Eosinophilia, asthma, NERD and the use of oral corticosteroids predict uncontrolled chronic rhinosinusitis with nasal polyps after surgery

BACKGROUND

Severe uncontrolled chronic rhinosinusitis with nasal polyps (CRSwNP) is a challenging condition to treat. The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 (EPOS2020) has the following criteria when considering biological therapy for severe uncontrolled CRSwNP: eosinophilia, need for oral corticosteroids (OCS), symptom score, loss of sense of smell and co-morbid asthma.

OBJECTIVE

This study aimed at finding associations of baseline factors with uncontrolled CRSwNP after endoscopic sinus surgery (ESS).

METHODS

Electronic health record data of CRSwNP patients (N = 137) undergoing ESS in 2002-17 were used. Endpoints of uncontrolled CRSwNP were revision ESS, purchased OCS and antibiotic courses during follow up. Baseline factors were chosen based on EPOS2020 and the data available: nasal polyp (NP) eosinophilia, peripheral blood eosinophilia, co-existing asthma and/or non-steroidal anti-inflammatory drug exacerbated respiratory disease (NERD), need for OCS during the previous year, previous ESS, endoscopic NP score, and Lund-Mackay score of sinus computed tomography scans.

RESULTS

During the follow-up of 10.1 ± 3.1 (mean ± standard deviation) years, 35 (25.5%) individuals underwent revision ESS. The best predictive model was obtained by a sum of baseline (1) blood eosinophilia ≥ 250 cells/≥l and/or NP eosinophilia ≥ 30% (Eos), (2) asthma/NERD, and (3) ≥ 1 OCS/year. It was significantly associated with revision ESS, purchased doctor-prescribed OCS and antibiotic courses during follow-up.

CONCLUSIONS

We identified similar predictive variables for uncontrolled CRSwNP that are used in the EPOS2020 indications of biological therapy, thus suggesting that these estimates are usable in clinical practice.

The Detection of Bacteria in the Maxillary Sinus Secretion of Patients With Acute Rhinosinusitis Using an Electronic Nose: A Pilot Study

OBJECTIVE

Detecting bacteria as a causative pathogen of acute rhinosinusitis (ARS) is a challenging task. Electronic nose technology is a novel method for detecting volatile organic compounds (VOCs) that has also been studied in association with the detection of several diseases. The aim of this pilot study was to analyze maxillary sinus secretion with differential mobility spectrometry (DMS) and to determine whether the secretion demonstrates a different VOC profile when bacteria are present.

METHODS

Adult patients with ARS symptoms were examined. Maxillary sinus contents were aspirated for bacterial culture and DMS analysis. k-Nearest neighbor and linear discriminant analysis were used to classify samples as positive or negative, using bacterial cultures as a reference.

RESULTS

A total of 26 samples from 15 patients were obtained. After leave-one-out cross-validation, k-nearest neighbor produced accuracy of 85%, sensitivity of 67%, specificity of 94%, positive predictive value of 86%, and negative predictive value of 84%.

CONCLUSIONS

The results of this pilot study suggest that bacterial positive and bacterial negative sinus secretion release different VOCs and that DMS has the potential to detect them. However, as the results are based on limited data, further conclusions cannot be made. DMS is a novel method in disease diagnostics and future studies should examine whether the method can detect bacterial ARS by analyzing exhaled air.

Ultra-low-dose CBCT: new cornerstone of paranasal sinus imaging

BACKGROUND

This study evaluates the clinical image quality (IQ) and usability of a sinonasal ultra-low-dose (ULD) cone-beam computed tomography (CBCT) scan. The results are compared to those of a high resolution (HR) CBCT scan to identify the strengths and weaknesses of a ULD CBCT protocol.

METHODOLOGY

Sixty-six anatomical sites in 33 subjects were imaged twice using two imaging modalities: HR CBCT (Scanora 3Dx scanner; Soredex, Tuusula, Finland) and ULD CBCT (Promax 3D Mid scanner; Plandent, Helsinki, Finland). IQ, opacification and obstruction, structural features and operative usability were assessed.

RESULTS

The overall IQ in subjects with "no or minor opacification" was excellent: 100% (HR CBCT) and 99% (ULD CBCT) of ratings were evaluated as sufficient for every structure. Increased opacification reduced the quality of both imaging modalities, resulting conchtoethmoidectomy, frontal sinusotomy, sphenotomy and posterior ethmoidectomy in cases with greater opacification.

CONCLUSIONS

IQ of paranasal ULD CBCT is sufficient for clinical diagnostics and should be considered for surgical planning. We recommend it as the primary imaging protocol for all patients who meet imaging criteria due to recurrent or chronic nasal symptoms. Additional or conventional imaging might be needed for patients with extensive chronic rhinosinusitis and/or indications of frontal sinus involvement.

Laboratory Test Results in Patients with Workplace Moisture Damage Associated Symptoms—The SAMDAW Study

The mechanisms of health effects of moisture damage (MD) are unclear, but inflammatory responses have been suspected. The usefulness of laboratory and allergy tests among patients in secondary healthcare with symptoms associated with workplace MD were examined. Full blood count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), total serum immunoglobulin E (IgE), fractional exhaled nitric oxide (FeNO), and skin prick testing were assessed and analyzed in relation to multiple chemical sensitivity (MCS) and perceived stress in 99 patients and 48 controls. In analysis, t-tests, Mann-Whitney tests, and chi-squared tests were used. Minor clinically insignificant differences in blood counts were seen in patients and controls, but among patients with asthma an elevated neutrophil count was found in 19% with and only in 2% of patients without asthma (p = 0.003). CRP levels and ESR were low, and the study patients’ FeNO, total IgE, or allergic sensitization were not increased compared to controls. The level of stress was high among 26% of patients and 6% of controls (p = 0.005), and MCS was more common among patients (39% vs. 10%, p < 0.001). Stress or MCS were not significantly associated with laboratory test results. In conclusion, no basic laboratory or allergy test results were characteristic of this patient group, and neither inflammatory processes nor allergic sensitization were found to explain the symptoms among these patients. While the value of basic laboratory tests should not be ignored, the use of allergy tests does not seem necessary when symptoms are indicated to be workplace-related.

Ultra-low-dose CBCT scan: rational map for ear surgery

PURPOSE

This study will evaluate the clinical quality and usability of peripheral image data from the temporal bone area obtained using a sinonasal ultra-low-dose (ULD) cone-beam computed tomography (CBCT) scan and compare them to those obtained using a high-resolution (HR) CBCT.

METHODS

The population consisted of 66 anatomical sites (ears of 33 subjects) imaged using two modalities: an HR CBCT (Scanora 3Dx scanner; Soredex, Tuusula, Finland) and a ULD CBCT (Promax 3D Mid scanner; Plandent, Helsinki, Finland). The image quality (IQ) for every anatomical site in each image was rated using a Likert scale from 0 to 5.

RESULTS

The quality of ULD CBCT scans was clinically sufficient in over 95% of the assessed images of the sigmoid sinus, jugular bulb, epitympanum and mastoid antrum as well as external acoustic meatus (all p > 0.05 compared to HR CBCT). The IQ was clinically sufficient in 75-94% of the assessed images of the scutum, mastoid segment of the facial nerve, cochlea and semicircular canals (all p < 0.05 compared to HR CBCT). The overall IQ of the HR CBCT scans was good or excellent.

CONCLUSION

CBCT imaging and the data at image margins are underutilized. CBCT can produce excellent structural resolution with conventional imaging parameters, even with off-focus images. Using ultra-low doses of radiation, the produced IQ is clinically sufficient. We encourage ear surgeons to check the patients' imaging history and to consider the use of imaging modalities that involve lower radiation doses especially when conducting repetitive investigations and with children.

Identifying chronic rhinosinusitis without nasal polyps by analyzing aspirated nasal air with an electronic nose based on differential mobility spectrometry

BACKGROUND

The diagnosis of chronic rhinosinusitis (CRS) is a complicated procedure. An electronic nose (eNose) is a novel method that detects disease from gas-phase mixtures, such as human breath.

AIMS/OBJECTIVES

To determine whether an eNose based on differential mobility spectrometry (DMS) can detect chronic rhinosinusitis without nasal polyps (CRSsNP) by analyzing aspirated nasal air.

MATERIALS AND METHODS

Adult patients with CRSsNP were examined. The control group consisted of patients with septal deviation. Nasal air was aspirated into a collection bag and analyzed with DMS. The DMS data were classified using regularized linear discriminant analysis (LDA) models with 10-fold cross-validation.

RESULTS

The accuracy of the DMS to distinguish CRSsNP from patients with septal deviation was 69%. Sensitivity and specificity were 67 and 70%, respectively. Bonferroni-corrected statistical differences were clearly noted. When a subgroup with more severe inflammatory disease was compared to controls, the classification accuracy increased to 82%.

CONCLUSIONS

The results of this feasibility study demonstrate that CRSsNP can potentially be differentiated distinguished from patients with similar nasal symptoms by analyzing the aspirated nasal air using DMS. Further research is warranted to evaluate the ability of this novel method in the differential diagnostics of CRS.

Baseline Conservative and Surgical Management in the Treatment of NSAID-Exacerbated Respiratory Disease

Non-steroidal anti-inflammatory drug (NSAID)-exacerbated respiratory disease (N-ERD) is a chronic medical condition that includes asthma, chronic rhinosinusitis with nasal polyposis, and hypersensitivity to aspirin and other NSAIDs. Eosinophilic inflammation in the upper and lower airways is treated with local corticosteroids, repeated antibiotics, oral corticosteroid courses, endoscopic sinus surgery, and in some cases aspirin treatment after desensitization (ATAD). Nevertheless, the disease may be uncontrolled and it has a great impact on quality of life. A better understanding of the pathomechanisms of the disease and the development of medications that target type 2 inflammation mediators may have a crucial role in achieving better disease control in patients with N-ERD.

Radiological score of computed tomography scans predicts revision surgery for chronic rhinosinusitis

Objective

Methods

Results

Conclusion

The Long-term Effect of Inferior Turbinate Surgery Techniques on Nasal Obstruction and Quality of Life

OBJECTIVE

The aim of the study was to compare the long-term effects of radiofrequency ablation (RFA), microdebrider-assisted inferior turbinoplasty (MAIT), and diode laser techniques on the severity of nasal obstruction and quality of life (QOL) in a 3-year follow-up.

METHODS

The patients filled a Visual Analog Scale (VAS) regarding the severity of nasal obstruction and the Glasgow Health Status Inventory (GHSI) questionnaire preoperatively and during the control visits at 3 months and 3 years. Acoustic rhinometry was also performed. A total of 78 patients attended both control visits.

RESULTS

All 3 techniques improved the VAS score for the severity of nasal obstruction and the GHSI total score significantly compared to the preoperative values at both 3 months and 3 years. Compared to the preoperative values, all 3 techniques increased the V2 to 5 cm values significantly at 3 months. After 3 years, compared to the preoperative values, the MAIT (P = .005) and diode laser (P < .001) still had a statistically significant volume increase in V2 to 5 cm, whereas the RFA (P = .06) did not achieve a statistically significant effect.

CONCLUSION

The RFA, MAIT, and diode laser all improved both the patients' subjective sensation of the severity of nasal obstruction and QOL significantly. The response was sustained during the 3-year follow-up period with all 3 techniques. A weakening in the objective treatment response to RFA was found in the longer follow-up, but that did not cause a weakening of the patients' subjective treatment response.

Clinical Findings among Patients with Respiratory Symptoms Related to Moisture Damage Exposure at the Workplace-The SAMDAW Study

BACKGROUND

Respiratory tract symptoms are associated with workplace moisture damage (MD). The focus of this observational clinical study was patients with workplace MD-associated symptoms, to evaluate the usefulness of different clinical tests in diagnostics in secondary healthcare with a special interest in improving the differential diagnostics between asthma and laryngeal dysfunction.

METHODS

In patients referred because of workplace MD-associated respiratory tract symptoms, we sought to systematically assess a wide variety of clinical findings.

RESULTS

New-onset asthma was diagnosed in 30% of the study patients. Laryngeal dysfunction was found in 28% and organic laryngeal changes in 22% of the patients, and these were common among patients both with and without asthma. Most of the patients (85%) reported a runny or stuffy nose, and 11% of them had chronic rhinosinusitis. Atopy was equally as common as in the general population.

CONCLUSIONS

As laryngeal changes were rather common, we recommend proper differential diagnostics with lung function testing and investigations of the larynx and its functioning, when necessary, in cases of prolonged workplace MD-associated symptoms. Chronic rhinosinusitis among these patients was not uncommon. Based on this study, allergy testing should not play a major role in the examination of these patients.

Hierarchical clustering in evaluating inflammatory upper airway phenotypes; increased symptoms in adults with allergic multimorbidity

BACKGROUND

Inflammatory upper airway diseases cause significant morbidity. They include phenotypes with different treatment; allergic or non-allergic rhinitis (AR, nAR), and chronic rhinosinusitis with or without nasal polyps (CRSwNP, CRSsNP). In clinical practice, these phenotypes are often difficult to distinguish and may overlap.

OBJECTIVE

To evaluate if hierarchical clustering can be used to distinguish these phenotypes based on the presence of nasal polyps, off-seasonal allergic symptoms, and self-reported background characteristics - e.g. atopic dermatitis (AD); and to further analyse the obtained clusters.

METHODS

We studied a random sample of 74 CRS (chronic rhinosinusitis) patients, and a control group of 80 subjects without CRS with/without AR (tertiary hospitals, 2006-2012). All underwent interview and nasal examination, and filled a questionnaire. Variables regarding demographics, off-seasonal symptoms, and clinical findings were collected. Hierarchical clustering was performed, the obtained clusters were cross-tabulated and analysed.

RESULTS

Four clusters were identified; 1: "Severe symptoms and CRSwNP" (n = 29), 2: "Asymptomatic AR and controls" (n = 39), 3: "Moderate symptoms and CRSsNP" (n = 36), and 4: "Symptomatic and AD" (n = 50). Cluster 1 had most sinonasal symptoms, cluster 3 had a high prevalence of facial pain. The presence of AR did not distinguish CRS groups. Of the AR subjects, 51 % belonged to cluster 4, where AR with off-seasonal airway symptoms and AD predominated.

CONCLUSIONS

Hierarchical clustering can be used to distinguish inflammatory upper airway disease phenotypes. The AR phenotype was subdivided by the presence of AD. Adult AR+ AD patients could benefit from active clinical care of the upper airways also off-season.

Satisfaction of young ENT surgeons with their work. A Finnish national study

The objective was to investigate work satisfaction among recently graduated otorhinolaryngologist – head and neck surgeons – (ENT surgeons). An electronic questionnaire was sent to all ENT surgeons graduated in Finland during a ten-year period. Answers about work satisfaction were analyzed in detail with regards to age, gender, university of specialist training, experience, place of work and further education.Altogether 125/129 (96.9%) responded. The majority (87.8%) of the respondents enjoyed their current main occupation. The older age group (≥40 vs <40 years) was more satisfied (93.7% vs. 81.7%; p=0.042). Consultation opportunities and workplace atmosphere were reported as good by 85.6% and 90.4% of the respondents, respectively. Training opportunities were considered good by 82.4%, albeit by only 60% of the private physicians (p=0.047). Private sector practitioners were also less satisfied with the versatility of their work (p<0.001). Work at a university hospital was considered more strenuous (p<0.001). Over half (54.8%) felt insecure about continuation of their employment status. Most of the recently graduated Finnish ENT surgeons are satisfied with their current occupation, consultation opportunities and workplace atmosphere. However, work at university hospitals in particular was considered often strenuous and over half of the respondents felt insecure about the continuity of their employment.

Factors Affecting the Control of Chronic Rhinosinusitis With Nasal Polyps: A Comparison in Patients With or Without NERD

Objectives

The aim was to compare the control of chronic rhinosinusitis with nasal polyps (CRSwNP) after endoscopic sinus surgery (ESS), in patients with/without nonsteroidal anti-inflammatory drug exacerbated respiratory disease (NERD).

Study Desing: A retrospective hospital-based sample of CRSwNP patients with/without NERD with follow-up.

Setting

Tertiary rhinology centers.

Methods

Electronic patient record data from 116 CRSwNP patients (46 with NERD and 70 without NERD) undergoing ESS during 2001–17 were studied. Mean follow-up time was 9.9 years (range 1.1–15.3). Endpoints reflecting uncontrolled CRSwNP were revision ESS, and need for rescue/advanced therapy (e.g. antibiotics, oral corticosteroids and/or biological therapy) during follow-up. NERD was variable of interest and gender, age, asthma, allergic rhinitis (AR), smoking, Lund-Mackay (LM) score of sinus computed tomography scans previous ESS and baseline total ethmoidectomy were used as covariates.

Results

Twenty-one (49.7%) NERD patients and 18 (25.7%) non-NERD patients underwent revision ESS within a mean ± SD of 4.3 ± 2.8 and 3.7 ± 2.6 years, respectively (p = .013, by Logrank test). In Cox´s regression models, NERD, female gender, young age, asthma, AR, previous ESS, and lack of total ethmoidectomy were associated with revision-ESS. In adjusted model, only the total ethmoidectomy predicted revision-free survival. In adjusted logistic regression model, there was an insignificant trend that NERD and LM score were associated with the need for rescue/advanced therapy in the follow-up.

Conclusions

Patients with NERD had higher risk of uncontrolled CRSwNP than patient group without NERD, as measured by revision ESS and/or need for rescue/advanced therapy in the follow-up. In addition, baseline total ethmoidectomy was associated with revision-free survival.

Factors affecting upper airway control of NSAID-exacerbated respiratory disease: A real-world study of 167 patients

BACKGROUND

Nonsteroidal anti-inflammatory drug (NSAID) exacerbated respiratory disease (N-ERD) is a triad with asthma, chronic rhinosinusitis with nasal polyps, and NSAID intolerance. Uncontrolled N-ERD forms a major public health problem due to frequent and difficult-to-treat exacerbations and/or requiring putatively frequent endoscopic sinus surgeries (ESS). Our aim was to study factors affecting control of N-ERD.

METHODS

Retrospective patient record data (patient characteristics, prior sinus surgeries, follow-up data in 2020) from 167 N-ERD patients undergoing consultation at three tertiary hospitals from 2001 to 2017 was used. Outcome measurements reflecting uncontrolled N-ERD were revision ESS, corticosteroids/biological therapy, and antibiotic courses during 2016-2020. Associations were analyzed by using nonparametric tests, Cox's proportional hazard, and binary logistic regression models.

RESULTS

Nasal polyp eosinophilia increased the risk of revision surgery during the follow-up (adjusted hazard ratio [aHR] 3.21, confidence interval 1.23-8.38). Also baseline oral corticosteroids (OCS; HR, 1.73, 1.04-2.89) and baseline surgery without total ethmoidectomy increased the risk of revision ESS (HR, 2.17, 1.07-4.42) in unadjusted models. In addition, both baseline OCS (adjusted odds ratio [aOR] 2.78, 1.23-6.26) and a history of ≥4 previous ESS (aOR, 2.15, 0.98-4.70) were associated with the use of OCS/biological therapy during the follow-up, but not with high number of antibiotics.

CONCLUSIONS

Nasal polyp eosinophilia, baseline OCS, and a history of recurrent ESS predict uncontrolled N-ERD. These factors might be clinically useful in risk-estimation of uncontrolled disease and for organizing follow-ups. Prospective cohort studies with larger sample size are needed to further study the factors affecting the upper airway control of N-ERD.

Lung function and side effects of Aspirin desensitization: a real world study

Introduction: NSAID-exacerbated respiratory disease (N-ERD) is mainly treated with topical and oral corticosteroids, as well as acetylsalicylic acid (ASA) treatment after desensitization (ATAD). During desensitization and ATAD, it is common to experience an exacerbation of respiratory symptoms and other side effects, which may lead to cessation of treatment. Objectives: The aim of this retrospective follow-up study was to evaluate the effect of ATAD on lung functions and respiratory symptoms, and to clarify the occurrence of adverse events. Methods: We analysed the patient data of 67 patients treated with ASA desensitization between 2006 and 2016 in three hospitals, concerning adverse events, respiratory symptoms, lung function tests, and reasons for discontinuation. Results: 26 patients discontinued AD or ATAD. The most common reasons for discontinuation were lack of response (9%) and side effects (18%). ATAD did not affect lung function values in the follow-up of up to 5 years. Upper respiratory symptoms improved in 31 (52%) and lower respiratory symptoms (LRS) in 7 (10%) cases. Side effects occurred in 42 (63%) cases, the most common being dyspepsia and lower respiratory symptoms. Conclusion: Our study suggests that ATAD has little effect on lower airway functions. Side effects were common, and discontinuation rates high.

The effect of inferior turbinate surgery on nasal symptoms and inferior turbinate contractility

OBJECTIVES

The aim of this study was to compare radiofrequency ablation (RFA), diode laser, and microdebrider-assisted inferior turbinoplasty (MAIT) in the treatment of chronic nasal obstruction in a one-year follow-up, and to pay special attention to the effect of the procedures on the contractility capacity of the inferior turbinates.

METHODS

The patients filled a Visual Analogue Scale (VAS) questionnaire regarding nasal symptoms pre- and postoperatively. Saccharin transit time (STT) evaluation and acoustic rhinometry were also performed. A total of 77 patients attended the one-year control visit and had technically reliable acoustic rhinometry results.

RESULTS

All the examined techniques decreased the VAS score for the severity of nasal obstruction statistically significantly. There was no deterioration found in the symptoms of crusting, nasal discharge, and sneezing, nor in mucociliary function in any of the groups. All the three techniques increased the non-decongested total V2-5 cm values and decreased the decongested total V2-5 cm values statistically significantly. The V2-5 cm change (%) values decreased statistically significantly in the RFA, diode laser, and the MAIT groups following the operations, the mean changes being -57 percentage points (pp), -53 pp, and -73 pp respectively.

CONCLUSION

All three techniques decreased the severity of nasal obstruction significantly in the one-year follow-up. Although submucosal fibrosis seemed to increase, all the techniques increased the anterior nasal cavity volume significantly. Inferior turbinate contractility decreased to the normal level from the preoperative congested state following the surgery with every examined technique.

Employment status of young otorhinolaryngologists in Finland during a 10-year period

We determined the employment status of recently graduated otorhinolaryngologist-head and neck surgeons (ENT doctors) in Finland during the past 10 years. We also investigated the job vacancy rate of the Departments of Otorhinolaryngology-Head and Neck Surgery (Department of ORL-HNS). An electronic questionnaire was sent to all ENT doctors who had graduated during 2007-2017 and to chief physicians of all Departments of ORL-HNS. Chi-square and Fisher's test were used in the analyses. Altogether 129 ENT doctors had graduated and 125 (96.9%) responded. Thirty (24%) physicians had been employed in a position that did not correspond to their ENT doctor training. All 30 chief physicians responded and a total of 306 physicians were working at their departments (215 ENT doctors, 91 residents). However, there were only 241 available positions (197 for ENT doctors, 44 for residents). It was estimated that 65 ENT doctors would retire within 10 years. At the moment there does not seem to be a significant shortage of ENT doctors in Finland. The current national volume of resident intake in the ENT training programme is twofold in comparison with the estimated retirement rate in the public sector.

Factors Predictive of Outcome in Inferior Turbinate Surgery

OBJECTIVES

The purpose of the study was to examine the various preoperative predictive factors of inferior turbinate surgery and to find possible factors that predict an optimal subjective response using 3 common surgical techniques-radiofrequency ablation (RFA), diode laser, and microdebrider-assisted inferior turbinoplasty (MAIT)-in a randomized, prospective study with a 1-year follow-up.

METHODS

The patients filled a visual analogue scale (VAS) questionnaire regarding the severity of nasal obstruction prior to and 1 year after surgery. A VAS score improvement of 3 points or more was chosen as an optimal subjective response. Univariate and multivariate regressions were used to evaluate the effect of the predictive factors. In total, 80 patients attended a 1-year control visit.

RESULTS

In the multivariate analysis, patients without anterior septal deviation had a statistically significantly higher odds ratio of a satisfactory subjective response compared to patients with anterior septal deviation (5.6; 95% CI: 1.4-23.1; P = .02). Patients treated with RFA had a statistically significantly higher odds ratio of an optimal subjective response compared to patients treated with MAIT (9.0; 95% CI: 1.5-54.2; P = .02).

CONCLUSIONS

Anterior septal deviation seems to decrease the likelihood of an optimal subjective response to inferior turbinate surgery, which supports the consideration of concomitant septoplasty at least in clear cases to optimize the subjective response. Radiofrequency ablation had a significantly higher likelihood of an optimal subjective response compared to MAIT. Further investigations regarding the findings are needed.

The Effect of Inferior Turbinate Surgery on Quality of Life: A Randomized, Placebo-Controlled Study

OBJECTIVE

The purpose of this prospective, randomized, single-blinded, placebo-controlled study was to investigate the effects of radiofrequency ablation (RFA), diode laser, and microdebrider-assisted inferior turbinoplasty (MAIT) techniques on patients' quality of life (QOL) and to compare the techniques with a placebo procedure.

METHODS

A total of 98 consecutive patients with enlarged inferior turbinates due to persistent year-round rhinitis were randomized into placebo, RFA, diode laser, and MAIT groups at a ratio of 1:2:2:2. All the procedures were carried out under local anesthesia with the patients' eyes covered. Assessments were conducted prior to surgery and 3 months subsequent to the surgery. Quality of life was assessed with the Glasgow Health Status Inventory (GHSI).

RESULTS

The GHSI total score increased statistically significantly in all the groups, including placebo. There were no significant differences in the GHSI total score change between RFA, diode laser, and MAIT groups. The MAIT procedure improved the GHSI total score significantly more than the placebo procedure (P = .04).

CONCLUSION

All inferior turbinate surgery techniques lead to a significant improvement in the patients' QOL, and no significant differences were found between the techniques. The placebo treatment also improved the QOL significantly. Only the MAIT technique improved the QOL significantly more compared to placebo.

Ethmoidal drug-eluting stent therapy is not superior to nasal corticosteroid spray in the prevention of endoscopic sinus surgery: Results from a randomised, clinical trial

OBJECTIVES

To evaluate whether an ethmoidal drug-eluting stent (DES) (the Relieva Stratus™ MicroFlow Spacer) could better prevent endoscopic sinus surgery (ESS) than standard non-invasive therapy using corticosteroid nasal spray in patients suffering from chronic rhinosinusitis (CRS).

DESIGN

Prospective, randomised clinical trial.

SETTING

Tertiary referral centre.

PARTICIPANTS

Sixty-three adult patients with ethmoidal involvement in cone beam computerised tomography (CBCT) whose first-line medical treatment with topical corticosteroids had failed and who were candidates for ESS were randomised either to a DES group, which received triamcinolone acetonide stents (n = 34), or to a topical intranasal corticosteroid group (n = 29) that used optimally dosed triamcinolone acetonide nasal spray.

OUTCOME MEASURES

Patients were followed up prospectively for 6 months and at 36 months. Freedom from ESS was the primary endpoint. Further, we identified those factors predicting ESS.

RESULTS

At 6 months, ESS could be prevented in almost half of the patients in both groups (DES 13/28, 46.4%, nasal spray 14/29, 48.3%). At 36 months, 20/28 (71.4%) patients in the DES group and 18/29 (62.1%) in the nasal spray group had been operated. The differences were not statistically significant at either timepoint. Patients who smoked (14/19, 73.7% vs 16/38, 42.1%) were more likely to be operated at 6 months.

CONCLUSION

Endoscopic sinus surgery can be prevented using both therapies in the medium term in almost half of cases with neither therapy being statistically superior. This effect was somewhat diminished in the long term with a trend towards more patients being operated in the DES group. Considering the additional costs, the need for general anaesthesia and the potential side effects associated with DES, its potential clinical role appears to be limited. Smoking was significantly associated with ESS.

Assessing Cut-off Points of Eosinophils, Nasal Polyp, and Lund-Mackay Scores to Predict Surgery in Nasal Polyposis: A Real-World Study

Background

Developing tools to identify chronic rhinosinusitis with nasal polyps (CRSwNP) patients requiring surgical treatment would help clinicians treat patients more effectively. The aim of this retrospective cross-sectional study was to identify cut-off values ​​for eosinophil percentage, nasal polyps (NP), and Lund-Mackay (LM) scores that may predict the need for surgical treatment in Finnish CRSwNP patients.

Methods

Data of CRSwNP patients (N = 378) undergoing consultation for ESS in 2001–19 were used. Data was collected from patient records and Lund-Mackay scores were determined from sinus computed tomography scans. The percentage of eosinophils was microscopically evaluated from the polyp samples available (n = 81). Associations were analyzed by Mann Whitney U test, and cut-off values by the area under the receiver operating characteristic curve (AUROC).

Results

ESS was performed to 293 (77.5%) of patients. Polyp eosinophilia was associated significantly with ESS (p = 0.001), whereas peripheral blood eosinophil count, LM- score and endoscopic NP- score were not (p > 0.05). AUROC values (95% CI) for detecting those needing ESS were for polyp eosinophilia 0.71 (0.60–0.83), p = 0.001, for LM score 0.59 (0.50–0.67), p = 0.054; for NP score 0.56 (0.48–0.64), p = 0.17, and for blood eosinophil count 0.68 (0.46–0.90), p = 0.08. With the threshold value of polyp eosinophilia (>25%), the sensitivity and specificity were optimal for detecting the group needing ESS from the group not undergoing ESS. The cut-off value of blood eosinophil count (>0.26 × 10⁹/L) had relatively good, yet statistically insignificant (underpowered), predictive potential. Moderate cut-off values were found for endoscopic LM score (≥14/24) and NP score (≥4/8).

Conclusions

Polyp eosinophilia (>25%) predicted ESS among Finnish hospital-level CRSwNP patients. A future challenge would be to find less invasive and cost-effective clinical factors predicting uncontrolled CRSwNP.

Observational cross-sectional study on Symptoms Associated to Moisture DAmage at Workplace: the SAMDAW study protocol

INTRODUCTION

Moisture damage (MD) exposure at work has been shown to increase the risk of new onset asthma and exacerbation of asthma. However, most of the studies in this field have been questionnaire studies. A small proportion of MD-exposed workers are diagnosed with asthma. Many patients with MD exposure at work referred to secondary healthcare report intermittent hoarseness, loss of voice or difficulty to inhale, referring to functional or organic problems of the larynx. For accurate treatment, proper differential diagnostics is paramount. We present an ongoing observational study in which we describe the prevalence of respiratory, voice and other symptoms related to MD at work in patients referred to secondary healthcare. Case-control setting will be used to evaluate the frequencies of the background factors, bronchial hyperreactivity and laryngeal findings.

METHODS AND ANALYSIS

The study sample consists of patients with workplace MD exposure and associated respiratory tract and/or voice symptoms referred to Tampere University Hospital. The clinical tests conducted to the study patients included comprehensive lung function tests, laboratory and skin prick tests, imaging and clinical evaluation by specialists of respiratory medicine, oto-rhino-laryngology and phoniatrics. The exposure assessment was performed by an occupational physician. The study patients filled out a questionnaire on previous illnesses and other background factors, which for comparison was also sent to 1500 Finnish-speaking people in the same hospital district randomly selected by the Finnish Population Information System. To explore how common laryngeal disorders and voice symptoms are in general, a part of the tests will be conducted to 50 asymptomatic volunteers.

ETHICS AND DISSEMINATION

The regional ethics committee of Tampere University Hospital approved the study. All study subjects gave their written informed consent, which is required also from the controls. The results will be communicated locally and internationally as conference papers and journal articles.

Pituitary apoplexy following endoscopic nasal surgery: A case report

Pituitary apoplexy develops as a consequence of acute haemorrhage and/or infarction in a pre-existing pituitary adenoma. Typical symptoms include sudden onset headache, visual acuity/field defects, and ocular palsies. We report a male patient with a known pituitary macroadenoma who underwent a right-sided endoscopic nasal surgery. Preoperatively, thickening of sphenoid mucosa was seen in computed tomography and magnetic resonance imaging. The patient developed pituitary apoplexy postoperatively. The presented report indicates that in patients with a pituitary adenoma, nasal surgery – like any other kind of surgery – is a possible precipitating factor for pituitary apoplexy. Isolated thickening of sphenoid mucosa is associated with pituitary apoplexy. It may also precede an apoplectic event.

In vitro detection of common rhinosinusitis bacteria by the eNose utilising differential mobility spectrometry

Acute rhinosinusitis (ARS) is a sudden, symptomatic inflammation of the nasal and paranasal mucosa. It is usually caused by respiratory virus infection, but bacteria complicate for a small number of ARS patients. The differential diagnostics between viral and bacterial pathogens is difficult and currently no rapid methodology exists, so antibiotics are overprescribed. The electronic nose (eNose) has shown the ability to detect diseases from gas mixtures. Differential mobility spectrometry (DMS) is a next-generation device that can separate ions based on their different mobility in high and low electric fields. Five common rhinosinusitis bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Staphylococcus aureus, and Pseudomonas aeruginosa) were analysed in vitro with DMS. Classification was done using linear discriminant analysis (LDA) and k-nearest neighbour (KNN). The results were validated using leave-one-out cross-validation and separate train and test sets. With the latter, 77% of the bacteria were classified correctly with LDA. The comparative figure with KNN was 79%. In one train-test set, P. aeruginosa was excluded and the four most common ARS bacteria were analysed with LDA and KNN; the correct classification rate was 83 and 85%, respectively. DMS has shown its potential in detecting rhinosinusitis bacteria in vitro. The applicability of DMS needs to be studied with rhinosinusitis patients.

Diagnostic Accuracy of Symptoms, Endoscopy, and Imaging Signs of Chronic Rhinosinusitis Without Nasal Polyps Compared to Allergic Rhinitis

Objectives The diagnosis of chronic rhinosinusitis without nasal polyps (CRSsNP) and distinguishing it from allergic rhinitis is difficult. Yet, early detection of CRSsNP is important to prevent progressive and severe chronic rhinosinusitis. Our aim was to compare diagnostic accuracy of symptoms, endoscopy, and imaging signs of CRSsNP and allergic rhinitis -only phenotypes. Setting Prospective controlled follow-up study. Participants Forty-two nonsmoking patients visiting tertiary care due to CRSsNP and 19 nonsmoking volunteer controls with allergic rhinitis filled a symptoms questionnaire and underwent nasal endoscopy off-seasonally. All CRSsNP patients underwent computed tomography scans of paranasal sinuses. All the allergic rhinitis control subjects and 14 of the CRSsNP patients underwent sinus magnetic resonance imaging. Results Radiologic Lund-Mackay score, duration of symptoms, visual analogue scale scores of symptoms, and Sinonasal Outcome Test 22 were significantly higher in the CRSsNP group compared to allergic rhinitis control group. These factors also correlated in part with each other. Endoscopic score did not correlate with other factors, nor did it differ between CRSsNP and allergic rhinitis groups. The highest area under curve value was demonstrated for visual analogue scale score of facial pain/pressure (0.93) and score ≥4/10 showed 60% sensitivity and 95% specificity for detecting CRSsNP group ( P < .001). Radiologic sign of obstructed osteomeatal complex showed 100% specificity and 38% sensitivity for detecting CRSsNP group ( P < .001). Conclusions CRSsNP phenotype could be primarily distinguished from allergic rhinitis by higher facial pain/pressure score and secondarily by radiologic sings of obstructed ostiomeatal complex and higher Lund-Mackay score. Endoscopic score has limited value in distinguishing CRSsNP from allergic rhinitis.

Correlation between Rhinometric Measurement Methods in Healthy Young Adults

The most common rhinometric measurement methods used in modern rhinology are acoustic rhinometry, rhinomanometry, and nasal peak expiratory flow (PEF) rate. In this prospective study, we wanted to clarify whether the parameters given by these three methods in the same subject support each other and can be used simultaneously in clinical practice. We also wanted to define the dimensions of normal nasal geometry and function based on these three methods. The rhinometric measurements were done in 249 healthy white subjects consisting of 171 women and 78 men. The geometry was analyzed with regard to body mass index (BMI) and smoking habits. The result could be used as some kind of reference value for the same kind of patient cohort as when rhinological pathology is investigated. The measurements obtained by acoustic rhinometry showed only statistically significant correlations between the measured volume and minimal cross-sectional area in the nasal cavities (r = 0.959). Rhinomanometry showed only a statistically significant correlation between the measured resistance in expiration and inspiration (r = 0.977). Acoustic rhinometry, rhinomanometry, and nasal PEF did not show any correlations and the BMI did not have any effect on the results. Although the smoking group was relatively small in this cohort, the rhinometric methods showed smaller nasal cavity volume, higher resistance, and lower nasal PEF values. Based on these results, we recommend the use of these three rhinometric methods as independent instruments in rhinological examinations. However, in the pathological nose, e.g., smokers, the methods show equal changes in measurements. It is important to measure at least acoustic rhinometry and rhinomanometry at the same time in clinical practice to achieve good quality of examinations.

A prospective, randomized, placebo-controlled study of inferior turbinate surgery

OBJECTIVES/HYPOTHESIS

The purpose of this study was to compare radiofrequency ablation, diode laser, and microdebrider-assisted inferior turbinoplasty techniques in the treatment of chronic nasal obstruction caused by inferior turbinate enlargement, and to compare these techniques with a placebo procedure.

STUDY DESIGN

Prospective, randomized, single-blinded, placebo-controlled study.

METHODS

A total of 98 consecutive patients with enlarged inferior turbinates due to persistent year-round rhinitis were randomized into a placebo, radiofrequency ablation, diode laser, and microdebrider-assisted inferior turbinoplasty groups in a ratio of 1:2:2:2. All the procedures were carried out under local anesthesia with the patients' eyes covered. Assessments were conducted prior to surgery and 3 months subsequent to the surgery.

RESULTS

The severity of nasal obstruction measured by visual analog scale score decreased statistically significantly in all the groups, including placebo. Radiofrequency ablation (P = .03), diode laser (P = .02), and microdebrider-assisted inferior turbinoplasty (P = .04) all decreased the symptom score of the severity of nasal obstruction statistically significantly more compared to the placebo procedure.

CONCLUSIONS

The placebo effect had a large role in the overall improvement of the severity of nasal obstruction after the inferior turbinate surgery. However, all three techniques provided a statistically significant additional reduction of the severity of nasal obstruction compared to the placebo procedure.

LEVEL OF EVIDENCE

1b. Laryngoscope, 128:1997-2003, 2018.

A prospective, randomized clinical study comparing drug eluting stent therapy and intranasal corticoid steroid therapy in the treatment of patients with chronic rhinosinusitis

OBJECTIVES

To conduct the first prospective, randomized controlled clinical trial comparing the efficacy of a drug-eluting stent (DES) (the Relieva StratusTM MicroFlow Spacer) and topical intranasal corticosteroid therapy in patients with chronic rhinosinusitis (CRS).

METHODS

Sixty-three adult patients with ethmoiditis were randomized into either the DES group (n=34) or nasal spray group (n=29). The main outcome variable was the Sinonasal Outcome Test 22, Visual Analogue Scale, nasal endoscopy, rhinometric measurements were performed at the beginning of the study, after three months and six months of follow-up.

RESULTS

Both treatments significantly improved quality of the life with no significant difference being found between the two groups. The VAS score decreased in both groups: improvements were significant at three and six months in the nasal spray group, but in the DES group a significant difference was noted only at three months. There was a statistically significant increase in total nasal cavity volumes in the corticosteroid spray group, but not in the DES group.

CONCLUSION

We found that patients benefitted from DES and the corticosteroid nasal spray. We could not find any significant difference between the treatments, except the greater increase in the total nasal cavity volumes favouring the nasal spray group. Because of the very good results for the nasal spray and the much higher material and operating room costs associated with DES, we cannot recommend the use of DES over nasal spray as a monotherapeutic treatment for CRS.

Eustachian Tube Dysfunction-Related Symptoms in Chronic Nasal Obstruction Caused by Inferior Turbinate Enlargement

OBJECTIVE

The aim of this study was to evaluate the relationship between chronic nasal obstruction caused by inferior turbinate enlargement and Eustachian tube dysfunction-related symptoms using the Eustachian Tube Dysfunction Questionnaire (ETDQ-7) as an assessment method.

METHODS

A total of 80 adults were enrolled. Group 1 comprised consecutive patients with enlarged inferior turbinates and group 2 comprised healthy controls. The ETDQ-7 scores and tympanometry results of both groups were analyzed and compared.

RESULTS

The median total scores of the ETDQ-7 in groups 1 and 2 were 1.9 (interquartile range, 1.4-2.8) and 1.1 (interquartile range, 1.0-1.7), respectively ( P < .001). There was no significant difference in the abnormal tympanometry results between the groups. There was no significant difference in the ETDQ-7 total score between the patients with allergic sensitization and other patients in group 1.

CONCLUSIONS

Patients with inferior turbinate enlargement have more symptoms related to Eustachian tube dysfunction than healthy controls. Most patients with Eustachian tube dysfunction had normal tympanometry and normal otoscopy, which indicates a baro-challenge-induced Eustachian tube dysfunction. Whether the patient has allergic sensitization or not does not seem to cause a difference in symptoms related to Eustachian tube dysfunction.

The effect of inferior turbinate surgery on ear symptoms

OBJECTIVE

The aim of this placebo-controlled study was to evaluate the effect of various inferior turbinate surgery techniques on Eustachian tube dysfunction-related symptoms.

STUDY DESIGN

Outcomes were evaluated using the Eustachian Tube Dysfunction Questionnaire (ETDQ-7) and tympanometry results.

METHODS

A total of 72 consecutively blinded and randomized adult patients with enlarged inferior turbinates due to persistent year-round rhinitis underwent either a radiofrequency ablation, diode laser, microdebrider-assisted inferior turbinoplasty, or sham surgery procedure. Assessments were conducted prior to surgery and 3 months subsequent to the surgery.

RESULTS

In the evaluation of all patients, radiofrequency ablation, microdebrider-assisted inferior turbinoplasty, and sham surgery procedures decreased the ETDQ-7 total score significantly. In a three-way analysis of covariance, there were no significant differences in the results between sham surgery and any of the active treatment procedures. Allergic sensitization, sex, and age also had no effect on the results. There were no significant changes in the pre- and postoperative amounts of abnormal tympanometry curves or in the pre- and postoperative tympanometric peak pressure values in the actively treated patients or in the sham surgery group.

CONCLUSION

The improvement of Eustachian tube dysfunction-related symptoms due to surgery of the anterior half of the inferior turbinate was found to be equal to placebo. The findings of this study do not support the use of reduction of the anterior half of the inferior turbinate as a sole procedure intended to treat the ear symptoms assessed by the ETDQ-7 questionnaire.

LEVEL OF EVIDENCE

1b. Laryngoscope, 128:568-572, 2018.

Quality of life after endoscopic sinus surgery or balloon sinuplasty: a randomized clinical study

OBJECTIVES

To conduct the first prospective randomized controlled trial that evaluates and compares the clinical outcome and impact of ballonsinuplasty and endoscopic sinus surgery (ESS) on the quality of life of patients suffering from chronic or recurrent rhinosinusitis (CRS) of the maxillary sinus.

METHODS

Adult patients with symptomatic chronic or recurrent rhinosinusitis without severe findings in the sinuses, as documented in the sinus’ Computer Tomography scan and clinical exam, were randomized in 2 groups: ESS and Balloon Sinuplasty.The main variable in our study is the Sinonasal Outcome Test-22 (SNOT 22) and its parameters. These parameters were analysed preoperatively and at 3 months, postoperatively.

RESULTS

There was a subjective improvement in symptoms after surgery. We also noticed an objective improvement in the quality of life of our patients seen as a decrease in the total SNOT 22 score. Both balloon sinuplasty and ESS significantly improved almost all the parameters of SNOT22, with no significant difference being found between these two groups.

CONCLUSION

Both balloon sinuplasty and endoscopic sinus surgery improved the quality of life of patients with mild chronic or recurrent rhinosinusitis. However, the remarkably higher material cost of balloon sinuplasty compared to ESS sets limits on its broad use. There is an obvious need for further study to find out if, as an office procedure, balloon sinuplasty could deliver cost-savings high enough to cover the higher material cost of balloon sinuplasty. Our study was, however, too small to enable firm conclusions to be drawn.

Inter-observer agreement of paranasal sinus computed tomography scans

CONCLUSION

The study demonstrated considerable inter-observer variation in certain surgically important structures. This would indicate the significance for consultation when evaluating sinus CT scans of CRS patients for planned advanced sinus surgery.

OBJECTIVES

After the failure of medical treatment of chronic rhinosinusitis (CRS), the need for surgery and the pre-operative planning of safe surgery is based on computed tomography (CT) findings. The aim of this prospective study was to compare inter-observer agreement of anatomical and surgical structures of sinus CT scans. The hypothesis was that the agreement between observers is good.

METHODS

Of these 57 CRS patients, Lund-Mackay (LM) scores and 43 other structural parameters were analyzed blinded. The reproducibility of the findings between three observers, a radiologist, an Ear, nose and throat (ENT) surgeon, and an ENT resident, were compared.

RESULTS

In general, there was moderate inter-observer agreement of the structures by Cohen's kappa coefficient. Poor reproducibility was observed in the following structures: optic nerve, insertion of the uncinated process, anterior ethmoidal artery, and Keros class.

Myxoinflammatory fibroblastic sarcoma of the nose: First reported case at an unusual location (nasal dorsum), with a review of the literature

Myxoinflammatory fibroblastic sarcoma (MIFS) is a rare, low-grade, malignant, soft-tissue tumor that typically affects the distal extremities of middle-aged patients. In most cases, it presents as a painless, slowly growing mass within the subcutaneous tissue. It is associated with a low rate of metastasis but a high rate of local recurrence. In addition to the distal extremities, MIFS has been reported in the thigh, arm, forearm, groin, upper back, neck, and temporal area. As far as we know, no case has been previously reported in the nasal area. We report for the first time a case of MIFS presenting on the dorsum of the nose. The painless, 3.0-cm tumor was initially mistaken for reticular erythematous mucinosis, a benign skin condition that occurs when fibroblasts produce abnormally large amounts of mucopolysaccharides. The tumor was surgically removed in its entirety with surgical margins of 3 to 5 mm. During 4 years of follow-up, no clinical or radiologic evidence of a recurrence or metastasis was seen. We discuss the imaging and histologic features of MIFS, as well as its clinical management and follow-up, and we review related reports in the literature.

Allergic rhinitis

There have been no major changes in the pharmacological treatment of allergic rhinitis in recent years. Treatment is symptomatic and tailored individually, taking into account the type and severity of symptoms. Few new products have entered the market, and treatment is still largely based on antihistamines and nasally administered glucocorticoids. However, the general strategies for treating allergic rhinitis have developed over the last decade due to the introduction of the Finnish National Allergy Program. The treatment should aim at improving tolerance. Avoiding allergens is not necessary but it may help in controlling the symptoms. Hyposensitization, the only disease-modifying therapy, is a recommended, effective and safe form of treatment. New, practical sublingual hyposensitization products have facilitated treatment implementation and moved it from outpatient clinics into homes, which is a more patient-oriented approach and also cost-effective in the long term. However, the unit costs of treatment are relatively high for the patients.

Decrease of nasal airway resistance and alleviations of symptoms after balloon sinuplasty in patients with isolated chronic rhinosinusitis: a prospective, randomised clinical study

OBJECTIVES

The aim of this study was to evaluate and compare the clinical outcome of balloon sinuplasty and uncinectomy for patients suffering from isolated chronic rhinosinusitis of the maxillary sinus.

DESIGN

A prospective, randomised, non-blinded, controlled trial was conducted.

SETTING

The study was carried out at the Department of Otolaryngology, Tampere University Hospital, Finland.

PARTICIPANTS

Adult patients with symptomatic isolated chronic or recurrent rhinosinusitis without severe findings in the sinuses, as documented in the sinus' Computer Tomography scan and clinical examination, were randomised into two groups: uncinectomy and balloon sinuplasty.

MAIN OUTCOME MEASURES

The variables in our study are the Sinonasal Outcome Test-22 (SNOT 22), acoustic rhinometry and rhinomanometry. These parameters were analysed preoperatively and postoperatively (after 3 and 6 months).

RESULTS

The preliminary results of our study have been previously published. Both balloon sinuplasty and uncinectomy significantly improved almost all the parameters of SNOT22 (P < 0.05), with no significant difference being found between these two groups (P > 0.05). Based on rhinomanometry results, airway resistance decreased after treatment. Regarding adverse effects, balloon sinuplasty was significantly associated with a lesser risk of synechia.

CONCLUSIONS

Both balloon sinuplasty and uncinectomy improved the quality of life and decreased upper airway resistance of patients with mild, isolated chronic or recurrent rhinosinusitis. The smaller risk of postoperative synechiae with balloon sinuplasty combined with its promising efficiency could partially compensate for its high material cost.

The effect of adenoidectomy on occlusal development and nasal cavity volume in children with recurrent middle ear infection

OBJECTIVES

The aim of the study was to examine the effect of adenoidectomy on occlusal/dentoalveolar development and nasal cavity volume in children who underwent tympanostomy tube insertion with or without adenoidectomy due to recurrent episodes of middle ear infection.

METHODS

This prospective controlled study consisted of two randomly allocated treatment groups of children, younger than 2 years, who had underwent more than 3-5 events of middle ear infection during the last 6 months or 4-6 events during the last year. At the mean age of 17 months tympanostomy tube placement without adenoidectomy (Group I, n=63) tympanostomy tube placement with adenoidectomy (Group II, n=74) was performed. At the age of 5 years 41 children of the original Group I (14 females, 27 males, mean age 5.2 yrs, SD 0.17) and 59 children of the original Group II (17 females, 42 males, mean age 5.2 yrs, SD 0.18) participated in the re-examination, which included clinical orthodontic examination defining morphological and functional craniofacial status and occlusal bite index to measure upper dental arch dimensions. Acoustic rhinometry and anterior rhinomanometry was made by otorhinolaryngologist at the same day.

RESULTS

No statistically significant differences were found between the groups in the frequencies of morphological or functional characteristics or upper dental arch measurements or in the minimal cross-sectional areas or inspiratory nasal airway resistance measurements.

CONCLUSION

Combining adenoidectomy with tympanostomy tube insertion in the treatment of recurrent middle ear infection at an early age (under the age of 2 years) does not seem to make any difference in occlusal development in primary dentition at the age of 5 years as compared to tympanostomy tube insertion only. Since adenoid size was not evaluated, the findings do not allow interpretation that hypertrophic adenoids should not be removed in children with continuous mouth breathing or sleep disordered breathing.

A Controlled, Randomized Clinical Study on the Impact of Treatment on Antral Mucociliary Clearance: Uncinectomy Versus Balloon Sinuplasty

OBJECTIVES

To find out the effect of minimal invasive sinus surgery and balloon sinuplasty on mucociliary clearance and compare different methods of measuring mucociliary clearance.

METHODS

Twenty-nine patients with chronic rhinosinusitis were randomized in 2 operative groups (uncinectomy or balloon sinuplasty). Before and 6 months after the treatment, patients filled out a quality of life questionnaire (Sino Nasal Outcome Test-22 [SNOT-22]), and mucociliary clearance was measured with endoscope and gamma camera after 0.03 ml of saccharine, methylene-blue dye, and human albumin labeled with Tc99m was introduced to the bottom of maxillary sinuses.

RESULTS

In uncinectomy group, SNOT-22 score decreased, but treatment had no effect on mucociliary clearance. Based on saccharine test, smoking was associated with worse mucociliary clearance (r = 0.618, P < .05). Methylene blue test results associated with saccharine test (r = 0.434, P < .05) and Tc99m-labeled tracer technique (r = 0.261, P = .039) separately.

CONCLUSION

Treatment positively affects patients' quality of life; however, it has no effect on mucociliary clearance. There was a statistically significant correlation between the Tc99m-labeled tracer technique and the methylene blue technique. The saccharine technique was even less accurate, but it can be useful in clinical practice because it is a quick, easy, and safe technique.

The Experience of Treating Drooling with Repeated Botulinum Toxin Injections

Botulinum toxin A (BTX-A) injections to the salivary glands are effective in the treatment of drooling, and complications are rare. However, there are only a few previous reports on the long-term use of BTX-A injections. This study retrospectively analyzes our experience of treating drooling with repeated BTX-A injections in patients with neurodegenerative diseases. All patients who received repeated BTX-A injections to the submandibular glands at Tampere University Hospital in 2004-2013 were included in the analysis. Six patients, aged from 6 to 21 years, were included in the study, and a total of 41 bilateral BTX-A injections were administered to their submandibular glands. The average number of injections per patient was 6 (range: 3-11). The average interval between the injections was 9.8 months (range: 4-18), and 95% (39/41) of the injections were performed with good response. The complication rate of the BTX-A injections was 2.4% (1/41), since one of the patients had swallowing problems after an injection. BTX-A injections to the submandibular glands are effective and have a low morbidity rate, and repeated injections can be recommended as long-term treatment of drooling.

Image-guided, navigation-assisted Relieva Stratus MicroFlow Spacer insertion into the ethmoid sinus

Anatomical complexity presents the main challenge in the administration of topical corticosteroid therapy to the paranasal sinus mucosa. This often leads to suboptimal drug delivery due to low concentrations of the therapeutic agent to the intended target area. The Relieva Stratus™ MicroFlow Spacer (Relieva Stratus) is a drug-eluting stent that is temporarily implanted into the ethmoid sinus. The reservoir of the stent is filled with triamcinolone acetonide, which is then slowly released from the device into the ethmoid sinus mucosa. The Relieva Stratus provides local and targeted delivery of the anti-inflammatory agent to the diseased mucosa. This minimally invasive implant is an option when treating ethmoid sinusitis. From January 2011 to November 2013, a total of 52 Relieva Stratus implantations into the ethmoidal cells were performed at the Department of Ear and Oral Diseases at Tampere University Hospital, Finland. C-arm fluoroscopy guidance was employed for 26 sinuses (13 patients) and optical image-guided surgery (IGS)-assisted insertions were performed on another 26 sinuses (13 patients). The accuracy of fluoroscopic insertion is not optimal, but this method is accurate enough to prevent the violation of the skull base and lamina papyracea. IGS enables the precise treatment of the diseased cells. From a technical perspective, IGS-guided insertion is a faster, safer and more exact procedure that guarantees the optimal positioning and efficacy of the implant. Moreover, IGS guidance does not entail the use of ionizing radiation.

Adipose stem cells used to reconstruct 13 cases with cranio-maxillofacial hard-tissue defects

Although isolated reports of hard-tissue reconstruction in the cranio-maxillofacial skeleton exist, multipatient case series are lacking. This study aimed to review the experience with 13 consecutive cases of cranio-maxillofacial hard-tissue defects at four anatomically different sites, namely frontal sinus (3 cases), cranial bone (5 cases), mandible (3 cases), and nasal septum (2 cases). Autologous adipose tissue was harvested from the anterior abdominal wall, and adipose-derived stem cells were cultured, expanded, and then seeded onto resorbable scaffold materials for subsequent reimplantation into hard-tissue defects. The defects were reconstructed with either bioactive glass or β-tricalcium phosphate scaffolds seeded with adipose-derived stem cells (ASCs), and in some cases with the addition of recombinant human bone morphogenetic protein-2. Production and use of ASCs were done according to good manufacturing practice guidelines. Follow-up time ranged from 12 to 52 months. Successful integration of the construct to the surrounding skeleton was noted in 10 of the 13 cases. Two cranial defect cases in which nonrigid resorbable containment meshes were used sustained bone resorption to the point that they required the procedure to be redone. One septal perforation case failed outright at 1 year because of the postsurgical resumption of the patient's uncontrolled nasal picking habit.

Towards a defined, serum- and feeder-free culture of stratified human oral mucosal epithelium for ocular surface reconstruction

PURPOSE

Ocular surface reconstruction with cultivated oral mucosal epithelial transplantation technique is a viable treatment option for severe ocular surface injuries and diseases with limbal stem cell deficiency. Currently, this technique is based on utilization of xenogenic, allogenic or undefined components such as murine 3T3 feeders, serum and amniotic membrane. In this study, we aimed to find a more defined culture method to generate stratified human oral mucosal epithelium.

METHODS

In this study, we have examined the formation of stratified cell sheets from human oral mucosal epithelial cells under serum-free culture environment both in the absence and presence of fibroblast-conditioned culture medium and elevated epidermal growth factor (EGF) concentration.

RESULTS

In all examined culture conditions, the cultivated oral epithelial cells formed a stratified tissue, which was positive for keratins K3/12, K4 and K13. The tissue-engineered oral epithelia also expressed proliferation and progenitor markers Ki67 and p63 in the basal layer of the cell sheets, suggesting that the epithelia still had regenerative capacity. The cultures presented expression of tight junction proteins ZO-1 and occludin and high transepithelial electrical resistance values.

CONCLUSION

In this culture method, we have been able to produce stratified cell sheets successfully without serum, conditioning of the medium or increased EGF concentration. We provide a novel protocol to produce tight multi-layered epithelium with proliferative potential, which can be easily adapted for cultivated oral mucosal epithelial transplantation.

[Airways dysfunction syndromes RADS and RUDS]

RADS is an airways dysfunction syndrome caused by a sudden, massive exposure to an irritative chemical. RADS is considered a subtype of occupational asthma. RADS patient may cure within months, but RADS may also become a permanent disability. RUDS is a dysfunction syndrome in upper airways caused by exposure to an irritative chemical. It seems that in RUDS there are problems in olfactory function in addition to inflammation of upper airways. We present a patient, who was suddenly exposed to chemical vapours in her workplace. She had RADS-like symptoms and was diagnosed with RUDS.

[Combined technique in the removal of parotid gland stones]

Sialendoscopy is used in the diagnostics and treatment of salivary gland swelling. Small intraductal stones can be removed with various instruments during sialendoscopy. In cases with larger fixed stones a combined technique can be applied. The stone is approached endoscopically, skin flap is raised or a small incision is made through the illuminated area and the stone is removed via the external route with minimal morbidity. In this series five out of seven patients treated by the combined technique became symptomless. Superficial parotidectomy was performed on one patient. The combined technique is recommended in the removal of stones that are large, fixed in the duct or located in the gland's hilus.

[Update on Current Care Guideline: Sinusitis]

Patients with common cold have often symptoms similar to sinusitis. These symptoms often resolve in time, but symptomatic treatment (e.g. analgesics, decongestants) may be used. If symptoms continue for over 10 days, or severe symptoms continue for over 3 days, or symptoms turn worse in the course of the disease, bacterial sinusitis should be suspected. Diagnosis is based on clinical findings, and can be confirmed with ultrasound examination. Amoxicillin, penicillin or doxicyclin are recommended for bacterial sinusitis. Patients with chronic or recurrent sinusitis should be referred to specialist care.

[Osler's disease or hereditary hemorrhagic telangiectasia]

According to current knowledge, Osler's disease may be caused by gene defects of several distinct genes, causing vascular fragility and lack of contractility. The most typical symptoms are recurrent spontaneous nose bleedings. Other target organs of the disease include skin, lungs, intestinal tract, brain and liver, but symptoms in these organs are less common. The diagnosis is based on clinical findings, family history and can, if necessary, be confirmed by a gene test. Osler's disease is treated symptomatically. There is no curative treatment.