Darrell H. Hunsaker

Bacterial biofilms on the sinus mucosa of human subjects with chronic rhinosinusitis

Introduction: Chronic rhinosinusitis (CRS) is a common disease poorly controlled by antibiotics. Postulated etiologies of CRS include allergy, fungi, functional factors, and biofilm.

Biofilms with fungi in chronic rhinosinusitis

Objectives Demonstrate that bacterial biofilm in sinus mucosal samples from patients with eosinophilic mucin chronic rhinosinusitis (EMCRS) and allergic fungal rhinosinusitis (AFRS) contains fungal elements; identify specific organisms in the biofilm. Methods Mucosa samples from 11 patients undergoing sinus surgery were collected. Patients were classified as having AFRS, EMCRS, or chronic rhinosinusitis (CRS) based on histopathologic findings. Three mucosal samples from controls were also collected. Samples were stained with specific bacterial fluorescent in situ hybridization (FISH) DNA probes (Haemophilus influenzae, Streptococcus pneumophilia, Staphylococcus aureus, and Pseudomonas aeruginosa) and a general pan-fungal FISH probe. The samples were analyzed for bacterial biofilm ultrastructure and fungal elements using epifluorescent microscopy. Results Bacterial biofilm was demonstrated in 9/11 samples and 2/3 controls. H. influenzae was the predominant biofilm present. There was a trend showing more fungal elements in AFRS and EMCRS biofilms than in CRS and controls. Conclusion This is a preliminary study demonstrating fungal elements within sinus mucosal biofilm and demonstrating biofilm in AFRS.

The relationship of biofilms to chronic rhinosinusitis.

Purpose of reviewTo provide an update on the state of biofilm research in otolaryngology. Recent findingsChronic rhinosinusitis is a polymicrobial infection, which includes planktonic and biofilm infections with bacterial and fungal elements. The importance of genetic shift in microbes, when converting into a biofilm state, as well as the multiple phenotypes in each bacterial colony cannot be overemphasized. This creates a very sophisticated community of pathogens, some of which will likely survive a simple chemical treatment.Sinus cultures cannot be expected to provide a complete knowledge of the cause of chronic sinusitis. A new diagnostic method and innovative treatment plans will be necessary to provide a lasting treatment of chronic rhinosinusitis. Surgery combined with postoperative treatment is the most effective mean of controlling the majority of chronic rhinosinusitis infections. The challenges associated with the treatment of chronic rhinosinusitis patients may be met by focusing more on the community of microorganism present in the sinuses. SummaryThe understanding of the implication of chronic biofilm infections is growing rapidly but will require an enormous effort to completely control chronic rhinosinusitis.

Fungus-Specific IgG and IgE in Allergic Fungal Rhinosinusitis:

OBJECTIVE: Our study goal was to study fungus-specific immunoglobulins G (sIgG) and E (sIgE) in polypoid rhinosinusitis with and without evidence of allergic fungal rhinosinusitis (AFS). STUDY DESIGN AND SETTING: A prospective analysis was conducted of fungal sIgG and sIgE using a 9-mold RAST panel in 13 AFS, 11 AFS-like, and 27 non-AFS polypoid rhinosinusitis patients. Nonpolyp controls included 17 volunteers with allergic rhinitis and 11 with no atopic history. RESULTS: All groups had elevated fungal sIgG levels. Polyps, increasing polyp severity, and AFS were associated with elevated fungal sIgG to a greater number of molds. The AFS group had sIgE elevations (≥class II) to an average of 5 molds versus only 0.1 in the non-AFS polyp group. Total IgE was 971 U/mL versus 64 U/mL, respectively. CONCLUSIONS: Multiple elevations of fungal sIgE are adequate diagnostic evidence of these fungi when fungal cultures and histologic examinations are negative in diagnosing AFS. The significance of increased fungal sIgG remains unclear. SIGNIFICANCE: Early recognition of AFS may be facilitated by screening polypoid rhinosinusitis patients with total serum IgE and RAST testing.

Safety of home-based and office allergy immunotherapy: A multicenter prospective study ☆ ☆☆ ★

During a 1-year period, 27 otolaryngic allergy practices recorded all systemic reactions to immunotherapy resulting from 635,600 patient visits and 1,144,000 injections. Sixty percent of injections were given at home. Major systemic reactions were observed after 0.005% of injections. There were no hospitalizations or deaths. Eighty-seven percent of major reactions began within 20 minutes of injection. Frequently observed risk factors for major reactions were buildup phase of immunotherapy, active asthma, and first injection from a treatment vial. Home and office injections had similar rates of total systemic reactions, but home-based immunotherapy had far fewer major reactions. Home-based immunotherapy was found to be safe. The methods and precautions used to treat patients with this degree of safety are specified and discussed.

A new anesthetic system for microlaryngeal surgery

Anesthesia for microlaryngeal surgery creates many obstacles for the anesthesiologist and otolaryngologist. Anesthetic techniques developed to improve surgical exposure have been met with significant limitations and are difficult for the anesthesiologist to monitor. A new subglottic jet ventilation anesthesia system is introduced that meets the needs of the otolaryngologist and the anesthesiologist. This new system is made up of two components: (1) The Hunsaker Mon-Jet tube is a laser-safe, subglottic jet ventilation tube constructed of a nonflammable fluoroplastic material. It allows monitoring of tracheal pressure and end tidal carbon dioxide, and it is designed with a basket-shaped distal extension to align the jet port away from the tracheal mucosa and to prevent trauma and submucosal injection of jetted gas. (2) An automatic jet ventilator, which has an adjustable respiratory rate, inspiratory/expiratory ratio, and flow rate, also monitors expiratory end peak airway pressures and has an automatic shutdown feature if either of these pressures are exceeded. This system was successfully used in 36 patients undergoing microlaryngeal surgery.

A Prospective Evaluation of ENT Telemedicine in Remote Military Populations Seeking Specialty Care

This study evaluated telemedicine use in remote military treatment facilities (MTFs) ashore over a 4-month period to help guide telemedicine applications for shipboard medical departments. A prospective study design was used to evaluate specialty care provided by an ear/nose/throat (ENT) physician via videoconferencing (VC) for patients at remote MTFs in TRICARE Region 9. The study provided a complete and continuous sample of ENT consultations during a planned 4-month period. Data sources included a telemedicine database and telephone interviews to assess attitudes of physician and nonphysician medical personnel. A total of 193 VC consultations (hereafter referred to as teleconsultations) were conducted following referrals from primary providers. Patients were mostly young, male, active-duty personnel. Forty-five percent of the 193 teleconsultations resulted in changed diagnosis by the ENT specialist relative to initial diagnosis by the referring provider. This rate of clinical impact was substantial, and it generalized across various ENT conditions, demographics, and MTFs. Medical personnel reported generally positive attitudes about telemedicine technologies and the telemedicine process in TRICARE Region 9. Nonphysician providers reported slightly more favorable attitudes compared to physicians. These results suggest that ENT telemedicine has substantial clinical impact in the military populations treated at MTFs. A high rate of changed diagnoses (45%) was observed across age, gender, military status, ENT conditions, and treatment facilities. Medical personnel reported positive attitudes about using the telemedicine system. These results support the use of telemedicine in shipboard medical departments.

Snoring significance in patients undergoing home sleep studies.

OBJECTIVE: To analyze the impact of snoring, independent of obstructive sleep apnea syndrome on patients referred for home sleep studies and to report a new technology for the reporting of snoring, using sophisticated sound collection and noise-canceling technology. STUDY DESIGN AND SETTING: A retrospective statistical review of consecutive anonymous data compiled from questionnaires and digital data of snoring loudness and duration measured at the upper lip during unattended home sleep studies in 4,860 patients referred for snoring and sleep-disturbed breathing. RESULTS: A strong relationship exists between a history of snoring and complaints of daytime sleepiness (80%), obesity (73%), and chronic fatigue (78%) (all yield P < 0.001). By contrast, only 42% to 48% of patients without these symptoms complain of snoring. In 3 multiple-regression analyses, the percent of time snoring, average loudness, and peak loudness are all significantly predicted by the apnea hypopnea index (all P < 0.003), body mass index (all P < 0.001), and age (P = 0.014). Daytime sleepiness was strongly predicted by percent time snoring (P = 0.014), weakly by average loudness (P = 0.046), and not at all by peak loudness (P = 0.303). CONCLUSION: By using a pair of microphones placed at the upper lip, one that samples breath sounds and the other ambient sound and artifact noise, the NovaSOM QSG measures snoring while canceling ambient noise. The clinical impact of snoring on the patient as well as the bed partner, independent of obstructive sleep apnea syndrome, is an unrecognized factor in sleep-disturbed breathing. SIGNIFICANCE: Measurable criteria to define snoring are suggested. Snoring loudness is not measured in most laboratory Polysomnograms. EBM rating: B-3b

Reliability of Disposable Intraoperative Facial Nerve Stimulators

Facial nerve injury is one major morbidity of surgery performed along the course of this nerve. Surgeons frequently employ stimulators to identify and protect the nerve. Both disposable devices as well as larger, reusable stimulators are available. Despite their common use, relatively little documentation exists regarding the safety and reliability of these devices. We tested the electrical output of the four disposable, single‐use motor nerve stimulators that are marketed in the United States. We found that each produced consistent stimulus output over time. One stimulator slightly exceeded the manufacturers listed output while three devices produced significantly less voltage and current than specified by the manufacturer.

Safety of intradermal skin tests for inhalants and foods: a prospective study

Intradermal skin testing is a useful allergy diagnostic tool. Although considered safe when properly performed, systemic reactions have been reported. This is the first large, prospective study to record and evaluate all systemic reactions from intradermal skin testing (IDT) to inhalant or food antigens.