- Email: [email protected]
Nasal polypi and allergic fungal sinusitis
P 176
Otolaryngology Head and Neck Surgery
Scientific Posters
presence of basic fibroblast growth factor (bFGF) in human saliva, bFGF is stimulating the proliferation of cells of mesodermal and neuroectodermal origin and is highly angiogenetic. Materials and methods: From 20 human volunteers of both sexes ages 20 to 50 years, saliva was collected and analyzed. For the analyses a commercially available kit for bFGF was used. Results: bFGF was detected in all samples. The mean concentration was 0.6 pg/ml (SD 0.16). Discussion and conclusions: bFGF is present in human saliva. It may even constitute a constant component. The physiological importance of this finding and the clinical aspects are discussed. 48 Study of Elastic Fibers in the Lamina Proprin of Vocal Folds Using Autofluorescent and Confacal Microscopy JOHN E. BUTLER, MD, STEVEN D, GRAY, MD, and ELIZABETH H. HAMMOND, MD, Salt Lake City, Utah
Objective: This study evaluates the morphologic characteristics of elastin fibers in the lamina propria using fluorescent microscopy and confocal reflected light microscopy. The confocal microscope produces three-dimensional imaging of the fibrous elastic architecture using computer-assisted "reconstruction" of successive noninvasive x-y sections. Methods: Normal human adult larynges were obtained postmortem with no history of instrumentation or laryngeal trauma. Vocal folds were excised, autoclaved to destroy the collagen, then processed and embedded in paraffin. Coronal 5 micron sections were examined under autofluorescence with cosin staining. Thicker sections were stained with cosin and examined under the confocal reflected light microscope for three-dimensional imaging of the elastic fibers. Results and conclusions: Both methods revealed a distribution of elastic fibers throughout the lamina propria, with more concentration in the intermediate layer. A fine reticular layer of elastic fibers were noted immediately below the basement membrane of the epithelium. Elastic fibers appeared thin, cylindrical, tortuous, and formed a loose network. The confocal microscopic studies revealed the threedimensional architecture of the elastic fibers within the lamina propria (photomicrographs to be included). 49 Use of Septoplasty Prior to Tympanoplasty ANNE1TE KREBS,MD, and WOLFGANG MAIER, MD, Freiburg, Germany
Objective: In case of chronic otitis media, the interactions between eustachian tube function and pathology of nose and nasopharynx have to be taken in account. To increase the success rate, septoplasty is recommended prior to tympanoplasty by several authors. Methods: To investigate the influence of nasal septal deviation On eustachian tube function, we examined 40 patients with airway obstruction caused by septal deviation
August 1997
before and after septoplasty. Eustachian tube function was examined in a pressure chamber using the dual impedance method. This method describes opening parameters of active and passive tubal function during the pressure change in the chamber. Results: Preoperatively more than 50% of our patients presented with pathologic active parameters and more than two thirds with pathologic passive parameters of eustachian tube function. One week postoperatively these parameters were even worth. The results if at all were better after 3 months. Conclusions: We conclude from our data that (1) impaired eustachian tube function occurs more often in patients with nasal septal deviation, (2) septoplasty may be useful in special cases but cannot be recommended generally, and (3) tympanoplasty should only be performed several months after septoplasty. 5O Primary Ciliary Dyskinesia in Patients With Repeated Upper Airway Infections SILVIO A. MONTEIRO, MD, PhD, ARACY PEREIRA SILVEIRA BALBANI, MD, and PAULO HILARIO NASCIMENTO SALDIVA, MD, PhD, Sao Paulo/SP, Brazil
Thirteen cases of repeated upper airway infections were evaluated to identify primary ciliary dyskinesia (PCD). There were nine men and four women between 3 and 30 years of age (mean, 17.2 years), and 38.4% of the patients had presented family history of relation by blood, lmmunodeficiencies (both congenital and acquired) and cystic fibrosis were ruled out. Perennial purulent nasal discharge was seen in 61.5% and secretory otitis media was diagnosed in 61.6% of those patients; paranasal sinus disease was diagnosed in all patients by plain RX. Five patients (38.4%) presented situs inversus totalis. Nasal mucosa biopsies studied by means of phase contrast optic microscopy revealed absence of ciliary beat in three cases, and electronic transmission microscopy showed ultrastructural ciliary defects in eight patients (whose findings were absence of dynein arms, microtubule alterations, and absence of cilia). The authors conclude that primary ciliary dyskinesia is an important differential diagnosis in the routine evaluation of recurrent upper airway infections. Tests of ciliary motility and ultrastructural pathology are very useful tools in this investigation. 51 Nasal Polypi and Allergic Fungal Sinusitis MOHAMMED YOUSEF-MIAN, MD, SENTHILKUMAREN, MD, FRCS, ABDULLA ABDULQADIR, MD, FRCP, and MOHAMMED PIRANI, MD, FRCPC, Riyadh, Saudi Arabia
Allergic fungal sinusitis (AFS) is increasingly being recognized as a separate entity characterized by a hypersensitivity reaction to fungi mediated by IgE and resembles al-
Otolaryngology Head and Neck Surgery Volume 117 Number 2
lergic bronchopulmonary aspergillosis. This study evaluates other parameters of this disease such as morphology of nasal polypi and correlation of CT scan and MRI findings with the contents of the nose and paranasal sinuses. Method: The study includes 20 patients, all immunocompetent (15 male, five female, average age 23), from 1988 to 1996. Blood from every patient was tested for an eosinophil count, serum-specific IgE, IgG, total IgE, and Rast. A radiologic assessment was done by CT scan and MRI. Nasal polypi, inspissated debris, and concretions from the nose and involved sinuses were sent for histologic, mycologic studies and biochemical assay. Results and conclusions: Most of the patients had atopy with raised serum IgE and high eosinophil count. The lesion showed high attenuation on CT and a hypo intense signal on MRI due to the presence of metals, glycoprotein, and macromolecular proteins in its contents. Aspergillis was the most frequently found fungus followed by Bipolaris, Helminthsporium and Curvularia. Sandwiched between the polyps are dark greenish brown concretion containing different metals. Histopathologically, the polyps are characterized by distended, dilated mucous glands, myxoid stroma, thick inflammatory exudates. Polyps are surrounded by allergic mucin consisting of mucinous material with eosinophils and Charcot-Leyden crystal interspersed with fungal hyphae. Morphologically these polyps behave like mucocoele and cause expansion and erosion. The lesion has a great propensity to recur after excision, establishing the sinus drainage and treatment with steroids and antifungal agents. 52 The Utility of Portable Chest X-ray as a Predictor of Endotracheal Tube Cuff Pressure JOSEPH VALENTINO, MD, ROBERT K. MEYERS, BA, MICHAEL D. BAKER, MD, and JOHN H. WOODRING, MD, Lexington, Ky.
Purpose: Elevated endotracheal tube cuff pressure causes mucosal ischemia that can result in tracheomalacia and tracheal stenosis. Endotracheally intubated patients frequently have portable chest x-rays (PCXRs) performed. Suggestions that an endotracheal tube cuff is overinflated based upon the air column's appearance in the PCXR are occasionally found in radiology reports: This study explores this previously uncharacterized relationship. Methods: We measured the endotracheal tube cuff pressure on 110 intensive care unit patients immediately prior to portable PCXR filming. We could measure the width of the tracheal air column below the tip of the endotracheal tube and at the maximal diameter of the endotracheal tube balloon in 64 of these PCXRS. We then analyzed the relationship of cuff pressure with tracheal dilation and tracheal dilation normalized by the nondilated tracheal diameter. Results: Regression analysis confirmed a linear relationship between cuff pressure and tracheal dilation (r = 0.435
Scientific Posters
P 177
with p < 0.001). Unfortunately there exists wide variance in this relationship. We performed an ANOVA of tracheal dilation for three groups: safe cuff pressures (0 to 19 mm Hg), unsafe cuff pressures (>30 mm Hg), and potentially dangerous cuff pressures (20 to 30 mm Hg). Although statistically significant, largely overlapping ranges exist in each group. Conclusions: The known variation in the endotracheal tube cuff characteristics as well as differences in tracheal distensibility between patients makes this not unexpected. Our analysis suggests that radiologic measurement of tracheal diameter is an unreliable predictor of cuff pressure. The utility of this measure as a screening tool for unsafe balloon pressures is questionable.
53 Angiogenesis in Chronic Inflammation of the Tracheal Mucosa Is Associated With Macrophages AKE DAHLQVIST, MD, PhD, ERIC Y. UMEMOTO, and DONALD M. McDONALD, San Francisco, Calif.
Objective: Angiogenesis is a characteristic feature of chronic inflammatory diseases that in humans can lead to stenosis of the trachea. Macrophages recruited to sites of inflammation are a potential source of angiogenic growth factors. In a rat model of chronic inflammation in the trachea caused by Mycoplasma pulmonis infection, we recently found a twofold increase in the number of macrophages in the tracheal mucosa and collections of macrophages closely associated with the angiogenic blood vessels. The objective of this study was to characterize the relationship of macrophages to angiogenic blood vessels. Methods: Wistar rats were inoculated with M. pulmonis. Pathogen-free rats were used as controls. Three or four weeks after inoculation, rats were anesthetized, injected with Monastral blue (1 mg/kg, iv) and substance P (5 pg/kg, iv) to label tachykinin-sensitive angiogenic blood vessels, and 5 minutes later perfused with 1% paraformaldehyde. Macrophages in tracheal whole mounts were stained immunohistochemicallywith the ED2 antibody. In three rats, the vasculature was stained by perfusion of biotinylated Lycopersicon esculentum lectin, and the tracheas were then mounted as whole mounts. Results: The tracheal mucosa of pathogen-free rats contained few Monastral blue-labeled vessels, and the labeled vessels rarely had macrophages nearby. In contrast, the mucosa of the infected rats was abnormally thick and contained abundant Monastral blue-labeled blood vessels and macrophages. Most of the labeled vessels and macrophages were located close to one another in polyp-like elevations of mucosa. The macrophages were round or oval in shape, lacked processes, and were near the abluminal surface angiogenic blood vessels. Regions of mucosa lacking Monastral blue-labeled vessels contained few or no macrophages. Lectin staining of the vasculature revealed that intravascular monocyte/macrophages were abundant in venules.
Otolaryngology Head and Neck Surgery
Scientific Posters
presence of basic fibroblast growth factor (bFGF) in human saliva, bFGF is stimulating the proliferation of cells of mesodermal and neuroectodermal origin and is highly angiogenetic. Materials and methods: From 20 human volunteers of both sexes ages 20 to 50 years, saliva was collected and analyzed. For the analyses a commercially available kit for bFGF was used. Results: bFGF was detected in all samples. The mean concentration was 0.6 pg/ml (SD 0.16). Discussion and conclusions: bFGF is present in human saliva. It may even constitute a constant component. The physiological importance of this finding and the clinical aspects are discussed. 48 Study of Elastic Fibers in the Lamina Proprin of Vocal Folds Using Autofluorescent and Confacal Microscopy JOHN E. BUTLER, MD, STEVEN D, GRAY, MD, and ELIZABETH H. HAMMOND, MD, Salt Lake City, Utah
Objective: This study evaluates the morphologic characteristics of elastin fibers in the lamina propria using fluorescent microscopy and confocal reflected light microscopy. The confocal microscope produces three-dimensional imaging of the fibrous elastic architecture using computer-assisted "reconstruction" of successive noninvasive x-y sections. Methods: Normal human adult larynges were obtained postmortem with no history of instrumentation or laryngeal trauma. Vocal folds were excised, autoclaved to destroy the collagen, then processed and embedded in paraffin. Coronal 5 micron sections were examined under autofluorescence with cosin staining. Thicker sections were stained with cosin and examined under the confocal reflected light microscope for three-dimensional imaging of the elastic fibers. Results and conclusions: Both methods revealed a distribution of elastic fibers throughout the lamina propria, with more concentration in the intermediate layer. A fine reticular layer of elastic fibers were noted immediately below the basement membrane of the epithelium. Elastic fibers appeared thin, cylindrical, tortuous, and formed a loose network. The confocal microscopic studies revealed the threedimensional architecture of the elastic fibers within the lamina propria (photomicrographs to be included). 49 Use of Septoplasty Prior to Tympanoplasty ANNE1TE KREBS,MD, and WOLFGANG MAIER, MD, Freiburg, Germany
Objective: In case of chronic otitis media, the interactions between eustachian tube function and pathology of nose and nasopharynx have to be taken in account. To increase the success rate, septoplasty is recommended prior to tympanoplasty by several authors. Methods: To investigate the influence of nasal septal deviation On eustachian tube function, we examined 40 patients with airway obstruction caused by septal deviation
August 1997
before and after septoplasty. Eustachian tube function was examined in a pressure chamber using the dual impedance method. This method describes opening parameters of active and passive tubal function during the pressure change in the chamber. Results: Preoperatively more than 50% of our patients presented with pathologic active parameters and more than two thirds with pathologic passive parameters of eustachian tube function. One week postoperatively these parameters were even worth. The results if at all were better after 3 months. Conclusions: We conclude from our data that (1) impaired eustachian tube function occurs more often in patients with nasal septal deviation, (2) septoplasty may be useful in special cases but cannot be recommended generally, and (3) tympanoplasty should only be performed several months after septoplasty. 5O Primary Ciliary Dyskinesia in Patients With Repeated Upper Airway Infections SILVIO A. MONTEIRO, MD, PhD, ARACY PEREIRA SILVEIRA BALBANI, MD, and PAULO HILARIO NASCIMENTO SALDIVA, MD, PhD, Sao Paulo/SP, Brazil
Thirteen cases of repeated upper airway infections were evaluated to identify primary ciliary dyskinesia (PCD). There were nine men and four women between 3 and 30 years of age (mean, 17.2 years), and 38.4% of the patients had presented family history of relation by blood, lmmunodeficiencies (both congenital and acquired) and cystic fibrosis were ruled out. Perennial purulent nasal discharge was seen in 61.5% and secretory otitis media was diagnosed in 61.6% of those patients; paranasal sinus disease was diagnosed in all patients by plain RX. Five patients (38.4%) presented situs inversus totalis. Nasal mucosa biopsies studied by means of phase contrast optic microscopy revealed absence of ciliary beat in three cases, and electronic transmission microscopy showed ultrastructural ciliary defects in eight patients (whose findings were absence of dynein arms, microtubule alterations, and absence of cilia). The authors conclude that primary ciliary dyskinesia is an important differential diagnosis in the routine evaluation of recurrent upper airway infections. Tests of ciliary motility and ultrastructural pathology are very useful tools in this investigation. 51 Nasal Polypi and Allergic Fungal Sinusitis MOHAMMED YOUSEF-MIAN, MD, SENTHILKUMAREN, MD, FRCS, ABDULLA ABDULQADIR, MD, FRCP, and MOHAMMED PIRANI, MD, FRCPC, Riyadh, Saudi Arabia
Allergic fungal sinusitis (AFS) is increasingly being recognized as a separate entity characterized by a hypersensitivity reaction to fungi mediated by IgE and resembles al-
Otolaryngology Head and Neck Surgery Volume 117 Number 2
lergic bronchopulmonary aspergillosis. This study evaluates other parameters of this disease such as morphology of nasal polypi and correlation of CT scan and MRI findings with the contents of the nose and paranasal sinuses. Method: The study includes 20 patients, all immunocompetent (15 male, five female, average age 23), from 1988 to 1996. Blood from every patient was tested for an eosinophil count, serum-specific IgE, IgG, total IgE, and Rast. A radiologic assessment was done by CT scan and MRI. Nasal polypi, inspissated debris, and concretions from the nose and involved sinuses were sent for histologic, mycologic studies and biochemical assay. Results and conclusions: Most of the patients had atopy with raised serum IgE and high eosinophil count. The lesion showed high attenuation on CT and a hypo intense signal on MRI due to the presence of metals, glycoprotein, and macromolecular proteins in its contents. Aspergillis was the most frequently found fungus followed by Bipolaris, Helminthsporium and Curvularia. Sandwiched between the polyps are dark greenish brown concretion containing different metals. Histopathologically, the polyps are characterized by distended, dilated mucous glands, myxoid stroma, thick inflammatory exudates. Polyps are surrounded by allergic mucin consisting of mucinous material with eosinophils and Charcot-Leyden crystal interspersed with fungal hyphae. Morphologically these polyps behave like mucocoele and cause expansion and erosion. The lesion has a great propensity to recur after excision, establishing the sinus drainage and treatment with steroids and antifungal agents. 52 The Utility of Portable Chest X-ray as a Predictor of Endotracheal Tube Cuff Pressure JOSEPH VALENTINO, MD, ROBERT K. MEYERS, BA, MICHAEL D. BAKER, MD, and JOHN H. WOODRING, MD, Lexington, Ky.
Purpose: Elevated endotracheal tube cuff pressure causes mucosal ischemia that can result in tracheomalacia and tracheal stenosis. Endotracheally intubated patients frequently have portable chest x-rays (PCXRs) performed. Suggestions that an endotracheal tube cuff is overinflated based upon the air column's appearance in the PCXR are occasionally found in radiology reports: This study explores this previously uncharacterized relationship. Methods: We measured the endotracheal tube cuff pressure on 110 intensive care unit patients immediately prior to portable PCXR filming. We could measure the width of the tracheal air column below the tip of the endotracheal tube and at the maximal diameter of the endotracheal tube balloon in 64 of these PCXRS. We then analyzed the relationship of cuff pressure with tracheal dilation and tracheal dilation normalized by the nondilated tracheal diameter. Results: Regression analysis confirmed a linear relationship between cuff pressure and tracheal dilation (r = 0.435
Scientific Posters
P 177
with p < 0.001). Unfortunately there exists wide variance in this relationship. We performed an ANOVA of tracheal dilation for three groups: safe cuff pressures (0 to 19 mm Hg), unsafe cuff pressures (>30 mm Hg), and potentially dangerous cuff pressures (20 to 30 mm Hg). Although statistically significant, largely overlapping ranges exist in each group. Conclusions: The known variation in the endotracheal tube cuff characteristics as well as differences in tracheal distensibility between patients makes this not unexpected. Our analysis suggests that radiologic measurement of tracheal diameter is an unreliable predictor of cuff pressure. The utility of this measure as a screening tool for unsafe balloon pressures is questionable.
53 Angiogenesis in Chronic Inflammation of the Tracheal Mucosa Is Associated With Macrophages AKE DAHLQVIST, MD, PhD, ERIC Y. UMEMOTO, and DONALD M. McDONALD, San Francisco, Calif.
Objective: Angiogenesis is a characteristic feature of chronic inflammatory diseases that in humans can lead to stenosis of the trachea. Macrophages recruited to sites of inflammation are a potential source of angiogenic growth factors. In a rat model of chronic inflammation in the trachea caused by Mycoplasma pulmonis infection, we recently found a twofold increase in the number of macrophages in the tracheal mucosa and collections of macrophages closely associated with the angiogenic blood vessels. The objective of this study was to characterize the relationship of macrophages to angiogenic blood vessels. Methods: Wistar rats were inoculated with M. pulmonis. Pathogen-free rats were used as controls. Three or four weeks after inoculation, rats were anesthetized, injected with Monastral blue (1 mg/kg, iv) and substance P (5 pg/kg, iv) to label tachykinin-sensitive angiogenic blood vessels, and 5 minutes later perfused with 1% paraformaldehyde. Macrophages in tracheal whole mounts were stained immunohistochemicallywith the ED2 antibody. In three rats, the vasculature was stained by perfusion of biotinylated Lycopersicon esculentum lectin, and the tracheas were then mounted as whole mounts. Results: The tracheal mucosa of pathogen-free rats contained few Monastral blue-labeled vessels, and the labeled vessels rarely had macrophages nearby. In contrast, the mucosa of the infected rats was abnormally thick and contained abundant Monastral blue-labeled blood vessels and macrophages. Most of the labeled vessels and macrophages were located close to one another in polyp-like elevations of mucosa. The macrophages were round or oval in shape, lacked processes, and were near the abluminal surface angiogenic blood vessels. Regions of mucosa lacking Monastral blue-labeled vessels contained few or no macrophages. Lectin staining of the vasculature revealed that intravascular monocyte/macrophages were abundant in venules.