First Report of Klebsiella subsp. Ozaenae Meningitis in Japan.

Although the frequency of community-acquired infections caused by Klebsiella pneumoniae subsp. ozaenae (K. ozaenae) is low, they are often detected in sputum specimens. In addition, lung abscesses, necrotizing pneumonia, and urinary tract infections caused by K. ozaenae have also been reported. We herein report the first detection of K. ozaenae as an etiological agent of bacterial meningitis in Japan. Cases of K. ozaenae meningitis complicated by diabetes mellitus and sinusitis have been reported elsewhere. When Klebsiella pneumoniae is detected in such cases, it is important to use other detection methods in addition to mass spectrometry for correct identification.

Middle meatus microbiome in patients with eosinophilic chronic rhinosinusitis in a Japanese population.

BACKGROUND: Chronic rhinosinusitis (CRS) is a common chronic inflammatory disease and is subdivided into eosinophilic and noneosinophilic forms. There are few reports investigating the nasal microbiome and its pathological functions in patients with CRS. OBJECTIVE: We sought to analyze factors contributing to variations of the nasal microbiome in CRS, and on the basis of these factors, to elucidate whether the bacterial metabolites were related to the pathogenesis. METHODS: Nasal swabs were collected, and the V3 to V4 variable region of the 16S ribosomal RNA gene was amplified and sequenced. Factors contributing to variations of the nasal microbiome in patients with CRS were compared. The most influential factor was whether CRS was eosinophilic, and we compared α- and ß-diversity, bacterial species, and predictive bacterial functions between the 2 patient groups. In addition, the metabolites of the key bacteria were extracted, and we evaluated the predicted bacterial functions in airway epithelial cells. RESULTS: In total, 110 patients with CRS and 33 control subjects were enrolled. On the basis of the factors of variation, it was found that patients with eosinophilic CRS (n = 65) had different microbiomes with weighted UniFrac ß-diversity and lower α-diversity compared with those with noneosinophilic CRS (n = 45). A higher abundance of Fusobacterium nucleatum and an increased LPS pathway were observed in patients with noneosinophilic CRS compared with those with eosinophilic CRS. In airway epithelial cells, LPS derived from F nucleatum suppressed the expression levels of ALOX15 induced by TH2 cytokines. CONCLUSIONS: The differences in the nasal microbiome may play a key role in the pathophysiology of CRS.

Preventive effects of skin protectants on the development of medical device-related pressure wounds in endoscopic sinonasal surgery.

OBJECTIVES: Medical device-related pressure ulcer (MDRPU) is a skin or subcutaneous tissue injury caused by medical devices. Skin protectants have been used to prevent MDRPU in other fields. In endoscopic sinonasal surgery (ESNS), rigid endoscopes and forceps can cause MDRPU; however, detailed investigations have not been conducted. This study aimed to investigate the frequency of MDRPU in ESNS and the preventive effects of skin protectants METHODS: Thirty-nine patients who received ESNS and consented to study participation were randomly assigned to the "protective agent" (n = 18) or "control" (n = 21) group. MDRPU presence around the nostril was evaluated for up to 7 days post-surgically based on physical findings and subjective symptoms. The occurrence ratio and severity of MDRPU were statistically compared between the groups to evaluate the efficacy of skin protective agents. RESULTS: Stage 1 MDRPU, according to the National Pressure Ulcer Advisory Panel classification, was seen in 20.5% (8/39) of the patients, and no patient had more high-grade ulceration. On postoperative days 2 and 3, skin erythema was predominantly observed on the nasal floor, with a comparatively lower incidence in the protective agent group. Significant pain reduction was observed in the nostril's floor on postoperative days 2 and 3 in the protective agent group. CONCLUSIONS: MDRPU occurred with a relatively high frequency around the nostrils after ESNS. Protective agent use in the external nostrils was effective especially in reducing post-operative pain on the nasal floor, where tissue damage can easily occur due to device-related friction.

Characteristics of Nasal Foreign Bodies and Equipment on Complications During Removal Procedures.

OBJECTIVE: The treatment of nasal foreign bodies involves safe and reliable removal. Few reports have investigated the relationship between equipment and the incidence of complications. METHODS: This retrospective study included 300 patients with nasal foreign bodies (average: 3.28 years, interquartile range: 2-4 years). Patients' background, characteristics of nasal foreign body, equipment to remove the nasal foreign body, and complications were obtained from medical records. Statistical analysis was performed using Pearson's chi-square test for associated factors and the incidence of epistaxis among the complications. RESULTS: Nasal foreign bodies were found and removed in 256 patients. Forceps, hooks, suction, modified paper clips, and cotton swabs were mainly used to remove the nasal foreign bodies. Epistaxis due to the removal procedure was observed in 26 patients. The occurrence of epistaxis differed depending on the equipment (p = 0.077) and was less frequent in suction and paper clips than in forceps (p < 0.05 and p = 0.077). Epistaxis was not observed when a cotton swab was used. Aspiration and septal perforation were not observed. A statistical relationship was not detected between the hardness of foreign bodies and the occurrence of epistaxis (p = 0.251). The incidence of epistaxis was higher in cases nasal foreign bodies remained for 1 day and over than in cases foreign bodies were removed within 1 day (p < 0.05). CONCLUSIONS: This study revealed that suction, modified paper clips, and cotton swabs could be beneficial options for minimizing complications in the removal of nasal foreign bodies. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:2553-2557, 2023.

A Covered Lateral and Posterior Wall Flap of the Maxillary Sinus Prevents Reocclusion of the Postoperative Maxillary Cyst.

Although the number of postoperative maxillary cyst (POMC) cases has declined recently, a few reports of refractory cases have also been reported. The indications for endoscopic sinus surgery (ESS) for POMC removal are broadening and attempts to prevent postoperative recurrence at the cyst opening site have been widely investigated. Here, we have advocated our original pedunculated mucoperiosteal flap (CLAP flap; covered lateral and posterior wall flap of the maxillary sinus), where the bony area exposed intraoperatively is covered, to prevent postoperative recurrence. We have also presented the method for creating the CLAP flap. We classified the POMC as being medial, lateral, or anterior superior type and performed ESS. We introduced the CLAP flap after 2015 for the lateral type and some of the medial types of POMCs. We examined the cyst opening rate using computed tomography, age, sex, cyst position, and a follow-up period in four patients (five sides) who did not undergo flap surgery, but who were managed in our hospital in 2015, and in eight patients (nine sides) who underwent the CLAP flap technique in our hospital. In the group with the CLAP flap, the cyst opening rate was significantly higher (P < 0.05). The CLAP flap was effective for preventing postoperative bony regrowth. It may be one of the options for covering the exposed bone surface as widely as possible. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s12070-021-02658-x.

Clinical Diagnosis of Central Vertigo in Patients With Dizziness in Emergency Practice.

BACKGROUND: Life-threatening diseases should be promptly identified to provide appropriate medical care for emergency outpatients experiencing dizziness. However, dizziness is associated with various medical conditions; thus, a definitive diagnosis is challenging. To accurately diagnose vertigo in an emergency outpatient, we conducted a survey on the need to identify vertigo patients in the current outpatient departments. MATERIALS AND METHODS: The participants included 509 patients who visited the outpatient department at our hospital from February 2014 to May 2017. Overall, 12 characteristics were retrospectively extracted from the patients' medical records: age, sex, visit method, medical history (diabetes, hypertension, cardiac, or cerebrovascular disease), dizziness history, vertigo characteristics, concomitant symptoms, systolic blood pressure, nystagmus, imaging history, diagnosis, and hospitalization department. Univariate and multivariate analyses were performed to identify factors related to central vertigo. RESULTS: The diagnosis of central vertigo was confirmed when intracranial lesions were detected through imaging. In multivariate analysis, the presence/absence of a history of headache and cardiovascular disease were significantly correlated with central vertigo (P=0.002 and 0.006, respectively), with odds ratios of 5.18 and 4.38, respectively. CONCLUSIONS: To avoid missing central dizziness in a patient, diagnostic abilities should be improved by including careful interviews and confirmation of the presence/absence of accompanying symptoms. Furthermore, collaboration with neurology and neurosurgery departments is important for improving the diagnosis in suspected cases.

Predictors of Visual Acuity and Usefulness of a Treatment Algorithm in Rhinogenous Optic Neuritis.

Rhinogenous optic neuritis, which causes neuropathy associated with visual dysfunction, greatly reduces patient quality of life and requires suitable early treatment. This study aimed to analyze visual outcome predictors in patients with rhinogenous optic neuritis and to develop and investigate the usefulness of an algorithm to facilitate early treatment. Prospective and retrospective investigations were conducted at the Department of Otorhinolaryngology. The visual outcomes after sinus surgery of 24 of 53 patients suspected of having rhinogenous optic neuritis were analyzed. Furthermore, the usefulness of the treatment algorithm was evaluated in 27 of these 53 patients. Data from 24 patients who underwent surgery were included in a multiple regression analysis to investigate the associations between visual outcomes and concomitant symptoms and the time from symptom onset to surgery. The mean time from the initial examination to a request for otorhinolaryngological examination to assess the usefulness of the treatment algorithm was compared in 27 patients who did not undergo an initial otorhinolaryngological examination. Visual acuity improved in 23 participants who underwent surgery. Multivariate analysis identified the time from onset to surgery and headache as significant predictors of postoperative visual acuity. The mean time from the initial examination to a request for otorhinolaryngological examination was significantly shorter after the algorithm was introduced (1.13 days, 8 patients; P = .008). Early surgical treatment is essential to avoid further postoperative visual acuity decreases in patients with rhinogenous optic neuritis. Patients who experience headache may have poorer postoperative outcomes.

Pathological Features of Free Graft and Pedicled Flap in the Nasal Cavity: An Animal Study.

OBJECTIVES/HYPOTHESIS: Recent developments in reconstructive techniques for mucosal defects using mucoperiosteal materials have enabled rapid recovery of physiological function after endoscopic sinus surgery. Clinical trials have described the advantages, disadvantages, and different outcomes of free graft and pedicled flap, which, respectively, sacrifice or preserve blood flow. However, histological changes, that affect the postoperative outcomes after reconstruction, remain unclear. We created an animal model for the reconstruction of mucosal defects using free grafts and pedicled flaps, and evaluated them histologically. STUDY DESIGN: Animal study. METHODS: We created mucosal defects in the left nasal septum of 20 rabbits and performed reconstruction with free grafts and pedicled flaps. The distribution of ciliary and goblet cells at the reconstruction site was evaluated after 7 and 28 days using hematoxylin and eosin-stained sections to calculate the Ciliary Cell Index and Goblet Cell Index. The severity of inflammation was assessed using the Cartilage Inflammatory Cell Score. RESULTS: Crusting and changes in the mucosal morphology at the reconstruction site occurred only in the free graft group. In addition, the pedicled flap group had significantly greater preservation of ciliary and goblet cells and less inflammatory cell infiltration into the septal cartilage (P < .05) than the free graft group. CONCLUSIONS: After reconstruction procedures for mucosal defects, histopathological differences were observed between the free graft and pedicled flap. Reconstruction with pedicled flaps had advantages including preservation of healthy mucosal epithelium and suppression of inflammation on the reconstruction site. This indicated that reconstruction with pedicled flaps might have advantages over that with free grafts. LEVEL OF EVIDENCE: NA Laryngoscope, 131:E428-E433, 2021.

Effects of Hangeshashinto on the nasal physiological function: An in vitro study.

OBJECTIVE: Hangeshashinto is a Japanese Kampo medicine applied for the treatment of oral mucositis and gastroenteritis. Hangeshashinto exhibits broad-spectrum antibacterial activity and suppresses prostaglandin (PG)E2 production in the mucosa and has the ability to improve the inflammatory condition. In addition to these effects, because cAMP, a composition of Hangeshashinto, facilitates ciliary beat, Hangeshashinto could also improve the physiological function of the nasal mucosa, consist of ciliated epithelium, but details were unknown. METHODS: This study was aimed to investigate the effects of Hangeshashinto on the nasal mucosa. Healthy nasal mucosal sections were collected from the nasal septum of ten Japanese white rabbits, placed in a collagen dish for tissue culture, and rinsed with two different concentrations of Hangeshashinto solution (1.0%, n = 10 and 2.5%, n = 10) and cAMP solution (50µM, n=10 and 100 µM, n=10) or saline (control, n = 10). Ciliary beat frequency (CBF) as a physiological function of the nasal mucosa was recorded at 1, 3 and 7 days after rinsing, and histological evaluation of epithelial damage was performed at 7 days after rinsing. RESULTS: CBF in the 1.0% but not in the 2.5% Hangeshashinto group, increased at 3 and 7 days compared with that in the control group (p < 0.05). This trend was also observed in the CBF in the 100 µM cAMP group, significant difference was not observed between the CBF of the 1.0% Hangeshashinto group and the 100 µM cAMP group at 1, 3 and 7 days after rinsing (p > 0.05). Histological score only in the 2.5% Hangeshashinto group was lower than that in the control group (p < 0.05), while a significant decline was not observed in the other groups compared to that in the control group (p > 0.05). CONCLUSION: Our results suggest that 1.0% Hangeshashinto solution facilitates the physiological function of the nasal mucosa by promoting ciliary functions without histological damage of cilia epithelium. When applied with the appropriate concentration, Hangeshashinto could have ability to improve the physiological functions of the nasal mucosal epithelium.

Effect of gauze placement soaked with adrenaline at suprabullar recess on hemostasis during endoscopic sinus surgery: A randomized controlled trial.

BACKGROUND: Topical application of vasoconstrictors is necessary for endoscopic sinus surgery (ESS) for a bloodless surgical view and reduced intraoperative bleeding. We aimed to verify the effectiveness of gauze placement soaked with adrenaline at suprabullar recess, where the anterior ethmoidal artery exists, on hemostasis during ESS. METHODS: A randomized, double-blinded trial was carried out for 26 patients receiving ESS. At the beginning of the surgery, gauze soaked with 2% lidocaine with or without 1:10 000 adrenaline was placed at the suprabullar recess for 8 minutes. Estimated blood loss, surgical field score, and operation time were compared between the two groups. RESULTS: Estimated blood loss and surgical field score were significantly smaller in the adrenaline group than in the no adrenaline group. Operation time was not significantly different between the two groups. CONCLUSION: Gauze placement soaked with adrenaline at suprabullar recess reduces estimated blood loss and clears the surgical field during ESS.

Effect of a Superior Lateral Anterior Pedicle Flap for Draf Procedures.

Several types of flap techniques have been developed to cover exposed bone after Draf procedures to reduce the possibility of re-stenosis. These techniques are relatively new and detailed measurements of the size of neo-Ostia during follow-up have not been reported. The authors aim to assess outcomes precisely by not only using endoscopic evaluation but also by measuring the diameter of the ostium and the thickness of the nasal beaks on pre- and postoperative computed tomography images. The authors reviewed 25 patients with 37 nasal cavities who have undergone a Draf surgery with a previously-reported superior lateral anterior pedicle flap technique. The anteroposterior (AP) distance of the frontal recess and the thickness of the nasal beaks were measured before, immediately after, and more than 6 months after surgery. Measured distances were statistically analyzed. The neo-ostium remained patent in long-term follow-up of all patients. The AP distance of the frontal recess and the thickness of the nasal beak were preserved during follow-up. Neither synechiae nor orbital injuries occurred. In conclusion, Draf type II and III procedures with superior lateral anterior pedicle flaps are safe and effective. Neo-Ostia remained patent throughout the follow-up period.