Dose-dependent relationship between nocturnal gastroesophageal reflux and chronic rhinosinusitis in a middle-aged population: results from the SCAPIS pilot.

BACKGROUND: Gastroesophageal reflux (GER) has been associated with several upper- and lower-airway diseases. It would be plausible if nightly occurring reflux via laryngopharyngeal reflux (LPR) might affect the upper airways. Still, the role of nocturnal gastroesophageal reflux (nGER) in chronic rhinosinusitis (CRS) is not fully established. The aim of this population-based study was to investigate the association between nGER and CRS. METHODOLOGY: This cross-sectional population-based study comprises 1,111 randomly selected subjects from Gothenburg, Sweden, aged 50-64 years. The study is based on self-reported validated questionnaires. CRS was defined according to EPOS criteria. nGER was reported in relation to frequency. RESULTS: CRS was more common among subjects with nGER than in those without (13 vs. 4.8%). There was a dose-response association between the frequency of nGER episodes and the risk of having CRS. In the logistic regression adjusted for (age, sex, BMI, educational level, smoking, and asthma). CRS was associated with nGER, OR 1.43 and the odds ratio increased if episodes were reported 'almost every night' OR 4.6. CONCLUSIONS: The study shows an association between nocturnal GER and CRS in a middle-aged population. The revealed dose dependency supports, though does not prove causality.

Surgery to relieve nasal obstruction: outcome for 366 patients operated on by one senior surgeon.

BACKGROUND: Studies of patient-rated outcome in septoplasty and turbinoplasty most frequently involve several surgeons with varying surgical skills, techniques and experience. The aim of the present study was to evaluate outcome based on one experienced surgeon. METHODS: Three hundred and sixty-six consecutive patients referred for nasal obstruction were included. All the patients were examined with nasal endoscopy before and after decongestion, they filled out a nose VAS and rated their overall general health before and three to six months after surgery. The patients underwent septoplasty, septoplasty plus turbinoplasty or turbinoplasty. RESULTS: The mean nose VAS for nasal obstruction (0-100) preoperatively was 64.7 for all patients. Patients undergoing septoplasty (n = 159) were younger than patients undergoing septoplasty + turbinoplasty (n = 79) or patients undergoing turbinoplasty alone (n = 128). The nose VAS for nasal obstruction improved significantly in all three groups and 25% had a normal nose VAS after surgery in the septoplasty and septoplasty + turbinoplasty groups compared to only 8% in the turbinoplasty alone group. There was no significant difference in the improvement in nasal obstruction between septoplasty and septoplasty + turbinoplasty, but the septoplasty + turbinoplasty group experienced a significantly greater improvement in general health. CONCLUSIONS: In 366 patients operated on by one experienced surgeon, septoplasty and septoplasty + turbinoplasty were more effective at relieving nasal obstruction than turbinoplasty alone. Septoplasty + turbinoplasty resulted in a greater improvement in general health than septoplasty alone, despite the same improvement in nasal obstruction, indicating a beneficial effect of additional turbinoplasty in septoplasty.

Occupational exposure and the risk of new-onset chronic rhinosinusitis â€" a prospective study 2013-2018.

BACKGROUND: The aetiology behind chronic rhinosinusitis (CRS) is still poorly understood. The aim of this study was to investigate the association between the onset of CRS and several common occupational exposures over time. METHODOLOGY: An adult random population from Telemark, Norway, comprising 7,952 subjects, who answered a comprehensive respiratory questionnaire including questions on CRS and occupational exposure first in 2013 and again in 2018. RESULTS: New-onset CRS during the five-year follow-up was independently associated with occupational exposure to hair-care products, cleaning agents among women, super glue, strong acids, cooking fumes and wood dust. CONCLUSION: In this random population cohort from Norway, exposure to several common occupational agents, such as hair-care products, super glue and wood dust, was associated with the onset of CRS. It is important that physicians who see patients with CRS inquire about workplace exposure.

Prognostic factors for outcome after septoplasty in 888 patients from the Swedish National Septoplasty Register.

BACKGROUND: The aim of this study was to identify predictors of outcome after septoplasty in 888 patients from the Swedish National Septoplasty Register. METHODOLOGY: This is an observational register study analysing data from patients undergoing septoplasty in Sweden between 2015 and 2016. The patients reported severity of nasal obstruction (mild, moderate, severe) pre- and again 12 months postoperatively (none, mild, moderate, severe), unplanned visits within 30 days after surgery. The examining doctor reported co-morbidities such as allergic rhinitis and snoring. The primary end-point was one level improvement of the nasal obstruction 12 months after surgery. RESULTS: Nasal obstruction had improved in 63% 12 months after surgery. Twelve months after surgery, 81% with severe nasal obstruction and 31% with mild nasal obstruction before surgery had improved. Only 56% reported that the results of the surgery were as they had expected. Higher patient age at surgery, no unplanned visits within 1 month of surgery and activity limitation before surgery were associated with improvements in nasal breathing in the logistic regression model. CONCLUSION: Septoplasty should be offered to patients with severe nasal obstruction and surgery should be avoided in mild nasal obstruction confirmed by both an improvement in nasal obstruction and patient expectations in this study.

Indirect costs related to caregivers' absence from work after paediatric tonsil surgery.

Tonsillotomy has gradually replaced tonsillectomy as the surgical method of choice in children with upper airway obstruction during sleep, because of less postoperative pain and a shorter recovery time. The aim of this study was to examine the costs related to caregivers' absenteeism from work after tonsillectomy (TE) and tonsillotomy (TT). All tonsillectomies and tonsillotomies in Sweden due to upper airway obstruction during 1 year, reported to the National Tonsil Surgery Register in children aged 1-11 were included, n = 4534. The number of days the child needed analgesics after surgery was used as a proxy to estimate the number of work days lost for the caregiver. Data from the Social Insurance Agency (Försäkringskassan) regarding the days the parents received temporary parental benefits in the month following surgery were also analysed. The indirect costs due to the caregivers' absenteeism after tonsillectomy vs tonsillotomy were calculated, using the human capital method. The patient-reported use of postoperative analgesic use was 77% (n = 3510). Data from the Social Insurance Agency were gathered for all 4534 children. The mean duration of analgesic treatment was 4.6 days (indirect cost of EUR 747). The mean number of days with parental benefits was 2.9 (EUR 667). The indirect cost of tonsillectomy was 61% higher than that of tonsillotomy (EUR 1010 vs EUR 629). The results show that the choice of surgical method affects the indirect costs, favouring the use of tonsillotomy over tonsillectomy for the treatment of children with SDB, due to less postoperative pain.

Nocturnal GERD - a risk factor for rhinitis/rhinosinusitis: the RHINE study.

BACKGROUND: It has been suggested that gastroesophageal reflux disease (GERD) is a risk factor for developing rhinitis/rhinosinusitis, but data are lacking. This is a prospective 10-year follow-up study of a large multicenter cohort from Northern Europe, evaluating the relationship between nocturnal GERD and noninfectious rhinitis (NIR). METHODS: The study comprised 5417 subjects born between 1945 and 1973, who answered a questionnaire in 1999-2001 and again in 2010-2012. Noninfectious rhinitis was defined as having nasal obstruction, secretion, and/or sneezing without having the common cold. Odds ratios for developing NIR in relation to age, gender, BMI, smoking, asthma, and nocturnal GERD were calculated. RESULTS: During the 10-year observation period, 1034 subjects (19.1%) developed NIR. Subjects reporting nocturnal gastroesophageal reflux in both 1999 and 2010 had more NIR in 2010 (2.8% vs 1.2%, P < 0.001). There was a significant dose-response relationship between the number of reflux episodes/week in 1999 and the risk of having NIR in 2010, P = 0.02. In the multiple regression adjusted for age, gender, BMI, tobacco smoke, and asthma, those with nocturnal GERD in 1999 (≥3 episodes of nocturnal gastroesophageal reflux symptoms per week) had an OR of 1.6 (95% CI 1.0-2.5, P = 0.03) to develop NIR in 2010. Smoking was associated both with an increased risk of developing NIR (30.7% vs 24.0%, P < 0.001) and with the development of nocturnal GERD. CONCLUSION: This large, population-based, 10-year study indicates that nocturnal GERD was a risk factor for noninfectious rhinitis/rhinosinusitis. GERD should therefore be considered in patients with rhinitis of known and unknown origin.

Simulated postnasal mucus fails to reproduce the symptoms of postnasal drip in rhinitics but only in healthy subjects.

BACKGROUND: Post nasal drip (PND) is a very common symptom associated with upper respiratory tract disorders. While easy to visualize, the concept of PND due to an increased volume of secretions which move from the posterior nasal choanae into the posterior nasopharynx/oropharynx may be overly simplistic. PND could also be associated with altered viscosity of nasal secretions. An alternative hypothesis is that the sensation of PND is due to mucosal inflammation resulting in heightened cough or irritant throat sensory dysfunction. The impact of viscous secretions on the symptoms of PND is assessed. METHODS: Healthy subjects and rhinitis patients were recruited. Patients were asked about PND symptoms with a 9 item PNDSS questionnaire at baseline and after the insertion of two different viscosities of artificial mucus utilizing hydroxypropyl methylcellulose at 1% and 4%. RESULTS: Sixty six patients were recruited. As expected, rhinitics had an increased sense of PND compared to healthy subjects at baseline. However, only healthy subjects could detect the increased viscosity of secretions and where rhinitics failed to respond. Cough was not induced in either group. CONCLUSION: The mechanisms of PND in chronic patients and those with rhinitis are likely to have other aetiologies other than simply increased or more viscous secretions.

Unmet challenges in septoplasty-nordic studies from a uniform healthcare and geographical area.

Purpose: Nasal septoplasty is one of the most common surgical procedures in otorhinolaryngology and optimising both patient selection and the surgery is a challenge. The Nordic countries have similar public healthcare systems and comparable populations in terms of size. Methods: This is a review of studies of outcome and predictors related to septoplasty from Denmark, Finland, Norway and Sweden, published during the last decade. The aim of this review was to identify areas in need of further research to meet the challenges of septoplasty in the Nordic countries with reference to international data. Results: Postoperative patient satisfaction at 6-12 months was reported in around 2/3 of the patients and well in line with international data. Patients with more severe symptoms had a higher chance of improvement. Lack of standardisation in patient selection, surgical methods and skills, and follow up procedures, still makes it difficult to explain the 25% failure rate in septoplasty surgery. Conclusion: This review of the Nordic studies from the last decade shows that septoplasty in general is effective in relieving nasal obstruction. There is a need for studies addressing the standardisation of diagnostic tools and algorithms and the systematic and continuous implementation of follow-up of the surgical results at both departmental and personal level. This includes an awareness of how surgical skills in septoplasty are obtained and maintained.

Allergic rhinitis and the common cold--high cost to society.

UNLABELLED: The common cold and allergic rhinitis constitute a global health problem that affects social life, sleep, school and work performance and is likely to impose a substantial economic burden on society because of absence from work and reduced working capacity. This study assesses the loss of productivity as a result of both allergic rhinitis and the common cold in the Swedish working population. METHODS: Four thousand questionnaires were sent to a randomized adult population, aged 18-65 years, in Sweden, stratified by gender and area of residence (metropolitan area vs rest of the country). The human capital approach was used to assign monetary value to lost productivity in terms of absenteeism (absence from work), presenteeism (reduced working capacity while at work) and caregiver absenteeism (absence from work to take care of a sick child). RESULTS: Thousand two hundred and thirteen individuals responded, response rate 32%. The mean productivity loss was estimated at 5.1 days or euro 653 per worker and year, yielding a total productivity loss in Sweden of euro 2.7 billion a year. Of the total costs, absenteeism (44%) was the dominant factor, followed by presenteeism (37%) and caregiver absenteeism (19%). Poisson regression analyses revealed that women, people in the 18-29 year age group, and respondents with 'doctor-diagnosed asthma' reported more lost days than the rest of the group. CONCLUSION: In Sweden, the cost of rhinitis is euro 2.7 billion a year in terms of lost productivity. A reduction in lost productivity of 1 day per individual and year would potentially save euro 528 million.

Total nasal airway resistance while sitting predicts airway collapse when lying down.

BACKGROUND: Nasal obstruction when lying down is a common complaint in patients with chronic nasal obstruction, but rhinomanometry is typically performed in the sitting position. This study aimed to analyse whether adding rhinomanometry in a supine position is a useful examination. METHOD: A total of 41 patients with chronic nasal obstruction underwent rhinomanometry and acoustic rhinometry, sitting and supine, before and after decongestion, as well as an over-night polygraphy. RESULTS: Total airway resistance was measurable in a supine position in 48 per cent (14 of 29) of the patients with total airway resistance of equal to or less than 0.3 Pa/cm3/second when sitting and in none (0 of 12) of the patients with total nasal airway resistance of more than 0.3 Pa/cm3/second when sitting. After decongestion, this increased to 83 per cent and 58 per cent, respectively. CONCLUSION: Increased nasal resistance when sitting predicts nasal breathing problems when supine. Rhinomanometry in a supine position should be performed to diagnose upper airway collapse when supine.

Genes regulating molecular and cellular functions in noninfectious nonallergic rhinitis.

BACKGROUND: Chronic noninfectious, nonallergic rhinitis (NINAR) is a complex syndrome with a principally unknown pathophysiology. New technology has made it possible to examine differentially expressed genes and according to network theory, genes connected by their function that might have key roles in the disease. METHODS: Connectivity analysis was used to identify NINAR key genes. mRNA was extracted from nasal biopsies from 12 NINAR patients and 12 healthy volunteers. Microarrays were performed using Affymetrix chips with 54 613 genes. Data were analysed with the Ingenuity Pathway System for organization of genes into annotated biological functions and, thereafter, linking genes into networks due to their connectivity. The regulation of key genes was confirmed with reverse transcription-polymerase chain reaction (RT-PCR). RESULTS: In all, 43 genes were differentially expressed. The functional analysis showed that these genes were primarily involved in cellular movement, haematological system development and immune response. Merging these functions, 10 genes were found to be shared. Network analysis generated three networks and two of these 'shared genes' in key positions, c-fos and cell division cycle 42 (Cdc42). These genes were upregulated in both the array and the RT-PCR analysis. CONCLUSION: Ten genes were found to be of pathophysiological interest for NINAR and of these, c-fos and Cdc42 seemed to be of specific interest due to their ability to interact with other genes of interest within this context. Although the role of c-fos and Cdc42 in upper airway inflammation remains unknown, they might be used as potential disease markers.

Healthcare provider contact for children with symptoms of sleep-disordered breathing: a population survey.

BACKGROUND: Symptoms of sleep-disordered breathing in children, such as frequent snoring, apnoea and choking, may lead to health problems if untreated. The caregiver's level of awareness of these symptoms has been poorly studied. This study aimed to study healthcare provider contact related to sleep-disordered breathing symptoms in a population of children aged 0-11 years. METHODS: A total of 1320 children were randomly selected from a national database that included all children living in Sweden. Caregivers answered a questionnaire about sleep-disordered breathing symptoms during the last month and healthcare provider contact related to these symptoms. RESULTS: A total of 754 answers were received. The prevalence of sleep-disordered breathing symptoms was 4.8 per cent. Of this subgroup, 69 per cent had not been in contact with a healthcare provider regarding their symptoms. CONCLUSION: This study shows that sleep-disordered breathing in children is underestimated and that there is a need to increase caregiver and healthcare provider awareness of sleep-disordered breathing in children.

A physiological study of the monosynaptic reflex responses of cat spinal alpha-motoneurons after partial lumbosacral deafferentation.

In adult cats the whole S1 and rostral half of the L7 dorsal roots were cut on the left side of the spinal cord to produce a partial monosynaptic deafferentation of the ipsilateral alpha-motoneurons. Three, 6 or 12 weeks later, monosynaptic reflexes (MSRs) were recorded from the L6, L7 and S1 ventral roots or from various peripheral nerves during stimulation of the L6 and remaining parts of the L7 dorsal roots. Also, monosynaptic excitatory postsynaptic potentials (EPSPs) were recorded intracellularly in different types of medial gastrocnemius alpha-motoneurons of the L7 segment during stimulation of various hind limb muscle nerves. The right side with an identical acute deafferentation served as control. On the chronically lesioned side the MSRs were increased in size, also during post-tetanic potentiation. The monosynaptic EPSPs had increased amplitudes in all motoneuron types, but the relation in EPSP size between different motoneuron types as well as between different synergistic inputs remained largely unchanged. EPSP rise times were not changed, and aberrant monosynaptic connections from non-synergist muscles were not observed. It is concluded that the extent of reactive reflex changes may be related to both the number of vacant synaptic sites and the degree of functional synergism between the eliminated and remaining monosynaptic pathways. Possible underlying mechanisms are discussed.

The action of 5-HT on calcium-dependent potassium channels and on the spinal locomotor network in lamprey is mediated by 5-HT1A-like receptors.

5-HT has a powerful modulatory action on the firing properties of single neurons as well as on locomotor activity. In lamprey, 5-HT increases the neuronal firing frequency in spinal neurons by reducing the conductance in Ca(2+)-dependent K+ channels (KCa) underlying the slow afterhyperpolarization (sAHP), and it also lowers the burst frequency of the spinal locomotor network. To elucidate which type of 5-HT receptor mediates these effects, different specific receptor agonists and antagonists were applied during intracellular current clamp recordings and during NMDA-induced fictive locomotion in the lamprey spinal cord in vitro preparation. The 5-HT1A receptor agonist 8-OH-DPAT ((+/-)-8-hydroxy-dipropylaminotetralin hydrobromide), the 5-HT1 receptor agonist 5-CT (5-carboxyamidotryptamine maleate) and the 5-HT2 receptor agonist alpha-CH3-5-HT (alpha-methylserotonin maleate) all reproduced the actions of 5-HT at both the cellular and the network levels. The effects of all agonists were completely or partially blocked by the 5-HT1A and 5-HT2 receptor antagonist spiperone (spiroperidol hydrochloride) while selective 5-HT2 receptor antagonists were ineffective. The selective 5-HT1A receptor antagonist S(-)-UH301 (S(-)-5-fluoro-8-hydroxy-dipropylaminotetralin hydrochloride) also counteracted the effect of 5-HT on the sAHP. 5-HT3 and 5-HT4 receptor agonists and antagonists were without effects. The intracellular coupling mechanism was not sensitive to pertussis toxin nor to the cAMP dependent protein kinase blocker (Rp)-cAMPS.(ABSTRACT TRUNCATED AT 250 WORDS)

Rhinitis increase the risk for adult-onset asthma--a Swedish population-based case-control study (MAP-study).

The aim of the study was to examine certain predictors, especially non-infectious rhinitis, and the risk for adult-onset asthma. A nested case-control study of adult-onset asthma was performed in a random sample from the general population (n = 15,813), aged 21 to 51 years. Cases for the study included subjects reporting physician-diagnosed asthma (n = 235) and controls (n = 2044) were randomly selected from the whole population sample. The case-control sample was investigated with a comprehensive respiratory questionnaire. Odds ratios were calculated stratified for sex, year of diagnosis and birth-year. Adult-onset physician-diagnosed asthma was associated with occurrence of non-infectious rhinitis before asthma onset (OR = 5.4, 95% CI 4.0-7.2), especially among smoking non-atopics (OR = 9.1, 95% CI 5.3-15.4). Smoking before asthma onset increased the risk for asthma (OR = 1.5, 95% CI 1.1-2.1). In conclusion, this population-based case-control study indicate that non-infectious rhinitis and current smoking, especially among non-atopics, are associated with increased risk for adult-onset asthma.

Nasal nitric oxide and its relationship to nasal symptoms, smoking and nasal nitrate.

Nitric oxide (NO) is produced in the nasal mucosa and in the paranasal sinuses. Increased nasal NO concentrations have been found in patients with asthma and/or rhinitis, and nasal NO has been suggested to be a marker of nasal inflammation. Measuring the stable end products of NO, nitrate and nitrite in nasal lavage fluid have been proposed as an indirect method for measuring NO concentration. The aim of this study was to measure nasal NO concentration, and to find out its relationship to nasal nitrate concentration and clinical parameters. 73 paper-mill workers were investigated with nasal and exhaled NO, nitrate in nasal lavage fluid and were given a respiratory questionnaire. Nasal air was sampled directly from a nasal mask and NO concentration was measured with a chemiluminescence analyser. Exhaled NO was measured with the subjects breathing tidal volumes and wearing nose clips. The nitric oxide metabolites were analysed as nitrate, after reduction of nitrite to nitrate. Smokers had lower nasal NO concentration (264 ppb) as compared to NO concentrations of 340 ppb among non-smokers (p = 0.02). There was no statistically significant relationship between nasal NO concentration and nitrate in nasal lavage fluid or nasal symptoms. Nasal NO concentration was significantly related to FVC (p = 0.047) and there was a relationship with borderline statistical significance (p = 0.06) to FEV1. In conclusion, we found no relationship between nitrate in nasal lavage and nasal NO, and neither of these were correlated to nasal symptoms or to nasal PIF. Nasal NO was significantly lower among smokers. Further controlled studies on subjects with rhinitis are needed, to evaluate the relation between nasal NO and nasal inflammation. In addition, there is also a need to develop methods for measuring nasal NO that minimise contamination from sinuses.

Computer simulation of the segmental neural network generating locomotion in lamprey by using populations of network interneurons.

Realistic computer simulations of the experimentally established local spinal cord neural network generating swimming in the lamprey have been performed. Populations of network interneurons were used in which cellular properties, like cell size and membrane conductance including voltage dependent ion channels were randomly distributed around experimentally obtained mean values, as were synaptic conductances (kainate/AMPA, NMDA, glycine) and delays. This population model displayed more robust burst activity over a wider frequency range than the more simple subsample model used previously, and the pattern of interneuronal activity was appropriate. The strength of the reciprocal inhibition played a very important role in the regulation of burst frequency, and just by changing the inhibitory bias the entire physiological range could be covered. At the lower frequency range of bursting the segmental excitatory interneurons provide stability as does the activation of voltage dependent NMDA receptors. Spike frequency adaptation by means of summation of afterhyperpolarization (AHP) serves as a major burst terminating factor, and at lower rates the membrane properties conferred by the NMDA receptor activation. The lateral interneurons were not of critical importance for the burst termination. They may, however, be of particular importance for inducing a rapid burst termination during for instance steering and righting reactions. Several cellular factors combine to provide a secure and stable motor pattern in the entire frequency range.

8-channel digital filter bank for hearing aid use: preliminary results in monaural, diotic and dichotic modes.

A digital 8-channel signal processing system has been implemented using a TMS 320C25 signal processor. Tests with hearing-impaired subjects showed that the system allows a better fit to a specified frequency response than when using conventional aids with analog filtering. The filter bank has also been tested in dichotic listening experiments, where odd-number channels were fed to one ear and even-number channels to the other. The preliminary results on three hearing-impaired subjects in repeated tests of speech recognition in noise showed an improvement in the order of 2 dB in speech-to-noise ratio for 50% correct recognition as compared to the complete broadband signal presented diotically. Temporal splitting of the signal by periodically switching of the odd and even bands between left and right ears did not show any improvement.

System identification of feedback in hearing aids.

The feedback problems of behind the ear (BTE), in the ear (ITE), and in the ear canal (ITEC) hearing aid categories have been investigated. All possible feedback paths (acoustical via vent, via tubing wall, mechanical, etc.) were converted to a single transfer function from the ear canal to the hearing aid microphone, here called the acoustic feedback equivalent (AFE). The attenuation of the AFE represents the maximum gain that can be used without the hearing aid starting to howl. Magnitude and phase responses of the AFE were identified on ten human subjects and on a Knowles ear manikin (KEMAR). The acoustic feedback via vent and leak between earmould and ear canal dominated the AFE. The transfer function from a reference point under the ear to the position of microphone of the different hearing aid categories was identified and used together with the AFE to calculate the maximum real ear aided gain (REAG) for the hearing aid categories. A model of the AFE, consisting of a fourth-order filter together with a delay, showed good agreement with the measured data.