[Show abstract][Hide abstract] ABSTRACT: To examine the existing evidence on gender differences in the prevalence, treatment, and quality of life of patients with chronic rhinosinusitis (CRS).
Review of the literature and expert opinion.
From a sociologic standpoint, women have historically been considered more likely to report symptoms, seek medical care, and give poorer self-evaluation of health, which may bias data toward increased prevalence and a greater effect of CRS on quality of life in women. However, the influence of gender seems to be restricted primarily to the evaluation of general quality of life, whereas the disease-specific health-related quality of life is not different between genders. Furthermore, migraine headaches, which are more common among women, may be misdiagnosed as CRS, which contributes to gender differences in the prevalence of CRS. The degree to which reported differences in prevalence and health utilization represent biologic or physiologic differences between genders is not known; however, differences in anatomic size, tobacco susceptibility, and hormonal factors have been speculated to increase the overall susceptibility to CRS in women compared with men.
Focused research that examines the effect of gender on the development, treatment, and outcomes of CRS is warranted.
[Show abstract][Hide abstract] ABSTRACT: The mechanisms that underlie the pathogenesis of chronic rhinosinusitis without nasal polyps (CRSsNP), with nasal polyps (CRSwNP) and aspirin exacerbated respiratory disease (AERD) are not clear.
To first evaluate the inflammatory profiles of CRSsNP and CRSwNP tissues and to then investigate whether clinical differences observed between CRSwNP and AERD are in part secondary to differences in inflammatory mediator expression within NP tissues.
Expression levels of numerous inflammatory mediators were determined by qRT-PCR, ELISA, and multiplex immunoassay.
CRSwNP NP had increased levels of type-2 mediators including IL-5 (p<0.001), IL-13 (p<0.001), Eotaxin-2 (p<0.001), and MCP-4 (p<0.01) compared to sinonasal tissue from CRSsNP and controls. Expression of IFNγ mRNA or protein was low and not different among CRS subtypes examined. Compared to CRSwNP, AERD NP had elevated protein levels of ECP (p<0.001), GM-CSF (p<0.01), and MCP-1 (p=0.01) as well as decreased gene expression of tissue plasminogen activator (t-PA) (p=0.02). Despite the higher eosinophilia in AERD, there was no associated increase in type-2 mediator protein levels observed.
CRSwNP was characterized by a predominant type-2 inflammatory environment while CRSsNP did not reflect a classic type-1 milieu, as has been previously suggested. AERD can be distinguished from CRSwNP by elevated ECP levels, but this enhanced eosinophilia is not associated with elevations in traditional type-2 inflammatory mediators associated with eosinophil proliferation and recruitment. However, other factors including GM-CSF, MCP-1, and t-PA may be important contributors to AERD pathogenesis.
American Journal of Respiratory and Critical Care Medicine 06/2015; 192(6). DOI:10.1164/rccm.201412-2278OC · 13.00 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objectives/HypothesisTo assess relevant variations in the anatomical course of the infraorbital nerve (ION). This understanding may reduce the risk of surgical injury.MethodsA total of 100 consecutive computed-tomography sinus studies obtained in a tertiary referral center were reviewed, and measurements were made of the 200 IONs. Anatomic variants were classified into three types based on the degree to which (if any) the nerve's course descended from the maxillary roof into the sinus lumen.ResultsA total of 60.5% of IONs were entirely contained within the sinus roof. In 27.0%, the nerve canal descended below the roof but remained juxtaposed to it. In 12.5%, the ION descended into the sinus lumen. The proportion of IONs descending into the sinus significantly increased to 27.7% when an infraorbital ethmoid cell was present (chi-square P < 0.001) and to 50% when the nerve was contained within a lamella of such a cell (chi-square P < 0.001). Descended nerves terminated in a foramen located an average of 11.9 ± 2.5 mm below the infraorbital rim, significantly further below the orbit than nondescended nerves (t test P < 0.001). Descended nerves were located a mean distance of 8.6 ± 2.9 mm below the sinus roof and traversed the sinus lumen diagonally for a mean length of 15.4 ± 3.1 mm.Conclusions
Descent of the ION into the maxillary sinus is a common anatomic variant that is more prevalent in the setting of an ipsilateral infraorbital ethmoid cell. Descended nerves are associated with the foramen significantly further below the inferior orbital rim than those of nondescended nerves. These observations may help surgeons avoid iatrogenic ION injury.Level of EvidenceN/A. Laryngoscope, 2015
The Laryngoscope 06/2015; 125(6). DOI:10.1002/lary.25089 · 2.14 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Up to 50% of patients with chronic rhinosinusitis (CRS) have comorbid asthma, and we have reported that a subset of CRS patients who have nasal polyps (CRSwNP) have elevated autoantigen-specific antibodies within their nasal polyps (NP). While increases in the prevalence and/or severity of both asthma and autoimmunity in women are well characterized, it is not known whether CRSwNP is more severe or frequent in women than men. We sought to determine whether CRSwNP demonstrated sex-specific differences in frequency and/or severity. Using a retrospectively collected database of tertiary care patients (n = 1393), we evaluated the distribution of sex in patients with CRSwNP with or without comorbid asthma or aspirin hypersensitivity. We further compared the severity of sinus disease between men and women with CRSwNP. Although women comprised 55% of CRS patients without NP (CRSsNP), a significantly smaller proportion of CRSwNP patients were female (38%, P < 0.001). Interestingly, women with CRSwNP were significantly more likely than men to have comorbid asthma (P < 0.001), and 61% of patients with the most severe form of disease (aspirin-exacerbated respiratory disease (CRSwNP plus asthma plus aspirin sensitivity)) were women (P < 0.05). Women with CRSwNP were significantly more likely to have taken oral steroids, and were more likely to have a history of revision surgeries (P < 0.05) compared to men. These data suggest that women with CRSwNP have more severe disease than men in a tertiary care setting. Future studies are needed to elucidate the mechanisms that drive disease severity in men and women, paving the way for the development of personalized treatment strategies for CRSwNP based on sex.
[Show abstract][Hide abstract] ABSTRACT: Objectives/HypothesisVarious intranasal landmarks have been described to aid in the localization of the natural sphenoid sinus ostium. The objectives of this study are to identify the ostium location relative to the skull base and assess the relationships between the location of the ostium and sphenoid disease or pneumatization pattern. DesignDescriptive study. Methods
Consecutive Xoran Mini-CAT (Ann Arbor, MI) scans of patients with no history of sinus surgery (n=202) were evaluated. The natural sphenoid ostium was identified in axial, coronal, and sagittal planes. Distances from the planum to the ostium and from the planum to the sinus floor were calculated. Lund-Mackay score and pneumatization pattern were recorded for each sphenoid sinus. ResultsThe mean distance from planum to ostium was 11.22.6 mm (range 4.4-19.2). On average, this encompassed 45.5%10% of the total sphenoid height. ANOVA with posthoc Tukey analysis revealed that the ostium was closer to the planum in sinuses with sellar (P=0.05) or presellar (P=0.02) pneumatization, compared to those with postsellar pneumatization. There was no significant relationship between the ostium location and degree of sinus disease. There was a significant difference in the pneumatization pattern between males and females (P=.04). More males had postsellar pneumatization than expected, and more females had sellar pneumatization than expected. Conclusions
The natural ostium of the sphenoid sinus is located at approximately the midpoint of the sphenoid face. Nevertheless, significant variability can be observed based on the pneumatization pattern. Surgeons should recognize that the ostium may be closer to the skull base when the sinus is less pneumatized. Level of Evidence4. Laryngoscope, 125:75-79, 2015
The Laryngoscope 01/2015; 125(1). DOI:10.1002/lary.24393 · 2.14 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objectives/HypothesisTo study the utilization of balloon catheter dilation (BCD) compared to traditional endoscopic sinus surgery (ESS) Study DesignCross-sectional analysis Methods
Cases identified by Current Procedural Terminology codes as BCD (2,717) or traditional ESS (31,059) were extracted from the State Ambulatory Surgery Databases 2011 for California, Florida, Maryland, and New York. Patient demographics, surgical center and surgeon volume, mean charge, and operating room (OR) time were compared. ResultsThere were 33,776 patients who underwent sinus surgery in the included states in 2011. Of these, 4.6% of maxillary, 5.6% of sphenoid, and 13.9% of frontal procedures were performed using BCD. Adjusted analyses found increased use of BCD in patients with chronic diseases(P<.001). Patients who had limited sinus surgery were less likely to have BCD compared to patients who had all four sinuses instrumented (P<.001). Surgeons who performed a medium (odds ratio 1.38 [1.14-1.65]) or high (odds ratio 1.71 [1.42-2.07]) volume of ESSs were more likely to use BCD compared to those who performed a low volume (P<.001). However, among surgeons who utilized BCD, there was a minimal relationship between the percentage of surgeries performed with BCD and the surgeon's total number of cases (R-2=0.055). Compared to traditional ESS, the median charges for maxillary/ethmoid procedures (mini-ESS) involving BCD were approximately $4,500 (P<.001) and maxillary/ethmoid/sphenoid/frontal procedures (pan-ESS) were approximately $2,950 (P=.003) greater, whereas the median OR time involving BCD was 8 minutes less for mini-ESS procedures(P=.01) but not statistically different for pan-ESS procedures (P=.58). Conclusions
In the study sample, balloon technology was used in 8.0% of ESS cases in 2011. Procedures using BCD were on average more expensive compared to traditional ESS procedures, with minimal decrease in OR time. Level of Evidence2c Laryngoscope, 125:49-56, 2015
The Laryngoscope 01/2015; 125(1). DOI:10.1002/lary.24901 · 2.14 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objectives/HypothesisTo systematically assess the prevalence of bacterial infection in adults with acute rhinosinusitis (ARS). Methods
Electronic databases were systematically searched for relevant studies published up to June 2012. ResultsTwenty-nine articles, evaluating a total of 9,595 patients with a clinical diagnosis of ARS, were included in the study. Of these, 14 (48%) studies required radiographic confirmation of sinusitis, one study (3%) required evidence of purulence, 10 studies (35%) required both for inclusion in the study population, and four studies (14%) required neither. The random effects model estimate of prevalence of bacterial growth on all cultures was 53.7% (CI 48.4%-59.0%), ranging from 52.5% (CI 46.7%-58.3%) in studies requiring radiographic confirmation of sinusitis to 61.1% (CI 54.0%-68.1%) in studies requiring neither radiographic evidence nor purulence on exam. Studies that obtained cultures from antral swab had a prevalence of bacterial growth of 61.0% (CI 54.7%-67.2%), whereas those utilizing endoscopic meatal sampling had a prevalence of 32.9% (CI 19.0%-46.8%). Conclusions
Few studies evaluate the recovery of bacteria via culture in adults with a diagnosis of ABRS or ARS based on clinical criteria alone. With radiographic and/or endoscopic confirmation, antral puncture and endoscopically guided cultures produce positive bacterial cultures in approximately one-half of patients. Opportunities exist to improve diagnostic accuracy for bacterial infection in ARS. Laryngoscope, 125:57-69, 2015
The Laryngoscope 01/2015; 125(1). DOI:10.1002/lary.24709 · 2.14 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Although chronic rhinosinusitis with nasal polyps (CRSwNP) is characterized by Th2 inflammation, the mechanism underlying the onset and amplification of this inflammation has not been fully elucidated. Dendritic cells (DCs) are major antigen presenting cells, central inducers of adaptive immunity and critical regulators of many inflammatory diseases. However, the presence of DCs in CRS, especially in nasal polyps (NPs), has not been extensively studied.
The objective of this study was to characterize DC subsets in CRS.
We used real-time PCR to assess the expression of mRNA for markers of myeloid DCs (mDCs; CD1c), plasmacytoid DCs (pDCs; CD303) and Langerhans cells (LCs; CD1a, CD207) in uncinate tissue (UT) from controls and patients with CRS as well as in NP. We assayed the presence of DCs by immunohistochemistry and flow cytometry.
Compared to UT from control subjects (n=15) and patients with CRS without NP (CRSsNP) (n=16) and CRSwNP (n=17), mRNAs for CD1a and CD1c were significantly elevated in NPs (n=29). In contrast, CD207 mRNA was not elevated in NPs. Immunohistochemistry showed that CD1c(+) cells but not CD303(+) cells were significantly elevated in NPs compared to control subjects or patients with CRSsNP. Flow cytometric analysis showed that CD1a(+) cells in NPs might be a subset of mDC1s, and that CD45(+) CD19(-) CD1c(+) CD11c(+) CD141(-) CD303(-) HLA-DR(+) mDC1s and CD45(+) CD19(-) CD11c(+) CD1c(-) CD141(high) mDC2s were significantly elevated in NPs compared to UT from controls and CRSsNP, but CD45(+) CD11c(-) CD303(+) HLA-DR(+) pDCs were only elevated in NPs compared to control UT.
Myeloid DCs are elevated in CRSwNP, especially in NPs. Myeloid DCs thus may indirectly contribute to the inflammation observed in CRSwNP. This article is protected by copyright. All rights reserved.
This article is protected by copyright. All rights reserved.
[Show abstract][Hide abstract] ABSTRACT: To discuss the current applications and indications for the use of pedicled flaps in the reconstruction of endoscopic skull base defects.
Current trends in endoscopic skull base surgery include the use of vascularized pedicled flaps rather than free tissue grafts (autograft or allograft) for the repair of anterior cranial base defects. In particular, recent evidence-based algorithms for skull base reconstruction suggest that use of pedicled flaps for clival defects and high-flow cerebrospinal fluid (CSF) leaks may reduce the incidence of postoperative CSF leaks. The primary workhorse continues to be the nasoseptal flap (NSF); however, other options exist in cases wherein this flap is unavailable because of prior sacrifice or unable to reach the area of interest (e.g., defects adjacent to the frontal recess).
Adoption of vascularized pedicled flaps over the last decade, particularly the recently popularized NSF, has greatly reduced complications associated with endoscopic skull base surgery. The need for vascularized flap reconstruction is governed primarily by defect size and location, and by the presence of a high-flow CSF leak. Additional vascularized flaps can be used in conjunction with the NSF, or as an alternative when the NSF is unfavorable or unavailable.
Current Opinion in Otolaryngology & Head and Neck Surgery 11/2014; 23(1). DOI:10.1097/MOO.0000000000000115 · 1.84 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objectives/HypothesisThe objective of this study was to report patients' knowledge and comfort level with computed tomography (CT) imaging for sinus disease and evaluate patient willingness to undergo empiric medical therapy (EMT) versus CT-directed therapy (CTDT).Study DesignProspective survey study.MethodsA 22-item survey was administered to patients with nasal/sinus symptoms in a tertiary care rhinology clinic. Questions elicited patient demographics, imaging history, and knowledge/comfort regarding imaging-related radiation exposure. Patients were presented with the theoretical choice of EMT versus CTDT, given the expected positive predictive value, in chronic rhinosinusitis (CRS) management.ResultsTwo hundred patients (52% female, age range 18–83 years) participated. Of these, 85% had symptoms for over 3 months. Only 91 patients (45.5%) were aware that CT imaging involved radiation exposure. Prior CT experience and past sinus surgery (P < .05), but not sex or education level, were associated with increased comfort with CT imaging. Most patients (78%) preferred CTDT over EMT. If a CT sinus was recommended, 77 patients (38.5%) had concerns, of which 26% identified radiation exposure as the leading concern. The majority (70%) were unsure about the relative radiation dose of a conventional CT.Conclusions
Patients with CRS symptoms prefer CTDT over EMT if a diagnosis cannot be established definitively using exam findings. Although most patients deferred to the physician regarding the decision to utilize CT imaging, there is low awareness of CT-related radiation exposure, and a significant minority of patients have radiation-related concerns with regard to medical imaging for nasal and sinus symptoms.Level of Evidence4. Laryngoscope, 2014
The Laryngoscope 10/2014; 125(4). DOI:10.1002/lary.24992 · 2.14 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Program Description: Failure of adequate response to endoscopic sinus surgery (ESS) is a frequent cause of frustration to chronic rhinosinusitis patients and their surgeons. Technical execution of ESS may be a factor in some common findings at revision ESS (middle meatal adhesions, lateralized middle turbinate, missed maxillary ostium, residual uncinate process, residual anterior and posterior ethmoid cells, sphenoid ostium stenosis, and frontal recess scarring). Using real-life demonstrative cases, our expert panel will share practical and key technical pearls on optimizing results from ESS. These include simple modifications in surgical techniques, selection of procedure appropriate to disease, and incorporation of state-of-the-art technology (endoscopes, instrumentation, navigation, etc).
Otolaryngology Head and Neck Surgery 09/2014; 151(1 Suppl):P26-P26. DOI:10.1177/0194599814538403a84 · 2.02 Impact Factor