Review of publications on the possible advantages of a direct cheek incision for accessory parotid gland masses.

Lesions of the accessory parotid gland (APG) are rare and surgical management is generally under-discussed. The surgical approach should provide complete resection, while minimising complications and aesthetic complaints. The current study reviews recent publications on the surgical management of APG masses, and discusses the advantages, and limitations of, and our experience with, direct cheek incision. Papers on the surgical management of APG masses published in the last 10 years were systematically searched. Information was obtained regarding the surgical approach, type of excision, and postoperative complications. In the included studies, 253 APG masses were selected for analysis, whereof six were treated with the direct cheek incision. Although no local recurrence or postoperative complications were observed after this, the approach was usually not recommended due to a higher reported risk of recurrence and complications in older papers. More recent studies, however, indicate that the direct cheek incision should be considered as a valuable alternative to standard approaches in selected patients.

Efficacy and complications of orbital fat decompression in Graves' orbitopathy: a systematic review and meta-analysis.

In Graves' orbitopathy, surgical decompression is often needed for functional and aesthetic reasons. This meta-analysis was performed to assess the efficacy and safety of fat removal orbital decompression (FROD) alone to treat exophthalmos in Graves' orbitopathy. A systematic search was conducted in PubMed/MEDLINE, Web of Science, and Cochrane Library for studies published before August 2018. Random-effects meta-analyses were applied; weighted means and weighted proportions with corresponding 95% confidence intervals (CI) were calculated. Study quality and quality of evidence for each individual outcome were analyzed. Of 1908 records initially identified, 13 observational studies were selected, representing 4820 orbits in 2514 patients. Weighted Hertel exophthalmometry was 23.10mm (95% CI 21.77-24.43mm) preoperative and 19.31mm (95% CI 17.81-20.81mm) postoperative. The weighted mean difference was 3.81mm (95% CI 3.41-4.21mm). Five studies reported an improvement of diplopia after surgery, occurring in 943 of 1172 patients (weighted proportion 0.50, 95% CI 0.15-0.85). Persistent new onset diplopia was reported in five studies, or 124 of 1277 patients (weighted proportion 0.15, 95% CI 0.03-0.27). No serious adverse events were reported. Results support the effectiveness and safety of FROD to treat mild-to-moderate exophthalmos in Graves' orbitopathy. Prospective and controlled trials are needed to improve the level of evidence.

A chest physician's guide to mechanisms of sinonasal disease.

The upper and lower airways are closely linked from an anatomical, histological and immunological point of view, with inflammation in one part of the airways influencing the other part. Despite the concept of global airway disease, the upper airways tend to be overlooked by respiratory physicians. We provide a clinical overview of the most important and recent insights in rhinitis and rhinosinusitis in relation to lower airway disease. We focus on the various exogenous and endogenous factors that play a role in the development and aggravation of chronic upper airway inflammation. In addition to the classical inhaled allergens or microorganisms with well-defined pathophysiological mechanisms in upper airway disease, environmental substances such as cigarette smoke, diesel exhaust particles and occupational agents affecting lower airway homeostasis have recently gained attention in upper airway research. We are only at the beginning of understanding the complex interplay between exogenous and endogenous factors like genetic, immunological and hormonal influences on chronic upper airway inflammation. From a clinical perspective, the involvement of upper and lower airway disease in one patient can only be fully appreciated by doctors capable of understanding the interplay between upper and lower airway inflammation.

Staphylococcus aureus enterotoxin B facilitates allergic sensitization in experimental asthma.

BACKGROUND: Staphylococcus aureus Enterotoxin B (SEB) has immunomodulatory effects in allergic airway disease. The potential contribution of SEB to the sensitization process to allergens remains obscure. OBJECTIVE: In order to study the effects of staphylococcal-derived toxins on the sensitization to ovalbumin (OVA) and induction of allergic airway inflammation, we have combined the nasal application of OVA with different toxins. METHODS: Nasal applications of OVA and saline, SEA, SEB, toxic shock syndrome toxin (TSST)-1, protein A or lipopolysaccharide (LPS) were performed on alternate days from day 0 till 12. On day 14, mice were killed for the evaluation of OVA-specific IgE, cytokine production by mediastinal lymph node (MLN) cells and bronchial hyperreactivity (BHR) to inhaled metacholine. The effect of SEB on dendritic cell (DC) migration and maturation, and on T cell proliferation was evaluated. RESULTS: Concomitant endonasal application of OVA and SEB resulted in OVA-specific IgE production, whereas this was not found with SEA, TSST-1, protein A, LPS or OVA alone. Increased DC maturation and migration to the draining lymph nodes were observed in OVA/SEB mice, as well as an increased T cell proliferation. Bronchial inflammation with an influx of eosinophils and lymphocytes was demonstrated in OVA/SEB mice, together with hyperresponsiveness and the production of IL-4, IL-5, IL-10 and IL-13 by MLN stimulated with OVA. CONCLUSIONS: Our data demonstrate that SEB facilitates sensitization to OVA and consecutive bronchial inflammation with features of allergic asthma. This is likely due to augmentation of DC migration and maturation, as well as the allergen-specific T cell proliferation upon concomitant OVA and SEB application.

Staphylococcus aureus enterotoxin B augments granulocyte migration and survival via airway epithelial cell activation.

BACKGROUND: Staphylococcus aureus enterotoxin B (SEB) has recently been postulated to be involved in the pathology of granulocyte-dominated disease. Studying the immunologic interaction between SEB and airway epithelial cells in immortalized cell lines or long-term epithelial cell cultures has obvious disadvantages. METHODS: We used a novel technique of freshly isolated and purified human nasal epithelial cells (HNEC) from healthy, nonallergic individuals, which were incubated for 24 h without/with SEB at different concentrations. Chemokine production was evaluated in the supernatant using Cytometric Bead Array. The chemotactic activity of the supernatant was studied in vitro using a Boyden chamber. Survival was evaluated with flow cytometry, using propidium iodide to identify dead cells. RESULTS: Staphylococcus aureus enterotoxin B showed a dose-dependent induction of interferon-inducible protein-10, monokine induced by interferon-gamma, regulated upon activation normal T cell expressed and secreted, monocyte chemoattractant protein 1 (MCP-1) and granulocyte colony stimulating factor production by epithelial cells in vitro. The supernatant of epithelial cells had chemotactic activity for granulocytes in vitro, which was enhanced in the supernatant of SEB-stimulated epithelial cells. Reduced number of propidium iodide positive granulocytes was found in the conditions where supernatant of SEB-stimulated epithelial cells was applied. CONCLUSION: Staphylococcus aureus enterotoxin B exerts a direct pro-inflammatory effect on HNEC, with induction of chemokine and growth factor release, resulting in the migration and prolonged survival of granulocytes in vitro.

Th2-associated immunity to bacteria in teenagers and susceptibility to asthma.

Bacterial colonisation of the airways is associated with increased risk of childhood asthma. Immunoglobulin (Ig)E against bacterial antigens has been reported in some asthmatics, suggesting a role for bacterial-specific type-2 immunity in disease pathogenesis. We aimed to investigate relationships between bacterial-specific IgE amongst teenagers and asthma susceptibility. We measured titres of IgE against Haemophilus influenzae, Streptococcus pneumoniae and Staphylococcus aureus in 1,380 teenagers, and related these to asthma symptomatology and immunophenotypes. IgE titres against S. aureus-derived enterotoxins were highest amongst atopics and were associated with asthma risk. Surprisingly, IgE titres against H. influenzae and S. pneumoniae surface antigens were higher, not stratified by atopy and independently associated with decreased asthma risk. The positive association between type-2 immunity to S. aureus and asthma phenotypes probably reflects IgE-mediated effector cell activation via enterotoxin super antigens which are secreted in soluble form. The contrasting benign nature of type-2 immunity to H. influenzae and S. pneumoniae antigens may reflect their lower availability in soluble forms that can crosslink IgE receptors. We theorise that instead they may be processed by antigen presenting cells and presented to type-2 memory cells leading to mucosal secretion of interleukin (IL)-4/IL-13, a mechanism widely recognised in other tissues to attenuate T-helper-1 associated bacterial-induced inflammation.