Novel treatment of a septal ulceration using an extracellular matrix scaffold (septal ulceration treatment using ECM).

BACKGROUND: Septal ulceration is a mucositis involving the mucous membranes of the nasal septum. Patients often complain of nasal irritation, crusting, and epistaxis. Presently, there is no gold standard for the treatment of septal ulcerations. Currently described therapies include local debridement, septal dermoplasty, septal flap reconstruction, and cadaveric dermal graft repair; however, no therapy has demonstrated a consistent improvement of symptoms. We present a novel approach for the treatment of chronic septal ulceration, using an extracellular matrix scaffold (MatriStem® Wound Care Matrix, ACell, Inc.) to repair unilateral partial septal mucosal defects. METHODS: This is a retrospective chart review of three patients with age range from 42 to 74years. All three patients underwent several years of unsuccessful conservative medical management and two patients had prior unsuccessful septoplasty and septal ulcer debridement procedure. There are no complications noted in the post-operative period. RESULT: All three patients had complete symptom relief on post-operative visit after chronic septal ulceration repair using an extracellular matrix scaffold mechanism. Patients were able to manage with conservative nasal regiment after surgery with significant improvement on quality of life. CONCLUSION: The use of extracellular matrix scaffolding provides the nasal septum with a framework for the in-growth of healthy mucosa over ulcerated areas. We propose this as a new treatment approach for patients who failed conservative medical management. Chronic septal ulcerations can be healed to provide improved quality of life to patients.

Maxillary sinusitis resulting from ostium plugging by dislodged bone graft: case report.

PURPOSE: To report an unusual case of severe maxillary sinusitis resulting from ostial plugging by dislodged bone graft material used for sinus elevation procedure. PATIENTS AND METHODS: A 49-year-old female presented to the oral surgery clinic with severe right maxillary sinusitis after a sinus elevation procedure and placement of a dental implant. She had completed an extended course of multiple antibiotics without culture and sensitivity studies or resolution of sinusitis. RESULTS: A CT scan was obtained which showed a dental implant protruding into the right maxillary sinus, sinusitis of the right ethmoid and maxillary sinuses, and dislodged bone graft material obstructing the ostium into the middle nasal meatus. The dental implant was removed, the patient was referred for functional endoscopic sinus surgery, and her sinusitis subsequently rapidly resolved. CONCLUSIONS: Surgeons performing this or similar procedures should be aware of the possible complications that can arise from foreign debris introduced into the maxillary sinuses. Also, the avoidance of empirically changing antibiotic regimens and the early use of CT scans should be considered.

Chronic daily headache: when to suspect sinus disease.

Migraine may be responsible for many headaches thought to be caused by the sinuses. Patients complaining of "sinus headache" must have a complete ear, nose, and throat examination. Occasionally, chronic headaches may arise from the sinuses; a thorough history is important to search for symptoms of facial pain and pressure along with other nasal sinus symptoms.

Impact of newly revised sterile medication compounding guidelines USP {797} on allergy vial preparation.

OBJECTIVES: To highlight newly revised guidelines on sterile medication compounding released by the United States Pharmacopeia (USP 797) in December 2007, and the implications on immunotherapy vial preparation. STUDY DESIGN AND METHODS: A policy review. RESULTS: The newly revised USP chapter on sterile medication guidelines was released December 2007 and becomes effective June 2008. The revised USP 797 now has specific guidelines addressing immunotherapy vial preparation that are a significant change from the previous version. The revised guidelines should be a useful tool for clinicians who are developing and setting office mixing standards. CONCLUSIONS/SIGNIFICANCE: Offices preparing immunotherapy vials should consider formalizing and implementing vial preparation guidelines. These guidelines should be based on expert opinion, experience, and scientific literature.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis.

BACKGROUND: Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR). METHODS: Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus. RESULTS: The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR. CONCLUSION: This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.

Surgical treatment for empty nose syndrome.

OBJECTIVES: To detail empty nose syndrome (ENS), an iatrogenic disorder characterized by a patent airway but a subjective sense of poor nasal breathing, and to explore repair options for patients with ENS. DESIGN: A case series of 8 patients with ENS detailing symptoms before and after submucosal implantation of acellular dermis. SETTING: Academic medical center. PATIENTS: Subjects who were evaluated for abnormal nasal breathing and determined to have ENS. Patients were diagnosed as having ENS if they described characteristic symptoms, had evidence of prior nasal turbinate surgery, and their symptoms improved after they underwent a cotton test. INTERVENTION: Acellular dermis was implanted submucosally to simulate missing turbinate tissue. MAIN OUTCOME MEASURES: Symptoms and symptom scores for the 20-item Sino-Nasal Outcome Test completed before and after the implantation were gathered. RESULTS: A statistically significant improvement in symptom scores for the Sino-Nasal Outcome Test was noted (P < or = .02). CONCLUSIONS: Careful assessment allows reconstructive surgery through submucosal implantation of acellular dermis. Symptoms of patients with ENS can improve with surgical therapy.

The implications of regulatory guidelines on allergen vial mixing for the practicing otolaryngologist.

OBJECTIVES: To introduce otolaryngologists to proposed standards regarding allergen vial mixing, to identify clinical implications, and to recommend efforts to address the issue of vial mixing standards. STUDY DESIGN AND METHODS: A policy review. RESULTS: The Institute of Medicine report on medical errors increased awareness of medication errors, spurring efforts to improve patient safety. One example is the United States Pharmacopoeia's (USP) Chapter 797, a standard for sterile medication compounding. This standard requires the use of a dedicated clean room, ventilation hood, air sampling, surface sampling, and formal testing of mixing personnel. Regulatory agencies may include allergy vial mixing under USP 797. Formal allergy vial mixing guidelines are presented as a standard created by the American Academy of Otolaryngic Allergy taskforce on allergen vial mixing. CONCLUSION/SIGNIFICANCE: Otolaryngologists must be involved the discussion regarding vial mixing standards to ensure that the standards developed are reasonable, safe, preserve patient access, and are based on evidence based medicine.

The implications of regulatory guidelines on allergen vial mixing for the practicing otolaryngologist.

OBJECTIVES: To introduce otolaryngologists to proposed standards regarding allergen vial mixing, to identify clinical implications, and to recommend efforts to address the issue of vial mixing standards. STUDY DESIGN AND METHODS: A policy review. RESULTS: The Institute of Medicine report on medical errors increased awareness of medication errors, spurring efforts to improve patient safety. One example is the United States Pharmacopoeia's (USP) Chapter 797, a standard for sterile medication compounding. This standard requires the use of a dedicated clean room, ventilation hood, air sampling, surface sampling, and formal testing of mixing personnel. Regulatory agencies may include allergy vial mixing under USP 797. Formal allergy vial mixing guidelines are presented as a standard created by the American Academy of Otolaryngic Allergy taskforce on allergen vial mixing. CONCLUSION/SIGNIFICANCE: Otolaryngologists must be involved the discussion regarding vial mixing standards to ensure that the standards developed are reasonable, safe, preserve patient access, and are based on evidence based medicine.

The effect of injection immunotherapy on mucociliary clearance in allergic patients.

OBJECTIVE: To assess the effect of injection immunotherapy on mucociliary clearance in allergic patients with the use of the saccharin test. METHODS: In this prospective cohort study, mucociliary clearance in 42 allergic patients treated with injection immunotherapy was determined with the saccharin test. Of these patients, 23 were retested 1 year later to assess changes in mucociliary clearance times. Mean results for historical controls were determined in a review and meta-analysis of the existing literature. RESULTS: Saccharin clearance times (SCTs) were initially prolonged in allergic patients who received injection immunotherapy when compared to historical controls (one-sided P value < 0.05). However, after 1 year of immunotherapy, there was a significant reduction in SCTs in our patient population. This finding was independent of other evaluated patient characteristics, with the exception of nasal steroid use, which was also significantly associated with a decrease in SCT. CONCLUSIONS: After 1 year of injection immunotherapy, there was a significant reduction in mean SCT in our patient population. Of the other factors studied, only nasal steroid was associated with decreased mucociliary clearance times. To our knowledge, this is the first report in the literature documenting the beneficial effect of injection immunotherapy on mucociliary clearance as measured by saccharin clearance times. Nevertheless, further research is warranted, given the confounding effect of nasal steroid use.

Pathophysiology of empty nose syndrome.

OBJECTIVES/HYPOTHESIS: To review current knowledge on nasal airflow sensation in relation to empty nose syndrome (ENS). STUDY DESIGN: PubMed searches. METHODS: Current literature pertaining to measurement of nasal patency, mechanism of sensory perception of nasal airflow, and ENS. RESULTS: A reliance on pure anatomical analysis of the anatomy in ENS falls short of explaining the disorder. Our understanding of subjective nasal sensation has advanced, as has our understanding of the flow of air through the nose. Neural healing following a surgical insult may not result in a return to a normal physiologic state. Aberrations in neurosensory systems from improper healing may play a major role in the abnormal sensations ENS patients experience. CONCLUSIONS: An evidence-based hypothesis for the development and symptoms of ENS is offered.

A patient with an allergy emergency.

Anaphylaxis is a severe life-threatening systemic reaction that otolaryngologists may come in contact with through emergency cases, or in their offices when delivering allergy immunotherapy. Rapid recognition of the entity should be followed by epinephrine administration. Anaphylaxis causes, including a hypothetical scenario, are described. Various risk factors for anaphylaxis, such as ß-blocker use, are discussed. The differential diagnosis of anaphylaxis and adjunct treatment are explained.

An interpretation method for objective assessment of nasal congestion with acoustic rhinometry.

OBJECTIVES: Acoustic rhinometry is a relatively new modality for evaluating the status of the nose. It assesses the geometry of the nasal cavity by analyzing reflected sound waves. Despite its expanding use, there is no established interpretation method. Our aims in the present descriptive study were to develop and test a protocol as a possible method to read these graphs for clinical use. STUDY DESIGN: We formulated a reading protocol to grade the congestion state of the nasal cavity. The percentile difference of cross-sectional area and volume values between the baseline and decongested states were classified into five categories based on normative values. METHODS: Fifty-six patients with allergic rhinitis were used. All the acoustic rhinometry readings were performed in blinded fashion according to the protocol; later, the clinical information was paired with the interpretation of the graph. RESULTS: The mean percentile differences of baseline and decongestion values in patients with allergic rhinitis were in the mild to moderate range difference according to our reading system. The range of nasal congestion in patients with allergic rhinitis patients was increased with additional pathological conditions such as sleep apnea. CONCLUSION: The percentile difference between the baseline values and values for maximally decongested state reflect mucosal congestion as a "congestion factor," which can be graded as mild, moderate, severe, or markedly severe, for objective evaluation of nasal congestion.

Quality of life in treatment of acute rhinosinusitis with clarithromycin and amoxicillin/clavulanate.

OBJECTIVES: Clarithromycin and amoxicillin/clavulanate (A/C) are first line antibiotics used to treat uncomplicated acute rhinosinusitis (ARS). This study examined the efficacy of clarithromycin and A/C for the treatment of ARS relative to the patient's quality of life (QOL). STUDY DESIGN: Twenty-two patients with uncomplicated ARS were randomly assigned treatment (single blinded relative to the investigator) using clarithromycin or A/C. Patients underwent assessment to confirm the diagnosis and treatment outcome at the initial screening and on completion of antibiotics (diagnosis + 14 days and 28 days). QOL was evaluated using the Allergy Outcomes Survey (AOS), the Rhinoconjunctivitis QOL Questionnaire (RQLQ), the Short Form 36 survey (SF-36), an instantaneous six-item Symptom Severity Survey (SSS-6), and a Visual Analogue Scale (VAS). Surveys were completed at the time of diagnosis, on completion of antibiotics, and at 28 days after diagnosis. RESULTS: Twenty patients completed the study. The SSS-6 and the RQLQ demonstrated significant improvement for all patients at week 4 (P =.002 and P =.003, respectively). The SSS-6 demonstrated significant improvement for clarithromycin at 14 days (P =.02) and at 28 days (P =.029), whereas A/C patients demonstrated significant improvement in symptoms only at 28 days (P =.046). The RQLQ, which reflects the previous 2 weeks, demonstrated significant improvement for the A/C patients at 28 days (P =.01). The Allergy Survey, the SF-36, and the VAS failed to demonstrate significant improvement in the combined data analysis. CONCLUSIONS: Clarithromycin and A/C were equally effective in treating ARS. The clarithromycin patients felt better more rapidly (at 14 days), but both groups of patients had long-term improvement in symptoms at 28 days.

Prevalence of allergy in patients with chronic rhinosinusitis.

OBJECTIVES: The purpose of this study was to provide further evidence that allergic rhinitis is an important factor in chronic and recurrent acute rhinosinusitis. Specifically, this study shows that perennial allergens play a more significant role than seasonal allergens. STUDY DESIGN AND SETTING: Census by chart review of patients with chronic and recurrent acute rhinosinusitis presenting to the Department of Otolaryngology at the MetroHealth Medical Center, Cleveland, OH. METHODS: All participants had allergy testing done either by RAST or intradermal skin endpoint titration utilizing a battery of seasonal and perennial antigens. RESULTS: Of the 48 voluntary participants analyzed in this study, 57.4% had a positive allergy test. Most patients in the study were sensitive to more than one allergen. Of the patients with a positive allergy test, 92% demonstrated sensitivity to one or more perennial allergens-most prominently, molds and dust mites. CONCLUSIONS: Perennial allergy has a statistically significant association with chronic and recurrent acute rhinosinusitis. SIGNIFICANCE: The diagnosis and management of perennial allergies may be beneficial when treating chronic sinus disease.

Acoustic rhinometry findings in patients with mild sleep apnea.

BACKGROUND: Nasal obstruction may contribute to the development of obstructive sleep apnea (OSA). Acoustic rhinometry (AR) measures nasal patency and congestion, which are useful parameters in objectively evaluating nasal obstruction. The nasal obstruction produced by allergic rhinitis may contribute to the development of OSA and can be easily assessed with AR. OBJECTIVE: This study was undertaken to assess the degree of nasal obstruction seen in allergic patients with and without OSA. STUDY DESIGN AND SETTING: This study was a retrospective data analysis from a tertiary referral center. The AR data from 10 patients with and 40 patients without mild OSA were compared. RESULTS: The mean congestion factors at the first cross-sectional area (CSA1) on the AR graph were found to be significantly higher in the OSA group than in the non-OSA group (P = 0.03). The classification of change in congestion factors demonstrated significant differences at CSA1, CSA2, and CSA3 and in volume (t distributions <0.001, 0.0312, <0.001, and <0.001, respectively). The non-OSA patients noted a significant subjective improvement in nasal congestion after topical nasal decongestion, whereas the OSA patients did not (P

Naturally draining ostium of an agger nasi cell: a case report.

We describe the case of a 61-year-old woman who underwent functional endoscopic sinus surgery for chronic hyperplastic rhinosinusitis. During surgery, we were able to visualize the natural ostium of her left agger nasi cell. To our knowledge, such a finding has not been previously documented in the literature.

A comparison of skin endpoint titration and skin-prick testing in the diagnosis of allergic rhinitis.

Among the many methods of allergy diagnosis are intradermal testing (IDT) and skin-prick testing (SPT). The usefulness of IDT has been called into question by some authors, while others believe that studies demonstrating that SPT was superior might have been subject to bias. We conducted a study to compare the validity of SPT and IDT--specifically, the skin endpoint titration (SET) type of IDT--in diagnosing allergic rhinitis. We performed nasal provocation testing on 62 patients to establish an unbiased screening criterion for study entry. Acoustic rhinometric measurements of the nasal responses revealed that 34 patients tested positive and 28 negative. All patients were subsequently tested by SET and SPT. We found that SPT was more sensitive (85.3 vs 79.4%) and more specific (78.6 vs 67.9%) than SET as a screening procedure. The positive predictive value of SPT was greater than that of SET (82.9 vs 75.0%), as was the negative predictive value (81.5 vs 73.0%). None of these differences was statistically significant; because of the relatively small sample size, our study was powered to show only equivalency. The results of our study suggest that the information obtained by the SET method of IDT is comparable to that obtained by SPT in terms of sensitivity, specificity, and overall performance and that both SET and SPT correlate well with nasal provocation testing for ragweed. Therefore, the decision as to which to use can be based on other factors, such as the practitioner's training, the desire for quantitative results, the desire for rapid results, and the type of treatment (i.e., immunotherapy or pharmacotherapy) that is likely to be chosen on the basis of test results.

The physiological mechanism for sensing nasal airflow: a literature review.

BACKGROUND: Nasal obstruction is a common otolaryngologic complaint, yet the mechanism of sensing airflow is not commonly understood. The objective of this work was to review current knowledge on the physiological mechanism for sensing nasal airflow. METHODS: Current literature pertaining to nasal sensation to airflow was retrieved using PubMed and Google Scholar searches. RESULTS: The primary physiological mechanism that produces the sensation of ample nasal airflow is activation of trigeminal cool thermoreceptors, specifically transient receptor potential melastatin family member 8 (TRPM8), by nasal mucosal cooling. The dynamic change in temperature is ultimately sensed. Nasal mucosal cooling is a result of conductive heat loss, driven by temperature gradient, and evaporative heat loss, driven by humidity gradient. The perception of ample nasal airflow is dependent on the overall nasal surface area stimulated by mucosal cooling, which is mainly governed by air flow patterns. Cool thermoreceptors in the nasal mucosa are connected to the respiratory centers and consequently can alter respiration patterns. Mechanoreceptors do not seem to play a role in sensing nasal airflow. Computational fluid dynamics (CFD) modeling could be a valuable objective tool in evaluating patients with nasal congestion. CONCLUSION: Understanding the physiological mechanism of how the nose senses airflow can aid in diagnosing the cause behind patient symptoms, which allows physicians to provide better treatment options for patients.

Surgery for allergic rhinitis.

BACKGROUND: Allergic rhinitis (AR) is a highly prevalent disorder that significantly impacts quality of life and affects millions of people annually. The most bothersome complaint is nasal obstruction, which is most commonly due to inferior turbinate hypertrophy. METHODS: This work presents a review of the literature and an overview of operative techniques. RESULTS: A variety of methods are available for addressing inferior turbinate hypertrophy in patients afflicted with AR. Although no single modality has been defined as the gold standard for treatment, the otolaryngologist should be familiar with an armamentarium of surgical techniques. CONCLUSION: The inferior turbinate is the initial deposit point for allergens and undergoes dynamic changes through the allergic cascade, which results in nasal obstruction. Targeting the inferior turbinate to augment the nasal airway is the mainstay of surgical treatment in AR. Judicious technique and a mucosal sparing philosophy are necessary to maximize outcomes and improve quality of life.

Endonasal repair of septal perforations using a rotational mucosal flap and acellular dermal interposition graft.

BACKGROUND: The closure of nasal septal perforations can be challenging based on the etiology, location, and method of closure. We report on a novel method of closure for nasal septal perforations using a unilateral mucosal rotational flap and acellular dermal interposition graft. METHODS: Twenty patients with nasal septal perforations of various etiologies underwent our method of repair through a closed, endonasal approach. RESULTS: Out of 20 patients, 17 demonstrated successful closure of their septal perforations, consistent with an 85% success rate. Based upon size, closure rates were 89% for small perforations (<1 cm), 80% for medium perforations (1-2 cm), and complete closure for a single large perforation (>2 cm). Of 20 patients, 19 were completely asymptomatic following surgical intervention, and of the 3 with failed repairs, only 1 patient required revision surgery for persistent symptoms. CONCLUSION: Nasal septal perforations may cause bothersome symptoms and present a significant reconstructive challenge. Native septal tissue is advantageous due to a rich vascular supply and proximity to the defect, while interposition grafts act as a scaffold for the migration of respiratory mucosa. The method described herein combines these principles to provide a suitable technique for the closure of nasal septal perforations.