Delayed symptomatic cerebral vasospasm after transsphenoidal resection of pituitary adenoma

Not required for Clinical Vignette.

Sphenomaxillary Plate: Landmine or Landmark?

OBJECTIVES

Sphenomaxillary plate (SMP) is an inconstant bony septum separating the maxillary and sphenoid sinuses. Neglecting the SMP during endoscopic sinus surgery may lead to mistaking the sphenoid sinus for the posterior ethmoid cell with potentially dangerous consequences. However, its proper identification may allow planned sphenoidotomy through the posterior wall of the maxillary sinus or to enlarge transnasal or transethmoidal sphenoidotomy. The aim of this study was to evaluate (1) the incidence and morphology of the SMP and (2) possibility and safety of trans-SMP sphenoidotomy.

METHODS

In the radioanatomical part of the study multiplanar reconstruction analysis of 117 consecutive paranasal sinus CT scans was conducted. In the clinical part of the research, trans-SMP sphenoidotomy was performed in consecutive patients operated on for chronic rhinosinusitis.

RESULTS

The SMP was found in 25% of sides (34% of patients). It was constantly located superolateral to the posterior insertion of the middle turbinate. The SMP formed the prominence on the posterior wall of the maxillary sinus that could be identified using volume rendering in 11% of sides (19% of patients). 30 trans-SMP sphenoidotomies were performed in 18 patients. The SMP prominence was identified in 15 sides. In absence of SMP prominence, identification of the SMP was still possible using other anatomical landmarks.

CONCLUSIONS

The SMP is present in over 30% Caucasian subjects at least on one side. Sphenoidotomy through the SMP is feasible and safe.

Frontal Angle: A New Predictor of Difficulty in Endoscopic Frontal Sinus Surgery-A Preliminary Computed Tomography Study

OBJECTIVES

The possibility of visualization of the frontal sinus during endoscopic surgery depends on 3-dimensional configuration of the frontal sinus opening (FSO). We aimed to determine the prevalence of unfavorable angulation of the lower part of the posterior wall of the frontal sinus and its relation to FSO diameter.

METHODS

One hundred and twenty-eight computed tomography (CT) scans were retrospectively reviewed to measure (1) the angle between the nasal floor and the plane tangent to the posterior table of the frontal sinus above the most posterior aspect of the anterior buttress (frontal angle, FA) and (2) dimensions of the FSO.

RESULTS

The FA ranged from below 30° to 90°. Nearly 13% of sinuses (16.4% of patients) showed FA about 90°, which should enable good visualization of the sinus with the 30° scope after opening and clearing the frontal recess, while 4% (6.25% of patients) showed FA ≤ 30°. The anterior-posterior diameter (A-PD) was below 5 mm in 17.6% of sinuses (26.6% of patients). There was a significant correlation between FA and A-PD. Unfavorable combination of FA and A-PD (<45°, <5 mm) was present in 5.2% of sinuses (8.6% of patients), and extremely unfavorable combination (<30°, <5 mm) in 0.8% (0.8% of patients).

CONCLUSIONS

The FA shows great interindividual variability, which is very likely to reflect the possibility of inspection of the frontal sinus. This implies a need for further prospective clinical studies to validate FA as a predictor of difficulty in frontal sinus surgery.

Impact of pre-transplantation sinus abnormalities assessed by Lund-Mackay scoring system on sinusitis occurrence after allogeneic hematopoietic cell transplantation in acute leukemia patients

INTRODUCTION

Screening sinonasal evaluation is routinely performed before allogeneic hematopoietic cell transplantation (allo-HCT), however, data supporting such evaluation is inconsistent. O b j e c t i v e s: Assessment of the utility of screening sinonasal evaluation with computed tomography (CT).

METHODS

A retrospective analysis of acute leukemia patients who underwent allo-HCT, for whom screening sinonasal CT scans were reevaluated, and for whom Lund-Mackay score (LMS) was calculated. R e s u l t s: Forty-eight patients, the median age at allo-HCT 38 years (18-58), 52% males, were included. 79% had acute myeloid leukemia (AML), 21% acute lymphoblastic leukemia (ALL). Conditioning intensity was myeloablative in 96% of patients, 21% of patients received total body irradiation. 19% of patients had a history of sinusitis before allo-HCT. Screening sinus CT was performed a median of 22 days before allo-HCT. The median LMS was 1 point (0- 10). The severity of sinus abnormalities was: no abnormalities (31%), mild (67%), moderate (2%), severe (0%). Mucosal thickening was the most frequent abnormality (69%). Eleven patients experienced sinusitis after a median of 93 days (11-607) after allo-HCT. 1-year cumulative incidence of sinusitis was 22%. No threshold of LMS and no type of sinus abnormalities were correlated with sinusitis development after allo-HCT. Mild sinus disease at screening did not negatively impact survival in comparison to no sinus disease. C o n c l u s i o n s: Despite the fact, that majority of analyzed patients had either no or mild sinus disease at screening a significant proportion of patients developed sinusitis after allo-HCT. Evaluation of LMS before allo-HCT did not help predict the development of sinusitis after the procedure.

Osteoma involving the olfactory groove: evaluation of the risk of a CSF leak during endoscopic surgery

Purpose

The olfactory groove (OG) is a common site of iatrogenic cerebrospinal fluid (CSF) leak during endoscopic sinus surgery. We aimed to evaluate the prevalence of CSF leak during endoscopic removal of osteomas involving the OG and identify CT findings indicating increased risk of this complication.

Methods

A retrospective review was conducted of patients operated on for frontoethmoidal osteoma from 11 years in a single institution. A retrospective review of the literature, 1999 to 2019, of perioperative complications in patients operated on for frontoethmoidal osteoma using endoscopic or combined approaches.

Results

Case series: 73 patients were identified including 17 with the OG involvement. The only case of CSF leak occurred in a patient with spongious part of osteoma at the OG. Among six osteomas with spongious component at the OG, one was detached and five had to be drilled down, leaving a small remnant in four. In contrast, all the 11 osteomas with ivory part at the OG were safely detached and completely removed from the OG after debulking. The prevalence of CSF leak was not statistically different between the patients without and with involvement of the OG. Systematic review of the literature: Among the 273 identified patients there were 8 cases of intraoperative CSF leaks (3%) including 2 from the OG (0.7%).

Conclusion

Involvement of the OG does not significantly increase the risk of intraoperative CSF leak. However, this risk may be increased in patients with the spongious part of the tumor attached to the OG.

Three-dimensional computed tomography analysis of frontoethmoidal cells: A critical evaluation of the International Frontal Sinus Anatomy Classification (IFAC)

OBJECTIVES

Two major classifications of frontoethmoidal cells, Lee and Kuhn and the IFAC (International Frontal Sinus Anatomy Classification), distinguish anterior, posterior and medial cells. The European anatomical position paper includes also lateral cells. According to the IFAC, anterior cells push the frontal sinus drainage pathway (FSDP) medially, posteriorly or posteromedially. Posterior cells push the FSDP anteriorly. The only medial cell, pushing the FSDP laterally is the frontal septal cell, which is attached to or located in the interfrontal sinus septum. The aim of this study was to verify the IFAC and characterise cells, which are inconsistent with this classification.

DESIGN

A radioanatomic analysis.

SETTING

Tertiary university hospital.

PARTICIPANTS

One hundred and three Caucasian adult patients with no inflammatory changes in paranasal sinuses CT.

MAIN OUTCOMES MEASURE

Results of assessment of multiplanar reconstruction of thin slice CT.

RESULTS

Two types of cells that cannot be classified using the IFAC were found: (a) Lateral cells extending between the skull base and the anterior buttress, pushing the FSDP anteromedially or medially, present in 34 (16.5%) of the sides, (b) Paramedian cells: medially based, not adjacent to the interfrontal septum, pushing the FSDP laterally and posteriorly, present in 33 (16%) of sides. Suprabulla cells and suprabulla frontal cells were found to push the FSDP in directions other than anterior 28% and 31% of the time respectively.

CONCLUSIONS

Neglecting lateral and paramedian cells may lead to inconsistent results between radioanatomical studies and impede communication between surgeons. They should be included in existing classifications of frontoethmoidal cells.

Lateral frontoethmoidal cell obstructing frontal sinus drainage pathway - report of six cases

The European Anatomical Position Paper on the Anatomical Terminology of the Internal Nose and Paranasal Sinuses distinguishes anterior, posterior, medial and lateral frontoethmoidal cells. The lateral cells have not been characterized yet. Other classifications (Lee and Kuhn, International Frontal Sinus Anatomy Classification) neglect them. The aim of this study is to describe lateral frontoethmoidal cells in rhinosinusitis patients.

METHOD

Analysis of medical records and computed tomography (CT) examinations using multiplanar reconstruction with adjustable planes. The lateral cell extending between the frontal beak and the skull base pushing the frontal sinus drainage pathway medially/anteromedially was identified in 6 patients. These cells could not be classified as anterior, posterior or medial according to existing classifications. Four patients were operated on previously due to sinonasal symptoms. The lateral frontoethmoidal cell is an underestimated anatomical variation that may contribute to the persistence of inflammatory disease and can be easily overlooked preoperatively.

The supreme turbinate and the drainage of the posterior ethmoids: a computed tomographic study

BACKGROUND

It is generally acknowledged that the posterior ethmoidal cells drain under the superior nasal turbinate (SorNT) or, rarely, under the supreme nasal turbinate (SmeNT), and the sphenoid ostium (SO) opens to the sphenoethmoidal recess. However, detailed relations between these structures are variable, complex and still not clear. There is no reliable data on the prevalence of SmeNT and drainage of the posterior ethmoidal cells under this structure. The aim of this study was to re-evaluate the anatomy of the aforementioned region.

MATERIALS AND METHODS

Multiplanar and three-dimensional reconstruction analysis of 100 thin slice paranasal sinus computed tomography scans.

RESULTS

SmeNT was identified in 77 subjects (136 sides). It formed the ostium to the posterior ethmoidal cell adjacent to the skull base or orbit in 58 subjects (91 sides). This cell drained independently from the remaining posterior ethmoidal cells. The sphenoethmoidal (Onodi) cell drained to supreme meatus in 41 subjects (54 sides), and to superior meatus in 37 subjects (49 sides). SO was always located medial to the posteroinferior attachment of SmeNT, or SorNT (in absence of SmeNT).

CONCLUSIONS

Patients with divergent drainage of the posterior ethmoids (with posterior ethmoidal cell draining to the supreme meatus) may require more extensive surgery to avoid persistence or recurrence of inflammatory disease. SmeNT is more common than thought, but due to its posterior and superior location to SorNT, it is rarely seen intraoperatively. If SmeNT is present, SO is always located medial to its posteroinferior attachment. (Folia Morphol 2018; 77, 1: 110-115).

Asymmetry of the anterior skull base at the level of frontal ostium, a radioanatomical study

BACKGROUND

Radioanatomical studies have shown that the ethmoid roof is asymmetric in 10 to 40% of individuals. The right ethmoid roof has been found on average to be lower compared to the left. The aim of this study was to extend existing results by assessing asymmetry between the right and left anterior skull base at the level of the frontal ostium.

METHODOLOGY

Curved multiplanar reconstruction was used to analyse 247 consecutive paranasal sinus CT scans. The corresponding left and right parasagittal profiles of the skull base marked from the anterior ethmoidal artery to the level of the orbital roof were superimposed and compared.

RESULTS

Asymmetry greater than 1 mm was found in 87% of patients, greater than 2 mm in 40.5% of patients, and greater than 3 mm in 8% of patients. The prevalence of the patients with lower skull base on the right side was greater than those with lower skull base on the left side at a ratio of more than 2:1.

CONCLUSION

Skull base asymmetry in the region of the frontal ostium is observed in a large percentage of the population and may be a potential source of complications during endoscopic sinus surgery.

Hidden unilateral aplasia of the frontal sinus: a radioanatomic study

BACKGROUND

Hidden unilateral frontal sinus aplasia is the absence of 1 frontal sinus with increased pneumatization of contralateral sinus toward the aplastic side. It may give the false impression of the presence of 2 separate frontal sinuses, creating potential for complications during the surgery. The aim of this study was to evaluate the prevalence and morphology of this anatomical variation using multiplanar reconstruction of computed tomography (CT) results.

METHODS

A total of 305 CT examinations were analyzed. Hidden unilateral frontal sinus aplasia was defined as lack of pneumatization of 1 frontal sinus beyond the level of the orbital roof, with increased pneumatization of the contralateral sinus, extending to the sagittal plane, crossing the lamina papyracea on the side of the aplastic sinus.

RESULTS

Eleven patients (3.6%) with hidden unilateral frontal sinus aplasia were identified, 5 on the left and 6 on the right side, in 5 female and 6 male patients. Twenty-four (7.8%) patients with "regular" frontal sinus aplasia (without hyperplastic contralateral frontal sinus) were found, 4 with bilateral aplasia and 20 with unilateral aplasia.

CONCLUSION

Hidden unilateral aplasia of the frontal sinus is a relatively uncommon anatomical variation. Its presence should be considered during routine preoperative CT evaluation because it poses the risk of intraoperative complications.

Asymmetry of the anterior skull base at the level of frontal ostium, a radioanatomical study

BACKGROUND

Radioanatomical studies have shown that the ethmoid roof is asymmetric in 10 to 40% of individuals. The right ethmoid roof has been found on average to be lower compared to the left. The aim of this study was to extend existing results by assessing asymmetry between the right and left anterior skull base at the level of the frontal ostium.

METHODOLOGY

Curved multiplanar reconstruction was used to analyse 247 consecutive paranasal sinus CT scans. The corresponding left and right parasagittal profiles of the skull base marked from the anterior ethmoidal artery to the level of the orbital roof were superimposed and compared.

RESULTS

Asymmetry greater than 1 mm was found in 87% of patients, greater than 2 mm in 40.5% of patients, and greater than 3 mm in 8% of patients. The prevalence of the patients with lower skull base on the right side was greater than those with lower skull base on the left side at a ratio of more than 2:1.

CONCLUSION

Skull base asymmetry in the region of the frontal ostium is observed in a large percentage of the population and may be a potential source of complications during endoscopic sinus surgery.

Endoscopic transnasal management of sinonasal malignancies - our initial experience

INTRODUCTION

Malignant tumors of the paranasal sinuses are traditionally managed through external approaches. Advances in endoscopic transnasal surgery have allowed for the endoscopic treatment of some of these tumors.

AIM

To present the results of treatment of a series of patients with paranasal sinus malignancies treated with an endoscopic approach at a single institution.

MATERIAL AND METHODS

The data on tumor type, operative technique, perioperative complications and postoperative course were analyzed.

RESULTS

Eleven patients meeting the inclusion criteria were identified. The histopathology was as follows: malignant melanoma in 3 patients, squamous cell carcinoma in 2, adenocarcinoma in 2, poorly differentiated carcinoma in 1, hemangiopericytoma in 1, adenoid cystic carcinoma in 1 and fibrosarcoma in 1. There were no severe perioperative complications with the exception of 1 case of cerebrospinal fluid leak, which was successfully closed. The mean observation period was 13.5 months. One of the patients died of disease, another was lost to follow-up, and one was reoperated on due to recurrence. The remaining 8 patients are alive with no signs of recurrence.

CONCLUSIONS

Our initial experience seems to confirm results obtained by other authors indicating that in selected cases endoscopic surgery of sinonasal malignancies is similarly effective as external approach surgery.

Effect of the nasal cycle on congestive response during bilateral nasal allergen provocation

BACKGROUND

Bilateral nasal allergen provocation usually produces more pronounced obstruction of one nasal passage. It was found that this could be related to the stage of the nasal cycle before the provocation.

OBJECTIVE

To discover whether the stage of the nasal cycle is decisive for asymmetry in congestive response observed during bilateral allergen nasal provocation. methods. Two bilateral nasal allergen provocations were performed in a group of 26 pollen-sensitive volunteers. Acoustic rhinometry measurements were taken during the nasal cycle, and then after the provocation. A cross-sectional area at the level of the inferior turbinate (CSA-2) was measured. Consecutive challenges were performed in the opposite phase of the nasal cycle: the side which had been wide just before the first challenge, was narrow before the second provocation.

RESULTS

Asymmetry in CSA-2 reduction between the nasal passages was observed in most cases. Significant difference was observed between mean CSA-2 reduction rate (reactivity) of the side that responded with greater congestion, and the opposite side. No significant difference was found in mean CSA-2 reduction rate between the side which was narrow, and the side which was wide before provocation.

CONCLUSIONS

Asymmetry of congestive response during bilateral nasal allergen provocation is not dependent on the stage of the nasal cycle preceding the challenge.

Frontal sinus and recess osteomas: an endonasal endoscopic approach

BACKGROUND

Over the last decade, there has been an increase in the use of the endonasal endoscopic approach for removing frontal sinus and frontal recess osteomas. This study aimed to describe an endoscopic endonasal treatment of osteomas without the need for an external approach.

MATERIALS AND METHODS

We performed a retrospective analysis of patients that had received operations over a 5-year period in a single center.

RESULTS

Twenty-nine patients underwent endoscopic osteoma resections. The osteomas were graded according to the Chiu and Kennedy grading system: 12 had type I, 2 had type II, 13 had type III, and 2 had type IV osteomas. The most common indication for surgery was frontal pain. Removal of the osteoma was incomplete in three patients. Of these, one underwent successful transnasal reoperation, and the other two had tumors that extended near the mid-orbital line and were attached to the orbital roof. Based on an 11-point scale (0--no pain, 10--maximum pain), the mean pain intensity decreased from 7.5 before surgery to 3.3 (p < 0.005) after surgery for patients that underwent surgery due to frontal pain.

CONCLUSION

We found that exclusively transnasal endoscopic resections of frontal sinus osteomas were safe. However, this approach can be inadequate under some conditions. An auxiliary external approach may be required when the frontal ostium is narrow and/or when tumors are extensively attached to the orbital roof, and grow close to the midorbital point.

[Angifibroma juvenile--evolution of surgical management]

INTRODUCTION

Juvenile Angiofibroma has been challenged generations of surgeons. The problem is, not only in specific clinical features of the tumour, but also in difficult surgical approach to anatomical area in which it is located.

THE AIM OF THE STUDY

was to analyze development of surgical techniques in treatment of juvenile angiofibroma and potential conditions which influence on therapy results.

MATERIAL AND METHOD

The retrospective study that analyzes 47 juvenile angiofibroma cases, which were treated in the Otorhinolaryngology Department of Warsaw Medical University in years 1980–2010.

RESULTS

The five surgical approaches were used in the group of patients, filled in this study. The use of midfacial degloving has become increasingly popular, replacing lateral rhinotomy and transpalatal approach, which were commonly used in early nineties of the last century. The infratemporal approach was used in one case of disease with parapharyngeal and infratemporal extension. One of the recent patients was treated, first time in history of the Department, using endoscopic approach. The routine protocol of treatment includes preoperative CT and MRI and angiography with embolization of the main tumour vessels. The gradual, but consequent improvement in therapy results is revealed as reduction of recurrence from 35% to 20%.

CONCLUSIONS

In therapy of juvenile angiofibroma become popular surgical techniques, which are not connected with visible scars and which reduce tissue trauma in operated area. Besides mastering surgical skills, the independent condition, which improves therapy results, is using modern diagnostic and therapeutic procedures. They contribute to better assessment of tumour location and extension, and reduction of intraoperative blood loss.

[Draf III procedures: the ENT Department, Medical University of Warsaw experience]

During last decades Draf III procedure gained popularity in treatment of different pathologies of the frontal sinus such as chronic sinusitis or benign tumors. We present a series of 10 patients treated with this procedure from a 2-year-period. Indications included: chronic rhinosinusitis--four patients, frontal sinus mucocele--four patients (one with destruction of the posterior table), osteoma--one patient (stage 3 according to Kennedy's grading system), and inverted papilloma--one patient (Krouse T3 lesion). Observation period ranged from 4 months to 2 years.

RESULTS

There were no early complications. Gradual narrowing of the created ostium was observed in all of the patients. This led to total obstruction in two, and stenosis (not allowing for passing with 4 mm endoscope) in another two patients. The patient after inverted papilloma removal showed no recurrence in 11 months follow-up.

CONCLUSION

Draf III procedure is alternative for external approach that can be used for treatment of chronic rhinosinusitis and benign frontal sinus tumors of different size.

[Correlation of mucosal involvement as evaluated by computed tomography and bone single-photon emission tomography findings SPECT in patients with chronic rhinosinusitis]

Osteitis has been proven to play important role in patophysiology of chronic rhinosinusitis (CRS). Computed tomography (CT), a standard diagnostic technique used to evaluate the extent of the sinus disease, fails to show the bone involvement in patients with CRS. In contrast single-photon emission tomography (SPECT) yields adequate information on remodeling and bone turnover. Persistent osteitis may be one of the reasons of failure of adequate medical and surgical therapy for CRS and discrepancies between extent of the disease as evaluated by CT and symptom scores.

THE AIM OF THE STUDY

is to evaluate correlation between the results of CT and SPECT in patients with CRS.

MATERIAL AND METHODS

29 patients with CRS (15 with nasal polyps and 14 without nasal polyps) were evaluated with CT and SPECT. The mucosal involvement of CRS graded on Lund-Mackay Scale (LMS) was compared to degree of bone involvement evaluated by SPECT with the use of modified LMS.

RESULTS

The mean LMS grade was 13,3 for CT and 9,8 for SCPECT (modified LMS). A positive correlation between the results of two imaging methods was found r = 0.72 (p < 0.0001).

CONCLUSIONS

The bone involvement as evaluated by SPECT correlates with the degree of mucosal changes showed by CT.

Prevalence of rhinitis in Polish population according to the ECAP (Epidemiology of Allergic Disorders in Poland) study

The prevalence of allergic disorders, especially allergic rhinitis (AR), has dramatically increased in the past few decades and multicentre, standardized, randomized epidemiological studies are required to quantify this phenomenon in Poland.

AIM

The aim of the study was to estimate the prevalence of rhinitis and allergic rhinitis in Poland.

MATERIAL AND METHOD

The ECAP study was conducted using the ECRHS II and ISAAC questionnaires translated into the Polish language and validated, in selected nine regions of Poland, including eight cities and one rural area. The respondents within the regions were selected by means of multistage proportional stratified random sampling based on the identity number (PESEL) as the operat. The survey was conducted in 20,454 subjects (response rate of 41.9%) and 18,617 questionnaires were valid. Approximately 25% of the subjects (n=4783) were subsequently evaluated by clinicians (response rate of 43.4%).

RESULTS

Rhinitis was self-reported by 36.08% of the respondents (37.8% of 6- 7-year-olds, 34.5% of 13- 14-year-olds, and 36.0% of adults). The lowest prevalence rate was in the rural region (22.9%). Allergic rhinitis (AR) was self-reported by 22.54% of the respondents (23.6% of 6- 7-year-olds, 24.6% of 13- 14-year-olds, and 21.0% of adults). Again, the lowest prevalence rate was in the rural region (16.0%). AR was more frequent in males (24.0%) than in females (21.2%) (OR = 1.079; 95% CI: 1.044-1.116). AR was actually diagnosed by a clinician in 28.9%, including intermittent AR in 47.7% and persistent AR in 52.3%. Seasonal AR was diagnosed in 15.55%, and perennial rhinitis in 15.2%.

CONCLUSION

Allergic rhinitis is common in Poland as it affects nearly 25% of the population and it is a major social problem. Standards of early detection and prevention of allergic rhinitis should be introduced.

[Iatrogenic CSF leak as a complication of osteoplastic flap surgery of the frontal sinus]

THE AIM OF THE STUDY

to evaluate CSF leak as a complication of osteoplastic flap surgery of the frontal sinus.

MATERIAL AND METHODS

Medical recordings of the patients that underwent osteoplastic flap surgery of the frontal sinus were analyzed.

RESULTS

among 62 patients operated between 2000 and 2007 there were 4 cases of intraoperative CSF leak (6.5% of cases). In all complicated cases indication for surgery was benign large tumor of the frontal sinus, among them there were two cases of osteoma, one cholesterol granuloma and ossifying fibroma. All CSF leaks were successfully closed with multilayer underlay or overlay graft. The technical aspects of the osteoplastic flap surgery of the frontal sinus are discussed.

A follow-up study of immunotherapy-treated birch-allergic patients: effect on the expression of chemokines in the nasal mucosa

BACKGROUND

Specific immunotherapy (SIT) is the only treatment producing lasting clinical improvement in patients with allergy. We investigated the long-term effect of SIT treatment on the expression of chemokines: eotaxin, RANTES (regulated upon activation, normal T cell expressed and secreted) and thymus and activation-regulated chemokine (TARC), and their receptors CCR3 and CCR4 in biopsies of nasal mucosa from birch-allergic individuals.

METHODS

Sixteen patients who completed a 3-year treatment programme 3-5 years ago, and 12 untreated, matched controls were included in the study. Patients recorded symptoms and use of rescue medication before and during the pollen season. Nasal mucosa samples obtained before and during the season were stained for eosinophil and mast cell markers and for eotaxin, RANTES, TARC, CCR3 and CCR4.

RESULTS

During the pollen season, rhinoconjunctivitis symptoms increased in both SIT and control groups (P=0.001 and 0.002, respectively). However, SIT patients had 37% fewer symptoms than controls. Medication use increased in both groups (P=0.002) during the season but the SIT group used 28% less than the controls (P=0.02). The number of eosinophils in the nasal mucosa increased in the control group (P=0.01) and the difference between the groups was significant during the season (P=0.01). No seasonal increase in the numbers of mast cells was seen, but during the pollen season, more (P=0.02) AA(+) cells were found in the controls than in the SIT group. The number of eotaxin(+) and RANTES(+) cells increased in the control group (P=0.01 and 0.03, respectively) and the difference between groups during the season was significant (P=0.01 and 0.01, respectively). The TARC(+) cell numbers were lower in the SIT group during the season (P=0.003). The CCR3(+) cells increased only in the control group during the pollen season and remained unchanged in SIT patients, while CCR4(+) cell numbers increased in both the control (P=0.03) and SIT (P=0.02) groups.

CONCLUSION

This study confirmed that decreased numbers of eosinophils in the nasal mucosa is a long-lasting effect of birch SIT. SIT also prevented seasonal rises in the number of cells expressing the chemokines eotaxin and RANTES.

Dynamics of early phase congestion after nasal allergen provocation

BACKGROUND

It is generally accepted that congestion during the nasal provocation is most pronounced at about 15 minutes after allergen application. However, it may reach its peak at a different time. This can cause inaccurate assessment of the nasal challenge. The aim of this study was to evaluate the dynamics of early phase congestion during nasal allergen provocation (NPT) and its reproducibility.

METHODS

Two nasal allergen challenges were performed in 26 allergic rhinitis volunteers. Acoustic Rhinometry measurements were recorded beJbre, and then every 5 minutes/for 30 minutes after the allergen application. The sum of cross-sectional areas at the level of the head of inferior nasal turbinate (CSA-2) of both nasal passages was analyzed.

RESULTS

The mean time to the occurrence of maximum congestion was 20 minutes. The maximum congestion differed significantly from that recorded at 10, 15 and 20 minutes. The observed patterns of congestive response were not consistent, with inter- and intra-individual differences regarding the time to maximum congestion. Percentage change in airway dimension recorded at the maximum congestion was found the least variable.

CONCLUSIONS

Evaluation of the maximum congestion pattern during the NPT gives more accurate data compared to a single measurement of nasal patency.

Changes in nasal cavity dimensions in children and adults by gender and age

OBJECTIVE

The aim of the study was to establish the dynamics of changes in the intranasal spaces of children and adults by gender and age.

MATERIALS AND METHODS

Each side of the nasal cavity was evaluated separately in 366 healthy subjects 9 to 74 years old. The following acoustic rhinometry parameters were analyzed: 1) I-C, distance between the isthmus nasi (I) and the head of the inferior turbinate (C); 2) CA-I, cross-sectional area at the isthmus nasi; 3) CA-C, at the head of the inferior turbinate; and 4) CA-F, the highest point on the rhinometric curve between points I and C.

RESULTS

Before age 11 years, the intranasal spaces were slightly larger in girls than in boys. After age 11 years the nasal parameters were larger in boys than in girls. The growth rates before age 17 years were as follows: I-C: 0.073 cm/yr, 0.135 cm/yr, CA-F: 0.055 cm2/yr, 0.133 cm2/yr (P < .00001), and CA-C: 0.010 cm2/yr, 0.034 cm2/yr (P < .02) in girls and boys, respectively. In subjects older than 16 years, the mean values of I-C were 1.707 cm, 1.934 cm (P < .0001), and of CA-C, 0.493 cm2, 0.611 cm2 (P < .0001) in women and men, respectively, and changed slightly over the year.

CONCLUSIONS

The parameters of intranasal spaces depend on age and gender. The dynamics of the changes is greater in boys than in girls and usually the growth is completed by the age of 16. After this age, nasal cavities are bigger in men than in women.

Znaczenie czynnościowej chirurgii nosa w leczeniu obturacyjnego bezdechu podczas snu (OBPS)

INTRODUCTION

Nasal obstruction is widely mentioned among the factors influencing pathophysiology of obstructed breathing disorders during sleep. However numerous observations confirms such relation, influence of nasal surgery on frequency and intensity of obstructive episodes during sleep remains modest and unpredictable in vast majority of cases. The aim of this study was to evaluate the role of functional nasal surgery in the treatment of Obstructive Sleep Apnea Syndrome (OSAS).

MATERIAL AND METHODS

The study included 83 subjects with OSAS diagnosed by polysomnography and elevated nasal resistance due to different deformities of nasal skeleton. All patients underwent appropriate surgical treatment. Evaluation of day somnolence using Epworth Scale and subjective analysis of snoring and other sleep disturbances using linear scale was carried before and after surgery. Objective results of treatment were assessed by polysomnograpy performed 3 to 4 months after operation.

RESULTS

The results obtained in our group of patients showed a large discrepancy between the subjective estimation of the treatment indicated by the patients and the objective determinations of the polysomnographic test. The average day somnolence intensity was decreased approximately 2 times and 72 (86%) patients stated that snoring intensity as well as other night time symptoms of sleep apnea greatly diminished. Furthermore in the group of 19 patients who continued nCPAP therapy after surgery the side effects of this treatment diminished and lower therapeutic pressure could be provided.

CONCLUSIONS

Correction of nasal obstruction have to be considered in all patients with OSAS because it may help relieve airway obstruction during sleep and improve the general quality of live at least in patients self estimation. Furthermore, an improvement of nasal patency diminishes the side effects of nCPAP therapy and provides lower therapeutic pressure.

[Rhinitis medicamentosa in cytological assessment of the nasal mucosa]

Long term use of topical vasoconstrictors for the nose may result in rhinitis medicamentosa, the rebound swelling of the nasal mucosa. Usually discovery of any underlying reason for decongestant use is impossible, therefore treatment could be problematic. The aim of this study was to establish the nasal mucosal cytology of patients with rhinitis medicamentosa and evaluation of usefulness of exfoliative cytology in diagnostics of underlying reason of nasal decongestants overuse. All patients had a history of six months regular use of popular intranasal alpha-adrenomimetics. All patients have used them constantly with different frequency in 24 h, but always before sleep. The exfoliative cytology was used as a method of nasal mucosa evaluation. Normal cytograms in rhinitis medicamentosa were in 16.4%. Cytograms of 13.4% patients showed a significant number of eosinophils and 29.9% predominant of squamous metaplasia. The study showed that the majority of cytograms in rhinitis medicamentosa indicates nasal mucosa injury. Method of the exfoliative cytology could facilitate the establishment of the underlying cause of intranasal decongestants overuse.

Bilateral nasal allergen provocation monitored with acoustic rhinometry. Assessment of both nasal passages and the side reacting with greater congestion: relation to the nasal cycle

BACKGROUND

The effect of bilateral nasal provocation on nasal mucosa measured with the use of acoustic rhinometry (AR) can be assessed for both nasal passages or for the side responding with greater congestion. Assessment of changes in nasal congestion during the nasal provocation test (NPT) can be affected by the nasal cycle (NC). The aim of this study was to find out the most accurate method to evaluate changes observed during bilateral nasal provocation.

METHODS

Cross-sectional areas (CSA) at the level of inferior nasal turbinate (CSA-2) were recorded by AR in 26 volunteers with allergic rhinitis during the NC for 5-7 h and subsequently during NPT. The risk of spontaneous total and unilateral CSA-2 decrease was established. Sensitivity of the NPT assessment for the total CSA-2 and for the side responding with greater congestion was evaluated at chosen thresholds. These thresholds were selected in a way that the risk levels of spontaneous decrease of unilateral and total CSA-2 were equal.

RESULTS

The assessment of the total CSA-2 was found to be more sensitive than the assessment of the side responding with greater congestion. The highest sensitivity and specificity of the test was achieved by using a combination of both assessments. Optimum thresholds of the CSA-2 decrease for assessment at 15 min after provocation, with this method, were 27% and 40% for the side responding with greater congestion and for the total CSA-2, respectively.

CONCLUSIONS

Recognition of the risk of spontaneous unilateral and total CSA-2 decreases enables introduction of combined assessment of bilateral NPT. This assessment seems to be the most accurate method for evaluation of the test results.

[Specific nasal challenge tests in the diagnosis of allergy]

The paper presents a review of current literature concerning the use and conduction of specific nasal challenge tests (SNCT). The authors call attention to the consensus of the German group of 1990 and report of the European Rhinologic Society (ERS) on nasal challenge tests of 2000. They present own experience and point to the unsolved questions: whether SNCT should be one- or two-sided with allergen on blotting paper or from a spray, and what methods of subjective and objective assessment should be applied. The authors call attention also to the unsolved problem of the influence of nasal cycle on the challenge test result. The paper includes the ERS instruction how to conduct nasal challenge test.

[Acoustic rhinometry--examination technique and discussion of the recommendation of the Committee for Standardisation of Acoustic Rhinometry, European Rhinologic Association ]

Acoustic rhinometry (AR) is a technique of nasal patency assessment, ever more frequently used in clinical practice. As yet, no generally accepted recommendations has been developed concerning the method of examination performing. In the paper the technique of examination is presented and the recommendations of the Committee for Standardisation of Acoustic Rhinometry, European Rhinologic Association are discussed.

[Nimesulide (Aulin)--the selective COX-2 inhibitor in the treatment of ENT diseases]

Nonsteroidal antiinflammatory drugs (NSAIDs) are widely used in the treatment of controlling inflammatory process and relief of pain in upper airways disorders, due to their inhibition of the cyclooxygenase (COX). After classical NSAIDs different adverse effects are observed, which limit their usage in many patients. The beginning of the nineties gave the evidences, that two cyclooxygenase isoforms existed: COX-1 and COX-2. The blockage of COX-1 in consequence cause the adverse effects of NSAIDs. And COX-2 is responsible for the most inflammatory symptoms, such as pain, oedema, fever, increase of vessel permeability. So the selective inhibitors of COX-2 would be much more safe drugs, comparing with the classical NSAIDs in the treatment of inflammatory diseases. Nimesulide belongs to the new generation of NSAIDs. It not only inhibits more selectively the activity of COX-2, but has also some other properties, that increase its antiinflammatory and analgesic function. Effectiveness of nimesulide has been demonstrated by numerous clinical studies in various inflammatory diseases of upper airways. Its anti-inflammatory, analgesic and antipyretic efficacy has been at least comparable with classical NSAIDs, but the adverse effects of nimesulide have been milder and less frequent. So all those facts suggest, that nimesulide should be taken into account in the treatment of the inflammatory diseases of the ear, nose and throat.

[Spontaneous changes of nasal patency, the nasal cycle, classification, frequency, and clinical significance]

The nasal cycle is classically defined as rhythmic, alternating side to side fluctuation in nasal airflow. It is known to be regulated by autonomic nervous system probably from the centres located in brainstem. Its classical form requires identical periods and equal amplitude of patency changes, with the total airflow remaining unchanged. This pattern was previously shown to occur in 75% healthy adults. In more recent studies is has been shown that spontaneous changes in nasal patency are in most cases of more irregular pattern. This article describes methods of detection, classification, current views on the role of the cycle.