Mucous Cytokine Levels in Chronic Rhinosinusitis-Associated Olfactory Loss

IMPORTANCE

Olfactory loss is a frequent symptom of patients with chronic rhinosinusitis (CRS), but our understanding of how inflammatory cytokines affect olfaction is limited.

OBJECTIVES

To examine whether inflammatory cytokines are present in the olfactory cleft and whether they correlate with objective olfaction.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study, patients with CRS underwent quantitative olfactory testing using the Sniffin Sticks test to calculate a composite threshold discrimination identification (TDI) score from October 21, 2013, to November 12, 2015. Nasal mucus was collected using a sponge placed in the olfactory cleft for 5 minutes, and Cytometric Bead Array was used to measure secreted immunomodulatory products. Correlations between TDI score and secreted mediators were then calculated. Data analysis was performed from October 15, 2015, to December 17, 2015.

MAIN OUTCOMES AND MEASURES

Composite TDI scores and mean secreted mediator levels in mucus from the olfactory cleft.

RESULTS

Thirty-four patients were enrolled (mean [SD] age, 57.3 [15.7] years; female, 21 [61.8%]; white, 26 [76.5]). The TDI scores were lower in patients with CRS with nasal polyps (CRSwNP) than in patients with CRS without nasal polyps (CRSsNP) (difference, 8.7; 95% CI, 2.5-15.0; P = .007). Interleukin (IL) 5 levels were inversely correlated with TDI scores in patients with CRSwNP and those with CRSsNP (mean [SE] β estimate, -46.56 [15.11]; P = .005), whereas IL-6, IL-7, and vascular endothelial growth factor A were positively correlated with TDI scores only in the CRSwNP cohort. Subscale olfactory TDI scores followed similar correlations to composite TDI scores.

CONCLUSIONS AND RELEVANCE

In this study, inflammatory cytokines were found in mucus collected from the olfactory cleft. Levels of IL-5, in addition to other cytokines, were associated with objective olfactory function. Further inquiry is needed to establish the source of mucous cytokines and establish whether they play a causal role in olfactory loss.

Superoxide dismutase reduces the inflammatory response to Aspergillus and Alternaria in human sinonasal epithelial cells derived from patients with chronic rhinosinusitis

BACKGROUND

Aspergillus fumigatus and Alternaria alternata are ubiquitous environmental fungal allergens that can exacerbate airway inflammation and contribute to the disease process in patients with chronic rhinosinusitis (CRS). These antigens have been shown to induce human sinonasal epithelial cells (HSNECs) to promote a proinflammatory response, but what is unclear is a means by which to reduce these effects. Inhaled pathogens can induce HSNECs to produce reactive oxygen species (ROS) that trigger cytokine production.

OBJECTIVE

This study aimed to determine whether the free radical scavenger superoxide dismutase (SOD) could reduce HSNEC-derived inflammation, as measured by interleukin (IL)-6 and IL-8 production, in response to Aspergillus or Alternaria exposure.

METHODS

Sinus tissue explants were collected at the time of surgery from control patients (n = 7) and patients with CRS with nasal polyps (CRSwNP) (n = 9). HSNECs were cultured from the explants and treated with Aspergillus, Alternaria, and SOD for 24 hours. Cell supernatants and lysates were collected, and IL-6 and IL-8 concentrations were measured using enzyme-linked immunosorbent assay.

RESULTS

In control and CRSwNP HSNECs, Aspergillus and Alternaria both increased cytokine production (p < 0.05), as measured by IL-6 and IL-8 concentration. SOD treatment reduced the inflammatory response to fungal antigen exposure from CRSwNP HSNECs but not control HSNECs. In CRSwNP patients, SOD significantly decreased IL-6 and IL-8 production after Alternaria exposure and IL-8 after Aspergillus exposure (p < 0.05).

CONCLUSIONS

When HSNECs from CRSwNP patients are treated with SOD concurrently with Aspergillus or Alternaria, SOD treatment decreases the fungal antigen-induced inflammatory response. The ability to attenuate inflammation induced by common fungal allergens with SOD treatment could provide a novel therapeutic or preventative approach for patients with CRS or other allergic inflammatory airway diseases.

The Olfactory Cleft Endoscopy Scale correlates with olfactory metrics in patients with chronic rhinosinusitis

BACKGROUND

Olfactory loss affects a majority of patients with chronic rhinosinusitis (CRS). Traditional objective measures of disease severity, including endoscopy scales, focus upon the paranasal sinuses and often have weak correlation to olfaction.

METHODS

Adults with CRS were prospectively evaluated by blinded reviewers with a novel Olfactory Cleft Endoscopy Scale (OCES) that evaluated discharge, polyps, edema, crusting, and scarring of the olfactory cleft. Objective olfactory function was assessed using "Sniffin' Sticks" testing, including composite threshold-discrimination-identification (TDI) scores. Olfactory-specific quality of life was evaluated using the short modified version of the Questionnaire of Olfactory Disorders (QOD-NS). Interrater and intrarater reliability was assessed among 3 reviewers for OCES grading. Multivariate linear regression was then used to test associations between OCES scores and measures of olfaction, controlling for potential confounding factors.

RESULTS

The OCES score was evaluated in 38 patients and had a high overall reliability (intraclass correlation coefficient [ICC] = 0.92; 95% confidence interval [CI], 0.91 to 0.96). The OCES significantly correlated with objective olfaction as measured by TDI score (p < 0.001), with TDI score falling by 1.13 points for every 1-point increase in OCES score. Similar significant associations were found for threshold, discrimination, and identification scores (p < 0.003 for all) after controlling for age, gender, race, and reviewer/review. The OCES was also highly associated with patient-reported QOD-NS scores (p = 0.009).

CONCLUSION

A novel olfactory cleft endoscopy scale, OCES, shows high reliability and correlates with both objective and patient-reported olfaction in patients with CRS. Further studies to determine prognostic value and responsiveness to change are warranted.

Predictors of 30-day morbidity and mortality in transnasal microscopic pituitary tumor excision

BACKGROUND

There is a lack of population-based, multi-institutional analyses of factors associated with morbidity and mortality following pituitary tumor excision.

METHODS

The American College of Surgeons National Surgical Quality Improvement Project files were used to compile information on patients that had undergone transnasal microscopic pituitary tumor resection from 2006 to 2012. Patient demographics, comorbidities, operative characteristics, and morbidity and mortality in the 30 days following surgery were included. Multivariate logistic regression was used for categorical variables and multivariate linear regression was used for continuous variables to evaluate factors leading to adverse events.

RESULTS

A total of 658 patients were included, of which 58 (8.81%) experienced a complication, reoperation or death in the 30 days following surgery. The most common complications were reoperation (3.37%), followed by unplanned reintubation (1.99%), urinary tract infection (1.68%), and transfusion (1.68%). Predictors of any complication, reoperation, or death include preoperative sepsis (odds ratio [OR] = 7.596) and lower preoperative serum albumin (OR = 6.667). Younger age predicted surgical complications (OR = 1.105). Predictors of medical complications include higher body mass index (OR = 1.112), chronic steroid use (OR = 6.568), preoperative sepsis (OR = 15.297), and lower preoperative serum hematocrit (OR = 1.225). Predictors of increased total length of hospital stay were older age (β = 0.146), higher body mass index (β = 0.188), chronic steroid use (β = 0.142), preoperative sepsis (β = 0.489), and lower preoperative serum albumin (β = -0.213).

CONCLUSION

Although adverse events following pituitary tumor excision are low, awareness of factors associated with morbidity and mortality in the early postoperative period may allow for improved patient monitoring and outcomes.

Multi-institutional study of risk factors for perioperative morbidity following transnasal endoscopic pituitary adenoma surgery

BACKGROUND

The goal of this study was to identify preoperative risk factors associated with increased perioperative morbidity after endoscopic pituitary surgery.

METHODS

A retrospective review of patients undergoing endoscopic pituitary adenoma surgery between 2002 and 2014 at 6 international centers was performed. Standard demographic and comorbidity data, as well as information regarding tumor extent and treatment were collected. Logistic regression was used to examine risk factors for the following 30-day outcomes: systemic complications, intracranial complications, postoperative cerebrospinal fluid (CSF) leaks, length of hospital stay, readmission, and reoperation.

RESULTS

Data was collected on 982 patients with a mean age of 52 years. The median body mass index (BMI) for all patients was 30.9 kg/m(2) with 56% female. The median hospital stay was 5 days and 23.8% of patients suffered a postoperative adverse event. Systemic complications occurred in 3.2% of patients and intraventricular extension was a risk factor (odds ratio [OR] 8.9). Intracranial complications occurred in 7.3% of patients and risk factors included previous radiation (OR 8.6) and intraventricular extension (OR 7.9). Reoperation occurred in 6.5% of patients and intraventricular extension (OR 7.3) and age (<40 years, OR 3.5; 40 to 64 years, OR 3.2) were risk factors. Postoperative CSF leaks occurred in 5.5% of patients and risk factors included female gender (OR 2.4), BMI ≥ 30 (OR 2.1), age (<40 years, OR 5.3; 40 to 64 years, OR, 7.9), and intraventricular extension (OR, 9.5).

CONCLUSION

Postoperative endoscopic pituitary adenoma surgery complications are associated with tumors with intraventricular extension, preoperative radiation, as well as common patient comorbidities. Identification of these factors may permit implementation of strategies to reduce postoperative complications.

Treatment of hereditary hemorrhagic telangiectasia with submucosal and topical bevacizumab therapy

OBJECTIVE/HYPOTHESIS

Bevacizumab delivered as a submucosal and topical intranasal therapy effectively controls hereditary hemorrhagic telangiectasia (HHT)-associated epistaxis.

STUDY DESIGN

Prospective institutional review board-approved study.

METHODS

Between December 2009 and December 2010, 19 patients with HHT-associated epistaxis were treated with 100 mg of intranasal submucosal bevacizumab. Following treatment, patients were contacted monthly to report their epistaxis severity score (ESS) for 9 or more months after their initial treatment. If a patient had a significant increase in their ESS, they were offered treatment with 100 mg of topical bevacizumab, administered via a metered dose atomizer. All treatments were recorded.

RESULTS

All 19 patients had a postinjection ESS documented through 9 months, whereas 17 patients had completed ESS data between months 10 and 12. Six of the 19 patients received eight additional 100 mg of topical bevacizumab treatments because they had an increase in their ESS. Results demonstrated a mean preinjection ESS of 8.12, with an ESS nadir of 2.00 reached at 2 months following submucosal injection (P < 0.0001). Over the following 12 months, the mean ESS steadily increased back to a maximum of 3.6 reached at 11 months following injection (P < .0001).

CONCLUSIONS

Intranasal submucosal bevacizumab effectively treats HHT-associated epistaxis for up to 12 months following treatment.

Efficacy of intranasal Bevacizumab (Avastin) treatment in patients with hereditary hemorrhagic telangiectasia-associated epistaxis

OBJECTIVES/ HYPOTHESIS

Intranasal Bevacizumab is an effective therapy for epistaxis in patients with hereditary hemorrhagic telangiectasia (HHT).

STUDY DESIGN

Retrospective chart review.

METHODS

In 32 successive patients presenting with recurrent HHT epistaxis 25-100 mg of Bevacizumab was applied intranasally either as a submucosal injection or as a topical spray between November 2008 and May 2010. In many of the injected patients, the Potassium Titanyl Phosphate (KTP) laser was used adjunctively for vessel photocoagulation. A phone interview was performed in July 2010 to assess for treatment efficacy.

RESULTS

All 32 treated patients were contacted with pre- and posttreatment epistaxis severity scores (ESS) compared. Seventeen patients received topical Bevacizumab, 10 patients received a submucosal injection, and 5 patients received both. In addition, 12 patients were also treated with the KTP laser at the time of their submucosal injection. In the pretreatment period the average ESS was 7.0 (SD = 2.1), whereas in the posttreatment group the average ESS was 2.9 (SD = 1.7). This represents a significant improvement in epistaxis severity (P < .0001).

CONCLUSIONS

In HHT patients intranasal Bevacizumab, applied as a topical spray or a submucosal injection, significantly improves epistaxis as measured by the Epistaxis Severity Score.

The association between interferon regulatory factor 6 (IRF6) and nonsyndromic cleft lip with or without cleft palate in a Honduran population

OBJECTIVES/HYPOTHESIS

Interferon regulatory factor 6 (IRF6), the gene that causes van der Woude syndrome (VWS), is a candidate gene for nonsyndromic cleft lip with or without cleft palate (NSCLP) because a number of studies have supported an association between NSCLP and single nucleotide polymorphisms (SNPs) in IRF6 in several populations. This project investigated the contribution of IRF6 to NSCLP in the Honduran population, a previously unstudied group with a high prevalence of NSCLP.

STUDY DESIGN

Family-based joint linkage and association study.

METHODS

A set of five SNPs in and around IRF6 previously reported to be associated with NSCLP were tested for association with NSCLP in 276 affected and unaffected Honduran individuals from 59 families with at least two members affected by clefting and at least one member with confirmed NSCLP.

RESULTS

We observed support of linkage for three SNPs-rs1856161, rs2235371, and rs2235377-under a dominant model (log of odds [LODs] = 1.97, 1.56, 1.73, respectively). Subsequent single-point, haplotype, and joint linkage and association analyses continued to support the association with NSCLP (P < or = .05) at these three SNPs. When analysis was restricted to NSCLP cases, excluding cleft palate only cases, support for association strengthened.

CONCLUSIONS

This is the first study to demonstrate that three candidate SNPs within IRF6 are significantly associated with NSCLP in the Honduran population, providing the first genetic clue to NSCLP observed in the Honduran population and confirming findings from populations in other parts of the world. Further studies are needed to identify the putative variant(s).