Chronic Rhinosinusitis: Potential Role of Microbial Dysbiosis and Recommendations for Sampling Sites.

Chronic rhinosinusitis (CRS) is an inflammatory condition that affects up to 12% of the human population in developed countries. Previous studies examining the potential role of the sinus bacterial microbiota within CRS infections have found inconsistent results, possibly because of inconsistencies in sampling strategies. The aim of this study was to determine whether the sinus microbiome is altered in CRS and additionally if the middle meatus is a suitable representative site for sampling the sinus microbiome. Swab samples were collected from 12 healthy controls and 21 CRS patients, including all eight sinuses for CRS patients and between one and five sinuses for control subjects. The left and right middle meatus and nostril swabs were also collected. Significant differences in the sinus microbiomes between CRS and control samples were revealed using high-throughput 16S rRNA gene sequencing. The genus Escherichia was over-represented in CRS sinuses, and associations between control patients and Corynebacterium and Dolosigranulum were also identified. Comparisons of the middle meatuses between groups did not reflect these differences, and the abundance of the genus Escherichia was significantly lower at this location. Additionally, intra-patient variation was lower between sinuses than between sinus and middle meatus, which together with the above results suggests that the middle meatus is not an effective representative sampling site.

Bacterial Communities Vary between Sinuses in Chronic Rhinosinusitis Patients.

Chronic rhinosinusitis (CRS) is a common and potentially debilitating disease characterized by inflammation of the sinus mucosa for longer than 12 weeks. Bacterial colonization of the sinuses and its role in the pathogenesis of this disease is an ongoing area of research. Recent advances in culture-independent molecular techniques for bacterial identification have the potential to provide a more accurate and complete assessment of the sinus microbiome, however there is little concordance in results between studies, possibly due to differences in the sampling location and techniques. This study aimed to determine whether the microbial communities from one sinus could be considered representative of all sinuses, and examine differences between two commonly used methods for sample collection, swabs, and tissue biopsies. High-throughput DNA sequencing of the bacterial 16S rRNA gene was applied to both swab and tissue samples from multiple sinuses of 19 patients undergoing surgery for treatment of CRS. Results from swabs and tissue biopsies showed a high degree of similarity, indicating that swabbing is sufficient to recover the microbial community from the sinuses. Microbial communities from different sinuses within individual patients differed to varying degrees, demonstrating that it is possible for distinct microbiomes to exist simultaneously in different sinuses of the same patient. The sequencing results correlated well with culture-based pathogen identification conducted in parallel, although the culturing missed many species detected by sequencing. This finding has implications for future research into the sinus microbiome, which should take this heterogeneity into account by sampling patients from more than one sinus.

Silastic splints reduce middle meatal adhesions after endoscopic sinus surgery.

BACKGROUND: Adhesions frequently form between the middle turbinate and lateral nasal wall after endoscopic sinus surgery (ESS) and are a possible cause for surgical failure. Many absorbable and nonabsorbable spacers have been tried to improve healing. This study was designed to ascertain whether placement of a thin silastic splint into the middle meatus after sinus surgery for 2 weeks reduces adhesion formation and whether a reduction in the adhesion rate improves patient outcomes in the early postoperative phase. METHODS: Forty-two patients who were scheduled to undergo ESS for chronic rhinosinusitis were randomized to have a silastic splint placed into the middle meatus on one side of the nose but not the other at the completion of surgery. Splints were removed 2 weeks postoperatively. Symptom scores were recorded for each side of the nose up to 12 weeks after surgery and ethmoid cavities were graded at the 6- and 12-week visits along with assessment of adhesions. Patients were blinded to which side was splinted as was the surgeon assessing ethmoid cavities at 6 and 12 weeks. RESULTS: Thirty-three patients completed 12 weeks of follow-up. Nasal obstruction and facial pain/discomfort were significantly higher on splinted sides for the first 2 weeks. More interventions were performed to debride adhesions in nonsplinted sides. Endoscopy revealed no adhesions at 12 weeks for sides treated with a splint whereas 9 of 33 nonsplinted sides had persistent adhesions. There were no significant differences in symptom or ethmoid cavity scores at 6 or 12 weeks between sides treated with splints versus sides treated without splints or between sides with adhesions versus without adhesions. CONCLUSION: Middle meatal silastic splints reduce adhesions after ESS but increase early nasal obstruction and discomfort. Their use did not significantly change symptom or ethmoid cavity scores at 12 weeks.

Efficacy of medical therapy in treatment of chronic rhinosinusitis.

Uncomplicated chronic rhinosinusitis (CRS) is generally treated with medical therapy initially and surgery is contemplated only after medical therapy has failed. However, there is considerable variation in the medical treatment regimens used and studies defining their efficacy are few. The aim of this study was to determine the proportion of patients treated medically who responded sufficiently well so that surgery was not required. Subgroup analysis to identify clinical features that predicted a favorable response to medical therapy was also performed. Eighty patients referred to the Otorhinolaryngology Clinic at North Shore Hospital were treated with a standardized medical therapy protocol (oral prednisone for 3 weeks, oral antibiotics and ongoing saline lavage and intranasal budesonide spray). Symptom scores were collected before and after medical therapy. Clinical features such as presence of polyps, asthma, and aspirin hypersensitivity were recorded. Failure of medical therapy was defined as the persistence of significant CRS symptoms, and those patients who failed medical therapy were offered surgery. Follow-up data were available for 72 (90%) patients. Of this group, 52.5%, (95% CI, 42.7%, 62.2%) failed to respond adequately to medical therapy and were offered surgery. The remaining patients (37.5%) were successfully treated with medical therapy and did not require surgery at the time of follow-up. The premedical therapy symptom scores were significantly higher than the postmedical therapy symptom scores (p < 0.01). The symptom scores of those patients postmedical therapy who proceeded to have surgery were significantly higher than the group who responded well to maximum medical therapy (MMT) and did not require surgery (p < 0.0001). There were no significant differences in the proportion of patients with asthma, aspirin sensitivity, or polyps between the groups failing or not failing MMT. In approximately one-third of patients with CRS, medical therapy improved symptoms sufficiently so that surgical therapy was avoided. Patients with more severe symptoms tended not to respond as well as those with less severe symptoms. Long-term follow-up is required for the group of responders to determine how many will eventually relapse.

Simultaneous tonsillectomy and nasal surgery in adult obstructive sleep apnea: a pilot study.

OBJECTIVE: Although adenotonsillectomy is the accepted treatment for obstructive sleep apnea (OSA) in the pediatric population, tonsillectomy has not been widely adopted in adults, and its success in this group has not been well reported. Despite the lack of current evidence, there may be an important role for tonsillectomy in selected adult cases, and further study is required. This is a pilot study from a larger group of subjects currently enrolled and awaiting surgery and repeat polysomnography. STUDY DESIGN: Retrospective series with chart review. SETTING: Tertiary referral teaching hospitals. SUBJECTS AND METHODS: Thirteen consecutive eligible subjects with tonsillar hypertrophy and OSA were identified after treatment. These patients had undergone pre- and postoperative polysomnography for assessment of the severity of sleep-disordered breathing. Post hoc analysis of key parameters was performed by Wilcoxon signed rank and paired t tests. Tonsillectomy was performed on all subjects, using the diathermy dissection technique. Nasal surgery was performed simultaneously in 11 subjects for symptomatic nasal blockage unresponsive to medical treatment. RESULTS: There was a statistically significant improvement in the severity of OSA after surgery. The total Respiratory Disturbance Index (RDI) was significantly decreased from median values of 31.7 to 5.5 (P = .0002). The RDI in rapid eye movement and non-rapid eye movement sleep and the arousal index were also significantly decreased. CONCLUSION: In selected adult subjects, tonsillectomy with intercurrent nasal surgery should be considered an effective treatment for OSA and may reduce the requirement for continuous positive airway pressure, oral appliances, or further therapeutic intervention.

Novel approach of medialization thyroplasty with arytenoid adduction performed under general anesthesia with a laryngeal mask.

OBJECTIVE: To objectively assess the voice outcomes of patients with unilateral vocal fold paralysis treated with medialization thyroplasty and arytenoid adduction suture. STUDY DESIGN: Case series of patients who underwent medialization thyroplasty and arytenoid adduction suture. Preoperative and postoperative voice testing was performed and the data were compared by statistical analysis. SETTING: Tertiary referral teaching hospital in Sydney, Australia. SUBJECTS: All patients had a unilateral vocal fold paralysis, with a large posterior glottic gap and vocal symptoms affecting their quality of life. METHODS: Thirteen patients with a diagnosis of a unilateral vocal fold paralysis with a large posterior glottic gap, vocal symptoms, and total denervation of the vocal fold underwent medialization thyroplasty and arytenoid adduction suture. The surgery was performed in a novel method under a general anesthetic using a laryngeal mask and with direct intraoperative endoscopic feedback. Preoperative and postoperative measures of voice performance were compared, including acoustic analysis (fundamental frequency, speech intensity against quiet and loud background noise, speech rate) and aerodynamic assessment (airflow, maximum phonation time). RESULTS: Medialization thyroplasty with arytenoid adduction suture significantly improved aerodynamic assessment and phonation duration for both male and female subjects overall. There were 2 of 13 treatment failures. Median follow-up time was 6 months. CONCLUSION: Preliminary results indicate that in selected patients with vocal fold paralysis, medialization thyroplasty with arytenoid adduction suture leads to significant improvements in objective voice measures. Longer follow-up data are required to further quantify the voice outcomes after this procedure.

Technique of temporoparietal fascia flap in ear and lateral skull base surgery.

OBJECTIVES: The temporoparietal fascia (TPF) is a distinct anatomic layer of the lateral scalp with a defined blood supply. The TPF flap has desirable properties for otologic surgery: high malleability, distinct vascularity, and close proximity to the temporal bone. This article describes our technique for preserving the TPF in approaches to the temporal bone and its subsequent use in otologic reconstructive surgery. INTERVENTIONS: A retrospective review of the senior author's personal database was undertaken over a 6-year period where a TPF flap was used. MAIN OUTCOME MEASURES: The indication for surgery, type of surgery, time taken for cavity healing, complications, and length of follow-up were recorded. RESULTS: Sixty-five TPF flaps were performed for ear and lateral skull base reconstructive operations. Indications for surgery included cholesteatoma, chronic otitis media, cerebrospinal fluid fistula, and meningoencephalocele. Cholesteatoma and chronic otitis media accounted for 88% of the cases (n = 57). Most (98%, n = 50) of the mastoidectomy cases underwent a posterior based flap. All mastoid cases were epithelialized at 6 weeks. Complications encountered and discussed were a mastoid-cutaneous fistula, mastoid hematoma, and canal stenosis (5%; n = 3). CONCLUSION: With appropriate technique and indications, the TPF flap is an important reconstructive option after ear and lateral skull base surgery.

Superantigens.

Superantigens (SAgs) are derived from diverse sources, including bacteria, viruses, and human hepatic tissue. SAgs initially cause lymphocyte activation but then result in clonal deletion and anergy, leading to immune tolerance. They can also act as superallergens by stimulating a broad spectrum of mast cells and basophils in patients with allergic conditions. The newly described staphylococcal SAg-like proteins subvert innate immune function by several mechanisms, which are distinct from SAgs' effects on lymphocytes and other acquired immune processes. There is mounting evidence to suggest that SAgs play a role in the pathophysiology of inflammatory airway disease. The pathophysiologic role of SAg-like proteins awaits clarification.

Screening for staphylococcal superantigen genes shows no correlation with the presence or the severity of chronic rhinosinusitis and nasal polyposis.

BACKGROUND: Staphylococcus aureus secretes numerous exotoxins which may exhibit superantigenic properties. Whereas the virulence of several of them is well documented, their exact biological effects are not fully understood. Exotoxins may influence the immune and inflammatory state of various organs, including the sinonasal mucosa: their possible involvement in chronic rhinosinusitis has been suggested and is one of the main trends in current research. The aim of this study was to investigate whether the presence of any of the 22 currently known staphylococcal exotoxin genes could be correlated with chronic rhinosinusitis. METHODOLOGY/PRINCIPAL FINDINGS: We conducted a prospective, multi-centred European study, analysing 93 Staphylococcus aureus positive swabs taken from the middle meatus of patients suffering from chronic rhinosinusitis, with or without nasal polyposis, and controls. Strains were systematically tested for the presence of the 22 currently known exotoxin genes and genotyped according to their agr groups. No direct correlation was observed between chronic rhinosinusitis, with or without nasal polyposis, and either agr groups or the presence of the most studied exotoxins genes (egc, sea, seb, pvl, exfoliatins or tsst-1). However, genes for enterotoxins P and Q were frequently observed in nasal polyposis for the first time, but absent in the control group. The number of exotoxin genes detected was not statistically different among the 3 patient groups. CONCLUSIONS/SIGNIFICANCE: Unlike many previous studies have been suggesting, we did not find any evident correlation between staphylococcal exotoxin genes and the presence or severity of chronic rhinosinusitis with or without nasal polyposis.

Laryngeal cryptococcosis: Clinical presentation and treatment of a rare cause of hoarseness.

OBJECTIVE: Laryngeal cryptococcosis is rare, with few reported cases in the literature. We present current investigation and treatment recommendations for this disease. STUDY DESIGN: A structured literature review; additional cases and expert opinion are presented. RESULTS: Localized laryngeal cryptococcal infection most commonly presents with persisting hoarseness. Clinical suspicion of the disease is required for accurate diagnosis, with treatment based on the patient's immune status. Early microbiological advice and adequate follow-up is recommended to ensure disease resolution. CONCLUSION: Isolated laryngeal cryptococcosis is a rare presentation of fungal infection. It is easily treated and should be considered in the differential diagnosis of patients with persisting hoarseness.

Olfactory disorders: the patients' view.

OBJECTIVE: To investigate the level of knowledge that patients had about their olfactory disorder at the time of presentation to a specialist Olfaction Clinic. DESIGN: Multi-centered, cohort study of consecutive patients presenting to specialist Olfaction Clinics surveyed using a standardized questionnaire. SETTING: Tertiary referral Olfactory Clinics in Geneva, Switzerland and Dresden, Germany. MAIN OUTCOME MEASURES: The number of prior medial consultations, the number and type of doctors they had consulted, a rating of the information they had received from these doctors, whether prognostic information had been given and whether they felt their problems had been well managed by the doctor were factors surveyed. Olfactory assessment was measured by the Sniffin' Sticks kit. RESULTS: Eighty percent of patients had sought previous medical advice, with a mean 2.1 past consultations. Of these patients, 60 % reported that they had received either no or unclear or unsatisfactory information about their diagnosis, 30% had received no information about their prognosis and 25 % felt they had not been managed well. CONCLUSION: The majority of patients with olfactory disorders seek medical advice before presenting to a specialist Olfaction Clinic. However, the majority reported receiving no or poor information about their diagnosis and prognosis. Considering the significant prevalence and potential consequences of olfactory disorders, it is our duty as specialists to improve the knowledge and communication of our medical colleagues about these diseases, so that patient education or referral can be improved.