Autonomic dysfunction, allergy and the upper airway

Improvements after dry needling for craniofacial pain in a patient with chronic rhinosinusitis: a case report

BACKGROUND

Typically treated medically, chronic rhinosinusitis (CRS) is a prevalent condition characterized by multiple craniofacial symptoms, some of which may respond favorably to dry needling intervention.

OBJECTIVE

To describe the outcomes of a patient presenting with craniofacial pain and symptoms consistent with a diagnosis of CRS who was treated with dry needling. Case Description: A 41-year-old male, self-referred to physical therapy with a diagnosis of CRS, with a 20-year history of signs and symptoms associated with CRS, including craniofacial pain and headaches. The patient had been treated with multiple medication regimens over this time, including antihistamines, anti-inflammatories, decongestants, leukotriene inhibitors, and antibiotics; all of which provided only short-term relief. On initial examination, the patient was tender to palpation in multiple muscles of the head, neck, and face. Intervention consisted of dry needling to these muscular tender points once or twice weekly over 2 months.

OUTCOMES

After 2 months of dry needling, the patient demonstrated clinically meaningful improvements in pain and quality of life, which included a decrease in both medication usage and the frequency of sinus infections.

CONCLUSION

Although CRS is generally managed medically, we observed areas of muscular tenderness in this case, which were effectively managed with dry needling. Rehabilitative providers may consider screening CRS patients for muscular impairments that may be modifiable with dry needling. Further research should be performed to determine whether dry needling has a role in the management of CRS.

Rationale and Design of a Panel Study Investigating Six Health Effects of Airborne Pollen: The EPOCHAL Study

Background: While airborne pollen is widely recognized as a seasonal cause of sneezing and itchy eyes, its effects on pulmonary function, cardiovascular health, sleep quality, and cognitive performance are less well-established. It is likely that the public health impact of pollen may increase in the future due to a higher population prevalence of pollen sensitization as well as earlier, longer, and more intense pollen seasons, trends attributed to climate change. The effects of pollen on health outcomes have previously been studied through cross-sectional design or at two time points, namely preceding and within the period of pollen exposure. We are not aware of any observational study in adults that has analyzed the dose-response relationship between daily ambient pollen concentration and cardiovascular, pulmonary, cognitive, sleep, or quality of life outcomes. Many studies have relied on self-reported pollen allergy status rather than objectively confirming pollen sensitization. In addition, many studies lacked statistical power due to small sample sizes or were highly restrictive with their inclusion criteria, making the findings less transferable to the "real world." Methods: The EPOCHAL study is an observational panel study which aims to relate ambient pollen concentration to six specific health domains: (1) pulmonary function and inflammation; (2) cardiovascular outcomes (blood pressure and heart rate variability); (3) cognitive performance; (4) sleep; (5) health-related quality of life (HRQoL); and (6) allergic rhinitis symptom severity. Our goal is to enroll 400 individuals with diverse allergen sensitization profiles. The six health domains will be assessed while ambient exposure to pollen of different plants naturally varies. Health data will be collected through six home nurse visits (at approximately weekly intervals) as well as 10 days of independent tracking of blood pressure, sleep, cognitive performance, HRQoL, and symptom severity by participants. Through repeated health assessments, we aim to uncover and characterize dose-response relationships between exposure to different species of pollen and numerous acute health effects, considering (non-)linearity, thresholds, plateaus and slopes. Conclusion: A gain of knowledge in pollen-health outcome relationships is critical to inform future public health policies and will ultimately lead toward better symptom forecasts and improved personalized prevention and treatment.

Rhinitis and Sinusitis in the Geriatric Population

Rhinitis and sinusitis are common medical conditions that affect the geriatric population and have a significant impact on their quality of life. Because few studies examine differences in the clinical management between the geriatric and general adult population, therapies should be based on current guidelines. Special considerations should be made when treating these patients in regards to multiple comorbidities and the potential for drug interactions from polypharmacy. Further research on the pathogenesis of sinusitis in the geriatric population may provide specific differences in the clinical management in this population.

General illness and psychological factors in patients with chronic nasal symptoms

OBJECTIVES

Only a minority of patients referred to specialists with sinonasal symptoms have clear evidence of chronic rhinosinusitis (CRS). This study aims to estimate the prevalence of and associations between (i) general illness factors (fatigue, autonomic dysfunction) and (ii) psychological factors (anxiety, depression, somatisation, personality traits) in patients presenting with sinonasal symptoms.

DESIGN

The following validated questionnaires were administered to patients: the Sino-Nasal Outcome Test-22 (SNOT-22) identifying symptom burden, Composite Autonomic Symptom Score-31 (COMPASS-31) measuring autonomic function, Chalder Fatigue Questionnaire, Patient Health Questionnaire-15 (PHQ-15) addressing somatisation symptoms, Hospital Anxiety and Depression Scale (HADS), and the International Personality Item Pool-50 (IPIP-50). Comparisons were made with normative and general population data, and relationships were analysed using nonparametric correlation.

SETTING

Secondary care ENT outpatients.

PARTICIPANTS

Adults referred with chronic sinonasal symptoms.

MAIN OUTCOME MEASURES

SNOT-22, COMPASS-31, Chalder, PHQ-15, HADS, and IPIP-50 questionnaire scores.

RESULTS

Sixty-one patients were included. There was a high prevalence of all general and psychological factors assessed compared with controls. Total SNOT-22 scores showed significant correlation with Chalder fatigue scores, total autonomic dysfunction score, anxiety, depression, somatisation tendencies and the emotionally unstable personality trait. Emotional instability and psychological dysfunction correlated significantly with sleep and psychological subscales of SNOT-22 but not the rhinological or ear/facial subscales.

CONCLUSION

Patients with sinonasal symptoms demonstrate high prevalence and complex associations of general illness factors, psychological distress and certain personality traits. The SNOT-22 is a valuable tool, but its utility is limited by correlations with these confounding factors (eg psychological factors) that may exaggerate the total score. The use of the SNOT-22 component subscales is likely to provide more clinically meaningful and discriminant information.

Effects of intranasal kinetic oscillation stimulation on heart rate variability

Background

Kinetic oscillation stimulation in the nasal cavity (KOS) has been shown to have positive symptomatic effects in subjects with non‐allergic rhinitis and in patients with migraine.

Methods

To evaluate the effect of KOS on autonomic function, we assessed heart rate variability (HRV) in this small exploratory study in 12 healthy subjects. KOS treatment was performed using a minimally invasive system with a single‐use catheter inserted into the nasal cavity. During treatment, the tip was inflated and oscillated with a mean pressure of 95 millibar and amplitude of the oscillations of 100 millibar at a frequency of 68 Hz. Treatment was given for 15 minutes sequentially on each side. Heart rate variability was assessed during five 30‐minutes periods before, during and immediately after KOS treatment and 3.5 hours thereafter. KOS resulted in a substantial reduction of HRV.

Results

As compared to baseline recorded during 30 minutes preceding treatment, VLF was reduced by 65%, LF by 55%, the ratio LF/HF by 44%, with somewhat smaller observed effects in the time domain; SDNN and RMSDD were reduced by of 36% and 18%, respectively. Heart rate remained stable during treatment with minimal mean changes from 68 ± 7 bpm before to 68 ± 9 and 69 ± 9 bpm during and after treatment. Reduction of HRV parameters was consistently seen in all subjects, with rapid onset and return towards baseline values during post‐treatment observation periods.

Conclusions

KOS has an effect on the autonomic balance with pronounced heart‐rate independent reduction on HRV.

Sphenopalatine Ganglion Acupuncture Improves Nasal Ventilation and Modulates Autonomic Nervous Activity in Healthy Volunteers: A Randomized Controlled Study

The study aimed to assess the effects of Sphenopalatine ganglion (SPG) acupuncture on nasal ventilation function and autonomic nervous system in health volunteers. 39 healthy subjects were randomly assigned to either active SPG acupuncture group (AA group) or sham-SPG acupuncture group (SA group). All subjects were assessed for self-reported nasal ventilation, nasal patency (nasal airway resistance (NAR) and nasal cavity volume (NCV), exhaled nasal nitric oxide (nNO), and neuropeptides (substance P(SP), vasoactive intestinal peptide (VIP) and neuropeptide Y (NPY)) in nasal secretions at baseline, 30 minutes, 2 hours, and 24 hours after acupuncture. Significantly more subjects in AA group reported improvements in nasal ventilation at all time points after acupuncture, compared to SA group. NAR and NCV were also significantly lower in AA group than SA group. The level of nNO in AA group was significantly decreased after 24 hours compared to SA group. The level of NPY was significantly increased in AA group at 30 minutes and 2 hours compared to baseline and SA group. The levels of SP and VIP were not significantly different in the two groups. We concluded that SPG acupuncture could help to improve nasal ventilation by increasing sympathetic nerve excitability in healthy volunteers.

Underlying Mechanisms in Episodic Laryngeal Breathing Disorders

The study and management of episodic laryngeal breathing disorders (ELBD)—characterized by paradoxical laryngeal movement patterns and dyspnea—has traditionally focused on clinical presentation of these conditions. However, the underlying mechanisms driving these entities are largely unknown. This article provides a review of potential underlying mechanisms driving clinical expression in ELBD and suggests approaches to the future study of ELBD etiology.

Thiamine and magnesium deficiencies: keys to disease

Thiamine deficiency (TD) is accepted as the cause of beriberi because of its action in the metabolism of simple carbohydrates, mainly as the rate limiting cofactor for the dehydrogenases of pyruvate and alpha-ketoglutarate, both being critical to the action of the citric acid cycle. Transketolase, dependent on thiamine and magnesium, occurs twice in the oxidative pentose pathway, important in production of reducing equivalents. Thiamine is also a cofactor in the dehydrogenase complex in the degradation of the branched chain amino acids, leucine, isoleucine and valine. In spite of these well accepted facts, the overall clinical effects of TD are still poorly understood. Because of the discovery of 2-hydroxyacyl-CoA lyase (HACL1) as the first peroxisomal enzyme in mammals found to be dependent on thiamine pyrophosphate (TPP) and the ability of thiamine to bind with prion protein, these factors should improve our clinical approach to TD. HACL1 has two important roles in alpha oxidation, the degradation of phytanic acid and shortening of 2-hydroxy long-chain fatty acids so that they can be degraded further by beta oxidation. The downstream effects of a lack of efficiency in this enzyme would be expected to be critical in normal brain metabolism. Although TD has been shown experimentally to produce reversible damage to mitochondria and there are many other causes of mitochondrial dysfunction, finding TD as the potential biochemical lesion would help in differential diagnosis. Stresses imposed by infection, head injury or inoculation can initiate intermittent cerebellar ataxia in thiamine deficiency/dependency. Medication or vaccine reactions appear to be more easily initiated in the more intelligent individuals when asymptomatic marginal malnutrition exists. Erythrocyte transketolase testing has shown that thiamine deficiency is widespread. It is hypothesized that the massive consumption of empty calories, particularly those derived from carbohydrate and fat, results in a high calorie/thiamine ratio as a major cause of disease. Because mild to moderate TD results in pseudo hypoxia in the limbic system and brainstem, emotional and stress reflexes of the autonomic nervous system are stimulated and exaggerated, producing symptoms often diagnosed as psychosomatic disease. If the biochemical lesion is recognized at this stage, the symptoms are easily reversible. If not, and the malnutrition continues, neurodegeneration follows and results in a variety of chronic brain diseases. Results from acceptance of the hypothesis could be tested by performing erythrocyte transketolase tests to pick out those with TD and supplementing the affected individuals with the appropriate dietary supplements.

Kinetic oscillation stimulation as treatment of non-allergic rhinitis: an RCT study

CONCLUSION

Kinetic oscillation stimulation (KOS) of nasal mucosa at low frequency seems to be a possibly effective and safe short-term treatment of non-allergic nasal stuffiness.

OBJECTIVE

To assess the relief of rhinitis symptoms, especially stuffiness, by comparing active treatment, i.e. KOS at low frequency of the nasal mucosa, with placebo.

METHODS

Patients were randomized to active or placebo treatment in this double-blinded parallel design study. Treatment with an inflatable oscillating catheter was administered on day 0, and symptom scores (stuffiness, secretion, and itching) were graded daily until day 14. An overall grading of symptoms from 1 week before treatment and during 14 days thereafter was made at day 14. Eighty-six patients (52 with non-allergic perennial rhinitis, NAR; 34 with rhinitis medicamentosa, RM) were randomized, and 71 were evaluated (active treatment, n = 35; placebo, n = 36).

RESULTS

Patients with either NAR or RM who received active treatment reported reduced symptom scores by some measures, e.g. median RQSS stuffiness measure fell from 2 to 1 on a scale from 0 to 3 during the week following treatment. No significant effect was observed for patients treated with placebo. Mild side effects were reported.

Nicotine enhances both excitatory and inhibitory synaptic inputs to inspiratory-activated airway vagal preganglionic neurons

The airway vagal preganglionic neurons (AVPNs) supply the essential excitatory drive to the postganglionic neurons and dominate the neural control of the airway both physiologically and pathophysiologically. The AVPNs express multiple subunits of nicotinic acetylcholine receptors (nAChRs), but the influences of exogenous nicotine and endogenous acetylcholine are unknown. This study examined the effects of nicotine and endogenous acetylcholine on retrogradely labelled, functionally identified inspiratory-activated AVPNs (IA-AVPNs) using the patch-clamp technique. Nicotine (10 μmol l(-1)) significantly increased the frequency and amplitude of the spontaneous EPSCs of IA-AVPNs, and these effects were insensitive to methyllycaconitine (MLA, 100 nmol l(-1)), an antagonist of the α7 type of nAChR, but was prevented by dihydro-β-erythroidine (DHβE, 3 μmol l(-1)), an antagonist of the α4β2 type of nAChR. Nicotine caused a tonic inward current in IA-AVPNs, which was reduced by MLA or DHβE alone, but was not abolished by co-application of MLA and DHβE. Nicotine caused a significant increase in the frequency of GABAergic and glycinergic spontaneous IPSCs and significantly increased the amplitude of glycinergic spontaneous IPSCs, all of which were prevented by DHβE. Nicotine had no effects on the miniature EPSCs or miniature IPSCs following pretreatment with TTX. Under current clamp, nicotine caused depolarization and increased the firing rate of IA-AVPNs during inspiratory intervals. Neostigmine (10 μmol l(-1)), an acetylcholinesterase inhibitor, mimicked the effects of nicotine. These results demonstrate that nicotine and endogenous ACh enhance the excitatory and inhibitory synaptic inputs of IA-AVPNs and cause a postsynaptic excitatory current and that the nicotinic effects are mediated presynaptically by activation of the α4β2 type of nAChR and postsynaptically by activation of multiple nAChRs, including α7 and α4β2 types.

Agonist of 5-HT1A/7 receptors but not that of 5-HT2 receptors disinhibits tracheobronchial-projecting airway vagal preganglionic neurons of rats

The vagus nerves supply the major cholinergic tone to airway smooth muscles physiologically and play critical roles in the genesis of airway hyperreactivity under some pathological conditions. Postganglionic airway cholinergic tone relies largely on the ongoing activity of medullary airway vagal preganglionic neurons (AVPNs), of which the tracheobronchial-projecting ones are primarily located in the external formation of the nucleus ambiguus (eNA). AVPNs are regulated by 5-HT, and 5-HT(1A/7) and 5-HT(2) receptors have been indicated to be involved. But the mechanisms at synaptic level are unknown. In the present study, tracheobronchial-projecting AVPNs (T-AVPNs) were retrogradely labeled from the trachea wall; fluorescently labeled T-AVPNs in the eNA were recorded with whole-cell voltage patch clamp; and the effects of 5-HT(1A/7) receptor agonist (±)-8-Hydroxy-2-(dipropylamino) tetralin hydrobromide (8-OH-DPAT) (1 μmol L(-1)) and 5-HT(2) receptor agonist 1-(2,5-dimethoxy-4-iodophenyl)-2-aminopropane (DOI) (10 μmol L(-1)) on the synaptic inputs were examined. 8-OH-DPAT significantly inhibited the GABAergic and glycinergic spontaneous inhibitory postsynaptic currents (sIPSCs) of T-AVPNs in both the frequency and amplitude but had no effect on the GABAergic and glycinergic miniature inhibitory postsynaptic currents (mIPSCs). The 8-OH-DPAT inhibition of the GABAergic and glycinergic sIPSCs was prevented by 5-HT(1A/7) receptor antagonist N-[2-[4-(2-Methoxyphenyl)-1-piperazinyl] ethyl]-N-2-pyridinylcyclohexanecarboxamide maleate salt (WAY-100635) (1 μmol L(-1)). 8-OH-DPAT had no effect on the glutamatergic spontaneous excitatory postsynaptic currents (sEPSCs) and caused no alterations in the baseline current and input resistance of T-AVPNs. DOI had no effect on any types of the synaptic inputs of T-AVPNs. These results suggest that 5-HT(1A/7) receptor agonist causes "disinhibition" of T-AVPNs, which might, in part, account for the reflex increase of airway resistance.

Inspiratory-activated and inspiratory-inhibited airway vagal preganglionic neurons in the ventrolateral medulla of neonatal rat are different in intrinsic electrophysiological properties

This study investigates the firing properties of the inspiratory-activated and inspiratory-inhibited airway vagal preganglionic neurons located in the external formation of the nucleus ambiguus. The results showed that inspiratory-activated and inspiratory-inhibited neurons are distributed with different density and site preference in this area. Inspiratory-inhibited neurons exhibit significantly more positive resting membrane potential, more negative voltage threshold and lower minimal current required to evoke an action potential under current clamp. The afterhyperpolarization in inspiratory-activated neurons was blocked by apamin, a blocker of the small-conductance Ca(2+)-activated K(+) channels; and that in inspiratory-inhibited neurons by charybdotoxin, a blocker of the large-conductance Ca(2+)-activated K(+) channels. Under voltage clamp, depolarizing voltage steps evoked tetrodotoxin-sensitive rapid inward sodium currents, 4-aminopyridine-sensitive outward potassium transients and lasting outward potassium currents. 4-Aminopyridine partially blocked the lasting outward potassium currents of inspiratory-activated neurons but was ineffective on those of inspiratory-inhibited neurons. These findings suggest that inspiratory-activated and inspiratory-inhibited neurons are differentially organized and express different types of voltage-gated ion channels.

Dysautonomia in autism spectrum disorder: case reports of a family with review of the literature

Case histories of a mother and her two children are reported. The mother was a recovered alcoholic. She and her two children, both of whom had symptoms that are typical of autistic spectrum disorder, had dysautonomia. All had intermittently abnormal erythrocyte transketolase studies indicating abnormal thiamine pyrophosphate homeostasis. Both children had unusual concentrations of urinary arsenic. All had symptomatic improvement with diet restriction and supplementary vitamin therapy but quickly relapsed after ingestion of sugar, milk, or wheat. The stress of a heavy metal burden, superimposed on existing genetic or epigenetic risk factors, may be important in the etiology of autism spectrum disorder when in combination. Dysautonomia has been associated with several diseases, including autism, without a common etiology. It is hypothesized that oxidative stress results in loss of cellular energy and causes retardation of hard wiring of the brain in infancy, affecting limbic system control of the autonomic nervous system.

Endoscopic diode laser polypectomy and high-dose intranasal steroids in recurrent nasal polyposis

BACKGROUND

The aim of this clinical investigation was to determine the outcomes of an outpatient videoendoscopic diode laser polypectomy (DLPE) and subsequent topical high-dose corticosteroid application in chronic rhinosinusitis with recurrent nasal polyposis (NP).

METHODS

After ineffective revision sinus surgery and prolonged mometasone furoate application, 19 consecutive mild and moderate NP patients suffering from nasal obstruction (NO) and olfactory dysfunction (OD) were prospectively entered into the study to undergo DLPE under topical anesthesia. Beginning 1 week postoperatively, 250 microg of beclomethasone dipropionate aerosol spray (BDPAS) was self-administered into each nostril twice a day. Treatment efficacy was assessed after 1, 6, and 12 weeks and at quarterly long-term follow-ups based on objective parameters (videoendoscopic photodocumentation and rhinomanometry) and subjective evaluation of NO, OD, and satisfaction (visual analog scales [VASs]).

RESULTS

VASs indicated very low values for intraoperative pain and discomfort and high postoperative satisfaction. After 6 weeks, subjective and objective data revealed a significant improvement of NO and OD (p < 0.0005). Topical BDPAS application was well tolerated. At a median follow-up of 32 months (range, 1-4 years), 21% of the patients developed NP disappearance, 53% had a stable disease, and 26% had a progressive disease.

CONCLUSION

In therapy-refractory NP, endonasal DLPE represents a minimally invasive, symptom-oriented, safe and easily reapplicable outpatient treatment option that provides effective improvement of NO and OD. Compared with the pre-DLPE period, the proposed long-term quarterly follow-up combined with high-dose topical BDPAS application might reduce or delay the need for major surgery and appears to be suitable for disease control.