Otolaryngologic Clinics of North America
Volume 43, Issue 1, Pages 111-121 (February 2010)
John H. Krouse, MD, PhDa, Kenneth W. Altman, MD, PhDb
Over the past 10 years, there has been increasing recognition of the interaction between the upper and lower airways in patients with a variety of infectious and inflammatory illnesses, including allergic rhinitis, rhinosinusitis, and asthma. Epidemiologic and mechanistic links have been proposed to demonstrate these relationships and to offer possible etiologic explanations to account for these observations. Among patients with upper respiratory illnesses, cough can be seen as a common symptom, both from the direct influences of upper airway inflammation, which incite reflex changes and bronchospasm, and from the exacerbation of associated pulmonary processes, such as asthma. Despite this increasing awareness of interaction between the upper and lower airways, the influence of both upstream and downstream respiratory inflammatory processes on laryngeal pathophysiology has not been extensively studied. Research suggests, however, that both direct stimulatory effects on the larynx and secondary effects of mucus production and mucus trafficking can create a range of laryngeal symptoms, including cough.
This review discusses the interaction of the upper and lower airway in respiratory disease, and focuses on the effect of these respiratory processes on laryngeal inflammation, function, and symptoms.
Monday, February 22, 2010
Saturday, February 20, 2010
Mastoid pneumocele with secondary pneumatocele causing external auditory canal obstruction and the influence of forced nose blowing.
Ear Nose Throat J. 2010 Jan;89(1):E3-5.Delabie G, Gordts F, Clement PA.
Department of Otorhinolaryngology, Head and Neck Surgery, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium.
We present a case involving a 36-year-old man who had a feeling that his right ear was obstructed and who had associated conductive hearing loss that was exacerbated by nose blowing. On otoscopy, a soft-tissue swelling was seen in the posterosuperior aspect of the right external auditory canal. Computed tomography revealed the presence of hyperaerated mastoid air cells and an air-containing cavity connected with the enlarged mastoid air cells, narrowing the external auditory canal. A radiographic diagnosis of a mastoid pneumocele with secondary pneumatocele was made. A novel hypothesis is presented, that high nasal pressures play an important role in the progressive formation of a pneumocele/pneumatocele as a result of air invasion via the eustachian tube. Symptoms disappeared after a myringotomy tube was placed. Computed tomography performed 6 months later showed an impressive remodeling of the temporal bone.
PMID: 20155688 [PubMed - in process]
Department of Otorhinolaryngology, Head and Neck Surgery, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium.
We present a case involving a 36-year-old man who had a feeling that his right ear was obstructed and who had associated conductive hearing loss that was exacerbated by nose blowing. On otoscopy, a soft-tissue swelling was seen in the posterosuperior aspect of the right external auditory canal. Computed tomography revealed the presence of hyperaerated mastoid air cells and an air-containing cavity connected with the enlarged mastoid air cells, narrowing the external auditory canal. A radiographic diagnosis of a mastoid pneumocele with secondary pneumatocele was made. A novel hypothesis is presented, that high nasal pressures play an important role in the progressive formation of a pneumocele/pneumatocele as a result of air invasion via the eustachian tube. Symptoms disappeared after a myringotomy tube was placed. Computed tomography performed 6 months later showed an impressive remodeling of the temporal bone.
PMID: 20155688 [PubMed - in process]
Nitric oxide formation in the oropharyngeal tract: possible influence of cigarette smoking
Nitric Oxide Volume 11, Issue 3, November 2004, Pages 247-255
H. Marteusa, A. Mavropoulosd, J.P. Palma, A.-K. Ulfgrenc, J. Bergströmb and K. Alvinga, ,
aDepartment of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
bDepartment of Odontology, Karolinska Institutet, Stockholm, Sweden
cRheumatology Research, Karolinska Hospital, Stockholm, Sweden
dDepartment of Odontology, Oslo University, Oslo, Norway
Received 17 February 2004; revised 31 August 2004. Available online 16 November 2004.
Abstract
Cigarette smoking reduces the level of nitric oxide (NO) in exhaled air by an unknown mechanism. The view that part of the effect of cigarette smoking on NO production should occur in the oropharyngeal tract is supported by several studies. We have therefore compared smokers and non-smokers regarding non-enzymatic formation of NO from nitrite in the oral cavity since this is a primary candidate target for cigarette smoke. We have also looked at NO synthase-dependent NO formation in the mucosa of the oropharyngeal tract as an alternative target for the inhibitory effect induced by cigarette smoke. Smokers exhaled 67% lower levels of NO than controls (p < 0.01, n = 15 each group). We could not detect any significant difference in salivary nitrite, nitrate or ascorbate between smokers and non-smokers. Mouthwash with the antibacterial agent chlorhexidine reduced salivary nitrite (−65%) and exhaled NO levels (−10%) similarly in the two groups. Immunohistochemical techniques revealed dense expression of inducible (but not endothelial or neuronal) NO synthase in the squamous epithelium of non-inflamed tonsillar and gingival tissue biopsies. In the same biopsies, significant Ca2+-independent citrulline-forming activity was detected. We found no difference between smoking and non-smoking subjects regarding NO-synthase expression and in vitro activity. In another group of non-smoking subjects (n = 10), spraying the oropharyngeal tract with the NO-synthase inhibitor NG-monomethyl-L-arginine (250 mg) significantly reduced exhaled NO levels for at least 30 min (−18%, p < 0.01). Our data suggest that cigarette smoking does not affect non-enzymatic NO formation from nitrite in saliva. However, NO is also formed by inducible NO synthase in the squamous epithelium of the normal oropharyngeal tract. We suggest that cigarette smoking may down-regulate enzymatic NO formation in the oropharyngeal compartment as well as in the bronchial compartment.
H. Marteusa, A. Mavropoulosd, J.P. Palma, A.-K. Ulfgrenc, J. Bergströmb and K. Alvinga, ,
aDepartment of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
bDepartment of Odontology, Karolinska Institutet, Stockholm, Sweden
cRheumatology Research, Karolinska Hospital, Stockholm, Sweden
dDepartment of Odontology, Oslo University, Oslo, Norway
Received 17 February 2004; revised 31 August 2004. Available online 16 November 2004.
Abstract
Cigarette smoking reduces the level of nitric oxide (NO) in exhaled air by an unknown mechanism. The view that part of the effect of cigarette smoking on NO production should occur in the oropharyngeal tract is supported by several studies. We have therefore compared smokers and non-smokers regarding non-enzymatic formation of NO from nitrite in the oral cavity since this is a primary candidate target for cigarette smoke. We have also looked at NO synthase-dependent NO formation in the mucosa of the oropharyngeal tract as an alternative target for the inhibitory effect induced by cigarette smoke. Smokers exhaled 67% lower levels of NO than controls (p < 0.01, n = 15 each group). We could not detect any significant difference in salivary nitrite, nitrate or ascorbate between smokers and non-smokers. Mouthwash with the antibacterial agent chlorhexidine reduced salivary nitrite (−65%) and exhaled NO levels (−10%) similarly in the two groups. Immunohistochemical techniques revealed dense expression of inducible (but not endothelial or neuronal) NO synthase in the squamous epithelium of non-inflamed tonsillar and gingival tissue biopsies. In the same biopsies, significant Ca2+-independent citrulline-forming activity was detected. We found no difference between smoking and non-smoking subjects regarding NO-synthase expression and in vitro activity. In another group of non-smoking subjects (n = 10), spraying the oropharyngeal tract with the NO-synthase inhibitor NG-monomethyl-L-arginine (250 mg) significantly reduced exhaled NO levels for at least 30 min (−18%, p < 0.01). Our data suggest that cigarette smoking does not affect non-enzymatic NO formation from nitrite in saliva. However, NO is also formed by inducible NO synthase in the squamous epithelium of the normal oropharyngeal tract. We suggest that cigarette smoking may down-regulate enzymatic NO formation in the oropharyngeal compartment as well as in the bronchial compartment.
Friday, February 19, 2010
Adverse Effects of Long-Term Proton Pump Inhibitor Use: A Review for the Otolaryngologist
Journal of Voice (Feb 2010) Chapman DB, Rees CJ, Lippert D, Sataloff RT, Wright SC;
OBJECTIVE: Proton pump inhibitors (PPIs) are the mainstay of current medical management for laryngopharyngeal reflux, and treatment often involves long-term use of this class of medications. The long-term adverse effects of PPI use have not been studied extensively, but several analyses have demonstrated epidemiological links between PPI use and adverse outcomes. These include altered mineral and vitamin absorption, orthopedic injury, acute coronary syndromes (ACS), and infectious risks.
STUDY DESIGN: A PubMed search was performed for subject headings, including PPIs and adverse outcomes. Relevant studies were included in this review. Studies were compiled, reviewed, and compared in a narrative form.
RESULTS: Several epidemiological links between PPI use and metabolic, infectious, cardiac, and orthopedic adverse outcomes were found. No definite causal effects were identified.
CONCLUSION: Given these epidemiological patterns, we recommend that the clinician be aware of these possible unintended consequences. In addition, we recommend consideration of dual-energy X-ray absorptiometry (DEXA) bone density scans in at-risk patients who have not been previously tested. We recommend consideration of vitamin B(12) and iron levels in selected patients who are at high risk. We also recommend close communication with our cardiology colleagues, as we attempt to ascertain the relationship between clopidogrel and PPI use. We recommend caution in the use of omeprazole in patients undergoing active treatment for ACS. Finally, we recommend consideration of Helicobacter pylori or serum gastrin level testing in patients with known risk factors for gastric carcinoma.
OBJECTIVE: Proton pump inhibitors (PPIs) are the mainstay of current medical management for laryngopharyngeal reflux, and treatment often involves long-term use of this class of medications. The long-term adverse effects of PPI use have not been studied extensively, but several analyses have demonstrated epidemiological links between PPI use and adverse outcomes. These include altered mineral and vitamin absorption, orthopedic injury, acute coronary syndromes (ACS), and infectious risks.
STUDY DESIGN: A PubMed search was performed for subject headings, including PPIs and adverse outcomes. Relevant studies were included in this review. Studies were compiled, reviewed, and compared in a narrative form.
RESULTS: Several epidemiological links between PPI use and metabolic, infectious, cardiac, and orthopedic adverse outcomes were found. No definite causal effects were identified.
CONCLUSION: Given these epidemiological patterns, we recommend that the clinician be aware of these possible unintended consequences. In addition, we recommend consideration of dual-energy X-ray absorptiometry (DEXA) bone density scans in at-risk patients who have not been previously tested. We recommend consideration of vitamin B(12) and iron levels in selected patients who are at high risk. We also recommend close communication with our cardiology colleagues, as we attempt to ascertain the relationship between clopidogrel and PPI use. We recommend caution in the use of omeprazole in patients undergoing active treatment for ACS. Finally, we recommend consideration of Helicobacter pylori or serum gastrin level testing in patients with known risk factors for gastric carcinoma.
Thursday, February 18, 2010
Subdural empyema complicating a concha bullosa pyocele
International Journal of Paediatric Otorhinolaryngology Volume 65, Issue 3, Pages 249-252 (24 September 2002)
Rémi Marianowskiab, Marcello Farragia, Michel Zerahc, Francis Brunelled, Yves Manacha
a Department of Pediatric Otorhinolaryngology, Hôpital Necker Enfants Malades, Paris, France
b Department of Otorhinolaryngology, Hôpital Morvan, 5 Avenue Foch, 29200 Brest, France
c Department of Pediatric Neurosurgery, Hôpital Necker Enfants Malades, Paris, France
d Department of Pediatric Radiology, Hôpital Necker Enfants Malades, Paris, France
Received 15 February 2002; received in revised form 22 May 2002; accepted 27 May 2002.
Abstract
Concha bullosa is the most common anatomic variant of the middle turbinate and remains usually asymptomatic. We report a case of concha bullosa pyocele with a subdural empyema in a 11-year-old girl presenting with a subcutaneous tumefaction without neurologic deficit. Computed tomography and magnetic resonance imaging confirmed a subdural empyema communicating with subcutaneous effusion and the presence of a concha bullosa pyocele being responsible for the obstruction of ostiomeatal complex leading to frontal sinusitis. Resection of the middle turbinate with a middle meatotomy and a frontal skin incision combined with an adequate antibiotic treatment allowed this child to recover within 6 weeks.
Rémi Marianowskiab, Marcello Farragia, Michel Zerahc, Francis Brunelled, Yves Manacha
a Department of Pediatric Otorhinolaryngology, Hôpital Necker Enfants Malades, Paris, France
b Department of Otorhinolaryngology, Hôpital Morvan, 5 Avenue Foch, 29200 Brest, France
c Department of Pediatric Neurosurgery, Hôpital Necker Enfants Malades, Paris, France
d Department of Pediatric Radiology, Hôpital Necker Enfants Malades, Paris, France
Received 15 February 2002; received in revised form 22 May 2002; accepted 27 May 2002.
Abstract
Concha bullosa is the most common anatomic variant of the middle turbinate and remains usually asymptomatic. We report a case of concha bullosa pyocele with a subdural empyema in a 11-year-old girl presenting with a subcutaneous tumefaction without neurologic deficit. Computed tomography and magnetic resonance imaging confirmed a subdural empyema communicating with subcutaneous effusion and the presence of a concha bullosa pyocele being responsible for the obstruction of ostiomeatal complex leading to frontal sinusitis. Resection of the middle turbinate with a middle meatotomy and a frontal skin incision combined with an adequate antibiotic treatment allowed this child to recover within 6 weeks.
Friday, February 12, 2010
Rhinitis medicamentosa: electron microscopic changes of human nasal mucosa
Otolaryngol Head Neck Surg. 2007 Jan;136(1):57-61.
Knipping S, Holzhausen HJ, Goetze G, Riederer A, Bloching MB.
Department of Otorhinolaryngology-Head and Neck Surgery, The Martin Luther University Halle Wittenberg, Germany. stephan.knipping@medizin.uni-halle.de
OBJECTIVE: Prolonged application of nasal vasoconstrictors causes rhinitis medicamentosa (RM). Nasal obstruction is induced by rebound swelling when the decongestive effect has disappeared. The aim of this study was to demonstrate ultrastructural changes in RM.
STUDY DESIGN AND SETTING: Tissue samples of inferior turbinates from 22 patients with RM and 10 patients without rhinitis were taken during nasal surgery. Ultrathin sections were investigated by using a transmission electron microscope (TEM).
RESULTS: The TEM findings revealed severe epithelial damages such as loss of ciliated cells. In the subepithelial region, the vascular endothelium showed gaps and ruptures of basal lamina.
CONCLUSION: RM is a drug-induced damage of human nasal mucosa. Loss and destruction of ciliated epithelial cells are the morphologic correlation of the disturbed mucociliary clearance. In addition, vascular endothelium revealed ultrastructural changes. This could be caused by an increased vascular permeability with consecutive interstitial edema.
SIGNIFICANCE: This study demonstrated new morphological aspects of rhinitis medicamentosa.
PMID: 17210334 [PubMed - indexed for MEDLINE]
Knipping S, Holzhausen HJ, Goetze G, Riederer A, Bloching MB.
Department of Otorhinolaryngology-Head and Neck Surgery, The Martin Luther University Halle Wittenberg, Germany. stephan.knipping@medizin.uni-halle.de
OBJECTIVE: Prolonged application of nasal vasoconstrictors causes rhinitis medicamentosa (RM). Nasal obstruction is induced by rebound swelling when the decongestive effect has disappeared. The aim of this study was to demonstrate ultrastructural changes in RM.
STUDY DESIGN AND SETTING: Tissue samples of inferior turbinates from 22 patients with RM and 10 patients without rhinitis were taken during nasal surgery. Ultrathin sections were investigated by using a transmission electron microscope (TEM).
RESULTS: The TEM findings revealed severe epithelial damages such as loss of ciliated cells. In the subepithelial region, the vascular endothelium showed gaps and ruptures of basal lamina.
CONCLUSION: RM is a drug-induced damage of human nasal mucosa. Loss and destruction of ciliated epithelial cells are the morphologic correlation of the disturbed mucociliary clearance. In addition, vascular endothelium revealed ultrastructural changes. This could be caused by an increased vascular permeability with consecutive interstitial edema.
SIGNIFICANCE: This study demonstrated new morphological aspects of rhinitis medicamentosa.
PMID: 17210334 [PubMed - indexed for MEDLINE]
Rhinitis: a complication to asthma
Allergy (Jan 2010)
Hansen JW, Nolte H, Backer V, Thomsen SF
Abstract
Background: Asthma and rhinitis often co-occur, and this potentially increases the disease severity and impacts negatively on the quality of life. We studied disease severity, airway responsiveness, atopy, quality of life and treatment in subjects with both asthma and rhinitis compared to patients with asthma or rhinitis alone.
Methods: We examined 878 patients: 182 with asthma, 362 with rhinitis and 334 with both asthma and rhinitis. All had a clinical interview concerning severity of symptoms, treatment, and quality of life, a skin prick test, a lung function test and a bronchial provocation with methacholine.
Results: Patients with both asthma and rhinitis had less severe asthma based on the frequency of respiratory symptoms compared to patients with asthma alone (55%vs 66%P = 0.01). On the contrary, they were more airway responsive (P<0.05) and had more perennial allergy (P<0.001). Asthmatics had poor perception of the general health, independent of rhinitis (P<0.001). No differences were found in asthma-specific quality of life, whereas rhinitis-specific quality of life was worse in those with both asthma and rhinitis compared to those with rhinitis alone (P<0.01). Subjects with both diseases were undertreated in 85% of the cases.
Conclusion: We encourage that these observations be used in the evaluation and treatment of patients with asthma and rhinitis and that they contribute to the understanding of asthma and rhinitis as a uniform airways disease.
Hansen JW, Nolte H, Backer V, Thomsen SF
Abstract
Background: Asthma and rhinitis often co-occur, and this potentially increases the disease severity and impacts negatively on the quality of life. We studied disease severity, airway responsiveness, atopy, quality of life and treatment in subjects with both asthma and rhinitis compared to patients with asthma or rhinitis alone.
Methods: We examined 878 patients: 182 with asthma, 362 with rhinitis and 334 with both asthma and rhinitis. All had a clinical interview concerning severity of symptoms, treatment, and quality of life, a skin prick test, a lung function test and a bronchial provocation with methacholine.
Results: Patients with both asthma and rhinitis had less severe asthma based on the frequency of respiratory symptoms compared to patients with asthma alone (55%vs 66%P = 0.01). On the contrary, they were more airway responsive (P<0.05) and had more perennial allergy (P<0.001). Asthmatics had poor perception of the general health, independent of rhinitis (P<0.001). No differences were found in asthma-specific quality of life, whereas rhinitis-specific quality of life was worse in those with both asthma and rhinitis compared to those with rhinitis alone (P<0.01). Subjects with both diseases were undertreated in 85% of the cases.
Conclusion: We encourage that these observations be used in the evaluation and treatment of patients with asthma and rhinitis and that they contribute to the understanding of asthma and rhinitis as a uniform airways disease.
An assessment of sinonasal anatomic variants potentially associated with recurrent acute rhinosinusitis
The Laryngoscope (Feb 2010)
Alkire BC, Bhattacharyya N;
OBJECTIVES/HYPOTHESIS:: To examine sinonasal anatomic variants that may predispose toward recurrent acute rhinosinusitis (RARS).
STUDY DESIGN:: Retrospective case-control.
METHODS:: Sinus computed tomography (CT) scans from a consecutive series of adult patients meeting strict diagnostic criteria for RARS were retrospectively reviewed. A control group was assembled from patients who underwent pituitary or temporal bone CT for a nonrhinosinusitis indication. CT scans were scored for the presence of Haller cells, concha bullosa, and impinging septal spurs. Maximal septal deviation (degrees), infundibular widths, and Lund staging were also assessed. The prevalence of these anatomic variants was statistically compared between the RARS and control groups.
RESULTS:: Thirty-six patients met diagnostic criteria for RARS (mean age, 47.2 years; 2:1 female preponderance); 42 control patients were identified. The mean Lund score for patients with RARS was 2.25 versus 1.27 for the control group (P<.001). Although RARS patients were more likely to manifest concha bullosa (41.7% vs. 28.6%) or impinging septal spurs (27.8% vs. 19.0%), these differences were not statistically significant (P = .165 and P = .260, respectively). However, patients with RARS were significantly more likely to radiographically demonstrate Haller cells (39.9% vs. 11.9%, respectively, P = .006). Finally, patients with RARS had significantly smaller mean infundibular widths when compared with control patients (0.591 mm vs. 0.823 mm, respectively, P<.001).
CONCLUSIONS:: The presence of Haller cells and smaller infundibular widths were statistically associated with RARS when compared to control patients. Our data suggest that anatomy could play a role in the pathogenesis of RARS. Further prospective study is warranted. Laryngoscope, 2010.
Alkire BC, Bhattacharyya N;
OBJECTIVES/HYPOTHESIS:: To examine sinonasal anatomic variants that may predispose toward recurrent acute rhinosinusitis (RARS).
STUDY DESIGN:: Retrospective case-control.
METHODS:: Sinus computed tomography (CT) scans from a consecutive series of adult patients meeting strict diagnostic criteria for RARS were retrospectively reviewed. A control group was assembled from patients who underwent pituitary or temporal bone CT for a nonrhinosinusitis indication. CT scans were scored for the presence of Haller cells, concha bullosa, and impinging septal spurs. Maximal septal deviation (degrees), infundibular widths, and Lund staging were also assessed. The prevalence of these anatomic variants was statistically compared between the RARS and control groups.
RESULTS:: Thirty-six patients met diagnostic criteria for RARS (mean age, 47.2 years; 2:1 female preponderance); 42 control patients were identified. The mean Lund score for patients with RARS was 2.25 versus 1.27 for the control group (P<.001). Although RARS patients were more likely to manifest concha bullosa (41.7% vs. 28.6%) or impinging septal spurs (27.8% vs. 19.0%), these differences were not statistically significant (P = .165 and P = .260, respectively). However, patients with RARS were significantly more likely to radiographically demonstrate Haller cells (39.9% vs. 11.9%, respectively, P = .006). Finally, patients with RARS had significantly smaller mean infundibular widths when compared with control patients (0.591 mm vs. 0.823 mm, respectively, P<.001).
CONCLUSIONS:: The presence of Haller cells and smaller infundibular widths were statistically associated with RARS when compared to control patients. Our data suggest that anatomy could play a role in the pathogenesis of RARS. Further prospective study is warranted. Laryngoscope, 2010.
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