Gregory R. Dion

Immunotherapy in allergic fungal sinusitis: The controversy continues. A recent review of literature

Allergic fungal sinusitis (AFS), also referred to as allergic fungal rhinosinusitis (AFRS), is a noninvasive, eosinophilic form of recurrent chronic allergic hypertrophic rhinosinusitis. AFS has distinct clinical, histopathological, and prognostic findings that differentiate it from other forms of sinusitis. The core pathogenesis and optimum treatment strategies remain debated. Concerns surround the use of immunotherapy for AFS because allergen-specific immunoglobulin G (IgG) induced by immunotherapy could theoretically incite a Gell and Coombs type III (complex mediated) reaction. Type I hypersensitivity is established by high serum levels of allergen-specific IgE to various fungal antigens and positive Bipolaris skin test results. Type III hypersensitivity is established by an IgG-mediated process defined by the presence of allergen-specific IgG that forms complexes with fungal antigen inducing an immunologic inflammatory response. These reveal the multiple immunologic pathways through which AFS can impact host responses. Recent literature establishing benefits of fungal immunotherapy and no evidence of type III-mediated reactions, severe local reactions, or delayed reactions, indicate that application of AFS desensitization is a reasonable therapeutic strategy for this difficult to manage entity. Our review should encourage further clinical acceptance of AFS desensitization because the existing literature on this subject shows benefits of fungal immunotherapy and no evidence of type III-mediated reactions, severe local reactions, or delayed reactions.

Diagnosing Aerodynamic Supraglottic Collapse With Rest and Exercise Flexible Laryngoscopy

OBJECTIVE Laryngomalacia is best known as a self-resolving infantile disorder characterized by inspiratory stridor with occlusion of the larynx by collapse of arytenoid tissues due to Bernoulli forces. Adult laryngomalacia has been sporadically described in the literature. We identified a series of patients with aerodynamic supraglottic collapse mimicking laryngomalacia in our Otolaryngology clinic. STUDY DESIGN Case series. METHODS/PATIENTS A series of five patients from our Otolaryngology clinic with aerodynamic supraglottic collapse presented with complaints ranging from noisy breathing to dyspnea with exertion. Diagnosis was made using rest and exercise flexible laryngoscopy. RESULTS Symptoms resolved in all patients who underwent traditional or modified supraglottoplasty. CONCLUSIONS These patients, all with abnormal corniculate/cuneiform motion occluding the airway during forceful inspiration, reinforce the diagnostic role of rest and exercise flexible laryngoscopy in patients with dyspnea and stridor. These results may suggest that aerodynamic supraglottic collapse is an underdiagnosed clinical entity.

Functional assessment of the ex vivo vocal folds through biomechanical testing: A review

The human vocal folds are complex structures made up of distinct layers that vary in cellular and extracellular composition. The mechanical properties of vocal fold tissue are fundamental to the study of both the acoustics and biomechanics of voice production. To date, quantitative methods have been applied to characterize the vocal fold tissue in both normal and pathologic conditions. This review describes, summarizes, and discusses the most commonly employed methods for vocal fold biomechanical testing. Force-elongation, torsional parallel plate rheometry, simple-shear parallel plate rheometry, linear skin rheometry, and indentation are the most frequently employed biomechanical tests for vocal fold tissues and each provide material properties data that can be used to compare native tissue to diseased or treated tissue. Force-elongation testing is clinically useful, as it allows for functional unit testing, while rheometry provides physiologically relevant shear data, and nanoindentation permits micrometer scale testing across different areas of the vocal fold as well as whole organ testing. Thoughtful selection of the testing technique during experimental design to evaluate a hypothesis is critical to optimize biomechanical testing of vocal fold tissues.

Characterization of Voice Disorders in Deployed and Nondeployed US Army Soldiers

OBJECTIVES/HYPOTHESIS To evaluate voice disorder differences between deployed and nondeployed US army soldiers. STUDY DESIGN Cross-sectional study. METHODS More than 1.3 million health records of active duty US army soldiers with no history of dysphonia were queried for voice disorder diagnoses over a 3.5-year period. A sample of 292 soldiers was further evaluated for known factors linked to dysphonia. RESULTS US army soldiers were 1.13 times more likely to have a diagnosis of dysphonia if they were deployed. Risk factors and exposures common to patients with dysphonia were not statistically different between deployed and nondeployed soldiers. Additionally, the type of dysphonia diagnosis was not significantly different between deployed and nondeployed soldiers. CONCLUSIONS US army soldiers deployed to war zones are more likely to be diagnosed with dysphonia. None of the reviewed parameters accounted for the difference in dysphonia rate between deployed and nondeployed soldiers, suggesting that occupational exposures of deployed soldiers account for the increase in the diagnoses of dysphonia.

Adjuvant Human Papillomavirus Vaccination for Secondary Prevention: A Systematic Review

Importance Human papillomavirus (HPV) vaccination is recommended for children and younger adults but not older adults or those with prior HPV exposure, leaving a large portion of the population at risk for HPV-mediated disease. Emerging data suggest a possible role for vaccination as an adjuvant treatment for individuals with HPV-related clinical disease. Objective To systematically review the literature regarding HPV vaccination for secondary disease prevention after treatment of active clinical disease across disease sites to serve as a platform for the management of HPV-related disease of the head and neck. Evidence Review A systematic search from August 3 to 21, 2015, of the PubMed, MEDLINE, EMBASE, CINAHL, Cochrane Library, Web of Science, Biosis Citation Index, Current Contents Connect, Scientific Library Online, and Global Health databases used PRISMA guidelines to identify 326 relevant articles related to adjuvant use of HPV vaccination. Primary search terms were (HPV vaccine OR human papillomavirus vaccine OR papillomarvirus vaccines OR alphapapillomavirus vaccine) AND (HPV OR human papillomavirus OR alphapapillomavirus OR papillomaviridae OR virus warts OR wart virus) AND (recurrence OR relapse OR reoccurrence OR recurrences OR relapses OR relapsing). Forty-five full texts in English were reviewed, with 19 articles included in the final review. In some studies, subpopulations of individuals with HPV DNA positivity and/or seropositivity were extracted for inclusion. Included studies were assessed for bias and separated based on the presence of active clinical disease or HPV DNA positivity or seropositivity. Findings Nineteen studies with 22 474 unique patients were included in the review. When HPV vaccination was used as an adjuvant treatment for active clinical disease, 9 of 12 studies reported decreased disease recurrence, decreased disease burden, or increased intersurgical interval. In contrast, none of the 7 studies of vaccination in individuals with HPV DNA positivity and/or seropositivity without clinical disease reported improved outcomes. Conclusions and Relevance Differences between adjuvant vaccination in HPV-mediated clinical disease and vaccination in HPV DNA–positive and/or HPV-seropositive populations posit underlying differences in disease and immune processes. These data suggest that additional evaluation of adjuvant HPV vaccination in individuals with active clinical disease is warranted.

Efficacy of nasal irrigations and nebulizations for nasal symptom relief.

Purpose of reviewTo review current literature regarding the use and utility of nasal saline irrigation in nasal and sinus diseases. Recent findingsNasal irrigations, in various forms, are a widely used and accepted means of treatment of the symptoms of chronic rhinosinusitis and other sinonasal disease processes. Over the past two decades, significant research has been done to evaluate the role of nasal irrigations in the treatment of sinonasal disease. The use of a high-volume, low-pressure system like a squeeze bottle remains the optimal delivery device. Although additional research is required for many of the additives discussed, the use of xylitol in chronic rhinosinusitis and topical fluconazole in allergic fungal sinusitis appear promising. SummaryUse of nasal saline irrigations can improve symptoms of sinonasal disease and may improve outcomes in certain settings. Ongoing research will continue to shape and optimize understanding of maximally effective nasal irrigations.

Approaching chronic sinusitis

Chronic sinusitis is a common disease that encompasses a number of syndromes that are characterized by sinonasal mucosal inflammation. Chronic sinusitis can be defined as two or more of the following symptoms lasting for more than 12 consecutive weeks: discolored rhinorrhea, postnasal drip, nasal obstruction, facial pressure or pain, or decreased sense of smell. Chronic sinusitis is further classified as chronic sinusitis with polyposis, chronic sinusitis without polyposis, or allergic fungal sinusitis using physical examination, and histologic and radiographic findings. Treatment methods for chronic sinusitis are based upon categorization of the disease and include oral and inhaled corticosteroids, nasal saline irrigations, and antibiotics in selected patients. Understanding the various forms of chronic sinusitis and managing and ruling out comorbidities are key to successful management of this common disorder.

Treatment of Neurogenic Cough with Tramadol: A Pilot Study

This study employs validated cough assessment tools to prospectively determine the impact of tramadol on cough severity and quality of life in subjects with neurogenic cough. The study was a prospective case series with planned data collection at a tertiary care academic medical center laryngology practice. Sixteen consecutive collected subjects with neurogenic cough prospectively completed pre- and posttreatment validated cough assessment tools, the cough severity index (CSI) and Leicester Cough Questionnaire (LCQ). All subjects in the study reported at least some improvement in their cough symptoms. In a Wilcoxon signed rank test that compared paired results, CSI scores improved from 23 to 14 and LCQ scores improved from 74 to 103 (P = .003 and P = .005, respectively). This small preliminary assessment suggests that tramadol warrants additional evaluation as a treatment for neurogenic cough.

SMAD3 expression and regulation of fibroplasia in vocal fold injury

Recent reports highlight the efficacy of small interfering RNA (siRNA) targeting SMAD3 to regulate transforming growth factor β (TGF‐β)‐mediated fibroplasia in vocal fold fibroblasts. The current study sought to investigate SMAD3 expression during wound healing in vivo and quantify the downstream transcriptional events associated with SMAD3 knockdown in vitro.

Current approaches to diagnosis and management of rhinitis.

Abstract Rhinitis affects >20% of the population and is a common reason patients visit their primary care physician. Proper therapeutic intervention initially requires differentiating rhinitis from acute and chronic rhinosinusitis. After establishing rhinitis as the etiology of a patient’s symptoms, a careful, thoughtful history and physical examination aids the cause. Rhinitis can be allergic, nonallergic, or mixed (having features of both allergic and nonallergic rhinitis). Therapeutic interventions vary, depending on the etiology of rhinitis. Symptoms that are refractory to avoidance and pharmacotherapy warrant referral to an allergist or otolaryngologist for consideration of immunotherapy or surgical intervention. In many cases, adhering to an evidence-based therapeutic treatment algorithm will allow physicians to effectively manage rhinitis.