Reducing Aerosolized Particles and Droplet Spread in Endoscopic Sinus Surgery during COVID-19.

OBJECTIVES: The presence of high SARS-Cov-2 viral loads in the upper airway, including the potential for aerosolized transmission of viral particles, has generated significant concern amongst otolaryngologists worldwide, particularly those performing endoscopic sinus surgery (ESS). We evaluated a simple negative-pressure mask technique to reduce viral exposure. METHODS: Two models simulating respiratory droplets >5-10 µm and fine respiratory nuclei <5 µm using fluorescein dye and wood smoke, respectively, were utilized in a fixed cadaveric study in a controlled environment. Using ultraviolet light, fluorescein droplet spread was assessed during simulated ESS with powered microdebrider and powered drilling. Wood smoke ejection was used to evaluate fine particulate escape from a negative-pressure mask using digital subtraction image processing. RESULTS: The use of a negative-pressure mask technique resulted in 98% reduction in the fine particulate aerosol simulation and eliminated larger respiratory droplet spread during simulated ESS, including during external drill activation. CONCLUSIONS: As global ear, nose & throat (ENT) services resume routine elective operating, we demonstrate the potential use of a simple negative-pressure mask technique to reduce the risk of viral exposure for the operator and theatre staff during ESS. LEVEL OF EVIDENCE: 5 Laryngoscope, 131:956-960, 2021.

Staphylococcus aureus internalization in mast cells in nasal polyps: Characterization of interactions and potential mechanisms.

BACKGROUND: Chronic rhinosinusitis (CRS) with nasal polyps is a common chronic condition. The exact cause of nasal polyps remains unknown. Recently, we made the novel observation of intracellular localization of Staphylococcus aureus within mast cells in nasal polyps. OBJECTIVE: This follow-up study aimed to further characterize interactions between S aureus and mast cells in this setting and elucidate potential internalization mechanisms with particular emphasis on the role of staphylococcal enterotoxin B (SEB). METHODS: A prospective study was performed using an explant tissue model with ex vivo inferior turbinate mucosa obtained from patients with chronic rhinosinusitis with nasal polyps (n = 7) and patients without CRS (n = 5). Immunohistochemistry was used to characterize S aureus uptake into mast cells and investigate the effects of SEB on this process. An in vitro cell-culture model was used to investigate mast cell-S aureus interactions by using a combination of fluorescent in situ hybridization, confocal laser scanning microscopy, scanning electron microscopy, transmission electron microscopy, and proliferation assays. RESULTS: S aureus was captured by extracellular traps and entered mast cells through phagocytosis. Proliferating intracellular S aureus led to the expansion and eventual rupture of mast cells, resulting in release of viable S aureus into the extracellular space. The presence of SEB appeared to promote internalization of S aureus into mast cells. CONCLUSION: This study provides new insights into the interactions between S aureus and mast cells, including the internalization process, and demonstrates a prominent role for SEB in promoting uptake of the bacteria into these cells.

Antimicrobial activity of a novel bioengineered honey against non-typeable Haemophilus influenzae biofilms: an in vitro study.

The opportunistic pathogen non-typeable Haemophilus influenzae (NTHi) plays an important role in many chronic respiratory diseases including otitis media, chronic rhinosinusitis, cystic fibrosis and chronic obstructive pulmonary disease. Biofilm formation has been implicated in NTHi colonisation, persistence of infection and recalcitrance towards antimicrobials. There is therefore a pressing need for the development of novel treatment strategies that are effective against NTHi biofilm-associated diseases. SurgihoneyRO is a honey-based product that has been bioengineered to enable the slow release of H2O2, a reactive oxygen species to which H. influenzae is susceptible. Treatment of established NTHi biofilms with SurgihoneyRO significantly reduced biofilm viability through enhanced H2O2 production and was shown to be more effective than the conventional antibiotic co-amoxiclav.

Reactive oxygen: A novel antimicrobial mechanism for targeting biofilm-associated infection.

Reactive oxygen species (ROS) is a novel therapeutic strategy for topical or local application to wounds, mucosa or internal structures where there may be heavy bacterial bioburden with biofilm and chronic inflammation. Bacterial biofilms are a significant problem in clinical settings owing to their increased tolerance towards conventionally prescribed antibiotics and their propensity for selection of further antibacterial resistance. There is therefore a pressing need for the development of alternative therapeutic strategies that can improve antibiotic efficacy towards biofilms. ROS has been successful in treating chronic wounds and in clearing multidrug-resistant organisms, including methicillin-resistant Staphylococcus aureus (MRSA), and carbapenemase-producing isolates from wounds and vascular line sites. There is significant antifungal activity of ROS against planktonic and biofilm forms. Nebulised ROS has been evaluated in limited subjects to assess reductions in bioburden in chronically colonised respiratory tracts. The antibiofilm activity of ROS could have great implications for the treatment of a variety of persistent respiratory conditions. Use of ROS on internal prosthetic devices shows promise. A variety of novel delivery mechanisms are being developed to apply ROS activity to different anatomical sites.

Cephalosporin-NO-donor prodrug PYRRO-C3D shows ß-lactam-mediated activity against Streptococcus pneumoniae biofilms.

Bacterial biofilms show high tolerance towards antibiotics and are a significant problem in clinical settings where they are a primary cause of chronic infections. Novel therapeutic strategies are needed to improve anti-biofilm efficacy and support reduction in antibiotic use. Treatment with exogenous nitric oxide (NO) has been shown to modulate bacterial signaling and metabolic processes that render biofilms more susceptible to antibiotics. We previously reported on cephalosporin-3'-diazeniumdiolates (C3Ds) as NO-donor prodrugs designed to selectively deliver NO to bacterial infection sites following reaction with ß-lactamases. With structures based on cephalosporins, C3Ds could, in principal, also be triggered to release NO following ß-lactam cleavage mediated by transpeptidases/penicillin-binding proteins (PBPs), the antibacterial target of cephalosporin antibiotics. Transpeptidase-reactive C3Ds could potentially show both NO-mediated anti-biofilm properties and intrinsic (ß-lactam-mediated) antibacterial effects. This dual-activity concept was explored using Streptococcus pneumoniae, a species that lacks ß-lactamases but relies on transpeptidases for cell-wall synthesis. Treatment with PYRRO-C3D (a representative C3D containing the diazeniumdiolate NO donor PYRRO-NO) was found to significantly reduce viability of planktonic and biofilm pneumococci, demonstrating that C3Ds can elicit direct, cephalosporin-like antibacterial activity in the absence of ß-lactamases. While NO release from PYRRO-C3D in the presence of pneumococci was confirmed, the anti-pneumococcal action of the compound was shown to arise exclusively from the ß-lactam component and not through NO-mediated effects. The compound showed similar potency to amoxicillin against S. pneumoniae biofilms and greater efficacy than azithromycin, highlighting the potential of C3Ds as new agents for treating pneumococcal infections.

Eustachian tube communicating with sphenoid sinus: report of a novel anatomical variant.

Reports of congenital anomalies of the Eustachian Tube (ET) are scarce, and often associated with chromosomal abnormalities. We report a unique case of a completely bony left Eustachian tube which communicated with the sphenoid sinus. This report details these findings and discusses the potential embryological basis and implications of such an unusual anatomy, in the context of a comprehensive literature review.

A novel insight into the immunologic basis of chronic granulomatous invasive fungal rhinosinusitis.

BACKGROUND: Chronic granulomatous invasive fungal rhinosinusitis (CGIFRS) is a rare disease. The underlying immune responses that drive the development of CGIFRS, as opposed to successful pathogen clearance and controlled inflammation, are not currently known. OBJECTIVE: To characterize the immune responses associated with CGIFRS. METHODS: In addition to a battery of basic investigations, more in-depth immunologic testing involves ex vivo whole-blood stimulation with the polyclonal T-cell mitogen phytohemagglutinin and fungal antigens with interleukin (IL) 12, was undertaken to investigate cell-mediated immune responses associated with CGIFRS. RESULTS: Ex vivo whole-blood stimulation with the polyclonal T-cell mitogen phytohemagglutinin and fungal antigens with IL-12 identified reduced interferon gamma and increased IL-17A levels within the supernatant, which indicated increased in vivo T-helper (Th)17 responses and impaired Th1 responses compared with healthy controls. CONCLUSION: These findings suggest that the development of CGIFRS may be associated with an abnormally exaggerated host Th17 response, which caused failure to clear the fungal pathogen with refractory fungal infection of mucosal membranes, resulting in chronic tissue inflammation.

Low Concentrations of Nitric Oxide Modulate Streptococcus pneumoniae Biofilm Metabolism and Antibiotic Tolerance.

Streptococcus pneumoniaeis one of the key pathogens responsible for otitis media (OM), the most common infection in children and the largest cause of childhood antibiotic prescription. Novel therapeutic strategies that reduce the overall antibiotic consumption due to OM are required because, although widespread pneumococcal conjugate immunization has controlled invasive pneumococcal disease, overall OM incidence has not decreased. Biofilm formation represents an important phenotype contributing to the antibiotic tolerance and persistence ofS. pneumoniaein chronic or recurrent OM. We investigated the treatment of pneumococcal biofilms with nitric oxide (NO), an endogenous signaling molecule and therapeutic agent that has been demonstrated to trigger biofilm dispersal in other bacterial species. We hypothesized that addition of low concentrations of NO to pneumococcal biofilms would improve antibiotic efficacy and that higher concentrations exert direct antibacterial effects. Unlike in many other bacterial species, low concentrations of NO did not result inS. pneumoniaebiofilm dispersal. Instead, treatment of bothin vitrobiofilms andex vivoadenoid tissue samples (a reservoir forS. pneumoniaebiofilms) with low concentrations of NO enhanced pneumococcal killing when combined with amoxicillin-clavulanic acid, an antibiotic commonly used to treat chronic OM. Quantitative proteomic analysis using iTRAQ (isobaric tag for relative and absolute quantitation) identified 13 proteins that were differentially expressed following low-concentration NO treatment, 85% of which function in metabolism or translation. Treatment with low-concentration NO, therefore, appears to modulate pneumococcal metabolism and may represent a novel therapeutic approach to reduce antibiotic tolerance in pneumococcal biofilms.

Common airborne fungi induce species-specific effects on upper airway inflammatory and remodelling responses.

OBJECTIVE: Whilst the exact cause of chronic rhinosinusitis (CRS) remains elusive, it is clear that both inflammation and remodelling are key disease processes. Environmental fungi have been linked to airway inflammation in CRS; however, their role in the pathogenesis of this condition remains controversial. The current consensus suggests that whilst fungi may not be directly causative, it is likely that CRS patients have deficits in their innate and potentially acquired immunity, which in turn may modify their ability to react to fungi. This study used a nasal polyp explant tissue stimulation model to study the inflammatory and remodelling responses related to challenge with common airborne fungal species. METHODS: Ex vivo nasal polyp tissue from six well phenotyped CRSwNP patients undergoing functional endoscopic sinus surgery was stimulated with 1, 10 and 100 µg/ml of Alternaria alternata, Aspergillus niger, Cladosporium sphaerospermum and Penicillium notatum and compared with unchallenged polyp tissue as control. Enzyme-linked immunosorbent assay (ELISA) was used to measure the levels of pro-inflammatory cytokines interleukin-6 (IL-6), granulocyte macrophage colony stimulating factor (GM-CSF) and tumour necrosis factor-α (TNF-α); and pro-remodelling cytokines transforming growth factor-b1 (TGF-b1), and basic fibroblast growth factor (bFGF) in the polyp supernatant. RESULTS: Aspergillus niger stimulation increased pro-inflammatory cytokines TNF-α, GM-CSF and IL-6 whilst having little effect on the remodelling cytokines bFGF and TGF-b1. In contrast, stimulation with Cladosporium sphaerospermum, Alternaria alternata and Penicillium notatum reduced pro-inflammatory cytokines TNF-α and IL-6, but induced a dose-dependent increase in remodelling cytokines TGF-b1 and bFGF. CONCLUSIONS: This study shows that common airborne fungi induce species-specific effects on the upper airway inflammatory and remodelling responses. These findings provide further immunological evidence of a disease-modifying role for fungi in CRS.

Use of the lymphocyte count as a diagnostic screen in adults with suspected Epstein-Barr virus infectious mononucleosis.

OBJECTIVES/HYPOTHESIS: To evaluate the predictive diagnostic accuracy of the lymphocyte count in Epstein-Barr virus-related infectious mononucleosis (IM). STUDY DESIGN: Retrospective case note and blood results review within a university-affiliated teaching hospital. METHODS: A retrospective review of 726 patients undergoing full blood count and Monospot testing was undertaken. Monospot testing outcomes were compared with the lymphocyte count, examining for significant statistical correlations. RESULTS: With a lymphocyte count of ≤4 × 10(9) /L, 99% of patients had an associated negative Monospot result (sensitivity of 84% and specificity of 94%). A group subanalysis of the population older than 18 years with a lymphocyte count ≤4 × 10(9) /L revealed that 100% were Monospot negative (sensitivity of 100% and specificity of 97%). A lymphocyte count of ≤4 × 10(9) /L correlated significantly with a negative Monospot result. CONCLUSIONS: A lymphocyte count of ≤4 × 10(9) /L appears to be a highly reliable predictor of a negative Monospot result, particularly in the population aged >18 years. Pediatric patients, and adults with strongly suggestive symptoms and signs of IM, should still undergo Monospot testing. However, in adults with more subtle symptoms and signs, representing the vast majority, Monospot testing should be restricted to those with a lymphocyte count >4 × 10(9) /L. LEVEL OF EVIDENCE: NA

Characterization of bacterial community diversity in chronic rhinosinusitis infections using novel culture-independent techniques.

BACKGROUND: Chronic rhinosinusitis (CRS) with or without polyps is a common chronic upper airway condition of multifactorial origin. Fundamental to effective treatment of any infection is the ability to accurately characterize the underlying cause. Many studies have shown that only a small fraction of the total range of bacterial species present in CRS is detected through conventional culture-dependent techniques. Consequently, culture data are often unrepresentative of the true diversity of the microbial community within the sample. These drawbacks, along with the length of time required to complete the analysis, strongly support the development of alternative means of assessing which bacterial species are present. As such, molecular microbiological approaches that assess the content of clinical samples in a culture-independent manner could significantly enhance the range and quality of data obtained routinely from such samples. We aimed to characterize the bacterial diversity present in tissue and mucus samples taken from the CRS setting using molecular nonculture-dependent techniques. METHODS: Through 16S ribosomal RNA (rRNA) gene clone sequencing and terminal restriction fragment length polymorphism (T-RFLP) analysis, the bacteria present in 70 clinical samples from 43 CRS patients undergoing endoscopic sinus surgery were characterized. RESULTS: Bacterial T-RFLP profiles were generated for 70 of 73 samples and a total of 48 separate bands were detected. Species belonging to 34 genera were identified as present by clone sequence analysis. Of the species detected, those within the genera Pseudomonas, Citrobacter, Haemophilus, Propionibacterium, Staphylococcus, and Streptococcus were found numerically dominant, with Pseudomonas aeruginosa the most frequently detected species. CONCLUSION: This study has validated the use of the culture-independent technique T-RFLP in sinonasal samples. Preliminary characterization of the microbial diversity in CRS suggests a complex range of common and novel bacterial species within the upper airway in CRS, providing further evidence for the polymicrobial etiology of CRS.

Transforming growth factor-beta gene expression studies in nasal mucosal biopsies in naturally occurring allergic rhinitis.

INTRODUCTION: Evidence has been provided of enhanced epithelial transforming growth factor-beta (TGF-beta) immunoreactivity in allergic rhinitis, including correlation with intra-epithelial mast cell numbers, and the co-localisation of TGF-beta receptors to mast cells, suggesting that the epithelial expression of TGF-beta may represent an important biological process involved in either the recruitment or retention of mast cells within the epithelium in naturally occurring allergic rhinitis. PATIENTS AND METHODS: In order to extend the above findings, evaluation was undertaken in whole nasal biopsies from subjects with naturally occurring allergic rhinitis, of levels of TGF-beta isotypes and receptors gene expression using real-time quantitative polymerase chain reaction (TaqMan RT-PCR), and the results compared to those for tumour necrosis factor-alpha (TNF-alpha), as a positive control. The study was also extended to evaluate gene expression for connective tissue growth factor (CTGF) and Smad proteins, as downstream markers of TGF-beta bioactivity, in the same populations. RESULTS: There were no significant differences between the rhinitic and non-rhinitic groups in the expression of TGF-beta isoforms or Smad-3, Smad-6 and Smad-7 proteins; however, there was increased gene expression for TGF-betaRI and TGF-betaRII along with CTGF in seasonal allergic rhinitis. TNF-alpha gene expression was also increased in seasonal allergic rhinitis, consistent with a more acute inflammatory response in this form of rhinitis. CONCLUSIONS: This study advances our understanding of the role of TGF-beta in the pathogenesis of the inflammatory response in allergic rhinitis.

Nasal mucosal immunoexpression of the mast cell chemoattractants TGF-beta, eotaxin, and stem cell factor and their receptors in allergic rhinitis.

BACKGROUND: Allergic rhinitis is characterized by the epithelial accumulation of cells, particularly mast cells and eosinophils. There is little information relating to the chemotaxins responsible for mast cell epithelial accumulation in this disease. OBJECTIVE: Expression of the mast cell chemoattractants TGF-beta, eotaxin, and stem cell factor and their receptors was investigated in tissue sections from biopsy specimens obtained from patients with naturally occurring allergic rhinitis. METHODS: Specific immunohistochemical staining was performed on thin sections of inferior turbinate biopsy specimens from patients with perennial and seasonal allergic rhinitis and, for comparison, from nonatopic and, where relevant, atopic healthy volunteers without rhinitis. Sequential staining of adjacent 2-microm sections was undertaken to colocalize TGF-beta receptors to mast cells. RESULTS: Evidence was found of significantly increased epithelial immunoreactivity for TGF-beta1, TGF-beta2, TGF-beta3, TGF-beta receptor I, TGF-beta receptor II, and TGF-beta receptor III in patients with perennial and seasonal allergic rhinitis compared with that seen in healthy control subjects. TGF-beta receptors I and II were found to colocalize to mast cells. Eotaxin epithelial immunoreactivity was significantly increased in the perennial group, although there were no corresponding disease-related differences found in relation to CCR-3 immunoreactivity at this site. There was no increase in stem cell factor immunoreactivity within the epithelium in naturally occurring disease. Significant correlations were found between epithelial immunoreactivity for TGF-beta1, TGF-beta2, TGF-beta receptor I, TGF-beta receptor II, and the number of epithelial mast cells. CONCLUSION: These findings of enhanced epithelial TGF-beta immunoreactivity in patients with rhinitis, the correlation with intraepithelial mast cell numbers, and the colocalization of TGF-beta receptors to mast cells suggest that the epithelial expression of TGF-beta might represent an important biologic process involved in either the recruitment or retention of mast cells within the epithelium in naturally occurring allergic rhinitis.

De novo papillary squamous carcinoma of the lacrimal sac.

We report a rare case of a papillary squamous carcinoma of the lacrimal sac diagnosed at first presentation. The initial presentation of the patient discussed here mimicked that of a lacrimal sac mucocele. This report highlights the clinicopathological characteristics of this tumour, as well as the multidisciplinary approach required in its management.

Traumatic fracture of the stapes suprastructure following minor head injury.

Traumatic fracture of the stapes occurs rarely following head injury. Ossicular dislocation is more commonly encountered. When present, stapes fractures are usually associated with an underlying temporal bone fracture. A higher incidence has been reported in childhood, possibly because of the greater flexibility of the skull in this age group. This report highlights the fact that these fractures can be associated with a relatively minor head injury. This possibility should be kept in mind when evaluating patients, especially children, who have a persistent conductive deafness of more than 30 dB with an intact tympanic membrane following any form of head injury. An exploratory tympanotomy with appropriate ossicular reconstruction, as described in this case, can yield excellent results.