Alan H. Shikani

Mucosal expression of aquaporin 5 and epithelial barrier proteins in chronic rhinosinusitis with and without nasal polyps

OBJECTIVESnThe purpose of this study is to characterize the association between altered epithelial barrier function, represented by changes in histology and differential expression of the mucosal water membrane permeability protein aquaporin 5 (AQP5), and the pathophysiology of chronic refractory sinusitis (CRS) in patients with and without nasal polyposis.nnnSTUDY DESIGNnProspective clinical study.nnnSETTINGnTertiary rhinology referral center.nnnPARTICIPANTSnSinonasal samples were obtained from seven CRS subjects with nasal polyps (CRSwNP), seven CRS without nasal polyposis (CRSsNP), and five control healthy patients.nnnMETHODSnMucosal membrane changes were evaluated through hematoxylin and eosin staining of the membrane barrier and immunohistochemical staining of AQP5 expression, a membrane channel protein that affects trans-epithelial water permeability and tissue edema. AQP5 expression was confirmed by real-time PCR (rt-PCR) and western blot. Levels of other membrane proteins, including E-cadherin and Septin-2, were also assessed.nnnRESULTSnCRSwNP patients showed substantial histologic evidence of membrane remodeling with increased edema and glandular hyperplasia. The epithelial expression of AQP5 was significantly lower in CRSwNP as compared to CRSsNP or control. There was no significant difference in the expression of E-cadherin and Septin-2.nnnCONCLUSIONSnCollectively, these data suggest that the mucosal epithelial barrier is compromised in the context of CRS (predominantly in CRSwNP) when compared to control and that AQP5 acts as a key tight junction protein in the maintenance of mucosal water homeostasis. We hypothesize that AQP5 plays a possible role in the pathophysiology of mucosal edema and polyp formation.

Endoscopically guided chitosan nasal packing for intractable epistaxis.

Background The purpose of this study was to evaluate the effectiveness and safety of endoscopically guided chitosan packing in controlling intractable epistaxis. A prospective case series was performed. Methods This is a prospective clinical study conducted in a tertiary rhinology fellowship training hospital between January 2009 and November 2009. The study population consisted of patients with intractable epistaxis that failed to respond to traditional anterior–posterior nasal packing using either a 10-cm Pope PVA Merocel or a Rapid-Rhino. The bleeding site was identified using a nasal endoscope and controlled using a pack made of a ChitoFlex chitosan dressing wrapped around a polyvinyl acetal nasal sponge. Results The intent-to-treat population consisted of 20 severe epistaxis subjects (8 men and 12 women) who continued to bleed despite traditional anterior–posterior nasal packing. The mean age was 67 years (±19 years). Sixteen subjects were on antiplatelets and/or anticoagulants. Eleven subjects (55%) presented with anterior epistaxis, and 7 subjects (35%) presented with posterior epistaxis. Chitosan nasal packing was performed on an outpatient basis and resulted in effective and immediate hemostasis in 19/20 subjects (95%). One subject had persistent bleeding after the first packing attempt and was successfully repacked within 30 minutes. Time to complete cessation of bleeding was 3.6 ± 2.2 minutes in the 19 subjects; the pack was removed after 48 hours, without any evidence of rebleeding or any serious side effects. Conclusion Endoscopically guided chitosan packing is a safe, effective, and well-tolerated outpatient treatment for the management of intractable epistaxis.

Office-Based Balloon Sinus Dilation: 1-Year Follow-up of a Prospective, Multicenter Study.

Objective: Balloon sinus dilation (BSD) instruments afford the opportunity for office-based sinus procedures in properly selected patients with chronic rhinosinusitis (CRS). This study evaluated patient-reported outcomes 1 year after office-based BSD. Methods: Adult patients with medically refractory CRS were prospectively enrolled into a multicenter, single-arm study and treated with office-based BSD under local anesthesia. Follow-up on 203 patients was conducted at 2, 8, and 24 weeks postsurgery using validated outcome measures for quality of life (SNOT-20) and computed tomography imaging (Lund-Mackay score). After 24 weeks, patients were re-enrolled for 1-year follow-up to evaluate changes in SNOT-20 scores and revisions. Results: All patients who re-enrolled (n = 122) completed the study, with an average follow-up of 1.4 years. Neither preoperative SNOT-20 nor Lund-Mackay CT scores were predictive of re-enrollment and return for follow-up. Compared to baseline, improvements in SNOT-20 scores remained statistically significant (P < .001) and clinically meaningful (mean decrease ≥ 0.8). In patients followed to 1.4 years, 9 of 122 (7.4%) had revision surgery. Conclusion: Following office-based BSD, significant improvements in quality of life observed at 24 weeks were maintained 1 year postsurgery. These extended results provide further evidence of office-based BSD as an effective, minimally invasive procedure for appropriately selected patients with CRS.

Topical gel therapy for sinonasal polyposis in Samter's triad: preliminary report.

Objectives: Rhinosinusitis and polyposis are difficult to treat in patients with Samters triad; they commonly recur despite sinus surgery, antibiotics, and/or nasal steroids. The present study assesses the efficacy of a multimodal regimen that includes topical corticosteroids and antibiotics delivered through a hydroxyethyl cellulose gel and by nebulization. Methods: Eleven patients with Samters triad who had polyposis and rhinosinusitis that recurred despite endoscopic sinus surgery were treated with a 6-week course of multimodal topical therapy consisting of a hydroxyethyl cellulose gel that releases corticosteroids and antibiotics, topical nebulization of corticosteroids and antibiotics, saline solution rinses, and sinus debridement. Clinical outcomes were evaluated by Lund-Kennedy endoscopic and symptom scores. Histologic assessment was evaluated by hematoxylin and eosin staining before and after treatment. Results: Both Lund-Kennedy symptom and endoscopic scores showed a progressive and statistically significant decline throughout the course of treatment, reaching at 6 weeks 42% of the pretreatment values (p = 0.005) for the Lund-Kennedy symptom score and 34% (p = 0.002) for the endoscopic score, respectively; however, the significance of the improvement was lost with time. Conclusions: Topical gel therapy improves clinical symptoms, endoscopic findings, and sinus membrane histologic features in patients with refractory Samters triad, but the improvement is transient, suggesting that a longer therapeutic period might be needed.

Neurenteric cyst of the Clivus

Neurenteric cysts are rare benign endodermal lesions of the central nervous system, mostly located in the spine; they are rarely reported in the clivus. We present herein a case of neurenteric cyst of the clivus, and discuss its embryology, pathology, differential diagnosis, and management. This case received the approval of the IRB for publication. A 79-year-old man presented to our emergency department with recent nausea and vomiting, along with a fourweek history of worsening headaches. His physical examination was normal. A CT scan of the head revealed a 2.2 1.7-cm expansile lesion thinning the anterior wall of the clivus, adjacent to the internal carotid artery (Fig 1). An MRI showed a well-defined osteolytic cystic lesion of the clivus, with intermediate-to-low signal on T1 and high signal intensity on T2 (Fig 2). The patient underwent an endoscopic transsphenoidal approach to the clivus using navigation. After the removal of the anterior wall and the floor of the sphenoid sinus, the cyst was noted to be eroding the anterior bone of the clivus and extending into the sphenoid sinus. The cyst was successfully unroofed and marsupialized into the sphenoid cavity and the nasopharynx. Moderate bleeding was easily controlled with Avitene and Gelfoam. Pathology revealed a fibrovascular cyst lined by cuboidal and columnar cells with acute and chronic inflammation, consistent with an inflamed cyst. The patient has been free of headaches for more than two years and without any endoscopic or radiologic evidence of recurrence.

New Unidirectional Airflow Ball Tracheostomy Speaking Valve

obstruction of airflow through the larynx and upper trachea. One of its main side effects is loss of essential functions, including warming and filtering of air, coughing, smelling, tasting, swallowing, and more devastatingly speaking. Voice production requires vibration of the vocal cords by a stream of air that passes through the larynx during exhalation. When a tracheotomy is present, exhaled air follows the path of least resistance and goes through the tube, reducing the vibratory movement of the vocal cords and hence limiting perceptual speech. This creates a psychological hardship because communication is critical to patients’ overall medical care and social interactions.1,2 This problem can be particularly disruptive in children because, as has been demonstrated previously,3,4 tracheotomy can affect the development of normal language skills. To redirect the air through the vocal cords, the patient may use a finger to occlude the tracheostomy tube. However, finger occlusion has several limitations: it requires manual dexterity that many patients lack, it requires coordination of phonation with breathing, and it is unsanitary. The use of a tracheostomy speaking valve enables tracheostomy patients to speak without having to occlude the tracheostomy tube with the finger. A variety of speaking valves have been described in the literature and are on the market. These include the Passy-Muir valve (Passy-Muir Inc), Shiley Phonate valve (Mallinckrodt Medical), Montgomery speaking valve (Boston Medical Products), and Kistner speaking valve (Pilling-Rusch Corp), which are all flapper valves, and the Olympic speaking valve (Olympic Medical Corp), which is a disk valve. Passy-Muir is a bias-closed valve (ie, closed at all times except on inspiration), and the rest are bias-open valves (ie, open at all times except on expiration). Fornataro-Clerici and Zajac5 investigated the resistance of 4 different valves (Kistner, Montgomery, Olympic, and Passy-Muir) and found that the Kistner valve had significantly higher resistance to airflow than the other 3 valves. Moreover, significantly higher pressures were required to open the Passy-Muir valve than to open the Olympic and Montgomery valves. The authors hypothesized that the resistance inherent to the valves may have an effect on patients’ tolerance of the valves, thereby affecting both patient and valve selection. We present a different type of speaking valve, which is a unidirectional flow ball valve. Because of the flexibility in the design of its coupling mechanism to a given cannula set, it has a lower resistance and is more easily hidden under clothing than either flapper or disk valves.

Topical Membrane Therapy for Chronic Rhinosinusitis

Chronic Rhinosinusitis (CRS) constitutes a longstanding disease process and a significant health hazard. Its pathophysiology may entail inherent epithelial irregularities, infectious insults, antigenic fermentations, and anatomic abnormalities, acting separately or in cooperation. Hence, various state-of-the-art treatment modalities have evolved, focusing on the surgical restoration of sinus homeostasis: endoscopic approach and visualization, fine surgical tools, power-instrumentation, precise imaging, combination of intranasal and external accesses, and navigation techniques. Despite the impressive technological advances in operative interventions, the medical aspects of CRS have not been investigated to the same extent, and the relevant remedies have changed very little over the years. Topical therapy in CRS is a relatively novel methodology, which relies on the local pharmacological management of sinus inflammatory status, and aims to supplement the existing treatment options. Topically applied medications have been used successfully for decades in dermatology, ophthalmology and urology. This chapter reviews the philosophy of topical therapy for CRS, its applications and effectiveness, as well as our institution’s experience and findings regarding a complete local treatment protocol utilized for the management of refractory CRS.

Rhinotopic Therapy forRefractory Rhinosinusitis:Clinical Effectiveness andImpact on the EpithelialMembrane and MucosalBiofilms

Objective: To evaluate the clinical effectiveness of rhinotopic therapy, and its impact on the mucosal membrane and mucosal biofilms of patients with refractory chronic rhinosinusitis (CRS). nStudy design: Prospective pilot clinical study. nSetting: Tertiary rhinology referral center. nSubjects and methods: Twenty-three patients with refractory CRS were treated with the rhinotopic protocol, a multimodality therapy consisting of topical sinus application of antibiotics and corticosteroids through gel and nebulization, endoscopic sinus debridement and saline irrigation. Clinical outcome was assessed using Lund-Kennedy (LK) symptom and endoscopic appearance scores. Mucosal epithelial barrier changes were evaluated through H & E stain. The impact on biofilms was assessed through colony forming units (CFUs) counts. nResults: Following treatment, there was a significant improvement in the patients’ LK symptom and endoscopic appearance scores, in the mucosal epithelial barrier and in the biofilms CFUs count. The clinical improvement was sustained at least 6 months following completion of therapy. nConclusion: Refractory CRS is a difficult to treat entity that does not respond to traditional medical therapy, including repeated oral antibiotics, commercial nasal steroids, nasal saline rinses and sinus debridement. This work shows that rhinotopic therapy is effective in improving clinical symptoms, healing mucosal damage and disrupting biofilm load in refractory CRS patients. Further work is needed to investigate if single aspects or a collective implementation of the different components of this therapy are responsible for improvement.

Experimental Assessment and Future Applications of the Shikani Tracheostomy Speaking Valve

PURPOSEnTracheostomy speaking valve use may increase airflow resistance and work of breathing. It remains unclear which valve offers the best performance characteristics. We compared the performance characteristics of the Shikani speaking valve (SSV; unidirectional-flow ball valve) with those of the Passy-Muir valve (PMV; bias-closed flapper valve).nnnMETHODnAirflow resistance was measured for both the SSV and the PMV at 8 flow amplitudes and in 3 orientations (-15°, 0°, +20°) in the bias-open and bias-closed configurations.nnnRESULTSnSignificantly lower airflow resistance was observed for the SSV (bias open) compared with the PMV at -15° (p < .001), 0° (p < .001), and +20° (p = .006) from the horizon. No significant difference was observed between the PMV and the SSV (bias-closed) configuration at any of the tested angles. A nonsignificant trend toward decreased airflow resistance was observed between the SSV bias-open and bias-closed configurations at each of the angles tested.nnnCONCLUSIONSnThe SSV demonstrated lower airflow resistance compared with the PMV across 8 flow amplitudes in the bias-open configuration at -15°, 0°, and +20° from the horizon. Further investigation is needed to determine the clinical impact of these findings on patient comfort, work of breathing, phonation, and airway protection during swallowing.

Metastatic hepatoma of maxillary sinus with atypical presentation.

Hepatocellular carcinoma (HCC) is the most frequent form of primary liver tumours, which are the third commonest cause of cancer deaths worldwide. Metastasis is a critical prognostic factor and intrahepatic spread occurs much more often than extrahepatic dissemination. The latter targets mainly the lungs, bones and adrenal glands. Metastasis of HCC to the sinonasal region is exceedingly rare, and only 18 cases have been reported so far. Here we report a case of metastatic hepatoma to the maxillary sinus with unilateral otalgia/hearing loss as unusual presenting symptoms. Our patient, a 57-year-old man, presented with a several week history of left-sided ear fullness, hearing loss and nasal congestion. Upon otoscopy, middle ear effusion was noted, and flexible endoscopy revealed a friable necrotic lesion of the left nasal cavity and nasopharynx. The mass extended from the middle meatus, posteriorly to the lateral nasopharyngeal wall and fossa of Rosenmüller. At that time, no cranial nerve deficits were noticed. A subsequent computed tomography (CT) scan showed complete opacification of the left maxillary sinus by a mass with aggressive radiographic features (Fig. 1). Biopsy of the lesion was positive for moderately differentiated HCC (Fig. 2). The patient had no history of abdominal/ gastrointestinal symptoms. Abdominal and pelvic CT scan demonstrated an ill-defined hepatic mass (Fig. 3), along with lytic lesions of the T11 vertebra, and the left iliac wing. The remaining metastatic work-up was negative. Manifestations from the maxillary metastasis progressed rapidly to dysphagia, facial swelling, cranial nerve deficits, as well as orbital invasion, and the patient was referred urgently for local radiotherapy to the sinonasal region, followed by chemotherapy. The facial tumour responded by significant regression to the local therapy, but unfortunately the patient expired 11 months after diagnosis due to liver failure. Tumour metastasis to the paranasal sinuses is a rare phenomenon, and the primary neoplasms in order of frequency are of renal, lung and breast origin. Hepatoma has been identified as the source of the sinonasal tumour only in 19 cases, including the present report. Interestingly, all patients are men. Similar to the case described here, the metastatic focus is localized in the maxillary sinus in the majority of reports (7/19, 36.8%), followed by the nasal cavity (6/19, 31.6%). Between these two adjacent subsites, the precise localization of the initial lesion can be challenging, if the carcinoma is advanced on diagnosis. Specifically for the tumours arising inside the maxillary sinus, three-dimensional expansion may affect several nearby craniofacial structures. As Table 1 shows, among all metastatic HCCs to the antrum, the present case demonstrates the greatest extent of spread on presentation, invading the nasopharynx and infratemporal fossa. The magnitude of the tumour is reflected on the initial manifesta tions. Notably, our patient presented with otalgia and hearing loss as the chief complaints, due to nasopharyngeal obliteration by the neoplasm. Comparatively, it seems that in terms of local infiltration, the metastatic HCC reported here shows particularly destructive properties, which are not even demonstrated by the patient’s primary hepatic tumour. It is well accepted that cells from hepatoma metastases are less differentiated and more capable of invasion and angiogenesis than their primary tumour progenitors. On their way to the paranasal metastatic site, through lymphogenous or hematogenous routes, cancer cells are likely to leave intermediate traces. Lymphogenous dissemination might have occurred via the hepatic lymphatics, followed by the thoracic duct, but in that case, metastatic deposits along this route, for example, in hepatic, celiac and para-aortic lymph nodes, would probably have been evident. Blood-borne metastases usually result from seeding of the pulmonary venous circulation, and genesis of metastatic emboli into the arterial tree. Yet, no lung metastases were noted in the present case. A less standard hematogenous track involves reflux of Fig. 1. Axial computed tomography scan of the sinuses, displaying a large left intramaxillary tumour that has eroded the sinus walls and infiltrated posteriorly the nasopharynx and the infratemporal fossa. Pterygoid plates have been entirely destroyed. Note the effusion inside the mastoid air cells, which was among the earliest manifestations of the disease. IMAGES FOR SURGEONS