Expansile Sphenoid Mycetoma Presenting With Headache and Galactorrhea.

This case report describes an immunocompetent woman in her 30s with daily vertex headaches over 13 months duration who developed spontaneous galactorrhea and was diagnosed with noninvasive fungal sinusitis.

Epithelial tight junction alterations in nasal polyposis.

OBJECTIVE: To explore alterations in expression of tight junction proteins (TJPs) in nasal polyposis and in respiratory epithelium under inflammatory conditions. Our hypothesis is that exposure of nasal and respiratory epithelium to inflammatory cytokines results in the altered expression of specific TJPs. METHODS: Human sinonasal mucosa (3 nasal polyp specimens and 3 nonpolypoid controls) were stained with immunofluorescent markers specific for TJPs claudin-1 and occludin and examined with confocal scanning laser microscopy. A complementary in vitro experiment involving exposure of cultured human bronchial epithelium to interferon gamma (IFN-γ) and tumor necrosis factor alpha (TNF-α) was also performed. Alterations in claudin-1 and occludin were localized by immunofluorescence labeling and confocal microscopy and quantified by western blotting. RESULTS: Nasal polyp epithelium from human tissue specimens had reduced claudin-1 expression along the basal aspect of the mucosal layer, whereas occludin expression was reduced in the apical and basal epithelial zones. In vitro experiments demonstrated stable or increased TJP expression after 24 hours of cytokine exposure (43% increase for claudin-1, 9% increase for occludin). However, a reduction in TJP expression was observed after 72 hours of cytokine exposure (18% reduction for claudin-1, and 43% reduction for occludin). CONCLUSION: Nasal polyposis is associated with epithelial TJP alterations. Further, the expression of TJPs in a model of inflamed respiratory mucosa is reduced in a similar fashion. Research on the histopathology of other epithelial inflammatory disorders suggests TJP alterations contribute to a self-perpetuating inflammatory state. Findings of this preliminary study support a similar process in nasal polyposis.

The utility of cadaver dissection in endoscopic sinus surgery training courses.

BACKGROUND: Understanding paranasal sinus anatomy is crucial for successful outcomes in endoscopic sinus surgery (ESS). This study was designed to evaluate subjective and objective differences in ESS cadaver dissections among participants of varying experience levels in association with the use of image guidance and computer-aided technologies in a physician training cadaver dissection laboratory. METHODS: Participants in a 2-day cadaver dissection course completed daily predissection surveys evaluating subjective comfort with ESS. Pre- and postdissection computer tomography (CT) scans assessed completeness of dissection. Images were analyzed for maxillary antrostomy, frontal and sphenoid sinusotomy, residual ethmoid cells and partitions, and residual frontal recess cells. RESULTS: Fifty-one sides were dissected. Participant comfort increased significantly from day 1 to 2 for overall ESS (p = 0.001) and for individual sinuses (p < 0.001 to p = 0.047). Participants with more years in practice had fewer unopened ethmoid cells (p = 0.015) and frontal recess cells (p = 0.014) on dissection day 1. Participants with increased comfort in ethmoid dissection had fewer retained ethmoid partitions on day 1 (p = 0.017). Observed differences on dissection day 1 for unopened ethmoid and frontal recess cells and retained ethmoid partitions were not present on day 2. No significant differences were found based on use of image guidance for any parameter. CONCLUSION: Surgeons with increased comfort and more years in practice had more complete endoscopic cadaver dissections initially. Differences among participants diminished on dissection day 2, indicating the ability to review postdissection CT scans may improve surgeon comfort level and completeness of dissection.

Inferior meatus endoscopy and directed treatment for epiphora: early experience with a novel approach.

OBJECTIVES: Epiphora results from obstruction along the nasolacrimal (NL) system. The inferior meatus (IM) is not routinely evaluated. IM pathology is common in patients with epiphora, allowing surgery to be directed at the IM. METHODS: Retrospective review of patients referred for epiphora. Patients underwent office endoscopy of the IM. Patients with identifiable pathology underwent intervention directed at the IM. RESULTS: Seventeen patients were evaluated, four with bilateral epiphora. Two had no IM disease, and one with pathology refused surgery. The remaining 14 (18 sides) had IM pathology. Two patients were successfully treated in the office. Twelve patients underwent surgery (16 sides). Three NLD orifices were obstructed by a cyst, and the remaining 13 by hypertrophied soft tissue at the level of the NLD orifice. Thirteen of 14 sides with distal NLD pathology had resolution or dramatic improvement and patent NL ducts with IM treatment alone. Obstruction extending proximal to Hasner's valve was found in four NL systems, and three developed recurrent epiphora. Median follow-up was 9 months. CONCLUSIONS: IM endoscopy identified pathology in most constant epiphora patients in this study. Pathology at the distal NL system portends a better outcome, whereas extension to the proximal NL duct had poorer outcome.

Contemporary considerations in cranial-base surgery.

The development of new surgical and medical management techniques in skull-base surgery allows for improved patient care. The operative complexities encountered in these procedures necessitate a team-based approach to address total care of the surgical patient. A review of contemporary considerations in management of the patient undergoing skull-base surgery reveals the need for pre- and postoperative planning of surgical and medical management.

Antibody response of healthy adults to recombinant thrombospondin-related adhesive protein of cryptosporidium 1 after experimental exposure to cryptosporidium oocysts.

Thrombospondin-related adhesive protein of Cryptosporidium 1 (TRAP-C1) belongs to a group of proteins that are also found in Toxoplasma gondii, Eimeria tenella, and Plasmodium species. TRAP-related proteins are needed for gliding motility, host-cell attachment, and invasion. The objective of this study was to characterize the antibody response to recombinant TRAP-C1 (rTRAP-C1) in healthy volunteers exposed to C. parvum and their association with clinical illness. A total of 31 healthy adult volunteers participated. Seven volunteers received the C. parvum TAMU isolate (inocula, 10 to 300 oocysts), and 24 volunteers received the C. parvum UCP isolate (500 to 10(5) oocysts). The total antibody (immunoglobulin M [IgM], IgG, and IgA) response to rTRAP C-1 was measured by enzyme-linked immunosorbent assays prior to and after exposure to Cryptosporidium parvum (days 0 to 45). Results of this study showed that individuals who were uninfected demonstrated higher reactivity at baseline compared to those who became infected. After challenge, increases in antibody reactivity were seen on days 30 and 45 compared to the results seen on days 0 to 5. The increases in antibody reactivity were statistically significant in subjects with diarrhea and with or without detectable oocysts compared to the results seen with those who were uninfected and asymptomatic. These findings suggest that increases in antibody reactivity to rTRAP-C1 occur after recent exposure to C. parvum.

Magnetic resonance angiography minimizes need for arteriography after inadequate carotid duplex ultrasound scanning.

PURPOSE: We prospectively evaluated whether magnetic resonance angiography (MRA) enabled definition of cerebrovascular anatomy after indeterminate or inadequate results at duplex ultrasound scanning to facilitate patient selection for carotid endarterectomy (CEA) and for technical planning. METHODS: After implementation of a protocol in October 1998 to minimize use of cerebral arteriography, MRA (arch/cervical two-dimensional and cranial three-dimensional time of flight technique) was performed in 138 consecutive patients with cerebrovascular occlusive disease and inconclusive duplex scans obtained by an ICAVL-approved laboratory. The ability of MRA to define anatomic features unresolved at duplex scanning was compared between categories of duplex scan inadequacies. Operative outcome was compared between patients requiring MRA before CEA (n = 66) and a concurrent cohort undergoing CEA on the basis of duplex scan results only (n = 69). RESULTS: Incomplete imaging of the carotid bifurcation, because of high bifurcation, long (>3 cm) internal carotid artery (ICA) plaque, or calcific shadows, was the most common reason for inadequate duplex scans (n = 74, 53%), followed by borderline severe ICA disease (23.17%), suspected extracervical disease (supra-aortic trunk, vertebral, or intracranial, 22, 16%), ICA near- occlusion (12.9%), and diffuse recurrent stenosis (7.5%). MRA enabled resolution of duplex scan inadequacies in 95% of patients with disease confined to the carotid bifurcation, and 90% of all patients, but was least accurate for delineation of extracervical lesions (77%) and near-occlusions (75%). In 5 of 8 patients (6%) arteriography was performed to determine operability of ICA near-occlusion or extracervical lesions. Combined stroke and death rates after CEA were not statistically different (P =.3) between patients requiring MRA (3 of 66, 4.6%) and the concurrent group in whom MRA was performed solely on the basis of duplex results (1 of 69, 1.5%). However, intraoperative technical adjustments (anatomy that precluded shunt use, extended endarterectomy length, ICA shortening due to tortuosity) were planned in 71% of patients (12 of 17) with MRA-defined anatomy, but only 36% of patients (4 of 11) with long CEA on the basis of duplex results only (P =.08). CONCLUSION: MRA replaces the need for cerebral arteriography in most patients after inadequate carotid duplex scanning. Delineation of cerebrovascular anatomy at MRA assists in determination of CEA candidacy and operative planning.