BACKGROUND:

A retrospective data analysis at a university tertiary referral center was conducted to characterize the natural history, clinical characteristics, management principles, and outcomes of paranasal sinus mucoceles.

METHODS:

A chart review was performed on 102 patients with a total of 133 paranasal sinus mucoceles who were treated between 1987 and 2011 at the Hospital of the University of Pennsylvania.

RESULTS:

The study population included patients with a mean age of 53.1 years (range, 22-82 years). Patients were diagnosed with a mucocele on average 5.3 years following prior functional endoscopic sinus surgery (FESS), 17.7 years following prior paranasal sinus trauma, and 18.1 years following prior open sinus surgery. The most common presenting symptoms were headache (42.1%) and maxillofacial pressure (28.6%). The most common sites were the frontal, frontoethmoidal, and ethmoid sinuses. Fifty-seven mucoceles (44.9%) had intraorbital extension, intracranial extension, or both. Out of 133 mucoceles, 114 underwent ESS without complication.

CONCLUSION:

The length of time between prior surgery or trauma and mucocele presentation highlights the importance of long-term follow-up in both patient care and in the understanding and reporting of surgical outcomes. In this study, most patients exhibited nonspecific symptomatology despite extensive mucoceles and a significant incidence of orbital and skull-base erosion. The endoscopic approach can be safely used for the management of such lesions.

BACKGROUND:

Patients with isolated mucosal cysts of the maxillary sinus (MMC) often undergo surgical treatment despite the absence of relevant symptoms. Some physicians believe that MMC might increase in size and cause complications in the future. The anticipated value of this study is to consolidate and improve the understanding of MMC based on published data and to contribute to avoiding unnecessary interventions.

METHODS:

We performed a comprehensive review of the literature regarding definition, etiology, epidemiology, natural course, and best treatment of MMC.

RESULTS:

Among the 988 papers found in the literature search, 33 studies were selected to be relevant. Among those studies, there are only a few prospective controlled studies. Their prevalence rates range broadly from 3.6% to 35.6% according to different diagnostic methods as well as different indications for imaging. Recent prospective studies showed no correlation of MMC with sinonasal complaints or Lund-Mackay computed tomography (CT) score. The natural course is characterized by a decrease in size of MMC in 30% of the cases, an unchanged status in 50% to 60%, and an increase in 8% to 20% of the cases.

CONCLUSION:

MMC are harmless, mostly asymptomatic lesions that usually do not need surgical treatment. If surgery is indicated, endonasal endoscopic techniques should be the gold-standard approach.

BACKGROUND:

P-glycoprotein (P-gp) is a membrane-bound efflux pump that is upregulated in chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP) and participates in epithelial cytokine secretion. Eosinophilic CRS (ECRS) shares a similar cytokine profile with CRSwNP and is associated with significant inflammation and poor surgical outcomes. The goal of this study is to determine if P-gp expression is associated with degree of eosinophilia and severity of radiographic inflammation in patients with CRS without polyps (CRSsNP).

METHODS:

An institutional review board (IRB)-approved study using sinus tissue in 39 steroid-naive patients with CRS. P-gp expression was calculated using quantitative fluorescent immunohistochemistry (Q-FIHC) to generate an epithelial to background staining ratio. Patients were stratified into low and high epithelial expression groups (<3 and ≥3, respectively). Average eosinophils per high powered field (hpf) and Lund-Mackay scores were calculated and compared with P-gp staining ratios using a 2-tailed Student t test.

RESULTS:

Among the 39 patients, 7 (17.95%) had high P-gp expression ratios (mean ± SD, 4.86 ± 1.33) while 32 (82.05%) had low expression ratios (1.91 ± 0.45). The number of eosinophils/hpf were significantly greater in the high P-gp expression group as compared to the low expression group (62.38 ± 83.69 vs 5.11 ± 10.12, p = 0.0003). The Lund-Mackay scores were significantly greater in the high P-gp expression group as compared to the low expression group (11.86 ± 2.79 vs 6.84 ± 4.19, p = 0.005).

CONCLUSION:

P-gp is known to be overexpressed in CRSwNP. This study suggests that among patients with CRSsNP, P-gp is similarly overexpressed in those with high tissue eosinophilia and correlates with severity of radiographic inflammation.

BACKGROUND:

A genetic basis to chronic rhinosinusitis (CRS) is postulated, but remains elusive. We have recently identified low levels of circulating CD8 lymphocytes as a frequent finding in difficult-to-treat or refractory CRS. In major histocompatibility complex 1 class 1 (MHC1) deficiency, low circulating levels of CD8 lymphocytes secondary to mutations in the cluster of differentiation 8a (CD8A), tapasin 1 (TAP1), tapasin 2 (TAP2), or tapasin binding-protein (TAPBP) genes lead to a clinical syndrome, which is associated with severe CRS. The objective of this work was to identify whether genetic factors associated with MHC1 deficiency are present in CRS.

METHODS:

Previous results from a genomewide association study of CRS were screened for polymorphisms in the CD8A, TAP1, TAP2, and TAPBP genes associated with MHC1 immunodeficiency syndrome. Significant polymorphisms were tested for associations with demographic factors characterizing severe CRS.

RESULTS:

Polymorphisms in the CD8A (rs3810831) and TAPBP (rs2282851) genes were significantly associated with CRS. Major allele homozygosity for CD8A (rs3810831) was associated with a higher frequency of affected relatives (p = 0.052), increased severity as characterized by age at diagnosis (p = 0.009), age at first surgery (p = 0.004), and number of surgeries (p = 0.008), whereas TAPBP (rs2282851) was associated increased risk for CRS (odds ratio [OR] = 2.48, p = 0.0076).

CONCLUSION:

Modified CD8A or TAPBP gene function may contribute to the development of refractory CRS via altered MHC1 function and reduction of circulating CD8 lymphocytes. Identification of markers in the CD8A or TAPBP genes via sequencing may offer a basis for genetic testing in CRS.

BACKGROUND:

Recent research suggest that B and plasma cells may play an important role in the pathogenesis of chronic rhinosinusitis with nasal polyposis (CRSwNP). The purpose of this study was to subcharacterize the B cell response in the sinus mucosa of control and CRS patients.

METHODS:

Representative tissue samples and peripheral blood samples were obtained from controls, CRS without nasal polyps (CRSsNP) and CRSwNP. Using single-cell suspension flow cytometry these samples were analyzed for overall and stage-specific B and plasma cell percentages.

RESULTS:

Both atopic and nonatopic CRSwNP patients showed an increase in local numbers of naive, active, and memory B cells compared to controls. CRSsNP patients only showed local elevations of naive B cells. Plasma cells were only significantly elevated in the sinus tissue of atopic CRSwNP patients. These local tissue increases did not correlate with increased numbers of circulating B cells.

CONCLUSION:

This study provides further evidence of an important role of B cells in CRSwNP patients. The local increase appears to be independent of a systemic response.

BACKGROUND:

Epithelial permeability is highly dependent upon the integrity of tight junctions, which are cell-cell adhesion complexes located at the apical aspect of the lateral membrane of polarized epithelial cells. We hypothesize that sinonasal epithelial exposure to Der p 1 house dust mite antigen decreases expression of tight junction proteins (TJPs), representing a potential mechanism for increased permeability and presentation of antigens across the sinonasal epithelial layer.

METHODS:

Confluent cultured primary human sinonasal epithelial cells were exposed to recombinant Der p 1 antigen vs control, and transepithelial resistance measurements were performed over 24 hours. Antibody staining for a panel of TJPs was examined with immunofluorescence/confocal microscopy and Western blotting. Tissue for these experiments was obtained from 4 patients total.

RESULTS:

Der p 1 exposed sinonasal cells showed a marked decrease in transepithelial resistance when compared to control cells. In addition, results of Western immunoblot and immunofluorescent labeling demonstrated decreased expression of TJPs claudin-1 and junction adhesion molecule-A (JAM-A) in Der p 1-exposed cultured sinonasal cells vs controls.

CONCLUSION:

Der p 1 antigen exposure decreases sinonasal epithelium TJP expression, most notably seen in JAM-A and claudin-1 in these preliminary experiments. This decreased TJP expression likely contributes to increased epithelial permeability and represents a potential mechanism for transepithelial antigen exposure in allergic rhinitis.

BACKGROUND:

Culture-directed antibiotic therapy remains imperative in the management paradigm of chronic rhinosinusitis (CRS). The objective of this study was to conduct a prospective, blinded comparison of endoscopically-guided swab and aspirate cultures from the same sinonasal site in patients presenting with acute infectious exacerbations post-sinus surgery.

METHODS:

Forty-nine CRS patients were prospectively enrolled in a tertiary care rhinology clinic. At the conclusion of the study, all cultures were unblinded to determine mean culture yield, most common pathogens, potential contaminants, and therapeutic correlation.

RESULTS:

The mean patient age was 49 years and 40.8% were males. All patients had evidence of symptomatic exacerbation with purulence on endoscopy at the time of presentation. There was a mean of 1.367 pathogens assayed per aspirate culture vs a mean of 1.102 per swab culture (p = 0.0032). The prevalence of Pseudomonas aeruginosa was 42% for aspirate vs 30% for swab cultures, respectively. The prevalence of Staphylococcus aureus was 49% for suction cultures vs 45% for swab cultures. There were 9 and 11 likely contaminants using aspirate and swab cultures, respectively. Therapeutic correlation was strong in 67%, moderate in 18%, and weak in 14% of patients.

CONCLUSION:

This prospective analysis demonstrated higher culture yield, particularly with Pseudomonas, with aspirate vs swab cultures in postoperative patients. There is a strong clinical correlation between the 2 methods, and both aspirate and swab techniques serve as acceptable alternatives for endoscopic-guided cultures in patients with post-functional endoscopic sinus surgery infectious exacerbations.

BACKGROUND:

The potentially severe complications resulting from cerebrospinal fluid (CSF) leak makes iatrogenic injury a medicolegal area of concern for otolaryngologists and neurosurgeons. The objectives of this analysis were to study legal outcomes as well as medical and nonmedical elements affecting malpractice litigation.

METHODS:

Public court records available in the Westlaw legal database (Thomson Reuters, New York, NY) were searched for medical malpractice litigation related to iatrogenic CSF leak. Of the 18 jury verdicts and settlements included, outcomes and awards, patient demographic data, and other factors instrumental in determining legal responsibility were recorded for comparison.

RESULTS:

Ten (55.6%) cases were resolved in the defendant's favor, 2 (11.1%) resulted in damages awarded by a jury, and 6 (33.3%) were settled out of court before resolution of trial. Mean damages awarded were $1.1 million, while out of court settlements averaged $966,887. Malpractice stemming from patients who underwent endoscopic sinus surgery comprised 77.8% of cases analyzed. The most frequent alleged factors cited for litigation included having to undergo additional surgery (88.9%), developing meningitis (50.0%), and failing to recognize complications in a timely manner (44.4%). Perceived deficits in informed consent were alleged in one-third of cases.

CONCLUSION:

Although a slight majority of cases were resolved in the defendant's favor, payments made were considerable, averaging approximately $1 million. Strategies to decrease liability and allow patients to make more informed decisions should include clear communication with patients that explicitly states potential risks, such as meningitis, and possible need to undergo additional reparative surgery.