Immunological profiling of key inflammatory drivers of nasal polyp formation and growth in chronic rhinosinusitis.

BACKGROUND: Chronic rhinosinusitis (CRS) is a chronic inflammatory condition of the upper airways, often associated with the formation of nasal polyps (CRSwNP). It is well established that macroscopically normal (non-polypoidal) sinonasal mucosa in CRSwNP patients can undergo polypoidal change over time, turning into frank polyps. However, little is known about what drives this process. This study aimed to investigate potential drivers of nasal polyp formation or growth through comparison of the immunological profiles of nasal polyps with contiguous non-polypoidal sinonasal mucosa, from the same patients. METHODS: The immune profiles of three types of tissue were compared; nasal polyps and adjacent non-polypoidal sinonasal mucosa from 10 CRSwNP patients, and sinonasal mucosa from 10 control patients undergoing trans-sphenoidal pituitary surgery. Nasal polyp and control samples were also stimulated with Staphylococcus aureus enterotoxin B (SEB) using a nasal explant model, prior to cytokine analysis. Real time quantitative polymerase chain reaction (IL-5, T-bet, IL-17A, FoxP3, TLR-4, IL-8, IL-1beta and IL-6) and Luminex (IFNgamma, IL-5 and IL-17A) were used to quantify pro-inflammatory responses. RESULTS: Nasal polyps and contiguous non-polypoidal sinonasal mucosa from CRSwNP patients displayed a very similar pro-inflammatory profile. When stimulated with SEB, nasal polyps displayed a Th2/Th17 mediated response when compared to controls. CONCLUSIONS: In CRSwNP, nasal polyps and non-polypoidal sinonasal mucosa from the same patient displayed a similar pro-inflammatory profile skewed towards the Th2/Th17 pathway in nasal polyps following SEB stimulation, with evidence of disordered bacterial clearance. These factors may contribute to enhanced survival of bacteria and development of a chronic inflammatory milieu, potentially driving new polyp formation and recurrence following surgical removal.

Scedosporium apiospermum causing otomycosis in an immunocompetent child with tympanostomy tubes: Management of this rare entity.

Infection following a tympanostomy tube insertion is a common occurrence. Scedosporium apiospermum is a filamentous fungus mainly isolated in water and soil. There have been no reported cases of S. apiospermum infection of an immunocompetent individual with a tympanostomy tube in situ. A child was referred with unilateral otorrhoea failing to respond to conventional treatment in the community. S. apiospermum was identified following specialist testing. An extended course of anti-fungal treatment led to complete resolution. Due to the rare occurrence of aural S. apiospermum and unreported nature, it should be managed in a multidisciplinary setting.

Patient reported outcome measures in septorhinoplasty surgery.

INTRODUCTION: Surgical procedures incorporating a cosmetic element such as septorhinoplasty and otoplasty are currently under threat in the National Health Service (NHS) as they are deemed to be procedures of 'limited clinical benefit' by many primary care providers. Patient reported outcome measures (PROMs), which assess the quality of care delivered from the patients' perspective, are becoming increasingly important in documenting the effectiveness of such procedures. METHODS: The Rhinoplasty Outcomes Evaluation (ROE) questionnaire, a validated PROM tool, was used to assess patient satisfaction in 141 patients undergoing septorhinoplasty surgery over a 90-month period at the University Hospital Southampton NHS Foundation Trust. RESULTS: Overall, 100 patients with a mean follow-up period of 36 months completed the study. The mean ROE score was 73.3%. In addition, 75% of patients questioned were happy with the final result of their operation and 83% would undergo the procedure again if required. These benefits occurred irrespective of age, sex and primary versus revision surgery, and were maintained for up to 71 months following surgery. CONCLUSIONS: This study has shown that patients are generally satisfied with their functional and cosmetic outcomes following septorhinoplasty surgery. These results help support the case for septorhinoplasty surgery to continue being funded as an NHS procedure.

Maxillary dentinogenic ghost cell tumour.

Dentinogenic ghost cell tumours are extremely rare, and pose significant diagnostic and therapeutic challenges as this case clearly demonstrates. An awareness of different clinical presentations and distinct histopathological features is important in establishing an early definitive diagnosis and instituting appropriate management. Furthermore, there is little precedent in the literature to guide management in such a case, and we therefore consider this report to be noteworthy and instructive in this respect.

YouTube as a source of information on rhinosinusitis: the good, the bad and the ugly.

OBJECTIVE: YouTube is an internet-based repository of user-generated content. This study aimed to determine whether YouTube represented a valid and reliable patient information resource for the lay person on the topic of rhinosinusitis. METHODS: The study included the first 100 YouTube videos found using the search term 'sinusitis'. Videos were graded on their ability to inform the lay person on the subject of rhinosinusitis. RESULTS: Forty-five per cent of the videos were deemed to provide some useful information. Fifty-five per cent of the videos contained little or no useful facts, 27 per cent of which contained potentially misleading or even dangerous information. Videos uploaded by medical professionals or those from health information websites contained more useful information than those uploaded by independent users. CONCLUSION: YouTube appears to be an unreliable resource for accurate and up to date medical information relating to rhinosinusitis. However, it may provide some useful information if mechanisms existed to direct lay people to verifiable and credible sources.

A prospective randomised single-blinded clinical trial comparing the efficacy and tolerability of the nasal douching products Sterimar™ and Sinus Rinse™ following functional endoscopic sinus surgery.

OBJECTIVES: To compare the efficacy and tolerability of two commonly used nasal douching products, low-volume high-pressure Sterimar™ and high-volume low-pressure Sinus Rinse™ following functional endoscopic sinus surgery. DESIGN: Prospective randomised single-blinded study. SETTING: Tertiary referral centre. PARTICIPANTS: Thirty-one patients, undergoing functional endoscopic sinus surgery for chronic rhinosinusitis with and without polyps, were recruited for the study. The patients acted as their own comparators self-administering each douche three times daily into one randomly allocated nostril for a period of 12 weeks following the surgery. MAIN OUTCOME MEASURES: The primary outcome measure was a blinded objective endoscopic assessment of each operated side using a modified Lund-Kennedy endoscopic assessment tool undertaken at 2, 4 and 12 weeks postoperatively. As secondary outcome measures, the patients were asked to express a preference between the two products based on perceived effectiveness and ease of use. RESULTS: Compared with the preoperative scores, there was a statistically significant improvement in the SNOT-22 score at all three postoperative time points (P < 0.001). Compared with week 2, there was a statistically significant reduction in the modified Lund-Kennedy endoscopic scores (P < 0.05) for both Sterimar™ and Sinus Rinse™ at weeks 4 and 12. When comparing Sterimar™ with SinuRinse™, there was a statistically significant lower modified Lund-Kennedy score at 2 and 4 weeks postoperatively for the side treated with Sinus Rinse™ (P ≤ 0.05), indicating a more favourable outcome. However, this difference was not apparent at 12 weeks postoperatively (P = 0.66). At all time points, patients perceived Sinus Rinse™ to be more effective than Sterimar™ (P < 0.0001), but there was no significant difference in the patients' preference for either product (P > 0.05). CONCLUSION: High-volume low-pressure saline irrigation is recommended as an efficacious, easy to use and well-tolerated adjunct to endoscopic sinonasal toilet in the early postoperative period following functional endoscopic sinus surgery.

Treatment algorithm for oral anticoagulant and antiplatelet therapy in epistaxis patients.

BACKGROUND AND OBJECTIVES: There is currently little published guidance on the management of anticoagulant and antiplatelet medication in patients admitted with epistaxis. The routine practice of withholding such medication in an attempt to control the epistaxis is common in the UK. However, this practice is not evidence-based, is often unnecessary, and can be associated with significant morbidity. This study introduces a treatment algorithm for oral anticoagulant and antiplatelet therapy in epistaxis patients, validated through a completed audit cycle. METHODS: One hundred patients admitted with epistaxis to the University Hospital Southampton NHS Foundation Trust were studied via a two-audit cycle covering the implementation of a new treatment algorithm formulated jointly by the otolaryngology and haematology departments. RESULTS: On admission, 58 per cent of patients were taking some form of anticoagulant or antiplatelet medication. The number of patients having such medication withheld decreased significantly between the two audits, for all drugs studied (i.e. aspirin, clopidogrel and warfarin). There was no significant increase in re-bleeding or re-admission rates between the audits. CONCLUSION: Implementation of this treatment algorithm would help standardise management for epistaxis patients taking anticoagulant or antiplatelet drugs, and should reduce morbidity associated with unnecessary routine discontinuation of such medication.

Should prophylactic antibiotics be used routinely in epistaxis patients with nasal packs?

INTRODUCTION: The current mainstream practice in otolaryngology departments relating to the use of prophylactic antibiotics in epistaxis patients requiring nasal packing is highly variable. This is due primarily to the lack of any validated guidelines. As such, we introduced a new treatment algorithm resulting in significant reduction of use in the systemic antibiotics, with emphasis instead on the use of topical antibiotics. The results were validated through a complete audit cycle. METHODS: A total of 57 patients undergoing nasal packing for spontaneous epistaxis were studied. Reaudit occurred after the implementation of new guidelines. Telephone surveys were conducted six weeks after hospital discharge, assessing infective nasal symptoms as well as rebleeding and readmission rates. RESULTS: Systemic antibiotic prescribing in anterior nasal packing fell by 58.2% between audit cycles with no statistically significant associated increase in infective nasal symptoms, rebleeding or readmission rates six weeks following hospital discharge. CONCLUSIONS: Systemic prophylactic antibiotics are unnecessary in the majority of epistaxis patients with nasal packs. The use of topical antibiotics such as Naseptin may be more appropriate, cheaper and as effective. Implementation of this treatment algorithm will help standardise systemic antibiotic usage in epistaxis patients with nasal packing and should reduce costs associated with unnecessary use of such medication.

Guillotine versus dissection tonsillectomy: randomised, controlled trial.

OBJECTIVE: This trial aimed to compare the guillotine technique of tonsillectomy with 'cold steel' dissection, the current 'gold standard'. DESIGN: A single centre, randomised, controlled trial. METHODS: One hundred children aged 3 to 11 years who were listed for bilateral tonsillectomy were recruited. Patients had one tonsil removed by each technique, and were blinded to the side. The operative time, intra-operative blood loss, haemostasis requirement and post-operative pain scores were recorded and compared. RESULTS: Operative time and intra-operative blood loss were both significantly less for the guillotine technique (p < 0.001) and there was a significantly reduced haemostasis requirement (p < 0.001). Pain was also less on the guillotine side (p < 0.001). There were no tonsillar remnants or palatal trauma for either technique. There was no significant difference between techniques in the frequency of secondary haemorrhage. CONCLUSION: This study provides level Ib evidence that guillotine tonsillectomy in children with mobile tonsils is an effective and time-efficient procedure which produces less intra-operative blood loss and post-operative pain than cold steel dissection.

Solitary extra-skeletal sinonasal metastasis from a primary skeletal Ewing's sarcoma.

INTRODUCTION: Ewing's sarcoma is a rare, malignant tumour predominantly affecting young adolescent males. We describe a unique case of an isolated extra-skeletal metastasis from a skeletal Ewing's sarcoma primary, arising in the right sinonasal cavity of a young man who presented with severe epistaxis and periorbital cellulitis. RESULTS: Histologically, the lesion comprised closely packed, slightly diffuse, atypical cells with round, hyperchromatic nuclei, scant cytoplasm and occasional mitotic figures, arranged in a sheet-like pattern. Immunohistochemical analysis showed positive staining only for cluster of differentiation 99 glycoprotein. Fluorescent in situ hybridisation identified the Ewing's sarcoma gene, confirming the diagnosis. MANAGEMENT: Complete surgical resection was achieved via a minimally invasive endoscopic transnasal approach; post-operative radiotherapy. Ten months post-operatively, there were no endoscopic or radiological signs of disease. CONCLUSION: Metastatic Ewing's sarcoma within the head and neck is incredibly rare and can pose significant diagnostic and therapeutic challenges. An awareness of different clinical presentations and distinct histopathological features is important to enable early diagnosis. This case illustrates one potential management strategy, and reinforces the evolving role of endoscopic transnasal approaches in managing sinonasal cavity and anterior skull base tumours.

Ossifying fibromyxoid tumour of the sphenoid sinus.

INTRODUCTION: Ossifying fibromyxoid tumour is a recently described, rare but morphologically distinctive soft tissue neoplasm characterised by a combination of myxoid and/or fibrous stroma with areas of ossification. Although most authors postulate a neuroectodermal origin for this peculiar tumour, there is no agreement in the literature regarding its histopathogenesis. To our knowledge, this is the first reported case of ossifying fibromyxoid tumour involving the sphenoid sinus. HISTOLOGICAL FINDINGS: Tumour of low cell density, composed of small, spindle-shaped or stellate cells with small, irregular nuclei set in a fibromyxoid stroma. MANAGEMENT: Following discussion at the skull base multidisciplinary team meeting, a combined surgical team including an otorhinolaryngologist and a neurosurgeon carried out resection of the lesion, using an endoscopic transnasal approach, followed by reconstruction of the defect. CONCLUSIONS: An awareness of the distinctive histopathological features of ossifying fibromyxoid tumour, and of its clinical effects, is crucial to establishing a definitive diagnosis and thereby instituting appropriate management. This case report also reinforces the evolving role of the endoscopic transnasal approach in the management of inflammatory and neoplastic disease involving the skull base. This is increasingly being made possible by close collaboration between multiple surgical specialties, including otorhinolaryngology and neurosurgery.

Transforming growth factor-beta in allergic inflammatory disease of the upper airways: friend or foe?

TGF-beta is a multi-functional cytokine with a huge array of effects on a variety of cell types. It is rapidly emerging as a key major player in the way the airway epithelium behaves and its ability to repair itself. This is not only of relevance to allergic airway diseases such as asthma and allergic rhinitis, which are increasing in prevalence worldwide, but in many other diseases. The full impact any disruption of TGF-beta signalling may have in the development and persistence of allergic inflammatory airway diseases is yet to be fully realized and remains the subject of ongoing research. There has been a recent revival of interest in the role of regulatory T cells in controlling allergic inflammation. Evidence is emerging of a significant contribution by TGF-beta to this regulatory process. This review aims to summarize current knowledge relating to TGF-beta in relation to allergic inflammatory upper airways disease, and attempts to clarify some of the discrepancies and inconsistencies in this area. It also considers the therapeutic implications of novel TGF-beta therapy, including potential future applications in the treatment of nasal polyposis and reduction of post-operative scar tissue formation following endoscopic sinus surgery.

Guillotine tonsillectomy: a neglected technique.

BACKGROUND: Increased post-operative tonsillectomy haemorrhage rates have been observed following 'hot' tonsillectomy techniques, compared with 'cold steel' dissection. Post-tonsillectomy haemorrhage rates and the degree of blood loss during guillotine tonsillectomy have not been reported in the recent literature. METHODS: This retrospective case note review assessed the degree of blood loss during guillotine tonsillectomy, as measured by the number of tonsil swabs used, and the post-tonsillectomy haemorrhage rate. RESULTS: In a group of 168 patients, no tonsil swabs were used in 13.1 per cent of cases, and less than two tonsil swabs were used in 41.1 per cent of cases. CONCLUSION: Guillotine tonsillectomy, when performed by the method described in this article, resulted in minimal intra-operative blood loss in 54 per cent of cases, and appeared to have comparable post-tonsillectomy haemorrhage rates to cold steel dissection techniques.

A case of cranial fasciitis masquerading as acute mastoiditis.

OBJECTIVE: We report a case of infection against a background of pre-existing cranial fasciitis. METHOD: Case report and review of world literature on cranial fasciitis. RESULTS: Cranial fasciitis of childhood is a benign condition and a rare variant of nodular fasciitis. We present the case of a 10-week-old infant with symptoms and signs consistent with a subperiosteal abscess complicating acute mastoiditis. Subsequent findings showed this to be an infection against a background of pre-existing cranial fasciitis. CONCLUSION: To our knowledge, this is the first such reported case in the literature. Knowledge of the distinctive histopathological features, coupled with an awareness of the condition, are crucial to establishing a definitive diagnosis of cranial fasciitis and, in turn, to instituting appropriate management. The aetiopathogenesis of the condition remains unclear.

Mechanisms and mediators of nasal symptoms in non-allergic rhinitis.

Non-allergic rhinitis may be a contributing factor in up to 60% of rhinitis patients and a sole contributor in a quarter. It is a highly heterogeneous condition with poorly understood pathophysiological mechanisms. Compelling evidence is emerging of a localized nasal mucosal allergic response in some non-allergic rhinitic subjects in the absence of systemic atopy. While the inflammatory disease pathway in non-allergic rhinitis may share some of the features of its allergic counterpart, overall the mechanisms remain unclear, and there are likely to be differences. In particular, symptoms of nasal congestion and rhinorrhoea tend to be more prominent and persistent in non-allergic rhinitic patients compared with allergic rhinitis. Our aim is to review the literature relating to mechanisms and mediators of nasal symptoms in non-allergic rhinitis. Better understanding of the underlying pathophysiological basis should enable the development of more accurate testing, and better targeted therapeutic options in the future.