David A. Sherris

The role of ubiquitous airborne fungi in chronic rhinosinusitis.

Chronic rhinosinusitis (CRS) is a confusing disease for both allergists and otorhinolaryngologists, partly because of its poorly understood pathophysiology and partly because of its limited treatment options. Several recent reports have provided evidence for a better understanding of the etiology and the relationship of CRS to airborne fungi—especially to Alternaria. First, the development of novel methods enables detection of certain fungi in mucus from the nasal and paranasal sinus cavities. Second, a non-IgE-mediated immunological mechanism for reactivity of patients with CRS to certain common fungi has been described. Third, these fungi are surrounded by eosinophils in vivo, suggesting that they are targeted by eosinophils. Finally, the preliminary results of studies using antifungal agents to treat patients with CRS are promising. Overall, these recent discoveries provide a logical mechanism for the pathophysiology of CRS, and they also suggest promising avenues for treatment of CRS with antifungal agents.

Improving the Detection of Fungi in Eosinophilic Mucin Seeing What We Could Not See Before

Objective To investigate the improvement in histologic detection of fungi with Gomori methenamine silver (GMS) stain by trypsin predigestion in the mucus of patients with chronic rhinosinusitis (CRS). Study Design Prospective, single group, descriptive analysis. Setting Multi-institutional. Subjects and Methods Thirty-four sinus specimens from 12 surgical patients with CRS were stained with hematoxylin and eosin, GMS stain, GMS with trypsin digestion, immunofluorescence stains for chitinase, and anti-Alternaria. All patients received skin testing, total IgE serology, and radioallergosorbent tests (RAST) for 23 fungal-specific IgE antibodies. Results The conventional GMS stain detected fungi in only 9 of 34 (27%) specimens. Predigesting the specimen with trypsin dramatically improved the visualization of fungi (31/34, 91%). The chitinase immunofluorescence visualized fungi in 32 of 34 (94%), and anti-Alternaria visualized 33 of 34 specimens (97%). Only 8 of 12 (75%) patients had detectable allergies. Conclusions This report describes a simple modification of the conventional GMS stain that can significantly improve the visualization of fungi on histology and explains the lack of detection in previous studies. These novel, more sensitive histologic methods reveal the presence of fungi within the eosinophilic mucin in allergic and also nonallergic CRS patients, further questioning a crucial role of an IgE-mediated pathophysiology.

Human Acellular Dermal Matrix Grafts for Rhinoplasty

Rhinoplasty often relies on graft material for structural support in the form of cartilage, bone grafts, or fascia. In addition, pliable grafts are often helpful for contouring and can function as a barrier. Unfortunately, grafts carry the disadvantage of requiring an additional donor site, with associated complications. Human acellular dermal matrix (ADM) biological implants offer an exciting alternative for structural support and nonstructural implantation in rhinoplasty procedures. To examine the efficacy of ADM placement in rhinoplasty and septoplasty, the authors report the results from a series of 51 patients. In this series, there were no cases of infection, skin discoloration, seroma formation, septal perforation, significant resorption, extrusion, or other complications related to ADM placement. Therefore, the authors believe that ADM offers a safe and effective alternative to traditional grafting methods for functional and aesthetic rhinoplasty.

Computed Tomography Scans as an Objective Measure of Disease Severity in Chronic Rhinosinusitis

Objectives A truly objective method of measuring disease severity in chronic rhinosinusitis (CRS) has only recently existed. We evaluated computed tomography (CT) scans of CRS patients using this novel objective 3D computerized system and compared results with a novel 2D computerized analysis of a single coronal slice through the osteomeatal complex (OMC) and subjective methods including Lund-Mackay and Zinreich’s modified Lund-Mackay. Study Design Prospective multicenter study. Setting Two academic tertiary referral centers. Subjects and Methods Forty-six adults with a diagnosis of CRS underwent CT examination and received an intramuscular triamcinolone injection, dosage weight dependent, followed by CT scan 4 to 5 weeks later. Recruitment lasted 21 months. Scans were evaluated with all 4 scoring methods over 5 months. Results The Lin’s concordance class correlation (CCC) of the OMC method revealed the best correlation to the 3D volumetric computerized values (0.915), followed by the Zinreich (0.904) and Lund-Mackay methods (0.824). Posttreatment results demonstrated that both the OMC (0.824) and Zinreich’s (0.778) methods had strong agreement with the 3D volumetric methods and were very sensitive to change, whereas the Lund-Mackay (0.545) had only moderate agreement. Conclusion Computerized CT analysis provides the most comprehensive, objective, and reproducible method of measuring disease severity and is very sensitive to change induced by treatment intervention. A 2D coronal image through the OMC provides a valid, user-friendly method of assessing CRS and is representative of CRS severity in all sinuses. Zinreich’s subjective method correlated well overall, but the Lund-Mackay method lagged behind in disease representation and sensitivity to change.

Correlation of Symptoms, Clinical Signs, and Biomarkers of Inflammation in Postsurgical Chronic Rhinosinusitis

Objective: The study aimed to evaluate symptoms described by patients with chronic rhinosinusitis with polypoid changes/nasal polyps and their correlation with computed tomography (CT), nasal endoscopy, and intranasal biomarkers. Study Design: Prospective multicenter study symptom data from postsurgical adult chronic rhinosinusitis study participants with recurrent disease refractory to medical therapy were analyzed in comparison with objective data. Methods: Using logistic regression analysis, participant-rated 16-question surveys from 258 participants were assessed for correlation with nasal endoscopy scores, CT percentage of sinus occlusion, and intranasal biomarkers of fungal antigens (Alternaria and Aspergillus), eosinophilic inflammation (eosinophil-derived neurotoxin [EDN] and major basic protein [MBP]), and inflammatory cytokines (interleukins 5 and 13). Results: Study participant assessments revealed increased CT occlusion in participants presenting with greater inability to smell (P < .019). Mucosal inflammation identified on nasal endoscopy was positively correlated with congestion (P < .028), runny nose (P < .002), and ear pain (P < .007). Elevated EDN was positively correlated in patients with bothersome congestion (P < .031) and runny nose (P < .011). Sneezing was positively correlated with multiple markers: Alternaria (P < .024), interleukin-13 (P < .027), MBP (P < .034), and interleukin-5 (P < .019). Conclusion: Nasal endoscopy, not CT imaging, has the strongest correlation with the 2 cardinal symptoms of congestion and runny nose in CRS patients; these correlate with biomarkers of eosinophilic inflammation.

Cutaneous Landmarks of the Supratrochlear Nerve in Forehead Rejuvenation Surgery

Cutaneous Landmarks of the Supratrochlear Nerve in Forehead Rejuvenation Surgery Complete resection of the corrugator supercilii and procerus muscles has previously been advocated for forehead rejuvenation surgery.1 These procedures are complicated due to the supratrochlear nerve, which commonly runs near the fibers of the corrugator supercilii muscle (Figure). Damage to the supratrochlear nerve after forehead rejuvenation can lead to undesirable sequelae such as paresthesia and dyesthesia. The incidence of these complications may be related to the surgical approach, specific technical execution, and/or the surgeon’s experience with the technique. Familiarity with the location of the supratrochlear nerve in relation to the corrugator supercilii and procerus muscles can minimize unpredictability and allow for a more systematic approach to precise muscle removal. The senior author postulates that the supratrochlear nerve branches demonstrate a significant investment pattern in relation to the corrugator supercilii muscle fibers and a close approximation to the overlying glabellar crease. The glabellar crease is the typical vertically oriented skin wrinkle located just medial to the brows. Although the investing topography of other peripheral points has been described, the supratrochlear nerve and its close relationship to the corrugator supercilii muscle fibers and cutaneous glabellar frown line requires further inspection.2 A comprehensive understanding of these anatomical relationships may assist surgeons of all levels of experience in obtaining successful outcomes when performing any of the surgical approaches for forehead rejuvenation. Methods | Fifteen fresh cadaver heads (30 corrugator muscles and 30 supratrochlear nerves) were labeled at the lines corresponding to the glabellar crease. They were then dissected using a cross-shaped incision centered over the radix, with the transverse component following the eyebrow arches (Figure). The frontalis and depressor supercilii muscles were dissected off the corrugator supercilii muscle and elevated along with the skin flaps. Once the full extent of the supratrochlear nerve and the corrugator supercilii muscle were well delineated, transcutaneous pins were placed through the glabellar crease at a position approximately 1 cm superior to the superior orbital rim, and standardized measurements of nerve relationships to the glabellar crease were taken.

Flap Basics I: Rotation and Transposition Flaps

In many cases of complex facial defects, because of advanced cutaneous malignancies, primary wound closure is impossible. In these instances, ideal results can be obtained through recruitment of adjacent tissue with the use of local flaps. Advances in local flap techniques have raised the bar in facial reconstruction; however, acceptable results to the surgeon and patient require high levels of planning and surgical technique. Defects resulting from Mohs surgery and other traumatic injuries can typically be repaired with local flaps. A well-planned and executed local flap can lead to excellent cosmetic results with minimal distortion of the surrounding facial landmarks.

The Role of Eosinophils in Rhinologic Diseases

The eosinophil granulocyte, although likely first observed by Wharton Jones in 1846 in unstained preparations of peripheral blood, was so named by Paul Ehrlich in 1879 because of the intense staining of its granules with the acidic dye eosin Gleich and Adolphson (Adv Immunol 39:177–253, 1986). Since that time, the eosinophil has been the subject of extensive investigation. Its occurrence in such disparate conditions as parasitic infections, presumably for the benefit of the human host, and hypersensitivity diseases, perhaps to the detriment of the patient, although paradoxical, has become better understood as a consequence of newer information. Eosinophils are resident and nonpathologic in various organs such as gastrointestinal tract and mammary glands, and they may play roles in tissue and immune homeostasis of these organs.