Endoscopic diode laser polypectomy and high-dose intranasal steroids in recurrent nasal polyposis.

BACKGROUND: The aim of this clinical investigation was to determine the outcomes of an outpatient videoendoscopic diode laser polypectomy (DLPE) and subsequent topical high-dose corticosteroid application in chronic rhinosinusitis with recurrent nasal polyposis (NP). METHODS: After ineffective revision sinus surgery and prolonged mometasone furoate application, 19 consecutive mild and moderate NP patients suffering from nasal obstruction (NO) and olfactory dysfunction (OD) were prospectively entered into the study to undergo DLPE under topical anesthesia. Beginning 1 week postoperatively, 250 microg of beclomethasone dipropionate aerosol spray (BDPAS) was self-administered into each nostril twice a day. Treatment efficacy was assessed after 1, 6, and 12 weeks and at quarterly long-term follow-ups based on objective parameters (videoendoscopic photodocumentation and rhinomanometry) and subjective evaluation of NO, OD, and satisfaction (visual analog scales [VASs]). RESULTS: VASs indicated very low values for intraoperative pain and discomfort and high postoperative satisfaction. After 6 weeks, subjective and objective data revealed a significant improvement of NO and OD (p < 0.0005). Topical BDPAS application was well tolerated. At a median follow-up of 32 months (range, 1-4 years), 21% of the patients developed NP disappearance, 53% had a stable disease, and 26% had a progressive disease. CONCLUSION: In therapy-refractory NP, endonasal DLPE represents a minimally invasive, symptom-oriented, safe and easily reapplicable outpatient treatment option that provides effective improvement of NO and OD. Compared with the pre-DLPE period, the proposed long-term quarterly follow-up combined with high-dose topical BDPAS application might reduce or delay the need for major surgery and appears to be suitable for disease control.

The scent-diffusing ventilator for rehabilitation of olfactory function after laryngectomy.

BACKGROUND: The larynx bypass (LB) is the only device capable of providing laryngectomy patients with the ability to smell. Our findings regarding one-time and long-term use did reveal an improved olfactory function in these patients. Because the LB is difficult to use, however, it is not appropriate for everyday use. Therefore, we devised a new instrument: the scent-diffusing ventilator (SV). METHODS: Between January 2006 and February 2007, we researched the olfactory function of 16 patients who had undergone a laryngectomy (13 men/3 women; median age, 63 years) by using the LB and the SV. Their olfactory function was measured with the Sniffin' Sticks test battery. Further practicability of both methods was determined through a visual analog scale (1-10). RESULTS: The patients' olfactory function significantly improved (SV median 8 versus LB median 7; p < 0.002). In addition, the SV was much easier to use than the LB (median, 6 versus 5; p < 0.001). CONCLUSION: Further technical improvements are necessary to make the SV an established part of the rehabilitation of the olfactory function after laryngectomy.

Rehabilitation of the olfactory sense after laryngectomy: long-term use of the larynx bypass.

Patients who undergo laryngectomy typically lose their sense of smell. One device that has been used to rehabilitate olfactory function in these patients is the larynx bypass. We conducted a long-term study of the larynx bypass in 16 laryngectomized patients. After undergoing objective and subjective baseline evaluations, patients were asked to use the device at home for at least 30 minutes each day for 3 months. They were also asked to record in a diary subjective ratings of their sense of smell and the practicability of using the device every day. At study's end, patients experienced a statistically significant improvement (p < 0.001) in olfactory function on objective measurement (Sniffin' Sticks testing). Subjective improvement was seen after 1 week (p < 0.001) and maintained throughout the study. Practicability scores improved statistically (p = 0.003), but the device remained difficult to use. The long-term use of the larynx bypass has not been studied previously, and we hope that our findings will serve as a basis for further investigation.

Multimodal fusion imaging ensemble for targeted sentinel lymph node management: initial results of an innovative promising approach for anatomically difficult lymphatic drainage in different tumour entities.

PURPOSE: There are situations where exact identification and localisation of sentinel lymph nodes (SLNs) are very difficult using lymphoscintigraphy, a hand-held gamma probe and vital dye, either a priori or a posteriori. We developed a new method using a simultaneous injection of two lymphotropic agents for exact topographical tomographic localisation and biopsy of draining SLNs. The purpose of this prospective pilot study was to investigate the feasibility and efficacy of this method ensemble. METHODS: Fourteen patients with different tumour entities were enrolled. A mixture of (99m)Tc-nanocolloid and a dissolved superparamagnetic iron oxide was injected interstitially. Dynamic, sequential static lymphoscintigraphy and SPECT served as pathfinders. MR imaging was performed 2 h after injection. SPECT, contrast MRI and, if necessary, CT scan data sets were fused and evaluated with special regard to the topographical location of SLNs. The day after injection, nine patients underwent SLN biopsy and, in the presence of SLN metastasis, an elective lymph node dissection. RESULTS: Twenty-five SLNs were localised in the 14 patients examined. A 100% fusion correlation was achieved in all patients. The anatomical sites of SLNs detected during surgery showed 100% agreement with those localised on the multimodal fusion images. SLNs could be excised in 11/14 patients, six of whom had nodal metastasis. CONCLUSION: Our novel approach of multimodal fusion imaging for targeted SLN management in primary tumours with lymphatic drainage to anatomically difficult regions enables SLN biopsy even in patients with lymphatic drainage to obscure regions. Currently, we are testing its validity in larger patient groups and other tumour entities.

Intervention at the level of the neuroendocrine-immune axis and postoperative pneumonia rate in long-term alcoholics.

RATIONALE: Postoperative pneumonia is three to four times more frequent in patients with alcohol use disorders followed by prolonged intensive care unit (ICU) stay. Long-term alcohol use leads to an altered perioperative hypothalamus-pituitary-adrenal (HPA) axis and immunity. OBJECTIVES: The aim of this study was to evaluate HPA intervention with low-dose ethanol, morphine, or ketoconazole on the neuroendocrine-immune axis and development of postoperative pneumonia in long-term alcoholic patients. METHODS: In this randomized, double-blind controlled study, 122 consecutive patients undergoing elective surgery for aerodigestive tract cancer were included. Long-term alcohol use was defined as consuming at least 60 g of ethanol daily and fulfilling the Diagnostic and Statistical Manual of Mental Disorders IV criteria for either alcohol abuse or dependence. Nonalcoholic patients were included but only as a descriptive control. Perioperative intervention with low-dose ethanol (0.5 g/kg body weight per day), morphine (15 mug/kg body weight per hour), ketoconazole (200 mg four times daily), and placebo was started on the morning before surgery and continued for 3 d after surgery. Blood samples to analyze the neuroendocrine-immune axis were obtained on the morning before intervention and on Days 1, 3, and 7 after surgery. MEASUREMENTS AND MAIN RESULTS: In long-term alcoholic patients, all interventions decreased postoperative hypercortisolism and prevented impairment of the cytotoxic T-lymphocyte type 1:type 2 ratio. All interventions decreased the pneumonia rate from 39% to a median of 5.7% and shortened intensive care unit stay by 9 d (median) compared with the placebo-treated long-term alcoholic patients. CONCLUSIONS: Intervention at the level of the HPA axis altered the immune response to surgical stress. This resulted in decreased postoperative pneumonia rates and shortened intensive care unit stay in long-term alcoholic patients.

Therapeutic lung lavages in children and adults.

BACKGROUND: Pulmonary alveolar proteinosis (PAP) is a rare disease, characterized by excessive intra-alveolar accumulation of surfactant lipids and proteins. Therapeutic whole lung lavages are currently the principle therapeutic option in adults. Not much is known on the kinetics of the wash out process, especially in children. METHODS: In 4 pediatric and 6 adult PAP patients 45 therapeutic half lung lavages were investigated retrospectively. Total protein, protein concentration and, in one child with a surfactant protein C mutation, aberrant pro-SP-C protein, were determined during wash out. RESULTS: The removal of protein from the lungs followed an exponential decline and averaged for adult patients 2-20 g and <0.5 to 6 g for pediatric patients. The average protein concentration of consecutive portions was the same in all patient groups, however was elevated in pediatric patients when expressed per body weight. The amount of an aberrant pro-SP-C protein, which was present in one patient with a SP-C mutation, constantly decreased with ongoing lavage. Measuring the optical density of the lavage fluid obtained allowed to monitor the wash out process during the lavages at the bedside and to determine the termination of the lavage procedure at normal protein concentration. CONCLUSION: Following therapeutic half lung lavages by biochemical variables may help to estimate the degree of alveolar filling with proteinaceous material and to improve the efficiency of the wash out, especially in children.

High resolution mass spectrometric alveolar proteomics: identification of surfactant protein SP-A and SP-D modifications in proteinosis and cystic fibrosis patients.

In the present study, one- and two-dimensional gel electrophoresis combined with high resolution Fourier transform-ion cyclotron resonance mass spectrometry (FT-ICR MS) have been applied as powerful approaches for the proteome analysis of surfactant proteins SP-A and SP-D, including identification of structurally modified and truncation forms, in bronchoalveolar lavage fluid from patients with cystic fibrosis, chronic bronchitis and pulmonary alveolar proteinosis. Highly sensitive micropreparation techniques were developed for matrix-assisted laser desorption/ionization (MALDI) FT-ICR MS analysis which provided the identification of surfactant proteins at very low levels. Owing to the high resolution, FT-ICR MS was found to provide substantial advantages for the structural identification of surfactant proteins from complex biological matrices with high mass determination accuracy. Several protein bands corresponding to SP-A and SP-D were identified by MALDI-FT-ICR MS after electrophoretic separation by one- and two-dimensional gel electrophoresis, and provided the identification of structural modifications (hydroxy-proline) and degradation products. The high resolution mass spectrometric proteome analysis should facilitate the unequivocal identification of subunits, aggregations, modifications and degradation products of surfactant proteins and hence contribute to the understanding of the mechanistic basis of lung disease pathogenesis.

Altered cell-mediated immunity and increased postoperative infection rate in long-term alcoholic patients.

BACKGROUND: Preoperative alteration of T cell-mediated immunity as well as an altered immune response to surgical stress were found in long-term alcoholic patients. The aim of this study was to evaluate perioperative T cell-mediated immune parameters as well as cytokine release from whole blood cells after lipopolysaccharide stimulation and its association with postoperative infections. METHODS: Fifty-four patients undergoing elective surgery of the aerodigestive tract were included in this prospective observational study. Long-term alcoholic patients (n = 31) were defined as having a daily ethanol consumption of at least 60 g and fulfilling the Diagnostic and Statistical Manual of Mental Disorders for either alcohol abuse or alcohol dependence. The nonalcoholic patients (n = 23) were defined as drinking less than 60 g ethanol/day. Blood samples to analyze the immune status were obtained on morning before surgery and on the morning of days 1, 3, and 5 after surgery. RESULTS: Basic patient characteristics did not differ between groups. Before surgery, the T helper 1:T helper 2 ratio (Th1: Th2) was significantly lower (P < 0.01), whereas plasma interleukin 1beta and lipopolysaccharide-stimulated interleukin 1ra from whole blood cells were increased in long-term alcoholic patients. After surgery, a significant suppression of the cytotoxic lymphocyte ratio (Tc1:Tc2), the interferon gamma:interleukin 10 ratio from lipopolysaccharide-stimulated whole blood cells, and a significant increase of plasma interleukin 10 was observed. Long-term alcoholics had more frequent postoperative infections compared with nonalcoholic patients (54%vs. 26%; P = 0.03). CONCLUSIONS: T helper cell-mediated immunity was significantly suppressed before surgery and possibly led to inadequate cytotoxic lymphocyte and whole blood cell response in long-term alcoholic patients after surgery. This altered cell-mediated immunity might have accounted for the increased infection rate in long-term alcoholic patients after surgery.