Effects of human rhinovirus on epithelial barrier integrity and function in children with asthma.

BACKGROUND: Bronchial epithelial tight junctions (TJ) have been extensively assessed in healthy airway epithelium. However, no studies have yet assessed the effect of human rhinovirus (HRV) infection on the expression and resultant barrier function in epithelial tight junctions (TJ) in childhood asthma. OBJECTIVES: To investigate the impact of HRV infection on airway epithelial TJ expression and barrier function in airway epithelial cells (AECs) of children with and without asthma. Furthermore, to test the hypothesis that barrier integrity and function is compromised to a greater extent by HRV in AECs from asthmatic children. METHODS: Primary AECs were obtained from children with and without asthma, differentiated into air-liquid interface (ALI) cultures and infected with rhinovirus. Expression of claudin-1, occludin and zonula occluden-1 (ZO-1) was assessed via qPCR, immunocytochemistry (ICC), in-cell western (ICW) and confocal microscopy. Barrier function was assessed by transepithelial electrical resistance (TER; RT ) and permeability to fluorescent dextran. RESULTS: Basal TJ gene expression of claudin-1 and occludin was significantly upregulated in asthmatic children compared to non-asthmatics; however, no difference was seen with ZO-1. Interestingly, claudin-1, occludin and ZO-1 protein expression was significantly reduced in AEC of asthmatic children compared to non-asthmatic controls suggesting possible post-transcriptional inherent differences. HRV infection resulted in a transient dissociation of TJ and airway barrier integrity in non-asthmatic children. Although similar dissociation of TJ was observed in asthmatic children, a significant and sustained reduction in TJ expression concurrent with both a significant decrease in TER and an increase in permeability in asthmatic children was observed. CONCLUSION: This study demonstrates novel intrinsic differences in TJ gene and protein expression between AEC of children with and without asthma. Furthermore, it correlates directly the relationship between HRV infection and the resultant dissociation of epithelial TJ that causes a continued altered barrier function in children with asthma.

Impaired airway epithelial cell responses from children with asthma to rhinoviral infection.

BACKGROUND: The airway epithelium forms an effective immune and physical barrier that is essential for protecting the lung from potentially harmful inhaled stimuli including viruses. Human rhinovirus (HRV) infection is a known trigger of asthma exacerbations, although the mechanism by which this occurs is not fully understood. OBJECTIVE: To explore the relationship between apoptotic, innate immune and inflammatory responses to HRV infection in airway epithelial cells (AECs) obtained from children with asthma and non-asthmatic controls. In addition, to test the hypothesis that aberrant repair of epithelium from asthmatics is further dysregulated by HRV infection. METHODS: Airway epithelial brushings were obtained from 39 asthmatic and 36 non-asthmatic children. Primary cultures were established and exposed to HRV1b and HRV14. Virus receptor number, virus replication and progeny release were determined. Epithelial cell apoptosis, IFN-ß production, inflammatory cytokine release and epithelial wound repair and proliferation were also measured. RESULTS: Virus proliferation and release was greater in airway epithelial cells from asthmatics but this was not related to the number of virus receptors. In epithelial cells from asthmatic children, virus infection dampened apoptosis, reduced IFN-ß production and increased inflammatory cytokine production. HRV1b infection also inhibited wound repair capacity of epithelial cells isolated from non-asthmatic children and exaggerated the defective repair response seen in epithelial cells from asthmatics. Addition of IFN-ß restored apoptosis, suppressed virus replication and improved repair of airway epithelial cells from asthmatics but did not reduce inflammatory cytokine production. CONCLUSIONS: Collectively, HRV infection delays repair and inhibits apoptotic processes in epithelial cells from non-asthmatic and asthmatic children. The delayed repair is further exaggerated in cells from asthmatic children and is only partially reversed by exogenous IFN-ß.

Adenotonsillar surgery in morbidly obese children: routine elective admission of all patients to the intensive care unit is unnecessary.

Morbidly obese children undergoing adenotonsillectomy, often with co-morbid obstructive sleep apnoea, may be considered at a higher risk of postoperative respiratory compromise. This retrospective study aimed to assess the frequency and severity of postoperative respiratory complications in these patients and to identify preoperative risks factors for such morbidity. Medical and nursing chart review of all consecutive elective post-adenotonsillectomy admissions of morbidly obese children (defined as >95th centile for body mass index adjusted for age and gender) to our intensive care unit over a 30-month period was performed. A total of 26 morbidly obese children were identified. The majority (14/26) had an uncomplicated recovery following surgery. Of those cases that required postoperative intervention, 10 patients required supplemental oxygen with or without suctioning and/or repositioning alone, whilst two required continuous positive airway pressure therapy. No patient required re-intubation. An oxygen saturation nadir of < 70% and the presence of more than one central apnoea, noted on preoperative overnight polysomnography, were associated with postoperative respiratory complications requiring intervention. Although the intervention group were younger, more obese and had a higher respiratory disturbance index, none of these factors were statistically significant. Routine admission to the paediatric intensive care unit of all morbidly obese children undergoing adenotonsillectomy may be unnecessary, once a suitable high level of nursing is available in an alternative setting, to administer simple positional and suctioning intervention and to perform regular patient observation. Special consideration should be given to the postoperative nursing environment for those patients with a SaO2 nadir < 70% noted preoperatively, indicating the presence of a significant central disease component.

Pharyngo-oesophageal fistula following iatrogenic perforation of a pharyngeal pouch.

A unique, previously undescribed case of iatrogenic perforation of a pharyngeal pouch which resulted in pharyngo-oesophageal fistulation is described. The correct management of such complications is discussed.

The management of benign thyroid goitre causing tracheo-oesophageal embarrassment.

The case of a massive benign thyroid goitre extending from the arch of aorta to the nasopharynx presenting with acute aerodigestive obstruction is reported. The management of the case is discussed and also a review of the relevant literature.

Age-related bone resorption in the normal incus: a case of maladaptive remodelling?

The changes that occur in the normal human incus with age have been investigated. Evidence for age-related changes in this ossicle, especially in the region of the long process, has been accumulating over the last 30-40 years and yet they have neither been confirmed quantitatively nor explained satisfactorily. In this study the results of a morphometric study of the long processes of a series of normal incudes are presented. These demonstrate that the lenticular and long processes undergo progressive symmetric resorption with advancing age. We consider these findings in the light of previous considerations of incudal remodelling and propose that these remodelling changes may reflect a normal adaptive response to the biomechanical milieu of the human middle ear.

Alar cartilage haematoma.

We present a previously undescribed site of a subperichondrial haematoma--the alar cartilage. Two children presenting acutely, following trauma, with the clinical appearance of a 'blueberry' within the nasal vestibule are described. We recommend early surgical drainage of this lesion, as delay in definitive treatment may give rise to a cosmetic deformity.

Lingual thyroid presenting after previous thyroglossal cyst excision.

Lingual thyroid is a rare lesion caused by maldescent of the thyroid gland. It is an important cause of a mass on the posterior third of the tongue, and may coexist with other developmental abnormalities such as thyroglossal cyst. The diagnosis is made by radioisotope scan. Treatment is indicated in the presence of symptoms and consists initially of thyroxine. Severe or unresponsive cases require complete excision through a lateral pharyngotomy. Hypothyroidism is common postoperatively, but may be avoided in some cases by transplantation of excised tissue. We present a case report and review of the literature.

The vascular supply of the lenticular and long processes of the incus.

Previous reports of the blood supply to the lenticular and long processes of the incus have failed to consider the potential contribution of the periosteal vascular plexus. This scanning electron microscopic study of vascular foramina on the cortical bone surface demonstrates that there is no statistical difference between the numbers of vascular foramina on the lenticular and long processes, as opposed to the body and short process. These results suggest that the blood supply to this portion of the ossicular chain may not be as tenuous as has been thought.

Clinical audit: is day-case adenotonsillectomy safe?

The trend towards day-case procedures is growing, as a consequence not only of improved medical care but the increasing importance of economic considerations in today's healthcare environment. In the largest worldwide study to date to assess the safety of day-case adenotonsillectomy, we reviewed the records of 4386 patients at the otolaryngology department of the Bradford Royal Infirmary. We found a reactionary haemorrhage rate of 0.57%. All patients who underwent surgery in the morning session had presented with haemorrhage and returned to the operating theatre before the end of the afternoon session. We discuss the implications of these findings, and consider that with careful monitoring day-case tonsillectomy and/or adenoidectomy may safely be introduced.

Remodelling of the normal incus.

Thirty normal incudes were examined using scanning electron microscopy (SEM) to assess the pattern and degree of bony remodelling. The body and short process appeared stable throughout life. By contrast, the lenticular and long processes demonstrated marked osteoclastic activity with a tendency to undergo progressive erosion with advancing age.

The cellular mechanism of ossicular erosion in chronic suppurative otitis media.

This is the first report of the application of a new examination technique for the assessment of cellular activity during bone resorption in chronic suppurative otitis media (CSOM). A total of nineteen includes removed during the course of tympanomastoid surgery were studied (retraction pocket: 2; tubo-tympanic CSOM: 4; attico-antral CSOM: 13). The microscopic surface topography of each specimen was examined using the scanning electron microscopy (SEM), and the appearances are interpreted in terms of cortical cellular activity. The results suggest that the mechanism of ossicular erosion in CSOM is similar regardless of the exact type of disease. Extensively pitted areas were seen in all specimens. These pits are morphologically indistinguishable from those characteristic of osteoclastic activity (Howship's lacunae). We conclude that in all causes the surface topography of eroded incudes is consistent with the activity of osteoclasts.

Jugular bulb phlebectasia.

Phlebectasia of the internal jugular vein (IJV) is a rare venous anomaly that usually presents in young children as a soft cystic swelling in the neck and represents a pathologically enlarged vein. We present a case of jugular bulb phlebectasia in a 4-year-old boy. He presented with a blue pulsatile swelling arising from the floor of the left middle ear cleft. The venous phase of digital subtraction vertebral arteriography (DSVA) and computerised axial tomography (CT) with contrast confirmed a diagnosis of phlebectasia of the lateral sinus and proximal part of the left IJV, with a complete bony defect in the floor of the middle ear. The child did not have any neck symptoms or signs. No active treatment was required. To our knowledge, this is the first case of jugular bulb phlebectasia presenting in the middle ear.

Antroconchopexy for surgical treatment of perennial rhinitis.

We report on a rhinomanometric assessment of eleven patients undergoing antroconchopexy for relief of a "stuffy" nose. This little-known procedure involves the lateralization of the inferior turbinate through a large intranasal antrostomy. Our results demonstrate a significant improvement in postoperative inspiratory and expiratory nasal resistance. There was also a significant improvement in patient's scoring for nasal obstruction. Finer points of the surgical technique, and indications for the procedure are discussed.

Oncocytic papillary cystadenomatosis of the larynx.

Symptomatic oncocytic disease of the larynx is rare. Review of the world literature reveals that isolated, symptomatic cases of oncocytoma of the larynx have been previously reported to involve discrete sites usually the laryngeal ventricles and vestibular folds. A unique case of multifocal cystic oncocytic hyperplasia necessitating laryngectomy is reported. CT scan of the larynx suggested destruction of the cartilage. Malignant histological features were not present. This report raises the question whether previously described cases of oncocytoma of the larynx also had diffuse involvement. If oncocytosis is a diffuse process then it is suggested that patients should be kept under review for recurring lesions.

Carbon dioxide laser cordectomy in the management of bilateral vocal cord paralysis.

Bilateral vocal cord paralysis is a rare but major complication of thyroid surgery. Since 1983, patients with bilateral cord paralysis have been managed in this department using the carbon dioxide laser. Six patients with bilateral cord paralysis secondary to thyroid surgery underwent partial cordectomy and arytenoidectomy. Two patients were operated on with tracheostomy tubes in situ, and both were successfully decannulated. In the remaining four patients, ventilation was maintained during anaesthesia using a Venturi jet ventilation system. None of these patients required a perioperative tracheostomy. Adequate airway improvement and satisfactory voice quality were achieved. Follow-up ranged from 6 to 17 months.

Verrucous carcinoma of the maxillary antrum.

Verrucous carcinoma is a rare variant of squamous cell carcinoma which occurs most frequently in the oral cavity and larynx. In this article we describe a patient with verrucous carcinoma of the maxillary antrum, and present a review of the literature.

Foreign bodies in the throat: a prospective study of 388 cases.

We present the results of a prospective study of 388 patients presenting with a history of swallowing a foreign body. We indicate whether the patients' symptoms and signs were associated with a retained foreign body. While tenderness on palpation was an unreliable sign, pooling at indirect laryngoscopy invariably predicted a retained object. In many patients, initial careful examination of the oropharynx by casualty officers would have shown a retained fishbone in the tonsil or tongue and would have resulted in 16 per cent fewer radiographs and 17 per cent fewer referrals to the ENT department. Radiography only improved management in a small minority and 35 per cent of films were interpreted incorrectly by casualty officers. A follow-up barium swallow disclosed a pathological lesion in a significant proportion of patients with bolus obstruction, whether or not this was passed spontaneously.