Chapter 8: Invasive fungal rhinosinusitis.

Invasive fungal rhinosinusitis (IFRS) is a disease of the paranasal sinuses and nasal cavity that typically affects immunocompromised patients in the acute fulminant form. Early symptoms can often mimic rhinosinusitis, while late symptoms can cause significant morbidity and mortality. Swelling and mucosal thickening can quickly progress to pale or necrotic tissue in the nasal cavity and sinuses, and the disease can rapidly spread and invade the palate, orbit, cavernous sinus, cranial nerves, skull base, carotid artery, and brain. IFRS can be life threatening if left undiagnosed or untreated. While the acute fulminant form of IFRS is the most rapidly progressive and destructive, granulomatous and chronic forms also exist. Diagnosis of IFRS often mandates imaging studies in conjunction with clinical, endoscopic, and histopathological examination. Treatment of IFRS consists of reversing the underlying immunosuppression, antifungal therapy, and aggressive surgical debridement. With early diagnosis and treatment, IFRS can be treated and increase patient survival.

Chapter 8: Invasive fungal rhinosinusitis.

Invasive fungal rhinosinusitis (IFRS) is a disease of the paranasal sinuses and nasal cavity that typically affects immunocompromised patients in the acute fulminant form. Early symptoms can often mimic rhinosinusitis, while late symptoms can cause significant morbidity and mortality. Swelling and mucosal thickening can quickly progress to pale or necrotic tissue in the nasal cavity and sinuses, and the disease can rapidly spread and invade the palate, orbit, cavernous sinus, cranial nerves, skull base, carotid artery, and brain. IFRS can be life threatening if left undiagnosed or untreated. While the acute fulminant form of IFRS is the most rapidly progressive and destructive, granulomatous and chronic forms also exist. Diagnosis of IFRS often mandates imaging studies in conjunction with clinical, endoscopic, and histopathological examination. Treatment of IFRS consists of reversing the underlying immunosuppression, antifungal therapy, and aggressive surgical debridement. With early diagnosis and treatment, IFRS can be treated and increase patient survival.

Surgical management of pharyngocutaneous fistula after total laryngectomy.

PURPOSE: The increased use of radiation in the primary management of laryngeal carcinoma has resulted in an increase in pharyngocutaneous fistula (PCF) formation after salvage laryngectomy. The impact of this practice on surgical management strategies has been analyzed. METHODS: A retrospective review of 177 patients treated by total laryngectomy for laryngeal or hypopharyngeal squamous cell carcinoma was performed. PCF formation was documented and management strategies were analyzed. RESULTS: Preoperative radiation therapy (XRT) was administered to 86 patients (48.6%). Postoperative PCF developed in 47 patients (26.5%), including 30 (34.9%) who had received preoperative XRT versus 17 (18.6%) who had not received XRT (P = 0.015). Spontaneous PCF closure occurred in 23 patients (48.9%). Two patients died with persistent, untreated PCF. Surgical closure of PCF was performed in 22 patients (46.8%), including 17 who had received preoperative radiation (77.3%). Reconstructive methods included 9 local flaps, 17 pectoralis major (PM) flaps, and 2 free jejunal flaps. Seven of the 9 (77.8%) patients treated with local flaps had received XRT. Three patients had successful fistula closure including 2 who had not received radiation. Six of 9 patients (66.7%) developed recurrent fistulization after local flap closure necessitating PM flap closure. Overall, 14 patients (82.4%) had received preoperative XRT prior to PM flap closure. Six patients (35.3%) who had received XRT developed recurrent fistulization and 5 of these fistulas eventually closed with local wound care. The remaining patient succumbed to a carotid artery rupture. Two patients required a completion pharyngectomy and free jejunal flap reconstruction. PM flaps were used in both cases to provide soft-tissue coverage. CONCLUSIONS: Preoperative XRT increases the risk of PCF after laryngectomy and the need for surgical closure. Local flap closure has a limited role in the surgical management of PCF. PM flap reconstruction has a high complication rate including recurrent fistulization in the setting of preoperative radiation.

TNF-α promotes c-REL/ΔNp63α interaction and TAp73 dissociation from key genes that mediate growth arrest and apoptosis in head and neck cancer.

Inflammation-induced activation of proto-oncogenic NF-κB/REL and dysfunction of tumor suppressor TP53/p63/p73 family transcription factors are key events in cancer progression. How inflammatory signaling coordinates dysregulation of these two transcription factor families during oncogenesis remains incompletely understood. Here, we observed that oncoprotein c-REL and tumor suppressor TAp73 are coexpressed and complex with ΔNp63α in the nucleus of a subset of head and neck squamous cell carcinoma (HNSCC) cell lines with mutant (mt)TP53. TNF-α, a proinflammatory cytokine, promoted c-REL nuclear translocation, c-REL/ΔNp63α interaction, and dissociation of TAp73 from ΔNp63α and the nucleus to the cytoplasm, whereas c-REL siRNA knockdown attenuated this effect. Overexpression of c-REL or a c-REL κB-site DNA-binding mutant enhanced protein interaction with ΔNp63α and TAp73 dissociation, implicating c-REL/ΔNp63α-specific interactions in these effects. We discovered that TNF-α or genetic alteration of c-REL expression inversely modulates ΔNp63α/TAp73 interactions on distinct p63 DNA-binding sites, including those for key growth arrest and apoptotic genes p21WAF1, NOXA, and PUMA. Functionally, c-REL repressed these genes and the antiproliferative effects of TNF-α or TAp73. Conversely, c-REL siRNA depletion enhanced TAp73 promoter interaction and expression of genes mediating growth arrest and apoptosis. Similar to TNF-α-treated HNSCC lines, human HNSCC tumors and hyperplastic squamous epithelia of transgenic mice overexpressing ΔNp63α that exhibit inflammation also show increased nuclear c-REL/ΔNp63α and cytoplasmic TAp73 localization. These findings unveil a novel and reversible dynamic mechanism whereby proinflammatory cytokine TNF-α-induced c-REL/ΔNp63α interactions inactivate tumor suppressor TAp73 function, promoting TNF-α resistance and cell survival in cancers with mtTP53.

ΔNp63 versatilely regulates a Broad NF-κB gene program and promotes squamous epithelial proliferation, migration, and inflammation.

Head and neck squamous cell carcinoma (HNSCC) and many other epithelial malignancies exhibit increased proliferation, invasion, and inflammation, concomitant with aberrant nuclear activation of TP53 and NF-κB family members ΔNp63, cRel, and RelA. However, the mechanisms of cross-talk by which these transcription factors coordinate gene expression and the malignant phenotype remain elusive. In this study, we showed that ΔNp63 regulates a cohort of genes involved in cell growth, survival, adhesion, and inflammation, which substantially overlaps with the NF-κB transcriptome. ΔNp63 with cRel and/or RelA are recruited to form novel binding complexes on p63 or NF-κB/Rel sites of multitarget gene promoters. Overexpressed ΔNp63- or TNF-α-induced NF-κB and inflammatory cytokine interleukin-8 (IL-8) reporter activation depended on RelA/cRel regulatory binding sites. Depletion of RelA or ΔNp63 by small interfering RNA (siRNA) significantly inhibited NF-κB-specific, or TNF-α-induced IL-8 reporter activation. ΔNp63 siRNA significantly inhibited proliferation, survival, and migration by HNSCC cells in vitro. Consistent with these data, an increase in nuclear ΔNp63, accompanied by increased proliferation (Ki-67) and adhesion (ß4 integrin) markers, and induced inflammatory cell infiltration was observed throughout HNSCC specimens, when compared with the basilar pattern of protein expression and minimal inflammation seen in nonmalignant mucosa. Furthermore, overexpression of ΔNp63α in squamous epithelial cells in transgenic mice leads to increased suprabasilar cRel, Ki-67, and cytokine expression, together with epidermal hyperplasia and diffuse inflammation, similar to HNSCC. Our study reveals ΔNp63 as a master transcription factor that, in coordination with NF-κB/Rels, orchestrates a broad gene program promoting epidermal hyperplasia, inflammation, and the malignant phenotype of HNSCC.

The increased risk of community-acquired methicillin-resistant Staphylococcus aureus neck abscesses in young children.

OBJECTIVES/HYPOTHESIS: To analyze the microbiological origins of deep neck space infections requiring surgical intervention in a pediatric population. STUDY DESIGN: Retrospective cohort study. METHODS: The study population (N = 136) included all pediatric patients surgically treated for deep neck space abscesses in a metropolitan tertiary care children's hospital over the course of 5 years (September 2004-August 2009). Demographic and clinical information was compared with microbiological isolate data. RESULTS: Microbiological analysis of 118 bacterial isolates demonstrated 49 (42%) methicillin-resistant Staphylococcus aureus (MRSA), 35 (30%) methicillin-sensitive S. aureus, and 34 (28%) non-S. aureus (N-SA) isolates. The median age was 16 months (range, 1 month-13years). Patients <16 months of age were 10 times more likely to have an S. aureus (SA) infection versus N-SA (P <.0001). MRSA comprised the majority of all SA isolates (58%). Eighty percent of all SA abscesses were located in the lateral neck. African American pediatric patients accounted for 70% of all deep neck space infections, and 86% of all MRSA infections. Clindamycin resistance was noted in 8% (4/49) of all community-acquired MRSA isolates. CONCLUSIONS: Children younger than 16 months and/or with lateral neck abscesses are at a significantly increased risk of having an SA infection, the majority being MRSA.

The p53 homologue DeltaNp63alpha interacts with the nuclear factor-kappaB pathway to modulate epithelial cell growth.

The p53 homologue DeltaNp63alpha is overexpressed and inhibits apoptosis in a subset of human squamous cell carcinomas (SCC). Here, we report that in normal keratinocytes overexpressing DeltaNp63alpha and in human squamous carcinoma cells, DeltaNp63alpha physically associates with phosphorylated, transcriptionally active nuclear c-Rel, a nuclear factor-kappaB family member, resulting in increased c-Rel nuclear accumulation. This accumulation and the associated enhanced proliferation driven by elevated DeltaNp63alpha are attenuated by c-Rel small interfering RNA or overexpression of mutant IkappaBalphaM, indicating that c-Rel-containing complex formation is critical to the ability of elevated DeltaNp63alpha to maintain proliferation in the presence of growth arresting signals. Consistent with a role in growth regulation, DeltaNp63alpha-c-Rel complexes bind a promoter motif and repress the cyclin-dependent kinase inhibitor p21WAF1 in both human squamous carcinoma cells and normal keratinocytes overexpressing DeltaNp63alpha. The relationship between DeltaNp63alpha and activated c-Rel is reflected in their strong nuclear staining in the proliferating compartment of primary head and neck SCC. This is the first report indicating that high levels of DeltaNp63alpha interact with activated c-Rel in keratinocytes and SCC, thereby promoting uncontrolled proliferation, a key alteration in the pathogenesis of cancers.

Deficient TP53 expression, function, and cisplatin sensitivity are restored by quinacrine in head and neck cancer.

PURPOSE: To determine the nature and potential pharmacologic reversibility of deficient TP53 expression and function in head and neck squamous cell carcinomas (HNSCC) with wild-type TP53, previously associated with decreased sensitivity to cisplatin therapy. EXPERIMENTAL DESIGN: TP53 genotype, mRNA and protein expression, TP53-induced p21 expression, and TP53 DNA-binding and reporter gene function were determined in a panel of nine previously characterized HNSCC cell lines from the University of Michigan squamous cell carcinoma (UM-SCC) series. The genotoxic drug doxorubicin and the anti-inflammatory and antimalarial drug quinacrine, previously identified as inducers of TP53, were used to examine the nature and potential reversibility of deficient TP53 expression and function. The specific role of inducible TP53 on function and cellular proliferation was confirmed using selective TP53 inhibitor pifithrin-alpha or short hairpin RNA knockdown. The capability of quinacrine to sensitize HNSCC to the cytotoxic effects of cisplatin was assessed. RESULTS: UM-SCC cell lines with wild-type TP53 genotype underexpressed TP53 mRNA and protein when compared with normal human keratinocytes or UM-SCC with mutant TP53. Although doxorubicin failed to induce TP53 expression or functional activity, quinacrine induced TP53 mRNA and protein expression, increased TP53 reporter activity and p21 protein expression, and induced growth inhibition in these wild-type TP53 cell lines. Quinacrine-induced TP53 reporter activity and growth suppression were attenuated by pifithrin-alpha and TP53 short hairpin RNA knockdown. Furthermore, quinacrine sensitized UM-SCC to cisplatin in vitro. CONCLUSIONS: Deficient TP53 mRNA and protein expression underlies decreased function in a subset of HNSCC with wild-type TP53 and can be restored together with cisplatin sensitization by quinacrine.

A novel nuclear factor-kappaB gene signature is differentially expressed in head and neck squamous cell carcinomas in association with TP53 status.

PURPOSE: To determine if gene signatures differentially expressed in head and neck squamous cell carcinomas (HNSCC) are related to alterations in transcription factors nuclear factor-kappaB (NF-kappaB) and TP53 previously associated with decreased cell death, response to therapy, and worse prognosis. EXPERIMENTAL DESIGN: Unique gene signatures expressed by HNSCC lines were identified by cDNA microarray, principal components, and cluster analyses and validated by quantitative reverse transcription-PCR (RT-PCR) and in situ hybridization. Bioinformatic analysis of the promoters and ontogeny of these clustered genes was done. Expression of proteins encoded by genes of a putative NF-kappaB signature, NF-kappaB p65, and TP53 were examined in HNSCC tissue specimens by immunostaining. Predicted promoter binding and modulation of expression of candidate NF-kappaB genes and cell survival were evaluated by p65 chromatin immunoprecipitation (ChIP) and small interfering RNA (siRNA) knockdown. RESULTS: Two groups of HNSCC exhibiting distinct gene signatures were identified: cluster A enriched for histone genes, with a higher prevalence of TP53 promoter binding motifs; and cluster B enriched for injury response genes with NF-kappaB regulatory motifs. Coexpression of cluster B proteins was observed with strong NF-kappaB phospho-p65 and weak TP53 staining, and NF-kappaB phospho-p65 was inversely associated with TP53 (P = 0.02). Promoter binding of the NF-kappaB signature genes was confirmed by p65 ChIP, and down-modulation of their expression and cell death were induced by p65 siRNA. CONCLUSION: NF-kappaB promotes expression of a novel NF-kappaB-related gene signature and cell survival in HNSCC that weakly express TP53, a subset previously associated with inactivated wild-type TP53, greater resistance to chemoradiotherapy, and worse prognosis.

Revision uvulopalatoplasty by Z-palatoplasty.

OBJECTIVE: To study the effectiveness of Z-palatoplasty (ZPP) for patients with persistent obstructive sleep apnea/hypopnea syndrome (OSAHS) after previous uvulopharyngopalatoplasty (UP3). SETTING: Prospective study of 31 subjects who sought revision surgery in university-affiliated medical center. STUDY DESIGN: In accord with Institutional Review Board approval, 40 consenting adult patients with persistent, progressive, or recurrent OSAHS of moderate/severe severity despite previous UP3 surgeries were enrolled. All patients had preoperative subjective assessment of daytime sleepiness, quality of life, and snoring level. All patients underwent revision ZPP, radiofrequency tongue-base reduction, and often repair of nasopharyngeal stenosis. Follow-up continued for 6 months. RESULTS: Thirty-one patients completed the study. No patient demonstrated clinically significant postoperative velopharyngeal incompetence after 14 weeks. No major perioperative complications occurred. Subjective improvement was achieved in all patients, and objective cure was achieved in 21 patients (67.7%). CONCLUSIONS: Z-palatoplasty is safe and effective for selected patients who have failed UP3.

Comparison of the incidences of obstructive sleep apnea-hypopnea syndrome in African-Americans versus Caucasian-Americans.

OBJECTIVE: To determine the relative incidence of obstructive sleep apnea-hypopnea syndrome (OSAHS) in African-Americans compared to a cohort of Caucasian-Americans. STUDY DESIGN AND SETTING: A prospective study of 2 groups of subjects (287 African-Americans and 236 Caucasian-Americans) to evaluate OSAHS severity based on subjective symptoms and anatomic findings. Subjects were from a public health and fitness fair attended by approximately 80,000 people where attendees were invited for an ENT screening. RESULTS: Using OSAHS scores based on subjective symptoms and anatomic findings, the African-American group had a significantly higher incidence of "probable" OSAHS. In addition to symptoms of OSAHS, the questionnaire ascertained that African-American bed partners are more likely to accept loud snoring as compared to Caucasian-American bed partners. CONCLUSIONS: OSAHS may be more common in African-Americans, but African-American bed partners are more likely to accept snoring. The medical community should strive to increase awareness and education about OSAHS in the African-American community. EBM RATING: B-3b.