Pre-surgery planning tool for estimation of resection volume to improve nasal breathing based on lattice Boltzmann fluid flow simulations

Purpose

State-of-the-art medical examination techniques (e.g., rhinomanometry and endoscopy) do not always lead to satisfactory postoperative outcome. A fully automatized optimization tool based on patient computer tomography (CT) data to calculate local pressure gradient regions to reshape pathological nasal cavity geometry is proposed.

Methods

Five anonymous pre- and postoperative CT datasets with nasal septum deviations were used to simulate the airflow through the nasal cavity with lattice Boltzmann (LB) simulations. Pressure gradient regions were detected by a streamline analysis. After shape optimization, the volumetric difference between the two shapes of the nasal cavity yields the estimated resection volume.

Results

At LB rhinomanometry boundary conditions (bilateral flow rate of 600 ml/s), the preliminary study shows a critical pressure gradient of −1.1 Pa/mm as optimization criterion. The maximum coronal airflow ΔA  := cross-section ratio \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\frac{\mathrm{virtual surgery }}{\mathrm{post}-\mathrm{surgery}}$$\end{document}virtualsurgerypost-surgery found close to the nostrils is 1.15. For the patients a pressure drop ratio ΔΠ  := (pre-surgery − virtual surgery)/(pre-surgery − post-surgery) between nostril and nasopharynx of 1.25, 1.72, −1.85, 0.79 and 1.02 is calculated.

Conclusions

LB fluid mechanics optimization of the nasal cavity can yield results similar to surgery for air-flow cross section and pressure drop between nostril and nasopharynx. The optimization is numerically stable in all five cases of the presented study. A limitation of this study is that anatomical constraints (e.g. mucosa) have not been considered.

Assessment of health-related quality-of-life in patients with chronic Rhinosinusitis - Validation of the German Sino-Nasal Outcome Test-22 (German-SNOT-22)

PURPOSE

The Sino-Nasal-Outcome-Test-22 (SNOT-22) represents the reference questionnaire to assess symptoms, health-related quality-of-life (HRQOL) and treatment-response in patients with chronic rhinosinusitis (CRS). The SNOT-22 has been validated for various languages, yet no validation is available for the German version. Thus, we provide a validation of the SNOT-22 for German.

METHODS

In this prospective observational study 139 CRS-patients and 36 control-participants were included. CRS-patients completed the German-SNOT-22 before treatment (T0) and four (T1), twelve (T2) and 48 weeks after inclusion (T3). At T0, Mackay-Naclerio-, Lund-Mackay- and Brief-Symptom-Inventory-18 (BSI-18) scores were collected as external reference for the German-SNOT-22 and its subscales. At T1, T2, and T3 health-transition-items (HTIs) were raised to explore responsivity. Control-participants completed the German-SNOT-22 at T0. Reliability (internal consistency, item-total correlation), validity (concurrent validity, discriminatory validity) and responsiveness (distribution- and anchor-based) were explored for the German-SNOT-22.

RESULTS

At T0, the mean German-SNOT-22 total-score for CRS patients was 38.0 (± 20.9) and responded to treatment (T1 = 26.3 ± 19.1; T2 = 25.8 ± 20.6; T3 = 20.5 ± 16.3). For control-participants, the mean total-score at T0 was 15.1 (±10.9). The German-SNOT-22 was reliable (excellent internal consistency α = 0.93; good overall item-total correlations r = 0.39-0.85), valid (significant correlations between Mackay-Naclerio-, Lund-Mackay- and BSI-18 scores, all r > 0.39, p < 0.01) and responsive (significant correlations between HTIs and mean change in German-SNOT-22 total-score F = 9.57, p < 0.001).

CONCLUSION

The German-SNOT-22 validated here matches the original SNOT-22. It is a reliable, valid and responsive questionnaire to assess symptoms, HRQOL and treatment-response in CRS-patients. Good psychometric properties were observed.

Slug Is A Surrogate Marker of Epithelial to Mesenchymal Transition (EMT) in Head and Neck Cancer

Background: Epithelial to mesenchymal transition (EMT) promotes therapy resistance in head and neck cancer (HNC) cells. In this study, EMT was quantified in HNC tumor samples by the cellular co-localization of cytokeratin/vimentin, E-cadherin/β-catenin and by Slug expression. Methods: Tissue samples from HNC patients were stained with antibody pairs against cytokeratin/vimentin and E-cadherin/β-catenin. Epithelial–mesenchymal co-localization was quantified using immunofluorescence multichannel image cytometry. Double positivity was confirmed using confocal microscopy. Slug was semi-quantified by 2 specialists and quantified by bright field image cytometry. Results: Tumor samples of 102 patients were investigated. A loss of E-cadherin positive cells (56.9 ± 2.6% vs. 97.9 ± 1.0%; p < 0.0001) and E-cadherin/β-catenin double positive cells (15.4 ± 5.7% vs. 85.4 ± 1.2%; p < 0.0001) was observed in tumor samples. The percentage of Slug positive cells was increased in tumor samples (12.1 ± 3.6% vs. 3.2 ± 2.6%; p = 0.001). Ordinal Slug scores judged by two specialists closely correlated with percentage of Slug-positive cells (Spearman’s rho = 0.81; p < 0.001). Slug score correlated negatively with the percentage of E-cadherin positive cells (r = 0.4; p = 0.006), the percentage of E-cadherin/β-catenin positive cells (r = 0.5; p = 0.001) and positively with cytokeratin/vimentin positive cells (r = 0.4, p = 0.003). Conclusion: EMT can be assessed in HNC tumor probes by cytokeratin/vimentin co-expression and loss of E-cadherin/β-catenin co-expression. Slug score provides a convenient surrogate marker for EMT.

European Position Paper on Rhinosinusitis and Nasal Polyps 2020

The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 is the update of similar evidence based position papers published in 2005 and 2007 and 2012. The core objective of the EPOS2020 guideline is to provide revised, up-to-date and clear evidence-based recommendations and integrated care pathways in ARS and CRS. EPOS2020 provides an update on the literature published and studies undertaken in the eight years since the EPOS2012 position paper was published and addresses areas not extensively covered in EPOS2012 such as paediatric CRS and sinus surgery. EPOS2020 also involves new stakeholders, including pharmacists and patients, and addresses new target users who have become more involved in the management and treatment of rhinosinusitis since the publication of the last EPOS document, including pharmacists, nurses, specialised care givers and indeed patients themselves, who employ increasing self-management of their condition using over the counter treatments. The document provides suggestions for future research in this area and offers updated guidance for definitions and outcome measurements in research in different settings. EPOS2020 contains chapters on definitions and classification where we have defined a large number of terms and indicated preferred terms. A new classification of CRS into primary and secondary CRS and further division into localized and diffuse disease, based on anatomic distribution is proposed. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, allergic rhinitis, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. All available evidence for the management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is systematically reviewed and integrated care pathways based on the evidence are proposed. Despite considerable increases in the amount of quality publications in recent years, a large number of practical clinical questions remain. It was agreed that the best way to address these was to conduct a Delphi exercise . The results have been integrated into the respective sections. Last but not least, advice for patients and pharmacists and a new list of research needs are included. The full document can be downloaded for free on the website of this journal: http://www.rhinologyjournal.com.

Surgical rescue for persistent head and neck cancer after first-line treatment

PURPOSE

Surgical rescue is a treatment option for persistent disease after first-line treatment treatment of head and neck cancer (HNC).

METHODS

Patients with persistent HNC treated with rescue surgery between 2008 and 2016 were included. Patients who received a rescue neck dissection (ND only) and who received primary site surgery ± ND were analysed separately (primary site surgery ± ND).

RESULTS

During the observation period, 35 patients received ND only and 17 primary site surgery ± ND. No perioperative mortality was observed. In nine patients with ND only and 12 patients with primary site surgery ± ND at least one complication was encountered. 41/52 (79%) patients had a complete response. Median overall survival of patients receiving rescue surgery was 56 months (95% CI 44-69 months). Median overall survival was best for patients with initial laryngeal and oropharyngeal cancer and worst for patients with hypopharyngeal cancer (p = 0.02). Functional deficits following rescue surgery were mainly observed in the domains speech, nutrition, and shoulder/arm mobility. The risk of functional impairment was higher for patients with rescue surgery at the primary tumor site (OR 2.5 ± 2; p = 0.07).

CONCLUSION

Rescue surgery offers patients with resectable, persistent disease a realistic chance to achieve long-term survival. Especially patients with laryngeal and oropharyngeal cancer profited from rescue surgery. Rescue neck dissection is an effective and safe procedure. Patients with rescue surgery at the primary tumor site ± ND should expect complications and permanent functional impairment.

Pleiotropic Effects of Epithelial Mesenchymal Crosstalk on Head and Neck Cancer: EMT and beyond

Epithelial mesenchymal crosstalk (EMC) describes the interaction of the tumor stroma and associated fibroblasts with epithelial cancer cells. In this study we analysed the effects of EMC on head and neck cancer cells. In tumor cell lines EMC was induced using media conditioned from a mix-culture of cancer cells and fibroblasts. Cell proliferation and chemotherapy response were assessed using direct cell counting. Flow cytometry, immunohistochemistry of markers of epithelial-mesenchymal transition (EMT) and subsequent TissueFaxs™ acquisition and quantification and western blot analysis were performed. Holotomographic microscopy imaging was used to visualize the effects of EMC on Cisplatin response of SCC-25 cells. EMC induced a hybrid epithelial-mesenchymal phenotype in SCC-25 cells with co-expression of vimentin and cytokeratin. This hybrid phenotype was associated with chemotherapy resistance and increased proliferation of the cells. The EMC conditioned medium led to an activation of the IL-6/STAT3 pathway with subsequent phosphorylation of STAT3. EMC induced a hybrid epithelial-mesenchymal phenotype in HNSCC cells accompanied by increased therapy resistance and cell proliferation. The IL-6/STAT3 pathway might be one of the major pathways involved in these EMC-related effects.

Tavipec in acute rhinosinusitis: a multi-centre, doubleblind, randomized, placebo-controlled, clinical trial

BACKGROUND

This randomized clinical trial was designed to evaluate the efficacy and safety of Tavipec® (Spicae aetheroleum), a phytomedicine obtained by steam distillation of the flowering tops of Lavandula latifolia, as compared to placebo in adult patients suffering from acute viral rhinosinusitis.

METHODOLOGY

Patients with acute viral rhinosinusitis were randomly assigned to treatment with 2 capsules Tavipec® 150 mg or placebo thrice daily over a period of 7 days in a double-blind, parallel-group design. No additional treatment was admitted. The efficacy endpoints comprised the improvement of the main rhinosinusitis symptoms as per Major Symptom Score (MSS) and Sino-Nasal Outcome Test (SNOT-22) as well as of quality of life (QoL) by global assessment scale, evaluated at baseline, day 5 and day 8, respectively.

RESULTS

288 patients were enrolled and randomized to treatment. At day 8 the patients in the Tavipec® group had a significantly lower MSS compared to placebo and the impact of rhinosinusitis symptoms on QoL was significantly reduced. A significantly higher proportion of Tavipec® treated patients experienced a change in SNOT-22 score greater than or equal to 10 points at day 5 or day 8. No new safety signals were identified.

CONCLUSIONS

The treatment with Tavipec® effectively reduced the symptoms of acute rhinosinusitis in adult patients.

Readout-Segmented Echo-Planar DWI for the Detection of Cholesteatomas: Correlation with Surgical Validation

BACKGROUND AND PURPOSE

MR imaging has become an important tool for the detection of cholesteatomas of the middle ear. Various diffusion-weighted imaging sequences are available and have shown promising results. This study aimed to evaluate readout-segmented echo-planar DWI for the detection of cholesteatoma and compare the results with surgical validation.

MATERIALS AND METHODS

Fifty patients with chronic otitis media (24 females and 26 males; range, 12-76 years of age; mean age, 41 years) who underwent MR imaging before an operation of the middle ear (1-169 days) were included. The MR imaging protocol consisted of axial and coronal readout-segmented echo-planar DWI with b-values of 0 and 1000 s/mm² and 3-mm slice thickness. The readout-segmented echo-planar diffusion-weighted images were fused with standard T2-weighted sequences for better anatomic assignment. The results of the MR imaging evaluation were correlated with the results from the operation.

RESULTS

Readout-segmented echo-planar DWI detected 22 of the 25 cases of surgically proved cholesteatoma. It has an accuracy of 92% (95% confidence interval, 80.8%-97.8%), a sensitivity of 88%, a specificity of 96%, a positive predictive value of 96%, and a negative predictive value of 89%. In 1 case, a positive finding for cholesteatoma with readout-segmented echo-planar DWI could not be proved by histology, and in 3 cases, histology yielded a cholesteatoma that was not detected with MR imaging.

CONCLUSIONS

Readout-segmented echo-planar DWI is a promising and reliable MR imaging sequence for the detection and exclusion of cholesteatoma.

mySinusitisCoach: patient empowerment in chronic rhinosinusitis using mobile technology

Mobile health technology is emerging to take a prominent position in the management of chronic diseases. These technologies aim at enhancing patient empowerment via education and self-management. To date, of all the different apps available for patients with sinus disease, none were developed by medical experts dealing with chronic rhinosinusitis (CRS). The European Forum for Research and Education in Allergy and Airway diseases (EUFOREA) has undertaken a multi-stakeholder approach for designing, developing and implementing a tool to support CRS patients in monitoring their symptoms and to provide patients with a digital support platform containing reliable medical information about their disease and treatment options. mySinusitisCoach has been developed by medical experts dealing with CRS in close collaboration with patients, primary care physicians and community pharmacists, meeting the needs of both patients and health care providers. From a research perspective, the generation of real life data will help to validate clinical studies, patient stratification and improve understanding of the socio-economic impact of CRS, thereby paving the way for better treatment strategies.

EAACI Position paper on the standardization of nasal allergen challenges

Nasal allergen challenge (NAC) is an important tool to diagnose allergic rhinitis. In daily clinical routine, experimentally, or when measuring therapeutic success clinically, nasal allergen challenge is fundamental. It is further one of the key diagnostic tools when initiating specific allergen immunotherapy. So far, national recommendations offered guidance on its execution; however, international divergence left many questions unanswered. These differences in the literature caused EAACI to initiate a task force to answer unmet needs and find a consensus in executing nasal allergen challenge. On the basis of a systematic review containing nasal allergen challenges of the past years, task force members reviewed evidence, discussed open issues, and studied variations of several subjective and objective assessment parameters to propose a standardized way of a nasal allergen challenge procedure in clinical practice. Besides an update on indications, contraindications, and preparations for the test procedure, main recommendations are a bilaterally challenge with standardized allergens, with a spray device offering 0.1 mL per nostril. A systematic catalogue for positivity criteria is given for the variety of established subjective and objective assessment methods as well as a schedule for the challenge procedure. The task force recommends a unified protocol for NAC for daily clinical practice, aiming at eliminating the previous difficulty of comparing NAC results due to unmet needs.

Eosinophil Cationic Protein in Nasal Secretions and Blood Serum in Grass-Pollen Allergic Rhinitis

Concentration of the Eosinophil Cationic Protein (ECP) measured in different body fluids has been demonstrated to be a good marker of eosinophilic inflammation. In allergic asthma, ECP levels in both broncho-alveolar-lavage (BAL) fluid and serum can be used to monitor disease activity. In allergic rhinitis, the value of ECP determinations in serum and nasal secretions was not directly compared, so far. In the present study, ECP levels in blood serum (Se) and nasal secretions (NS) of grass pollen allergic and healthy individuals under pollen exposure were analyzed. Forty-three grass-pollen allergic subjects and 19 healthy volunteers were included. Grass-pollen counts were measured using Burkhard traps and a symptom scoring performed. In the allergic subjects, the mean ECP concentration in nasal secretions was 789 ± 515 ng/mL compared with 12.1 ± 7.4 ng/mL in serum; in the healthy volunteers it was 29.6 ± 15.4 ng/mL in NS compared to 9.4 ± 6.9 ng/mL in Se. ECP concentration in NS was significantly higher in allergic than in healthy subjects (P < 0.001) and in both significantly higher than in Se (P < 0.01). ECP concentration in Se did not differ significantly in patients and healthy volunteers (P > 0.05). In the allergic subjects, ECP concentration in NS but not in Se was closely correlated to symptom score and pollen exposure. We conclude that ECP levels in NS are a better marker of eosinophilic inflammation in allergic rhinitis than ECP serum levels.

Intratympanic steroid use for idiopathic sudden sensorineural hearing loss: current otolaryngology practice in Germany and Austria

AIMS

The frequency of the use of intratympanic steroids (ITS) as a treatment for idiopathic sudden sensorineural hearing loss (ISSNHL) in Europe is still unknown and remains a contentious issue amongst otolaryngologists. We undertook a survey of otolaryngologists in Germany and Austria to establish if there is any professional consensus with which to form a protocol for its use.

METHODS

A survey of 21 questions was distributed electronically to otolaryngologists in Germany and Austria and data on demographics, indications for intratympanic treatment, procedure, follow-up, and outcomes were analysed.

RESULTS

We received 908 responses. 49.1% of otolaryngologists used ITS for ISSNHL. Of those otolaryngologists who use ITS, 73.7% do not use it as primary treatment. 20.6% use ITS in conjunction with oral steroids for primary treatment and only 5.8% use ITS as monotherapy for primary treatment. 90.5% use ITS as salvage therapy. 81.1% do not consider the use of ITS after 2 weeks from the onset of symptoms. 8.3% used a tympanostomy tube and while the most commonly used steroid was dexamethasone at a concentration of 4 mg/ml (61%), a wide variety or other steroids and concentrations were used.

CONCLUSIONS

This survey illustrates wide variation of current practice of intratympanic corticosteroid injection for ISSHL in Germany and Austria. In the absence of high-level evidence, knowing what current practice is allows clinicians to assess what they do against what their colleagues are doing, and if they do something very different, make them question their practice. Moreover, the obtained data will help to direct future clinical trials with the aim to compare the outcomes of more commonly used protocols.

Saline irrigations following sinus surgery - a controlled, single blinded, randomized trial

BACKGROUND

Chronic rhinosinusitis (CRS) is a common health problem. If medical treatment fails, endonasal sinus surgery is a valuable treatment option. A thorough postsurgical treatment is needed including, among others, nasal saline irrigations (NSI). In this prospective, controlled, single blinded, randomized trial, we aimed to evaluate efficacy of nasal saline irrigations following endonasal sinus surgery in CRS-patients with nasal polyps.

METHODOLOGY

We examined patient's nasal symptoms, general quality of life and postoperative condition of the mucosa. We also investigated whether or not NSI reduced the number of missed workdays after surgery (MWD). Patients were randomized into an irrigation and non-irrigation arm.

RESULTS

Following treatment, mean nasal sum-score in the irrigation arm was 4.4 and in the non-irrigation arm it was 6.3. Accordingly, mean general sum-score in the irrigation arm was 2.5 and in the non-irrigation arm 4.8. Thus, nasal irrigation led to a more pronounced improvement of nasal and general symptoms than in the non-irrigation arm. No differences were observed in postoperative condition of mucosa or number of MWD.

CONCLUSIONS

Nasal irrigation improves symptoms score after ESS in patients with CRSwNP.

A randomized, 5-arm dose finding study with a mite allergoid SCIT in allergic rhinoconjunctivitis patients

BACKGROUND

The safety and tolerability of a mite allergoid subcutaneous allergen immunotherapy (SCIT) product was previously established. The aim of this study (EudraCT number: 2011-000393-61) was to find the optimally safe and effective allergoid dose by evaluating several dosages in patients with house dust mite (HDM)-induced allergic rhinoconjunctivitis (ARC) using a titrated nasal provocation test (TNPT).

METHODS

In total, 290 adult ARC patients (148 females; 142 males) with established HDM allergy and with a positive TNPT were randomized to receive placebo or mite allergoid SCIT 6667, 20 000, 50 000 or 100 000 AUeq/ml for 12 months. Patients were updosed weekly, followed by monthly maintenance dosing. The primary study endpoint comprised the clinical response to TNPT after 12 months of treatment. Secondary endpoints included response to TNPT after 6 months, PNIF measurements, symptom and medication scores during the last 8 weeks of treatment, serum immunoglobulins and safety assessments.

RESULTS

After 12 months, a dose-response was observed showing statistically significant improvements in the TNPT with SCIT concentrations of ≥20 000 AUeq/ml, while no significantly different outcomes were reached after 6 months. Specific serum IgG and IgG4 levels were dose dependently increased. In the highest dose group, more treatment-emergent adverse events were observed compared with the lower dose groups.

CONCLUSION

In this mite allergoid SCIT dose finding study in HDM-induced ARC, concentrations of ≥20 000 AUeq/ml showed both immunological effects and clinical efficacy in the TNPT compared with placebo. The risk-benefit ratio favours 20 000 AUeq/ml and 50 000 AUeq/ml strengths for further clinical development.

[Actinic Keratosis]

Actinic keratosis is a cutaneous lesion characterized by proliferation of atypical epidermal keratinocytes due to prolonged exposure to exogenous factors such as ultraviolet radiation. AKs are in-situ-squamous cell carcinomas (PEC) of the skin. AK typically presents as erythematous, scaly patch or papule (classic AK), occasionally as thick, adherent scale on an erythematous base. Mostly fair-skinned adults are affected. AKs typically occur in areas of frequent sun exposure (balding scalp, face, "H-region", lateral neck, décolleté, dorsum of the hand and lower extremities). Actinic Cheilitis is the term used for AKs appearing on the lips. The diagnosis of AK is based on clinical examination including inspection and palpation. The typical palpable rough surface of AK often precedes a visible lesion. Dermoscopy may provide additional information. If diagnosis is uncertain and invasion suspected, biopsy and histopathologic evaluation should be performed. The potential for progression to invasive PECs mandates therapeutic intervention. Treatment options include topical and systemic therapies. Topical therapies are classified into physical, medical and combined physical-chemical approaches and a sequential combination of treatment modalities is possible. Topical-physical cryotherapy is the treatment of choice for isolated, non-hypertrophic AK. Topical-medical treatment, e. g. 5-fluoruracil (5FU) cream or Imiquomod or Ingenolmebutat application is used for multiple, non-hypertrophic AKs. For hypertrophic AKs, a dehorning pretreatment with salicinated vaseline is recommended. Isolated hypertrophic AKs often need cryotherapy with prolonged freezing time or several consecutive applications. Sequentially combined approaches are recommended for multiple, hypertrophic AKs. Photodynamic therapy (PDT) as example for a combined physical-chemical approach is an established treatment for multiple, non-hypertrophic and hypertrophic AKs. Prevention includes avoidance of sun and application of sunscreen with high sun protection factor. Regular clinical checkups aid in early recognition of AKs.

[Safety in physical education - a teacher's perspective]

BACKGROUND

A high percentage of all sports injuries occur during school sports. The aim of this study was to collect statements and opinions of sports teachers for safety in physical education.

METHODS

In a cross-sectional study, 296 teachers (202 with, 94 without a teaching qualification in "exercise and sports") at 77 Tyrolean "New Middle Schools" (former secondary schools) were interviewed. They judged various statements on school sports safety using a 5-point verbal rating scale.

RESULTS

Irrespective of gender, teachers with a teaching qualification stated significantly more frequently (p = 0.015) that they have participated in continuing education on accident prevention than had their colleagues without qualification. The same applies to the checking of gymnastic and sports equipment before use (p < 0.001) and warming up at the beginning of the lesson (p < 0.001). Female sports teachers allowed their pupils more often (p = 0.002) to participate without adequate sportswear in physical education than did their male counterparts. Of all respondents, 57 % knew about technical faults in sports halls, which have also been reported to the school administration. In more than half (58 %) of these, reported defects were repaired completely and in one-third (36 %), a partial repair was reported. Participants estimated that the major risk for school sports injuries was due to the low motor skills of the pupils, inhomogeneous groups, large numbers of pupils, outdated sports equipment, and ball games.

CONCLUSION

Since about a third of all surveyed teachers had no teaching qualification in exercise and sports, this group should come into the focus of regular continuing education in accident prevention.

[Sport injuries in full contact and semi-contact karate]

BACKGROUND

Karate enjoys great popularity both in professional and recreational sports and can be classified into full, half and low contact styles. The aim of this study was the analysis of sports injuries in Kyokushinkai (full contact) and traditional Karate (semi-contact).

METHODS

In a retrospective study design, 215 active amateur karateka (114 full contact, 101 semi-contact) were interviewed by means of a standardised questionnaire regarding typical sport injuries during the last 36 months. Injuries were categorised into severity grade I (not requiring medical treatment), grade II (single medical treatment), grade III (several outpatient medical treatments) and grade IV (requiring hospitalisation).

RESULTS

In total, 217 injuries were reported in detail. 125 injuries (58%) occurred in full contact and 92 (42%) in semi-contact karate. The time related injury rate of full contact karateka was 1.9/1000 h compared to 1.3/1000 h of semi-contact karateka (p < 0.05). The most common types of injuries were musculoskeletal contusions (33% full contact, 20% semi-contact), followed by articular sprains with 19% and 16%. The lower extremity was affected twice as often in full contact (40%) as in semi-contact (20%) karate. Training injuries were reported by 80% of the full contact and 77% of the semi-contact karateka. Most injuries, both in training and competition, occurred in kumite. 75% of the reported injuries of full contact and 70% of semi-contact karateka were classified as low grade (I or II).

CONCLUSION

The high rate of injuries during training and kumite (sparring) points to specific prevention goals. The emphasis should be put on proprioceptive training and consistent warm-up. In the actual competition the referees play a vital role regarding prevention.

[Acute rhinosinusitis in adults--EPOS 2012 Part II]

Rhinosinusitis (RS) is an inflammatory disorder of the mucous membranes of the nose and paranasal sinuses, which are almost always affected concurrently. The EPOS2012 position paper initiated by the European Rhinologic Society and the European Academy of Allergy and Clinical Immunology is a recent comprehensive source on this common disease affecting approximately 20% of the population worldwide. Inflammation, not infection, is considered the cornerstone of RS, which is considered a temporal and pathophysiologic disease continuum with various subtypes. Acute rhinosinusitis is diagnosed, if typical symptoms last less than 12 weeks. It affects approximately 10% of the European population. Acute RS is further subdivided into acute viral, acute postviral and acute bacterial RS. Acute viral RS lasts less than 10 days with decreasing symptom intensity, while acute postviral RS is characterized by longer duration or a sudden increase of symptom severity around the 5th day ('double sickening'). Acute bacterial RS is assumed if 3 of the following 5 criteria are additionally met: Discoloured discharge (with unilateral predominance), severe local pain (with unilateral predominance), fever (>38ºC), elevated ESR/CRP, and 'double-sickening'. For the treatment of acute viral RS, nasal saline irrigations and OTC cold remedies are advised. In acute postviral RS, additional topical steroids are suggested. Advantages and disadvantages of antibiotic treatment in acute bacterial RS are detailed. Overall, the new EPOS position paper infers a reorientation in this area of high medical, pharmaceutical and economic relevance.

Radiological detection of extracapsular spread in head and neck squamous cell carcinoma (HNSCC) cervical metastases

BACKGROUND

Extracapsular spread of cervical lymph nodes deteriorates the prognosis of patients with head and neck squamous cell carcinoma. Postoperative radiochemotherapy is superior to postoperative radiotherapy alone in patients with histologically proven extracapsular spread. If extracapsular spread can be detected preoperatively, patients may favor primary radiochemotherapy instead of primary surgery plus postoperative radiochemotherapy.

METHODS

Computed tomography (CT) scans of nodal positive head and neck squamous cell carcinoma patients treated between 2008 and 2010 with comprehensive neck dissection as part of first line surgical treatment were retrospectively scanned for extracapsular spread by two blinded radiologists. If a positive lymph node was identified by the pathologist, CT scans were assessed for extracapsular spread retrospectively. CT criteria for Extracapsular spread were apparent fat and soft tissue infiltration or infiltration of sternocleidomastoid muscle, internal jugular vein or carotid artery. Radiologic judgment was compared with histological evidence of extracapsular spread and specificity and sensitivity of CT detection was calculated.

RESULTS

Forty-nine patients with histologically proven positive lymph nodes (pN+) were included. Extracapsular spread was histologically proven in 17 cases; the number of all affected lymph nodes was not listed. Radiologist 1 found extracapsular spread in CT scans of 15/49 patients and radiologist 2 in 16/49 patients (Cohen's kappa=0.86; p<0.01). Sensitivity of radiologic extracapsular spread detection was 73% (95% confidential index (CI): 44.0-89.7%) and specificity 91% (75.0-98.0%).

CONCLUSION

Extracapsular spread depicted on computed tomography using strict criteria has high specificity.

[Chronic Rhinosinusitis - EPOS 2012 Part I]

An expert group of the European Academy of Allergy and Clinical Immunology (EAACI) and the European Rhinologic Society (ERS) has recently published the revised position paper for acute and chronic rhinosinusitis (EPOS 2012). In the following article, the most important aspects of the EPOS 2012 paper concerning chronic rhinosinusitis (CRS) are referenced. Every 10th European is suffering from a chronic inflammation of the nose and paranasal sinuses.2 EPOS key messages according CRS are: 1. CRS is an inflammatory disease, not an infection. 2. CRS comes in 2 different subtypes, namely CRS without polyps (CRSsNP) and CRS with polyps (CRSwNP). CRSwNP is diagnosed, when nasal polyps are visible at an appropriate nasal endoscopic examination. Otherwise CRSsNP is classified. In the EPOS 2012 paper the current pathogenetic knowledge of these 2 different CRS subtypes are discussed. Current research focuses on epithelial/immune cell interactions, the biofilm hypothesis and the superantigen hypothesis. Both CRS subtypes may be associated with different frequencies with other diseases, especially allergies, asthma and aspirin exacerbated respiratory disease (AERD). These comorbidities should be recorded and treated. The standard diagnostic procedures include medical history, nasal endoscopy, CT-scans of the paranasal sinus, and allergy test of common inhalant allergens. The classification of disease severity in mild, moderate and severe was complemented with a concept of symptom control in controlled, partly controlled and uncontrolled. Also, a 'difficult-to-treat-CRS' was defined. The choice of therapy depends upon symptom intensity. In patients with moderate and severe symptoms, usually several weeks of conservative treatment including topical steroids are administered. In non-responders, surgical treatment (functional endonasal sinus surgery) is indicated. The EPOS Group offers evidence-based treatment algorithms for general practitioners and ENT-specialists.

[Frequency, nature and distribution of school sport injuries at different types of schools]

BACKGROUND

A high percentage of all sports injuries occur during school sports. It was analysed whether there are differences in frequency, nature and distribution of school sport injuries at two different types of schools.

METHODOLOGY

School sport injuries of all secondary modern schools (n = 106) and in lower classes of grammar Schools (n = 17) in the federal state of Tyrol, Austria, from the ten school years 2001/02 to 2010/11 were analysed. All physical injuries occurring during school sports and resulting in the consultation of a medical doctor and therefore being reported to the general accident department (Allgemeine Unfallversicherungsanstalt [AUVA]) were assessed.

RESULTS

During the evaluation period an average number of 32,935 (±1584) school children attended the two types of schools in Tyrol per year. The average incidence of school sports injuries in this ten-year period in both types of schools was 36.4/1,000 (mean) with a standard deviation of 4.4/1,000 per school child per year. The incidence increased from 30.3 in the school year 2001/02 to 40.4 in the school year 2010/11 (r = 0.91; b = 1.34; p < 0.0001). The incidence of school sport injuries at secondary modern schools (37.4 ± 4.9 per 1,000 school children per year) was higher than at the lower classes of grammar schools (32.9 ± 4.0 per 1,000 school children per year; relative risk 1.138; 95% CI = 1.09-1.19; p = 1.8 × 10-8). In addition, the sports injuries of the school year 2010/11 were analysed in detail and a comparison was made between the two types of schools. The distribution pattern of school sports injuries did not show any significant differences between both school types. At the secondary modern schools, as well as in the lower classes of grammar schools, injuries to the upper extremities prevailed (>50%). Ball sports were responsible for every second injury. Secondary modern school pupils had a significantly higher risk of suffering a school sports injury than pupils in the lower classes of grammar schools. The injury pattern did not show differences between the two types of schools.

CONCLUSION

The consistently higher frequency of injuries at secondary modern schools compared to the lower classes of grammar schools indicates the need for school type-specific accident research and prevention efforts.

Optical and electromagnetic tracking for navigated surgery of the sinuses and frontal skull base

BACKGROUND

New hardware and software algorithms in electromagnetic tracking for computer assisted surgery (CAS) have been developed. We aimed to compare electromagnetic tracking for navigated procedures in frontal skull base surgery to optical tracking.

METHODS

Target registration error (TRE) was determined in 6 anatomic specimens in an experimental wet-lab. As targets, 6 titanium screws were evenly distributed over the surgical areas of interest from the frontal sinus to the clivus. Optical tracking and electromagnetic tracking was evaluated in identical software environment using a last generation commercially available navigation system.

RESULTS

Submillimetric application accuracy could be achieved with both tracking modalities. Optical was more accurate than electromagnetic tracking and its reliability was better. Target position did not influence TRE, however TRE varied significantly from skull to skull.

CONCLUSIONS

Although less accurate than optical tracking, electromagnetic tracking still offers excellent accuracy and reliability for anterior skull base surgery. Electromagnetic tracking is not dependent on direct line of sight between its hardware components and therefore easily integrated even in cluttered operating theatres.

[Fungal sinusitis]

The incidence of fungal sinusitis is subjected to significant geographical variation. Basically, invasive and non-invasive fungal sinusitis is distinguished. Invasive fungal sinusitis is observed mainly in immunocompromised hosts. The diagnopsis is based on positive fungus detection combined with characteristic clinical features. The treatment of invasive fungal sinusitis is based on surgical debridement and systemic antifungal therapy. Non-invasive fungal sinusitis is either treated with surgery alone or surgery combined with systemic steroid therapy. The majority of studies showed no benefit of postoperative antimycotic medical treatment in patients with non-invasive fungal sinusitis.

Local production of aspergillus fumigatus specific Immunoglobulin E in nasal polyps

BACKGROUND

Aspergillus spp. play a significant role in the etiology of immunoglobulin (Ig)E mediated allergic fungal sinusitis (AFS). It is unclear whether Aspergillus spp. are also involved in nasal polyps without the characteristic clinical features of AFS.

OBJECTIVES

The frequency of Aspergillus spp. and Aspergillus-specific IgE in nasal lavages and serum of patients with severe nasal polyps (n = 33) without clinical features of AFS should be investigated.

STUDY DESIGN

Prospective study.

METHODS

An aliquot of nasal lavage fluid was treated with dithiothreitol and examined for Aspergillus fumigatus by culture and an Aspergillus-specific polymerase chain reaction (PCR) assay. An additional aliquot of nasal fluid and serum of the same patient were tested for specific IgE (Unicap, Pharmacia, Freiburg, Germany) to recombinant Aspergillus fumigatus allergen (rAspf) 1 to 6.

RESULTS

All patients had negative skin prick tests for Aspergillus fumigatus. Four of 33 (12%) lavage samples were positive for Aspergillus spp. by PCR. In one of these samples, rAspf-specific IgE was detected but none in the serum. Nasal lavage and serum samples of the remaining 29 patients were negative for rAspf-specific IgE.

CONCLUSIONS

Aspergillus spp. detection is rare in patients with severe nasal polyps without characteristic clinical features of AFS. Specific IgE in nasal secretions may be elevated in patients with negative skin prick tests and serum IgE. In these cases, immunologic mechanisms similar to AFS may be involved. Fungal etiology has been proposed to underlie severe nasal polyps in general. However, Aspergillus spp. seem not to play a significant role.

External nasal valve collapse - a case-control and interventional study employing a novel internal nasal dilator (Nasanita)

BACKGROUND

Nasal alar collapse is a common problem and difficult to assess and treat.

METHODS

In 10 healthy controls and 10 patients with alar collapse, the size of the external nasal valve was analyzed on standardized nasal base photographs during quiet breathing and forced inspiration. A novel internal nasal dilator (Nasanita, Siemens & Co, Germany) was employed to assess the effects of a therapeutic intervention. In addition, active anterior rhinomanometry was performed.

RESULTS

During quiet breathing, the external nasal valves were significantly smaller in patients with alar collapse (0.3 +/- 0.08 cm2) than in controls (0.7 +/- 0.2 cm2; p < 0.001). In heal-thy controls, forced inspiration did not significantly alter the size of the external nasal valve (-1.8% +/- 27.5%; p = 0.84), whereas it significantly decreased the external valve area in patients with alar collapse (-42.1% +/- 26.4%; p = 0.001). The internal nasal dilator significantly increased external valve areas during quiet breathing and forced inspiration and completely abolished alar collapse. Nasal airflow at a transnasal pressure difference of 150 Pa was not correlated with external valve size. Nasal airflow increased significantly after inserting the internal nasal dilator to 1300 +/- 370 ml/s (p < 0.001) in controls and 1300 +/-300 ml/s (p < 0.01) in patients.

CONCLUSION

A small sized external nasal valve appears to be a major causative factor of alar collapse. A novel internal nasal dilator effectively enlarged the external nasal valve, abolished alar collapse and improved nasal airflow.

Absence of inflammatory response from upper airway epithelial cells after X irradiation

Radiotherapy of head and neck tumors causes adverse reactions in normal tissue, especially mucositis. The dose- and time-dependent response of upper airway cells to X radiation should be analyzed in terms of the pro-inflammatory potential. Immortalized BEAS-2B lung epithelial cells were treated with 2, 5 and 8 Gy. Out of 1232 genes, those that were transcribed differentially after 2, 6 and 24 h were assigned to biological themes according to the Gene Ontology Consortium. Enrichment of differentially regulated gene clusters was determined with GOTree ( http://bioinfo.vanderbilt.edu/gotm ). Eleven cytokines were measured in culture supernatants. The cell cycle response up to 24 h and induction of apoptosis up to 4 days after exposure were determined by flow cytometry. A significant dose- and time-dependent gene activation was observed for the categories response to DNA damage, oxidative stress, cell cycle arrest and cell death/apoptosis but not for immune/inflammatory response. This correlated with functional G(2) arrest and apoptosis. Pro-inflammatory cytokines accumulated in supernatants of control cells but not of X-irradiated cells. The complex gene expression pattern of X-irradiated airway epithelial cells is accompanied by cell cycle arrest and induction of apoptosis. In vivo, this may impair the epithelial barrier. mRNA and protein expression suggest at most an indirect contribution of epithelial cells to early radiogenic mucositis.

[Diagnostics of primary ciliary dyskinesia]

Primary ciliary dyskinesia (PCD) is an autosomal recessive inherited disease characterized by abnormal ciliary motion and impaired mucociliary clearance. The prevalence of PCD is approximately 1 : 15 000 - 1 : 20 000 in live births. Cilia dysfunction is also implicated in a wider spectrum of diseases due to impaired organ genesis and body symmetry. Cilia are highly conserved in animals and show complex structures containing more than 250 proteins for their formation. Recent studies have begun to locate the PCD genes in the genome and characterize functional mutations. Specific diagnosis of the ciliary dysfunction requires physiological measurements as well as light- and electron microscopy. Abnormalities in ciliary motion and ultrastructural studies can be performed with nasal mucosal epithelium.

Staphylococcus aureus in nasal lavage and biopsy of patients with chronic rhinosinusitis

BACKGROUND

Staphylococcus aureus may play a relevant etiologic role in chronic rhinosinusitis (CRS) and may explain the T(H2) shift observed in CRS with nasal polyps (CRSNP(+)). Naturally occurring S. aureus small colony variants (SASCV) escape immune surveillance, antibiotic treatment and microbiologic routine diagnostic techniques. The frequency of S. aureus and SASCV in CRS patients and S. aureus-related effects on the local immune response should be prospectively investigated.

METHODS

Nasal lavages and mucosal biopsies of CRS patients were examined with bacterial culture suitable for detecting SASCV, real time PCR and fluorescence in situ hybridization. To assess the effects of S. aureus positivity, interleukin-5 (IL-5), interferon-gamma, total immunoglobulin E (IgE), eotaxin, granulocyte-colony stimulating factor, and eosinophil cationic protein in nasal lavages were determined and gene transcription analysis of nasal biopsies from S. aureus positive and negative CRSNP(+) patients was performed.

RESULTS

Thirty-one CRSNP(+) patients, 13 CRS patients without polyps, and 21 control patients were evaluated. Staphylococcus aureus was detected by any method in 25 patients (39%). Staphylococcus aureus detection rates did not differ between the three disease groups (P = 0.3). Staphylococcus aureus small colony variants were not found. In nasal lavages, IL-5 and total IgE levels were higher in CRSNP(+) patients than in CRSNP(-) patients or controls (P < 0.05). Staphylococcus aureus positivity did not influence biomarker concentrations in nasal lavages. Genes for T(H2) cytokines were not differentially transcribed.

CONCLUSIONS

We could not observe a higher prevalence of S. aureus in CRS patients with or without nasal polyps than in controls. We could not substantiate that S. aureus intensifies the T(H2) shift in CRSNP(+) patients. Staphylococcus aureus small colony variants were not detected in any sample.

Long-term treatment with aspirin desensitization: a prospective clinical trial comparing 100 and 300 mg aspirin daily

BACKGROUND

The daily dose of aspirin in desensitization in aspirin-sensitive asthmatics with nasal polyps is still a matter of debate.

AIMS OF THE STUDY

To compare two doses of aspirin during the first year of desensitization and to evaluate long-term effects on nasal/pulmonary symptoms.

METHODS

Patients with positive aspirin provocation test were treated with either 100 or 300 mg aspirin daily.

RESULTS

In all patients taking 100 mg aspirin (n = 7) recurrent nasal polyps were observed. No patient experienced reduction of asthma medication or improvement of pulmonary function. In the 300 mg group no recurrent nasal polyps were seen. Asthma medication could be reduced in three patients, pulmonary function was improved in five patients. Thirty-nine consecutively desensitized patients, taking 300 mg aspirin, showed significant improvement of olfaction and polyp-free nasal passages during the first year of therapy. After a median follow-up of 27 months no sinus revision surgery was necessary.

CONCLUSIONS

Aspirin desensitization followed by 300 mg aspirin daily is efficacious and results in polyp-free nasal airways, improvement of sense of smell, and reduction of the need for sinus revision surgery for recurrent nasal polyps. Aspirin in a dose of 100 mg daily is not sufficient to effectively reduce nasal and bronchial or pulmonary symptoms and to prevent recurrent nasal polyps by at least the first 12 months of treatment.

[Role of surgery in multimodal treatment of oral and oropharyngeal cancer]

BACKGROUND

The value of surgery in multimodal treatment concepts of oral and oropharyngeal cancer, respecting quality of life and survival rates, should be evaluated.

PATIENTS

Patients with oral or oropharyngeal cancer were grouped, if tumor-targeted surgery was part of a multimodal treatment concept or if the patients received radiotherapy with or without chemotherapy only. Surgical versus non-surgical therapy, age, disease extent, tumor site and comorbidity as measured by the American Society of Anesthesiologists (ASA) physical status score were included in a Cox proportional hazard analysis. Quality of life was assessed 3 years following treatment employing the EORTC-C30 and H&N35 questionnaires.

RESULTS

Patients treated with radiotherapy with or without chemotherapy only (63/140) had a worse survival (hazard ratio 1.7037, 95 % CI 0.9981 to 2.9080, p = 0.0508) than patients treated with surgery (77/140) as a part of a multimodal treatment concept. Disease extent (p < 0.01) and ASA score (p < 0.01) had a significant impact on survival. Quality of life scores were remarkably similar in surgically and non-surgically treated patients.

CONCLUSIONS

The results of this study indicate that surgery remains a core modality of oral and oropharyngeal cancer treatment. External beam radiotherapy only, also if applied in current fractionation techniques, may not be sufficient to achieve adequate results.

[Secondarily accelerated foreign bodies as a source of danger from airbag deployment]

BACKGROUND

The use of airbag systems in motor vehicle construction has led to a significant reduction in both the frequency and intensity of injuries during traffic accidents. However, recent reports have shown numerous cases in which it is assumed that the airbag was the major cause of serious injury.

CASE REPORT

In a collision with a wild boar, both airbags in the automobile deployed. The driver suffered facial abrasion and belt contusion to the left shoulder. The passenger held a glass bottle in her hands during the impact that, secondarily accelerated through the airbag, hit both eyes and the bridge of her nose. On clinical admission, the patient showed fractures of the nasal bridge, of both medial orbital walls on both sides and a massive periocular haematoma which required direct examination under narcosis. Both eyes showed an orbital contusion, a large area of corneal abrasion, traumatic mydriasis with sphincter tears such as bilateral 90% hyphema. During surveillance, a progressive reduction in visual acuity occurred. After posterior chamber vitrectomy with epiretinal peeling and posterior chamber lens implantation in the left eye, visual acuity was 0.05 in the left eye and 0.01 in the right.

CONCLUSIONS

A considerable danger emanates from objects which are situated between head and airbag in the moment of airbag deployment. This requires public education and, in addition, airbag systems which are adapted to the drivers height and weight, as well as to objects in its immediate vicinity.

[Mitomycin C in head and neck surgical procedures]

Mitomycin C (MMC) is frequently used in combination chemotherapy. Its metabolites bind to DNA-molecules and causes DNA crosslinking, which interferes with the synthesis of DNA, RNA and proteins. MMC is thus able to reduce fibroblast proliferation. Moreover, MMC particularly inhibits the synthesis of extracellular matrix proteins including fibronectin and various collagens. These properties have been demonstrated in several experimental studies. Beside its merits in treatment of malignancies, MMC may thus be useful to prevent hypertrophic scars and keloids, adhesions and ostial restenosis following head and neck surgical procedures. Clinically, MMC has been applied to prevent scarring after ophthalmologic surgery. Recent experimental and clinical trials investigating the effects of MMC on wound healing following head and neck surgical procedures are reviewed.

[Burning mouth syndrome]

Burning mouth syndrome (BMS) is characterized by oral dysesthesia, xerostomia and dysgeusia without visible alterations of oral mucosa. While secondary BMS results from an underlying general condition such as diabetes or iron deficiency, no causal disorder can be identified in primary BMS. The estimated prevalence is 1 - 2%, postmenopausal women are substantially more frequently affected than men. Current etiologic concepts assume a focal peripheral and central neuropathy. Only few controlled drug trials have yet been conducted. Thioctic acid appears the medical treatment of choice due to its comparatively good evidence for efficacy and low incidence of adverse reaction. Gabapentin and pregabalin are modern GABA-analogue anticonvulsants, which are also efficient in the treatment of peripheral neuropathies. Also conceptually appropriate for BMS treatment, current evidence for efficacy in BMS is insufficient. In two trials, local oral treatment with clonazepam has been beneficial in BMS. The efficacy of antidepressants is equivocal.