An approach to olfactory impairments in the general practice setting.

BACKGROUND: Olfactory impairment is a common condition, particularly in the geriatric population, which can be underrecognised as a result of clinician and patient unfamiliarity. OBJECTIVE: The aim of this article is to bring awareness to olfactory impairment, describe the common aetiologies and provide a framework for its diagnosis and management in the general practice setting, including advice about when to refer. DISCUSSION: A thorough history and examination can often elucidate the common causes, which include rhinosinusitis, upper respiratory tract viral illnesses and head trauma. Rhinosinusitis is the most readily managed aetiology in the general practice setting, with other causes often requiring multidisciplinary input. Chronic olfactory impairment is often irreversible and can be a debilitating condition, causing disability in day-to-day living and impairing quality of life.

Toxicity evaluation and nasal mucosal tissue deposition of dexamethasone-infused mucoadhesive in situ nasal gelling systems.

To demonstrate safety of a developed intranasal dexamethasone-infused in situ gelling formulation, quantification of a validated clinical biomarker indicative of cytotoxic potential using a human sinonasal explant model was first confirmed. Systematic cytotoxicity studies using the lactate dehydrogenase (LDH) detection assay revealed no elevation from baseline, in LDH levels, with tissue integrity of explanted human nasal mucosa also maintained; this was further corroborated using tissue histopathological examination. Next, with safety confirmed ex vivo, freshly excised human nasal tissue was utilised to quantify dexamethasone release from the lead sol-gel systems; this being achieved through development and validation of a HPLC-UV analytical method, which reliably quantified controlled therapeutic release and deposition into mucosal tissue. Collectively, these findings indicate promise in the safety of each excipient within the concentrations employed in the functional sol-gel system, complemented by successful and reliable drug release and deposition into human nasal mucosal tissue. These findings pave the way for application of the dexamethasone-based sol-gel system to the extended delivery of corticosteroids to nasal mucosa in the management of localised inflammatory conditions of an acute and chronic nature, such as chronic rhinosinusitis, which can be expected to benefit from controlled and extended drug delivery characteristics imparted by appropriately engineered in situ gelling systems.

Differentiating between benign and malignant thyroid nodules: An evidence-based approach in general practice

BACKGROUND: The widespread use of imaging techniques has led to more frequent detection of thyroid nodules, and while the majority are benign, the risk of malignancy in an adult ranges from 7% to 15%. General practitioners (GPs) must be able to evaluate thyroid nodules and refer cases when appropriate. OBJECTIVES: The aim of this article is to bring GPs up to date on the evidence-based management of thyroid nodules, with specific focus on neoplastic nodules, while highlighting significant changes in the 2015 American Thyroid Association guidelines. DISCUSSION: Thyroid nodules frequently occur in the general population. Differentiating between a benign and malignant nodule can be challenging, and community guidelines have standardised investigation, management and follow-up procedures. The key tests for risk stratification of thyroid nodules include serum thyroid-stimulating hormone testing, ultrasonography and fine-needle aspiration. GPs should be aware of the latest evidence-based recommendations for the appropriate management of a thyroid nodule.

Formulation, functional evaluation and ex vivo performance of thermoresponsive soluble gels - A platform for therapeutic delivery to mucosal sinus tissue.

Mucoadhesive in situ gelling systems (soluble gels) have received considerable attention recently as effective stimuli-transforming vectors for a range of drug delivery applications. Considering this fact, the present work involves systematic formulation development, optimization, functional evaluation and ex vivo performance of thermosensitive soluble gels containing dexamethasone 21-phosphate disodium salt (DXN) as the model therapeutic. A series of in situ gel-forming systems comprising the thermoreversible polymer poloxamer-407 (P407), along with hydroxypropyl methyl cellulose (HPMC) and chitosan were first formulated. The optimized soluble gels were evaluated for their potential to promote greater retention at the mucosal surface, for improved therapeutic efficacy, compared to existing solution/suspension-based steroid formulations used clinically. Optimized soluble gels demonstrated a desirable gelation temperature with Newtonian fluid behaviour observed under storage conditions (4-8°C), and pseudoplastic fluid behaviour recorded at nasal cavity/sinus temperature (≈34°C). The in vitro characterization of formulations including rheological evaluation, textural analysis and mucoadhesion studies of the gel form were investigated. Considerable improvement in mechanical properties and mucoadhesion was observed with incorporation of HPMC and chitosan into the gelling systems. The lead poloxamer-based soluble gels, PGHC4 and PGHC7, which were carried through to ex vivo permeation studies displayed extended drug release profiles in conditions mimicking the human nasal cavity, which indicates their suitability for treating a range of conditions affecting the nasal cavity/sinuses.

A general practice approach to Bell's palsy.

BACKGROUND: Bell's palsy is characterised by an acute onset of unilateral, lower motor neuron weakness of the facial nerve in the absence of an identifiable cause. Establishing the correct diagnosis is imperative and choosing the correct treatment options can optimise the likelihood of recovery. OBJECTIVE: This article summarises our understanding of Bell's palsy and the evidence-based management options available for adult patients. DISCUSSION: The basic assessment should include a thorough history and physical examination as the diagnosis of Bell's palsy is based on exclusion. For confirmed cases of Bell's palsy, corticosteroids are the mainstay of treatment and should be initiated within 72 hours of symptom onset. Antiviral therapy in combination with corticosteroid therapy may confer a small benefit and may be offered on the basis of shared decision making. Currently, no recommendations can be made for acupuncture, physical therapy, electrotherapy or surgical decompression because well-designed studies are lacking and available data are of low quality.

Surgery for adult patients with obstructive sleep apnoea: A review for general practitioners.

BACKGROUND: Obstructive sleep apnoea (OSA) is a complex disease process that involves collapse of the upper airway during sleep and subsequent reduction or cessation of airflow. Continuous positive airway pressure (CPAP) is the primary treatment for OSA and is the recommended first-line treatment for patients with moderate-to-severe forms of the disease. However, some patients are unable to tolerate CPAP or are unwilling to accept it as a form of permanent management. In these cases, surgical management aimed at addressing anatomical obstruction may be useful and warranted. OBJECTIVE: This article presents an overview of the surgical options available for OSA. The review also describes a useful approach for selecting appropriate patients for surgery. DISCUSSION: On the basis of an OSA model that accounts for observed increased risk of stroke, cardiovascular disease and motor vehicle accidents, there is evidence to support that surgery is beneficial and cost-effective for patients with severe OSA who are intolerant of CPAP. There are many surgical options available for OSA.

Pathologic occult neck disease in patients with metastatic cutaneous squamous cell carcinoma to the parotid.

OBJECTIVE: The aim of this study was to document the rate of pathologic neck disease in patients presenting with metastatic cutaneous squamous cell carcinoma (CSCC) to the parotid gland following parotidectomy and neck dissection in the clinically and radiologic negative neck. STUDY DESIGN: Case series with chart review. SETTING: Tertiary referral center. SUBJECTS AND METHODS: The study involved a retrospective chart review from 1999 to 2008 of patients presenting with metastatic CSCC to the parotid at the Princess Alexandra Hospital, Brisbane, Australia. RESULTS: Eighty-one patients with metastatic parotid disease were identified. A total of 51 (63%) patients had no clinical or radiological evidence of cervical nodal disease. Forty-five patients (88%) were male, median age was 69 (range, 42-91) years, and the median follow-up was 16 (interquartile range, 9-44) months. Thirty-four of these patients underwent a parotidectomy and neck dissection with/without postoperative radiotherapy (RT). Occult pathological cervical nodal disease was found in 5 (14.7%) patients. Of those who received a neck dissection, 3 patients relapsed in the parotid, 1 in the neck alone, and 1 distantly. CONCLUSION: This series has shown that the rate of pathologically involved neck nodes in patients with metastatic CSCC to the parotid in the clinically node negative neck is low. Given many of these patients warrant postoperative RT to the parotid bed, an elective neck dissection may not be warranted as the parotid and neck may be treated in continuity with RT.