Bradford A. Woodworth

Baby shampoo nasal irrigations for the symptomatic post-functional endoscopic sinus surgery patient.

Background Symptoms of postnasal drainage and thickened mucus are commonly seen in patients with chronic rhinosinusitis (CRS) recalcitrant to sinus surgery and conventional medical therapies. Chemical surfactants can act as a mucolytic by reducing water surface tension and have the potential to serve as an antimicrobial agent. Baby shampoo is an inexpensive, commercially available solution containing multiple chemical surfactants. This is an in vitro study of its antimicrobial effects on Pseudomonas biofilms with translation to a clinical study for use as an adjuvant nasal wash in patients with CRS who remain symptomatic despite adequate sinus surgery and conventional medical therapies. Methods In vitro testing was performed to determine the optimal concentration of baby shampoo that disrupted preformed bacterial biofilms and inhibited biofilm formation. This concentration was then used in a prospective study of symptomatic post–functional endoscopic sinus surgery (FESS) patients who irrigated twice a day for 4 weeks. Validated outcome forms and objective smell testing was performed before and after therapy. Results One percent baby shampoo in normal saline was the optimal concentration for inhibition of Pseudomonas biofilm formation. Baby shampoo had no effect on the eradication of preformed Pseudomonas biofilms. Eighteen patients with CRS with an average of 2.8 surgeries were studied after irrigating with 1% baby shampoo solution. Two patients discontinued use because of minor nasal and skin irritations; 46.6% of patients experienced an overall improvement in their subjective symptoms, and 60% of patients noted improvement in specific symptoms of thickened mucus and postnasal drainage. Conclusion Baby shampoo nasal irrigation has promise as an inexpensive, tolerable adjuvant to conventional medical therapies for symptomatic patients after FESS. Its greatest benefit may be in improving symptoms of thickened nasal discharge and postnasal drainage.

Endoscopic closure of CSF rhinorrhea: 193 cases over 21 years.

Objective: Endoscopic repair of cerebrospinal fluid (CSF) leaks has become a routine approach. This study describes endoscopic closure of a large series over 21 years, focusing on management, surgical technique, and long-term outcomes. Study Design: Chart review. Subjects and Methods: CSF leak patients treated by the senior author and at the University of Pennsylvania from 1987 to 2008. The data included body mass index (BMI), etiology, defect location, graft material, presence of encephalocele, lumbar drain, history of meningitis, intracranial pressure, recurrence, and follow-up. Results: A total of 193 cases were identified. Follow-up ranging from 1 month to 9 years (mean 21 months) was available on 166 patients. The etiology was spontaneous in 77 patients (40%), traumatic in 109 (56%), and congenital in 7 (4%). The average BMI of spontaneous CSF leak patients (35) was greater (P < 0.001) than both traumatic (30) and congenital patients (23). Defects were most commonly located in the sphenoid (n = 62, 32%) and ethmoid (n = 60, 31%) The initial success rate was 91 percent (n = 176) and overall success rate was 98 percent (n = 190). Conclusion: The overall success rate (98%) and low morbidity in this large series support endoscopic approach as standard of care for CSF leak closure.

Spontaneous CSF leaks : A paradigm for definitive repair and management of intracranial hypertension

Objective To report our outcomes with the repair of spontaneous cerebrospinal fluid (CSF) leaks and to demonstrate how management of underlying intracranial hypertension improves outcomes. Study Design Retrospective review of spontaneous CSF leaks treated at the University of Pennsylvania Health System from 1996 to 2006. Data collected included demographics, nature of presentation, body mass index (BMI), site of skull base defect, surgical approach, intracranial pressure, and clinical follow-up. Results Fifty-six patients underwent repair of spontaneous CSF leaks. Eighty-two percent (46 of 56) were obese (average BMI 36.2 kg/m2). Nine patients had multiple CSF leaks. Fifty-four patients (96%) had associated encephaloceles. Fifty-three CSF leaks (95%) were successfully repaired at first attempt (34 months of follow-up). Intracranial pressures averaged 27 cm H2O. Patients were treated with acetazolamide or, in severe cases, with a ventriculoperitoneal shunt. Conclusions Spontaneous CSF leaks have the highest recurrence rate of any etiology. With treatment of underlying intracranial hypertension coupled with endoscopic repair, the success rate (95%) approaches that of other etiologies of CSF leaks.

The canalith repositioning procedure for benign positional vertigo: A meta-analysis

Objective: To review the effectiveness of the canalith repositioning procedure (CRP) in the treatment of benign paroxysmal positional vertigo (BPPV) with a critical review of the literature and meta‐analysis.

Clinical outcomes of endoscopic and endoscopic-assisted resection of inverted papillomas : A 15-year experience

Background The endoscopic resection of sinonasal inverted papillomas (IPs) has been well described. However, the majority of published reports in the literature are small case series with limited clinical follow-up. The aim of this retrospective study was to review the experience with the endoscopic and endoscopic-assisted resection of IPs at a major academic tertiary care facility and assess long-term outcomes. Methods A retrospective review of endoscopic and endoscopic-assisted resections of IP was performed. Charts were reviewed for standard demographic data, operative technique, adjuvant approaches, complications, and postoperative follow-up times. Results One hundred fourteen patients (average age, 56 years) underwent endoscopic or endoscopic-assisted resection for IPs with a mean disease-free follow-up of 40 months (7–135 months). Seventeen patients developed disease after endoscopic or endoscopic-assisted resection for a recurrence rate of 15%. Average time to recurrence was 23 months. Combined approaches were used when indicated in 34% (39/114) of patients, including adjuvant osteoplastic flap, midface degloving, trephine, or Caldwell-Luc approaches. Four patients (4%) had cerebrospinal fluid leaks that were successfully repaired endoscopically. Conclusion In this large series of endoscopically resected IPs with extensive clinical follow-up, recurrences occurred an average of 23 months after the procedure. This emphasizes the importance of long-term endoscopic follow-up to detect recurrences in all patients. Endoscopic or endoscopic-assisted resection of IPs is a valid technique in this series with recurrence rates comparable with open approaches.

The delta F508 mutation in cystic fibrosis and impact on sinus development.

Background Cystic fibrosis (CF) patients often have widespread inflammatory paranasal sinus disease with an increased incidence of frontal, maxillary, and sphenoid hypoplasia. The most common genetic defect in CF is the delta F508 mutation. The effect of specific CF genotypes on phenotypic sinus development and infections is not well understood. The purpose of this study was to determine whether the homozygous delta F508 mutation is associated with an increased incidence of sinus hypoplasia when compared with other mutations. Methods This study is a retrospective review of all adult patients seen at our CF center from 1996 to 2005. Patients ≥18 years old with a CF diagnosis using genetic and sweat chloride testing and sinus CT scans were included. Frontal sinus aplasia/hypoplasia and maxillary and sphenoid sinus hypoplasia were documented using published criteria. Data collected included patient demographics, genetic mutations, and prior sinus surgeries. Results Forty-five patients were identified with an average age of 32 years (range, 18–48 years). Thirty-one patients had prior sinus surgeries. Delta F508 homozygotes (n = 25) had a significantly increased frequency of underdeveloped frontal (98%), maxillary (70%), and sphenoid (100%) sinuses (p < 0.001) when compared with other mutations (69, 8, and 50%, respectively). Conclusion CF patients homozygous for the delta F508 mutation have a greater incidence of hypoplastic or underdeveloped sinuses. Whether this is secondary to an increased frequency of sinus infections or a phenotypic expression of the genetic mutation itself remains an area for further investigation.

Endoscopic repair of frontal sinus cerebrospinal fluid leaks

OBJECTIVEnTo describe endoscopic management of frontal sinus cerebrospinal fluid (CSF) leaks.nnnSTUDY DESIGNnRetrospective.nnnMETHODSnWe reviewed all frontal sinus CSF leaks treated using an endoscopic approach at our institutions from 1998 to 2003. CSF leaks originated immediately adjacent to or within the frontal recess or frontal sinus proper for inclusion in the study. Data collected included demographics, presenting signs and symptoms, site and size of skull-base defect, surgical approach, repair technique, and clinical follow up.nnnRESULTSnSeven frontal sinus CSF leaks in six patients were repaired endoscopically. Average age of presentation was 45 years (range 25-65 years). Aetiology was idiopathic (three), congenital (one), accidental trauma (one), and surgical trauma (two). All patients presented with CSF rhinorrhea; two patients presented with meningitis. Four defects originated in the frontal recess, while two others involved the posterior table and frontal sinus outflow tract. Four patients had associated encephaloceles. We performed endoscopic repair in all six patients with one patient requiring an adjuvant osteoplastic flap without obliteration. All repairs were successful at the first attempt with a mean follow up of 13 months. All frontal sinuses remained patent on both post-operative endoscopic and radiographic exam.nnnCONCLUSIONSnEndoscopic repair of frontal sinus CSF leaks and encephaloceles can be an effective method if meticulous attention is directed toward preservation of the frontal sinus outflow tract, thus avoiding an osteoplastic flap and obliteration. The major limiting factor for an endoscopic approach is extreme extension superiorly or laterally within the posterior table beyond the reach of current instrumentation.

Murine tracheal and nasal septal epithelium for air-liquid interface cultures : A comparative study

Background Air–liquid interface cultures using murine tracheal respiratory epithelium have revolutionized the in vitro study of airway diseases. However, these cultures often are impractical because of the small number of respiratory epithelial cells that can be isolated from the mouse trachea. The ability to study ciliary physiology in vitro is of utmost importance in the research of chronic rhinosinusitis (CRS). Our hypothesis is that the murine nasal septum is a better source of ciliated respiratory epithelium to develop respiratory epithelial air–liquid interface models. Methods Nasal septa and tracheas were harvested from 10 BALB/c mice. The nasal septa were harvested by using a simple and straightforward novel technique. Scanning electron microscopy was performed on all specimens. Cell counts of ciliated respiratory epithelial cells were performed at one standard magnification (1535×). Comparative analysis of proximal and distal trachea, midanterior and midposterior nasal septal epithelium, was performed. Results Independent cell counts revealed highly significant differences in the proportion of cell populations (p < 0.00001). Ciliated cell counts for the trachea (106.9 ± 28) were an average of 38.7% of the total cell population. Nasal septal ciliated epithelial cells (277.5 ± 16) comprised 90.1% of the total cell population. Conclusion To increase the yield of respiratory epithelial cells harvested from mice, we have found that the nasal septum is a far superior source when compared with the trachea. The greater surface area and increased concentration of ciliated epithelial cells has the potential to provide an eightfold increase in epithelial cells for the development of air–liquid interface cultures.

An in vitro model of Pseudomonas aeruginosa biofilms on viable airway epithelial cell monolayers.

Background Chronic rhinosinusitis (CRS) that is refractory to medical or surgical intervention may involve a particularly resistant form of infection known as a bacterial biofilm. Bacterial biofilms are three-dimensional aggregates of bacteria that often are recalcitrant to antibiotics secondary to physical barrier characteristics. To date, all studies investigating biofilms in CRS have been descriptive in either human or animal tissue. To better understand the interactions of bacterial biofilms with respiratory epithelium, we describe an in vitro model of biofilm sinusitis by establishing mature biofilms on airway epithelial air-liquid interface cultures. Methods Airway epithelial cell cultures were grown on collagen-coated semipermeable support membranes as an air-liquid interface on tissue culture inserts. Confluent air-liquid interface cultures were inoculated with the biofilm-forming PAO-1 strain of Pseudomonas aeruginosa and compared with cultures inoculated with two mutant strains (sad-31 and sad-36) unable to form biofilms. Inoculated tissue transwells were incubated for 20 hours, allowing for biofilm growth. The semipermeable membranes were then harvested and imaged with confocal laser scanning microscopy and scanning electron microscopy. Results Microscopic analysis revealed the formation of biofilm-forming towers in the PAO-1 inoculated wells. The bacterial biofilms were supported by a viable airway epithelial cell surface monolayer. Conclusion This study shows a reliable method for analysis of in vitro interactions of bacterial biofilms and airway epithelium. The experimental manipulation of this air-liquid interface model will help explore novel treatment approaches for bacterial biofilm-associated CRS.

Immunolocalization of surfactant protein A and D in sinonasal mucosa.

Background Surfactant-associated proteins (SP) A and D are in the family of collectin proteins that play an integral part in the innate defense system. SP-A and SP-D expression and function are altered in a variety of inflammatory and infectious diseases of the lungs, such as asthma, allergies, and cystic fibrosis. Our prior studies are the first to identify the presence of these proteins in the human sinonasal cavity. The objective of this study was to immunolocalize SP-A and SP-D in human sinonasal tissue. Methods Sinonasal mucosal biopsies were performed in patients with various forms of chronic hyperplastic rhinosinusitis with nasal polyposis and nondiseased mucosa from patients undergoing transsphenoidal hypophysectomy. (n = 10) Immunolocalization of surfactant proteins was performed with antibodies to SP-A and SP-D using immunoperoxidase staining technique. Isotype-negative controls were performed on all specimens. Results Analyses of mucosal biopsy specimens from human sinonasal tissue reveals staining within respiratory and intermediate (metaplastic)-type surface epithelium. In addition, staining was intense in the submucosal ductal epithelium of the seromucinous glands. These properties appear to be consistent regardless of disease state and location within the sinuses. Conclusion This is the first study to immunolocalize SP-A and SP-D in sinonasal human mucosa. These are secreted proteins that are intricately involved in innate immunity in the lungs. Their secretion in the upper airway indicates that future studies may allow manipulation of these proteins and development of novel treatments for sinonasal pathology.