Objectives Structured histopathology reporting has been recently described for detailing immunopathological characteristics of chronic rhinosinusitis (CRS), and can be utilized for subtyping CRS and personalizing management. This study scrutinized elements of structured histopathology to identify characteristics that prognosticate outcomes following endoscopic sinus surgery (ESS) for CRS patients with nasal polyps (CRSwNP) and without nasal polyps (CRSsNP). Methods Outcomes following ESS were measured using the patient‐reported 22‐item sinonasal outcome test (SNOT‐22). Changes in total SNOT‐22 scores at 6 and 12 months postoperatively were analyzed. Thirteen parameters reported in structured histopathology of sinus surgical tissue were studied for association with outcomes postsurgery. The overall cohort of all CRS patients was studied, along with subgroup analyses of CRSwNP and CRSsNP patients. Results In the entire CRS cohort (n = 171), eosinophil count >10 per high power field (HPF) was associated with greater improvement in SNOT‐22 scores at 6 months post‐ESS (P = .039). At 12 months follow‐up, no histopathological characteristic was associated with change in total SNOT‐22 score. In the CRSwNP (n = 66) subgroup, the presence of fibrosis (P = .006) and eosinophil count ≤10 per HPF (P = .025) were associated with less favorable changes in SNOT‐22 scores at 12 months follow‐up. Fibrosis remained statistically significant in multivariable analysis (P = .007). Conclusions At 6 months post‐ESS, tissue eosinophilia is associated with significantly higher improvement in SNOT‐22 scores, but this difference is diluted by 12 months. Fibrosis was associated with less favorable outcomes in SNOT‐22 scores for CRSwNP patients at 12 months and may be a prognosticator for poorer long‐term outcomes. Level of Evidence 4
ObjectivesThere is interest in identifying chronic rhinosinusitis (CRS) endotypes that align pathophysiology with clinical observation and outcomes. CRS with polyps (CRSwNP) has classically been studied with reference to tissue eosinophilia, but the role of other cellular infiltrates remains uncharacterized. No particular tissue prognosticators have been described for CRS without nasal polyps (CRSsNP). Predominance of leukocytes seen in surgical tissue may be useful for differentiating CRS subtypes, severity of inflammation, and outcomes.MethodsStructured histopathology reports were examined for 277 patients undergoing endoscopic sinus surgery for CRSwNP (n = 115), CRSsNP (n = 141), and recurrent acute rhinosinusitis (RARS, n = 21). Inflammatory predominance was examined for associations with nasal polyposis, asthma, allergic rhinitis, aspirin exacerbated respiratory disease (AERD), immune deficiency, preoperative Lund‐Mackay score, and outcome (SNOT‐22 score change).ResultsIn order of frequency, the prevalence of predominant inflammatory patterns accounting for 93.5% of CRS patients were: lymphoplasmocytic (n = 111), lymphocytic (n = 74), eosinophilic (n = 50), and lymphoplasmocytic with eosinophilic (n = 24). Eosinophilic predominance was 97.4% specific for nasal polyps (95% confidence interval [CI], 93.4%‐99.3%), although sensitivity was 43.4% (95% CI, 33.8%‐53.4%). The absence of eosinophilic predominance was 100% sensitive for RARS (95% CI, 82.4%‐100%), however specificity was 30.8% (95% CI 25.1%‐37.1%). There were no significant differences in preoperative SNOT‐22 scores or change postoperatively.ConclusionsEosinophilic inflammatory predominance was predictive for nasal polyps and against RARS. Nevertheless, the majority of CRSwNP patients had a different inflammatory predominance, demonstrating heterogeneity in CRS, even among patients with nasal polyps. Symptomatic outcomes were not associated with inflammatory predominance through 12 months follow up.Level of Evidence4.
BACKGROUND Trigeminal neuralgia (TN) refractory to medical management is often treated with microvascular decompression (MVD) involving the intracranial placement of Teflon. The placement of Teflon is an effective treatment, but does apply distributed pressure to the nerve and has been associated with pain recurrence. OBJECTIVE To report the rate of postoperative pain recurrence in TN patients who underwent MVD surgery using a transposition technique with fibrin glue without Teflon. METHODS Patients were eligible for our study if they were diagnosed with TN, did not have multiple sclerosis, and had an offending vessel that was identified and transposed with fibrin glue at our institution. All eligible patients were given a follow-up survey. We used a Kaplan-Meier (KM) model to estimate overall pain recurrence. RESULTS A total of 102 patients met inclusion criteria, of which 85 (83%) responded to our survey. Overall, 76 (89.4%) participants responded as having no pain recurrence. Approximately 1-yr pain-free KM estimates were 94.1% (n = 83), 5-yr pain-free KM estimates were 94.1% (n = 53), and 10-yr pain-free KM estimates were 83.0% (n = 23). CONCLUSION Treatment for TN with an MVD transposition technique using fibrin glue may avoid some cases of pain recurrence. The percentage of patients in our cohort who remained pain free at a maximum of 17 yr follow-up is on the high end of pain-free rates reported by MVD studies using Teflon. These results indicate that a transposition technique that emphasizes removing any compression near the trigeminal nerve root provides long-term pain-free rates for patients with TN.
domains and have physical and economic consequences, such as absence from work, decreased neurologic function, and high healthcare costs. 3 This article describes the anatomy and pathophysiology of CTS and its treatment options so clinicians can better prepare patients and streamline referrals for improved outcomes. ANATOMYThe carpal tunnel is a narrow space located on the palmar surface that allows the passage of various structures such as the median nerve and various fl exor tendons (Figures 1 and 2). The borders of this tunnel include the fl exor retinaculum (roof), carpal bones (base), the hook of the hamate, pyramidal bone, pisiform bone (ulnar edge), scaphoid and trapezoid bones, as well as the tendon of the fl exor carpi radialis (FCR) muscle forming the radial edge. 11 The tendons passing through the carpal tunnel are the four fl exor digitorum superfi cialis, the four fl exor digitorum profundus, and the fl exor pollicis longus.The median nerve enters the hand through the carpal tunnel and divides into six branches (Table 1). Of these, the recurrent branch supplies the muscles of the thumb, which predominantly help with opposition, including the abductor pollicis brevis, opponens pollicis, and the superfi cial portion of the fl exor pollicis brevis.The proper palmar digital nerves compose the next three branches. These are cutaneous digital branches that innervate both the radial and ulnar sides of the thumb. The fi nal branch innervates the radial side of the index fi nger along with motor innervation to the fi rst lumbrical. The fi nal two branches, the common palmar digital branches, © PROSTOCK-STUDIO/SHUTTERSTOCK.COM C arpal tunnel syndrome (CTS) is the most common entrapment neuropathy, defi ned as nerve damage (specifi cally the median nerve) at narrow passage sites. [1][2][3] The fi rst case reports of compression of the median nerve were published by Paget in 1854. 4 Studies by Phalen in the 1950s became the foundational principles for understanding CTS. 5 The condition tends to affect patients ages 40 to 60 years; prevalence is estimated between 4% and 5% of the population. 6 Various studies have shown that CTS is more common in women than men (2.2 to 5.4 women to 1.1 to 3 men per 1,000 people). 7-10 Short-and long-term effects of these neuropathies span various ABSTRACT Carpal tunnel syndrome (CTS) is an entrapment neuropathy affecting the median nerve. Prevalence is estimated at 4% to 5% of the population. A solid understanding of the anatomy, presentation, and diagnostics is key to effi cient diagnosis and appropriate referral. Both surgical and nonsurgical interventions have led to improved clinical outcomes. Clinicians who have an in-depth knowledge of CTS symptoms and treatment options can prepare patients and streamline referrals for improved patient outcomes.
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