Rhinolithiasis misdiagnosed as intranasal osteoma: Diagnostic challenges in the telehealth era

Rhinolithiasis is a rare clinical presentation and may be a diagnostic challenge, often mimicking other intranasal pathologies and difficult to differentiate based on imaging alone. We present the case of a 50-year-old patient with rhinolithiasis who presented with chronic left nasal obstruction and unilateral cyclic pain with foul discharge. After review of her imaging, she was initially misdiagnosed with an intranasal osteoma via telehealth and scheduled for surgical resection. Her true pathology of rhinolithiasis was subsequently identified and treated during an in-person pre-operative clinic visit. In this case report, we review the key characteristic elements of rhinolithiasis presentation, and in doing so, we reveal the limitations inherent to telehealth evaluations, and the considerations needed to be taken into account by providers evaluating intranasal lesions. Specifically, in-person assessment with a detailed endoscopy is critical as part of the complete workup of nasal cavity lesions.

Social Perception of External Laryngeal Anatomy Related to Gender Expression in a Web-based Survey

OBJECTIVE(S)

To quantify the effect of laryngeal prominence size on socially perceived attributes relating to gender expression. Chondrolaryngoplasty ("tracheal shave") is a common procedure performed for transgender women to feminize neck appearance. The extent of thyroid cartilage resection needed to convey socially-perceived feminine gender expression without destabilizing the voice is incompletely understood.

METHODS

Cross-sectional evaluation of a randomized allocation of images of varying laryngeal prominence to a non-repeated, random sample from November 2021 to December 2021. Photos of laryngeal prominence were isolated against a constant neck baseline with lateral, oblique, and frontal views. The images were embedded into a web-based survey with visual analog scales to capture perceived scaled gender expression (masculinity, femininity) and social traits (e.g., attractiveness, friendliness, leadership). We performed bivariate and multivariate analyses relating the laryngeal prominence to perceived gender expression and social traits.

RESULTS

The analytic sample included 1,026 respondents. Laryngeal grades similar to the demonstrated "grade M" in this study and smaller demonstrated similar perceptions of increased femininity and decreased masculinity. Grades larger than M demonstrate significantly increased perceived masculinity and significantly decreased perceived femininity. The lateral and oblique views of the neck appear to be the most gender-informative.

CONCLUSION

This crowd-sourced analysis of external laryngeal anatomy by a large population of observers provides clear, reproducible insights into social perceptions of gender identity and specifically femininity. These data will meaningfully inform patient counseling and surgical planning for gender-affirming interventions by establishing normative data representing the general public's perceptions.

LEVEL OF EVIDENCE

NA Laryngoscope, 133:2292-2300, 2023.

Predicting Gag, Discomfort, and Laryngeal Visualization in Patients Undergoing Flexible Laryngoscopy with Stroboscopy

OBJECTIVE

To investigate potential associations between the Predictive Gagging Survey (PGS) with patient experience of gag and discomfort as well as provider perception of patient gag and level of laryngeal visualization during flexible laryngoscopy with stroboscopy (FL-S).

METHODS

A total of 53 adult patients undergoing FL-S were recruited for this prospective non-controlled study. PGS was completed before FL-S. Patients rated perceived level of gag and discomfort on a 10-point severity scale after FL-S. Additionally, providers completed a Gagging Severity Index (GSI) reflecting their impression of patient gag and level of laryngeal visualization following FL-S. Spearman rank correlation coefficients were used to assess associations.

RESULTS

There was a positive association with PGS score and patient perception of gagging (0.34; P = .013) and patient perception of discomfort (0.38; P = .005). No significant association was found between PGS score and provider GSI (-0.12; P = .39) or level of laryngeal visualization (0.15; P = .29). A negative association was found between level of laryngeal visualization and patient perception of gagging (-0.34; P = .012) and discomfort (-0.44; P = .001). No significant differences were found between current and former smokers compared to never smokers for GSI or patient-perceived gag or discomfort.

CONCLUSIONS

While not predictive of GSI or level of laryngeal visualization, the PGS was found to be a useful tool in predicting patient experience of gagging and discomfort during FL-S, further reinforcing the subjective experience of this procedure. Use of the PGS may be helpful in identifying specific candidates who may struggle with subjective discomfort or gagging during FL-S for future studies considering interventions to manage and meaningfully decrease discomfort. Having such an instrument is important given the low number of individuals who struggle with discomfort during the exam.

Postoperative dysphagia immediately following pediatric endoscopic laryngeal cleft repair

OBJECTIVES

In pediatric patients undergoing endoscopic laryngeal cleft repair, immediate postoperative dysphagia is not well-characterized. This study examined whether worsened dysphagia is present in the immediate postoperative period as detected by clinical swallow evaluation, and evaluated how this relates to postoperative change in presenting symptoms and findings on swallow studies.

METHODS

A retrospective cohort was conducted at a tertiary academic medical center, evaluating all pediatric patients who underwent endoscopic laryngeal cleft repair by a single surgeon from October 2014 through December 2018. All patients underwent instrumental swallow evaluation preoperatively and clinical swallow evaluation within 24 h following surgery.

RESULTS

Thirty-nine patients met inclusion criteria. Based on clinical swallow evaluation performed within 24 h after surgery, 4 patients (10%) were recommended to thicken their diet from preoperative baseline; all others were unchanged. All patients were admitted to the PICU for observation; 34 (87%) discharged on postoperative day 1. Thirty-seven patients attended 6-week follow-up, with 2 (5%) requiring thicker diet since discharge; all others were stable or improved. Prevalence of recurrent respiratory infections, subjective dysphagia, chronic cough, and wheezing significantly decreased after surgery. No statistically significant change occurred in prevalence of aspiration or penetration on instrumental swallow studies postoperatively.

CONCLUSION

Endoscopic laryngeal cleft repair is well-tolerated in pediatric patients, and most do not have obviously worsened dysphagia at immediate postoperative evaluation. Improvement in symptoms postoperatively may be a more useful indicator of surgical outcomes beyond instrumental swallow studies alone. The relative stability of these patients provides further evidence that they can likely be managed on the floor or as outpatients rather than in the ICU postoperatively.

Creation of a New Educational Podcast: “Headmirror’s ENT in a Nutshell”

Podcasts are online digital audio programs that are disseminated via online subscription that are easily accessible through computers or smartphones. Increasingly, residents and medical students are prioritizing podcasts for asynchronous medical education due to ease of use, convenience (eg, use while exercising or commuting), and repeatability. Some trainees have found podcasts more useful than traditional didactic lectures. Given the increasing requirements of social distancing and the need for distance medical education platforms, podcast production can serve as a useful tool to complement resident and medical student education and is a resource that will remain accessible in perpetuity. An otolaryngology specialty podcast, “Headmirror’s ENT in a Nutshell,” was created to augment asynchronous learning and address the acute need for distance learning opportunities. Over the first 7 weeks of production, 50 episodes were created. Episodes were posted on www.headmirror.com, with subscription services available through Apple Podcast, Spotify, and other platforms.

Identification of aggressive Gardner syndrome phenotype associated with a de novo APC variant, c.4666dup

Gardner syndrome describes a variant phenotype of familial adenomatous polyposis (FAP), primarily characterized by extracolonic lesions including osteomas, dental abnormalities, epidermal cysts, and soft tissue tumors. We describe a 2-yr-old boy presenting with a 2-cm soft tissue mass of the forehead. Pathologic evaluation revealed a nuchal-type/Gardner-associated fibroma. Sequencing of the APC gene revealed a pathologic variant c.4666dupA. Parental sequencing of both blood and buccal tissue supported the de novo occurrence of this pathologic variant. Further imaging revealed a number of additional lesions including a large lumbar paraspinal desmoid, a 1-cm palpable lesion posterior to the left knee, firm lesions on bilateral heels, and multiple subdermal lesions. Colonoscopy was negative. This case illustrates a genetic variant of Gardner syndrome resulting in an aggressive early childhood phenotype and highlights the need for an individualized approach to treatment.

Efficacy and safety of Privigen, a novel liquid intravenous immunoglobulin formulation, in adolescent and adult patients with chronic immune thrombocytopenic purpura

Intravenous immunoglobulin (IVIG) has become a mainstay of treatment for acute and chronic immune thrombocytopenic purpura (ITP). The efficacy and safety of Privigen, a new, ready-to-use, 10% liquid human IgG formulation, was evaluated in this open-label, multicentre study. Privigen infusions (1 g/kg per day for 2 consecutive days, days 1 and 2) were given to 57 adolescent and adult patients with chronic ITP and platelet counts < or =20 x 10(9)/l. By day 7, 80.7% of patients (95% CI, 69.2, 89.3) achieved platelet counts of > or =50 x 10(9)/l. Correspondingly, haemorrhage number and severity were significantly reduced. Adverse events were generally mild or moderate and typical of underlying disease and IVIG treatment. Privigen was well tolerated - 104 of 114 infusions were performed at the maximum permitted infusion rate (4 mg/kg/min). Thus, in patients with chronic ITP, a two-day regimen of Privigen was effective in increasing platelet count, reducing bleeding events and was well tolerated.

Purification and characterization of subtilisin cleaved actin lacking the segment of residues 43-47 in the DNase I binding loop

The protease subtilisin has been reported to cleave skeletal muscle G-actin between Met 47 and Gly 48 generating a core fragment of 33 kDa and a small N-terminal peptide, which remains attached to the core fragment [Schwyter, D. Phillips, M., & Reisler, E. (1989) Biochemistry 28, 5889-5895]. However, amino acid sequencing and mass spectroscopy of subtilisin cleaved-actin revealed two cleavage sites, one between Met 47 and Gly 48 and a second between Gly 42 and Val 43, generating an actin core of 37 kDa and a nicked 4.4 kDa N-terminal peptide. Here we describe a procedure for purifying the actin core fragment and the attached N-terminal peptide from the linking pentapeptide comprising amino acid residues 43-47 under native conditions by anion exchange chromatography. After removal of the pentapeptide, the salt-induced polymerization of actin was abolished. However, the purified fragments could be polymerized by addition of salt plus myosin subfragment 1 or salt plus phalloidin as shown by sedimentation and fluorescence increase using N-(1-pyrenyl)iodoacetamide labeled actin. These results confirm earlier reports proposing that cleavage in the DNase I binding loop is affecting the ion induced polymerization of actin [Higashi-Fujime, S., et al. (1992) J. Biochem. (Tokyo) 112, 568-572; and Khaitlina, S., et al. (1993) Eur. J. Biochem. 218, 911-920]. Monomeric and filamentous subactin exhibited reduced abilities to inhibit deoxyribonuclease I (DNase I) and to stimulate the myosin subfragment 1 ATPase activity. Direct binding of subactin to DNase I was verified by gel filtration and to myosin subfragment 1 by affinity chromatography, chemical cross-linking, and electron microscopy.

Evidence for an F-actin like conformation in the actin:DNase I complex

We demonstrate that a ribose modified analogue of ATP, TNP-ATP, can exchange with a resident nucleotide in F-actin, but fails to bind to G-actin. TNP-ATP is also able to bind to actin in the actin:DNase I complex, suggesting that the nucleotide binding site in the actin:DNase I complex adopts a conformation similar to that found in F-actin. This result is consistent with the hypothesis that the two major domains of actin on either side of the cleft are able to "flex" or move relative to each other in G-actin, but that this flexing motion is limited as a consequence of either polymerisation or DNase I binding. F-actin, in which approximately 80% of the bound nucleotide is TNP-ADP, appears to be functionally similar to native ADP-F-actin. It can superprecipitate with myosin and, following regulation with troponin-tropomyosin, exhibits a Ca(2+)-sensitivity during superprecipitation. Sonication induced nucleotide exchange in regulated F-actin was not sensitive to the presence of Ca2+ which argues against a significant conformational change in the vicinity of the nucleotide binding site during Ca(2+)-sensitive thin filament regulation.

Both isoforms of skeletal muscle subfragment 1 (S1A1 and S1A2) can induce actin polymerization with equal speed in the absence of ATP

The ability of myosin subfragment 1 to induce actin polymerization was reinvestigated using the DNase I inhibition assay, by electron microscopy after negative staining, cosedimentation, measurement of viscosity and the fluorescence increase of pyrenyl-labeled actin. Using these techniques we demonstrate that rabbit skeletal muscle myosin subfragment 1 containing either the alkali light chain 1 (S1A1) or the alkali light chain 2 (S1A2) is able to promote actin polymerization even in the absence of divalent cations or salt. In the presence of ATP the rate of induction of actin polymerization by S1A2 is slower than by A1A1. In contrast, in the absence of free ATP, both subfragment 1 variants exhibit equal ability to induce actin polymerization. Evidence is given that the slower rate of induction of actin polymerization by S1A2 in the presence of free ATP is due to a slower rate of ATP-hydrolysis by S1A2 and thus to a slower rate of ATP depletion. We therefore assume that the formation of rigor type complexes involving the subfragment 1 heavy chain is necessary for the induction of actin polymerization. The ability of subfragment 1 to induce actin polymerization is retarded by a synthetic heavy chain mimetic peptide which inhibits its actin binding or after proteolytic cleavage of the subfragment 1 heavy chain by trypsin.

Evidence that the presumptive second nucleotide interacting site on actin is of low specificity and affinity

The contractile protein actin contains one mole of firmly bound nucleotide and a number of divalent cations bound with different affinities. During recent years evidence for a second nucleotide interacting site on actin has been reported. Therefore, a specific search for the presence of a second nucleotide-interacting site on actin was undertaken. For this purpose G- and F-actin or actin in complex with deoxyribonuclease I (DNase I) was passed over ADP-agarose which was found to retain all three forms of actin. Nucleotide bound to the high affinity site of actin did not exchange during passage and retention to agarose-immobilized ADP, thus indicating the presence of a second nucleotide interacting site. This site was found to be equally accessible in G- and F-actin and in the actin-DNase I complex, whereas DNase I alone passed unretained through this column. A number of nucleotides and phosphorylated compounds were tested for their ability to compete with immobilized ADP for actin interaction. It was found that all forms of actin are liberated only by high concentrations (5mM) of ADP, ATP and NADH, by 1mM CTP and ITP, and by high salt concentrations (150mM NaCl). Since it was found that EDTA- and heat-treated actin were also retained on ADP-agarose, we conclude that this second nucleotide interacting site is of limited specificity, low affinity, and not dependent on the native configuration of actin. It exhibits characteristics of an unspecific, polyanionic site, but may represent the low affinity phosphate binding site.

Red pulp of the spleen in hereditary elliptocytosis

Electron microscopic study of the spleen of an adult with hereditary elliptocytosis demonstrated features of erythrocyte pooling in the splenic cords with decreased red cells in transit through the basement membrane slits between the sinus littoral cells and decreased erythrocytes in splenic sinuses. Cordal reticulum cells, macrophages, and platelets were prominent. Light microscopy demonstrated relatively empty sinuses, and electron microscopy confirmed that the sinuses contained variable numbers of intact red cells. The morphology of the splenic red pulp in hereditary elliptocytosis was found to simulate that seen in hereditary spherocytosis but to a lesser degree.