Christopher D. Brook

Utility of Allergy Testing in Patients with Chronic Laryngopharyngeal Symptoms Is It Allergic Laryngitis

Objective To determine the utility of allergy evaluation in patients with chronic refractory laryngeal symptoms. Study Design Case series with chart review. Setting Tertiary academic medical center. Subjects All patients who underwent in vitro allergy testing at a single institution from 2006 to 2010, for a total of 998 patients. Methods Charts of patients who underwent in vitro allergy testing were identified. The charts were reviewed for the primary indication for allergy testing, as categorized into rhinitis complaints, chronic sinusitis, otitis media, and refractory laryngeal symptoms (globus, cough, throat clearing, increased secretions, and hoarseness). Results of allergy tests and comorbid conditions were analyzed and compared among groups. Results The positive yield of allergy testing in patients with primary laryngeal indications was 51.8%, 63.3% for rhinitis, 60.9% for sinusitis, and 33.3% for otitis media. The odds ratio of having a positive test was not statistically different for patients with laryngeal symptoms, rhinitis, or sinusitis. Patients with chronic laryngeal symptoms and positive allergy testing were most often sensitized to dust mites (63%) and least often sensitized to molds (1.3%). Conclusions Allergy testing in patients with chronic laryngeal symptoms yields positive results in equivalent proportion to patients with other common presenting symptoms. Dust mites sensitization is the most common sensitization in patients with allergic laryngitis.

Management of Wire Brush Bristle Ingestion Review of Literature and Presentation of an Algorithm

Objectives: To increase awareness of wire brush bristle ingestion, review the literature relating to wire brush bristle ingestion, and describe an algorithm for management of wire brush bristle foreign bodies as well as a technique for bedside removal. Methods: The authors present a case of an accidental wire bristle ingestion that was successfully treated with bedside removal and describe a successful bedside technique for removal. For the literature review, the PubMed journal database and Google Scholar were queried using the search terms wire bristle, wire brush, grill brush, and grill bristle. Results: Twenty-three wire brush ingestions with upper aerodigestive presentations were identified in the medical literature. Bedside visualization was attempted in 10 patients and successful in 5. The foreign body was able to be removed at the bedside in 3 of these patients. Two patients were managed conservatively. The authors developed an algorithm for management based on these literature findings. Conclusion: Wire brush bristle ingestion is increasingly common in the literature, and a definitive algorithm does not exist for management. The authors present an algorithm for management and describe a technique for successful removal at the bedside.

The Prevalence of High-Riding Jugular Bulb in Patients with Suspected Endolymphatic Hydrops

Background To determine the prevalence of a high-riding jugular bulb (HRJB) in the endolymphatic hydrops population. Methods This was a retrospective chart and radiology review of patients seen at a tertiary care medical center. Patients were identified using the International Classification of Diseases, 9th edition, code 386.xx (Meniere disease-unspecified), and were required to have undergone an imaging study that included views of the jugular bulb that were available for review. A radiologist then evaluated all of the imaging studies for evidence of HRJB or inner ear dehiscence with a jugular bulb abnormality. Results The prevalence of a HRJB in all endolymphatic hydrops patients was 9.0% (7 of 78), and it was 4.5% (7 of 156) in all ears. The prevalence of HRJB ipsilateral to an ear with endolymphatic hydrops was 4.6% (4 of 88 ears); it was 4.4% (3 of 68 ears) in ears without endolymphatic hydrops. The incidence of inner ear dehiscence with a HRJB was 1.3% (1 of 78). Electrocochleography results were not correlated with jugular bulb volume. Discussion The results of this study indicate that a small subset of patients treated for endolymphatic hydrops patients have a HRJB. Overall, these results suggest that HRJB does not play a major role in endolymphatic hydrops, although it may play a role in a few isolated patients.

Time to Competency, Reliability of Flexible Transnasal Laryngoscopy by Training Level A Pilot Study

Objective To determine the progression of flexible transnasal laryngoscopy reliability and competency in otolaryngology residency training. Study Design Prospective case control study. Setting Academic otolaryngology department. Subjects Medical students, otolaryngology residents, and otolaryngology attending physicians. Methods Fourteen otolaryngology residents from PGY-1 to PGY-5 and 3 attending otolaryngologists viewed 25 selected and digitally recorded flexible transnasal laryngoscopies. The evaluators were asked to rate 13 items relating to abnormalities in the oropharynx, hypopharynx, larynx, and subglottis. The level of concern and level of comfort with the diagnosis were assessed. Intraclass correlations were calculated for each topic and by level of training to determine reliability within each class and compare competency versus attending interpretations. Results Intraclass correlation of residents compared to attending physicians demonstrated significant improvements by year for left and right vocal fold immobility, subglottic stenosis, laryngeal mass, left and right vocal cord abnormalities, and level of concern. Additionally, pooled vocal cord mobility and pooled results in categories with good attending reliability demonstrated stepwise improvement as well. For these categories, resident reliability was found to be statistically similar to attending physicians in all categories by PGY-3. There were no trends for base of tongue abnormalities, pharyngeal abnormalities, and pharyngeal and hypopharyngeal masses. Conclusions Resident competency for flexible transnasal laryngoscopy progresses during residency to reliability with attending otolaryngologists by the PGY-3 year over key facets of the examination.

Predictive findings of allergic disease in fiberoptic nasolaryngoscopy

To determine whether findings on fiberoptic nasolaryngoscopy beyond the nasal cavity can aid in diagnosis of atopy.

Angioedema of the upper aerodigestive tract: risk factors associated with airway intervention and management algorithm

Angioedema of the upper aerodigestive tract can lead to significant airway obstruction. To date no articles have delineated risk factors for progression after initial evaluation.

Periostin as a Biomarker for Nasal Polyps in Chronic Rhinosinusitis

Objective Periostin is an extracellular matrix protein that is elevated in the sinonasal tissues of patients with chronic rhinosinusitis (CRS). The purpose of this study was to determine whether serum periostin could serve as a molecular biomarker of nasal polyp burden in sinonasal disease. Study Design Prospective cohort study. Setting Academic medical center. Subjects and Methods Serum periostin levels were measured by ELISA on blood samples collected from patients undergoing sinus surgery for CRS (n = 71), further stratified by phenotype as defined by nasal polyps and asthma. Results were compared with assays performed on control subjects (n = 62). Results Mean serum periostin levels were markedly elevated in patients with CRS versus controls (66.1 ng/mL [95% CI, 51.6-80.6] vs 38.7 ng/mL [95% CI, 34.4-42.9], respectively, P = .004). In addition, mean periostin levels were significantly higher in CRS patients with nasal polyps as compared with those without polyps (94.8 ng/mL [95% CI, 67.3-122.4] vs 41.1 ng/mL [95% CI, 35.2-47.0], respectively, P < .001). Periostin levels did not correlate with sex (P = .473), smoking history (P = .748), aspirin-exacerbated respiratory disease status (P = .136), oral steroid use within 1 month of surgery (P = .281), use of topical steroid nasal spray (P = .864), or number of prior sinus operations (P = .973). Conclusion Serum periostin appears to be a novel molecular biomarker for the presence of nasal polyps and may serve as an indicator of CRS endotypes.

Causes of Dacryocystorhinostomy Failure: External versus Endoscopic Approach

Objectives To compare the causes of failure between external and endoscopic dacryocystorhinostomy (DCR) techniques for the treatment of lacrimal obstruction. Study Design A retrospective cohort study. Methods The study population consisted of 53 consecutive patients who underwent revision endoscopic DCR from 2002 to 2013 for lacrimal duct obstruction. Identified causes of previous DCR failure were compared between patients whose initial surgery was performed through an external versus an endoscopic approach. Results Reasons for surgical failure after external (n = 21) versus endoscopic (n = 32) DCR included cicatricial closure of the internal lacrimal ostium (52.4 versus 53.1%; p = 0.96), inadequate removal of bone overlying the lacrimal sac (23.8 versus 9.4%; p = 0.15), sump syndrome (9.5 versus 9.4%; p = 0.99), and intranasal adhesions (65 versus 37.5%; p = 0.05). Adhesions that involved the middle turbinate were a particularly impactful cause of failure when the DCR was performed through an external versus the endoscopic approach (57.1 versus 28.1%; p = 0.04). Septoplasty was more likely to be needed at the time of revision surgery if the initial procedure was performed externally (71.1 versus 15.6%; p = 0.02). Surgical success rates for revision DCR were comparable between the groups (75.0% external versus 73.3% endoscopic; p = 0.90), with a mean follow-up of 12.7 months. Conclusion DCR failure associated with intranasal adhesions was more likely to occur when the surgery was performed through an external rather than an endoscopic approach. Endoscopic instrumentation allowed for identification and correction of intranasal pathology at the time of DCR, includingan enlarged middle turbinate or a deviated septum, which may improve surgical outcome.

The association of allergic sensitization with radiographic sinus opacification

Background The relationship between allergic sensitization and radiographic sinus inflammation remains unclear. Objectives To determine whether specific allergen sensitization is correlated with sinonasal radiographic opacification. Methods Patients with chronic sinonasal symptoms were selected and included if they had allergy testing and a computed tomography (CT) of the paranasal sinuses. Data regarding demographic characteristics, in vitro allergy test results, and comorbidities were collected. CTs were reviewed, and an overall Lund-Mackay score (LMS) was calculated for each patient. A two-sample t-test was used to compare mean LMS between patients who were sensitized and patients who were not sensitized. A multiple linear regression model was used to determine whether a relationship existed among LMS and allergy results, asthma, nasal polyps, immunoglobulin E (IgE) level, medication usage, in-season versus out-of-season CTs, age, and sex. Significance was determined at an alpha level of 0.05. Results There were 437 patients included, of whom, 251 had positive specific allergen test results and 186 had negative test results. A total of 282 patients had allergic rhinitis symptoms without a documented diagnosis of sinusitis, and 155 carried a diagnosis of chronic rhinosinusitis. The mean LMS did not differ between patients who were sensitized and patients who were not sensitized (5.56 versus 5.28; p = 0.61). Linear regression demonstrated an increase in LMS in patients with asthma (p = 0.02), male sex (p < 0.01), elevated IgE (p < 0.01), a history of anaphylaxis (p = 0.03), and nasal polyps (p < 0.01). There was a statistically significant decrease in LMS in patients with an in-season CT (p = 0.02). Conclusions Patients with a positive specific in vitro allergen test result did not have higher overall rates of radiographic sinus inflammation. Asthma, male sex, polyps, elevated IgE, and a history of anaphylaxis were associated with higher LMS.

Factors influencing the need for endoscopic sinus surgery in adult patients with cystic fibrosis.

Background Risk factors in adult patients with cystic fibrosis (CF) associated with surgical intervention have not been delineated. Objective To identify characteristics of adult patients with CF and with chronic rhinosinusitis that predict surgical intervention with endoscopic sinus surgery (ESS). Methods Patients were identified in a tertiary sinus center by the International Classification of Diseases, Ninth Revision codes 277.00-277.03, which represent CF. Charts were reviewed for the CF transmembrane conductance regulator (CFTR) gene mutation, Lund-Mackay score (LMS), the 22-item Sino-Nasal Outcome Test (SNOT-22) score, previous ESS, and occurrence of ESS after presentation. The Fisher exact test was used to test frequency of events between the groups, and the Mann Whitney U test and the t-test were used to compare means among LMS, SNOT-22, and age. The Cox proportional hazard analysis was used to calculate hazard ratios (HR) for the impact of LMS, SNOT-22 score, previous ESS, and CFTR gene mutation status on the occurrence of ESS after presentation. Results One hundred and fifteen patients met the inclusion criteria for the study. Patients with a history of surgery more often underwent ESS after presentation (p ≤ 0.01). The LMS and the SNOT-22 score were not significantly different between the groups of previous ESS and no previous ESS (p = 0.23 and p = 0.28, respectively). A severe mutation genotype was predictive of ESS after presentation (p = 0.03). SNOT-22 scores did not differ between the severe and mild groups (36.0 and 32.4, respectively; p = 0.57), but the mean LMS was significantly higher in the severe mutation group (12.5 and 9.7; p ≤ 0.01). Univariate Cox proportional hazard analysis revealed an increased occurrence of ESS for patients with severe mutations (HR, 3.6; p ≤ 0.01) or a history of ESS (HR, 2.3; p ≤ 0.01). Conclusion The occurrence of ESS in adult patients with CF was predicted by previous ESS intervention as well as the severity of CFTR mutation.