Diagnosis, Prognosticators, and Management of Acute Invasive Fungal Rhinosinusitis: Multidisciplinary Consensus Statement and Evidence-Based Review with Recommendations

BACKGROUND

Acute invasive fungal sinusitis (AIFS) is an aggressive disease that requires prompt diagnosis and multidisciplinary treatment given its rapid progression. However, there is currently no consensus on diagnosis, prognosis, and management strategies for AIFS, with multiple modalities routinely employed. The purpose of this multi-institutional and multidisciplinary evidence-based review with recommendations (EBRR) is to thoroughly review the literature on AIFS, summarize the existing evidence, and provide recommendations on the management of AIFS.

METHODS

The PubMed, EMBASE, and Cochrane databases were systematically reviewed from inception through January 2022. Studies evaluating management for orbital, non-sinonasal head and neck, and intracranial manifestations of AIFS were included. An iterative review process was utilized in accordance with EBRR guidelines. Levels of evidence and recommendations on management principles for AIFS were generated.

RESULTS

A review and evaluation of published literature was performed on 12 topics surrounding AIFS (signs and symptoms, laboratory and microbiology diagnostics, endoscopy, imaging, pathology, surgery, medical therapy, management of extrasinus extension, reversing immunosuppression, and outcomes and survival). The aggregate quality of evidence was varied across reviewed domains.

CONCLUSION

Based on the currently available evidence, judicious utilization of a combination of history and physical examination, laboratory and histopathologic techniques, and endoscopy provide the cornerstone for accurate diagnosis of AIFS. In addition, AIFS is optimally managed by a multidisciplinary team via a combination of surgery (including resection whenever possible), antifungal therapy, and correcting sources of immunosuppression. Higher quality (i.e., prospective) studies are needed to better define the roles of each modality and determine diagnosis and treatment algorithms.

Otolaryngology Considerations of Pituitary Surgery: What an Endocrinologist Should Know

Endoscopic endonasal skull base surgery is the preferred surgical approach for the management of pituitary adenomas. Perioperative management of pituitary lesions requires multidisciplinary care and typically includes a dual surgeon team consisting of a neurosurgeon and an otolaryngologist. The involvement of the otolaryngologist allows for a safe surgical approach with excellent intraoperative visualization of the tumor to enable an effective resection of the tumor by the neurosurgeon. Detection and treatment of sinonasal pathology is essential prior to surgery. Patients may experience sinonasal complaints following endoscopic transsphenoidal surgery, although this is typically temporary. Sinonasal care in the postoperative period can expedite recovery to baseline. Here we discuss the perioperative factors of endoscopic pituitary surgery that endocrinologists should be aware of, ranging from preoperative patient selection and optimization to postoperative care, with a particular emphasis on anatomic and surgical factors.

Scientific Advancements That Empower Us to Understand CRS Pathophysiology

BACKGROUND

Chronic rhinosinusitis with nasal polyposis (CRSwNP) is a multifactorial inflammatory condition that remains poorly understood. Over the past decade, we have witnessed impressive scientific advancements that have allowed us to better understand the molecular and cellular mechanisms that underlie the inflammatory processes in mucosal diseases including asthma, allergic rhinitis, and CRSwNP.

OBJECTIVE

The present review aims to summarize and highlight the most recent scientific advancements that have enriched our understanding of CRSwNP.

METHODS

A comprehensive review of the available literature on the use of new scientific techniques in CRSwNP was performed. We evaluated the most recent evidence from studies using animal models, cell cultures, and genome sequencing techniques and their impact on our understanding of CRSwNP pathophysiology.

RESULTS

Our understanding of CRSwNP has rapidly progressed with the development of newer scientific techniques to interrogate various pathways involved in its pathogenesis. Animal models remain powerful tools and have elucidated the mechanisms behind esinophilic inflammation in CRSwNP; however, animal models reproducing polyp formation are relatively sparse. 3D cell cultures have significant potential to better dissect the cellular interactions with the sinonasal epithelium and other cell types in CRS. Additionally, some groups are starting to utilize single-cell RNA sequencing to investigate RNA expression in individual cells with high resolution and on a genomic scale.

CONCLUSION

These emerging scientific technologies represent outstanding opportunities to identify and develop more targeted therapeutics for different pathways that lead to CRSwNP. An additional understanding of these mechanisms will be critical for developing future therapies for CRSwNP.

Olfaction Now and in the Future in CRSwNP

BACKGROUND

Chronic rhinosinusitis (CRS) is the leading cause of olfactory dysfunction in the general population. Olfactory dysfunction is more common in patients with CRS with nasal polyposis (CRSwNP) compared to those without polyps.

PURPOSE

The present review aims to summarize the current literature on the mechanism behind olfactory dysfunction in CRSwNP and the impact of therapy on olfactory outcomes in this patient population.

METHODS

A comprehensive review of the available literature on olfaction in CRSwNP was performed. We evaluated the most recent evidence from studies on the mechanisms behind smell loss in CRSwNP and the impact of medical and surgical therapy for CRS on olfactory outcomes.

RESULTS

The mechanism behind olfactory dysfunction in CRSwNP is not completely understood, but evidence from clinical research and animal models suggests both an obstructive component causing conductive olfactory loss and an inflammatory response in the olfactory cleft leading to sensorineural olfactory loss. Oral steroids and endoscopic sinus surgery have both shown efficacy in improving olfactory outcomes in CRSwNP in the short term; however, the long-term response of these treatments remains uncertain. Newer targeted biologic therapies, such as dupilumab, have also shown remarkable and durable improvement in smell loss for CRSwNP patients.

CONCLUSION

Olfactory dysfunction is highly prevalent in the CRSwNP population. Although significant advances have been made in our understanding of olfactory dysfunction in the setting of CRS, additional studies are needed to elucidate cellular and molecular changes mediated by type 2-mediated inflammation in the olfactory epithelium with potential downstream effects on the central olfactory system. Further identification of these underlying basic mechanisms will be vital for developing future therapies targeted to improve olfactory dysfunction in patients with CRSwNP.

Impact of HPV status on immune responses in head and neck squamous cell carcinoma

The main objective of our study was to understand the impact of immune cell composition and the tumor-reactivity of tumor infiltrating lymphocytes (TIL) in HPV-positive (HPV⁺) and HPV-negative (HPV^-) head and neck squamous cell carcinoma (HNSCC). TIL cultures were established from primary HNSCC tumors, the T cell subsets were phenotypically characterized using flow cytometry, and Interferon (IFN)-γ ELISA assay was used to determine TIL function. NanoString Immune Profiler was used to determine an immune signature by HPV-status, and multiplex immunohistochemistry (MIHC) was used to quantify immune cell distributions and their spatial relationships. Results showed that HPV⁺ and HPV^- HNSCC had similar capacity to expand IFN-γ reactive TIL populations, and these TIL populations had similar characteristics. NanoString analysis revealed increased differential expression of genes related to B cell functions in HPV⁺ HNSCC, which were significant at a Benjamini-Yekutieli adjusted p-value of < 0.001. MIHC also displayed increased CD8⁺ T cell and CD19/CD20⁺ B cell densities in the tumor region of HPV⁺ HNSCC as opposed to HPV^- HNSCC (p < 0.01). Increases in a combined metric of tumor B cell content and stromal plasma cell content was associated with increased progression-free survival in HPV^- HNSCC patients treated with immune checkpoint inhibitor therapy (p = 0.03). In summary, TIL populations expanded from HPV⁺ and HPV^- HNSCC displayed similar IFN-γ reactivity. However, we identified a strong B-cell signature present within HPV⁺ HNSCC, and higher B and plasma cell content associated with improved PFS in HPV^- HNSCC patients treated with immune checkpoint inhibitors.

Initial Presentation of Granulomatosis with Polyangiitis as Progressive Skull Base Osteomyelitis

A healthy man in his 30s presented with a 2-week history of severe bitemporal pain and pressure. He was initially treated for presumed acute rhinosinusitis, but his symptoms continued to worsen and underwent endoscopic sinus surgery at an outside community facility. He developed left abducens nerve palsy postoperatively, and magnetic resonance imaging (MRI) demonstrated evidence of extensive skull base osteomyelitis. He was initiated on intravenous (IV) broad-spectrum antibiotics but was subsequently found to have prostatic and submandibular sterile fluid collections. The patient subsequently developed new right abducens and left vagal nerve palsies and underwent revision endoscopic sinus surgery. Pathology revealed extensive inflammation, necrotizing granulomas, and evidence of small and medium vessel vasculitis. Extensive laboratory workup was negative, except for anti-PR-3 antibody positivity. Given the characteristic findings on pathology and laboratory findings, the patient was diagnosed with granulomatosis with polyangiitis (GPA). High-dose glucocorticoid therapy as well as rituximab infusion were promptly initiated. He had marked improvement in his symptoms and resolution of his right CN VI palsy but left-sided CN VI and CN X palsies persisted. This patient presented without the typical rhinologic manifestations of GPA, and rather presented with progressive sinusitis, skull base osteomyelitis with associated cranial neuropathies, and aseptic systemic abscesses. Prompt diagnosis of GPA is particularly important in those with otorhinolaryngological manifestations, as early initial immunosuppressive therapy has been linked to lower relapse and mortality rates. Vigilance and early differentiation between GPA and other forms of sinusitis is of critical importance, particularly when symptoms are refractory to standard rhinosinusitis therapies.

Intratympanic Steroid Injection Complicated by Iatrogenic Perilymphatic Fistula: A Cautionary Tale

Intratympanic (IT) steroid therapy is a mainstay treatment for sudden sensorineural hearing loss (SSNHL) for both initial therapy and salvage therapy. We report a rare case of iatrogenic perilymphatic fistula that resulted from trauma during an IT steroid injection for SSNHL. We discuss the diagnosis and treatment in the current case and compare it with previous reports from the literature. Laryngoscope, 131:2088-2090, 2021.

Abstract 2841: Differential immune responses to HPV-positive and HPV-negative head and neck cancer

Background: Immune checkpoint inhibitors (ICIs) have been effective in treating several solid tumor malignancies, including head and neck squamous cell carcinoma (HNSCC); however, less than 20% of patients benefit from even the most promising ICI drugs. There is a lack of accurate predictors for response to ICI treatment in HNSCC and little is known about which types of immune cells have a more dominant impact on T-cell infiltration in HPV-positive and HPV-negative HNSCC. The main objective of our study was to identify the unique immune signatures of HPV-positive and HPV-negative HNSCC and to determine the major immune suppressive entities within their respective tumor microenvironments.

Methods: We retrospectively analyzed a cohort of 102 HNSCC patients (44 HPV-positive, 58 HPV-negative), a subset of whom went on to receive ICI therapy later in their treatment course. We determined an immune signature by HPV-status using multiplex gene expression analysis (NanoString Immune Profiler). We also used multiplex immunohistochemistry (MIHC) to simultaneously evaluate markers for macrophages (CD68/CD163), neutrophils (CD66b), cytotoxic T-cells (CD8), B-cells (CD19/CD20), tumor cells (cytokeratin), PD-L1 expression, and DAPI. Immune cell distributions and their spatial relationships were quantified with HALO image analysis software (Indica Labs).

Results: Nanostring analysis revealed increased differential expression of genes related to B-cell functions in HPV-positive HNSCC, such as MS4A1, CD79B, and CD27, which were significant at a Benjamini-Yekutieli adjusted p-value of &lt;0.001. T-cell function genes (e.g. CTLA4 and LAG3) also had significantly increased expression in HPV-positive HNSCC compared to HPV-negative HNSCC. MIHC displayed increased CD8+ T-cell and CD19/CD20+ B-cell densities in the tumor region of HPV-positive HNSCC as opposed to HPV-negative HNSCC (p&lt;0.01). There was a negative correlation in the densities of neutrophils and macrophages in the stroma region compared to density of T-cells in the tumor region in HPV-negative tumors (p&lt;0.05), but not for HPV-positive tumors.

Conclusions: HPV-positive HNSCC appears to have a B-cell and T-cell dominant gene expression profile with increased infiltration of these cells in the tumor region compared to HPV-negative HNSCC. The infiltration of CD8+ T-cells appears to be affected by myeloid cell burden in the stroma in HPV-negative HNSCC. The B-cell signature in HPV-positive HNSCC is particularly of interest, given that B-cells typically play a major role in resolving viral infections. Further analysis will involve correlating the differential patterns of gene expression with immune cell infiltration data to identify which immune cells have a more dominant effect on T-cell infiltration, and subsequently determine the effect on prognosis and response to ICI treatment.

Citation Format: Hannan A. Qureshi, Xiaodong Zhu, Sylvia M. Lee, Eduardo Mendez, A. McGarry Houghton. Differential immune responses to HPV-positive and HPV-negative head and neck cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 2841.

National Institutes of Health Funding for Obstructive Sleep Apnea: An Opportunity for Otolaryngologists

OBJECTIVE

To describe current levels and trends of funding for the National Institutes of Health (NIH) in obstructive sleep apnea (OSA) and to recognize the current status of otolaryngologists in OSA research.

STUDY DESIGN

Scientometric analysis.

METHODS

The NIH RePORTER database was queried for the search term "obstructive sleep apnea" for all available years. Sex, degree, academic department, NIH funding source, geography, funding totals and years, and h-index of principal investigators (PIs) were collected and summarized.

RESULTS

A total of 397 projects spanning 1242 total funding years were funded. Of the 273 individual PIs, 33.3% (91/273) were female. Regarding credentials, 52.4% of PIs (143/273) were MD or MD/PhD, and 41.0% (112/273) were PhD alone. Academic departments of PIs were most often medicine (34.1%), pediatrics (12.1%), cell biology/physiology (10.6%), and psychiatry (7.7%). Seven otolaryngology faculty members had received NIH funding for OSA research (2.6% of total PIs) since 2000. They accounted for 8 grants (0.25% of total grants) and $7,235,729 (1.5% of total dollars) of research funding.

CONCLUSION

Despite studies showing increasing levels of OSA surgery being performed and major areas of research and clinical opportunity, otolaryngologists represent a small minority of OSA research funding. This information may help direct our specialty when setting priorities regarding research funding, as research into the basic science and clinical management of OSA represents a broad and interdisciplinary pursuit.

Reducing margins of wide local excision in head and neck melanoma for function and cosmesis: 5-year local recurrence-free survival

BACKGROUND

The proximity of head and neck (H&N) melanomas to critical anatomical structures requires that surgeons achieve a balance between adequate margins of excision and the functional and cosmetic needs of patients. This study sought to determine the risk associated with reducing margins of wide local excision (WLE) in H&N melanoma and to identify risk factors of recurrence.

METHODS

Seventy-nine cases of primary, invasive H&N melanoma were treated by WLE and followed prospectively for local recurrence. Forty-two WLEs were performed according to current practice guidelines (1cm for lesions<1.0 mm thick, 1-2 cm for lesions 1.01-2.0 mm thick, and 2 cm for lesions >2.0 mm thick). Reduced margins (0.5 cm for lesions ≤1.0 mm thick, 0.5-1.0 cm for lesions 1.01-2.0 mm thick, and 1.0 cm for lesion >2.0 mm thick) were utilized in 37 cases to preserve critical anatomical structures such as the eyelid, nose, mouth and auricle.

RESULTS

Overall local recurrence rate was 8.9% over a mean follow-up period of 71.3 months and a minimum of 60 months. Reducing margins of WLE did not increase local recurrence rates as demonstrated by local recurrence-free survival (90.4% vs. 91.9%, P = 0.806).

CONCLUSION

Margins of WLE may be safely reduced in melanomas in close proximity to structures of the H&N without affecting local recurrence rates.

National Trends in Retropharyngeal Abscess among Adult Inpatients with Peritonsillar Abscess

Objectives

To describe national trends in retropharyngeal abscess (RPA) complicating peritonsillar abscess (PTA) and to determine factors associated with RPA in patients with PTA.

Study Design

Cross-sectional analysis.

Setting

Nationwide Inpatient Sample, 2003-2010.

Subjects and Methods

PTA patients ≥18 years old, with or without RPA, were extracted according to ICD-9-CM codes. The cohort was analyzed with descriptive statistics and multivariate regression modeling to identify factors associated with RPA.

Results

Of the 91,647 (95% CI: 86,433-95,449) patients identified with PTA, 885 (1.0%) also had a concurrently coded RPA. The annual rate of concomitant RPA increased from 0.5% (95% CI: 0.3%-0.8%) to 1.4% (95% CI: 1.0%-2.0%) between 2003 and 2010 ( P < .001). PTA patients with RPA more frequently underwent tonsillectomy (23.5% vs 11.1%), endotracheal intubation (7.1% vs 1.5%), and mechanical ventilation (13.2% vs 2.0%) than those without RPA (all P < .001). PTA patients with RPA were significantly older (41 vs 34 years old), had a longer hospital stay (6.4 vs 2.5 days), and had more procedures (2.5 vs 0.9) when compared to patients without RPA (all P < .001). Upon multivariate regression analysis, factors associated with RPA included the age groups of 40 to 64 years (odds ratio, 2.256; P < .001) and 65 and older (odds ratio, 2.086; P = .045). Median total charges for PTA inpatients with concomitant RPA were approximately $8700 greater ( P < .001) when compared to patients with PTA alone.

Conclusions

The incidence of RPA among adult inpatients with PTA is increasing, and patients with RPA have higher in-hospital resource utilization. Further studies may help validate factors predictive of RPA to enable prevention or earlier identification.

Hydration status regulates sodium flux and inflammatory pathways through epithelial sodium channel (ENaC) in the skin

Although it is known that the inflammatory response that results from disruption of epithelial barrier function after injury results in excessive scarring, the upstream signals remain unknown. It has also been observed that epithelial disruption results in reduced hydration status and that the use of occlusive dressings that prevent water loss from wounds decreases scar formation. We hypothesized that hydration status changes sodium homeostasis and induces sodium flux in keratinocytes, which result in activation of pathways responsible for keratinocyte-fibroblast signaling and ultimately lead to activation of fibroblasts. Here, we demonstrate that perturbations in epithelial barrier function lead to increased sodium flux in keratinocytes. We identified that sodium flux in keratinocytes is mediated by epithelial sodium channels (ENaCs) and causes increased secretion of proinflammatory cytokines, which activate fibroblast via the cyclooxygenase 2 (COX-2)/prostaglandin E2 (PGE2) pathway. Similar changes in signal transduction and sodium flux occur by increased sodium concentration, which simulates reduced hydration, in the media in epithelial cultures or human ex vivo skin cultures. Blockade of ENaC, prostaglandin synthesis, or PGE2 receptors all reduce markers of fibroblast activation and collagen synthesis. In addition, employing a validated in vivo excessive scar model in the rabbit ear, we demonstrate that utilization of either an ENaC blocker or a COX-2 inhibitor results in a marked reduction in scarring. Other experiments demonstrate that the activation of COX-2 in response to increased sodium flux is mediated through the PIK3/Akt pathway. Our results indicate that ENaC responds to small changes in sodium concentration with inflammatory mediators and suggest that the ENaC pathway is a potential target for a strategy to prevent fibrosis.

National Trends and Associated Factors of Retropharyngeal Abscess among Adult Inpatients with Peritonsillar Abscess

Objectives:

(1) Describe national trends in retropharyngeal abscess (RPA) complicating peritonsillar abscess (PTA). (2) Determine factors associated with RPA in patients with PTA.

Methods:

Years 2003 to 2010 of the Nationwide Inpatient Sample (Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality) were queried for PTA (ICD-9 code: 475) and RPA (ICD-9 code: 478.24) in adult patients (age ≥18 years old). The cohort was analyzed using descriptive statistics and multivariate regression modeling to identify factors associated with RPA.

Results:

Of the 90,941 (95% confidence interval [CI]: 86,433-95,449) patients identified with PTA, 885 (1.0%) also had a concurrently coded RPA. The annual rate of concomitant RPA doubled ( P < .001) from 0.5% (95% CI: 0.3%-0.8%) to 1.4% (95% CI: 1.0%-2.0%) between 2003 and 2010. Patients with RPA were more likely to undergo tonsillectomy (23.5% vs 11.1%) and mechanical ventilation (13.2% vs 2.0%) than those without RPA (all P < .001). RPA patients were significantly (all P < .001) older (41 vs 34 years old), had a longer hospital stay (6.4 vs 2.5 days), and had more procedures (2.5 vs 0.9) compared with patients without RPA. Upon multivariate regression analysis, factors associated with RPA included age groups 40 to 64 years (odds ratio [OR] = 2.073, P < .001), 65 years and older (OR = 2.148, P = .021), and teaching hospital (OR = 1.838, P < .001). When controlling for age, sex, and hospital characteristics, general linear modeling demonstrated that RPA accounted for $27,240 ( P < .001) in excess total charges per patient.

Conclusions:

The incidence of RPA among adult inpatients with PTA is increasing, and patients with RPA have higher in-hospital resource utilization. Further studies may help validate factors predictive of RPA to enable earlier identification.

National Trends and Associated Factors of Endotracheal Intubation among Adult Inpatients with Peritonsillar Abscess

Objectives:

(1) Describe national trends in peritonsillar abscess (PTA) requiring endotracheal intubation (ETI). (2) Determine factors associated with ETI in patients with PTA.

Methods:

Years 2003 to 2010 of the Nationwide Inpatient Sample (Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality) were queried for PTA (ICD-9 code: 475) and ETI (ICD-9 code: 96.04) in adult patients (age ≥18 years old). Descriptive statistics and multivariate regression modeling were employed to identify factors associated with ETI.

Results:

From 2003 to 2010, 90,941 (95% CI:86, 433-95, 449) admissions associated with a PTA were identified, of which 1357 (1.5%) underwent ETI. These patients had a higher prevalence of concurrently coded sepsis (7.3% vs 1.2%), severe sepsis (13.0% vs 0.2%), and death (7.9% vs 0.1%) compared with patients without ETI. Intubated patients were significantly (all P < .001) older (45 vs 34 years old), had a longer hospital stay (10.8 vs 2.4 days), and had more procedures (5.4 vs 0.9). Multivariate regression analysis displayed factors associated with intubation included age group 65 and older (odds ratio [OR] = 6.408, P < .001), transfer from another hospital (OR = 2.917, P = .029), alcohol abuse (OR = 6.445, P < .001), anemia (OR = 2.957, P = .002), and obesity (OR = 3.301, P < .001). When controlling for age, sex, hospital characteristics, and number of procedures, general linear modeling demonstrated intubation accounted for $24,374 ( P < .001) in excess total charges per patient. Overall charges for admissions with ETI accounted for $123 million over the study period.

Conclusions:

Patients with PTA undergoing ETI have worse in-hospital outcomes along with higher hospital charges. This study identifies characteristics of a PTA patient in whom clinicians should be wary of respiratory decompensation.

Fibroblast Growth Factor 19 Activates the Unfolded Protein Response and Mitogen-Activated Protein Kinase Phosphorylation in H-69 Cholangiocyte Cells

Background

Cholangiocytes are injured in many biliary tract diseases that result in cirrhosis, cholangiocarcinoma and need for liver transplantation. Recent studies demonstrate that the hormone Fibroblast Growth Factor 19 (FGF19) is produced in the ileum and regulates hepatic gene expression via the enterohepatic circulation. However, the role of FGF19 on cholangiocytes remains largely unknown. The purpose of this study was to elucidate the effect of FGF19 on cholangiocyte gene and protein expression.

Methods

Cultured human cholangiocyte-derived H69 cells were treated with FGF19 (0-50ng/ml) and expression of genes and proteins involved in the Unfolded Protein Response (UPR) and mitogen-activated protein kinase (MAPK) pathways were studied using RT-PCR and Western blot analysis.

Results

FGF19-induced gene and protein expression of the UPR genes BiP and CHOP increased in a dose-responsive pattern. The UPR protein P-eIF2a displayed a bimodal pattern of protein expression, with 10ng/ml of FGF19 maximally reducing and 50ng/ml maximally increasing expression. MAPK pathway protein expression (P-JNK, P-ERK, P-38) displayed a similar bimodal pattern of expression with 2.5ng/ml of FGF19 decreasing expression and 25ng/ml of FGF19 increasing expression.

Conclusions

FGF19 treatment of H69 cells selectively activates BiP and CHOP in a dose-dependent manner. FGF19 also regulates P-eIF2a and MAPK protein expression with a bimodal response. We speculate that FGF19 has an important role in the pathogenesis of many human cholangiopathies and cholestatic liver disorders.