A validation study of an esophageal probe-based polygraph against polysomnography in obstructive sleep apnea

STUDY OBJECTIVES

The aim of this study was to validate the automatically scored results of an esophageal probe-based polygraph system (ApneaGraph® Spiro) against manually scored polysomnography (Nox A1, PSG) results. We compared the apnea-hypopnea index, oxygen saturation index, and respiratory disturbance index of the devices.

METHODS

Consenting patients, referred for obstructive sleep apnea workup, were tested simultaneously with the ApneaGraph® Spiro and Nox A1® polysomnograph. Each participant made one set of simultaneous registrations for one night. PSG results were scored independently. Apnea-hypopnea index, oxygen desaturation index, and respiratory disturbance index were compared using Pearson's correlation and scatter plots. Sensitivity, specificity, and positive likelihood ratio of all indices at 5, 15, and 30 were calculated.

RESULTS

A total of 83 participants had successful registrations. The apnea-hypopnea index showed sensitivity of 0.83, specificity of 0.95, and a positive likelihood ratio of 5.11 at an index cutoff of 15. At a cutoff of 30, the positive likelihood ratio rose to 31.43. The respiratory disturbance index showed high sensitivity (> 0.9) at all cutoffs, but specificity was below 0.5 at all cutoffs. Scatterplots revealed overestimation in mild OSA and underestimation in severe OSA for all three indices.

CONCLUSIONS

The ApneaGraph® Spiro performed acceptably when OSA was defined by an AHI of 15. The equipment overestimated mild OSA and underestimated severe OSA, compared to the PSG.

A comparative study of two grading systems for epistaxis in hereditary haemorrhagic telangiectasia

BACKGROUND

Different institutions use different grading systems for hereditary haemorrhagic telangiectasia (HHT)-associated epistaxis. It is important to have a universal, standardized grading system to compare and evaluate the effectiveness of different treatment options. We introduced the "Intensity, Frequency and need for Blood Transfusion" (IFT) grading system for HHT-associated epistaxis in 2008. Hoag et al. proposed the "Epistaxis Severity Score" (ESS) for the International HHT foundation in 2010. This study aimed to evaluate the potential correlation between the ESS and IFT grading systems.

METHODS

The study included 354 simultaneous reports using the IFT and ESS from 106 patients. The correlation between the ESS, IFT and haemoglobin levels was measured using Pearson's correlation coefficient. The ESS and IFT were scored simultaneously by the patient and doctor in 48 cases to evaluate if there was a discrepancy in the scoring applied by either set of responders.

RESULTS

The measured correlation between the two grading systems was good (0.75). The grade of epistaxis reported by patients and doctors respectively showed no significant difference. Both the IFT and ESS grading systems correlate significantly to the haemoglobin level.

CONCLUSIONS

Both the IFT and ESS scores correlate to each other, and their results are comparable. Whether the IFT or ESS scoring was performed by the patient or doctor had no significant impact.

Minimal unilateral peak nasal inspiratory flow correlates with patient reported nasal obstruction

BACKGROUND

Nasal septoplasty is a common surgical procedure, but a significant number of patients report equal, or some even worsened, symptom load postoperatively. Rhinologists struggle to find objective tests that adequately reflects disease burden. This study aimed to evaluate the correlation between the PNIF measurement of the most obstructed side with patient reported outcomes.

METHODS

Bilateral and unilateral PNIF measurements were performed before and after topical decongestion in 528 patients scheduled for surgery due to nasal obstruction. Subjective outcomes were measured using Nasal Obstruction VAS and SNOT-22 with subdomains. Correlations between subjective and objective measurements were calculated and further explored using multivariate regression analyses.

RESULTS

Significant negative correlations between PNIF and patient reported outcomes were found. Both bilateral and minimal unilateral PNIF correlations with NO-VAS were equal and stronger than correlations with SNOT-22 including subdomains concerning problems with nasal obstruction. Minimal unilateral PNIF did not show statistically significant gender difference. Topical decongestion decreased statistical correlations.

CONCLUSIONS

The minimal unilateral PNIF shows a statistically significant but weak negative correlation with preoperative patient reported nasal obstruction, and values do not differ between genders. Clinical evaluation of patients presenting complaints of nasal obstruction could be supported by minimal unilateral PNIF.

The new agreement of the international RIGA consensus conference on nasal airway function tests

The report reflects an agreement based on the consensus conference of the International Standardization Committee on the Objective Assessment of the Nasal Airway in Riga, 2nd Nov. 2016. The aim of the conference was to address the existing nasal airway function tests and to take into account physical, mathematical and technical correctness as a base of international standardization as well as the requirements of the Council Directive 93/42/EEC of 14 June 1993 concerning medical devices. Rhinomanometry, acoustic rhinometry, peak nasal inspiratory flow, Odiosoft-Rhino, optical rhinometry, 24-h measurements, computational fluid dynamics, nasometry and the mirrow test were evaluated for important diagnostic criteria, which are the precision of the equipment including calibration and the software applied; validity with sensitivity, specificity, positive and negative predictive values, reliability with intra-individual and inter-individual reproducibility and responsiveness in clinical studies. For rhinomanometry, the logarithmic effective resistance was set as the parameter of high diagnostic relevance. In acoustic rhinometry, the area of interest for the minimal cross-sectional area will need further standardization. Peak nasal inspiratory flow is a reproducible and fast test, which showed a high range of mean values in different studies. The state of the art with computational fluid dynamics for the simulation of the airway still depends on high performance computing hardware and will, after standardization of the software and both the software and hardware for imaging protocols, certainly deliver a better understanding of the nasal airway flux.

Causes of higher symptomatic airway load in patients with chronic rhinosinusitis

Background

Chronic rhinosinusitis display a variety of different phenotypes. The symptoms of disease are characterised by various signs and symptoms such as nasal congestion, nasal discharge, pressure sensation in the face and reduced or complete loss of smell.

In a patient population undergoing functional endoscopic sinonasal surgery (FESS) for chronic rhinosinusitis, we wanted to investigate the clinical features and explore if the presence of biofilm, nasal polyps or other disease characteristic could serve as predictor for the symptomatic load. A patient group undergoing septoplasty without disease of the sinuses was included as control.

Methods

The Sinonasal outcome test (SNOT-20), EPOS visual analogue scale (VAS) and the Lund-Mackey CT score (LM CT score) were used to examine 23 patients with chronic rhinosinusitis without nasal polyps (CRSsNP), 30 patient with nasal polyps (CRSwNP) and 22 patients with septal deviation. Tissue samples were collected prospectively during surgery. The cohort has previously been examined for the presence of biofilm.

Results

Patients with CRSsNP and CRSwNP had significantly higher degree of symptoms compared to the septoplasty group (SNOT-20 scores of 39.8, 43.6 and 29.9, respectively, p = 0.034). There were no significant differences in the total SNOT-20 or VAS symptoms scores between the CRSsNP and CRSwNP subgroups. However patients with nasal polyps showed significantly higher scores of symptoms related to sinonasal discomfort such as cough, runny nose and need to blow nose (p = 0.011, p = 0.046, p = 0.001 respectively). Patients with nasal polyps showed a significantly higher LM CT score compared to patients without polyps (12.06 versus 8.00, p = 0.001). The presence of biofilm did not impact the degree of symptoms.

Conclusion

The presence of nasal polyp formations in CRS patients was associated with a higher symptomatic airway load as compared to patients without polyps. These findings suggest that nasal polyps could be an indicator of more substantial sinonasal disease. The presence of biofilm did not impact the degree of symptoms, however, as biofilm seem to be a common feature of chronic rhinosinusitis (89% in this cohort), it is more likely to be involved in the development of the CRS, rather than being a surrogate marker for increased symptomatic load.

Electronic supplementary material

The online version of this article (10.1186/s12901-017-0048-6) contains supplementary material, which is available to authorized users.

Bacterial biofilms in chronic rhinosinusitis; distribution and prevalence

CONCLUSION

Biofilms were more prevalent in patients with CRSwNP compared to both CRSsNP and controls, and also on the ethmoid bulla compared to the middle turbinate, supporting a biofilm-related pathogenesis of CRSwNP.

OBJECTIVE

To investigate the prevalence of biofilms in patients with chronic rhinosinusitis with nasal polyps (CRSwNP) compared to patients with chronic rhinosinusitis without nasal polyps (CRSsNP) and controls. To examine the prevalence of biofilms in different anatomical localizations.

STUDY DESIGN

Cross-sectional.

METHODS

This study comprised 27 patients with CRSsNP, 34 patients with CRSwNP, and 25 controls. Biopsies from the middle turbinate, the uncinate process, and the ethmoid bulla were harvested pre-operatively, snap frozen in isopentane, cooled, and stored at -80°C. Prepared with Invitrogens' Baclight LiveDead kit and investigated with confocal scanning laser microscopy.

RESULTS

Biofilms were studied in 33/34 (97%) CRSwNP, 22/27 (82%) CRSsNP, and 14/25 (56%) controls. The difference in point prevalence between patients with CRSwNP vs CRSsNP (p = 0.042, χ(2) = 4.12), CRSwNP vs Controls (p < 0.001, χ(2) = 15.0), and CRSsNP vs controls (p = 0.047, χ(2) = 3.96) were all significant. Biofilms were found in 43/54 (80%) ethmoid bulla, 39/55 (71%) uncinate process, and 31/50 (62%) middle turbinate. The difference between the ethmoid bulla and the middle turbinate locations (p = 0.047, χ(2) = 3.93) was significant.

Bacterial biofilms in patients with chronic rhinosinusitis: a confocal scanning laser microscopy study

BACKGROUND

Recent research into the pathophysiology of chronic rhinosinusitis suggests an important role for biofilms. They can be detected in both healthy and diseased nasal mucosa. Several different methods of detecting biofilms have been described. This study investigates the presence of biofilm in a larger group of patients with chronic rhinosinusitis undergoing primary functional endoscopic surgery.

METHODS

Sixty-one patients with chronic rhinosinusitis and 25 controls, with septal deviation, were included from 2010 to 2012. Endonasal biopsies were harvested during surgery, snap frozen in isopentane, cooled on dry ice and stored at -80oC. The samples were prepared with Invitrogens’ BacLight LiveDead kit, and investigated with confocal scanning laser microscopy for the presence of biofilm.

RESULTS

In the chronic rhinosinusitis group 55/61 were biofilm positive as opposed to 14/25 in the control group. The difference was highly significant. The odds ratio was 7.2.

CONCLUSION

Patients with chronic rhinosinusitis have a highly significant increased point prevalence of biofilms compared to controls.

Beta-trace protein in pediatric otitis media with effusion

OBJECTIVES

The middle ear cleft connects by membranes to the inner ear and the subarachnoid space particularly in infants. In order to gain more insight about the permeability between the two compartments we quantified the concentration of beta-trace protein - a highly specific marker for CSF and perilymph but not for serum and mucosal effusion - in middle ear secretions from children with otitis media with effusion.

METHODS

One-hundred and three patients were included and 93 samples from secretory otitis media were collected during myringotomy or explorative tympanotomy. Thirty-eight patients of 103 had to be excluded (36.9%). Of the 93 collected samples from 65 subjects, 82 viscous samples were pre-diluted 1:1 with tyloxapol. In spite of the attempt to pre-dilute the viscous samples, 30 glue-like samples of 93 were not applicable for nephelometry. The final analysis was made on 63 samples of 52 subjects (median age 3 years) which were quantified for beta-trace protein using immunonephelometry.

RESULTS

In 3/63 samples the beta-trace protein values were below the detection range (<0.2 mg/L) and in 1/63 it was beyond with 18.3mg/L. The median beta-trace protein value for 59 samples within the measuring range was 2.4 mg/L, range 0.2-14.2.

CONCLUSION

In pediatric middle ear effusions, the beta-trace protein concentration was found to have a high range compared to other body fluids from other studies. In other studies, the values for serum (0.59 mg/L) or mucosal secretion (0.003-0.12 mg/L) were lower and the values in CSF (18.4 mg/L) or perilymphatic fluid (23.5 mg/L) were highest. This finding might indicate a weak barrier between the cerebrospinal fluid space or inner ear fluid compartments on the one side and the tympanic cavity on the other side given the condition of otitis media with effusion. The detection of beta-trace protein might be important to assess the risk of impending complications.

Living with hereditary haemorrhagic telangiectasia: coping and psychological distress - a cross-sectional study

PURPOSE

The purpose of this study was to examine the relationship between coping strategies measured by Coping Orientation to Problems Experienced Scale (COPE) and psychological distress measured by Hospital Anxiety and Depression Scale (HADS) and Becks Hopelessness Scale (BHS) in individuals living with Hereditary hemorrhagic telangiectasia (HHT) and to examine if coping strategies might have a mediating role between experienced illness and psychological distress. HHT is mainly caused by mutations in the ENG- or ALK1-genes and associated with a shorter life span. 90% of patients have recurrent nosebleeds.

METHOD

66 individuals affected of HHT participated in this cross-sectional study, completing questions due to demographic variables, Experience of illness, COPE, BHS and HADS. X(2) test, bivariate correlations with Pearson r and hierarchical multiple regression were used using PASW 18.

RESULTS

Experience of illness made the highest variance in anxiety, depression and hopelessness and the coping strategy "behavioral disengagement" seems to have a mediating role between nose bleedings, being afraid of complications, satisfied with life and psychological distress.

CONCLUSIONS

Experience of illness is of big importance in psychological distress in individuals affected of HHT, and behavioral disengagement explained the actual relationship between experience of illness and psychological distress.

Quality of life in patients with hereditary hemorrhagic telangiectasia in Norway: a population based study

Hereditary hemorrhagic telangiectasia (HHT) is a rare, autosomal dominant disease characterized by the presence of recurrent epistaxis and small characteristic malformations of the peripheral blood vessels near the surface of the skin or mucosal linings. Arteriovenous malformations (AVM) of the lung, liver, and CNS are also known clinical findings. The purpose of this study was to examine quality of life (QoL) in patients with HHT in Norway. Sixty-six affected patients (39 women and 27 men) were included. QoL on overall-, health-related (HR-QoL), and disease-specific levels were measured with Cantril's Ladder (CL), Short Form 36 (SF-36), and a Symptom-specific QoL question in HHT patients (SFB-HHT-Q), respectively. Comparisons were made between patients and an age and gender adjusted normative sample from the Norwegian population (N = 990). Overall, the results reflected that several HHT disease-related variables were associated with reduced QoL on all three levels; overall QoL (CL), HR-QoL (SF36) as well as disease-specific QoL (SFB-HHT-Q), while demographic variables impacted HR-QoL in HHT patients. Compared to the normative sample, all subscales of SF36, but bodily pain, were significantly poorer in the HHT patients. HHT disease variables had the strongest association with QoL compared to demographic variables. The results substantiate that disease severity is associated with poorer QoL in this patients. Pain contributed independently to all levels of QoL.

Transpterygoid Trans-sphenoid Approach to the Lateral Extension of the Sphenoid Sinus to Repair a Spontaneous CSF Leak

OBJECTIVE AND IMPORTANCE

Cerebrospinal fluid (CSF) fistula from the middle cranial fossa into the sphenoid sinus is a rare condition. In the past, the treatment of choice has been closure via a craniotomy. Only few geriatric cases are known, which were successfully operated by endoscopic surgery. We present a further case of nontraumatic CSF fistula originating from the middle cranial fossa. A new endoscopic technique was applied. We discuss treatment options for this rare defect.

CLINICAL PRESENTATION

A 76-year-old patient presented with a 2-year history of rhinorrhea. High levels of beta-trace protein pointed to a diagnosis of CSF fistula. The defect was located at the anterior and inferior aspect of the pterygoid recess of the left sphenoid sinus.

INTERVENTION

The patient was operated using an endoscopic trans-sphenoidal approach. After endoscopic opening of the maxillary and sphenoid sinus, a complete posterior ethmoidectomy was performed. The medial part of the pterygoid process was removed, allowing endoscopic exposure and closure of the defect. At 1-year follow-up, the CSF fistula had not recurred and the patient had no sequel from the surgical procedure.

CONCLUSION

In selected cases, this new endoscopic partial transpterygoid approach to the middle cranial fossa is recommended for surgical repair of CSF fistula involving the lateral extension of the sphenoid sinus. To our knowledge, ours is the oldest patient with this condition successfully operated by endoscopic means at the world's most northern university hospital.

The Natural History of Epistaxis in Patients with Hereditary Hemorrhagic Telangiectasia in the Norwegian population: A Cross-sectional Study

Background

Epistaxis is usually the first and most common symptom in hereditary hemorrhagic telangiectasia (HHT), which is known also as Rendu-Osler-Weber syndrome. The severity of HHT-associated epistaxis is highly variable and can affect the patient's quality of life. In the literature, the natural history of epistaxis in HHT patients has been described in a few countries but not from the Norwegian population.

Objective

This work focused on the natural history of epistaxis in the Norwegian population in a cross-sectional study.

Material and Methods

Ninety-eight patients with three or four Curaçao criteria were included. The severity of epistaxis was graded depending on epistaxis intensity, frequency, and the amount of blood transfusion during a period of 4 weeks. The epistaxis grades were studied in association with age, gender, gene mutation, age of onset, and whether the patient had or had not been treated for epistaxis during the last 2 years.

Results

Most of the HHT patients (90%) complained of mild-to-moderate epistaxis. Seventy-seven percent of the patients started epistaxis by or before the age of 20 years. The progression of HHT-associated epistaxis with age could not be proved statistically in this study. There was no statistically significant difference in the grades of epistaxis between HHT1 and HHT2 type, neither between female and male patients. Most of the patients started epistaxis by or before the age of 20 years. There was a significant difference in the grade of epistaxis between non-ENG, non-ALK1 carrier patients, and ENG or ALK1 carrier patients.

Conclusion

Compared with other populations, the grading of epistaxis in Norwegian patients with HHT gave generally similar results. A multicenter epidemiological study is required to get a larger study population. A common internationally accepted grading or classification system for epistaxis in HHT is highly recommended.

A grading scale for epistaxis in hereditary haemorrhagic teleangectasia

BACKGROUND

Epistaxis is the most common symptom in patients with Hereditary Haemorrhagic Telangiectasia (HHT). Different institutions are using different treatment modalities and different grading systems. The treatment options depend on the grade of epistaxis. It is important to have a common grading system to compare and evaluate the effectiveness of different treatment options. Furthermore, it is important to correlate quality of life with an epistaxis grading system. The aim of this work was to propose a new grading system for epistaxis in HHT.

METHODS

A medical literature search was performed for grading systems of epistaxis in HHT. A questionnaire on five criteria's for a new grading system was sent to 22 internationally renowned medical experts, who have published results on epistaxis in HHT.

RESULTS

Four different grading systems are currently in use for the grading of epistaxis in HHT. The response rate of the questionnaire was 43%. All the experts who answered the questionnaire agreed that the aimed grading system should be easy to understand for the patients. 90% of them wanted the system to focus on a definite time period. 70% answered that blood transfusion should be included in the grading system as an important factor. There was no clear consensus on whether the system should be a single multi-item scale or a composite scale consisting of more than one single scales, and similarly there was no clear consensus on whether is should be an absolute or a relative scale.

CONCLUSION

The proposed system should be easy to understand for the patients, focus on a definite time period of observation, and include blood transfusion as one of its parameters. For statistical reasons, an epistaxis grading scale with at least one absolute end point would be preferable.

[Surgery at the skull base with transnasal endoscopic control]

INTRODUCTION

Skull base surgery is targeted to diseases in the posterior, lateral or anterior skull base. Development of endoscopic paranasal sinus surgery has contributed to expand the indications for transnasal surgery at the anterior skull base. Patients do not have visible scars and have less postoperative pain after endoscopic surgery and a decreased postoperative morbidity in general results in a shorter hospital stay.

MATERIAL AND METHODS

An overview is given of transnasal endoscopic skull base surgery, based on literature retrieved from PubMed and illustrated by three patients operated at the University Hospital of Northern Norway.

RESULTS AND INTERPRETATION

Transethmoid meningoencephalocele, pituitary conditions and the need for biopsy from the cavernous sinus are presented as suitable indications for transnasal endoscopic skull base procedures. From an anatomical point of view, the skull base is situated between the orbit, the ear and the paranasal sinuses on one side and the brain on the other side. Several specialties are therefore involved in skull base surgery, and interdisciplinary cooperation is important. Computer-assisted surgical instruments and navigation systems based on digital imaging enable an improved perioperative orientation and thereby improves the safety of skull base surgery. Endoscopic surgery at the skull base may contribute to reduce surgical morbidity and hospitalization and thereby has a health economic potential.

Diagnostic values of beta-2 transferrin and beta-trace protein as markers for cerebrospinal fluid fistula

INTRODUCTION

During recent decades, beta2-transferrin and beta-trace protein (prostaglandin D synthase) have been used as immunological markers for the diagnosis of CSF fistula. A method for detecting CSF traces should be non invasive, reliable and cheap.

METHODS

The characteristics of the two immunological markers are described based on own experience and a literature review. PubMed (1966-2007) was searched and 39 articles were retrieved from the period 1987-2007.

RESULTS

The beta2-transferrin marker showed a high reliability during the last decades using immunofixation or immunoblotting. The performance of beta2-transferrin assay requires between two and four hours hands-on time in the laboratory depending on the assay. The beta-trace protein protein marker showed a high reliability when assayed using immunoelectrophoresis or laser-nephelometry. Laser-nephelomety is automated, non- time consuming, provides quantitative results and last but not least, is cheap. A cut-off point at 1.11 mg/l for beta-trace protein gave the best trade-off between high sensitivity and high specificity when including the secretion/serum ratio.

CONCLUSION

Both beta2-transferrin and beta-trace protein are reliable immunological markers for the detection of CSF traces. High diagnostic accuracy values were found for both beta2-transferrin and beta-trace protein protein.

Incidence of CSF fistula after paranasal sinus surgery: the Northern Norwegian experience

STATEMENT OF PROBLEM

Cerebrospinal fluid (CSF) fistula is a well-known complication of paranasal sinus surgery. Not only manifest, but also occult CSF fistulas occur. The incidence of occult CSF fistula has been described only once and has not been tested since.

MATERIAL AND METHODS

In a prospective diagnostic study, the incidence of manifest and occult CSF fistulas was measured. Forty four patients operated for paranasal sinus diseases were included between 2002 and 2006. Seventy four fluid samples were collected by pressing nasal tamponades the day after surgery, and were measured for beta-trace protein using laser-nephelometry. In patients with a beta-trace value in secretion between 0.68 and 1.11 mg/l, a serum sample was taken and measured for beta-trace protein.

RESULTS

Thirty-one patients had a secretion beta-trace protein value below 0.68 mg/l. Thirteen patients had a secretion beta-trace protein value between 0.68 and 1.11 mg/l. The secretion/serum ratio in this group was below 1.57, not indicating the presence of CSF traces. The incidence of CSF fistula in this study population was zero.

PRINCIPAL CONCLUSION

A previously described incidence of occult CSF fistula after paranasal sinus surgery was not confirmed in the present study.

First clinical experience with β-trace protein (prostaglandin D synthase) as a marker for perilymphatic fistula

A diagnosis of perilymphatic fistula is still controversial. Recently, a case report indicated that β-trace protein (prostaglandin D synthase) might be a potential marker for perilymphatic fluid. In this multicentre clinical case series study β-trace protein was used as a marker for perilymphatic fluid fistula. Fifteen fluid samples were collected during diagnostic tympanoscopy. In addition, five samples were collected from patients with tympanic membrane perforation for use as as negative controls. Samples were obtained using precision glass capillaries and were analysed for β-trace protein using laser nephelometry. The diagnosis of perilymphatic fistula was defined by the patient's history, the audiological and vestibular investigation and the findings at tympanoscopy. The cut-off level of β-trace protein for perilymph-positive samples was chosen at 1.11 mg/l. The sensitivity and specificity were calculated using a 2 × 2 contingency table. There was no false positive result, but in two cases a false negative result was found. The specificity was 1 and the sensitivity was 0.81. The material of this first clinical study is small owing to the rarity of patients undergoing diagnostic tympanoscopy for perilymphatic fluid fistula. However, according to these preliminary results β-trace protein might be a promising marker in the diagnosis of perilymphatic fluid fistulas.

[Treatment of Frey's syndrome using botulinum toxin]

BACKGROUND

Frey's syndrome, also known as gustatory sweating, has been known for 150 years. However, effective treatment was established only as recently as in 1994, with botulinum toxin used for the treatment of torticollis or other forms of spasticity.

MATERIAL AND METHODS

We present an overview over Frey's syndrome. Diagnosis with Minors sweating test and treatment with botulinum toxin is presented on the basis of our own experience. Relevant literature was found through Medline.

RESULTS AND INTERPRETATION

Botulinum toxin injected intracutaneously is a safe and effective method for the treatment of Frey's syndrome. The results are convincing and the method is well documented in the literature. So far, no serious side effects have been found.