Empfehlungen zur Überprüfung der Wirksamkeit und Verlaufsdokumentation von Mepolizumab bei chronischer Rhinosinusitis mit Nasenpolypen (CRSwNP) im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der AGs Klinische Immunologie, Allergologie und Umweltmedizin und Rhinologie und Rhinochirurgie der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC)

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a multifactorial inflammatory disease of the mucous membranes of the nose and sinuses. Eosinophilic inflammation is described as a common endotype. The anti-IL5 antibody mepolizumab was approved in November 2021 as an add-on therapy to intranasal glucocorticosteroids for the treatment of adults with severe chronic rhinosinusitis with nasal polyps when systemic glucocorticosteroids or surgery do not provide adequate disease control. While national and international recommendations exist for the use of mepolizumab in CRSwNP, it has not yet been adequately specified how this therapy is to be monitored, what follow-up documentation is necessary, and when it should be terminated if necessary.

METHODS

A literature search was performed to analyze previous data on the treatment of CRSwNP with mepolizumab and to determine the available evidence by searching Medline, Pubmed, the national and international trial and guideline registries and the Cochrane Library. Human studies published in the period up to and including 10/2022 were considered.

RESULTS

Based on the international literature and previous experience by an expert panel, recommendations for follow-up, adherence to therapy intervals and possible therapy breaks, as well as termination of therapy when using mepolizumab for the indication CRSwNP in the German health care system are given on the basis of a documentation sheet.

CONCLUSIONS

Understanding the immunological basis of CRSwNP opens up new non-surgical therapeutic approaches with biologics for patients with severe, uncontrolled courses. Here, we provide recommendations for follow-up, adherence to therapy intervals, possible therapy pauses, or discontinuation of therapy when mepolizumab is used as add-on therapy with intranasal glucocorticosteroids to treat adult patients with severe CRSwNP that cannot be adequately controlled with systemic glucocorticosteroids and/or surgical intervention.

Empfehlungen zur Überprüfung der Wirksamkeit und Verlaufsdokumentation von Dupilumab bei chronischer Rhinosinusitis mit Nasenpolypen (CRSwNP) im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der AGs Klinische Immunologie, Allergologie und Umweltmedizin und Rhinologie und Rhinochirurgie der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC)

BACKGROUND

 Chronic rhinosinusitis with nasal polyps (CRSwNP) is a multifactorial inflammatory disease of the nasal and paranasal mucosa. A Type-2 inflammation is described as the most common endotype. Since October 2019 the anti-IL-4/-IL-13 antibody dupilumab has been approved in Germany as an add-on therapy to intranasal corticosteroids for the treatment of adults with severe chronic rhinosinusitis with nasal polyps, when systemic corticosteroids alone or surgery do not provide adequate disease control. While recommendations for the use of dupilumab in CRSwNP exist at both national and international levels, until now it has not been adequately established, how therapy should be monitored and when it should be discontinued in the German Health Care System.

METHODS

 A literature search was performed analyzing previous data on the treatment of CRSwNP with dupilumab and to determine the available evidence by searching Medline, Pubmed, the national and international trial and guideline registries and the Cochrane Library. Human studies published in the period up to 05/2022 were included.

RESULTS

 Based on international literature and previous experience, recommendations are given by an expert panel for follow-up and possible therapy breaks, therapy intervals or termination of therapy when using dupilumab for the indication CRSwNP in the German health care system based on a documentation form.

CONCLUSIONS

 Understanding the immunological basis of CRSwNP opens new non-surgical therapy approaches with biologics for patients with severe courses. The authors give recommendations for follow-up, possible therapy breaks, therapy intervals and a termination for dupilumab treatment as add-on therapy with intranasal corticosteroids for the treatment of adult patients with severe CRSwNP that cannot be adequately controlled with systemic corticosteroids and/or surgical intervention.

Positionspapier: Empfehlungen zur Anwendung von Mepolizumab bei chronischer Rhinosinusitis mit Polyposis nasi (CRSwNP) im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der AGs Klinische Immunologie, Allergologie und Umweltmedizin und Rhinologie und Rhinochirurgie der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Hals-Chirurgie (DGHNO-KHC)

BACKGROUND

 Chronic rhinosinusitis with nasal polyps (CRSwNP) is a multifactorial inflammatory disease of the paranasal sinus mucosa with eosinophilic inflammation as the most common endotype. The anti-IL5 antibody mepolizumab was approved for the treatment of severe CRSwNP in the EU in November 2021.

METHODS

 A literature search was performed to analyze the immunology of CRSwNP and determine the available evidence by searching Medline, Pubmed, and the German national and international trial and guideline registries and the Cochrane Library. Human studies published in the period up to and including 12/2021 that investigated the effect of mepolizumab in CRSwNP were considered.

RESULTS

 Based on the international literature and previous experience, recommendations for the use of mepolizumab in CRSwNP in the German health care system are given by an expert panel on the basis of a documentation form.

CONCLUSIONS

 Understanding about the immunological basis of CRSwNP opens new non-surgical therapeutic approaches with biologics for patients with severe courses. Mepolizumab is approved since November 2021 for add-on therapy with intranasal corticosteroids for the treatment of adult patients with severe CRSwNP who cannot be adequately controlled with systemic corticosteroids and/or surgical intervention.

Positionspapier: Empfehlungen zur Anwendung von Omalizumab bei chronischer Rhinosinusitis mit Polyposis nasi (CRSwNP) im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der AGs Klinische Immunologie, Allergologie und Umweltmedizin und Rhinologie und Rhinochirurgie der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC)

Hintergrund Die chronische Rhinosinusitis mit Nasenpolypen (CRSwNP) ist eine multifaktorielle entzündliche Erkrankung der paranasalen Schleimhäute, der als Endotyp meistens eine TH2-Inflammation zugrunde liegt. IgE-Antikörper spielen dabei eine wichtige Rolle. Der anti-IgE-Antikörper Omalizumab wurde im August 2020 für die Therapie der schweren CRSwNP zugelassen.

Methoden In einer Literatursuche wurde die Immunologie der CRSwNP analysiert und die Evidenz zur Wirkung von Omalizumab bei dieser Erkrankung ermittelt durch Recherchen in Medline, Pubmed sowie den nationalen und internationalen Studien- und Leitlinien-Registern und der Cochrane Library.

Ergebnisse Basierend auf diesen Angaben aus der internationalen Literatur werden von einem Expertengremium Empfehlungen für die Anwendung von Omalizumab bei CRSwNP im deutschen Gesundheitssystem gegeben.

Schlussfolgerung Omalizumab ist zugelassen für Patienten ab 18 Jahren mit schwerer chronischer Rhinosinusitis mit Nasenpolypen als Zusatztherapie zu intranasalen Kortikosteroiden (INCS), wenn durch eine Therapie mit INCS keine ausreichende Krankheitskontrolle erzielt werden kann.

Positionspapier: Hinweise zur Patienteninformation und -aufklärung vor Anwendung von Biologika bei chronischer Rhinosinusitis mit Nasenpolypen (CRSwNP) – Teil 2: Omalizumab – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC)

Hintergrund Die chronische Rhinosinusitis mit Nasenpolypen (CRSwNP) ist eine multifaktorielle entzündliche Erkrankung, oftmals auf der Grundlage einer Typ-2-Inflammation. Für die Behandlung von Patienten mit einer schweren Ausprägung ohne ausreichendes Ansprechen auf die Standardtherapie mit topischen nasalen Steroiden und/oder Zustand nach endonasaler Operation sind als Biologika aktuell Dupilumab und Omalizumab für die Therapie zugelassen. Nachdem wir in einer früheren Publikation für Dupilumab bereits entsprechende Hinweise gegeben haben, ist das Ziel der vorliegenden Arbeit die Standardisierung von Patienteninformation und -aufklärung vor einer Therapie mit Omalizumab.

Methoden Auf Grundlage des aktuellen Wissensstandes zur Immunologie der CRSwNP und zu den erwünschten und möglichen unerwünschten Wirkungen von Omalizumab werden Empfehlungen für die Patienteninformation entwickelt.

Ergebnisse Basierend auf der internationalen Literatur, der aktuellen Fachinformation und Erfahrungen aus der praktischen Anwendung und den derzeitigen Pharmakovigilanz-Daten hat ein Expertengremium Empfehlungen für die Patienteninformation und -aufklärung zur Anwendung von Omalizumab bei CRSwNP entwickelt und auf dieser Grundlage einen Patienteninformations- und Aufklärungsbogen erstellt.

Schlussfolgerung Die Information und Einwilligung des Patienten wird vor der Verordnung bzw. Verabreichung von allen Biologika, damit auch Omalizumab, empfohlen. Das vorliegende Positionspapier enthält wichtige Informationen zur praktischen Umsetzung und einen Vorschlag für eine Patienteninformation.

[The first year of the SARS-CoV-2 pandemic-impact on otorhinolaryngology]

BACKGROUND

The first year of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has already affected our public health care system to an enormous extent and will continue to do so in the future. Otorhinolaryngologists (ORLs) are suspected to be at high risk of infection, due to the high viral load in the mucosa of the upper airways. The current review evaluates the impact of the pandemic on ORLs' activities and assesses the risk infection.

METHODS

A selective literature research was conducted using relevant English and German terms for ORL, SARS-CoV‑2, risk, and infection at PubMed, medRxiv, and bioRxiv, as well as in the Deutsches Ärzteblatt and on the websites of the Robert Koch Institute and the Johns Hopkins University.

RESULTS

Protection recommendations for ORL include general hygiene measures and wearing KN95 masks for routine professional activities. When in contact with coronavirus disease 2019 (COVID-19) patients, it is recommended to extend the personal protective equipment by eye protection, gloves, cap, and gown. International otorhinolaryngology societies have released guidelines for procedures (e.g., tracheostomy, sinus surgery), propagating personal protection for the surgical team and reduction of aerosols. Testing for SARS-CoV‑2 in patients and medical staff can contribute to reducing the risk of infection. Vaccination would provide some additional protection for ORLs and other health care professionals with increased exposure to aerosols. There is increasing evidence that ORLs are at a high risk of contracting SARS-CoV‑2.

CONCLUSION

Consequent personal protection, frequent testing of patients and health care professionals, and the promised SARS-CoV‑2 vaccinations may provide adequate protection for highly exposed persons.

Prevalence and risk factors of smell dysfunction - a comparison between five German population-based studies

BACKGROUND

The prevalence of olfactory impairment increases with age and is known to be an early sign of different neurodegenerative diseases. Only few population-based studies examined the prevalence of olfactory impairment and comparisons across studies are scarce. Aim of this analysis was to compare the prevalence and determinants of normosmia across five population based studies in Germany.

METHODOLOGY

Data from five population-based, cross-sectional studies were included. They were independently conducted and used the same test system (Sniffin' Sticks Screening 12) to measure olfactory function. This system consists of 12 odor-dispensing felt-tip pens; the task is a forced-choice selection among four alternative odors per pen. Sociodemographic information and comorbidities were assessed in face-to-face interviews. Univariate, descriptive statistics and multivariable logistic regression models stratified by study, were performed to determine risks, i.e. prevalence odds ratios, associated with olfactory function.

RESULTS

The prevalence of normosmic participants varied considerably across studies. Olfactory function was lower in men, decreased with age, and increased with higher education. Several individual comorbidities and a comorbidity index were associated with olfactory dysfunction. Recognition performance for three of the 12 pens was especially low in all studies.

CONCLUSION

Four factors, well known to describe population composition, contribute to explain differences in the prevalence of olfactory function between studies when the same test system is used. Our results indicate that comorbidities and educational level should always be considered when test systems based on smell recognition are used in population-based studies.

Positionspapier: Hinweise zur Patienteninformation und -aufklärung vor Anwendung von Biologika bei chronischer Rhinosinusitis mit Polyposis nasi (CRSwNP) – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC) – Teil 1: Dupilumab

Hintergrund Die chronische Rhinosinusitis mit Nasenpolypen (CRSwNP) ist eine multifaktorielle entzündliche Erkrankung der nasalen und paranasalen Schleimhaut, der oftmals eine Typ-2-Inflammation zugrunde liegt. Durch die Entwicklung von Biologika, die in diese Entzündungsmechanismen eingreifen können, steht eine neuartige Therapiemöglichkeit zur Verfügung.

Methoden Auf Grundlage des aktuellen Wissensstandes zur Immunologie der CRSwNP und der Wirkung von Biologika sowie deren mögliche unerwünschte Wirkungen werden Empfehlungen für die Patienteninformation entwickelt.

Ergebnisse Basierend auf der internationalen Literatur und bisherigen Erfahrungen hat ein Expertengremium Empfehlungen für die Patienteninformation und -aufklärung zur Anwendung von Biologika bei CRSwNP entwickelt und auf dieser Grundlage einen Aufklärungsbogen erstellt.

Schlussfolgerung Die Information und Einwilligung des Patienten ist vor der Verordnung bzw. Verabreichung von Biologika erforderlich. Das vorliegende Positionspapier enthält wichtige Informationen hierzu und einen Vorschlag für eine Patienteninformation.

Positionspapier: Anwendung von Biologika bei chronischer Rhinosinusitis mit Polyposis nasi (CRSwNP) im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der AGs Klinische Immunologie, Allergologie und Umweltmedizin und Rhinologie und Rhinochirurgie der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC)

Hintergrund Die chronische Rhinosinusitis (CRS) betrifft weltweit ca. 5–12 % der Allgemeinbevölkerung und wird traditionell eingeteilt in einen Phänotyp ohne (CRSsNP) und einen mit Ausbildung von Nasenpolypen (CRSwNP). Wurden Nasenpolypen bis vor kurzem eher als mechanisches Hindernis mit der Notwendigkeit einer operativen Beseitigung betrachtet, wird die CRSwNP heute als eine multifaktorielle entzündliche Erkrankung der nasalen und paranasalen Schleimhäute angesehen, der als Endotyp häufig eine T2-Inflammation zugrunde liegt. Biologika, die mit diesen Entzündungsmechanismen interferieren, stellen interessante neue Therapiemöglichkeiten dar.

Methoden Das aktuelle Wissen zur Immunologie der CRSwNP und Wirkung von Biologika wurde mittels einer Literaturanalyse durch Recherchen in Medline, PubMed sowie den nationalen und internationalen Studien- und Leitlinienregistern und der Cochrane Library zusammengestellt.

Ergebnisse Basierend auf der internationalen Literatur und bisherigen Erfahrungen werden von einem Expertengremium Empfehlungen für die Anwendung von Biologika bei CRSwNP im deutschen Gesundheitssystem auf der Grundlage eines Dokumentationsbogens gegeben.

Schlussfolgerung Das Verständnis über die immunologischen Grundlagen der CRSwNP eröffnet neue nichtoperative Therapieansätze mit Biologika für Patienten mit schweren Verlaufsformen.

Positionspapier: Empfehlungen zur Behandlung der chronischen Rhinosinusitis während der COVID-19-Pandemie im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNO-KHC) – Diese Empfehlungen basieren auf dem EAACI Positionspapier „Treatment of chronic RhinoSinusitis with nasal polyps (CRSwNP) in the COVID-19 pandemics – An EAACI Position Paper”, Allergy, 2020 und wurden auf die Situation im deutschen Gesundheitswesen angepasst

Hintergrund  Von der chronischen Rhinosinusitis (CRS) sind weltweit etwa 5–12 % der Allgemeinbevölkerung betroffen. Die CRS gilt als chronische Atemwegserkrankung, die nach den Empfehlungen der WHO ein Risikofaktor für COVID-19-Patienten sein kann. Die entzündlichen Veränderungen der Nasenschleimhäute bei chronischer Rhinosinusitis mit Nasenpolypen (CRSwNP) sind in den meisten Fällen vom Entzündungsendotyp 2 (T2).

Methoden  Der aktuelle Wissensstand sowohl zu COVID-19 als auch zu den Behandlungsmöglichkeiten von CRSwNP wurde durch eine Literaturrecherche in Medline, Pubmed, internationalen Leitlinien, der Cochrane Library und im Internet analysiert.

Ergebnisse  Auf Grundlage der internationalen Literatur, der aktuellen Empfehlungen der WHO und anderer internationaler Organisationen sowie der bisherigen Erfahrungen gab ein Expertengremium von EAACI und ARIA Empfehlungen für die Behandlung von CRSwNP während der COVID-19-Pandemien.

Schlussfolgerung  Intranasale Kortikosteroide stellen die Standardbehandlung für CRS bei Patienten mit einer SARS-CoV-2-Infektion dar. Chirurgische Behandlungen sollten auf ein Minimum reduziert werden und nur bei Patienten mit lokalen Komplikationen und solchen, für die keine anderen Behandlungsmöglichkeiten bestehen, durchgeführt werden. Systemische Kortikosteroide sollten bei COVID-19-Patienten vermieden werden. Die Behandlung mit Biologika kann bei nicht infizierten Patienten unter sorgfältiger Überwachung fortgesetzt werden und sollte während einer SARS-CoV-2-Infektion vorübergehend unterbrochen werden.

[Non-allergic Rhinitis: Epidemiology, Diagnostic and Therapy]

Non-allergic rhinitis is a heterogenous group of medical diseases without an IgE-mediated pathophysiology. In this review, typical subgroups are presented with data regarding their frequency, clinical symptoms and recommendations for an effective and efficient diagnostic and therapeutic approach are indicated. The most common subtype is the non-allergic rhinopathy, also known as idiopathic or vasomotoric rhinitis. Because medication induced rhinitis is still a frequent clinical problem, a step wise approach to wean the patient is presented.

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

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

[Perioperative pain and anxiety in endoscopic sinus surgery]

BACKGROUND

Aim of this study was to evaluate the perioperative level of pain and anxiety for endoscopic sinus surgery, and to compare 3 different types of nasal packing.

MATERIAL AND METHODS

Prospective, controlled, randomized study comparing different types of nasal packing in regard to perioperative anxiety and pain. Patients suffered from chronic rhinosinusitis with nasal polyps involving all paranasal sinuses. Patients daily evaluated by standardized questionnaires (FPI-R, KASA, STAI) and also visual analog scale for pain on 5 consecutive days before and after endoscopic sinus surgery of all paranasal sinuses. Nasal packings were removed on 2(nd) postoperative day.

RESULTS

A total of 73 patients (polyvinyl acetate packing N = 14, glove packing N = 37, glove packing with breathing tubes N = 22) completed the study. Female gender, bad preoperative mood and absence of pain were associated with increased preoperative state anxiety based on regression analysis. Also, preoperative gathering of additional information from relatives and friends was correlated with increased preoperative anxiety. Patients had significantly minor preoperative anxiety if they could expect use of nasal packings with breathing tubes.

CONCLUSION

Female patients, who gathered information about the operation from friends or relatives or patient in worse preoperative mood are at risk for increased state anxiety and should be identified prior to rhinosurgical procedures. Use of nasal packing with at least partially preserved nasal breathing is recommended in clinically anxious patients.

Comparative investigations of anatomy and physiology in mammalian noses (Homo sapiens--Artiodactyla)

BACKGROUND

Knowledge of airflow in animal noses is sparse. Such knowledge could be important for selection of animal models used in environmental studies. From the phylogenetic and ontogenetic point of view, a comparison between the animal and human nose is interesting.

METHOD

Nose models of 5 even-toed ungulate species (he-goat, sheep, cow, roebuck, wild boar) and two humans (new born infant and adult) were examined. Anatomical and physiological features of the nasal cavities of all species were compared. All models were rinsed with water and the flow was visualized for observation. Geometric and rhinoresistometric measurements were then performed.

RESULTS AND CONCLUSIONS

Even-toed ungulates have two turbinates directly in the main part of the nasal airflow (respiratory turbinates) and a different number of turbinates in a so-called dead space of the nasal airflow above the nasopharyngeal duct (ethmoidal turbinates). The latter correspond with the upper and middle turbinate in analogy to the human nose. Respiratory turbinates of even-toed ungulates insert immediately behind the external nasal ostium. Thus, the whole nasal cavity acts as a functional area with the exception of a small area acting as dead space only detectable in ruminants, possibly indicating a small evolutionary progress from suinae to bovidae. The shape of the animal nasal cavity is stretched and flat. The airflow runs nearly completely turbulent through the nose. The nasal cavity in the adult human is relatively short and high. The area between the external nasal ostium and the head of the inferior turbinate is called inflow area. It distributes the airflow over the whole nasal cross section and generates a turbulent flow. So the airflow is prepared to contact the mucosa in the functional area (turbinate area). The morphology of the inflow area is approximately formed by the shape of the external nose. The nasal cavity of a newborn child is also stretched and flat and more similar to the nasal shape of the investigated animals. The inflow area in the newborn nose is not yet developed and corresponds with the growing external newborn nose. One can hypothesize that the inflow area in human noses is a morphological adaptation in the changed length-height-ratio of the nasal cavity.

Physiologic and pathologic septal deviations: subjective and objective functional rhinologic findings

OBJECTIVE

A high incidence of septal deviation with significant inter-rater variability has been reported. An explanation could be the presence of physiological septal deviation besides pathological ones. We differentiated an unselected cohort by their nasal resistance into groups with physiological normal and pathologically increased resistance to detect differences and analogies in comparison to healthy subjects and a pathological cohort.

STUDY DESIGN

Prospective cohort study.

SETTING

A total of 356 patients were assessed using rhinoresistometry, acoustic rhinometry, endoscopy and visual analogue scales. After definition of a benchmark between physiological and pathological nasal resistance, group differences were calculated and correlations analysed.

RESULTS

The normal one-sided inspiratory nasal resistance was defined as less or equal to 0.35 sPa/cm^3 at a flow-velocity of 250 cm^3/s (R250). Using this benchmark, the unselected group of non-rhinological patients was differentiated into 114 subjects with physiological nasal resistance and 44 with pathological septal deviation. Nasal resistance after decongestion was significantly lower for normal or patients with a physiological septal deviation in comparison to the rhinological one on both nasal sides. Healthy subjects and patients with physiological septal deviation showed similarities in objective rhinological parameters as well as rhinological patients and patients with pathological septal deviation derived from the unselected group of non-rhinological patients. Furthermore, this benchmark of nasal resistance shows significant correlations with subjective assessment of nasal breathing.

CONCLUSION

Inspiratory nasal resistance obtained at a flow-velocity of 250 cm^3/s using rhinoresistometry may be useful to distinguish patients with physiological and pathological septal deviation. Correlation with subjective assessment and endoscopic findings is improved.

[Wound healing after endoscopic sinus surgery and postoperative management]

Understanding the physiological concepts of wound healing after rhinologic procedures facilitates detection and management of more or less obvious problems of wound healing. In this review, the physiologic processes involved in wound healing are explained, and typical clinical constellations are presented. Based on challenges of anatomy and physiology, recent findings are summarized, and possible conclusions for managing the postoperative mucosa are drawn.

[Bacterial biofilms]

Today, 65 % of all infections are regarded as a consequence of local biofilms. In Otorhinolaryngology frequent diseases including chronic tonsillitis, chronic sinusitis, otitis media with effusion and cholesteatomas fulfill the clinical criteria of biofilm-associated diseases such as recalcitrant disease, inefficiently treated with long-term antibiotics. Apart from affecting a great proportion of our clinical spectrum, ENT-specialist frequently insert implants into ventilated area such as trachea, middle ear and paranasal sinuses, all susceptible for biofilm attachment. In short, relevant characteristics of biofilms and their development are summarized, clinical knowledge of otorhinolaryngologic diseases is presented and current and future therapeutic approaches are discussed.

Otolith Function Assessed with the Subjective Postural Horizontal and Standardised Stance and Gait Tasks

If otolith function is essential to maintain upright standing while moving along slanted or uneven surfaces, subjects with an otolith deficit should have difficulty judging whether the inclination of the surface on which they are standing is tilted or not. We tested this judgement and compared it with the ability to control trunk sway during standardised stance and gait tests. Thirteen patients with unilateral vestibular nerve neurectomy at least 6 months prior to testing and 39 age-matched controls were asked to move a dynamic posturography platform on which they were standing back to their subjective 'horizontal' position after the platform had been slowly tilted at 0.4 degrees/s to 5 degrees in 8 different directions. Normal subjects left the platform deviated in pitch (forwards-backwards) at about 0.7 degrees on describing the platform as levelled off for all directions of tilt. Patients showed larger deviations of about 1.3 degrees in pitch with significant differences for forward right tilt (1.58+/-0.73 degrees compared to 0.73+/-0.11 degrees for normals; mean and SEM) and for forward left. Roll (lateral) deviations were about 0.4 degrees for normals and 0.5 degrees larger for the patients (for example, for backward left, 1.13+/-0.24 degrees compared to 0.4+/-0.07 degrees in normals). Except for a tendency towards greater deviations to the lesion side of patients with eyes closed, no differences were noted between tests under eyes open and closed conditions. However, for backward and roll tilts patients needed to steady themselves first by grasping a handrail when tested with eyes closed. Stance tests on foam showed increases in roll and pitch trunk sway with respect to controls. Patients had significantly larger trunk roll sway deviations during 1-legged stance tests and during gait trials. For stance trials, the patients lost their balance control prior to the end of the standard 20-second recording time. We conclude that a unilateral loss of otolith inputs due to nerve resection permanently impairs the ability to judge whether the support surface is horizontal, and leads to excessive trunk sway when standing on a compliant surface as well as excessive trunk roll sway during gait.

[Review: pathophysiology and methodology of nasal packing]

Nasal packing is a frequent procedure to control spontaneous nasal bleeding or postoperative oozing following different types of nasal surgery. It strives for internal stabilization of the nasal framework and for optimizing wound healing by prevention of stenosis or synechia. A lot of different materials is used and there is no accepted standard concerning the type and application. A review on pathophysiology of the packed nose is given together with a survey on customary packing materials focussing on the specific merits, demerits and side-effects including economical aspects.

New split scar cheek flap in reconstruction of noma sequelae

The use of a split-scar cheek flap is demonstrated for restoration of lining in reconstructing the oral commissure in cases of noma.