Sino-orbital spelunking: stalagmite formation in fibrous dysplasia with dystrophic calcification.

Fibrous dysplasia (FD) involving the mid-face may be associated with cystic and other secondary changes that make diagnosis more difficult. We present a case of FD associated with a remote history of blunt facial trauma and extensive cystic changes involving the medial orbit and sinuses. An endoscopic exploration revealed "stalagmites" along the floor of the cystic cavity that were consistent with dystrophic calcification. This case was unusual given the degree of dystrophic calcification and the presence of sino-orbital stalagmites within the cystic cavity. Radiologic and pathologic features of the stalagmites are characterized.

Improving patient care via development of a protein-based diagnostic test for microbe-specific detection of chronic rhinosinusitis.

OBJECTIVES/HYPOTHESIS: The hypothesis is that signature bacterial proteins can be identified in sinus secretions via high-throughput, proteomic based techniques. Nontypeable Haemophilus influenzae (NTHI) is the most common bacterial pathogen associated with sinusitis and serves as proof of principle pathogen for identifying biomarkers. STUDY DESIGN: In vitro and in vivo studies using proteomic-based analysis of cultures of NTHI and a novel, experimental chinchilla polymicrobial sinusitis model. METHODS: Nano-liquid chromatography /tandem mass spectrometry (nano-LC-MS/MS) was performed to annotate the secretome from an NTHI biofilm. A model of NTHI-induced sinusitis was developed in a chinchilla, and NTHI proteins were detected in chinchilla secretions. A reference standard RT-PCR-based assay was adapted to allow for sensitivity and specificity testing of the identified signature biomarkers in human patients. RESULTS: Outer membrane proteins P2 (OMP-P2) and P5 (OMP-P5) were identified as promising candidates for the detection of NTHI biofilms and positively detected in nasopharyngeal secretions of chinchillas experimentally infected with NTHI. An RT-PCR based test for the presence of NTHI biofilms demonstrated 100% sensitivity and 100% specificity when tested against eight unique strains commonly found in human bacterial rhinosinusitis. CONCLUSIONS: Proteomic analysis was successful in identifying signature proteins for possible use as a biomarker for chronic rhinosinusitis (CRS). OMP-P2 and OMP-P5 were validated as promising candidates and were positively detected from nasopharyngeal secretions from chinchillas experimentally infected with NTHI. Collectively, these data support the use of OMP-P2 and OMP-P5 as biomarkers for a human clinical trial to develop a point-of-care medical diagnostic test to assist in the diagnosis and treatment of CRS.

Antibodies directed against integration host factor mediate biofilm clearance from Nasopore.

OBJECTIVES/HYPOTHESIS: Intranasal resorbable packing, such as Nasopore, is commonly used during sinus surgery despite a paucity of evidence that demonstrates clinical benefit. We theorized that Nasopore supports bacterial growth and biofilm formation. The DNABII family of bacterial nucleic acid binding proteins stabilizes the extracellular polymeric substance of the biofilm, thus protecting bacteria from host defenses and traditional antibiotics. We tested the hypothesis that use of anti-IHF antibodies in conjunction with antibiotics would enhance biofilm eradication from Nasopore. STUDY DESIGN: In vitro experiments. METHODS: Nontypeable Haemophilus influenzae (NTHI) biofilms were grown on Nasopore. Following 24-hour incubation, biofilms were incubated for an additional 16 hours with either medium alone, naïve rabbit serum, rabbit anti-IHF serum, amoxicillin/clavulanate, or anti-IHF serum + amoxicillin/clavulanate. Computer statistics (COMSTAT) analysis was performed on images of biofilms obtained via confocal microscopy. RESULTS: NTHI readily formed a biofilm on Nasopore. Treatment with amoxicillin/clavulanate alone mediated an increase in biomass by 92% to 6.63 µ(2) /µ(3) compared to incubation in sterile medium alone (3.46 µ(2) /µ(3)). Treatment with anti-IHF alone reduced the biomass by 77% to 1.29 µ(2) /µ(3) compared to incubation with naïve rabbit serum (5.53 µ(2) /µ(3)). Anti-IHF + amoxicillin/clavulanate reduced biomass by 88% to 0.66 µ(2) /µ(3) (P <0.02) compared to incubation with naïve rabbit serum. CONCLUSION: Antibiotics alone were ineffective in eradicating NTHI biofilms that had formed on Nasopore in vitro. Anti-IHF antibodies plus amoxicillin/clavulanate therapy synergistically reduced biofilm biomass by 88%. These data support clinical studies for the use of anti-IHF combined with antibiotics to reduce biofilm formation on intranasal packing.

Sprayable chitosan/starch-based sealant reduces adhesion formation in a sheep model for chronic sinusitis.

OBJECTIVES/HYPOTHESIS: Postoperative adhesion formation after endoscopic sinus surgery (ESS) remains a complication associated with high revision rates. This study determines the efficacy of a sprayable chitosan/starch-based sealant for reducing adhesions in an ESS sheep model for chronic sinusitis. STUDY DESIGN: Prospective, blinded, randomized controlled trial. METHODS: Sheep (n = 14) with eosinophilic rhinitis (determined by the presence of eosinophilia in nasal secretions) underwent ESS with middle turbinectomies, standardized mucosal injuries created on the lateral nasal wall, and partial thickness wounds created around the ethmoid cell region. Surgery was performed bilaterally (28 nasal cavities). Animals were randomized into treatment with sprayable chitosan/starch-based sealant (n = 7, 14 nasal cavities) or no treatment (n = 7, 14 nasal cavities). Two animals in the treatment group expired due to anesthetic complications associated with the turbinectomies, leaving five animals (10 sites) that completed the study. Presence of adhesions was assessed by endoscopic evaluation at days 14 and 28 after initial surgery. Adhesion formation was confirmed via necropsy of sinus cavities at day 28 after initial surgery. RESULTS: Adhesions were observed in all seven control animals, resulting in an 86% (95% confidence interval [CI], 65-100) adhesion rate (12 of 14 sites). The five surviving treatment animals had a 10% (95% CI, 0-33) adhesion rate (one of 10 sites). Treatment with the sprayable chitosan/starch-based sealant resulted in a 76% reduction (95% CI, 32-100) of adhesions (P < .002). CONCLUSIONS: In this sheep model for chronic sinusitis, treatment with sprayable chitosan/starch-based sealant reduced adhesion formation by 76% after ESS (P < .002).

A chitosan-based sinus sealant for reduction of adhesion formation in rabbit and sheep models.

OBJECTIVE: Chronic sinusitis is the most prevalent chronic disease in the United States in adults aged 18 to 44 years, with approximately 250,000 operations performed annually. Although often successful, sinus surgery fails in greater than 15% of patients. Adhesion formation is a common complication and cause for subsequent revision surgery. Here, the authors evaluate a sprayable chitosan/starch-based sinus sealant and demonstrate its ability to reduce adhesion formation both in vitro and in 2 animal models. STUDY DESIGN: Randomized, controlled, animal trials. SETTING: Academic medical center (fibroblast experiments) and animal laboratories (sheep and rabbit studies). SUBJECTS AND METHODS: This sinus sealant was applied to human cultured fibroblasts obtained from surgically removed polyps to examine its ability to inhibit fibroblast migration and proliferation. The sinus sealant was applied to New Zealand White rabbits (n = 20) in an established cecal-sidewall abrasion model and to sheep (n = 10) in a sinus surgical adhesion model to examine its ability to reduce adhesion formation. RESULTS: This sinus sealant inhibited migration and proliferation of human cultured fibroblasts and reduced the total adhesion score from 4.9 to 0.3 for a total reduction of 94% (95th percentile confidence interval [CI], 78%, 100%; P < .001) in a well-established rabbit cecal-sidewall model commonly used for adhesion testing. Moreover, this sealant reduced adhesion formation from 80% to 10% for a total reduction of 70% (95th percentile CI, 57%, 93%; P = .003) in a sheep sinus adhesion surgical model. CONCLUSION: This chitosan-based sealant demonstrates promise for reducing adhesion formation in sinus surgery.

2012 update on meaningful use of electronic health records: recommendations from the AAO-HNS Medical Informatics Committee.

In 2011, the US federal government implemented an oversight program to encourage the adoption and meaningful use of electronic health records (EHRs). Otolaryngologists may receive as much as $44,000 under Medicare or $63,750 under Medicaid as part of this law. To receive this full benefit, otolaryngologists must acquire a certified EHR and demonstrate stage 1 meaningful use requirements by the end of 2012. Furthermore, the Office of the National Coordinator for Health IT intends to advance meaningful use requirements to stage 2 (estimated to go in effect in 2014) and stage 3 requirements. This commentary discusses updated recommendations from the Academy of Otolaryngology-Head and Neck Surgery Medical Informatics Committee for implementing meaningful use of EHRs, receiving incentive payments, and preparing for potential stage 2 and stage 3 requirements.

Meaningful use of electronic health records in otolaryngology: recommendations from the American Academy of Otolaryngology--Head and Neck Surgery Medical Informatics Committee.

Under the Health Information Technology for Economic and Clinical Health (HITECH) Act, passed as a part of the American Recovery and Reinvestment Act of 2009, the US Congress implemented new regulations to encourage the adoption of electronic health records (EHRs). The federal government will expend up to $27 billion in incentive payments to physicians and hospitals to increase adoption and implement "meaningful use" of EHRs. Otolaryngologists may receive as much as $44,000 under Medicare or $63,750 under Medicaid as part of this law. In July 2010, the US Department of Health and Human Services announced final rules to support "meaningful use." This commentary discusses recommendations from the American Academy of Otolaryngology--Head and Neck Surgery Medical Informatics Committee for implementing "meaningful use" of EHRs to improve safety, quality, and efficiency of patient care and receiving incentive payments as defined by these new regulations.

Effects of smoking on quality of life following sinus surgery: 4-year follow-up.

OBJECTIVES/HYPOTHESIS: The purpose of this study is to report on long-term outcomes in a prospective study comparing the quality-of-life outcomes in smokers and nonsmokers undergoing functional endoscopic sinus surgery. STUDY DESIGN: : Prospective clinical trial. METHODS: A total of 235 patients were prospectively enrolled at a single tertiary academic center. Preoperative Sino-Nasal Outcomes Test (SNOT)-20 scores and comprehensive demographic and smoking data were obtained. Preoperative SNOT-20 scores were compared to postoperative SNOT-20 scores. RESULTS: Long-term follow-up results were available in 111/185 nonsmokers (60%) and 26/50 smokers (52%). Nonsmokers had a mean preoperative SNOT-20 score of 26.2, a short-term follow-up score of 10.1 (mean, 3.1 months) and a long-term follow-up score of 11.4 (mean, 44.2 months). Smokers had a mean preoperative SNOT-20 score of 27.8, a short-term follow-up score of 5.7 (mean, 3.1 months) and a long-term follow-up score of 8.3 (mean, 40.3 months). The mean improvement in SNOT-20 scores for smokers was significantly greater than nonsmokers in short-term follow-up (P = .044), however, no significant difference in improvement was seen between smokers and nonsmokers at long-term follow-up. CONCLUSIONS: Both smokers and nonsmokers continue to maintain a highly significant improvement in SNOT-20 scores following endoscopic sinus surgery at long-term follow-up. Although smoking remains a well-documented cause of medical morbidity, smokers maintained an improvement in quality of life after long-term follow-up from endoscopic sinus surgery in this prospective study.

Proteomics blood testing to distinguish chronic rhinosinusitis subtypes.

OBJECTIVES: To evaluate the potential of surface enhanced laser desorption/ionization time-of-flight mass spectrometry (SELDI-TOF-MS) proteomic profiling of serum samples to distinguish chronic rhinosinusitis subtypes. STUDY DESIGN: Translational study of serum samples from prospectively enrolled patients undergoing sinus surgery. METHODS: Patients undergoing endoscopic sinus surgery for chronic rhinosinusitis with nasal polyposis were prospectively enrolled in an ongoing, institutional review board approved proteomics study. SELDI-TOF-MS was performed on 42 serum samples in patients with chronic rhinosinusitis with nasal polyposis (15 patients diagnosed with allergic fungal rhinosinusitis, 10 patients with Samter's triad, and 17 with chronic rhinosinusitis with nasal polyposis). Classification tree analysis on protein spectra developed from peaks detected in the 0 to 100 kD range was performed to identify disease subtypes. RESULTS: SELDI-TOF-MS correctly identified patients with allergic fungal rhinosinusitis from serum samples with 84% sensitivity and 90% specificity, and correctly identified patients with Samter's triad with 88% sensitivity and 88% specificity in two subtype comparison groups. SELDI-TOF-MS correctly identified patients with allergic fungal rhinosinusitis with 76% sensitivity and 82% specificity, and correctly identified patients with Samter's triad with 80% sensitivity and 90% specificity in three subtype comparison groups. CONCLUSION: The study provides molecular evidence that allergic fungal rhinosinusitis is a discrete subtype of chronic rhinosinusitis. SELDI-TOF-MS is a promising technology that could lead to the development of a rapid blood test, to identify severe chronic rhinosinusitis subtypes. Further investigation into the utility of this technology is warranted.

Serum inflammatory protein profiles in patients with chronic rhinosinusitis undergoing sinus surgery: a preliminary analysis.

BACKGROUND: The specific aim of this study was to evaluate surface-enhanced laser desorption/ionization time-of-flight mass spectroscopy (SELDI-TOF-MS) as a clinical screening tool in differentiating patients with chronic rhinosinusitis (CRS) from healthy control patients. METHODS: Serum samples were prospectively collected at a tertiary care academic medical center from 96 CRS patients who underwent functional endoscopic sinus surgery (FESS) and 38 control volunteers who were negatively screened according to the Rhinosinusitis Task Force guidelines on CRS. SELDI-TOF-MS was performed on serum samples to detect protein profiles in the range of 1-100 kDa. Analysis of spectral data was performed to determine the sensitivity and specificity of SELDI-TOF-MS in distinguishing patients with CRS requiring FESS from healthy controls and to determine potential markers for protein purification. RESULTS: Serum protein profiles generated from SELDI-TOF-MS in the range of 1-100 kDa were analyzed. Classification and regression tree analysis based on peak expression correctly classified patients with CRS with 77.1% sensitivity and 65.8% specificity, a positive predictive value of 88%, and a negative predictive value of 53%. Underexpression of a protein peak at 8.4 kDa was associated with CRS in 77% of cases. CONCLUSION: SELDI-TOF-MS serum protein profile analysis is able to distinguish CRS patients requiring FESS from healthy, negatively screened controls with a sensitivity of 77.1% and specificity of 65.8%. Additional investigation is required to determine if SELDI-TOF-MS will make an effective clinical tool.

The use of portable intraoperative computed tomography scanning for real-time image guidance: a pilot cadaver study.

BACKGROUND: This study was performed to assess the feasibility of using intraoperative computed tomography (CT) to provide real-time updates to image guidance systems (IGSs) during surgery. METHODS: The xCAT ENT portable intraoperative CT scanner (Xoran Technologies, Ann Arbor, MI) was used to acquire scans before, midway, and at the end of six cadaver dissections during the Southern States Rhinology Course, Augusta, GA, in October 2006. These scans were used to recalibrate three different IGSs used during the dissection. Time measurements were recorded and dosimetry was obtained from the cornea, sphenoid sinus (near the optic chiasm), and from the operative field during acquisition of the images. IGS accuracy was determined at the skull base and lamina papyracea. Surgeons were interviewed on benefits of real-time updates to the IGS after completion of dissections. RESULTS: The xCAT ENT scanner was compatible with all three IGS platforms. The average time to update the IGS was 13 minutes. Radiation doses to the cornea were 620 mrad per scan, and optic chiasm was 800 mrad/scan. The accuracy at the anterior skull base improved from 1.58 to 0.62 mm (p=0.026). The accuracy at the posterior skull base improved from 1.46 to 0.71 mm (p=0.014). The accuracy at the lamina was not significantly changed. CONCLUSION: Intraoperative portable CT scanning with real-time IGS updates is feasible and likely would add little additional time. Accuracy is improved at the skull base. Prospective studies on actual patients are warranted.

The effects of smoking on short-term quality of life outcomes in sinus surgery.

OBJECTIVE: The purpose of this study was to prospectively compare the short-term benefit of endoscopic sinus surgery for smokers and nonsmokers using a disease specific, clinically validated, quality of life outcomes measure, the Sinonasal Outcomes Test-20 (SNOT-20). STUDY DESIGN: Prospective clinical trial. METHODS: A total of 235 patients were prospectively enrolled at a single tertiary academic center. Preoperative SNOT-20 scores and comprehensive demographic data were obtained. All patients underwent endoscopic sinus surgery under the supervision of the senior author. Preoperative SNOT-20 scores were compared to short-term postoperative SNOT-20 scores. RESULTS: Short-term postoperative results were available for 221 patients for comparison. Preoperative SNOT-20 scores in 49 smokers (mean: 27.8) and 172 nonsmokers (mean: 26.2) were statistically similar. Both smokers and nonsmokers achieved a highly significant reduction in SNOT-20 scores at short-term follow-up evaluations. (P < .0005) Smokers achieved a greater reduction in SNOT-20 scores (mean difference: 22.1) at short-term follow-up compared to nonsmokers (mean difference: 16.1). This result was statistically significant (P < .044). CONCLUSIONS: This study confirms that smokers and nonsmokers achieve a highly significant short-term benefit from endoscopic sinus surgery using a clinically-validated symptom severity scale in a prospective study. Interestingly, smokers achieved a greater short-term benefit than nonsmokers did. This study calls into question the notion that current smokers are poorer candidates for endoscopic sinus surgery. Further prospective studies to confirm these results and provide long-term analysis should be performed.

High-resolution computed tomography analysis of the greater palatine canal.

BACKGROUND: The greater palatine foramen injection is effective for minimizing bleeding during sinus surgery. The correct depth is important to minimize risk of orbital penetration. This study analyzed the length of the greater palatine canal using high-resolution computed tomography (HRCT). METHODS: HRCT sinus scans from 100 adults were analyzed. One thousand two hundred measurements were performed by three observers. RESULTS: The mean distance of the greater palatine foramen to the orbital floor was 40+/-3 mm in men and 37+/-3 mm in women (range, 32-46 mm). The mean distance of the greater palatine foramen to the sphenopalatine foramen was 28+/-2 mm in men and 27+/-2 mm in women (range, 23-33 mm). CONCLUSION: The greater palatine foramen injection is an appropriate method to minimize bleeding during endoscopic sinus surgery. The authors recommend an injection depth of 25 mm in adults to minimize the risk of intraorbital complications.

Bilateral cochlear implantation: current concepts.

PURPOSE OF REVIEW: Recent experience has shown an advantage of bilateral cochlear implantation over unilateral implantation. These documented benefits include improved speech perception in noisy environments and improved sound localization. Recently, investigators have studied the long-term benefit, evaluation of neural integration, programming, vestibular effects, and complications of bilateral cochlear implantation. This article summarizes the current research endeavors to improve our understanding and utilization of bilateral cochlear implantation. RECENT FINDINGS: Numerous positive benefits of bilateral cochlear implantation have been confirmed. Patients receive significant head shadow benefit from bilateral implantation, and obtain nominal benefits from summation and squelch effects. Sound localization benefits have been confirmed. Speech perception in noise with bilateral implantation is significantly better than unilateral implantation and continues to improve 24 months after implantation. Areas for further improvement have also been identified. Despite technological improvements in speech processing strategies, measured intraaural time differences in bilateral cochlear implant recipients remain considerably greater than those with normal hearing. Programming challenges persist to optimize sound processing with bilateral implants. Vestibular effects of bilateral cochlear implantation appear safe but need further study. Important considerations including the duration of implant function, long-term complication rate, and improvements in implant technology will continue to strongly influence the role of bilateral cochlear implantation. SUMMARY: Bilateral cochlear implantation provides advantages over unilateral implantation including improved speech perception in noise and improved sound localization. Further research is needed to define the optimal indications and to maximize the benefit of bilateral implantation.

Cytokine amplification by respiratory syncytial virus infection in human nasal epithelial cells.

OBJECTIVES: Respiratory syncytial virus (RSV) is an important cause of upper respiratory infections and is known to play a causal role in the pathogenesis of rhinitis, sinusitis, acute otitis media, and pneumonia. RSV appears to prime the respiratory tract to secondary inciting events, such as bacterial or antigen challenges. To study the proinflammatory priming effects of RSV infection, cytokine expression was measured in well-differentiated human nasal epithelial cells (WD-NE) after RSV infection alone or after subsequent tumor necrosis factor (TNF)-alpha stimulation. STUDY DESIGN: In vitro investigation. METHODS: Human nasal epithelial cells were obtained from surgical specimens and allowed to differentiate in air-liquid interface cultures until ciliation and mucus production were evident. Two experimental paradigms were used. First, accumulation of cytokines in the media was measured by real-time, quantitative reverse-transcriptase polymerase chain reaction (RT-PCR) and enzyme-linked immunosorbent assay after RSV infection alone. In the second set of experiments, cytokines were also measured after TNF-alpha stimulation in both RSV-infected and uninfected cultures. RESULTS: RSV infection of WD-NE resulted in significant accumulations of interleukin (IL)-6, IL-8, and RANTES when compared with findings in control samples. Real-time, quantitative RT-PCR demonstrated significant increases in IL-8 gene expression following RSV infection when compared to controls. Secondary TNF-alpha stimulation following well-established (i.e., 72 h) RSV infection induced marked increases in IL-6, IL-8, and RANTES when compared with both RSV infection alone and TNF-alpha stimulation alone. CONCLUSIONS: These findings suggest that RSV infection primes nasal epithelial cells to secondary proinflammatory challenge, resulting in a hyperimmune response. RSV-induced priming of a hyperimmune response may be important in the pathogenesis of sinusitis, acute otitis media, and pneumonia.