Eosinophil peroxidase induces the expression and function of acid-sensing ion channel-3 in allergic rhinitis: in vitro evidence in cultured epithelial cells.

BACKGROUND: Acid-sensing ion channels (ASIC) are a family of acid-activated ligand-gated cation channels. As tissue acidosis is a feature of inflammatory conditions, such as allergic rhinitis (AR), we investigated the expression and function of these channels in AR. OBJECTIVES: The aim of the study was to assess expression and function of ASIC channels in the nasal mucosa of control and AR subjects. METHODS: Immunohistochemical localization of ASIC receptors and functional responses to lactic acid application were investigated. In vitro studies on cultured epithelial cells were performed to assess underlying mechanisms of ASIC function. RESULTS: Lactic acid at pH 7.03 induced a significant rise in nasal fluid secretion that was inhibited by pre-treatment with the ASIC inhibitor amiloride in AR subjects (n = 19). Quantitative PCR on cDNA isolated from nasal biopsies from control and AR subjects demonstrated that ASIC-1 was equally expressed in both populations, but ASIC-3 was significantly more highly expressed in AR (P < 0.02). Immunohistochemistry confirmed significantly higher ASIC-3 protein expression on nasal epithelial cells in AR patients than controls (P < 0.01). Immunoreactivity for EPO+ eosinophils in both nasal epithelium and submucosa was more prominent in AR compared with controls. A mechanism of induction of ASIC-3 expression relevant to AR was suggested by the finding that eosinophil peroxidase (EPO), acting via ERK1/2, induced the expression of ASIC-3 in epithelial cells. Furthermore, using a quantitative functional measure of epithelial cell secretory function in vitro, EPO increased the air-surface liquid depth via an ASIC-dependent chloride secretory pathway. CONCLUSIONS: This data suggests a possible mechanism for the observed association of eosinophils and rhinorrhoea in AR and is manifested through enhanced ASIC-3 expression.

Complexities of revision mastoid surgery in a migratory population cohort.

We present a review of patients from Eastern Europe who have recently immigrated to Ireland with complicated otological disease. We carried out a retrospective chart review of these patients. These are a complicated cohort of 7 patients, 5 (71.4%) of whom had previous ear surgery, none had old notes and there was often a need for interpreters (3 or 42.8%) and challenging surgery. Follow up was also problematic with many of the patients. In summary this is a case series to highlight a relatively new group of patients to emphasize the need for pre-operative CT scans, facial nerve monitoring and the difficult nature of revision surgery with no old notes.

The accuracy of dry surgical field sublabial biopsy in the diagnosis of sicca syndrome.

BACKGROUND: Sublabial gland biopsy is the 'gold standard' in establishing the diagnosis of primary Sjögren's syndrome. Bleeding and nerve damage are complications. Our centre has adopted the use of the chalazion clamp to provide a dry surgical field to address these challenges. This study aimed to assess the accuracy of minor salivary gland harvest rate using this technique. METHOD: A retrospective review of all minor salivary gland biopsies was carried out in a single tertiary referral centre over a five-year period. RESULTS: Forty-one biopsy patients were identified, with a mean age of 56.1 years. There was 100 per cent accuracy in harvest rate in our series. Twelve patients (29 per cent) were positive for primary Sjögren's syndrome. No patients had a complication immediately or at one month follow up. CONCLUSION: Dry surgical field sublabial gland biopsy is a safe and highly effective technique in the diagnosis of primary Sjögren's syndrome. Initial results indicate it may provide a higher harvest rate with fewer complications than traditional non-ischaemic techniques.

Dry surgical field minor salivary gland harvest using a chalazion clamp for sicca syndrome.

BACKGROUND: Sjögren's syndrome is a rheumatological condition. Diagnosing Sjögren's syndrome can be challenging given the overlapping nature of clinical presentations. Currently, minor salivary gland biopsy is considered the definitive test for diagnosing Sjögren's syndrome. Various surgical techniques have been described, targeting biopsy of minor salivary glands from the lower lip. Identification of minor salivary glands is often difficult because of bleeding. One common complication of minor salivary gland biopsy is lip paraesthesia from iatrogenic sensory nerve injury. OBJECTIVES: To describe a minor salivary gland biopsy technique in a bloodless operative field using a chalazion ophthalmic clamp under local anaesthesia, and to report our clinical outcomes. METHODS: A prospective study was performed on patients who underwent minor salivary gland biopsy using a chalazion ophthalmic clamp between July 2017 and April 2018. RESULTS: The study included 23 patients. The histopathological reports positively identified minor salivary glands for all patients. In nine cases, the histological findings were positive for Sjögren's syndrome. No lip paraesthesia complications were reported post-operatively. CONCLUSION: This technique facilitates a superior yield, ensures adequate sampling of appropriate glands for histopathological analysis, and minimises the complications associated with traditional techniques.

Complete branchial cleft fistula: diagnosis and surgical management.

Branchial cleft fistulae are rare congenital abnormalities that arise from the abnormal persistence of branchial apparatus remnants. A complete fistula is a tract that has an internal opening and an external opening. Second branchial cleft fistulae pass deep to second arch structures and over third arch structures, in a direction extending from the anterior border of sternocleidomastoid (SCM) muscle to the upper pole of the ipsilateral tonsil fossa. Because of this anatomical route, these long tubular structures are intimately associated with major neuro-vascular structures in the neck. Fistulae are usually clinically apparent after birth with up to 80% being diagnosed before age 5 years. There may be an obvious opening in the anterior neck between the hyoid bone and suprasternal notch. Recurrent mucoid discharge becoming purulent during acute infection or associated with upper respiratory tract infection is the usual course. Treatment is complete surgical excision of all abnormally placed epithelium, while preserving surrounding neurovascular structures, and using cosmetically acceptable incisions. Complete fistulae in adults are rare and diagnosis can be difficult. We present the clinical presentation and surgical management of a long (14 cm) second branchial cleft fistula, in a 25-year-old female. Preoperative CT and MRI scans of the neck clearly demonstrated the fistula. We recommend a "stepladder" or Mc Fee incision and intra-oral pull-through fistulectomy to allow safe and complete excision.

The Diagnostic Accuracy of Contrast-Enhanced CT of the Neck for the Investigation of Sialolithiasis.

BACKGROUND AND PURPOSE: Sialolithiasis is a common benign pathology affecting the salivary glands but it is unclear if contrast-enhanced CT, which is commonly used for investigation of head and neck pathology, can identify calculi as accurately as noncontrast CT. The aim of this study was to assess the diagnostic accuracy of contrast-enhanced CT of the neck in the diagnosis of sialolithiasis compared with noncontrast CT of the neck used as the criterion standard. MATERIALS AND METHODS: This was a retrospective, case-control study of 92 consecutive cases in 90 patients who underwent both noncontrast CT of the neck and contrast-enhanced CT of the neck in 2 tertiary referral centers from January 2011 to December 2015 for investigation of sialolithiasis. Axial 3-mm-section images were assessed by a fellowship-trained diagnostic neuroradiologist and diagnostic neuroradiology fellow in consensus. Blinded assessment of the contrast-enhanced CT of the neck was performed first, followed by noncontrast CT of the neck after a 2-week interval. The presence or absence of a stone and stone location and size were documented. Statistical analysis was undertaken to assess the agreement between CT protocols and calculate the sensitivity and specificity of contrast-enhanced CT of the neck. RESULTS: Fifty calculi were identified on noncontrast CT of the neck in 31 cases; and 48 calculi, in 31 cases on contrast-enhanced CT of the neck. No calculi were identified in the remaining 61 cases. The sensitivity and specificity of contrast-enhanced CT of the neck in the detection of sialolithiasis was 96% (95% CI, 86.3%-99.5%) and 100% (95% CI, 94.1%-100%), respectively. The positive predictive value of contrast-enhanced CT of the neck was 100% (95% CI, 92.6%-100%), and the negative predictive value was 96.8% (95% CI, 89%-99.6%). The accuracy of contrast-enhanced CT of the neck in diagnosing the presence or absence of salivary calculi was 98%. CONCLUSIONS: Contrast-enhanced CT of the neck is accurate in the detection of sialolithiasis, with no difference in diagnostic accuracy compared with noncontrast CT of the neck.

The use of botulinum toxin in Frey's Syndrome.

Frey's Syndrome, or gustatory sweating, occurs in over 50% of patients following superficial parotidectomy. In the vast majority of cases, these symptoms are not severe enough to require surgical treatment and can be effectively treated with topical anticholinergics and antihyperhydrotics. Patients with recalcitrant Frey's Syndrome can be treated by a variety of surgical procedures. However, the potential risks and side effects of these surgical procedures often outweigh the benefits. Botulinum toxin A has recently emerged as a popular treatment option for a number of head and neck conditions. The anticholinergic effects of Botox make it particularly suitable for the treatment of Frey's Syndrome. We report our experience.

Surgical tracheostomy in morbidly obese patients: technical considerations and a two-flap technique for access.

OBJECTIVE: In an era in which percutaneous tracheostomies are frequently performed in 'suitable' necks, more technically complex cases are referred to the otolaryngologist. We describe the surgical technique used and close cooperation required in securing the airway of a morbidly obese patient. CASE REPORT: A 52-year-old, morbidly obese man with significant comorbidities was referred for surgical tracheostomy following spinal fractures. This was complicated by a previous percutaneous dilatational tracheostomy scar. Tension-free skin advancement was not possible with a deeply plunging trachea; a vertical skin incision was dropped inferiorly to the sternum for access. A size 8 Shiley XLT Proximal Extension cuffed tracheostomy tube was inserted successfully. CONCLUSION: We describe safe airway surgery in a morbidly obese man, and outline requirements including the use of a specially designed operating table, the need for an elongated proximal limb tracheostomy tube, and the use of a distal two-flap technique for access to a deeply plunging trachea.

Efficacy of the Power Balance Silicone Wristband: a single-blind, randomized, triple placebo-controlled study.

INTRODUCTION: The Power Balance Silicone Wristband (Power Balance LLC, Laguna Niguel, CA) (power balance band; PBB) consists of a silicone wristband, incorporating two holograms, which is meant to confer improvements in balance on the wearer. Despite its popularity, the PBB has become somewhat controversial, with a number of articles being published in the news media regarding its efficacy. The PBB has not been formally evaluated but remains popular, largely based on anecdotal evidence. This study subjectively and objectively measured the effects of the PBB on balance in normal participants. METHODS: A prospective, single-blind, randomized, triple placebo-controlled crossover study was undertaken. Twenty participants underwent measurement using the modified Test of Sensory Interaction on Balance (mCTSIB) and gave subjective feedback (visual analogue scale [VAS]) for each of four band conditions: no band, a silicone band, a deactivated PBB, and the PBB. Participants acted as their own controls. RESULTS: The mean of the four mCTSIB conditions (eyes open and closed on both firm and compliant surfaces) was calculated. This mean value and condition 4 of the mCTSIB were compared between band conditions using path length (PL) and root mean square (RMS) as outcome measures. No significant differences were found between band conditions for PL (p  =  .91 and p  =  .94, respectively) and RMS (p  =  .85 and p  =  .96, respectively). VASs also showed no difference between bands (p  =  .25). CONCLUSION: The PBB appears to have no effect on mCTSIB or VAS measurements of balance.

Isolated hypoglossal nerve palsy: a harbinger of malignancy.

The hypoglossal nerve is an underrated nerve usually consigned to a few words in anatomical text books, under the last four cranial nerves. However, paralysis of this nerve may be the first indication of a serious underlying disorder. Excluding previous surgery, radiotherapy and trauma, 50 per cent of cases of isolated hypoglossal nerve palsy are idiopathic. A further 20 per cent are malignant, 20 per cent are vascular and 10 per cent are due to miscellaneous causes. Presentation of an isolated hypoglossal nerve palsy is therefore an ominous sign. There is confusion over both cause and investigation, and management protocols for isolated hypoglossal nerve palsy are ill-defined. We present a case of isolated hypoglossal palsy which was due to a metastatic skull base deposit. This case illustrates the fact that magnetic resonance imaging is the investigation of choice in assessing the entire course of the hypoglossal nerve.