Welby Winstead

Double-Blind, Placebo-Controlled Trial with Single-Dose Pantoprazole for Laryngopharyngeal Reflux

OBJECTIVES:Results of randomized treatment trials for laryngopharyngeal reflux (LPR) are mixed. The cause and effect between gastroesophageal reflux and laryngeal symptoms remain elusive.AIMS:To determine the efficacy of single-dose pantoprazole in newly diagnosed LPR and to correlate hypopharyngeal reflux with symptom improvement.METHODS:Randomized, double-blind, placebo-controlled trial was performed with a 2-wk run-in, 12-wk treatment period (pantoprazole 40 mg q.a.m. or placebo), and 4-wk follow-up. Study criteria were laryngeal complaints >3 days/wk and a positive triple-sensor pH test. Laryngeal exam was graded using a reflux finding score before and after treatment. Repeat pH test was performed on study drug at week 12. Weekly diaries were kept on symptom severity and global assessment. Total laryngeal symptom score was defined as the sum of six laryngeal symptoms. Mann-Whitney U, Wilcoxon, and Pearson tests were used.RESULTS:Thirty-nine subjects (13 M/26 F, median age 39 yr) were randomized; 35 completed the study. During the treatment period, total laryngeal symptom scores significantly improved compared with pretreatment scores in both study groups, but there were no significant differences between them. Forty percent of pantoprazole group reported adequate relief at week 12, compared with 42% of placebo group (p = 0.89). No significant improvement in hypopharyngeal reflux was found in either study group. There were no significant correlations between laryngeal reflux finding scores and hypopharyngeal reflux episodes with symptom improvement.CONCLUSIONS:Response was similar between single-dose pantoprazole and placebo in newly diagnosed LPR. Our results suggested that laryngeal exam was not useful in following treatment response. Hypopharyngeal reflux may represent acid reflux or artifacts, but is not likely the underlying cause.

Endoscopic biopsy of human olfactory epithelium as a source of progenitor cells.

Background The adult central nervous system contains progenitor cells; however, invasive surgery is required for their harvest. Olfactory neuroepithelium (ONe) has attracted attention because it is extracranial and contains progenitor cells that account for its regenerative capacity. Olfactory progenitor cells have been cultured from postmortem ONe. Our aim was to determine if olfactory progenitors could be obtained via biopsy from patients in a feasible, effective, and safe manner. Methods Endoscopic biopsy was performed on individuals undergoing sinus surgery (n = 42). Olfactory function was assessed pre- and postoperatively. Specimens were cultured under conditions for olfactory progenitor cell development. Results Progenitor cells emerged in cultures from 50% of our patients. The superior turbinate, biopsied with cutting punch forceps, gave the highest yield. No adverse impact on olfaction or complications with the biopsy were observed. Conclusion Endoscopic biopsy of ONe for obtaining olfactory progenitor cells from living donors is feasible, effective, and safe.

Clonal analysis of adult human olfactory neurosphere forming cells

Olfactory neuroepithelium (ONe) is unique because it contains progenitor cells capable of mitotic division that replace damaged or lost neurons throughout life. We isolated populations of ONe progenitors from adult cadavers and patients undergoing nasal sinus surgery that were heterogeneous and consisted of neuronal and glial progenitors. Progenitor lines have been obtained from these cultures that continue to divide and form nestin positive neurospheres. In the present study, we used clonal and population analyses to probe the self-renewal and multipotency of the neurosphere forming cells (NSFCs). NSFCs plated at the single cell level produced additional neurospheres; dissociation of these spheres resulted in mitotically active cells that continued to divide and produce spheres as long as they were subcultured. The mitotic activity of clonal NSFCs was assessed using bromodeoxyuridine (BrdU) incorporation. Lineage restriction of the clonal cultures was determined using a variety of antibodies that were characteristic of different levels of neuronal commitment: β-tubulin isotype III, neural cell adhesion molecule (NCAM) and microtubule associated protein (MAP2), or glial restriction: astrocytes, glial fibrillary acidic protein (GFAP); and oligodendrocytes, galactocerebroside (GalC). Furthermore, nestin expression, a marker indicative of progenitor nature, decreased in defined medium compared to serum-containing medium. Therefore, adult human ONe-derived neural progenitors retain their capacity for self-renewal, can be clonally expanded, and offer multipotent lineage restriction. Therefore, they are a unique source of progenitors for future cell replacement strategies in the treatment of neurotrauma and neurodegenerative diseases.

Role of Transcription Factors in Motoneuron Differentiation of Adult Human Olfactory Neuroepithelial‐Derived Progenitors

Neurosphereforming cell (NSFC) lines have been established from cultures of human adult olfactory neuroepithelium. Few of these cells ever express mature neuronal or glial markers in minimal essential medium supplemented with 10% fetal bovine serum or defined medium. However, these neural progenitors have the potential to differentiate along glial or neuronal lineages. To evaluate the potential of NSFCs to form motoneurons, transcription factors Olig2, Ngn2, and HB9 were introduced into NSFCs to determine if their expression is sufficient for motoneuron specification and differentiation, as has been shown in the early development of the avian and murine central nervous systems in vivo. NSFCs transfected with Olig2, Ngn2, and HB9 alone exhibited no phenotypic lineage restriction. In contrast, simultaneous transfection of Ngn2 and HB9 cDNA increased the expression of Isl1/2, a motoneuron marker, when the cells were maintained in medium supplemented with retinoic acid, forskolin, and sonic hedgehog. Furthermore, a population of Olig2‐expressing NSFCs also expressed Ngn2. Cotransfection of NSFCs with Olig2 and HB9, but not Olig2 and Ngn2, increased Isl1/2 expression. Coculture of NSFCs trans‐fected with Ngn2‐HB92 or Olig2 and HB9 with purified chicken skeletal muscle demonstrated frequent contacts that resembled neuromuscular junctions. These studies demonstrate that transcription factors governing the early development of chick and mouse motoneuron formation are able to drive human adult olfactory neuroepithelial progenitors to differentiate into motoneurons in vitro. Our long‐term goal is to develop cell populations for future studies of the therapeutic utility of these olfactory‐derived NSFCs for autologous cell replacement strategies for central nervous system trauma and neurodegenerative diseases.

Design and Implementation of an Ambulatory pH Monitoring Protocol in Patients with Suspected Laryngopharyngeal Reflux

Objective/Hypothesis: Adding a hypopharyngeal sensor to esophageal pH monitoring has been advocated for laryngopharyngeal reflux (LPR). However, selecting the proper pH catheter is problematic because esophageal lengths are variable among individuals.

Hypopharyngeal pH monitoring artifact in detection of laryngopharyngeal reflux

Hypopharyngeal pH artifacts have been a concern in the detection of laryngopharyngeal reflux. Our purpose was to analyze and quantify artifacts from dual-sensor hypopharyngeal pH monitoring. In all, 42 hypopharyngeal and 58 esophageal pH studies were reviewed. Type 1 (out of range), type 2 (pH drift), and type 3 (isolated pH drop) artifacts were identified. The proportion of proximal-sensor pH drop to <4 that was artifactual was determined. The median number (range) of artifacts was 1 (0–17) and 2 (0–28) for hypopharyngeal and esophageal pH studies, respectively (P = NS). The median proportion of artifactual pH drop to <4 was 1% (0–84%) and 2% (0–74%) for hypopharyngeal and esophageal pH studies, respectively (P = NS). The diagnosis did not change in any patient after excluding pH artifacts. In all, 19% of the combined 2432 hypopharyngeal pH drops of <4 were artifacts. In conclusion, hypopharyngeal pH artifacts per study were uncommon but can be prominent in a few patients. One can identify these artifacts and exclude them from analysis.

The human vomeronasal organ: part IV. Incidence, topography, endoscopy, and ultrastructure of the nasopalatine recess, nasopalatine fossa, and vomeronasal organ.

Background Previous reports on the human vomeronasal organ (VNO) have been inconsistent. Observations of fossae on the nasal septum have been reported as the VNO. Methods Adult human subjects (210) and cadavers (31) were examined using rigid nasal endoscopy, serial histology, and biopsy ultrastructure (5). Results The nasopalatine fossa (NPF) and the nasopalatine recess (NPR) are discrete, but variable, structures located adjacent to the VNO region. The NPF is not a vomeronasal pit. A septal mucosal pit could hide the vomeronasal duct opening. The VNO is a submucosal structure located 2–8 mm superior to the NPR and cannot be positively identified either macroscopically or endoscopically. Conclusion The VNO has long been mistaken for the NPF and septal mucosal pits. We show that serial histology is the correct method for identifying the VNO.

Endoscopic Endonasal Surgery for Remission of Cushing Disease Caused by Ectopic Intracavernous Macroadenoma: Case Report and Literature Review

BACKGROUND Complete surgical resection of an adrenocorticotropic hormone (ACTH)-secreting pituitary adenoma is the gold standard of treatment of Cushing disease. Ectopic location of these adenomas is an extremely rare condition that may compromise the diagnosis and surgical success. We present the first case of an ectopic intracavernous ACTH-secreting macroadenoma totally resected with endoscopic endonasal surgery (EES). CASE DESCRIPTION A 36-year-old woman presented with Cushing syndrome. Increased ACTH, serum cortisol, and free urine cortisol levels were identified; however, pituitary magnetic resonance imaging failed to show a pituitary tumor; instead, a parasellar lesion in the left cavernous sinus (CS) was noticed. Inferior petrosal sinus sampling showed a significant central to peripheral and lateralized left-sided ACTH gradient. The patient underwent EES. No tumor was found in the sella; however, the left CS was widely explored and a tumor was found lateral to the paraclival segment of the carotid artery. There were no complications after EES. Pathology confirmed the diagnosis of an ACTH-secreting adenoma. During the immediate postoperative course, serum cortisol levels decreased lower than 5 μg/dL. Postoperative magnetic resonance imaging showed complete tumor resection. At 20 months follow-up, the patient remained in clinical and biochemical remission of Cushing disease. CONCLUSIONS Only 12 cases of ectopic intracavernous ACTH-secreting adenomas have been reported and all were microadenomas. The presence of an ectopic ACTH-secreting macroadenoma in the CS represents a surgical challenge. EES is the ideal approach for complete resection of ectopic intracavernous adenomas, allowing for a wide exploration of the CS with no surgical complications.

Effects of brain-derived neurotrophic factor on sodium-induced apoptosis in human olfactory neuroepithelial progenitor cells

Low levels of brain-derived neurotrophic factor (BDNF) peptide are linked to the pathophysiology of mood disorders. Several single-nucleotide polymorphisms (SNPs) across the BDNF gene (BDNF) have been associated with bipolar illness. Since both elevated intracellular sodium and apoptosis are believed to contribute to cellular dysfunction in bipolar disorder, it is important to determine the effect of exogenous BDNF on apoptosis induced by the high levels of intracellular sodium seen in ill bipolar patients. Human olfactory neuroepithelial progenitor cells were treated with monensin, a sodium ionophore that increases intracellular sodium and leads to apoptosis. Apoptosis was quantified with enzyme-linked immunosorbent assay (ELISA) for mono- and oligonucleosomes. Elevation of intracellular sodium concentration by monensin induced apoptosis. BDNF 100ng/mL pretreatment or co-treatment attenuated the monensin-induced apoptosis. Pretreatment with BDNF for 24h reduced monensin-induced apoptosis by 93%. Co-treatment of BDNF and monensin increased intracellular sodium concentration and reduced apoptosis by 66%. Monensin for 24h models a process that is believed to occur during ill phases of bipolar illness. Treatment with BDNF greatly attenuates or prevents monensin-induced apoptosis. The functional consequences of BDNF SNPs, known to be associated with bipolar illness, need to be examined.

Rhinoscleroma: A Case Report and Clinical Update

Rhinoscleroma is a chronic granulomatous inflammatory disease caused by Klebsiella rhinoscleromatis. Initially described as a lesion of the nose, rhinoscleroma may involve any part of the respiratory tract. Although it is endemic in many parts of the world, rhinoscleroma has been rarely recognized in the U.S. In this report, we present a case of rhinoscleroma that illustrates the diagnostic challenge and therapeutic dilemma this disease presents. The significance of laryngeal involvement is emphasized. We review the clinical presentation, diagnosis, and treatment of rhinoscleroma. Ciprofloxacin was found effective in controlling acute symptom; however, longterm, high dose treatment has not been curative.