Anti-IL-5 immunomodulates the effect of Staphylococcus aureus enterotoxin on T cell response in nasal polyps.

BACKGROUND: Chronic rhinosinusitis with nasal polyps (CRSwNP) is a T helper-2 (Th2) inflammatory disease with considerable impact on the quality of life. Staphylococcus aureus enterotoxins (SAEs) can induce and/or amplify inflammation. In this study, we investigated the immunomodulatory effect of SAEs on cytokine production by T cell obtained from nasal polyps (NPs) and examined whether neutralizing interleukin 5 (IL-5) can reverse the immunological effect mediated by those toxins. METHODS: NP tissues were obtained from all patients who underwent endoscopic sinus surgery for CRSwNP. NP cells were isolated and stimulated in vitro with SAEs in the presence or absence of anti-IL-5. Flow cytometry (FACS) analyses were performed to measure specific T lymphocyte cytokine production. RESULTS: Seventeen patients (mean age 48 years) were enrolled. SAEs significantly increased the IL-4, IL-5 (Th2) and interferon (INF)-γ (Th1) cytokines released from T lymphocytes of NPs. The addition of anti-IL-5 suppressed IL-4 and INF-γ release, which was most evident on NP tissue with high basal levels of IL-5. CONCLUSIONS: Neutralizing IL-5 is a potential therapeutic modality in patients with NPs, the effect of which is dependent on IL-5 levels.

Aspirin desensitization for ASA triad patients--prospective study of the rhinologist`s perspective.

UNLABELLED: OBJECTIVES/PROBLEM: To determine the sinonasal effect of aspirin salicylic acid (ASA) desensitization in patients with nasal polyps, asthma and aspirin intolerance (ASA triad). METHODS OF STUDY: Patients with ASA triad were recruited from the outpatient otolaryngology clinic. They underwent a program of ASA desensitization (2005 - 2008) with prospective assessment of subjective and objective responses. Incremental doses of aspirin were given to reach a target of 625 mg twice daily during a period of 3 - 5 days. A maintenance dose was then given for the study period. The patients also received inhaled and topical nasal steroids, antihistamines and beta agonists for asthma control, but no systemic steroid treatment. MAIN RESULTS: Of the original 27 enrolled subjects, 10 elected to discontinue treatment and five dropped out because of treatment complications. The objective evaluation of the polypoid sinonasal disease in the remaining 12 patients (4 males, 8 females, age range 22 - 63 years) revealed only mild improvement. In contrast, the patients` subjective feeling of nasal congestion, nasal discharge and overall discomfort improved significantly. CONCLUSIONS: Aspirin desensitization has a favorable subjective effect on certain nasal symptoms among ASA triad patients, but the objective effect on polypoid mass is not significant.

Treatment of hypoxemia in obstructive sleep apnea.

Many patients suffering from obstructive sleep apnea (OSA) have intermittent oxygen desaturation associated with periods of apnea or hypopnea. Oxygen saturation levels below 90% are considered harmful. Usually, treatment is directed at correcting the apnea, which will in turn prevent hypoxemia. Unfortunately, many patients fail or are not candidates for nasal continuous positive airway pressure (CPAP) or surgical correction of their OSA. Forty-three patients with persistent OSA and nocturnal hypoxemia below 90% who were not candidates for additional surgical or CPAP therapy were treated with nocturnal oxygen supplementation. Standard symptoms associated with OSA and the Epworth Sleepiness Scale (ESS) were recorded before treatment and 30 days after the start of the treatment. In 21 patients, polysomnography studies were performed to compare the Respiratory Disturbance Index (RDI) score and minimum oxygen saturation levels when the patients were breathing room air or breathing 4 L/minute of oxygen by nasal cannula. Subjective symptoms of obstructive sleep apnea improved, and the ESS score significantly decreased after a 30-night treatment with oxygen. Split-night polysomnography showed a significant increase in minimum oxygen saturation during oxygen administration. The RDI did not significantly change with treatment. Oxygen administration for the correction of OSA-related nocturnal hypoxemia was both safe and effective in alleviation of OSA-related symptoms. It also appeared to have a beneficial effect on minimum oxygen saturation levels. Thus, oxygen therapy may be considered a treatment option in patients who fail to comply with CPAP and are not candidates for a surgical procedure.

The occurrence of sleep-disordered breathing among patients with head and neck cancer.

OBJECTIVE: To identify the incidence of obstructive sleep apnea (OSA) in patients treated for head and neck cancer. Obstructive sleep apnea is a relatively common and highly morbid condition that affects 9.1% of male and 4% of female middle-aged adults.1 Patients who have been successfully treated for head and neck cancer may often have a partially obstructed upper airway which is functional during the day, but collapses during sleep. STUDY DESIGN/METHODS: Twenty-four patients successfully treated for tumors of the tongue-base, pharynx, or supraglottic larynx were enrolled. Through OSA-related questionnaires, physical examination, and polysomnography, the incidence of OSA in this patient population was determined and compared with that of the general population. RESULTS: The incidence of OSA (91.7%) in this head and neck cancer patient population was found to be significantly (P =.001) higher than that of the general population. (In a random sampling of middle-aged adult males between the ages of 30 and 60 years old with a respiratory disturbance index (RDI) >15, the prevalence was previously reported to be 9.1%.1) Sixteen of 24 patients (72.7%) had clinically defined symptoms of sleep apnea. Ten of 24 patients (41.7%) received radiation therapy; all had an RDI >15. Eleven of the 14 patients (78.5%) who did not receive radiation therapy also had an RDI >15. Eight patients (33.3%) continue to regularly use continuous positive airway pressure with significant improvement in symptoms. CONCLUSIONS: Identification and treatment of OSA may be an important factor in improving quality of life for patients with head and neck cancer.

A computer-assisted anatomical study of the nasofrontal region.

OBJECTIVES/HYPOTHESIS: Objectives were as follows: 1) to define the variations of the uncinate process' superior attachment, 2) to study the diameter of the frontal sinus ostium, 3) to study the prevalence of the agger nasi cells, and 4) to evaluate the side-to-side variability of these structures. STUDY DESIGN: A retrospective clinical study at a tertiary care center. METHODS: One hundred forty-four consecutive computed tomography scans were studied with image-guided surgery software (InstaTrak, Visualization Technology, Inc., Wilmington, MA) that provides continuous coronal, sagittal, and axial sections. We reported the superior attachment sites of the uncinate process, the diameter of the frontal sinus ostium, and prevalence of the agger nasi cells. RESULTS: The uncinate process' main superior attachment into the surrounding structures was found to have the following distribution: 52% to the lamina papyracea, 18.5% to the posteromedial wall of the agger nasi cell, 17.5% to the lamina papyracea and the junction of the middle turbinate with the cribriform plate, 7% to the junction of the middle turbinate with the cribriform plate, 3.6% to the ethmoid roof, and 1.4% to the middle turbinate. The frontal ostium anterior-posterior diameter (mean +/- SD) was 7.22 +/- 2.78 mm and its transverse diameter (mean +/- SD) was 8.92 +/- 2.95 mm. Agger nasi cells were found in 78% of the scans. CONCLUSIONS: The frontal sinus opens into the middle meatus medial to the uncinate process in 88% of the patients and lateral to the uncinate process in 12% of the patients. The naturally wide dimensions of the frontal ostium help to explain why postoperative patency can be achieved merely by exposing the ostium without the need to enlarge it. The frontal ostium dimensions in one side may differ considerably from the contralateral side. An agger nasi cell or a terminal recess, or both, are found in most cases. Image-guided surgery software is a helpful new tool for anatomical studies and for preoperative evaluation.

Endoscopic sinus surgery in patients infected with HIV.

OBJECTIVES: To be able to plan appropriate surgical treatment for patients with HIV infection who have sinusitis refractory to medical therapy. DESIGN: We retrospectively reviewed the charts of 186 patients with HIV who required surgical treatment for sinusitis between 1987 and 1998. One hundred six charts provided the necessary information and an adequate follow-up to be included in the study. Collected data included preoperative and postoperative symptoms, radiographic staging, CD4 count at the time of surgery when available, and type and extent of surgery. RESULTS: Surgical treatment evolved over the 12 years from limited surgery to standard endoscopic sinus surgery (ESS). Eighteen patients had invasive fungal disease or complications of sinusitis requiring radical surgery. Thirty-six patients were treated with minimal procedures to address involved sinuses only. These patients were treated between 1987 and 1991. Recurrent disease or further complications occurred in 80.6% of the patients in this group. Since 1992, 52 patients were treated with standard ESS following the same indications for HIV- patients. This group had an improvement of symptoms in 75% of the cases, a rate comparable to the success rate in HIV- patients. CONCLUSIONS: HIV+ patients undergoing standard ESS enjoy a satisfactory success rate. HIV+ patients with surgical indication for endoscopic sinus surgery should be treated as non-HIV+ patients. Apparently, low CD4 count (< 100) does not serve as a contraindication for definitive surgery.

E2F4 is essential for normal erythrocyte maturation and neonatal viability.

The retinoblastoma protein (pRB) plays a key role in the control of normal development and proliferation through the regulation of the E2F transcription factors. We generated a mutant mouse model to assess the in vivo role of the predominant E2F family member, E2F4. Remarkably, loss of E2F4 had no detectable effect on either cell cycle arrest or proliferation. However, E2F4 was essential for normal development. E2f4-/- mice died of an increased susceptibility to opportunistic infections that appeared to result from craniofacial defects. They also displayed a variety of erythroid abnormalities that arose from a cell autonomous defect in late stage maturation. This suggests that E2F4 makes a major contribution to the control of erythrocyte development by the pRB tumor suppressor.

[Tracheoesophageal puncture after total laryngectomy: follow-up of healing procedure].

Total laryngectomy due to malignant laryngeal tumors is followed by loss of speaking ability. Voice restoration in laryngectomized patients is the main target in their rehabilitation. Until the late 70's, esophageal speech was considered the most effective rehabilitation method. In 1980 Singer and Blom introduced a prosthesis for tracheoesophageal speech which has been gaining popularity. Tracheoesophageal puncture (TEP) can be performed either at the time of total laryngectomy, or later. 30 of our patients underwent TEP between 1991 and 1999, 15 at the time of total laryngectomy and 15 as a delayed secondary procedure. Mean follow-up was 36 months (range 6 months to 8 years) during which all regained speaking ability. Over the long range, speech rehabilitation with the prosthesis was successful in 24 (80%). In only 1 in the primary TEP group did treatment fail, as the prosthesis had to be removed due to local recurrence of the tumor. Long range failure in 5/15 patients after secondary TEP stemmed from difficulties some patients had in handling the prosthesis and from psychological difficulties in adapting to the new speech device. Complications were mostly minor and occurred mainly in the secondary TEP group. TEP performed at the time of total laryngectomy, or later as a secondary procedure, is effective for speech rehabilitation after laryngectomy.

Middle turbinate medialization and preservation in endoscopic sinus surgery.

OBJECTIVE/HYPOTHESIS: Lateral synechia formation between the middle turbinate (MT) and the lateral nasal wall is the most common complication of endoscopic sinus surgery. In an attempt to prevent this complication, a simple technique to preserve and medialize the MT was studied. METHODS: Five hundred patients underwent endoscopic sinus surgery with MT medialization and preservation. The caudal end of the MT and the opposing septal mucosa were abraded with a microdebrider for controlled synechia formation in an attempt to avoid lateralization of the MT. Follow-up ranged from 6 to 18 months, with a mean follow-up of 10 months. RESULTS: Ninety-three percent of the patients had successful MT medialization with a well-defined synechia between the septum and the MT. CONCLUSIONS: MT medialization with a microdebrider is simple, is reliable, and should be considered an alternative to turbinate resection or to other turbinate medialization techniques.

Effect of improved nasal breathing on obstructive sleep apnea.

OBJECTIVES: The goal was to compare the effect of an improved nasal airway on obstructive sleep apnea (OSA) by use of subjective and objective measures. METHODS: A prospective study of 50 consecutive patients with nasal airway obstruction and OSA was carried out. RESULTS: Subjectively, nasal breathing improved in 49 (98%) patients, whereas snoring decreased or disappeared in 17 (34%); the remaining 33 (66%) patients did not notice any significant change in their snoring. Daytime energy levels increased in 39 (78%) patients and remained unchanged or worsened in 11 (22%). In review of the polysomnographic data, the group overall did not have significant changes in respiratory disturbance index (RDI) or lowest oxygen saturation levels (LSaO(2)). Continuous positive airway pressure (CPAP) levels required to correct OSA decreased after nasal surgery (P < 0.01). Patients with mild OSA showed significant worsening in RDI (P < 0.05), whereas LSaO(2) levels were improved in the group with moderate OSA (P < 0.05). In patients with severe OSA neither the RDI levels nor the LSaO(2) changed, but CPAP levels required to alleviate the obstruction after surgery were reduced (P < 0.01). CONCLUSIONS: Most patients report improvement in nasal and sleep symptoms after correction of nasal airway obstruction. However, nasal surgery alone does not consistently improve OSA when measured objectively. Depending on the severity of OSA, nasal airway reconstruction may contribute to a decrease in CPAP level and improvement in oxygen saturation. Correction of the obstructed nasal airway should certainly be included in the overall treatment plan for OSA.

Frontal sinus surgery: endoscopic technique and preliminary results.

Endoscopic frontal sinus surgery, once the last frontier in the evolution of endoscopic sinus surgery, is considered difficult, risky to the patient, and likely to result in a high failure rate. We clarify the surgical anatomy for frontal sinus surgery that, based on a review of our data, provides safe and predictable access to the frontal sinus. We studied 200 consecutive patients with respect to indications, endoscopic and radiographic findings, results, and complications. The study will describe the technique in detail, including the following points: 1) computed tomography identification of the superior attachment of the uncinate process; 2) complete removal of the uncinate process, including its superior attachments, by using the microdebrider; 3) removal of the agger nasi cell, if present; and 4) verification of an open frontal sinus by a transillumination or image-guided system. Postoperative assessment of patients' symptoms and the confirmation of a patent frontal sinus by office endoscopy and transillumination indicated a 90% patency for short-term follow-up (average 12.2 months). There were no major complications. Postoperative complications included frontal recess stenosis, polypoid mucosa occluding the frontal recess, and middle turbinate lateralization. All of these situations may lead to recurrence of infection and symptoms. In-depth understanding of anatomic variations of the uncinate process and precise surgical removal of its superior attachments provide surgical access to the frontal sinus that is based on the natural ostia and is, therefore, more likely to remain patent.

Clinical predictors of obstructive sleep apnea.

OBJECTIVE: To identify physical findings that can be standardized to predict the presence and the severity of obstructive sleep apnea (OSA). STUDY DESIGN: One hundred seventy-two patients who answered questionnaires with responses that suggested they might have OSA were included in this prospective study. METHODS: All patients underwent a physical examination and polysomnography. The physical examination included the measurement of four parameters used by anesthesiologists to identify patients likely to have difficult intubation to determine if these same parameters predict OSA. We recorded modified Mallampati grade (MMP), tonsil size, and body mass index (BMI) and measured thyroid-mental distance (TMD) and hyoid-mental distance (HMD) in the study population. RESULTS: When the physical findings were correlated singly with the respiratory disturbance index (RDI), we found that MMP (P < .001), tonsil size grading (P = .008), and BMI (P = .003) were reliable predictors of OSA. A greater correlation with OSA emerged when an "OSA score" was formulated by factoring the MMP, tonsil grade, and BMI grade (RDI = 7.816 x MMP + 3.988 x Tonsil Size + 4.675 x BMI - 7.544). A high score was not only predictive of OSA but also correlated well with OSA severity. Neither HMD nor TMD correlated with the severity of RDI. CONCLUSIONS: An OSA score may help identify those patients who should have a full sleep evaluation.

A safe, alternative technique for inferior turbinate reduction.

OBJECTIVE: Submucous resection of the inferior turbinates is a conventional technique for reducing their size to achieve patent nasal airways in situations where an enlarged turbinate contributes to airway obstruction. Many techniques and complications have been described in the past. We describe a new inferior turbinate reduction technique performed with powered instrumentation and assess its success and complication rates. STUDY DESIGN: A prospective study of 120 consecutive patients who underwent submucous resection of the inferior turbinates with a microdebrider. METHODS: Patient questionnaires were used for subjective assessment of symptoms before and after the procedure. We graded each patient's inferior turbinates for size from I to III before and 6 weeks after surgery for objective analysis. RESULTS: The common complications of standard submucous resection of inferior turbinates include excessive resection, postoperative bleeding, and crusting. The advantage of the microdebrider technique is the precise control of the amount of tissue and location of tissue that is removed on a submucosal plane. The complications encountered with this technique are limited to postoperative bleeding that occurred in 1.6% of patients. There was no crusting or excessive removal of tissue. CONCLUSION: The results show that submucous resection of inferior turbinates with a microdebrider is a safe method of achieving turbinate size reduction with minimal morbidity.

Effects of middle turbinate medialization on olfaction.

OBJECTIVE/HYPOTHESIS: Turbinate medialization techniques have gained popularity in an attempt to prevent turbinate lateralization. Theoretically, adhesions between the septum and middle turbinate will prevent lateralization but may compromise airflow to the olfactory neuroepithelium and affect the sense of smell. No studies have addressed this issue. The objective of this study is to evaluate effects of middle turbinate medialization on olfaction. STUDY DESIGN: A prospective controlled study of olfaction before and after middle turbinate medialization using the University of Pennsylvania Smell Identification Test (UP-SIT) and patient questionnaires. METHODS: Fifty patients underwent endoscopic sinus surgery (ESS) with middle turbinate medialization and preservation. The caudal end of the middle turbinate and the opposing septal mucosa were abraded with a microdebrider for iatrogenic synechia formation in an attempt to avoid lateralization of the middle turbinate. Each of the patients underwent preoperative assessment with a questionnaire and UPSIT. All patients were reevaluated approximately 5 weeks after surgery by endoscopic examination, questionnaire, and the UPSIT. The preoperative and postoperative questionnaire responses were compared for subjective analysis. Objectively, the preoperative and postoperative UPSIT scores were compared using the Student t test. RESULTS: The questionnaires showed that the study population's subjective sense of smell either did not change or improved compared with the preoperative state. Objectively, there was a mean increase of UPSIT scores after surgery. This difference was not statistically significant (P = .4). CONCLUSION: Middle turbinate medialization has no detectable adverse effect on olfaction.

Subjective comparison of Nd:YAG, diode, and CO2 lasers for endoscopically guided inferior turbinate reduction surgery.

Lasers using different wavelengths and delivery systems have been used to reduce the inferior turbinate mass when hypertrophic inferior turbinates obstruct the nasal airway. Different laser systems produce different laser-tissue interactions. This study presents a comparison between three laser systems: CO2, Nd:YAG, and Diode lasers for inferior turbinate reduction surgery, all performed under endoscopic control. A total of 46 patients were randomized into three treatment groups and followed for more than 1 year. Subjective and objective data were collected. Subjective impressions of improved nasal airway was achieved in 41% (Diode), 47% (Nd:YAG) and 57% (CO2) and was not statistically significant. There was more postoperative bleeding in the CO2 laser group, with 3 patients requiring tamponade. The CO2 laser procedure also took longer to perform. These results failed to show a significant difference between the different lasers for inferior turbinate reduction. Overall, the results were not impressive.

[Lateral sinus thrombophlebitis].

Lateral sinus thrombophlebitis (LST) is an intracranial complication of otitis media. Its incidence has markedly decreased in the era of antibiotic therapy but mortality is still high. A 13-year-old girl presented with fever, ear discharge and torticollis. On the day of admission LST was diagnosed from the clinical presentation and CT-scan. She was operated immediately and intravenous antibiotics were administered. Despite the rapid intervention, the course was protracted, with recurrent events of septic pulmonary embolism. Despite internal jugular vein ligation, fever continued and anticoagulant therapy was begun. The possibility of LST should be considered in patients with ear discharge and fever. CT-scan enables early diagnosis of LST and MRI has a role in detecting additional intracranial septal foci. Surgical intervention should be early and aggressive. The efficacy of jugular vein ligation is unclear; anticoagulant therapy should be considered.

Pelvic stresses in vitro--I. Malsizing of endoprostheses.

Seven embalmed human cadaveric hemi-pelves have been stripped of all soft tissues except the articular cartilage and instrumented with 25 strain-gauge rosettes on both the medial and lateral surfaces. Loads up to 2.5 kN were applied, without simulated muscle forces, to mimic the line-of-action of the resultant joint-force in a single-legged stance. In this parametric study, endoprostheses were studied at the 'correct' size and in sizes of 1 and 2 mm above and below the correct size. The correct size of endoprosthesis produced similar periacetabular stress data to those obtained with the normal femoral head; however, significant changes in stress on the medial and lateral aspects of the ilium suggested the correctly-sized spherical endoprosthesis had a different moment arm than its anatomical counterpart. Endoprostheses of 1 mm greater than the correct size caused major increases in the magnitude of both periacetabular and medial-wall stresses, while prostheses of +2 mm created dramatic and significant increases in magnitudes of these stresses. Endoprostheses smaller than the correct size caused only small but significant changes in the pattern of stresses up to -2 mm malsizing and, in particular, were associated with the disappearance of all periacetabular tensile stresses; however, stress data on the medial and lateral aspects of the ilium were more closely matched to the 'normal' for this -2 mm of undersizing.

Pelvic stresses in vitro--II. A study of the efficacy of metal-backed acetabular prostheses.

Six embalmed human cadaveric hemi-pelves with their associated proximal femurs have been tested in vitro using 25 strain-gauge rosettes on each hemi-pelvis. Loads were applied up to 2.5 kN and principal stresses were computed from the principal strain data. Acetabular prostheses, cemented in place upon a cartilage-devoid but intact subchondral bone-plate, showed little change in stress-patterns when compared with the normal data, regardless of whether or not the component employed metal-backing. The use of 30 anchoring holes of 6.4 mm diameter, in the intact subchondral bone-plate, had little effect upon the stress-patterns, regardless of whether metal-backing was employed upon the prosthesis. When the subchondral bone-plate was removed, there were notable changes in the stress-pattern in the periacetabular region and on the medial wall of pelvis. The metal-backed prosthesis did not produce such notable changes as its plastic counterpart, when the subchondral bone-plate was removed. The use of a plastic prosthesis cemented in a Protrusio ring, in an acetabulum devoid of subchondral bone, produced notable changes in the stress-patterns in the whole periacetabular region and on the medial wall.