Rhinology Journal

We have deliberately printed the June issue early so that it would be readily available for our European Rhinologic Society biennial meeting in Toulouse, which I very much hope you will be attending (www.ers-isian2012.com). Toulouse is a wonderful city (la Ville Rose) especially in July and is a cultural and gastronomic epicentre, which will provide us with a wonderful backdrop to what I know will be an excellent scientific meeting. Some of the topics covered in this issue will undoubtedly be the subject of discussion in the many plenary sessions, symposia, free papers and posters during the meeting.

This double blind, parallel study compared flunisolide 2 X 25 mcg in each nostril twice daily, with placebo in the prophylaxis of nasal polyposis recurrence after surgery. The treatment lasted for 12 months. The study was conducted according to the recommendations of the Declaration of Helsinki, and the patients gave verbal consent to participate. The study was reviewed by the Norwegian Medicines Control Authority. Forty-one patients with first or recurrent polypectomy were enrolled. Thirty-seven patients completed the 12 months' period. Four patients dropped out prematurely for reasons unrelated to the test drug. Flunisolide was significantly superior to placebo in preventing recurrence of polyps during 6 to 12 months' treatment, both with respect to number (p = 0.05) and size (p = 0.03) of polyps. Nasal symptoms of sneezing and stuffiness decreased significantly for flunisolide treated patients during treatment. In the placebo group, there was a significant increase in stuffiness throughout the year. For runny nose, there was no difference between the treatments. Six flunisolide patients and 10 placebo patients reported side effects during the one year treatment, transient mild itching being the most common complaint. Three cases of secretion with bloody traces were reported. No patient withdrew for drug related reasons. In this study, flunisolide was significantly more effective than placebo in preventing recurrence of nasal polyposis during one year's treatment after polypectomy.

The efficacy, safety and optimal dose of TL-102, a powder mixture of beclomethasone dipropionate (BDP) and hydroxypropylcellulose (HCP) were studied in 250 patients with perennial nasal allergy in an intergroup comparative double-blind manner. Four different capsules containing respectively 30 micrograms of HCP and 1.5 micrograms, 12.5 micrograms, 25 micrograms and 50 micrograms of BDP, were prepared and the drug was applied intranasally evenly between both nostrils at a dose of 2 cap./day b.i.d. for one week. The degrees of overall improvement, usefulness, improvement of nasal symptoms (sneezing, nasal discharge, nasal blockage) and improvement of rhinoscopical findings (mucosal swelling and nasal secretion) were found to be dose-dependent. Antigen provocation reaction and nasal eosinophil count were both inhibited as compared with the TL 1.5 g group. The incidence of side effects was 4.5%, but all side effects observed were mild. Using TL-102 resulted in a therapeutic effect comparable to the conventional BDP preparations using a dose 1/4th of the normal dose of these BDP preparations. The incidence of side effects was 1/3th in comparison with conventional BDP. It was suitable to administer BDP 50 micrograms capsule containing 30 mg of HCP twice a day.

The in vivo model of nasal microvascular leakage was used for the nasal allergic challenge in ovalbumin (OA)-sensitized guinea pigs, or nasal stimulation with leukotriene D4 (LTD4) in non-sensitized animals. An intravenous injection of Evans blue dye was given as an index of nasal microvascular leakage. Following the nasal stimulation with LTD4, the concentration of dye in the nasal lavage fluid rapidly increased. Oral administration of ONO-1078 (pranlukast) (3-30 mg/kg) significantly inhibited the LTD4-induced nasal microvascular leakage. In OA-sensitized guinea pigs, the excretions of dye into nasal lavage fluid were recognized soon after the topical antigenic stimulation and continued for over 60 minutes. Oral administration of ONO-1078 (30 mg/kg) significantly inhibited the antigen-induced microvascular leakage. These results suggest that ONO-1078 may be of therapeutic use for nasal allergy.

Between June 1972 and November 1977, 108 patients had medical-grade Silastic buttons inserted transnasally into a perforation of the nasal septum. This nonsurgical technique was done as an office procedure with use of 5% cocaine applied topically in 97 of the 108 patients. The Silastic button has remained in place in 70.4% of the patients, with follow-up ranging from 9 months to 6 years. This mechanical device is inserted easily and has reduced crusting and bleeding considerably in many patients. The failures frequently were related to patient intolerance or poor mechanical fit and occurred in the first few days or first few months after insertion.

The measurement of peak nasal inspiratory flow (PNIF) is a simple, quick, easy to perform and cheap tool for determining the extent of nasal airway patency. However, normative data are rare and not available for Dutch children aged 6 to 11 years. Repeated PNIF measurements were obtained from 212 Dutch children of primary school age. Of these 212 children, 166 fulfilled the inclusion criteria of our study. The influence of age, gender, ethnicity, weight and height on PNIF was studied. Age is the only parameter of influence on PNIF. All other parameters do not influence PNIF. Normative data are presented. PNIF measurements are possible in children aged six years and older. Age does influence PNIF, but gender, weight, height and ethnicity do not.

Not much is known about long-term satisfaction of septoplasty. The goal of this study was to assess disease specific quality of life outcomes as well as satisfaction at more than 10 years follow-up after septoplasty. The study was conducted as a retrospective questionnaire study (based on the NOSE scale) in which a questionnaire was sent to every patient and followed up by a telephone interview conducted in a tertiary otorhinolaryngologic clinic. 238 out of 369 patients who underwent septoplasty accepted to participate of which 222 were eligible. We found a significant reduction in NOSE score from 56.9 before surgery to 31.9 at follow-up. 68.0% experienced improved nasal breathing and 55.9% were satisfied with the overall outcome. Predictive analysis showed that only severity of symptoms before surgery was predictive of all final outcome parameters. Long-term outcome of septoplasty appears to be in line with shorter follow-up. Surprisingly a sizable difference was noted between rate of satisfaction and improvement in nasal breathing. It is important that the surgeon and patient have the same expectations to septoplasty as to avoid any inappropriate disappointment, which is more likely to occur if symptoms are not severe.

A total of 115 patients with sinonasal cancer was assessed during the period 1978-1995. Ninety-one patients received treatment with curative intent. A combination of irradiation and operation was used. The 5-year crude survival for patients, who were treated with curative intent, was 41%; the disease-specific survival throughout the period was 48%. Primary irradiation followed by maxillectomy was widely used in the first half of the period. Treatment in the last part was changed to primary lateral rhinotomy with post-operative irradiation whenever possible. Twelve maxillectomies were performed during the first half of the period, and during the last part, only two. Disease-specific survival was equal in the first and the second halves of the period.

Melanomas account for 4% of sinonasal malignancies. We present the largest single institution series reported thus far and analyze the outcome with reference to lymph node involvement, radiotherapy and endoscopic resection. Survival and recurrence data were analyzed on sinonasal melanoma cases collected from 1963-2010 to compare treatment strategies and to ascertain factors predicting outcome. 115 cases (mean age 65.9) were treated at our institution during this period. All underwent surgical resection of the tumour, 31 (27%) endoscopically, and 51 (44%) also received radiotherapy. Five year overall survival was 28% and disease-free survival was 23.7%. Local control was achieved for a median of 21 months, 5-year disease control rate of 27.7%. Endoscopically resected cases showed a significant overall survival advantage up to 5 years. Radiotherapy did not improve local control or survival. Cervical metastases conferred a dramatically worse outcome. Endoscopic resection of sinonasal melanoma does not prejudice outcome. The role of radiotherapy is unproven.

To assess the effectiveness and factors associated with restenosis after Draf type III (Endoscopic Modified Lothrop) frontal sinus drainage procedure. Retrospective analysis of prospectively collected data. A hundred and twenty two consecutive patients undergoing Draf III procedure for recalcitrant chronic frontal rhinosinusitis (CRS) (71%), frontal sinus mucocoele (15%), benign frontal sinus tumours (9%) and cystic fibrosis with severe CRS (5%) were followed up for an average of 33 months. Symptom burden (Visual Analogue Scale and Rhinosinusitis Outcome Measure), patency of neo-ostium and revision surgery. At the end of follow up, ninety percent of patients had a patent neo-ostium, while 88% were either clinically better or completely asymptomatic. Thirty-nine patients required endoscopic revision surgery and 9 eventually underwent frontal sinus obliteration. Sixty percent of revision operations were performed during the first two years. RSOM showed a significant improvement in both general and nasal symptoms while on a VAS, headache improved significantly. The only factor weakly associated with re-stenosis was the presence of allergy. There were no major complications during any of the procedures. Draf III Procedure is safe and effective for patients who have failed conventional frontal sinus procedures and a valid alternative to frontal sinus obliteration. Although the revision rate may appear to be quite significant, it can often be performed as an outpatient procedure and needs to be balanced against the reduced morbidity and the ease of follow-up.

Endoscopic transnasal approaches to the skull base have revolutionized the treatment of cerebrospinal fluid (CSF) fistulae, making repair less invasive and more effective compared with craniotomy or extracranial techniques. This study evaluated, retrospectively, the results of endoscopic repair of dural defects with the use of mucoperiostal grafts taken from the lower turbinate. Between January 1997 and January 2007, 125 cases of anterior skull base CSF fistulae were treated endoscopically at the Instituto Felippu de Otorrinolaringologia, Sao Paolo, Brazil, and at the Department of Otolaryngology of the University Hospital "Ospedali Riuniti", Foggia, Italy. Fistula closure was achieved by overlay apposition of a lower turbinate mucoperiostal graft fixated with fibrin glue and Surgicell. The etiology of the fistula was accidental trauma in 41 cases, iatrogenic trauma in 29, skull base tumour in 12, and spontaneous in 43. The site of the defect was the sphenoid sinus in 43 patients, the cribriform plate in 42, the anterior ethmoid roof in 21, the posterior ethmoid roof in 17, and the posterior wall of the frontal sinus in 2. The success rate at first attempt was 94.4%; the 7 cases of postoperative recurrent CSF leakage involved patients presenting with spontaneous fistula and elevated intracranial pressure; 5 of these had a body-mass index > 30 and 3 suffered from diabetes mellitus. In our hands, the success rate of endoscopic fistula repair was high, even in defects larger than 2 cm. Success rates may be further improved with accurate diagnosis of elevated intracranial pressure, a contributing factor to failure of spontaneous fistula repair.

Two hundred and nineteen children with sinusitis treated as in-patients at Huddinge University Hospital during the period 1980-1992 have been reviewed. Epidemiological data, the clinical picture, treatment and complications are described. The prevalence of significant predisposing conditions (such as upper airway allergy, asthma, and immunoglobulin deficiency) has been estimated. Serious sinusitis complications are few, surgery is only rarely required, and previously-recognized important predisposing paediatric conditions are not significantly more common than in the general juvenile population. Improved medication and prevention may have reduced the incidence of serious sinus infections in risk groups today. Children with cystic fibrosis have been reviewed with regard to the necessity of both sinus and nasal polyp surgery. Aggressive medical therapy appears to have reduced their need for sinus surgery as well as polypectomy.

Neutral endopeptidase (NEP, EC 3.4.24.11), angiotensin-converting enzyme (ACE, EC 3.4.15.1) and carboxypeptidase N (CPN, EC 3.4.17.3) are potentially important enzymes which regulate the degradation of neuropeptides, such as bradykinin (BK) and substance P (SP), in the respiratory mucosa. Some neuropeptides are also degraded by these enzymes in vitro and in vivo. We investigated the localization of these enzymes in the human nasal mucosa by an indirect immunohistochemical technique (immunogold silver staining). NEP-immunoreactive areas were present in the epithelium, the serous cells of the submucosal glands, and the endothelial cells of small vessels. The epithelium and the serous cells were the predominant areas of NEP immunoreactivity in the nasal mucosa. ACE-immunoreactive areas were seen in the outer layer of the epithelium, the endothelial cells of vessels, and widely distributed in the superficial lamina propria. The endothelial cells of the vessels showed maximum positive intensity to ACE. CPN-immunoreactive areas were observed in the epithelium, the endothelium of vessels and the superficial lamina propria, except for the gland cells. The superficial lamina propria exhibited maximum immunoreactivity for CPN. We observed that the enzymes were widely distributed in the nasal mucosa. The epithelium, including the epithelial cells and glycocalyx, contains all three enzymes. These enzymes play an important role in the mucosal immunity of the respiratory mucosa by degrading active neuropeptides. These results show that NEP secretion is regulated by a glandular, cholinergic control. On the other hand, ACE and CPN secretion are regulated by vascular permeability.

A 133Xenon washout test is presented and interpreted. It was developed on the basis of studies into the accumulation of aerosols of different makes (lithium chloride in the form of ultrasonic, vibratory and pressurized aerosols) in the paranasal sinuses and sequential scintigraphy with radioactively labeled aerosols (99m Technetium colloidal sulfur) and is designed to shed light on the gas exchange in the paranasal sinuses and the patency of their orifices. The test constitutes a valuable addition to the battery of diagnostic tools for assessing paranasal sinus function and, at the same time, documents the true value of aerosol therapy.

In a retrospective study 136 patients with neoplasms of the paranasal sinuses had been analysed. Survival was plotted against localization, TNM-grading, histology, treatment modalities, and various other parameters. Treatment of choice seems to be radical surgery and postoperative high voltage irradiation.

The occurrence of foreign bodies (FB) in otorhinolaryngological practice is a common and serious problem among pediatric patients. The aim of this work is to characterize the risk of complications and prolonged hospitalization due to FBs in the nose in terms of the characteristics of the injured patients (age, gender), typology and features of the FBs, the circumstances of the accident and the hospitalization's details. A retrospective study of FB associated injuries, assessing the characteristics of the injured child and the FB, the circumstances of the accident and finally the hospitalization details took place on children aged 0-14 in major hospitals of 19 European countries. In total 688 cases were assessed. Complications and hospitalization occurred in 59 and 52 cases, respectively. Over 51% of patients were females. The median age of children who experienced a complication was four years. In the majority of cases FB removal was accomplished by means of a non-invasive technique (rhinoscopy with a nasal speculum or rigid fiberoptic endoscope. The majority of children were directly referred to the ENT department. The most common FBs associated with complications and hospitalization were nuts, seeds, berries, corn and beans, batteries and other inorganic objects such as broken parts of pens, paper clips and pearls. Over 38% of the injuries occurred under adults' supervision. FB injuries in the nose are commonly encountered in clinical practice. Even if the presence of a FB is not usually life threatening, it may result in long-term complications such as perforation of the septum. Because the risks associated with FB injuries, public education about this problem is recommended.

The management of nasal polyps is undoubtedly a controversial subject. The medical treatment remains the undisputed therapeutic mainstay but most of the publications are aimed at the registration of new molecules from the pharmaceutical industry which explains why they are confined to a single agent. The aim of this study is focused on the evaluation of a dual modality on a series of 152 subjects treated according to a standardized protocol combining a short-term administration of prednisolone and the daily intranasal spraying of beclomethasone. Over the follow-up period of one year, this modality proved to be successful in 68.5% of the subjects; only 31.5% had to undergo surgery after its failure. In the former group, after a six months period, the average symptom reduction reached an improvement rate varying from 35 to 80%, according to the symptom type. During the ensuing six months follow-up period, the improvement was maintained. The average utilization of prednisolone and beclomethasone was assessed for each individual patient. Management of nasal polyps should be primarily medical. Resorting to surgical procedures should not be envisaged before a six months trial of dual steroid therapy under strict compliance to treatment.

Although nasal turbinates had already been described by Hippocrates, it was not until the 15th century that they were depicted. The inferior turbinate was shown for the first time rather true-to nature in the works of the Middle Rhenic Master circa 1450-1460 and Leonardo da Vinci in 1489. The posterior ends of the middle turbinates were depicted on a woodcut by Georg Thomas for Dryander's "Anatomiae ... pars prior" in 1536. These and a few other examples show that some artists were ahead of the medical profession in demonstrating anatomical details in the 15th and 16th century.

Silent sinus syndrome (SSS) is a rare idiopathic collapse of the maxillary sinus and orbital floor. We present the second largest series of sixteen patients with SSS and describe their management. A cohort of 16 patients with spontaneous SSS between 1999 and 2009 were reviewed at the Royal National Throat Nose and Ear Hospital. All patients were initially referred from a postgraduate ophthalmic hospital, Moorfields Hospital. Fourteen patients required endoscopic sinus surgery to re-establish maxillary sinus drainage and the remaining two settled with intranasal medical therapy consisting of steroids and decongestions. Follow- up ranged from 6 months to 4 years with a mean of 2.6 years. An improvement in enophthalmos and was seen in all surgically treated patients with a mean improvement of 2.2mm and range 0.5-4mm. SSS arises from congestion of the ostiomeatal complex resulting in negative pressure within the maxillary sinus and a gradual implosion of the antral cavity. Endoscopic sinus surgery successfully re-establishes maxillary aeration in our series and leads to clinical and aesthetic improvement in the degree of enophthalmos and has avoided the need for orbital floor repair in all but two cases.

The aim of this study was to evaluate in how far cerebral blood flow changes in male subjects when exposed to a pheromone that they cannot consciously smell. We used a boar taint steroid (5a-Androst-16-en-3-one), which is similar to human axillary sweat but could not be detected by the human volunteers who participated in this study. The pheromone produced activation of the orbitofrontal and frontal cortex in comparison to a baseline condition. The same regions were activated when the subjects smelled a rose-like odour. This study shows that a pheromone, which is not consciously detected, can evoke a response in the brain that is similar to a detectable odour.

Interleukin-6 (IL-6) is an inflammatory mediator linked to nasal polyposis and asthma, with a single nucleotide poly- morphism -174 G/C that seems to promote an inflammatory status. We aimed to analyze the relationship between this polymor- phism and asthmatic nasal polyposis patients. Cross-sectional study to investigate IL-6 - 174 G/C genotypes of 45 nasal polyposis with asthma patients, 63 nasal polyposis-only patients, 45 asthma-only patients and 81 subjects without both diseases. Aspirin intolerance and atopy were main exclusion criteria. IL-6 genotyping was performed using the PCR method with specific primers followed by restriction enzyme analysis, classifying patients in GG, GC or CC genotype. The GG genotype was the most frequent in all inflammatory groups. Less than 40% of controls presented with the GG ge- notype. There were significant differences between inflammatory groups and control group. No significant differences were seen when comparing inflammatory groups to each other, other than between nasal polyposis-only group and asthma-only group. The IL-6 74 GG genotype was found more frequently in all inflammatory groups than in controls. This genotype could influence nasal polyposis and asthma, and seems to be more important in the latter.

Nasal polyposis is a chronic disease with unknown etiopathogenesis, although inflammatory mechanisms seem to play a role. One of several inflammatory mediators linked to nasal polyposis is Interleukin-6, which has a single nucleotide polymorphism -174 G/C that seems to promote an inflammatory reaction. To compare the prevalence of the -174 G/C single nucleotide polymorphism between a group of patients with nasal polyposis and a control group. Cross-sectional study with two groups (thirty two patients with nasal polyposis and fifty five controls) to investigate the -174 G/C polymorphism in blood samples. Asthma, aspirin intolerance and atopy were main exclusion criteria. IL-6 genotyping was performed using the PCR method with forward primer 5'-ATGCCAAGTGCTGAGTCACTA-3' and reverse primer 5'-GGAAAATCCCACATTTGATA-3', amplifying a 226-bp DNA fragment that contained the - 174 position. The amplified fragment can be cleaved by restriction enzyme NlaIII when the -174 position presented the C allele in two fragments of 117 and 109-bp, visualized by electrophoresis, classifying participants in GG, GC and CC. In the nasal polyposis group, 65.62% of the patients had the GG genotype, while in the control group, 41.82% had two G alleles, a statistically significant difference, with an odds ratio of 2.65. The -174 GG genotype was found more frequently in nasal polyposis patients than in controls, when asthma, aspirin intolerance and atopy were excluded.

To analyze the surgical results after Functional Endoscopic Sinus Surgery (FESS) in patients with paranasal sinus fungus ball. Retrospective analysis of the results of FESS performed in 175 patients suffering from paranasal sinus fungus balls. All maxillary (n = 150), sphenoidal (n = 20), and ethmoidal (n = 4) locations have been treated exclusively by FESS to obtain a wide opening of the affected sinuses, allowing a careful extraction of all fungal material without removal of the inflamed mucous membrane. No major complication occurred. Postoperative care was reduced to nasal lavage with topical steroids for 3 to 6 weeks. Only 1 case of local failure have been observed (maxillary sinus, n = 1), and 6 cases of persisting of fungus ball (maxillary sinus, n = 4; frontal sinus, n = 2) with a mean follow-up of 5 years. No medical treatment (antibiotic, antifungal) was required. Surgical treatment of a fungus ball consists in opening the infected sinus cavity at the level of its ostium and removing fungal concretions while sparing the normal mucosa. No antifungal therapy is required. Finally, through this 175 patients study, FESS appears a reliable and safe surgical treatment with a low morbidity.

This study evaluates the most extensive long-term treatment outcome of paranasal sinus mucocoeles with particular emphasis on the efficacy of endonasal micro-endoscopic management. It is a retrospective, consecutive case review of 255 patients with 290 mucocoeles including 125 frontal sinus, 23 frontoethmoid, 41 ethmoid, 72 maxillary sinus and 26 sphenoid mucocoeles. The median follow-up of the patients is 12 years (range 1 - 19 years). Sixtysix percent of the mucocoeles resulted after previous sinus surgery, whereas only 1.5% developed after endonasal micro-endoscopic surgery. The median period until mucocoele appearence was 10.8 years. Two hundred one mucocoeles (69.3%) were managed endonasally micro-endoscopically, 18.6% via the osteoplastic approach, 10% endoscopically in combination with an osteoplastic procedure, and 2% according to Lynch/Howarth. Thereafter, recurrence was found in 4 patients only (2.2%). In relation to the endonasal approach the recurrence rate was 1.6%. None of the patients treated endonasally had any complication. In view of these results this paper verifies endonasal micro-endoscopic surgery as a reliable treatment with favourable long-term outcome for paranasal sinus mucocoele management, but also describes contraindications for an endonasal procedure.

CT-scan was used to examine rhinosinusitis in the developing sinuses; 196 children aged from 3 to 14 years were selected on the base of their chronic rhinorrhea, nasal congestion and cough. The patients were subdivided into six age groups (3-4, 5-6, 7-8, 9-10, 11-12 and 13-14 years). In the youngest age group, the authors noted maxillary involvement in 63%, ethmoidal involvement in 58%, and even sphenoidal sinus involvement in 29% of the children. Involvement decreased gradually with age, with 10% of ethmoidal and 0% of sphenoidal involvement in the 13-14 years age group. Maxillary sinusitis, however, persisted very frequently in the oldest age group (65%). Frontal involvement seems to become significant at the age of 7-8 years (7%) but it never exceeds 15% (11-12 age group). Septal deviations occurred in 16% of the youngest up to 72% in the oldest age group. The prevalence of bullous conchae increased with age too, although less prominently.

To establish population-based trends for sinonasal mucosal melanoma (SNMM) in Sweden. We identified 186 patients from the Swedish National Cancer Registry diagnosed with primary melanomas arising from the nasal cavity, paranasal sinuses, or both, during the period 1960 through 2000. Incidence, gender and age, primary anatomical sites, geographic distribution, treatment and survival were investigated. The age-standardized incidence of SNMM increased significantly during the 41-year-period, with a higher overall incidence for females than males, but with a more rapid increase for males than for females. The incidence increased with age, peaking after the eightieth year in both genders. About 70 % of the cases were clinically amelanotic. The most common primary treatment was surgery. Five-year, disease-specific survival rates were poor for all these patients, but women had a significantly better survival time than men. For both genders the survival rate lengthened during the study period, irrespective of therapeutic strategy. SNMM is a rare disease, but the incidence in Sweden has increased significantly from 1960 through 2000, although not at the same pace as that of cutaneous malignant melanoma. Both the incidence and the survival were significantly higher in females than in males, but the reason for these gender differences is unknown.

Sinonasal malignancies (SNM) are rare and the prognosis is generally poor. Recently, a change in incidence for SNM has been reported. In this study, we investigated population-based trends for SNM in Sweden. We identified 3,221 patients from the Swedish National Cancer Registry diagnosed with primary malignancies arising from the nasal cavity, paranasal sinuses, or both, during the period 1960 through 2010. Incidence, gender and age, anatomical sites and relative survival were investigated. The incidence for SNM decreased except for sinonasal malignant melanoma (SNMM) and adenoid cystic cancer (even though a very small group) during the study period. More than 50 % of the malignancies involved the nasal cavity. The five-year relative survival was highest for adenoid cystic cancer followed by adenocarcinoma. SNMM and undifferentiated carcinoma had the poorest prognosis. We found that the incidence for SNM has decreased during the study period 1960 through 2010, except for SNMM that has increased.

Isolated sphenoid sinus disease (ISSD) is rare. Fungus ball (FB) is the third most common ISSD. We analysed the characteristics of isolated sphenoid FB based on demographic data, presenting symptoms, preoperative computed tomography (CT), magnetic resonance imaging (MRI), and treatment outcomes. From 1999 to 2012, 29 patients were identified with isolated sphenoid FB. Demographic data; clinical characteris- tics; endoscopic, CT, and MRI findings and treatment outcomes were retrospectively analysed. The most common symptom was headaches, which were localized in various regions of the brain. Other symptoms were uncommon. The most common CT findings were sclerosis, calcification, enlarged sinus and total opacification. On T2-weighted MRI images, we most commonly observed signal void. Endoscopic transnasal paraseptal sphenoidotomy was performed in all patients, and for most, this was performed under local anaesthesia. No recurrence was observed in any patient. Isolated sphenoid FB is predominantly observed in older women, and it is characterised by headaches and sclerosis of the sinus wall observed on CT scans. In cases of isolated sphenoid FB, endoscopic transnasal paraseptal sphenoidotomy can be successfully performed under local anaesthesia, which may facilitate rapid recovery and a low morbidity rate.

This review is an excursion into the past to find the prototypes of the various nasal specula around the beginning of our century. The oldest prototype is documented in the ancient Hindu text Sushruta-samhita (6th century BC): a tubular nasal speculum. The bivalved forceps-like nasal speculum was mentioned by Hippocrates and can be followed with and without self-retaining mechanisms to the modifications of Killian and of Cottle. U- or Y-shaped springlike devices to open the nares have been known since the publication of Arnold de Villanova from the 13th century. They were reintroduced in a modification by Thudichum in 1868. Fraenkel's speculum (1872) combines fenestrated blades with a screw-set for self-retaining. Duply (1868) modified the split and funnel-shaped ear speculum of Bonnafont, the branches of which can be varied by a screw. In addition to this description of the prototypes of specula a short development of the facilities to illuminate the inner nose is given starting with the sun light and ending with the glass fiberoptic.

Chronic rhinosinusitis without and with nasal polyps (CRSwNP and CRSsNP), and antrochoanal polyps are different phenotypes with different pathomechanisms. Indoleamine 2,3-dioxygenase (IDO) is an enzyme expressed in many cells involved in the catabolism of the essential amino acid tryptophan to kynurenine. IDO might have a role in allergic airway inflammation. The aim was to evaluate if IDO expression is associated with CRSsNP, CRSwNP, or ACP. One hundred fifty specimens from the nasal cavity and sinus mucosa were immunohistochemically stained with mAb anti-IDO. The expression of epithelial and leukocyte IDO was associated with CRSwNP and ACP. The presence of ASA intolerance, asthma, atopy, smoking and use of medication did not significantly change the results. The different expression of IDO could putatively indicate the differences in the pathomechanisms of CRSsNP, CRSwNP and ACP. Further studies on the role of IDO in upper airways pathologies are required.

In 132 objects of art (mainly paintings and drawings, a few sculptures, and one mosaic) dating from the pre-classical period in ancient Greece to our days, nosebleeding due to different reasons could be detected in museums, churches, galleries and art-books. Children and adults were bleeding from their noses because of mechanical injury, infectious diseases, haemorrhagic diathesis, and drugs. Some artists depicted nosebleeding in a very realistic manner, others represented this symptom in an exaggerated or caricaturistic way. From a total of 132 examples of nosebleeding 53 are presented, including 18 with figures.

There are two approaches for septorhinoplasty, the endonasal approach and the external approach. The external approach is much criticized for the risk of columellar skin flap necrosis and visible scar formation. This series of patients has shown that the risk can be minimized using a mid-columellar broken incision with a meticulous closure technique. The exposure of the surgical anatomy is much better than with the endonasal approach, leading to better insight in nasal deformities and more detailed reconstruction. There seems to be no reasonable objection which can be raised against the columellar incision to reject the open approach.

The European Position Paper on Rhinosinusitis and Nasal Polyps 2012 is the update of similar evidence based position papers published in 2005 and 2007. The document contains chapters on definitions and classification, we now also proposed definitions for difficult to treat rhinosinusitis, control of disease and better definitions for rhinosinusitis in children. More emphasis is placed on the diagnosis and treatment of acute rhinosinusitis. Throughout the document the terms chronic rhinosinusitis without nasal polyps (CRSsNP) and chronic rhinosinusitis with nasal polyps (CRSwNP) are used to further point out differences in pathophysiology and treatment of these two entities. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. Last but not least all available evidence for management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is analyzed and presented and management schemes based on the evidence are proposed. This executive summary for otorhinolaryngologists focuses on the most important changes and issues for otorhinolaryngologists. The full document can be downloaded for free on the website of this journal: http://www.rhinologyjournal.com.

During 4 weeks of the grass pollen season in the south of Sweden 27 patients with seasonal allergic rhinitis were treated topically with a beta-adrenoceptor stimulant, KWD 2131, which in an earlier rhinomanometric study had shown a prophylactic effect at nasal allergen provocations in hay-fever patients. A clinical effect of KWD 2131 could not be documented in this randomized placebo-controlled, double-blind comparative study. The results contribute to conclusions in the clinical implications of rhinomanometric data.

Develop a useful and cost-effective olfactometer for routine clinical use by providing a standardised threshold test for patients with olfactory disorders presenting in the ENT clinic. A prospective study of olfactory thresholds in 48 healthy volunteers on 2 consecutive occasions, undergoing quantitative testing with an olfactometer. Further studies of 10 subjects performing 20 tests and 100 subjects performing a single test were performed. An olfactometer was designed to deliver a semi-automated threshold test for an odour. It contains 8 logarithmic dilutions of an odour along with a control valve operated by software from a laptop computer. Common potential variables for olfactory threshold testing were considered including peak inspiratory flow rate. The odours used were phenethyl alcohol (PEA) and eucalyptol (EUC). Subjects were asked to perform 2 tests within 1 month of each other and the mean threshold score for each was calculated to derive a test-retest score. Consistent olfactory thresholds for PEA were achieved with a mean concentration of 10-4. Test-retest reliability score (r(x)) for the olfactometer was r(x) = 0.78 (95% CI 0.67 to 0.89). The Leicester Olfactometer provides a simple and cost-effective method of reliably assessing olfactory thresholds in the outpatient clinic.

There has been a great expansion in patient-based outcome measures to face the ever-increasing demand to demonstrate surgical efficacy. However, surgeons have not adopted until now any systematic outcome instrument. The 22-item Sino-Nasal Outcome Test (SNOT-22) is a validated sinonasal outcome score in sinonasal and septorhinoplasty surgery but does not measure aesthetic outcome. The aim of this paper is to validate a modification to the Sino-Nasal Outcomes Test-22 (SNOT-22) with a new question regarding the shape of the nose (SNOT-23). We conducted a prospective cohort study on 69 consecutive patients undergoing septorhinoplasty and a control group of healthy volunteers. Reproducibility, responsiveness to treatment, known group differences and validity of the SNOT-23 were analysed. Scores were compared to visual analogue scales, nasal obstruction symptoms evaluation (NOSE) score and nasal inspiratory peak flow. SNOT-23 has good test-retest reliability and is a valid outcome measure for assessing response to surgery especially with regards to shape of the nose and nasal obstruction when compared to other patient reported measures. SNOT-23 is a valid and reliable tool that can be easily used in routine clinical practice to assess the functional and aesthetic outcomes from septorhinoplasty surgery. The SNOT-23 could be adopted as a universal, easy to use tool in rhinology clinics for the assessment of response to septorhinoplasty and sinus surgery.

A prospective study in a healthy French population to evaluate the normal range of PNIF. In total, 234 subjects separated into 2 groups (group 1: patients with VAS >or= 8, n = 151 and group 2: patients with VAS < 8, n = 83) have been prospectively enrolled in this study from September 2003 to April 2004. For all participants, nasal obstruction was evaluated through a VAS and two PNIF measurements. The mean PNIF measurements in group 1 and group 2 were 87.5 L/min and 84.7 L/min, respectively with a significant difference between male and female in both groups (p < 0.0001). The reproducibility in group 1 and group 2 was 5.1 L/min and 4.4 L/min respectively. A slight tendency to a reduction due to the age was observed except for patients over 60. This study confirms that the technique of PNIF measurement is reliable and simple. The normal range of PNIF in a healthy French population has been determined although our results show lower values than previous published reports from other countries. However, it remains an attractive method for the follow-up and survey of patients complaining of nasal obstruction.

Smell tests for clinical use have been developed in different countries, but no single test has gained general acceptance. The objectives of the study were to evaluate the smell outcomes in a Spanish population. A prospective study on healthy volunteers (n = 120) without olfactory disturbances was performed. The volunteers were differentiated by gender, age, and smoking habit groups. We used a new olfactory test, the Barcelona Smell Test 24 (BAST-24) that consists of 24 odours scoring smell detection, identification, and forced choice. Volunteers showed the highest scores on smell detection for both 1st (99%) and 5th cranial nerve (98%) odours. Spontaneous smell identification (54.7% and 59.3%) and forced choice (72.2% and 42.6%) scores were lower than those of smell detection, for both 1st and 5th cranial nerves respectively. On smell identification, volunteers scored higher in the left than in the right nostril. Females had better smell identification for both 1st and 5th cranial nerves (62.8%, 66.7%) than males (50.3%, 58.8%). Non-smokers had higher scores (65%) than smokers (59%) on smell identification for the 5th CN. For smell identification, females, non-smokers, and left nostril had higher scores than males, smokers, and right nostril respectively. BAST-24 is a good and reliable method to test the olfactory function in the clinical practice.

This retrospective analysis reflects the outcome of various techniques used in a series of 41 cases of choanal atresia treated at the Department of Otoloaryngology, Head- and Neck Surgery at the University of Mainz between 1980 and 2006. Thirteen bilateral and 28 unilateral cases are included. After endonasal management in 38 and a transpalatine approach in 3 cases a total of 15 patients needed revision surgery between 1 and 5 times to establish a stable result. Postoperative stenting was used in 23 patients with a failure rate of 35%, whereas only 11% of the 18 patients without stenting had to be revised. None of those 5 cases where Mitomycin C had been applied intraoperatively in combination with postoperative transnasal dilations needed surgical revision. We conclude that the endonasal micro-endoscopic surgical approach is successful if combined with postoperative dilations for up to one year. Stenting should be abandoned as it stimulates granulation formation that frequently leads to restenosis. The intraoperative application of Mitomycin C offers a promising adjunct in achieving a stable

We have investigated a human nasal cell line, RPMI 2650 (ATCC), as an in vitro model to assess the absorption and tolerability of nasally administrated peptides. This cell line was cultured on different filters (i.e. Nunc, Costar, Falcon, Millipore, and Becton) which were uncoated or coated with collagen types I or IV, laminin, fibronectin and extracellular matrix. Cell line morphology, capability of forming a cell layer and phenotype were analyzed by light-, fluorescence- and electron microscopy. The morphological analysis showed that RPMI 2650 cells were forming cell clusters on one group of filters (i.e., Nunc, Costar, Falcon and Becton filters coated with collagen types I or IV, laminin and extracellular matrix). On the second group of filters (i.e., Becton and Millipore filters, coated with fibronectin) the cells had the tendency to spread in a cell layer. In both groups of filters, the cells never showed cell polarization, nor microvilli and tight junctions. Phenotyping of this cell line was performed by indirect immunofluorescence using monoclonal antibodies against human cytokeratins 10, 17 and 18 (markers of epithelial cells), desmin (markers of mesothelial cells) and vimentin (marker of mesothelial cells). Vimentin was strongly expressed, cytokeratins 10, 17 and 18 were weakly expressed, and desmin was not expressed. The human nasal cell line RPMI 2650 was not able to form a tight cell layer under these cell culture conditions. The limits of this cell line as an in vitro nasal model for drug absorption is discussed.

When comparing the outcome of different treatment modes for acute maxillary sinusitis, the roentgenological examination can be recommended for the objective evaluation as a complement to the clinical examination. Using the occipito-mental projection and an additional occipito-mental side view, the diagnosis can be established in a cheap and simple way, and the treatment effect can be followed during the course of treatment in the form of radiological sinus changes. The treatment outcome of 27 different treatment modes in 1320 cases of acute maxillary sinusitis (2039 maxillary sinuses) was compared. There was little difference between the treatment groups as to therapeutic effect, whether using antral drainage alone, antibiotics alone or the combination of both. Factors other than treatment outcome must be important for the consideration of treatment choice, e.g. pharmacokinetics, administration, dosage, treatment cost, number and type of side effects, etc.

Between 1966 and 1987 we have treated 34 angiofibromas. The patients were between 9 to 28 years of age (average 16.5 years). The tumour extension was determined formerly by tomography and angiography, but these two methods have been replaced by angioscanning, which give the best results. Nineteen patients were classified stage I, fourteen stage II and one stage III. The surgical approach was transmaxillary in most cases. After tumour resection, two local recurrences were seen and a second operation was necessary to achieve a definitive cure in these patients.

The health related quality of life (QOL) of patients with allergic rhinitis and/or conjunctivitis (ARc) as measured by the SF-36 questionnaire, has been shown to be impaired in a similar way to that of asthmatic patients in France and several other countries. We used the SF-36 questionnaire (Thai version) to evaluate the QOL of Thai ARc patients compared to healthy subjects. The SF-36 questionnaire (Thai version) consists of 36 items covering 8 dimensions and one health transition report question. Higher scores indicated better QOL. The internal consistency reliability of the questionnaire was analysed using Cronbach's alpha-coefficient. A total of 705 healthy persons and 900 ARc patients were included in this study. The mean difference of the scores between healthy and ARc groups in each dimension showed higher scores in the healthy group. This difference was statistically significant (p < 0.05 and p < 0.001) for all dimensions, except for the Social Functioning dimension. The internal reliability of the SF-36 questionnaire was confirmed by Cronbach's alpha-coefficient which was above 0.7 for seven of the dimensions; the exception was the Social Functioning dimension. Men were shown to have higher scores than women in several dimensions. In conclusion, this study has confirmed that the SF-36 questionnaire is sensitive enough to discriminate ARc patients from healthy persons with high reliability. QOL of ARc patients was significantly more impaired than healthy persons and hypertensive patients in several dimensions. These findings were similar to reports from other countries using the same instruments. Therefore the SF-36 questionnaire (Thai version) can be a useful tool in evaluating the impact of ARc on a patient's QOL and the improvement in QOL after therapeutic intervention in Thai patients.

The diagnosis of cerebrospinal fluid (CSF) rhinorrhoea should be established beyond reasonable doubt before surgical intervention is embarked upon. It is important not to miss the diagnosis in view of the real potential complication of meningitis if it is left untreated. We describe a management algorithm which centers around the selective use of nasal endoscopy, immunofixation of beta2 transferrin, high resolution coronal CT scans, and fluorescein lumbar puncture. This management strategy is illustrated with 36 cases. We have developed a minimally invasive endoscopic technique to repair CSF leaks, and in 30 patients we had a success rate of 93% after one procedure.

The aim of this study was to evaluate symmetry of the lip and nose in patients with CUCLP after primary cheiloseptoplasty (Afroze technique), in comparison to non-cleft controls. In this prospective study, forty-four patients with operated non-syndromic CUCLP were included. The control group consisted of 44 volunteers without cleft defects of approximately the same age and sex. Primary septoplasty was performed in conjunction with the cleft lip (CL) repair using the Afroze incision. 3D facial images were acquired using 3D stereophotogrammetry. After a 3D cephalometric analysis of the lip and nose was performed in both groups, linear and volumetric data were acquired. Lip and nose symmetry were calculated and compared using Student`s t-tests as well as the Chi square test. For all measurements, the control group was up to 36% closer to perfect symmetry compared to the CUCLP group after primary surgery. This difference was statistically significant. After primary cheiloseptoplasty according to the Afroze technique in patients with CUCLP, asymmetry in the nose and lip area still exists as compared to non-cleft controls. Although non-cleft individuals also show some degree of asymmetry, the results of this study stress the difficulty in obtaining near normal symmetrical relations.