Skeletal muscle sodium and potassium changes after successful surgery in acromegaly: relation to body composition, blood glucose, plasma insulin and blood pressure

The aim of this study was to investigate the skeletal muscle sodium/potassium (Na/K) ratio in acromegaly before and 1 year after trans-sphenoidal removal of a growth hormone (GH)-secreting pituitary adenoma. Muscle biopsies were taken and skeletal muscle electrolytes, body composition, glucose, insulin and blood pressure were studied. Fasting blood glucose and plasma insulin levels, but not blood pressure, were higher in acromegalic patients (N = 9) than in controls (N = 6). The skeletal muscle potassium content was higher (p < 0.01) but the sodium content and the Na/K ratio were lower (p < 0.05 and p < 0.001, respectively) in untreated patients with acromegaly as compared to weight-matched healthy controls. Elevated GH, glucose and insulin levels normalized after surgery. Blood pressure remained unchanged. The total body potassium content, the lean body mass and the total body water content decreased and the body fat content increased while the body weight was unchanged. The skeletal muscle potassium content decreased from [medium (range)] 9.8 (9.2-11.5) to 7.7 (5.7-9.5) mmol/100 g wet wt (p < 0.001). The skeletal muscle sodium content increased from 2.8 (2.5-3.9) to 5.1 (4.3-6.7) mmol/100 g wet wt (p < 0.001) and the Na/K ratio increased from 0.28 (0.26-0.38) to 0.56 (0.51-1.18) (p < 0.001) after surgery, which is a higher level than the controls with a Na/K ratio of 0.47 (0.39-0.84) (p < 0.01). These changes seem to be mediated by a decreased GH effect on the Na/K pump after successful trans-sphenoidal surgery in acromegaly.

Potential impact on tumor control and organ preservation with cisplatin and 5-fluorouracil for patients with advanced tumors of the paranasal sinuses and nasal fossa. A prospective pilot study

METHODS

Twelve patients with advanced epithelial nonadenocarcinoma of the paranasal sinuses and nasal fossa were treated with three cycles of cisplatin (100 mg/m2, day 1) and 5-fluorouracil (1000 mg/m2/24 hours on days 1-5 by continuous infusion), followed by preoperative external radiation therapy of 48 Gy and limited surgery, clearing the paranasal sinuses and nasal fossa.

RESULTS

After chemotherapy, 11 of 12 patients were free of the previous symptoms of disease. Clinical response rates were different, however, with an overall response rate of approximately 70% with no complete responses. Histopathologic analysis of resected specimens showed no vital tumor in eight patients, minimal microscopic disease in three patients, and infiltrating tumor in one patient. Local control was achieved in 11 of 12 patients. Ten patients are alive with no evidence of disease (mean follow-up, 27 months). Surgical mutilation was avoided, with no functional or cosmetic loss.

CONCLUSIONS

The results of this small pilot study seem to indicate a high chemosensitivity of carcinomas of the paranasal sinuses and nasal fossa, which, in this study, has meant significant relief of symptoms and an unusually high rate of local control (90%) without mutilation.

Clinical evaluation of the nasal dilator Nozovent. The effect on snoring and dryness of the mouth

When the lateral walls of the nostrils are dilated with Nozovent, inhalation requires less force, thus reducing the risk of vibrations of the soft palate creating the snoring sound. There is also less need for mouth-breathing. When 17 patients were tested during 10 nights, every second night using Nozovent, the sleeping partners noted significantly less snoring these nights than during the nights without Nozovent. The patients themselves also noted significantly less dryness of the mouth when they dilated the nostrils with Nozovent, being able to avoid mouth-breathing.

The effects of nasal dilation on snoring and obstructive sleep apnea

The effects of nasal valve dilation on snoring and obstructed breathing were studied in 11 patients with habitual snoring and/or obstructive sleep apnea. The anterior part of the nose, the valve region, was dilated by means of a plastic device. Ten patients underwent polysomnographic investigation including pulse oximetry and measurement of snoring noise with and without the nasal dilator in a randomized manner. Snoring, nocturnal arousals, and daytime hypersomnolence were rated by the patient and partner on a questionnaire before and after a 10-day treatment period with the dilator. The nasal airflow, as assessed by rhinomanometry when awake in the sitting position, increased by 18% (range, 5.5% to 45%) when the nasal dilator was used. The frequency and severity of obstructed breathing decreased significantly with the nasal dilator. The apnea index with and without the nasal dilator was 6.4 (range, 1.3 to 15) and 18 (range, 1.8 to 60), respectively. The mean decrease of the apnea index was 47%. The overnight minimum arterial oxygen saturation (with and without the nasal dilator was 84% (range, 76% to 88%) and 78% (range, 68% to 89%), respectively. There was a substantial decrease in snoring noise (number of epochs with Leq values, equal energy level, above 55 or 60 dB) with the dilator in all patients who presented with snoring noise above these levels during the control night. No subjective effects on arousal frequency or daytime hypersomnolence were reported. Four of 11 patients were positive to continue using the nasal dilator.

Regenerating human nasal mucosa cells express peptide growth factors

The goal of this study was to investigate if the distribution of peptide growth factors in the human nasal mucosa could be correlated to its maintenance and to repair processes. Biopsy specimens from clinically healthy humans, aged 6 months to 70 years, were investigated immunohistochemically. In the intact human nasal mucosa, only scattered basal epithelial cells and rare, randomly distributed cells in the lamina propria expressed peptide growth factor immunoreactivity. In contrast, in areas with deficient epithelial lining and infiltration of inflammatory cells, intense insulinlike growth factor I immunoreactivity was demonstrable in reactive epithelial cells, while adjacent, more differentiated cells were nonreactive. Vascular wall cells, fibroblasts, macrophages, and exocrine gland cells in the reactive nasal mucosa showed variable insulinlike growth factor I immunoreactivity and, at lower frequencies and intensities, immunoreactivity to insulinlike growth factor II, basic fibroblast growth factor, platelet-derived growth factor, and transforming growth factor beta, as did cells in the normally nonreactive exocrine glands. Macrophages and vascular smooth-muscle cells could in addition express platelet-derived growth factor immunoreactivity. Increased cell proliferation was recognized in reactive areas of the nasal mucosa specimens, ie, in those concomitantly showing distinct peptide growth factor immunoreactivity. We concluded that a complex pattern of peptide growth factor immunoreactivity is transiently expressed by reactive and regenerating nasal mucosal cells, contrasting with the nonreactive normal, differentiated cells. The close correlation between the appearance of peptide growth factors and the local repair and maintenance processes supports our working hypothesis that peptide growth factors are of functional importance for the nasal mucosa.

Nasal mucosal changes in children treated with gammaglobulin. Aspects on middle ear pathology and nasopharyngeal bacteriology

The present study was undertaken to evaluate possible beneficial effects of gammaglobulin treatment every 3 weeks during 6 months of 6-month to 2-year-old children. Every second of 44 children with recurrent acute otitis media (RAOM) received gammaglobulin, the other 22 served as controls. Nasal mucosal biopsy specimens were taken at 6-month intervals and analysed by light microscopy (LM) and scanning electron microscopy (SEM). Additional biopsies were obtained from another 15 children with RAOM and from 27 "healthy" children. No morphological differences in nasal mucosa could be demonstrated between the gammaglobulin treated and non-treated children. The structural changes observed in the first biopsy specimens usually persisted for at least 6 months, i.e. the study period, and were most prominent in the epithelium. Children with two or more episodes of acute otitis media (AOM) during the study period had more microabscesses compared to the children without any episode of AOM. Microabscesses were also more common in cases with secretory otitis media compared to cases with normal middle ear status. No morphological differences could be revealed related to the age of the children. Microabscesses, cell destruction and discontinuity of the epithelial lining were more common in children who harboured Branhamella catarrhalis in their nasopharynx. We conclude that intramuscular administration to children of gammaglobulin every 3 weeks during half a year neither improved their resistance to RAOM nor reduced the frequency or extent of structural changes in their nasal mucosa.

The importance of nose-breathing for the systolic blood pressure rise during exercise

The effect of nose breathing on the systolic blood pressure was examined in ten healthy men. Nose breathing was increased above normal by exercise and tested by maximum bicycle ergometry. When the anterior part of the nose was dilated with Nozovent the nasal airflow increased by on average 29%. In this condition, all ten men could cycle at maximum load without mouth breathing and there was a significantly lower increase (13 mmHg) in the systolic blood pressure than when the nasal dilator was not used. The reason for this lower blood pressure increase is unknown. The hypothesis is put forward, however, that facilitated nose breathing decreases the respiratory work, which in turn lowers the systolic blood pressure during exercise.

Snoring can be reduced when the nasal airflow is increased by the nasal dilator Nozovent

The ability to breath through the nose can be increased above normal by dilating the narrow nasal valve area with the plastic nasal device Nozovent. For 10 nights, 10 patients used Nozovent every other night, and the sleeping partners of the patients judged the snoring sound level using a snoring score. The results showed a significant decrease in snoring, from moderate to slight, when Nozovent was used, or from a barely tolerable to a tolerable noise level. In about 1 night out of 4, when the nostrils were dilated, the sleeping partners did not note any snoring at all. An increased nasal airflow is achieved with less negative intrathoracic pressure, which presumably results in less opportunities for vibrations of the soft palate.

Decompression of the orbit using a lateral rhinotomy approach in patients with malignant endocrine exophthalmos

Malignant endocrine exophthalmos is a complication seen in 1-2% of patients treated for thyrotoxicosis. A variety of surgical techniques have been used to prevent loss of vision due to compression of the optic nerve. In this study, nine patients with rapidly diminishing vision were operated upon using a lateral rhinotomy technique creating the largest possible space for expansion into the nose and decompressing the optic nerve far back in the orbit. In all patients the vision was improved 1 year after surgery and the proptosis was decreased.

Extensive variations in nasal mucosa in infants with and without recurrent acute otitis media. A scanning electron-microscopic study

Biopsy specimens of the nasal mucosa from the inferior turbinate of infants aged 2 to 26 months were examined by scanning electron microscopy. The specimens were obtained from 23 clinically healthy infants and compared with those from 43 infants with recurrent acute otitis media (RAOM). Potentially pathogenic bacteria were isolated from 61% of the control subjects and 90% of those with RAOM. Infants with RAOM had about as extensive alterations as the healthy ones. A single healthy child and one with RAOM had what was interpreted as a normal nasal mucosa; all others showed reduced frequencies of ciliated cells, deformation of cilia, extensive loss of normal mucosal epithelium, and metaplasia in their nasal epithelial lining. Severely damaged area could be seen close to more normal ones. Nasal mucosa in clinically healthy infants rarely had a normal appearance, probably due to frequent infections and the fairly long time needed for the repair process. We proposed that the high frequency of damaged, incompletely healed nasal mucosa may constitute an important factor with regard to the susceptibility to further infections.

Involution of juvenile nasopharyngeal angiofibroma with intracranial extension. A case report with computed tomographic assessment

In September 1979 the patient, a man born in 1964, noticed pain and swelling of the right cheek in combination with periods of epistaxis. A computed tomographic scan revealed a tumor extending from the middle of the right nasal cavity into the right maxillary antrum and up toward the orbital floor with destruction of the medial and lateral walls of the antrum and continuing into the sphenoid sinus on the right side and dorsal to the pterygoid process up under the base of the skull. Angiography showed arterial supply mainly from the right external carotid artery, but also from the right internal carotid artery and the left external carotid artery. The process was diagnosed as a juvenile nasopharyngeal angiofibroma. In spite of two attempts at resection of the tumor and arterial embolization, the tumor progressed intracranially. Further operative attempts were decided against, and the patient was followed with repeated computed tomographic scans. The tumor eventually became involuted; eight years after the initial diagnosis, there was no evidence of computed tomographic scans of intracranial growth of the tumor.

Immunohistochemical demonstration of insulin-like growth factor I in inflammatory lesions in Wegener's granulomatosis and idiopathic midline destructive disease

The immunoreactivity of the trophic peptide insulin-like growth factor I (IGF-I; somatomedin C) was mapped in nasal mucosa biopsies from three patients with Wegener's granulomatosis (WG) and one with idiopathic midline destructive disease (IMDD; idiopathic midline granuloma). Strongly increased IGF-I immuno-reactivity restricted to cells bordering and in vessel walls and in granulomas (WG) was demonstrated, while necrotic and noninflammatory areas were negative. Treatment with steroids and cyclophosphamide reduced the IGF-I immunoreactivity. The abnormally increased IGF-I immunoreactivities in WG and IMDD probably reflects the reactive growth processes in diseased tissue and is not thought to be the primary cause of either disease. IGF-I may be formed locally by cells in and close to the vascular walls in areas with active disease resulting in e.g. vascular growth, granuloma formation, and finally vessel obliteration and necrosis. IGF-I is likely to form, possibly in concert with other trophic factors, a link in the chain of events resulting in the tissue abnormalities in WG and IMDD.

Plasma growth hormone profile in acromegaly before and ten days after transsphenoidal surgery

Profiles of plasma GH, plasma somatomedin-C and serum PRL concentrations as well as serum GH response to iv TRH were determined in 11 patients with acromegaly before and 10 days after surgery. Blood for profile determinations was drawn from a peripheral vein with a continuous withdrawal pump changing the recipient tube at 30-min intervals. Before surgery all patients had high plasma GH concentrations with irregular peaks and somatomedin-C concentrations were elevated. The response to TRH was abnormal in 8 patients. Three patients had slightly elevated PRL concentrations and one had high PRL concentration (6900 mU/l). Ten days after surgery GH concentrations were still high in 2 patients (greater than 5 mU/l), as were somatomedin-C concentrations (3.2 and 2.4 U/l, respectively). In 3 patients basal GH concentrations were less than 5 mU/l and somatomedin-C concentrations were normal, but there were no major peaks in plasma GH concentrations. In 2 patients major peaks in GH concentrations appeared after surgery, but basal GH concentrations were 1.9 and 0.95 mU/l, respectively. One patient with hyperprolactinemia still had slightly elevated PRL concentration (486 mU/l), but the response to TRH was normalized. Finally, in 4 patients, mean GH concentrations were markedly reduced, somatomedin-C concentrations normalized and apparently normal plasma GH profiles appeared with low or undetectable basal levels separating major peaks. The results indicate that in some patients with acromegaly apparently normal GH secretion can be demonstrated 10 days postoperatively. Characterization of circadian GH rhythms during the early postoperative stage may contribute to the evaluation of the effect of surgery.

Improvement of the nasal airflow by the nasal dilator Nozovent

The lateral wall of the nostril is considered as the functional unit in the regulation of the nasal resistance causing more than half of the total resistance. In 16 test-subjects both nostrils were dilated with a plastic nasal device, Nozovent, and the airflow through the nose was measured with and without the device. In each object the mean value of ten inspirations at 150 Pa was calculated. Before the application the mean value of the subjects was 0.68 l/sec and with the device 0.84 l/sec. The improvement of airflow was comparable with that of treatment with nose-drops. The device ought to be helpful in patients with or without collapsing ala nasi during the night to increase nasal airflow when sleeping.

Insulinlike growth factor I immunoreactivity in nasal polyps

Nasal polyps from 15 patients were all found to express increased insulinlike growth factor I immunoreactivity. A hypothesis for the formation of nasal polyps is described: macrophages, seen in allergic and infectious reactions, produce and release growth factors, tentatively including insulinlike growth factor I. In enclosed paranasal sinuses this results in an accumulation of insulinlike growth factor I stimulating the growth of both epithelium and blood vessels in the sinuses. The mucosa increasingly bulges out through the ostium after having filled out the sinusity. Continuing growth stimulation is supplied by the inflammatory reaction, endothelial cells in the polyp, and activated macrophages inside or outside the polyp.

A lateral rhinotomy approach to transsphenoidal hypophysectomy

The transsphenoidal approach to the sella turcica is nowadays more often used than the transcranial. The disadvantages of the transantral and transseptal approaches are a narrow and distant operative field and various complications. A fluoroscope often has to be used for orientation. With our lateral rhinotomy technique, no fluoroscope is needed as the whole sphenoid can be inspected. Furthermore, the operative field is wide and closer to the surgeon, few instruments are needed, bleeding is easily controlled, the anterior wall of the sella can be properly sealed, CSF rhinorrhoea prevented and the sphenoidal mucosa restored. The whole operation can be performed within 2 h. Fifty-seven patients were operated upon with good results and few complications.

Insulin-like growth factor I is a possible pathogenic mechanism in nasal polyps

High concentrations of the trophic peptide insulin-like growth factor I (IGF-I; somatomedin C; SmC) were demonstrated immunocytochemically in all nasal polyps examined, except in areas with necrosis or tissue defects. Most epithelial cells, activated macrophages, and proliferating blood vessels, proved positive, contrasting with the low degree of cellular staining in adjacent normal nasal mucosa. It is proposed that nasal mucosal inflammatory reactions induce local formation and accumulation of IGF-I, which may eventually result in very high IGF-I concentrations in the paranasal sinuses due to the tendency these have to be enclosed, i.e. producing reduced drainage. Assuming that IGF-I constitutes the pathogenic factor, appropriate treatment should be given to reduce the inflammatory reactions and improve drainage.

Juvenile nasopharyngeal angiofibroma. A report of eighteen cases

Juvenile nasopharyngeal angiofibroma is a disease afflicting mainly adolescent males. The lesion is benign but characterized by local aggressive growth. In advanced cases the tumour may extend intracranially. In this study 18 cases of juvenile nasopharyngeal angiofibroma were investigated. Tumour extension was assessed with the use of angiograms and CT and the individual cases staged in four different categories on the basis of tumour extension. Two cases were staged as I (tumour confined to the nasopharynx), 7 cases as II (tumour extending into nasal cavity and/or sphenoid sinus), 8 as III (tumour extending into one or more of the following: antrum, ethmoid sinus, pterygomaxillary and infratemporal fossae, orbit and/or cheek) and one as IV (tumour extending into the cranial cavity). Preoperative arterial embolization was performed in 8 cases. All patients underwent surgery; none received irradiation. The follow-up period was 6 yrs 4 mo (6 months-17 years). In one case of intracranial extension, tumour recurrence occurred. It is concluded that with the aid of CT and arteriograms to evaluate the extension of the tumour and preoperative embolization, this lesion can be cured in the vast majority of cases, with surgery as the method of choice.

Nasal mucosal changes in children with frequent infections

Children with frequent recurrent respiratory tract infections and constant mucopurulent secretion from the nose were thoroughly examined, including bacteriologic and immunologic analyses. Biopsy specimens from the nasal mucosa were investigated by light and electron microscopy. Eight different histopathologic factors were distinguished and evaluated in relation to the continual nasal discharge. The mucus production was increased, due to an increased number of goblet cells or submucosal glands. The mucus transport was impaired owing to a decreased number of ciliated cells or different deficiencies in the structure of the cilia. The secretion of periciliary fluid was altered due to dysfunction of microvilli-equipped cells and the availability of tissue fluid due to vascular changes. Leakage of tissue fluid partly reflects deficiencies in the epithelial lining. Purulent discharge was observed from microabscesses. Reactive changes in the nasal mucosa are described and discussed in relation to treatment schedules aimed at reducing short- and long-term discomfort and complications.

Haemostatic disorders in habitual nose-bleeders

Ninety-one habitual nose-bleeders were screened for haemostatic disorders. 46 screening results in 38 nose-bleeders were outside the normal range. After extended investigation, it was found that 25 (27 per cent) habitual nose-bleeders had haemostatic disorders, all except one in the primary haemostasis. The disorders found could be classified as mild bleeding disorders (MBD) and compared to the estimated frequency of MBD in the population there was an increased incidence of haemostatic disorders in the habitual nose-bleeders. Abnormal vessels in the nasal mucosa were present in 85 per cent of the investigated nose-bleeders, equally distributed between nose-bleeders with and without haemostatic disorders. This indicates that abnormal vessels and haemostatic disorders in habitual nose-bleeders, it is possible to detect previously unknown but clinically important disorders.

Survival after surgical treatment in maxillary neoplasms of epithelial origin

During 1968-1979, 55 cases of epithelial neoplasms originating from the maxillary antrum were diagnosed and treated within the referral area of 1.5 million inhabitants. A majority of the patients were operated upon after pre-operative irradiation therapy (40-50 Gy). No significant difference in survival rate was found between patients operated on by total maxillectomy, including orbital exenteration, and patients subjected to partial maxillectomy. Patients with tumours not completely removed during primary surgery and patients with glandular involvement had a poor prognosis despite additional surgery and radiotherapy. The prognosis for the remaining patients was considerably better, with a 5-year survival rate of 60 per cent.

The clinical condition of IgA-deficient patients is related to the proportion of IgD- and IgM-producing cells in their nasal mucosa

Nasal biopsy specimens from 15 adult patients with selective IgA deficiency but normal IgG-subclass levels were examined by immunohistochemistry for the presence of immunocytes producing various Ig isotypes. The mucosal samples were completely IgA-deficient except in two cases where 0.9% and 8.4% IgA cells were found, respectively (normal, 69.8%). Numerous IgG- (mainly IgG1-) producing cells were present in 10 samples; in five of these there were additional IgM- but virtually no IgD-producing cells, whereas in the other five a marked dominance of the IgD over the IgM isotype was seen. The latter category of patients had more upper airways infections (recurrent acute rhinosinusitis, otitis media, and tonsillitis) than the former, who had no recurrent upper respiratory tract infections except one patient with recurrent acute rhinosinusitis. The five remaining samples, which contained very few Ig-producing cells, were derived from patients with even more frequent infections than those showing IgD predominance. Our results indicate that IgM acts as a compensatory secretory Ig in the upper respiratory tract of some IgA-deficient subjects. However, immunoregulatory events favouring local IgD responses apparently do not support mucosal defence satisfactorily, either because local production of IgM is hampered or because IgD (which is not a secretory Ig) blocks complement-dependent reactions mediated by IgG and IgM antibodies within the mucosa.

Humoral immunity in nasal mucosa of patients with common variable immunodeficiency

Humoral immunodeficiency, as reflected by the low serum immunoglobulin (Ig) concentrations in adult patients with common variable immunodeficiency (CVID), was even more severely expressed at the B-cell level in their nasal mucosa. No Ig-producing cells could be detected by immunohistochemistry in 11 of 19 mucosal specimens. The epithelial distribution of secretory component (SC) was normal in all specimens, but a sign of SC-dependent IgM transport was seen in only three. Epithelial IgA was completely lacking. All patients had had recurrent lower respiratory tract infections and 16 had recurrent or chronic infections of the upper respiratory tract. A previous report indicated that the intestinal mucosa is a privileged site for maturation of B cells in patients with CVID; the present study shows that this does not hold true for the nasal mucosa. This difference in B-cell maturation may in part explain the preferential susceptibility to infections in the respiratory tract of patients with CVID.

Immunohistochemical study of nasal mucosa in patients with selective IgA deficiency

Fifteen nasal biopsy specimens from adult patients with selective IgA deficiency were examined in a 'blind' immunohistochemical study for the presence of immunocytes producing various immunoglobulin (Ig) classes. Three groups of patients could be identified. One group had a predominance of IgG- and IgM-producing cells in their nasal mucosa, a second group revealed mainly IgG- and IgD-producing cells, and a third group had very few mucosal immunocytes. The clinical examinations showed that upper respiratory tract infections were most common in patients with few immunocytes while such infections were least common in patients with predominance of IgG and IgM immunocytes. Our results indicated that IgM, in contrast to IgD, acts as a compensatory secretory Ig in some patients with selective IgA deficiency.