Clinically important estimates of improvement after septoplasty.

OBJECTIVE: A statistically significant improvement in nasal obstruction ratings following septoplasty is not necessarily clinically important. This study aimed to establish useful measures of septoplasty success, namely the minimal clinically important difference and the desirable clinically important difference. METHODS: Patients rated nasal obstruction on a 0-100 visual analogue scale pre-operatively and at 5.5 months post-operatively. Global outcome rating (completely, much, or somewhat improved, unchanged or worse) served as the anchor post-operatively. Minimal clinically important difference is the visual analogue scale value between 'somewhat improved' and 'unchanged', and the desirable clinically important difference is that between 'much' and 'somewhat improved'. RESULTS: Statistically significant improvement in visual analogue scale scores was not clinically important. The minimal clinically important difference (daytime value of 9.5) represented 15.1 per cent improvement and the desirable clinically important difference (daytime value of 28.5) represented 45.2 per cent, without gender or age differences. CONCLUSION: Clinical success can be defined using a minimal clinically important difference of 15 per cent improvement over a patient's baseline value. Other studies' ratings of 'satisfactory' outcome coincided with a desirable clinically important difference of 45 per cent over baseline. These values are suggested as relevant indicators of septoplasty success.

Self-Reported Complications after Tonsillectomy: Comparison of Responders and Nonresponders to a Mailed Questionnaire.

Some studies of tonsillectomy outcomes have low response rates to mailed quality control questionnaires. This study evaluated the effect of nonresponders to mailed questionnaires about posttonsillectomy complications by determining whether mail responders and nonresponders differ. Questionnaires were mailed to patients 3-6 weeks after tonsillectomy to assess postoperative complications, defined as contact with a private practitioner and/or hospital readmission related to postsurgical bleeding, pain, or infection. Nonresponders to the mailed questionnaire were interviewed by telephone 7-11 weeks postoperatively, and responses of mail and telephone responders were compared. Of 818 patients undergoing tonsillectomy during the study period, 66.3% responded by mail, and 29.5% were interviewed by telephone, for a total response rate of 95.7%. The mail response rate was significantly higher among parents of pediatric patients than among adult patients (71.4% versus 58.7%, p < 0.001). In the pediatric group, overall complication rates were 65% higher among mail responders than telephone responders (20.9% versus 12.7%, p=0.049), likely due to their higher rates of both visits to private practitioners and infection, as there were no differences in rates of pediatric readmission, bleeding, or pain between the responder groups. Among adult patients, mail and telephone responders did not differ with respect to their overall complication rate (40.9% versus 34.1%, p=0.226) or their rates of readmission or bleeding. However, similar to the pediatric group, visits to a private practitioner were slightly more common among adult mail responders than telephone responders (30.6% versus 21.1%, p=0.065), as were reports of pain (p=0.001) and infection (p=0.006). Studies relying on mailed questionnaires with low response rates likely overestimate the rate of minor complications handled outside the hospital, but rates of major complications involving readmission are unlikely to be seriously biased by low response rates. Supplementing mailed questionnaires with telephone interviews may increase the validity of surgical outcome studies.

Unilateral and Bilateral PNIF in Quality Control of Nasal Septal Surgery.

The aim of this study was to explore the usefulness of unilateral, combined unilateral (left + right), and bilateral peak nasal inspiratory flow (PNIF) measurements in assessing the results of nasal septal surgery. Nasal obstruction was recorded subjectively and objectively before and 4 months after nasal septoplasty using a visual analogue scale (VAS) and a PNIF meter. Nasal septoplasty (58 patients) and septoplasty with turbinoplasty (68 patients) were performed on 126 patients (85 males; 41 females) with a mean age of 32.8 years. The results showed a significant improvement in VAS scores, as well as unilateral, combined unilateral, and bilateral PNIF values after both septoplasty and septoplasty with turbinoplasty. Septoplasty with turbinoplasty showed better improvement in VAS and PNIF scores than septoplasty alone and this was significant for bilateral PNIF scores. The best unilateral pre- and postoperative correlations between VAS and PNIF measurements were found using the lower of the two unilateral PNIF scores, irrespective of side. In the total material, VAS/PNIF correlations were mostly significant, but weak (all r<0.30). We found VAS and PNIF to be useful instruments in reporting results of surgery. The weak correlations between VAS and PNIF measurements suggest that these subjective and objective instruments may target different aspects of nasal obstruction.

A questionnaire using vocal symptoms in quality control of phonosurgery: vocal surgical questionnaire.

BACKGROUND: Quality control after phonosurgery is important and may be time consuming. Often questionnaires focusing on quality of life are applied. We aimed at investigating the use of organ specific symptoms, such as hoarseness and voice failure with the use of self-reported visual analogue scales (VAS) and Likert-scales. METHODS: A vocal surgical questionnaire using VAS and Likert-scales for hoarseness, voice failure and factors that could influence voice quality was given twice consecutively to a group of healthy volunteers (n = 57, 45 female) and a group of voice patients (n = 34, 21 females) for a test/re-test study. Secondly, a group of patients undergoing surgery (n = 90, 61females) answered the questionnaire preoperatively and postoperatively. The difference between test/retest, healthy volunteers and patients, and between pre- and postoperative results were compared. RESULTS: There was no significant difference in the test/retest results in healthy volunteers nor in the patient group. There was statistically significant difference between the healthy volunteers and patients, and between the preoperative and postoperative results after phonosurgery. CONCLUSION: This short and organ specific questionnaire clearly demonstrates the effect of phonosurgery, making it an easy and relevant tool in quality control and potentially reducing the need of postoperative controls in the outpatient clinic.

Preoperative Signs and Symptoms as Prognostic Markers in Nasal Septoplasty.

Identification of preoperative signs and symptoms that may predict the outcome of surgery is important, for both patient selection and the development of interventions for improving outcomes. The purpose of this study was to assess the value of some selected preoperative signs and symptoms for predicting outcomes of nasal septoplasty. Patients undergoing septoplasty with or without turbinoplasty responded to the Nasal Surgical Questionnaire (NSQ) preoperatively and six months postoperatively. The questionnaire contains visual analogue scales (VAS) for nasal obstruction during the day and at night. We compared preoperative and postoperative VAS scores in patients with unilateral versus bilateral septal deviation and patients with low versus high preoperative scores. Of 446 patients undergoing septoplasty from September 2014 to December 2015 who had responded to the preoperative NSQ, 286 (64.1%) also returned the postoperative version. There was greater improvement in obstruction in patients with preoperative unilateral compared to bilateral septal deviation (day scores, p = 0.04). The grade of deviation and the presence of concomitant bony conchal hypertrophy did not influence results. Patients with lower preoperative VAS scores obtained better end results than those with higher scores (p = 0.04). Type of septal deviation and preoperative VAS scores may aid in predicting outcome of nasal surgery.

Evaluation of strategies for increasing response rates to postal questionnaires in quality control of nasal septal surgery.

BACKGROUND: Postal questionnaires are often used to assess the results of nasal septoplasty, but response rates vary widely. This study assesses strategies designed to increase the response rate. METHODS: Postoperative questionnaires using visual analogue scales (VAS) for nasal obstruction were mailed to 160 consecutive patients alternately allocated to one of two groups. Group A received the questionnaire in the usual manner and group B received a modified cover letter with hand-written name and signature and a hand-stamped return envelope. RESULTS: Of the 80 patients in each group, 47 (58.8%) in group A and 54 (67.5%) in group B returned the questionnaire (p = 0.25). There were no age or gender differences between the groups, nor did the pre- and postoperative VAS scores differ between the groups. CONCLUSION: The strategies used in this study increased the response rate to postal questionnaires by 8.7% points, but this was not a statistically significant or clinically meaningful improvement.

Evaluation of the Nasal Surgical Questionnaire for Monitoring Results of Septoplasty.

Monitoring the results of surgery is important. The otorhinolaryngology department of our hospital currently uses preoperative and postoperative versions of the Nasal Surgical Questionnaire (NSQ) for continuous evaluation of nasal septoplasty. In this study, 55 patients undergoing septoplasty answered the preoperative version twice to assess the NSQ's test-retest precision, and 75 patients answered the preoperative questionnaire before and the postoperative one 6 months after surgery to evaluate the NSQ's ability to detect change in symptoms following surgery. Both the pre- and postoperative versions of the NSQ use separate visual analogue scales (VAS) to assess nasal obstruction during the day, at night, and during exercise. Other nasal symptoms are graded as secondary outcomes using 4-point Likert scales. The mean VAS scores for the two preoperative obstruction ratings were not significantly different. The scores were significantly higher than in a normal population. There were also significant differences between preoperative and postoperative ratings. The mean pre- and postoperative scores at night for those who reported complete improvement were 66.1 and 8.4, substantial improvement 74.5 and 24.2, and no improvement 83.3 and 76.4. The NSQ reliably assesses nasal symptoms in patients and may be useful for both short and long term prospective studies of septoplasty.

Silicone button in nasal septal perforation. Long term observations.

OBJECTIVE: To assess the long-term survival rate of silicone buttons in nasal septal perforation and to improve selection criteria. To employ a symptom score that might also be used in comparative studies METHODS: Prospective and retrospective study of patients treated with commercially available silicone buttons in a tertiary treatment centre. The observation period of retained buttons was a minimum of four years. RESULTS: The removal rate in 45 patients was 67%, which is higher than in other studies probably due to the long observation period (mean thirteen years). Large perforations and those that are due to septal resection (Killian) are associated with a poor prognosis. Symptom score improvement for all symptoms except snoring was 55%, but for the main nasal symptoms it was 70%. Those who still kept the button were satisfied even though most of them would have preferred operation. Only 11% of all patients consider prosthetic treatment optimal. CONCLUSION: Silicone button is an acceptable treatment for nasal septal perforation in a third of the patients. It is optimal only in a minority. Unfortunately results of surgery expressed in symptom score are not available for comparison. The present scoring system might be preferred.

Nasal septal perforation 1981-2005: changes in etiology, gender and size.

BACKGROUND: Septal perforation is an uncommon but very bothersome illness and treatment is difficult particularly with large perforations. We wanted to establish the etiology and size of nasal septal perforations in an attempt to implement preventive measures. METHODS: This is an open, prospective clinical study of patients seen at our hospital from 1981 to 2005. The clinical data of size, gender and etiology have been recorded consecutively. RESULTS: One hundred and ninety seven patients (100 male, 97 female) were evaluated. Between 1981 and 1995 nasal septal perforation was caused by surgery in 40 of 102 (39.2 %). In the period 1995 to and inclusive of 2005 this percentage decreased as septal resection has been replaced by septo/septorhinoplasty. The latter was the cause for septal perforation in 14.7% in the last period. Nasal steroid and decongestive sprays have emerged as an important cause (28.4 %) during the last ten years particularly in females. In the first period 44 (43.1 %) and in the last 53 (55.7 %) patients were females. There was a noticeable reduction in the number of septal perforations 15 mm or larger in the last period. CONCLUSION: Nasal steroid and decongestive sprays are now important causes for septal perforation. Information about this complication should be given with an advice to immediately report increasing and bothersome crusting and bleeding. Warning of the simultaneous use of nasal steroid and decongestive sprays should be addressed particularly to females. All patients with symptoms of septal perforation should promptly be referred to otolaryngologists for treatment.

Insect sting allergy. A study from 1980 to 2003 of patients who started treatment with venom immunotherapy between 1980 and 1998.

BACKGROUND: Previously we treated patients with insect sting allergy with venom immunotherapy (IT) using whole body insect extracts. From 1980 we changed to insect venoms. The purpose of this study was to analyse data from the patients in order to improve our treatment. METHODS: This is an open, single centre study on patients treated with venom IT 14 years or older with a history of a systemic allergic reaction to an insect sting, a positive skin prick test (SPT) or a positive RAST and willingness to comply with five years of IT. Clinical and laboratory data were registered prospectively at the start of IT and after five years of treatment until 2003 on patients who started IT between 1980 and 1998. Questionnaires were answered in 1989, 1993 and 2003. Statistical analysis was done with Pearson's chi square, Fisher's exact or the t-test. RESULTS: Of 315 patients treated, 44 were given bee, 248 common wasp and 23 both venoms. Of the common wasp sting incidents 5.5 % resulted in a severe allergic reaction (SAR) during adequate IT and 22% after cessation. Seventy-one per cent of the patients carried epinephrine. Precautionary steps were taken by 77% of the patients during or after inadequate IT. On or after adequate IT 83% felt completely or substantially safe. Surprisingly 29 % of those inadequately treated felt safer and 50% were satisfied with having had the opportunity to be treated. The SPT became negative in 68% of the wasp allergic patients after five years of adequate IT. Increased risk of experiencing SAR to a future sting in wasp allergic patients after cessation of adequate IT was significantly associated with a SAR due to IT during the rush regimen. SAR due to IT occurred very rarely during maintenance dosing. CONCLUSION: Adequate venom IT is very effective while ongoing but somewhat less effective after cessation, while inadequate treatment gives poor results. More of our patients should complete five years of IT and some should continue IT. The type of reaction to IT during incremental dosing may be of help in deciding who should continue beyond five years. Maintenance IT may be taken over by the general physician.

Morning versus evening dosing of desloratadine in seasonal allergic rhinitis: a randomized controlled study [ISRCTN23032971].

BACKGROUND: A circadian rhythm of symptoms has been reported in allergic rhinitis and some studies have shown the dosing time of antihistamines to be of importance for optimizing symptom relief in this disease. The objective of this study was to examine the efficacy of morning vs. evening dosing of the antihistamine desloratadine at different time points during the day. METHODS: Patients >/= 18 years, with seasonal allergic rhinitis received desloratadine 5 mg orally once daily in the morning (AM-group) or evening (PM-group) for two weeks. Rhinorrhea, nasal congestion, sneezing and eye symptoms were scored morning and evening. Wilcoxon rank sum and 2-way ANOVA test were used. RESULTS: Six-hundred and sixty-three patients were randomized; 336 in the AM-group; 327 in the PM-group. No statistically significant differences were seen between the AM and PM group at any time points. In the sub-groups with higher morning or evening total symptom score no difference in treatment efficacy was seen whether the dose was taken 12 or 24 hours before the higher score time. There was a circadian variation in baseline total symptom score; highest during daytime and lowest at night. The circadian variation in symptoms was reduced during treatment. This reduction was highest for daytime symptoms. CONCLUSIONS: A circadian rhythm was seen for most symptoms being more pronounced during daytime. This was less apparent after treatment with desloratadine. No statistically significant difference in efficacy was seen whether desloratadine was given in the morning or in the evening. This gives the patients more flexibility in choosing dosing time.

Human nasal mucosa contains antigen-presenting cells of strikingly different functional phenotypes.

Professional antigen-presenting cells (APCs) constitute a heterogeneous leukocyte population that controls T cell induction. Experimental animal studies have delineated the principal APCs of the airway mucosa as a network of intraepithelial dendritic cells (DCs). Whether the situation is comparable in the human airways is unknown. Here we performed a detailed characterization of putative APCs residing in the normal upper airway mucosa, employing confocal microscopy of whole-mount preparations combined with immunophenotyping. A dense network of human leukocyte antigen-DR+ cells with dendritic morphology was found not only in the epithelium (median number, 573/mm2), but also in the lamina propria. In both compartments these cells could be divided into two main populations based on their phenotypic characteristics: the majority expressed a macrophage-like phenotype (CD11b+CD14+CD64+CD68+RFD7+), whereas the smaller population was predominantly constituted by CD1c+CD11c+ immature DCs intermingled with the former. These immature DCs corresponded to the lineage-negative human leukocyte antigen-DR+CD11c+ DC subset present in peripheral blood. Thus, the human upper airway mucosa, in contrast to the rodent counterpart, contains a heterogeneous dense network of dendritic APCs consisting of spatially closely related macrophages and DCs. How these two cell populations regulate the tone of the local adaptive immune system should be the focus of further studies.

[Sinus radiography and low-dose CT in the diagnosis of acute sinusitis. ]. / Røntgen bihuler og lavdose-CT ved akutt sinusitt.

Background. Although CT is considered the method of choice in the evaluation of inflammatory sinus disease, plain film radiography is still used, as repetitive CT examinations may impart a considerable radiation dose to the lens. We designed a new low-dose CT examination and compared this and plain film radiography to standard-dose CT. Methods and materials. The new CT low-dose protocol consisted of ten coronal scans at 40 mAs and 1 mm collimation. 47 patients referred for acute sinusitis were examined with plain film radiography, low-dose and standard-dose CT on the same day. The latter was used as "the gold standard". Results. The sensitivity of plain film radiography was low (< 50 %) except for the maxillary sinus (80 %). The overall sensitivity of low-dose CT was 95 % and the specificity 97 %. Effective dose and lens dose of low-dose CT were 3 % and 2 % respectively compared to standard-dose CT. Corresponding values for conventional radiography were 13 % and 2 %. Interpretation. Low-dose CT had image quality comparable to standard-dose CT and a dose to the eye lens equal to plain film radiography. Low-dose CT should be the method of choice in patients referred for acute sinusitis.