Andrew N. Goldberg

Sinus microbiome diversity depletion and Corynebacterium tuberculostearicum enrichment mediates rhinosinusitis.

Enrichment of Corynebacterium tuberculostearicum caused by depletion of the sinus microbiome contributes to chronic rhinosinusitis. Nosing in on Chronic Sinusitis If the frequency of ads for sinus-clearing drugs tells us anything, sinusitis is a widespread problem that directly affects an individual’s quality of life. Indeed, chronic rhinosinusitis (CRS), which is defined as sinusitis lasting longer than 12 weeks, affects more than 30 million Americans. CRS is characterized by persistent mucosal inflammation and microbial infection, which can be expected to perturb the mucosal microbiota; however, the contribution of sinus microbiota to CRS remains unclear. Now, Abreu et al. identify both a potential pathogenic species that is more prevalent in CRS patients than in healthy controls as well as a bacterial candidate that may protect against this pathogenic species. The authors performed comparative microbiome profiling of patients with CRS and healthy controls. They found reduced bacterial diversity in the CRS patients, with specific depletion of lactic acid bacteria and a relative increase in Corynebacterium tuberculostearicum. In a murine model, C. tuberculostearicum contributed to the development of sinusitis in the absence of a normal microbiota. Moreover, Lactobacillus sakei was sufficient to protect against C. tuberculostearicum–induced sinusitis, even when the microbiome was depleted. If these effects are consistent in humans, L. sakei may serve as a new therapeutic for CRS. Persistent mucosal inflammation and microbial infection are characteristics of chronic rhinosinusitis (CRS). Mucosal microbiota dysbiosis is found in other chronic inflammatory diseases; however, the relationship between sinus microbiota composition and CRS is unknown. Using comparative microbiome profiling of a cohort of CRS patients and healthy subjects, we demonstrate that the sinus microbiota of CRS patients exhibits significantly reduced bacterial diversity compared with that of healthy controls. In our cohort of CRS patients, multiple, phylogenetically distinct lactic acid bacteria were depleted concomitant with an increase in the relative abundance of a single species, Corynebacterium tuberculostearicum. We recapitulated the conditions observed in our human cohort in a murine model and confirmed the pathogenic potential of C. tuberculostearicum and the critical necessity for a replete mucosal microbiota to protect against this species. Moreover, Lactobacillus sakei, which was identified from our comparative microbiome analyses as a potentially protective species, defended against C. tuberculostearicum sinus infection, even in the context of a depleted sinus bacterial community. These studies demonstrate that sinus mucosal health is highly dependent on the composition of the resident microbiota as well as identify both a new sino-pathogen and a strong bacterial candidate for therapeutic intervention.

Safety and outcomes of balloon catheter sinusotomy: A multicenter 24-week analysis in 115 patients

OBJECTIVE: The aim of this study was to further evaluate the safety and effectiveness of balloon catheter devices to dilate obstructed sinus ostia/perform sinusotomy. METHODS: Through a prospective, multicenter evaluation, safety was assessed by rate of adverse events, patency was determined by endoscopic examination, and sinus symptoms were determined by the Sino-Nasal Outcome Test (SNOT 20). RESULTS: At the conclusion of the 24-week analysis, endoscopy determined that the sinusotomy was patent in 80.5% (247 of 307) sinuses and nonpatent in 1.6% (5 of 307), and could not determine ostial patency status in 17.9% (55 of 307). Of the ostia visualized on endoscopy, 98% were patent (247 of 252), while 2% (5 of 252) were considered nonpatent. SNOT 20 scores showed consistent symptomatic improvement over baseline. Revision treatment was required in 3 sinuses (3 of 307 sinuses, 0.98%) in 3 patients (3 of 109 patients, 2.75%). CONCLUSION: Balloon catheter technology appears safe and effective in relieving ostial obstruction. Patients were pleased and indicated that they experienced symptomatic improvement.

Test-retest reliability of drug-induced sleep endoscopy

Objective: To determine the test-retest reliability of drug-induced sleep endoscopy (DISE). Methods: Prospective cohort study. Patients with OSA underwent two separate DISE examinations. The following outcomes were measured: a global assessment of obstruction at the palate and/or hypopharynx; the degree of obstruction at the palate and hypopharynx; and the contribution of individual structures (palate, tonsils, tongue, epiglottis, and lateral pharyngeal walls) to obstruction. Results: Thirty-two patients underwent two separate DISE examinations. The preoperative sleep study apnea-hypopnea index was 40.7 ± 21.1, and the lowest oxygen saturation was 79.8 ± 17.4 percent. Point estimates for the intraclass correlation coefficient analogs related to palatal obstruction ranged from 0.41 to 0.89; related to the hypopharyngeal airway, the point estimates ranged from 0.57 to 0.84. Conclusion: The test-retest reliability of DISE appears good, especially in the evaluation of the hypopharyngeal airway. Larger studies can generate more precise confidence interval estimates and test the generalizability of these findings.

Interrater Reliability of Drug-Induced Sleep Endoscopy

OBJECTIVE To determine the interrater reliability of drug-induced sleep endoscopy (DISE). DESIGN Prospective cohort; blinded comparison. SETTING Academic referral center. PARTICIPANTS Subjects with obstructive sleep apnea unable to tolerate positive airway pressure therapy. INTERVENTIONS Drug-induced sleep endoscopy was performed with intravenous propofol infusion to achieve sedation, and the videoendoscopy recording was evaluated by 2 independent reviewers. MAIN OUTCOME MEASURES The following outcomes were measured: a global assessment of obstruction at the palate and/or hypopharynx; the degree of obstruction at the palate and hypopharynx; and the contribution of individual structures (palate, tonsils, tongue, epiglottis, and lateral pharyngeal walls) to obstruction. RESULTS A total of 108 subjects underwent DISE examination. Diagnostic sleep studies demonstrated a mean (SD) apnea-hypopnea index of 39.6 (24.0). Three-quarters of the subjects demonstrated multilevel airway obstruction at the palate and hypopharynx, with a diversity of individual structures contributing to obstruction. The interrater reliability for the presence of obstruction at the palate and hypopharynx (kappa values, 0.76 and 0.79, respectively) was higher than for the degree of obstruction (weighted kappa values, 0.60 and 0.44). The interrater reliability for the assessment of primary structures contributing to obstruction at the palate and hypopharynx (0.70 and 0.86) was higher than for the contributions of individual structures (kappa values, 0.42-0.71). The interrater reliability for evaluation of the hypopharyngeal structures was higher than for those of the palate region. CONCLUSION The interrater reliability of DISE is moderate to substantial. Trial Registration clinicaltrials.gov Identifier: NCT00695214.

Laryngeal preservation with supracricoid partial laryngectomy results in improved Quality of Life when compared with total laryngectomy

Objectives/Hypotheses Study 1: To assess the oncologic outcome following supracricoid partial laryngectomy (SCPL). Study 2: To compare the quality of life (QOL) following SCPL to total laryngectomy (TL) with tracheoesophageal puncture (TEP). Study 3: To analyze whole organ TL sections to determine the percentage of lesions amenable to SCPL.

Endoscopic Management of Sinonasal Inverted Papilloma

Since 1992, 42 patients at the University of Pennsylvania have been treated for inverted papilloma (IP). Thirty-three patients were managed endoscopically with or without a Caldwell Luc approach (CLA) and retrospectively analyzed. The CLA, which involves a gingivobuccal incision for access to the maxillary sinus, is distinguished from a formal Caldwell Luc procedure. These 33 patients with histologically confirmed IP were without evidence of malignancy. They also did not have evidence of intracranial, orbital, or frontal sinus IP. Seventeen of 33 patients (17/33) were without prior treatment (primary). Sixteen of 33 (16/33) presented from an outside institution with recurrent IP (secondary). The recurrence rate using this method to treat primary IP was 6% (1/17), and for secondary IP was 25% (4/16). Scheduled postoperative endoscopic surveillance permitted early detection of recurrence and continued endoscopic control of IP. All 33 patients were endoscopically free of disease at the end of the study. These preliminary data are encouraging for the use of intranasal endoscopy with and without CLA as a means of managing and controlling IP in selected cases.

UPPER AIRWAY ASSESSMENT: RADIOGRAPHIC AND OTHER IMAGING TECHNIQUES

Upper airway imaging is a powerful technique to study the mechanisms underlying the pathogenesis and biomechanics of sleep apnea and the mechanisms underlying the efficacy of therapeutic interventions in patients with sleep disordered breathing. The primary upper airway imaging modalities include nasopharyngoscopy, cephalometrics, CT scanning, and MR imaging. Imaging studies using these modalities have provided important insights into the static and dynamic structure and function of the upper airway and surrounding soft-tissue structures during wakefulness and sleep. Such imaging studies have highlighted the importance of the lateral pharyngeal walls in mediating upper airway caliber. These imaging modalities have also been used to study the effect of respiration, weight loss, mandibular repositioning devices, and upper airway surgery on the upper airway. Three-dimensional reconstruction of the airway and surrounding soft-tissue structures can be performed with MR imaging and CT scanning. Clinical indications for upper airway imaging are evolving such that imaging studies should be considered in patients with sleep apnea who are being treated with dental appliances or upper airway surgery.

Complications of frontal sinusitis and their management

Because of the anatomic location and venous drainage pattern of the frontal sinus, complications commonly involve intracranial structures but can involve the orbit and adjacent bony and soft tissue structures also. Evaluation of patients by a thorough history and physical examination, culture of purulent discharge or infected bone, and axial and coronal CT scanning with contrast is important for diagnosis and treatment planning. Treatment of complications uniformly involves the use of intravenous antibiotics and appropriate drainage procedures to arrest the infection and allow for resolution of the inflammatory complication. Significant morbidity and mortality from complications can occur despite aggressive medical and surgical treatment.

Balloon catheter sinusotomy: one-year follow-up--outcomes and role in functional endoscopic sinus surgery.

Objective The primary objective was to assess the long-term effectiveness of balloon catheter sinusotomy. Methods Patients who had sinus ostia dilated with balloon catheters were prospectively evaluated 1 year after surgery with nasal endoscopy, a CT scan, and the Sino-Nasal Outcome Test (SNOT-20). Results Sixty-six patients (202 sinuses) were examined. One hundred seventy-two of 202 sinus ostia (85%) were endoscopically patent, 1 percent (2/202) were nonpatent, and ostial patency could not be determined by endoscopy in 28 of 202 (14%). In these “indeterminate” sinuses, the CT scans were normal in 13, implying functional patency in 91.6 percent of sinuses (185/202). Sinus CT scan scores were 1.95 at 1 year versus 8.89 at baseline (P < 0.001), and 1-year SNOT-20 scores (0.91) were significantly improved from baseline (2.14, P < 0.0001). Conclusion Balloon catheter sinusotomy results were durable over the study period, showing long-term effectiveness.

Preoperative imaging to predict orbital invasion by tumor.

Our purpose was to examine the accuracy of preoperative imaging in assessing tumor invasion of the orbit and nasolacrimal system.