Using thermal effect of 970 nm diode laser to reduce nasal swell body.

In recent decades, semiconductor lasers have been successfully used in rhinology. However, their usage in the reduction of the nasal swell body (NSB) is barely studied. Our research aimed to conduct an experimental selection of the laser exposure mode in the NSB zone using a 970 nm diode laser for safe and effective NSB reduction. The thermometric parameters of a diode laser with a wavelength of 970 nm were evaluated in a continuous contact mode of exposure at the power from 2 W to 10 W with 2 W step. The laser was targeted at the liver of cattle, given its similar optical properties to the NSB region. After a series of experiments with every power rate and the analysis of temperature data, we estimated an optimal exposure mode at a power of 4 W. The collected thermometric data demonstrate the safety of this mode in a clinical setting for NSB reduction due to causing no thermal damage to the adjacent tissue. Based on the experiment, a technique for laser reduction of the NSB was developed to improve nasal breathing in patients with severe hypertrophy of this area. The proposed technique was applied to 39 patients with chronic vasomotor rhinitis and the NSB. All patients were divided into 2 groups. Group 1 consisted of 20 patients who underwent surface contact laser-turbinectomy and the NSB reduction using a 970 nm diode laser. Group 2 included 19 patients with the same pathology who underwent laser-turbinectomy, without reduction of the NSB. No statistically significant difference was observed during the dynamic observation with an objective assessment of nasal respiration according to active anterior rhinomanometry when comparing these subgroups with each other according to the t-criterion for independent samples (p > 0.05). As a result of comparing the data obtained on the NOSE scale using the Student's t-test, a statistically significant difference is observed (p < 0.001). Thus, patients who did not perform the reduction of the NSB subjectively noted the insufficiency of nasal breathing. This fact indicates that the NSB is involved in the regulation of airflow.

[Treatment of allergic and vasomotor rhinitis: the role of beclomethasone dipropionate and hyaluronic acid (with high molecular weight).] / Trattamento delle riniti allergiche e vasomotorie: il ruolo del beclometasone dipropionato e dell'acido ialuronico (ad alto peso molecolare).

Inflammatory rhinitis is a very common disorder. It includes allergic rhinitis (AR) and non-allergic rhinitis (NAR). Nasal inflammation is shared by both disorders. So, anti-inflammatory treatment is indicated for both. Beclomethasone dipropionate (BDP) is a corticosteroid that is long time available both as intranasal spray and aerosol solution. BDP is a corticosteroid with proved efficacy in the treatment of rhinitis, both as spray and aerosol. Safety issue has been satisfactory explored, thus BDP is usually safe and well tolerated. Hyaluronic acid (HA) with high molecular weight has anti-inflammatory activity associated with wetting-lubricating effect. BDP may be usefully employed in acute forms, HA may be also used in chronic ones.

Determination of oxidative stress and effect of erdosteine on rhinitis medicamentosa in a rat model.

We aimed to determine the presence of oxidative stress in rhinitis medicamentosa (RM) and to evaluate the effect of erdosteine (ED) on mucosal changes in a rat model. Twenty-four male rats were used in this experimental study. Three groups were created. Group 1 (n=8) was the control group. Two puffs of 0.05% oxymetazolin were sprayed into the nasal cavities of the remaining rats (n=16) three times daily for eight weeks. One of these 16 rats was scarified at the end of the eight weeks and examined to confirm the presence of RM. Seven of the remaining 16 rats were killed, and venous blood samples were taken (Group 2). Group 3 (n=8) received 10mg/kg of an ED suspension orally for seven days. All rats were put on formalin for light microscopy. The total antioxidant status (TAS) was similar in all groups (p=0.073). The total oxidative status (TOS) of the RM group was significantly higher than that of the control group and RM+ED group (Group 3) (p=0.003 and p=0.011, respectively). The pathological recovery of the nasal mucosa of the rats was similar in the RM+ED and control groups. The TOS was high in this RM rat model, and oxidative stress was associated with RM. ED significantly ameliorated nasal mucosal changes induced by RM, suggesting that oxidative stress may play an important role in the pathophysiology of this condition.

Therapeutic effectiveness of endoscopic vidian neurectomy for the treatment of vasomotor rhinitis.

CONCLUSION: Our results indicate that vidian neurectomy may be recommended as an effective method for the treatment of vasomotor rhinitis (VMR). OBJECTIVE: The aim of this work was to study the feasibility and effectiveness of vidian neurectomy treatment under the nasal endoscope for VMR. METHODS: The study included 45 patients with VMR. They were all assigned to functional endoscopic surgery with vidian neurectomy. RESULTS: The obtained data showed that, using the rhinoconjunctivitis quality of life questionnaire, vidian neurectomy treatment relieved the symptoms of VMR in 82.2% of the patients. Vidian neurectomy also led to the reduction of expression of several cytokines, including vasoactive intestinal polypeptide, calcitonin gene-related peptide, substance P, interleukin (IL)-4, and IL-5.

Nonallergic rhinitis: therapeutic options.

PURPOSE OF REVIEW: The purpose of this review is to briefly discuss methods for classifying Nonallergic rhinitis (NAR), the current understanding of its immunopathogenesis, scientific evidence-based treatment options along with anecdotal clinical experience for selecting different treatment regimens for these challenging patients. RECENT FINDINGS: NAR also known as idiopathic rhinitis, irritant-induced rhinitis and vasomotor rhinitis is a heterogeneous condition that has been classified many different ways, but currently there is no consensus on definition for this condition due to its poorly elucidated mechanism(s) of action. A typical patient presents with nasal congestion, postnasal drainage with or without a cough associated with, to a lesser extent, some degree of sneezing, itching, and rhinorrhea. Recent studies have proposed more specific approaches for characterizing rhinitis subtypes. It is speculated that this condition is due to an autonomic imbalance resulting in an overactive parasympathetic and perhaps an underactive sympathetic nervous system. Our poor understanding of NAR mechanism(s) of action has significantly hindered progress in developing novel therapies for this condition. SUMMARY: Further investigation is required to understand the neurogenic signaling pathways that lead to this aberrant response. Until we have selective therapies for NAR, treatment requires selecting the medication or combination of medications best suited to the symptomatic needs of the patient.

Cytologic alterations in nasal mucosa after sphenopalatine artery ligation in patients with vasomotor rhinitis.

BACKGROUND: Vasomotor rhinitis (VR) seems to be related to an imbalance between cholinergic and adrenergic activity in the autonomic nervous system. The nerve fibers of the sympathetic and parasympathetic nervous systems reach the nose through the posterior nasal nerve, which, after crossing the sphenopalatine foramen, distributes to the mucosa following the branches of the sphenopalatine vessels. This study was designed to evaluate the effect of sphenopalatine artery ligation on nasal function and nasal cytology in patients with VR. METHODS: Thirty patients with VR and bilateral inferior turbinate hypertrophy (ITH) were randomly assigned to receive endoscopic inferior turbinoplasty either with or without sphenopalatine artery ligation. Pre- (baseline) and postsurgical (1-year follow-up) assessment included fiber endoscopy, active anterior rhinomanometry, measurement of mucociliary transport time (MTt), and nasal cytology examination. RESULTS: At 1-year follow-up there was a statistically significant improvement in nasal resistances in both groups but not on intergroup comparison; MTt significantly decreased in both groups (p < 0.01) and was significantly better (p < 0.05) in the group that had undergone sphenopalatine artery ligation. Among the patients in this group, significantly fewer were found to have altered ciliated cells (p < 0.005) or a hyperchromatic supranuclear stria (p < 0.005) on nasal cytology; the differences were statistically significant also on intergroup comparison (p < 0.005 and p < 0.001, respectively). CONCLUSION: In patients with vasomotor rhinopathy and ITH, improvement in symptoms, nasal resistance, ciliated cell trophism, and MTt was observed after sphenopalatine artery ligation.

[Comparative assessment of cryosurgical treatment results in allergic and non-allergic rhinitis]. / Porównawcza ocena wyników leczenia alergicznych i niealergicznych niezytów nosa za pomoca kriochirurgii.

INTRODUCTION: The aim of the work was to assess the treatment efficiency in patients with allergic and non-allergic vasomotor rhinitis after cryoablation procedures. MATERIAL AND METHODS: The study covered 60 patients, including 32 women and 28 men, aged 18-66. The patients were divided into two groups: I - 30 patients with chronic allergic rhinitis, II - 30 patients with non-allergic vasomotor rhinitis. The study methodology involved: an otorhinolaryngological interview with a questionnaire and an allergological interview, an objective otolaryngological and rhinomanometrical examination with Homoth apparatus, a subjective evaluation questionnaire for nasal blockage intensification (the scale ranging from 0 to 10), skin tests to aeorallergens and food allergens (Allergopharma Co.), nasal endoscopy with a straight rigid Eleps endoscope before the treatment and 3 months following it. The cryoablation of nasal conchas was performed under local infiltration anesthesia (1% Xylokaina solution) using the Cryo-S apparatus from CryoFlex Poland Company and a flat probe in a spatula shape (L-50) that was placed on the outer surfaces of the inferior nasal concha. RESULTS: The inferior nasal concha cryoablation resulted in a statistically significant improvement in the subjective assessment scale in group I by 82.6% and group II by 141.2%. In the endoscopic examination 3 months following the cryoablation a good nasal patency was achieved in 63.3% patients from group I and 76.7% patients from group II. The conducted studies show a better nasal passages patency in patients with non-allergic rhinitis than in those with allergic rhinitis. CONCLUSIONS: Cryoablation procedures on the inferior nasal conchas are not the primary therapy, but together with other methods they can immensely improve the life comfort of a rhinitis patient.

[Mucociliary clearance in chronic hypertrophic and chronic vasomotor rhinitis in the light of morphometric data].

This study included a total of 90 patients of whom 35 ones suffered chronic hypertrophic (CHR) and chronic vasomotor (CVR) rhinitis. All the patients were examined in the saccharine test and underwent morphometry for the measurement of the ciliary beating rate (CBR) and the magnitude of extrusion of ciliary epithelium. Saccharine transit time in the group of CHR patients was found to vary from 20 to 43 minutes and CBR to equal 3.75 Hz. All these patients showed enhanced epithelial extrusion. Saccharine transit time in patients with CVR increased up to 17-29 min, with CBR being decreased to a mean of 4.56 Hz in 33 (60%) of them. In 22 (40%) cases of CVR, CBR remained normal. Interestingly, patients with CVR exhibited no signs of epithelial atrophy whereas most of them had reduced CBR.

Allergic and idiopathic rhinitis: an ultrastructural study.

Nasal hyperreactivity is one of the most important underlying mechanisms in both allergic (AR) and idiopathic rhinitis (IR). In order to study the pathomorphological changes in this entity, tissue samples from patients with AR, IR, and from patients without chronic inflammation were taken during nasal surgery. Primary antibodies against Substance P (SP), calcitonin gene-related peptide (CGRP), and endothelial nitric oxide synthases (NOS III) were applied and the immunocomplexes were visualized by immunocytochemistry. The nasal mucosa of patients with AR and IR showed similarities on the ultrastructural level. Neurogenic inflammation was indicated by a strong innervation pattern with sensory nerve fibers containing SP and CGRP. We could show that extensive edema and cellular infiltration might be characteristic for AR. On other hand there was no evidence of eosinophilic or NO involvement in IR. Finally, on the ultrastructural level, AR and IR showed many similarities. Based on these findings anti-inflammatory therapy modalities could be recommended for both types of rhinitis.

[The roles of three peptides in the pathogenesis of vasomotor rhinitis].

OBJECTIVE: To explore the possible roles of three neuropeptides in the pathogenesis of vasomotor rhinitis by studying the expression and distribution of neuropeptides in the mucosa of vasomotor rhinitis, such as Substance P(SP), calcitonin gene-related peptide (CGRP) and vasoactive intestinal peptide(VIP). METHOD: The mucosa specimens of thirty vasomotor rhinitis patients who had typical symptoms and signs were selected randomly as the experiment group and were divided into two subgroups depending on if received treatment or not. While the normal middle turbinate mucosa specimens of nine cases were selected as the control group. The expression and distribution of neuropeptides were examined by immunohistochemical SP method and computer image disposing and analyzing system. RESULT: The terminals of SP, CGRP and VIP in the treated experiment group wer and untreated experiment group were markedly increased in density of immunostaining compared to the control group,and the difference is significant (P < 0.01). CONCLUSION: Neuropeptides, such as SP, CGRP and VIP, may play important roles in the pathophysiological mechanism of vasomotor rhinitis.

Radiofrequency for the treatment of vasomotor rhinitis.

OBJECTIVES: We assessed the efficacy of submucosal application of radiofrequency to the inferior turbinate for the treatment of vasomotor rhinitis. PATIENTS AND METHODS: Twenty patients with vasomotor rhinitis (9 males, 11 females; mean age 29.2 years; range 20 to 40 years) were treated with radiofrequency applied to the inferior turbinate. Symptoms such as nasal obstruction, sneezing, and watery nasal discharge were graded with the use of a visual analog scale (VAS) before, and on days 1, 3, 7, 30, 60, 90, and 180 after the treatment. RESULTS: The severity of symptoms began to decrease following the first week after the application. Maximum relief was achieved between 30 to 60 days after the intervention. The highest rate of improvement (85.4%) was reported in sneezing, followed by nasal obstruction (76.4%) and nasal discharge (67.7%). The mean VAS scores showed a significant improvement in all symptoms between 7 to 180 days after the procedure (p<0.05). The rate of patient satisfaction was 90% for the relief of nasal obstruction and sneezing, and 80% for nasal discharge. Complaints about vasomotor rhinitis increased up to a severity near the pretreatment level in eight patients on the 180th postoperative day and the procedure was repeated. CONCLUSION: These findings indicate that radiofrequency may be used as an alternative treatment option in patients with vasomotor rhinitis.

Immunohistochemical localization of 3-nitrotyrosine in the nasal respiratory mucosa of patients with vasomotor rhinitis.

CONCLUSION: This study demonstrates that, in the nasal respiratory mucosa of patients with vasomotor rhinitis, oxidative stress following peroxynitrite formation is confined to the respiratory epithelium. This suggests that the role of peroxynitrite in vasomotor rhinitis differs from its role in other diseases of the respiratory tract. The results of this study also support the concept that different pathogenetic mechanisms are probably involved in vasomotor rhinitis. OBJECTIVE: Previous studies indicated that nitric oxide (NO) is involved in the pathogenesis of vasomotor rhinitis, strong expression of NO synthase being detected in the smooth muscle cells of the cavernous sinuses and in the respiratory epithelium. However, most adverse effects of high levels of NO originate from the reaction of NO with superoxide anions to form peroxynitrite. Therefore, in this study we evaluated the involvement of peroxynitrite in the pathogenesis of vasomotor rhinitis. MATERIAL AND METHODS: Sites of peroxynitrite formation were identified by immunolabelling for 3-nitrotyrosine (3NT), its footprint in tissues. Samples of nasal mucosa were obtained from vasomotor rhinitis patients and from control subjects who had undergone corrective surgery of the nasal septum. All samples were obtained by reduction of the inferior turbinate. RESULTS: Examination of specimens from vasomotor rhinitis patients revealed that 3NT is absent in epithelium with a normal appearance, cells of the subepithelial connective tissue, the glands and the blood vessels, including the cavernous sinuses. In contrast, intense 3NT immunolabelling was found in the disrupted respiratory epithelium. 3NT was not present in any of the specimens from control subjects.

Use of mometasone furoate aqueous nasal spray in the treatment of rhinitis medicamentosa: an experimental study.

OBJECTIVE: We aimed to investigate, histopathologic changes in the nasal mucosa of guinea pig's after prolonged administration of oxymetazoline and the development of rhinitis medicamentosa, and the efficacy of mometasone furoate aqueous nasal spray and saline in reversing the ultrastructural changes attributable to rhinitis medicamentosa. METHODS: In the study, 24 male guinea pigs (500 to 600 gr) were used. Oxymetazolin (0.05%) was sprayed into the nasal cavities of the guinea pigs 3 times daily for 8 weeks. At the end of this period, 6 guinea pigs were killed and examined to make sure that the animals had developed rhinitis medicamentosa. The remaining guinea pigs were randomly divided into 3 groups. In the first group, one spray-puff of 0.05% mometasone furoate aqueous nasal spray (50 microg) was applied twice daily for 14 days. In the second group, saline solution (0.9% NaCl) was applied twice daily for 14 days. No treatment was performed in the third group. At the end of the treatment period, nasal mucosal changes were evaluated by light microscopy and electron microscopy. RESULTS: After oxymetazolin application for 8 weeks, the main histologic changes were edema, congestion, proliferation of subepithelial glands, and squamous cell metaplasia. After topical mometasone furoate aqueous spray application for 2 weeks, the edema fluid was found to diminish markedly. In the saline and no treatment groups, edema and congestion continued. In these groups of guinea pigs, fibrosis has been seen in the nasal mucosa. CONCLUSION: We found that mometasone furoate nasal spray was effective against experimentally induced rhinitis medicamentosa in guinea pigs. Mometasone furoate nasal spray may have value in the treatment of patients with rhinitis medicamentosa.

Vasomotor rhinitis update.

PURPOSE OF REVIEW: This review was conducted to examine new data on vasomotor rhinitis, a common clinical problem. RECENT FINDINGS: Recent publications highlight advances in the study of the pathophysiology of vasomotor rhinitis. Electron microscopic and ultracytochemical evaluation of the nasal mucosa in vasomotor rhinitis demonstrates an emerging role of neuropeptides and nitric oxide in the pathogenesis of vasomotor rhinitis. Ozone, cigarette smoke, and other environmental factors may trigger neurogenic mechanisms that lead to vasomotor rhinitis. Objective tests have documented the presence of hypoactive sympathetic autonomic dysfunction. Such assessments also suggest autonomic dysfunction as a possible link between vasomotor rhinitis and gastroesophageal reflux disease. Recent publications propose nasal secretory protein analysis as a possible diagnostic tool. Evidence-based review of treatment outcomes shows topical sprays of azelastine, budesonide, and ipratropium to be of benefit in vasomotor rhinitis. SUMMARY: A better understanding of the role of nitric oxide and neuropeptides in the pathogenesis of vasomotor rhinitis has opened new avenues in research, diagnosis, and management. Clinical diagnosis may be aided by the analysis of nasal secretory proteins. Effective treatments include antihistamine, anticholinergics, and steroid nasal sprays.

Ultrastructural and ultracytochemical study of the human nasal respiratory epithelium in vasomotor rhinitis.

OBJECTIVES: Several pieces of evidence have suggested that nitric oxide (NO) fulfills important functions in the respiratory mucosa, under both normal and pathological conditions. This study was performed to investigate the role of NO in the nasal respiratory epithelium of patients affected by vasomotor rhinitis. The structure and ultrastructure of the epithelium were also examined. MATERIAL AND METHODS: The localization of NO synthase activity was determined by means of reduced nicotinamide adenine dinucleotide phosphate (NADPH)-diaphorase ultracytochemistry. Nasal mucosa was obtained from patients who had undergone surgical therapy for reduction of the inferior turbinate. RESULTS: Examination of hematoxylin-eosin-stained sections revealed that most of the nasal mucosa covering the surgical samples was characterized by severe epithelial damage. The ultrastructural study confirmed the light microscopic observations. Ciliary loss, absence of the intercellular junctions and distension of the intercellular spaces were found in the damaged epithelium. The basement membrane was frequently interrupted. Some epithelial cells were identified as basal cells. Other cells of the damaged epithelium were probably involuted ciliated and goblet cells. The ultracytochemical study showed that the basal cells were NADPH-diaphorase-negative in healthy subjects and strongly NADPH-diaphorase-positive in subjects with vasomotor rhinitis. CONCLUSIONS: It is suggested that NO has cytotoxic effects and causes inhibition of mitotic activity in the basal cells, leading to epithelial disruption and breakdown of the protective functions of the epithelium.

[The influence of botulinum toxin type A on vasomotor rhinitis and morphological study].

OBJECTIVE: To investigate the effect and mechanisms of botulinum toxin type A(BTA) on vasomotor rhinitis. METHOD: A retrospective study of 32 patients with vasomotor rhinitis who received BTA injection at 4 points in bilateral nasal cavities with 2.5 units at each point had been done. The state of rhinorrhea, nasal obstruction, sneeze and nasal mucosa edema of each patient were recorded and scored before and after the application of BTA respectively with follow-ups of 6-30 months. Twelve guinea pigs were randomly divided into 2 groups: BTA group and control group. Merocel sponge soaked with 10 units (0.2 ml) BTA was put into left nasal cavity under general anesthesia for one hour in BTA group. Saline replaced BTA in control group. The inferior turbinate mucosa of guinea pig ware harvested under general anesthesia at 7, 14, 28 days after BTA treatment and was observed with HE staining and electron microscope. RESULT: Rhinorrhea improved significantly in all 32 patients while sneeze, nasal obstruction and mucosa edema reduced partly. The reducing of rhinorrhea lasted averagely 6 weeks. Twelve patients had an episode of nasal dryness or increased rhinorrhea at the day of injection. No other complications were found. Seven, fourteen days after local BTA application, the degenerations of glandular epithelium and canal epithelium were observed in nasal mucosa of guinea pigs. Most of the glandular cells showed normal at 28 days after BTA treatment. CONCLUSION: BTA can induce the degeneration of glandular cells in nasal mucosa and thus obviously relieve over rhinorrhea of patients with vasomotor rhinitis.

Histopathological verification of clinical indications to partial inferior turbinectomy.

Surgical treatment in cases where disturbances of the nasal patency causes changes in the nasal inferior turbinates is controversial. The authors performed light- and electron microscopy and morphometric examinations of the mucous membrane of the nasal inferior turbinates obtained after partial inferior turbinectomy in patients with vasomotor and perennial allergic rhinitis and compensation hypertrophy of the nasal inferior turbinate accompanied by nasal deviation of the septum. In specimens obtained from patients with vasomotor rhinitis, a small number of glands and fibrosis of the lamina propria was observed. In specimens obtained from perennial allergic rhinitis patients, plenty of glands and large oedema was observed. In the group with compensatory hypertrophy of the inferior turbinate, normal glands and fibred areas around the vessels were observed. The largest histopathological changes of degeneration and hypertrophy of the nasal mucosa were observed in vasomotor rhinitis patients. Histopathological examination of nasal mucosa slides confirmed the usefulness of a partial inferior turbinectomy, but only in vasomotor rhinitis patients.

[Histopathological verifications clinical indications in the inferior turbinoplasty]. / Weryfikacja histopatologiczna wskazan klinicznych do turbinoplastyki dolnej.

Surgical treatment in cases of disturbances of nasal patency caused changes in the nasal inferior turbinates are controversial. The authors performed the microscopic (light microscope) and morphometric examinations of mucous membrane of the nasal inferior turbinates obtained after inferior turbinoplasty in patients with vasomotor and perennial allergic rhinitis and compensation hypertrophy of nasal inferior turbinate accompanied of nasal deviation septum. Analysing of morphologic changes in mucous membrane of the nasal inferior turbinates verified of clinic indications to inferior turbinoplasty.

Ultracytochemical localization of the NADPH-d activity in the human nasal respiratory mucosa in vasomotor rhinitis.

OBJECTIVES: Description of the ultrastructural localization of nitric oxide synthase in the blood vessels of the nasal respiratory mucosa in patients with vasomotor rhinitis. STUDY DESIGN: This research was conducted on seven patients--men and women, ages 20 to 45 years--suffering from vasomotor rhinitis and who had undergone surgical therapy for reduction of the inferior turbinates. METHODS: To study the ultrastructural localization of nitric oxide synthase, NADPH-diaphorase cytochemistry was employed. Samples of the nasal mucosa were obtained from inferior turbinates. RESULTS: The endothelial cells of the arterioles, capillaries, venules and cavernous sinuses revealed a distribution of the enzymatic activity similar to that found in unaffected subjects. A strong enzymatic activity was recognized in the smooth muscle cells of the cavernous sinuses. The smooth muscle cells of arterioles and venules were generally found to be negative to enzymatic reaction. CONCLUSIONS: This study suggests that the vascular disorders of the vasomotor rhinitis depend, at least in part, from nitric oxide synthase induction in the smooth muscle cells of the cavernous sinuses.

[Correction of microcirculatory disorders with low-energy laser radiation in children with vasomotor rhinitis]. / Mikrotsirkuliatornye rasstroistva i vozmozhnosti ikh korrektsii nizkoénergeticheskim lazernym izlucheniiem u bol'nykh vazomotornym rinitom v detskom vozraste.

Turbinated bone's mucosa of 46 children aged 6 to 15 years was exposed to radiation of low-energy laser for neurovegetative vasomotor rhinitis. Repeated biomicroscopy stated that abnormal microcirculation recovered after 10 sessions of the radiation even in severe alterations of the microcirculatory bed and long history of the disease. The conclusion is made that low-energy laser radiation is effective in correction of microcirculatory disorders and tissue mechanisms of homeostasis in children with neurovegetative vasomotor rhinitis.