Background Commonly used computed tomography (CT) staging systems for chronic rhinosinusitis (CRS) focus on the sinuses and do not quantify disease in the olfactory cleft. The goal of the current study was to determine whether precise measurements of olfactory cleft opacification better correlate with olfaction in patients with CRS. Methods Olfaction was assessed using the 40-item Smell Identification Test (SIT-40) before and after sinus surgery in adult patients. Olfactory cleft opacification was quantified precisely using three-dimensional, computerized volumetric analysis, as well as via a semi-quantitative Likert scale estimations at predetermined anatomic sites. Sinus opacification was also quantified using the Lund-Mackay staging system. Results The overall cohort (n=199) included 89 (44.7%) patients with CRS with nasal polyposis (CRSwNP) and 110 (55.3%) with CRS without nasal polyposis (CRSsNP). The olfactory cleft opacified volume correlated with objective olfaction as determined by the SIT-40 (Rs= −0.461; p<0.001). The correlation was significantly stronger in the CRSwNP subgroup (Rs= −0.573; p<0.001), whereas no appreciable correlation was found in the CRSsNP group (Rs= −0.141; p=0.141). Correlations between sinus-specific Lund-Mackay CT scoring and SIT-40 scores were weaker in the CRSwNP (Rs= −0.377; p<0.001) subgroup but stronger in the CRSsNP (Rs= −0.225; p=0.018) group when compared to olfactory cleft correlations. Greater intra-class correlations (ICC) were found between quantitative volumetric measures of olfactory cleft opacification (ICC=0.844; p<0.001) as compared with semi-quantitative Likert grading (ICC=0.627; p<0.001). Conclusions Quantitative measures of olfactory cleft opacification correlate with objective olfaction, with the strongest correlations seen in patients with nasal polyps.
BACKGROUND Abnormal olfaction is common with chronic rhinosinusitis (CRS) and associates with various measures of sinonasal inflammation. The Brief Smell Identification Test (BSIT) has demonstrated improvements in abnormal olfactory detection following endoscopic sinus surgery (ESS), but olfaction remains understudied using this instrument. Discerning longitudinal, postoperative durability in olfaction is critical for patient counseling. METHODS Adult participants with medically recalcitrant CRS were prospectively enrolled into a multi-institutional cohort study and observed for 18-months following ESS. Olfaction was operationalized using BSIT scores collected at baseline, 6-months, 12-months, and 18-months postoperatively and compared using repeated measures ANOVA. RESULTS 122 participants met inclusion criteria and were recruited between March, 2011 and February, 2014. Improvement in mean BSIT scores at 6-month follow-up were reported for all participants (p=0.014) with greatest improvement in subjects with nasal polyposis (p=0.001). No differences in mean BSIT scores were found between 6-month and 18-months overall, however subjects with comorbid asthma (F(2)=5.29; p=0.010) and nasal polyposis (F(2)=3.99; p=0.033) reported significant mean worsening. Prevalence of abnormal olfaction decreased from 28% preoperatively to 17% at 6-months (p=0.015), for all subjects, without significant change 12-months (19%; p=0.791) or 18-months (21%; p=0.581) postoperatively. CONCLUSIONS Postoperative improvement in olfaction was reported 6-months after ESS using BSIT scores, with greatest improvements in patients undergoing polypectomy. Overall improvement persisted between 6-month and 18-month following ESS for most patient subgroups, however, dysosmia worsened after initial improvement in patients with asthma and nasal polyps, highlighting the need for further identification of prognostic factors associated with abnormal olfaction in CRS.
AFRS and CRSwNP have increased numbers of DCs displaying costimulatory molecules, DC chemoattractants, and their corresponding receptors in the sinus mucosa compared to controls. These differences represent a possible mechanism for increased numbers of DCs with a T helper 2 (Th2)-skewed profile seen in CRSwNP and AFRS.
Background The immunopathogenesis of chronic rhinosinusitis (CRS) is largely unknown, but it is thought that different inflammatory profiles are responsible for the different CRS subtypes. 25-hydroxyvitamin-D (25-VD3) has been shown to alter inflammatory mediators in other disease processes and 25VD3 deficiency is associated with CRS with nasal polyps (CRSwNP), but it is unknown if 25VD3 levels impacts local inflammation in CRS. This study investigated the correlation between plasma 25-VD3 and sinonasal mucus MCP-1, RANTES and bFGF levels in patients with CRS. Methods Study subjects undergoing endoscopic sinus surgery (ESS) for CRS were prospectively enrolled from January 2012-August 2014. Control subjects included patients undergoing ESS for non-inflammatory pathology. Blood and sinonasal mucus were collected at the time of ESS. Plasma 25-VD3 was measured by ELISA and mucus levels of MCP-1, RANTES, and bFGF by cytometric bead array (CBA). Results A total of 57 patients were enrolled and categorized as CRS without nasal polyps (CRSsNP) (n=31), CRSwNP (n=14) and controls (n=12). No significant correlation was found between MCP-1 and 25-VD3. There was a significant negative correlation between 25-VD3 and RANTES (r= −0.612; p=0.026) and bFGF (r= −0.578; p=0.039) in CRSwNP patients; however, there was no significant correlation in CRSsNP patients. Conclusion This data suggests that 25-VD3 may play a role in regulation of RANTES and bFGF expression in CRSwNP. This may occur through regulation of nasal polyp fibroblasts or other immune cells. Further investigation is warranted to better elucidate the role of RANTES, bFGF and 25-VD3 in CRSwNP.
ROS are differentially expressed in various subtypes of CRS. SHS exposure increases ROS in sinus tissue of control patients, but the clinical significance of this is unclear.
Objective: We present two patients with recurrent, metastatic head and neck squamous cell carcinoma (R/M HNSCC) after platinum-based chemotherapy and radiotherapy (RT) with complete response via abscopal effect following combined immunotherapy (IT) and stereotactic body radiation therapy (SBRT). We review the literature for patients undergoing combined treatment with IT and RT to identify potential cases of abscopal response. Study Design: This is a case series with a contemporary review of the literature. Methods: Retrospective chart review identified two patients with potential abscopal responses after IT and RT for R/M HNSCC. The MEDLINE database was queried using the search terms “abscopal AND head and neck squamous cell carcinoma” and “immunotherapy AND stereotactic body radiation therapy.” Results: Two patients with metastatic HNSCC developed complete responses via a possible abscopal effect following combined SBRT and IT. Interim follow-up of both patients revealed a sustained, complete response. We examine the immunogenic effects of RT and report the first cases of potential abscopal effect for R/M HNSCC. We also review several preclinical studies demonstrating the synergistic efficacy of combined RT and IT with a discussion of possible mechanism. Conclusion: Observation of abscopal effect with combined IT and RT is currently under investigation through several preclinical studies and trials. To the best of our knowledge, these are the first two reported cases of abscopal effect for patients with HNSCC. We report two patients with R/M HNSCC with sustained, complete response after systemic IT and local RT.
Background Nasal irrigation is a significant component of effective medical management in patients with chronic rhinosinusitis (CRS). Irrigations facilitate distribution of topical medical therapies to affected mucosal surfaces and lavage of hypersecretory mucin and inflammatory products. Objective To compare the effectiveness of cadaveric nasal irrigation distribution and force following different surgical techniques commonly used to open the maxillary sinus. Methods Fresh human cadaver heads were dissected sequentially with uncinectomy, maxillary antrostomy, endoscopic maxillary mega-antrostomy, and modified endoscopic medial maxillectomy. After each surgical technique was performed, the corresponding nasal cavity was irrigated with 240 mL irrigation bottles containing 1/1000 10% fluroscein-labeled free water. A nasal endoscope passed through the canine fossa into a fixed position in the maxillary sinus recorded the extent of sinus irrigation. These videos then underwent blinded assessment by 2 observers assessing for irrigation sinus penetration (scored as 0–4) and force (0–2). Ordinal correlation scores were assessed using Kendall’s tau-B. Results A total of 17 sinuses (age 53.4 ± 12.6, 36.4% female) were assessed. There was a statistically significant positive correlation between increasing extent of maxillary sinus dissection and both sinus penetration and force as assessed by both observers (Kendall’s tau-B P < .0001). Conclusion Increasing the extent of surgical dissection appears to improve penetration and force of the nasal irrigation into the maxillary sinus. This study suggests that while a standard maxillary antrostomy may be sufficient to achieve good topical therapy distribution, more extensive surgery such as a modified medial maxillectomy may be required for sufficient force of sinus lavage.
The incidence of oropharyngeal squamous cell carcinoma (OPSCC) is increasing in the USA despite a decline in traditional risk factors. This trend is attributed to human papillomavirus (HPV)-associated malignancies and is particularly notable in a younger patient demographic with fewer comorbid diseases and longer life expectancies. Therefore, both oncologic and functional outcomes are important to consider when managing OPSCC in the modern era. The historical management of OPSCC was typically surgical, but traditional open approaches resulted in significant morbidity. As the paradigm shifted, organ-preserving treatment regimens, namely, radiotherapy (RT) and chemoradiation (CRT), replaced surgery as the primary treatment modality. However, these treatment strategies are not without risk of significant sequelae and functional impairment. Transoral robotic surgery (TORS) is a minimally invasive surgical approach that offers surgical access to the oropharynx without the morbidity of open procedures while achieving excellent oncologic and functional outcomes. The appropriate application of this new technology is still being investigated but the current literature supports TORS as a viable option in the management of OPSCC.
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