A New Patient-reported Outcomes Measure for Surgically Treated Epiphora: Tearing Assessment and Rating Scale-12 (TEARS-12)

BACKGROUND

No widely accepted, validated instrument currently exists to measure clinical outcomes in patients who undergo dacryocystorhinostomy (DCR) for treatment of epiphora.

OBJECTIVE

To develop a patient-reported outcome measure applicable to this population.

METHODS

Psychometric evaluations, consultation with experts, and review of the literature informed item generation of a 12-question questionnaire to incorporate the most relevant symptoms experienced by patients with nasolacrimal duct obstruction. This questionnaire, known as the Tearing Assessment and Rating Scale-12 (TEARS-12), was administered to 32 patients before and after intervention, in the form of endoscopic DCR. Statistical analysis was performed to measure internal consistency, responsiveness, and test-retest reliability.

RESULTS

Pre-operative and post-operative TEARS-12 scores (28.2 [standard error (SE) 3.19] vs 11.8 [SE 3.25], respectively, P = 0.001) demonstrated improved patient outcome within 6 weeks following endoscopic DCR. Cronbach's alpha for the questionnaire was 0.90, indicating high overall reliability. Additionally, each question demonstrated internal reliability, with a corrected item-total correlation greater than 0.30. The intraclass correlation between the two pre-operative scores was 0.858 (P < 0.001), indicating high test-retest reliability.

CONCLUSION

TEARS-12 is a statistically valid, easy-to-administer instrument to measure clinical outcomes in patients who undergo endoscopic DCR.

Infection After Endoscopic Dacryocystorhinostomy: Incidence and Implications

BACKGROUND

Endoscopic dacryocystorhinostomy (EN-DCR) is an increasingly common procedure performed by otolaryngologists. While EN-DCR has a high rate of success at relieving blockage of the lacrimal system, little is known regarding associated postoperative infection (POI) rates and risk factors.

OBJECTIVE

The purpose of this study was to identify factors associated with the occurrence of postoperative orbital and rhinologic infection in a large cohort of patients undergoing EN-DCR.

METHODS

A retrospective review of 582 patients who underwent EN-DCR was performed. All patients received antibiotic prophylaxis as a single intraoperative intravenous administration and a ten-day postoperative oral course. Clinical and demographic information was reviewed, including the occurrence of acute orbital or rhinologic infection within 30 days of surgery. Multivariable analysis was performed to identify risk factors associated with POI.

RESULTS

Fifteen of 582 patients (2.6%) developed POI following EN-DCR. The most common POI was acute rhinosinusitis (10/15, 66.7%), followed by acute dacryocystitis (2/15, 13.3%), preseptal cellulitis (2/15,13.3%), and acute bacterial conjunctivitis (1/15, 6.7%). The majority of patients (464/582, 79.7%) underwent concurrent endoscopic sinus surgery (ESS). In most cases (302/464, 65.1%), ESS was performed to address comorbid rhinosinusitis, whereas 7.8% (36/464) of patients underwent surgery to enhance surgical access to the lacrimal sac. Patients who underwent concurrent ESS were less likely to develop POI (OR: 0.17, CI: 0.04-0.80, p < 0.05). Evidence of mucopurulence at surgery increased the likelihood of POI (OR: 6.24, CI: 1.51-25.84, p < 0.05).

CONCLUSION

Mucopurulence at the time of surgery significantly increased the risk of POI, whereas concurrent ESS, performed most commonly to address comorbid rhinosinusitis, significantly decreased the risk of POI. Awareness of risk factors for POI and appropriate surgical management of concurrent rhinosinusitis can lead to reduced infectious complications after EN-DCR.

Korean Red Ginseng aqueous extract improves markers of mucociliary clearance by stimulating chloride secretion

Background

Abnormal chloride (Cl^-) transport has a detrimental impact on mucociliary clearance in both cystic fibrosis (CF) and non-CF chronic rhinosinusitis. Ginseng is a medicinal plant noted to have anti-inflammatory and antimicrobial properties. The present study aims to assess the capability of red ginseng aqueous extract (RGAE) to promote transepithelial Cl^- secretion in nasal epithelium.

Methods

Primary murine nasal septal epithelial (MNSE) [wild-type (WT) and transgenic CFTR^-/-], fisher-rat-thyroid (FRT) cells expressing human WT CFTR, and TMEM16A-expressing human embryonic kidney cultures were utilized for the present experiments. Ciliary beat frequency (CBF) and airway surface liquid (ASL) depth measurements were performed using micro-optical coherence tomography (μOCT). Mechanisms underlying transepithelial Cl^- transport were determined using pharmacologic manipulation in Ussing chambers and whole-cell patch clamp analysis.

Results

RGAE (at 30μg/mL of ginsenosides) significantly increased Cl^- transport [measured as change in short-circuit current (ΔI_SC = μA/cm²)] when compared with control in WT and CFTR^-/- MNSE (WT vs control = 49.8±2.6 vs 0.1+/-0.2, CFTR^-/- = 33.5±1.5 vs 0.2±0.3, p < 0.0001). In FRT cells, the CFTR-mediated ΔI_SC attributed to RGAE was small (6.8 ± 2.5 vs control, 0.03 ± 0.01, p < 0.05). In patch clamp, TMEM16A-mediated currents were markedly improved with co-administration of RGAE and uridine 5-triphosphate (8406.3 +/- 807.7 pA) over uridine 5-triphosphate (3524.1 +/- 292.4 pA) or RGAE alone (465.2 +/- 90.7 pA) (p < 0.0001). ASL and CBF were significantly greater with RGAE (6.2+/-0.3 μm vs control, 3.9+/-0.09 μm; 10.4+/-0.3 Hz vs control, 7.3 ± 0.2 Hz; p < 0.0001) in MNSE.

Conclusion

RGAE augments ASL depth and CBF by stimulating Cl^- secretion through CaCC, which suggests therapeutic potential in both CF and non-CF chronic rhinosinusitis.

Osteoplastic Flap Without Obliteration: How I Do It

Background The osteoplastic flap provides access to pathology of the frontal sinus and is often performed with obliteration, which can result in significant long-term complications. Objective To describe the authors' approach to osteoplastic flap without obliteration. Methods Descriptive analysis. Results Osteoplastic flap without obliteration preserves frontal sinus function while permitting direct access to the frontal sinus. In this study, we demonstrate a combined nonobliterated approach, accessing the frontal sinus with a Draf III approach to remove a large frontal sinus osteoma. Conclusion The approach provides excellent exposure for large tumors not otherwise accessible via purely endoscopic procedures, permits improved surveillance, and minimizes long-term complications of obliterated sinuses.

Submucosal gland mucus strand velocity is decreased in chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) may be initiated by innately impaired host defense mechanisms that predispose the upper airways to infection. Recent evidence suggests tethering of submucosal gland mucus strands represents an inciting event within cystic fibrosis (CF) airways, occurring prior to onset of chronic infection. Submucosal gland hypertrophy and defective mucociliary clearance (MCC) are present in actively inflamed sinuses, but mucus strand velocity may also be affected as a secondary event, further contributing to chronic disease. The objective of this study is to assess whether mucus strand velocity is decreased in patients with CRS.

METHODS

Mucosal explants from patients with and without CRS were submerged in Ringer's solution mixed with fluorescent nanospheres. Methacholine was then added, and videos demonstrating strand growth and detachment were generated from a time-lapse of Z-stack images using a multiphoton confocal microscope. Dynamic mucus strands were identified and individual velocities quantified with the MTrackJ plug-in of ImageJ.

RESULTS

Fifteen patients met criteria for ex vivo analysis of mucus strand velocities (CRS, n = 9 vs controls, n = 6). Mucus strands were recorded (pixels/second) streaming from the submucosal gland openings. Average mucus strand velocities were significantly decreased in patients with CRS (1.53 ± 0.67 vs controls, 4.86 ± 1.68 pixels/second; p < 0.001).

CONCLUSION

This study is the first to report evidence of abnormal mucus strand velocity from submucosal glands in diseased sinonasal mucosa. Future pharmacologic studies targeting this critical component of MCC are warranted.

The imaginative use of religious symbols in subjective experiences of anorexia nervosa

Clinicians working with contemporary women with anorexia nervosa have commented on the ascetic component in anorexia, meaning their self-denial, heightened morality, opposition between body and spirit, asexuality, and denial of bodily death (Mogul, 1980; Palazzoli, 1978; Rampling, 1985; Sabom, 1985; Turner, 1984). While these clinicians have commented on the asceticism in contemporary anorexia nervosa, they have little to say about the role of culture in subjective experiences of this asceticism. As we have seen, Jane and Margaret used notions of asceticism about food and the body that are a part of their religious beliefs to create a personal meaning system through which they expressed their self-starvation. These cases, while supporting clinical studies that point to an ascetic component in modern anorexia, go further to suggest that in some cases, this asceticism may be encoded in religion. Religious anorectics like Jane and Margaret challenge models of anorexia nervosa that understand the condition exclusively in terms of cultural foci on "dieting" and secular ideals of beauty and bodily thinness for women (Bemporad, Hoffman, & Herzog, 1989; Chernin, 1985; Garner et al., 1980; Orbach, 1986; Rost, Newhaus, & Florian, 1982). They also suggest a continuing persistence into the twentieth century of an association between religiosity and self-starvation noted by historians during the early Christian, medieval, and late-Victorian periods in the West (Bell, 1985; Brown, 1988; Brumberg, 1985, 1988; Bynum, 1987). The above discussion points to the new directions in psychological anthropology which challenge a strict and opposing dichotomy between the conscious and unconscious, between culture (seen as "public") and the individual mind (seen as "private" and idiosyncratic). Obeyesekere's concept of "the work of culture," (Obeyesekere, 1990) and Stephen's concept of the "autonomous imagination" are especially useful in understanding how persons like Jane and Margaret use in imaginative ways cultural symbols, such as notions of asceticism about food and the body that are a part of religion, to give meaning to their personal concerns with growth, separation, and sexuality. We saw how Jane and Margaret transform cultural symbols and language to express their starvation and deep anxieties. These cases lend support to views that culture and religion, as symbolic systems, have underpinnings in deep motivation (Obeyesekere, 1981, 1990; Spiro, 1965, 1987). They also suggest that the relations between culture and the individual mind (and between culture and "illness," between "normal" and "abnormal") must be viewed as a moving continuum, with culture constantly worked and reworked by the individual imagination in innovative and creative ways.

'Culture' in culture-bound syndromes: the case of anorexia nervosa

Anorexia nervosa is presently considered a Western culture-bound syndrome. A cultural focus on dieting and ideals of thinness for women are assumed to be implicated in the disorder. While research indicates that the majority of non-anorectic women in the United States are preoccupied with body weight and dieting, it is not clear what 'thinness' means to anorectics themselves or that norms about dieting are always involved in subjective experiences of anorexia. Meaning-centered studies of anorectics--especially those in non-clinical settings--are needed to clarify the cultural contexts of the disorder. Case studies of two anorectic women from Minneapolis-Saint Paul, Minnesota, show that for some anorectics self-starvation is encoded in religious idioms and symbols about the body, food, and self. A review of the literature illustrates a long-standing relation between self-starvation and religious ideals in Western culture and points to an association between contemporary anorexia nervosa and asceticism. The case studies presented here demonstrate that this asceticism may be subjectively expressed through religious concepts about the body and food and suggest that future research formally investigate the religious practices and beliefs of anorectics seen clinically. The author explores the implications of these findings for definitions of 'normality' and 'abnormality,' key issues in ethnopsychiatry. These findings also suggest that future cross-cultural research might examine asceticism about the body and food in religions other than Judeo-Christian, cultural groups with rituals of fasting and vomiting, and the presence of fundamentalist churches and missionaries in those non-Western cultures for which there are recent reports of eating disorders. Anorexia nervosa's designation as a syndrome limited to Western cultures or to those cultures influenced by them may reflect unexamined assumptions on the part of researchers that dieting and secular ideals of slimness are primarily involved in the disorder.