Jeb M. Justice

Outcomes of Sinonasal Cancer Treated With Proton Therapy

PURPOSE To report disease outcomes after proton therapy (PT) for sinonasal cancer. METHODS AND MATERIALS Eighty-four adult patients without metastases received primary (13%) or adjuvant (87%) PT for sinonasal cancers (excluding melanoma, sarcoma, and lymphoma). Common histologies were olfactory neuroblastoma (23%), squamous cell carcinoma (22%), and adenoid cystic carcinoma (17%). Advanced stage (T3 in 25% and T4 in 69%) and high-grade histology (51%) were common. Surgical procedures included endoscopic resection alone (45%), endoscopic resection with craniotomy (12%), or open resection (30%). Gross residual disease was present in 26% of patients. Most patients received hyperfractionated PT (1.2 Gy [relative biological effectiveness (RBE)] twice daily, 99%) and chemotherapy (75%). The median PT dose was 73.8 Gy (RBE), with 85% of patients receiving more than 70 Gy (RBE). Prognostic factors were analyzed using Kaplan-Meier analysis and proportional hazards regression for multiple regression. Dosimetric parameters were evaluated using logistic regression. Serious, late grade 3 or higher toxicity was reported using the National Cancer Institute Common Terminology Criteria for Adverse Events, version 4. The median follow-up was 2.4 years for all patients and 2.7 years among living patients. RESULTS The local control (LC), neck control, freedom from distant metastasis, disease-free survival, cause-specific survival, and overall survival rates were 83%, 94%, 73%, 63%, 70%, and 68%, respectively, at 3 years. Gross total resection and PT resulted in a 90% 3-year LC rate. The 3-year LC rate was 61% for primary radiation therapy and 59% for patients with gross disease. Gross disease was the only significant factor for LC on multivariate analysis, whereas grade and continuous LC were prognostic for overall survival. Six of 12 local recurrences were marginal. Dural dissemination represented 26% of distant recurrences. Late toxicity occurred in 24% of patients (with grade 3 or higher unilateral vision loss in 2%). CONCLUSIONS Dose-intensified, hyperfractionated PT with or without concurrent chemotherapy results in excellent LC after gross total resection, and results in patients with gross disease are encouraging. Patients with high-grade histology are at greater risk of death from distant dissemination. Continuous LC is a major determinant of survival justifying aggressive local therapy in nearly all cases.

Evidence that human papillomavirus causes inverted papilloma is sparse.

Controversy exists regarding the pathogenesis of inverted papilloma as it relates to the involvement of human papillomavirus (HPV). The purpose of this report is to describe the prevalence of HPV in nondysplastic, “early inverted papilloma” and to summarize HPV detection rates in the general population and in other HPV related neoplasia.

Recalcitrant Rhinosinusitis, Innate Immunity, and Mannose-Binding Lectin:

Background: Mannose-binding lectin (MBL) is a protein produced by the liver that participates in innate immunity by tagging the surface of microbes for opsonization. Mannose-binding lectin deficiency is present in 7% of the population and has been implicated in recurrent respiratory tract infections in children. Mannose-binding lectin deficiency has not been explored in rhinosinusitis but is associated with increased mortality in adult pneumococcal infection. The purpose of this report is to describe a tertiary rhinology patient experience with MBL deficiency and recalcitrant rhinosinusitis. Methods: This retrospective case series report characterizes predominantly adult patients with low MBL levels from January 2010 to June 2012. Indications for MBL testing, sinus culture data, immunological testing results, and treatments used to control rhinosinusitis are described. Results: Mannose-binding lectin levels were deficient in 12 of 36 patients (33.3%) tested. IgG subclasses were abnormally low in 5 of 12 patients; IgA was normal in 11 of 12 patients; and IgM was normal in 11 of 12 patients. Staphylococcus aureus, coagulase-negative Staphylococcus species, and Pseudomonas aeruginosa, known to be “tagged” by MBL, were the most common organisms grown on culture. Treatments included culture directed systemic antimicrobial therapy and topical steroids/antibiotics. Conclusion: Mannose-binding lectin, an important component of the lectin complement pathway and innate immunity, is possibly associated with recalcitrant adult rhinosinusitis. Steroid/antibiotic irrigations appear to benefit patients with recalcitrant rhinosinusitis and possibly those with MBL deficiency. Given that the prevalence of MBL deficiency in this case series is 4 times that seen in the normal population, additional investigations are warranted to further elucidate the role of MBL deficiency in rhinosinusitis.

Clinically Significant Rhinosinusitis Can Be Asymptomatic.

junior surgeon and the tutor can see the same magnified images during surgery, thus facilitating the tutoring. Using a common surgical microscope instead, the surgeon benefits by 3-dimensional images, whereas the observers have a 2-dimensional view. The microscope therefore offers to the surgeon an immediate depth perception that the endoscope lacks. However, movements of the endoscope allow perception of a relative positional anatomy, which can minimize this limitation. Like all other endoscopic procedures, endoscopic surgery of the ear requires practice to develop the necessary handeye coordination and skills. Even though M&T is a relatively simple procedure, we recommend avoiding it in difficult cases at the beginning of the learning curve. We agree that a narrow, very tortuous ear canal or the presence of osteomas may represent a challenging anatomic condition. Therefore, in these cases, we recommend to perform M&T using the technique with which the surgeon is more confident. Paradoxically, M&T in children could be easier than in adults because the child’s ear canal, though narrower, is shorter and straighter than that of adults, thus facilitating endoscopic surgery. Regarding intraoperative bleeding, even though this aspect could limit the endoscopic approach, we were not penalized by using a 1-hand technique. Indeed, complete control of the surgical field and reduced bleeding, typical of this procedure, limit the need to use the suction tip, allowing the surgeon to operate with the right hand without difficulty while the left hand supports the endoscope. Finally, we totally agree with Dr Bakshi regarding a need of a larger prospective randomized trial comparing microscopic and endoscopic techniques for M&T.

Progressive Left Nasal Obstruction and Intermittent Epistaxis

A man in his 20s presented to a tertiary rhinology center in southwestern Florida with a 3-month history of progressive left nasal obstruction and intermittent epistaxis. Two years previously, the man had similar presenting symptoms at an outside facility and was treated with surgery to excise a sinonasal mass. He did not have any visual changes, pain, or purulent nasal discharge. He reported no olfactory impairment. He was originally from Bangladesh but had moved to the United States 6 years earlier. In-office flexible fiberoptic nasal endoscopy revealed a soft, friable polypoid mass with a strawberry-like appearance originating from the lateral nasal wall and filling the left nasal cavity (Figure, A). Computed tomography of the sinuses revealed a left nasal cavity mass without bony destruction or paranasal sinus involvement (Figure, B). The patient underwent endoscopic sinus surgery on the left side, where complete surgical excision of the mass was performed along with electrocautery of attachment sites. The mass was found to have multiple attachments surrounding the maxillary sinus ostium and mucosa overlying the lacrimal bone. Pathologic evaluation revealed squamoid-type mucosa with large, thick-walled sporangia with numerous endospores. Also present was an exuberant mixed inflammatory infiltrate consisting of polymorphonuclear leukocytes, plasma cells, and lymphocytes (Figure, B and C). What is your diagnosis? A B

Comparison between the Sinus and Gut Microbiome in Patients with Chronic Sinus Disease

Objectives: Associations between the gut microbiome and various non-GI related diseases have been detailed in recent studies. This investigation aims to directly compare the gut and sinus microbes in patients with chronic sinus disease and in control patients to determine if any link exists between the sinus and gut microbiota. Methods: This was a prospective study conducted from February 2016 to August 2017. It was conducted at a tertiary care academic rhinology practice on 16 patients undergoing rhinologic surgery. The primary outcome measure was to determine if any overlap exists between the gut and sinus microbiome in a given subject. A secondary outcome was to assess the effect of prior antibiotic therapy on the diversity of the gut microbiome. Results: There were 7 patients with chronic rhinosinusitis (CRS) with polyps, 6 patients with CRS without polyps and 3 control patients. Only one patient demonstrated an overlap of sinus and gut microbiotia. In patients receiving a reduced number of antibiotic courses over the past 24 months (0 or 1 course), there was a mean of 7.7 (SD 2.2) gut bacteria isolated from stool samples. In patients receiving more antibiotic courses (2+ courses), there was a mean of 5.1 (SD 2.3) gut bacteria isolated. This difference reached statistical significance (p=0.043). Conclusion: Minimal overlap between the sinus and gut microbiome was demonstrated, but further studies are needed to elucidate this potential association. This study supports the theory that antibiotics tend to reduce microbial diversity in the gastrointestinal tract.

Significant orbital and intracranial complications from balloon sinus dilation as a stand-alone and powered dissector-assisted procedure: Balloon Complications

Chronic rhinosinusitis is one of the most common chronic conditions affecting millions of people in the United States every year. Balloon sinus dilation is a minimally invasive intervention that was introduced as a possible alternative to endoscopic sinus surgery (ESS). In select patients, balloon dilation has been advocated as a relatively safe procedure with comparable efficacy to traditional ESS. Over the past 12 months, significant intracranial and intraorbital complications have been observed on five patients who underwent balloon sinus dilation as a stand‐alone procedure, as well as what could be termed a power dissector‐assisted balloon dilation procedure, obviating the need for a wide sinusotomy or any significant ethmoid surgery, which are typically performed to establish anatomical landmarks before the introduction of power instruments into dependent sinus cavities. Laryngoscope, 2455–2459, 2018