Prevention of relapses of nasal polyposis with intranasal triamcinolone acetonide after polyp surgery: a prospective double-blind, placebo-controlled, randomised study with a 9-month follow-up.

OBJECTIVE: To determine whether intranasal triamcinolone acetonide prevents the regrowth of nasal polyps after polyp surgery. STUDY DESIGN: Randomised, double-blind, placebo-controlled, prospective study. SETTING: Helsinki University Central Hospital. PARTICIPANTS: Sixty patients with nasal polyps entered the study. Patients were included upon arrival for elective polyp operations determined according to our standard clinical criteria. The recurrence of nasal polyposis was followed up for 9 months after surgical treatment at 3-month intervals. MAIN OUTCOME MEASURES: Anterior rhinoscopy, nasal endoscopy, olfactory threshold measurement, active anterior rhinomanometry and acoustic rhinometry were performed at every follow-up visit. RESULTS: On the whole, there was a significant inter-group difference in the change in polyp size of acetylsalicylic acid (ASA)-tolerant patients during the follow-up. In patients with acetylsalicylic acid intolerance, there was no inter-group difference (P = 0.28). No significant differences were noted for nasal resistance, nasal cavity volume, sense of smell and nasal symptoms. CONCLUSION: Triamcinolone acetonide prevents regrowth of nasal polyps after polyp surgery in acetylsalicylic acid-tolerant patients, but not in acetylsalicylic acid-intolerant patients.

Wegener's granulomatosis in Finland in 1981-2000: clinical presentation and diagnostic delay.

OBJECTIVE: To determine the features of clinical presentation and the diagnostic delay of Wegener's granulomatosis (WG) in Finland in 1981-2000. METHODS: A retrospective cohort study using hospital discharge registers with review of hospital case reports. We determined the spectrum of WG symptoms in relation to individual organ groups and ELK (Ear, nose, throat, Lung, Kidney) score within the first 6 months from disease onset. Diagnostic delay and contributing factors were analysed. RESULTS: Of 513 WG patients treated at Finnish specialized medical care hospitals, 489 patients had sufficient information in the first 6 months of their disease. The ENT (Ear, Nose, and Throat) system was involved in 63%; the pulmonary system in 59%, and 60% had general symptoms. Over time, the general symptoms became more common at presentation. The diagnostic delay had decreased from 17 to 4 months. CONCLUSIONS: The initial symptoms of WG remained essentially unchanged. The proportion of general symptoms increased. A considerable shortening of diagnostic delay occurred, mostly between the 5-year periods of 1981-1985 and 1986-1990, when anti-neutrophil cytoplasmic antibody (ANCA) tests were brought into routine use. ELK scores of 2 and 3 and the presence of pulmonary and general symptoms predicted a shorter diagnostic delay.

Incidence of Wegener's granulomatosis in Finland 1981-2000.

OBJECTIVE: To determine the incidence and clinical presentation of Wegener's granulomatosis (WG) in Finland during the 20-year period 1981-2000. METHODS: We performed a study with retrospective data retrieval using the hospital discharge register in Finland. All available hospital case reports were reviewed. We included those patients diagnosed with and treated for WG. Demographic and clinical data at diagnosis were recorded. RESULTS: Of the 492 patients diagnosed with WG, 49% were male. Mean age at diagnosis was 53.2 years (SD 18.1). The highest rate of incidence occurred in men and women aged 65-74 years. The annual incidence per million of the population increased from 1.9 (95% CI 1.4 to 2.6) during 1981-1985 to 9.3 (95% CI 8.1 to 10.6) during 1996-2000 with gender age-adjusted incidence rate ratio 4.5 (CI 3.6 to 5.7). Only minor changes in the signs and symptoms at diagnosis occurred during the 20-year span. In 83% of cases, the ACR criteria (>or=2 criteria) were fulfilled. The mean age at diagnosis rose from 45.8 to 55.0 years and the median diagnostic delay decreased from 17 to 4 months during the two decades. CONCLUSION: The incidence of WG has increased during the last two decades with little change in clinical symptoms at presentation. At the same time, the mean age of the patients has increased and the diagnostic delay has considerably shortened.

Neurofilament profile in olfactory mucosa of patients with a clinical diagnosis of Alzheimer's disease.

In an attempt to find a reliable peripheral marker of Alzheimer's disease (AD), pieces of olfactory mucosa were removed by biopsy from 11 patients with probable AD and from eight control patients. The samples were analysed immunocytochemically using monoclonal and polyclonal antibodies. The olfactory and peripheral neurons of the olfactory mucosa in both AD and control patients typically exhibited immunoreactivity to neurofilament (NF) triplet proteins, including both phosphorylated and non-phosphorylated epitopes, as well as to synaptophysin, but lacked reactivity to other intermediate filament proteins, microtubule-associated protein 2 and tau. Our results do not support the recent findings suggesting the lack of NF proteins in olfactory neurons or the preferential phosphorylated status of NF proteins in olfactory neurons solely in AD.

The effect of esophageal pressure monitoring on nasal airway resistance.

OBJECTIVE: Artificial obstruction of nasal airflow has been shown to increase the amount of apneas and arousals. An esophageal catheter inserted through the nasal cavity is used in sleep studies to show intrathoracic pressure variations as sign of obstructive apneas and increased respiratory resistance. This study evaluates the effect of transnasal esophageal catheter on nasal airflow. STUDY DESIGN AND SETTING: Fifty patients with problem snoring referred to our ENT clinic underwent overnight limited sleep study with an esophageal catheter. Nasal airway resistance was measured the following morning with active anterior rhinomanometry. After exclusion of 17 measurements, the results of 33 patients were compared with same parameters obtained earlier without nasal manipulation. RESULTS AND CONCLUSION: The ipsilateral nasal resistance was clearly elevated when measured with a catheter used overnight compared with the control measurement (P < 0.05). However, the combined nasal resistance was not significantly increased in this material with patent nasal airways. In patients with already compromised nasal airflow, the possibility of clinically relevant changes in nasal airflow during catheter use should be taken in account.

Nasal histamine reactivity; relationships to skin-test responses, allergen provocation and symptom severity in patients with long-continuing allergic rhinitis.

It has been reported that skin-test reactivity and rhinitis symptom severity weaken in the course of time. A corresponding weakening might also be seen in non-specific nasal hyper-reactivity, but the relationships of these responses are poorly understood. Our aim was to measure nasal responsiveness to histamine in a series of patients with long-continuing allergic rhinitis and to compare these measurements with skin test responses, allergen provocation and changes in severity of allergic rhinitis symptoms. A total of 73 patients in whom allergic rhinitis had been verified over 20 years earlier were re-interviewed and re-investigated. Skin prick tests with common allergens were performed and the presence of nasal allergy was confirmed by allergen provocation. Non-specific nasal hyper-reactivity was determined with nasal histamine challenge using four concentrations of histamine phosphate. The response was registered by counting sneezes, recording changes in nasal discharge and mucosal swelling and measuring nasal airway resistance. Sneezing and discharge scores showed that milder non-specific nasal hyper-reactivity was associated with lack of reactivity in skin prick tests and nasal allergen challenge. No association was observed between allergy test results and changes in nasal airway resistance during the histamine provocation. In most patients the symptoms of rhinitis had become milder or disappeared during the follow-up, but the results of the histamine challenge showed no relationship with the changes in symptom severity. In patients with allergic rhinitis, reactivity to histamine is associated with a concomitant change in skin and nasal mucosal reactivity to allergens.

Effect of erythromycin on adenoid bacteria.

Seventy-eight patients with secretory otitis media were given erythromycin ethylsuccinate 50 mg/kg/day, divided into 2 doses, for 7-8 days before undergoing adenoidectomy and tympanostomy. Nasopharyngeal swabs for bacterial culture were obtained before medication and at surgery and the adenoid homogenate was also studied for bacteria. Pneumococci and Branhamella strains became significantly reduced, while Hemophilus influenzae showed no change. Pneumococcus and Branhamella strains partially returned one month after surgery and in part were found in patients who had not had these strains before antimicrobial therapy. Erythromycin ethylsuccinate can sterilize neither the adenoids nor the middle ear space if the causative agent is Hemophilus influenzae.

Cystic fibrosis gene mutations deltaF508 and 394delTT in patients with chronic sinusitis in Finland.

Previous studies have shown that cystic fibrosis (CF) gene mutations are linked to several severe chronic infections. Chronic sinusitis is one condition that may well be influenced by a mutation in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. We studied two prevalent CF mutations (AF508 and 394delTT) in a population with a low incidence of CF. The carrier frequency of the CF mutations in the Finnish population is approximately 1 in 80. We examined DNA specimens from 127 chronic sinusitis patients and found one patient who was heterozygous for 394delTT gene mutation. None of the DNA specimens had any AF508 mutation. This study shows that in a population with a low incidence of CF there was no abnormal carrier distribution of the two most common CF gene mutations in a group of chronic sinusitis patients. Routine screening of sinusitis patients for CF mutations provides no additional information on the etiology of chronic sinusitis.

Nasal reactions elicited by unilateral allergen challenge.

Nasal reactions to unilateral allergen provocation were studied separately in both nasal cavities of 9 subjects with established seasonal allergic rhinitis. Three tests with the same allergen at the same concentration were performed in the same cavity at 48-h intervals. The parameters observed were clinical symptoms, changes in nasal airway resistance on rhinomanometry, and amount, weight and histamine content of the collected secretion. Nasal obstruction increased significantly on the provoked side but not contralaterally. Secretion increased symmetrically but the histamine content rose only on the provoked side. No priming effect was observed. The results are compatible with the view that the release of histamine has a 2-fold effect. Histamine directly caused vasodilatation of capacitance vessels and capillaries, which resulted in obstruction on the provoked side, and indirectly the histamine release led to stimulation of sensory nerve endings, which by triggering parasympathetic reflexes caused rhinorrhea in both nasal halves.

Breast cancer metastasis presenting as ethmoiditis.

Metastasis from primary tumours to the paranasal sinuses is infrequent. We report an unusual case of breast cancer metastasis presenting as ethmoiditis in MRI. MRI changes are unspecific and sometimes inflammatory lesions can not be distinguished from neoplastic lesions. Inflammatory changes in the paranasal sinuses are also frequently noted on MRI even in normal persons without disease. A high index of metastasis suspicion in any patient with breast cancer must be kept in mind.

Nasal challenge.

Seven years' experience of nasal challenge is presented. On the basis of a material of 1492 controlled provocation tests performed on 715 patients, practical problems concerning the performance period of the provocation, application methods, allergen preparations, interpretation of the results as well as the relevance and correlation of different investigation methods of allergic rhinitis are discussed.

Long-term clinical course of hypersensitive rhinitis.

Information on the long-term clinical course of hypersensitive rhinitis was collected among 180 patients who had previously participated in an allergological study. The time period between the initial study and the follow-up questionnaire study was about 18.2 years. Of the patients, 72 were men and 108 women, aged 3.6-69.3 years (mean age 28.5 years) at the time of the initial study. Initially, atopic rhinitis had been verified by allergological investigations in 61.7% while 38.3% of the cases had been designated as intrinsic. During the 18-year period symptoms decreased in severity in 37.2% and ceased completely in 27.2%. Total disappearance of symptoms was more frequent in the intrinsic than in the atopic group.

A comparison between intranasal budesonide aerosol and budesonide dry powder in the treatment of hay fever symptoms.

Sixty patients with seasonal allergic rhinitis due to birch pollen were enrolled in an open, randomized parallel group study. Efficacy and side effects were studied after intranasal administration of budesonide given as a freon propellant aerosol or as dry powder with a sniff actuated inhalation device. Medication started a few days before the actual peak pollen season and lasted for three weeks. The dose was 400 micrograms once daily. Efficacy was assessed daily by patient-rated symptoms scores and by nasal peak inspiratory flow measurements at the visits to the clinic. Safety was assessed by monitoring clinical adverse events. No clear changes in nasal symptom scores or nasal peak flow occurred during the pollen season in either treatment group as compared to the pretreatment period, although the pollen season was very difficult in Finland during the study, ad 12000 grains per m3. Substantial or total control of symptoms was achieved in 93% of the patients in the aerosol group and in 79% in the powder group. Side effects were minimal in both groups. We conclude that dry powder administration of budesonide is as effective and well tolerated as the aerosol in the treatment of seasonal allergic rhinitis.

Unilateral blindness in a child with acute sinusitis.

Orbital infection in association with sinusitis is an emergency. It may cause visual disturbances, and in rare cases even permanent blindness by affecting the optic nerve. We report an unusual case of acute sinusitis that was complicated by irreversible visual loss in a young patient. As there is increasing evidence that respiratory viruses play an important role in the pathogenesis of acute community acquired sinusitis and spontaneous healing with only symptomatic treatment is common, the use of antibiotics in the treatment of acute sinusitis may not be needed in all cases. If the general policy to use antibiotics in acute sinusitis will be changed to more restrained and expectant, we have to be even more aware of these nowadays rare complications.

Clinical findings in patients with allergic rhinitis.

Clinical observations, X-ray findings and results of laboratory tests were evaluated in 770 patients with allergic rhinitis. Anamnestic data and results of the allergological examination of these patients have been presented elsewhere (Holopainen et al., 1979b; Binder et al., 1982). Allergic symptoms were seasonal in 54.5% and perennial in 45.5% of the patients. Mucosal changes as seen on rhinoscopy were significantly more common among patients with perennial than among patients with seasonal rhinitis. Watery discharge was the most common nasal finding, observed in 90% of all patients. Nasal smears showed increased numbers of eosinophilic leucocytes in 70% of the cases. Relationships between the cellular population of the nasal secretion, other laboratory test results and clinical findings are described. X-ray examination revealed pathological changes in the paranasal sinuses in 53.4% of the patients.

Astemizole in combination with pseudoephedrine in the treatment of seasonal allergic rhinitis.

The efficacy and side effects of once-daily astemizole-D, a combination of 10 mg astemizole and 240 mg pseudoephedrine, were compared with those of twice-daily brompheniramine-D, a combination of 12 mg brompheniramine and 50 mg phenylpropanolamine (Lunerin), in 64 patients with seasonal allergic rhinitis caused by birch pollen. Efficacy was monitored by patient's diary scores, investigator assessments of nasal and eye symptoms and need of rescue medication during the 4-week study period. Both astemizole-D and brompheniramine-D reduced nasal and eye symptoms of allergy. There were no significant differences between the treatment groups regarding obstruction, but brompheniramine-D alleviated symptoms of rhinorrhoea and itchy eyes significantly more than astemizole-D. On the other hand, the patients in the brompheniramine-D group reported dry mouth, tiredness and drowsiness more often than those in the astemizole-D group. The results indicate that the two drugs are effective in the treatment of seasonal allergic rhinitis, but astemizole-D is better tolerated than brompheniramine-D.