[Rhinosinusitis guidelines--unabridged version: S2 guidelines from the German Society of Otorhinolaryngology, Head and Neck Surgery]

[Initial assessment of ENT emergencies-a feasibility study]

In Germany, an increased volume of patient cases in the emergency department has been observed for several years, many of which do not represent hospital emergencies. To improve the triage and management of patient flows, the Structured Initial Medical Assessment (Strukturierte medizinische Ersteinschätzung in Deutschland, SmED) triage system was developed. This certified medical product is intended to assess both the urgency of everyday complaints and their adequate medical care in a targeted, faster, and safer manner. It supports medical professionals in triage by suggesting courses of action, whereby the ultimate responsibility remains with the professionals themselves. For otorhinolaryngology, a content review was carried out with regard to plausibility and patient safety in the head and neck region on the basis of nine specific emergencies. The cases were simulated by nine otorhinolaryngologists and triaged on the basis of the SmED by medical staff and medical students by assigning a care level and timepoint (urgency). The majority of cases were correctly assigned. The SmED initial assessment system is a good tool for assessing urgent clinical pictures in ear, nose, and throat (ENT) medicine. The long-term goal of the initial assessment is to relieve the capacities of outpatient departments. In order to achieve this and to shorten patient waiting times, it would be necessary to refer patients quickly to otorhinolaryngology. It is therefore necessary to ensure that patients are referred to an ENT on-call service via the online tool.

[Digital volume tomography : Dedicated scanner and cone beam CT with C‑arm systems]

CLINICAL/METHODICAL ISSUE

Digital volume tomography (DVT) and cone-beam computed tomography (CT) with C‑arm systems have become established three-dimensional imaging systems as an alternative to CT in some application areas.

STANDARD RADIOLOGICAL METHODS

The technology of the systems is well developed so that they have become a competing method to CT imaging in terms of image quality and radiation exposure.

PERFORMANCE

An advantage is the better spatial resolution, preferably with dedicated scanner systems, especially in the z direction. The radiation exposure of CT, cone beam CT and DVT are comparable, if the exposure parameter in CT imaging can be adjusted to the lower exposure levels.

ACHIEVEMENTS

Advantages of these systems are that they can be used for imaging in a better workflow or to acquire images under conditions not possible in CT, e. g. imaging under stress in orthopedics or to take images in the corona technique with a horizontal gantry in cone-beam CT mammography PRACTICAL RECOMMENDATIONS: The use of three-dimensional imaging is becoming more frequent and will replace planar radiography in additional clinical situations. The three-dimensional imaging without superpositioning of structures has advantages in the visibility of structures and the spatial relation to other organs and structures. In guidelines and recommendations, the number of recommendations given for the use of three-dimensional imaging is increasing. This leads to a small increase in the radiation exposure of patients, a trend which is reflected in the annual reports of the Federal Office for Radiation Protection.

Dexpanthenol: An Overview of its Contribution to Symptom Relief in Acute Rhinitis Treated with Decongestant Nasal Sprays

Nasal blockage is the most bothersome symptom of acute rhinitis. Nasal decongestant sprays containing alpha-sympathomimetics, such as oxymetazoline and xylometazoline, have a rapid onset of action. However, this effect decreases with repeated application and, furthermore, the ciliary function of the nasal mucosa is practically paralyzed. Dexpanthenol promotes cell proliferation and protects the epithelium. Combining these two agents has demonstrated beneficial synergetic effects on the symptoms of acute rhinitis. In a post hoc analysis of a large-scale double-blind, active-controlled study including 152 patients, we could demonstrate that the benefit of added dexpanthenol appears as early as on the third day of the combined application of xylometazoline and dexpanthenol in terms of complete or near-to-complete freedom from symptoms. After 5 days, 47% of the patients were cured under the combined treatment compared with only 1% under xylometazoline monotherapy. These data show that the addition of dexpanthenol to an alpha-sympathomimetic nasal spray not only improves its tolerability but also further increases its effectiveness and leads to expedited cure.

FUNDING

Klosterfrau Healthcare Group.

Indications of cone beam CT in head and neck imaging in children

For imaging of bony structures, especially for the anterior and lateral skull base in ORL medicine, cone beam computed tomography (CBCT) is an increasingly used alternative to CT, with a lower exposition to plain radiography that makes its use for imaging, particularly in children, very interesting. The aim of this study was to analyse possible indications and settings for CBCT in children and compare them to those of adults. A total of 554 patients (age range 0-18 years, mean age 10.36 years), who underwent CBCT between 01/2004-06/2013 in the ENT department at the university clinic of Marburg were enrolled in this retrospective analysis to evaluate technical parameters and indications. Data on CBCT of all children were compared with previously published data collected from 1730 adults who were diagnosed with the help of CBCT in the ENT department at the university clinic of Marburg, during the years 2012-2013. The most frequent indications of CBCT in children vs. adults were in the anterior skull base region: mid-facial trauma (60.4%) vs. chronic rhinosinusitis (54.8%), disturbed nasal breathing (13.9% vs. 13.0%) and chronic rhinosinusitis (12%) vs. mid-facial trauma (10.8%). For the lateral skull base the main indications were cholesteatoma (20.3%) vs. position control of cochlear implant (CI) electrode (31.2%), chronic otorrhoea (17.5%) vs. cholesteatoma (20.9%), and position control of CI electrode (11.8%) vs. chronic otitis media mesotympanalis (6.8%). CBCT is a suitable imaging modality for bony structures in adults and children. Settings mainly depend on the region of interest. One aim should also be to reduce exposure to radiation in both adults and children.

Reduction of Radiation Dosage in Visualization of Paranasal Sinuses in Daily Routine

Background. Preoperative imaging of the nose and paranasal sinus is standard in otorhinolaryngology. Previous studies on phantoms demonstrated the potential for dose reduction of cone beam computed tomography (CBCT) by varying the application parameters. Methodology. Based on previous studies, the standard protocol of paranasal sinus imaging by CBCT was altered. One hundred and fifty examinations using the old protocol (01/2010–01/2011, high dosage) and 150 examinations using the new protocol (09/2012–09/2013, low dosage) were evaluated and compared for the visibility of 17 anatomical structures, the Lund-Mackay Score, and technical parameters. Results. Alteration of the protocol resulted in a significant reduction in dosage (6.64 mGy versus 2.88 mGy). Both groups showed the same amount of pathology (Lund-Mackay Score: 4.95 ± 3.79 versus 5.26 ± 5.77; p = 0.558). There was a significant better visibility of the anatomical structures (all visible = 1, nothing visible = 4) (results: 1.25 versus 1.17; p = 0.001) in the low-dosage group. Conclusion. Despite a significant reduction in the applied dosage, reliable visualization of the bony anatomy of the anterior skull base is possible by CBCT. This demonstrates the need for the discussion of the required clinical imaging quality.

Evidence and evidence gaps in therapies of nasal obstruction and rhinosinusitis

Therapeutic decisions in otorhinolaryngology are based on clinical experience, surgical skills, and scientific evidence. Recently, evidence-based therapies have gained increased attention and importance due to their potential to improve the individual patient's treatment and their potential at the same time to reduce treatment costs. In clinical practice, it is almost impossible to stay ahead of the increasing mass of literature and on the other hand critically assess the presented data. A solid scientific and statistical knowledge as well as a significant amount of spare time are required to detect systematic bias and other errors in study designs, also with respect to assessing whether or not a study should be part of an individual therapeutic decision. Meta-analyses, reviews, and clinical guidelines are, therefore, of increasing importance for evidence-based therapy in clinical practice. This review is an update of the availability of external evidence for the treatment of nasal obstruction and rhinosinusitis. It becomes evident that both groups of diseases differ significantly in the availability of external evidence. Furthermore, it becomes obvious that surgical treatment options are normally based on evidence of significantly lower quality than medical treatment options.

Epidemiology of chronic rhinosinusitis, selected risk factors, comorbidities, and economic burden

Chronic rhinosinusitis (CRS) is a relevant and prevalent medical condition in Germany, Europe and the world. If analysed in detail, the prevalence of CRS shows regional and temporary variety. In this review, currently available data regarding the prevalence of CRS is therefore sorted by country and/or region, time point of data collection and the CRS-definition employed. Risk factors like smoking and gastroesophageal reflux are discussed regarding their influence on CRS prevalence. Moreover, comorbidities of CRS, like asthma, conditions of the cardiovascular system and depression are listed and their influence on CRS is discussed. Furthermore, data on CRS prevalence in special cohorts, like immunocompromised patients, are presented. To estimate the economic burden of CRS, current data e.g. from Germany and the USA are included in this review.

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.

Positron emission tomography-computed tomography versus positron emission tomography-magnetic resonance imaging for diagnosis of oral squamous cell carcinoma: A pilot study

Diagnostic imaging of head and neck cancer has made enormous progress during recent years. Next to morphological imaging modalities (computed tomography [CT] and magnetic resonance imaging [MRI]), there are also hybrid imaging systems that combine functional and morphological information (positron emission tomography [PET]/CT and PET/MRI). The aim of this study was to compare the diagnostic accuracy of PET/MRI in the diagnosis of head and neck cancer with other imaging modalities (MRI, CT, PET/CT). Ten patients (nine male and one female) with histologically proven oral squamous cell carcinoma participated in an 18 F-FDG-PET/CT scan and an additional 18 F-FDG PET/MRI scan prior to surgery. The morphological and functional results were compared with the histological results. Inclusion criteria were histologically proven oral squamous cell carcinoma and no prior surgical intervention, medical therapy, or local external radiation. There was no significant correlation between tumor differentiation and maximum standard uptake values. Functional imaging showed a slightly better correlation with the measurement of the maximal tumor diameter, whereas pure morphological imaging showed a better correlation with the measurement of infiltration depth. Only with PET/MRI could correct lymph node staging be reached; the other imaging tools showed false-negative or false-positive results. In conclusion, we showed in our limited patient cohort that PET/MRI is superior to the morphological imaging modalities, especially for lymph node staging.

Indications of cone beam CT in head and neck imaging

CONCLUSION

Cone Beam Computed Tomography (CBCT) can be widely used in imaging of bony structures of the anterior and lateral skull base. Significant differences of applied dosages result from the different protocols of the various indications.

OBJECTIVES

CBCT is increasingly being used in head and neck imaging. Until now, no precise knowledge about its dedicated usage existed.

METHODS

All CBCT of 2012 and 2013 were analysed with regard to the technical parameters, the performance, and the indication for imaging.

RESULTS

In total, 1862 patients were examined in 2012 and 2013. The top eight indications of the anterior skull were (1) chronic rhinosinusitis with disturbed nasal breathing (30.3%); (2) chronic rhinosinusitis (17.6%); (3) midfacial traumatology (13.7%); (4) disturbed nasal breathing (12.8%); (5) acute rhinosinusitis (7.9%); (6) polyposis nasi (6.3%); (7) search for focus (3.9%); and (8) persistent rhinorrhea (1.2%). For the lateral skull base, the top eight were (1) control after cochlear implantation (28.4%); (2) cholesteatoma (19.7%); (3) visualization of ear anatomy (8.7%); (4) chronic otitis media mesotympanalis (6.3%); (5) conductive hearing loss (5.1%); (6) suspected mastoiditis (4.8%); (7) pathology of external auditory canal (4.8%); and (8) otosclerosis (3.3%). Applied dosage for the anterior skull base was significantly lower than for the lateral skull base (2.90 mGy vs 5.92 mGy, p < 0.05); 2.4% and 3.6% of patients' images, respectively, had to be repeated.

[Olfactory disorders and their therapy]

Among the main causes of olfactory disorders are chronic rhinosinusitis, head trauma, acute infections of the upper respiratory tract and neurodegenerative diseases. Olfactory disorders can impose major restrictions on our lives. Although there are numerous approaches for the therapy of olfactory disorders, double-blind comparison studies are needed to distinguish between the effects of these therapies and spontaneous remission of olfactory disorders. The most significant aspects of treatments seem to be anti-inflammatory measures and the regenerative capabilities of the olfactory neuroepithelium.

In vitro studies of a distillate of rectified essential oils on sinonasal components of mucociliary clearance

BACKGROUND

Herbal remedies predate written history and continue to be used frequently for many common ailments. The essential oil mixture standardized is a phytopharmaceutical with a distillate of a mixture of rectified essential oils of eucalyptus, sweet orange, myrtle, and lemon as active ingredients used to treat respiratory diseases such as bronchitis and rhinosinusitis. We evaluated the pharmacologic effects of a distillate of rectified essential oils standardized on primary human upper respiratory epithelial cultures specifically addressing electrolyte transport, cilia beat frequency (CBF), airway surface liquid (ASL) hydration, and mucus transport velocity.

METHODS

Well-differentiated primary human sinonasal epithelial cultures grown at an air-liquid interface were treated on the apical or basolateral surface with varying concentrations of a distillate of rectified essential oils standardized. Changes in CBF were determined using the Sissons-Ammons Video Analysis system while changes in chloride flux were determined using the fluorescent dye 6-methoxy-N-(3-sulfopropyl)quinolinium. ASL hydration was quantified using Texas red dextran and mucociliary transport velocity was measured using fluorescent microspheres and time lapse photography.

RESULTS

When applied to the basolateral surface, a distillate of rectified essential oils standardized activated chloride efflux and ciliary beat in a dose-dependent fashion, increasing ASL height and accelerating mucociliary transport velocity. The ancillary apical application of a distillate of rectified essential oils standardized had minimal effects on the CBF.

CONCLUSION

Basolateral application of a distillate of rectified essential oils standardized stimulates both chloride efflux and cilia beat frequency resulting in a synergistic effect dramatically augmenting mucociliary transport velocity. These in vitro data support the clinical efficacy of this phytopharmaceutical in respiratory inflammatory disorders.

Thermal water applications in the treatment of upper respiratory tract diseases: a systematic review and meta-analysis

Background. Thermal water inhalations and irrigations have a long tradition in the treatment of airway diseases. Currently there exists no systematic review or meta-analysis on the effectiveness of thermal water treatment in upper respiratory tract diseases. Methods. A systematic search in the databases of MEDLINE, EMBASE, CENTRAL, ISI Web of Science, and MedPilot was accomplished. Results. Eight evaluable outcome parameters from 13 prospective clinical studies were identified for 840 patients. Mucociliary clearance time improves significantly (P < 0.01) for the pooled thermal water subgroup and the sulphurous subgroup after 2 weeks (-6.69/minutes) and after 90 days (-8.33/minutes), not for isotonic sodium chloride solution (ISCS). Nasal resistance improved significantly after 2 weeks (Radon, ISCS, and placebo), after 30 days (sulphur and ISCS), and after 90 days (sulphur). Nasal flow improved significantly with the pooled thermal water, radon alone, and ISCS subgroups. For the IgE parameter only sulphurous thermal water (P < 0.01) and ISCS (P > 0.01) were analyzable. Adverse events of minor character were only reported for sulphurous treatment (19/370). Conclusion. Thermal water applications with radon or sulphur can be recommended as additional nonpharmacological treatment in upper airway diseases. Also in comparison to isotonic saline solution it shows significant improvements and should be investigated further.

[Treatment of chronic rhinosinusitis using balloon sinuplasty. A quality of life analysis]

BACKGROUND

Balloon sinuplasty (functional endoscopic dilation surgery, FEDS) has become established as a safe therapeutic procedure for treatment of chronic rhinosinusitis. Our goal was to assess the effect on quality of life (QoL) using validated tools and identify predictive factors.

MATERIALS AND METHODS

A consecutive cohort of 14 patients was evaluated using the disease-specific QoL questionnaire Sino-Nasal Outcome Test 20 (SNOT-20). The measured postoperative changes were then correlated to the results of preoperative CT scan analyses performed according to Lund.

RESULTS

Both the overall SNOT-20 scores and those corresponding to subsections regarding primary nasal symptoms (PNS) and secondary rhinogenic symptoms (SRS) showed a highly significant improvement (p < 0.01). Changes in PNS but not in SRS correlated with the CT scan analyses (p < 0.05). Eighty five percent of patients said that they would choose to undergo FEDS again.

CONCLUSIONS

FEDS is an effective technique that can alleviate symptoms and improve QoL. Patient selection should not be based on CT data alone but a CT scan can be used to determine whether or not the FEDS technique is applicable to the individual patient.

Potential of dosage reduction in cone-beam-computed tomography (CBCT) for radiological diagnostics of the paranasal sinuses

More than 10 years ago, cone-beam-computed tomography (CBCT) was introduced in ENT radiology. Until now, the focus of research was to evaluate clinical limits of this technique. The aim of this work is the evaluation of specific dosages and the identification of potential optimization in the performance of CBCT of the paranasal sinuses. Based on different tube parameters (tube current, tube voltage, and rotation angles), images of the nose and the paranasal sinuses were taken on a phantom head with the Accu-I-tomo F17 (Morita, Kyoto, Japan). The dosages applied to the lens and parotid gland were measured with OSL dosimetry. The imaging quality was evaluated by independent observers. All datasets were reviewed according to a checklist of surgically important anatomic structures. Even for lowest radiation exposure (4 mA, 76 kV, 180°, computed tomography dosage index (CTDI) = 1.8 mGy), the imaging quality was sufficient. Of course a significant reduction of the imaging quality could be seen, so a reliable mean was set for 4 mA, 84 kV, and 180° rotation angle (CTDI = 2.4 mGy). In this combination, a reduction of 92 % in lens-dose and of 77 % of dosage at the parotid gland was observed in comparison to the maximal possible adjustments (8 mA, 90 kV, 360°, CTDI = 10.9 mGy). There is potential for optimization in CBCT. Changing the rotation angle (180° instead of 360°) leads to a dose reduction of 50 %. Furthermore from clinical point of view in case of chronic rhinosinusitis a relevant reduction of dosage is possible. Therefore, it is necessary to intensify the interdisciplinary discussion about the disease specifics required quality of imaging.