Recurrent and prolonged frontal sinusitis.

The purpose of the study was to find the factors that predict the prolongation or recurrence of frontal sinusitis, to analyse the results of endoscopic surgery and trephination and also to analyse the value of the clinical estimation made by the treating specialist. The study was partly prospective, partly retrospective, and it was carried out in 1995-97. The follow-up continued until the end of 1998. The sample consisted of 456 patients (264 men and 192 women) treated for acute frontal sinusitis in Turku University Central Hospital. The collected information consisted of patient history, treatment, outcome and possible re-operations. To be able to evaluate conservative treatment in relation to operative treatment in patients with prolonged disease, a matched conservatively treated patient was selected for each endoscopically operated patient. Of the 456 patients, 359 healed normally, 85 developed prolonged disease, while recurrences were found in 50 patients. Endoscopic surgery was performed in 35 patients. The mean time interval between the endoscopic sinus operation (FESS) and healing was 8.2 weeks. Trephination was performed in 52 patients and FESS in 35 patients. In the statistical analysis, the factors having significance in predicting the outcome of the disease were, in the bivariate analysis, atopy and type of primary operation, chronic rhinitis, polyps, type of previous operations and of re-operations. Neither trephination nor FESS proved markedly better than the other one. Our conclusion was that the prognosis of frontal sinusitis is difficult to predict with any single factor, but is affected by many of them.

Secondary otalgia in an adult population.

OBJECTIVE: To analyze the associations of secondary otalgia with general health, stress, insomnia, bruxism, and recurrent head and neck region pains. DESIGN: A population-based survey. SETTING: General community. SUBJECTS: A total of 391 randomly selected subjects (186 men, 205 women) aged 25, 35, 45, 55, or 65 years. METHODS: Standardized interview and self-report questionnaires of general health and stress. RESULTS: Otalgia was statistically significantly associated with all the studied factors. However, in the whole study group, independent predictors of otalgia were the obvious need for temporomandibular disorder treatment, high frequency of stress symptoms, and bruxism. When analyzed in women, the predictors of otalgia were the obvious need for temporomandibular disorder treatment, high frequency of stress symptoms, and age. When analyzed in men, recurrent neck pain was a predictor of otalgia. CONCLUSIONS: We suggest that after ruling out otorhinolaryngologic infectious diseases and temporomandibular disorder in patients with secondary otalgia, the next step is to explore the frequency of stress symptoms, bruxism, and recurrent neck pain. Furthermore, women and men may need a different approach in diagnostics of secondary otalgia. By diagnosing and treating these predictors of otalgia, it may be possible to reach a more successful outcome.

Radical meatoplasty in the treatment of severe chronic external otitis.

In the beginning, external otitis is an inflammation of the skin of the external ear canal. Partial or total obliteration of the meatus causes cleaning problems, which worsen the obliteration, and hence, the infection. Immunosuppressive medication or illness, certain dermatological problems or frequent infections may lead to irreversible changes and to the malignant form of external otitis with life-threatening sequelae. Conservative treatments in the beginning are aimed at regaining the normal skin functions by helping the cleaning process and curing the acute infection with repeated irrigation, proper antibacterial medication and corticosteroids and anti-inflammatory analgesics. In rare prolonged cases, surgical procedures are needed to help the cleaning process by removing the irreversibly thickened skin and bone affections, and using grafts. On the basis of our experience, even the removal of the diseased skin and enlarging of the external ear canal are insufficient procedures in the most difficult cases. In the present paper, we describe a new surgical method that we have performed to treat chronic bilateral obliterative external otitis in 2 patients, with favorable results.

Validity of ultrasonography in diagnosis of acute maxillary sinusitis.

BACKGROUND: Accurate diagnosis of maxillary sinusitis is difficult on the basis of clinical examination only because the signs and symptoms of sinusitis are nonspecific. A simple, rapid, and readily available method for diagnosing maxillary sinusitis in primary care would increase the accuracy of the diagnoses and thus reduce unnecessary antibiotic treatment. OBJECTIVE: To investigate the validity of ultrasonography compared with radiography and magnetic resonance imaging (MRI) in detection of maxillary sinusitis. DESIGN: Ultrasonography and plain-film radiography of the paranasal sinuses were performed on all patients and MRI was performed on 40 randomly selected patients on day 7 of the study. SETTING: Study office at the Department of Pediatrics of Turku University Hospital, Turku, Finland. PATIENTS: One hundred ninety-seven young adults who contacted the study office within 48 hours of the onset of symptoms of the common cold. MAIN OUTCOME MEASURES: Detection rates of maxillary sinusitis by ultrasonography, radiography, and MRI. RESULTS: Acute maxillary sinusitis was diagnosed in 24% of the sinuses by radiography and in 28% by MRI. Compared with MRI findings, the sensitivity of ultrasonography for detection of maxillary sinusitis was 64% (specificity, 95%). Using a 2-step diagnostic approach in which radiological findings were additionally considered in cases of negative ultrasound findings, a sensitivity of 86% (specificity, 95%) was observed. CONCLUSIONS: The high specificity of ultrasonography indicates that a positive ultrasound finding can be regarded as evidence of maxillary sinusitis. The addition of plain-film radiography in cases of negative ultrasound findings increases the diagnostic sensitivity to clinically acceptable levels without loss in specificity. Active use of ultrasonography would substantially decrease the need for radiological imaging of the sinuses and also help reduce unnecessary antibiotic treatment in primary care. Arch Otolaryngol Head Neck Surg. 2000;126:1482-1486

Obliteration of the frontal sinus cavity with bioactive glass.

BACKGROUND: Bioactive glass (BG) is a glass ceramic material. It has been used as surgical bone replacement material in ear and oral surgery, orthopedics, and dentistry. METHODS: Bioactive glass was used as obliteration material in a series of osteoplastic frontal sinus operations on 10 patients suffering from chronic frontal sinusitis, which other, more-conservative treatment modalities had failed to cure. RESULTS: Bioactive glass is easy to handle, and complete obliteration of all sinusal recesses and excavations is easily achieved. No adverse effects of the implant material have been seen over a mean follow-up period of 5.0 years. One patient with a local recurrent infection in the outer table of the sinus was reoperated on 5 months after primary surgery. Repeated postoperative computed tomographic scans analyzed by digital region-of-interest (ROI) selection showed no remarkable changes in the frontal sinus cavities but a slight, yearly decrease in the density of the occlusion material. Laboratory monitoring of patients and histopathologic examination of two postoperative biopsy specimens indicated that the material is well tolerated and stable. CONCLUSIONS: Bioactive glass is a promising and well-tolerated bone graft suitable for osteoplastic frontal sinus operations. Total accurate obliteration of the sinus is achieved with different sizes of granules and blocks. The results of the obliteration are maintained owing to the stability of the material.

Operative treatment of frontal sinusitis.

When the medical therapy fails trephination is the primary operation indicated in acute eroding sinusitis when drainage is necessary to avoid severe complications. In recent years also endoscopic transnasal surgery has been recommended for exenteration of the underlying disease in the ostiomeatal unit as well as for opening of the obstructed nasofrontal duct in acute phase of the disease. In Turku University Central Hospital endoscopic frontal sinus surgery is still reserved for cases with prolonged or delayed disease performed as a secondary operation after trephination and CT examination. Failures are common after these operations and both types of surgical treatment may be needed. Three percent of our patients developed a persistent chronic infection inside the frontal sinus. In these cases external osteoplastic approach is recommended. In these operations we have used bioactive glass as obliteration material with promising clinical results.

Report on results of frontal sinus obliterations in Turku University Central Hospital 1977-1994.

When a sinusitis develops into a chronic stage, for which endoscopic sinus surgery is not radical or successful enough, we currently perform in our hospital obliteration of the infected frontal sinuses. The present study is a partly retrospective and partly prospective evaluation of the outcome of patients operated on by osteoplastic approach. Obliteration materials used during years 1977-1994 have been ossar, collagen matrix and since 1990 bioactive glass. Although major differences between the obliteration materials could not be demonstrated the obliteration with bioactive glass has proven to be a safe and effective method for patients who did not show any improvement after endoscopic sinus surgery.

The effect of laser-uvulopalatopharyngoplasty on the nasal and nasopharyngeal volume measured with acoustic rhinometry.

Nasal breathing is considered as an important factor in sleep apnea and snoring, and nasal obstruction can lead to an increased respiratory resistance and to inflammatory reactions in the nasal mucosa. Uvulopalatopharyngoplasty is an effective treatment for sleep apnea and snoring. Different operation techniques with minor variations have been introduced during the last few years. Uvulopalatopharyngoplasty with laser technique (LUPPP) has made it possible to perform the operation in local anesthesia. Acoustic rhinometry is a new method for the evaluation of the nasal cavities and the nasopharynx. We measured the volume of nasal cavities and nasopharynx of 29 patients using acoustic rhinometry before and 6 months after the LUPPP operation. There was a tendency to a better nasal patency in the turbinate area, but no change was found in the nasopharyngeal volume. Acoustic rhinometry is a useful tool for measuring the turbinate area, and this part of the nasal cavities seems to be influenced by the LUPPP operation, maybe due to a better ventilation or reduction of the inflammation of the nose. However, technical and methodological improvements are needed before reliable measurements are achieved from the nasopharynx area.

A prospective study using rhinomanometry and patient clinical satisfaction to determine if objective measurements of nasal airway resistance can improve the quality of septoplasty.

In the ENT Department of University Central Hospital, Turku, the waiting list for elective septoplasty grew to 4 to 5 years in the late 1980s. Therefore, a prospective clinical project was initiated during which all patients waiting for septal surgery were re-examined and nasal airway function was measured with rhinomanometry. Patients with high nasal resistance or other specific indications for nasal obstruction were selected for surgery (n = 432). The remaining patients were excluded from surgery and followed up (n = 284). Results showed that if patients were referred for septal surgery without rhinomanometric study, about 10% became symptom-free within 3 to 5 years. Patients operated on after defining a high preoperative intranasal resistance had a higher postoperative satisfaction level (85%) than those operated on with normal nasal resistances but other indications for correcting the nasal septum (69%). After 3 years, the majority of patients not treated surgically were satisfied with their conservative treatments, although certain patients still required some form of nasal surgery to relieve recurring nasal and/or sinus complaints.

Longitudinal analysis of human salivary immunoglobulins, nonimmune antimicrobial agents, and microflora after tonsillectomy.

In order to study the role of tonsils in the host defense in the oral region one pre- and two postoperative (1 and 6 months) whole saliva samples were collected from 25 young adults referred for tonsillectomy. Saliva samples were analyzed for selected host defense factors, representing both immune (total IgA, IgG, IgM, anti-Streptococcus mutans, anti-EBV, anti-CMV, and anti-adenovirus IgA and IgG) and nonimmunoglobulin (lysozyme, lactoferrin, salivary peroxidases, thiocyanate, hypothiocyanite, and agglutinins) mediators. Following tonsillectomy, a significant (P < 0.04) reduction was observed in specific IgG antibodies, suggesting that tonsils participate in local IgG response to oral antigens. Total IgM levels also decreased (P< 0.006), which may to some extent reflect reduced antigenic stimuli compared to preoperative status with frequent tonsillitis. Saliva-derived nonimmunoglobulin host defense factors, except lactoferrin, which declined significantly, remained normal throughout the study period. Our study indicates that tonsils play a role in local oral IgG-mediated immune response but tonsillectomy does not seem to lead to any significant long-term impairment of salivary defense capacity.

Prediction of the clinical outcome of acute frontal sinusitis with ventilation measurement of the nasofrontal duct after trephination: a long-term follow-up study.

Acute frontal sinusitis has become an increasing clinical problem in the region that is served by the hospital represented by the authors of this study. The standard surgical treatment protocol after the failure of conservative therapy has been to perform trephination of the involved frontal sinus. More sophisticated procedures have been used in patients with prolonged or recurrent disease. The authors have developed a simple ventilation test of the nasofrontal duct that can be used to determine which patients require further surgery. In a long-term follow-up study of 85 patients, this ventilation test was shown to predict the cases that would heal uneventfully after trephination and the cases that would require further surgery because of an obstructed nasofrontal duct. The findings of this study are of special interest for modern functional endoscopic sinus surgery, the purpose of which is to open up the nasofrontal region.

Pre- and postoperative evaluation of patients with nasal obstruction undergoing endoscopic sinus surgery.

Functional endoscopic endonasal sinus surgery (FESS) is at present the surgical method of choice for many clinicians treating chronic sinusitis and nasal polyposis. Postoperatively, patients have felt that patency of the nasal airway is improved, although all previous studies have failed to objectively measure changes produced. By using anterior active rhinomanometry, decreased unilateral and total nasal resistance was measured. Although improvement in total resistance was not statistically significant, reduction in unilateral resistance was. All patients demonstrated subjective improvements in unilateral and total nasal patencies. The reduction in nasal resistance was more pronounced in baseline resistance values than after decongestion, indicating that FESS had a positive effect on mucosal edema but did not alter the structural anatomy of the main nasal passages.

Complications of uvulopalatopharyngoplasty.

Since the introduction of uvulopalatopharyngoplasty (UVPP) life-threatening complications have been encountered. In our retrospective review of 101 patients undergoing UVPP the overall incidence of early post-operative complications was 25%. One patient died because of post-operative airway obstruction. The risk of early post-operative breathing difficulty was related to the patient's weight, previous heart disease, and severity of OSAS measured by the percentage of obstructive apnoeic episodes and minimum oxygen saturation during sleep. As late as one year after surgery 57% of patients had some kind of problem in relation to the operation, the most common complaint being nasopharyngeal regurgitation (24%). Despite these late complications over 90% of the patients reported improvement in daytime somnolence and snoring.

A critical look at the treatment of maxillary sinusitis with long-term draining tubes.

Long-term draining tubes (LTD) have become a common treatment in complicated and prolonged forms of maxillary sinus empyema. Since not all patients show good recovery with this treatment we used sinus-manometry, mathematical calculations, and scanning electron microscopy (SEM) to critically analyze 6 cases with a prolonged history of the disease. Five out of the 6 patients recovered quickly after removal of the LTDs, normally performed sinus punctures, and an appropriate antibacterial treatment. One patient underwent functional endoscopic sinus surgery. Two of the 6 patients had uncommon bacterial cultures (Pseudomonas mirabilis, Klebsiella oxytoga) in their sinus secreta. Two of the removed LTDs were examined with SEM. The porous polyethylene was shown to have absorbed bacterial plague which, besides narrowing the lumen, can cause recurrent infections. In 5 other patients, the draining pressure (DP) was 0.9 +/- 0.16(M +/- SD) kg/cm2, as measured during irrigation with a No. 2 Lichtwitz needle (1.8 mm, i.d). Mathematical calculation using the Hagen-Boisseouille equation indicated that with our LTDs (0.7 mm, i.d.) the DP needs to be 40 times greater than the DP when using an ordinary Lichtwitz needle to get equal flushing capacity. We recommend i) LTD treatment of maxillary sinus empyema be closely followed up ii) that, in prolonged cases, the LTDs should be removed and the sinuses repeatedly irrigated with an ordinary needle or antrostomy, and iii) that a more suitable tubing material and insertion system (to allow a larger radius of the tube) be developed.

Few surgical complications after 5,000 to 6,500 cGy pre-operative irradiation for carcinoma of the tongue.

Twenty-four patients with squamous cell carcinoma of the tongue were treated with 5,000 cGy to 6,500 cGy pre-operative irradiation. Surgery usually consisted of resection of the tongue, possibly the floor of mouth, and modified or radical neck dissection. Musculocutaneous flaps for reconstruction were used in three cases and a forearm flap in one case. Despite the high radiation dose, no major difficulties were encountered at surgery or during the convalescence period, except for one osteoradionecrosis of the mandible, which was successfully treated by microvascular osteomyocutaneous grafting. Residual carcinoma was seen on histological examination of the excised tissue in 9 out of 18 (50 per cent) patients who received > or = 6,000 cGy, and in 4 out of 6 (67 per cent) patients who received about 5,000 cGy tumour dose. The 2-year crude survival rate was 65 per cent. The data suggest that high dose pre-operative irradiation is feasible and does not compromise surgical treatment.

Increase of acute frontal sinusitis in southwestern Finland.

The number of patients hospitalized for acute infection in the frontal sinuses at the Department of Oto-Rhino-Laryngology of Turku University Hospital has increased markedly during the last decade. Causes for this increase were evaluated by comparing the backgrounds and medical findings of the 134 patients treated in the years 1977-81 and those of the 421 patients treated in the years 1982-86. Nasal polyps and history of allergic rhinitis were considerably more common in the latter patient group. The disease also seems to recur increasingly in the same patients. Of the aerobic bacteria Streptococcus pneumoniae and Haemophilus influenzae were the most common pathogens and the share of H. influenzae increased slightly, becoming the commonest pathogen in the latter 5-year period. Increasing air pollution in the city area of Turku is worth consideration and should be investigated further.

Long-term safety of budesonide nasal aerosol: a 5.5-year follow-up study.

The effects of prolonged treatment with intranasally applied budesonide was studied in twenty-four patients with perennial allergic or non-allergic rhinitis. Patients on continuous treatment were followed up for 5.5 years. At entry and follow-up visits, rhinoscopic findings, nasal symptom scores, blood chemistry, haematology, urine analysis and determination of plasma cortisol levels, before and after stimulation with ACTH (Synacthen, Ciba-Geigy AG, Basel, Switzerland), were registered. Biopsies of the nasal mucosa were taken before entry into the study, after 1 year of treatment, and after varying time intervals ranging from 2.5 to 5.5 years during the treatment. The biopsy specimens were examined blindly by an independent pathologist. The analyses revealed no histopathological changes in the nasal mucosa. All nasal symptom parameters assessed by the patients were significantly reduced from the baseline during the entire follow-up period. No clinically significant changes in the haematological and blood chemistry parameters were observed. Plasma cortisol analyses before and after challenge with ACTH revealed no influence on the hypothalamic pituitary adrenal (HPA) axis. The present study suggests that intranasal budesonide in the dose of 200-400 micrograms/day is also a safe treatment for prolonged treatment of perennial rhinitis.