Human hnRNP Q re-localizes to cytoplasmic granules upon PMA, thapsigargin, arsenite and heat-shock treatments.

Eukaryotic gene expression is regulated on different levels ranging from pre-mRNA processing to translation. One of the most characterized families of RNA-binding proteins is the group of hnRNPs: heterogenous nuclear ribonucleoproteins. Members of this protein family play important roles in gene expression control and mRNAs metabolism. In the cytoplasm, several hnRNPs proteins are involved in RNA-related processes and they can be frequently found in two specialized structures, known as GW-bodies (GWbs), previously known as processing bodies: PBs, and stress granules, which may be formed in response to specific stimuli. GWbs have been early reported to be involved in the mRNA decay process, acting as a site of mRNA degradation. In a similar way, stress granules (SGs) have been described as cytoplasmic aggregates, which contain accumulated mRNAs in cells under stress conditions and present reduced or inhibited translation. Here, we characterized the hnRNP Q localization after different stress conditions. hnRNP Q is a predominantly nuclear protein that exhibits a modular organization and several RNA-related functions. Our data suggest that the nuclear localization of hnRNP Q might be modified after different treatments, such as: PMA, thapsigargin, arsenite and heat shock. Under different stress conditions, hnRNP Q can fully co-localize with the endoplasmatic reticulum specific chaperone, BiP. However, under stress, this protein only co-localizes partially with the proteins: GW182-GWbs marker protein and TIA-1 stress granule component.

MR evaluation of frontal sinus osteoplastic flaps with autogenous fat grafts.

PURPOSE: To investigate the MR findings in patients who have had osteoplastic frontal sinus flaps placed for inflammatory sinonasal disease. METHODS: The MR images of 13 patients who had improvement of symptoms after osteoplastic frontal sinus flap placement with fat autograft were prospectively evaluated for the presence of high intensity on T2-weighted scans, contrast enhancement, and replacement of frontal sinus fat by lower-signal soft tissue. All studies were performed on a 1.5-T unit using a 5-in round surface coil placed over the nasion. Sagittal T1-weighted, axial and coronal fast spin-echo T2-weighted, and precontrast and postcontrast axial and coronal T1-weighted images were obtained through the operative bed. The T2-weighted and postgadolinium sequences were done with a fat-suppression technique. RESULTS: Hyperintensity within the frontal sinuses on T2-weighted images and enhancement (peripherally and/or centrally where fat was replaced with soft tissue) were found to some degree in all patients. The degree of replacement of frontal sinus fat with soft tissue ranged from 4% to 85% (mean, 43%). Five patients with persistent symptoms had no distinguishing MR features when compared with asymptomatic patients. CONCLUSIONS: Although increased T2-weighted intensity, fat replacement, and enhancement are findings compatible with inflammation, these changes may be seen in patients who are asymptomatic after placement of osteoplastic frontal sinus flaps; they may represent the normal granulation process. MR findings after flap placement are nonspecific and have limited utility in distinguishing symptomatic patients with recurrent inflammatory disease from asymptomatic patients whose imaging findings are related to postoperative scar tissue.

Heterotopic brain in the pterygopalatine fossa.

Heterotopic brain outside the cranial vault is uncommon. It occurs most frequently in the nasal region, although rests elsewhere in the aerodigestive tract have been reported. We describe a case of heterotopic brain in the pterygopalatine fossa.

Endoscopic repair of cerebrospinal fluid fistulae and encephaloceles.

The authors review their experience with endoscopic repair of skull base defects associated with cerebrospinal fluid (CSF) rhinorrhea and/or encephaloceles involving the paranasal sinuses. Between January 1991 and December 1995, 51 patients were evaluated for anterior and middle cranial fossa defects at a tertiary care facility. Of these patients, 36 underwent endoscopic repair of skull base defects. Factors related to surgical success were analyzed. These factors included etiology, defect location, number of prior attempts at repair, type of graft(s) used, fluorescein use, complications, durations of lumbar drain placement, and duration of CSF leakage prior to repair. During the first attempt, successful endoscopic repair was accomplished in 34 (94.4%) of the 36 patients. The mean duration of follow-up was 24.6 months, with a range of 2 to 57 months. The authors conclude that an endoscopic approach provides a safe and effective means for repairing many skull base defects.

Advantages and disadvantages of three-dimensional computed tomography intraoperative localization for functional endoscopic sinus surgery.

Intraoperative three-dimensional computed tomography (3-D-CT) localization has been available for use during functional endoscopic sinus surgery (FESS) for several years, although relatively few otolaryngologists operate in conjunction with this technology. Proponents of intraoperative localization believe that operating with stereotaxis enhances surgical precision and reduces complications. A 1-year review was conducted at the University of Pennsylvania from January 1994 through January 1995. During this period 5% of sinus operations were performed in conjunction with intraoperative localization. The advantages and disadvantages of using intraoperative localization were evaluated for each case. Also examined were type and indication for surgery, anesthesia used, added time, and cost. Overall, intraoperative localization was found to be helpful when anatomy was distorted or obscured. However, selecting patients who may have benefited from localization was often not possible using preoperative data. Ideally, localization should be available for all FESS. Criteria are outlined which will need to be met prior to localization becoming a significant aspect of FESS.

In situ hybridization for Aspergillus and Penicillium in allergic fungal sinusitis: a rapid means of speciating fungal pathogens in tissues.

Allergic fungal sinusitis (AFS) is a serious form of sinonasal fungal disease that is commonly associated with Aspergillus or Dematiaceous fungi. This study was performed to determine the incidence of Aspergillus or Penicillium in AFS by using in situ hybridization (ISH) for Aspergillus and Penicillium ribosomal RNA (rRNA). The Fontana-Masson melanin stain (FMMS) was also used to detect pigmented fungi (A. niger and Dematiaceous fungi). ISH was performed on 26 patients: 17 AFS cases with histologic evidence of fungi, 5 AFS cases without histologic evidence of fungi, 3 cases of invasive fungal sinusitis (IFS), and 1 case of fungus ball. Nine AFS specimens with histologic evidence of fungi were ISH positive. Positivity was also noted in two of three IFS cases, while no staining was seen in the fungus ball and in six AFS specimens without fungi demonstrable by silver stains. Six ISH-positive cases were FMMS positive, suggesting A. niger. Five ISH-negative AFS specimens were FMMS positive, suggesting Dematiaceous fungi. In summary, many AFS patients in our institution demonstrate Aspergillus/Penicillium organisms. Ancillary techniques may help identify fungi responsible for AFS if cultures are negative or not performed. ISH for rRNA is a useful means for rapidly speciating fungi in human tissues.

Early complications of airway management in head-injured patients.

Head-injured patients are frequently young, healthy individuals whose excellent medical condition is suddenly altered by trauma. The purpose of this study is to evaluate the early complications of airway management which occur in head-injured patients and to determine if these are different from what has been reported in patients with chronic illnesses (i.e., diabetes, atherosclerosis, or immunosuppression). Chart review of 52 head-injured patients reveals an early complication rate of 61% for endotracheal intubation and 20% for tracheotomy. Discriminant analysis shows that increasing duration of intubation is the most significant factor in predicting airway management complications (P less than 0.008). The incidence of complications seen in head-injured patients is similar to that of the chronically ill. Complications of endotracheal intubation are judged to be more severe than those of tracheotomy. Data from this study supports the early tracheotomy of severely head-injured patients who are likely to require prolonged airway management.

The effect of human olfactory biopsy on olfaction: a preliminary report.

Normal human olfactory function is subject to a wide variety of factors. Although biopsy of human olfactory neuroepithelium has been reported by several researchers, there are no studies which have evaluated the effect of this procedure on olfactory function. In this retrospective study, we sought to determine if tissue removal from the olfactory cleft has an adverse influence on the sense of smell. Nineteen subjects underwent bilateral olfactory testing and subsequent endoscopic olfactory mucosal biopsy. All subjects were retested 6 weeks to 1 year after olfactory neuroepithelial biopsy. No statistical difference was found between olfactory tests performed before or after biopsy. These data suggest that biopsy of human olfactory neuroepithelium has no discernible adverse effect on the ability to smell.

Histology and histomorphometry of ethmoid bone in chronic rhinosinusitis.

Mucosal changes have been well described in chronic sinusitis, yet little is known about the underlying bone, despite clinical and experimental evidence suggesting that bone may be involved in chronic sinusitis. Techniques of undecalcified bone analysis were used for detailed histologic examination of ethmoid bone in chronic sinusitis compared with controls. Bone synthesis, resorption, and inflammatory cell presence were specifically assessed. Additionally, histomorphometry techniques were used to determine ethmoid bone physiology in individuals undergoing surgery for chronic sinusitis. Overall, individuals undergoing surgery for chronic sinusitis were found to have evidence of marked acceleration in bone physiology with histologic changes including new bone formation, fibrosis, and presence of inflammatory cells. These findings are compared with osteomyelitis in long bone and the jaw. The suggestion that underlying bone may serve as a catalyst for chronic sinusitis is supported and implications for therapy are discussed.

Histiocytic necrotizing lymphadenitis (Kikuchi's disease).

Histiocytic necrotizing lymphandenitis (HNL), or Kikuchi's disease, is a newly recognized disease of unknown origin that causes cervical lymphadenitis, usually in young women. Initially described in Japan, cases of HNL are being reported in the United States and other western countries with increasing frequency. Symptoms of HNL include tender cervical adenopathy, fever, weight loss, and night sweats. Laboratory studies reveal leukopenia with relative granulocytopenia and lymphocytosis. Lymph node biopsy reveals areas with frank cellular necrosis, karyorrhexis, and absence of plasma cells. The histologic features of HNL are distinctive but can be confused with those of lymphoma. We describe two cases of HNL and present recommendations for diagnosis and treatment.

Computer-assisted resection of benign sinonasal tumors with skull base and orbital extension.

OBJECTIVE: To use freehand, real-time, intraoperative, 3-dimensional computed tomography (3-D CT) localization to assist with resection of sinonasal lesions with skull-base and/or orbital extension. DESIGN: The 3-D CT is computer-assisted technology using the preoperative CT scan as a road map for resection of lesions. Previous technology, while resulting in little intraoperative error, required use of a somewhat cumbersome rigid articulated arm and attached probe, limiting mobility and requiring rigid fixation of the head to maintain system reference. A new freehand version of this technology, eliminating these limitations, has been used for resection of benign sinonasal lesions with skull-base and/or orbital extension. SETTING: Tertiary care, university-based practice. PATIENTS: Seven patients prospectively selected with benign lesions involving the sinonasal cavity and orbit and/or skull base. INTERVENTION: All patients underwent surgical resection of their tumors using endoscopic, open, or combined procedures with the assistance of freehand 3-D CT localization. MAIN OUTCOME ASSESSMENTS: Surgeon assessment of usefulness. RESULTS: In several cases, the device assisted the operator in determining the exact location of a displaced optic nerve, ensuring vision preservation, while in other cases, the location and depth of skull-base penetration was clearly determined, allowing resection via a transnasal endoscopic approach. In addition, the device was useful for determining the depth of necessary resection for optimal cosmetic result. In all cases, system accuracy was within less than 2 mm at the operative site. System limitations included need for an additional preoperative CT and time required at the beginning of the case for system setup and registration. CONCLUSIONS: Freehand 3-D CT, while still with limitations, offers the advantage of increased surgical safety, aiding anatomic understanding in distorted surgical fields for resection of benign sinonasal tumors with orbital and skull-base extension.

New technology.

Our Academy has proposed this primer, The Ethical Otolaryngologist, to serve as guide to help individual otolaryngologists determine the ethical nature of technologic advancements. Ultimately, each otolaryngologist will decide for himself or herself what he or she believes to be ethical. However, we otolaryngologists should make these decisions while recalling our sworn responsibility to our patients and our responsibility to our chosen profession in otolaryngology. Examples and questions that were presented are intended to assist each of us in making ethical determinations about the care we render to patients. There are many facets to the ethical implications of new technology touched on in this chapter, and they include the following: 1. Categories of new technology and technology assessment studies. 2. Otolaryngologists adopting or developing new technologies. 3. Otolaryngologists teaching and learning new technologies. 4. Supervision of clinical applications of new technologies. In conclusion, nearly all of us who are otolaryngologists have entered this aspect of health care because we enjoy patient contact, the challenges of surgery, the continuing education process, and above all, we are interested in helping our patients prevent and alleviate disease. Our training has encouraged us to put the patient's best interests above all else. This is our utmost ethical responsibility.

Use of the superior meatus and superior turbinate in the endoscopic approach to the sphenoid sinus.

Endoscopic surgery of the posterior ethmoid and sphenoid sinuses can present the operator with a considerable challenge. Although endoscopic training and physician experience have increased significantly in the past decade, surgical complications such as optic nerve trauma and cerebrospinal fluid leak still occur. Surgeons reporting such complications cite a lack of orientation within the dissection field as a primary cause. Because endoscopic sinus surgery is now being performed more routinely, surgical strategies designed to reduce the risk of complications are more important than ever. An anatomic landmark that could reliably orient the dissection within the posterior ethmoids and guide the surgeon to the sphenoid sinus could reduce the possibility of such adverse outcomes. In our experience identification of the superior meatus and superior turbinate provides a reliable landmark within the dissection field that can ensure surgical orientation to the operator. This technique allows safe, reliable dissection of the posterior ethmoids and an efficient approach to the sphenoid sinus, especially in patients undergoing revision surgery. In this article our technique for the identification and definition of the superior meatus and superior turbinate is presented, and the advantages of using this landmark in sinus surgery are discussed. In our experience identification of the superior meatus, superior turbinate, posterior skull base, and medial orbital wall defines a parallelogram-shaped box, which delineates the sphenoid face. This box provides the necessary orientation to guide the surgeon's entrance into the sphenoid sinus through the posterior ethmoid sinus (as Messerklinger described). Techniques for identifying the superior turbinate and meatus and for entering the sphenoid are detailed.

Complications of ethmoidectomy: a survey of fellows of the American Academy of Otolaryngology-Head and Neck Surgery.

A survey regarding complications of sinus surgery was mailed to 6969 otolaryngologists; 3933 responses (56.44%) were obtained, and 3043 of these physicians (77.37%) reported that they performed ethmoidectomy. Completed questionnaires were available for review from 42.21% of all Academy fellows (2942 physicians). Responses were tabulated and summarized question by question. Physicians generally did not rate their residency training in ethmoidectomy highly. The survey confirmed that there has been a marked rise in the frequency of ethmoidectomy and in the amount of training in ethmoidectomy since 1985. Empirical complication rates were calculated for different procedures and time periods. Poisson regression models were then constructed to describe the rate of complications under varying conditions such as the type of surgery performed, time period, experience and training of the surgeon, and type of complication encountered. The models permitted determination of the statistical significance of variables in relation to incidence or complications. The study did not demonstrate a clear and consistent statistical relationship between the incidence of complications, the type of surgery performed, and the quality of training. Moreover, physicians who provided data from record review tended to report higher rates than those who estimated responses. The majority of physicians discussed specific potential complications with their patients before surgery and routinely performed preoperative computed tomography. The study demonstrated that physicians who experienced complications at higher rates were more likely to discuss these complications with patients before surgery.

Long-term impact of functional endoscopic sinus surgery on asthma.

Using objective and subjective criteria, we performed a study to assess the long-term impact of functional endoscopic sinus surgery (FESS) in patients with chronic rhinosinusitis and asthma at an average follow-up of 6.5 years. One hundred twenty patients who underwent FESS for chronic rhinosinusitis were followed up for an average of 6.5 years (range 6.0 to 10.6 years). Seventy-two (60%) patients responded to a follow-up questionnaire, and 30 (42%) of them reported a history of asthma. Subjective levels of improvement and assessments of medication need were evaluated and statistically assessed with parametric and nonparametric methods. Of these 30 patients, 27 (90%) reported that their asthma was better than it had been before FESS, 6.5 years ago. Average reported improvement increased from 49% at 1.1 years after surgery to 65% at 6.5 years after surgery. Asthma attacks declined in 20 of 27 (74.1%). Medication use for asthma showed similar improvement, with approximately half reporting less inhaler usage and nearly two thirds reporting less oral steroid use. This study demonstrates that a combination of FESS, careful postoperative care, and appropriate medical therapy for chronic rhinosinusitis has a favorable long-term effect on asthma in patients with symptomatic chronic sinusitis. In this study asthma severity, frequency of attacks, and medication need were all improved.

Endoscopic septoplasty: indications, technique, and results.

Endoscopic septoplasty is an attractive alternative to traditional "headlight" approaches to septoplasty. The primary advantage of the technique is the ability to reduce morbidity and postoperative swelling in isolated septal deviations by limiting the dissection to the area of the deviation. This ability to markedly reduce the extent of subperichondrial dissection is particularly valuable in patients who have undergone prior septal cartilage resection. Other advantages include improved visualization, particularly in posterior septal deformities; improved surgical transition between septoplasty and sinus surgery; and its use as an effective teaching tool. We present our experience with endoscopic septoplasty in a series of 111 patients. Surgical indications, technique, and complications are discussed.

Head and neck manifestations of eosinophilia-myalgia syndrome.

Eosinophilia-myalgia syndrome (EMS) is a multisystemic disease that occurs in patients who have consumed products containing L-tryptophan. Prominent features include incapacitating myalgias, arthralgias, neuropathies, and eosinophilia. Despite the frequent association of dysphagia, dyspnea, and the potential for aspiration, the otolaryngology literature is devoid of information on EMS. In order to determine the frequency of otolaryngic symptoms, questionnaires were distributed to patients with EMS in 33 different US states. Among the 28 various head and neck manifestations studied, 70% of EMS patients complained of generalized muscle spasms, 66% xerostomia, 62% dyspnea, and 56% dysphagia. In addition, the epidemiology, clinical presentation, diagnostic criteria, and treatment options are discussed. This paper assesses the frequency of otolaryngic manifestations of EMS, as well as introduces this syndrome to the otolaryngologist-head and neck surgeon. It is important for the otolaryngologist to be aware of EMS and its manifestations and treatments so that patients with this potentially lethal disease can receive appropriate evaluation and expeditious treatment.

Acoustic rhinometry in the study of the acute nasal allergic response.

Acoustic rhinometry is a recently developed method for the objective assessment of nasal patency. In this study, acoustic rhinometry was used to measure changes in nasal cavity dimensions in the immediate response to nasal allergen challenge in eight pollen-sensitive subjects. Acoustic rhinometric changes were compared with subjective symptoms, as well as histamine in nasal secretions, cytology of nasal mucosal scrapings, and changes in olfactory function. A significantly greater decrease in nasal airway caliber occurred following allergen challenge as compared to buffer diluent challenge in the same individuals (70% +/- 7% versus 22% +/- 5%). During an allergic response, a strong correlation was found between the minimum cross-sectional area and the volume of the nasal cavity measured by acoustic rhinometry (r = .9). However, no correlation was observed between nasal airway caliber and concomitant subjective congestion reported by the subjects. A modest decrease in olfactory function was seen following allergen challenge (3.1 +/- 1.4 fewer odors identified correctly out of 20; p = .08). However, the alterations of olfactory function did not correlate with changes in nasal patency. The results presented in this study demonstrate that acoustic rhinometry has great potential as a reproducible method for the objective assessment of nasal obstruction occurring in nasal allergen challenge studies.

Predictive value of the Glasgow Coma Scale for tracheotomy in head-injured patients.

Patients with severe head trauma often require prolonged intubation and subsequent tracheotomy. The Glasgow Coma Scale (GCS), an indicator of the severity of head injury, may help identify that subpopulation of trauma victims who will ultimately undergo tracheotomy. This retrospective study demonstrates through discriminant analysis that the likelihood of tracheotomy is significantly greater in patients with a GCS rating less than or equal to 7 than it is in patients with a GCS rating greater than 7 (p = .0001). Conversely, the presence of thoracoabdominal or maxillofacial injury is associated with but not predictive of eventual tracheotomy. In the hope of minimizing complications and enhancing the utilization of hospital resources, this study argues for early tracheotomy in patients with a GCS score less than or equal to 7 who do not undergo craniotomy and are otherwise stable.