Philip G. Harries

Mechanisms and mediators of nasal symptoms in non-allergic rhinitis.

Non‐allergic rhinitis may be a contributing factor in up to 60% of rhinitis patients and a sole contributor in a quarter. It is a highly heterogeneous condition with poorly understood pathophysiological mechanisms. Compelling evidence is emerging of a localized nasal mucosal allergic response in some non‐allergic rhinitic subjects in the absence of systemic atopy. While the inflammatory disease pathway in non‐allergic rhinitis may share some of the features of its allergic counterpart, overall the mechanisms remain unclear, and there are likely to be differences. In particular, symptoms of nasal congestion and rhinorrhoea tend to be more prominent and persistent in non‐allergic rhinitic patients compared with allergic rhinitis. Our aim is to review the literature relating to mechanisms and mediators of nasal symptoms in non‐allergic rhinitis. Better understanding of the underlying pathophysiological basis should enable the development of more accurate testing, and better targeted therapeutic options in the future.

Characterization of bacterial community diversity in chronic rhinosinusitis infections using novel culture-independent techniques

Background Chronic rhinosinusitis (CRS) with or without polyps is a common chronic upper airway condition of multifactorial origin. Fundamental to effective treatment of any infection is the ability to accurately characterize the underlying cause. Many studies have shown that only a small fraction of the total range of bacterial species present in CRS is detected through conventional culture-dependent techniques. Consequently, culture data are often unrepresentative of the true diversity of the microbial community within the sample. These drawbacks, along with the length of time required to complete the analysis, strongly support the development of alternative means of assessing which bacterial species are present. As such, molecular microbiological approaches that assess the content of clinical samples in a culture-independent manner could significantly enhance the range and quality of data obtained routinely from such samples. We aimed to characterize the bacterial diversity present in tissue and mucus samples taken from the CRS setting using molecular nonculture-dependent techniques. Methods Through 16S ribosomal RNA (rRNA) gene clone sequencing and terminal restriction fragment length polymorphism (T-RFLP) analysis, the bacteria present in 70 clinical samples from 43 CRS patients undergoing endoscopic sinus surgery were characterized. Results Bacterial T-RFLP profiles were generated for 70 of 73 samples and a total of 48 separate bands were detected. Species belonging to 34 genera were identified as present by clone sequence analysis. Of the species detected, those within the genera Pseudomonas, Citrobacter, Haemophilus, Propionibacterium, Staphylococcus, and Streptococcus were found numerically dominant, with Pseudomonas aeruginosa the most frequently detected species. Conclusion This study has validated the use of the culture-independent technique T-RFLP in sinonasal samples. Preliminary characterization of the microbial diversity in CRS suggests a complex range of common and novel bacterial species within the upper airway in CRS, providing further evidence for the polymicrobial etiology of CRS.

Use of the lymphocyte count as a diagnostic screen in adults with suspected epstein–barr virus infectious mononucleosis

Objectives/Hypothesis To evaluate the predictive diagnostic accuracy of the lymphocyte count in Epstein–Barr virus–related infectious mononucleosis (IM). Study Design Retrospective case note and blood results review within a university-affiliated teaching hospital. Methods A retrospective review of 726 patients undergoing full blood count and Monospot testing was undertaken. Monospot testing outcomes were compared with the lymphocyte count, examining for significant statistical correlations. Results With a lymphocyte count of ≤4 × 109/L, 99% of patients had an associated negative Monospot result (sensitivity of 84% and specificity of 94%). A group subanalysis of the population older than 18 years with a lymphocyte count ≤4 × 109/L revealed that 100% were Monospot negative (sensitivity of 100% and specificity of 97%). A lymphocyte count of ≤4 × 109/L correlated significantly with a negative Monospot result. Conclusions A lymphocyte count of ≤4 × 109/L appears to be a highly reliable predictor of a negative Monospot result, particularly in the population aged >18 years. Pediatric patients, and adults with strongly suggestive symptoms and signs of IM, should still undergo Monospot testing. However, in adults with more subtle symptoms and signs, representing the vast majority, Monospot testing should be restricted to those with a lymphocyte count >4 × 109/L. Level of Evidence NA Laryngoscope, 123:2401–2404, 2013To evaluate the predictive diagnostic accuracy of the lymphocyte count in Epstein–Barr virus–related infectious mononucleosis (IM).

Eustachian tube communicating with sphenoid sinus: report of a novel anatomical variant

Reports of congenital anomalies of the Eustachian Tube (ET) are scarce, and often associated with chromosomal abnormalities. We report a unique case of a completely bony left Eustachian tube which communicated with the sphenoid sinus. This report details these findings and discusses the potential embryological basis and implications of such an unusual anatomy, in the context of a comprehensive literature review.

A novel insight into the immunologic basis of chronic granulomatous invasive fungal rhinosinusitis

Background Chronic granulomatous invasive fungal rhinosinusitis (CGIFRS) is a rare disease. The underlying immune responses that drive the development of CGIFRS, as opposed to successful pathogen clearance and controlled inflammation, are not currently known. Objective To characterize the immune responses associated with CGIFRS. Methods In addition to a battery of basic investigations, more in-depth immunologic testing involves ex vivo whole-blood stimulation with the polyclonal T-cell mitogen phytohemagglutinin and fungal antigens with interleukin (IL) 12, was undertaken to investigate cell-mediated immune responses associated with CGIFRS. Results Ex vivo whole-blood stimulation with the polyclonal T-cell mitogen phytohemagglutinin and fungal antigens with IL-12 identified reduced interferon gamma and increased IL-17A levels within the supernatant, which indicated increased in vivo T-helper (Th)17 responses and impaired Th1 responses compared with healthy controls. Conclusion These findings suggest that the development of CGIFRS may be associated with an abnormally exaggerated host Th17 response, which caused failure to clear the fungal pathogen with refractory fungal infection of mucosal membranes, resulting in chronic tissue inflammation.

Use of the lymphocyte count as a diagnostic screen in adults with suspected epstein-barr virus infectious mononucleosis: Lymphocyte Count as Diagnostic Screen

Objectives/Hypothesis To evaluate the predictive diagnostic accuracy of the lymphocyte count in Epstein–Barr virus–related infectious mononucleosis (IM). Study Design Retrospective case note and blood results review within a university-affiliated teaching hospital. Methods A retrospective review of 726 patients undergoing full blood count and Monospot testing was undertaken. Monospot testing outcomes were compared with the lymphocyte count, examining for significant statistical correlations. Results With a lymphocyte count of ≤4 × 109/L, 99% of patients had an associated negative Monospot result (sensitivity of 84% and specificity of 94%). A group subanalysis of the population older than 18 years with a lymphocyte count ≤4 × 109/L revealed that 100% were Monospot negative (sensitivity of 100% and specificity of 97%). A lymphocyte count of ≤4 × 109/L correlated significantly with a negative Monospot result. Conclusions A lymphocyte count of ≤4 × 109/L appears to be a highly reliable predictor of a negative Monospot result, particularly in the population aged >18 years. Pediatric patients, and adults with strongly suggestive symptoms and signs of IM, should still undergo Monospot testing. However, in adults with more subtle symptoms and signs, representing the vast majority, Monospot testing should be restricted to those with a lymphocyte count >4 × 109/L. Level of Evidence NA Laryngoscope, 123:2401–2404, 2013To evaluate the predictive diagnostic accuracy of the lymphocyte count in Epstein–Barr virus–related infectious mononucleosis (IM).

Characterization of Bacterial Community Diversity in Chronic Rhinosinusitis Infections Using Novel Culture-Independent Techniques

Objective: Chronic rhinosinusitis (CRS) is a common condition involving a microbial component. Only a small fraction of the total range of bacterial species present in CRS is detected through conventional culture-dependent techniques. We aimed to characterize the bacterial diversity in CRS samples using the novel molecular technique TRFLP. Method: Through 16S ribosomal RNA (rRNA) gene clone sequencing and Terminal Restriction Fragment Length Polymorphism (TRFLP) analysis, the bacteria present in 70 clinical samples from 43 CRS patients undergoing endoscopic sinus surgery were characterized. Results: Bacterial TRFLP profiles were generated for 70 from 73 samples, and a total of 48 separate bands were detected. Species belonging to 34 genera were identified as present by clone sequence analysis. Of the species detected, those within the genera Pseudomonas, Citrobacter, Haemophilus, Propionibacterium, Staphylococcus, and Streptococcus were found to be numerically dominant, with Pseudomonas aeruginosa being the most frequently detected species. Conclusion: This study has validated the use of the culture-independent molecular technique TRFLP in sinonasal samples. Preliminary characterization of the microbial diversity in CRS suggests a complex range of common and novel bacterial species within the upper airway in CRS, providing further evidence for the polymicrobial etiology of this disease.

Fashioning of the dacryocystorhinostomy mucosal flap - a simple modification.

Sir, With advances in endoscopic sinus surgery, the dacryocystorhinostomy (DCR) procedure is increasingly being performed by rhinologists. Based on the principles of wide sac exposure and mucosal healing by primary intention, the powered endoscopic DCR described by Wormald is a well-established technique, with comparable success rates to external methods. One of the steps during the procedure involves trimming of the posteriorly-based DCR flap to create superior and inferior flaps to cover the areas of raw bone above and below the marsupialised sac. This step is usually performed towards the end of the procedure, after the lacrimal sac has been marsupialised and before lacrimal intubation (if required). It entails the use of paediatric through-biting Blakesely forceps (Medtronic Xomed, Jacksonville, FL, USA) or soft tissue scissors from the Skull Base set (Bellucci scissors) to remove most of the central part of the flap leaving the upper and lower limb of this flap the same thickness as the raw bone above and below the marsupialised sac. However, this step can often be technically challenging. Accurate fashioning of the flap can be difficult due to various factors including excessive flap mobility, poor surgical field – more likely towards the end of the procedure, and lack of suitably sharp instrumentation which can result in tearing or even loss of the flap altogether. The rationale for performing this step at a later stage in the procedure is the ability to determine the required width of the mucosal flaps by estimating the extent of raw bone above and below the sac. Our experience suggests that accurate trimming of the flap is often difficult, and that the size of the flaps does not appear to be crucial so long as they are present, with a degree of raw bone coverage almost always possible.