Eosinophils are the dominant type2 marker for the current indication of biological treatment in severe uncontrolled chronic rhinosinusitis with nasal polyps.

The latest European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS2020) defines markers for type2 inflammation in the context of indicating biological therapy in severe uncontrolled chronic rhinosinusitis with nasal polyps (CRSwNP) as either a total serum immunoglobulin E (total-IgE) <100 kU/L, a blood eosinophil count (BEC, expressed as -109 cells / L) >=0.25, or a tissue eosinophil count >=10 per high power field (HPF) (1). Recently, an EPOS/EUFOREA expert panel advised to lower the threshold for BEC from >=0.25 (EPOS2020) to >=0.15 (EUFOREA2023) to align with thresholds used for biological indication in asthma patients (2). As far as we know, there is no literature supporting the cut-off value for total-IgE.

[A patient with an acute naso-labial swelling]. / Een patiënt met een acuut pijnlijke paranasale zwelling.

A patient presented herself with a painful swelling in the left nostril and next to the nose. It appeared to be a rarely occurring naso-labial cyst. This has to do with a developmental disorder resulting from a persistent embryonic glandular duct epithelium. The cyst was drained under local anaesthetic and was removed 3 months later, under general anaesthetics, by an oral and maxillofacial surgeon and an ENT-specialist working together.

[Hypoxaemia during non-intubated adenotonsillectomy; more common in sitting or supine position?] / Hypoxemie bij adenotonsillectomie zonder intubatie: vaker in liggende of zittende operatiehouding?

OBJECTIVE: To investigate the incidence of hypoxaemia, bradycardia and post-operative bleeding in non-intubated Sluder method adenotonsillectomy patients in sitting versus supine position. DESIGN: Explorative study. METHOD: A retrospective database was drawn up with data from all patients on whom a Sluder method non-intubated adenotonsillectomy was performed in a Dutch district general hospital between 01 January 2012 and 01 May 2018. Depending on the preference of the surgeon and following discussion with the anaesthesiologist, the operation was performed with the patient in either a sitting or supine position. The primary outcome measure was hypoxaemia, defined as SpO2 < 85% for ≥ 60 seconds. Secondary outcome measures included bradycardia and post-operative bleeding. RESULTS: We analysed the data of 723 adenotonsillectomy patients (46% female, average age 4.5 years), of whom 193 (27%) in sitting and 530 (73%) in supine position. Hypoxaemia occurred in 13 (7%) 'sitting' cohort patients and in 13 (2%) of the supine cohort patients (p = 0.011). No perioperative complications developed as a result of the hypoxaemia. The frequency of bradycardia did not differ between the two cohorts (4 vs 2%; p = 0.442). None of the patients developed both hypoxaemia and bradycardia. In 8 (1%) patients, a secondary intervention was required due to the occurrence of post-operative haemorrhage. CONCLUSION: Patients who undergo non-intubated Sluder guillotine method adenotonsillectomy when in a sitting position are more likely to develop hypoxaemia than those who are operated on in a supine position. In order to make an informed recommendation, a randomized trial is indicated.

Considerations on the application of microarray analysis in rhinology.

Molecular biological tools are finding their way into modern rhinological research. This overview aims to discuss the merits and pitfalls of micro-array analysis as one of these molecular tools. The outcome of a micro-array experiment will describe which genes are active in a given cell type or tissue, allowing us to investigate healthy and diseased conditions on a large scale and in extreme detail. Although this will deepen our understanding of our disease of interest, we should not expect that micro-array analysis will resolve all our questions. In this overview we have indicated points that we feel are critical for any application of micro-array analysis in modern rhinological research. Choices on experimental design and patient inclusion will influence the outcome data of the experiment and the extend of the conclusions that can be drawn from these data. A second important issue is the size of the data set, which can comprise of hundreds of different genes, making it difficult to come to grips with the affected processes in a disease. New visualization and analysis tools for microarray data are discussed in this overview that deal with these complex issues.

The fungal debate: where do we stand today?

Chronic rhinosinusitis (CRS) is an inflammatory disorder affecting the nose and paranasal sinuses. Although bacteria have long been implicated as pathogens in most forms of CRS, it has been recognized that fungi may be responsible for some forms of CRS. Recent studies have shown that under optimal conditions, fungi can be identified within the nose and paranasal sinuses of nearly every individual. Considerable controversy exists concerning the proper diagnosis of and potential overlap between 'allergic fungal rhinosinusitis' and 'chronic rhinosinusitis'. Although the disease name 'allergic fungal rhinosinusitis' is suggestive of an immunoglobulin E (IgE) mediated reaction to fungi, recent studies demonstrate the presence of elevated serum IgE levels to one fungus while another fungus is present in CRS mucin of the same individual, questioning the role of type I hypersensitivity. Several mechanisms explaining the role of fungi in the pathogenesis of CRS, all requiring additional investigations with adequate controls, have been suggested and will be reviewed. Although preliminary trials suggest a beneficial effect of topical and oral antifungal agents in the treatment of CRS patients, several double-blind placebo controlled trials do not. Presently, in the absence of convincing immunological data and evidence of clinical improvement of CRS upon therapy with antifungal agents, the case against the fungus remains unproven.

[A man with a swelling of the forehead]. / Een man met een zwelling van het voorhoofd.

A 39-year-old male was admitted to the emergency room with a swelling of the forehead. He had a fever since 5 days and increasing pain on his forehead. He was diagnosed with Pott's puffy tumour, a complication of sinusitis.

Cochlear implantation in obstructed cochleas: the effect of the degree of obstruction on the number of activated electrodes and the amount of postoperative speech perception.

OBJECTIVE: With cochlear implantation, insertion of the electrodes can be hampered by cochlear obstructions. The aim of this study was to investigate the effects of these obstructions on the number of activated electrodes and postoperative speech perception. STUDY DESIGN AND SETTING: Retrospective analysis of the operation reports and CT-scans of patients who underwent cochlear implantation, at the Department of Otorhinolaryngology of the University Medical Center of Utrecht (n = 295). PATIENTS AND INTERVENTIONS: Fifty patients with a certain degree of cochlear obstruction were included. Based on the surgical intervention to overcome these obstructions they were subdivided into first-, second- and third degree obstructions. The number of implanted and activated electrodes was determined. MAIN OUTCOME MEASURES: Three different speech perception tests after 12 months of cochlear implant use. RESULTS: The number of activated electrodes significantly diminished with increasing obstruction degree (P < 0.01). This was caused by a lower amount of implanted electrodes combined with a higher amount of switched off electrodes. With a higher degree of obstruction the amount of postoperative speech perception decreased significantly (P < 0.01). This is partly explained by the lower number of activated electrodes and partly explained by the fact that a higher obstructions degree correlates with a higher degree of (retro-) cochlear pathology. Significantly more electrodes can be inserted into the severely obstructed cochlea using a Double Array Cochlear Implant. CONCLUSION: Cochlear obstructions pose a surgical threat and negatively influence the postoperative speech perception results. Fortunately, due to surgical techniques, first and second degree obstructed cochleas can often be bypassed. Implanting of a Double Array implant brightens the prospects of patients with third (severe) degree obstructed cochleas.