Middle ear damages

Middle ear damages. The eardrum and middle ear are often exposed to blunt and penetrating trauma, blasts, thermal or caustic injuries. These injuries may result in tympanic membrane perforation, middle ear haemorrhage, dislocation and fracture of the ossicular chain, perilymphatic fistula and damage to the chorda tympani and/or facial nerve. In case of life-threatening injuries and/or mass casualty incidents, middle ear trauma obviously does not take highest priority. However, middle ear lesions should be suspected and recognized as early as possible. After meticulous history taking, physical examination consists of cranial nerve evaluation, thorough inspection of the outer ear, otoscopy and assessment of hearing and vestibular function. In the majority of cases, traumatic tympanic membrane perforations by penetrating and blunt injuries have a good prognosis with spontaneous resolution. Tympanic membrane perforations from blast trauma, thermal or caustic injuries are less likely to heal spontaneously. Perforations lasting six months after injury warrant surgery. A high resolution CT scan of the temporal bone is required in case of immediate complete facial nerve paralysis and when oval window pathology or perilymphatic fistula is suspected. Early surgical intervention is needed in case of early onset facial nerve paralysis, when there is suspicion of a perilymphatic fistula with persisting or increasing vestibular symptoms or neurosensory hearing loss and in case of vestibular dislocation of the stapes footplate. When ossicular chain damage is suspected, elective tympanoplasty is indicated. As any traumatic tympanic membrane perforation runs the risk of cholesteatoma formation, biannual follow-up during a minimum of two years is recommended.

Clinical aspects of chronic ENT inflammation in children

In children, all ENT cavities are particularly prone to the development of chronic inflammation. This is due to many predisposing factors, of which the most common are unfavourable anatomy, absence of nasal blowing, day care attendance, allergy, immature immunity, gastro-oesophageal reflux and tobacco smoke exposure. The aim of this paper is to outline the most specific paediatric clinical aspects of chronic pharyngo-tonsillitis, rhinosinusitis, otitis media, adenoiditis and laryngotracheitis and the important influence that some of these pathologies exert on the others.

Basic principles for paediatric care: what ENT professionals should know

Children undergoing medical or surgical treatment for ENT disorders should receive care from doctors familiar with the specificities of paediatric ENT pathology working in dedicated clinics where there are facilities for the activities that children usually indulge in and accommodation for parents. Many aspects of care for children with ENT problems involve a multidisciplinary team consisting of ENT surgeons working alongside a range of medical and paramedical professionals and nurses specifically trained in childcare, as well as in ENT nursing. Within this multidisciplinary approach, we will discuss some important aspects of the psychosocial approach and nursing, anaesthesia and pharmacotherapy that should be considered in order to raise the safety and quality of patient care in paediatric otorhinolaryngology.

The ARIA guidelines in specialist practice: a nationwide survey

PROBLEM

In 2001, the ARIA guidelines were published to assist healthcare practitioners in managing allergic rhinitis (AR) according to the best evidence. Very limited information, however, is avail-able on the impact of these guidelines on clinical practice.

METHODS

All Belgian Otorhinolaryngologists were invited to complete a questionnaire, covering demographic and professional characteristics, knowledge, use and perception of the ARIA guidelines and 4 clinical case scenarios of AR.

RESULTS

Of the 258 (44%) Belgian Otorhinolaryngologists who participated, almost 90% had ever heard about ARIA and 64% had followed a lecture specifically dedicated to the ARIA guidelines. Furthermore, 62% stated to always or mostly follow the ARIA treatment algorithms in the daily management of AR patients. In the clinical case section, adherence to the ARIA guidelines raised with increased self-reported knowledge and use of the ARIA guidelines and among participants that considered the guidelines more userfriendly. Of the respondents, 51% were considered as good com-pliers. Younger age was a significant predictor for good compliance.

CONCLUSION

More efforts are required to improve the translation of scientific knowledge into clinical practice and to further identify which factors may influence guideline compliance.

Critical look at the clinical practice guidelines for allergic rhinitis

Allergic rhinitis (AR) is a major health concern and numerous guidelines have been developed to standardize and to improve the management of this disease. As in many other areas of medicine, the methodology of the AR guidelines has evolved from opinion-based to evidence-based medicine. Although evidence-based medicine has many benefits, it also has limitations and cannot cancel the value of the individual clinical expertise. More important than the methodology of guideline development is the efficacy of guidelines to change patient and physician behaviour and to improve clinical outcomes. At present, however, studies on the effectiveness of guidelines are few. The International Consensus on Rhinitis from 1994 is the only guideline for AR that has been assessed for its effects on health outcomes. Furthermore, there is a lack of valid and reliable instruments to assess physician's and patient's attitude towards and compliance with guideline recommendations. There is no single effective way to ensure the use of guidelines into practice, but a carefully developed and multifaceted dissemination and implementation strategy and targeting and adapting guideline recommendations to the local and individual level are key elements. The final and most important step of putting guidelines into practice occurs at the level of the patient. Patients should be considered as effective partners in health care. Education of the patient and efforts to change patient's behaviour can maximize compliance, increase satisfaction and optimize health outcomes.

Detection of budesonide in human urine after inhalation by liquid chromatography-mass spectrometry

Budesonide, a corticosteroid frequently used in the treatment of asthma, is most often administered via inhalation. Its use in sports is allowed when medically necessary. A fast, sensitive and accurate LC-MS method was developed and validated for the quantification of budesonide and its major metabolite 16alpha-hydroxyprednisolone in urine samples after inhalation of a metered dose (Pulmicort-Turbohaler 200). Sample preparation consists of an alkaline liquid-liquid extraction with ethyl acetate. Analysis was performed using liquid chromatography-tandem mass spectrometry with electrospray ionization (ESI). The method was linear in the range of 5-100 and 0.5-10ng/mL for 16alpha-hydroxyprednisolone and budesonide, respectively. The limits of quantification were 5ng/ml for 16alpha-hydroxyprednisolone and 0.5ng/mL for budesonide. The accuracy ranged from 2.2 to 3.5% for 16alpha-hydroxyprednisolone and from 0.8 to 16.4% for budesonide. After administration of 200microg of budesonide to five healthy volunteers budesonide could not be detected in any urine sample whereas 16alpha-hydroxyprednisolone was detectable up to 12h post-administration.

Classification and management of allergic rhinitis patients in general practice during pollen season

BACKGROUND

Allergic rhinitis (AR) represents a major challenge in primary care. The Allergic Rhinitis and its Impact on Asthma (ARIA) group proposed a new classification for AR and developed evidence-based guidelines for the management of this disease. We conducted this study to further characterize the classes of AR described by ARIA, and to evaluate whether the management of AR in general practice is in accordance with the ARIA guidelines.

METHODS

During the pollen season of 2003, 95 Belgian general practitioners (GPs) enrolled 804 patients who presented with symptoms of AR. For each patient, a questionnaire comprising the clinical presentation and management was completed.

RESULTS

In 64% of the patients, AR was classified as intermittent and in 36% as persistent. Persistent rhinitis caused more discomfort than intermittent rhinitis. Only 50% of the patients had ever undergone allergy testing. Among them, 51% were allergic to both seasonal and perennial allergens. Eighty-two per cent of the persistent rhinitics were allergic to at least one seasonal allergen and 72% of the intermittent rhinitics to at least one perennial allergen. When compared strictly with the ARIA recommendations, 49% of the patients with mild and/or intermittent AR were overtreated, whereas about 30% of those with moderate/severe persistent rhinitis were undertreated.

CONCLUSION

This study confirms that the previous classification of AR into 'seasonal' and 'perennial' is not satisfactory and that intermittent and persistent AR are not equivalent to seasonal and perennial AR respectively. Furthermore, persistent rhinitis has been shown to be a distinct disease entity. Further efforts are required to disseminate and implement evidence-based diagnostic and treatment guidelines for AR in primary care practice.

Glucocorticosteroids in allergic inflammation: clinical benefits in allergic rhinitis, rhinosinusitis, and otitis media

Allergic rhinitis, rhinosinusitis, and otitis media are among the most common health problems encountered in general practice. Although frequently trivialized, they affect the quality of life, represent a significant socioeconomic burden, and are associated with some serious complications. In addition, allergic rhinitis, rhinosinusitis, and otitis media are often considered as comorbidities. These disorders involve an inflammatory process of the respiratory mucosa of the nose, paranasal sinuses, or middle ear. Because of their well-known anti-inflammatory effects, the role of glucocorticosteroids in the management of these three disorders has been questioned, evaluated, and, in some cases, established.

Nasal polyps in patients with and without cystic fibrosis: a differentiation by innate markers and inflammatory mediators

BACKGROUND

The dysfunction of the mucosal interface of the upper respiratory tract in cystic fibrosis (CF) patients is clinically visible by the development of nasal polyps (NP) at a young age. Innate defence markers and inflammatory mediators in NP from patients with CF were compared with non-cystic fibrosis nasal polyps (non-CF-NP) to determine a possible different immunological background in macroscopically similar tissue.

METHODS

Surgical samples were obtained from patients with non-CF-NP, cystic fibrosis patients with nasal polyps (CF-NP) and control patients (CO). With real time PCR, the mRNA expression of human beta defensins (HBD) 2 and 3, toll-like receptors (TLR) 2 and 4 and the macrophage mannose receptor (MMR) were measured. On homogenates of the surgical samples eotaxin, myeloperoxidase (MPO), IL-5 and IL-8 protein content was measured using commercial ELISA kits; IgE and eosinophilic cationic protein (ECP) were measured by the Unicap system.

RESULTS

In CF-NP we found a statistically significant higher mRNA expression of HBD 2 compared with non-CF-NP and CO and of TLR 2 compared with non-CF-NP. In the non-CF-NP group, MMR mRNA expression was significantly elevated compared with CO and CF-NP. For TLR 4 mRNA expression no statistically significant differences were found between groups. IL-5 was below detection level in all CO and CF-NP, but was measurable in 80% of the non-CF-NP. MPO and IL-8 concentrations were significantly higher in CF-NP compared with CO and non-CF-NP, whereas ECP, eotaxin and IgE were significantly higher in the non-CF-NP group.

CONCLUSIONS

We here demonstrate that CF-NP and non-CF-NP not only differ in terms of inflammatory mediator profile, but also in terms of innate markers.

Management of allergic rhinitis

Due to its high and increasing prevalence, its impact on quality of life, the association with multiple comorbidities and the considerable socio-economic burden, allergic rhinitis is a major respiratory disorder and represents a global health concern. The ARIA working group has proposed a new classification for allergic rhinitis into intermittent or persistent, based on the duration of symptoms. The severity of allergic rhinitis is graded according to the impact of the disease on the quality of life. The diagnosis of allergic rhinitis involves a thorough history and clinical examination. In patients suspected of having persistent AR a complete and systematic nasal examination is an absolute requirement. Anterior rhinoscopy provides limited information. Nasal endoscopy is more useful, not to confirm AR but in particular to exclude other conditions, such as polyps, foreign bodies, tumours and septal deformations. To confirm the allergic origin of rhinitis symptoms, allergy tests must be performed. The first choice test is the skin prick test. Patients with allergic rhinitis should be evaluated for asthma and patients with asthma should be evaluated for rhinitis. A stepwise therapeutic approach is recommended based on the duration and severity of disease. The treatment of allergic rhinitis consists of allergen avoidance, pharmacotherapy and immunotherapy.

[New insights into the pathology of nasal polyposis: the role of superantigens and IgE]

Although the etiology of nasal polyposis is still not revealed, insights in the pathogenesis have largely expanded over the last years. Usually nasal polyps occur in adults, are bilateral and are characterized by a manifest tissue eosinophilia. Deposition of plasma-proteins (albumin), potentially driven by subepithelial eosinophilic inflammation, seems to be an early and key pathogenic factor in the development of nasal polyps. Accumulation and activation of eosinophils is favoured by low TGF-beta1 concentrations and overproduction of IL-5 and eotaxin. In nasal polyps high IgE concentrations are measured. Our findings indicate that this IgE is produced locally. Total IgE and the expression of specific IgE is unrelated to skin prick tests, but correlates with the degree of eosinophilia. In addition, we demonstrated the organisation of secondary lymphoid tissue in nasal polyps and a polyclonal hyper-immunoglobulinemia E, associated with the presence of IgE specific to Staph. aureus enterotoxins (SAE), colonization with Staph. aureus and increased eosinophilic inflammation in a relevant subgroup of NP patients (about 50%). In about half of the nasal polyps we thus find a local immune response against SAE. SAE can hereby act as conventional allergens, triggering T- en B-cells to produce sIgE against SAE. On the other hand, SAE can also act as superantigens and induce polyclonal B-cell activation and hyper-immunoglobulinemia. In addition, the presence of IgE antibodies to SAEs seems to be associated with the severity of asthma and nasal polyposis disease. Nasal and oral corticosteroids are currently the standard treatment for NP. This treatment however, is not always sufficient and oral corticosteroids have several side effects. Often surgery is required, which in turn is not free of complications and recurrencies. Increasing insights in the pathophysiology of NP opens perspectives for new pharmacological treatment options, with eosinophilic inflammation, IgE and Staph. aureus as potential targets.