Coblation versus BiZact extra-capsular tonsillectomy in adults: a randomized control trial.

INTRODUCTION: Tonsillectomy is a frequently performed otolaryngological procedure and is associated with significant postoperative pain and bleeding. A number of studies have investigated methods to reduce pain and bleeding. Coblation and BiZact devices have both been claimed to have favourable pain outcomes following tonsillectomy. This study was designed to investigate these two techniques in a direct comparison of postoperative pain and bleeding. METHODS: In this single blinded, randomized control trial, 61 patients were randomly assigned to undergo tonsillectomy with either the BiZact or Coblation device. Pain scores were collected for 14 days postoperatively using a Visual Analogue Score scale. Secondary outcome data was collected for duration of surgery, intra-operative bleeding, return to normal, and secondary bleeding rates. RESULTS: Coblation was found to have lower postoperative pain on day 1 (P < 0.05). BiZact was found to have lower postoperative pain on day 7 (P < 0.05) and day 11 (P < 0.05). Pain scores for other days were not significant. There was no significant difference in set-up time, procedural time and return to normal activities. The BiZact group had a longer time to achieve haemostasis (P < 0.001) and greater intraoperative blood loss (P < 0.01). There was a trend towards more significant secondary bleeding in the BiZact arm, however, this study was not adequately powered to assess this finding. CONCLUSION: Both Coblation and BiZact devices appear to provide a safe and effective method for tonsillectomy in adults. Reduced pain on day 1 may make Coblation more suitable for day-case surgery.

Current Understanding of the Role of Eosinophils in CRSwNP and Implications for Treatment with Mepolizumab and Benralizumab.

BACKGROUND: International consensus statements now subdivide chronic rhinosinusitis (CRS) into several phenotypes and endotypes, including the presence of polyps (CRSwNP) and eosinophilia (eCRSwNP). Biological treatments aimed at blocking eosinophilic inflammation in CRSwNP via interleukin 5 (IL5) or the interleukin 5 receptor (IL5R) have demonstrated limited efficacy thus far. OBJECTIVE: To review the pathophysiology of eCRSwNP, the evidence for mepolizumab (anti-IL5) and benralizumab (anti-IL5R) in CRSwNP, and to highlight areas for future research and therapeutic intervention. METHODS: Primary and secondary literature search. RESULTS: Clinical trials on mepolizumab and benralizumab in CRSwNP are limited and restricted by trial design which prevents direct comparison with other interventions, including surgery. Both agents would appear to provide some benefit in reducing nasal polyp size but limited clinical patient benefit. Molecular biological research highlights that eCRSwNP can occur in the absence of IL5 and that other cells/cytokines play an important part in the disease's pathophysiology. CONCLUSION: Blockade of IL5/IL5R alone would appear to provide limited "real life" clinical benefit in patients with CRSwNP due to the complexities of the pathophysiology of the condition. Therapy aimed at several simultaneous cytokine targets has logic but well-designed trials are unlikely to be forthcoming in the short term due to the financial cost and commercial conflicts of interest.

The Nasal Innate Immune Proteome After Saline Irrigation: A Pilot Study in Healthy Individuals.

BACKGROUND: Previous research has shown diminished nasal immune function following nasal saline irrigation (NSI), returning to baseline at 6 hours. The aim of this study was to examine the immune nasal proteome before and after 14 days of nasal irrigation. METHODS: Seventeen healthy volunteers received either isotonic (IsoSal) or low salt (LowNa) NSI. Nasal secretions were collected before and 30 min after NSI at baseline and again after 14 days. Specimens were analyzed using mass spectrometry to detect proteins of relevance to nasal immune function. RESULTS: One thousand eight hundred and sixty-five proteins were identified with significant changes in 71 proteins, of which 23 were identified as part of the innate immune system. Baseline analysis demonstrated an increase of 9 innate proteins after NSI, most after IsoSal. After 14 days, a greater increase in innate peptides was present, with most now in the LowNa group. When NSI solutions were compared, a significant increase in 4 innate proteins, including a 211% in lysozyme, was detected in the LowNa group. CONCLUSION: LowNa NSI demonstrates evidence of improving the innate immune secretions, especially lysozyme, in healthy volunteers.

Customised acoustic therapy delivered through a web-based platform-An innovative approach to tinnitus treatment.

OBJECTIVES: Customised acoustic therapy aims to moderate the neural pathways implicated in the pathophysiology of tinnitus. This study aimed to assess the efficacy of customised acoustic therapy administered via a web-based treatment platform. DESIGN: Clinical trial with prospective recruitment. Fifty-eight participants underwent 6 weeks of customised acoustic therapy. SETTING: Treatment was delivered for 2 h each day using a smartphone, tablet or computer. Treatment was integrated into usual daily activities. PARTICIPANTS: Participants with subjective tinnitus were recruited through public and private otolaryngology clinics and electronic and print media. MAIN OUTCOMES MEASURED: FiveQ, a novel 5 question tinnitus questionnaire, was measured at baseline and each week of treatment. Statistical analyses, including Wilcoxon, Mann-Whitney and mixed linear regression, were used to assess treatment efficacy and identify factors associated with treatment response. RESULTS: 39/58 participants (67.2%) had an improvement in symptom severity scores, 4 had no change (6.9%) and 15 had a decline from baseline (25.9%). Mean FiveQ scores improved by 22.9% from 40.8 (SD = 21.4) at baseline to 31.5 (SD = 21.3) following 6 weeks of treatment (p < 0.001). With the exception of the slight tinnitus group, all other groups (from mild to catastrophic) demonstrated a treatment response. Participants with low frequency tinnitus (<2000 Hz) had a significantly greater treatment response (p < 0.001). CONCLUSION: Customised acoustic therapy administered via a web-based platform demonstrated encouraging efficacy. At least mild symptoms at baseline and low frequency tinnitus were associated with a greater treatment response. Customised acoustic therapy offers accessible and efficacious tinnitus treatment, however longer term clinical studies are required to confirm the observed initial benefit is maintained.

Volumetric magnetic resonance imaging analysis of multilevel upper airway surgery effects on pharyngeal structure.

STUDY OBJECTIVES: The Sleep Apnea Multilevel Surgery (SAMS) trial found that modified uvulopalatopharyngoplasty with tonsillectomy (if tonsils present) combined with radiofrequency tongue ablation reduced obstructive sleep apnea (OSA) severity and daytime sleepiness in moderate-severe OSA. This study aimed to investigate mechanisms of effect on apnea-hypopnea index (AHI) reduction by assessing changes in upper airway volumes (airway space, soft palate, tongue, and intra-tongue fat). METHODS: This is a case series analysis of 43 participants of 51 randomized to the surgical arm of the SAMS trial who underwent repeat magnetic resonance imaging (MRI). Upper airway volume, length, and cross-sectional area, soft palate and tongue volumes, and tongue fat were measured. Relationships between changes in anatomical structures and AHI were assessed. RESULTS: The participant sample was predominantly male (79%); mean ± SD age 42.7 ± 13.3 years, body mass index 30.8 ± 4.1 kg/m2, and AHI 47.0 ± 22.3 events/hour. There were no, or minor, overall volumetric changes in the airway, soft palate, total tongue, or tongue fat volume. Post-surgery there was an increase in the minimum cross-sectional area by 0.1 cm2 (95% confidence interval 0.04-0.2 cm2) in the pharyngeal airway, but not statistically significant on corrected analysis. There was no association between anatomical changes and AHI improvement. CONCLUSIONS: This contemporary multilevel upper airway surgery has been shown to be an effective OSA treatment. The current anatomical investigation suggests there are not significant post-operative volumetric changes associated with OSA improvement 6-month post-surgery. This suggests that effect on OSA improvement is achieved without notable deformation of airway volume. Reduced need for neuromuscular compensation during wake following anatomical improvement via surgery could explain the lack of measurable volume change. Further research to understand the mechanisms of action of multilevel surgery is required. CLINICAL TRIAL: This manuscript presents a planned image analysis of participants randomized to the surgical arm or the clinical trial multilevel airway surgery in patients with moderate-severe obstructive sleep apnea (OSA) who have failed medical management to assess change in OSA events and daytime sleepiness. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=266019&isReview=true%20Australian%20New%20Zealand%20Clinical%20Trials%20Registry%20ACTRN12514000338662, prospectively registered on March 31, 2014.

Effect of Multilevel Upper Airway Surgery vs Medical Management on the Apnea-Hypopnea Index and Patient-Reported Daytime Sleepiness Among Patients With Moderate or Severe Obstructive Sleep Apnea: The SAMS Randomized Clinical Trial.

Importance: Many adults with obstructive sleep apnea (OSA) use device treatments inadequately and remain untreated. Objective: To determine whether combined palatal and tongue surgery to enlarge or stabilize the upper airway is an effective treatment for patients with OSA when conventional device treatment failed. Design, Setting, and Participants: Multicenter, parallel-group, open-label randomized clinical trial of upper airway surgery vs ongoing medical management. Adults with symptomatic moderate or severe OSA in whom conventional treatments had failed were enrolled between November 2014 and October 2017, with follow-up until August 2018. Interventions: Multilevel surgery (modified uvulopalatopharyngoplasty and minimally invasive tongue volume reduction; n = 51) or ongoing medical management (eg, advice on sleep positioning, weight loss; n = 51). Main Outcomes and Measures: Primary outcome measures were the apnea-hypopnea index (AHI; ie, the number of apnea and hypopnea events/h; 15-30 indicates moderate and >30 indicates severe OSA) and the Epworth Sleepiness Scale (ESS; range, 0-24; >10 indicates pathological sleepiness). Baseline-adjusted differences between groups at 6 months were assessed. Minimal clinically important differences are 15 events per hour for AHI and 2 units for ESS. Results: Among 102 participants who were randomized (mean [SD] age, 44.6 [12.8] years; 18 [18%] women), 91 (89%) completed the trial. The mean AHI was 47.9 at baseline and 20.8 at 6 months for the surgery group and 45.3 at baseline and 34.5 at 6 months for the medical management group (mean baseline-adjusted between-group difference at 6 mo, -17.6 events/h [95% CI, -26.8 to -8.4]; P < .001). The mean ESS was 12.4 at baseline and 5.3 at 6 months in the surgery group and 11.1 at baseline and 10.5 at 6 months in the medical management group (mean baseline-adjusted between-group difference at 6 mo, -6.7 [95% CI, -8.2 to -5.2]; P < .001). Two participants (4%) in the surgery group had serious adverse events (1 had a myocardial infarction on postoperative day 5 and 1 was hospitalized for observation following hematemesis of old blood). Conclusions and Relevance: In this preliminary study of adults with moderate or severe OSA in whom conventional therapy had failed, combined palatal and tongue surgery, compared with medical management, reduced the number of apnea and hypopnea events and patient-reported sleepiness at 6 months. Further research is needed to confirm these findings in additional populations and to understand clinical utility, long-term efficacy, and safety of multilevel upper airway surgery for treatment of patients with OSA. Trial Registration: Australian New Zealand Clinical Trials Registry: ACTRN12614000338662.

Australian contribution to global otolaryngology research: 2008-2018.

BACKGROUND: Obtaining research funding in Otolaryngology - Head and Neck Surgery (ORL-HNS) can be challenging. In this paper, an analysis of research output in ORL-HNS in Australia and worldwide between 2008 and 2018 was conducted and then adjusted for the number of specialist surgeons in each country. METHODS: Scopus by Elsevier was used to measure research output of Ear, Nose and Throat (ENT) surgeons in Australia between 2008 and 2018. Each individual's career and 10-year h-index was identified and then repeated with self-citations excluded. Total and 10-year citations were also recorded. The top 15 countries in terms of research output in ORL-HNS were also ranked based on the number of ENT articles published in the 10-year period, and then adjusted by the number of actively practicing ENT surgeons per country. RESULTS: Between 2008 and 2018, Australia published 1510 articles out of a total global output of 48 613 papers in ORL-HNS with the top 10 authors having an h-index placing them within the world's top 100. Whilst the USA made the greatest total contribution with 12 912 publications, when adjusted for the number of specialist ORL-HNS clinicians in each country, Australia, Canada and India in order topped the rankings. CONCLUSION: Australia has established itself as a research leader in the global field of ORL-HNS, publishing more articles per surgeon than any other country between 2008 and 2018. The Australian ORL-HNS Academic Surgeons also rank highly on an individual basis when compared to global peers.

Sleep Apnea Multilevel Surgery (SAMS) trial protocol: a multicenter randomized clinical trial of upper airway surgery for patients with obstructive sleep apnea who have failed continuous positive airway pressure.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) is a serious and costly public health problem. The main medical treatment, continuous positive airway pressure, is efficacious when used, but poorly tolerated in up to 50% of patients. Upper airway reconstructive surgery is available when medical treatments fail but randomized trial evidence supporting its use is limited. This protocol details a randomized controlled trial designed to assess the clinical effectiveness, safety, and cost-effectiveness of a multilevel upper airway surgical procedure for OSA. METHODS: A prospective, parallel-group, open label, randomized, controlled, multicenter clinical trial in adults with moderate or severe OSA who have failed or refused medical therapies. Six clinical sites in Australia randomly allocated participants in a 1:1 ratio to receive either an upper airway surgical procedure consisting of a modified uvulopalatopharyngoplasty and minimally invasive tongue volume reduction, or to continue with ongoing medical management, and followed them for 6 months. RESULTS: Primary outcomes: difference between groups in baseline-adjusted 6 month OSA severity (apnea-hypopnea index) and subjective sleepiness (Epworth Sleepiness Scale). Secondary outcomes: other OSA symptoms (e.g. snoring and objective sleepiness), other polysomnography parameters (e.g. arousal index and 4% oxygen desaturation index), quality of life, 24 hr ambulatory blood pressure, adverse events, and adherence to ongoing medical therapies (medical group). CONCLUSIONS: The Sleep Apnea Multilevel Surgery (SAMS) trial is of global public health importance for testing the effectiveness and safety of a multilevel surgical procedure for patients with OSA who have failed medical treatment. CLINICAL TRIAL REGISTRATION: Multilevel airway surgery in patients with moderate-severe Obstructive Sleep Apnea (OSA) who have failed medical management to assess change in OSA events and daytime sleepiness. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366019&isReview=true Australian New Zealand Clinical Trials Registry ACTRN12614000338662, prospectively registered on 31 March 2014.

Real-life treatment of rhinitis in Australia: a historical cohort study of prescription and over-the-counter therapies for patients with and without additional respiratory disease.

BACKGROUND: The aim of the study was to explore rhinitis therapy purchases in different Australian regions for patients with and without additional respiratory disease, using both doctor's prescriptions and over-the-counter (OTC) medications. PATIENTS AND METHODS: It was a historical cohort study of pharmacy-related claims that included prescription or OTC rhinitis therapy, with or without asthma/COPD therapy, from January 2013 to December 2014. RESULTS: Overall, 4,247,193 prescription and OTC rhinitis treatments were purchased from 909 pharmacies over a calendar year; the majority were single-therapy purchases for rhinitis only patients. More multiple-therapy was purchased for rhinitis and asthma/COPD patients (4.4%) than for rhinitis only patients (4.0%), with a greater proportion purchased in VIC, SA and TAS (4.7% of rhinitis only patients and 4.5% of rhinitis and asthma/COPD patients) than in other areas. Dual therapy of oral antihistamine (OAH) and intranasal corticosteroid (INS) were the most frequently purchased multiple-therapy, with higher purchasing rates for rhinitis and asthma/COPD patients (2.6%) than for rhinitis only patients (1.6%). The most frequently purchased single therapy was OAH (70.1% of rhinitis only patients and 57.3% of rhinitis and asthma/COPD patients). First-line INS therapy was more likely to be purchased for rhinitis and asthma/COPD patients (15.3% by prescription and 11.7% OTC) than for rhinitis only patients (5.0% by prescription and 9.2% OTC); however, geographical differences in the proportion of therapies purchased OTC were noted, with a lower proportion of OTC OAH and INS purchases in Queensland and the Northern Territory for patients with and without comorbid respiratory disease. CONCLUSION: Purchases of first-line INS therapy are more likely for patients with comorbid respiratory disease if they have received prescriptions and information/advice from their general practitioner. The study results indicate a need for patient information/education at the point-of-sale of OTC OAHs to enable patients to assess their nasal symptoms and receive treatment support from pharmacists. Greater availability to INSs in pharmacies as well as guidance from current guidelines and instruction in correct intranasal technique may also lead to greater uptake of INSs.

Effectiveness of primary surgery versus primary radiotherapy on unknown primary head and neck squamous cell carcinoma: a systematic review protocol.

REVIEW QUESTION: The review question is: what is the effectiveness of primary surgery versus primary radiotherapy on disease-free survival and quality of life in adults with an unknown primary, head and neck squamous cell carcinoma?

Seasonal patterns of oral antihistamine and intranasal corticosteroid purchases from Australian community pharmacies: a retrospective observational study.

PURPOSE: To explore patterns in the purchase of prescription and over-the-counter (OTC) oral antihistamines (OAHs) and intranasal corticosteroids (INCSs) by patients, from pharmacies in different geographical regions of Australia. PATIENTS AND METHODS: Retrospective observational study using a database containing anonymous pharmacy transaction data from 20.0% of the pharmacies in Australia that link doctor prescriptions and OTC information. Pharmacy purchases of at least one prescription or OTC rhinitis treatment during 2013 and 2014 were assessed. RESULTS: In total, 4,247,193 prescription and OTC rhinitis treatments were purchased from 909 pharmacies over 12 months. Of treatments purchased, 75.9% were OAHs and 16.6% were INCSs. OTC purchases of both treatments exceeded purchases through prescription. OTC OAHs purchasing patterns were seasonal and almost identical in the Australian Capital Territory, Victoria, Western Australia, South Australia, and New South Wales, and similar seasonal patterns for OTC INCSs were noted in most regions except for South Australia and Tasmania. Prescription purchasing patterns of both OAHs and INCSs remained unchanged throughout the year in most regions. CONCLUSION: This large-scale retrospective observational study identified seasonal purchasing patterns of OTC and prescription OAHs and INCSs in a real-world setting. It highlighted that seasonality only affects OTC purchasing patterns of OAHs and INCSs across Australia and that practitioner prescribing remains unchanged, suggesting that it is only for persistent disease.

Draf III frontal sinus surgery: "How I do it".

BACKGROUND: The Draf III approach to the frontal sinus can be used during revision endoscopic sinus surgery for chronic rhinosinusitis and to provide access for tumor resection, mucoceles, and repair of cerebrospinal fluid leaks. OBJECTIVE: To describe a simple and safe way to perform a Draf III approach by using the "outside-in" approach. METHODS: By using a 0° endoscope and a single 15°, 5-mm, coarse diamond burr, the main steps of the procedure are the following: (1) elevation of the mucosal flaps and creation of the septal window, (2) drilling out the frontal beak, (3) creation of neo-ostium and removal of the interfrontal septum, (4) joining the neo-ostium with the frontal recesses, (5) smoothing off the cavity and lowering of the "frontal T," and (6) use of mucosal flaps and grafts to cover exposed bone. CONCLUSION: This approach is a quick and easy way to perform a Draf III, and reduces operative time and minimizes complications.

'Waiting for' and 'waiting in' public and private hospitals: a qualitative study of patient trust in South Australia.

BACKGROUND: Waiting times for hospital appointments, treatment and/or surgery have become a major political and health service problem, leading to national maximum waiting times and policies to reduce waiting times. Quantitative studies have documented waiting times for various types of surgery and longer waiting times in public vs private hospitals. However, very little qualitative research has explored patient experiences of waiting, how this compares between public and private hospitals, and the implications for trust in hospitals and healthcare professionals. The aim of this paper is to provide a deep understanding of the impact of waiting times on patient trust in public and private hospitals. METHODS: A qualitative study in South Australia, including 36 in-depth interviews (18 from public and 18 from private hospitals). Data collection occurred in 2012-13, and data were analysed using pre-coding, followed by conceptual and theoretical categorisation. RESULTS: Participants differentiated between experiences of 'waiting for' (e.g. for specialist appointments and surgery) and 'waiting in' (e.g. in emergency departments and outpatient clinics) public and private hospitals. Whilst 'waiting for' public hospitals was longer than private hospitals, this was often justified and accepted by public patients (e.g. due to reduced government funding), therefore it did not lead to distrust of public hospitals. Private patients had shorter 'waiting for' hospital services, increasing their trust in private hospitals and distrust of public hospitals. Public patients also recounted many experiences of longer 'waiting in' public hospitals, leading to frustration and anxiety, although they rarely blamed or distrusted the doctors or nurses, instead blaming an underfunded system and over-worked staff. Doctors and nurses were seen to be doing their best, and therefore trustworthy. CONCLUSION: Although public patients experienced longer 'waiting for' and 'waiting in' public hospitals, it did not lead to widespread distrust in public hospitals or healthcare professionals. Private patients recounted largely positive stories of reduced 'waiting for' and 'waiting in' private hospitals, and generally distrusted public hospitals. The continuing trust by public patients in the face of negative experiences may be understood as a form of exchange trust norm, in which institutional trust is based on base-level expectations of consistency and minimum standards of care and safety. The institutional trust by private patients may be understood as a form of communal trust norm, whereby trust is based on the additional and higher-level expectations of flexibility, reduced waiting and more time with healthcare professionals.

Comparing surgical experience with performance on a sinus surgery simulator.

BACKGROUND: This study evaluates whether surgical experience influences technical competence using the Flinders sinus surgery simulator, a virtual environment designed to teach nasal endoscopic surgical skills. METHODS: Ten experienced sinus surgeons (five consultants and five registrars) and 14 novices (seven resident medical officers and seven interns/medical students) completed three simulation tasks using haptic controllers. Task 1 required navigation of the sinuses and identification of six anatomical landmarks, Task 2 required removal of unhealthy tissue while preserving healthy tissue and Task 3 entailed backbiting within pre-set lines on the uncinate process and microdebriding tissue between the cuts. RESULTS: Novices were compared with experts on a range of measures, using Mann-Whitney U -tests. Novices took longer on all tasks (Task 1: 278%, P < 0.005; Task 2: 112%, P < 0.005; Task 3: 72%, P < 0.005). In Task 1, novices' instruments travelled further than experts' (379%, P < 0.005), and provided greater maximum force (12%, P < 0.05). In Tasks 2 and 3 novices performed more cutting movements to remove the tissue (Task 2: 1500%, P < 0.005; Task 3: 72%, P < 0.005). Experts also completed more of Task 3 (66%, P < 0.05). CONCLUSIONS: The study demonstrated the Flinders sinus simulator's construct validity, differentiating between experts and novices with respect to procedure time, instrument distance travelled and number of cutting motions to complete the task.

The microbiome of otitis media with effusion in Indigenous Australian children.

INTRODUCTION: Indigenous Australian children have a high prevalence of otitis media with effusion (OME) and associated conductive hearing loss. Only three microbiological studies of middle ear fluid (MEF) from Indigenous Australian children with OME have been reported. All of these were reliant on culture or species-specific PCR assays. The aim of this study was to characterise the middle ear fluid (MEF), adenoid and nasopharyngeal (NP) microbiomes of Indigenous Australian children, using culture-independent 16S rRNA gene sequencing. METHODS: MEF, NP swabs and adenoid specimens were collected from 11 children in the Alice Springs region of Central Australia. Bacterial communities in these specimens were characterised using 16S rRNA gene sequencing. RESULTS: The microbiota in MEF samples were dominated (>50% relative abundance) by operational taxonomic units (OTUs) consistent with Alloiococcus otitidis (6/11), Haemophilus influenzae (3/11) or Streptococcus sp. (specifically, Mitis group streptococci which includes Streptococcus pneumoniae) (1/11). Anatomical site selectivity was indicated by the presence of a single conserved Haemophilus OTU in 7/11 MEF samples. In comparison, there were ten distinct Haemophilus OTUs observed across the NP and adenoid samples. Despite significant differences between the MEF and NP/adenoid microbiomes, Streptococcus sp., H. influenzae and Moraxella catarrhalis OTUs were common to all sample types. Co-occurrence of classical otopathogens in paired MEF and NP/Adenoid samples is consistent with earlier culture-based studies. CONCLUSION: These data highlight the need to further assess H. influenzae traits important in otitis media and to understand the role of canal flora, especially A. otitidis, in populations with a high prevalence of tympanic membrane perforation.

The effect of nasal irrigation formulation on the antimicrobial activity of nasal secretions.

BACKGROUND: Saline-based irrigation solutions are evidence-based rhinological treatments; however, the formulation of these solutions could theoretically alter the function of innate antimicrobial peptides. The aim of this study was to determine if the antimicrobial activity of normal human nasal secretions in vivo is altered by commercially available large volume irrigation solutions. METHODS: Minimally manipulated sinonasal secretions were collected from patients with chronic rhinosinusitis (CRS; n = 10) and normal healthy volunteers (n = 20). In a subset of control patients (n = 10) secretions were collected prior to, and at 1 hour, 6 hours, and 24 hours after nasal irrigation with 4 commercial irrigation solutions. Lysozyme and lactoferrin levels were analyzed and the antimicrobial activity of secretions determined using a radial diffusion assay. RESULTS: The antimicrobial activity of nasal secretions was reduced in CRS patients compared to healthy volunteers (p < 0.01), but there was no significant difference in antimicrobial peptide concentrations. Isotonic nasal irrigation reduced lysozyme and lactoferrin levels, which returned to baseline levels by 6 hours; in addition to a sustained decrease in antimicrobial activity before returning to baseline at 24 hours. Low-salt solution stimulated peptide secretion by approximately 40% at 6 hours and 24 hours, but produced a transient decrease in antimicrobial activity, returning to baseline levels by 6 hours. Hypertonic solution initially decreased lysozyme and lactoferrin levels but maintained baseline levels of antimicrobial activity and increased peptide secretion by approximately 30% at 24 hours. CONCLUSION: The formulation of nasal irrigation solutions significantly affects the measured levels and functionality of sinonasal antimicrobial peptides.

A randomized controlled trial of a middle meatal silastic stent for reducing adhesions and middle turbinate lateralization following endoscopic sinus surgery.

BACKGROUND: Endoscopic sinus surgery (ESS) is indicated for patients with recalcitrant chronic rhinosinusitis symptoms. However, surgical revision can be required because of adhesion formation and middle turbinate lateralization. We investigate the efficacy of a middle meatal silastic stent in reducing these complications after ESS. METHODS: Thirty-six patients were randomized to receive a silastic stent in the middle meatus unilaterally after ESS. The surgeon was blinded to the side receiving the stent until completion of the ESS. The contralateral side, with no stent, was the control side. Patients completed a 7-day, postoperative, visual analog scale symptom diary and were blinded to the stent side until its removal at the first postoperative visit. Patients were followed up after 2, 8, and 24 weeks. Endoscopic video of the sinus cavities were recorded at all visits and 2 blinded, independent ear/nose/throat (ENT) surgeons assessed the videos using a modified Lund-Kennedy scoring system. RESULTS: Thirty-five of 36 patients completed 6-months' follow-up. Middle turbinate lateralization was observed in 13 sides without a stent vs 1 side with a stent. There was a significant reduction in adhesions at weeks 2 and 8 (p < 0.001) and crusting (p < 0.01) in the stent side compared to control. Video scores at 6 months after surgery for stent and control sides remained unchanged from the 8-week visit. There was no difference between sides for symptom scores, edema, or nasal discharge. CONCLUSION: Middle meatal silastic stents are well tolerated by patients and effective in reducing middle turbinate lateralization, adhesions, and crusting postoperatively in ESS.

Aquaporin expression profiles in normal sinonasal mucosa and chronic rhinosinusitis.

BACKGROUND: Thickened secretions, mucosal edema, and polyp formation are pathological features in chronic rhinosinusitis (CRS) that could theoretically be caused by aberrant water flow through sinonasal mucosa. Aquaporins (AQPs) are a family of proteins with roles in water transport, with tissue-specific expression profiles. This study aims to determine if AQP expression in sinonasal mucosa is different between normal controls and patients with CRS, either with (CRSwNP) or without (CRSsNP) nasal polyps. METHODS: During endoscopic sinus surgery or transsphenoidal surgery, sinonasal tissue was collected and classified as CRSwNP (n = 13), CRSsNP (n = 10), or normal (n = 10). Messenger RNA (mRNA) expression of human AQP0 to AQP12b was determined using quantitative real-time polymerase chain reaction (qRT-PCR). Cellular localization of AQP1, AQP3, AQP4, AQP5, AQP7, and AQP11 was determined by immunohistochemistry. RESULTS: mRNA of AQP0 to AQP11 was identified in all samples. AQP12b mRNA was not detected. Significant differences in the mRNA expression levels of AQP4 and AQP11 were identified between normal and CRSwNP patients (p < 0.05). Differences in the cellular localization of AQPs were observed in both CRSsNP and CRSwNP patients vs normal controls. More intense localization to the cell cytoplasm was observed for AQP5 in glandular epithelium (CRSwNP; p < 0.05) and surface epithelium (CRSsNP; p < 0.05), and AQP4 in glandular epithelium (CRSsNP; p < 0.05). CONCLUSION: This study characterized AQP mRNA expression and protein localization in normal human sinonasal tissue. Significant differences in mRNA expression were found for AQP4 and AQP11 in CRSwNP and differences in protein localization patterns of AQP4 and AQP5 were identified in both types of CRS.