Nitric oxide production in the sphenoidal sinus by the inducible and constitutive isozymes of nitric oxide synthase

OBJECTIVE

To study the production of nitric oxide (NO), and the presence of different isoforms of the NO-synthesising enzyme, NO-synthase (NOS), in the paranasal sinus.

MATERIALS AND METHODS

Ten patients, undergoing surgery for pituitary adenoma, were examined for the presence of NO gas in the sphenoidal and maxillary sinus. The distribution of different NOS isozymes in mucosal biopsies from sphenoid and maxillary sinus and ethmoidal cells was studied.

RESULTS

The mean concentration of NO was 2575 ppb in the sphenoidal sinus and 6792 ppb in the maxillary sinus. Morphological analyses revealed intense NADPH-diaphorase staining throughout the epithelium. Immunoreactivity against NOS2 (inducible NOS) was observed in the apical cell layer but not of the basal layer. NOS1 (neuronal NOS)-immunoreactivity was mainly seen in the subapical part of the epithelium and NOS3 (endothelial NOS)-immunoreactivity was observed only in the most apical part of the epithelium.

CONCLUSION

NO concentration in the sphenoidal sinus is about the same as in the nasal cavity and approximately half of the concentration found in the maxillary sinus. All of the three main different isozymes of NOS can be demonstrated in the mucosa of the sphenoidal and maxillary sinus and ethmoidal cells, NOS2 being the most abundant isoform.

Nasopharyngeal glioma in a new-born girl

Nasal gliomas are uncommon tumours of neurogenic origin that occur sporadically. They are diagnosed with MRI and a preoperative biopsy, and surgery is the treatment of choice. Most of the gliomas emerge from the nasal cavity, but only a few cases of nasopharyngeal gliomas have been reported. We present one case of a nasopharyngeal glioma and two cases of nasal gliomas.

Pure sesame oil vs isotonic sodium chloride solution as treatment for dry nasal mucosa

OBJECTIVE

To evaluate whether there was any difference in efficacy when nasal mucosa dryness was treated with pure sesame oil (Nozoil) compared with isotonic sodium chloride solution (ISCS).

DESIGN

In a randomized, crossover study, 79 subjects with nasal mucosa dryness were enrolled. Half the subjects received pure sesame oil for 14 days followed by ISCS for 14 days, and the other half received ISCS for 14 days followed by pure sesame oil for 14 days. During the test period from March 13 to May 30, 2000, the outdoor absolute humidity was low. Nasal mucosa dryness, stuffiness, and crusts were scored every evening with a visual analog scale.

SETTING

The County Hospital, Skellefteå, Sweden.

RESULTS

Nasal mucosa dryness improved significantly when pure sesame oil was used compared with ISCS (P<.001). The improvement in nasal stuffiness was also better with pure sesame oil (P<.001) as was improvement in nasal crusts (P<.001). Eight of 10 subjects reported that their nasal symptoms had improved with pure sesame oil compared with 3 of 10 for ISCS (P<.001). Adverse events were few and temporary.

CONCLUSION

When nasal mucosa dryness due to a dry winter climate was treated, pure sesame oil was shown statistically to be significantly more effective than ISCS.

Different methods for evaluating daytime tiredness in snoring men

Many snorers complain of daytime tiredness and reduced mental energy. In 42 middle-aged snoring men, the results of sections relating to mental energy in 2 quality-of-life instruments, energy in the Nottingham Health Profile (NHP) and vitality in the Psychological General Well-Being (PGWB) questionnaire, were compared with those of population samples. The snorers were significantly more tired than the population samples (p < 0.001). The scores for the NHP and PGWB were then correlated with a visual analogue scale (VAS) of drowsiness. The correlation coefficient between NHP (energy) and the corresponding VAS value was r = 0.52 (p < 0.001). The correlation coefficient between PGWB (vitality) and the VAS value for drowsiness was r = -0.56 (p <0.001). When nasal breathing was improved with the use of the Nozovent nostril dilator at night for 1 month, NHP (energy) and the VAS value for drowsiness improved significantly (p < 0.001). A single VAS value for drowsiness is a good instrument for evaluating daytime tiredness and for measuring the clinical effect of treatment in snorers.

Fewer problems with dry nasal mucous membranes following local use of sesame oil

Many people experience problems with a dry nasal mucous membrane, often without wondering why. Their noses itch and burn and dried mucus collects there. These problems are exacerbated during the winter, in air-conditioned environments and after nasal irradiation. Twenty patients experiencing problems with dryness of the nose were selected from outpatient clinics, together with twenty patients who had previously undergone nasal irradiation. During the first five days no treatment was administered. For the following twenty days the patients sprayed sesame oil into each nostril three times a day. For the last five days no treatment was given. When both groups received treatment and sprayed sesame oil (Nozoil) in their noses, the nasal problems decreased significantly. The greatest effect is exerted on dryness. The side effects from using this oil are few in number and mild.

Better quality of life when nasal breathing of snoring men is improved at night

OBJECTIVE

To evaluate whether improved nasal breathing changes the quality of life in snoring men and improves the female sleeping partners' well-being in the morning.

DESIGN

During 1 month, 42 heavily snoring men slept with a nostril dilator. Before and after 1 month, the snorers rated their daytime tiredness and completed the Nottingham Health Profile questionnaire. Female sleeping partners rated the snoring, the quality of their sleep, and their sense of well-being in the morning. A population sample was used for comparison.

SETTING

The Central Hospital, Skövde, Sweden.

RESULTS

The snorers' quality of life before the study was significantly worse (P<.001) than that of the comparison population and improved significantly (P = .001). The men were significantly (P<.001) less tired during the day when their nasal airflow was increased. Female sleeping partners had significantly (P = .005) better sleep and an improved sense of well-being in the morning during the test period. Both were correlated with a significant reduction in the snoring (P<.001).

CONCLUSIONS

When nasal breathing of snoring men was improved at night, their quality of life was significantly improved. The female sleeping partners had a reduction in sleep disturbance that correlated well with an improvement in their own sleep and feelings of well-being in the morning.

Improved nasal breathing in snorers increases nocturnal growth hormone secretion and serum concentrations of insulin-like growth factor 1 subsequently

In snoring men improved nasal breathing during sleep has been shown to decrease snoring and morning tiredness. The aim was to evaluate whether improved nasal breathing had any effect on growth hormone (GH) secretion, the nocturnal secretion of GH being associated with deep sleep. Forty-two snoring men, mean age 45 years and mean body mass index 26 kg.m-2, slept every night during one month with the Nozovent nostril dilator. Before and at the end of the test period, we analysed serum insulin-like growth factor 1 (IGF-1), thyrotropin (TSH), free thyroxine (free T4), free 3,5,3'-triiodothyronine (free T3), cortisol and testosterone in blood sampled at 08:00 h. Fifteen of the 37 snoring men who completed the study experienced a reduction in snoring and were less tired in the morning during the test period. In this group, the mean IGF-1 concentration was significantly increased (p < 0.05) after one month. There was no significant difference in mean IGF-1 level between the snorers and a population sample. Likewise, TSH, free T4, free T3, cortisol and testosterone concentrations were within normal limits. Snorers with reduced snoring and morning tiredness due to improved nasal breathing showed an increase in morning IGF-1 concentration which can probably be explained by higher nocturnal GH secretion induced by more deep sleep.

Evaluation of the quality of life of male snorers using the Nottingham Health Profile

Many snorers complain of tiredness during the day, but little is known about the impact of snoring on daily life in other respects. The objective of this study was to assess the quality of life of middle-aged men who were heavy snorers. We used the Nottingham Health Profile (NHP), which has been utilized during the last two decades as an instrument for evaluating the influence different medical conditions have on quality of life. Forty-two men (median 45 years, mean BMI 26 kg/m2 and mean Respiratory Disturbance Index 8.6) completed quality of life questionnaires. The answers were compared with those of a population sample of 786 men from the region with the same mean age. There were significant differences between the snorers and the population sample in the total score for quality of life (p=0.001) and the sections about energy (p < 0.001) and emotional reactions (p=0.02). There were highly significant differences in the frequency of health-related problems among the snoring men compared with the population sample in the ability to perform tasks around the home (p < 0.001). social life (p=0.003), family relationship (p < 0.001 ) and sexual life (p=0.001). When the snorers were compared with results reported from patients suffering from other medical conditions (hypertensives, growth hormone deficiency, myocardial infarction, chronic obstructive pulmonary disease), we found an equal level of total mean score and negative influence on their quality of life. The study illustrates that snoring men have a poor quality of life, comparable to that of patients with chronic diseases.

Transsphenoidal adenomectomy in Cushing's disease via a lateral rhinotomy approach

BACKGROUND

Cushing's disease may be treated by surgical pituitary adenomectomy. We present a surgical approach to the pituitary gland that increases the possibilities of a selective adenomectomy, and compare our results with those of other studies.

METHODS

A retrospective study of patients with Cushing's disease undergoing transsphenoidal selective adenomectomy via a lateral rhinotomy at Sahlgrenska University Hospital from 1984-93 is presented. Thirty-one patients (26 women, five men; mean age: 44 years, range: 13-75 years) with Cushing's disease were followed for a median time of 4.5 years after operation (range: 1-10 years). Preoperative and postoperative urinary and serum cortisol, and circadian rhythm of serum cortisol were measured. We also measured serum TSH, T4, PRL, FSH, LH, and testosterone as well as urine and plasma osmolality.

RESULTS

Our remission rate was 77% and the recurrence rate 3%. Hormonal insufficiency was rare. Hypothyroidism and hypogonadism were present in 3% of the patients, and diabetes insipidus occurred in 6% of the patients.

CONCLUSION

Selective adenomectomy with its good opportunities for cure and improvement should be regarded as the treatment of choice for Cushing's disease. Using the lateral rhinotomy approach to the sphenoidal cavity results in good accessibility to the sella turcica and its pituitary adenomas, a low frequency of postoperative pituitary insufficiency, and a high remission rate.

Improved nasal breathing reduces snoring and morning tiredness. A 6-month follow-up study

BACKGROUND

Dilation of the nasal valve region can increase the ability to breathe through the nose and reduce the negative intrathoracic pressure required for inspiration. Vibrations of the palate and soft tissues of the throat, which generate snoring sounds, can be prevented when patients inhale less heavily.

OBJECTIVES

To evaluate the effect a nostril dilator has on patient snoring and tiredness in the morning and to determine how many patients would continue to use the device for half a year.

DESIGN

For 6 months, 42 men who were heavy snorers graded their average tiredness in the morning and the patient's sleeping partner graded the average snoring using a visual analog scale from 0 to 100.

SETTING

All patients were examined at the Department of Otorhinolaryngology, Central Hospital, in Skövde, Sweden.

RESULTS

When the nostril dilator was used there was a significant decrease in snoring after both 1- and 6-month reports. There was a significant correlation between diminution of snoring and less tiredness in patients in the morning. The compliance was good since 60% of patients continued to use the device during the 6-month test period.

CONCLUSIONS

This study illustrates the benefits that reducing nasal airway resistance during sleep has on snoring and morning tiredness in patients.

Reduced nocturnal asthma by improved nasal breathing

The nose and not the mouth should be used for breathing as the nose has better air conditioning capacity. When air is inhaled through the mouth it may dry and cool the respiratory mucosa, which can lead to bronchoconstriction in sensitive patients with asthma. By dilating the nostrils you can increase nasal breathing in most subjects. The aim of this study was to investigate whether sleeping with dilated nostrils reduces nocturnal asthma. At the Asthma and Allergy Research Centre, Gothenburg, 15 out-patients with nocturnal asthma were selected. Every other night for 10 nights the test subjects slept with the nasal dilator Nozovent which has been shown to increase the nasal air-flow and decrease the need for mouthbreathing. Every morning the patients self-reported on a form whether they had woken with asthma during the night or if they had had to take asthma medication. When sleeping with the nasal dilator the patients woke up with asthma on 17 of 75 nights as compared with 32 of 75 when sleeping without the device (p < 0.01). Reduced nocturnal asthma was observed by 12 patients and less need for asthma medication at night by 7. None of the patients noted any side-effects due to the device. In conclusion, the easy-to-use and cheap medical device, Nozovent, which mechanically dilates the nostrils and improves nasal breathing, can reduce nocturnal asthma.

Effect of local tranexamic acid gel in the treatment of epistaxis

In patients with nosebleedings, the hemostatic effect of local application of tranexamic acid gel or placebo was compared in a randomized, double-blind, multicenter clinical trial with parallel groups. The times needed to arrest the initial bleeding were recorded, as well as any rebleedings within 10 days. The results showed no significant differences in any of the efficacy variables. Tranexamic acid was no better than placebo in the early treatment of nose bleedings, but the gel itself seemed to have a beneficial effect. The gel preparations were easy to insert into the nasal cavity and caused no discomfort to the patients.

Five-year follow-up of nonsecreting pituitary adenomas

Nowadays, nonsecreting pituitary adenomas are usually operated on by means of a transsphenoidal approach, and the transseptal way is the most widely used. Since 1982 we have been using lateral rhinotomy instead, resecting bone in the piriform aperture up to the orbit to obtain a good intrasellar view during surgery. In all, 48 patients were operated on between 1982 and 1987, and all of them have since been evaluated in a 5-year follow-up. The only recurrence occurred in the only patient previously operated on transcranially. Computed tomography was performed in 44 patients (92%) after an average of 4 years and revealed no signs of tumor in any of them. New pituitary insufficiencies developed in six (12%). An improvement in vision was observed in 38 patients (79%), none of whom suffered an impaired visual field or acuity. The frequency of new hormonal insufficiencies and improvement of vision that we observed in our patients is comparable with that reported by other investigators, but the recurrence rate is lower and the optic nerves and chiasma were never damaged thereby causing an impairment of vision. These benefits can most probably be explained by the surgical approach we used, in which the tumor and surrounding structures are very well visualized because the operative field is broader and closer than it is with the transseptal approach, which is normally used for this kind of tumor.

Results of the lateral rhinotomy approach in transsphenoidal microsurgery for growth hormone-secreting pituitary adenoma

The results of transsphenoidal microsurgery for growth hormone (GH)-secreting pituitary adenomas in a series of 47 patients are presented. A modified transsphenoidal approach with lateral rhinotomy was employed for the access to the sphenoid sinus. Remission, defined as mean GH concentration less than 2.5 ng/ml, was achieved in 79% of the patients. Macroadenoma size of the tumour and a GH concentration more than 50 ng/ml were factors unfavourable for the outcome. The experience of the lateral rhinotomy approach in transsphenoidal surgery of acromegaly has been favourable. The distance from the incision to the sella is shorter than in rhinoseptal approaches, where the depth of the operative field is determined by the distance from the nasal spine to the sella. The lateral rhinotomy also allowed an exposure of the sella of adequate width in all patients. These aspects of the procedure facilitated adenoma removal.

Serum lipoproteins in acromegaly before and 6-15 months after transsphenoidal adenomectomy

OBJECTIVES

Acromegaly is a rare disorder characterized by over-secretion of GH, most often because of a pituitary adenoma. The disease is associated with disturbances in lipoprotein metabolism and an increased cardiovascular mortality. The aim of the present study was to investigate whether treatment of acromegaly results in changes in serum concentrations of lipids and apolipoproteins, including lipoprotein(a) (Lp(a)).

DESIGN

Fourteen patients with clinical features of acromegaly and increased GH secretion were studied 1-10 months before and 6-15 months after transsphenoidal adenomectomy in an open study.

PATIENTS

Three patients had diabetes mellitus before surgery and two of these patients had normalized serum glucose levels post-operatively. Mean and baseline plasma GH levels were determined from 24-hour GH profiles. Serum samples were taken in the morning after an overnight fast. All patients were normocholesterolaemic, and four patients were hypertriglyceridaemic before treatment.

RESULTS

Mean plasma GH levels decreased from 34.5 +/- 7.4 to 2.1 +/- 0.4 mU/l (mean +/- SEM). Serum IGF-I, insulin and free T3 levels decreased and serum SHBG concentrations increased post-operatively. There was no effect of treatment on serum cholesterol concentrations, but serum triglyceride concentrations decreased. Serum apolipoprotein (apo) B and apoE levels were unaffected by treatment. Serum apoA-I levels increased and Lp(a) levels decreased post-operatively.

CONCLUSIONS

Successful treatment of acromegaly, resulting in normal mean GH values (< 5 mU/l) and/or normal responsiveness to TRH, have beneficial effects on serum lipoproteins with increased serum apoA-I levels and decreased serum levels of triglycerides and Lp(a). These effects seem to be independent of improvement in glucose tolerance, since patients with diabetes mellitus before surgery and normal fasting blood glucose levels post-operatively had similar lipoprotein responses to treatment as those with normal fasting blood glucose levels before surgery.

Increased nasal breathing decreases snoring and improves oxygen saturation during sleep apnoea

For many years ENT-specialists have performed surgery to create a good air passage in patients with different kinds of nasal deformities. When having a blocked nose one realizes the importance of being able to breathe through the nose. By moving the nasal wings aside with the fingers, or the medical device Nozovent, most people experience that it is easier to breathe through the nose than ever before, which can also be shown with rhinomanometry. When it is easier to inhale there is less energy in the air passing the palate which means less risk for vibrations creating snoring sounds. In different studies it has been possible to show that snoring can be decreased or prevented when the nasal dilator Nozovent is used. It has also been shown to result in a decrease of the sleep apnoea index and improvement of arterial oxygen saturation during sleep apnoea.

Secretion from gland and goblet cells in infected sinuses

The number of goblet cells in the normal mucosa in the paranasal sinuses is comparable to that in the nasal mucosa. There are relatively few mucosal glands in the sinuses. In recent years, the maxillary sinus of the rabbit has been used for experimental studies. After induced infections, the number of goblet cells increases. In pneumococcal sinusitis, the number reaches a peak after 3 weeks and then declines. In sinusitis induced by St. aureus and the anaerobic bacteria B. fragilis, the number is more progressive over time and persistent during 12 weeks. The number of glands shows no hyperplasia, but occasionally atypical glands can be found. In patients with chronic sinusitis, the number of goblet cells is usually not affected but the number of glands increases, and the glands usually have a pathological shape. A decreased ciliary beating frequency correlates well with an increase in number of goblet cells. However, 75% of patients with chronic sinusitis have a normal frequency. When performing studies in patients with sinusitis one should be aware of the dynamic course of the disease and the difficulty in evaluating single mucosal biopsies.

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.