Elizabeth J. Mahoney

Nd-YAG laser photocoagulation for epistaxis associated with hereditary hemorrhagic telangiectasia.

INTRODUCTION Hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu disease, is an autosomal dominant disorder characterized by recurrent epistaxis, cutaneous or visceral telangiectasias, and a family history of the disease. First described over a century ago, HHT continues to be erroneously perceived as a rare condition. Wider recognition of this disorder in recent years has prompted researchers to recognize milder undiagnosed individuals, and recent evidence suggests that the condition is far more common than previously reported. Prevalence in the general population is estimated to be at least 1 in 10,000. HHT is a disorder of localized angiodysplasia, and the recognized manifestations of HHT are all caused by abnormalities of vascular structure. Telangiectases of the mucosal surfaces are nearly universal, and arteriovenous malformations (AVMs) may occur in multiple organ systems, most commonly the lung, gastrointestinal tract, and brain. The most common presentation of HHT is epistaxis, affecting approximately 90% of HHT patients. Thus, the otolaryngologist is typically involved in managing the challenging problem of recurrent epistaxis, which plagues the vast majority of the HHT patient population. A wide variety of treatments have been applied in the management of epistaxis in HHT patients including electrocauterization, nasal packing, and systemic estrogen therapy. Few therapies, however, have shown the efficacy demonstrated by the precise coagulation of telangiectasias with the Nd-YAG laser. Although treatment with Nd-YAG laser photocoagulation has shown improvements in the frequency and intensity of epistaxis, success with this modality requires appropriate patient selection and critical attention to detailed technique to achieve a successful outcome. In the present report, we outline details of our technique, based on 20 years of experience, for performing Nd-YAG laser treatment of nasal telangiectasias and AVMs. We emphasize meticulous surgical technique and careful selection of appropriate patients.

Angioedema and angiotensin-converting enzyme inhibitors: Are demographics a risk?:

Objectives The use of angiotensin-converting enzyme inhibitors (ACEI) has become the leading cause of acquired angioedema. Previous studies have suggested that certain patient populations may be at a higher risk for ACEI-induced angioedema. The objective of this study was to evaluate any demographic associations. Study Design A retrospective chart review. Materials and Methods Angioedema patients from 1999 to 2004 treated at a tertiary care hospital were reviewed. Demographics, inciting factors, and comorbid conditions were examined. Results One hundred eighty-two patients met inclusion criteria. Sixty-three percent of patients with angioedema had ACEI triggers. Eighty-one percent of all ACEI angioedema occurred in black patients. Of all angioedema patients, 70% (95% confidence interval [CI], 62%-78%) of black patients noted an ACEI as the inciting agent compared with 44% (95% CI, 30%-59%) in other patient groups. Black patients were 3.03 times more likely to have angioedema from an ACEI than all other patient groups (95% CI, 1.54-5.94). Conclusion This study represents the largest series of patients with angioedema. Although retrospective in nature, the data show that black patients are at a higher risk for ACEI-induced angioedema.

Sjögren's disease

In summary, Sjögrens syndrome is a chronic autoimmune disorder characterized by lymphocytic infiltration of the exocrine glands, particularly the salivary and lacrimal glands. The sicca complex of xerophthalmia and xerostomia are the hallmark features of Sjögrens symptomatology. In addition to these hallmark symptoms of oral and ocular dryness, one third of patients with Sjögrens syndrome present with extraglandular manifestations. Many osf these extraglandular manifestations, as well as the sicca symptoms, have otolaryngologic relevance. Because patients with Sjögrens syndrome may present with vague or nonspecific head and neck complaints, ranging from oral dryness to hoarseness to hearing loss, an otolaryngologists high index of suspicion for this disorder may prevent delay in diagnosis, allow appropriate diagnostic evaluation, and optimize therapeutic intervention.

Analysis of recurrent angiotensin converting enzyme inhibitor-induced angioedema.

Objective/Hypothesis: A known risk for patients taking angiotensin converting enzyme‐inhibitors (ACE‐Is) is angioedema that can involve the face, lips, oral cavity, and larynx. Such upper airway obstruction may be severe enough to require an emergency department visit or even necessitate prompt airway intervention. Once a patient has had an episode of ACE‐inhibitor induced angioedema (AIIA), certainly a thrust of continuing case management would be to avoid the occurrence of subsequent episodes of AIIA that potentially can be life‐threatening. Nevertheless, recurrent episodes of AIIA do occur. This study aims to characterize a patients risk for recurrent AIIA, determine the cause for repeat episodes of AIIA and recommend steps to be taken to minimize the recurrence of AIIA.

New classification of nasal vasculature patterns in hereditary hemorrhagic telangiectasia.

Background Hereditary hemorrhagic telangiectasia (HHT) is a disorder characterized by the triad of recurrent epistaxis, telangiectasia, and a family history of the disease. Management of recalcitrant epistaxis in HHT remains a challenging problem for otolaryngologists. The precise coagulation of telangiectasias with the Nd-YAG laser has shown efficacy in the treatment of HHT-associated epistaxis, but results can be variable and patient selection is critical in ensuring a successful outcome. We propose a new classification of nasal vasculature patterns in HHT as a means for selecting the Nd-YAG laser for photocoagulation treatment. Methods The records of 40 patients who underwent Nd-YAG laser photocoagulation for HHT were reviewed retrospectively. Outcomes after Nd-YAG laser treatment were correlated with three observed nasal vasculature patterns: (I) isolated punctate telangiectasias or individual small arteriovenous malformation; (II) diffuse interconnecting vasculature with “feeder” vessels; and (III) large solitary arteriovenous malformation, which may be associated with scattered telangiectasia. Results Types I and II were the most common vasculature patterns seen in this patient population. Patients with patterns I and III showed greater improvement in epistaxis after Nd-YAG laser photocoagulation. Patients with pattern II fared better with septodermoplasty. Conclusion These findings suggest that analysis of nasal vasculature patterns can improve therapeutic stratification of patients with HHT. Proper patient selection using this new classification scheme may improve the management of epistaxis in patients with HHT.

Food allergy in adults and children.

Food allergy is defined as an adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food and is distinct from food intolerance. Clinical manifestations of food allergy are varied and involve many systems including respiratory, cutaneous, and gastrointestinal. The double-blinded placebo-controlled oral food challenge remains the gold standard for the diagnosis of IgE-mediated food allergy. Areas of ongoing research include improved understanding of determinants for the development of tolerance versus sensitization for foods, the role of diagnostic testing for specific epitopes for food allergens, and the use of oral immunotherapy for IgE-mediated food allergy.

Palliative Care for the Patient with Refractory Chronic Rhinosinusitis

Most otolaryngologists encounter patients with chronic rhinosinusitis who, despite conventional medical and surgical therapy, fail to show significant symptomatic improvement. Many paradigms have been proposed to explain the mechanisms responsible for refractory disease in these patients, including superantigen activation, biofilm formation, and eosinophil activation triggered by fungal elements. Although the precise underlying etiology of this clinical scenario remains unclear, the resultant pathophysiologic events share a final common pathway marked by inflammatory changes of the sinonasal mucosa. This article reviews the proposed hypotheses as to why some patients with chronic sinusitis fail conventional therapy and highlights treatment options useful in the palliative treatment of these patients.

Survey on Tobacco-Cessation Practices and Policies (SToPP)

Objective: 1) Analyze current practices and policies of otolaryngologists on tobacco-cessation counseling. 2) Analyze the relationship between formal training in tobacco-cessation and confidence in counseling and prescription therapy behavior by otolaryngologists. Method: This survey of smoking cessation practices was performed at the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and associated meetings in September 2010. Attendees were surveyed, and the results were compiled. Regression analysis was performed to further assess the effects of training on otolaryngologists’ confidence in counseling. Results: A total of 207 surveys were collected; 202 respondents indicated training in otolaryngology. A total of 88.5% of otolaryngologists ask most or all of their patients about tobacco use at an initial encounter; 83.7% advise most to all of their patients to quit at this encounter; 64.5% assess most to all of their patients’ interest in quitting; 49.7% assess their reasons to quit; 22.3% arrange support between visits for most to all of their patients. Regression analysis revealed that training during medical school and after residency were independently associated with higher levels of confidence and higher rates of prescribed therapy for patients (all P < .025). Conclusion: Otolaryngologists counsel their patients on tobacco at a low rate, and fewer provide patients with the support necessary to assist them in quitting. Formal training in tobacco-cessation was associated with higher levels of confidence. Further research is indicated to assess the utility and cost-effectiveness of tobacco-cessation training programs for otolaryngologists.