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Follicular helper T (Tfh) cells are necessary for germinal center B cell maturation during primary immune responses; however, the T cells that promote humoral recall responses via memory B cells are less well defined. In this article, we characterize a human tonsillar CD4+ T cell subset with this function. These cells are similar to Tfh cells in terms of expression of the chemokine receptor CXCR5 and the inhibitory receptor PD-1, IL-21 secretion, and expression of the transcription factor BCL6; however, unlike Tfh cells that are located within the B cell follicle and germinal center, they reside at the border of the T cell zone and the B cell follicle in proximity to memory B cells, a position dictated by their unique chemokine receptor expression. They promote memory B cells to produce Abs via CD40L, IL-10, and IL-21. Our results reveal a unique extrafollicular CD4+ T cell subset in human tonsils, which specialize in promoting T cell–dependent humoral recall responses.

We performed an economic evaluation using a decision-tree model to analyze the relative cost effectiveness from the United States Centers for Medicare and Medicaid Services (CMS) perspective of two different methods of tonsillectomy (traditional total tonsillectomy and partial intracapsular) for pediatric obstructive sleep apnea (OSA). Procedural costs were drawn from published literature and Medicare values. Effectiveness and probabilities were drawn from medical literature. Primary intervention was monopolar-technique total tonsillectomy or microdebrider-assisted partial intracapsular tonsillectomy. Secondary interventions included operative control of hemorrhage, treatment of severe dehydration, or revision tonsillectomy. The decision model starts with pediatric patients with OSA, choosing between total and partial tonsillectomy. Outcomes were measured by costs (US dollars), effectiveness [quality-adjusted life year (QALY)], and a willingness-to-pay threshold of US$100,000/QALY. Base case analysis, probabilistic sensitivity analysis (PSA) and deterministic sensitivity analyses were performed. Primary outcome was incremental cost-effectiveness ratio (ICER) for each of the two tonsillectomy techniques. Base case analysis demonstrated that total tonsillectomy was more cost effective at US$12,453.40 per QALY gained. In PSA, 82.84% of the simulations show total tonsillectomy to be the more cost-effective strategy. Deterministic sensitivity analyses showed that when the rate of OSA recurrence is lower than 3.12%, partial tonsillectomy would be more cost effective. When the failure rate of partial tonsillectomy is below 1.0%, it is more cost effective even when total tonsillectomy is 100% successful. Study results suggest that overall monopolar-technique total tonsillectomy is more cost effective. However, with varying adjustments for disutility caused by procedural complications, intracapsular tonsillectomy could become a more cost-effective technique for treating pediatric OSA.

Due to the potentially unforgiving nature of epiglottitis and supraglottitis, the clinician should have a firm understanding of the presentation, work up, and management of a patient presenting with worrisome symptoms.

Anthracotic pigmentation in the bronchial mucosa is a bronchoscopic finding of pneumoconiosis, or evidence of heavy atmospheric soot. This pigmentation in the tracheobronchial mucosa is surrounded by calcified or noncalcified lymph nodes. Anthracosis is not a previously known cause of left vocal fold paralysis. We present what we believe to be the first reported case of anthracosis-caused vocal fold paralysis.

1. Eric D. Baum, MD* 1. *Clinical Instructor, Department of Surgery (Otolaryngology), Yale University School of Medicine, New Haven, Conn. After completing this article, readers should be able to: 1. Recognize disease states associated with adenotonsillar hypertrophy and infection. 2. Understand the indications for, general surgical approach to, and complications of adenotonsillectomy. 3. Discuss the role of myringotomy and tube insertion in the management of middle ear disease. 4. Be familiar with common complications after myringotomy and tube insertion. A variety of head and neck problems are seen frequently in general pediatric practice, and issues related to adenotonsillar disease and middle ear disease are among the most common causes of these visits. Sleep-disordered breathing, a range of disorders that includes primary snoring and obstructive sleep apnea syndrome (OSAS), is strongly related to adenotonsillar hypertrophy. Recurrent and chronic pharyngitis are addressed less commonly surgically than in past decades but still are important causes of morbidity in children. Myringotomy with tube insertion is one of the most common surgical procedures performed on Americans and is an important tool in the management of chronic middle ear disease in the pediatric population. The superior part of the pharynx contains a ring of lymphoid tissue roughly extending from the level of the skull base in the posterior portion of the nose down to the level of the larynx. Centered superiorly on the posterior wall of the nasopharynx are the pharyngeal tonsils, commonly known as the adenoids or adenoid pad. The two palatine tonsils (generally termed only “tonsils”) are situated on either side of the oropharynx. Inferiorly, near the base of the tongue and more inferior portions of the pharyngeal walls are the lingual tonsils. Disease states associated with these different aggregations of tissue often are affected by their precise anatomic location. …

We report 2 cases of pediatric hypopharyngeal perforation that occurred during endoscopy and 1 case of esophageal perforation that developed during nasogastric tube insertion at a tertiary care academic medical center. These cases were identified during a retrospective chart review. All 3 patients were treated with intravenous antibiotics and nasogastric tube feedings, and none experienced further sequelae. Perforations of the hypopharynx and esophagus in children during endoscopy or insertion of endotracheal and nasogastric tubes are not uncommon. Many affected children can be managed conservatively without surgical drainage, depending on the cause and specific location of the perforation and the timing of the diagnosis. We discuss the clinical criteria for various management options, and we offer an algorithm that outlines important clinical considerations in the decision-making process. Our aim in presenting these cases is to increase awareness of the management options for children with hypopharyngeal and esophageal perforations and to demonstrate the effectiveness of nonsurgical management in selected cases.

We conducted a study of 47 patients with various voice disorders to determine the prevalence of concomitant psychopathology. The prevalence of psychiatric symptoms varied considerably among patients with the three most common voice disorders: 63.6% among patients with vocal fold paralysis, 29.4% among those with functional dysphonia, and 7.1% among those with spasmodic dysphonia. Levels of anxiety and depression correlated moderately with the severity of voice symptoms in patients with vocal fold paralysis, but not in those with functional or spasmodic dysphonia. Certain abnormal personality traits--including interpersonal sensitivity and distrust of others--were more common among patients with functional dysphonia. The low rate of psychopathology among patients with spasmodic dysphonia is consistent with rates reported in previous investigations. Our findings suggest that the prevalence of psychopathology in patients with voice disorders varies according to the specific voice diagnosis, as does the relationship between specific psychiatric and voice symptoms.

Background The aim of this study was to review our early experience with the UPenn Otolaryngology Referral Center Website, ENTConsult.org. Methods ENTConsult.org is an interactive website that allows a referring physician to select a University of Pennsylvania Health System otolaryngologist and share clinical information, including uploaded pictures, radiographs, and other images via the Internet. Traditional methods of long-distance consultation involve mailing clinical information, which often is slow and unwieldy, thus discouraging consultation. ENTConsult.org seeks to take advantage of Internet functionality to facilitate efficient and timely consultation regardless of any of the participants’ locations. Results In this report we reviewed our initial experience with ENTConsult.org, including an overview of the website functionality and a detailed review of critical logistical considerations. Conclusion The UPenn Otolaryngology Referral Center Website ENTConsult.org offers considerable promise as an avenue for long-distance referral and consultation.

Multiple circumferential skin folds have been reported as part of the Michelin tire baby syndrome (MTBS). There has been a wide spectrum of associated clinical findings reported in children with MTBS. We report a case of MTBS associated with a thickened epiglottis.

Although sarcoidosis is predominantly a pulmonary disorder, it often produces disease in the head and neck. For this reason, otolaryngologists should be comfortable in evaluating and treating the disease. The diagnosis of sarcoidosis often can be made with a biopsy of conjunctival or oral mucosa, even when disease manifestations are not apparent in those parts of the body. In a case of sarcoidosis involving the nose, a 54-year-old black man had a proliferation of small lumps on the tip of his nose. For many years, he had had daily epistaxis, anosmia and severe difficulty breathing through this nose. The bridge of his nose was deformed, and he had a large anterior septal perforation. Physical examination revealed palpable bilateral cervical lymphadenopathy. Laboratory test results were, for the most part, normal; however, fine-needle aspiration of one of the cervical lymph nodes showed multiple epithelioid granulomas with interspersed lymphocyte, and an incisional biopsy of the nasal tissue was highly suggestive of sarcoidosis. Unenhanced computed tomography also revealed widespread nasal inflammation and an abnormal soft tissue mass anterior to the maxilla consistent with chronic osteomyelitis. The patient's condition dramatically improved following treatment with oral prednisone; however, he considered undergoing reconstructive surgery for the noticeable nasal septal deformity.

Background Observational studies suggest that asthma control improves after adenotonsillectomy, but longitudinal studies that correlate the effect of the procedure on the levels of biomarkers associated with airway inflammation are limited. Methods We conducted a longitudinal, observational study on pediatric patients, both with and without asthma, undergoing adenotonsillectomy. Asthma Control Test (ACT) scores and chitinase activity in the circulation were measured at time of surgery and at 6-month follow-up. Results 66 children with asthma and 64 control subjects were enrolled. Mean ACT scores improved by 3 points (p< 0.001) after 6 months. 85% of children with poorly-controlled asthma demonstrated an increase in ACT score of at least 3 points or a decrease in Emergency Department/Urgent Care visits, oral corticosteroid courses, or rescue short acting bronchodilator usage. Chitinase activity decreased significantly in asthmatics who improved (p< 0.01). Higher chitinase activity levels at baseline were associated with improved asthma control following surgery (p< 0.01). Conclusions In children with high pre-operative circulating chitinase activity levels, asthma control and healthcare utilization were significantly improved after adenotonsillecotmy. Chitinase activity decreased after surgery in children with improved control. This suggests that adenotonsillectomy modulates chitinase activity, affecting airway inflammation and improving airway disease.

Subglottic hemangioma is a rare, potentially life threatening tumor of infancy which poses serious treatment challenges. A number of medical and surgical therapies over the years have met with variable success, and are associated with numerous potential morbidities. A potential windfall in the management of infantile hemangiomas has arisen with the recent identification of propanolol as a highly efficacious and relatively safe new treatment modality. At least five reports in the literature have described the rapid, successful treatment of airway hemangiomas with oral propanolol. We describe the first reported treatment failure with propanolol for subglottic hemangioma in an infant who initially responded dramatically to the medication.

This review paper introduces an algorithm for non-surgical local wound care in head and neck cancer patients who have delayed and complicated wound healing. Wound complications are common in patients undergoing head and neck cancer treatment, regardless of whether their primary treatment modality is surgery or chemoradiation. The risk for complications is compounded by the vital structures in the regional anatomy of these tumors and by the toxicities and long-term consequences of the cancer treatments employed. There is limited empirical and clinical evidence to specifically guide and improve local wound healing outcomes in head and neck cancer patients. The algorithm, based on an analysis of the medical literature, begins with the assessment of five simple wound environment characteristics: exudate volume; slough and eschar; large vessel exposure; proliferation; and systemic nutrition and perfusion. Assessing these wound characteristics is the basis for planning local care. The wound characteristics are discussed in relation to the pertinent literature, product categories, and other known interventions presented herein.

Photodynamic therapy is a technique for killing cells with visible light after pretreatment with a photosensitizing agent. We demonstrated significant in vitro fungicidal activity against Aspergillus fumigatus of the photosensitizer Green 2W, activated with 630 nm light. This effect was both inoculum- and light dose-dependent. At a Green 2W concentration of 31.5 mg/L, there was complete killing of 2.7 x 10 1 cfu/mL with a light dose of 110 J/cm 2 and up to 2.7 x 10 6 cfu/mL with a light dose of 385 J/cm 2 .