Joel Guss

Methacholine Challenge Testing in the Diagnosis of Paradoxical Vocal Fold Motion

Objective: The purpose of this study was to determine whether methacholine challenge testing (MCT) combined with serial laryngoscopy could elicit and visualize paradoxical vocal fold motion (PVFM) during asymptomatic periods and suggest laryngeal dysfunction as an etiology of episodic dyspnea.

Olfactory Dysfunction in Allergic Rhinitis

Background: Olfactory dysfunction in patients with allergic rhinitis has long been thought to be secondary to coexisting chronic rhinosinusitis and polyposis with obstruction of airflow over the olfactory epithelium. Recent evidence suggests that the allergic inflammatory infiltrate may itself affect olfaction in the absence of mucosal hypertrophy. Objective: We undertook a study to determine olfactory function in patients with allergic rhinitis in the presence and absence of chronic sinusitis. Methods: Fifty-one subjects with symptoms of rhinitis who presented for allergy testing were administered the University of Pennsylvania Smell Identification Test. In addition each patient underwent computed tomography (CT) scanning of the sinuses. Results: Eighty percent of subjects were allergic. Subjects with allergic rhinitis and no evidence of sinusitis scored on average in the 30th percentile (95% CI 20–40th percentile) on objective olfactory testing compared to age- and gender-specific norms. Half the allergic patients were classified as normosmic, while half had some degree of hyposmia. Conclusions: Our study demonstrates that even in the absence of mucosal disease on CT scan, a significant subset of patients with allergic rhinitis will exhibit hyposmia, mostly to a mild or moderate degree. The pathophysiology and potential treatments for olfactory loss in these patients should be further explored.

Fluoroquinolone-Resistant Pseudomonas aeruginosa in Chronic Rhinosinusitis

Background:Pseudomonas aeruginosa is cultured in nearly 1 of 5 patients with chronic rhinosinusitis and a history of sinus surgery. Fluoroquinolones are the only enterally administered antibiotics with efficacy against P. aeruginosa, but their frequent empiric use in the community raises concern for a rise in resistance. Objective: It was the aim of this study to determine the prevalence of fluoroquinolone-resistant P. aeruginosa in a tertiary rhinology practice. Methods: All bacterial sinus culture results from the outpatient otolaryngology clinic that yielded P. aeruginosa over a 5-year period (2002–2007) were reviewed along with the medical records of a randomly selected subset of patients. Results: In total, 689 culture results of 324 patients were examined. Nearly all patients had a history of endoscopic sinus surgery. Of all P. aeruginosa cultured, 13% were resistant to levofloxacin and 5% were intermediately sensitive, while 5% were resistant to ciprofloxacin and 7% intermediately sensitive. Of the 324 patients in the study, 19 and 15% had a history of a P. aeruginosa culture resistant to levofloxacin or ciprofloxacin, respectively. Mucoid strains of P. aeruginosa were significantly more likely to be fluoroquinolone resistant. No patient comorbidities were associated with a higher rate of resistance. The prevalence of resistant cultures remained stable over the 5-year study period. Conclusions:P. aeruginosa is cultured primarily in patients with previous sinus surgery. Nearly 20% of isolates are resistant to fluoroquinolones. Resistance to levofloxacin is more common than resistance to ciprofloxacin. This study supports the use of culture-directed therapy in the management of the postfunctional endoscopic sinus surgery patient and the avoidance of empiric use of fluoroquinolones.

Botulinum Neurotoxin for Head and Neck Disorders

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Oromandibular Dystonia in Cerebrotendinous Xanthomatosis

She was treated with speech therapy and serial titrated electromyography-guided BTX injections (Figure 5). A maximum of 15 units of BTX were administered to each of the external pterygoid muscles and 5 units of toxin were administered to each anterior belly of the digastric muscles. Following chemodenervation of these muscles, the patient experienced decreased frequency, intensity, and duration of the dyskinesias. Her speech articulation and fluency improved. Her ability to masticate and swallow both solids and liquids improved, although she remained PEG dependent. She is currently working with a nutritionist to maximize her oral caloric intake, with the goal of reducing or eliminating her PEG dependence. Oromandibular dystonia (OMD) is a neurologic disorder characterized by involuntary movements of the masticatory, lingual, and pharyngeal muscles. Oral pharmacologic agents have limited efficacy in alleviating the symptoms of OMD. OMD complicated by recurrent temporomandibular joint dislocation has previously been described in a patient with CTX4. BTX is a safe and effective treatment for OMD5. In addition to directly weakening the affected muscles, some authors suggest that BTX also modulates inhibitory and excitatory intracortical pathways6.

Adjunctive Surgical Therapies in the Treatment of Rhinosinusitis

Rhinosinusitis refers to any inflammatory condition of the nose and paranasal sinuses. Although the terms rhinitis and sinusitis are often used independently, the term rhinosinusitis reflects an understanding that most pathological processes will affect the entire mucous membrane of the nose and sinuses. Rhinosinusitis represents a heterogeneous group of diseases and is the end result of a myriad of pathophysiological processes that include infection, allergy, autoimmunity, environmental exposure, structural abnormalities, hormonal effects, and genetic disease. The interaction of multiple processes in each individual patient further complicates the understanding and management of the disease. Rhinosinusitis is very common. Approximately 32 million adults in the United States received a diagnosis of rhinosinusitis in 1998, reflecting 16% of the adult population [1]. Approximately 40 million Americans are estimated to be affected by allergic rhinitis each year, with half of these experiencing symptoms during 4 or more months of the year [2]. The direct health care costs associated with the management of sinusitis in the United States exceed

Antibiotic-resistant Staphylococcus aureus in community-acquired pediatric neck abscesses

6 billion annually [1]. The indirect cost of rhinosinusitis, including missed days of work or school and decreased productivity while at work, may far exceed even this number. Further, these figures do not account for the costs of treating possible complications of rhinosinusitis such as asthma, otitis media, and sleep-disordered breathing. Rhinosinusitis also has a profound impact on quality of life that has long been overlooked. For example, in 2006 a large-scale survey of patients with allergic rhinitis found that 40% thought the disease impacted their life a “moderate amount” or “a lot” [3]. While nasal congestion, postnasal drip, rhinorrhea, and headache were labeled “extremely bothersome” by the largest number of subjects, the psychosocial morbidity of the disease appeared to be great as well. Forty-four percent of patients claimed they were frequently tired during allergy season, while 29% and 13%, respectively, frequently felt miserable and depressed.