Turkish Guideline for Diagnosis and Treatment of Allergic Rhinitis (ART)

OBJECT

To prepare a national guideline for Otorhinolaryngologist who treat allergic rhinitis patients.

METHODS

The study was conducted by three authors, namely the writing support team. The support team made the study plan, determined the writing instructions, chose the subgroups including the advisory committee, the advisors for authors and the authors. A workshop was organized at the very beginning to explain the details of the study to the team. Advisors took the chance to meet their coworkers in their subgroups and determined the main headings and subheadings of the guideline, together with the authors. After key words were determined by the authors, literature search was done in various databases. The authors keep in touch with the advisors and the advisors with the advisory committee and the support group at every stage of the study. National and International published articles as well as the abstracts of unpublished studies, imperatively presented in National Congresses, were included in this guideline. Only Guideline and meta-analyses published in last seven years (2013-2017) and randomized controlled studies published in last two years (2015-2017) were included. After all work was completed by the subgroups, support team brought all work together and edited the article.

RESULTS

A detailed guideline about all aspects of allergic rhinitis was created.

CONCLUSION

The authors believe that this guideline will enable a compact and up-to-date information on allergic rhinitis to healthcare professionals. This guideline is the first in the field of Otolaryngology in Turkey. It should be updated at regular intervals.

Evaluation of Ultrastructural Changes in Paranasal Sinus Mucosa after Functional Endoscopic Sinus Surgery in Patients with Chronic Rhinosinusitis

The purpose of this study was to compare the preoperative and postoperative ultrastructural changes of paranasal sinus mucosa in patients treated with functional endoscopic sinus surgery for chronic rhinosinusitis. Twelve patients undergoing functional endoscopic sinus surgery for the treatment of chronic rhinosinusitis were involved. The ethmoid sinus mucosa was sampled during the operation and ∼6 months after the operation. The ciliated epithelium of sinus mucosa was evaluated with transmission electron microscopy. The samples were taken at the Otolaryngology Department of Istanbul University School of Medicine. Electron microscopic study was performed at the Histology and Embryology Department of the same University. Preoperatively, ciliated epithelial cells of the sinus mucosa of the patients showed degenerated ultrastructure with decreased number of cilia, cytoplasmic protrusions, cisternal dilatations of endoplasmic reticulum, and mitochondrial swellings. Remnants of degenerated cells and cellular separations at cell junctions were evident in the diseased epithelium. Goblet cells were frequent along the epithelial lining. Postoperatively, normal architecture and ultrastructure of the ciliated epithelium was restored. These observations showed that unlike other surgical operations, paranasal sinus mucosa can regenerate and the ciliated epithelium can return to normal after functional endoscopic sinus surgery.

Olfactory Function Assessment of Blind Subjects Using the Sniffin' Sticks Test

OBJECTIVE

In recent years, a growing number of studies have focused on the olfactory abilities of blind individuals as well as their tactile and auditory senses. In this study, we aimed to investigate possible alterations in the sense of smell in early- and late-blind subjects as compared with sighted controls, using a Sniffin' Sticks test battery.

STUDY DESIGN

Prospective clinical study.

SETTING

Tertiary referral center.

SUBJECTS AND METHODS

A total of 66 subjects were included in the study. The subjects were divided into 2 groups: blind subjects-who were then subgrouped as subjects with congenital blindness (n = 17) and those with acquired blindness (n = 16)-and sighted subjects (n = 33). We compared both congenitally and acquired blind subjects with sighted counterparts using the Sniffin' Sticks test for odor threshold, odor discrimination, odor identification, and total odor scores.

RESULTS

The blind subjects were more successful than their sighted counterparts in odor discrimination and odor threshold tasks. There was no statistically significant difference between the blind participants and the sighted individuals in terms of odor identification value. Another important finding was that the difference between individuals with congenital blindness and those with acquired blindness was not significant in any of the parameters.

CONCLUSION

This finding may suggest that odor discrimination and odor threshold in blind people were superior to those of controls. There was no difference in any of the results of tasks among congenital and acquired blind subjects.

Evaluation of Factors Concerning the Olfaction Using the Sniffin’ Sticks Test

Objective. This study aimed to research the normative values of olfactory function in the Turkish population using the Sniffin’ Sticks test and to relate olfactory performance to age, sex, smoking, educational level, and the side examined. It also aimed to compare the results with other countries’ normative values, especially Europe, using the same test and procedure.

Study Design. Prospective clinical study.

Setting. Tertiary referral center.

Subjects and Methods. This study was a prospective clinical trial conducted in a tertiary clinic. A total of 100 healthy subjects were included in the study. Of these, 50 were men and 50 were women. The mean (SD) age of the subjects was 37.7 (14.8) years (range, 18-77 years).

Results. Odor scores were lower than the scores of other countries, and the scores decreased significantly with age. There was no relationship between olfaction and sex or smoking. Subjects with a lower educational status had lower scores compared with the scores of median and highly educated subjects.

Conclusion. This is the first study that evaluated the relationship between education level and olfaction. According to the results, the cultural differences, education level, and age seemed to influence odor scores. The Sniffin’ Sticks test can be used to assess olfactory performance in a Turkish population, but identification of odors in this test battery may show variability because of local and cultural factors.

Comparison of the efficacy of nasal drop and nasal spray applications of fluticasone propionate in nasal polyps

OBJECTIVES

We assessed the efficacy of different forms of fluticasone propionate in the treatment of bilateral nasal polyposis in adult patients.

PATIENTS AND METHODS

This double-blind, randomized, parallel group study included 34 patients, aged 16 years or over, with a diagnosis of bilateral nasal polyposis. The patients were randomized to three groups to receive fluticasone propionate in the form of aqueous nasal spray 100 microg twice daily, or nasal drop preparation 400 microg once or twice daily for 12 weeks. Once every four weeks, nasal volumes were measured by acoustic rhinometry and polyp size was assessed by a 4-mm rigid endoscope. Clinical symptom scores were assessed once a week.

RESULTS

The mean nasal polyp scores decreased significantly in all the groups (p<0.005). Total nasal volume did not improve significantly with the nasal spray. Although single daily nasal drop application increased total nasal volume significantly only at the end of treatment (p<0.05), increases with twice daily application were significant at 4, 8, and 12 weeks, compared to the baseline values and corresponding values of the other two groups (p<0.005). Nasal blockage and rhinitis symptom scores improved in all the groups (p<0.05), but the difference from the baseline was highest with twice daily nasal drop application. Smelling showed a significant improvement only with twice daily nasal drop application (p<0.05). In none of the groups did nasal discomfort scores differ significantly from the baseline at the end of treatment.

CONCLUSION

Nasal drop preparation of fluticasone propionate given twice daily showed the highest efficacy in increasing total nasal volume, decreasing nasal polyp size, and improving smelling and nasal blockage.

Treatment of allergic rhinitis during pregnancy

BACKGROUND

Allergic rhinitis (AR) affecting approximately 20-30% of women in childbearing age can be considered one of the most common group of medical conditions that complicate pregnancy. AR with symptoms of nasal obstruction, sneezing, and itching may require pharmacotherapy. However, there are concerns regarding the safety of different available agents that can be used during pregnancy with respect to both maternal and fetal well being.

CONCLUSIONS

The best first-line approach in the management of AR is avoidance of allergens. If environmental modification is ineffective, then the pharmacologic agents should be chosen. For symptoms of rhinorrhea, sneezing, or itching, intranasal cromolyn, with its excellent safety profile, should be considered as first-line therapy. If cromolyn is ineffective or poorly tolerated, first-generation (e.g., chlorpheniramine and tripelennamine) and second generation (e.g., cetirizine and loratadine) antihistamines can be given. Intranasal steroids (e.g., beclomethasone dipropionate, and budesonide) can be added to first-line therapy especially for severe nasal obstruction. There are no epidemiological studies with newer intranasal steroids (e.g., flunisolide, triamcinolone acetonide, fluticasone propionate, and mometasone furoate) during the first trimester of pregnancy. Immunotherapy has not proven to be teratogenic and is clinically useful in improving symptoms. Oral and topical decongestants can be considered as second-line therapy, for short-term relief, when no safer alternative is available.

p21, p53, and p27 Kip1 alterations in benign and malignant tumors of sinonasal epithelium

OBJECTIVE

The goal of this study was to investigate alterations of cell cycle-related molecules, including p27, p21, and p53, in inverted papillomas (IPs) and squamous cell carcinomas (SCCs) of the sinonasal epithelium. Study design Sixteen IPs and 6 SCCs of the sinonasal epithelium, surgically resected at Istanbul Faculty of Medicine, Department of Otorhinolaryngology, from 1992 to 2000 were immunohistochemically investigated (p27, p21, and p53).

RESULTS

A significant decrease in p27 nuclear staining was observed for SCCs of paranasal sinus compared with inverted papillomas (P = 0.0072). In SCCs there was no association between p27 expression and the presence of keratinization and tumor grade. p21 and p53 expressions were not associated with IPs (dysplastic and nondysplastic) and SCCs.

CONCLUSION

Reduced levels of p27 expression correlate with increased cell proliferation in tumors of sinonasal region. Our findings indicate that p27 immunohistochemistry can be recommended to analyze the dysregulation of cell kinetics in these tumors.

Treating allergic rhinitis in the athlete

Allergic rhinitis may affect athletes like any other member of society. It is a major problem for the atopic athlete. Either perennial or seasonal, it may cause problems with nasal function depending upon the type and quantity of allergen exposure. Moreover, exposure to irritants, chemicals and air pollutants may exacerbate allergic rhinitis. In this patient group, special diagnostic and particularly therapeutic considerations are warranted for the disease. Treatment of the athlete should be based on two important principles: no medication given should be on any list of doping products and no medication used should affect the athlete's performance. Antihistamines, topical cromolyn, and topical steroids may be used to control allergic rhinitis without violating 'anti-doping' regulations.

[Evaluation of hearing performance in cochlear implant patients]

OBJECTIVES

To determine the speech perception levels of cochlear implant patients and to evaluate the possible effects of implant type, duration of deafness, and bacterial meningitis on the patients' hearing performance.

PATIENTS AND METHODS

A three-section test battery on speech perception was administered to 21 cochlear implant patients (12 males, 9 females; mean age 25 years; range 9 to 40 years). The patients' performance was assessed with respect to single- or multi-channel implant design, duration of hearing loss, and etiologic factors of hearing loss.

RESULTS

The overall mean success score was 74.6 (range 49-100). No significant difference was found between patients using single- or multi-channel implants. The mean score of 12 patients whose duration of hearing loss was below the average (8.2 years) was significantly higher than those of nine patients with a longer history of hearing loss (85.7 versus 59.6, p=0.001). Patients with meningitis-associated hearing loss exhibited a significantly lower performance than those presenting with other etiologic factors (61.9 versus 84.1, p=0.001).

CONCLUSION

Early diagnosis and rehabilitation are essential to achieve better performance following cochlear implantation.

[The efficacy of laser-assisted uvulopalatoplasty in the treatment of snoring and obstructive sleep apnea]

OBJECTIVES

We evaluated the efficacy of laser-assisted uvulopalatoplasty in the treatment of snoring and obstructive sleep apnea syndrome (OSAS).

PATIENTS AND METHODS

Laser-assisted uvulopalatoplasty was performed in 34 patients (30 males, 4 females; mean age 45.7 years; range 17 to 70 years) with simple snoring and mild OSAS. The patients were evaluated preoperatively and in the first and sixth months postoperatively with the use of the Epworth sleepiness scale, polysomnography, and snoring scores. A questionnaire was administered to assess patient satisfaction.

RESULTS

All patients had decreased snoring. The quality of sleep increased in 79%. The clinical improvement seen in the first month continued through the sixth postoperative month. Satisfaction rates for the patients and their families were 88% and 85%, respectively. Significant decreases were found in the Epworth sleepiness scale (p=0.000) and visual snoring scores (p<0.001). In addition, postoperative desaturation indices decreased and minimal desaturation levels increased. However, no significant decreases occurred in the apnea/hypopnea index. No complications were encountered during and after operation.

CONCLUSION

Laser-assisted uvulopalatoplasty has high efficacy in the treatment of snoring and mild OSAS, with such additional advantages as ease, low complication rate, and no need for hospitalization.

The prognostic relevance of angiogenesis and mast cells in squamous cell carcinoma of the oesophagus

AIMS

Angiogenesis, an important prognostic factor in several tumours, is a complex event mediated by angiogenic factors released from cancer cells and host immune cells. Among the host immune cells, a role has been implicated for mast cells in tumour progression via promoting angiogenesis. Data have been recorded that indicate a correlation between intratumoral neovascularisation, as assessed by microvessel density (MVD), and prognosis in squamous cell carcinoma (SCC) of the oesophagus. However, a correlation between mast cell density (MCD) and either prognosis or angiogenesis has not been delineated yet in this disease. The aim of this study was to investigate the prognostic value of MVD and MCD in SCC of the oesophagus. The correlation between MVD and MCD was also evaluated.

METHODS

MVD and MCD were investigated in tumour specimens from 53 patients diagnosed with SCC of the oesophagus. Intratumoral microvessels were stained with anti-CD34 antibody and mast cells with toluidine blue before being measured by light microscopy.

RESULTS

Both MVD and MCD were associated with the depth of wall invasion, lymph node metastasis, and tumour progression (stage). A significant correlation was noted between MVD and MCD values (r = 0.72). The prognosis was significantly worse in patients with high MVD (> or = 92) and high MCD (> or = 18) values. Multivariate analysis indicated that MVD and stage were independent predictors of survival.

CONCLUSIONS

These findings support the suggestion that MVD is a reliable prognostic marker in SCC of the oesophagus. Moreover, MCD may have a role in the angiogenesis of these tumours and might be responsible for their aggressive behaviour.

Endonasal endoscopic surgical treatment of paranasal sinus inverted papilloma--first experiences

PURPOSE

Surgical excision is generally regarded as the treatment of choice for inverted papilloma. However, the approach and extent of surgery has been subject of much debate. The purpose of this study is to evaluate the results of endoscopic sinus surgery in the treatment of paranasal sinus inverted papilloma.

PATIENTS AND METHODS

Thirteen cases of inverted papilloma of the paranasal sinuses treated via endoscopic sinus surgery were evaluated. The follow-up averaged from 9 months to 48 months with a mean of 27 months.

RESULTS

A close follow-up of all patients was maintained. Seventy-seven per cent (10/13) of the patients had no recurrence after the initial endoscopic procedure. Three patients had recurrences of their tumor within 11 months after surgery, which means a rate of 23% (3/13). In 2 patients, the recurrences were treated endoscopically. In one patient, recurrence and malignant transformation (squamous cell carcinoma) developed after 36 months, which means that the associated carcinoma rate was 7% (1/13). This patient underwent radical maxillectomy and postoperative radiotherapy. None of the patients died of inverted papilloma.

CONCLUSION

Endoscopic sinus surgery is a viable treatment alternative for paranasal sinus inverted papilloma in selected cases. This approach should be performed by experienced surgeons and a close follow-up is mandatory. When the disease is more extensive, it should be approached by radical surgery, e.g. en-bloc excision by medial maxillectomy via lateral rhinotomy or mid-facial degloving.

Evaluation of the effect of passive smoking on otitis media in children by an objective method: urinary cotinine analysis

OBJECTIVES

We aimed to determine objectively the effect of the passive smoking on otitis media with effusion (OME) and recurrent otitis media (ROM) by using the method of cotinine urinalysis.

STUDY DESIGN

We designed a prospective case-control study with follow-up of the case group for 1 year after insertion of tympanostomy tubes to evaluate postoperative complications such as otorrhea and early extrusion (<6 months), in case a significant risk factor was found.

METHODS

One hundred fourteen children between 3 and 8 years of age requiring tympanostomy tubes because of OME and ROM were chosen and compared with 40 age-matched children. Exposure to environmental tobacco smoke was assessed by cotinine urinalysis, which was performed by means of the radioimmunoassay method.

RESULTS

In this study, 73.7% (84 of 114) of the children in the case group and 55.0% (22 of 40) of the children in the control group were found to be "exposed" (P = .0461). This difference was statistically significant. Comparing the cotinine urinalysis results with parental smoking histories, 23.1% (9 of 39) of the children without parental smoking histories were "exposed" to tobacco smoke versus 84.3% (97 of 115) of the children with parental smoking histories (at least one person smoking).

CONCLUSIONS

Our results indicate that sidestream smoking increases the risk of OME and ROM. Legal regulations and guidelines must be established to protect children from passive smoking. Because cotinine urinalysis is a noninvasive and reliable method for the determination of passive smoking, it can be used for that purpose.

Relationship of passive cigarette smoking to otitis media

OBJECTIVE

To determine the effect of passive smoking on otitis media with effusion (OME) and recurrent otitis media (ROM).

DESIGN

A case-control study of children who received ventilation tubes and who were followed up for 1 year to determine the risk of developing postoperative otorrhea and early extrusion in relation to exposure to passive cigarette smoke.

SETTING

Otorhinolaryngology Clinic of Istanbul School of Medicine, Istanbul, Turkey.

PATIENTS

A total of 166 children 3 to 7 years old who required tympanostomy tubes because of OME and ROM (case group) compared with an age-matched control group of 166 children. The control group consisted of children who did not meet and never had met criteria for insertion of tympanostomy tubes.

MAIN OUTCOME MEASURES

Statistical analysis of factors associated with a higher prevalence of OME or ROM, postoperative otorrhea, and early tube extrusion.

RESULTS

Passive smoking was a significant risk factor for OME and ROM. The case group was exposed to a mean of 19.6 cigarettes per day vs 14.4 cigarettes per day for the control group (P<.004). Only maternal smoking was a significant factor (P<.001); no association was found with paternal smoking. Prospective follow-up of the case group showed no significant difference in the clinical course of OME and ROM between maternally exposed and non-maternally exposed children.

CONCLUSIONS

Passive smoking increases the risk of OME and ROM in children between 3 and 7 years old. The avoidance of daily exposure to domestic tobacco smoke could have a public health impact.

The effects of different levels of air pollution on atopy and symptoms of allergic rhinitis

We evaluated the prevalence of symptoms of allergic rhinitis and atopy among two groups living in areas with different pollution levels. The study was conducted among high school students living in Bayrampaşa (polluted by SO2 and TSP) and Beykoz (unpolluted, residential area) in Istanbul (n = 386). Each subject filled out a standardized self-administered questionnaire. Atopic status was evaluated by skin-prick testing using eight different allergens. Also, anterior active rhinomanometry was performed to evaluate the symptoms objectively. Significantly higher prevalence rates for symptoms of allergic rhinitis were found in Bayrampaşa (22.8%) compared to Beykoz (6%). However, no significant difference was found for atopic status among the two groups. When we evaluated the atopic status of subjects with symptoms of allergic rhinitis between the two areas, the prevalence of atopic students was found to be relatively higher in the unpolluted area (BZ). This difference was not statistically significant. Within the atopic population, subjects complaining of symptoms of allergic rhinitis were significantly more frequent in the polluted area (BP), suggesting that air pollution causes an increase in symptoms of allergic rhinitis in the atopic population, but this is not significantly higher than the increase in symptoms of allergic rhinitis of the total study group. Our results suggest that pollutants exert irritant effects on mucous membranes of the population in general rather than aggrevating symptoms in predisposed individuals. Smoking was more frequent in the unpolluted area. Exposure to parental smoking in childhood and heating systems in houses were evenly distributed. Household crowding was lower in Beykoz. Rhinomanometric measurements among the two groups did not show significant difference. Multiple logistic regression models estimating the role of each risk factor independently showed significant odds ratio associated with residence in Bayrampaşa for symptoms of allergic rhinitis (OR = 4.6, 95% CI = 9.0-2.3). In conclusion, this study suggests that outdoor pollution has adverse effects on the symptoms of allergic rhinitis, while it has no effect on the prevalence of atopy in Istanbul in the 1990s.

Physiologic and hypertonic saline solutions impair ciliary activity in vitro

OBJECTIVE/HYPOTHESIS

Physiologic saline (NaCl 0.9%) is commonly used in treating acute and chronic rhinosinusitis. Moreover, physiologic saline is used as a control medium, vehicle, or solvent in studies on ciliary beat frequency (CBF). Hypertonic saline (NaCl 7% and 14.4%) has been applied in attempts to enhance mucociliary transport in patients with cystic fibrosis or asthma and in healthy subjects. Therefore the objective of this study is to document in vitro effects of saline solutions in different concentrations on CBF.

STUDY DESIGN

Experimental, in vitro.

METHODS

The effects on CBF of cryopreserved mucosa of the sphenoidal sinus was measured by a photoelectrical method. Initial frequencies, measured in Locke-Ringer's solution (LR), were compared with CBF after exposure to NaCl in concentrations of 0.9%, 7.0%, and 14.4% (w/v).

RESULTS

NaCl 0.9% has a moderately negative effect on CBF. The 7% solution leads to a complete ciliostasis within 5 minutes, although this effect turns out to be reversible after rinsing with LR. A hypertonic solution of 14.4% has an irreversible ciliostatic effect.

CONCLUSION

LR is an isotonic solution that has no effect on CBF. Therefore it is probable that this solution is more appropriate than saline for nasal irrigation and nebulization or antral lavage. Moreover, the results of this study suggest that mucolytic effects induced by hyperosmolarity should be attained preferably with hypertonic saline 7% in patients with cystic fibrosis or asthma. At this concentration, the ciliostatic effect is reversible, whereas irreversible changes are to be expected at higher concentrations.

Objective and subjective assessment of nasal obstruction in patients undergoing endoscopic sinus surgery

Functional endoscopic sinus surgery (FESS) is the surgical treatment of choice for many physicians in chronic inflammatory diseases of the sinuses. Although subjective benefit has been claimed after surgery, there are not enough studies reporting objective improvement. We evaluated 40 patients undergoing FESS for chronic and recurrent sinusitis with visual analog scale (VAS) scoring of sensation of nasal obstruction and active anterior rhinomanometry of nasal resistance. The results of postoperative measurements demonstrated that baseline total nasal resistance measured with rhinomanometry and evaluated with VAS scoring (baseline and after decongestion) were significantly lower than preoperative measurements. However, improvement in nasal resistance was not statistically significant after decongestion, whereas VAS scoring was. These findings indicate that FESS improves nasal mucosal edema but does not change the structural anatomy of the nose.

The impact of outdoor pollution on upper respiratory diseases

We evaluated the prevalence of upper airway diseases among two groups living in areas with different pollution levels. The study was conducted among highschool students living in Bayrampasa (an area polluted by SO2 and total suspended particulates) and Beykoz (an unpolluted residential area) in Istanbul (n = 386). Each subject filled out a standardized zelf-administered questionnaire. Also, anterior active rhinomanometry was performed to objectively evaluate the symptoms in all students. A significantly higher prevalence rate for rhinitis was found in Bayrampaşa, as compared to Beykoz. However, the prevalence rate for pharyngitis was not significantly different between both groups. Smoking was more frequent in the unpolluted area. Exposure to parental smoking in childhood and heating systems in houses were evenly distributed. Household crowding was lower in Beykoz. Rhinomanometric measurements did not show any significant difference between both groups. Multiple logistic regression models estimating the role of each risk factor independently, showed a significant odds ratio associated with residence in Bayrampasa for rhinitis (OR: 2.0; 95% CI: 3.0-1.3). In conclusion, this study indicates that outdoor pollution has adverse effects on the degree of upper airway diseases in Istanbul in the 1990s.