Mohannad Al-Qudah

High prevalence of humoral immunodeficiency patients with refractory chronic rhinosinusitis

Background The purpose of this study was to investigate the prevalence and contribution of humoral immunodeficiency in refractory chronic rhinosinusitis (RCRS). This study was performed at a tertiary care academic referral center. Methods RCRS patients who had at least three episodes of documented sinusitis in the previous year despite antibiotic therapy, who had endoscopic sinus surgery performed at University of Iowa Health Care (UIHC), and who were evaluated by the UIHC Adult Immune Disorder Clinic were included. Exclusion criteria included allergic fungal sinusitis, human immunodeficiency virus, and other causes of secondary immunodeficiency. Sixty-seven patients fulfilled the inclusion and exclusion criteria. The results of their immunologic evaluation for atopy and humoral immune function were examined. Results The average age of these patients was 50 years (±11.6 years). Twenty-eight (42%) patients had at least one positive result on allergy skin testing. Determination of quantitative immunoglobulins showed low IgG in 9%, low IgA in 3%, and low IgM in 12% of patients. Common variable immunodeficiency was diagnosed in one case. Immunoglobulin G subclasses were tested in 31 cases and found low in 6 patients. Fifty-one patients underwent a dynamic assessment of their antibody response by examining the increase in antibody titer to an unconjugated pneumococcal polysaccharide vaccine. Sixty-seven percent of patients failed to produce more than a fourfold increase in postimmunization antibody titer for >7 of 14 serotypes being tested and were considered to have functional antibody deficiency. Conclusion This retrospective review shows an unexpectedly high prevalence of humoral immune dysfunction in patients with RCRS. These findings suggest that assessment of immune function should be undertaken routinely in RCRS. Immune assessment should first include measurement of serum immunoglobulin levels; if these are normal, then functional antibody responses should be evaluated.

The relationship between anatomical variations of the sino-nasal region and chronic sinusitis extension in children

OBJECTIVE To report the prevalence of paranasal sinus anatomic variations and their relationship with the extent of chronic sinusitis in pediatric population. METHOD This is a prospective study of all the cases of persistent pediatric chronic sinusitis despite medical therapy that presented to the otolaryngology clinics of King Abdullah University Hospital in Irbed, Jordan, and had coronal computed tomography examination of the nose and paranasal sinuses as part of their diagnostic or preoperative work up, between the periods of April 2006 and August 2007. Sixty-five cases met inclusion criteria and were analyzed. Cases were further subdivided into three groups according to age. Group 1: with ages from 5 to 7 years; group 2: ages 8-12; and group 3: above 12 years. The scans were analyzed for the presence of anatomical variations, and disease extension. Correlation between anatomical variations and disease extension was the primary outcome measure. RESULTS There were 30 boys and 35 girls with an average age of 11.4 (age ranges from 5 to 16). The maxillary sinus was the most commonly involved sinus, followed by the ethmoid, sphenoid, and frontal sinuses. Agger nasi cell was the most common anatomical variation, followed by concha bullosa of middle turbinate. The frequency of most of these variants differed widely between groups 1 and 2, groups 1 and 3, but not between groups 2 and 3. No significant correlation was found between these anatomical variants and the extent of chronic sinusitis. CONCLUSION Anatomical variations in the nose and paranasal sinuses are common in children with chronic sinusitis. Although the prevalence of these variations changes during childhood development they are unlikely to predict the extent and severity of chronic rhinosinusitis in pediatric age group.

Acute adult supraglottitis: current management and treatment.

Acute adult supraglottitis can be a serious, life-threatening disease because of its potential for sudden upper airway obstruction. Symptoms and signs of this disease may be nonspecific and may resemble those of upper respiratory tract infection. Unexplained sore throat with tenderness of the anterior neck over the hyoid bone warrant careful examination by flexible laryngoscopy to rule out laryngeal congestion and edema. Laboratory tests are usually not helpful in picking up the diagnosis. Following diagnosis, patients should be hospitalized, started on intravenous antibiotics and their airway closely monitored, as airway obstruction may develop.

Endoscopically guided chitosan nasal packing for intractable epistaxis.

Background The purpose of this study was to evaluate the effectiveness and safety of endoscopically guided chitosan packing in controlling intractable epistaxis. A prospective case series was performed. Methods This is a prospective clinical study conducted in a tertiary rhinology fellowship training hospital between January 2009 and November 2009. The study population consisted of patients with intractable epistaxis that failed to respond to traditional anterior–posterior nasal packing using either a 10-cm Pope PVA Merocel or a Rapid-Rhino. The bleeding site was identified using a nasal endoscope and controlled using a pack made of a ChitoFlex chitosan dressing wrapped around a polyvinyl acetal nasal sponge. Results The intent-to-treat population consisted of 20 severe epistaxis subjects (8 men and 12 women) who continued to bleed despite traditional anterior–posterior nasal packing. The mean age was 67 years (±19 years). Sixteen subjects were on antiplatelets and/or anticoagulants. Eleven subjects (55%) presented with anterior epistaxis, and 7 subjects (35%) presented with posterior epistaxis. Chitosan nasal packing was performed on an outpatient basis and resulted in effective and immediate hemostasis in 19/20 subjects (95%). One subject had persistent bleeding after the first packing attempt and was successfully repacked within 30 minutes. Time to complete cessation of bleeding was 3.6 ± 2.2 minutes in the 19 subjects; the pack was removed after 48 hours, without any evidence of rebleeding or any serious side effects. Conclusion Endoscopically guided chitosan packing is a safe, effective, and well-tolerated outpatient treatment for the management of intractable epistaxis.

Modified osteoplastic flap approach for frontal sinus disease.

Objectives: We review the use and outcomes of osteoplastic flap surgery in the current era of almost entirely endoscopic management of frontal sinus disease. Methods: A retrospective review was performed of 312 consecutive sinus surgeries performed for frontal sinus disease at the University of Iowa Hospitals and Clinics from July 2002 to July 2008. Results: Seventeen subjects (10 men and 7 women; mean age, 56 years) were identified. The indications for osteoplastic flap surgery were laterally located mucoceles in 8 patients, tumors in 7 patients, and osteomyelitis in 2 patients. Ten patients had skull base erosion, and 5 underwent cranialization for large posterior frontal bone defects. The average blood loss was 175 mL, and the average hospital stay was 3 days. There were no major intraoperative or perioperative complications. Two patients with mucoceles required revision surgery for disease recurrence. The mean follow-up was 25 months (range, 6 to 66 months). Conclusions: Osteoplastic flap surgery is an uncommon procedure in the modern endoscopic era of sinus surgery. In our series it was most commonly indicated for laterally located disease. Osteoplastic flap surgery is relatively safe and effective for a wide range of recalcitrant and complicated frontal sinus disorders.

Role of Dexamethasone in Reducing Pain After Endoscopic Sinus Surgery in Adults: A Double-Blind Prospective Randomized Trial

Objectives: We sought to study postoperative pain after endoscopic sinus surgery and to evaluate the efficacy of dexamethasone sodium phosphate in reducing pain and rescue analgesic requirements. Methods: In a prospective, double-blind, placebo-controlled clinical trial, 62 patients with chronic rhinosinusitis who were undergoing general anesthesia for endoscopic sinus surgery were randomized to receive either 8 mg (2 mL) of intravenous dexamethasone sodium phosphate or 2 mL of saline solution at the time of induction of anesthesia. After surgery, the patients were observed for 24 hours and were given 1 g of acetaminophen every 6 hours. Pain severity was reported immediately and 6 and 24 hours after surgery on a 10-cm visual analog scale. The need for rescue analgesia with tramadol hydrochloride was recorded and compared between the two groups. Results: The two groups were matched by demographic data, clinical indications, and intraoperative details. The average postoperative pain severity scores at the 3 time intervals were 3.6, 2, and 1 in the dexamethasone group and 3.6, 2.5, and 1.6 in the saline solution group. These differences were not statistically significant. Ten patients in the dexamethasone group required rescue analgesia, compared to 12 in the saline solution group. The average patient required 0.53 doses of rescue analgesic in the dexamethasone group, versus 0.67 doses in the saline solution group. Again, these differences were not statistically significant. Conclusions: Dexamethasone injection at the time of induction of general anesthesia is not superior to placebo in controlling early postoperative pain in patients who undergo endoscopic sinus surgery.

Endoscopic sphenopalatine ganglion blockade efficacy in pain control after endoscopic sinus surgery.

The objective of this study was to evaluate the efficacy of bilateral endoscopic injection of lidocaine with epinephrine in the sphenopalatine ganglion at the end of endoscopic sinus surgery (ESS) in controlling postoperative pain and rescue analgesic requirements.

Image-Guided Sinus Surgery in Sinonasal Pathologies With Skull Base/Orbital Erosion.

Objective:The aim of the study was to review the use and outcomes of image-guided sinus surgery (IGSS) in sinonasal pathologies with skull base/orbital erosion without intracranial or intraorbital extension. Method:A retrospective charts and medical records review was performed for 474 consecutive sinonasal surgeries performed by a single surgeon at tertiary, academic center from August 2010 to December 2013. Result:Fourteen subjects (mean age 27 years; 8 men and 6 women) were identified. Mucocele and tumor were the most common pathological indication for IGSS use in this case series. Orbital wall erosion was detected in 57%, skull base in 29%, and both sites in 14%. The average blood loss was 80 mL, the average operative time was 190 minutes, and the average hospital stay was 3 days. There was no major intra- or postoperative complications. Two patients required revision endoscopic sinus surgery. The mean follow-up was 14 months (range 8–36 months). Conclusion:Image-guided sinus surgery alone is safe and effective procedure for a variety of sinonasal pathologies with orbital and skull base erosion.

Efficacy of lidocaine with or without epinephrine in rigid nasal endoscopy.

Background This study evaluates if there is any benefit of adding epinephrine to lidocaine in patients undergoing diagnostic rigid nasal endoscopy. A prospective, randomized, double-blinded study was performed. Methods Seventy patients were randomized to receive either 2% lidocaine or 2% lidocaine with 0.2% epinephrine before rigid nasal endoscopy examination. Patients were asked to report the intensity of pain and discomfort they experienced using visual analog scale. An endoscopist recorded the ease to perform the procedure using the same scale. Intranasal structures visualized were also reported. Results There were no significant differences in pain, discomfort or ease of exam, or in the percentage of visualized nasal structures between the two groups. In the whole series, there were no significant differences in the studied variables based on gender or indication to perform endoscopy. Conclusion Adding epinephrine to lidocaine has no advantages in patients undergoing diagnostic rigid nasal endoscopy.

Multimodality topical therapy for refractory chronic rhinosinusitis: our experience in thirteen patients with and twelve patients without nasal polyps.

experience in thirteen patients with and twelve patients without nasal polyps Shikani, A.H.,* Kourelis, K., Alqudah, M.A., Shikani, H.J., Cope, E., Kirk, N.,** Bergstedt, D.,** Basaraba, R.J.** & Leid, J.G. *Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Department of Otolaryngology-Head and Neck Surgery, UnionMemorial Hospital, Baltimore,MD,USA, JordanUniversity of Science&Technology, Irbid, Jordan, Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA, Center for Microbial Genetics andGenomics, NorthernArizonaUniversity, Flagstaff, AZ,USA, and **Department ofMicrobiology Immunology andPathology, Colorado State University, Fort Collins, CO, USA