Richard Louis Voegels

International Consensus Statement on Allergy and Rhinology: Rhinosinusitis

Isam Alobid, MD, PhD1, Nithin D. Adappa, MD2, Henry P. Barham, MD3, Thiago Bezerra, MD4, Nadieska Caballero, MD5, Eugene G. Chang, MD6, Gaurav Chawdhary, MD7, Philip Chen, MD8, John P. Dahl, MD, PhD9, Anthony Del Signore, MD10, Carrie Flanagan, MD11, Daniel N. Frank, PhD12, Kai Fruth, MD, PhD13, Anne Getz, MD14, Samuel Greig, MD15, Elisa A. Illing, MD16, David W. Jang, MD17, Yong Gi Jung, MD18, Sammy Khalili, MD, MSc19, Cristobal Langdon, MD20, Kent Lam, MD21, Stella Lee, MD22, Seth Lieberman, MD23, Patricia Loftus, MD24, Luis Macias‐Valle, MD25, R. Peter Manes, MD26, Jill Mazza, MD27, Leandra Mfuna, MD28, David Morrissey, MD29, Sue Jean Mun, MD30, Jonathan B. Overdevest, MD, PhD31, Jayant M. Pinto, MD32, Jain Ravi, MD33, Douglas Reh, MD34, Peta L. Sacks, MD35, Michael H. Saste, MD36, John Schneider, MD, MA37, Ahmad R. Sedaghat, MD, PhD38, Zachary M. Soler, MD39, Neville Teo, MD40, Kota Wada, MD41, Kevin Welch, MD42, Troy D. Woodard, MD43, Alan Workman44, Yi Chen Zhao, MD45, David Zopf, MD46

Endoscopic Ligature of the Sphenopalatine Artery for Severe Posterior Epistaxis

OBJECTIVE: To present our experience with endoscopic ligature of the sphenopalatine artery in the treatment of severe posterior epistaxis of patients who had previously undergone conservative procedures. METHODS: Eleven patients with severe posterior epistaxis were treated during a 25-month period with an endoscopic ligature of the sphenopalatine artery. The basic principle of the surgical technique is to identify the branches of the sphenopalatine artery through an endoscopic endonasal approach and to apply a titanium clip under direct vision. RESULTS: The endoscopic ligature of the sphenopalatine artery was performed unilaterally in 10 patients and bilaterally in 1 patient, with a total of 12 ligatures. It was possible to identify the sphenopalatine artery in all cases with a successful outcome using this surgical technique alone. CONCLUSION: Endonasal endoscopic ligature of the sphenopalatine artery has been an effective surgical technique for treating severe posterior epistaxis.

ICON: chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a public health problem that has a significant socio-economic impact. Moreover, the complexity of this disease due to its heterogeneous nature based on the underlying pathophysiology - leading to different disease variants - further complicates our understanding and directions for the most appropriate targeted treatment strategies. Several International/national guidelines/position papers and/or consensus documents are available that present the current knowledge and treatment strategies for CRS. Yet there are many challenges to the management of CRS especially in the case of the more severe and refractory forms of disease. Therefore, the International Collaboration in Asthma, Allergy and Immunology (iCAALL), a collaboration between EAACI, AAAAI, ACAAI, and WAO, has decided to propose an International Consensus (ICON) on Chronic Rhinosinusitis. The purpose of this ICON on CRS is to highlight the key common messages from the existing guidelines, the differences in recommendations as well as the gaps in our current knowledge of CRS, thus providing a concise reference. In this document we discuss the definition of the disease, its relevance, pharmacoeconomics, pathophysiology, phenotypes and endotypes, genetics and risk factors, natural history and co-morbidities as well as clinical manifestations and treatment options in both adults and children comprising pharmacotherapy, surgical interventions and more recent biological approaches. Finally, we have also highlighted the unmet needs that wait to be addressed through future research.

Prevalence of chronic rhinosinusitis in Sao Paulo

BACKGROUND Glucocorticoids (GCs) are considered drugs of choice for treating nasal polyps (NPs). However, a subset of patients shows a limited clinical response even to high doses of GCs. Altered expression of glucocorticoid receptors (GRs), namely GR-alpha; and GR-beta;, is a potential mechanism underlying GC insensitivity. GCs modulate the expression of several cytokines, including transforming growth factor-beta (TGF-beta), which may contribute to cellular proliferation in NPs. The study investigates some biomolecular features of GC-resistant NPs, and examines possible differences from normal mucosa (NM). METHODOLOGY Radioligand binding assay (binding) was used to determine GR-alpha; binding capacity; Western blotting was used to evaluate GR-alpha;, GR-beta;, and TGF-beta; expression and GR-alpha; subcellular distribution. NPs were sampled in 32 patients during ethmoidectomy; NM was taken from 15 healthy patients during rhinoplasty. RESULTS GR-alpha; was present in NPs and NM, with lower affinity for the ligand in NPs. GR-alpha; was prevalent in the cytosol of NPs that were GR-alpha-negative to the binding assay. GR-beta was expressed in NPs and absent in the majority of NM. TGF-beta1 expression was higher in NPs than in NM. CONCLUSIONS GR-beta and TGF-beta1 might be involved in NP pathogenesis, but their role in modulating GC sensitivity is still unclear.INTRODUCTION Studies designed to investigate chronic rhinosinusitis (CRS) epidemiology play an important role to assess population`s distribution and risk factors to result in the development and promotion of public health policies. METHOD This study design is a survey carried out with a complex two-stage cluster sampling plan. Personal interviews were carried out with 2,003 individuals. The questionnaire included the epidemiological criteria for CRS. Demographic data, history of physician-diagnosed respiratory diseases (asthma, sinusitis, rhinitis), smoking, family income, educational attainment, and household characteristics were also evaluated. RESULTS The overall response rate was 93.9% of the households. Mean age was 39.8 +- 21 years; 45.33% were male. The overall prevalence of CRS in the city of Sao Paulo was 5.51%. We found a significant association between diagnosis of CRS and diagnosis of asthma and CRS and diagnosis of rhinitis and a significant association between presence of CRS and belonging to the low-income subgroup. CONCLUSION The municipality of Sao Paulo has an urban population of 11 million. According to the present study, the prevalence of CRS is 5.51%, which represents more than 500,000 individuals affected by this condition in the city.

Severe Posterior Epistaxis–Endoscopic Surgical Anatomy

Objective: To describe the anatomy of the sphenopalatine foramen (SPF) region and possible anatomical variations.

Endoscopic ligation of the anterior ethmoidal artery: a cadaver dissection study

UNLABELLED Anterior ethmoidal artery (AEA) ligation may be necessary in cases of severe epistaxis not controllable with traditional therapy. Endoscopic endonasal ligation of the AEA is not used frequently; there are few studies in the literature for standardization of the endoscopic technique for this vessel. AIM To demonstrate the feasibility of periorbital AEA ligation in a transethmoidal endoscopic approach. METHODS A prospective study where 50 nasal cavities were dissected. After anterior ethmoidectomy and partial removal of lamina papyracea, the periorbital area was carefully dissected along a subperiosteal plane to identify the AEA. The vessel was exposed within the orbit and dissected. RESULTS Data on technical difficulties, complications, the learning curve and anatomical variations were gathered. CONCLUSION An endonasal endoscopic approach to the AEA within the orbit was shown to be feasible. Identifying the artery is not difficult, and this technique avoids external incisions. This approach appears to be an excellent alternative for approaching the AEA. Further clinical studies are needed to demonstarte the benefits of this technique.

Nasal polyposis and allergy: is there a correlation?

Nasal polyposis (NP) is a chronic inflammatory disease of the nasal mucosa. The etiology and formation of NP are still not elucidated and have been debated for many years. The objective of the present study was to investigate the role of nasal allergy in the development of NP. The following aspects were analyzed: age, sex, and patients symptoms; correlation between asthma, aspirin intolerance, and NP; serum immunoglobulin levels and eosinophil; and concentration of interleukins 1β, 3, and 4 in NP. Thirty-nine patients with NP were selected, 13 of them allergic and 26 non-allergic. A control group of 11 individuals was also studied. The concentrations of interleukins 1β, 3, and 4 were measured by enzyme-linked immunosorbent assay (ELISA). There was a higher incidence of NP after the fourth decade of life and among men. We found no correlation of asthma or aspirin intolerance with the presence or absence of allergy. Serum levels of IgE and eosinophils were significantly higher in patients with allergy and NP and the concentrations of interleukins 3 and 4 were positively correlated with NP. There was no difference in interleukin 3 and 4 concentration between the non-allergic group with NP and the control group, suggesting that these interleukins do not play an important role in the etiology and formation of NP. These results suggest that the immunologic pathway involved in the etiology of NP is different from the one correlated with allergy (IgE-mediated).

Biofilms in Chronic Rhinosinusitis with Nasal Polyps

Objective. (1) Evaluate the presence of biofilms in patients with chronic sinusitis with nasal polyps (CRSwNP) and (2) investigate the association of biofilm presence and CRSwNP. Study Design. Cross-sectional study. Setting. University-based tertiary care center. Subjects and Methods. The study group consisted of 33 consecutive patients undergoing functional endoscopic sinus surgery for CRSwNP. The control group consisted of 27 control patients undergoing septoplasty for nasal obstruction without diagnosis of chronic sinusitis. Mucosal samples were harvested intraoperatively for scanning electron microscopic examination to determine biofilm presence. Statistical analysis was performed. For all statistical tests, P = .05 was considered significant. Results. Biofilms were found in 24 (72.7%) of the 33 patients with CRSwNP and in 13 (48.1%) of the 27 septoplasty patients (odds ratio = 2.87; 95% confidence interval, 0.98-8.42; P = .051). Conclusion. (1) Biofilms were present in patients undergoing functional endoscopic sinus surgery for CRSwNP and also in controls without chronic sinusitis. This suggests that biofilms may not be sufficient to cause chronic sinusitis without other cofactors. Host factors could be the responsible for the pathogenesis of biofilms. (2) Although the prevalence of biofilms in patients with CRSwNP was not significantly different from that in the controls, the extremely wide 95% confidence interval, which is just below unity, suggests that a meaningful clinical difference may have been missed because of low statistical power. Further studies are necessary.

Rabdomiossarcoma de cabeça e pescoço: 24 casos e revisão da literatura

O rabdomiossarcoma (RMS) e o tumor maligno de partes moles mais comum na infância, localizando-se principalmente na cabeca e pescoco. Apresenta comportamento clinico-biologico variado, devendo receber terapia individualizada. OBJETIVO: Descrever os dados de pacientes portadores de RMS de cabeca e pescoco diagnosticados e tratados em um hospital comparando-os aos da literatura. Forma de Estudo: Descritivo retrospectivo. MATERIAL E METODO: Analise retrospectiva de dados de prontuarios de 24 pacientes portadores de RMS de cabeca e pescoco diagnosticados e tratados em um hospital no periodo de 1994 a 2008. RESULTADOS: A media de idade foi de 7,79 anos. Quanto ao sexo, encontramos 54,17% do sexo masculino e 45,83% do sexo feminino. Todos os pacientes foram submetidos a quimioterapia (QT), sendo que 62,5% destes tambem realizaram radioterapia (RT) e 16,67% foram submetidos a cirurgia. Dos 24 pacientes, 8 (33,3%) foram a obito, 6 (25%) encontravam-se livres de neoplasia e 2 ( 8,3%) apresentaram recidiva do tumor. CONCLUSAO: O RMS de cabeca e pescoco frequentemente se apresenta com sintomas inespecificos. Terapia multimodal individualizada deve ser realizada, incluindo cirurgia, quimioterapia e radioterapia.

Antibiotics in septoplasty: is it necessary?

UNLABELLED The use of antibiotics is a common practice among otorhinolaryngogists for surgical procedures. The majority of the American Rhinology Society members uses post-operative antibiotics routinely in septoplasties, which is considered unnecessary by many authors. AIM To study the real necessity of the antibiotic usage in septoplasties, as well as the main post-operative complications described in the literature. STUDY DESIGN clinical prospective with transversal cohort. MATERIAL AND METHOD We studied prospectively 35 patients who were undergone to septoplasty with or without turbinectomy, in the Clinical Hospital of the University of São Paulo. The patients were split in three groups: Group A: without antibiotics; Group B: antibiotics (cefazolin) only during the anesthesic induction; Group C: antibiotics both in the anesthesic induction and post-operatively for seven days. A questionnaire was applied in the immediate post-operatory, in the 7th post-operative day and in the 30th post-operative day asking for bleeding, fever, pain, nausea, vomits and followed by physical and endoscopic evaluation looking for hematoma, septal abscess and purulent secretion which as quantified. RESULT We do not observed significative difference among the groups concerning to pain, fever, nausea, vomits, bleeding and purulent secretion. None of the patients had hematoma or septal abscess. The groups also do not differ in respect to the quantity of purulent secretion. CONCLUSION The nasal surgeries are clean contamined and do not need antibioticprophilaxy because of the low infection risk.