Eustachian tuboplasty and shrinkage of ostial mucosa with new devices : Including a proposal of a classification system

OBJECTIVE

A new combined approach to Eustachian tube dysfunction (ETD) employing new minimally invasive devices is described.

STUDY DESIGN

An anatomoclinical classification of ETD was conceived to allow correct categorization of patients and enable comparative studies to be performed. Herein, the authors report on their experience with a consecutive series of obstructive ETD patients treated by balloon dilation of the Eustachian tube using AERA (Acclarent, Menlo Park, CA, USA), combined with a quantic molecular resonance (QMR)-mediated rhinopharyngeal tubal ostial mucosa shrinkage technique with a dedicated "Mitto" hand piece (Telea, Sandrigo-Vicenza, Italy).

METHODS

A prospective study was conducted in 102 patients with ETD. Medical history, complete clinical ENT evaluation and oto-functional examinations were performed in all patients. In all cases, balloon dilatation of the Eustachian tube was performed via the transnasal approach under video-endoscopic control. This was followed by decongestion of the torus tubarius and the inferior turbinate by QMR, with immediate shrinkage of the mucosa of the turbinate and a reduction of the prolapse of the mucosal plica on the tubal ostium.

RESULTS

Comparison of pre- and postoperative oto-functional examinations revealed a significant improvement. The postoperative hearing symptoms were reduced in a statistically significant manner on the visual analog scale (VAS). It was possible to perform the postoperative "swallowing-opening-Toynbee-Valsalva" (SOTV) test in a significant percentage of cases compared to the preoperative test.

CONCLUSION

The combined surgical procedure of balloon tubodilation with simultaneous QMR-mediated shrinkage of the tubal ostial mucosa and reduction of the posterior portion of the inferior turbinate was found to be an effective, safe, and complete treatment for tubal dysfunction in the majority of patients.

Comparative study on the effectiveness of Coblation-assisted turbinoplasty in allergic rhinitis

OBJECTIVES

To evaluate the efficacy of adding Coblation-assisted inferior turbinoplasty to a medical treatment regimen for symptoms associated with hypertrophic inferior turbinates.

STUDY DESIGN/SETTING

Prospective, open-label, non-randomized trial with outpatient treatment. Patients were assigned to treatment groups in order of enrolment into the study.

SUBJECTS AND METHODS

From June 2007 to June 2008, 220 patients with allergic rhinitis and hypertrophic inferior turbinates were enrolled and assigned into two groups: the surgical group who received radiofrequency thermal ablation inferior turbinoplasty and medical therapy, and the medical group who received medical therapy only. Groups were further divided into two allergen types based on antigen sensitivity: perennial and seasonal. Subjective complaints (nasal obstruction, itching, rhinorrhea, sneezing), clinical rhinoendoscopy and rhinomanometry tests results were recorded at the start of the study and 2 months post-treatment. Effect sizes for the mean improvements after treatment were tabulated for all groups.

RESULTS

All study outcomes improved within all groups. Comparison between medical and surgical groups showed higher improvement in both perennial and seasonal, respectively, in nasal obstruction, sneezing, rhinomanometry, and rhinomanometry after NPT. Itching improved only in perennial allergen type. Rhinoendoscopy clinical score showed improvement in surgical group over medical group in both allergen types.

CONCLUSION

Coblation-assisted turbinate reduction is a promising adjunct to medical therapy in patients with persistent symptoms associated with allergic rhinitis. Patients undergoing this surgery had greater reduction of symptoms than patients receiving medical therapy alone, where patients with perennial allergies appeared to benefit most.

Foreign body inhalation in children: an update

Accidental inhalation of both organic and non-organic foreign bodies continues to be a cause of childhood morbidity and mortality, requiring prompt recognition and early treatment to minimize the potentially serious and sometimes fatal consequences. In the past, the majority of data on foreign body injuries in children came from single-centre retrospective studies, covering a range of about 3-10 years. Recently, several review papers have discussed the main clinical aspects, Country-specific experiences have been presented, and systematic collections of foreign bodies have been started. Fully aware of the difficulty in meta-analysing data, in an observational context, the aim of the present report is: an attempt to synthesize the epidemiological data published in the literature presenting the evidence on foreign body distribution in a review of the meta-analyses of papers focusing on European and North-American data; improve our ability to prevent and to treat these complex and high risk situations.

Nasal and lung function in competitive swimmers

Nasal and sinusal complaints are considered common among swimmers. Aim of the present study was to evaluate the nasal and bronchial functions, before and after swimming, and the relationship between nasal resistances and FEV1 in competitive swimmers. A group of 30 competitive swimmers were examined: spirometry and nasal respiratory tests were carried out before and after swimming. Moreover, both the competitive swimmers and the 150 visitors of a swimming pool were asked to complete a specific questionnaire. In this questionnaire, 18% of the population reported nasal-sinusal symptoms after swimming. The differences between nasal volumes and resistances before and after swimming were not statistically significant. Nasal patency increased or remained unchanged in 21/30 athletes. The variations in FEV1 were not statistically significant. In conclusion, results showed that swimming is able to increase nasal patency or to leave it unchanged. Temporary worsening of the nasal patency was observed in only a few hyper-reactive patients. In the whole group, no variations, at bronchial level, were found.

Psychological aspects and treatment of patients with nasal septal perforation due to cocaine inhalation

Use of cocaine, by inhalation, is currently increasing in Western Countries and its use is superseding heroin in the rising generation. Young people of the third millennium use narcotics to avoid the negative conditions of daily life and to escape on "unreal" trips, as happened in the '60s and '70s for the heroin-addicted. Today, on the contrary, people addicted to cocaine want to be more competitive and "winners" and believe that cocaine can help them to reach this goal. A series of 104 patients (75 male, 29 female), aged between 16 and 54 yrs, all habitual inhaling cocaine users (> or = 10 times per month) have been observed for 2 years. Among them, 11 (10.5%) had nasal septal perforation, which is frequently related to cocaine use. Of these 11 patients, 8 (72.7%) had nasal septal perforation of the quadrangular cartilage, while in the other 3 (27.3%) the perforation involved also the bony tract (vomer-perpendicular ethmoidal lamina). Psychological analysis of these 104 patients is reported: 62 patients (59.6%) answered that they inhaled cocaine to improve endurance and to feel stronger and less tired; 34 patients (32.7%) in order to enjoy themselves more during parties and to communicate more effectively with other people; 5 patients (4.8%) to gain confidence and to overcome their shyness, 2 patients (1.9%) to improve their sexual performance and 1 patient (1%) to drink more alcoholic drinks for a longer time without feeling sleepy. All the patients underwent psychotherapeutic treatment, but the lack of compliance and constantly missing the scheduled follow-up visits resulted in complete therapy being performed in only 16 patients (15.3%). All the patients with nasal septal perforation underwent rhino-endoscopy, at T0, with 0 degrees, 45 degrees endoscopes, computed tomography scan of nose and paranasal sinuses and biopsy. At the time of the observational period, none of the 11 patients who presented nasal septal perforation agreed to stop cocaine abuse; therefore, a temporary solution has been offered to all the patients (accepted by 3 of them), i.e., the positioning of a silicone button to close the perforation and, thus, improve the air flow in the nose and reduce progression of local necrosis. Together with the button, the positioning is described, under local anaesthesia, of two layers per septal side of hyaluronic acid, at different levels of esterification, kept in site by the button as a "sandwich" in order to obtain better re-growth of the mucosa and fewer scabs and bleeding.

[Clinical evaluation of the efficacy of Salsomaggiore (Italy) thermal water in the treatment of rhinosinusal pathologies]

OBJECTIVES

Aim of the research was to demonstrate the efficacy of a treatment with thermal water as nasal spray (Salsomaggiore Italy) vs saline on chronic rhinosinusitis with/out nasal polyps.

MATERIALS AND METHODS

55 patients affected by chronic rhinosinusitis with/out I degree nasal polyposis randomised into two groups were enrolled. 30 patients of the study group were treated with thermal water nasal spray 4 times/day for 4 weeks. 25 patients of the control group were treated, with the same protocol, with saline. At the beginning and at the end of the study, in all the subjects the clinical history, objective examination and the instrumental analysis of nasal functions by active anterior rhinomanometry, mucociliary transport (MCT) time determination and nasal cytology were performed.

RESULTS

At the end of the treatment patients in the study group showed an improvement statistically significant, with respect to the control group, of headache, rhinorrea and hiposmia. Significant differences were also observed between the study and control group concerning objective examination (nasal mucosa appearance and crusts) and instrumental analysis (rhinomanometric values and mucociliary transport times). Nasal cytology (epithelial and goblet cells, neutrophils, eosinophils, bacteria) improved in both groups without any statistical difference.

CONCLUSIONS

Thermal water (Salsomaggiore Italy) nasal spray showed a greater efficacy with respect to saline in the treatment of patients affected by chronic rhinosinusitis.

Group A streptococcus and its antibiotic resistance

Acute pharyngo-tonsillitis caused by beta-haemolytic group A Streptococcus is a common disease in childhood. Epithelial cells are the initial sites of the host invasion by group A Streptococcus. Although group A Streptococcus has been considered an extracellular pathogen, recent studies have demonstrated that strains of this bacterium can internalize into epithelial cells both in vitro and in vivo. As adherence to and internalization into host cells significantly contributes to the pathogenesis of group A Streptococcus infections, internalization of group A Streptococcus by human epithelial cells has been extensively studied during the past decade. Multiple mechanisms are involved in this process. Most strains of Streptococcus pyogenes express the fibronectin-binding proteins F1 and F2, which promote bacterial adherence to and entry into human cells. Strains containing the gene for the protein Fl have been proved to be responsible for the failure of antibiotic treatment to eradicate Streptococcus pyogenes. Thus, in a significant number of cases, streptococcal internalization might contribute to eradication failure and persistent throat carriage. Since treatment failure, asymptomatic group A Streptococcus carriers and recurrent group A Streptococcus infections represent the main group A Streptococcus reservoir, from which the bacteria are spread in the general population, the choice of antibiotic is crucial. Beta-lactams select a large number of F1-positive organisms: therefore, macrolides, and, possibly, last generation molecules, are the best and first choice for antibiotic treatment against group A Streptococcus.

Quality of life and psycho-social development in children with otitis media with effusion

Purpose of this study was to correlate results from a survey on otitis media and the State-Trait Anxiety Inventory test. This survey investigated prevalence of otitis media (OM) in our territory, influence on development of language and personality and social costs. State-Trait Anxiety Inventory is a suitable test to differentiate state anxiety caused by a specific event [in this case, otitis media with effusion (OME)] from a trait anxiety (anxious personality) in parents and caregivers. The otitis media study was conducted, retrospectively, in two primary public schools in Colle Val D'Elsa (Siena) on 252 children (6-11 years old). The State-Trait Anxiety Inventory test had been administered to the parents or caregivers of 20 paediatric outpatients (4-12 years, mean 6.8) at the ENT Department of Siena University. The results of the OM survey showed a correlation between OM and difficulties in speech and reading, delayed answering and limited vocabulary. All these problems improved as children grew up. On the other hand, psycho-social development appeared to be more problematic even in the 4th and 5th class, mostly due to persistent attention disturbances. In the State-Trait Anxiety Inventory test, 50% of parents or caregivers had a high state-anxiety score and so were mostly concerned with health status of the children. The State-Trait Anxiety Inventory results indicated that 50% of parents or caregivers had a high trait-anxiety score and thus had an anxious personality. These findings could be helpful in understanding the real severity of symptoms. The two proposed tests could provide complementary data to evaluate children with OME: the OM survey can be used as a screening test to detect children with non-symptomatic OME, to establish whether delayed language development may be associated with OME, to predict prognosis and children's quality of life as well as social costs of OME; the State-Trait Anxiety Inventory test can be used to reveal a state or a trait anxiety in parents and caregivers in order to better understand their point of view. Parents' and caregivers' personality has a marked influence on the impact of OME on the children's quality of life. Quality of life in children with otitis media with effusion is one of the most important parameters to be taken into consideration on account of the possible correlation with problems in development.

A two-year course of specific immunotherapy or of continuous antihistamine treatment reverse eosinophilic inflammation in severe persistent allergic rhinitis

Aim of the study was to evaluate the effect of a 2-year course of subcutaneous specific immunotherapy or continuous oral antihistamine treatment on the eosinophilic inflammation in nasal secretions of patients with severe persistent allergic rhinitis caused by house dust-mites. After informed consent, 31 rhinitis patients, sensitive to dust-mite antigens, were enrolled: 12 were randomly assigned to specific immunotherapy (group A), 11 to continuous oral antihistamine (cetirizine) treatment (group B), and 8 to an oral antihistamine (cetirizine) on demand (group C). Nasal scrapings were performed with a cotton-tipped swab and cells counted before and after 24 months of therapy. Intercellular adhesion molecule-1 and eosinophil cationic protein expression in cytological smears were assessed by immuno-histochemistry. All patients completed the study. The percentage of inflammatory cell types was comparable in the 3 groups at the beginning of the study. Eosinophils, identified as cells expressing eosinophil cationic protein, significantly decreased dropping to zero after 2 years of treatment in groups A and B, while no change was observed in group C. Expression of intercellular adhesion molecule-1 also decreased significantly in groups A and B, but not in group C. This decrease was associated with a significant reduction in epithelial shedding. In the 2-year period studied, specific subcutaneous immunotherapy and continuous oral antihistamine treatment were found to be effective in reducing eosinophilic infiltration and adhesion molecule expression in the nasal mucosa of patients with persistent allergic rhinitis. Furthermore, immunotherapy was more effective in controlling epithelial disruption while antihistamines appeared to be more active in controlling nasal inflammation. Both treatments induced a significant decrease in intercellular adhesion molecule-1 expression in epithelial cells and also a dramatic reduction of eosinophil cationic protein positive staining. These parameters can be considered useful means for controlling the state of persistent inflammation which is typical of persistent respiratory allergy. Nasal scraping was demonstrated to be a simple and safe procedure for monitoring some nasal inflammation parameters.

Do tryptase, ECP and specific IgE measurement by nasal incubation increase the specific nasal provocation test sensitivity?

The specific Nasal Provocation Test (sNPT) is a third level diagnostic tool. Fitted to reproduce natural exposure condition to pick the responsible allergen for nasal symptoms out, it is applied when prick test and RAST responses are doubtful. SNPT results have been evaluated measuring nasal resistance (anterior rhinomanometry) and nasal symptoms (clinical score), reaching 50% of sensitivity. This study focused on the determination of allergic response markers, triggered by nasal challenge: tryptase levels in the nose, specific IgE and ECP (Eosinophil Cationic Protein). The aim was to increase sNPT sensitivity. Twenty patients suffering from allergic rhinitis and 16 age-matched-nonallergic subjects were enrolled in the study. Tryptase, specific IgE and ECP were determined in nasal mucosa applying a new method, based on in situ incubation, before and after sNPT. The latter was performed following a standardized method. Tryptase levels increased in 13 patients (65%), were unchanged in four patients (20%), and slightly decreased in three patients (15%). The increase recorded was significant in mite allergic patients (p=0.005), but not significant (p> 0.05) in pollen allergic patients. ECP values increased in 13 patients (65%), were unchanged in two patients (10%), and highly decreased in five patients (25%). ECP increase was not significant (p> 0.05). Specific IgE levels increased in seven patients (35%), were unchanged in 11 patients (55%) and decreased in two patients (10%). The IgE increase was significant in pollen-allergic patients (p<0.05), while it was not significant in mite-allergic patients (p>0.05). Tryptase, ECP, and specific IgE were not detected in the control group. The data obtained showed a positive sNPT response in 12 patients (60%). Comparing our results with those derived from classical-parameter employment, we gathered an improvement of 10%. On the basis of the usual parameters, in fact, we recorded 50% positivity, while the use of mediators provided an additional 10% improvement in sNPT sensitivity: taking together the usual parameters and nasal allergic mediators values, we reached an sNPT over-all sensitivity of 85%.

State and trait anxiety in patients affected by nasal polyposis before and after medical treatment

The present study aimed to establish whether anxiety and depression in nasal polyposis play a role in genesis of the disease, or are a consequence of symptoms. Anxiety levels were evaluated in state and trait forms, and depression, in 30 consecutive patients presenting nasal polyposis before and after effective 7 months' medical treatment with nasal mometasone, loratadine and montelukast. Before and at the end of treatment, patients were asked to fill in the State and Trait Anxiety Inventory and the Zung self-rating depression scale. In 63.15% of patients with high levels of state anxiety before therapy, these were reduced (p < 0.004) after treatment. In 61.9% of patients with high levels of trait anxiety before treatment, these were reduced (p < 0.002) after treatment. There were no significant differences in depression. Anxiety in nasal polyposis is present both as a state and as a trait, and is significantly reduced after effective medical treatment, showing that anxiety is a reversible consequence of nasal polyposis in most cases.

Topical versus systemic diclofenac in the treatment of temporo-mandibular joint dysfunction symptoms

The most frequent symptom of craniomandibular dysfunction is pain in the preauricular area or in the temporo-mandibular joint, usually localized at the level of the masticatory musculature. Patients sometimes also complain of reflect otalgia, headaches and facial pain. Osteoarthrosis is a frequent degenerative debilitating chronic disorder that can affect the temporomandibular joint. It causes pain and articular rigidity, a reduction in mobility, and radiological alterations are visible in stratigraphy. The aim of this study was to compare the efficacy of a topically applied non-steroid anti-inflammatory drug that has recently become commercially available (diclofenac sodium in a patented carrier containing dimethyl sulfoxide, that favours transcutaneous absorption) which is commonly used to alleviate pain in knee or elbow joints, versus oral diclofenac, in the treatment of symptoms of temporomandibular joint dysfunction. Dysfunction of the temporomandibular joint was diagnosed in 36 adult patients. The patients were randomized in two age- and gender -matched groups. Group A (18 patients) received oral diclofenac sodium administered after a meal in 50-mg tablets twice a day for 14 days. Group B (18 patients) received 16 mg/ml topical diclofenac (diclofenac topical solution, 10 drops 4 times a day for 14 days). All patients completed a questionnaire at the start and end of therapy. Patients were asked to quantify on a graded visual analogue scale and to reply to questions about the pain and tenderness of the temporomandibular joint and the functional limitation of mouth opening. Patients were also requested to report side-effects of the treatment. All patients showed relief from pain after treatment: the difference between the two groups was not significant (p > 0.05). Post-treatment, 16 patients of group A had epigastralgic symptoms. Three patients treated with topical diclofenac showed a modest irritation of the temporomandibular joint region, and disappeared spontaneously. Our results demonstrate that topically applied diclofenac and oral diclofenac are equally effective in the treatment of temporomandibular joint dysfunction symptoms. Topical diclofenac has the advantage that it does not have adverse systemic effects, whereas oral diclofenac had untoward effects on the gastric apparatus. The efficacy of diclofenac topically applied on the temporomandibular joint region observed in group B is explained by the association of diclofenac with dimethyl-sulfoxide, which enables a rapid effective penetration into the joint tissues. It is noteworthy that dimethyl-sulfoxide favours transuctaneous absorption when used in a multi-dose regime as in our study with 4 doses a day. Thus, single, "as required", applications should be avoided because this practice results in scarce absorption of diclofenac.

Pauci-symptomatic large epidermoid cyst of cerebellopontine angle: case report

It is estimated that 10% of intra-cranial tumours are localized in the cerebellopontine angle and internal auditory canal and early symptoms of the different histological forms are almost identical. Acoustic neuroma account for 90% and meningioma for 5-10% of these tumours, while a small percentage of rare tumours exist, the most frequent being epidermoid cyst, also known as congenital cholesteatoma or keratoma. The case is reported here of a large epidermoid cyst of the right cerebellopontine angle, and the clinical-radiological course is reviewed. The patient, a 35-year-old, male, initially presented an episode of objective rotatory vertigo, and a history of right ear fullness, of a few months' duration, with normal otoscopy. Audiometric test was normal in left ear, while slight pantonal sensori-neural hypoacusia was observed in the right ear. The impedenzometric findings were normal as was the vestibular test. Auditory brainstem evoked response showed an increased latency of fifth wave. Gadolinium-enhanced magnetic resonance imaging of brain revealed the presence of a voluminous epidermoid cyst occupying the extra-axial side of the right cerebellopontine cistern with superior extension into the cistern. Due to the low-grade of symptoms, we had chosen to wait and not perform surgery immediately, with otologic and vestibular test-controls every 6 months, with cerebral magnetic resonance imaging to control extension of the mass, without radiation exposure for the patient. One year after diagnosis, at the last control, otofunctional findings were not modified and repeat magnetic resonance imaging did not demonstrate important variations compared to the first. Thus, the choice not to proceed with surgery was justified since surgery is burdened by the risk of important complications. At magnetic resonance imaging, the epidermoid cyst, unlike the majority of intra-cranial tumours, such as acoustic neuroma and meningioma, does not show gadolinium-enhancement; this again supporting the important role of magnetic resonance imaging in the differential diagnosis of intra-cranial neoformations. It is, therefore, worthwhile stressing the validity of the approach, step by step, in the diagnosis of patients with otologic symptoms, together with the importance of magnetic resonance imaging that, in comparison with computed tomography, allowed us to exactly assess the growth rate of the mass and to "wait and see" without risks and without radiations for the patient.

Psychological profile of dysfunctional dysphonia

A high degree of emotional maladjustment can be detected in dysfunctional dysphonia. In these patients, it is not rare to observe an immediate resolution of the phoniatric disorder, but it is equally as common to identify a significant rate of recurrence (> 10%) in the short and long term. This phenomenon may be due to poor adaptive ability in the presence of mood disorders. Aims of this study were: a. selection of a suitable instrument to identify "minor" and "major" symptoms of psychiatric nature in dysphonic subjects; b. evaluation of profile of mood disorders in dysfunctional dysphonic adults. Hopkins Symptom Check List 90 was chosen. This is a scale of self-evaluation, adapted in Italian, complete (9 dimensions) and easy to use. It is employed to evaluate the following dimensions: somatization, obsessive compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, psychoticism, sleep disorders. Three groups were studied: group 1:40 patients (36 female, 4 male; aged 18-62 years, mean 42) with dysfunctional dysphonia; group 2: 20 patients (18 female, 2 male; aged 19-61 years, mean 43) with ENT disorders; group 3: 20 subjects (18 female, 2 male; aged 18-62 years, mean 42.2) as controls. In the statistical analysis, a one-way variance between the three groups and a post-hoc analysis using Schiffé test (level of significance 0.05) were carried out. Results showed significant differences between group 1 and groups 2 and 3 as far as concerns anxiety, phobia, obsessive-compulsive, interpersonal sensitivity and somatization variables. A significant difference was found only between groups 1 and 3 as far as concerns the variables: sleep disorders, depression and paranoid ideation. No significant difference emerged between the groups regarding psychoticism and anger/hostility dimensions. The present study identified a definite profile of minor personality disorders, of an anxious nature, with evidence of somatization, interpersonal sensitivity and obsessive-compulsive type traits, significantly prevailing in dysfunctional dysphonic subjects. Symptom Check List-90 has, therefore, proven to be an adequate instrument in the more complete definition of subjects affected by dysfunctional dysphonia aiming at referral to an integrated protocol which focuses on phoniatric treatment using an approach which acts upon the behavioural aspects of communication.

Simplified local nasal immunotherapy in mite dust allergic rhinitis

The present work aimed at evaluating the efficacy and tolerance of an alternative schedule of local nasal immunotherapy for the treatment of mite dust allergic rhinitis. The authors suggest the nasal administration of the maximum tolerated dosage chosen on the basis of nasal provocation test threshold, comparing allergen extracts in micronized powder and watery solution. Forty-five patients (25 men and 20 women), aged 18 to 66 years, affected by allergic rhinitis to Dermatophagoides (Dpt) were selected and treated either by local immunotherapy in watery solution (15) or in powder form (15) or by parenteral specific hyposensitizing treatment (15). Before and one year after the beginning of the study, the clinical diaries and the total and specific IgE variation were evaluated. The monthly symptoms and drugs use are comparable among the three treatment groups. No significant difference was found, with the exception of local symptomatology, which improved more in patients undergoing local immunotherapy (p > 0.05); and oral antihistamines use, which was lower in patients treated with the watery solution (p < 0.05). Thus, local simplified hyposensitizing treatment is able to combine the absence of symptomatological worsening with the decrease of both local and systemic drugs use. The advantages of the LNIT protocol proposed herein are as follows: simplified schedule for self-administration; improved patient compliance; reduction of local side effects; clinical efficacy comparable with subcutaneous specific immunotherapy.

Nasal allergy and atmospheric pollution

Among the effects that pollution of the air causes on human health, irritation of the exposed mucosa is the earliest and the most obvious one. Pollutants damage the anatomical and functional integrity of the primary airways, in particular they cause alteration of the mucociliary system. The mucosa undergoing continuous aggression by an aerosol loaded with pollutants assumes the characteristics of a tissue with chronic inflammatory processes with dysepithelialised areas that could be an easy entrance for airborne allergens. The loss of integrity of epithelial lining, the interference with the repulsion of extraneous particles trapped in the mucus, the infiltration of the inflammatory cells and lymphocytes called into action by the phlogistic reaction multiply the occasion of meeting between environmental allergens and the immunological system of the host and basically of setting in motion the process of sensitisation. So there is a strict relationship between nasal allergy and pollution, that should not be ignored: allergy is the cause of considerable disturbances interfering with study, work and social activity and can lead to local and distal complications.

Treatment of hypertrophy of the inferior turbinate: long-term results in 382 patients randomly assigned to therapy

A number of surgical techniques are commonly performed to control the symptoms of inferior turbinate hypertrophy unresponsive to medical treatment. We report long-term results in 382 patients randomly assigned to receive electrocautery (62), cryotherapy (58), laser cautery (54), submucosal resection without lateral displacement (69), submucosal resection with lateral displacement (94), and turbinectomy (45). Outcomes of objective test results from rhinomanometry, acoustic rhinometry, mucociliary transport time, and secretory immunoglobulin A levels were compared to the symptom scores before and yearly after surgical treatment. These data indicate that submucosal resection with lateral displacement of the inferior turbinate results in the greatest increases in airflow and nasal respiratory function with the lowest risk of long-term complications.

[Longitudinal study on nasal polyposis: etiopathogenetic, clinical and therapeutic aspects]

The etiopathogenesis of nasal polyposis is yet uncertain; furthermore surgical treatment often is not able to completely resolve this problem, being recurrence very common. In our Clinic, we operated 647 patients for nasal polyposis, either by traditional surgical or endoscopy, in the last ten years. The aim of this study is to compare the results of different surgical techniques, considering the percentage of recurrence. We found that endoscopic surgery give better result than traditional one because it allows to see the place of origin of nasal polyps in the ethmoide. The follow-up was lasting between 1 and 10 years; during this time we administered a topical corticosteroide, to a group of patients, for 1 month; in a second group, we administered furosemide, a diuretic drug. According to our data, the percentage of recurrence in the group treated with furosemide was smaller than in other group treated with corticosteroide.

The rheological characteristics of nasal mucus in patients with rhinitis

In this paper we have analyzed the physical properties of nasal mucus from 120 outpatients with rhinitis. We focused on the most relevant rheological features: viscosity, elasticity, adhesiveness, as well as ability to be spun ("spinability") or poured ("pourability"). A double-capillary type viscometer was used to measure viscosity and elasticity and the platinum ring method to measure adhesiveness. "Spinability" was measured with an automatic apparatus (Filancemetre Sefam) and "pourability" was determined by describing flow under gravity. Efficacy of nasal clearance was analyzed by measuring mucociliary transport time with an inert tracer using vegetal charcoal powder. Results showed that impaired nasal mucosal function in patients with rhinitis could be determined by studying rheological features in addition to measuring mucociliary activity. Information provided proved invaluable when considering possible treatment with agents affecting kinesis of nasal mucus.

[Comparative study of most recent surgical techniques for the treatment of the hypertrophy of inferior turbinates]

The choice among the several techniques carried out to treat the hypertrophy of inferior turbinates is still difficult and matter of great interest. In the present study the Authors evaluated the efficacy and sequelae of the most common operations suitable for this pathology. The surgical procedures taken into consideration were (1) electrocautery; (2) cryotheraphy; (3) lasertherapy; (4) submucosal decongestion without lateral outfracture; (5) sub-mucosal decongestion with lateral outfracture; (6) turbinectomy. The six groups of patients (total 382) have been followed up for 4 years after surgery. At this aim the rhinomanometry, acoustic rhinometry, MCTt and SIgA dosage have been checked up together with the symptomatologic score. The conclusion was that the submucosal decongestion with lateral outfracture was the most effective technique for the chronic nasal obstruction, able to respect all the nasal functions.

[Can the recurrence of nasal polyposis be prevented? A new therapeutic approach]

Nowadays nasal polyposis must be still considered an unsolved problem as the surgical procedures are unable to treat this pathology and the recurrence is very common. For this reason several Authors starting from the pathogenesis and the histological features have chosen a medical point of view at the aim of preventing the natural course of this disease. The present study experimented the effect of the furosemide locally administered in the prevention of polyps relapsing in subjects previously operated on. The Authors pointed out that the furosemide was able to decrease the nasal reactivity to the challenge with ultrasonic nebulized distilled water. Besides this drug locally administered for 3 months (once a day) maintained the nasal mucosa of the patients affected with hyperreactivity in a good functional condition without nasal obstruction. In fact no polyps were found at the objective examinations performed during the three years follow up and the values of acoustic rhinometry measurements were within the normal range. Finally the present research gave the opportunity to hypothesize the role of sodium, potassium and calcium ions transport regulated by drugs or other physiopathological events, in the physiology of the nasal mucosa.

Diurnal activity of the nasal mucosa. Relationship between mucociliary transport and local production of secretory immunoglobulins

Within the ambit of the cyclic activity of the nasal mucosa the purpose of this study was to verify the existence of possible correlation between the rate of mucociliary transport (MCT) during the day and the circadian changes of the SIgA concentrations already found in a previous study. In the present work, a daily fluctuation of the SIgA concentrations was confirmed and it was shown that the values decrease from the greatest limit at 4.00 a.m. to the lowest at 10.00 a.m. Circadian changes of the MCT times are also shown. Moreover, the comparison of the data pertaining to these two parameters showed opposite patterns: when the mucociliary transport velocity decreases, the secretory immunoglubulins reach the highest levels. The phase-displacement of the two examined functions thus makes it possible to compensate cyclic impairments of one activity with contemporary improvement of the other.

[Cyclic activity of the nasal mucosa: relationship between muco-ciliary transport and local production of secretory immunoglobulin]

The aim of the present work has been to study the existence, presumed on the basis of recollection, of a correlation between circadian changes in SIgA concentrations in nasal secretum and the M.C.T. rate throughout the day. In order to reconfirm previously obtained data, again in this case a fluctuation in SIgA concentration was studied, finding peak values at 4 a.m. and the lowest at 10 a.m. Circadian changes were also witnessed between M.C.T. times, thus making it possible to reveal further information regarding cyclic activity of the nasal mucosa. Comparison of these two parameters showed an inverse rate; in fact, when the SIgA concentration increases the muco-ciliary transport rate decreases and vice versa. In other words, the muco-ciliary transport time is more efficient when the production of secretory immunoglobulins by the nasal mucosa is lower, as though a temporary lack in nasal defense is made up for by simultaneous improvement of the other activity.