Jun Myung Kang

Rhinocerebral Mucormycosis: consideration of prognostic factors and treatment modality.

OBJECTIVES Rhinocerebral mucormycosis is rare, rapidly progressive, potentially life-threatening disease, and it usually occurs in immunocompromised patients. We present our clinical experience with 12 cases and we attempt to identify the prognostic features and proper treatment protocols. PATIENTS AND METHODS All the cases of mucormycosis were proven by histology or culture. The prognosis was analyzed according to the predisposing factors, including underlying disease, extent of disease and surgical intervention. RESULT The overall mortality rate in our series was 33.3%. 7 of the 10 operated patients recovered, while 1 of the 2 non-operated patients expired. The associated conditions included diabetes mellitus (n=9) and hematological disease (n=3). A poor prognosis was primarily related with uncontrolled underlying disease. Other associated prognostic factors were the extent of disease including orbital or intracranial extension. Surgical debridement is essential for a good prognosis, but timely intervention and complete aggressive debridement are not always needed in all patients. The patient who had slowly progressive disease also survived after conventional medical management and limited surgical debridement, including orbital preservation. CONCLUSION Control of the underlying predisposing illness along with prompt parenteral administration of amphotericin B and aggressive surgical debridement remain the essential treatments even today. Contrary to this, as described in this study, for the patients with slowly progressive disease, the aggressive surgical debridement is spared, and a successful result may be obtained with the conventional management, including medical treatment and timely limited surgical intervention.

An anatomic study using three-dimensional reconstruction for pterygopalatine fossa infiltration via the greater palatine canal

The pterygopalatine fossa (PPF) is accessed via the greater palatine canal (GPC) in an attempt to reduce bleeding during paranasal sinus surgery. This study aims to investigate the anatomy of the greater palatine foramen (GPF), GPC, and the PPF, with reference to PPF infiltration using three‐dimensional reconstruction of computer tomographic (CT) scan measurements. The CT scans of 50 patients were retrospectively evaluated. The morphology of the GPF, GPC, and the PPF was assessed in a three‐dimensional model. The thickness of the mucosa over the GPF was evaluated in the parasagittal plane. The mean length of the GPC was 13.8 ± 2.0 mm, and the mean height of the PPF was 21.0 ± 3.4 mm. The mean angles of the GPC in relation to the hard palate and the PPF were 67.4° ± 6.9° and 159.8° ± 7.1°, respectively. The GPF was 16.2 ± 1.3 mm lateral to the sagittal plane of the posterior nasal spine (PNS) and 6.1 ± 1.7 mm anterior to the coronal plane of the PNS. The mean volume of the PPF was 1039.9 ± 280.0 mm3. The mean thickness of the mucosa overlying the GPF was 10.7 ± 1.8 mm. We recommend that the PNS may be used as the bony landmark to locate the position of the GPF during PPF infiltration. The needle delivering the anesthetic should be bent 25 mm from the tip at a 45° angle, and a 1‐ml injection of anesthetic should be administered in adults. Clin. Anat. 24:576–582, 2011.

Effect of oral tolerance in a mouse model of allergic rhinitis

Objective: Induction of oral tolerance (OT) is known to prevent allergic inflammation in models of asthma. This study investigated the preventive effect of OT and airway remodeling in a mouse model of allergic rhinitis (AR). Study Design: An in vivo study using an animal model. Setting: Catholic Research Institutes of Medical Science. Methods: Forty six-week-old, female BALB/c mice were divided into four groups: control, AR, low-dose OT, and high-dose OT. To induce OT, mice were fed ovalbumin (OVA) before sensitization with OVA/aluminum hydroxide, 1 mg for six days in the low-dose OT group and a 25 mg single dose in the high-dose OT group. Mice in the AR group were fed phosphate-buffered saline. After sensitization followed by challenges with OVA during six weeks, nasal behaviors, interleukin (IL)-13 and interferon gamma (IFN-γ) levels in nasal lavage (NAL) fluids, as well as OVA-specific IgE levels in serum, were measured. The degree of goblet cell hyperplasia and thickness of lamina propria were observed in nasal tissues by periodic acid-Schiff and Massons trichrome stain. A P value < 0.05 was accepted as statistically significant. Results: Both OT groups showed a significant decrease in inflammatory cells, IL-13 and IFN-γ in NAL fluids, as well as OVA-specific IgE levels in serum compared with the AR group. In addition, the degree of goblet cell hyperplasia and thickness of lamina propria were attenuated in both OT groups compared with the AR group. Further, these alterations did not differ significantly between the two OT groups. Conclusion: These results suggest that OT may effectively reduce allergic inflammation as well as airway remodeling in a mouse model of AR.

Toll like Receptor 3 & 4 Responses of Human Turbinate Derived Mesenchymal Stem Cells: Stimulation by Double Stranded RNA and Lipopolysaccharide

Background and objectives Multipotent mesenchymal stromal cells (MSCs) represent a promising cell-based therapy for a number of inflammatory or autoimmune diseases. Herein, Toll like receptor (TLR) expression by MSCs and their immune regulatory roles are investigated. In this study, we investigated the influence of TLR on the immune response, proliferation, and differentiation potential of human turbinated MSC (hTMSC) cultures in vitro. Subjects and Methods After isolating hTMSCs from discarded inferior turbinate tissue, FACS analysis was used to assess the expression of TLRs such as TLR2, TLR3, TLR4, and TLR5 in hTMSCs and cell proliferation was assessed using a cell counting kit (CCK)-8. Cytokine and chemokine secretions were analyzed with multiplex immunoassays for IL-1α, IL-1β, IL-4, IL-6, IL-8, IL-10, IL-12, IP-10 (CXCL10), RANTES (CCL5), TNF-a, GM-CSF, and IFN-γ. The differentiation potential of hTMSCs was evaluated in the osteogenic, chondogenic, and adipogeinc media and analyzed by histology and gene expression related to differentiation. Results FACS analysis revealed that TLR3 and TLR4 expression consisted of a relatively high percentage of the surface proteins expressed by hTMSCs. The proliferation of hTMSCs was influenced and significantly increased by the presence of TLR4 agonists. In particular, hTMSCs produced a set of cytokines and chemokines and the expression of IL-6, IL-8, IL-12, IP-10 (CXCL10), RANTES (CCL5), TNF-α, and GM-CSF were up-regulated in response to the TLR4 agonist LPS. The osteogenic and adipogeinc differentiation potential of hTMSCs was not affected by TLR agonists. Conclusions We conclude that TLR4 stimulation affects TLR expression, proliferation, and the immunomodulation potential of hTMSCs. Understanding the mechanism behind TLRs influence on hTMSCs and their immunomodulating properties would be useful for providing a novel target to exploit in the improvement of stem cell-based therapeutic strategies.

The efficacy of gabapentin/pregabalin in improving pain after tonsillectomy: A meta-analysis

Gabapentin and pregabalin are useful for treating neuropathic pain because of their antiallodynic and antihyperalgesic properties, which may be beneficial in managing acute postoperative pain. The goal of this meta‐analysis was to perform a systematic review of the literature on the effect of gabapentinoids on postoperative pain following tonsillectomy, and its adverse effects in patients.

Anatomical analysis of nasal obstruction: nasal cavity of patients complaining of stuffy nose.

To evaluate the relationship between subjective symptoms of nasal obstruction and the corresponding nasal anatomical parameters using paranasal computed tomography (PNS CT).

Three-dimensional computed tomography analysis to help define an endoscopic endonasal approach of the pterygopalatine fossa.

Background The pterygopalatine fossa (PPF) can be entered endoscopically, but the endoscopic landmarks to localize the bony structures in the PPF are not well described. This study aimed to investigate the anatomy of the sphenopalatine foramen (SPF), vidian canal (VC), and foramen rotundum (FR) with regard to an endoscopic endonasal approach to the PPF using three-dimensional reconstruction of computed tomography (CT) scans. Methods The CT scans of 98 patients were retrospectively evaluated. The morphology of the SPF, VC, and FR as well as the spatial relationship between the SPF and VC were measured on a three-dimensional model. Results The mean diameters of the SPF, VC, and FR were 5.3 ±1.3 mm, 2.4 ± 0.7 mm, and 2.8 ± 0.5 mm, respectively. The mean distance between the VC and posteroinferior margin of SPF was 3.8 ± 1.0 mm. The mean vertical and horizontal distances on the surface plane of sphenoid bone between the VC and FR were 5.8 ± 1.9 mm and 8.5 ± 1.9 mm, respectively. The whole or partial margin of the VC was above the inferior margin of the SPF in 92% (180/196) of the VC and lateral to the posterior margin of the SPF in 98% (195/196) of the VC. The distance between the VC and SPF had a positive correlation with the distances between the VC and FR. Conclusion The endoscopic endonasal approach to the PPF will be performed with greater accuracy and safety through comprehension of the spatial relationships between the SPF, VC, and FR.

A comparative analysis of intranasal volume and olfactory function using a three-dimensional reconstruction of paranasal sinus computed tomography, with a focus on the airway around the turbinates

The aim of this study was to investigate the relationship between the intranasal airway around the turbinates and olfactory function. In total, 32 nostrils of 16 patients who were awaiting septal surgery were involved in this study. For measurements of the volume of the nasal cavity, paranasal sinus computed tomography scans were performed and reconstructed into three-dimensional images. The Butanol Threshold Test and Cross-Cultural Smell Identification Test were used to evaluate olfactory function. The results were analyzed with Pearson’s test. The volume around the turbinates was significantly correlated with the olfactory threshold. However, olfactory identification had no significant correlation with each volume. The airway around the turbinates is very important for nasal airflow and its volume influences olfactory function. Understanding such relationships may help in preserving or improving olfactory function in septal, turbinate or sinus surgery. Further studies are needed regarding the relationships between not only the volume of the nasal cavity and nasal airflow, but also between nasal volume changes and olfactory function.

Do sinus computed tomography findings predict olfactory dysfunction and its postoperative recovery in chronic rhinosinusitis patients

Background Olfactory dysfunction secondary to chronic rhinosinusitis (CRS) is a mixed disorder of conductive and sensorineural olfactory impairment. Although endoscopic sinus surgery has some beneficial effects on olfaction, the outcomes are challenging to predict. The aim of this study was to assess the olfactory outcomes after surgery, to investigate the correlation between the severity of regional computed tomography (CT) findings and olfactory performance, and to identify the predictors of postoperative outcomes based on unilateral olfactory threshold analysis. Methods This study included 167 CRS nostrils of 97 patients with/without polyps (68/99 nostrils) undergoing sinus surgery between January 2007 and December 2011. Olfactory function was evaluated using the butanol threshold test (BTT) before and 6 months after surgery. Clinical and nasal factors from sinus CT scan (sinuses, ostiomeatal complex, olfactory cleft [OC], nasal polyps, and unilateral Lund-Mackay CT score) were analyzed to correlate them with pre- and postoperative olfactory performances. Results Eighty-two percent of the CRS nostrils had anosmia or hyposmia. After surgery, 42% of them showed an improvement in BTT score. Despite improvement, most of the subjects remained with residual hyposmia. The BTT scores deteriorated after surgery in 23% of the total subjects. The disease severity of the OC, posterior ethmoid, and frontal sinus were the significant risk factors for CRS-related anosmia. The strongest risk factor for anosmia was totally obstructed OC (odds ratio [OR], 16.56; 95% CI, 4.31-63.71; p = 0.000). The nostrils with anosmia or partly opacified anterior ethmoid benefited from surgery with respect to olfaction. Conclusion Our results can give support to the combined use of the butanol threshold and sinonasal CT findings in the evaluation of olfaction in CRS patients and help us counsel the patients about the likelihood of postoperative olfactory recovery.

Characteristics of Human Turbinate-Derived Mesenchymal Stem Cells Are Not Affected by Allergic Condition of Donor

The characteristics of mesenchymal stem cells (MSCs) derived from human turbinates (hTMSCs) have not been investigated in allergic rhinitis. We evaluated the influence of allergic state of the donor on the characteristics, proliferation, and differentiation potential of hTMSCs, compared with hTMSCs derived from non-allergic patients. hTMSCs were isolated from five non-allergic and five allergic patients. The expression of toll-like receptors (TLRs) in hTMSCs was measured by FACS, and cell proliferation was measured using a cell counting kit. Cytokine secretion was analyzed using multiplex immunoassays. The osteogenic, chondrogenic, and adipogenic differentiation potentials of hTMSCs were evaluated by histology and gene expression analysis. In allergic patients, FACS analysis showed that TLR3 and TLR4 were more highly expressed on the surface of hTMSCs than TLR2 and TLR5. The proliferation of hTMSCs was not influenced by the presence of TLR priming. The expression of IL-6, IL-8, IL-12, IP-10, and RANTES was upregulated after the TLR4 priming. The differentiation potential of hTMSCs was not influenced by TLR priming. These characteristics of hTMSCs were similar to those of hTMSCs from non-allergic patients. We conclude that the allergic condition of the donor does not influence TLR expression, proliferation, or immunomodulatory potential of hTMSCs.