- Email: [email protected]
Diminished levels of S100 proteins in chronic rhinosinusitis
Depression and quality of life in chronic rhinosinusitis Jamie R Litvack, MD, MS (presenter); Timothy Smith, MD, MPH; Jess Collin Mace, MPH; Kenneth James OBJECTIVES: 1) To objectively measure the prevalence of depression in patients with chronic rhinosinusitis (CRS). 2) To evaluate the impact of depression on patients quality-of-life (QoL) and disease-severity. METHODS: In this prospective cohort study, the Patient Health Questionnaire-9 (PHQ-9), a screening instrument for depressive disorders and a measure of depression severity, was administered to 73 patients with CRS. Scores ⬎ or ⫽ 10 on the PHQ-9 with depressed mood and/or anhedonia more than half the days in the past two weeks were deemed positive. Computed tomography scan, endoscopy exam, disease-specific quality-of-life (QoL) and general QoL (Medical Short-Form 36) were collected. Differences in scores were analyzed using the Mann-Whitney U test, independent t-test, and chi-squared test. RESULTS: Only 9.6% of patients reported a history of depression. However, 20.5% of patients with CRS scored within the range of a major depressive disorder (mean score 14.8 (SD 3.4)). Prevalence was similar in men and women (20.9% vs 20.0%; p⫽0.92). Disease-specific QoL was worse in patients with depressive symptoms (Rhinosinusitis Disability Index total score: 62.7 (SD 18.2) vs 45.3 (SD 16.3); p⫽0.001). Seven of eight measures of general QoL were significantly worse in patients with depression, including bodily pain (p⫽ 0.001), physical function (p⫽ 0.009), and social function (p⫽ 0.001). CONCLUSIONS: Depression was common and under-reported in patients with CRS. Depressed patients reported worse disease-specific and general QoL than other CRS patients. In contrast to previous studies, depression was equally common in men and women. Development of an animal model for sinus wound healing Kristina Tansavatdi, MD (presenter); Richard Orlandi, MD; Sterling Riggs, MD; Lawrence McGill, DVM, PhD OBJECTIVES: 1) To establish a model for sinonasal wounding in chronically inflamed mice and compare the histologic characteristics of wounded normal and inflamed sinonasal mucosa. 2) To compare mediators of inflammation in wounded normal and inflamed sinonasal mucosa. METHODS: Exploratory controlled study in which chronic eosinophilic nasal and sinus inflammation was established in mice. Two groups of mice were then examined to study histologic characteristics and the other to study gene expression in inflamed and uninflamed animals. In both groups, inflamed and uninflamed mice were wounded and sacrificed at day
P111 three, seven, and 14 after wounding. Unwounded mice were sacrificed at day zero and served as controls. The presence and degree of inflammation were assayed by light microscopic examination and sections were scored by two blinded pathologists. PCR analysis of several mediators of inflammation was performed as well. RESULTS: In unwounded mice, higher histologic inflammatory scores were found in inflamed mice over uninflamed mice and this difference persisted after wounding. Gene expression analysis revealed statistically significant differences in gene expression for TGF-1b, IGF-1, MMP-7, MMP-9, TIMP-1, and PTGER4 prior to wounding. These changes persisted only for IGF-1, TIMP-1, and MMP-9 following wounding. MMP-9 levels were decreased in inflamed animals compared to uninflamed animals. CONCLUSIONS: We successfully constructed a model in which wound healing in a setting of chronic eosinophilic inflammation can be studied. In this exploratory pilot we demonstrated differences in the inflammatory response after wounding in some of the proteins studied. Diminished levels of S100 proteins in chronic rhinosinusitis David Tieu, MD (presenter); Rakesh Chandra, MD; Robert Scheimer; Robert Kern, MD; Anju Peters, MD; David Conley, MD; Derek Carter OBJECTIVES: Decreased mRNA expression of S100A7, S100A8, and S100A9 have been reported in CRS. Since these proteins are involved in both host defense and barrier maintenance, we assessed whether there might be a pathogenetic role of diminished S100 proteins in CRS. We determined levels of S100 proteins in nasal lavage and sinonasal tissue extracts from CRS patients using ELISA and immunohistochemistry. METHODS: Tissue extracts and nasal lavages were obtained from three groups: normal (n⫽13), CRSsNP (n⫽14), and CRSwNP (n⫽12). Concentrations of each S100 protein were determined using ELISA. Tissue expression of each protein was confirmed using immunohistochemical analysis of nasal polyp tissue from CRSwNP patients and uncinate tissue from all three groups. RESULTS: Expression levels of all three S100 proteins were decreased in nasal lavage fluids from both CRS groups (p ⬍ 0.05). Similarly, expression of these proteins assessed by immunohistochemistry demonstrated clear reductions in epithelium, both mucosal and glandular. Interestingly, levels of S100A8/A9 were increased in nasal polyp tissue despite lower levels in lavage fluid. Levels of S100A8/A9 in nasal tissues were correlated with levels of neutrophils as assessed by quantitation of neutrophil elastase. CONCLUSIONS: Members of the S100 proteins have previously been implicated in various allergic and inflammatory diseases in the skin and lungs. We demonstrate significant
ORALS
Program Oral Presentations
P112
Otolaryngology-Head and Neck Surgery, Vol 141, No 3S1, September 2009
decreases in S100 proteins in CRS epithelium which may lead to diminished innate immune response and barrier function. Increased levels of S100A8/A9 in nasal polyp tissue may reflect neutrophil recruitment and a compensatory mechanism. Future studies will be important to determine whether reduced levels of S100 proteins lead to either decreased antimicrobial responses or defects in barrier function and whether reduced S100 proteins plays an etiologic role in CRS pathogenesis and susceptibility to infectious disease. Endoscopic embolization and resection of JNA: A new approach Michael Bublik, MD (presenter); Jose Ruiz, MD; Bjorn Herman, MD; Ramzi Tamer Younis, MD OBJECTIVES: 1) To report the first cases of endoscopic embolization (EE) of juvenile nasopharyngeal angiofibroma (JNA). 2) Demonstrate the procedure through video and 3D imagery. 3) Describe all outcomes and results. METHODS: Four patients presented to a tertiary care academic medical center with repeated episodes of unilateral epistaxis diagnosed with fiberoptic and radiographic examination as nasal JNA. Subsequently, in conjunction with neurosurgery, endoscopic visualization was provided to perform intratumor needle insertion, through which the liquid embolic agent Onyx was infused to embolize the JNAs under fluoroscopic guidance. The day after EE, endoscopic resection was performed. Operating room time, estimated blood loss (EBL), and other intraoperative and postoperative results are reported and compared to published literature. RESULTS: A total of four patients (all males), had EE of JNA and subsequent endoscopic resection. Average EBL during surgery was 412.5 milliliters (range 150-800) with an average operating room time of 228 minutes (range 95-485). We experienced no bleeding from the tumor or its attachments, only from the approach. Two patients experienced mild numbness in the V2 distribution, which began to resolve one week postoperatively. No other complications were encountered. CONCLUSIONS: This is the first published report of direct endoscopic embolization of JNA. Although further studies are needed, it seems to provide a safe, less invasive alternative to traditional embolization and endoscopic resection, but must be done in cooperation with interventional neurosurgery to maximize its safety profile. Endoscopic training with sino-nasal and skull-base model Joao F Nogueira, MD (presenter); Aldo Stamm, MD, PhD; Maria Silva, MD; Fabio Santos, MD; Thiago Souza, MD OBJECTIVES: Show the development of an endoscopic nasal and skull-base surgery model, discuss the effectiveness in
anatomical knowledge gain, and present major advantages and disadvantages. METHODS: Prospective study with the development of models used by 10 otolaryngologists divided into three groups according to levels of experience. Scores were requested for consistency, tissue color, and identification of anatomical structures. The results were compared and analyzed statistically. RESULTS: The mean score assigned by participants for consistency was 3,2, for a maximum of 4. For the color the overall average was 3,6 (maximum 4). The mean score for identification of anatomical structures was 9,4 (maximum 10). CONCLUSIONS: We presented an endoscopic nasal surgery model, showing the steps of development. 70% of participants reported improvement in anatomical knowledge. The advantages are: Use of instruments similar to the real and no involved biological hazards. The disadvantage was the single dissection at the nasal lateral wall. Epistaxis: Prospective study of merocoele vs rapidrhino Sunil H Vyas, MBChB (presenter) OBJECTIVES: To assess: 1) The efectiveness of merocoele and rapidrhino packs in controlling aterior epistaxis. 2) Associatd patient discomfort. METHODS: 112 patients with anterior epistaxis which failed to respond to silver nitrate cautery were randomised into two groups: Group A (52), packed with merocoele, and group B (60), with rapid-rhino packs. Nasal lidocaine was applied before packing and patient discomfort was assessed, via a Visual Analogu Score (VAS, 0-5, where 5 is the worst pain). Patients that continued to bleed, requiring further treatment, were excluded from the study. Packs were left in for 24-30 hours and patients monitored in the ward. After removal of the packs, discomfort was further assessed using the VAS. Difficulty of insertion (DI, 0-5 scale) of packs, were also assessed. RESULTS: VAS at insertion: Group A (52): 0-2 (12/52, 23.1%). Above 2-3 (34/52, 65.4%). Above 3-5 (6/52, 11.5%). Group B (60): 0-2 (15/60, 25.0%). Above 2-3 (37/60, 61.7%). Above 3-5 (8/60, 13.3%). VAS at removal: Group A (50): 0-2 (40/50, 80.0%). Above 2-3 (8/50, 16.0%). Above 3-5 (2/50, 4.0%). Group B (57): 0-2 (40/57, 70.2%). Above 2-3 (10/57, 17.5%). Above 3-5 (7/57, 12.3%). For DI: Group A (52): 0-2(41/52, 78.9%). Above 2-3 (9/52, 17.3%). Above 3-5 (2/52, 3.8%). Group B (60): 0-2(45/60, 75.0%). Above 2-3 (11/60, 18.3%). Above 3-5 (4/60, 6.7%). Over a 3-month period, there are no significant differences in recurrence rates of epistaxis. CONCLUSIONS: Both merocoele and rapidrhino packs are effective in controlling anterior epistaxis, without any significant differences in patient discomfort, during insertion or removal.
P111 three, seven, and 14 after wounding. Unwounded mice were sacrificed at day zero and served as controls. The presence and degree of inflammation were assayed by light microscopic examination and sections were scored by two blinded pathologists. PCR analysis of several mediators of inflammation was performed as well. RESULTS: In unwounded mice, higher histologic inflammatory scores were found in inflamed mice over uninflamed mice and this difference persisted after wounding. Gene expression analysis revealed statistically significant differences in gene expression for TGF-1b, IGF-1, MMP-7, MMP-9, TIMP-1, and PTGER4 prior to wounding. These changes persisted only for IGF-1, TIMP-1, and MMP-9 following wounding. MMP-9 levels were decreased in inflamed animals compared to uninflamed animals. CONCLUSIONS: We successfully constructed a model in which wound healing in a setting of chronic eosinophilic inflammation can be studied. In this exploratory pilot we demonstrated differences in the inflammatory response after wounding in some of the proteins studied. Diminished levels of S100 proteins in chronic rhinosinusitis David Tieu, MD (presenter); Rakesh Chandra, MD; Robert Scheimer; Robert Kern, MD; Anju Peters, MD; David Conley, MD; Derek Carter OBJECTIVES: Decreased mRNA expression of S100A7, S100A8, and S100A9 have been reported in CRS. Since these proteins are involved in both host defense and barrier maintenance, we assessed whether there might be a pathogenetic role of diminished S100 proteins in CRS. We determined levels of S100 proteins in nasal lavage and sinonasal tissue extracts from CRS patients using ELISA and immunohistochemistry. METHODS: Tissue extracts and nasal lavages were obtained from three groups: normal (n⫽13), CRSsNP (n⫽14), and CRSwNP (n⫽12). Concentrations of each S100 protein were determined using ELISA. Tissue expression of each protein was confirmed using immunohistochemical analysis of nasal polyp tissue from CRSwNP patients and uncinate tissue from all three groups. RESULTS: Expression levels of all three S100 proteins were decreased in nasal lavage fluids from both CRS groups (p ⬍ 0.05). Similarly, expression of these proteins assessed by immunohistochemistry demonstrated clear reductions in epithelium, both mucosal and glandular. Interestingly, levels of S100A8/A9 were increased in nasal polyp tissue despite lower levels in lavage fluid. Levels of S100A8/A9 in nasal tissues were correlated with levels of neutrophils as assessed by quantitation of neutrophil elastase. CONCLUSIONS: Members of the S100 proteins have previously been implicated in various allergic and inflammatory diseases in the skin and lungs. We demonstrate significant
ORALS
Program Oral Presentations
P112
Otolaryngology-Head and Neck Surgery, Vol 141, No 3S1, September 2009
decreases in S100 proteins in CRS epithelium which may lead to diminished innate immune response and barrier function. Increased levels of S100A8/A9 in nasal polyp tissue may reflect neutrophil recruitment and a compensatory mechanism. Future studies will be important to determine whether reduced levels of S100 proteins lead to either decreased antimicrobial responses or defects in barrier function and whether reduced S100 proteins plays an etiologic role in CRS pathogenesis and susceptibility to infectious disease. Endoscopic embolization and resection of JNA: A new approach Michael Bublik, MD (presenter); Jose Ruiz, MD; Bjorn Herman, MD; Ramzi Tamer Younis, MD OBJECTIVES: 1) To report the first cases of endoscopic embolization (EE) of juvenile nasopharyngeal angiofibroma (JNA). 2) Demonstrate the procedure through video and 3D imagery. 3) Describe all outcomes and results. METHODS: Four patients presented to a tertiary care academic medical center with repeated episodes of unilateral epistaxis diagnosed with fiberoptic and radiographic examination as nasal JNA. Subsequently, in conjunction with neurosurgery, endoscopic visualization was provided to perform intratumor needle insertion, through which the liquid embolic agent Onyx was infused to embolize the JNAs under fluoroscopic guidance. The day after EE, endoscopic resection was performed. Operating room time, estimated blood loss (EBL), and other intraoperative and postoperative results are reported and compared to published literature. RESULTS: A total of four patients (all males), had EE of JNA and subsequent endoscopic resection. Average EBL during surgery was 412.5 milliliters (range 150-800) with an average operating room time of 228 minutes (range 95-485). We experienced no bleeding from the tumor or its attachments, only from the approach. Two patients experienced mild numbness in the V2 distribution, which began to resolve one week postoperatively. No other complications were encountered. CONCLUSIONS: This is the first published report of direct endoscopic embolization of JNA. Although further studies are needed, it seems to provide a safe, less invasive alternative to traditional embolization and endoscopic resection, but must be done in cooperation with interventional neurosurgery to maximize its safety profile. Endoscopic training with sino-nasal and skull-base model Joao F Nogueira, MD (presenter); Aldo Stamm, MD, PhD; Maria Silva, MD; Fabio Santos, MD; Thiago Souza, MD OBJECTIVES: Show the development of an endoscopic nasal and skull-base surgery model, discuss the effectiveness in
anatomical knowledge gain, and present major advantages and disadvantages. METHODS: Prospective study with the development of models used by 10 otolaryngologists divided into three groups according to levels of experience. Scores were requested for consistency, tissue color, and identification of anatomical structures. The results were compared and analyzed statistically. RESULTS: The mean score assigned by participants for consistency was 3,2, for a maximum of 4. For the color the overall average was 3,6 (maximum 4). The mean score for identification of anatomical structures was 9,4 (maximum 10). CONCLUSIONS: We presented an endoscopic nasal surgery model, showing the steps of development. 70% of participants reported improvement in anatomical knowledge. The advantages are: Use of instruments similar to the real and no involved biological hazards. The disadvantage was the single dissection at the nasal lateral wall. Epistaxis: Prospective study of merocoele vs rapidrhino Sunil H Vyas, MBChB (presenter) OBJECTIVES: To assess: 1) The efectiveness of merocoele and rapidrhino packs in controlling aterior epistaxis. 2) Associatd patient discomfort. METHODS: 112 patients with anterior epistaxis which failed to respond to silver nitrate cautery were randomised into two groups: Group A (52), packed with merocoele, and group B (60), with rapid-rhino packs. Nasal lidocaine was applied before packing and patient discomfort was assessed, via a Visual Analogu Score (VAS, 0-5, where 5 is the worst pain). Patients that continued to bleed, requiring further treatment, were excluded from the study. Packs were left in for 24-30 hours and patients monitored in the ward. After removal of the packs, discomfort was further assessed using the VAS. Difficulty of insertion (DI, 0-5 scale) of packs, were also assessed. RESULTS: VAS at insertion: Group A (52): 0-2 (12/52, 23.1%). Above 2-3 (34/52, 65.4%). Above 3-5 (6/52, 11.5%). Group B (60): 0-2 (15/60, 25.0%). Above 2-3 (37/60, 61.7%). Above 3-5 (8/60, 13.3%). VAS at removal: Group A (50): 0-2 (40/50, 80.0%). Above 2-3 (8/50, 16.0%). Above 3-5 (2/50, 4.0%). Group B (57): 0-2 (40/57, 70.2%). Above 2-3 (10/57, 17.5%). Above 3-5 (7/57, 12.3%). For DI: Group A (52): 0-2(41/52, 78.9%). Above 2-3 (9/52, 17.3%). Above 3-5 (2/52, 3.8%). Group B (60): 0-2(45/60, 75.0%). Above 2-3 (11/60, 18.3%). Above 3-5 (4/60, 6.7%). Over a 3-month period, there are no significant differences in recurrence rates of epistaxis. CONCLUSIONS: Both merocoele and rapidrhino packs are effective in controlling anterior epistaxis, without any significant differences in patient discomfort, during insertion or removal.