Steven M. Houser

Allergic fungal rhinosinusitis: Pathophysiology, epidemiology, and diagnosis

Allergic fungal rhinosinusitis (AFRS) is believed to have a cause similar to allergic bronchopulmonary aspergillosis (ABPA). Both are thought to be mediated by both type I (IgE) and type III (IgE-antigen immune complexes) Gell and Coombs reactions. ABPA patients also exhibit unique characteristics, such as HLA-DR2 or HLA-DR5 genotypes, and elevated suppressor T cell activity. While the pathophysiology of AFRS is similar histopathologically, similar immunologic studies have not been as well documented. Most cases of AFRS involve dematiaceous fungi, rather than Aspergillus. A suggested laboratory work-up for the disease is presented.

The Diagnosis and Management of Empty Nose Syndrome

Empty nose syndrome (ENS) is a poorly understood and rare iatrogenic disorder resulting from the destruction of normal nasal tissue. In severe forms, it can be debilitating. In this article, the authors elucidate the distinction between ENS and atrophic rhinitis, and provide a systematic approach to the diagnosis and management of ENS. They urge a judicious and cautious approach to turbinate resection, to help better prevent this sequela of nasal surgery. They state that patients with ENS can be rehabilitated and their quality of life substantially improved with nasal augmentation as a means to help restore nasal anatomy toward the premorbid state.

The Role of Allergy and Smoking in Chronic Rhinosinusitis and Polyposis

Objectives/Hypothesis: The article considers the interrelatedness of allergic rhinitis and chronic rhinosinusitis (CRS). The negative impact of perennial allergy and tobacco use on polyposis in sinus surgery patients is explored.

Prevalence of allergy in patients with chronic rhinosinusitis

OBJECTIVES: The purpose of this study was to provide further evidence that allergic rhinitis is an important factor in chronic and recurrent acute rhinosinusitis. Specifically, this study shows that perennial allergens play a more significant role than seasonal allergens. STUDY DESIGN AND SETTING: Census by chart review of patients with chronic and recurrent acute rhinosinusitis presenting to the Department of Otolaryngology at the MetroHealth Medical Center, Cleveland, OH. METHODS: All participants had allergy testing done either by RAST or intradermal skin endpoint titration utilizing a battery of seasonal and perennial antigens. RESULTS: Of the 48 voluntary participants analyzed in this study, 57.4% had a positive allergy test. Most patients in the study were sensitive to more than one allergen. Of the patients with a positive allergy test, 92% demonstrated sensitivity to one or more perennial allergens—most prominently, molds and dust mites. CONCLUSIONS: Perennial allergy has a statistically significant association with chronic and recurrent acute rhinosinusitis. SIGNIFICANCE: The diagnosis and management of perennial allergies may be beneficial when treating chronic sinus disease. (Otolaryngol Head Neck Surg 2004;130:545-52.)

Dysphagia in patients with inclusion body myositis

Objectives: Inclusion body myositis (IBM) is an inflammatory myopathy with a 40% reported incidence of dysphagia. A protracted course, refractory to medical therapy, frequently leads to consultation with an otolaryngologist for dysphagia management. We studied the incidence, symptoms, and mechanisms of dysphagia in patients with IBM. Study Design: Retrospective study of medical records and self‐reported follow‐up survey; dysphagia is defined as difficulty in swallowing. Materials: Twenty‐two patients with biopsy‐proven IBM. Results: The rate of dysphagia was more than 80% (16 of 19), twice as high as previously reported. Progressive dysphagia was associated with a significantly worse functional class. Relevant management guidelines are established, including the timing for appropriate surgical intervention. Conclusion: Progressive dysphagia may signify more aggressive IBM or an episodic worsening in status. Recognition of the disease manifestations will afford proper patient management. Informed otolaryngologists can have a favorable impact on the dysphagia associated with IBM.

Empty nose syndrome associated with middle turbinate resection

Empty Nose Syndrome (ENS), a term coined by Eugene Kern, describes the appearance of a sinus CT scan after tissue loss; an iatrogenic version of atrophic rhinitis. The syndrome is most notable for paradoxical nasal obstruction: the patient describes the sensation of nasal stuffiness, while an examination demonstrates a widely patent nasal cavity. Commonly the inferior turbinate (IT) has been surgically resected, though middle turbinate (MT) resection is also associated with ENS. The patient underwent functional endoscopic sinus surgery in December 1996. He did well until he developed a left-sided sinus infection, which medications failed to clear. He had revision sinus surgery in January 1999 with subtotal left MT resection and his ENS symptoms began shortly thereafter. A sphenopalatine ganglion ablation minimally improved his symptoms. He had a 5-year course of allergy immunotherapy. The patient’s symptoms included: cool air shocks the nose, then worsens with heat exposure; pain in the back of the left nasal cavity, radiating to the palate; stuffier on the left side. His symptoms tend to improve with an upper respiratory tract infection. Placing moist cotton into the patient’s left nasal cavity restricted his airflow and improved his symptoms. On January 7, 2003 he underwent a minor revision of his left ethmoid cavity, and an acellular dermal (Alloderm) septal submucoperiosteal implant was placed to mimic the missing MT. The acellular dermal implant consisted of 2 layers of 1 cm 2 cm dimension sutured together. The leading edge of the graft was rolled and sutured into position to resemble a sled. The left nasal cavity was packed with strip gauze for 1 week, and postoperative antibiotics were maintained for 3 weeks. The patient’s symptoms fluctuated while he healed. After 3 months the patient felt he was perhaps 40% better off after the implant. A Cymetra (injectable acellular der-

Clinical Consensus Statement Appropriate Use of Computed Tomography for Paranasal Sinus Disease

Objective To develop a consensus statement on the appropriate use of computed tomography (CT) for paranasal sinus disease. Subjects and Methods A modified Delphi method was used to refine expert opinion and reach consensus by the panel. Results After 3 full Delphi rounds, 33 items reached consensus and 16 statements were dropped because of not reaching consensus or redundancy. The statements that reached consensus were grouped into 4 categories: pediatric sinusitis, medical management, surgical planning, and complication of sinusitis or sinonasal tumor. The panel unanimously agreed with 13 of the 33 statements. In addition, at least 75% of the panel strongly agreed with 14 of 33 statements across all of the categories. Conclusions For children, careful consideration should be taken when performing CT imaging but is needed in the setting of treatment failures and complications, either of the pathological process itself or as a result of iatrogenic (surgical) complications. For adults, imaging is necessary in surgical planning, for treatment of medical and surgical complications, and in all aspects of the complete management of patients with sinonasal and skull base pathology.

Pathophysiology of empty nose syndrome.

To review current knowledge on nasal airflow sensation in relation to empty nose syndrome (ENS).

The Surgical Management of Allergic Rhinitis

In their discussion of the treatment of allergic rhinitis, the authors present key features of the disease and its management, allergen responses, the role of the inferior turbinate, and reviews of outcomes with submucosal resection, total inferior turbinectomy, cryosurgery, laser cautery, radical turbinectomy, submucous turbinectomy, submucous electrocautery, and microdebriber turbinoplasty. The authors discuss radiofrequency ablation and coblation outcomes and complications, along with the role of endoscopic sinus surgery in allergic rhinitis and emphasize the need for Otolaryngologists to be facile with a variety of procedures for best outcomes.

Quality of life in treatment of acute rhinosinusitis with clarithromycin and amoxicillin/clavulanate.

Objectives: Clarithromycin and amoxicillin/clavulanate (A/C) are first line antibiotics used to treat uncomplicated acute rhinosinusitis (ARS). This study examined the efficacy of clarithromycin and A/C for the treatment of ARS relative to the patients quality of life (QOL).