The Meat of the Matter: Understanding and Managing Alpha-Gal Syndrome.

Alpha-gal syndrome is an unconventional food allergy, characterized by IgE-mediated hypersensitivity responses to the glycan galactose-alpha-1,3-galactose (alpha-gal) and not to a food-protein. In this review, we discuss how alpha-gal syndrome reframes our current conception of the mechanisms of pathogenesis of food allergy. The development of alpha-gal IgE is associated with tick bites though the possibility of other parasites promoting sensitization to alpha-gal remains. We review the immune cell populations involved in the sensitization and effector phases of alpha-gal syndrome and describe the current understanding of why allergic responses to ingested alpha-gal can be delayed by several hours. We review the foundation of management in alpha-gal syndrome, namely avoidance, but also discuss the use of antihistamines, mast cell stabilizers, and the emerging role of complementary and alternative therapies, biological products, and oral immunotherapy in the management of this condition. Alpha-gal syndrome influences the safety and tolerability of medications and medical devices containing or derived from mammalian products and impacts quality of life well beyond food choices.

Decompression of Cavernous Sinus for Trigeminal Neuropathic Pain From Perineural Spread of Tumor: 2-Dimensional Operative Video.

Head and neck malignancies with perineural spread are rare. Patients can present with neuropathic pain and cranial nerve palsies.1 Skull base approaches for surgical decompression are a consideration for patients to provide symptom relief.2 We demonstrate a frontotemporal extradural approach for a patient with worsening visual symptoms and refractory neuropathic pain in the V1, V2, and V3 distributions and briefly review the relevant anatomy.3-7 A 41-yr-old female with a poorly differentiated carcinoma of the head and neck with an infiltration of the cavernous sinus and perineural spread along the trigeminal nerve presented with severe neuropathic facial pain and anesthesia. She had previously undergone radiosurgery. Magnetic resonance imaging (MRI) demonstrated an interval increase in perineural disease within the cavernous sinus with extension intradurally. Her pain was medically refractory. A 2-dimensional intraoperative video illustrates the microsurgical decompression of her perineural invasion along the skull base as a palliative procedure. The patient recovered well postoperatively and had a symptomatic improvement in her pain and visual symptoms. Her preoperative facial numbness persisted postoperatively as expected. Postoperative imaging demonstrates a gross total resection of the intradural component of the tumor with decompression and expected expansion of the cavernous sinus. Because of the retrospective nature of this report, informed consent was not required. Images within the video have been reproduced from Fukuda et al4 with permission from © Georg Thieme Verlag KG; and Matsuo et al5 by permission of the Congress of Neurological Surgeons.