Management of intra-operative cerebrospinal fluid leak in transnasal transsphenoidal pituitary microsurgery: use of post-operative lumbar drain and sellar reconstruction without fat packing

BACKGROUND

This study aims at describing primary reconstruction of sella turcica using lyophilized dura graft and fibrin glue without fat packing of the sphenoid sinus, together with postoperative lumbar drain in the management of intraoperative cerebrospinal fluid (CSF) leak.

METHOD

Records of 127 consecutive patients undergoing 129 transnasal transsphenoidal procedures were reviewed retrospectively with respect to intra- and post-operative CSF leak and lumbar drain use. One hundred and ten patients had adenomas (60 secreting adenomas, 48 non-functioning), 10 Rathke's cleft cysts and 9 miscellaneous lesions.

FINDINGS

Intra-operative leak was detected in 43 (33.3%) of 129 procedures: 38 (34.5%) of 110 adenoma related procedures and 5 (26.3%) of 19 non-adenomas. Among adenomas, leak occurred in 35 (41.2%) of 85 patients with suprasellar extension (SSE) and in 3 (12%) of 25 without SSE (p = 0.007). Lumbar drain was used in 61 cases (47.3%): in 34 it was inserted immediately before and in 27 at the end of procedure. In 24 of 34 patients (70.6%) with pre-operative drain (all adenomas), saline infusion was used to mobilize SSE. Only 2 patients (1.6%) developed post-operative leak, requiring an endoscopic procedure with fascia and muscle obliteration of the sphenoid sinus.

CONCLUSIONS

Meticulous duroplasty and routine postoperative lumbar drain has shown satisfactory results in dealing with intra-operative CSF leaks. It compares favorably with other techniques and obviates the need for fat harvesting. In patients with SSE, where leak occurs more frequently, we recommend inserting the lumbar drain before the procedure. As an adjunctive benefit, this allows for the saline-infusion method to mobilize the SSE without producing the venous engorgement of the Valsalva maneuver.

Effects of passive smoking on odour identification in children

BACKGROUND AND OBJECTIVE

The effect of passive smoking on odour identification in children has rarely been reported. This study assessed the ability of such young subjects to identify a variety of odours.

METHODS

The study population consisted of 20 children, 10 who were exposed to passive smoke at home and 10 with nonsmoking parents. Ten odourants were tested: vinegar, ammonia, peppermint, roses, bleach, vanilla, cough drops, turpentine, licorice, and mothballs. Each child was presented with five test trays containing all 10 odourants in random order.

RESULTS

Of the total of 500 odours presented, the control group correctly identified 396 (79%) and the study group identified 356 (71%) (p < .005). The study group tended to misidentify 4 of the 10 odourants tested, namely, vanilla, roses, mothballs, and cough drops-56 of 200 (28%), compared with 96 of 200 (48%) in the control group. This was a highly significant finding (p < .0005).

CONCLUSION

This work demonstrated that children exposed to passive smoke have difficulty identifying odours in comparison with children raised in relatively smoke-free environments. The identification of four odourants, vanilla, roses, mothballs, and cough drops, was particularly diminished in this study group.

Analysis of human papillomavirus in schneiderian papillomas as compared to chronic sinusitis and normal nasal mucosa

Schneiderian papillomas (SPs) are tumours arising from the surface epithelium (schneiderian epithelium) of the nasal cavity and paranasal sinuses. Evidence points toward a viral etiology, specifically human papillomavirus (HPV). Although substantial data indicate HPV as a likely etiology, little is known about the role of HPV in benign nasal pathologies or in normal nasal mucosa. The objective of this study was to characterize the relationship between HPV and SP, chronic sinusitis (CS), and normal nasal mucosa. A case-control study was undertaken, matching patients with SP to patients with CS. Patients with normal nasal mucosa served as a control group. All patients had their tissues analyzed for the presence of various HPV subtypes using line blot assay. A total of 168 patients were identified (74 SP, 74 CS, 20 control). Of these, 70 (41.7%) had detectable deoxyribonucleic acid and 9 of 70 (12.9%) had detectable HPV of subtypes 6, 11, and 16. None had detectable HPV type 18. Significant differences were detected in the presence of HPV in the CS, SP, and control groups, as well as in the presence of low- versus high-risk subtypes among investigation and control groups. Significant differences exist in HPV infectivity among SP, benign nasal pathologies such as CS, and normal nasal mucosa. Human papillomavirus plays an important role, at least in part, in the development of SP, with types 6, 11, and 16 being more pivotal than other types. Line blot assay is a useful technique in identifying HPV in SP.

Rathke's cleft cyst presenting as sphenoid sinusitis

Rathke's cleft cysts are developmental abnormalities of the craniopharyngeal duct composed of retained stratified ciliated cuboidal cells of the respiratory type. Incidentally found in the pars intermedia in 13% to 33% of routine autopsies, they are discovered in growing numbers on CT and MRI scans. From 1991 to 1999, 9 cases of Rathke's cleft cysts were encountered by the senior authors, 4 of which were treated surgically (3 by using a transsphenoidal approach and one by using a transcranial subfrontal approach). Of the 3 patients treated with a transsphenoidal approach, 2 presented with symptoms mimicking sphenoid sinusitis and were initially referred for otolaryngologic evaluation. The clinical, pathologic, and radiologic features, as well as management and follow-up of those 2 patients, are reviewed. There has been only one previous case report of Rathke's cleft cysts presenting as sinusitis. Nevertheless, the otolaryngologist should be aware of this condition because it may present with other significant symptomatic extracranial extensions.

Clinical manifestations of sinonasal pathology during pregnancy

OBJECTIVE

Pregnancy may confer a number of conditions related to the head and neck. The objective of this study was to evaluate the clinical manifestations of sinonasal pathology that occur during pregnancy.

METHODS

Thirty-three pregnant patients were evaluated for the occurrence of rhinorrhea, congestion, epistaxis, or acute sinusitis during the first trimester of pregnancy, controlling with 28 women of child-bearing age. A visual analogue scale was used to grade the severity of each symptom. Statistical analysis was carried out to assess for significant differences in the prevalence and severity of symptomatology between cases and controls.

RESULTS

Compared to the control group, there was no statistically significant difference in the prevalence of congestion, epistaxis, rhinorrhea, or acute sinusitis. There was no statistically significant difference in the severity of any presenting symptom between pregnant and control group patients.

CONCLUSION

Pregnancy is not associated with an increased prevalence or severity of nasal symptomatology during early pregnancy. The influence of hormonal changes on nasal physiology during pregnancy is discussed with a view toward safe management.

Local synthesis of epsilon germline gene transcripts, IL-4, and IL-13 in allergic nasal mucosa after ex vivo allergen exposure

BACKGROUND

The production of epsilon germline gene transcripts (Iepsilon(+)/Cepsilon(+) RNA) precedes class switch recombination to IgE and is induced by IL-4 and/or IL-13. Although Iepsilon and Cepsilon RNA(+) B cells have been identified within nasal tissue after in vivo allergen exposure, suggesting local germline transcription, whether these were resident or infiltrating B lymphocytes was not clear.

OBJECTIVE

We sought to examine whether B cells resident to the nasal mucosa undergo epsilon germline transcription.

METHODS

Nasal mucosal biopsy specimens were obtained from asymptomatic patients with seasonal allergic rhinitis and exposed to allergen ex vivo. Using immunocytochemistry, B lymphocytes were enumerated; with in situ hybridization, the number of cells expressing Iepsilon, Cepsilon, IL-4, and IL-13 messenger (m)RNA(+) cells was examined.

RESULTS

Tissue cultured in medium containing specific allergen exhibited significantly more Iepsilon and Cepsilon RNA(+) cells compared with medium alone (P <.05). IL-4 and IL-13 mRNA synthesis also resulted from ex vivo allergen exposure; there were significantly more cells expressing transcripts for these cytokines within allergic nasal mucosal tissue cultured with allergen than medium alone (P <.05). Within allergen-stimulated tissue obtained from allergic patients, 30% of total B cells were Iepsilon RNA(+), and the majority of IL-4 and IL-13 mRNA(+) cells were T cells (68% and 44%, respectively) and mast cells (32% and 19%, respectively).

CONCLUSION

These results demonstrate that the nasal mucosa is a site of epsilon germline gene transcription and suggest that local T cell and mast cell production of IL-4 and IL-13 may regulate this event.

Connections of the facial and vestibular nerves: an anatomic study

The facial and vestibulocochlear nerves emanate from the brain stem and then run parallel to each other within the internal auditory canal prior to their more peripheral distribution. Although anatomic connections between the facial and cochlear nerves have been described, reports outlining facial-vestibular anastomoses are few and may be found primarily in the non-English literature. The present study documents the existence of vestibulofacial neural connections as part of an anatomic dissection of 17 fresh human temporal bones.

Septal deviation and chronic sinus disease

The introduction of computerized tomography in the identification of sinonasal pathology and associated anatomic variants has contributed to a greater understanding of the factors leading to ostiomeatal complex (OMC) obstruction and chronic sinus disease. The OMC and paranasal sinus regions were prospectively evaluated in 150 consecutive patients as a function of the degree of nasal septal deviation and compared with matched controls. These data were correlated with paranasal sinus disease, lateral nasal wall findings, and middle turbinate abnormalities. An increased incidence and severity of bilateral chronic sinus disease was present with increasing septal deviations (p < 0.05). Similarly, patients with increasing nasal septum deviations were noted to have a higher incidence of OMC obstruction (p < 0.05). Ostiomeatal complex obstruction in the direction of septal angulation was associated with nasal septal deformity; however, contralateral OMC obstruction was associated with middle turbinate and lateral nasal wall abnormalities (p < 0.05). The evaluation of the degree of septal angulation has helped better understand the factors contributing to chronic sinus disease and OMC obstruction.

Outcome analysis of endoscopic sinus surgery for chronic sinusitis in patients having Samter's triad

A study was conducted to assess outcome analysis in acetylsalicylic acid (ASA) triad patients after endoscopic sinus surgery (ESS). The control group consisted of patients with chronic sinusitis, with or without asthma, who had also undergone ESS. The study group contained 18 patients with the classic triad who were compared with 22 controls. The study was conducted in retrospective fashion highlighting clinical presentation, radiologic evaluation, surgical findings, and recurrence rate of nasal polyps. Although both groups had a relatively similar age of onset of symptoms, the symptomatic picture was different in the two groups. Radiologic evaluation of the nose and paranasal sinuses revealed more extensive involvement of the sinuses in ASA triad patients. Furthermore, ASA triad patients underwent a greater number of repeat operations. This review suggests that ASA triad patients respond less well to surgical intervention and that other treatment modalities should perhaps be explored.

In vivo expression of signal transducer and activator of transcription factor 6 (STAT6) in nasal mucosa from atopic allergic rhinitis: effect of topical corticosteroids

BACKGROUND

The allergen-induced late nasal response is associated with a high local expression of interleukin (IL) -4, a TH2-type cytokine implicated in immunoglobulin (Ig) E production, tissue eosinophilia and other events considered to be relevant to allergic inflammation. Interaction of IL-4 with its receptor activates at least two distinct signalling pathways that culminate in the transcription of specific target genes. One pathway involves the activation of a transcription factor termed signal transducer and activator of transcription factor 6 (STAT6).

OBJECTIVE

To investigate the expression of STAT6 in the allergen-induced late nasal response and to examine the effect of local steroid treatment on STAT6 expression.

METHODS

Inferior turbinate biopsies were obtained from subjects with allergic rhinitis out of the allergen season. Subjects were then randomized into topical steroid- (n = 6) and placebo-treated (n = 6) groups in a double-blind fashion. After a 6-week treatment period, a second nasal biopsy was performed 24 h after local challenge with allergen. STAT6 immunoreactivity was examined in biopsy specimens by immunocytochemistry using a specific monoclonal antibody. Numbers of inflammatory cells (CD3+ T cells and MBP+ eosinophils) and IL-4 mRNA+ cells were investigated by immunocytochemistry and in situ hybridization, respectively.

RESULTS

STAT6 immunoreactivity was detected in all biopsies studied and localized predominantly to inflammatory tissue of the nasal mucosa. After allergen challenge, expression of STAT6 was markedly increased in placebo-treated patients (P < 0.01). By confocal microscopy, STAT6 was localized to the cytoplasm and the nucleus of positively-staining cells. The allergen-induced increase in STAT6 immunoreactive cells was not observed in the steroid-treated patients. The change in STAT6 immunoreactivity after allergen challenge correlated significantly with the change in numbers IL-4 mRNA+ cells (r = 0.74, P = 0.006) and CD3+ T cells (r = 0.76, P = 0. 004), but not MBP+ eosinophils.

CONCLUSION

This study provides the first evidence of increased STAT6 expression in vivo in human allergic inflammation. The results support a role for STAT6 and IL-4 in the pathogenesis of late nasal response and show that decreases in STAT6 expression parallel the reduction in IL-4 expression that occurs with topical steroid treatment.

Unique characteristics of malignant schneiderian papilloma

PURPOSE

To ascertain the characteristics unique to malignant schneiderian papilloma (MSP).

METHODS

A case-control study of all schneiderian papilloma (SP) patients treated between 1978 and 1997 was conducted. Comparison was made between patients with MSP and patients with benign SP (BSP).

RESULTS

A diagnosis of SP was made in 72 patients. Malignant changes, all of them the inverted papilloma subtype, were found in 8 of these patients. Three were diagnosed carcinoma in situ, and 5 were defined as invasive squamous cell carcinoma. At presentation, the MSP patients had significantly larger tumor spread into the ethmoid and sphenoid sinuses. The recurrence rate was significantly lower in SP patients treated with extensive surgical procedures. An association was found between the presence of malignant lesions and positive smoking history, subjective awareness of a nasal mass, and ethmoid and sphenoid sinus involvement. Also, histologic multicentricity was a feature more often seen in MSP than BSP and was a significant correlate with malignancy.

CONCLUSION

The physician evaluating a patient with SP should be aware of the features described and of their possible association with a malignant lesion.

Expression of interleukin (IL)-12 (p40) and IL-12 (beta 2) receptors in allergic rhinitis and chronic sinusitis

BACKGROUND

Interleukin (IL)-12 is a relatively new and structurally distinct TH1-associated cytokine produced by B cells and macrophages, which may play a suppressive role in the development of allergic sinonasal mucosal responses.

OBJECTIVE

We investigated the expression of IL-12 (inducible p40 subunit) and its receptor (IL-12R beta2 subunit) in tissue biopsies of naturally exposed patients with allergy-associated (ACS) and nonallergy-associated chronic sinusitis (NCS) and compared it with controls. We also examined IL-12 and IL-12R expression in biopsies from a ragweed allergen challenge model. In the allergen challenge model, the effect of pretreatment with topical corticosteroids on IL-12 and IL-12R expression was assessed.

METHODS

To detect IL-12 and IL-12R mRNA, we employed the technique of in situ hybridization using digoxigenin-labelled riboprobes.

RESULTS

In both ACS and NCS subjects there was decreased expression of IL-12 as compared with control (P < 0.05). IL-12R (beta2) expression was decreased in ACS subjects as compared with control (P < 0.05), however, there was no significant difference found between NCS subjects and control. In the allergen challenge subjects, there was a significant decrease in IL-12 expression following challenge (P < 0.05). This effect was abrogated by pretreatment of the subjects with topical corticosteroids. However, IL-12R (beta2) expression showed no change following allergen challenge while pretreatment with topical corticosteroids resulted in increased expression of the (beta2) receptor after allergen challenge (P < 0.05).

CONCLUSION

Our data suggest that IL-12 plays a role in the in vivo suppression of the allergic inflammatory response and that the control of this suppression may be exerted largely via the IL-12 (beta2) receptor.

Monocyte chemotactic proteins in allergen-induced inflammation in the nasal mucosa: effect of topical corticosteroids

BACKGROUND

Human allergen-induced rhinitis is associated with the recruitment and activation of inflammatory cells, particularly eosinophils and CD4(+) T cells, in the nasal mucosa. Chemokines are inflammatory mediators capable of attracting specific inflammatory cell populations. Monocyte chemotactic proteins (MCPs), a subfamily of CC chemokines, have been shown to induce chemotactic activity particularly in eosinophils, T cells, and monocytes under in vitro assay conditions.

OBJECTIVE

To assess the contribution of MCPs in the recruitment of inflammatory cells in vivo, we investigated the allergen-induced late response in subjects with allergic rhinitis.

METHODS

Patients were randomized to receive a 6-week treatment with either topical corticosteroid (n = 6) or a matched placebo (n = 6). Nasal inferior turbinate biopsy specimens were obtained from all subjects before and during allergen-induced late responses. By using immunocytochemistry, tissue sections were examined for the presence of MCP-1, MCP-3, and MCP-4 and for the phenotype of infiltrating cells within the nasal mucosa. In addition, double sequential immunocytochemistry was used to confirm the phenotype of MCP-immunoreactive positive cells. Furthermore, the effect of topical corticosteroids on the expression of MCPs and on the cellular infiltrate was also examined.

RESULTS

MCP-1, MCP-3, and MCP-4 were expressed in all the baseline samples, with prominent staining observed within the nasal epithelium. Biopsy specimens taken after challenge exhibited significant upregulation in the expression of MCP-3 and MCP-4 (P <.001). On the other hand, this increase in response to allergen was reduced in patients pretreated with topical corticosteroids. Colocalization experiments revealed that the majority of MCP+ cells in the subepithelium were macrophages, followed by T cells and eosinophils.

CONCLUSION

Our results demonstrate that allergen-induced rhinitis is associated with an increased expression of MCP-3 and MCP-4, which may be closely related to the influx of inflammatory cells and may thus contribute to the pathogenesis of allergic rhinitis.

Endoscopic repair of cerebrospinal fluid rhinorrhea: is it the treatment of choice?

Between 1991 and 1998, 12 patients with cerebrospinal fluid rhinorrhea were operated on using the intranasal endoscopic approach. The procedure was successful in 10 cases. The endoscopic approach failed in two patients who had larger bony defects and herniating meningoencephaloceles. This paper analyzes the case material with respect to the etiology and site of leakage. The value of computed tomography and magnetic resonance imaging for preoperative localization of the leak is discussed. The technique of underlay fascia graft is described and discussion ensues regarding potential pitfalls that may lead to failure of leak closure.

Th-2 type cytokine receptors in allergic rhinitis and in response to topical steroids

OBJECTIVES

Th-2 type cytokine production (Interleukin-4 [IL-4] and interleukin-5 [IL5]) has been demonstrated to play a significant role in the pathophysiology of allergic rhinitis (AR), and the treatment of AR with topical corticosteroids has been shown to reduce the expression of Th-2 type cytokines in vivo. However, the contribution and expression of Th-2 type cytokine receptors in AR and their response to corticosteroid treatment remain to be clarified. Objectives of the current study are 1. To examine the expression of the cytokine IL-4 and IL-5 receptors (IL-4R and IL-5R) in a nasal allergen challenge model and to contrast this with the expression of the receptor for the Th-1 type cytokine, interferon-gamma receptor (IFN-gammaR), and 2. to examine the effects of pretreatment with topical corticosteroid before allergen challenge on the expression of these same receptors.

STUDY DESIGN

Randomized prospective study involving 14 ragweed-allergic subjects evenly divided between placebo and corticosteroid pretreatment.

METHODS

Immunocytochemistry (alkaline phosphatase-antialkaline phosphatase labeling [APAAP] technique) was used to stain nasal biopsy specimens before and after allergen challenge. Antibodies used included anti-CD3, CD4, CD8, major basic protein (MBP), IL-4R, IL-5R, and IFN-gammaR.

RESULTS

Following allergen challenge, we observed a significant increase in the Th-2 type cytokine receptors (IL-4R and IL-5R; P<.05), as well as a significant decrease in the expression of the Th-1 type cytokine receptor (IFN-gammaR; P<.05). Pretreatment with topical corticosteroids before nasal allergen challenge resulted in decreased expression of IL-4R (P<.05) and IL-5R (P<.05) and increased expression of IFN-gammaR (P<.05). Further, IL-4R and IL-5R expression correlated with eosinophil infiltration in the tissues.

CONCLUSIONS

We have demonstrated that in AR, cytokine receptors for IL-4, IL-5, and IFN-gamma follow a similar pattern to their ligands. In addition, pretreatment with topical corticosteroids was shown to alter the cytokine receptor expression pattern from a Th-2 profile more toward a Th-1 profile.

Effect of steroids on nasal inflammatory cells and cytokine profile

OBJECTIVES

To assess the cellular and humoral effects of unilateral topical steroid application on the nasal mucosa of chronic sinusitis patients.

STUDY DESIGN

Cohort study with randomized grouping.

METHODS

Chronic sinusitis patients awaiting endonasal sinus surgery were randomly divided into a study group and a control group. All patients underwent allergy studies and categorized as allergic or nonallergic. Patients in the study group were exposed unilaterally to fluticasone propionate nasal spray, 100 microg/day for 4 to 6 weeks before the planned surgery. The control group was not exposed to steroids. At the time of surgery, anterior ethmoid mucosa specimens were obtained. The samples were immunostained for CD3, MBP, CD68, elastase, and tryptase. In situ hybridization was used for the detection of interleukin (IL)-4, IL-5, and interferon gamma (IFN-gamma) mRNA. The results were compared between the treated and untreated sides of exposed patients, as well as with nontreated controls.

RESULTS

Twenty-one patients consented to participate in the study. The number of CD3-, MBP-, and tryptase-positive cells was significantly less in the treated and untreated sides of exposed patients, compared with unexposed controls. IL-4 and IL-5 mRNA were significantly downregulated in the treated side of allergic patients, as compared with nontreated patients. This effect could not be shown for IL-4 in nonallergic patients.

CONCLUSIONS

Topical steroid therapy had an anti-inflammatory effect on both allergic and nonallergic chronic sinusitis patients. The unilateral application of the steroid spray affected the contralateral side as well.

One-year outcome analysis of functional endoscopic sinus surgery for chronic sinusitis

OBJECTIVE

This study was conducted to assess treatment results in patients undergoing functional endoscopic sinus surgery for chronic sinusitis, with evaluation of prognostic indicators of success and failure.

METHOD

The study included 393 patients who underwent endoscopic sinus surgery for chronic sinusitis over a 4-year period. The diagnosis of chronic sinusitis was based on ongoing symptomatology for greater than 3 months and the presence of mucosal disease on computerized tomography (CT). A retrospective analysis was done looking at patient data, presenting symptoms, CT findings, operative reports, pathology reports, and outcome at 6- and 12-month follow-up. The prognostic significance of selected factors was evaluated using chi-square analysis.

RESULTS

A positive history for asthma, allergy, and ASA triad was present in 29.5%, 34.6%, and 10.9% of patients, respectively. Previous sinus surgery was done in 31.9%, and 15.7% of patients were smokers. The most common presenting complaint was nasal congestion/obstruction, followed by facial pain/headaches and olfactory disturbance. A positive outcome was achieved in 80.5% of patients at 6 months and in 69.7% at 12-month follow-up. Revision surgery within a year was needed in 4.1% of patients. Factors affecting outcome included asthma, smoking, polyposis, previous surgery, and pansinusitis.

CONCLUSIONS

Extent of disease, as reflected by polyposis, pansinusitis, and premorbid history, is the most important determinant of outcome. Concomitant changes in ciliary motility secondary to asthma or smoking further impede surgical outcome. Future studies focusing on the disease process of chronic sinusitis are needed.

Monocyte chemotactic protein expression in allergy and non-allergy-associated chronic sinusitis

OBJECTIVE

Chronic sinusitis (CS) is characterized by inflammatory mucosal thickening and polyp formation with a predominantly eosinophilic infiltrate. Chemokines are a novel group of inflammatory mediators capable of attracting specific inflammatory cell populations. Monocyte chemotactic proteins (MCP) are a subfamily of chemokines (MCP-1, MCP-2, MCP-3, and MCP-4) that share a number of functional properties including chemotactic activity for eosinophils. The purpose of this study was to investigate the expression of the MCP family of chemokines in allergy and non-allergy-associated chronic sinusitis using the technique of immunocytochemistry.

METHOD

We examined the expression of MCP-1, MCP-3, and MCP-4 in biopsies from the ethmoid sinuses of patients with CS and normal controls.

RESULTS

MCPs were localized to the epithelial cells and a subset of inflammatory cells within the mucosa. The expression of both MCP-3 and MCP-4 immunoreactivity were significantly increased in patients with both allergy and non-allergy-associated CS compared to normal controls (p < .001). There was no significant difference in the expression of MCP-1 in nasal biopsies from individuals with CS and normals. The level of expression of MCP-3 and MCP-4 correlated with eosinophil (p < .001) and CD4-positive T-cell infiltrate (p < .001) but not with CD8-positive T-cell infiltration.

CONCLUSIONS

Our data suggest biologic redundancy in the expression of eosinophil chemoattractants in CS and a potential role for MCP-3 and MCP-4, but not MCP-1, in the pathophysiology of this disorder. Further, chemokines may be a common link between the eosinophilia of allergy-associated and non-allergy-associated CS, a finding that may have therapeutic implications.

Th-2 type cytokine receptors in allergic rhinitis and in response to topical steroids

OBJECTIVES

Th-2 type cytokine production (interleukin-4 [IL-4] and interleukin-5 [IL-5]) has been demonstrated to play a significant role in the pathophysiology of allergic rhinitis (AR), and the treatment of AR with topical corticosteroids has been shown to reduce the expression of Th-2 type cytokines in vivo. However, the contribution and expression of Th-2 type cytokine receptors in AR and their response to corticosteroid treatment remain to be clarified. Objectives of the current study are 1. To examine the expression of the cytokine IL-4 and IL-5 receptors (IL-4R and IL-5R) in a nasal allergen challenge model and to contrast this with the expression of the receptor for the Th-1 type cytokine, interferon-gamma receptor (IFN-gammaR), and 2. to examine the effects of pretreatment with topical corticosteroid before allergen challenge on the expression of these same receptors.

STUDY DESIGN

Randomized prospective study involving 14 ragweed-allergic subjects evenly divided between placebo and corticosteroid pretreatment.

METHODS

Immunocytochemistry (alkaline phosphatase-antialkaline phosphatase labeling [APAAP] technique) was used to stain nasal biopsy specimens before and after allergen challenge. Antibodies used included anti-CD3, CD4, CD8, MBP, IL-4R, IL-5R, and IFN-gammaR.

RESULTS

Following allergen challenge, we observed a significant increase in the Th-2 type cytokine receptors (IL-4R and IL-5R; P < .05), as well as a significant decrease in the expression of the Th-1 type cytokine receptor (IFN-gammaR; P < .05). Pretreatment with topical corticosteroids before nasal allergen challenge resulted in decreased expression of IL-4R (P < .05) and IL-5R (P < .05) and increased expression of IFN-gammaR (P <.05). Further, IL-4R and IL-5R expression correlated with eosinophil infiltration in the tissues.

CONCLUSIONS

We have demonstrated that in AR, cytokine receptors for IL-4, IL-5, and IFN-gamma follow a similar pattern to their ligands. In addition, pretreatment with topical corticosteroids was shown to alter the cytokine receptor expression pattern from a Th-2 profile more toward a Th-1 profile.

Sinonasal schneiderian papilloma

OBJECTIVE

Schneiderian papilloma of the paranasal sinuses is a locally aggressive benign epithelial tumour with malignant potential.

METHOD

A retrospective analysis of 72 patients as seen at our institution from 1978 to 1997 was conducted.

RESULTS

The most frequent symptoms at time of presentation were nasal obstruction, presence of a nasal mass, and nasal discharge. The most common sites of involvement were the maxillary antrum (58.3%), lateral nasal wall (41.7%) and ethmoid sinus (37.5%). Histologic examination confirmed all 72 instances of schneiderian papilloma, with 55/72 (76.4%) being of the inverted type, 13/72 (18.1%) being the fungiform type, and 4/72 (5.5%) being the cylindrical type. An associated malignancy or potential premalignant condition was present in 15 patients (20.8%), with 8 (11.1%) exhibiting dysplastic changes, 4 patients (5.5%) found to have carcinoma in situ, and 3 patients (4.2%) found to have invasive carcinoma. Conservative surgical excision was performed in 37 (51.4%) with more radical surgery, including lateral rhinotomy and medial maxillectomy performed in 35 (48.6%) patients. Recurrence was seen in 17/37 (45.9%) patients treated conservatively compared to 0/35 (0.0%) patients treated aggressively.

CONCLUSIONS

Our results indicate that more aggressive surgery is associated with a more definitive treatment and significantly less recurrence and, as such, is the management of choice in cases of schneiderian papilloma. Furthermore, our results indicate the need for long-term follow-up, and the applicability of sinus endoscopy in doing so.

Human nasal ciliary-beat frequency in normal and chronic sinusitis subjects

OBJECTIVE

Ciliary-beat frequency (CBF) is an important factor influencing mucociliary flow in the respiratory tract. A significant correlation exists between CBF and mucus transport time (MTT), which suggests that CBF is the main factor in nasal mucociliary clearance in healthy individuals. Mucociliary clearance is influenced by the temperature of the inspired air and decreases at temperatures below 33 degrees C. It is unknown whether CBF varies in different sites within the nasal chamber and exactly how CBF is altered in disease states such as chronic sinusitis (CS) and nasal polyposis (NP). Our study was conducted in an attempt to answer these questions.

METHOD

CBF was measured in nasal biopsies from eight normal control subjects: 6 CS and 8 NP patients. Biopsies from the regions of the maxillary, ethmoid, frontal, and sphenoid sinus ostia were also obtained. The material was analyzed using a computerized image-processing system.

RESULTS

Our data demonstrated a significant decrease in CBF at 22 degrees C compared to at 35 degrees C for all sinus biopsies (p < .05). We found no statistical difference between the CBF of biopsies from the regions of the various sinus ostia. A comparison between the patients with CS and normal controls again revealed no significant difference in CBF, a finding which contradicts previously published reports. Surprisingly, an increase in CBF was observed in NP patients compared to control and CS patients (p < .05).

CONCLUSIONS

We conclude that our technique is a viable model for studying sinonasal CBF in the human. Our data suggest that a mechanism other than decreased CBF may account for the decreased mucociliary clearance observed in chronic sinusitis.

Expression of IgE heavy chain transcripts in the sinus mucosa of atopic and nonatopic patients with chronic sinusitis

We have recently shown the increased mRNA expression of interleukin (IL)-4 and IL-13 in sinus biopsies from allergic subjects with chronic sinusitis (ACS), whereas only IL-13 mRNA was elevated in biopsies obtained from nonallergic subjects with chronic sinusitis (NCS). In the lymph nodes and spleen, these cytokines may promote IgE production through transcriptional activation of the germline IgE heavy chain promoter, an event which precedes immunoglobulin isotype switching to IgE in B cells. We hypothesized that local expression of IL-4 and/or IL-13 might act by inducing germline IgE heavy chain transcript expression locally in the sinus mucosa of chronic sinusitis patients. Mucosal sinus biopsies were obtained from 13 patients with ACS, 12 subjects with NCS, and 11 normal control individuals. The numbers of B cells in the sinus mucosa were studied by immunocytochemistry with anti-CD20 monoclonal antibodies. In situ hybridization was performed using antisense radiolabeled riboprobes complementary to the IgE epsilon -heavy chain germline (Iepsilon) and heavy chain constant region (Cepsilon) gene transcripts. Riboprobes specific for the IgG gamma-heavy chain constant region (Cgamma) were used as an isotype control. Immunocytochemical analysis indicated augmented numbers of CD20-positive B cells in the biopsies obtained from ACS patients compared with NCS subjects (P < 0.05) and normal control subjects (P < 0.01). Statistically significant increases were observed in the numbers of cells expressing Iepsilon and Cepsilon transcripts in the sinus mucosa of ACS patients compared with those with NCS (P < 0. 001) and normal controls (P < 0.001), while Cgamma RNA expression did not differ significantly between the groups. In three randomly selected ACS biopsies, 92-100% of cells expressing Cepsilon transcripts and 100% of Iepsilon RNA-positive cells coexpressed CD20 immunoreactivity. Cells expressing Cepsilon transcripts were also significantly increased in NCS compared with normal controls (P < 0. 05). The results of this study suggest that local IgE class switching occurs in the pathogenesis of ACS and that ACS and NCS are both associated with increased expression of Cepsilon transcripts.

Interleukin-4, interleukin-5, and granulocyte-macrophage colony-stimulating factor receptor expression in chronic sinusitis and response to topical steroids

Chronic sinusitis and its associated eosinophilic infiltrate are believed to be mediated, at least in part, by the upregulation of Th-2 cytokines, including interleukin-4, interleukin-5, and granulocyte-macrophage colony-stimulating factor (GM-CSF). Interleukin-4 is involved in IgE production and in eosinophil recruitment through upregulation of vascular cell adhesion molecule-1. Interleukin-5 and GM-CSF are involved in eosinophil growth and survival. The aim of this study was to investigate the expression of receptors for these cytokines in the sinus mucosa of subjects with chronic sinusitis. Using the technique of in situ hybridization to detect specific cytokine receptor messenger RNA, we studied the sinus mucosa of subjects with nonallergic chronic sinusitis, subjects with allergic chronic sinusitis, subjects with allergic chronic sinusitis treated with topical steroids, and normal controls. Our data demonstrate higher expression of interleukin-4 receptor in subjects with allergic chronic sinusitis than in controls (p < 0.001) and higher expression of interleukin-5 receptor in both subjects with nonallergic chronic sinusitis and subjects with allergic chronic sinusitis than in controls (p < 0.001, p < 0.001). The expression of interleukin-4 receptor and interleukin-5 receptor was higher in subjects with allergic chronic sinusitis than in subjects with nonallergic chronic sinusitis (p < 0.001). GM-CSF receptor expression was also found to be higher in subjects with allergic chronic sinusitis and subjects with nonallergic chronic sinusitis than in controls (p < 0.001, p < 0.001). In contrast to interleukin-4 receptor and interleukin-5 receptor, however, expression of GM-CSF receptor was higher in subjects with nonallergic chronic sinusitis than in subjects with allergic chronic sinusitis (p < 0.001). In subjects with allergic chronic sinusitis treated with topical corticosteroids, the expression of interleukin-4 receptor and interleukin-5 receptor messenger RNA levels was significantly lower than levels in patients with allergic chronic sinusitis who were not taking topical steroids (p < 0.001, p < 0.001). Steroid treatment had no effect on GM-CSF receptor messenger RNA expression. In conclusion, our data support a role for Th-2 cytokine receptors in the pathophysiology of chronic sinusitis. Further, our data lend support to the theory that differential activation of distinct cytokine pathways mediates inflammation in chronic sinusitis depending on whether there is associated allergy. Finally, treatment with topical corticosteroids has been demonstrated in chronic sinusitis to downregulate receptors for interleukin-4 and interleukin-5.

Paraseptal structural changes and chronic sinus disease in relation to the deviated septum

OBJECTIVE

This study was conducted to evaluate the use of computerized tomography in the delineation of the ostiomeatal complex to enhance the endoscopic surgeon's understanding of associated and contributing anatomic features.

METHODS

The ostiomeatal complex region (OMC) was prospectively evaluated in 122 consecutive patients as a function of the degree of nasal-septal deviation. This data was correlated with paranasal sinus disease, lateral nasal-wall findings, and middle-turbinate abnormalities.

RESULTS

Patients with increasing nasal-septal deviations were associated with a higher incidence of OMC obstruction (p < .05). OMC obstruction in the direction of septal angulation was attributable to nasal septal deformity. However, contralateral OMC obstruction was related to middle-turbinate and lateral nasal-wall abnormalities, which appeared with increased frequency on the side opposite to the septal deviation (p < .05). Furthermore, an increased incidence and severity of sinus disease was noted with increasing septal deviation (p < .05).

CONCLUSION

Increasing angles of septal deviation are associated with bilateral sinus disease and contralateral middle turbinate abnormalities and ethmoid bulla prominence.

IL-4 and IL-13 expression in chronic sinusitis: relationship with cellular infiltrate and effect of topical corticosteroid treatment

OBJECTIVE

Chronic sinusitis with allergy (ACS) and without allergy (NCS) are inflammatory diseases with considerable morbidity. The present study was undertaken to investigate, by in situ hybridization, the expression of IL-13 and IL-4 mRNA in sinus biopsy sections.

METHOD

Specimens were obtained from subjects with NCS (n = 12), ACS (n = 13), ACS on steroid therapy (n = 11), and normal controls (n = 11). The composition of the inflammatory infiltrate was also examined in all cases.

RESULTS

The number of cells expressing IL-4 and IL-13 transcripts was significantly higher in subjects with ACS compared to normal controls. In contrast, the numbers of IL-13 but not IL-4 mRNA-positive cells were increased in the NCS subjects compared to the normal controls. IL-4 and IL-13 mRNA expression was suppressed in ACS subjects on topical steroid therapy compared to untreated patients. There was no significant difference in the numbers of eosinophils between the ACS subjects treated with steroids and those who were not treated, but the steroid-treated patients demonstrated significantly higher numbers of CD8+ cells in the sinus mucosa. Increased numbers of CD8+ cells were also observed in subjects with NCS compared with ACS subjects and normal controls.

CONCLUSIONS

These results demonstrate that increased IL-13 expression is an important feature of allergic and nonallergic patients with chronic sinusitis. Furthermore, our data indicate that IL-13 and IL-4 are under differential regulation in NCS subjects.

Upregulation of Th-2 cytokine receptors in atopy- and nonatopy-associated chronic sinusitis

OBJECTIVE

This study was conducted to investigate the expression of alpha IL5 and alpha GM-CSF receptors (alpha IL5r and alpha GM-CSFr) mRNA in the paranasal sinus mucosa of atopic and nonatopic subjects with chronic sinusitis compared to controls.

DESIGN

This was a prospective study of patients presenting with the diagnosis of chronic sinusitis of at least 6 months' duration.

METHOD

Fourteen patients with stable chronic sinusitis (7 atopic, 7 nonatopic) and 7 controls were included, from whom sinus mucosal biopsies were obtained and examined for membrane-bound alpha IL5r and alpha GM-CSFr mRNA using in situ hybridization.

RESULTS

There was a significant difference in the number of cells expressing alpha IL5r mRNA per high-power field in both atopic and nonatopic subjects compared to controls, and in the number of cells expressing alpha GM-CSFr mRNA in both atopic and nonatopic subjects compared with controls. The number of alpha IL5r mRNA-positive cells was significantly greater in the atopic versus nonatopic groups, whereas alpha GM-CSFr mRNA-positive cells were greater in number in the nonatopic versus atopic groups.

CONCLUSION

Both alpha IL5r and alpha GM-CSFr are upregulated in chronic sinusitis, suggesting that increases in both Th-2 cytokines and their receptors may be important in the pathology of the disease. Furthermore, the predominant associations of alpha IL5r with atopic chronic sinusitis and alpha GM-CSFr with nonatopic chronic sinusitis suggest that the chronic inflammation in this condition may arise from differential activation of distinct cytokine pathways depending on whether or not there is associated atopy.

Parotidectomy for the treatment of chronic recurrent parotitis

OBJECTIVE

To assess the success of superficial parotidectomy in the treatment of chronic parotitis (a potentially debilitating disease heralded by recurrent painful swellings) and purulent sialorrhea.

DESIGN

A retrospective review.

METHODS

Ten patients who were managed by superficial parotidectomy after failure of all conservative measures at the Department of Otolaryngology, McGill University were studied.

RESULTS

Eight had complete resolution of their disease, and two had minor persistence on follow-up. None of them had permanent facial nerve injury.

CONCLUSION

We therefore advocate superficial parotidectomy for this condition on failure of conservative measures.

Development of a standardized proforma for reporting computerized tomographic images of the paranasal sinuses

The complex regional anatomy of the paranasal sinuses has only recently been elucidated through the use of modern imaging techniques. The advent of computerized tomography in the delineation of sinonasal pathology and anatomic variation has proven invaluable to the otolaryngologist in preoperative planning for functional endoscopic sinus surgery (FESS). Frequently, the radiologic reporting schemes for these studies are not standardized, and in many respects have been found to be inadequate. This study attempts to develop a simple reporting proforma that the head and neck radiologist can routinely use in order to facilitate the presentation of CT scan findings in evaluating sinus, nasal, or upper airway pathology. Over 100 CT sinus reports that had previously been reported were re-read according to this reporting scheme and were analyzed in order to determine whether any significant discrepancies existed. These differences were then classified according to their incidental, minor, and major surgical significance. It is hoped that through the development of a standardized proforma, the complementary relationship between preoperative imaging and endoscopic intervention can be consolidated and further enhanced.

Effects and management of barometric change on cavities in the head and neck

Changes in atmospheric pressure may result in barotrauma to a variety of head and neck structures including the middle and inner ears, the sinus cavities, the teeth and some cranial nerves. This article outlines the pathophysiology of these injuries and suggestions are offered for prevention and treatment.

Viral implications in the formation of multicentric inverting papilloma

There is growing information to support a viral etiology in inverting papilloma formation. Evidence for this hypothesis comes from clinical findings of multicentricity, high recurrence rates, identification of human papilloma virus (HPV), and the presence of viral-like particles within the tumour tissue. Four cases of multicentric inverting papilloma are presented. In one patient, a squamous papilloma (wart) of the nasal vestibule recurred as an inverting papilloma. Another patient also had a cutaneous wart on the right index finger. These cases and others from the literature are discussed with respect to a viral mode of transmission.

Endoscopic repair of anterior skull base cerebrospinal fluid fistulas: an emphasis on postoperative nasal function maximization

Endoscopic repair of cerebrospinal fluid (CSF) fistulas has been proposed as an alternative to the traditional intracranial and extracranial approaches. This study reports on four consecutive adult cases of anterior skull base CSF fistulas. The technique used for endoscopic repair, which was designed to maximize postoperative nasal function, is described in detail. The results and complications recorded, using this technique, are reported. Endoscopic repair appears to be a safe and successful approach in the surgical treatment of CSF fistulas while preserving nasal function.

Mycobacterial infections of the head and neck

Despite the decline of pulmonary tuberculosis in the Western world, the incidence of cervical mycobacterial infections has remained relatively unaffected. A retrospective review was conducted of 20 patients treated for head and neck tuberculosis from 1984 to 1991. They were mostly an immigrant group coming from underdeveloped countries close to the equator. All cases were treated with antituberculous chemotherapy; 18 patients also underwent surgical excision of their lymphadenopathy. Sixteen patients showed complete response to combined treatment and one relapse was successfully retreated with antituberculous medication. Three patients died from unrelated causes--two from human immunodeficiency virus infection and one from nasopharyngeal carcinoma. The most reliable indicator of mycobacterial infection was the pathologic specimen, making the need for surgical intervention an important diagnostic consideration. As with other reports, most patients in our series had negative chest x-ray films, variable responses to skin testing, and negative cultures. The epidemiology, pathogenesis, and management of this disease are discussed.

Polypoid lipoma of the palatine tonsil

A polypoid, pedunculated tumour of the left palatine tonsil was incidentally detected in a 42-year-old female. It was composed of mature fat and was covered by a nonkeratinizing squamous epithelium with an underlying rim of fibrous tissue. The literature on tonsillar lipoma is reviewed and the differential diagnosis of polypoid lesions of the tonsil is discussed.

Fourth branchial cleft cyst

Remnants of the fourth branchial arch are uncommon clinical entities. They may present in either the neck or chest in association with aortic arch development. They are encountered more frequently in younger individuals as an asymptomatic left-sided neck mass, recurrent neck abscess or suppurative thyroiditis. In view of the rarity of this lesion, we thought it worthwhile to present the case of a 25-year-old female with a diagnosed fourth branchial cleft cyst in her left lower neck. The embryology and management of these cases is discussed.

Spindle cell myoepithelioma of the nasal cavity

Minor salivary gland neoplasms with mesenchymal-like features are uncommon in the sinonasal tract. We herein report a case of spindle cell myoepithelioma of the nasal cavity in a 69-year-old woman who presented with a rapidly expanding tumor accompanied by episodes of epistaxis. Although initially considered as a mesenchymal neoplasm, ultrastructural and immunophenotypical characterization demonstrated its myoepithelial nature. In the sinonasal setting, this unusual neoplasm may be confused with soft tissue tumors showing spindle cell or myxoid features. Staining for cytokeratin is found to be the most useful adjunct to diagnosis.

Foregut duplication arising from the pharynx

An unusual case of duplication of the foregut arising from the posterior pharyngeal wall is presented. Pertinent embryological and etiological considerations are discussed and a literature review included.

Thyroglossal duct cyst presenting as an anterior tongue fistula

An unusual case of thyroglossal duct cyst occurring in the tongue base and fistulizing to the anterior tongue is presented. No previous descriptions have been found in the literature associating this embryological remnant with fistulization to the anterior tongue. The treatment was successfully accomplished through a combined transhyoid and intraoral approach.

Immunopathological characteristics of nasal polyps

The presence of immunoglobulins in nasal polyps and surrounding mucosa was studied by direct immunofluorescence in 14 patients. Specific and total IgE were determined in polyps and in the sera of this group. Significant immunofluorescence to IgE was demonstrated in 12 polyps but in only four samples of adjacent mucosa. Eight polyps showed significant immunofluorescence to IgM. Six patients had elevated total IgE levels within polyp sac fluid in the absence of elevated serum values. In seven cases, specific IgE was found in polyp sac fluid which could not be detected on skin or serum testing. These results may suggest local production of IgE and support the concept of nasal polyps being a manifestation of a local allergic phenomenon.

Management of the undescended thyroid

Ectopic thyroid can occur throughout the neck but is found most commonly at the tongue base. Management includes Tc99m radionuclide scanning to confirm the presence and location of the thyroid tissue. Dysfunction should be assessed by T4, TSH, and thyroid antibody testing. Hormonal therapy is the primary treatment but surgery may be necessary in cases of airway obstruction. Six children with undescended thyroid are presented and a management protocol based on the presence or lack of symptomatology is proposed.

Local specific IgE production in nasal polyps associated with negative skin tests and serum RAST

Eighteen of 24 patients undergoing nasal polypectomies demonstrated polyp fluid total IgE higher than corresponding serum values. Allergen-specific IgE was detected in polyp fluid of 19/24 patients. Since only 9/19 had positive skin tests, ten patients had specific IgE locally in polyp tissue which could not be detected systemically.

Alternating combination chemotherapy using cisplatin-bleomycin with sequential methotrexate-5-FU plus leucovorin rescue in patients with head and neck cancer

Thirty-two patients (only two had previously untreated disease) with squamous cell carcinoma of the head and neck were treated with alternating combination chemotherapy. The regimen consisted of cisplatin (50 mg/m2) and bleomycin (30 units) given iv on Days 1 and 2, alternated with 1 hour of sequential methotrexate (200 mg/m2) and 5-FU (600 mg/m2) given iv, plus oral leucovorin rescue on Day 22. The entire cycle was repeated every 5 weeks (less than or equal to five cycles). Objective tumor regression was obtained in 33% of the 30 evaluable patients, with 13% complete regression. The median duration of response was only 3 months. Evidence of response occurred within one cycle, and was maximal after two cycles. Toxicity was very mild. Alternating combination chemotherapy is not more effective than either combination chemotherapy alone.

Measurement of antigen-specific IgE in nasal secretions of patients with perennial rhinitis

Sixteen of 53 patients with rhinitis had positive skin tests corresponding with serum-specific IgE (RAST). Concomitant positive nasal secretion (NS) RAST was found in 10/16. Four patients with both negative skin tests and serum RAST had positive NS RAST. In a subset of patients with perennial rhinitis, specific IgE may be detected only in NS. Further studies are necessary to document the clinical relevance of such NS IgE antibodies.