A randomized study of temperature-controlled versus bipolar radiofrequency for inferior turbinate reduction.

UNLABELLED: The objective of this study is to compare outcomes of temperature-controlled radiofrequency (TCRF) and bipolar radiofrequency (BRF) for inferior turbinate reduction in patients with chronic rhinitis (CR). This was a prospective, randomized non-inferiority trial. Eighty-four adult patients with CR refractory to medication were randomized into two intervention groups: TCRF(42) or BRF(42). Primary outcomes consisted of patient-orientated visual analog scale (VAS; 0-10) of nasal obstruction at 4th postoperative week. Secondary subjective outcomes included VAS of nasal discharge, sneezing, hyposmia, and postnasal drip. Objective outcomes included crusting, mucociliary transportation time, minimal cross-sectional area, total nasal volume, and nasal airway resistance performed by blind assessors before and at 4th postoperative week and 1-year follow-up. Baseline and perioperative data showed no statistically significant difference between both groups, except for longer operative time in TCRF (481.5 ± 36.2 vs. 37.1 ± 3.0 s, p < 0.001) and slightly more crusts in BRF group (p = 0.04). Both intention-to-treat and per-protocol analyses, TCRF(39) versus BRF(41), revealed no significant difference among subjective and objective outcomes between two groups at 4th postoperative week. The 95% confidence intervals of mean differences of VAS scores of all subjective symptoms were within defined margin (-1.5 to 1.5), except for nasal discharge. At 1-year follow-up, there was still no significant difference in the outcomes. Minimal pain and minor bleeding without serious adverse effects from both interventions were reported. Both BRF and TCRF resulted in similar short-term outcomes, while less operative time was found in BRF group. Further studies, particularly, on cost-effectiveness should be conducted for better treatment selection. LEVEL OF EVIDENCE: 1b.

Radiofrequency inferior turbinate reduction improves smell ability of patients with chronic rhinitis and inferior turbinate hypertrophy.

Radiofrequency inferior turbinate reduction (RFITR) of inferior turbinate hypertrophy (ITH) is an effective way to treat patients with intractable nasal mucosal obstruction. The objective of this study was to assess smell ability, nasal symptoms, inferior turbinate grading (ITG), peak nasal inspiratory flow (PNIF) of patients with chronic rhinitis (CR), and ITH before and after RFITR. Patients with CR and ITH, aged 18-60 years, who underwent RFITR, were prospectively recruited. Smell ability (measured by smell detection threshold [SDT]), visual analog scale (VAS) of nasal symptoms, ITG, and PNIF before and 6-10 weeks after RFITR were compared. Forty-eight subjects were included. All nasal symptoms were significantly decreased after RFITR. After surgery, SDT (tested by phenyl ethyl alcohol) was worsened in 7 patients (14.6%), improved in 8 patients (16.7%), and did not change in 33 patients (68.7%). SDT after RFITR of six patients in the worsened SDT group were still within normal range (> -6.5). There was only one patient whose SDT changed from normosmia to mild hyposmia (-7.25 to -5.38). In the improved SDT group, two of eight patients had obviously better SDT after RFITR, which changed from moderate hyposmia to normosmia (-3.65 to -10; -3.73 to -10), whereas six of eight patients had little better SDT after RFITR. RFITR also significantly reduced ITG and improved PNIF. In conclusion, the treatment of patients with CR and ITH with RFITR significantly improved PNIF, ITG, and nasal symptoms assessed by VAS, although SDT after RFITR could be the same or improved or worsened.

Adjustable thermoplastic mandibular advancement device for obstructive sleep apnea: outcomes and practicability.

OBJECTIVES/HYPOTHESIS: To assess outcomes including efficacy, adverse effects, and quality of life (QOL) of an adjustable thermoplastic mandibular advancement device (AT-MAD) fitted by an otolaryngologist for obstructive sleep apnea (OSA) treatment. STUDY DESIGN: Prospective, nonrandomized, before-after study. METHODS: Sixty-four adult patients (40 men and 24 women) were recruited. Inclusion criteria were OSA patients who had failed or refused treatment with continuous positive airway pressure and surgery. Exclusion criteria were insufficient teeth, active intraoral disease, and temporomandibular joint (TMJ) disorders. Outcomes were measured using polysomnography, symptom questionnaires, Epworth Sleepiness Scale (ESS), and Functional Outcomes of Sleep Questionnaire (FOSQ) before treatment and 4 to 6 months thereafter. RESULTS: Mean apnea-hypopnea index (AHI) and ESS scores decreased from 17.7 ± 14.6 to 7.5 ± 10.9 and from 8.7 ± 4.9 to 6.5 ± 4.4, respectively, after treatment (P < .001). Thirty-nine patients (60.9%) achieved post-treatment AHI of <5, with the highest success rate in those with mild OSA (75%). FOSQ global scores increased from 16.4 ± 2.8 to 17.7 ± 3.0 (P < .05), along with most FOSQ subscale scores. Thirty-four patients (53.1%) regularly used the device for ≥5 nights per week. Adverse effects include TMJ discomfort, dry mouth, and excessive salivation, which were largely tolerable. Only four patients withdrew from the study because of adverse effects. CONCLUSIONS: This is the first study in Asians demonstrating that an AT-MAD, if done properly, is a practical short-term treatment of OSA, with good outcomes including improved QOL. Its advantages are its low cost and ready-to-use nature. However, further randomized controlled trials are required.

Mastoid obliteration with postconchal soft tissue and postauricular pericranial flap.

OBJECTIVE: To report the technique and the result of mastoid obliteration with postconchal soft tissue and postauricular pericranial flap. MATERIAL AND METHOD: Retrospective chart reviews were performed in the patients who underwent mastoid obliteration after canal wall-down mastoidectomy by the first author in the Department of Otolaryngology, Faculty of Medicine Siriraj Hospital, Mahidol University between January 2004 and January 2008. RESULTS: Fifteen patients were included in the present series. All patients had final round dry cavities within six to eight weeks except one who had wet discharging cavity from accumulated keratin because of total flap atrophy. Some atrophic change at the distal part of the flap was found in five cases (33%) resulting in small pockets at attic and aditus area after a 6-month follow-up period. CONCLUSION: Postconchal soft tissue and postauricular pericranial flap were reliable for mastoid obliteration. The new cavity was finally round, dry, and healthy. It could be simply accessed, cleaned, and examined for recurrent disease during the follow-up period. Some shrinkage of the flap could be expected at the distal part after the 6-month follow-up period.

A randomized, prospective, double-blind study of the efficacy of dexpanthenol nasal spray on the postoperative treatment of patients with chronic rhinosinusitis after endoscopic sinus surgery.

OBJECTIVE: To assess the efficacy of dexpanthenol nasal spray compared with normal saline spray in the postoperative treatment of patients with chronic rhinosinusitis (CRS) who underwent endoscopic sinus surgery (ESS). MATERIALS AND METHOD: A prospective, randomized controlled study was conducted in CRS patients who underwent ESS. The enrolled patients had never been operated intranasally. These patients received either dexpanthenol or normal saline nasal spray intranasally four times a day for six weeks post-operatively. RESULTS: Fifty CRS patients were recruited in the present study. Age ranged from 23 to 63 years (means 43.4 +/- 11.2 years). Forty-four percent of patients were diagnosed as CRS without nasal polyps (NP) (CRSs NP) and 56% were CRS with NP (CRSw NP). Twenty-five cases were randomly assigned to use dexpanthenol nasal spray whereas the other 25 cases used normal saline nasal spray. The preoperative severity of CRS, determined by the computerized tomography (CT) scan scoring system of Lund-McKay was 13.9 +/- 6.2 in the dexpanthenol group and 13.6 +/- 6.9 in the normal saline group, which were not statistically different (p > 0.05). The endoscopic scoring was 10.2 +/- 2 in the dexpanthenol group and 10.7 +/- 3 in the normal saline group, which were not statistically different (p > 0.05). The mucociliary transit time improvement (time difference between pre- and post-treatment by nasal spray) was 8.4 +/- 3.3 minutes in the dexpanthenol group and 1.7 +/- 1.2 minutes in the normal saline group, which were statistically different (p < 0.05). CONCLUSION: The majority of the postoperative symptom scores and all of the endoscopic scores of the dexpanthenol group were not statistically different from those of the normal saline group. However, dexpanthenol nasal spray has superior efficacy compared with normal saline nasal spray on improvement of mucociliary clearance and nasal discharge in the postoperative care of CRS patients after ESS.

Epworth sleepiness scale in obstructive sleep disordered breathing: the reliability and validity of the Thai version.

PURPOSES: The objectives of this study are to test the reliability and validity of the Thai version of the Epworth sleepiness scale (ESS) and to assess the relationship between the ESS score and the severity of obstructive sleep disordered breathing. METHODS: A total of 228 subjects (149 males and 79 females) were recruited. In order to check the discriminant validity of the ESS, we included 32 healthy volunteers and 39 patients with primary snoring to be the control groups and 126 patients with obstructive sleep apnea (OSA) confirmed by full polysomnography to be the disease groups. The test-retest reliability was investigated in 71 subjects. To check the responsiveness properties of the questionnaire, we asked a separate group of 31 patients who were successfully treated with either continuous positive airway pressure (CPAP) or upper airway surgery to complete the ESS before and after treatment at 3-6 months. RESULTS: The internal consistency demonstrated by Cronbach's alpha coefficients for standardized item was 0.87 and a range from 0.84 to 0.86 if some items were deleted. The test-retest reliability was shown by intra-class correlation coefficients of 0.79. There was a statistically significant difference between the mean of the ESS scores of the control groups (6.1 ± 3.0) and the OSA patients (9.9 ± 5.3) (p < 0.001). The ESS scores decreased significantly after a successful treatment with both CPAP and surgery (p < 0.001); however, there was no statistically significant difference among different severities of OSA. CONCLUSIONS: Our Thai version of the ESS showed an excellent internal consistency and test-retest reliability. It is able to discriminate between control subjects and OSA patients and to assess the response of treatment; however, it has a weak relationship with the apnea-hypopnea index. Therefore, we recommend use it to combine with more comprehensive clinical evaluation in obstructive sleep disordered breathing patients.

Choanal atresia.

Choanal atresia is caused by failure of resorption of the bucco-pharyngeal membrane during embryonic development. The atresia can be membranous or bony in nature, but is usually mixed in most cases. When the atresia is bilateral, newborns can have severe airway distress and cyanosis is alleviated by crying. Bilateral choanal atresia is managed with an oropharyngeal airway. Flexible nasal endoscopy and computed tomography can confirm the diagnosis. Surgery is the definitive treatment with two main approaches, namely transnasal or transpalatal. The transnasal route is currently the preferred procedure and can be performed in a minimally invasive fashion with endoscopic instrumentation. It is a safe and rapid procedure even in very young children, with no complications and a high rate of success. The use of a navigation system for surgical planning and intraoperative guidance and powered instrumentation can improve treatment outcome. The transpalatal approach is more invasive and reserved for failed endoscopic cases.

How to overcome laryngotracheal stenosis.

OBJECTIVES: To review and evaluate the outcome of the treatment of laryngotracheal stenosis (LTS). DESIGN: Descriptive review cases. SETTING: Tertiary care university hospital. PATIENTS: Series of LTS patients who were treated by the first author (TW) from January 2000 to January 2003. MAIN OUTCOME MEASURES: Leading causes of LTS, details of the lesions, therapeutic procedures, complications of treatment, time to and success in decannulation. RESULTS: Twenty-one patients (9 females and 12 males), ranging in age from 1 to 32 years old were included in the present study. Half of the patients were under 10 years old. The most common site of the lesion was the subglotic lumen (14 cases), followed by the cervical trachea (5 cases). Patients were treated using endoscopic methods (6 cases), laryngotracheal reconstruction (LTR) (9 cases), tracheal resection (3 cases), and partial cricotracheal resection (3 cases). Decannulations were achieved in 19 patients (90.5%). Endoscopic treatment succeeded within 2-4 procedures in properly selected cases. Despite LTR, multiple sessions of endoscopic laser surgery, and arytenoidectomy, decannulation was not achieved in two of the cases, both of whom had all-level laryngeal stenosis. Time to decannulation ranged from 2 to 210 days. The major causes of delayed decannulation were the presence of a large bare area of cartilaginous grafts and restenosis with granulation tissue formation CONCLUSION: Appropriate LTS treatment, which is based on the description of the lesion, results in a high decannulation rate within a proper time. Multilevel LTS, especially in the supraglottic and glottic area, is refractory to various treatment modalities, and full function of the larynx may not be restored.

Treatment of nasal inflammation decreases the ability of subjects with asthma to condition inspired air.

We previously showed that individuals with seasonal allergy have a reduced ability to condition air, which was improved by nasal inflammation. We also showed that subjects with asthma have a reduced ability to condition air. Because individuals with asthma usually have inflammation in the nose, we hypothesized that treatment with an intranasal steroid would reduce nasal inflammation and further decrease nasal conditioning capacity. We performed a randomized, double blind, placebo-controlled, 2-way crossover study on 20 subjects with asthma comparing the effect of treatment with intranasal budesonide for 2 weeks on nasal conditioning. Treatment with budesonide caused no significant effect on nasal conditioning as compared with placebo. When we evaluated the subgroup of nonsmoking subjects, budesonide caused a significant reduction in nasal conditioning. We speculate that nasal inflammation in nonsmoking individuals with asthma increases the conditioning capacity and reducing it with an intranasal steroid worsens the ability of the nose to condition air. In addition, smoking causes an increase in nasal conditioning capacity by non-steroid-dependent factors. These observations help us understand the pathophysiology of nasal conditioning, but do not negate the positive clinical benefits of budesonide on treating nasal inflammation.

Nasal granuloma gravidarum presenting with recurrent massive epistaxis.

Nasal granuloma gravidarum is a rare condition associated with pregnancy and minor trauma. This condition presents with a nasal mass with varying degree of bleeding and obstruction. We report a patient with nasal granuloma gravidarum in the third trimester of pregnancy. Surgical excision is the definite treatment for this condition in order to stop the vicious cycle of recurrent massive bleeding. Possible etiology, clinical features and management are discussed.

Sclerosing lipogranuloma of the nose: a new treatment using adipose tissue transplantation.

We report a series of 45 patients visiting our clinic with distorted contour of the nose after having their noses augmented with injectable substances. The most common clinical presentation was a palpable mass on the dorsum of the nose, erythema with or without telangiectasia on the overlying skin, and nodularity of the nose. The onset of symptoms varied from 1 to 16 years after injection. They were treated by surgical excision, but this was always followed by a saddle-nose deformity. To correct this defect, we propose a new technique of adipose tissue transplantation that yields satisfactory results. Pathological reports of the excised mass showed a foreign body granuloma known as a sclerosing lipogranuloma (paraffinoma or siliconoma).

Effects of intranasal azelastine on the response to nasal allergen challenge.

OBJECTIVES/HYPOTHESIS: Azelastine, a second-generation H1-receptor antagonist, is available for topical administration. The aim of the study was to evaluate the effects of topical intranasal azelastine on the early-phase and the late-phase allergic responses and on nasal hyper-responsiveness to methacholine. STUDY DESIGN: Double-blind, placebo-controlled, two-way crossover study in 20 subjects with seasonal allergic rhinitis, out of their allergy season. METHODS: Subjects were randomly assigned to receive either placebo or two puffs of azelastine twice a day (548 microg/d) for 2 weeks followed by nasal challenge with allergen. Twenty-four hours later, while still receiving treatment, subjects underwent a nasal lavage and a nasal challenge with methacholine. End points included symptom scores, levels of mediators and number of eosinophils in nasal lavages, and the weight of secretions after methacholine challenge. RESULTS: Compared with placebo, treatment with intranasal azelastine resulted in significant reductions in allergen-induced sneezing, rhinorrhea, itching, nasal congestion, and levels of albumin during the early-phase response (P <.05). Azelastine had no effect on levels of histamine or tryptase during the early-phase response. There was a significant eosinophil influx 24 hours after challenge, which was not inhibited by azelastine. Treatment with azelastine had no effect on the levels of albumin, interleukin-4, interleukin-5, intercellular adhesion molecule-1, tumor necrosis factor-alpha, and eosinophil cationic protein during the late-phase response. However, azelastine did show a significant inhibitory effect on the methacholine response 24 hours after nasal allergen challenge (P <.05). CONCLUSIONS: The effects of intranasal azelastine are similar to those of oral second-generation antihistamines.