Jim Bartley

Therapeutic ultrasound as treatment for chronic rhinosinusitis: preliminary observations.

BACKGROUND Bacterial biofilms have been implicated in the pathogenesis of chronic rhinosinusitis. In the laboratory setting, ultrasound is effective in disrupting such biofilms; however, few clinical studies have evaluated the role of therapeutic ultrasound in chronic rhinosinusitis. OBJECTIVE This study was performed to investigate the short-term effectiveness of therapeutic ultrasound as a treatment modality for chronic rhinosinusitis. METHODS Twenty-two patients with a positive history of chronic rhinosinusitis, according to the criteria set out by the Rhinosinusitis Task Force, together with a previous computed tomography scan compatible with a diagnosis of chronic rhinosinusitis, and who had failed previous, aggressive medical management, were treated with therapeutic pulsed ultrasound at 1 MHz two to three days per week for six sessions. Patients completed an assessment of individual sinus symptom severity and the 20-Item Sino-Nasal Outcome Test questionnaire before treatment, prior to session four and after completion of session six. RESULTS Two patients were unable to complete the study protocol. After completion of session six, 18 patients had experienced improvement in symptoms, while two patients noted a worsening of symptoms. Median percentage improvement of the total overall symptom score was 16.7 per cent (Wilcoxon signed rank, p < 0.001). The 20-Item Sino-Nasal Outcome Test score improved by 34.1 per cent (Wilcoxon signed rank, p < 0.0001). CONCLUSION This study demonstrated a significant improvement in chronic rhinosinusitis symptoms after a six-session course of pulsed ultrasound therapy. Treatment with ultrasound alone or combined with antibiotics may provide a strategy to target biofilms on the sinus mucosa. Therapeutic ultrasound warrants further investigation as a potential treatment modality for chronic rhinosinusitis.

Could glial activation be a factor in migraine

Migraine represents a central neural hypersensitivity. During an attack, migraine sufferers can be hypersensitive to normal levels of sound, light, smell and movement. Sensory processing dysfunction in the brain stem or diencephalic nuclei has been implicated. Most scientific migraine research has focused on neuronal function because of their central role in the processing, integration and transmission of sensory information. However the supporting glia, their receptors and their secreted mediators are now recognised as having an important role in neuronal function regulation. Activated microglia and astrocytes produce and release a variety of neuroexcitatory substances including nitric oxide, excitatory amino acids and proinflammatory cytokines. Spinal glial activation and the subsequent release of proinflammatory mediators initiate and maintain a range of enhanced pain states. The focus on neuronal function has ignored the potential contribution of glial cell activation to neural hypersensitivity and pain. If the central neuronal hypersensitivity associated with migraine represents glial cell activation, drugs that block glial cell activation and the subsequent release of neuroexcitatory substances could have therapeutic potential in both acute migraine treatment and migraine prophylaxis.

Ultrasound as a treatment for chronic rhinosinusitis

Bacteria are now recognised as existing in two forms--free floating (planktonic) or in sophisticated communities called biofilms. Bacteria within biofilms are difficult to culture and highly refractory to antibiotic treatment. Biofilms could explain some of the paradoxes associated with chronic rhinosinusitis. Many patients are refractory to antibiotic therapy, bacteriology culture swabs frequently do not grow bacteria and positive bacteriology swabs often do not correlate with clinical findings. As antibiotics are largely ineffective in the treatment of bacterial biofilms, alternative therapeutic strategies including blocking molecular communication (quorum sensing) between bacteria, inhibiting biofilm matrix production and interventions that damage bacterial membranes are being explored as treatment options. So far these approaches have been largely unproductive. While physical therapies such as short wave diathermy and therapeutic ultrasound have been advocated as treatments for rhinosinusitis for many years, critical evaluation of these therapeutic interventions is virtually non-existent. Until recently any benefit has been difficult to explain using conventional microbiological paradigms. However, in the laboratory setting ultrasound enhances the killing of bacteria in biofilms both in vitro and in animal models. The successful application of ultrasound to sinus disease could mean the development of a new paradigm in our treatment of chronic rhinosinusits, a reduction in antibiotic resistance and improved medical management with a subsequent reduction in surgical intervention.

Post herpetic neuralgia, schwann cell activation and vitamin D.

While the underlying pathophysiology of herpes zoster infection has been well characterised, many of the mechanisms relating to the subsequent development of post herpetic neuralgia (PHN) remain uncertain. The dorsal horn atrophy and reduction in skin innervation seen in PHN patients does not adequately explain many clinical features or the efficacy of a number of topical treatments. In the central nervous system the glia, their receptors and their secreted signalling factors are now known to have a major influence on neural function. In the peripheral nervous system, schwann cell activation in response to infection and trauma releases a number of neuroexcitatory substances. Activation of the nervi nervorum in the peripheral nervous system also leads to the release of calcitonin gene related peptide, substance P and nitric oxide. Schwann cell and/or nervi nervorum activation could be an additional mechanism of pain generation in PHN. Such a paradigm shift would mean that drugs useful in the treatment of glial cell activation such as naloxone, naltrexone, minocycline, pentoxifyllline, propentofylline, AV411 (ibudilast) and interleukin 10 could be useful in PHN. These drugs could be used systemically or even topically. High dose topical vitamin D would appear to offer particular promise because vitamin D has the ability to both reduce glial inflammation and reduce nitric oxide production.

Does milk increase mucus production

Excessive milk consumption has a long association with increased respiratory tract mucus production and asthma. Such an association cannot be explained using a conventional allergic paradigm and there is limited medical evidence showing causality. In the human colon, beta-casomorphin-7 (beta-CM-7), an exorphin derived from the breakdown of A1 milk, stimulates mucus production from gut MUC5AC glands. In the presence of inflammation similar mucus overproduction from respiratory tract MUC5AC glands characterises many respiratory tract diseases. beta-CM-7 from the blood stream could stimulate the production and secretion of mucus production from these respiratory glands. Such a hypothesis could be tested in vitro using quantitative RT-PCR to show that the addition of beta-CM-7 into an incubation medium of respiratory goblet cells elicits an increase in MUC5AC mRNA and by identifying beta-CM-7 in the blood of asthmatic patients. This association may not necessarily be simply cause and effect as the person has to be consuming A1 milk, beta-CM-7 must pass into the systemic circulation and the tissues have to be actively inflamed. These prerequisites could explain why only a subgroup of the population, who have increased respiratory tract mucus production, find that many of their symptoms, including asthma, improve on a dairy elimination diet.

Could Vitamin D Have a Potential Anti-Inflammatory and Anti-Infective Role in Bronchiectasis?

Bronchiectasis is a chronic infective and inflammatory respiratory disease that causes significant morbidity and mortality. Patients with non-cystic-fibrosis bronchiectasis are frequently vitamin D deficient, and vitamin D levels correlate with disease severity. Infection-specific actions of vitamin D include the enhancement of innate immunity and the moderation of inflammation caused by the adaptive immune response. Potentially, vitamin D could influence the processes that lead to bronchiectasis and the frequency and severity of acute exacerbations. Randomized trials of vitamin D supplementation have shown effects that are likely to be protective against the development of bronchiectasis. Several issues need to be clarified before the development of clinical trials to investigate the role of vitamin D in bronchiectasis. These include an optimal vitamin D supplementation dose and appropriate and sensitive outcome measures that include assessment of exacerbation frequency and severity, lung function, and health-related quality of life.

Model demonstrates functional purpose of the nasal cycle

BackgroundDespite the occurrence of the nasal cycle being well documented, the functional purpose of this phenomenon is not well understood. This investigation seeks to better understand the physiological objective of the nasal cycle in terms of airway health through the use of a computational nasal air-conditioning model.MethodA new state-variable heat and water mass transfer model is developed to predict airway surface liquid (ASL) hydration status within each nasal airway. Nasal geometry, based on in-vivo magnetic resonance imaging (MRI) data is used to apportion inter-nasal air flow.ResultsThe results demonstrate that the airway conducting the majority of the airflow also experiences a degree of ASL dehydration, as a consequence of undertaking the bulk of the heat and water mass transfer duties. In contrast, the reduced air conditioning demand within the other airway allows its ASL layer to remain sufficiently hydrated so as to support continuous mucociliary clearance.ConclusionsIt is quantitatively demonstrated in this work how the nasal cycle enables the upper airway to accommodate the contrasting roles of air conditioning and the removal of entrapped contaminants through fluctuation in airflow partitioning between each airway.

Prevalence of Vitamin D Deficiency Among Patients Attending a General Otolaryngology Clinic in South Auckland

Objectives: We performed a prospective observational study to estimate the prevalence of vitamin D deficiency in patients attending a general otolaryngology clinic in South Auckland, New Zealand. Methods: From July 21, 2008, to August 7, 2008, all new patients presenting to otolaryngology clinics at which one of the authors (D.R.) was present had their vitamin D status assessed by measurement of their plasma 25-hydroxyvitamin D [25(OH)D] level. Results: Of 48 patients, 2% had 25(OH)D levels of 17.5 nmol/L or less (a level associated with osteomalacia), 58% had 25(OH)D levels of 50 nmol/L or less (a level associated with vitamin D deficiency), and 100% had 25(OH)D levels of 80 nmol/L or less. Conclusions: Most of the patients attending a general otolaryngology clinic in South Auckland are vitamin D–deficient. It is unclear whether low vitamin D levels are associated more directly with otolaryngological disorders or skin type, because the small size of this study and the broad range of conditions seen precluded a meaningful statistical analysis. Further research into the relationship of vitamin D to specific otolaryngological presentations is required.

Higher serum 25(OH)D concentration is associated with lower risk of chronic otitis media with effusion: a case–control study

Vitamin D supplementation and higher 25(OH)‐vitamin D concentration are associated with reduced risk of acute respiratory infection. This study examined whether there is a similar association between higher serum 25(OH)D concentration and lower risk of chronic otitis media with effusion (COME).

Nasal airway responses to nasal continuous positive airway pressure breathing: An in-vivo pilot study

The nasal cycle, through variation in nasal airflow partitioning, allows the upper airway to accommodate the contrasting demands of air conditioning and removal of entrapped air contaminants. The purpose of this study was to investigate the influence of nasal continuous positive airway pressure (nCPAP) breathing has on both nasal airflow partitioning and nasal geometry. Using a custom-made nasal mask, twenty healthy participants had the airflow in each naris measured during normal nasal breathing followed by nCPAP breathing. Eight participants also underwent magnetic resonance imaging (MRI) of the nasal region during spontaneous nasal breathing, and then nCPAP breathing over a range of air pressures. During nCPAP breathing, a simultaneous reduction in airflow through the patent airway together with a corresponding increase in airway flow within the congested nasal airway were observed in sixteen of the twenty participants. Nasal airflow resistance is inversely proportional to airway cross-sectional area. MRI data analysis during nCPAP breathing confirmed airway cross-sectional area reduced along the patent airway while the congested airway experienced an increase in this parameter. During awake breathing, nCPAP disturbs the normal inter-nasal airflow partitioning. This could partially explain the adverse nasal drying symptoms frequently reported by many users of this therapy.