Computational fluid dynamics as surgical planning tool: a pilot study on middle turbinate resection

Controversies exist regarding the resection or preservation of the middle turbinate (MT) during functional endoscopic sinus surgery. Any MT resection will perturb nasal airflow and may affect the mucociliary dynamics of the osteomeatal complex. Neither rhinometry nor computed tomography (CT) can adequately quantify nasal airflow pattern changes following surgery. This study explores the feasibility of assessing changes in nasal airflow dynamics following partial MT resection using computational fluid dynamics (CFD) techniques. We retrospectively converted the pre- and postoperative CT scans of a patient who underwent isolated partial MT concha bullosa resection into anatomically accurate three-dimensional numerical nasal models. Pre- and postsurgery nasal airflow simulations showed that the partial MT resection resulted in a shift of regional airflow towards the area of MT removal with a resultant decreased airflow velocity, decreased wall shear stress and increased local air pressure. However, the resection did not strongly affect the overall nasal airflow patterns, flow distributions in other areas of the nose, nor the odorant uptake rate to the olfactory cleft mucosa. Moreover, CFD predicted the patient's failure to perceive an improvement in his unilateral nasal obstruction following surgery. Accordingly, CFD techniques can be used to predict changes in nasal airflow dynamics following partial MT resection. However, the functional implications of this analysis await further clinical studies. Nevertheless, such techniques may potentially provide a quantitative evaluation of surgical effectiveness and may prove useful in preoperatively modeling the effects of surgical interventions.

Cognitive dysfunction associated with pain and quality of life in chronic rhinosinusitis

BACKGROUND

Cognitive dysfunction and its relationship to both pain and disease-specific quality of life (QOL) in chronic rhinosinusitis (CRS) have not been investigated previously. We sought to analyze the correlations of pain and disease-specific QOL with cognitive function in CRS.

METHODS

Adults with CRS were prospectively enrolled in a cross-sectional study. Participants' cognitive function was assessed using the Cognitive Failures Questionnaire. Pain was characterized using the Short-Form McGill Pain Questionnaire (SF-MPQ) and the Brief Pain Inventory Short Form. Disease-specific QOL was ascertained using the Rhinosinusitis Disability Index (RSDI) and 22-item Sinonasal Outcome Test (SNOT-22). Disease severity was assessed using nasal endoscopy and computed tomography. Bivariate correlations of pain and cognitive dysfunction, disease-specific QOL, and clinical measures of disease severity were ascertained.

RESULTS

In patients with CRS (n = 70) there was a significant correlation between cognitive dysfunction and pain severity scores (Spearman's correlation [R(s)] = 0.321, p < 0.01). A similar correlation was identified with pain interference (R(s) = 0.317, p < 0.01) and cognitive dysfunction scores. This is mirrored by a significant correlation between another measure of pain severity, the SF-MPQ and cognitive dysfunction (R(s) = 0.498, p < 0.01). In patients with CRS there was a significant correlation between disease-specific QOL scores and cognitive function scores as measured by the SNOT-22 (R(s) = 0.395, p < 0.01) and the RSDI (R(s) = 0.528, p < 0.01).

CONCLUSION

In patients with CRS, increasing pain and worse QOL are associated with cognitive dysfunction. Possible mechanisms for this cognitive dysfunction include differential neural activation secondary to chronic pain and/or the sequela of a chronic inflammatory state.

Olfactory change after intensity-modulated radiotherapy for nasopharyngeal carcinoma

BACKGROUND

Radiotherapy is the mainstay of treatment for nasopharyngeal cancer (NPC), but many side effects were reported in NPC patients receiving radiotherapy. This study was conducted to evaluate the long-term effects of intensity-modulated radiotherapy (IMRT) on olfactory function.

METHODS

The olfactory function of 41 NPC patients was assessed by a traditional Chinese version of the University of Pennsylvania Smell Identification Test (UPSIT-TC). The patients also filled out a Taiwanese version of the 22-item Sino-Nasal Outcome Test (TWSNOT-22) questionnaire and received imaging examinations of the sinuses before IMRT and 1 year after IMRT. The sinus imaging was scored according to the Lund-Mackay system.

RESULTS

The mean UPSIT-TC scores were 30.6 before IMRT and 28.0 after IMRT and the decrease in UPSIT-TC scores was significant (p = 0.001). The mean TWSNOT-22 scores were 32.1 before IMRT and 28.8 after IMRT. The change in TWSNOT-22 scores was not significant, but the scores for item 5 "loss of smell or taste" significantly increased after IMRT (p = 0.035). The mean total computed tomography (CT) scores were 1.7 before IMRT and 3.2 after IMRT, and the mean ethmoid CT scores were 0.5 before IMRT and 1.2 after IMRT. The increase in total CT and ethmoid CT scores was both significant (p = 0.004 and 0.002). The decrease in UPSIT-TC scores was moderately negatively correlated with the increase in total CT and ethmoid CT scores (r = -0.348 and -0.423).

CONCLUSION

Our results showed that the olfactory function of NPC patients was mildly impaired after IMRT, which can cause rhinosinusitis.

Clinical practice guideline (update): adult sinusitis

OBJECTIVE

This update of a 2007 guideline from the American Academy of Otolaryngology--Head and Neck Surgery Foundation provides evidence-based recommendations to manage adult rhinosinusitis, defined as symptomatic inflammation of the paranasal sinuses and nasal cavity. Changes from the prior guideline include a consumer added to the update group, evidence from 42 new systematic reviews, enhanced information on patient education and counseling, a new algorithm to clarify action statement relationships, expanded opportunities for watchful waiting (without antibiotic therapy) as initial therapy of acute bacterial rhinosinusitis (ABRS), and 3 new recommendations for managing chronic rhinosinusitis (CRS).

PURPOSE

The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing adult rhinosinusitis and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to improve diagnostic accuracy for adult rhinosinusitis, promote appropriate use of ancillary tests to confirm diagnosis and guide management, and promote judicious use of systemic and topical therapy, which includes radiography, nasal endoscopy, computed tomography, and testing for allergy and immune function. Emphasis was also placed on identifying multiple chronic conditions that would modify management of rhinosinusitis, including asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia.

ACTION STATEMENTS

The update group made strong recommendations that clinicians (1) should distinguish presumed ABRS from acute rhinosinusitis (ARS) caused by viral upper respiratory infections and noninfectious conditions and (2) should confirm a clinical diagnosis of CRS with objective documentation of sinonasal inflammation, which may be accomplished using anterior rhinoscopy, nasal endoscopy, or computed tomography. The update group made recommendations that clinicians (1) should either offer watchful waiting (without antibiotics) or prescribe initial antibiotic therapy for adults with uncomplicated ABRS; (2) should prescribe amoxicillin with or without clavulanate as first-line therapy for 5 to 10 days (if a decision is made to treat ABRS with an antibiotic); (3) should reassess the patient to confirm ABRS, exclude other causes of illness, and detect complications if the patient worsens or fails to improve with the initial management option by 7 days after diagnosis or worsens during the initial management; (4) should distinguish CRS and recurrent ARS from isolated episodes of ABRS and other causes of sinonasal symptoms; (5) should assess the patient with CRS or recurrent ARS for multiple chronic conditions that would modify management, such as asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia; (6) should confirm the presence or absence of nasal polyps in a patient with CRS; and (7) should recommend saline nasal irrigation, topical intranasal corticosteroids, or both for symptom relief of CRS. The update group stated as options that clinicians may (1) recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of viral rhinosinusitis; (2) recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation) for symptomatic relief of ABRS; and (3) obtain testing for allergy and immune function in evaluating a patient with CRS or recurrent ARS. The update group made recommendations that clinicians (1) should not obtain radiographic imaging for patients who meet diagnostic criteria for ARS, unless a complication or alternative diagnosis is suspected, and (2) should not prescribe topical or systemic antifungal therapy for patients with CRS.

Clinical consensus statement: pediatric chronic rhinosinusitis

OBJECTIVE

To develop a clinical consensus statement on the optimal diagnosis and management of pediatric chronic rhinosinusitis (PCRS).

METHODS

A representative 9-member panel of otolaryngologists with no relevant conflicts of interest was assembled to consider opportunities to optimize the diagnosis and management of PCRS. A working definition of PCRS and the scope of pertinent otolaryngologic practice were first established. Patients of ages 6 months to 18 years without craniofacial syndromes or immunodeficiency were defined as the targeted population of interest. A modified Delphi method was then used to distill expert opinion into clinical statements that met a standardized definition of consensus.

RESULTS

After 2 iterative Delphi method surveys, 22 statements met the standardized definition of consensus while 12 statements did not. Four statements were omitted due to redundancy. The clinical statements were grouped into 4 categories for presentation and discussion: (1) definition and diagnosis of PCRS, (2) medical treatment of PCRS, (3) adenoiditis/adenoidectomy, and (4) endoscopic sinus surgery (ESS)/turbinoplasty.

CONCLUSION

Expert panel consensus may provide helpful information for the otolaryngologist in the diagnosis and management of PCRS in uncomplicated pediatric patients.

Aspirin-exacerbated respiratory disease: characteristics and management strategies

Aspirin-exacerbated respiratory disease is a clinical entity comprising chronic rhinosinusitis with nasal polyposis, asthma and intolerance to COX-1 inhibiting drugs. The pathogenesis is not completely understood at this point, but abnormal arachidonic acid metabolism is a key feature in this syndrome. The diagnosis is confirmed only by direct drug challenge. Aspirin desensitization followed by daily aspirin therapy is a useful treatment option in these patients. In this review article are discussed the important characteristics and treatment of aspirin-exacerbated respiratory disease.

Proinflammatory mediators alter expression of nuclear factor kappa B-regulating deubiquitinases in sinonasal epithelial cells

BACKGROUND

Nuclear factor κB (NF-κB) is a vital transcription factor that is activated by numerous inflammatory stimuli. Its activity is tightly regulated by a family of deubiquitinating enzymes (A20, Cezanne, cylindromatosis [CYLD]) that function in a negative-feedback loop, a process that prevents chronic and systemic inflammation. This study seeks to characterize the expression and functional role of NF-κB-regulating deubiquitinases in the sinonasal epithelium.

METHODS

Expression of A20, Cezanne, and CYLD was assessed in normal sinonasal tissue using immunohistochemistry. Cultured sinonasal epithelial cells (SNECs) were stimulated with proinflammatory cytokines (tumor necrosis factor α [TNF-α], interleukin 4 [IL]-4, IL-13) or lipopolysaccharide (LPS) and changes in NF-κB activation and deubiquitinase expression were assessed using Western blots and quantitative real-time polymerase chain reaction (qRT-PCR), respectively.

RESULTS

NF-κB was activated in response to LPS and TNF-α, but not IL-4 or IL-13. A20, Cezanne, and CYLD were all expressed in sinonasal tissue, primarily along the apical surface of the epithelium. Proinflammatory mediators primarily affected expression of A20, with upregulation by LPS and TNF-α and downregulation by IL-4 and IL-13.

CONCLUSION

The NF-κB-regulating deubiquitinases A20, Cezanne, and CYLD are expressed in sinonasal tissue and are differentially induced by proinflammatory cytokines and the microbial antigen, LPS. These results suggest an important role for NF-κB-regulating deubiquitinases in mucosal immunity and homeostasis.

From modeling to remodeling of upper airways: Centrality of hyaluronan (hyaluronic acid)

After traumatic events (accidental or surgical), the respiratory tract activates specific and prolix repairing mechanisms which tend to claw back the primitive differentiated state. The attempt of reactivation of the normal tissue functions is called 'remodeling' and its aim is to reinstate the modeling mechanisms that existed before the damaging event or the pathology's establishment. Endoscopic sinus surgery represents the gold standard treatment for inflammatory, malformative, benign, and, in selected cases, malignant diseases. The surgical technique is commonly described as minimally invasive as the nostrils are used as an access route and therefore does not leave any external scars. Currently, the surgical procedures, even though minimally invasive regarding the way in, are in fact widely destructive towards the surgical target. The healing process and re-epithelialization will depend on the amount of bony tissue that has been exposed and it will be important to stratify the different surgical typologies in order to foresee the increasing difficulty of mucosal healing process. As far as upper inflammatory diseases are concerned, recent studies demonstrated how intranasal hyaluronic acid can positively regulate mucosal glands secretion and modulate inflammatory response, being a useful tool for the improvement of remodeling after endoscopic sinus surgery. Acid has shown to be able to regulate mucosal glands secretion and modulate the inflammatory response.

Sinus mucosa status in patients with nasopharyngeal carcinoma treated with intensity-modulated radiotherapy: A 5-year follow-up

BACKGROUND

Sinus mucosa abnormalities on image studies, which is the major diagnostic measure for sinusitis, were investigated in patients with nasopharyngeal carcinoma (NPC) after intensity-modulated radiotherapy (IMRT).

METHODS

A retrospective review of the MRIs for patients with NPC was conducted. Sinus mucosa abnormalities were staged by the Lund-Mackay system.

RESULTS

A total of 94 patients were enrolled in this study. The rate and severity of sinus abnormalities were highest on the third postradiotherapy month (p < .005, t test). There was no significant increase in the incidence of abnormalities on the fifth postradiotherapy year (t test). The anterior ethmoid and maxillary sinuses were the most affected sinuses before and after radiotherapy (p < .005, chi-square test).

CONCLUSION

Our data showed that the anterior ethmoid and maxillary sinuses were the most vulnerable sinuses for therapeutic toxicity after IMRT in patients with NPC. In the long run, however, the application of IMRT does not significantly increase the incidence of sinus toxicities.

Nasal lavage levels of granulocyte-macrophage colony-stimulating factor and chronic nasal hypereosinophilia

BACKGROUND

The aim of the present study was to measure levels of granulocyte-macrophage colony-stimulating factor (GM-CSF) in nasal lavage of patients affected by chronic eosinophilic sinonasal inflammation to clarify the relationship with eosinophilic tissue infiltration and clinical features.

METHODS

Between November 2012 and June 2013, we selected 70 patients with chronic eosinophilic inflammation (average age 41.8 years) who were classified into the following groups: persistent allergic rhinitis (group 1), noninfectious non-allergic rhinitis with eosinophilia syndrome (group 2) and chronic rhinosinusitis with polyps (group 3). Finally, we enrolled 20 healthy subjects as controls (group 4). All patients underwent symptoms score questionnaire based on a visual analogue scale, nasal endoscopy and/or computed tomography (CT) scan, and allergy testing. Nasal cytology by scraping of the mucosa and GM-CSF assays in nasal lavage were performed in all subjects.

RESULTS

Detectable levels of GM-CSF were found in 34 of 70 (48.57%) patients, with an average concentration of 2.67 ± 0.8 pg/mL, whereas in controls only 1 of 20 individuals showed detectable GM-CSF levels. Eosinophil infiltration was significantly higher in patients with detectable GM-CSF compared to those with undetectable levels (49.4% vs 39.2%, respectively; p < 0.05). Furthermore, significant weakly-moderate correlation was found between GM-CSF levels and percentage of eosinophil infiltration in tissue (p < 0.05). Correlation between symptom scores and GM-CSF levels was significant only in group 2, which showed higher average concentrations of GM-CSF compared to groups 1 and 3 (2.9 pg/mL vs 1.6 pg/mL and 1.8 pg/mL, respectively; p < 0.05).

CONCLUSION

Our data confirm that GM-CSF is more frequently detectable in nasal lavages of patients affected by chronic sinonasal eosinophilic inflammation than in controls. Statistical analyses revealed a significant weakly-moderate correlation between GM-CSF levels in nasal lavage of all patients and percentage of eosinophil infiltration of nasal mucosa.

Eosinophilic Mucin Otomastoiditis and Otopolyposis: A Progressive Form of Eosinophilic Otitis Media

OBJECTIVE

The purpose of this study is to introduce and define a disease entity on a continuum of eosinophilic otitis media: eosinophilic mucin otomastoiditis and otopolyposis.

METHODS

A case of a 66-year-old woman with complicated chronic otitis media is reported. A literature review of the National Library of Medicine's online database, with a focus on eosinophilic otitis media and eosinophilic mucin rhinosinusitis, was performed.

RESULTS

The authors report the case of a 66-year-old woman with a history of asthma, chronic rhinosinusitis, nasal polyposis, and chronic otitis media who presented with allergic middle ear mucin and otic polyps. Treatment involved a tympanomastoidectomy with removal of otic polyps and steroid therapy.

CONCLUSION

Eosinophilic mucin otomastoiditis with otopolyposis is a disease entity on a continuum of eosinophilic otitis media. This disease process shares similarities with eosinophilic mucin rhinosinusitis. Otic polypectomy and steroids are suggested therapeutic measures.

A randomized clinical trial comparing pulsed ultrasound and erythromycin phonophoresis in the treatment of patients with chronic rhinosinusitis

Therapeutic ultrasound, an important physiotherapy modality, has been used successfully in the treatment of patients with chronic rhinosinusitis (CRS). No study has compared pulsed ultrasound (PUS) with erythromycin phonophoresis (EP). The aim of this randomized, double-blind, parallel group study with concealed allocation was to compare PUS with EP. Sixty CRS patients were randomly allocated into two groups. Group 1 had PUS and Group 2 had EP. Patients were treated 3 days a week for 10 sessions over 4 weeks. The severity of nine CRS symptoms was self-rated by patients on an ordinal scale of 0-3 (absent, mild, moderate or severe) at baseline and after the 10th treatment session. Individual symptom scores were summed to obtain a "Total Symptom Score" (TSS). The outcome measure included percentage improvement in the TSS. A statistically significant improvement in TSS occurred with both PUS and EP therapy groups (p < 0.05). The percentage improvement in the EP group was statistically greater than in the PUS group (67.2 versus 49.3%) (p = 0.03). The effect sizes in both therapy groups were large; PUS: d = 1.36 and EP: d = 2.15. EP was found to be superior over PUS therapy.

Clinical predictors of neo-osteogenesis in patients with chronic rhinosinusitis

BACKGROUND

Neo-osteogenesis of the paranasal sinuses is a radiologic finding of unclear clinical significance. Although current evidence suggests that these bony changes represent an inflammatory response rather than an infectious osteitis, bacteria associated with the sinonasal mucosa may induce inflammatory mediators as a mechanism of neo-osteogenesis. The objectives of this study were (1) to determine whether there is an association between bacteria isolated on sinus culture and neo-osteogenesis, and (2) to identify other predictive factors for neo-osteogenesis.

METHODS

Ninety patients undergoing sinus surgery for medically refractory CRS were recruited. Radiologic evidence of neo-osteogenesis was assessed by the Global Osteitis Scoring Scale (GOSS) and mucosal disease severity was assessed by the Lund-Mackay score (LMS). Bacterial culture was obtained endoscopically at the preoperative office visit or during surgery. Multiple and logistic regression models were used to evaluate the association between the types of bacterial species isolated, number of previous surgeries, and severity of neo-osteogenesis.

RESULTS

Thirty of the 90 (33.3%) patients had radiologic evidence of neo-osteogenesis. Pseudomonas aeruginosa was significantly associated with neo-osteogenesis (odds ratio [OR], 3.97; 95% confidence interval [CI], 1.12 to 13.56), whereas Staphylococcus aureus was not. The number of previous surgeries, especially 2 or more previous surgeries, was associated with the extent of neo-osteogenesis (OR, 3.48; 95% CI, 1.14 to 10.51). The LMS was also significantly associated with the extent of neo-osteogenesis.

CONCLUSION

The presence of P. aeruginosa in the sinuses is an independent predictor of neo-osteogenesis, whereas S. aureus is not. The number of previous surgeries and the LMS are also independently associated with the severity of neo-osteogenesis.

Molecular mechanisms of nasal epithelium in rhinitis and rhinosinusitis

Allergic rhinitis, nonallergic rhinitis, and chronic rhinosinusitis are multifactorial upper airway diseases with high prevalence. Several genetic and environmental factors are proposed to predispose to the pathogenesis of the inflammatory upper airway diseases. Still, the molecular mechanisms leading toward the onset and progression of upper airway diseases are largely unknown. The upper airway epithelium has an important role in sensing the environment and regulating the inhaled air. As such, it links environmental insults to the host immunity. Human sinonasal epithelium serves as an excellent target for observing induced early-phase events, in vivo, and with a systems biological perspective. Actually, increasing number of investigations have provided evidence that altered homeostasis in the sinonasal epithelium might be important in the chronic upper airway inflammation.

Evaluation of nested PCR in diagnosis of fungal rhinosinusitis

BACKGROUND AND OBJECTIVE

Given the importance of rapid diagnosis for fungal rhinosinusitis, this study aimed to evaluate the use of nested PCR to identify Aspergillus and Mucor species in clinical samples from patients with suspected fungal rhinosinusitis.

METHODS

Functional endoscopic sinus surgery specimens were collected from 98 patients with rhinosinusitis from 2012 to 2013. All samples were ground and cultured on sabouraud dextrose agar. The isolated fungi were identified based on their macroscopic and microscopic features. Fungal DNA was extracted from the tissue samples and nested PCR was performed with two sets of primers for Mucor and Aspergillus.

RESULTS

Direct microscopic showed that 5.1% contained fungal components and 9.2% exhibited growth of fungi in culture. The most common agents isolated were Aspergillus fumigatus (n= 3), Aspergillus flavus (n=2), Penicillium sp (n=3) and Alternaria sp. (n=1). Mucor sp. was identified in the pathology smear from 1 patient. Positive results for fungal rhinosinusitis were obtained for a total of 10.2% by culture or pathology smear. Positive PCR results were obtained in 72 samples for Aspergillus and 31 samples for Mucor.

CONCLUSION

Our results suggest that endoscopic sinus surgery specimens are not suitable for nested PCR, probably because of the accumulation of fungi that contaminate the environmental air. This drawback is a limiting factor for diagnosis with nasal cavity specimens. Therefore, molecular methods and conventional culture techniques are helpful complementary diagnostic methods to detect fungal rhinosinusitis and determine appropriate management for these patients.

Complete mitochondrial genome sequence and mutations of the rhinosinusitis model inbred C57BL/6 mice strain

In the present work, we undertook the complete mitochondrial genome sequencing of an important rhinosinusitis model inbred rat strain for the first time. The total length of the mitogenome was 16,308 bp. It harbored 13 protein-coding genes, 2 ribosomal RNA genes, 22 transfer RNA genes, and 1 non-coding control region (D-loop region). The mutation events were also reported.

Diseases of the nose and paranasal sinuses in child

Diseases of the pediatric nose and nasal sinuses as well as neighboring anatomical structures encompass a variety of pathologies, especially of inflammatory nature. Congenital disease, such as malformations and structural deviations of the nasal septum, as well as systemic metabolic pathologies affecting the nose and sinuses, rarely require medical therapy from an Otolaryngologist.

The immunological function of the mucosa and genetic factors play a role in the development of disease in the pediatric upper airway tract, especially due to the constantly changing anatomy in this growth phase. Disease description of the nose and nasal sinuses due to mid-facial growth must also take developmental age differences (infant, toddler, preschool, and school age) into account. Epidemiological examinations and evidence based studies are often lacking in the pediatric population.

The wide range of inflammatory diseases of the nose and paranasal sinuses, such as the acute and chronic rhinosinusitis, the allergic rhinitis, and adenoid disease, play a role in the susceptibility of a child to infection. The susceptibility to infection depends on the pediatric age structure (infant, young child) and has yet to be well defined. The acute rhinosinusitis in children develops after a viral infection of the upper airways, also referred to as the “common cold” in the literature. It usually spontaneously heals within ten days without any medical therapy. Antibiotic therapy is prudent in complicated episodes of ARS. The antibiotic therapy is reserved for children with complications or associated disease, such as bronchial asthma and/or chronic bronchitis. A chronic rhinosinusitis is defined as the inflammatory change in the nasal mucosa and nasal sinus mucosa, in which the corresponding symptoms persist for over 12 weeks. The indication for CT-imaging of the nasal sinuses is reserved for cases of chronic rhinosinusitis that have been successfully treated with medication. A staged therapeutic concept is followed in CRS based on conservative and surgical methods. Nasal sinus surgery is considered nowadays as effective and safe in children. Based on the assumption that adenoids are a reservoir for bacteria, from which recurrent infections of the nose and nasal sinus originate, the adenoidectomy is still defined as a cleansing procedure in rhinosinusitis. 69.3% of the children had benefit from adenoidectomy.

Comorbidities, such as pediatric bronchial asthma, presently play an even more important role in the therapy of rhinosinusitis; therefore, it is often wise to have the support of pediatricians. In western European countries 40% of children presently suffer from allergic rhinitis, in which pronounced nasal obstruction can cause disturbed growth in facial bones. An early therapy with SIT may prevent the development of bronchial asthma and secondary sensitization to other allergens. Therefore, SIT is recommended in treatment of allergic rhinitis whenever, if possible. The assessment of diagnostic tools is for the examiner not often possible due to the lack of evidence. Rhinosurgical approaches are often described in study reports; however, they lack the standard prospective randomized long-term study design required nowadays and can only be evaluated with caution in the literature.

Air pollutants cause release of hydrogen peroxide and interleukin-8 in a human primary nasal tissue culture model

BACKGROUND

A component of primary innate defense of the nasal mucosa against inhaled pathogens includes continuous, low-level release of hydrogen peroxide (H2 O2 ) into luminal secretions. Epidemiologically, an association exists between poor air quality and increased prevalence of sinonasal disease. To understand the effects of particulate matter (PM) in nasal mucosa, we studied the release of H2 O2 and interleukin 8 (IL-8) after PM exposure.

METHODS

Human nasal specimens were collected from surgery and cultured in serum-free growth medium. Cell integrity and recovery during culture was monitored by lactate dehydrogenase (LDH) release into the medium. Cultures were exposed to PM for 24 hours in the presence/absence of diphenyleneiodonium sulfate (DPI; a nicotinamide adenine dinucleotide phosphate [NADPH] oxidase inhibitor). Luminex cytokine and Amplex-Red H2 O2 assays were performed.

RESULTS

LDH levels dropped rapidly within 2 days, indicative of stabilization and cell recovery after harvest. All cultures released H2 O2 into the medium. Exposure to PM (20 μg/cm(2) ) increased H2 O2 levels significantly (94.6 ± 7.7 nM) compared to untreated controls (55.8 ± 4.0 nM; p = 0.001). PM-induced H2 O2 production was partially inhibited by DPI (80.1 ± 3.8nM), indicating that cellular NADPH oxidase may be a primary source of H2 O2 production. Exposure to PM increased IL-8 levels in a dose-dependent fashion (control = 2301 ± 412 MFI; 20 μg/cm(2) = 5002 ± 1327 MFI; 40 μg/cm(2) = 8219 ± 1090 MFI; p = 0.022).

CONCLUSION

PM increases the quantity of H2 O2 released by nasal epithelial cells, indicating that PM can contribute to oxidative stress in part by activating a normal cellular defense mechanism. Exposure to PM resulted in elevated IL-8 levels and mucin production in explants. Efforts to reduce airborne PM may lead to reduced H2 O2 and mucin production in sinonasal epithelium.

Current perioperative practice patterns for minimizing surgical site infection during rhinologic procedures

BACKGROUND

There is a paucity of information in the literature regarding the best practices to reduce surgical site infections associated with rhinologic surgery.

METHODS

We surveyed the American Rhinologic Society (ARS) membership to assess current perioperative infection control measures performed for rhinologic procedures, with the goal of establishing a baseline of current practice.

RESULTS

Results revealed that for most rhinologic procedures performed in the operating room (OR) setting, the majority of physicians gown and drape in a sterile fashion and perform a complete surgical scrub of their hands and forearms but do not prep the facial skin with an antimicrobial agent. For rhinologic procedures performed in the office setting, the majority of physicians do not perform any of the aforementioned perioperative measures for any of the office procedures. Interestingly, for physicians that perform inferior turbinate reductions in both settings, 45% gown and drape in a sterile fashion and 28% perform a complete surgical scrub of their hands in the OR setting but not in the office setting. The most stringent measures were performed for endoscopic skull-base procedures, with over 90% of responders administering perioperative antibiotics, gowning and draping in a sterile fashion, and performing a complete surgical scrub of their hands. Despite lack of demonstrated benefit, antibiotics were used variably for the other procedures.

CONCLUSION

This survey demonstrates that there is great variability in the perioperative measures rhinologists perform to reduce surgical site infection, which differs by the practice site. These data serve as a baseline for future studies.

Features of mesenchymal transition in the airway epithelium from chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) defines a group of disorders characterized by persistent inflammation of the sinonasal tract. Epithelial changes and structural remodelling are present, but whether epithelial differentiation is altered remains uncertain.

METHODS

To evaluate the differentiation state of the sinonasal epithelium in CRS, sinonasal biopsies from patients with CRS with nasal polyps (CRSwNP) or CRS without nasal polyps (CRSsNP), or with allergic rhinitis (AR), as compared to controls, were processed by immunohistochemistry and RT-qPCR for terminal differentiation (E-cadherin, high molecular weight cytokeratins (Hmw CK) and CK5, vimentin) and lineage differentiation (ß-tubulin IV+ ciliated cells, MUC5AC+ goblet cells, p63 + basal cells). Findings were correlated with subepithelial fibrosis and clinical CT score.

RESULTS

Expression of E-cadherin was decreased at protein and mRNA levels in CRSwNP and CRSsNP, as compared to controls. Staining for Hmw CKs was also reduced in CRSwNP and CRSsNP, and CK5 mRNA was decreased in CRSwNP. These features were not due to changes in lineage specification, but associated with increases in vimentin-expressing epithelial cells. In addition, vimentin expression correlated with the basement membrane thickening and with CT score, as well as with tissue eosinophils.

CONCLUSION

Features of epithelial dedifferentiation towards a mesenchymal phenotype are observed in CRSwNP and CRSsNP and correlate with airway fibrosis and inflammation.

Agreement between upper respiratory diagnoses from self-report questionnaires and medical records in an occupational health setting

BACKGROUND

The Fire Department of the City of New York World Trade Center Health Program (FDNY-WTCHP) monitors and treats WTC-related illnesses through regular physical exams, self-administered health questionnaires and treatment visits, as indicated.

METHODS

We measured positive and negative predictive values (PPV, NPV) of self-reported diagnoses of GERD and rhinosinusitis from the health questionnaires in relation to FDNY physician diagnoses from the medical record.

RESULTS

Self-reported GERD had PPV and NPV of 54.0% and 95.7%, respectively; for rhinosinusitis, the PPV and NPV were 48.2% and 91.9%. These characteristics improved considerably (PPV 78.0% GERD and PPV 76.5% rhinosinusitis) in a subpopulation receiving medications from the FDNY-WTCHP.

CONCLUSION

The PPV of self-reported diagnoses demonstrates only modest value in predicting physician diagnoses, although high NPVs suggest benefit in ruling out disease. In subgroups selected for their higher disease prevalence, self-reported diagnoses may be considerably more useful.

Impact of treatment time on the survival of patients suffering from invasive fungal rhinosinusitis

BACKGROUND

Invasive fungal rhinosinusitis is an uncommon disease with high mortality rates. There is currently no consensus on the best treatment timing. We studied the impact of the treatment timing on the survival of patients experiencing invasive fungal rhinosinusitis.

METHODS

We conducted a retrospective study of patients suffering from invasive fungal rhinosinusitis. The duration of symptoms, clinical presentations, clinical signs, diagnoses, treatments, and outcomes were collected.

RESULTS

It was observed that more than 70% of the mortalities occurred within the subgroup of patients who exhibited symptoms of the disease within 14 days before admission.

After adjusting for the confounders, the time taken to treat the patients was the most statistically significant predictor for mortality (P = 0.045). We found no significant relationships between mortality and its significant covariates, which included the underlying diseases (P = 0.91) or complications (P = 0.55).

CONCLUSIONS

Our study demonstrates that the time taken to treat the patients is an important determinant for the survival of patients who are afflicted with invasive fungal rhinosinusitis. The appropriate treatments should be administered within 14 days from the time the symptoms begin to manifest.

The effects of concomitant GERD, dyspepsia, and rhinosinusitis on asthma symptoms and FeNO in asthmatic patients taking controller medications

Background

Losing the sense of smell, which suggests eosinophilic rhinosinusitis, is a subjective symptom, sometimes reported in asthmatic patients taking controller medication. Upper abdominal symptoms, suggesting gastroesophageal reflux disease (GERD) or functional dyspepsia, occur also in these patients. However, the relationship between these symptoms, concomitant with asthma, and the intensity of eosinophilic airway inflammation remains obscure.

Objective

To assess the symptoms of asthma and rhinosinusitis, and to examine the relationship between the symptoms and bronchial inflammation, a new questionnaire, the G scale, was developed. To investigate the effects of GERD, dyspepsia, and rhinosinusitis on asthma symptoms and bronchial inflammation, the symptoms of asthma and rhinosinusitis obtained by the G scale, upper abdominal symptoms obtained by the modified F scale, a questionnaire for GERD and dyspepsia, and fractional exhaled nitric oxide (FeNO) were analyzed.

Methods

A prospective, observational study was performed in four hospitals in Gunma prefecture, and a retrospective analysis was done using data obtained from five hospitals in Gunma prefecture and Fukui prefecture, Japan. A total of 252 patients diagnosed as having asthma participated in the prospective study.

Results

The frequency of daytime phlegm or losing the sense of smell had a positive correlation with FeNO levels in asthmatic patients taking controller medication. Upper abdominal symptoms, as well as symptoms suggesting rhinitis, were well correlated with asthma symptoms. However, neither upper abdominal symptoms nor rhinitis symptoms increased FeNO levels, which reflect eosinophilic airway inflammation during treatment for asthma. On the other hand, the degree of upper abdominal symptoms or dyspepsia symptoms had a weak but significant negative correlation with FeNO levels.

Conclusion

Daytime phlegm and losing the sense of smell suggest that eosinophilic airway inflammation persists, despite anti-inflammatory therapy, in patients with asthma. Although rhinitis and GERD made the subjective symptoms of asthma worse, they did not seem to enhance eosinophilic airway inflammation.

Rhinosinusitis in oral medicine and dentistry

Rhinosinusitis is a very common condition which is normally readily recognizable. Given the intimate anatomic relationship between the antrum and the posterior maxillary teeth, maxillary sinusitis can present as odontalgia. Distinguishing between odontogenic orofacial pain and pain associated with maxillary sinusitis is important to prevent unnecessary dental intervention and to direct patients to medical colleagues. Conversely, odontogenic infection can spread to involve the antrum, termed odontogenic sinusitis, or maxillary sinusitis of dental origin. Odontogenic sinusitis accounts for about 10-40% of all cases of sinusitis, and usually requires combined dental and medical treatment. Maxillary sinusitis can also be a complication of exodontia, resulting from tuberosity fractures, displaced teeth or root fragments and the creation of oroantral communications and fistulae. Dental implants and endodontic materials can also impinge on the maxillary sinus, and are rare causes of sinusitis. Often it is stated that rhinosinusitis may contribute to a halitosis complaint, and widely used diagnostic protocols for rhinosinusitis sometimes list halitosis as a minor criterion. However, gold standards in halitotosis research such as organoleptic assessment or gas chromatography have not been used to validate a correlation between objective (genuine) halitosis and sinusitis. The pathophysiology of this mechanism is unclear, and the relative importance of this alongside other causes of extraoral halitosis is debated.

Sleep and quality of life improvements after endoscopic sinus surgery in patients with chronic rhinosinusitis

BACKGROUND

Recent investigation has demonstrated that approximately 75% of patients with medically refractory chronic rhinosinusitis (CRS) report abnormal sleep quality, with strong correlation between worse sleep quality and more severe CRS disease severity. It remains unknown whether the treatment effect of endoscopic sinus surgery (ESS) for CRS results in appreciable sleep quality improvements.

METHODS

Adult patients (aged ≥18 years) with a current diagnosis of recalcitrant chronic rhinosinusitis (CRS), who voluntarily elected ESS as the next treatment modality (n = 301), were prospectively evaluated within 4 academic, tertiary care centers using treatment outcome instruments: the Rhinosinusitis Disability Index, the 22-item Sinonasal Outcome Test, the 2-item Patient Health Questionnaire, and the Pittsburgh Sleep Quality Index (PSQI) both before and after ESS.

RESULTS

Seventy-two percent (72%) of patients with CRS were found to have poor sleep (PSQI > 5) at baseline with a mean (standard deviation) global PSQI score of 9.4 (4.6). Surgery improved overall mean global PSQI scores (by 2.2 points), and all 7 subdomain scores of the PSQI. Similarly, the odds of good sleep quality (PSQI ≤ 5) in patients treated with sinus surgery increased significantly (odds ratio [OR] 5.94; 95% confidence interval [CI], 3.06 to 11.53; p < 0.001). Stepwise multivariate linear regression found that acetylsalicylic acid (ASA) intolerance (β [standard error], -1.94 [0.93]; 95% CI, -3.77 to -0.11; p = 0.038), history of prior sinus surgery (β [standard error], 1.10 (0.54); 95% CI, 0.03 to 2.16; p = 0.044), and frontal sinusotomy (β [standard error], -1.03 [0.62]; 95% CI, -2.26 to 0.20; p = 0.099) were found to significantly associate with improvement in PSQI sleep scores.

CONCLUSION

Among patients with CRS, reduced sleep quality, poor disease-specific quality of life, and greater disease severity were improved following ESS.

Recalcitrant rhinosinusitis, innate immunity, and mannose-binding lectin

BACKGROUND

Mannose-binding lectin (MBL) is a protein produced by the liver that participates in innate immunity by tagging the surface of microbes for opsonization. Mannose-binding lectin deficiency is present in 7% of the population and has been implicated in recurrent respiratory tract infections in children. Mannose-binding lectin deficiency has not been explored in rhinosinusitis but is associated with increased mortality in adult pneumococcal infection. The purpose of this report is to describe a tertiary rhinology patient experience with MBL deficiency and recalcitrant rhinosinusitis.

METHODS

This retrospective case series report characterizes predominantly adult patients with low MBL levels from January 2010 to June 2012. Indications for MBL testing, sinus culture data, immunological testing results, and treatments used to control rhinosinusitis are described.

RESULTS

Mannose-binding lectin levels were deficient in 12 of 36 patients (33.3%) tested. IgG subclasses were abnormally low in 5 of 12 patients; IgA was normal in 11 of 12 patients; and IgM was normal in 11 of 12 patients. Staphylococcus aureus, coagulase-negative Staphylococcus species, and Pseudomonas aeruginosa, known to be "tagged" by MBL, were the most common organisms grown on culture. Treatments included culture directed systemic antimicrobial therapy and topical steroids/antibiotics.

CONCLUSION

Mannose-binding lectin, an important component of the lectin complement pathway and innate immunity, is possibly associated with recalcitrant adult rhinosinusitis. Steroid/antibiotic irrigations appear to benefit patients with recalcitrant rhinosinusitis and possibly those with MBL deficiency. Given that the prevalence of MBL deficiency in this case series is 4 times that seen in the normal population, additional investigations are warranted to further elucidate the role of MBL deficiency in rhinosinusitis.

Clinical features of cytotoxic CD8+ T-lymphocyte deficiency in chronic rhinosinusitis patients: a demographic and functional study

BACKGROUND

Identification of Staphylococcus aureus intracellularly in chronic rhinosinusitis (CRS) suggests an underlying cellular immunodeficiency. Supporting this, we have previously reported low CD8+ (cytotoxic) T-lymphocyte levels in a subpopulation of CRS patients and identified polymorphisms in the CD8A gene associated with CRS. In order to better understand the role of low CD8+ in CRS, we wished to determine the phenotype for CRS/Low CD8+ in comparison to that of conventional CRS.

METHODS

Sixty-seven low CD8+ CRS patients identified during investigation of CRS were compared for demographics, disease evolution, and bacteriology on endoscopic culture were compared with an existing population of 480 patients with CRS with nasal polyposis previously recruited for genetic association studies.

RESULTS

Mean level of CD8+ in the CRS/Low CD8+ population was 0.15 × 10(9)/L (range, 0.20-1.5 × 10(9)/L). There was no difference between both groups in terms of history of allergy, asthma, eczema, acetylsalicylic acid (ASA) intolerance or smoking. The bacteriology was similar between both groups (S. aureus: CRS/Low CD8+: 35%; CRS 32%, p = 0.643). Evolution of disease was somewhat milder in CRS/Low CD8+, with fewer patients requiring surgery, and first surgery performed at a more advanced age. However, antibiotic use was higher in CRS/Low CD8+. Subgroup analysis restricted to CRS with nasal polyposis (CRSwNP)/Low CD8 or CRS without nasal polyposis (CRSsNP)/Low CD8 phenotypes did not substantially alter these results.

CONCLUSION

Low CD8+ levels are often identified in CRS patients; however, these patients have disease remarkably similar to those with conventional CRS. This suggests that immune deficiency, whether systemic or locally mediated, is well tolerated and may be present in other forms in CRS. CRS patients with low CD8+ levels may possibly require antibacterial therapies as part of ongoing management.

Occupational upper airway disease: how work affects the nose

Chronic inflammation of the upper airways is common and can arbitrarily be divided into rhinitis and rhinosinusitis. Infection and allergy represent two well-characterized and most frequently diagnosed etiologies of upper airway inflammation. Persistent upper airway inflammation caused by agents inhaled in the work environment represents a diagnostic challenge in clinical practice, and its pathophysiology has been little studied. Occupational rhinitis is a recognized medical condition with diagnostic and therapeutic guidelines. In contrast, only limited evidence is available about the relationship between work exposures and rhinosinusitis. This review aims at providing a comprehensive overview of the available literature on occupational upper airway disease with a focus on pathophysiological mechanisms and with an emphasis on the current unmet needs in work-related upper airway disease.

Interleukin-4 and interleukin-13 compromise the sinonasal epithelial barrier and perturb intercellular junction protein expression

BACKGROUND

Altered expression of epithelial intercellular junction proteins has been observed in sinonasal biopsies from nasal polyps and epithelial layers cultured from nasal polyp patients. These alterations comprise a "leaky" epithelial barrier phenotype. We hypothesize that T helper 2 (Th2) cytokines interleukin (IL)-4 and IL-13 modulate epithelial junction proteins, thereby contributing to the leaky epithelial barrier.

METHODS

Differentiated primary sinonasal epithelial layers cultured at the air-liquid interface were exposed to IL-4, IL-13, and controls for 24 hours at 37°C. Epithelial resistance measurements were taken every 4 hours during cytokine exposure. Western blot and immunofluorescence staining/confocal microscopy were used to assess changes in a panel of tight and adherens junction proteins. Western blot densitometry was quantified with image analysis.

RESULTS

IL-4 and IL-13 exposure resulted in a mean decrease in transepithelial resistance at 24 hours to 51.6% (n = 6) and 68.6% (n = 8) of baseline, respectively. Tight junction protein junctional adhesion molecule-A (JAM-A) expression decreased 42.2% with IL-4 exposure (n = 9) and 37.5% with IL-13 exposure (n = 9). Adherens junction protein E-cadherin expression decreased 35.3% with IL-4 exposure (n = 9) and 32.9% with IL-13 exposure (n = 9). Tight junction protein claudin-2 showed more variability but had a trend toward higher expression with Th2 cytokine exposure. There were no appreciable changes in claudin-1, occludin, or zonula occludens-1 (ZO-1) with IL-4 or IL-13 exposure.

CONCLUSION

Sinonasal epithelial exposure to Th2 cytokines IL-4 and IL-13 results in alterations in intercellular junction proteins, reflecting increased epithelial permeability. Such changes may explain some of the phenotypic manifestations of Th2-mediated sinonasal disease, such as edema, nasal discharge, and environmental reactivity.

Practice patterns regarding noninvasive rhinosinusitis in the immunosuppressed patient population

The number of immunosuppressed patients is growing remarkably. Currently, there is no guideline on how treatment of noninvasive sinusitis in these patients may differ from that of the general population, and practice patterns vary widely across the country. The purpose of this survey was to examine practice patterns and management for this patient population. A survey and literature review were performed. The survey was sent to the membership list serve of the American Rhinologic Society. Twelve questions were asked. Four demographic questions were asked about the physicians and their practices. Four questions were asked about the type of immunocompromised patients they saw. Two questions were asked about management in the setting of significant acute and chronic sinusitis. The responses were collected and analyzed using Pearson independent chi-square testing. Of 871 members on the list serve only 89 physicians responded. The majority of responders were sinus and skull base surgeons practicing in an academic setting. There was a large range of geographic location, years in practice, and patient population. Two significant findings related years in practice to management of chronic sinus immunocompromised patients (p = 0.012) and correlated the choice of management option in acute and chronic sinus immunocompromised patients (p = 0.006). There is no standardized method of treating the vulnerable patient population of immunocompromised patients with noninvasive acute and chronic sinusitis and this survey shows the wide range of practice. Clinical research is needed to standardize and optimize treatment for these patients.

Osteitis is a misnomer: a histopathology study in primary chronic rhinosinusitis

BACKGROUND

The histological features of osteitis in chronic rhinosinusitis (CRS) in animal studies induced by bacterial inoculation into maxillary sinuses revealed inflammatory involvement of the underlying bone matrix and/or the Haversian system; however, human studies do not mention these findings. The objective of this study was to investigate the inflammatory characterization of osteitis in CRS.

METHOD

A prospective study of primary CRS patients undergoing sinus surgery was conducted (August 2012 to April 2013). Bone-mucosa samples were taken from a predetermined site that correlated to a computed tomography location. Radiological bone thickness was measured. A blinded histopathological assessment included inflammatory infiltrate of bone, periosteal reaction, presence of osteoblasts or osteoclasts, fibrosis, and the percentage of new woven bone to total bone thickness, together with an overall opinion of whether neo-osteogenesis was present.

RESULTS

Twenty-two primary CRS patients (age 45.8 ± 15.6 years; 59.1% female) were recruited. CRS with polyps accounted for 59.1% of patients. The bony thickness measured radiologically was a median 1.72 (interquartile range [IQR], 2.38; range, 0.3-12.14) mm. No samples (0%) had evidence of inflammatory infiltrate of bone; 90.9% had both osteoblasts present and new woven bone formation. Woven bone was greater with periosteal reaction (80.83% ± 9.25% vs. 47.50% ± 29.37%; p = 0.006), greater with osteoclasts present (80.00% ± 12.58% vs 59.00% ± 28.52%; p = 0.03), and greater when fibrosis was present (69.75% ± 24.14% vs 25.00% ± 7.07%; p = 0.003).

CONCLUSION

Most primary CRS patients demonstrated evidence of new woven bone formation. True "osteitis" with inflammatory infiltrate of the bone was not observed. "Osteitis" is likely a process of neo-osteogenesis and bone remodeling, rather than bone inflammation in primary CRS.

Incidence of middle turbinate lateralization after axillary flap approach to the frontal recess

BACKGROUND

The axillary flap approach (AFA) to the frontal recess improves visualization and clearance while minimizing use of angled endoscopes. However, some argue that it destabilizes the middle turbinate (MT) and increases risk of MT lateralization (MTL). We aimed to establish rates of MTL after AFA, as well as to determine whether other surgical or disease factors affect lateralization.

METHODS

This study was a retrospective chart review. Endoscopic postoperative videos between 3 and 9 months (short-term) and greater than 9 months (long-term) were reviewed blind to surgery performed. Presence of MTL, ability to pass an endoscope into the middle meatus, and ability to evaluate the frontal recess were recorded. Surgical characteristics obtained from the chart review included: MT conchopexy, septoplasty, concha bullosa, and primary vs revision surgery. Patient characteristics included age, sex, polyposis, asthma, and smoking. Cases were excluded if the MT was absent.

RESULTS

A total of 124 patients (248 operated sides) were included in the short-term cohort. Similar numbers of primary (52.4%) and revision (47.6%) cases were performed, 42.3% had polyposis, and 38% asthmatics. Overall rate of MTL was 14.5%, with an inability to examine the frontal recess in 12.1%. Suture conchopexy of the MT through the septum did not affect lateralization. Results were statistically similar in the long-term cohort.

CONCLUSION

The AFA yielded a 14.5% and 17.4% MTL in the short-term and long-term cohorts, respectively. This rate appears consistent with reports in the literature that did not use the axillary flap. No patient or surgical factor was found to affect rates of lateralization.

Sinonasal alterations in computed tomography scans in cystic fibrosis: a literature review of observational studies

BACKGROUND

Almost all cystic fibrosis (CF) patients reveal upper airway involvement in computed tomography (CT) scans. Sinonasal pathology has become a challenging issue because there are few studies to guide appropriate management. The objective of this study was to provide information about paranasal sinus CT manifestations in CF patients, mainly in adulthood.

METHODS

We performed a literature review of descriptive studies about CT sinonasal findings in CF patients using the following databases: MEDLINE, EMBASE, Web of Science, LILACS, Scielo, and Cochrane.

RESULTS

Eighteen articles were included in this review. There was a high variability in methodological aspects for most of the studies. The most prevalent findings reported were opacification of sinuses, presence of frontal and sphenoidal aplasia or hypoplasia, underdevelopment of paranasal sinuses, and medial bulging of the lateral nasal wall in CT scans.

CONCLUSION

There are few studies in the CF adult population regarding sinonasal CT alterations. Many studies report specific pathological features in CF upper airways that could help in the diagnosis of doubtful cases.

Chronic illness associated with mold and mycotoxins: is naso-sinus fungal biofilm the culprit?

It has recently been demonstrated that patients who develop chronic illness after prior exposure to water damaged buildings (WDB) and mold have the presence of mycotoxins, which can be detected in the urine. We hypothesized that the mold may be harbored internally and continue to release and/or produce mycotoxins which contribute to ongoing chronic illness. The sinuses are the most likely candidate as a site for the internal mold and mycotoxin production. In this paper, we review the literature supporting this concept.

Expression of IL-33 and its receptor ST2 in chronic rhinosinusitis with nasal polyps

OBJECTIVES/HYPOTHESIS

Interleukin (IL)-33 is a novel member of the IL-1 cytokine family and a ligand for the orphan IL-1 family receptor ST2. IL-33 induces T helper 2-type inflammatory responses and is considered to play a crucial role in allergic inflammatory reactions such as asthma and atopic dermatitis. However, the role of IL-33 and its receptor ST2 in chronic rhinosinusitis remains unclear.

STUDY DESIGN

In vitro study.

METHODS

The expression patterns of IL-33 and ST2 at both mRNA and protein levels in nasal polyps from eosinophilic chronic rhinosinusitis (ECRS) patients (n = 10) and non-ECRS patients (n = 13), as well as in seemingly normal mucosa of the uncinate processes in patients without sinusitis (control; n = 5), were compared using immunohistochemical staining, enzyme-linked immunosorbent assay, and real-time polymerase chain reactions.

RESULTS

ST2-positive cells in the inflammatory cells in the subepithelial layer were significantly higher in the ECRS group than other groups. The expression of ST2 mRNA in polyps of the ECRS group was significantly increased compared with controls. Many ST2-positive eosinophils were observed in the mucosa of ECRS but not in the mucosa of non-ECRS patients. The expression level of IL-33 mRNA was not significantly different among the three groups.

CONCLUSIONS

The current study suggests that IL-33 and its receptor ST2 may play important roles in the pathogenesis of chronic rhinosinusitis, especially in ECRS, through the increased expression of ST2 in eosinophils.

LEVEL OF EVIDENCE

N/A.

Incidence of unplanned admissions after sinonasal surgery: a 6-year review

BACKGROUND

There has been an increasing transition from hospital-based surgeries to ambulatory surgery center (ASC)-based surgeries. A significant portion of ASC cases are otolaryngological procedures, with sinonasal surgery as one of the most common procedures. However, admissions into the hospital from the ASC can be difficult for the patient and the provider. This study evaluates the incidence of unplanned admissions after sinonasal surgery in a 6-year period and identifies the factors for these admissions.

METHODS

A retrospective study was conducted of patients who had ambulatory sinonasal surgeries from January 2007 to December 2012 at Weill Cornell Medical Center/New York Presbyterian Hospital performed by the senior author (A.K.). Electronic medical records were reviewed for age, gender, procedure/surgery performed, and admission and/or discharge information.

RESULTS

A total of 750 patients who underwent sinonasal surgeries from January 2007 to December 2012 were eligible for review. The study sample had a mean age of 46 years and 55.6% were male. There were a total of 24 admissions, of which 6 were unplanned (0.8%). Reasons for unplanned admissions included pain (most common, 50%), followed by epistaxis, nausea, and other.

CONCLUSION

The rate for unplanned admissions for sinonasal surgeries was 0.8%, which is lower than the national rate (2.65%), indicating that sinonasal surgeries are appropriate as ambulatory cases. Because the reason for unplanned admission was highest for pain, patients should be further evaluated for more effective methods of pain control postoperatively or preemptively.

Epidemiology and differential diagnosis of nasal polyps

BACKGROUND

Chronic rhinosinusitis (CRS) is one of the most common chronic medical conditions, with a significant impact on patient quality of life. CRS is broadly classified into two groups: CRS with nasal polyposis (CRSwNP) and CRS without NP (CRSsNP). Clinically, the major subtypes of CRSwNP may be divided into eosinophilic chronic rhinosinusitis (e.g., allergic fungal rhinosinusitis and aspirin-exacerbated respiratory disease [AERD]) and nasal polyps associated with neutrophilic inflammation (e.g., cystic fibrosis [CF]). CF is characterized by mutation of the gene encoding the CF transmembrane conductance regulator. Functional endoscopic sinus surgery is usually required for most NP patients with increased frequency in patients with AERD. This study provides a review of the epidemiology and major classification of CRSwNP.

METHODS

A review was performed of the literature regarding different subtypes of CRSwNP.

RESULTS

Many definitions of CRSwNP exist and estimates of prevalence vary.

CONCLUSION

CRSwNP is a clinical syndrome with a heterogeneous inflammatory profile. Of the subtypes associated with eosinophilic inflammation, AERD remains the most recalcitrant to medical and surgical therapeutic interventions.

Interferon gamma causes olfactory dysfunction without concomitant neuroepithelial damage

BACKGROUND

Olfactory loss is a debilitating symptom of chronic rhinosinusitis (CRS). The pathophysiology of inflammatory olfactory dysfunction likely involves both conductive and sensorineural components. To study the interaction of CRS-associated inflammatory cytokines with the olfactory epithelium (OE), a transgenic mouse model was developed that allows temporally-controlled local gene expression. Interferon-gamma (IFN-γ) is a prototypical T helper 1 (Th1) cytokine linked to nonpolypoid CRS (CRSsNP), as well as sinonasal viral and bacterial infections. In this study, the effects of chronic IFN-γ expression on olfactory histology and function were investigated.

METHODS

IFN-γ secretion by olfactory sustentacular cells was induced in the transgenic mouse. Viability and gross behavior were unaffected. Mice were euthanized after 6 weeks of IFN-γ expression, and olfactory tissue was studied by histology, immunohistochemistry, and electro-olfactography (EOG). Findings were compared with uninduced littermates.

RESULTS

IFN-γ expression did not result in alteration of the normal histologic architecture of the neuroepithelium or lamina propria. However, EOG recordings demonstrated a significant decrease in odorant responses after IFN-γ expression. In addition, a marked increase in submucosal CD45-positive cells was observed, the majority of which were CD3-positive and CD4-positive lymphocytes.

CONCLUSION

Chronic IFN-γ expression in the mouse OE results in diminished odorant responsiveness, despite the absence of inflammatory tissue damage. This suggests a direct effect of IFN-γ on olfactory neuron function that may underlie olfactory loss in CRSsNP or viral infections. The infiltration of submucosal lymphocytes raises the possibility that other downstream cytokines also contribute to olfactory dysfunction.

Cystic fibrosis chronic rhinosinusitis: a comprehensive review

BACKGROUND

Advances in the care of patients with cystic fibrosis (CF) have improved pulmonary outcomes and survival. In addition, rapid developments regarding the underlying genetic and molecular basis of the disease have led to numerous novel targets for treatment. However, clinical and basic scientific research focusing on therapeutic strategies for CF-associated chronic rhinosinusitis (CRS) lags behind the evidence-based approaches currently used for pulmonary disease.

METHODS

This review evaluates the available literature and provides an update concerning the pathophysiology, current treatment approaches, and future pharmaceutical tactics in the management of CRS in patients with CF.

RESULTS

Optimal medical and surgical strategies for CF CRS are lacking because of a dearth of well-performed clinical trials. Medical and surgical interventions are supported primarily by level 2 or 3 evidence and are aimed at improving clearance of mucus, infection, and inflammation. A number of novel therapeutics that target the basic defect in the cystic fibrosis transmembrane conductance regulator channel are currently under investigation. Ivacaftor, a corrector of the G551D mutation, was recently approved by the Food and Drug Administration. However, sinonasal outcomes using this and other novel drugs are pending.

CONCLUSION

CRS is a lifelong disease in CF patients that can lead to substantial morbidity and decreased quality of life. A multidisciplinary approach will be necessary to develop consistent and evidence-based treatment paradigms.

Resveratrol prevents development of eosinophilic rhinosinusitis with nasal polyps in a mouse model

BACKGROUND

Since the recent establishment of a murine model of eosinophilic chronic rhinosinusitis with nasal polyps (CRSwNP), both the development of new drugs for treatment or prevention of eosinophilic CRSwNP and elucidation of their pathogenesis have been feasible. We investigated the therapeutic effects of resveratrol on CRSwNP and its mechanism of action using a murine model.

METHODS

After induction of eosinophilic CRSwNP, the therapeutic effects of resveratrol were tested and compared with those of triamcinolone acetonide. Histopathologic changes were evaluated using hematoxylin and eosin for overall inflammation, Sirius red for eosinophils, and Masson's trichrome stain for collagen. The expression levels of the interleukin (IL)-4, IL-5, prostaglandin D synthase, and leukotriene C4 synthase genes were assessed by quantitative real-time PCR. Cyclooxygense-2 and 5-lipoxygense levels were evaluated by immunohistochemical staining and Western blot analysis.

RESULTS

The degree of eosinophilic infiltration and subepithelial fibrosis was significantly decreased by administration of high-dose resveratrol, the potency of which was similar to that of triamcinolone acetonide. The expression levels of the IL-4, IL-5, prostaglandin D synthase, and leukotriene C4 synthase genes were significantly decreased by administration of low- or high-dose resveratrol. The production of 5-lipoxygenase was strongly inhibited by high-dose resveratrol.

CONCLUSIONS

Resveratrol may be useful for the prevention of eosinophilic CRSwNP. A key mechanism of its action is believed to be its anti-inflammatory effect, particularly on eosinophils, by inhibiting the lipoxygenase pathway.

Retained drug-eluting stents and recalcitrant chronic rhinosinusitis: A case report

Corticosteroids are the mainstay of treatment for refractory chronic rhinosinusitis. The off-label use of steroid-eluting stents has increasingly gained popularity in functional endoscopic sinus surgery for decreasing postoperative inflammation and synechiae formation. However, there is a paucity of data outlining the safety profile of this device despite its widespread use. This study was designed to report a newly described complication of retained drug-eluting stents from endoscopic sinus surgery for refractory rhinosinusitis. This report highlights a potential risk of the drug-eluting stent in the treatment of recalcitrant rhinosinusitis and the need for further clinical investigations whenever a novel medical device becomes available on the market.

Chronic rhinosinusitis and emerging treatment options

This review describes the epidemiology and various treatments in chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). Evidence for short-term use of systemic corticosteroids has been shown to be favorable in CRSwNP, but still limited in CRSsNP. Topical corticosteroids improve symptom scores in both CRS subgroups. The role of microbes in CRS is still controversial. Culture-directed antibiotics are recommended for CRSsNP with exacerbation. Long-term use of low dosage antibiotics is recommended for CRSsNP for their anti-inflammatory effects. Other emerging treatment options are also discussed.

Regulation of inflammation-associated olfactory neuronal death and regeneration by the type II tumor necrosis factor receptor

BACKGROUND

Olfactory loss is a debilitating symptom of chronic rhinosinusitis. To study the impact of inflammation on the olfactory system, the inducible olfactory inflammation (IOI) transgenic mouse was created in which inflammation can be turned on and off within the olfactory epithelium. In this study, the type II tumor necrosis factor (TNF) receptor (TNFR2) was knocked out, and the effect on the olfactory loss phenotype was assessed.

METHODS

IOI mice were bred to TNFR2 knockout mice to yield progeny IOI mice lacking the TNFR2 receptor (TNFR2(-/-) ). TNF-α expression was induced within the olfactory epithelium for 6 weeks to generate chronic inflammation. Olfactory function was assayed by electro-olfactogram (EOG), and olfactory tissue was processed for histology and immunohistochemical staining.

RESULTS

Compared to IOI mice with wild-type TNFR2, IOI mice lacking the TNFR2 demonstrated similar levels of inflammatory infiltration and enlargement of the subepithelial layer. However, IOI-TNFR2(-/-) mice differed markedly in that the neuronal layer was largely preserved and active progenitor cell proliferation was present. Odorant responses were maintained in the IOI-TNFR2(-/-) mice, in contrast to IOI mice.

CONCLUSION

TNFR2 is the minor receptor for TNF-α, but appears to play an important role in mediating TNF-induced disruption of the olfactory system. This finding suggests that neuronal death and inhibition of proliferation in CRS may be mediated by TNFR2 on olfactory neurons and progenitor cells. Further studies are needed to elucidate the subcellular pathways involved and develop novel therapies for treating olfactory loss in the setting of CRS.

Complementary and integrative treatments: rhinosinusitis

Rhinosinusitis is characterized by inflammation of the mucosa involving the paranasal sinuses and the nasal cavity and is one of the most common health care problems, with significant impairment of quality of life. There is a growing amount of interest in the use of complementary and integrative medicine for the treatment of rhinosinusitis. This article focuses on an integrative approach to rhinosinusitis.

Upper airway inflammation exacerbates bronchial hyperreactivity in mouse models of rhinosinusitis and allergic asthma

BACKGROUND

Recent studies have suggested that upper airway inflammation has a strong impact on lower airway diseases. The purpose of this study was to assess whether nasal inflammation could exacerbate allergic asthma in a mouse model.

METHODS

Mice were assigned to 4 groups: control (Cont), either rhinosinusitis (R) or allergic asthma (A) alone, and both rhinosinusitis and allergic asthma (R&A). Mice underwent induction of nasal inflammation (R and R&A) or sham surgery (Cont and A) on day 1. Mice in the A and R&A groups were sensitized to ovalbumin on days 1, 7, and 14, followed by aerosol challenge on days 18 to 20, whereas in the Cont and R groups only saline was administered. All mice were assessed for airway hyperresponsiveness (AHR) and were euthanized on day 21. The sera, bronchoalveolar lavage fluids (BALFs), and nasal and lung tissues were collected for further analyses.

RESULTS

Histology findings confirmed upper and lower airway inflammation in experimental mice. Significantly increased AHR and total serum immunoglobulin E (IgE) were observed in the R&A group when compared with those of the Cont, R, and A groups. Responses to IgG2a induction were also found in sera and BALFs from mice with rhinosinusitis (R and R&A). Higher levels of interleukin 4 (IL-4) and IL-13, and increased eosinophilic inflammation were detected in BALFs and lung tissues from the experimental groups when compared with those from the Cont group.

CONCLUSION

Our results confirm that upper airway inflammation could exacerbate allergic asthma, and provide support to the concept of "one airway, one disease.

Safety and outcomes following hybrid balloon and balloon-only procedures using a multifunction, multisinus balloon dilation tool

BACKGROUND

A multicenter prospective study was conducted to assess the safety and sustained effectiveness of a new instrument possessing multifunctionality as an ostium seeker, suction-irrigator, and malleable balloon-dilator indicated for treating multiple sinuses.

METHODS

Endoscopic balloon-only and hybrid-balloon procedures involving dilation of the frontal recesses, maxillary ostia, and/or sphenoid sinus ostia were performed in 175 patients. One-month follow-up was required for all patients. The first 50 patients enrolled also consented to a 1-year follow-up. Complications and sinus symptom severity were assessed at the 1-month visit. Symptom severity and ostial patency of the treated sinuses were evaluated at the 1-year visit.

RESULTS

A total of 497 balloon dilations (279 frontal, 138 sphenoid, and 80 maxillary) were attempted in 175 patients. Over 96% (479/497) of the attempted sinus dilations were successfully completed, while 18 dilations were converted to traditional dissection due to an inability to access or dilate the targeted anatomy. Two (1.1%) nonserious adverse events were reported following hybrid-balloon dilation and both were unrelated to the device or the procedure. Forty-four of 50 patients in the extended follow-up cohort completed the 1-year follow-up. Sinus symptom improvement in this group improved significantly from an average severity of 1.9 ± 1.1 to 0.8 ± 0.7 (p < 0.0001) and 1-year ostial patency was 91.6% (76/83). One revision surgery (2.3%) was performed.

CONCLUSION

These results indicate that a multifunctional, malleable, balloon-dilating device can be safely and successfully used to treat multiple sinuses with sustained ostial patency and symptom improvement for at least 1 year.

Infections and foreign bodies in ENT

Infections play a major role in the practice of ENT. Microbial penetration into tissues of the head and neck can initiate a focal reaction causing superficial self-resolving infections. However, some of these have the potential to develop into life-threatening disease. We provide an overview of the most common ENT infections with focus on the presentation, diagnosis and management. Foreign bodies of the ear, nose and throat are a common presentation to primary and emergency care. Most commonly these are seen in children and include plastic toys, beads and foodstuffs inserted into the ears and nose. Diagnosis is often delayed as insertion is usually not witnessed. In exceptional cases airway foreign bodies can present as a life-threatening emergency. Removal of foreign bodies can usually be achieved by a skilled practitioner with minimal complications. Methods of removal include suction catheters, syringing, and use of instrumentation. In adults, the treatment of oesophageal food bolus obstruction may require a combination of medical and surgical intervention.

Nose and lungs: one way, one disease

It's well established that asthma, allergic rhinitis and rhinosinusitis are three closely related disease. In pediatrics, these conditions represent a common issue in daily practice. The scientific community has recently started to simply evaluate them as different manifestations of a common pathogenic phenomenon. This consideration relates to important implications in the clinical management of these diseases, which may affect the daily activity of a pediatrician. The unity of the respiratory tract is confirmed both from a morphological and from a functional point of view. When treating rhinitis, it is often necessary to assess the presence of asthma. Patients with sinusitis should be evaluated for a possible concomitant asthma. Conversely, patients with asthma should always be evaluated for possible nasal disease, especially those suffering from difficult-to-treat asthma, in which an occult sinusitis may be detected. The medications that treat nasal diseases appear to be useful in improving asthma control and in reducing bronchial hyperresponsiveness. It seems therefore important to analyze the link between asthma and sinusitis, both in terms of clinical and pathogenic features, as well the therapeutic approach of those patients presenting with these diseases.

Nontypeable Haemophilus influenzae biofilms: role in chronic airway infections

Like many pathogens inhabiting mucosal surfaces, nontypeable Haemophilus influenzae (NTHi) forms multicellular biofilm communities both in vitro and in various infection models. In the past 15 years much has been learned about determinants of biofilm formation by this organism and potential roles in bacterial virulence, especially in the context of chronic and recurrent infections. However, this concept has not been without some degree of controversy, and in the past some have expressed doubts about the relevance of NTHi biofilms to disease. In this review, I will summarize the present information on the composition and potential role(s) of NTHi biofilms in different clinical contexts, as well as highlight potential areas for future work.