BACKGROUND:

Intranasal and oral corticosteroids are widely used in the management of chronic rhinosinusitis with nasal polyps (CRSwNP). Higher-dose topical nasal steroids (HDTNS) such as budesonide irrigations are increasingly used for long-term maintenance in these patients. Oral steroids have the potential to cause increased intraocular pressure (IOP) and glaucoma. It is unclear whether HDTNS have the same potential. The objective of this study was to determine the effect of intranasal budesonide irrigations on IOP.

METHODS:

Two groups of patients with CRSwNP treated with budesonide irrigations were prospectively enrolled. Patients with history of elevated IOP or glaucoma were excluded. Patients in group 1 had been using budesonide for at least 1 month and had IOP measured once at the time of enrollment. Group 2 consisted of patients who were placed on budesonide at the time of enrollment and had IOP measured both before and after at least 4 weeks of therapy.

RESULTS:

Ten patients in group 1 and 8 patients in group 2 completed the study. In group 1, the average duration of therapy at enrollment was 6.3 months (1-22 months). Only 1 patient had a single eye pressure above 21 mmHg. None of the patients in group 2 had a significant change in IOP or IOP over 21 mmHg.

CONCLUSION:

Intranasal budesonide irrigations given for a period of at least 1 month do not appear to increase IOP.

To evaluate TGF-β1 expression in polypoid mucosa (epithelium and stroma) of patients with chronic rhinosinusitis with nasal polyposis (CRSwNP).Cross-sectional study with two groups: 17 patients with nasal polyposis and 11 controls. Polyps and normal nasal mucosa were processed by immunohistochemical methods for TGF-β1 visualization. Then, the percentage of TGF-β1 expression in stroma and epithelium was objectively quantified using UT Morph software.A lower percentage of positive expression was found in the epithelium of CRSwNP patients (32.44%) versus normal controls (55.91%) (p < 0.05), and a higher percentage of positive expression in the stroma of CRSwNP patients (23.24%) versus controls (5.88%) (p < 0.05).The lower percentage of TGF-β1 expression in the nasal epithelium of CRSwNP patients may have an impact on epithelium-directed topical treatments employed in this patient population.

OBJECTIVES

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HYPOTHESIS:

Quantitative analysis of endoscopic high-speed video recordings of vocal fold vibrations has been growing in importance in recent years. The videos have mainly been analyzed using subjective evaluation, but this is examiner dependent, and the results show inadequate interobserver agreement. The aims of this study were therefore to identify appropriate objective parameters for analyzing high-speed recordings to differentiate healthy voice production from organic disorders.

STUDY DESIGN:

 

METHODS:

A total of 152 females were examined, divided into 77 healthy and 75 with four different pathological conditions: laryngeal epithelial thickening, Reinke edema, vocal fold polyps, and vocal fold cysts. Vocal fold vibrations were recorded with a high-speed camera (4,000 Hz, 256 × 256 pixels) during sustained phonation. Parameters computed from the glottal area waveform (GAW) and from phonovibrogram (PVG) were analyzed. Multiparametric linear discriminant analysis was performed to classify pathological conditions versus the healthy group.

RESULTS:

Twenty of 44 parameters were identified that are capable of distinguishing between the individual types of pathology. PVG parameters showed better performance than GAW parameters. Parameters representing vibrational periodicity via standard deviation showed better performance than absolute parameters. In addition, linear discriminant analysis achieved reliable differentiation between healthy and pathological vocal fold vibrations: 72% for the five-class problem (all groups separately) and 88% for the two-class problem (healthy vs. all pathologies taken as one class).

CONCLUSIONS:

The study succeeded in defining objective parameters for analyzing endoscopic high-speed videos and suggesting first parameters for differentiation between healthy dynamics and dynamics of organic pathologies.

LEVEL OF EVIDENCE:

3b.

PLUNC (palate, lung, and nasal epithelium clone) is an epithelium-secreted protein that plays a crucial role in the host's defense against bacterial infection. The function of PLUNC in the sinus remains poorly understood. To examine whether the expression levels of PLUNC could serve as a predictive outcome biomarker for patients with CRSwNP and bacterial colonization, we investigated the association of PLUNC expression levels with bacterial colonization in the sinuses. A total of 174 patients who underwent sinus surgery for chronic rhinosinusitis with nasal polyps (CRSwNP) were enrolled in this study. The tissue samples obtained from patients were examined using preoperative sinus computed tomography (CT) scans, postoperative bacterial cultures, and nasal polyp examinations. PLUNC mRNA and protein expression were quantified using RT-PCR and immunohistochemistry. We identified that decreased PLUNC expression is associated with multibacterial colonization (P = 0.0001), specifically those mediated by Staphyloccocus aureus (P = 0.037) and Pseudomonas aeruginosa (P = 0.002). The patients who required repeated sinus surgeries for recurrent or persistent sinusitis also presented much lower PLUNC expression than those who did not require repeated sinus surgery (P = 0.001). However, gender, age, and CT scores were not associated with PLUNC expression. These results suggest that reduced PLUNC expression is associated with bacterial colonization as well as treatment outcome in CRSwNP patients. Investigation of the association between PLUNC expressions and chronic rhinosinusitis may lead to the development of a novel biomarker for treatment outcome in CRSwNP patients.

The concomitant appearance of an inverted papilloma and a fungus ball in unilateral maxillary sinus is rare. These disease entities may be difficult to distinguish before surgery.A male patient presented with the characteristic symptoms of chronic rhinosinusitis. A preoperative sinus computed tomography scan revealed unilateral sinus opacification, hyperdense calcified spots, and bony erosion of the medial maxillary sinus wall.During the operation, a cheesy, clay-like fungus ball was removed. In addition, a papillary appearance of the sinus mucosa led to the suspicion of inverted papilloma behind the fungus ball and nasal polyps. The histopathology showed an inverted papilloma concomitant with a fungal ball and some inflammatory polyps.In addition to preoperative imaging, one should be aware of the potential etiology; careful intraoperative reevaluation is imperative for clinicians to avoid misdiagnosis and to provide adequate management of the underlying disease.

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:

Nasal polyposis (NP) is common in cystic fibrosis (CF) patients. The prevalence of the CF phenotype with NP after lung transplantation (LTx) is unknown. Risk factors for the development of NP after LTx are not well described.

METHODS:

CF patients with LTx at our center between November 1992 and December 2009 were included. They were regularly investigated with nasal endoscopy and aspiration of sinus secretions with microbiological evaluation. Patients with and without development of NP were compared along the following parameters: gender, age, dF508, diabetes, acute rejection, NP at LTx, and microbiology of the sinuses before and after LTx. A multivariate Cox regression analysis was performed.

RESULTS:

The study included 94 patients; 21 were excluded because of incomplete data. Thirty-five (48%) of the remaining 73 patients developed NP. Mean time to diagnosis of NP was 4.2 (2.9-5.6) years after LTx. Prevalence of NP was 11% after the first year and 18%, 33%, and 44% after the first 2, 5, and 10 years, respectively. Patients with posttransplantation NP were younger, had NP before LTx, and were chronically infected with Pseudomonas aeruginosa (PA) in the nose. Multivariate analysis demonstrated that chronic infection with PA was the only significant risk factor for the development of nasal polyps after LTx (hazards ratio, 7.2; 95% confidence interval, 2.1-24.2; P=0.001).

CONCLUSIONS:

In contrast to pretransplantation patients, NP is more common after LTx. Development of NP occurs throughout the whole observation time. Chronic sinonasal PA infection seems to be the only significant risk factor for NP after LTx.

Invasive as well as non-invasive methods are available for assessment of the endometrium.The purpose of this clinical guide is to provide evidence-based advice on endometrial assessment in peri and postmenopausal women.Literature review and consensus of expert opinion.Presuming speculum examination and cervical cytology are assessed, transvaginal ultrasound should be undertaken initially as it is non-invasive and will not only measure endometrial thickness, but will also detect other pelvic pathology such as leiomyomas and ovarian tumours. The main indication for invasive methods is to obtain endometrial tissue to diagnose or exclude the presence of endometrial cancer or pre-malignancies. Biopsy is mainly undertaken as an outpatient procedure, but sampling is 'blind'. Hysteroscopy is used when focal lesions affecting the uterine cavity are suspected such as endometrial polyps or sub-mucous fibroids. None of the available methods are perfect. Ultrasound evaluation is dependent on the experience of the examiner, the equipment and the quality of visualization. Hysteroscopy too is dependent on the examiner and fibroids may obstruct visualization. Blind endometrial biopsy procedures often miss focal lesions. Thus re-examination is necessary when symptoms persist and no explanation for these has been identified. This clinical guide will evaluate the different methods of endometrial assessment, their indications and limitations. Guidance is also given about dealing with inconclusive investigations and persistent symptoms.

A middle-aged male presented with unilateral nasal blockage, reduced sense of smell and daily nosebleeds. He had a history of nasal polyps, and had undergone a left-sided polypectomy and ethmoidectomy some 10 years previously. A large polpypoid mass was visible within the right nasal cavity upon examination, with CT and MRI imaging confirming the presence of a large soft tissue abnormality with no intracranial extension. Following biopsy suggestive of angioma, the patient underwent embolisation of the mass prior to endoscopic resection. Subsequent pathology revealed the mass to be a capillary haemangioma. The man made good postoperative progress and was asymptomatic at early follow-up.