolotarevski Lidija,Zecević Rados D
INTRODUCTION:Granulomatosis Wegener is anti-neutrophil cytoplasmic antibodies (ANCAs)-associated systemic vasculitis of unknown etiology. It is manifested as granulomatous necrotizing inflammation of the upper and lower parts of the respiratory tract, glomerulonephritis and systemic vasculitis involving most frequently the skin and oral mucous membrane. Sera markers of this disease are c-ANCA and pANCA. CASE REPORT:We presented a female patient aged 52 years with purpuric spots that had appeared on the lower legs ten months before admission to our hospital. The disease ran an aggressive course, and a month before admission hemorrhagic bullae, skin ulcers, hoarseness, dyspnea, generalized arthralgia, fatigue and fever had rapidly developed. Histopathological examination of a skin sample revealed necrotizing vasculitis, so that sera markers concentrations were elevated (c-ANCA, p-ANCA). There was a perforation of the nasal septum found on rhinoscopy. During hospitalization acute abdominal pain occurred, a possible tumor in the small intestine and possible granulomas in the liver were seen by multislice computed tomography (MSCT) examination, with normal findings on the lungs and kidneys. The treatment started with methylprednisolone: 500 mg/d i.v. infusion for consecutive 3 days, then 60 mg/d. On exploratory laparotomy small bowel perforation and diffuse peritonitis were found. Unstable in the postoperative period, the patient died on the day 12 of hospitalization. CONCLUSION:The reported patient was with fulminant Wegener's granulomatosis, dominantly with skin changes and with gastrointestinal manifestation. This case accents the need for rapid systemic clinical evaluation in a severely ill patient with unclear diagnosis.
A randomised prospective trial of trans-septal suturing using a novel device versus nasal packing for septoplasty.
Korkut Arzu Y,Teker Aysenur Meric,Eren Sabri B,Gedikli Orhan,Askiner Omer
BACKGROUND:Nasal packing or trans-septal sutures are used to prevent postoperative complications in septoplasty. Trans-septal suturing is not commonly used, since it takes time and is technically difficult with the available devices following septoplasty. METHODS:This study included 64 patients who underwent septoplasty. Following septoplasty, the patients were divided into two groups: group 1 had trans-septal sutures placed using a novel device and group 2 had the nose packed with a tampon. The duration of surgery, postoperative symptoms and complications were compared. RESULTS:All of the postoperative symptoms were significantly less in the group with trans-septal sutures. The mean duration of surgery was 34.9 minutes in the nasal packing group and 37.8 minutes in the trans-septal suture group, and the difference was significant (p = 0.026). No postoperative bleeding, submucoperichondrial haematomas, infections or abscesses occurred in any of the patients, whilst nasal perforation was observed in one patient in each group. Two (5.4%) patients in group 1 and one (3.7%) patient in group 2 had postoperative adhesions. CONCLUSIONS:We have developed a simple, inexpensive device for performing trans-septal suturing that is easy to use in the nasal cavity. We conclude that the use of continuous septal suturing with our device is an easy modification of the standard procedure, with only a small increase in operating time.
Acquired immune deficiency syndrome (AIDS) presenting as a nasal septal perforation.
Rejali S D,Simo R,Saeed A M,de Carpentier J
Patients infected with the Human Immunodeficiency Virus (HIV) and those with AIDS may present with many head and neck manifestations. We report a case of an undiagnosed HIV positive male who presented with symptoms due to a nasal septal perforation, and rapidly developed AIDS. The histopathology of the perforation margins revealed active chronic inflammation with no evidence of neoplasia or granuloma. No viral or fungal infection was demonstrable on immunological testing and fungal stain. This is the first reported case of a patient developing AIDS presenting with a nasal septal perforation.
Two cases of pyoderma gangrenosum complicated with nasal septal perforation.
Matsumura T,Sato-Matsumura K C,Ota M,Yokota T,Arita K,Kodama K,Inokuma D,Kobayashi H
The British journal of dermatology
We report two patients with pyoderma gangrenosum complicated with nasal septal perforation. An 18-year-old woman and a 65-year-old man had typical lesions of pyoderma gangrenosum on the legs that responded well to oral prednisolone. Both patients complained of mild nasal discharge, and nasal fibroscopy revealed nasal septal perforation. Biopsy of the nasal lesions showed an active inflammatory infiltrate, mainly of neutrophils. Systemic investigations failed to show any pulmonary or renal lesions of Wegener's granulomatosis. Cytoplasmic immunofluorescent pattern antineutrophil cytoplasmic antibody was negative. In both cases, intense neutrophilic infiltration was observed not only in skin lesions but also in nasal lesions, which may indicate that the nasal lesions had a pathogenesis in common with the skin lesions.
Primary nasal tuberculosis presenting with septal perforation.
Lai Ting-Yun,Liu Po-Jen,Chan Lai-Ping
Journal of the Formosan Medical Association = Taiwan yi zhi
Tuberculosis is a serious, worldwide health problem that affects people in many developing countries. The acquired immunodeficiency syndrome epidemic and the development of antibiotic-resistant strains of mycobacteria have contributed to the increasing international incidence of tuberculosis in recent years. Yet, extrapulmonary tuberculosis remains comparatively rare. We present the case of a 44-year-old laborer who complained of bilateral nasal obstruction and postnasal drip for many years. Endoscopic examination disclosed septal perforation with marginal crusting. A biopsy of the marginal tissue was performed and Ziehl-Neelsen staining revealed acid-fast bacilli. Subsequent to a 6-month course of antituberculous medication, the perforation remained, but the crusting subsided.
Is nonabsorbable nasal packing after septoplasty essential? A meta-analysis.
Kim Jong Seung,Kwon Sam Hyun
OBJECTIVES:Septoplasty is one of the most frequently performed rhinologic surgeries. Complications include nasal bleeding, pain, headache, septal hematoma, synechia, infection, residual septal deviation, and septal perforation. In this study, we aimed to compare complication rates among patients according to packing method. METHODS:We performed a literature search using PubMed, Embase, and the Cochrane Library through August 2016. Our systematic review followed Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Random effect models were used to calculate risk differences and risk ratio with 95% confidence intervals (CIs). Cases referred to the nonpacking group included patients treated with transseptal sutures or septal splints. Cases referred to as the packing group included patients treated with nonabsorbable packing such as Merocel or gauze. RESULTS:Our search included 20 randomized controlled trials (RCTs) with a total of 1,321 subjects in the nonpacking group and 1,247 subjects in the packing group. There were no significant differences between packing methods regarding bleeding, hematoma, perforation, infection, and residual septal deviation. The risk differences of postoperative pain, headache, and postoperative synechia were -0.50 [95% CI: -0.93 to -0.07, P = .02], -0.42 [95% CI: -0.66 to -0.19, P = .0004], and -0.03 [95% CI: -0.06 to -0.01, P = .01], respectively. CONCLUSIONS:Nonabsorbable nasal packing is no more effective than treatments without packing after septoplasty. Septal splints and transseptal sutures reduce postoperative pain, headache, and synechia. LEVEL OF EVIDENCE:1B Laryngoscope, 127:1026-1031, 2017.
Nasal septal ulceration.
Sardana Kabir,Goel Khushbu
Clinics in dermatology
Nasal septal ulceration can have multiple etiologies. Determining the exact cause depends on who the consulting specialist is, who could either be the ENT surgeon or the dermatologist. The common causes are infections (tuberculosis, leprosy, leishmaniasis), vasculitis (Wegener's granulomatosis and Churg-Strauss syndrome), and lupus erythematosus. Traumatic causes and malignancy can also be seen in tertiary referral centers. The diagnosis often requires thorough investigations and multiple tissue specimens from various sites, and in chronic cases, a suspicion of lymphoma should be considered. Apart from disease-specific therapy, a multidisciplinary approach is required in most cases to tackle the cosmetic disfigurement.
Nasal septum perforation and bevacizumab.
Power Derek G,Kemeny Nancy E
Medical oncology (Northwood, London, England)
The use of targeted/biologic therapies is now commonplace in the treatment of malignant and non-malignant diseases. The novel mode of action of these drugs has resulted in unpredictable and in some cases unexpected side effects. Given the widespread use of bevacizumab and its distinct mode of action, it is important that oncologists report any unexpected adverse events that may be associated with the drug. Herein, we report three cases of spontaneous nasal septum perforation secondary to bevacizumab. We hypothesize an etiology for this rare event and reasons why it is reasonable to rechallenge the patient.
Pyoderma gangrenosum associated with nasal septal perforation, oropharyngeal ulcers and IgA paraproteinemia.
Isomura Iwao,Miyawaki Saori,Morita Akimichi
The Journal of dermatology
We report a case of pyoderma gangrenosum (PG) associated with nasal septal perforation, pharyngeal ulcers and IgA paraproteinemia. A 28-year-old woman first developed painful undermined ulcers on her perianal, inguinal and axillary areas when she was 22 years old. Histological findings from the cutaneous ulcers showed dermal and epidermal infiltrate of neutrophils, which was compatible with PG. Laboratory examinations did not detect any associations of systemic diseases other than polyclonal IgA paraproteinemia. Nasal fiberscopy revealed septal perforation and multiple ulcers on her pharynx. The biopsy specimen from the pharyngeal ulcers showed a polymorphous cellular infiltrate without necrotizing vasculitis or granuloma. However, there were no atypical lymphocytes that are typically seen in nasal NK/T lymphoma. By immunohistochemical analysis, the infiltrated lymphocytes were proved to be T cells and Epstein-Barr virus encoded RNA (EBER) was not detected. No pulmonary or renal lesions resembling Wegener's granulomatosis were found. Taken together, the nasal septal perforation was considered as nasal involvement of PG.
An observational study of nasal cavity toxicity in cancer patients treated with bevacizumab.
D'Amico Mauro,Pagano Mauro,Pasa Ambra,Puntoni Matteo,Clavarezza Matteo,Gennari Alessandra,Gozza Alberto,Zanardi Silvia,Defferrari Carlotta,Provinciali Nicoletta,Campazzi Eleonora,Campora Sara,Paleari Laura,Marra Domenico,Petrera Marilena,DeCensi Andrea
Expert opinion on drug safety
BACKGROUND:The nasal cavity is a vulnerable zone which may be damaged by vascular disorders. We systematically assessed the frequency and severity of nasal cavity alterations during bevacizumab treatment, to determine its clinical relevance and factors contributing to its onset. PATIENTS AND METHODS:We conducted a hospital-based cohort study in 47 consecutive patients with advanced cancers who were on treatment with chemotherapy and bevacizumab at different doses. All patients underwent otolaryngology (ENT) examination at the time of study initiation. RESULTS:The mean number of cycles at first ENT examination was 16 (standard deviation = 14). A total of 45 patients (96%) showed nose mucosal lesions, of whom 30% had erosions and 62% had grade 1 - 2 epistaxis. One patient had septal perforation. Grades 1 - 4 sinus disorders were noted in 60%. There was a significant trend to a higher risk of grade ≥ 2 nasal events for bevacizumab doses > 7.5 mg/kg, concomitant taxane use and digital nasal self-manipulation. CONCLUSIONS:We found a high incidence of nasal cavity lesions in patients receiving bevacizumab, with evidence for a dose-related effect. Most cases were low grade and manageable without drug interruption, but severe toxicity may rarely occur. Oncologists should be aware of this unusual event.
Saddle nose deformity and septal perforation in granulomatosis with polyangiitis.
Coordes A,Loose S M,Hofmann V M,Hamilton G S,Riedel F,Menger D J,Albers A E
Clinical otolaryngology : official journal of ENT-UK ; official journal of Netherlands Society for Oto-Rhino-Laryngology & Cervico-Facial Surgery
BACKGROUND:Patients who have granulomatosis with polyangiitis (GPA, syn. M. Wegener) often develop an external nose deformity which may have devastating psychological effects. Therefore, reconstruction of nasal deformities by rhinoplasty may become necessary to achieve a normal appearance. OBJECTIVE OF REVIEW:The aim of this systematic review was to investigate the efficacy and safety of surgical reconstruction in external nasal deformities and septal perforation in GPA patients. SEARCH STRATEGY:A systematic literature search with defined search terms was performed for scientific articles archived in the MEDLINE-Database up to 10 June 2016 (PubMed Advanced MEDLINE Search), describing management of cases or case series in GPA patients with saddle nose deformity and/or septal perforation. RESULTS:Eleven of 614 publications met the criteria for this analysis including 41 GPA patients undergoing external nasal reconstruction and/or septal reconstruction with a median follow-up of 2.6 years. Overall, saddle nose reconstruction in GPA patients is safe even if an increased rate of revision surgery has to be expected compared with individuals without GPA undergoing septorhinoplasty. Most implanted grafts were autografts of calvarial bone or costal cartilage. For septal perforation reconstruction, few studies were available. Therefore, based on the available data for surgical outcomes, it is impossible to make evidence-based recommendations. All included GPA patients had minimal or no local disease at the time of reconstructive surgery. Therefore, the relationship between disease activity and its impact on surgical outcomes remains unanswered. The potential impact of immune-modulating medications on increased complication rates and the impact of prophylactic antibiotics are unknown. CONCLUSIONS:This study systematically reviews the efficacy and safety of surgical reconstruction of external nasal deformities in GPA patients for the first time. Saddle nose reconstruction in GPA patients with minimal or no local disease is a safe procedure despite an increased rate of revision surgery. Further research is required regarding the impact of antibiotic prophylaxis, immune-modulating therapy, long-term outcomes and functional outcomes measured with subjective and objective parameters.
Nasal septal perforation: a novel clinical manifestation of systemic juvenile idiopathic arthritis/adult onset Still's disease.
Avcin Tadej,Silverman Earl D,Forte Vito,Schneider Rayfel
The Journal of rheumatology
Nasal septal perforation has been well recognized in patients with various rheumatic diseases. To our knowledge, this condition has not been reported in children with systemic juvenile idiopathic arthritis (SJIA) or patients with adult onset Still's disease (AOSD). We describe 3 patients with persistent SJIA/AOSD who developed nasal septal perforation during the course of their disease. As illustrated by these cases, nasal septal perforation may develop as a rare complication of SJIA/AOSD and can be considered as part of the clinical spectrum of the disease. In one case the nasal septal perforation was associated with vasculitis.
Pathophysiology and progression of nasal septal perforation.
Lanier Bobby,Kai Guan,Marple Bradley,Wall G Michael
Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology
OBJECTIVE:To review the prevalence, causes, and treatments of nasal septal perforation (NSP). DATA SOURCES:A literature search was conducted in MEDLINE to identify peer-reviewed articles related to NSP using the keywords nasal septal perforation and septal perforation for articles published between January 1, 1969, and December 31, 2006, and references cited therein. STUDY SELECTION:Articles were selected based on their direct applicability to the subject matter. RESULTS:Causes of NSPs include piercings, exposure to industrial chemicals, illicit drug use, intranasal steroid use, surgical trauma, bilateral cautery, and possibly improper use of nasal applicators. Prevalence is poorly reported. Mechanisms of substance-induced NSP formation are not understood. Progression from epistaxis to ulceration to NSP could not be substantiated by the literature. CONCLUSION:Depending on the patient, NSP may be viewed as desirable (nose rings), problematic (whistling, congestion), or inconsequential. Understanding the pathogenesis of NSP is important for the practicing physician required to make decisions about whether to recommend surgical correction or medical treatment. Although the etiology of NSP is overwhelmingly iatrogenic, there is an association with a number of medical diseases in addition to use of illicit drugs and/or prescription nasal sprays.
Bevacizumab-induced nasal septal perforation: incidence of symptomatic, confirmed event(s) in colorectal cancer patients.
Ramiscal Judi Anne B,Jatoi Aminah
Acta oncologica (Stockholm, Sweden)
PURPOSE:In breast cancer patients, Mailliez and others described that 5 of 70 patients (7%) developed a bevacizumab-induced nasal septal perforation. However, to date, no studies have reported such rates in colorectal cancer patients, who derive a survival advantage with this drug. METHODS:This study examined the incidence of bevacizumab-induced, clinically symptomatic, otolaryngology specialist-confirmed nasal septal perforation among 100 patients who had been consecutively-treated for metastatic colorectal cancer. RESULTS:The incidence of nasal septal perforation was 1% (95% confidence intervals: -0.95% to 2.95%). This single adverse event was successfully managed conservatively. Within the whole group, 94 had been treated with bevacizumab at 5 mg/kg every two weeks, except for four patients treated at higher doses. The median number of bevacizumab doses (range) was seven (1-96). Concomitant chemotherapy had been prescribed to all patients, consisting of oxaliplatin, 5-fluorouracil, leucovorin, as per one of the FOLFOX regimens (44 patients); irinotecan, 5-fluorouracil, leucovorin, as per the FOLFIRI regimen (13 patients); both these regimens and no other (five patients); or a different regimen (38 patients). CONCLUSION:Nasal septal perforation from bevacizumab occurs infrequently among colorectal cancer patients.
Nasoseptal Perforation: from Etiology to Treatment.
Pereira Carla,Santamaría Alfonso,Langdon Cristobal,López-Chacón Mauricio,Hernández-Rodríguez José,Alobid Isam
Current allergy and asthma reports
PURPOSE OF REVIEW:Nasal septum perforation (NSP) is a communication between the two nasal cavities. This review contributes to the better knowledge of NSP causes, diagnosis, and treatment. RECENT FINDINGS:NSP prevalence is about 1%. Clinical presentation may range from absence of symptoms to the presence of bothersome sinonasal symptoms. NSP is more frequently caused by trauma or post-surgery, inflammatory diseases, and abuse substances. Conservative management (nasal irrigation, topical use of antibiotic or lubricant ointments, or placement of prosthesis) is considered the first-line treatment. Symptomatic NSP not improving with local therapies usually requires surgical approach. Selection of the technique for the endoscopic septal repair depends on perforation characteristics and surgeon experience. When NSP is diagnosed, its cause has to be promptly determined. Most of them can be controlled with conservative measures. Surgical/endoscopic approaches are usually needed in refractory cases, and new repair techniques have to be considered.
Total septal perforation repair with a pericranial flap: Radio-anatomical and clinical findings.
Alobid Isam,Langdon Cristóbal,López-Chacon Mauricio,Enseñat Joaquim,Carrau Ricardo,Bernal-Sprekelsen Manuel,Santamaría Alfonso
OBJECTIVES/HYPOTHESIS:Endonasal surgeries are the primary cause of septal perforation (SP). However, trauma, inflammation, infections, neoplasms, or abuse of inhaled drugs can also cause SP. Septal repair is indicated in patients who experience nasal obstruction, crusting, intermittent epistaxis, purulent discharge, or nasal whistling and in those who fail conservative treatment. Multiple approaches have been suggested to repair the SP; however, none has been universally adopted. This study explores the feasibility of repairing a total SP using the pericranial flap (PCF). STUDY DESIGN:Anatomical cadaver and radiological study plus case study. METHODS:Total nasal septectomy and endoscopic reconstruction with a PCF was performed in 12 injected cadaveric specimens. Maximum length and area of the nasal septum and the PCF were measured in 75 computed tomography scans. Based on the anatomical study and the radiological measurements of the cadavers, one patient underwent total nasal septum repair. RESULTS:Anatomic measurements showed that the nasal septum has a mean length of 5.8 ± 0.7 cm, whereas the PCF was on average 18.4 ± 1.3 cm long (mean surface area 121.6 ± 17.7 cm ). Radiological measurements revealed that the PCF should provide a surface area of 40.9 ± 4.2 cm to account for the total septal area and an additional 30% to account range for potential scar retraction. For total septum repair, the distal edge of the PCF had to be placed 0.8 ± 2.0 cm (3.4 ± 8.7°) from the adopted reference point (vertical projection of the external ear canal). Total septal reconstruction was performed successfully in one patient without complications. CONCLUSIONS:Radio-anatomical data and a case study demonstrate that a PCF allows complete endoscopic repair of the nasal septum. LEVEL OF EVIDENCE:NA. Laryngoscope, 128:1320-1327, 2018.
Nasal and sinus endoscopy for medical management of resistant rhinosinusitis, including postsurgical patients.
Tichenor Wellington S,Adinoff Allen,Smart Brian,Hamilos Daniel L
The Journal of allergy and clinical immunology
Nasal endoscopy has been practiced by allergists since the early 1980s; however, allergists in general have not embraced endoscopic evaluation of patients with sinus disease, either before or after surgery. Allergists are in a unique position to render medical (as opposed to surgical) care of patients with sinusitis. There has been a growing realization that endoscopy is a valuable procedure for the evaluation and medical treatment of patients with difficult sinusitis. This has resulted in the need for a resource to allow allergists to understand the nature of endoscopic findings in patients with sinusitis, either preoperatively or postoperatively. This article introduces the findings at endoscopy that are common in patients with sinusitis, including those that may be seen after surgery. The findings include perforation of the septum, retained secretions, small surgical ostium caused by postoperative ostial stenosis, previous Caldwell Luc procedure, recirculation of mucus, hyperplastic nasal disease, synechiae, recurrent disease in previously unaffected sinuses, empty nose syndrome, frontal sinus disease, dental disease, and other, more complicated entities.
Septoplasty with or without concurrent turbinate surgery versus non-surgical management for nasal obstruction in adults with a deviated septum: a pragmatic, randomised controlled trial.
van Egmond Machteld M H T,Rovers Maroeska M,Hannink Gerjon,Hendriks Carine T M,van Heerbeek Niels
Lancet (London, England)
BACKGROUND:Septoplasty (surgical correction of the deviated nasal septum) is the most frequently performed ear, nose, and throat operation in adults, but no randomised controlled trials or non-randomised comparative studies on the effectiveness of septoplasty have been published. Consequently, health-care providers, health insurance companies, and policy makers are concerned about the effectiveness of the procedure. We aimed to assess the effectiveness of septoplasty for nasal obstruction in adults with a deviated septum. METHODS:We did this open, multicentre, pragmatic, randomised controlled trial in 16 secondary and two tertiary referral hospitals in the Netherlands. Adults (aged ≥18 years) with nasal obstruction, a deviated septum, and an indication to have septoplasty done were randomly allocated (1:1) to receive either septoplasty with or without concurrent turbinate surgery or non-surgical management. Patients were stratified by sex, age (<35 years or ≥35 years), and deviation severity (mild, moderate, or severe). The primary outcome was health-related quality of life, measured with the validated Glasgow Health Status Inventory at 12 months. Analyses were done on an intention-to-treat basis. The trial is registered with the Netherlands Trial Register, number NTR3868. FINDINGS:Between Sept 2, 2013, and Dec 12, 2016, we randomly assigned 203 participants to receive either septoplasty with or without concurrent turbinate surgery (n=102) or non-surgical management (n=101). 189 participants were analysed at 12 months. At 12 months, mean score on the Glasgow Health Status Inventory of patients assigned to septoplasty was 72·2 (SD 12·2) and for those assigned to non-surgical management was 63·9 (SD 14·5, mean difference 8·3 [95% CI 4·5-12·1], favouring septoplasty). Septal abscess occurred in one surgical patient and septal perforation in two surgical patients. No side-effects of nasal medication were reported. INTERPRETATION:Septoplasty is more effective than non-surgical management for nasal obstruction in adults with a deviated septum. This effect was sustained up to 24 months of follow-up. FUNDING:The Netherlands Organisation for Health Research and Development (ZonMw).
Acellular Human Dermal Allograft as a Graft for Nasal Septal Perforation Reconstruction.
Conrad Dustin J,Zhang Han,Côté David W J
Plastic and reconstructive surgery
BACKGROUND:Nasal septal perforations pose a troubling source of morbidity for patients and a difficult problem for the otolaryngologist. Multiple surgical techniques have been tried, with inconsistent success. Prosthetic nasal buttons also have limitations, including patient intolerance and dissatisfaction. Acellular human dermal allograft (AlloDerm) has been described as an alternative material for septal perforation repair. The authors studied objective and subjective outcomes, including quantification of the patient's symptoms in septal perforation repair with AlloDerm. METHODS:The authors performed a prospective cohort study of 12 patients with 1- to 2-cm anterior septal perforations who were recruited from a tertiary care practice. Patients with admitted smoking or cocaine use in the previous 3 months or vascular or granulomatous diseases were excluded. Subjective scores on the Sino-nasal Outcome Test-22, along with objective nasal endoscopy and acoustic rhinometry measures, were collected at baseline and 2, 4, and 12 weeks postoperatively. Patients were followed for reperforation 9 to 20 months postoperatively. Data were normalized to baseline values and analyzed using analysis of variance and Bonferroni correction. RESULTS:Successful closure of the septal perforation was obtained in 10 of 12 patients and confirmed with rigid nasal endoscopy. Nasal symptom scores (Sino-nasal Outcome Test-22 ) were significantly reduced to 52.8 percent (95 percent CI, 35.1 to 70.5 percent; p < 0.01) of baseline symptoms at 4 weeks postoperatively. At 12 weeks postoperatively, symptoms were measured at 26.6 percent (95 percent CI, 10.9 to 42.1 percent; p < 0.01) of baseline symptoms. Acoustic rhinometry confirmed perforation closure, demonstrating a reduction in cross-sectional nasal area from baseline of 55.1 percent (95 percent CI, 37.7 to 66.8 percent; p < 0.01). CONCLUSION:This is the first study to use objective and subjective measurements to confirm success with acellular dermis allograft as an adjunct for septal perforation repair, demonstrating a statistically significant reduction in patient nasal symptoms following repair. CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, IV.
Case Report: Mucosal Leishmaniasis Presenting with Nasal Septum Perforation after Almost Thirty Years.
Rojas-Jaimes Jesùs,Frischtak Helena L,Arenas Jose,Lescano Andres G
The American journal of tropical medicine and hygiene
Mucosal leishmaniasis (ML) is associated with progressive tissue destruction and granuloma formation, often after a considerable period of latency from an initial cutaneous infection. We report a case of recurrent epistaxis of 3 years duration and nasopharyngeal obstruction in a woman with treated cutaneous leishmaniasis nearly 30 years before and with no further exposure to Leishmania. Computed tomography revealed nasal septal perforation and histopathology demonstrated chronic inflammation. Microscopy was negative for amastigotes, but molecular testing of nasal mucosa biopsy detected . The patient underwent 28 days of treatment with IV sodium stibogluconate and her symptoms improved significantly. Sixteen months after treatment, she continues to have episodic epistaxis and detectable parasite load in her nasal lesion. Although ML is known to take years to decades to develop, there are few reported cases in the literature of such a long latency period. This report highlights the importance of considering ML in the differential diagnosis of chronic epistaxis in countries where leishmaniasis is endemic or in immigrants from these countries, even when presentation occurs decades after leaving an endemic region.
Pediatric nasal septal perforation.
Jennings Jesse J,Shaffer Amber D,Stapleton Amanda L
International journal of pediatric otorhinolaryngology
OBJECTIVE:1.) Describe demographic and clinical characteristics of pediatric nasal septal perforations (NSP), 2.) Analyze efficacy of treatment modalities in symptom management and resolution of pediatric NSP, 3.) Describe the surgical technique of external rhinoplasty with vascularized nasal septal flaps in the treatment of nasal septal perforations. METHODS:IRB-approved retrospective chart review of pediatric patients ages 0-18 years with nasal septal perforations treated at a tertiary care pediatric otolaryngology practice. Demographic and clinical characteristics including gender, age, race, and presenting symptoms, and location, size, and etiology of perforation were collected. Outcomes including persistence of perforation and symptoms at 1 year and most recent visit were recorded. A total of 20 patients were included. Statistical analysis used Fisher's t-test for categorical variables and Wilcoxon rank-sum for continuous variables. RESULTS:Median age was 167.5 months (1.5-221.0). The most common etiology was iatrogenic (40%), followed by button battery (20%). Thirty percent of patients underwent surgical repair. Fifty percent of patients who underwent surgical repair achieved closure of their perforation at most recent follow up. CONCLUSION:Pediatric NSP is a challenging issue with limited literature to date. Iatrogenic causes (40%) and button batteries (20%) were the most common etiologies of nasal septal perforation in our study. We introduce an advancement in our center's surgical technique with a case illustration with repair via external rhinoplasty and bilateral vascularized nasal septal flaps. Future larger studies may further elucidate characteristics and treatment modalities associated with successful closure.
Nasal septal perforation in children: Presentation, etiology, and management.
Chang David T,Irace Alexandria L,Kawai Kosuke,Rogers-Vizena Carolyn R,Nuss Roger,Adil Eelam A
International journal of pediatric otorhinolaryngology
OBJECTIVE:The presentation, etiology, and treatment of nasal septal perforation have been described in the adult literature; however, reports in the pediatric population are limited. In this study, we review our experience with pediatric nasal septal perforations with a focus on presentation, pathogenesis, management, and outcomes of surgical repair. METHODS:A retrospective chart review was performed on pediatric patients diagnosed with nasal septal perforations from 1998 to 2015. Data regarding patient demographics, perforation characteristics, and treatment were extracted and analyzed. RESULTS:Twenty-seven patients met inclusion criteria. Mean age was 10.8 years (range 2 months-17 years). Nasal crusting (n = 19, 73%) and epistaxis (n = 15, 58%) were the most common complaints at presentation. The most common etiologies were trauma (n = 9, 33%), iatrogenic sources (n = 5, 19%), and neoplasm (n = 3, 11%). Septal perforations were primarily located in the anterior septum (n = 17, 81%) and the average size was 0.9 cm (±0.37) in diameter. Four patients were managed with a nasal septal button. Successful closure was achieved in four out of six patients (66.7%) who underwent surgical repair. CONCLUSIONS:In our series, septal perforations in children occurred most frequently due to digital nasal trauma, and crusting was the most common symptom. Factors to consider prior to repair include symptomatology, the etiology of the perforation, co-morbidities, ability to comply with post-operative care/restrictions, availability of adjacent tissue/grafts, and potential effects on nasal growth. Even with careful consideration of these factors, successful closure was limited to two-thirds of patients who were offered repair.