The Transverse Turbinate Line: A Reliable Landmark for the Maxillary Sinus Natural Ostium

OBJECTIVES

Approximating the maxillary sinus natural ostium's (MSNO) natural position during anterograde surgery is challenging, as only a single visual "landmark," the maxillary line, is routinely offered to guide the identification of the MSNO in three-dimensional space. Despite almost 40 years of endoscopic sinus surgery (ESS) experience in North America, maxillary recirculation and discontinuity between the natural and surgical ostia are commonly encountered during revision ESS. Consequently, we feel an additional visual landmark would assist in localizing the MSNO with or without image guidance. In this study, we aim to provide a second reliable landmark in the sinonasal cavity.

METHODS

We present a cadaveric anatomical landmark series that provides a second visual landmark for the MSNO, which we have labeled the transverse turbinate line (TTL): a 2-millimeter zone of confidence for the craniocaudal positioning of the MSNO that can be combined with the anteroposterior (AP) landmark of the maxillary line.

RESULTS

In our study, 40 cadaveric sinuses were dissected, and the TTL was found to correspond consistently with the zone between the superior and inferior aspects of the MSNO.

CONCLUSION

We anticipate that this second relational landmark may decrease the time required for anterograde access to the MSNO in trainees, increase the accuracy of identification, and translate to lower long-term recirculation and maxillary surgery failure rates.

LEVEL OF EVIDENCE

NA Laryngoscope, 133:3285-3291, 2023.

Sinonasal IgG4-related sclerosing disease: A rare entity and challenging diagnosis

Objectives

To describe the rare presentation, imaging and histological findings, and treatments in patients with IgG4-related disease (IgG4-RD) and diagnostic pitfalls and difficulties.

Methods

Cases of sinonasal IgG4-RD were retrieved, and clinicopathological features were reviewed.

Results

Seven cases of sinonasal IgG4-RD were identified over an 11-year period, including four males and three females, with an age range of 19-66 years (median 58 years). Patients presented with symptoms related to the mass effect of the lesions or the destructive nature of the disease including fullness, swelling, obstruction, and pain. Serum IgG and IgG4 levels, IgG/IgG4 ratios, storiform fibrosis, obliterative phlebitis, and plasma cell infiltration were seen in varying proportions. Bony erosion and tissue inflammation were present in some cases.

Conclusion

Sinonasal IgG4-RD is exceedingly rare among other IgG4-RD and varied in its clinical presentation thus posing as a clinically difficult disease to diagnosis. Proper clinical, pathological, and immunohistopathological analysis is required for accurate diagnosis. Such disease should be considered in all cases of similar presentation to those in this study.Level of Evidence: 4.

Utilization of Nasal Mucus to Investigate the Pathophysiology of Chronic Rhinosinusitis

BACKGROUND

Nasal mucus is proving to be a useful means by which to study the pathogenesis of chronic rhinosinusitis (CRS). Given the increase in publications examining nasal mucus and the lack of a review on this topic, we will focus on this noninvasive approach to studying CRS. Particular attention will be drawn towards inflammatory cytokines and biomarkers and their influence on disease severity.

METHODS

A literature review of papers published in English pertaining to nasal mucus was performed using the PubMed database. The search utilized combinations of the following keywords: sinusitis, polyps, sample collection, nasal mucus, or nasal secretion. Studies solely on acute or bacterial sinusitis, allergic rhinitis, or cystic fibrosis were not included.

RESULTS

A wide variety of materials and methods have been used to collect nasal mucus. Numerous assay types have been performed with the most common being ELISA, cytometric bead array, and proteomics. Most studies have focused on examining the levels of Th1/Th2 cytokines along with chemokines associated with type 2 immunity. Other factors identified include growth factors, senescence-associated proteins, complement, and antimicrobial defenses have also been identified. Nasal mucus cytokines have proven useful in cluster analysis and predicting postoperative improvement in Sino-nasal Outcome Test (SNOT-22) scores. One limitation of the use of nasal mucus is that some studies have suggested that nasal mucus does not always reflect the tissue microenvironment.

CONCLUSIONS

Nasal mucus represents a critical tool by which to examine the sinonasal microenvironment in a noninvasive manner. Unlike studies of tissue, it can be utilized in both surgically and medically managed patients and avoids the trauma of biopsies. However, studies are still needed to determine the most effective method for nasal mucus collection. Studies should also take care to confirm that nasal mucus markers do, in fact, reflect the levels of the product studied in the tissue.

Transformation from Sinonasal Seromucinous Hamartoma to Adenocarcinoma: A Case Report

OBJECTIVES

Sinonasal hamartomas are benign neoplasms composed of disorganized mature tissue elements. Epithelial variants include respiratory epithelial adenomatoid hamartoma (REAH) and seromucinous hamartoma (SMH). Malignant transformation of REAH is rarely reported; however, the malignant transformation of SMH to adenocarcinoma has not been described. We report the first case of a transformation from SMH to adenocarcinoma.

METHODS

The medical records of a patient presenting with sinonasal SMH with malignant transformation to adenocarcinoma were reviewed. The NCBI database was queried for the literature regarding SMH and malignant transformation of sinonasal hamartomas.

RESULTS

A 39-year-old man presented with a left nasal mass, nasal obstruction, and epistaxis. Computed tomography and magnetic resonance imaging demonstrated a nonaggressive and heterogeneous left nasal mass with involvement of the middle turbinate and posterior ethmoid sinuses. He underwent endoscopic sinus surgery with complete excision of the mass. Pathology revealed SMH with focal areas of transition to low-grade adenocarcinoma characterized by stromal invasion but no bony, perineural, or lymphovascular invasion. Adjuvant treatment was not recommended. Literature review revealed no reported cases of malignant transformation of SMH.

CONCLUSION

We report the first case of malignant transformation of SMH. Patients with SMH must be counseled that there is an extremely rare and potentially unrecognized risk of malignancy that may influence treatment and postoperative monitoring.

The best COVID-19 predictor is recent smell loss: a cross-sectional study

BACKGROUND

COVID-19 has heterogeneous manifestations, though one of the most common symptoms is a sudden loss of smell (anosmia or hyposmia). We investigated whether olfactory loss is a reliable predictor of COVID-19.

METHODS

This preregistered, cross-sectional study used a crowdsourced questionnaire in 23 languages to assess symptoms in individuals self-reporting recent respiratory illness. We quantified changes in chemosensory abilities during the course of the respiratory illness using 0-100 visual analog scales (VAS) for participants reporting a positive (C19+; n=4148) or negative (C19-; n=546) COVID-19 laboratory test outcome. Logistic regression models identified singular and cumulative predictors of COVID-19 status and post-COVID-19 olfactory recovery.

RESULTS

Both C19+ and C19- groups exhibited smell loss, but it was significantly larger in C19+ participants (mean±SD, C19+: -82.5±27.2 points; C19-: -59.8±37.7). Smell loss during illness was the best predictor of COVID-19 in both single and cumulative feature models (ROC AUC=0.72), with additional features providing no significant model improvement. VAS ratings of smell loss were more predictive than binary chemosensory yes/no-questions or other cardinal symptoms, such as fever or cough. Olfactory recovery within 40 days was reported for ~50% of participants and was best predicted by time since illness onset.

CONCLUSIONS

As smell loss is the best predictor of COVID-19, we developed the ODoR-19 tool, a 0-10 scale to screen for recent olfactory loss. Numeric ratings ≤2 indicate high odds of symptomatic COVID-19 (10<OR<4), especially when viral lab tests are impractical or unavailable.

MYB-activated models for testing therapeutic agents in adenoid cystic carcinoma

OBJECTIVE

There are no effective systemic therapies for adenoid cystic cancer (ACC) and lack of tumor lines and mouse models have hindered drug development.We aim to develop MYB-activated models for testing new therapeutic agents.

MATERIALS AND METHODS

We studied new ACC patient-derived xenograft (PDX) models and generated a matched cell line from one patient. In addition, we generated a genetically-engineered MYB-NFIB mouse model (GEMM) that was crossed with Ink4a^+/-/Arf^+/- mice to study tumor spectrum and obtain tumor lines. Using human and murine ACC-like tumor lines, we analyzed MYB expression by RNA-Seq and immunoblot and tested efficacy of new MYB inhibitors.

RESULTS

We detected MYB-NFIB transcripts in both UFH1 and UFH2 PDX and observed tumor inhibition by MYB depletion using shRNA in vivo. We observed rapid loss of MYB expression when we cultured UFH1 in vitro, but were able to generate a UFH2 tumor cell line that retained MYB expression for 6 months. RNA-Seq expression detected an ACC-like mRNA signature in PDX samples and we confirmed an identical KMT2A/MLL variant in UFH2 PDX, matched cell line, and primary biopsy. Although the predominant phenotype of the MYB-NFIB GEMM was B-cell leukemia, we also generated a MYB-activated ACC-like mammary tumor cell line. We observed tumor inhibition using a novel MYB peptidomimetic in both human and murine tumor models.

CONCLUSIONS

We generated and studied new murine and human MYB-activated tumor samples and detected growth inhibition with MYB peptidomimetics. These data provide tools to define treatment strategies for patients with advanced MYB-activated ACC.

Detection of Microbiota in Post Radiation Sinusitis

OBJECTIVES

A shift in the microbiota of chronic rhinosinusitis has been described after radiotherapy to the sinonasal cavity and skull base. There is a paucity of literature characterizing the bacteriology of post radiation sinusitis using next-generation gene sequencing techniques. This study aims to describe and compare the microbial flora of rhinosinusitis after radiotherapy using both culture and molecular techniques for microbial DNA detection.

METHODS

The medical records of patients treated with external beam radiation for sinonasal, nasopharyngeal, or skull base malignancy were reviewed at a tertiary care facility. Patients' sinonasal cavities were swabbed for routine culture or brushed for molecular gene sequencing. Swab specimens were processed for standard microbial culture, and brush specimens were sent for gene sequencing at Micro GenX Laboratory (Lubbock, Texas, USA).

RESULTS

Twenty-two patients were diagnosed with chronic sinusitis after undergoing radiotherapy. Staphylococcus aureus was the most common organism identified by both culture and gene sequencing, followed by Pseudomonas aeruginosa. Several additional organisms were detected by gene sequencing that were not isolated by routine culture techniques. Gene sequencing identified pathogens differing from culture results in 50% of patients examined.

CONCLUSION

The bacteriology of post radiation sinusitis appears to resemble the microorganisms responsible for chronic sinusitis in healthy adults. Next generation gene sequencing techniques may reveal additional organisms responsible for sinusitis and provide complementary results that may impact the medical treatment of post radiation sinusitis.

Isolated leptomeningeal progression from sinonasal carcinomas: Implications for staging workup and treatment

PURPOSE

To evaluate the rate and risk factors of isolated leptomeningeal progression in sinonasal carcinomas.

METHODS

We retrospectively reviewed imaging and clinical records to determine progression patterns, and estimated rates using the Kaplan-Meier method. We evaluated risk factors using proportional hazard regression.

RESULTS

We analyzed 120 patients who received adjuvant or primary radiotherapy for sinonasal carcinomas. Most patients had T4 disease (68%) and underwent surgery (84%) and chemotherapy (72%). Twenty-seven (23%) patients developed distant metastases (DM), including 20 (17%) with isolated DMs. Leptomeningeal progression was the most common site of isolated DMs (n = 9; 45%) with an average disease-free interval of 1.2 years (0.1-4.3 years). High-grade histology (P = 0.0003), intracranial invasion (P < 0.0001), and neuroendocrine histology (P = 0.06) were associated with increased risk.

CONCLUSIONS

Isolated leptomeningeal progression is a common pattern of DM in advanced sinonasal carcinomas. We recommend adding cerebrospinal fluid cytology and contrast-enhanced spine MRI to routine staging evaluations for high-risk patients.

Spontaneous cerebrospinal fluid leak from the optic canal

Objective

To present a case of successful repair of a spontaneous cerebrospinal fluid leak in a previously unreported anatomic site.

Methods

Retrospective chart review.

Results

A 48-year-old woman developed a spontaneous cerebrospinal fluid leak from the optic nerve sheath and underwent a multilayer endoscopic closure with no damage to the optic nerve.

Conclusion

Endoscopic surgeons can successfully repair cerebrospinal fluid leaks from the optic nerve sheath without causing loss of vision.

Recalcitrant rhinosinusitis, innate immunity, and mannose-binding lectin

BACKGROUND

Mannose-binding lectin (MBL) is a protein produced by the liver that participates in innate immunity by tagging the surface of microbes for opsonization. Mannose-binding lectin deficiency is present in 7% of the population and has been implicated in recurrent respiratory tract infections in children. Mannose-binding lectin deficiency has not been explored in rhinosinusitis but is associated with increased mortality in adult pneumococcal infection. The purpose of this report is to describe a tertiary rhinology patient experience with MBL deficiency and recalcitrant rhinosinusitis.

METHODS

This retrospective case series report characterizes predominantly adult patients with low MBL levels from January 2010 to June 2012. Indications for MBL testing, sinus culture data, immunological testing results, and treatments used to control rhinosinusitis are described.

RESULTS

Mannose-binding lectin levels were deficient in 12 of 36 patients (33.3%) tested. IgG subclasses were abnormally low in 5 of 12 patients; IgA was normal in 11 of 12 patients; and IgM was normal in 11 of 12 patients. Staphylococcus aureus, coagulase-negative Staphylococcus species, and Pseudomonas aeruginosa, known to be "tagged" by MBL, were the most common organisms grown on culture. Treatments included culture directed systemic antimicrobial therapy and topical steroids/antibiotics.

CONCLUSION

Mannose-binding lectin, an important component of the lectin complement pathway and innate immunity, is possibly associated with recalcitrant adult rhinosinusitis. Steroid/antibiotic irrigations appear to benefit patients with recalcitrant rhinosinusitis and possibly those with MBL deficiency. Given that the prevalence of MBL deficiency in this case series is 4 times that seen in the normal population, additional investigations are warranted to further elucidate the role of MBL deficiency in rhinosinusitis.

An update on attitudes and use of image-guided surgery

BACKGROUND

The aim of this study was to compare 2010 access to, usage of, and attitudes toward image-guided surgery (IGS) for endoscopic sinus surgery and anterior skull-base surgery to those in 2005.

METHODS

A mail survey of American Rhinologic Society (ARS) members was performed in January 2010. Results were compared to results from the same survey mailed in January 2005.

RESULTS

Significantly more respondents in 2010 had access to IGS compared to 2005 (94.6% vs 86%, p = 0.002). Compared to 2005, IGS was used in a greater percentage of cases in 2010 (p < 0.0001). More respondents in 2010 felt that IGS is indicated for primary anterior ethmoidectomy, revision anterior ethmoidectomy, primary total ethmoidectomy, Lothrop procedure, cerebrospinal fluid (CSF) leak repair, tumor surgery, orbital decompression, and optic nerve decompression (all p < 0.05). Similar to 2005, region, residency completion date, and availability of IGS in residency had no measureable effect on attitudes toward IGS. As in 2005, availability of IGS was associated with a greater feeling of its necessity in 2010.

CONCLUSION

IGS availability has grown significantly and nearly all ARS members now have access. Estimates of use by respondents have also increased over the last 5 years, particularly for ethmoid and advanced procedures. Revision surgery and advanced procedures continue to be chief indications for IGS use. As in 2005, the results of this survey reflect the opinion of the respondents, and do not necessarily reflect the views of the ARS or of practicing otolaryngologists in general.

Endothelial cell regulation of nitric oxide production during hypoxia in coronary microvessels and epicardial arteries

Nitric oxide (NO) synthesized by endothelial cell nitric oxide synthase (eNOS) elicits vasodilation of resistance-sized coronary microvessels. Since coronary blood flow increases during hypoxia, we tested the hypotheses that: (1) hypoxia results in increased blood flow through increased NO production mediated by the upregulation of both eNOS mRNA and protein and (2) the regulation of NO production in response to hypoxia differs in microvascular endothelial cells and nonresistance, epicardial endothelial cells. Monocultures of vascular endothelium from resistance (approximately 100 micro) and nonresistance epicardial arteries were established and characterized. Nitric oxide was quantitated using a chemiluminescence method. Hypoxia (pO(2) = 10 mmHg) significantly increased NO production in both cell lines, with less NO produced in microvascular endothelium. Western blots demonstrated that hypoxia caused a time-dependent increase in eNOS protein in both lines, with an average 2.5-fold increase in nonresistance, epicardial endothelial cells compared to an average 1.7-fold increase in protein from microvascular endothelium. Total mRNA recovery increased 2.4 +/- 0.6-fold within 30 min of hypoxia in nonresistance, epicardial endothelial cells with no increase in microvascular endothelial cells. Although hypoxia increased NO production in both populations of endothelial cells, the increase in NO production and eNOS protein in microvascular endothelium was less compared to nonresistance, epicardial endothelial cells. Furthermore, there was no significant upregulation of total mRNA for eNOS in microvascular endothelium. The data indicate that increased NO production in microvascular endothelium during hypoxia may be through translational or posttranslational modifications of the enzyme, whereas transcriptional upregulation may account for the increased NO production in nonresistance, epicardial endothelial cells. Oxygen-sensitive response mechanisms that modulate NO production may be different in endothelium from different coronary artery vascular beds.

Hydrophobicity and subunit interactions of rod outer segment proteins investigated using Triton X-114 phase partitioning

Triton X-114 phase partitioning, a procedure used for purifying integral membrane proteins, was used to study protein components of the mammalian visual transduction cascade. An integral membrane protein, rhodopsin, and two isoprenylated protein complexes, cyclic GMP phosphodiesterase and Gt beta gamma, partitioned into the detergent-rich phase. Arrestin, a soluble protein, accumulated in the aqueous phase. Gt alpha distributed about equally between phases whether GDP (Gt alpha.GDP) or GTP (Gt alpha.GTP) was bound. Gt beta gamma increased recovery of Gt alpha.GDP but not Gt alpha.GTP in the detergent phase. Trypsin-treated Gt alpha, which lacks the fatty acylated amino-terminal 2-kDa region, accumulated to a greater extent in the aqueous phase than did intact Gt alpha. Trypsinized cGMP phosphodiesterase, which lacks the isoprenyl group, partitioned into the aqueous phase. A carboxyl-terminal truncated mutant (Val-331 stop) of Gt alpha accumulated more in the aqueous phase then did recombinant full-length Gt alpha, supporting the role of the carboxyl terminus in increasing its hydrophobicity. N-Myristoylated recombinant Go alpha was more hydrophobic than recombinant Go alpha without myristate. ADP-ribosylation of Gt alpha catalyzed by NAD:arginine ADP-ribosyltransferase, but not by pertussis toxin, increased hydrophilicity. Triton X-114 phase partitioning can thus semiquantify the hydrophobic nature of proteins and protein domains. It may aid in evaluating changes associated with post-translational protein modification and protein-protein interactions in a defined system.

Involvement of N-myristoylation in monoclonal antibody recognition sites on chimeric G protein alpha subunits

Monoclonal antibody, LAS-2, directed against the alpha subunit of transducin (Gt alpha), inhibited Gt beta gamma-dependent, pertussis toxin-catalyzed ADP ribosylation of Gt alpha and was specific for Gt alpha. Immunoblotting studies on proteolytic fragments of Gt alpha were consistent with an amino-terminal epitope. To define the antibody recognition site, recombinant Gt alpha was synthesized in Escherichia coli cotransfected with or without yeast N-myristoyl-transferase. Amino-terminal fatty acylation of Gt alpha, verified by use of radiolabeled fatty acid, was required for immunoreactivity. LAS-2 did not react with a chimeric protein consisting of residues 1-9 of Gt alpha and the remainder Go alpha, regardless of its myristoylation. Immunoreactivity was observed when amino acids 1-17 of Gt alpha were present in a Go alpha chimera and the protein was amino-terminally myristoylated; there was no reactivity without myristoylation. It appears that the LAS-2 epitope requires both Gt alpha-specific sequence in amino acids 10-17 and a fatty acyl group in proximity to these residues. These results are consistent with the hypothesis that the myristoyl group is essential for protein structure; conceivably it "folds back" on and stabilizes the amino-terminal structure of Gt alpha as opposed to protruding from an amino-terminal alpha-helix and serving as an amino-terminal membrane anchor.

Effect of temperature and host factors on the activities of pertussis toxin and Bordetella adenylate cyclase

Pertussis toxin and adenylate cyclase toxin both contribute to the pathogenesis of whooping cough. Production of these proteins is controlled by the bvg locus, which is inactive at 25 degrees C, but at 37 degrees C produces a Vir+ phenotype. In view of the temperature dependence of virulence factor synthesis, the effects of temperature and host factors on their action were examined. The NAD glycohydrolase activity of the S1 subunit of pertussis toxin was enhanced by CHAPS, a zwitterionic detergent, with a temperature optimum of approximately 35 degrees C. Similar temperature optima for the ADP-ribosylation by pertussis toxin of transducin and recombinant Go alpha were observed. Since the temperature--activity relationship of S1 differed from that of S1 in activated holotoxin, and since S1 in activated holotoxin was more stable at 42 degrees C than was S1, it appears that S1 associated with the B oligomer components may, in fact, be an active species. Bordetella pertussis adenylate cyclase is activated by a host factor, calmodulin. In the absence of calmodulin, the temperature optimum for enzymatic activity was approximately 25 degrees C, whereas in its presence it was approximately 35 degrees C. Thus, the temperature optima for pertussis and adenylate cyclase toxins, virulence factors whose production is increased through the bvg locus at physiological temperatures, are either at or near these temperatures when stimulated by host factors.

Role of chemotactic factor inactivator in modulating alveolar macrophage-derived neutrophil chemotactic activity

The stimulated alveolar macrophage is a potent source of neutrophil chemotactic activity. The release of this chemotactic activity can be inhibited by pretreating alveolar macrophages with anti-C5 antibody. We hypothesized that C5a, a fragment cleaved from C5 when C5 is activated, might activate the alveolar macrophage to release neutrophil chemotactic activity and that chemotactic factor inactivator, a serum inhibitor of C5a, could decrease this release. Activated complement components including C5a were found to stimulate guinea pig macrophages to release chemotactic activity into their culture supernatants at levels that were significantly higher than the chemotactic activity of C5a alone (P less than 0.001). Chemotactic factor inactivator was found to cause a marked reduction in the chemotactic activity released by macrophages stimulated with phagocytic and nonphagocytic stimuli (P less than 0.001, all comparisons). These data indicate that C5a can stimulate alveolar macrophages to release chemotactic activity in vitro, and that chemotactic factor inactivator may play a role in modulating this process.