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.

Immunohistochemical study of nasal mucosa in patients with common variable immunodeficiency

The presence of immunoglobulin (Ig)-producing cells was studied immunohistochemically in nasal mucosa obtained from adult patients with common variable immunodeficiency. In 11 of 19 biopsy specimens no such cells could be detected and with one exception very few appeared in the others. Distinct sign of epithelial IgM transport mediated by secretory component (SC) was seen in three specimens although the epithelial distribution of SC appeared normal in all cases. All patients had recurrent lower respiratory tract infections and 16 had recurrent infections of the upper respiratory tract. The localization of the infections primarily to the respiratory tract might be explained by the fact that the immunodeficiency, as reflected by the low serum Ig concentrations, was still more severely expressed at the B cell level in the nasal mucosa.

Transection of varicose vessels in the nasal mucosa of patients with recurrent epistaxis. A 2-year follow-up

Twenty-two patients with recurrent nose bleeds and varicose vessels on the nasal septum were subjected to transection of the vessels and followed-up for 2 years. One month after the operation, it was not possible to identify the original vessels. In other locations new varicose vessels began to appear after 1 month, and at the end of the follow-up period were observed on 9 out of 10 operated sides. The transection resulted in an immediate decrease in the frequency of nose bleeds and at the end of the control period 12 (55%) of the patients had had less than 4 bleeds during the previous year in spite of the observed rapid formation of new vessels. Mucosal atrophy with symptoms of increased nasal crusting occurred in 3 patients. Transection of varicose vessels in patients with nose bleeds leads to a decrease in the number of bleeds.

Changes in the nasal mucosa of habitual nose-bleeders

121 habitual nose-bleeders were investigated. In all but one, local changes were found in the nasal mucosa. Abnormal vessels (varicose vessels, telangioma, or a network of small vessels) were found in 102 (84%), and 18 (15%) had mucosal atrophy (rhinitis anterior sicca or septal perforation) without abnormal vessels. The occurrence of abnormal vessels was significantly increased when the bleeders were compared with subjects in a control group. Mucosal atrophy was also significantly more common in the habitual nose-bleeders but only in association with abnormal vessels. Varicose vessels were the most frequent abnormality in both the habitual nose-bleeders and the control group. Telangiomas were only present in the habitual nose-bleeders. Heredity seems to be important in explaining the occurrence of varicose vessels as well as telangiomas in habitual nose-bleeders.

Reconstruction of the anterior nasal septum by transplantation

Different implantation materials have been used for reconstruction of the infrastructures of the nose. Preserved allografts from the nasal septum or autografts from costal cartilage are regarded as the best. A new technique for reconstruction of the anterior septum has been used in 14 patients during 1979-1982. A pocket (13-18 mm X 22-27 mm) was first prepared between the mucous membranes from the nasal spine to the dorsum of the nose. With a piece of 1 mm thick Silastic as a model a cartilage graft was taken from the superior part of the auricle. The perichondrium on both sides was preserved to permit a good revascularisation, keep the cartilage viable and prevent resorption. The graft was kept in place in the pocket with Silastic splint on each side of the septum for two weeks. In none of the patients was any resorption noted.

Occurrence of epistaxis in habitual nose-bleeders and analysis of some etiological factors

The occurrence of epistaxis in 121 habitual nose-bleeders has been analysed together with the importance of different etiological factors. Heredity for recurrent nose-bleeds was noted by 42% of the bleeders, which was significantly more than in the control group (p less than 0.001). The start of the nose-bleeds was mostly spontaneous. Both common cold and stress or tiredness were frequently experienced before the occurrence of the nose-bleeds. The blood pressure distribution of the habitual nose-bleeders did not differ from that of the population samples used for comparison. Diseases reported by the habitual bleeders were few, and the blood routine tests revealed only few diseases that could be related to the recurrent nose-bleeds.

Nasal mucosa changes after acute and long-term exposure to dicumylperoxide. An experimental study on animals

Workers exposed to dicumylperoxide at a chemical plant had crusting and increased occurrence of visible superficial mucosal vessels in the anterior part of the nasal septum. To elucidate the pathogenesis of their symptoms we examined rabbits after acute and long-term experimental airway exposure to dicumylperoxide. An increased amount of mucus containing red blood cells were seen after one hour exposure, as were many club-shaped or distorted cilia. Areas lacking cilia but still covered with microvilli and with goblet cells appeared after a week. After one month's exposure scattered islands with metaplastic, non-ciliated cells were observed and many of the ciliated and microvilli-covered cells, not only the cilia per se, appeared distorted. Goblet cells, scarce in the controls, were observed in increased frequency. Blood vessels with thick, non-fenestrated endothelium were observed in increased frequency and remained two months after the exposure. Free radical scavengers seem to reduce the extent of damage supporting our hypothesis of peroxides as damaging agent.

The nasal mucosa in immunodeficiency. Surface morphology, mucociliary function and bacteriological findings in adult patients with common variable immunodeficiency or selective IgA deficiency

Twenty-two adult patients suffering from common variable immunodeficiency (CVID) and sixteen patients with selective IgA deficiency were examined with regard to the mucocilliary function of the nose. The surface structures of the nasal mucosa, e.g. cell distribution and degree of destruction and metaplasia, were judged from scanning electron microscopy of nasal biopsies. Bacteria were isolated from nasopharyngeal swabs. The results of the clinical and morphological investigations were analysed with regard to the duration of the disease and possible benefit of adequate prophylaxis with immunoglobulin. It was found that patients with CVID had a slower mucociliary transport rate and more extensive mucosal damages than patients with selective IgA deficiency. Most likely these alterations were due to repeated infections as patients who had had few infections or adequate immunoglobulin prophylaxis (CVID patients) had better mucociliary function and showed less extensive mucosal changes. Potentially pathogenic bacteria in the nasopharynx were found in equal numbers in both patient groups.

Infections of the nose and paranasal sinuses in adult patients with immunodeficiency

Twenty-two patients with common variable immunodeficiency (CVID) and 18 patients with selective IgA deficiency were examined with respect to previous and present infections of the upper respiratory tract (URT), especially of the nose and paranasal sinuses. Recurrent acute rhinosinusitis was common in both groups of patients, but the development of chronic rhinosinusitis was only found in patients with CVID, indicating the more severe nature of this condition compared with selective IgA deficiency. The infections of the URT occurred several years before the appearance of lower respiratory tract (LRT) infections. Once the infections of the LRT had started, the patients had a tendency to neglect the symptoms from the URT. Early detection of antibody deficiency syndromes is of vital importance for prevention of repeated and chronic infections often causing tissue damage in the respiratory tract.

Goblet cell number in the nasal mucosa relates to cell-mediated immunity in patients with antibody deficiency syndromes

Histopathological changes in the nasal mucosa were studied in biopsies from the inferior turbinate in 22 patients with common variable immunodeficiency (CVID) and 16 patients with selective IgA deficiency. Most patients with CVID had fewer goblet cells than the healthy controls (p less than 0.001), whereas patients with selective IgA deficiency often had manyfold increased numbers (p less than 0.001). The number of goblet cells showed a significant (p less than 0.001) relationship to the cell-mediated immune function. Patients with lowered cell-mediated immune function, as measured by in vivo and in vitro tests, showed reduced numbers or lack of goblet cells. These patients had an increased number of subepithelial, seromucous gland acini compared with healthy controls (p less than 0.01) and patients with selective IgA deficiency (p less than 0.05). The production of mucus may be a compensatory mechanism, participating in the protection of the mucosal surface of the antibody-deficient patient. The increase in the number of goblet cells, but not of subepithelial, seromucous gland acini seems dependent on the cell-mediated immune system.

Structural and functional aspects of cells in the nasal mucociliary system

The regulation of the fluid balance of the mucus is important for a good function of the mucociliary system in the nose. The nasal glands and the goblet cells have been proposed to be the main source of fluid. Microvilli-equipped epithelial cells, ciliated and nonciliated, constituting 70% to 90% of the cells on the turbinates in the nose, are of importance for the regulation of the hydration of the mucus. These cells have the same characteristics as other fluid-secreting cells elsewhere in the body. They have microvilli, a terminal web, folding of the basolateral membrane, and numerous cell organelles. Blockage of the energy supply strongly reduces the fluid secretion.

Formation of new blood vessels in the nose after exposure to dicumylperoxide at a chemical plant

Eighteen workers exposed to dicumylperoxide in a chemical plant were subjected to examination of the nose by rhinoscopy, mucociliary function test and rhinomanometry. Eight other workers at the plant and 20 hospital workers were used as controls. The mucociliary function and nasal air flow were the same in subjects exposed and those not exposed to peroxide. Nine of the workers exposed to dicumylperoxide had visible blood vessels in the mucosa on the anterior part of the nasal septum. Only 2 persons in the other groups had visible blood vessels. Both had a common cold at the time of the examination. The possibility that dicumylperoxide may initiate formation of new blood vessels is discussed. To test this hypothesis, experiments on laboratory animals will be done with airborne dust containing peroxides.