[Exercise rhinomanometric test in the diagnosis of vasomotor rhinopathy]

The Authors examined 55 patients divided into two groups, one of 30 vasomotor rhinopatic patients and the other of 25 normal subjects. The aim of the study was to set up an objective diagnostic rhinomanometer test through observation and evaluation of reaction brought about by physical exertion following an exertion test of 5 minutes which employed a computerized climb simulator. Nasal resistance was measure before and immediately after exertion and then at intervals of 10, 20 and 50 minutes. Our data reveal a noteworthy decrease in nasal resistance brought about by the sympathetic nervous system in normal and rhinopathic subjects. Return to pre-exertion values, however occurred difference in the two groups: in the control group nasal resistance returned to pre-exertion values slowly, while in the rhinopathic group, it decreased rapidly and a rebound effect was observed. In vasomotor rhinopathy the orthosympathetic system is overcome by the para sympathetic system with regard to nasal vascularization control and, therefore, in rhinopatic patients exertion stimulates efficacions activation of the orthosympathetic system a phenomenon which does not occur in healthy subject. On the basis of our results an intensive stimulus such as physical exertion seems to have a different effect on the two groups suggesting that the vessels of nasal mucosa do not always respond in the same way, and that in vasomotor patients there is an alternate reactivity of neural control of nasal mucosa. The rhinomanometric exercise test seems to be useful in revealing this phenomenon and to be diagnostically reliable. The method is easily reproducible, non-invasive and can be usefully applied in clinical practice associated with the normal rhinomanometric challenge test.

Endoscopic sinus surgery

Endoscopic nasal surgery has become the single major advance in the specialty of otolaryngology since the introduction of the operating microscope and middle ear surgery. The value of improved assessment of nasal and sinus pathology using the endoscope diagnostically cannot be overstated. Once pathology is better evaluated, therapy will at least be more appropriate. It is now possible to carry out such nasal surgery as polypectomy, antrostomy and turbinoplasty more accurately and more safely, as well as provide better postoperative care. The use of the endoscope has afforded a useful sub-cranial route for the repair of at least small cerebrospinal fluid leaks, while it is likely that such procedures as dacrocystorhinostomy will eventually be mostly performed using the nasal endoscope. Some orbital decompressions will also be suitable for medial orbitotomy via the endoscope. Additionally, assessment of the extent of extrusion of orbital contents after blow-out injury has been invaluable, as is evaluation of the posterior wall of the frontal sinus after frontal bone trauma. Functional endoscopic sinus surgery (FESS) has an undoubted place in the surgery of frontoethmoidal mucocoeles. While few oncologists would be sanguine about its use in the surgery of nasal tumors, it is still of great value in evaluation and biopsy. Although FESS confined to the osteomeatal complex in the presence of early sinus disease is almost certainly an advance, what is still not proven, is the place of endoscopic sphenoethmoidectomy in the treatment of chronic rhinosinusitis.

Role of skull base surgery for local control of sarcoma of the nasal cavity and paranasal sinuses

Sarcomas of the nose and paranasal sinuses are rare neoplasms and comprise less than 1% of the malignancies arising in the sinonasal tract. From 1977 to 1989, we had the opportunity to treat 15 patients presenting with these tumors at The Eye & Ear Institute of the University of Pittsburgh. The clinical charts of these patients were reviewed retrospectively for demographic data, characteristics of disease, treatment considerations and clinical outcome. Data were also analyzed with special attention to the role of skull base surgery for the local control of tumors. Seven patients underwent cranial base surgery as part of their original therapy. Two of these patients are alive with no evidence of disease, one patient died of other causes, and four are dead of disease. Two patients died with local disease. Although not statistically significant due to the small number of patients, these data suggest that cranial base surgery can improve the local control of sarcomas of the sinonasal tract that approach or invade the skull base.

Sarcomas of the nasal cavity and paranasal sinuses

Sarcomas of the nose and paranasal sinuses are rare malignancies. Key issues remain unresolved in the management of these tumors, particularly with regard to the role of radiotherapy. To help clarify these issues, 48 consecutive cases of nasal and paranasal sinus sarcomas treated at the University of California, Los Angeles, between 1958 and 1988 were retrospectively reviewed. Six of 16 patients managed initially with surgery alone were cured. All had negative surgical margins and 5 of the 6 had low-grade tumors. Of 5 patients with high-grade lesions treated with surgery only, 1 was rendered free of disease. Twelve patients with positive surgical margins were treated with adjuvant radiotherapy; 5 were cured with this approach. Grade and surgical margin status were found to be significantly related to outcome for sinonasal sarcoma. There were 14 patients with rhabdomyosarcoma; 3 were cured with modern combined-modality therapy. Patients with positive surgical margins should be treated with adjuvant radiotherapy. Surgical therapy is effective for low-grade lesions that are completely excised.

[Amelanotic mucous melanoma of the nasal cavity. Report of a case]

We report a case of mucosal melanoma of the nasal cavity, of amelanotic nature, in a fifty five years old white man. Clinical course started with nasal obstruction and bloodstained rhinorrhea. We want to emphasize the extreme uncommonness of this type of tumor, its bad prognosis, and its difficult diagnosis. The treatment offers long term remission to a limited number of patients. For all these reasons, we have carried out a literature search on this topic and this paper shows the results.

Removal of nasal foreign bodies with a Fogarty biliary balloon catheter

Twenty-five children with a range of nasal foreign bodies, which were not easily amenable to anterior instrumental extraction, were considered for this study. These foreign bodies were removed by the use of a Fogarty biliary balloon catheter (Intimax) successfully in 23 children. In two children no foreign body was found. None of the children had any complications. This is a safe procedure which can be performed as an out-patient. Whilst the cost of the catheter may appear expensive, in comparison to the cost of admission for removal of similarly sited foreign bodies under general anaesthesia, the catheter fares favourably.

Changes in cell proliferation in the developing olfactory epithelium following neonatal unilateral naris occlusion

Surgical closure of an external naris reduces airflow through one side of the nasal cavity. Previous studies using [3H]thymidine autoradiography have demonstrated that rats subjected to the procedure on Postnatal Day 1 (P1) exhibit reduced cellular proliferation in the olfactory mucosa by P30. We investigated cell production at earlier ages to determine (a) when the effect first emerges, and (b) whether septal, dorsal, and lateral regions of the nasal cavity responded similarly. Both short (2-h) and long (30-day) survival groups were tested. Results from the first group indicate that changes in proliferation emerge between P10 and P20, and that the septum is more affected than other regions of the nasal cavity. No differences were observed in the long survival groups, perhaps due to changes in patterns of cell production or death.

Occult follicular carcinoma metastasizing to the sinonasal tract

We report a 34-year-old woman with a clinically occult primary carcinoma of the thyroid metastasizing to the sinonasal tract. The metastasis showed intensive vascularization and involved the nose, the maxillary, ethmoid and sphenoid sinuses, extending to the intracranial cavity. After embolization, the lesion was removed and histopathologically diagnosed as follicular carcinoma of the thyroid. A subsequent total thyroidectomy revealed an 8-mm primary lesion within the left lobe. Thyroid metastases, although rare, need to be considered in the differential diagnosis of hypervascular tumors in the sinonasal tract.

Epstein-Barr virus in nasal T-cell lymphomas (polymorphic reticulosis/midline malignant reticulosis) in western China

Polymorphic reticulosis (PR) or midline malignant reticulosis (MMR) is considered to be malignant, or at least pre-malignant T-cell proliferations of the nose or midline area. Recent reports of small series of nasal T-cell lymphomas have shown a strong association with Epstein-Barr virus (EBV). Furthermore, a peculiar phenotype is described, with expression of CD56 and not of CD3, suggesting a possible origin from natural killer (NK) cells. We have analysed a series of 38 cases of PR/MMR for the presence of EBV by in situ hybridization (ISH) of the EBV-encoded RNAs 1 and 2 (EBER). Twenty cases were tested for expression of EBV-encoded latent membrane protein 1 (LMP-1). Special attention was also paid to the expression of CD3 and the NK cell-related marker CD56. Thirty-two cases (84 per cent) showed positive EBER ISH. In 5 of 20 cases, LMP-1 expression was detected. In three cases, a few scattered cells were positive, and in two cases, LMP-1 was detected in clusters of atypical cells. Most of the neoplasms showed expression of CD3 (89 per cent) and in 27 cases (71 per cent), CD56 was detected. These results are consistent with an aetiopathogenetic role for EBV in most, but not all, cases of PR/MMR. Our findings are less supportive of a major role for LMP-1 in tumour genesis. CD3 expression in most of the cases of PR/MMR underlines the T-cell origin of these neoplasms, often with aberrant expression of CD56.

[Radiotherapy results in the treatment of malignant tumors of the nasal fossa and vestibule]

The authors report their personal experience in the treatment of malignant tumors of the nasal cavity and vestibule with irradiation alone or combined with surgery. From January 1976 to December 1989 we treated 40 patients with 22 squamous cell carcinomas, 12 adenocarcinomas or other glandular types, and 6 other histologic types of lesions: 23 patients received irradiation alone and 17 patients were treated with surgery and postoperative irradiation. The protocol included surgery as the treatment of choice: irradiation alone was administered to inoperable tumors or to the patients refusing surgery; postoperative irradiation was given when macroscopic or microscopic residual disease was observed after surgery or to particular histologic types. In the whole series of patients, 3- and 5-year local control rates were 70% and 50%, respectively; better results were obtained in the patients receiving the combined treatment (64% at 5 years) than in the patients receiving irradiation alone (43% at 5 years). Disease stages (I and II versus III and IV) were the only statistically significant prognostic factor; worse results in irradiated patients might be due to the higher rate of advanced lesions in this group. Salvage therapy (irradiation in 8 cases, surgery in 2 and chemotherapy in 1) was successfully performed in 5 of 11 treated patients. The 3- and 5-year overall survival rates were 88% and 70%, respectively. Severe complication rate was lower than 10% (3 cases only).

Button battery as a foreign body in the nasal cavities. Special aspects

Alkaline batteries as foreign bodies in the nasal cavities are dangerous because they can cause liquefaction necrosis with subsequent severe local tissue destruction. Batteries found in the nasal cavities should be removed immediately to prevent sequelae such as septal perforations or nasal meatus stenosis. Due to the common use of these batteries (e.g. watches, electronic toys and games, calculators) physicians and the general public should be more aware of this type of foreign body and the peculiarities in their management. We present five cases of button battery foreign bodies in the nasal cavities and review 12 cases described in the literature and discuss the special aspects of these foreign bodies.

Olfactory neuroblastoma: results of combined therapy

Olfactory neuroblastomas are seldom encountered in otolaryngologic practice. Eleven such patients were treated by combined therapy over a nine year period. Two cases who initially underwent surgery only required salvage for a local recurrence by a combined modality. Nine patients were disease-free at the end of two years, with four of them being so for five years. Adjuvant chemotherapy was used in four cases, one of whom developed distant cutaneous metastasis after two years. Craniofacial resection was performed on three patients. A combined therapy is recommended for all stages of olfactory neuroblastoma.

MR of esthesioneuroblastoma (olfactory neuroblastoma) and appearance after craniofacial resection

PURPOSE

To analyze the MR characteristics of a series of patients with esthesioneuroblastoma and discuss the typical surgery and its postoperative MR appearance.

METHODS

The MR studies of 15 patients with the pathologic diagnosis of esthesioneuroblastoma (also known as olfactory neuroblastoma) were retrospectively reviewed and correlated with CT and surgical findings. The postoperative MR studies of 10 patients who underwent craniofacial resection were also reviewed.

RESULTS

In all cases the tumors arose in the superior nasal cavity and extended into the ethmoid cells. In some instances the tumors extended into the other paranasal sinuses, orbits, anterior cranial fossa, and cavernous sinus. The tumors were typically expansile and destructive in their growth patterns. Compared with brain gray matter, the tumors were hypointense on T1-weighted images and isointense to hyperintense on T2-weighted images. Nine tumors were heterogeneous and 6 were homogeneous. Contrast enhancement ranged from mild to marked. MR was useful for characterizing the various tissues and distinguishing fluid in the postoperative nasal cavity.

CONCLUSIONS

Esthesioneuroblastoma, although an uncommon tumor, may be suspected in lesions of the superior nasal cavity demonstrating both expansile and destructive growth properties. The MR findings are otherwise nonspecific. MR is the imaging modality of choice for depicting local tumor extension and evaluating for recurrence after craniofacial resection.

Increased nasal breathing decreases snoring and improves oxygen saturation during sleep apnoea

For many years ENT-specialists have performed surgery to create a good air passage in patients with different kinds of nasal deformities. When having a blocked nose one realizes the importance of being able to breathe through the nose. By moving the nasal wings aside with the fingers, or the medical device Nozovent, most people experience that it is easier to breathe through the nose than ever before, which can also be shown with rhinomanometry. When it is easier to inhale there is less energy in the air passing the palate which means less risk for vibrations creating snoring sounds. In different studies it has been possible to show that snoring can be decreased or prevented when the nasal dilator Nozovent is used. It has also been shown to result in a decrease of the sleep apnoea index and improvement of arterial oxygen saturation during sleep apnoea.

A subjective evaluation of a nasal dilator on sleep & snoring

A noninvasive external nasal dilator device was used by 20 subjects with a history of mild snoring in a 2 week open label study. The baseline assessments were obtained during the first week. Treatment effects were evaluated during the second week. Subjects were evaluated using: pre- and post-sleep questionnaires; Stanford Sleepiness Scales completed at breakfast, lunch and dinner; and post-sleep bed partner questionnaires. All twenty subjects completed the study. A significant number of subjects' scores improved for sleepiness. Mean scores for the subjective assessment for ease of breathing during sleep improved compared to baseline by 25.6%, snoring loudness improved by 34%, sleep quality improved by 21.8%, and the Stanford Sleepiness Scale revealed a 26% reduction in daytime sleepiness.

Esthesioneuroblastoma. Long-term outcome and patterns of failure--the University of Virginia experience

BACKGROUND

Esthesioneuroblastoma is a rare tumor arising from olfactory epithelium. This retrospective review analyzed the patterns of failure and long term outcome of patients with esthesioneuroblastoma evaluated at a single institution.

METHODS

Forty patients with esthesioneuroblastoma were evaluated at the University of Virginia, with a median follow-up of 130 months. In most cases, treatment consisted of combined-modality therapy, including radiotherapy and surgery for Stages A and B disease and the addition of chemotherapy for Stage C disease. Fifteen patients received chemotherapy that included cyclophosphamide plus vincristine. Thirty-eight patients received radiotherapy, with a median dose of 50 Gy. Initial surgery for 23 patients included craniofacial resection, whereas the remainder had less extensive surgery (3 had no initial surgery). Five patients were salvaged with high dose chemotherapy and autologous bone marrow transplantation (CTX/BMT).

RESULTS

Actuarial survivals at 5, 10, and 15 years are 78%, 71%, and 65% respectively. Fifty-five percent of patients failed therapy, and 68% of the failures were locoregional. Thirty-nine percent of recurrences occurred later than 5 years from diagnosis. Three of the five patients were successfully salvaged with CTX/BMT compared with four of seventeen patients who underwent conventional salvage therapy.

CONCLUSIONS

Esthesioneuroblastoma is associated with long term survival and late recurrences. Multimodality therapy should be used initially. Durable remissions of failures can be achieved with CTX/BMT:

[Four cases of olfactory neuroblastoma treated with craniofacial surgery]

We report 4 cases of olfactory neuroblastoma with anterior cranial fossa extension treated by craniofacial surgery. Three patients have been alive and well for 4 years, 1 year and 11 months after the initial treatment without major surgical complications but one patient died of local recurrence 11 months after treatment. Multidisciplinary surgery for olfactory neuroblastoma with intracranial extension permits radical tumor excision and reconstruction of the anterior skull base. This one-stage procedure combining neurosurgery and plastic surgery with pre or post-operative radiotherapy is considered to be essential for eradicating this tumor.

Angiomyolipoma of the nasal cavity: case report and review of the literature

An unusual localization of intranasal angiomyolipoma is described in an adult male patient with no signs of tuberous sclerosis. The lesion was composed of mature fat cells, vascular spaces with lack of elastic tissue, and presence of bundles of mature smooth muscle cells. Antibodies to intermediate filaments revealed presence of vimentin and absence of desmin in both smooth muscle bundles and in vessel walls. A review of the literature has shown that this is only the third reported case of the angiomyolipoma of the nasal cavity, and some important differences between this entity and renal angiomyolipoma are described.

Detection of Epstein-Barr viral RNA in sinonasal undifferentiated carcinoma from Western and Asian patients

Undifferentiated carcinoma of the nasopharynx has a well-known association with Epstein-Barr virus (EBV), but only an inconsistent relationship has been identified in undifferentiated carcinomas occurring at other sites. We investigated 22 formalin-fixed, paraffin-embedded cases of sinonasal undifferentiated carcinomas (SNUCs) occurring in Western and Asian patients. A highly sensitive in situ hybridization method was performed using an antisense oligonucleotide probe to the EBER1 gene of EBV. We identified EBV RNA in seven of 11 SNUCs from Asian patients, but in none of the Western SNUC patients (0/11). The EBER1 signal was present in all or virtually all of the tumor cell nuclei in the seven EBV-RNA-positive Asian SNUCs. The latent membrane protein-1 (LMP1) of EBV was not identified in any of the five positive cases tested. Our results suggest that genetic predisposition or environmental/geographical cofactors play an important role in determining the strength of the association of SNUC with EBV.

A nose stud retainer clip lost within the nasal cavity discovered on dental radiographs

It is fairly common for a dental surgeon to come across patients with foreign bodies in the nasal cavity. In this paper we report an unusual case of a nose stud retainer clip being displaced into the nasal cavity by trauma, and its discovery on radiographs taken to assess dental injuries. We also present a review of the literature since 1982, and assess the possible sequelae to nasal foreign bodies.

Maximizing the stability of oxygen delivered via nasal cannula

BACKGROUND

The effective fractional inspired oxygen concentration (FiO2) of supplemental oxygen provided to infants via nasal cannula may be adjusted by changing cannula flow rate or oxygen concentration, factors within our control. However, FiO2 also varies with changes in the patient's breathing, factors beyond our control. While a stable oxygen delivery is desirable, combinations of flow and concentration that maximize stability over time need to be studied.

OBJECTIVE

To assess the impact of different weaning strategies on the stability of inspired oxygen concentrations delivered to infants via nasal cannulas and to identify optimum strategies maximizing that stability.

DESIGN

Theoretical analysis and comparison with previously published measurements.

METHODS

We derived equations predicting the FiO2 delivered to infants via nasal cannula, incorporating traditional adjustments of cannula flow rate and oxygen concentration, as well as considering the impact of the infant's inspiratory time, tidal volume, and fraction of nasal breathing. We compared predicted results with previously published measures and evaluated strategies to maximize oxygen delivery stability over time.

RESULTS

Predicted values correlated well with published hypopharyngeal measurements (r = .97) and were unbiased, accurate predictors of FiO2. Effective FiO2 was least likely to be affected by changes in patient-controlled controlled factors when the nasal cannula flow rate was as low as possible.

CONCLUSIONS

To minimize variability in oxygen delivery via nasal cannula to infants, cannula flow should be reduced to the lowest possible flow by using undiluted (100%) oxygen. Supplemental oxygen may then be weaned by making small reductions in cannula flow. Cannula oxygen concentration should be reduced below 100% only after the minimum calibrated flow rate is reached. Such a strategy may maximize the stability of delivered oxygen over time as well as minimize the size of changes in delivered oxygen at each step of the weaning process.