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BACKGROUND: In the 5 years that have passed since the publication of the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-Allergic Rhinitis 2018), the literature has expanded substantially. The ICAR-Allergic Rhinitis 2023 update presents 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the 2018 document. Originally presented topics from 2018 have also been reviewed and updated. The executive summary highlights key evidence-based findings and recommendation from the full document.METHODS: ICAR-Allergic Rhinitis 2023 employed established evidence-based review with recommendation (EBRR) methodology to individually evaluate each topic. Stepwise iterative peer review and consensus was performed for each topic. The final document was then collated and includes the results of this work.RESULTS: ICAR-Allergic Rhinitis 2023 includes 10 major content areas and 144 individual topics related to AR. For a substantial proportion of topics included, an aggregate grade of evidence is presented, which is determined by collating the levels of evidence for each available study identified in the literature. For topics in which a diagnostic or therapeutic intervention is considered, a recommendation summary is presented, which considers the aggregate grade of evidence, benefit, harm, and cost.CONCLUSION: The ICAR-Allergic Rhinitis 2023 update provides a comprehensive evaluation of AR and the currently available evidence. It is this evidence that contributes to our current knowledge base and recommendations for patient evaluation and treatment.

OBJECTIVES/HYPOTHESIS Psychological comorbidity is common in patients with chronic rhinosinusitis (CRS) and is correlated with decreased overall and disease-specific quality of life (QoL). Prior research reported that anxiety and depression, as measured by the hospital anxiety and depression scale (HADS), are associated with worse CRS-specific QoL, as assessed via the Rhinosinusitis Disability Index (RSDI). Furthermore, patients prone to anxiety/depression may display an exaggerated response to real or anticipated discomfort; the pain catastrophizing scale (PCS) is a validated instrument designed to measure this phenomenon. This study is intended to explore the role of pain catastrophizing in relation to anxiety, depression, and disease-specific QoL in patients with facial pain attributed to CRS. STUDY DESIGN Prospective cohort study. METHODS Diagnosis of presumed CRS was based upon current American Academy of Otolaryngology - Head & Neck Surgery (AAO-HNS) guidelines; all participants reported facial pain as a component of their CRS symptomatology. RSDI, HADS, and PCS questionnaires were administered upon presentation prior to intervention, and objective measurements of sinonasal inflammation were obtained via nasal endoscopy and computed tomography (CT). RESULTS Seventy-five patients were enrolled in the study. Significant positive correlations were found between PCS and HADS, total RSDI, and RSDI emotional sub-scores (P

Invasive fungal sinusitis is a morbid pathology that typically affects immunocompromised patients and may quickly progress to fulminant disease. The purpose of this study was to measure the sensitivity and specificity of touch preparation of nasal debridement specimens as a rapid diagnostic tool for invasive fungal sinusitis. A retrospective chart review was performed of 22 patients undergoing nasal debridement due to suspicion for invasive fungal sinusitis over a 10-year period. Thirteen patients had touch preparation of nasal specimens followed by routine histologic processing; 2 of these patients underwent two and 1 patient had three separate debridements, for a total of 17 touch preparations performed. The sensitivity and specificity of touch preparation were calculated by correlating the initial results with the presence of fungal invasion on final pathologic analysis. The sensitivity of touch preparation was 56% (95% confidence interval [CI]: 0.23 to 0.85), specificity was 100% (95% CI: 0.60 to 1.00), positive predictive value was 100% (95% CI: 0.46 to 1.00), and negative predictive value was 67% (95% CI: 0.35 to 0.89). This procedure may be a useful adjunct in situations requiring rapid diagnosis of invasive fungal sinusitis but should not be used as the sole criterion for determining the need for surgical intervention.

Objectives YouTube is the second most visited website in the world and can be a useful resource for patients to gain insight into surgical procedures. A multitude of studies have evaluated the quality of otolaryngology-specific healthcare information available on the YouTube platform, but to our knowledge, the online content regarding functional endoscopic sinus surgery available on this site has not been systematically evaluated. Study Design Cross sectional study. Setting Online. Methods YouTube was searched using the keywords “sinus surgery.” Variables including video length, total number of views, authorship (academic, private practice physician, patient, or third party), objective (advertisement, informative, or patient perspective), inclusion of intra-operative footage, and discussion of balloon sinuplasty were recorded and analyzed by a single reviewer. Results Two-hundred twenty-two videos met inclusion criteria, with a median length of 4 minutes, and a median of 3349 views. The majority of videos were informative (n = 145, 65%), narrated (n = 151, 68%), and did not mention balloon sinuplasty (n = 189, 85%) nor contain intra-operative footage (n = 116, 52%). Private practice physicians were the most common authors (n = 113, 51%), followed by patients (n = 70, 32%), third parties (n = 28, 13%) and academics (n = 11, 5%). Conclusions Sinus surgery is one of the most common ambulatory procedures performed. Online resources such as YouTube can be useful for improving health literacy and patient comfort with medical topics such as functional endoscopic sinus surgery, but it is important for clinicians and patients to understand that there is a spectrum in the authorship, content, and quality of sinus surgery related videos posted online.

Introduction Facial pain is a common manifestation of sinonasal disease but may be due to a variety of other conditions. Misattribution of pain to chronic rhinosinusitis may result in worse quality of life in populations both with and without objective evidence of sinonasal disease. The purpose of this study was to determine if there is an association between pain-related comorbidities and worse chronic rhinosinusitis specific quality of life in patients with and without objective evidence of sinonasal inflammation. Methods Retrospective cohort study of 299 patients meeting diagnostic criteria for sinusitis evaluated at a tertiary academic medical center from 2017 to 2018. Objective evidence was measured using the Lund-Kennedy and Lund-MacKay scoring systems; for the purposes of this study a score >3 on either scale was considered indicative of disease. Quality of life was determined by the rhinosinusitis disability index. Results A total of 191 patients were included in the study, with an average age of 52.7. (SD=15.3). The average Lund-Kennedy and Lund-MacKay scores were 4.7 and 8.3, respectively. The average rhinosinusitis disability index was 32.1. When stratified by the presence of pain-related comorbidities, there was no significant difference in Lund-Kennedy (p = 0.203), Lund-MacKay (p = 0.101), or rhinosinusitis disability index (p = 0.421). Conclusion Although prior studies have suggested a correlation between the presence of pain-related comorbidities and worse chronic rhinosinusitis specific quality of life, this relationship was not evident within the current cohort of patients. The relationship between pain and sinusitis specific quality of life is likely complex and requires further research to fully elucidate.

Background: Understanding the morphology of nasal airways is important in determining the nasal airway deposition of inhaled aerosol. Moreover, objective assessment of the anatomy of human nasal ai...

Background Prior research has established that anxiety and depression, as measured by the Hospital Anxiety Depression Score (HADS), are strongly correlated with disease-specific quality of life (Rhinosinusitis Disability Index - RSDI) in chronic rhinosinusitis (CRS). We hypothesized that anxiety and depression would decrease after functional endoscopic sinus surgery (FESS), and furthermore that HADS would predict improvement in RSDI following surgery. Methodology The study cohort from 2014 consisted of 99 CRS patients who underwent nasal endoscopy, RSDI, and HADS evaluation. The cohort was segregated by whether or not they underwent FESS and an updated HADS was administered. For 44 surgical patients, pre- and post-operative RSDI (n=38), Lund-Kennedy (LK) (n=34) and HADS (n=18) scores were compared. Delta RSDI was compared between patients with varying levels of anxiety and depression. Results Lund-Kennedy scores improved from 5.8 ± 4.1 to 3.2 ± 2.6 following surgery, as did total RSDI (39.3 ± 26.8 to 24.6 ± 29.2). Total HADS (9.8 ± 6.4 to 11.3 ± 7.4) and depression and anxiety subscores were unchanged. Linear regression did not reveal a correlation between HADS and change in RSDI following FESS. Delta RSDI was not significantly different between patients with varying levels of anxiety and depression. Conclusions Despite improvements in objective evidence of sinonasal inflammation (LK) and disease-specific quality of life (RSDI), neither depression nor anxiety improved after FESS, nor did the magnitude of psychological comorbidity predict post-operative improvement in quality of life. Improvement in RSDI was not different among patients with varying levels of anxiety and depression. Levels of depression and anxiety may be hard-wired, and therefore not influenced by changes in objective or perceived sinonasal disease burden.

Quantifying drug delivery to the site of action using locally-acting nasal suspension sprays is a challenging but important step toward understanding bioequivalence (BE) between test and reference products. The main objective of this study was to investigate the in vitro deposition pattern of two common but different locally-acting nasal suspension sprays using multiple nasal cavities. Twenty anatomically accurate nasal replicas were developed from high-resolution sinonasal computed tomography scans of adults with healthy nasal airways. The airways were segmented into two regions of anterior and posterior to the internal nasal valve. Both sides of the septum were considered separately; hence, 40 nasal cavities were studied. The positioning of the spray nozzle in all 40 cavities was characterized by the head angle, coronal angle, and the insertion depth. Despite using a controlled protocol to minimize the anterior losses, a wide range of variability in posterior drug delivery was observed. The observed intersubject variability using this in vitro method may have important implications for understanding BE of locally-acting nasal suspension sprays.

The optimal method for radiographic evaluation of the internal nasal valve (INV) has not been established. The objective of this study was to develop a method to assess the cross-sectional area and the angle of the INV using anatomically-accurate 3D digital nasal airway models. Axial CT images of the paranasal sinuses of twenty adult subjects with healthy nasal airways (50% female and 50% age ≥ 50) were used to create the models. Patients with significant radiographic evidence of sinonasal disease were excluded. A primary cutting plane that passed through the edge of the nasal bone, upper lateral cartilage, and the head of the inferior turbinate was defined in coronal view. This primary coronal cutting plane was then rotated in 5° increments anteriorly while ensuring the anatomic criteria for the INV were still met. The cutting plane resulting in the minimum INV area was identified as the optimal cutting plane and the total cross-sectional area of INV in this plane,198.79 ± 54.57 mm2, was significantly less than the areas obtained using the existing methods for radiographic evaluation of the INV. The angle between the optimal cutting plane and nasal dorsum was 75.00 ± 10.26°, and the corresponding INV angle was 10.77 ± 6.02°.

Nasal airway obstruction (NAO) is a common otolaryngic complaint with many potential causes, frequently structural or inflammatory in nature. Patients typically have multiple coexisting factors leading to symptoms. Good patient outcomes require careful preoperative evaluation, including nasal endoscopy, to accurately identify sources of obstruction and tailor intervention appropriately. Common structural causes of NAO include inferior turbinate hypertrophy, nasal septal deviation, and narrowing or collapse of the internal or external nasal valves. The internal nasal valve has the narrowest cross-sectional area within the nasal airway and is thus most sensitive to changes in dimension due to anatomic variation or surgical intervention.

Background Epithelial-myoepithelial carcinoma (EMC) is a rare tumor of the major and minor salivary glands. Sinonasal EMC is extremely uncommon and hitherto not described within the frontal or ethmoid sinuses. Objective To present a novel sinonasal subsite and review the literature regarding sinonasal EMC. Methods A case of frontoethmoidal EMC was presented. A medical literature data base was queried from January 1, 1950, to August 8, 2017, for all reports of sinonasal EMC. Results A 69-year-old man underwent combined open and endoscopic craniofacial resection of a right frontoethmoidal EMC, a previously undescribed primary location for this tumor. A comprehensive review of the literature revealed 13 additional cases of sinonasal EMC. Conclusion EMC is an uncommon neoplasm typically found in the major salivary glands; occurrence in the nose or paranasal sinuses is extremely rare. EMC often follows an indolent clinical course, although, in a minority of cases, particularly in large tumors with nuclear atypia, more aggressive behavior may be observed.

PURPOSE OF REVIEW To identify long-term management strategies and outcomes for the treatment of spontaneous cerebrospinal fluid (CSF) rhinorrhea related to idiopathic intracranial hypertension (IIH). RECENT FINDINGS Adjuvant treatments following surgical repair of spontaneous CSF leaks are aimed at normalizing intracranial pressure (ICP) to minimize the risk of recurrence. IIH is closely linked to obesity, and growing evidence suggests that weight loss, both through conservative and surgical approaches, is effective at addressing the root cause of this disorder. Recent data also support the use of acetazolamide and dural venous sinus stenting as adjuncts for reducing ICP. SUMMARY Spontaneous CSF rhinorrhea associated with IIH represents a challenging clinical entity, with an increased risk of recurrence compared to CSF leaks because of other causes. Adjunct therapies intended to reduce ICP likely improve outcomes after surgical repair, but further research is necessary to better characterize the effects of these treatment modalities.

Objectives/Hypothesis Evaluate the effectiveness of an educational curriculum on general tracheostomy care principles and determine the effect of this educational curriculum on the level of provider comfort with tracheostomy care. Study Design Cross-sectional questionnaire in an academic medical center. Materials and Methods A 25-question multiple choice and true/false quiz was given to nonotolaryngology health care providers (nurses and physicians) who routinely provide tracheostomy care. This was followed by an education module, and the quiz was repeated. Participants were also asked to rate their level of comfort (0–100 point scale) managing a tracheostomy before and after the module. A 6-month follow-up assessment was also obtained. Results A total of 94 health care providers participated in the education module (50 physicians, 37 nurses, 7 fourth-year medical students). The average number of correct answers increased by 3.1 (P

Objective Determine whether the elimination of pain improves accuracy of clinical diagnostic criteria for adult chronic rhinosinusitis. Study Design Retrospective cohort study. Methods History, symptoms, nasal endoscopy, and computed tomography (CT) results were analyzed for 1,186 adults referred to an academic otolaryngology clinic with presumptive diagnosis of chronic rhinosinusitis. Clinical diagnosis was rendered using the 1997 Rhinosinusitis Taskforce (RSTF) Guidelines and a modified version eliminating facial pain, ear pain, dental pain, and headache. Results Four hundred seventy-nine subjects (40%) met inclusion criteria. Among subjects positive by RSTF guidelines, 45% lacked objective evidence of sinonasal inflammation by CT, 48% by endoscopy, and 34% by either modality. Applying modified RSTF diagnostic criteria, 39% lacked sinonasal inflammation by CT, 38% by endoscopy, and 24% by either modality. Using either abnormal CT or endoscopy as the reference standard, modified diagnostic criteria yielded a statistically significant increase in specificity from 37.1% to 65.1%, with a nonsignificant decrease in sensitivity from 79.2% to 70.3%. Analysis of comorbidities revealed temporomandibular joint disorder, chronic cervical pain, depression/anxiety, and psychiatric medication use to be negatively associated with objective inflammation on CT or endoscopy. Conclusion Clinical diagnostic criteria overestimate the prevalence of chronic rhinosinusitis. Removing facial pain, ear pain, dental pain, and headache increased specificity without a concordant loss in sensitivity. Given the high prevalence of sinusitis, improved clinical diagnostic criteria may assist primary care providers in more accurately predicting the presence of inflammation, thereby reducing inappropriate antibiotic use or delayed referral for evaluation of primary headache syndromes. Level of Evidence 4. Laryngoscope, 127:1011–1016, 2017

Introduction Subcutaneous emphysema [SCE] can develop due to traumatic, infectious, and spontaneous causes and usually localizes to the periorbital space. Case We present a case of an 18-year-old male with an 8-day history of migraine-like headaches followed by the acute onset of frontofacial swelling after vigorous sneezing. Radiologic and physical exam findings supported a diagnosis of frontofacial SCE in the setting of frontal sinusitis. Discussion A sneeze, although usually benign, causes a significant increase in intranasal pressure. When coupled with a history significant for facial trauma or rhinosinusitis, this rise in pressure can be sufficient to cause fracturing of the bone overlying a paranasal sinus, leading to the formation of SCE.

Objectives/Hypothesis: We have previously described a novel, automated, nonrigid, model-based method for determining the intrascalar position of cochlear implant (CI) electrode arrays within human temporal bones using clinically available, flat-panel volume computed tomography (fpVCT). We sought to validate this method by correlating results with anatomic microdissection of CI arrays in cadaveric bones. Study Design: Basic science. Methods: Seven adult cadaveric temporal bones were imaged using fpVCT before and after electrode insertion. Using a statistical model of intracochlear anatomy, an active shape model optimization approach was employed to identify the scalae tympani and vestibuli on the preintervention fpVCT. The array position was estimated by identifying its midline on the postintervention scan and superimposing it onto the preintervention images using rigid registration. Specimens were then microdissected to demonstrate the actual array position. Results: Using microdissection as the standard for ascertaining electrode position, automatic identification of the basilar membrane coupled with postintervention fpVCT for electrode position identification accurately depicted the array location in all seven bones. In four specimens, the array remained within the scala tympani; in three, the basilar membrane was breached. Conclusions: We have anatomically validated this automated method for predicting the intrascalar location of CI arrays using CT. Using this algorithm and pre- and postintervention CT, rapid feedback regarding implant location and expected audiologic outcomes could be obtained in clinical settings. Laryngoscope, 2010

We conducted a retrospective chart review to determine if performing simultaneous nasal surgery and tympanoplasty jeopardizes tympanic membrane graft survival and the surgical outcome. Our study population consisted of 14 consecutively presenting adults with nasal septal deviation and otologic pathology who had undergone simultaneous nasal and otologic procedures at an academic tertiary care medical center. Surgical procedures included septoplasty and bilateral inferior turbinate submucous reduction with concurrent primary or revision tympanoplasty with or without mastoidectomy and ossicular chain reconstruction. Follow-up ranged from 1.8 to 29.8 months (mean: 12.8 ± 10.8). The primary outcomes measures were tympanic membrane graft survival and surgical success; the latter was defined as an absence of middle ear effusion and a lack of need for pressure-equalization tube placement in patients with intact grafts. We found that 13 of the 14 tympanic membrane grafts (92.9%) survived at the most recent follow-up and that 11 patients (78.6%) achieved an aerated middle ear without the need for a pressure-equalization tube. These rates compare favorably with those quoted in the literature for tympanoplasty performed without concomitant nasal surgery. We conclude that septoplasty can be safely and effectively performed at the same time as tympanoplasty with or without mastoidectomy with no increase in the risk of surgical failure.

Objectives/Hypothesis. Exostoses of the external auditory canal are benign bony tumors associated with frequent cold-water exposure. Obstruction may lead to conductive hearing loss and recurrent otitis externa, requiring surgical correction when symptoms become intolerable. This study aimed to characterize the prevalence of exostoses in white-water kayakers and identify associated risk factors and protective measures. Study Design. Cross-sectional. Methods. Six hundred eleven white-water kayakers from across the United States were included in the study. Percent occlusion was graded as minimal ( 75%). Subjects completed a survey of risk factors and protective measures. Kruskal-Wallis and χ2 tests were performed to determine significant associations with percent occlusion. A multivariate proportional odds regression model was fit to adjust for confounding between the variables. Results. The prevalence of exostoses in kayakers was 79% (482/611); 13% (78/611) had ≥75% occlusion. Percent occlusion was associated with total years kayaked (P < .001), frequency ≥1 day/week (P < .001), male gender (P < .001), and increasing age (P = .005), although frequency, gender, and age were confounded by total years. Styles that involve repeated submersion were also associated with greater occlusion (freestyle, P = .036; squirt, P = .016). Subjects who used earplugs for a greater proportion of their kayaking career were less likely to have exostoses (P < .001). When adjusted for confounding, only total years (P = .0003) and age (P = .0027) remained significant. Conclusions. Kayakers are the first inland population to experience exostoses at the rates seen in coastal populations (e.g., surfers). When used long-term, earplugs may be protective. Laryngoscope, 2010

Cochlear implantation is a procedure performed to treat profound hearing loss. Accurately determining the postoperative position of the implant in vivo would permit studying the correlations between implant position and hearing restoration. To solve this problem, we present an approach based on parametric Gradient Vector Flow snakes to segment the electrode array in post-operative CT. By combining this with existing methods for localizing intra-cochlear anatomy, we have developed a system that permits accurate assessment of the implant position in vivo. The system is validated using a set of seven temporal bone specimens. The algorithms were run on pre- and post-operative CTs of the specimens, and the results were compared to histological images. It was found that the position of the arrays observed in the histological images is in excellent agreement with the position of their automatically generated 3D reconstructions in the CT scans.

Objectives:(1) Present a case of metastatic calcinosis of the true vocal cords. (2) Discuss the pathogenesis, diagnosis, and treatment strategies for this condition.Methods:This is a case report of a 52-year-old male with a history of end-stage renal disease and tobacco abuse who presented to clinic with complaints of dysphagia, cough, and subtle voice changes. Transnasal fiberoptic laryngoscopy revealed bilateral patches of leukoplakia on the anterior third of the vocal cords. After a 3-month period of conservative management with a proton pump inhibitor and serial scope examinations, the lesions were noted to be slowly enlarging. It was determined that an excisional biopsy should be performed to rule out malignancy. The patient underwent micro-suspension direct laryngoscopy with microflap excision of the bilateral vocal cord lesions.Results:Surgical pathology revealed benign squamous mucosa with calcinosis, parakeratosis, and submucosal hyalinization. These findings were characteristic of metastatic cal...

Evaluate the effectiveness of an educational curriculum on general tracheostomy care principles and determine the effect of this educational curriculum on the level of provider comfort with tracheostomy care.Cross-sectional questionnaire in an academic medical center.A 25-question multiple choice and true/false quiz was given to nonotolaryngology health care providers (nurses and physicians) who routinely provide tracheostomy care. This was followed by an education module, and the quiz was repeated. Participants were also asked to rate their level of comfort (0-100 point scale) managing a tracheostomy before and after the module. A 6-month follow-up assessment was also obtained.A total of 94 health care providers participated in the education module (50 physicians, 37 nurses, 7 fourth-year medical students). The average number of correct answers increased by 3.1 (P 0.001). The level of confidence in tracheostomy care improved by 18.8 points (P 0.001). At the 6-month assessment, there was still a significant improvement in the number of correct questions and level of confidence when compared to preeducation values (P 0.02 for both). There was no significant change in the 6-month values when compared to the posteducation values.A standardized education module for tracheostomy care teaching resulted in significant increases in provider knowledge and confidence. Standardization of tracheostomy education and care is essential in academic hospital medical centers where multiple specialties may be performing tracheostomies and health care providers frequently change.N/A.

Objective: The goal of this study was to use highly accurate nonrigid algorithms to locate the position of cochlear implant (CI) electrodes and correlate this with audiological performance. Patients: After obtaining institutional review board approval, adult patients who had bilateral CIs were identified, and those with preoperative temporal bone computed tomographic scans were asked to return for a postintervention computed tomography. Sixteen adult patients agreed. Demographics, cause of deafness, length of auditory deprivation, and audiological performance were recorded. Intervention: Using a nonrigid model of the shape variations of intracochlear anatomy, the location of the basilar membrane was specified in relationship to the electrode array. The number of electrodes within each compartment of the cochlea was correlated with hearing in noise and consonant-noun-consonant scores for the known confounding variable: length of deafness. Main Outcomes: Mann-Whitney U tests of differences were used to compare the hearing performance resulting from implants completely in the scala tympani (ST) versus those not completely in the ST. Results: Of all implants, 62.5% were fully inserted in the ST; 34.4% were partially inserted into the ST and 3.1% was fully inserted in the scala vestibuli. Controlling for the known contributing variable of length of auditory deprivation, our results show that the location of electrodes in relationship to the scala is not predictive of audiological performance. Conclusion: We have assessed electrode placement and correlated it with audiological outcome. The presence of the electrodes solely in the ST was not predictive of outcome. We estimate that it would take analyzing data of thousands of CI patients before any valid correlations can be made.

Exostoses of the external auditory canal are benign bony tumors associated with frequent cold-water exposure. Obstruction may lead to conductive hearing loss and recurrent otitis externa, requiring surgical correction when symptoms become intolerable. This study aimed to characterize the prevalence of exostoses in white-water kayakers and identify associated risk factors and protective measures.Cross-sectional.Six hundred eleven white-water kayakers from across the United States were included in the study. Percent occlusion was graded as minimal (25%), moderate (25%-75%) or severe (75%). Subjects completed a survey of risk factors and protective measures. Kruskal-Wallis and chi(2) tests were performed to determine significant associations with percent occlusion. A multivariate proportional odds regression model was fit to adjust for confounding between the variables.The prevalence of exostoses in kayakers was 79% (482/611); 13% (78/611) hador=75% occlusion. Percent occlusion was associated with total years kayaked (P.001), frequencyor=1 day/week (P.001), male gender (P.001), and increasing age (P = .005), although frequency, gender, and age were confounded by total years. Styles that involve repeated submersion were also associated with greater occlusion (freestyle, P = .036; squirt, P = .016). Subjects who used earplugs for a greater proportion of their kayaking career were less likely to have exostoses (P.001). When adjusted for confounding, only total years (P = .0003) and age (P = .0027) remained significant.Kayakers are the first inland population to experience exostoses at the rates seen in coastal populations (e.g., surfers). When used long-term, earplugs may be protective.

Objective Perinatal pharyngoesophageal instrumentation, including endotracheal intubation, oral suctioning, and feeding tube placement, is often necessary but risks tissue damage. Our objective was to estimate the incidence of iatrogenic perinatal pharyngoesophageal injury (IPPI) in preterm versus term infants in a children's hospital neonatal intensive care unit (NICU). A secondary goal was to explore the clinical characteristics and outcomes associated with these complications. Methods All NICU discharge summaries from 2004 to 2008 were searched for IPPI-related keywords. Highlighted records were reviewed and the incidence of complications calculated by gestational age and weight. Results Of 5910 total NICU discharges, 6 cases of IPPI were identified, for an overall incidence of 0.10%. All injuries occurred in infants less than 33 weeks gestational age and 1500 g, with a trend towards higher incidence with increasing prematurity. The incidence of IPPI rose to 4/1321 (0.30%) at 27–32 weeks and 2/521 (0.38%) at less than 27 weeks gestation. Similarly, IPPI occurred in 3/675 (0.44%) babies born at 1000–1500 g and 3/642 (0.47%) babies below 1000 g. All affected infants survived with conservative management. Conclusions IPPI is a rare but serious complication of perinatal airway instrumentation and is primarily a disease of prematurity. In this sizeable cohort, no complications occurred in term infants, and the incidence of injury increased with decreasing gestational age and weight. This increased propensity towards injury should prompt special care when performing even routine airway procedures on premature neonates.

Establish the time required to perform cochlear implantation (CI) in academic settings.Historical cohort study.German and American academic centers.A total of 2639 patients underwent CI (1997-2007). We excluded patients receiving an experimental device or technique and those with abnormal cochlear anatomy or incomplete charts, leaving 2253 for analysis.Unilateral, bilateral, and revision CI with devices approved in the U.S. and Europe.Mean surgical time (ST) and total operating room time (TORT).Mixed model analysis was used; estimated marginal means were calculated in minutes after adjusting for random effect of individual surgeon. There were no differences between unilateral (ST = 171, TORT = 245) and revision CI (ST = 160, TORT = 232), but bilateral procedures were longer (ST = 295, TORT = 377, P0.001). In unilateral surgeries, Cochlear Limited (CL) devices were implanted faster (ST = 165, TORT = 225) than Advanced Bionics (ABC) (ST = 183, P = 0.001; TORT = 240, P = 0.023) or MedEl (ST = 193, P0.001; TORT = 253, P = 0.002) devices. There were no differences for unilateral CI between ABC and MedEl devices. For revision CI, ABC devices (ST = 141, TORT = 219) were implanted faster than CL devices (ST = 181, P = 0.001; TORT = 266, P0.001). There were no differences by age group or between Germany and the U.S. ST and TORT were shorter for 575 CIs performed in the final two years of the study (unilateral CI: ST = 145, TORT = 209; bilateral CI: ST = 259, TORT = 330; revision CI: ST = 138, TORT = 205). For unilateral CI, ST and TORT decreased yearly (linear regression, P0.001) and inversely correlated with surgeon experience (linear regression, P0.01).We report the time required to perform CI in academic settings-data that are vital for cost-benefit analyses and assessing new CI techniques.

Antibiotic resistant strains of Staphylococcus aureus pose a growing threat to public health, and immunotherapy offers potential modalities to combat antibiotic resistance. We prepared bispecific monoclonal antibody complexes (heteropolymers, HP), specific for the primate erythrocyte complement C3b receptor (CR1) and type 5 capsular polysaccharide of the T5 isolate of S. aureus. Fluorescence microscopy and flow cytometry revealed that HP promote binding of S. aureus to human erythrocytes. Incubation of erythrocyte-bound, HP-opsonized S. aureus with human monocyte/macrophages or mouse macrophage cell lines led to transfer, internalization and killing of bacteria by macrophages with little erythrocyte loss. This reaction is similar to the process in which C3b-opsonized substrates, bound to erythrocyte CR1 by immune adherence, are transferred to acceptor phagocytes. Our results provide the basis for development of an in vivo paradigm focused on immunotherapeutic approaches for treatment of infections due to antibiotic resistant bacteria.

We investigated deposition of the complement protein fragment C3b and its breakdown products (collectively designated as C3b(i)) on CD20-positive cells treated with rituximab (RTX) in the presence of normal human serum (NHS). Radioimmunoassay (RIA) demonstrates that about 500 000 C3b(i) molecules deposit per cell, and fluorescence microscopy reveals that C3b(i) colocalizes with bound RTX. Use of mAb 3E7, specific for C3b(i) bound to substrates, enhances C3b(i) deposition; > 1 million C3b(i) deposit when cells are incubated with NHS, RTX and mAb 3E7. Treatment of Raji cells in NHS plus RTX leads to robust cell killing (95%) after 24 to 48 hours, and mAb 3E7 significantly enhances RTX-mediated killing of Raji and DB cells. A cynomolgus monkey model based on intravenous infusion of RTX followed by mAb 3E7 demonstrated that RTX rapidly binds to B cells and promotes complement activation and C3b(i) deposition; fluorescence microscopy analyses revealed the same pattern of colocalization of C3b(i) on cell-bound RTX in vivo as observed in vitro. Preliminary in vitro studies with blood samples from patients with chronic lymphocytic leukemia lead to similar findings. These experiments suggest that complement plays a key role in the mechanism of action of RTX; moreover, the in vivo molecular form of RTX (and possibly other antitumor mAbs) in the circulation or in tissues may include C3b(i) molecules covalently bound to the therapeutic mAb, thus allowing it to interact with cells containing both Fc and complement receptors.

High avidity anti-dsDNA IgG antibodies are believed to play an important role in the pathogenesis of the autoimmune disease systemic lupus erythematosus (SLE) and therefore attempts have been made to reduce the concentration of these antibodies in the bloodstream of SLE patients. Previously we reported the development of an antigen based heteropolymer (AHP), a bispecific complex prepared by using the avidin-biotin system to crosslink dsDNA to a mAb specific for the human erythrocyte (E) complement receptor. Our studies indicated that this AHP could bind anti-dsDNA antibodies to E and facilitate clearance of these autoantibodies from the circulation of a monkey without E destruction. Here we report an improved covalent crosslinking procedure and purification scheme in which the AHP construct is isolated by precipitation in 50% saturated ammonium sulfate. We used a dsDNA binding dye, PicoGreen, to demonstrate specificity of binding of dsDNA to E via the AHP. The efficacy of the AHP in binding IgG anti-dsDNA antibodies to E was demonstrated in a sensitive and quantitative assay, based on the time resolved fluorescence properties of europium-labeled anti-human IgG mAbs used to probe the E. We also used this assay to screen SLE patient and normal plasmas for levels of anti-dsDNA IgG. The results of this assay correlate very well with the Farr assay, and therefore this approach may be useful in the development of informative and specific assays for a variety of autoantibodies. Treatment of SLE plasmas with E-AHP under conditions close to physiological led to substantial reductions (> or = 90%) in anti-dsDNA titers. It should be possible to test these new AHP for their ability to target and safely remove IgG anti-dsDNA antibodies from the circulation in animal models.