Comparison of Nasal Nitric Oxide Levels between the Inferior Turbinate Surface the Middle Meatus in Patients with Symptomatic Allergic Rhinitis

ABSTRACTBackground: Because of the anatomical complexity and the high output of the human nose, it has been unclear whether nasal nitric oxide (NO) serves as a reliable marker of allergic rhinitis (AR). We examined whether nasal NO levels in the inferior turbinate (IT) surface and the middle meatus (MM) differ in symptomatic AR patients.Methods: We measured fractional exhaled NO (FeNO) and nasal NO in normal subjects (n = 50) and AR patients with mild symptoms (n = 16) or moderate or severe symptoms (n = 27). Nasal NO measurements were obtained using an electrochemical analyzer connected to a catheter and an air-suction pump (flow rate 50 mL/ sec).Results: Compared to the normal subjects, the AR patients showed significantly higher nasal FeNO and nasal NO levels in the IT area. No significant difference in the MM area was observed among the three groups. The MM area showed higher NO levels than the IT area in all three groups. The ratio of nasal NO levels of the MM area to the IT area (MM/IT ratio) was significantly lower in the AR groups. The moderate/severe AR patients showed significantly higher nasal NO in the IT area (104.4 vs. 66.2 ppb) and lower MM/IT ratios than those in the mild AR patients. The analysis of nasal brushing cells revealed significantly higher eosinophil cationic protein and nitrotyrosine levels in the AR groups.Conclusions: Nasal NO assessment in the IT area directly reflects persistent eosinophilic inflammation and may be a valid marker to estimate the severity of AR

Pemphigus Vulgaris with Marked Stenosis of the Esophageal Orifice from an Osteoporosis Drug: a Case Study with Long-term Follow-up

Pemphigus vulgaris produces multiple and intractable erosions of the oral mucosa in the head and neck region. We describe a case of pemphigus vulgaris that showed erosions in the hypopharynx and stenosis of the esophageal orifice from an osteoporosis drug. A 73-year-old woman was admitted with oral intake difficulty and erosions in the hypopharynx. During the first admission, we could not make a definite diagnosis by biopsy or blood examination. The condition of the mucosa worsened subsequently; an esophagram showed marked stenosis of the esophageal orifice. As a possible factor exacerbating the stenosis, an osteoporosis drug was considered. The stenosis was improved by balloon expansion. One year after the first medical examination, we finally made a definite diagnosis of pemphigus vulgaris from the results of a blood examination in which anti-desmoglein 3 turned positive when the hypopharyngeal erosions and stenosis of the esophageal orifice became worse. Systemic treatment with a steroid was effective for the control of pemphigus vulgaris; restenosis of the esophageal orifice was recognized twice during a state of remission, and careful follow-up will be necessary in the future

A Case of Primary Osteosarcoma of the Mandible That Responded to Preoperative Chemotherapy: p16 as a Potential Prognostic Factor

We report a case of mandibular osteosarcoma in a Japanese woman in her 70s who was p16-positive. Despite the rapid growth of the tumor, the patient responded well to chemotherapy and was then able to undergo surgery. Head and neck osteosarcoma (HNOS) is a very rare cancer, and although the importance of surgery has been pointed out, the effectiveness of chemotherapy is unclear. Resection margin negativity and response to chemotherapy have been reported as prognostic factors; another report assessed the effectiveness of the immunohistochemical expression of p16 protein as a predictor of response to chemotherapy

Baseline Neutrophil-to-Lymphocyte Ratio and Glasgow Prognostic Score are Associated with Clinical Outcome in Patients with Recurrent or Metastatic Head and Neck Squamous Cell Carcinoma Treated with Nivolumab

Recurrent or metastatic head and neck squamous cell carcinoma (R/MHNSCC) has a poor prognosis. Although nivolumab is approved in Japan for treating R/MHNSCC, the response rate is low. Therefore, identifying pretreatment prognostic factors is necessary. This study assessed the utility of the neutrophil-to-lymphocyte ratio (NLR) and Glasgow Prognostic Score (GPS) as biomarkers of response to nivolumab. We retrospectively collected the data of 56 R/MHNSCC patients treated with nivolumab between May 2017 and December 2019. The Kaplan–Meier method and log-rank test were used to estimate overall survival (OS) and progression-free survival (PFS), and multivariate Cox hazard regression analysis was used to identify independent predictors of survival. Patients with a low pretreatment NLR had prolonged OS, and patients with a low pretreatment GPS had increased OS and PFS. A performance score (PS) of 0-1, development of immune-related adverse events, and GPS of 0-1 were significantly associated with OS in multivariate analysis. In summary, baseline pretreatment NLR and GPS are independently associated with OS in R/MHNSCC patients treated with nivolumab. Administration of nivolumab while maintaining the PS reflects a immune status of the host and leads to a good OS

Management of Intractable Nasal Hyperreactivity by Selective Resection of Posterior Nasal Nerve Branches

The posterior nasal nerves emerge from the sphenopalatine foramen and contain sensory and autonomic nerve components. Posterior nasal neurectomy is an effective method to remove pathological neural networks surrounding the inferior turbinate that cause unregulated nasal hypersensitivity with excess secretion in patients with severe allergic rhinitis (AR). We describe the sophisticated endoscopic surgical procedure that allows feasible access to the confined area and selective resection of the nerve branches with the preservation of the sphenopalatine artery (SPA). We retrospectively analyzed the cases of 23 symptomatic severe AR patients who failed to respond to standard medical treatment and underwent surgery. There have been no major complications after surgery including nasal bleeding or transient numbness of the upper teeth. The mean total nasal symptom scores (TNSS) were decreased by 70.2% at 12 months after the procedure. Our comparison of the clinical effectiveness based on the number of severed nerve branches revealed that the improvement of the TNSS was significantly higher in patients with >2 branches. We conclude that this minimally invasive technique that preserves the SPA is clinically useful and decreases the rate of postoperative complications. This trial is registered with UMIN000029025

Ganglioneuroma in The Neck Region: A Case Report

Ganglioneuroma, which rarely occurs in the neck region, is a well-differentiated benign tumor of the sympathetic nervous system. A 39-year-old man presented with neck swelling for a year. A giant tumor was located on the left side of the neck. Schwannoma was suspected on preoperative cytology and core needle biopsy, and the postoperative diagnosis on pathological examination was ganglioneuroma. The origin of the tumor was considered to be the sympathetic nervous system based on the postoperative appearance of Horner’s syndrome. The treatment choice for ganglioneuromas is complete surgical resection, contrary to the nerve-sparing resection of schwannomas. Therefore, making the definitive diagnosis before surgical resection could be important. In this report, we focus on the differential diagnosis obtained with radiological findings and the treatment strategy for the tumor with a literature review

Evaluation of Role of Prophylactic Swallowing Rehabilitation in Chemoradiotherapy for Advanced Head and Neck Cancer Using Novel Software Analysis of Videofluorography Images

Concurrent chemoradiotherapy (CRT) for head and neck cancer (HNC) is associated with substantial side effects, most notably those related to swallowing function. Recently, early implementation of protective exercises has been recommended as an important intervention in patients treated with chemoradiotherapy. Several studies, including randomized controlled trials, have evaluated prophylactic swallowing exercises and swallowing outcomes. Although several clinical outcome measures to assess the severity of swallowing dysfunction are available, they are indirect measures. Videofluorography is the most popular and efficient examination that visually demonstrates the dynamic state of swallowing. This study aimed to determine whether prophylactic swallowing rehabilitation provided to HNC patients receiving CRT would result in better swallowing outcomes. Thirty patients were enrolled in this study. Fifteen patients (the control group) received swallowing rehabilitation after CRT on demand, and the other 15 (the rehabilitation group) received prophylactic swallowing rehabilitation from the beginning. Swallowing motion was evaluated with motion analysis software. There were statistically significant differences in hyoid bone displacement, duration of swallowing onset, larynx elevation time, and total swallowing time between the control and rehabilitation groups. Based on the results of this study, prophylactic swallowing rehabilitation seems to reduce the extent and severity of the functional problems that occur after CRT.This study was supported in part by Tsuchiya Medical Foundation Grant (no. 3010281)

Pathological Mechanisms and Clinical Features of Eosinophilic Chronic Rhinosinusitis in the Japanese Population

ABSTRACT: The overall pathological view of paranasal sinus inflammation in the Japanese population has profoundly changed in recent years. Eosinophilic chronic rhinosinusitis (ECRS) is a clinical entity of intractable chronic sinus inflammation accompanied by numerous infiltrations of activated eosinophils in the paranasal sinus mu- cosa and/or nasal polyps. Several pathologic processes are considered to act in concert to promote the accumulation of eosinophils in ECRS. They include infiltration of progenitor cells, increase in local IL-3, IL-5, IL-13, GM-CSF and eotaxin production, and upregulation of adhesion molecules. The role of nasal allergen sensitization and innate immunity responses in the sinus mucosa has also been proposed in the development of ECRS. Various pathogens including TLRs ligands may trigger an abnormal immune response at the mucosal surface. The objectives of ECRS management should focus directly on inhibition of local eosinophil infiltration. Surgical procedures include widely opening the bony wall septum of every affected sinus and mechanical removal of diseased mucosal lesion. The use of local and/or systemic steroids, leukotriene receptor antagonists, and Th2 cytokine antagonists is recommended. Local administration of steroids is a potent treatment strategy for preventing relapse of nasal polyposis and is considered to be the first-line treatment for ECRS patients. KEY WORDS: endoscopic sinus surgery, eosinophilic chronic rhinosinusitis, glucocorticoids, Toll-like receptor, transcription factor

Measurements of Nasal Fractional Exhaled Nitric Oxide with a Hand-held Device in Patients with Allergic Rhinitis: Relation to Cedar Pollen Dispersion and Laser Surgery

Background: There has been an increasing interest in monitoring the fractional concentrations of exhaled NO (FeNO) levels in allergic rhinitis (AR) patients. In the present study, we examined whether the nasal FeNO measurement might reflect the degree of local allergic inflammation as well as subjective symptoms. Methods: The FeNO measurement was performed using a handheld electrochemical analyzer (NObreath®) with a nose adaptor. In the cross-sectional study, 56 patients with perennial AR patients, 18 AR patients with bronchial asthma (BA), 12 patients with vasomotor rhinitis, and 30 normal subjects were enrolled. For the follow-up study, 12 seasonal allergic rhinitis (SAR) patients against Japanese cedar and 10 perennial AR patients who underwent laser surgery were examined. Results: The AR patients and vasomotor rhinitis patients showed significantly higher oral FeNO levels as compared with the normal subjects. The nasal FeNO levels were significantly higher in the perennial AR patients with or without BA than in the normal subjects and vasomotor rhinitis patients. There were positive correlations between the nasal symptom scores and FeNO levels. The SAR patients showed a significant decrease in the nasal FeNO level after the pollen dispersion season. In addition, the therapeutic effects of laser surgery in the AR patients accompanied a significant reduction in the nasal FeNO levels one month after treatment. Conclusions: The nasal FeNO measurement by NObreath® is easy to perform and suitable for monitoring AR patients in various treatment modalities. Furthermore, it may have potential usefulness as a tool to improve daily clinical care