Monica O. Patadia

Evaluation of the presence of B-cell attractant chemokines in chronic rhinosinusitis

Background B-cell responses may play a role in the pathogenesis of nasal polyposis via local IgA and IgE production and activation of eosinophils and mast cells. B-cell attracting chemokines may therefore have relevance in the pathogenesis of chronic rhinosinusitis with nasal polyps (CRSwNPs) Methods Polyp and inferior turbinate tissues were obtained from CRSwNPs, CRS without NPs (CRSsNPs), and control patients; ELISA and reverse-transcription polymerase chain reaction were used to detect levels of protein and mRNAfor selected B-cell chemokines (B-cell attracting chemokine 1 [CXCL13/BCA-1/BLC]), thymus expressed chemokine (CCL25/TECK), mucosae-associated epithelial chemokine (CCL28/MEC), stromal cell–derived factor-1alpha (CXCL12/SDF-1alpha), and selected chemokine receptor genes (CXCR4, CXCR5, and CXCR7). Results BCA-1 and SDF-1alpha protein levels were significantly increased in polyp tissue compared with turbinate tissue from CRSsNP patients and controls (p < 0.05 and p < 0.01, respectively). Differences in TECK and MEC were not significant. For mRNA, expression of BCA-1 was significantly up-regulated in polyp tissue and levels correlated with CD20 mRNA expression. Additionally, significant up-regulation of mRNA for the SDF-1alpha receptors CXCR7 and CXCR4 was detected in polyps, while there was a trend for up-regulation of the BCA-1 receptor CXCR5. Conclusions Elevated levels of the BCA-1 and SDF-1alpha and their receptors may account for an increased presence of B cells and their products, contributing to eosinophilic inflammation in patients with CRSwNP.

Diagnosis of Nasal Airway Obstruction

Nasal airway obstruction is the source of significant patient discomfort and financial burden; hence, otolaryngologists encounter this symptom on an almost daily basis. This article provides a thorough yet concise summary of common and more specialized techniques that are instrumental in diagnosing nasal obstruction. The article begins with a brief overview of significant nasal anatomy and physiology. Ultimately, the main focus is on exploring the role of nasal endoscopy, radiographic imaging, acoustic rhinomanometry and other diagnostic tests that assist in the diagnosis of nasal airway obstruction.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis

Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).

Poor radiotherapy compliance predicts persistent regional disease in advanced head/neck cancer.

To determine if poor compliance to chemoradiation results in an increased rate of persistent neck disease.

Role of immunotherapy in allergic fungal rhinosinusitis

Purpose of review Our understanding of the pathogenesis and treatment of allergic fungal rhinosinusitis (AFRS) continues to evolve. This article serves to update the reader on the diagnosis and management of AFRS and pays particular attention to the recent literature regarding efficacy and safety of immunotherapy in this patient population. Recent findings The mainstay of treatment of AFRS remains a thorough surgery; however, adjunctive medical management is also critical to achieve optimal outcomes. Oral steroid use in AFRS remains recommended. Immunotherapy, both fungal and nonfungal, may be considered for patients exhibiting a type I hypersensitivity to specific allergens. To date, limited studies do show improvement with reduction of postoperative exacerbations and revision surgeries. There remains no evidence of unusual side-effects or formation of immune complexes from immunotherapy in AFRS patients. Double-blind placebo controlled trials on immunotherapy and AFRS are lacking, and ultimately, conclusive evidence of efficacy is not present to date. Summary Treatment of AFRS requires multimodality therapy with immunotherapy playing a significant, yet inconclusive, role. Further studies remain warranted.

Recurrent asystole as an electrocardiographic artifact during microdebrider use in functional endoscopic sinus surgery.

Introduction Electrocardiographic (EKG) artifacts can lead to unnecessary treatment and costly diagnostic workup. Two previous studies reported a ventricular tachycardia artifact as a result of microdebrider malfunction. In this study, we report the first case of EKG artifacts that mimick asystole from microdebrider use during functional endoscopic sinus surgery (FESS). Case A healthy 19-year-old woman presented with chronic rhinosinusitis, nasal polyposis, and a deviated nasal septum. She was scheduled for a bilateral FESS and septoplasty. During surgery, the microdebrider was changed after 1 hour. While using the second microdebrider, the EKG monitor showed three distinct asystolic events, all lasted approximately 3 seconds. The EKG tracing returned to normal sinus rhythm every time the microdebrider was stopped. The patients oxygen saturation remained at 100%, and blood pressure remained stable during the episodes. The procedure was aborted, and an extensive cardiology workup was performed, which returned negative results. Biomedical engineering investigated the microdebrider and found a far greater than expected chassis leak, which likely caused electrical interference. Six months later, the patient underwent a right-sided FESS and revision left frontal FESS. There were no EKG abnormalities during the second surgery. Discussion Although other EKG artifacts have been reported in the literature, this is the first case report of an artifact that mimicked asystole that stemmed from microdebrider use. Improved awareness of this potential EKG artifact for both the surgeon and the anesthesiologist may prevent an unnecessary costly workup.

Neurological Complications of Acute and Chronic Sinusitis

Purpose of ReviewAcute and chronic sinusitis can give rise to a wide array of intracranial and orbital complications. These complications include brain abscess, subdural empyema, epidural abscess, meningitis, venous sinus thrombosis, frontal bone osteomyelitis, and orbital cellulitis and abscess. Despite numerous medical advances, these complications carry a risk of mortality and significant morbidity.Recent FindingsRecent studies have shown improvement in both the mortality and the morbidity associated with the neurologic complications of acute and chronic sinusitis. However, there are still a large portion of patients with long-term sequelae, and the literature reports a morbidity rate of approximately 30%. The most common post-treatment morbidities include permanent changes in vision, seizures, and hemiparesis.SummaryAlthough the overall incidence of neurologic complications from a sinogenic source are rare, the potential long-term complications can be devastating making prompt diagnosis and treatment vital to improving outcomes.

Inhalant Allergy Evaluation in ENT Patients

Purpose of ReviewThe purpose of this article is to educate the reader on the current trends in the evaluation of allergic rhinitis, with a focus on inhalant allergy, in otolaryngic patients.Recent Findings and SummaryRecent literature emphasizes the need for a thorough history and physical examination that can lead the practitioner to a clinical diagnosis of allergic rhinitis. Looking at patient cues such as allergic shiners, the allergic salute, polypoid tissue on middle turbinate, tonsillar and adenoid hypertrophy, laryngeal edema, and patients with chronic suppurative otitis media or otitis media with mucopurulent drainage may lead to further diagnostic testing. Diagnostic testing should be determined on an individual basis dependent on their particular geographic location. Negative testing does not rule out allergen sensitivity, and patients should be treated based on their symptoms.

Outcomes of Patients Undergoing Endoscopic Endonasal Skull Base Surgery at a VA Hospital

Author Contributions: Drs Tarola and Zenati had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Tarola, Haime, Leissner, Zenati. Acquisition, analysis, or interpretation of data: All Authors. Drafting of the manuscript: Tarola, Haime, Gabany, Zenati. Critical revision of the manuscript for important intellectual content: Quin, Haime, Taylor, Leissner, Zenati. Statistical analysis: Tarola. Obtaining funding: Zenati. Administrative, technical, or material support: Haime, Gabany, Taylor, Leissner, Zenati. Study supervision: Quin, Gabany, Zenati.

Rhinosinusitis and Parotid Enlargement in a Young African American Man

AyoungAfricanAmericanmanpresentedwith a6-monthhistoryof nasal congestion, facial pressure, purulent rhinorrhea, and hypo-osmia that had not improved despite multiple coursesofantibiotics andsteroids.Hismedical historywassignificant for chronic rhinosinusitis, allergic rhinitis, andasthma, forwhichhetookfluticasonepropionateandsalmeterol (Advair) and albuterol. A review of systems revealed epiphora and ocular crusting for 4 months. Findings on nasal endoscopy includedbilateral turbinate hypertrophy and significant nasal crusting.A computed tomographic (CT) scanof the sinuses revealeddiffusemucosal thickening consistent with pansinusitis (Figure, A). All laboratory results from an autoimmune workup were normal for angiotensin-converting enzyme (ACE) level, antineutrophil cytoplasmic antibodies, antinuclear antibody, and immunoglobulin levels. He had a normal chest radiograph. The patient was lost to follow-up but returned several months later with 6weeks of progressive bilateral parotid swelling (Figure, B). His parotid glands were diffusely enlarged and tender, and his facial function was normal. Radiologically, nomasses or sialoliths were seen (Figure, C). His only associated symptomswere fevers and fatigue. A history of recent tuberculosis exposure was obtained. Test results for SSa/SSb levels, human immunodeficiency virus (HIV), polymerase chain reaction (PCR), mumps titers, rapid plasma reagin, amylase, cytomegalovirus PCR, and quantiferon testing were negative. A superficial parotid biopsy revealed noncaseating granulomatous inflammation (Figure, D). Parotid biopsy specimen D Axial postcontrast CT of neck C Preoperative photograph B Coronal noncontrast CT image A