Changed sense of smell - what can be done? / Endret luktesans ­ hva kan gjøres?

Olfactory dysfunction is common. Otorhinolaryngologists can perform examinations, but GPs can also provide treatment where the cause is known.

A validation study of an esophageal probe-based polygraph against polysomnography in obstructive sleep apnea.

STUDY OBJECTIVES: The aim of this study was to validate the automatically scored results of an esophageal probe-based polygraph system (ApneaGraph® Spiro) against manually scored polysomnography (Nox A1, PSG) results. We compared the apnea-hypopnea index, oxygen saturation index, and respiratory disturbance index of the devices. METHODS: Consenting patients, referred for obstructive sleep apnea workup, were tested simultaneously with the ApneaGraph® Spiro and Nox A1® polysomnograph. Each participant made one set of simultaneous registrations for one night. PSG results were scored independently. Apnea-hypopnea index, oxygen desaturation index, and respiratory disturbance index were compared using Pearson's correlation and scatter plots. Sensitivity, specificity, and positive likelihood ratio of all indices at 5, 15, and 30 were calculated. RESULTS: A total of 83 participants had successful registrations. The apnea-hypopnea index showed sensitivity of 0.83, specificity of 0.95, and a positive likelihood ratio of 5.11 at an index cutoff of 15. At a cutoff of 30, the positive likelihood ratio rose to 31.43. The respiratory disturbance index showed high sensitivity (> 0.9) at all cutoffs, but specificity was below 0.5 at all cutoffs. Scatterplots revealed overestimation in mild OSA and underestimation in severe OSA for all three indices. CONCLUSIONS: The ApneaGraph® Spiro performed acceptably when OSA was defined by an AHI of 15. The equipment overestimated mild OSA and underestimated severe OSA, compared to the PSG.

Causes of higher symptomatic airway load in patients with chronic rhinosinusitis.

BACKGROUND: Chronic rhinosinusitis display a variety of different phenotypes. The symptoms of disease are characterised by various signs and symptoms such as nasal congestion, nasal discharge, pressure sensation in the face and reduced or complete loss of smell.In a patient population undergoing functional endoscopic sinonasal surgery (FESS) for chronic rhinosinusitis, we wanted to investigate the clinical features and explore if the presence of biofilm, nasal polyps or other disease characteristic could serve as predictor for the symptomatic load. A patient group undergoing septoplasty without disease of the sinuses was included as control. METHODS: The Sinonasal outcome test (SNOT-20), EPOS visual analogue scale (VAS) and the Lund-Mackey CT score (LM CT score) were used to examine 23 patients with chronic rhinosinusitis without nasal polyps (CRSsNP), 30 patient with nasal polyps (CRSwNP) and 22 patients with septal deviation. Tissue samples were collected prospectively during surgery. The cohort has previously been examined for the presence of biofilm. RESULTS: Patients with CRSsNP and CRSwNP had significantly higher degree of symptoms compared to the septoplasty group (SNOT-20 scores of 39.8, 43.6 and 29.9, respectively, p = 0.034). There were no significant differences in the total SNOT-20 or VAS symptoms scores between the CRSsNP and CRSwNP subgroups. However patients with nasal polyps showed significantly higher scores of symptoms related to sinonasal discomfort such as cough, runny nose and need to blow nose (p = 0.011, p = 0.046, p = 0.001 respectively). Patients with nasal polyps showed a significantly higher LM CT score compared to patients without polyps (12.06 versus 8.00, p = 0.001). The presence of biofilm did not impact the degree of symptoms. CONCLUSION: The presence of nasal polyp formations in CRS patients was associated with a higher symptomatic airway load as compared to patients without polyps. These findings suggest that nasal polyps could be an indicator of more substantial sinonasal disease. The presence of biofilm did not impact the degree of symptoms, however, as biofilm seem to be a common feature of chronic rhinosinusitis (89% in this cohort), it is more likely to be involved in the development of the CRS, rather than being a surrogate marker for increased symptomatic load.

Bacterial biofilms in chronic rhinosinusitis; distribution and prevalence.

CONCLUSION: Biofilms were more prevalent in patients with CRSwNP compared to both CRSsNP and controls, and also on the ethmoid bulla compared to the middle turbinate, supporting a biofilm-related pathogenesis of CRSwNP. OBJECTIVE: To investigate the prevalence of biofilms in patients with chronic rhinosinusitis with nasal polyps (CRSwNP) compared to patients with chronic rhinosinusitis without nasal polyps (CRSsNP) and controls. To examine the prevalence of biofilms in different anatomical localizations. STUDY DESIGN: Cross-sectional. METHODS: This study comprised 27 patients with CRSsNP, 34 patients with CRSwNP, and 25 controls. Biopsies from the middle turbinate, the uncinate process, and the ethmoid bulla were harvested pre-operatively, snap frozen in isopentane, cooled, and stored at -80°C. Prepared with Invitrogens' Baclight LiveDead kit and investigated with confocal scanning laser microscopy. RESULTS: Biofilms were studied in 33/34 (97%) CRSwNP, 22/27 (82%) CRSsNP, and 14/25 (56%) controls. The difference in point prevalence between patients with CRSwNP vs CRSsNP (p = 0.042, χ(2) = 4.12), CRSwNP vs Controls (p < 0.001, χ(2) = 15.0), and CRSsNP vs controls (p = 0.047, χ(2) = 3.96) were all significant. Biofilms were found in 43/54 (80%) ethmoid bulla, 39/55 (71%) uncinate process, and 31/50 (62%) middle turbinate. The difference between the ethmoid bulla and the middle turbinate locations (p = 0.047, χ(2) = 3.93) was significant.

Beta-trace protein in pediatric otitis media with effusion.

OBJECTIVES: The middle ear cleft connects by membranes to the inner ear and the subarachnoid space particularly in infants. In order to gain more insight about the permeability between the two compartments we quantified the concentration of beta-trace protein - a highly specific marker for CSF and perilymph but not for serum and mucosal effusion - in middle ear secretions from children with otitis media with effusion. METHODS: One-hundred and three patients were included and 93 samples from secretory otitis media were collected during myringotomy or explorative tympanotomy. Thirty-eight patients of 103 had to be excluded (36.9%). Of the 93 collected samples from 65 subjects, 82 viscous samples were pre-diluted 1:1 with tyloxapol. In spite of the attempt to pre-dilute the viscous samples, 30 glue-like samples of 93 were not applicable for nephelometry. The final analysis was made on 63 samples of 52 subjects (median age 3 years) which were quantified for beta-trace protein using immunonephelometry. RESULTS: In 3/63 samples the beta-trace protein values were below the detection range (<0.2 mg/L) and in 1/63 it was beyond with 18.3mg/L. The median beta-trace protein value for 59 samples within the measuring range was 2.4 mg/L, range 0.2-14.2. CONCLUSION: In pediatric middle ear effusions, the beta-trace protein concentration was found to have a high range compared to other body fluids from other studies. In other studies, the values for serum (0.59 mg/L) or mucosal secretion (0.003-0.12 mg/L) were lower and the values in CSF (18.4 mg/L) or perilymphatic fluid (23.5 mg/L) were highest. This finding might indicate a weak barrier between the cerebrospinal fluid space or inner ear fluid compartments on the one side and the tympanic cavity on the other side given the condition of otitis media with effusion. The detection of beta-trace protein might be important to assess the risk of impending complications.

Living with hereditary haemorrhagic telangiectasia: coping and psychological distress - a cross-sectional study.

PURPOSE: The purpose of this study was to examine the relationship between coping strategies measured by Coping Orientation to Problems Experienced Scale (COPE) and psychological distress measured by Hospital Anxiety and Depression Scale (HADS) and Becks Hopelessness Scale (BHS) in individuals living with Hereditary hemorrhagic telangiectasia (HHT) and to examine if coping strategies might have a mediating role between experienced illness and psychological distress. HHT is mainly caused by mutations in the ENG- or ALK1-genes and associated with a shorter life span. 90% of patients have recurrent nosebleeds. METHOD: 66 individuals affected of HHT participated in this cross-sectional study, completing questions due to demographic variables, Experience of illness, COPE, BHS and HADS. X(2) test, bivariate correlations with Pearson r and hierarchical multiple regression were used using PASW 18. RESULTS: Experience of illness made the highest variance in anxiety, depression and hopelessness and the coping strategy "behavioral disengagement" seems to have a mediating role between nose bleedings, being afraid of complications, satisfied with life and psychological distress. CONCLUSIONS: Experience of illness is of big importance in psychological distress in individuals affected of HHT, and behavioral disengagement explained the actual relationship between experience of illness and psychological distress.

Quality of life in patients with hereditary hemorrhagic telangiectasia in Norway: a population based study.

Hereditary hemorrhagic telangiectasia (HHT) is a rare, autosomal dominant disease characterized by the presence of recurrent epistaxis and small characteristic malformations of the peripheral blood vessels near the surface of the skin or mucosal linings. Arteriovenous malformations (AVM) of the lung, liver, and CNS are also known clinical findings. The purpose of this study was to examine quality of life (QoL) in patients with HHT in Norway. Sixty-six affected patients (39 women and 27 men) were included. QoL on overall-, health-related (HR-QoL), and disease-specific levels were measured with Cantril's Ladder (CL), Short Form 36 (SF-36), and a Symptom-specific QoL question in HHT patients (SFB-HHT-Q), respectively. Comparisons were made between patients and an age and gender adjusted normative sample from the Norwegian population (N = 990). Overall, the results reflected that several HHT disease-related variables were associated with reduced QoL on all three levels; overall QoL (CL), HR-QoL (SF36) as well as disease-specific QoL (SFB-HHT-Q), while demographic variables impacted HR-QoL in HHT patients. Compared to the normative sample, all subscales of SF36, but bodily pain, were significantly poorer in the HHT patients. HHT disease variables had the strongest association with QoL compared to demographic variables. The results substantiate that disease severity is associated with poorer QoL in this patients. Pain contributed independently to all levels of QoL.

The natural history of epistaxis in patients with hereditary hemorrhagic telangiectasia in the Norwegian population: a cross-sectional study.

BACKGROUND: Epistaxis is usually the first and most common symptom in hereditary hemorrhagic telangiectasia (HHT), which is known also as Rendu-Osler-Weber syndrome. The severity of HHT-associated epistaxis is highly variable and can affect the patient's quality of life. In the literature, the natural history of epistaxis in HHT patients has been described in a few countries but not from the Norwegian population. OBJECTIVE: This work focused on the natural history of epistaxis in the Norwegian population in a cross-sectional study. MATERIAL AND METHODS: Ninety-eight patients with three or four Curaçao criteria were included. The severity of epistaxis was graded depending on epistaxis intensity, frequency, and the amount of blood transfusion during a period of 4 weeks. The epistaxis grades were studied in association with age, gender, gene mutation, age of onset, and whether the patient had or had not been treated for epistaxis during the last 2 years. RESULTS: Most of the HHT patients (90%) complained of mild-to-moderate epistaxis. Seventy-seven percent of the patients started epistaxis by or before the age of 20 years. The progression of HHT-associated epistaxis with age could not be proved statistically in this study. There was no statistically significant difference in the grades of epistaxis between HHT1 and HHT2 type, neither between female and male patients. Most of the patients started epistaxis by or before the age of 20 years. There was a significant difference in the grade of epistaxis between non-ENG, non-ALK1 carrier patients, and ENG or ALK1 carrier patients. CONCLUSION: Compared with other populations, the grading of epistaxis in Norwegian patients with HHT gave generally similar results. A multicenter epidemiological study is required to get a larger study population. A common internationally accepted grading or classification system for epistaxis in HHT is highly recommended.

ß-trace protein as a diagnostic marker for perilymphatic fluid fistula: a prospective controlled pilot study to test a sample collection technique.

OBJECTIVES: The diagnosis of perilymphatic fluid (PLF) fistula is still challenging. Perilymphatic fluid fistula is one possible complication after stapedotomy or cochlear implant surgery. We have performed a prospective diagnostic pilot study to further investigate ß-trace protein (ß-TP) as a marker for PLF fistula. In this pilot study, we tested the sensitivity of the ß-TP marker using a simple method for sample collection from the tympanic cavity. DESIGN: Prospective controlled diagnostic study. SETTING: Two-center tertiary referral hospitals. PATIENTS: A total of 35 adult patients undergoing ear surgery were included. Subjects were divided into 2 groups: 1) 19 patients undergoing stapedotomy were investigated for PLF fistula in samples obtained from the tympanic cavity and 2) 16 patients undergoing myringoplasty were investigated for PLF fistula in samples from the tympanic cavity. This group served as the control. Mean age +/- SD at surgery was 49.9 +/- 8.0 years in the study group and 39.69 +/- 15.47 years in the control group. INTERVENTION: ß-Trace protein (prostaglandin D synthase) in tympanic cavity samples and serum samples was analyzed. The samples were collected by gradually filling the tympanic cavity with 100 to 200 µl sodium chloride and by immediately collecting a volume of 60 to 100 µl in a mucus specimen set container. MAIN OUTCOME MEASURES: The concentration of ß-TP was quantified using laser nephelometry. RESULTS: The median ß-TP in the study group was 0.8 mg/L (range, 0.05-4.5 mg/L). In the control group, the median ß-TP value was 0.16 mg/L (range, 0.01-0.36 mg/L). Thirty-five percent of the values in the study group were below the highest value in the negative control group. The ß-TP values of the tympanic cavity samples were significantly higher in the study group than in controls (p = 0.0001). The serum values were 0.55 +/- 0.18 and 0.53 +/- 0.11 mg/L, respectively. CONCLUSION: It may be feasible to test for PLF fistula using ß-TP in samples from the tympanic cavity. Our results, however, suggest a relative low diagnostic sensitivity, given a cutoff that is set to obtain a high specificity when using a simple sample collection method. Furthermore, the test does not permit the distinction between PLF fistula and cerebrospinal fluid fistula. Further studies should focus on minimal dilution at sampling and on minimizing sample volumes.

[Surgery at the skull base with transnasal endoscopic control]. / Skallebasiskirurgi med transnasal endoskopisk kontroll.

INTRODUCTION: Skull base surgery is targeted to diseases in the posterior, lateral or anterior skull base. Development of endoscopic paranasal sinus surgery has contributed to expand the indications for transnasal surgery at the anterior skull base. Patients do not have visible scars and have less postoperative pain after endoscopic surgery and a decreased postoperative morbidity in general results in a shorter hospital stay. MATERIAL AND METHODS: An overview is given of transnasal endoscopic skull base surgery, based on literature retrieved from PubMed and illustrated by three patients operated at the University Hospital of Northern Norway. RESULTS AND INTERPRETATION: Transethmoid meningoencephalocele, pituitary conditions and the need for biopsy from the cavernous sinus are presented as suitable indications for transnasal endoscopic skull base procedures. From an anatomical point of view, the skull base is situated between the orbit, the ear and the paranasal sinuses on one side and the brain on the other side. Several specialties are therefore involved in skull base surgery, and interdisciplinary cooperation is important. Computer-assisted surgical instruments and navigation systems based on digital imaging enable an improved perioperative orientation and thereby improves the safety of skull base surgery. Endoscopic surgery at the skull base may contribute to reduce surgical morbidity and hospitalization and thereby has a health economic potential.

Diagnostic values of beta-2 transferrin and beta-trace protein as markers for cerebrospinal fluid fistula.

INTRODUCTION: During recent decades, beta2-transferrin and beta-trace protein (prostaglandin D synthase) have been used as immunological markers for the diagnosis of CSF fistula. A method for detecting CSF traces should be non invasive, reliable and cheap. METHODS: The characteristics of the two immunological markers are described based on own experience and a literature review. PubMed (1966-2007) was searched and 39 articles were retrieved from the period 1987-2007. RESULTS: The beta2-transferrin marker showed a high reliability during the last decades using immunofixation or immunoblotting. The performance of beta2-transferrin assay requires between two and four hours hands-on time in the laboratory depending on the assay. The beta-trace protein protein marker showed a high reliability when assayed using immunoelectrophoresis or laser-nephelometry. Laser-nephelomety is automated, non- time consuming, provides quantitative results and last but not least, is cheap. A cut-off point at 1.11 mg/l for beta-trace protein gave the best trade-off between high sensitivity and high specificity when including the secretion/serum ratio. CONCLUSION: Both beta2-transferrin and beta-trace protein are reliable immunological markers for the detection of CSF traces. High diagnostic accuracy values were found for both beta2-transferrin and beta-trace protein protein.

Incidence of CSF fistula after paranasal sinus surgery: the Northern Norwegian experience.

STATEMENT OF PROBLEM: Cerebrospinal fluid (CSF) fistula is a well-known complication of paranasal sinus surgery. Not only manifest, but also occult CSF fistulas occur. The incidence of occult CSF fistula has been described only once and has not been tested since. MATERIAL AND METHODS: In a prospective diagnostic study, the incidence of manifest and occult CSF fistulas was measured. Forty four patients operated for paranasal sinus diseases were included between 2002 and 2006. Seventy four fluid samples were collected by pressing nasal tamponades the day after surgery, and were measured for beta-trace protein using laser-nephelometry. In patients with a beta-trace value in secretion between 0.68 and 1.11 mg/l, a serum sample was taken and measured for beta-trace protein. RESULTS: Thirty-one patients had a secretion beta-trace protein value below 0.68 mg/l. Thirteen patients had a secretion beta-trace protein value between 0.68 and 1.11 mg/l. The secretion/serum ratio in this group was below 1.57, not indicating the presence of CSF traces. The incidence of CSF fistula in this study population was zero. PRINCIPAL CONCLUSION: A previously described incidence of occult CSF fistula after paranasal sinus surgery was not confirmed in the present study.

Transpterygoid Trans-sphenoid Approach to the Lateral Extension of the Sphenoid Sinus to Repair a Spontaneous CSF Leak.

OBJECTIVE AND IMPORTANCE: Cerebrospinal fluid (CSF) fistula from the middle cranial fossa into the sphenoid sinus is a rare condition. In the past, the treatment of choice has been closure via a craniotomy. Only few geriatric cases are known, which were successfully operated by endoscopic surgery. We present a further case of nontraumatic CSF fistula originating from the middle cranial fossa. A new endoscopic technique was applied. We discuss treatment options for this rare defect. CLINICAL PRESENTATION: A 76-year-old patient presented with a 2-year history of rhinorrhea. High levels of beta-trace protein pointed to a diagnosis of CSF fistula. The defect was located at the anterior and inferior aspect of the pterygoid recess of the left sphenoid sinus. INTERVENTION: The patient was operated using an endoscopic trans-sphenoidal approach. After endoscopic opening of the maxillary and sphenoid sinus, a complete posterior ethmoidectomy was performed. The medial part of the pterygoid process was removed, allowing endoscopic exposure and closure of the defect. At 1-year follow-up, the CSF fistula had not recurred and the patient had no sequel from the surgical procedure. CONCLUSION: In selected cases, this new endoscopic partial transpterygoid approach to the middle cranial fossa is recommended for surgical repair of CSF fistula involving the lateral extension of the sphenoid sinus. To our knowledge, ours is the oldest patient with this condition successfully operated by endoscopic means at the world's most northern university hospital.

First clinical experience with beta-trace protein (prostaglandin D synthase) as a marker for perilymphatic fistula.

A diagnosis of perilymphatic fistula is still controversial. Recently, a case report indicated that beta-trace protein (prostaglandin D synthase) might be a potential marker for perilymphatic fluid. In this multicentre clinical case series study beta-trace protein was used as a marker for perilymphatic fluid fistula. Fifteen fluid samples were collected during diagnostic tympanoscopy. In addition, five samples were collected from patients with tympanic membrane perforation for use as as negative controls. Samples were obtained using precision glass capillaries and were analysed for beta-trace protein using laser nephelometry. The diagnosis of perilymphatic fistula was defined by the patient's history, the audiological and vestibular investigation and the findings at tympanoscopy. The cut-off level of beta-trace protein for perilymph-positive samples was chosen at 1.11 mg/l. The sensitivity and specificity were calculated using a 2 x 2 contingency table. There was no false positive result, but in two cases a false negative result was found. The specificity was 1 and the sensitivity was 0.81. The material of this first clinical study is small owing to the rarity of patients undergoing diagnostic tympanoscopy for perilymphatic fluid fistula. However, according to these preliminary results beta-trace protein might be a promising marker in the diagnosis of perilymphatic fluid fistulas.

[Treatment of Frey's syndrome using botulinum toxin]. / Behandling av Freys syndrom med botulinumtoksin.

BACKGROUND: Frey's syndrome, also known as gustatory sweating, has been known for 150 years. However, effective treatment was established only as recently as in 1994, with botulinum toxin used for the treatment of torticollis or other forms of spasticity. MATERIAL AND METHODS: We present an overview over Frey's syndrome. Diagnosis with Minors sweating test and treatment with botulinum toxin is presented on the basis of our own experience. Relevant literature was found through Medline. RESULTS AND INTERPRETATION: Botulinum toxin injected intracutaneously is a safe and effective method for the treatment of Frey's syndrome. The results are convincing and the method is well documented in the literature. So far, no serious side effects have been found.