Benralizumab in severe eosinophilic asthma in real life: confirmed effectiveness and contrasted effect on sputum eosinophilia versus exhaled nitric oxide fraction - PROMISE

Background

Randomised controlled trials have shown that benralizumab, an anti-interleukin-5 receptor monoclonal antibody, reduces exacerbations and oral corticosteroid dose and improves asthma control and lung function in severe eosinophilic asthma. The aim of this study was to confirm results of randomised controlled trials in real life in a population of 73 patients with severe eosinophilic asthma treated with benralizumab for at least 12 months.

Methods

Patients underwent careful monitoring of asthma exacerbations, exhaled nitric oxide fraction, lung function, asthma control and quality of life questionnaire responses and sputum induction, and gave a blood sample at baseline, after 6 months and then every year.

Results

We found significant reductions in exacerbations (by 92%, p<0.0001) and oral corticosteroid dose (by 83%, p<0.001) after 6 months that were maintained over time, with 78% of patients able to stop oral corticosteroid therapy. Patients improved their Asthma Control Test (ACT) score (from 11.7±5.1 to 16.9±5.35, p<0.0001), Asthma Control Questionnaire (ACQ) score (from 2.88±1.26 to 1.77±1.32, p<0.0001) and Asthma Quality of Life Questionnaire score (+1.04, p<0.0001) at 6 months and this was maintained during follow-up. Only 35% and 43% of patients reached asthma control according to an ACT score ≥20 and ACQ score <1.5, respectively. We observed stable post-bronchodilation lung function over time and a significant reduction in sputum eosinophil count, with 85% of patients exhibiting sputum eosinophil counts <3% after 6 months (p<0.01) with no effect on exhaled nitric oxide fraction.

Conclusion

In our real-life study, we confirm the results published in randomised controlled trials showing a sharp reduction in exacerbations and oral corticosteroid therapy, an improvement in asthma control and quality of life, and a dramatic reduction in sputum eosinophil count.

Temporal Stability of Ciliary Beating Post Nasal Brushing, Modulated by Storage Temperature

Primary ciliary dyskinesia is a heterogeneous, inherited motile ciliopathy in which respiratory cilia beat abnormally, and some ultrastructural ciliary defects and specific genetic mutations have been associated with particular ciliary beating alterations. Ciliary beating can be evaluated using digital high-speed videomicroscopy (DHSV). However, normal reference values, essential to assess ciliary beating in patients referred for a PCD diagnostic, vary between centres, as minor variations in protocols might influence ciliary beating. Consequently, establishment of normal values is essential for each PCD diagnostic centre. We aimed to evaluate whether delay after sampling, and temperature for conservation of respiratory ciliated samples, might modify assessments of ciliary beating. In total, 37 healthy nasal brushing samples of respiratory ciliated epithelia were collected. Video sequences were recorded at 37 °C immediately using DHSV. Then, the samples were divided and conserved at 4 °C or at room temperature (RT). Ciliated beating edges were then recorded at 37 °C, at 3 h and at 9 h post sampling. In six samples, recordings were continued up to 72 h after sampling. Ciliary beating was assessed manually by ciliary beat frequency (CBFM) and ciliary beat pattern (CBP). A semi-automatic software was used for quantitative analysis. Both CBF and CBP evaluated manually and by a semi-automated method were stable 9 h after sampling. CBFM was higher when evaluated using samples stored at RT than at 4 °C. CBP and the semi-automated evaluation of ciliary beating were not affected by storage temperature. When establishing normal references values, ciliary beating can be evaluated at 37 °C up to 9 h after nasal brushing, but the storage temperature modifies ciliary beating and needs to be controlled.

From nose to brain: The effect of lemon inhalation observed by whole brain voxel to voxel functional connectivity

Lemon fragrance is known for its stimulating properties, but its mechanisms of action are not well known yet. This study aimed to examine the effect of lemon essential oil inhalation on healthy participants' alertness level and their neural correlates using magnetic resonance imaging (MRI). Twenty-one healthy men underwent functional MRI scans in different conditions: a resting state condition, a condition where they were exposed to passive lemon smelling (alternating exposure to lemon and breathing fresh air), and a control condition without lemon fragrance diffusion -the order of the last two conditions being randomized. Alertness levels were assessed immediately after each condition using the Karolinska Sleepiness Scale. Voxel-wise whole-brain global functional connectivity and graph theory analyses were computed to investigate brain functional connectivity and network topology alterations. After lemon fragrance inhalation, we observed a higher level of alertness as compared to resting state -but not compared to control condition. During lemon fragrance inhalation, we found increased global functional connectivity in the thalamus, paralleled by decreased global connectivity in several cortical regions such as precuneus, postcentral and precentral gyrus, lateral occipital cortex and paracingulate gyrus. Graph theory analysis revealed increased network integration in cortical regions typically involved in olfaction and emotion processing such as olfactory bulb, hypothalamus and thalamus, while decreased network segregation in several regions of the posterior part of the brain during olfaction as compared to resting state. The present findings suggest that lemon essential oil inhalation could increase the level of alertness.

Validation of mandibular movements’ analysis to measure sleep in adults with sleep complaints by comparison with actigraphy and polysomnography

Objective

In adults with sleep complaints, we assessed the software of automatic analysis of mandibular movements to identify sleep and wake states by confrontation with the polysomnography (PSG) and the actigraphy (ACTG).

Material and Methods

Simultaneous and synchronized in-lab PSG, ACTG, and JAWAC were carried out in 100 patients with a sleep complaint. Epoch by epoch analysis was realized to assess the ability to sleep-wake distinction. Sleep parameters as measured by the three devices were compared. These included three regularly reported parameters: total sleep time (TST), sleep onset latency (SOL), and wake after sleep onset (WASO). Also, two supplementary parameters, wake during sleep period (WDSP) and latency to arising (LTA) were added to measure separately the quiet wakefulness states.

Results

The epoch by epoch analysis showed that the JAWAC, as compared to ACTG, classified sleep and wake states with greater specificity, while the overall accuracy and sensitivity of the two devices were comparable. The sleep parameters analysis showed that for the JAWAC estimates, the differences in TST, SOL, and LTA values were not statistically significant. However, WDSP and subsequently WASO were slightly underestimated. In contrast, the dissimilarities between ACTG estimates and PSG measurements of all the above sleep parameters were statistically significant; TST was overestimated whilst SOL, LTA, WDSP, and WASO were underestimated.

Conclusion

This study indicated that, besides its ability to reliably estimate TST, the JAWAC based on mandibular movements’ analysis was able, in adults with sleep complaints, to overcome the important problem of the recognition of the state of quiet wakefulness.

Use of Vandenberg and Kuse Mental Rotation Test to Predict Practical Performance of Sinus Endoscopy

OBJECTIVES

The aim of this study was to assess the predictive value of the Vandenberg and Kuse Mental Rotation Test (MRT) on performance of novice medical students for manipulation of a nasal endoscope on a cadaveric model.

MATERIAL AND METHOD

We randomly selected 39 medical students who had never handled a nasal endoscope and subjected them to the MRT. General information including experience in manual, technical, or surgical activities and testing of anatomical knowledge were collected to exclude possible confounding factors. They were then asked to perform series of cadaveric model exercises using a nasal endoscope. Their cadaver performance was evaluated by 2 blinded observers, using a standardized scale.

RESULTS

We found that medical students with higher mental rotation skills had significantly increased endoscopic sinus performance (P = .0002 using multivariate regression adjusted for specialty choice, previous surgical exposure, and anatomy knowledge). Higher anatomy knowledge was also associated with better endoscopic sinus performance (P = .0141). Other parameters had no impact on endoscopic sinus performance measured by the endoscopic scale (P > .05).

CONCLUSION

The score obtained on the MRT was correlated with the practical performance of manipulating the nasal endoscope in cadaver. It could therefore be a useful spatial ability tool for directing targeted training in rhinology.

Nasal Brushing Sampling and Processing using Digital High Speed Ciliary Videomicroscopy - Adaptation for the COVID-19 Pandemic

Primary Ciliary Dyskinesia (PCD) is a genetic motile ciliopathy, leading to significant otosinopulmonary disease. PCD diagnosis is often missed or delayed due to challenges with different diagnostic modalities. Ciliary videomicroscopy, using Digital High-Speed Videomicroscopy (DHSV), one of the diagnostic tools for PCD, is considered the optimal method to perform ciliary functional analysis (CFA), comprising of ciliary beat frequency (CBF) and beat pattern (CBP) analysis. However, DHSV lacks standardized, published operating procedure for processing and analyzing samples. It also uses living respiratory epithelium, a significant infection control issue during the COVID-19 pandemic. To continue providing a diagnostic service during this health crisis, the ciliary videomicroscopy protocol has been adapted to include adequate infection control measures. Here, we describe a revised protocol for sampling and laboratory processing of ciliated respiratory samples, highlighting adaptations made to comply with COVID-19 infection control measures. Representative results of CFA from nasal brushing samples obtained from 16 healthy subjects, processed and analyzed according to this protocol, are described. We also illustrate the importance of obtaining and processing optimal quality epithelial ciliated strips, as samples not meeting quality selection criteria do now allow for CFA, potentially decreasing the diagnostic reliability and the efficiency of this technique.

Responsiveness of acoustic rhinometry to septorhinoplasty by comparison with rhinomanometry and subjective instruments

OBJECTIVES

Nose patency measures and instruments assessing subjective health are increasingly being used in rhinology. However, there is very little evidence of comparing existing methods' responsiveness to change. We evaluated the responsiveness of acoustic rhinometry to nasal valve surgery by comparison with rhinomanometry and patient-reported outcome instruments.

DESIGN

Prospective case-control study.

SETTING

Tertiary referral University Hospital.

PARTICIPANTS

Sixty consecutive patients with internal nasal valve dysfunction and 20 healthy volunteers as control group were enrolled. Prospectively collected data included acoustic rhinometry, rhinomanometry, NOSE scale, SNOT-23 questionnaire, visual analogue scale and demographics.

MAIN OUTCOME MEASURES

Primary endpoint was the responsiveness of acoustic rhinometry to functional septorhinoplasty surgery at 3 months. Secondary endpoints were ability of acoustic rhinometry to reflect "known group" differences and correlation to subjective symptoms.

RESULTS

Acoustic rhinometry was highly responsive to septorhinoplasty (P < 0.0001) while anterior rhinomanometry was not (P = 0.08). Based on the quartiles of the postoperative change in NOSE score, patients were classified as, respectively, non-responders, mild, moderate and good responders to surgery. Logistic regression model showed that acoustic rhinometry was able to discriminate non-responders to responders to surgery (P = 0.019), while anterior rhinomanometry failed (P = 0.611). Sensitivity and specificity of acoustic rhinometry were significantly higher (ROC area = 0.76) than rhinomanometry (ROC area = 0.48). Acoustic rhinometry was also superior than rhinomanometry to discriminate patients from control subjects and agreed better with patients-based subjective questionnaires.

CONCLUSIONS

Our study confirms and quantifies the responsiveness of acoustic rhinometry to nasal valve surgery, with a higher sensitivity and specificity than rhinomanometry.

Validation of the sino-nasal outcome test-23 in septorhinoplasty surgery

BACKGROUND

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).

METHODOLOGY

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.

RESULTS

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.

CONCLUSION

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.

Validation of midsagittal jaw movements to measure sleep in healthy adults by comparison with actigraphy and polysomnography

OBJECTIVE

In a device based on midsagittal jaw movements analysis, we assessed a sleep-wake automatic detector as an objective method to measure sleep in healthy adults by comparison with wrist actigraphy against polysomnography (PSG).

METHODS

Simultaneous and synchronized in-lab PSG, wrist actigraphy and jaw movements were carried out in 38 healthy participants. Epoch by epoch analysis was realized to assess the ability to sleep-wake distinction. Sleep parameters as measured by the three devices were compared. This included three regularly reported parameters: total sleep time, sleep onset latency, and wake after sleep onset. Also, two supplementary parameters, wake during sleep period and latency time, were added to measure quiet wakefulness state.

RESULTS

The jaw movements showed sensitivity level equal to actigraphy 96% and higher specificity level (64% and 48% respectively). The level of agreement between the two devices was high (87%). The analysis of their disagreement by discrepant resolution analysis used PSG as resolver revealed that jaw movements was right (58.9%) more often than actigraphy (41%). In sleep parameters comparison, the coefficient correlation of jaw movements was higher than actigraphy in all parameters. Moreover, its ability to distinct sleep-wake state allowed for a more effective estimation of the parameters that measured the quiet wakefulness state.

CONCLUSIONS

Midsagittal jaw movements analysis is a reliable method to measure sleep. In healthy adults, this device proved to be superior to actigraphy in terms of estimation of all sleep parameters and distinction of sleep-wake status.

Three-dimensional analysis of craniofacial bones and soft tissues in obstructive sleep apnea using cone beam computed tomography

A total of 154 adult patients with sleep complaints underwent a polysomnography and a craniofacial cone beam computed tomography (CBCT). OSA was defined as an apnea and hypopnea index (AHI) or an oxygen desaturation index (ODI) ≥ 10. Soft tissues and craniofacial bones volumes were prospectively measured by CBCT and collected blindly from sleep polysomnography. Among the study patients, 127 (83%) suffered from OSA and 27 (17%) did not. OSA patients demonstrated a narrower maxillo-palatine core volume (11.7±3.2 vs 14.6±4.9cm³) even when adjusting for age, gender, height, neck circumference and body mass index. These upper airway measures provide a comprehensive analysis of bony structures and soft tissues, which can be involved in OSA.

The need for an objective measure in septorhinoplasty surgery: are we any closer to finding an answer?

OBJECTIVES

To assess the reliability of nasal inspiratory peak flow (NIPF) in providing a clinically accurate objective measure following functional septorhinoplasty by comparing it to the validated disease-specific quality-of-life questionnaire, SNOT-22. Studies so far have demonstrated poor correlation between bilateral NIPF and symptom-specific nasal questionnaires following septorhinoplasty.

DESIGN

To perform a prospective comparative analysis between NIPF and the validated disease-specific quality-of-life questionnaire SNOT-22 and to determine whether a correlation exists following septorhinoplasty surgery.

SETTING

The Royal National Throat Nose and Ear Hospital, London.

PARTICIPANTS

A total of 122 patients (78 males, 44 females; mean age 33.5 ± 12.2 years) were recruited from the senior authors rhinology clinic and underwent functional septorhinoplasty surgery.

MAIN OUTCOME MEASURES

Preoperative and postoperative nasal inspiratory peak flow (NIPF) measurements were performed in addition to the completion of three subjective quality-of-life and symptom assessment tool questionnaires; Sinonasal Outcome Test 22 (SNOT-22), Nasal Obstruction Symptom Evaluation (NOSE) and Visual Analogue Scale (VAS: 0-10).

RESULTS

The mean preoperative NIPF was 88.2 L/min, and the postoperative value was 101.6 L/min and showed a significant improvement following surgery (P = 0.0064). The mean total SNOT-22 score improved significantly from 48.6 to 26.6 (P < 0.0001); the NOSE score from 14.1 to 6.6 (P < 0.0001); and the Visual Analogue Scale (VAS) blockage score from 6.9 to 3.2 (P < 0.0001). All individual domains assessed showed improvements postoperatively, but no correlation was found between the NIPF and SNOT-22 score. Equally, we did not find a correlation between NIPF and the symptom-specific NOSE questionnaire and the nasal blockage domain on the Visual Analogue Scale (VAS) scale.

CONCLUSION

We have demonstrated that NIPF does not correlate with the SNOT-22 disease-specific questionnaire, although both outcomes significantly improve postoperatively. At present, we are still lacking a clinically accurate objective measure of nasal function for the evaluation of patients undergoing septorhinoplasty surgery.

Safety of human olfactory mucosal biopsy for the purpose of olfactory ensheathing cell harvest and nerve repair: a prospective controlled study in patients undergoing endoscopic sinus surgery

BACKGROUND

Nasal olfactory mucosa is an accessible source of olfactory ensheathing cells for spinal cord regeneration. However, safety of the biopsy technique and the effects on sense of smell and nasal function have not been robustly assessed in the form of a prospective controlled study.

METHODOLOGY

National Health Service ethical approval was granted for this study of 131 patients. The primary outcome measure was olfactory function and the secondary outcomes included postoperative complication rates as well as the SNOT 22, NOSE scale scores and surgeon reported (Lund-Kennedy score) nasal function outcomes.

RESULTS

65 patients underwent functional endoscopic sinus surgery (FESS) and superior turbinate biopsy, and 66 patients underwent FESS only as the control group. There was no significant difference in complication rates between the two groups. All Olfactory function outcomes were unaffected following olfactory biopsy. We demonstrated that the patients quality of life and nasal patency as well as surgeon reported outcome measurements remain unaffected following olfactory harvesting.

CONCLUSIONS

We have uniquely provided level 2a evidence for the safety of endoscopic biopsy of olfactory mucosa, which does not affect nasal function or the sense of smell compared to standard FESS without biopsy.

[Upper airway's 3D analysis of patients with obstructive sleep apnea using tomographic cone beam]

The progress of medical imaging over the last decades has led to a better understanding of the upper airway structure in sleep-disordered patients. The Obstructive Sleep Apnea Syndrome (OSA) is attributed to a functional narrowing of the upper airway, particularly of the oropharynx, during sleep. This narrowing is multifactorial. We have shown that in 60% cases, the maxilla (nasal pyramid) seems too narrow. A mandible retroposition may also play a dominant role in 30% of the cases. Both scenarios can be combined. Cone Beam Computed Tomography (CBCT) is a new medical imaging technique that permits to visualize the upper airway with less ionizing radiation than the conventional scanner. To date, only five authors have performed an upper airway's 3D analysis of sleep apnea patients with cone beam. A better understanding of the affected segment of the upper airway should help refine treatment options.

External nasal valve collapse: validation of novel outcome measurement tool

BACKGROUND

We aim to validate a clinical scoring system of external nasal valve collapse. External nasal valve collapse is a rare and challenging condition. We attempted to simplify the examination of the external valve, the surgical planning and the outcome measure. To validate our external valve score, we first assessed its reliability (inter-rater agreement and test-retest repeatability). We secondly considered the clinical relevance by using our scoring system in patients undergoing septorhinoplasty for external valve collapse.

METHODOLOGY

For validation, 16 Rhinologists scored patients separately on two occasions. For the clinical relevance, 26 patients with external valve collapse were scored pre- and post-operatively (responsiveness). The external valve score was correlated to peak nasal inspiratory flow.

RESULTS

The devised scoring system was reliable (substantial agreement between 16 surgeons with reproducibility over time). All patients in our prospective series showed significant improvement in their external valve score. The quality of life measured by the SNOT-22 tool showed significant improvement after surgery.

CONCLUSION

External nasal valve collapse can be diagnosed and graded using this simple scoring system in the outpatient clinic. This paper reinforces the pivotal role of septorhinoplasty surgery in nasal airway reconstruction and the ongoing need to quantify success.

Sphenoid sinus fungall ball: a retrospective study over a 10- year period

A fungal ball consists of a dense conglomerate of fungal hyphae growing at the surface of the sinus mucosa without tissue infiltration. The maxillary sinus is by far the most commonly involved paranasal sinus cavity followed by the sphenoid sinus. The present study is a retrospective study of 25 consecutive cases treated during the last 10 years in the two hospitals be- longing to the Catholic University of Louvain (CHU Mont-Godinne and UCL Saint Luc). We report the symptomatology, the imaging and discuss the different surgical managements. We conclude that the clinician must have a high index of suspicion when dealing with a unilateral rhinosinusitis persisting despite a maximal and well conducted medical treatment. This is particularly so in elderly women when associated with facial pain and post nasal drip, particularly when the computed tomography shows an unilateral opacity of the sphenoid sinus with or without a sclerosis or an erosion of the bony walls, a polyp in the sphenoethmoidal recess or a hyperdensity mimicking a foreign body. An endonasal endoscopic sphenoidotomy is the treatment of choice in most cases, allowing good ventilation of the sinus and radical removal of all the fungal concretion. A biopsy of the sinus mucosa adjacent to fungal elements is of upmost important to confirm the non- invasiveness of the fungi within the tissue. Antifungal medication is not required in uncomplicated forms. All host factors producing some degree of immunosuppression must be corrected when present and must alert the clinician to rule out any forms of invasive disease.

Cystic dilation of the distal end of the nasolacrimal duct: underrated cause of epiphora in adults and its endoscopic treatment

Epiphora is a frequent reason for ophthalmologic consultation. Among the multiple causes, obstructions of the lacrimal excretory system are common. Sacal and postsacal obstructions are much more frequent than presacal obstructions. Obstruction at the level of the Hasner's valve is rare and likely underestimated. The authors report the clinical history and the imaging of 3 patients with a cystic dilation of the distal end of the nasolacrimal duct (NLD). These patients were easily managed by an ENT surgeon. In one case, the surgery consisted of an endonasal DCR where in the 2 other cases, a marsupialisation of the cystic expansion of the nasolacrimal duct was successfully performed with the micro- debrider. The authors review the world literature on this specific topic. They conclude that a coronal sinus CT scan and an inferior meatus endoscopy should be included in the ophthalmologic work-up performed in all cases of low obstruction of the lacrimal system. When there is a dilation of the distal end of the NLD the marsupialisation of the cystic expansion in the inferior meatus is the option of treatment instead of performing a DCR. ENTs must play a role in the assessment and treatment of low obstructions of the lacrimal excretory system.

Is the Sino-Nasal Outcome Test-22 a suitable evaluation for septorhinoplasty?

OBJECTIVES/HYPOTHESIS

It is becoming increasingly important for clinicians to demonstrate the impact of their interventions. The Sino-Nasal Outcome Test-22 (SNOT-22) questionnaire is a disease-specific questionnaire involving 22 symptoms combining rhinologic issues with general health issues. We evaluated the SNOT-22 score as a quality-of-life outcome measure in septorhinoplasty surgery.

STUDY DESIGN

Outcome research.

METHODS

We carried out a prospective case series in 76 patients undergoing septorhinoplasty. Their SNOT-22 scores were compared pre- and postoperatively. We also recorded individual symptom scores to study the impact of surgery. To check its reliability, the SNOT-22 score was correlated to patient-reported symptoms on a visual analogue scale. Patients were screened for comorbid conditions. Interactions with the surgical technique and/or with the initial sinonasal disease were sought.

RESULTS

The SNOT-22 is a reliable and responsive outcome measure in septorhinoplasty surgery. Septorhinoplasty was especially effective at addressing nasal obstruction, discharge, olfaction, related sleep disturbance, and emotional symptoms such as embarrassment or frustration. Comparison to the visual analogue scale instrument confirmed the outcome measured by the SNOT-22.

CONCLUSIONS

The SNOT-22 could be used in routine clinical practice to highlight the impact of nasal disease in each patient and to measure the outcome and the effectiveness of the surgical intervention.

Retropharyngeal abscess in adults

OBJECTIVES

Retropharyngeal abscess in adults can be life-threatening. The otolaryngologist is on the front line in making the diagnosis and treatment of this disease. The aim of this study is to review the clinical features, the diagnostic tools and the management of retropharyngeal abscesses in adults.

PATIENTS AND METHODS

Retrospective study of retropharyngeal abscesses in adults admitted in the ENT department from 2005 to 2010.

RESULTS

In total 4 patients were included in this study: mean age of 53 years (range 45 to 62 years), sex ration F/M = 3. Cultures obtained from the abscesses identified group A beta-hemolytic streptococci susceptible to amoxicilline-clavulanate in three cases. The treatment consisted in surgical drainage of the collection and intravenous antibiotics.

CONCLUSIONS

Retropharyngeal abscesses in adults are critical infections requiring prompt diagnosis and treatment. Computed tomography scan was the crucial tool for the diagnosis, notably to differentiate cellulitis from abscesses. The management includes intravenous broad-spectrum antibiotics associated, if necessary, with surgical drainage in cases of persistent abscess. The outcome is usually good.

Sudden sensorineural hearing loss: when ophthalmology meets otolaryngology

OBJECTIVES

Sudden sensorineural hearing loss is a perplexing entity in otology. Susac's syndrome (also called retinocochleocerebral vasculopathy) is a rare disorder that consists of microangiopathy of the brain, retina, and inner ear, and usually affects women in young adulthood. We describe the clinical aspects, radiographic findings, and management of one such case.

CASE REPORT

A 30-year-old woman was admitted to the hospital because of sudden onset of bilateral deafness and headache. During her hospitalization, she developed discrete right hemiparesis and hypoesthesia.

RESULTS

Magnetic resonance imaging revealed multiple signal hyperintensities and atrophy of the corpus callosum. The differential diagnosis was a myelinating condition, such as multiple sclerosis or acute demyelinating encephalomyelitis.

CONCLUSION

Retinal fluorescein angiography helped the diagnosis of Susac's syndrome.

Anatomical variations of the lateral nasal wall: The secondary and accessory middle turbinates

The aim of the current anatomical and clinical study was to audit our cases of patients who presented with secondary and/or accessory middle turbinates during a two-year period. We investigated the incidence and the clinical impact of these variations. Twenty-eight patients, 19 males and 9 females with a mean age of 41.5 years, representing different ethnic origins, were diagnosed with double middle turbinates based on endoscopic examination. Of those, 92.8% had a main symptom of refractory frontal headache. A secondary nasal symptom was sensation of blocked nose. Patients who underwent endoscopic surgery (n = 13) for reduction of the extra turbinate, reported significant symptom scores improvement (P < 0.0001) of frontal headache and blocked nose, from means of 9.07 ± 0.26 and 8.57 ± 1.39 to 1 ± 0.31, and 1.42 ± 0.35, respectively. Our results indicate that double middle turbinates may be encountered in rhinology practice (2%). Clinically they may present with refractory headache and blocked nose. Endoscopic surgical approach seems to be an effective way of improving the symptoms.

Type III frontal sinusotomy: surgical technique, indications, outcomes, a multi-university retrospective study of 120 cases

Draf in 1991. The procedure--which is also known as the modified endoscopic Lothrop procedure--aims to create the largest possible anteroposterior and lateral to lateral opening between both frontal sinuses and the nasal cavities. This requires the resection of the medial floor of both frontal sinuses, the intersinus septum and the superior nasal septum. The authors present a retrospective study including a cohort of 120 patients who underwent surgery in six Belgian university ENT departments. Mean follow-up was 24.6 months (range: 5-36 months). This paper describes the surgical procedure and reviews the indications, comorbidities, outcomes and complications of the type III frontal sinusotomy. Some correlations are also established with the data published in the worldwide literature. The authors conclude that the Draf III is a demanding procedure requiring considerable expertise in endoscopic sinus surgery. The procedure is effective with a success rate of 87.5%. Indeed, 12.5% of patients only experienced closure of the neoostium while 20% of all the patients had unchanged or worse symptomatology. The percentage of post-operative complications is 7.5%. All complications were managed successfully.

Delayed GM‐CSF treatment stimulates axonal regeneration and functional recovery in paraplegic rats via an increased BDNF expression by endogenous macrophages

Macrophages (monocytes/microglia) could play a critical role in central nervous system repair. We have previously found a synchronism between the regression of spontaneous axonal regeneration and the deactivation of macrophages 3-4 wk after a compression-injury of rat spinal cord. To explore whether reactivation of endogenous macrophages might be beneficial for spinal cord repair, we have studied the effects of granulocyte-macrophage colony stimulating factor (GM-CSF) in the same paraplegia model and in cell cultures. There was a significant, though transient, improvement of locomotor recovery after a single delayed intraperitoneal injection of 2 microg GM-CSF, which also increased significantly the expression of Cr3 and brain-derived neurotrophic factor (BDNF) by macrophages at the lesion site. At longer survival delays, axonal regeneration was significantly enhanced in GM-CSF-treated rats. In vitro, BV2 microglial cells expressed higher levels of BDNF in the presence of GM-CSF and neurons cocultured with microglial cells activated by GM-CSF generated more neurites, an effect blocked by a BDNF antibody. These experiments suggest that GM-CSF could be an interesting treatment option for spinal cord injury and that its beneficial effects might be mediated by BDNF.

Repetitive transcranial magnetic stimulation improves open field locomotor recovery after low but not high thoracic spinal cord compression-injury in adult rats

Electromagnetic fields are able to promote axonal regeneration in vitro and in vivo. Repetitive transcranial magnetic stimulation (rTMS) is used routinely in neuropsychiatric conditions and as an atraumatic method to activate descending motor pathways. After spinal cord injury, these pathways are disconnected from the spinal locomotor generator, resulting in most of the functional deficit. We have applied daily 10 Hz rTMS for 8 weeks immediately after an incomplete high (T4-5; n = 5) or low (T10-11; n = 6) thoracic closed spinal cord compression-injury in adult rats, using 6 high- and 6 low-lesioned non-stimulated animals as controls. Functional recovery of hindlimbs was assessed using the BBB locomotor rating scale. In the control group, the BBB score was significantly better from the 7th week post-injury in animals lesioned at T4-5 compared to those lesioned at T10-11. rTMS significantly improved locomotor recovery in T10-11-injured rats, but not in rats with a high thoracic injury. In rTMS-treated rats, there was significant positive correlation between final BBB score and grey matter density of serotonergic fibres in the spinal segment just caudal to the lesion. We propose that low thoracic lesions produce a greater functional deficit because they interfere with the locomotor centre and that rTMS is beneficial in such lesions because it activates this central pattern generator, presumably via descending serotonin pathways. The benefits of rTMS shown here suggest strongly that this non-invasive intervention strategy merits consideration for clinical trials in human paraplegics with low spinal cord lesions.

The effect of treadmill training on motor recovery after a partial spinal cord compression-injury in the adult rat

Locomotor training on a treadmill is a therapeutic strategy used for several years in human paraplegics in whom it was shown to improve functional recovery mainly after incomplete spinal cord lesions. The precise mechanisms underlying its effects are not known. Experimental studies in adult animals were chiefly performed after complete spinal transections. The objective of this experiment was to assess the effects of early treadmill training on recovery of spontaneous walking capacity after a partial spinal cord lesion in adult rats. Following a compression-injury by a subdurally inflated microballoon, seven rats were trained daily on a treadmill with a body weight support system, whereas six other animals were used as controls and only handled. Spontaneous walking ability in an open field was compared weekly between both groups by two blinded observers, using the Basso, Beattie and Bresnahan (BBB) locomotor rating scale. Mean BBB score during 12 weeks was globally significantly greater in the treadmill-trained animals than in the control group, the benefit of training appearing as early as the 2nd week. At week 7, locomotor recovery reached a plateau in both animal groups, but remained superior in trained rats. Daily treadmill training started early after a partial spinal cord lesion in adult rats, which accelerates recovery of locomotion and produces a long-term benefit. These findings in an animal model mimicking the closed spinal cord injury occurring in most human paraplegics are useful for future studies of optimal locomotor training programs, their neurobiologic mechanisms, and their combination with other treatment strategies.