Quantification of Aerosol Concentrations During Endonasal Instrumentation in the Clinic Setting.

OBJECTIVE: Recent anecdotal reports and cadaveric simulations have described aerosol generation during endonasal instrumentation, highlighting a possible risk for transmission of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) during endoscopic endonasal instrumentation. This study aims to provide a greater understanding of particle generation and exposure risk during endoscopic endonasal instrumentation. STUDY DESIGN: Prospective quantification of aerosol generation during office-based nasal endoscopy procedures. METHODS: Using an optical particle sizer, airborne particles concentrations 0.3 to 10 microns in diameter, were measured during 30 nasal endoscopies in the clinic setting. Measurements were taken at time points throughout diagnostic and debridement endoscopies and compared to preprocedure and empty room particle concentrations. RESULTS: No significant change in airborne particle concentrations was measured during diagnostic nasal endoscopies in patients without the need for debridement. However, significant increases in mean particle concentration compared to preprocedure levels were measured during cold instrumentation at 2,462 particles/foot3 (95% CI 837 to 4,088; P = .005) and during suction use at 2,973 particle/foot3 (95% CI 1,419 to 4,529; P = .001). In total, 99.2% of all measured particles were ≤1 µm in diameter. CONCLUSION: When measured with an optical particle sizer, diagnostic nasal endoscopy with a rigid endoscope is not associated with increased particle aerosolization in patient for whom sinonasal debridement is not needed. In patients needing sinonasal debridement, endonasal cold and suction instrumentation were associated with increased particle aerosolization, with a trend observed during endoscope use prior to tissue manipulation. Endonasal debridement may potentially pose a higher risk for aerosolization and SARS-CoV-2 transmission. Appropriate personal protective equipment use and patient screening are recommended for all office-based endonasal procedures. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:E1415-E1421, 2021.

Endonasal instrumentation and aerosolization risk in the era of COVID-19: simulation, literature review, and proposed mitigation strategies.

BACKGROUND: International experience with coronavirus 2019 (COVID-19) suggests it poses a significant risk of infectious transmission to skull base surgeons, due to high nasal viral titers and the unknown potential for aerosol generation during endonasal instrumentation. The purpose of this study was to simulate aerosolization events over a range of endoscopic procedures to obtain an evidence-based aerosol risk assessment. METHODS: Aerosolization was simulated in a cadaver using fluorescein solution (0.2 mg per 10 mL) and quantified using a blue-light filter and digital image processing. Outpatient sneezing during endoscopy was simulated using an intranasal atomizer in the presence or absence of intact and modified surgical mask barriers. Surgical aerosolization was simulated during nonpowered instrumentation, suction microdebrider, and high-speed drilling after nasal fluorescein application. RESULTS: Among the outpatient conditions, a simulated sneeze event generated maximal aerosol distribution at 30 cm, extending to 66 cm. Both an intact surgical mask and a modified VENT mask (which enables endoscopy) eliminated all detectable aerosol spread. Among the surgical conditions, cold instrumentation and microdebrider use did not generate detectable aerosols. Conversely, use of a high-speed drill produced significant aerosol contamination in all conditions tested. CONCLUSION: We confirm that aerosolization presents a risk to the endonasal skull base surgeon. In the outpatient setting, use of a barrier significantly reduces aerosol spread. Cold surgical instrumentation and microdebrider use pose significantly less aerosolization risk than a high-speed drill. Procedures requiring drill use should carry a special designation as an "aerosol-generating surgery" to convey this unique risk, and this supports the need for protective personal protective equipment.

Herpes simplex virus of the nose masquerading as invasive fungal sinusitis: A pediatric case series.

The management of invasive fungal sinusitis differs greatly from the management of herpes simplex virus (HSV) of the nose in immunocompromised patients. However, the diagnosis may be uncertain and a delay in treatment can lead to mortality. Here we describe the successful medical management of a series of immunocompromised pediatric patients with HSV lesions of the nose with the initial concern for invasive fungal sinusitis. The diagnosis of HSV herpes was supported by positive polymerase chain reaction (PCR) testing of the nasal lesion. To our knowledge, these are the first cases described in the pediatric literature, emphasizing the need to include this entity on the differential.

Giant Orf on the Nose.

Orf is a zoonotic infectious disease caused by parapoxvirus. Orf lesions are typically seen on the hand, but they have rarely been reported on the nose. Herein, the authors report a rare patient of an orf lesion on the nose of a 52-year-old man after the Muslim celebration of the feast of the sacrifice. The lesion spontaneously recovered 8 weeks after the initial appearance and showed no evidence of recurrence after 1 year of follow-up. Orf virus infections may occur more often after the celebration of the feast of the sacrifice in Muslim countries.

Low prevalence of oral and nasal human papillomavirus in employees performing CO2-laser evaporation of genital warts or loop electrode excision procedure of cervical dysplasia.

Risk of human papillomavirus (HPV) transmission during laser vaporisation of genital warts or loop electrode excision procedure is controversial. An oral rinse, a nasal swabs, history of HPV related diseases and data on HPV exposure were collected from 287 employees at departments of dermato-venerology and gynaecology in Denmark. A mucosal HPV type was found among 5.8% of employees with experience of laser treatment of genital warts as compared to 1.7% of those with no experience (p = 0.12). HPV prevalence was not higher in employees participating in electrosurgical treatment or cryotherapy of genital warts, or loop electrode excision procedure compared with those who did not. HPV 6 or 11 were not detected in any samples. Hand warts after the age of 24 years was more common among dermatology than among non-dermatology personnel (18% vs. 8.0%, p = 0.03). Mucosal HPV types are infrequent in the oral and nasal cavity of health care personnel, however, employees at departments of dermato-venereology are at risk of acquiring hand warts.

Genetic variability and in vitro transcriptional permissibility of primary ovine beta-retrovirus promoter isolates.

OBJECTIVE: To assess genomic sequence conservation and variation in the proviral promoter of enzootic nasal tumor virus (ENTV) and Jaagsiekte sheep retrovirus (JSRV) in tissue samples from 3 sheep with nasal adenocarcinoma associated with ENTV and 3 sheep with pulmonary adenocarcinoma associated with JSRV and to identify a cell culture system that supports transcriptional activity of the ENTV and JSRV viral promoters. ANIMALS: 6 adult sheep. PROCEDURES: Standard PCR procedures for detection of the ENTV and JSRV long terminal repeat (LTR) promoter region were performed on samples from the 3 nasal adenocarcinomas and 3 pulmonary adenocarcinomas, respectively. The LTRs were cloned into shuttle vectors, amplified, sequenced, and analyzed. The cloned LTR regions were transferred into reporter plasmids and multiple human and ruminant cell lines, and primary cells were transfected with the promoter-reporter plasmids. The viral promoter activity was evaluated by use of an in vitro ß-galactosidase reporter assay. RESULTS: Each isolate had a unique nucleotide sequence. Single nucleotide polymorphisms were the most common LTR mutation and rarely occurred at transcription factor binding sites. Relative to ENTV, the JSRV promoter isolates had a conserved 66-bp U3 insertion, including the lung-specific transcription factor HNF-3ß binding site. Among the cell lines used, human embryonic kidney (293T) and goat synovial membrane cells supported promoter transcription. CONCLUSIONS AND CLINICAL RELEVANCE: The LTRs of ENTV and JSRV have extensive blocks of sequence conservation. Human 293T and goat synovial membrane cell lines may be suitable in vitro cell culture systems for further research of viral promoter functions.

[Rosai-Dorfman disease: clinicopathologic, immunohistochemical and etiologic study of 16 cases].

OBJECTIVES: To study the clinicopathologic features of Rosai-Dorfman disease (RDD), expression of various antigens, human herpes virus type 8 (HHV8), human papillomavirus (HPV)-DNA and Epstein-Barr virus (EBV)-mRNA, and compare the findings with those in the literature. METHODS: The clinicopathologic findings of 16 Rosai-Dorfman disease cases were retrospectively reviewed. Immunohistochemical study for S-100 protein, CD68 (PG-M1), CD163, CD21, CD1a, CD20, CD45RO, CD4, CD8, M-CSF and HHV8 was carried out in 9 of the 16 cases. In-situ hybridization for EBV-mRNA and HPV-DNA was also performed. RESULTS: The male-to-female ratio of the patients was 4.33:1. Amongst the 16 cases studied, 62.5% (10/16) presented nodal RDD, with cervical lymph node predominantly involved. Half of these cases had affected lymph nodes in more than one anatomic site. Extranodal RDD represented 37.5% (6/16) of the cases. The relapse rate of extranodal RDD was higher than that of nodal RDD. Histologically, nodal RDD was characterized by dilated sinuses filled with large polygonal histiocytes which contained lymphocytes and plasma cells. For extranodal lesions, various degrees of stromal fibrosis were seen in association with mixed inflammatory cells (especially plasma cells). The large polygonal histiocytes varied in number and were distributed in clusters or patches. Immunohistochemical study showed that the abnormal histiocytes were strongly positive for S-100 protein. They also expressed CD68, CD163 and M-CSF, but were negative for CD1a, CD21 and HHV8. The lymphocytes in cytoplasm of these histiocytes were positive for both T and B cell markers (with T cell predominance, including a mixture of CD4- and CD8-positive cells). HPV-DNA and EBV-mRNA were not detected by in-situ hybridization. To date, 62 cases of RDD have been reported in mainland China, including 34 cases of nodal RDD and 18 cases of extranodal RDD. The remaining 10 cases involved both lymph nodes and extranodal sites. Compared with overseas reports, RDD occurring in China tended to affect older patients and with slight male predilection. CONCLUSIONS: Rosai-Dorfman disease is relatively rare in China. Pathologic diagnosis of extranodal RDD may be difficult. The demographic data of RDD in China, including age and sex of patients, are different from those in the literature.

[Herpes simplex virus type 1-induced rising dbl quote, left (low)tumor" in the nasal vestibule. The problem of resistance development of herpes simplex in a patient with chronic lymphatic B-cell leukemia]. / Ein Herpes-simplex-Virus Typ 1-induzierter ,,Tumor" im Vestibulum nasi. Die Problematik der Resistenzentwicklung von Herpes-simplex-Viren im Rahmen einer chronisch-lymphatischen B-Zell-Leukämie.

Herpes simplex viruses are known to be among the most common disease-causing microorganisms. Their prevalence can exceed 90% depending on the socioeconomic status of the population. Since the number of immunocompromised patients has increased because of the increased incidence in the acquired immunodeficiency syndrome and an increase in organ transplantation, herpes virus infection may have a greater clinical significance. While treatment of otherwise healthy individuals will not usually cause any clinical problems herpes infection in an immunocompromised patient can have severe consequences. Additionally, development of viral resistance can be observed that may require alternative drugs in treatment. We present a case history of a man with a B-cell chronic lymphocytic leukemia that was associated with a very unusual herpes simplex virus infection in the nasal vestibule. Possible causes for the development of resistance in herpes infections and the use of famciclovir and forscarnet as two therapeutic alternatives to aciclovir are discussed.

Skin lesions caused by orthopoxvirus infection in a dog.

A seven-year-old male dobermann was presented for examination of a non-pruritic ulcerated lesion occurring at the site of a suspected rat bite on the muzzle. Biopsy revealed focal ulcerative dermatitis, with cells in the epidermis, follicular infundibula and interposed sebaceous glands undergoing ballooning degeneration and containing large acidophilic intracytoplasmic structures resembling poxvirus inclusion bodies. The diagnosis of orthopoxvirus infection was confirmed by transmission electron microscopy and immunohistochemistry. The biopsy site healed uneventfully, without evidence of recurrence or development of further cutaneous or internal lesions, and a serum sample collected eight weeks after first presentation had a low titre of poxvirus antibodies. This report demonstrates that orthopoxvirus infection should be considered as a cause of ulcerative skin lesions in dogs, particularly if there has been recent contact with rodents or other small mammals.

Macrophage inflammatory protein-1alpha and RANTES are present in nasal secretions during ongoing upper respiratory tract infection.

Macrophage inflammatory protein-1alpha (MIP-1alpha) and RANTES (regulated upon activation, normal T-cell expressed and secreted) were measured by enzyme-linked immunosorbent assay (ELISA) from virus-infected respiratory cell culture supernatants and from 100 nasal wash samples obtained from patients aged 8 d to 10 yr. The results of the nasal wash samples were analyzed in relation to the etiology of the viral infection. In vitro, respiratory syncytial virus (RSV) induced the production of MIP-1alpha, while both RSV and adenovirus were associated with the production of RANTES. Both MIP-1alpha and RANTES were detected in nasopharyngeal secretions from pediatric patients with acute upper respiratory tract RSV, adenovirus, influenza, and parainfluenza virus infection (p<0.001 by Fisher's exact test). As both of these chemokines have potent effects on the recruitment and degranulation of eosinophils and basophils, further understanding of their role in upper respiratory tract infections may provide valuable insights into the immunopathogenesis of respiratory viral infections.

Cutaneous verruciform xanthoma: a report of five cases investigating the etiology and nature of xanthomatous cells.

Verruciform xanthoma is a rare clinicopathologic entity of uncertain etiology that occurs primarily in the oral mucosa. Aggregates of foam cells in the submucosal stroma or papillary dermis in association with verrucous epithelial hyperplasia are the hallmark of this lesion. Extraoral (cutaneous) occurrence of verruciform xanthoma is much rarer and has been reported mostly in the genital skin. Five cases of extraoral cutaneous verruciform xanthoma (three from the scrotum, one from the penis, and one from the nose) and one histologic "simulant" (from skin of the nose) were studied. The lesions were solitary, raised, or polypoid with cup-shaped craters filled with parakeratotic cells that blended into keratinocytes of an acanthotic and papillomatous epidermis. There was a neutrophilic infiltrate of varying intensity between plump parakeratotic cells and keratinocytes, near the surface of the epidermis. Aggregates of foam cells were present in the papillary dermis, which was highly vascular. A plasma cell predominant infiltrate was seen at the base in a bandlike fashion. Despite the architectural resemblance of verruciform xanthoma to verrucous mucocutaneous lesions related to human papillomavirus infection, it was not detected by either immunohistochemistry, in situ hybridization, polymerase chain reaction, or Southern blot analysis in any case. The foam cells were weakly positive for cytokeratin and for Factor XIIIa but negative for S-100 protein. The KP1 and Mac 387 immunostain showed focal weak staining in foam cells. We postulate that a cascade of events pursue after initial keratinocytic damage attracting neutrophils, with subsequent phagocytosis of necrotic keratinocytic debris by dermal dendrocytes, eventually leading to the ultimate manifestation of the lesion as verruciform xanthoma. The etiologic agent remains elusive, but based on our findings, we conclude that verruciform xanthoma is most likely not a human papillomavirus-associated squamoproliferative lesion and that the foam cells, a histologic hallmark of the lesion, are most likely derived from dermal dendritic cells.

Unilateral nasal infection of cotton rats with respiratory syncytial virus allows assessment of local and systemic immunity.

An in vivo model for the study of local and systemic effectors of immunity to respiratory syncytial virus (RSV) is described. Cotton rats (Sigmodon fulviventer) inoculated in one nostril with a small volume (2 microliters) of virus suspension contracted a unilateral nasal infection which did not extend to the contralateral nasal turbinates, nor to the lungs. Immunity to subsequent RSV challenge could be induced by small priming doses ( < 10 p.f.u. per animal), but was dependent upon viral replication, as virus inactivated by UV light was not immunogenic. Immunity occurred in the absence of detectable neutralizing serum antibody. The onset of resistance to viral challenge occurred simultaneously in ipsilateral nasal, contralateral nasal and pulmonary tissues. However, low levels of transient viral replication occurred in contralateral nasal turbinates and in lungs following virus challenge, thus indicating that local components of immunity acting at the ipsilateral site of infection were more effective than systemic components acting at the other sites. Further evidence is provided to suggest that three types of immunological effectors - local, persistent, systemic and transient systemic - participate in the immune response to RSV infection.

Rhinitis as a mechanism of respiratory defense.

The incidence of rhinitis is on the increase, especially in towns and cities with high levels of pollution from motor traffic and industry. There is a growing body of evidence which links this increased incidence of rhinitis to chronic nasal irritation from industrial pollution. Studies on the mechanisms of nasal inflammation and the nasal immune response are now providing insights into the etiology of rhinitis. This knowledge will help in the development of therapies aimed at alleviating the symptoms of rhinitis and controlling the development of rhinitis in susceptible individuals. This review discusses some of the factors that may explain the increased incidence of rhinitis and examines basic mechanisms involved in the nasal response to infection and allergy.