Steven D. Pletcher

Sinus microbiome diversity depletion and Corynebacterium tuberculostearicum enrichment mediates rhinosinusitis.

Enrichment of Corynebacterium tuberculostearicum caused by depletion of the sinus microbiome contributes to chronic rhinosinusitis. Nosing in on Chronic Sinusitis If the frequency of ads for sinus-clearing drugs tells us anything, sinusitis is a widespread problem that directly affects an individual’s quality of life. Indeed, chronic rhinosinusitis (CRS), which is defined as sinusitis lasting longer than 12 weeks, affects more than 30 million Americans. CRS is characterized by persistent mucosal inflammation and microbial infection, which can be expected to perturb the mucosal microbiota; however, the contribution of sinus microbiota to CRS remains unclear. Now, Abreu et al. identify both a potential pathogenic species that is more prevalent in CRS patients than in healthy controls as well as a bacterial candidate that may protect against this pathogenic species. The authors performed comparative microbiome profiling of patients with CRS and healthy controls. They found reduced bacterial diversity in the CRS patients, with specific depletion of lactic acid bacteria and a relative increase in Corynebacterium tuberculostearicum. In a murine model, C. tuberculostearicum contributed to the development of sinusitis in the absence of a normal microbiota. Moreover, Lactobacillus sakei was sufficient to protect against C. tuberculostearicum–induced sinusitis, even when the microbiome was depleted. If these effects are consistent in humans, L. sakei may serve as a new therapeutic for CRS. Persistent mucosal inflammation and microbial infection are characteristics of chronic rhinosinusitis (CRS). Mucosal microbiota dysbiosis is found in other chronic inflammatory diseases; however, the relationship between sinus microbiota composition and CRS is unknown. Using comparative microbiome profiling of a cohort of CRS patients and healthy subjects, we demonstrate that the sinus microbiota of CRS patients exhibits significantly reduced bacterial diversity compared with that of healthy controls. In our cohort of CRS patients, multiple, phylogenetically distinct lactic acid bacteria were depleted concomitant with an increase in the relative abundance of a single species, Corynebacterium tuberculostearicum. We recapitulated the conditions observed in our human cohort in a murine model and confirmed the pathogenic potential of C. tuberculostearicum and the critical necessity for a replete mucosal microbiota to protect against this species. Moreover, Lactobacillus sakei, which was identified from our comparative microbiome analyses as a potentially protective species, defended against C. tuberculostearicum sinus infection, even in the context of a depleted sinus bacterial community. These studies demonstrate that sinus mucosal health is highly dependent on the composition of the resident microbiota as well as identify both a new sino-pathogen and a strong bacterial candidate for therapeutic intervention.

Complications and the time to repair of mandible fractures

Objective: Treatment delays in the operative management of mandible fractures are often unavoidable. We were interested in determining whether delays increased the incidence of complications in these patients.

Microdebrider eustachian tuboplasty: A preliminary report

Objective To evaluate microdebrider eustachian tuboplasty for treatment of patients with eustachian tube dysfunction. Study Design A prospective study of 20 patients with eustachian tube dysfunction who underwent microdebrider eustachian tuboplasty (mETP) was performed at an academic medical center. Surgery involved use of a microdebrider to remove hypertrophied mucosa from the posterior eustachian tube cushion. All patients had concurrent sinonasal disease and underwent endoscopic sinus surgery at the time of mETP. Results There were no surgical complications. Following mETP, subjective symptoms of ear blockage improved in 14 of 20 patients (70%). Mean pure tone average improved by 6 dB (27 dB pre-op vs 21 dB post-op; P = 0.013). Abnormal tympanogram improved in 11 of 17 patients (65%). Failure of the procedure correlated with severity of mucosal disease as measured by both elevated tissue eosinophil count and advanced sinus CT stage (P = 0.018 and P = 0.014, respectively). Mean follow-up was 13 months (range 3-34 months). Conclusion Microdebrider eustachian tuboplasty appears to be a safe procedure for the treatment of eustachian tube dysfunction.

Postoperative Packing After Septoplasty: Is It Necessary?

The use of nasal packing following septoplasty has been proposed to serve multiple purposes. One of the most common reasons for use of packing is to prevent postoperative complications such as bleeding and formation of either synechiae or a septal hematoma. Stabilization of the remaining cartilage to prevent postoperative deviation is another reason that packing may be used. Although it appears intuitive that packing may prevent or decrease the incidence of these complications, evidence supporting this assertion is limited at best. Furthermore, certain types of nasal packing have been demonstrated to increase postoperative pain and have been implicated as a causative factor of catastrophic complications, such as toxic shock. With limited evidence to suggest a beneficial effect and a potential for deleterious side-effects, the routine use of postoperative packing following septoplasty should be questioned.

Endoscopic Ligation of the Anterior Ethmoid Artery

INTRODUCTION When severe epistaxis does not respond to nasal packing, other treatment modalities must be considered.1 Both arterial embolization and surgical ligation have a high success rate for control of bleeding in the posterior nasal cavity arising from the sphenopalatine artery and its branches. When bleeding arises from the anterior ethmoid artery (AEA); however, treatment options are more limited. As a branch of the internal carotid artery in close proximity to the ophthalmic artery, the AEA is not a suitable candidate for embolization resulting from risks of blindness and stroke. Intraoral and intranasal approaches that avoid an external facial scar have been used for many years to treat posterior epistaxis arising from the sphenopalatine artery. With the advent of endoscopic techniques, transantral ligation of the internal maxillary artery has largely been replaced by endoscopic ligation of the sphenopalatine artery.2–6 This endoscopic approach appears to provide both improved efficacy and decreased patient morbidity.6,7 A reliable endoscopic technique for treatment arising from the AEA and its branches, however, has not been described. The purpose of this report is to share the authors’ preliminary experience with the use of an endoscopic transnasal approach for ligation of the AEA to treat patients with refractory epistaxis.

Risk factors for postoperative cerebrospinal fluid leak and meningitis after expanded endoscopic endonasal surgery

Postoperative cerebrospinal fluid (CSF) leak is a serious complication of transsphenoidal surgery, which can lead to meningitis and often requires reparative surgery. We sought to identify preoperative risk factors for CSF leaks and meningitis. We reviewed 98 consecutive expanded endoscopic endonasal surgeries performed from 2008-2012 and analyzed preoperative comorbidities, intraoperative techniques, and postoperative care. Univariate and multivariate analyses were performed. The most common pathologies addressed included pituitary adenoma, Rathke cyst, chordoma, esthesioneuroblastoma, meningioma, nasopharyngeal carcinoma, and squamous cell carcinoma. There were 11 CSF leaks (11%) and 10 central nervous system (CNS) infections (10%). Univariate and multivariate analysis of preoperative risk factors showed that patients with non-ideal body mass index (BMI) were associated with higher rate of postoperative CSF leak and meningitis (both p<0.01). Also, patients with increasing age were associated with increased CSF leak (p = 0.03) and the length of time a lumbar drain was used postoperatively was associated with infection in a univariate analysis. In addition, three of three endoscopic transsphenoidal surgeries combined with open cranial surgery had a postoperative CSF leak and CNS infection rate which was a considerably higher rate than for transsphenoidal surgeries alone or surgeries staged with open cases (p<0.01 and p=0.04, respectively) In this series of expanded endoscopic transsphenoidal surgeries, preoperative BMI remains the most important preoperative predictor for CSF leak and infection. Other risk factors include age, intraoperative CSF leak, lumbar drain duration, and cranial combined cases. Risks associated with complex surgical resections when combining open and endoscopic approaches could be minimized by staging these procedures.

Compositionally and functionally distinct sinus microbiota in chronic rhinosinusitis patients have immunological and clinically divergent consequences

BackgroundChronic rhinosinusitis (CRS) is a heterogeneous disease characterized by persistent sinonasal inflammation and sinus microbiome dysbiosis. The basis of this heterogeneity is poorly understood. We sought to address the hypothesis that a limited number of compositionally distinct pathogenic bacterial microbiota exist in CRS patients and invoke discrete immune responses and clinical phenotypes in CRS patients.ResultsSinus brushings from patients with CRS (n = 59) and healthy individuals (n = 10) collected during endoscopic sinus surgery were analyzed using 16S rRNA gene sequencing, predicted metagenomics, and RNA profiling of the mucosal immune response. We show that CRS patients cluster into distinct sub-groups (DSI-III), each defined by specific pattern of bacterial co-colonization (permutational multivariate analysis of variance (PERMANOVA); p = 0.001, r2 = 0.318). Each sub-group was typically dominated by a pathogenic family: Streptococcaceae (DSI), Pseudomonadaceae (DSII), Corynebacteriaceae [DSIII(a)], or Staphylococcaceae [DSIII(b)]. Each pathogenic microbiota was predicted to be functionally distinct (PERMANOVA; p = 0.005, r2 = 0.217) and encode uniquely enriched gene pathways including ansamycin biosynthesis (DSI), tryptophan metabolism (DSII), two-component response [DSIII(b)], and the PPAR-γ signaling pathway [DSIII(a)]. Each is also associated with significantly distinct host immune responses; DSI, II, and III(b) invoked a variety of pro-inflammatory, TH1 responses, while DSIII(a), which exhibited significantly increased incidence of nasal polyps (Fisher’s exact; p = 0.034, relative risk = 2.16), primarily induced IL-5 expression (Kruskal Wallis; q = 0.045).ConclusionsA large proportion of CRS patient heterogeneity may be explained by the composition of their sinus bacterial microbiota and related host immune response—features which may inform strategies for tailored therapy in this patient population.

Risk Factors for Cerebrospinal Leak after Endoscopic Skull Base Reconstruction with Nasoseptal Flap

Objective The use of expanded endonasal surgery (EES) in the treatment of skull base neoplasms has increased significantly in recent years. Since 2006, the nasoseptal flap (NSF) has become the workhorse for the closure of skull base defects involving the anterior and central skull base. We hypothesized that defect site impacts the rate of cerebrospinal fluid (CSF) leak following EES. Study Design Retrospective cohort study. Setting/Subjects/Methods Patients who underwent skull base defect repair using a NSF at the University of California at San Francisco (UCSF) minimally invasive skull base center were retrospectively reviewed. Patient demographics, disease, and defect location and size were recorded along with the presence of a postoperative CSF leak. Data were analyzed using Fisher’s exact test. Results One hundred and twenty-one patients met inclusion criteria. Ten patients had a NSF failure with CSF leakage, 2 in the anterior skull base (frontal sinus, ethmoid, cribriform, planum), and 8 in the central skull base (sella, clivus) (P = .047). Dural defect size ≥2.0 cm2 in the central skull base strongly correlated with the risk of flap failure (P = .034). Conclusions This study of endoscopic closure of skull base defects using a NSF demonstrates there is an association between both surgical site and dural defect size with NSF failure. Expanded defects of the sella and clivus have an increased risk of failure and may warrant augmented techniques.

Use of acupuncture in the treatment of sinus and nasal symptoms: results of a practitioner survey.

Background The use of complementary medicine is increasingly popular in the United States. The use of acupuncture and its efficacy in treating chronic sinus and nasal symptoms is not well studied. Methods Regional licensed acupuncturists (1516) were mailed our acupuncture and chronic sinus and nasal symptoms survey. Results Three hundred thirty-one surveys (22%) were returned. Ninety-nine percent of those who returned surveys reported treating patients with chronic sinus and nasal symptoms. On a five-point scale the mean perceived efficacy for the overall treatment of chronic sinus and nasal symptoms was 4.2. The mean cost of an acupuncture treatment course for chronic sinus and nasal symptoms was calculated to be

Treatment of recurrent sinonasal polyposis with steroid-infused carboxymethylcellulose foam.

730.00. Conclusion Complementary medicine practitioners frequently use acupuncture in the treatment of patients with chronic sinus and nasal symptoms. Although practitioners report good efficacy using acupuncture to treat such patients, quantitative data are certainly needed to substantiate these self-reports.