Andrew James Wood

Coronoidectomy for the Treatment of Trismus in Head and Neck Cancer Patients

Objectives: Trismus is a common adverse effect of tumor extension or treatment for those with head and neck malignancy. Physical therapy is the mainstay of treatment, but many patients still fail to maintain adequate mouth opening. Coronoidectomy is a treatment option for those with trismus, and the purpose of this study was to evaluate the effectiveness of coronoidectomy in treating trismus refractory to physical therapy.

Pathogenesis and treatment of chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is one of the most common diseases in western societies, causing significant morbidity and resulting in great financial cost. Some patients suffer persistent or recurrent symptoms despite receiving optimal medical and surgical treatment. The recent publication of revised diagnostic criteria and management guidelines will assist both clinical research and practice. Multiple theories have been advanced regarding the underlying pathogenesis including allergy, bacterial or fungal infection, genetic predisposition and structural anomalies, but at present the majority of cases are still considered idiopathic. Recent studies have shown that traditional laboratory culture techniques may fail to detect microorganisms growing within biofilms or within host mucosal cells. Both bacteria and fungi possess a number of mechanisms for both the evasion and modulation of host immune responses, including the formation of biofilms and the production of superantigens. Historically, treatments such as antibiotics that had been directed at putative causative agents have often been disappointing. There are, however, a broad range of medical and surgical therapies with proven efficacy available to the treating physician. Endoscopic surgical management is evolving rapidly, and there have been pronounced improvements in outcome and reduction in the risk of complications. Recent advances in the understanding of the pathogenesis of this condition have led to some promising therapeutic developments, particularly in respect to topical treatments. Despite improvements in therapy, CRS remains a challenging condition to manage.

Intramucosal bacterial microcolonies exist in chronic rhinosinusitis without inducing a local immune response.

Background Although chronic rhinosinusitis (CRS) causes very significant morbidity, much about its pathogenesis remains uncertain. Recent studies have identified polymicrobial biofilms on the surface of sinus mucosa and Staphylococcus aureus within the sinus mucosa of patients with CRS, both with and without nasal polyps. The pathogenic implications of intramucosal bacteria in CRS are unknown. This study was designed to determine the prevalence and species of bacterial colonies within the sinus mucosa of adult patients with and without CRS and to describe the relationship of these bacterial colonies to the host immune response. Methods Sinus mucosa from patients with and without CRS was examined using Gram and Giemsa staining, immunohistochemistry, bacterial culture, and fluorescence in situ hybridization techniques. Results Bacterial microcolonies were observed within the mucosa in 14 of 18 patients with CRS. In 10 of these patients colonies were positively identified as S. aureus. Staphylococcal microcolonies were observed at a lower level (1 of 8 patients) in normal sinus mucosa. There was no correlation between detection of S. aureus on the mucosal surface and microcolonization of the mucosa. Surprisingly, there was no evidence of an immune reaction to microcolonies. Indeed, fewer T lymphocytes (p = 0.03) and eosinophils (p = 0.03) were counted immediately surrounding the microcolonies compared with uninfected areas of the same tissue. Conclusion Bacterial microcolonies are prevalent within paranasal sinus mucosa and are commonly S. aureus. These microcolonies do not provoke immune detection and may represent a phenotype that actively evades host immunity. This may underpin the rcalcitrance of CRS to antibiotic therapy. These findings challenge classic views of both infection and mucosal immunity in human chronic disease. The presence of intramucosal bacteria in samples of normal sinus mucosa also questions the sensitivity of detecting nasal carriage of pathogens by swabbing the surface of the anterior nares.

Is chronic rhinosinusitis caused by persistent respiratory virus infection

Many chronic rhinosinusitis (CRS) patients recall an upper respiratory tract infection as the inciting event of their chronic illness. Viral infections have been shown to cause obstruction of the osteomeatal complex, which is likely to be a critical step in the development of CRS. There is clear overlap between the pathogenesis of CRS and asthma. Infections with respiratory viruses in childhood increase the risk of subsequently developing asthma. Viral infections in established asthmatics are associated with acute exacerbations. We sought to determine whether respiratory viruses could be detected within the sinonasal mucosa of CRS patients using polymerase chain reaction (PCR) techniques.

Are biofilms associated with an inflammatory response in chronic rhinosinusitis

Bacterial biofilms have been identified on the sinonasal mucosa of patients with chronic rhinosinusitis (CRS) but also on control samples. Their role in the disease pathogenesis is unproven. The objective of this study was to further evaluate the role of biofilms in CRS by assessing whether they are associated with an inflammatory response.

The interaction between bacteria and mucosal immunity in chronic rhinosinusitis: a prospective cross-sectional analysis.

BACKGROUND We have detected intramucosal bacteria within the sinus mucosa of patients with chronic rhinosinusitis (CRS), but our attempts at characterizing these did not yield any discernible genotypic or phenotypic differences from surface bacteria. We hypothesized that the presence of intramucosal microcolonies reflected host mucosal immune dysfunction. This study characterizes the activation status of T cells, B cells, and macrophages in the sinus mucosa of patients with CRS and controls and determines the impact of bacteria on mucosal immunology. METHODS Swabs and mucosal biopsy specimens were taken from 27 patients with CRS undergoing sinus surgery and 9 patients with normal sinuses having transnasal pituitary surgery. Microcolonies were detected using Gram staining, and the immune cells were characterized by immunohistochemical techniques. RESULTS Swab culture rates for Staphylococcus aureus were similar between CRS and controls. However, there were significantly more intramucosal microcolonies in CRS (59% versus 11%) than in controls (p = 0.02). There were significantly more immune cells in CRS. Percentage of activated T and B cells were similar between CRS and controls, but there were significantly more CD163(+) M2 macrophages in patients with CRS (p = 0.0004). Furthermore, percentage of CD163(+) macrophages showed a positive correlation with disease severity. The presence of bacteria had no impact on immunology or disease severity. CONCLUSION Tolerance of intramucosal microcolonies in CRS may reflect altered macrophage function in the host mucosa. The clinical severity of CRS is also dependent on the host mucosa immune dysfunction, rather than the presence of intramucosal microcolonies.Background We have detected intramucosal bacteria within the sinus mucosa of patients with chronic rhinosinusitis (CRS), but our attempts at characterizing these did not yield any discernible genotypic or phenotypic differences from surface bacteria. We hypothesized that the presence of intramucosal microcolonies reflected host mucosal immune dysfunction. This study characterizes the activation status of T cells, B cells, and macrophages in the sinus mucosa of patients with CRS and controls and determines the impact of bacteria on mucosal immunology. Methods Swabs and mucosal biopsy specimens were taken from 27 patients with CRS undergoing sinus surgery and 9 patients with normal sinuses having transnasal pituitary surgery. Microcolonies were detected using Gram staining, and the immune cells were characterized by immunohistochemical techniques. Results Swab culture rates for Staphylococcus aureus were similar between CRS and controls. However, there were significantly more intramucosal microcolonies in CRS (59% versus 11%) than in controls (p = 0.02). There were significantly more immune cells in CRS. Percentage of activated T and B cells were similar between CRS and controls, but there were significantly more CD163+ M2 macrophages in patients with CRS (p = 0.0004). Furthermore, percentage of CD163+ macrophages showed a positive correlation with disease severity. The presence of bacteria had no impact on immunology or disease severity. Conclusion Tolerance of intramucosal microcolonies in CRS may reflect altered macrophage function in the host mucosa. The clinical severity of CRS is also dependent on the host mucosa immune dysfunction, rather than the presence of intramucosal microcolonies.

Bacterial microcolonies exist within the sphenoid bone in chronic rhinosinusitis and healthy controls.

Some patients with chronic rhinosinusitis (CRS) exhibit thickening of the sinus bones that has been termed osteitis. The histopathology and microbiology of these changes have not been fully described. The aim of this study was to look for the presence of bacteria and immune cells within samples of bone from patients with and without CRS and correlate these findings to radiological findings.

Chronic rhinosinusitis and cystic fibrosis: the interaction between sinus bacteria and mucosal immunity

Chronic rhinosinusitis (CRS) is highly prevalent in cystic fibrosis (CF) patients, in whom a close correlation exists between the microbiology of the upper and lower respiratory tracts. We have reported intramucosal bacterial microcolonies in the sinus mucosa from idiopathic CRS patients and have made observations suggesting that these may result from mucosal immunotolerance secondary to altered macrophage function. In this study, we sought to determine whether intramucosal microcolonies exist in the mucosa of CF patients with CRS, and to investigate the associated mucosal immunology.

Staphylococcus aureus. Letters to the editor.

To the Editor: RE: Kim ST, Chung SW, Jung JH et al. Association of T cells and eosinophils with Staphylococcus aureus exotoxin A and toxic shock syndrome toxin 1 in nasal polyps. Am J Rhinol Allergy 25:19–24, 2011. We share with others an interest in the production of virulence factors by Staphylococcus aureus in chronic rhinosinusitis.1 We therefore read with interest the article by Kim et al. published in this journal.2 The study reported the detection using immunohistochemistry (IHC) of Staphylococcus enterotoxin A and toxic shock syndrome toxin 1 in frozen sections of mucosa from a proportion of nasal polyposis patients. The published image of positive staining showed a diffuse homogeneous staining across the tissue section with relative sparing of the epithelial layer. Negative control sections in which

Effectiveness of extensive sinus surgery with post-operative medical management for chronic rhinosinusitis

OBJECTIVE To prospectively assess treatment outcomes of chronic rhinosinusitis patients undergoing functional endoscopic sinus surgery and post-operative medical treatment over a prolonged follow-up period. METHODS Patients undergoing functional endoscopic sinus surgery in the tertiary referral practice of a single surgeon were studied prospectively. Symptoms were scored by patients pre-operatively and over a minimum follow-up period of 12 months. RESULTS The study comprised 200 non-consecutive patients. The median pre-operative symptom score was 16 (out of a maximum of 25) (95 per cent confidence interval = 15 to 17). Symptom scores reduced to a median of 7 (95 per cent confidence interval = 6 to 8) after 12 months of follow up (p < 0.0001). The median symptom score improved for all symptoms and across all patient subgroups. CONCLUSION Extensive functional endoscopic sinus surgery offers significant and durable symptom improvement in patients with chronic rhinosinusitis refractory to medical treatment. This improvement extends to all patient subgroups. Prolonged medical therapy is recommended after functional endoscopic sinus surgery.