Release of cyclooxygenase-2 and lipoxin A4 from blood leukocytes in aspirin-exacerbated respiratory disease.

BACKGROUND: The release of cyclooxygenase-2 (COX-2) and lipoxin A4 (LXA4) from blood mononuclear cells in patients with aspirin-exacerbated respiratory disease (AERD) is only partially understood. OBJECTIVE: To investigate the presence of COX-2 and LXA4 in peripheral blood mononuclear cells (PBMC) derived from patients with AERD and with nasal polyps (NP) (designated as the AERD-NP group), patients with NP without AERD (the NP group), and healthy controls without sinus disease (the control group). METHODS: Blood was taken from 14 patients in the AERD-NP group, 6 patients in the NP group, and 8 healthy subjects in the control group. After culturing of human PBMC, the presence of COX-2 protein and LXA4 (ELISA) was detected in the supernatant, and the results were compared among the groups. RESULTS: COX-2 and LXA4 were detectable after culturing of PBMC in all patients in the AERD-NP and NP groups and in the control subjects. COX-2 was highest in the patients in the AERD-NP group, but the difference was not significant compared with patients with non-AERD polyp and with the control subjects. LXA4 was also highest in the AERD-NP group, but the difference was also not significant compared with the patients who were non-AERD polyp and the control subjects. CONCLUSION: Neither the release of COX-2 or LXA4 was different between the patients with AERD and with NPs, the patients without AERD and with NPs, and the healthy control group. The release of these proteins in AERD needs further investigation.

Altered inhibitory function of the E-type prostanoid receptor 4 in eosinophils and monocytes from aspirin-intolerant patients.

Prostaglandin (PG) E2 has been implicated in the pathogenesis of aspirin-exacerbated respiratory disease (AERD). E-type prostanoid (EP) receptor 4 is known to confer inhibitory signals to eosinophils and monocytes, amongst others. In this study, we investigated whether the responsiveness of eosinophils and monocytes to PGE2 and EP4 receptor activation is altered in AERD patients. While the expression of the EP4 receptor in eosinophils was unaltered in AERD patients, inhibition of eosinophil chemotaxis by PGE2 or the EP4 agonist CAY10598 was less pronounced in AERD patients as compared to healthy control subjects. In monocytes, we found no changes in basal or lipopolysaccharide (LPS)-stimulated PGE2 synthesis, but the response to EP4 receptor activation with respect to inhibition of LPS-induced tumor necrosis factor-α release was reduced in AERD patients, especially in the presence of aspirin (acetylsalicylic acid). Our data point towards a decreased sensitivity of inhibitory EP4 receptor that may play a role in AERD.

Cyclooxygenase 2 and lipoxin A4 in nasal polyps in cystic fibrosis.

BACKGROUND: The etiology of nasal polyps (NPs) and sinusitis in cystic fibrosis (CF) patients is still unknown. This study investigates the presence of cyclooxygenase 2 (COX-2) and lipoxin A(4) (LXA(4)) in epithelial cultures derived from NPs and turbinates in patients with CF and without CF. METHODS: NPs and turbinates were evaluated from eight CF patients with obstructing NPs undergoing sinus surgery. NPs and tissue from the hypertrophic inferior turbinate from 14 patients without history of CF undergoing sinus surgery served as control specimens. After tissue culturing, the presence of COX-2 protein and LXA(4) (ELISA) was detected in CF polyps and turbinates and compared with that of the control group. RESULTS: COX-2 and LXA(4) were detectable in tissue specimens of all CF patients and control patients. COX-2 was highest in CF polyps, but the difference was not significant compared with CF turbinates or polyps and turbinates of patients not suffering from CF. LXA(4), however, was significantly higher in CF NPs compared with CF turbinate tissue. Compared with NPs of patients not having CF disease, CF polyps showed markedly higher concentrations of LXA(4). CONCLUSION: LXA(4) is significantly elevated in CF NPs, whereas COX-2 is only slightly increased. The present data support the concept that LXA(4) plays an important role in CF nasal polyposis. Chronic infection in nasal polyposis and, because of inflammation, induced COX-2 in CF NPs may be related to increased LXA(4). The suspected interaction of COX-2 and LXA(4) needs further investigation.

Lipopolysaccharide induction of cyclooxygenase-2 in long-term nasal epithelial cultures in cystic fibrosis.

OBJECTIVE: To evaluate the lipopolysaccharide induction of cyclooxygenase-2 (COX-2) in long-term epithelial cultures from nasal polyp tissue of patients with cystic fibrosis (CF) and severe nasal polyposis. DESIGN: Experimental and histologic study. SETTING: Department of Otorhinolaryngology, University of Ulm, Ulm, Germany. PARTICIPANTS: Nasal polyp tissue was evaluated from 9 patients with CF and obstructing nasal polyps undergoing elective sinus surgery. Nasal mucosa from the hypertrophic inferior turbinate of 9 patients without a history of CF or aspirin intolerance undergoing nasal corrective surgery served as control specimens. INTERVENTIONS: Tissue culturing, Western blotting, and tissue staining with hematoxylin-eosin. MAIN OUTCOME MEASURES: The expression and lipopolysaccharide induction of COX-2 was detected and compared with those of the control group. Tissue was analyzed for the presence of inflammatory cells such as neutrophils, eosinophils, mast cells, plasma cells, lymphocytes, and monocytes. RESULTS: COX-2 was detectable in tissue specimens from all of the patients with CF and control subjects. In patients with CF, however, COX-2 expression was significantly lower in lipopolysaccharide-stimulated, long-term cultured epithelial cells compared with control tissue. Polyps from patients with CF contained markedly more neutrophils, macrophages, and plasma cells than did nasal mucosa from hypertrophic inferior turbinates of controls. CONCLUSIONS: COX-2 expression in lipopolysaccharide-stimulated, long-term cultured epithelial cells in patients with CF is decreased compared with that in hypertrophic turbinate mucosa. The estimated defect in lipopolysaccharide responsiveness and the reduced induction of COX-2 needs further investigation.

Surgical treatment of hypopharyngeal diverticulum (Zenker's diverticulum).

The goal of this study was to evaluate the outcome of various modalities in the treatment of hypopharyngeal diverticulum (Zenker's diverticulum, HD) as performed in the ENT department, University of Ulm. A retrospective analysis of 40 consecutive patients with the diagnosis of a HD was conducted. The three different modalities of surgery applied had been endoscopic laser diverticulotomy (ELD), conventional endoscopic esophagodiverticulotomy (CEE) and transcervical open technique involving diverticulectomy and cricopharyngeal myotomy. Medical records had been reviewed to determine preoperative symptoms and diagnostic findings, operative time, length of hospital stay, time of oral intake, postoperative laboratory parameters, and postoperative complications. Significant differences (P < 0.05) could be observed between the three surgical groups concerning the postoperative time to oral intake, the length of the hospital stay, and the length of time with a nasogastric tube. Patients after ELD had statistically significantly less thoracic pain than patients after CEE. In conclusion, the comparison of three different surgical approaches in the treatment of HD showed that endoscopic techniques versus open-neck technique result in statistically significant shorter operative times and shorter hospital stays. Conventional endoscopic diverticulotomy is not safer than ELD or transcollar open technique.

Nasal-air conditioning in patients with chronic rhinosinusitis and nasal polyposis.

OBJECTIVES: To compare nasal-air conditioning in patients with chronic rhinosinusitis with nasal polyposis with healthy control subjects without nasal pathologic conditions, to investigate nasal-air conditioning after endoscopic sinus surgery with and without septoplasty and turbinoplasty 4 to 6 weeks after surgery, to examine the parameters of nasal patency and nasal geometry that possibly influence nasal-air conditioning before and after endonasal surgery, and to determine their relationship to nasal-air conditioning parameters. DESIGN: Prospective cohort study. SETTING: Tertiary referral center. PARTICIPANTS: Twenty-five patients (median age, 51 years; age range, 20-74 years) having a diagnosis of chronic rhinosinusitis with nasal polyposis refractory to medical treatment and 22 healthy control subjects (median age, 25 years; age range, 18-52 years). INTERVENTION: Patients underwent endoscopic sinus surgery with or without septoplasty and turbinoplasty during 6 months and were followed up 4 to 6 weeks after surgery. MAIN OUTCOME MEASURES: Nasal-air conditioning was measured and acoustic rhinometry and active anterior rhinomanometry were performed before and after nasal surgery. RESULTS: Nasal airflow and nasal volume were significantly higher postoperatively than preoperatively. The preoperative heat increase and water gradient were lower in the patients compared with the controls. The postoperative heat increase was significantly higher than the preoperative values. The water gradient did not change after endonasal surgery. Nasal patency and volume were positively correlated with nasal heating, whereas nasal humidification showed a significant negative correlation with nasal volume. CONCLUSIONS: Patients with chronic rhinosinusitis with nasal polyposis seem to benefit from endoscopic sinus surgery with or without septoplasty and turbinoplasty because nasal heating is improved postoperatively. Four to 6 weeks after endonasal surgery, nasal humidification is neither improved nor worsened compared with preoperative values.

Effects of nasal mask leak and heated humidification on nasal mucosa in the therapy with nasal continuous positive airway pressure (nCPAP).

The purpose of this study was to determine the objective short-term influence of nasal continuous positive airway pressure (nCPAP) therapy, nasal mask leak (NML) and heated humidifiers (HH) to nasal conditioning of spontaneously breathing subjects. This was a prospective, non-randomized, non-blinded day-time study. Eighteen healthy subjects were enrolled in the study. All subjects received nCPAP therapy for 60 min in three different conditions successively: (1) nCPAP without humidification, (2) nCPAP with a defined leakage of nasal mask (slashed circle 28.3 mm2) and (3) nCPAP with HH. Nasal humidity and temperature were measured in the anterior turbinate area using a miniaturized thermocouple and a relative humidity sensor. The measurements were accomplished at the beginning of therapy, after 60, 120 and 180 min. Absolute humidity (aH) in the anterior turbinate area decreased significantly (p = 0.0075) from 17.41 +/- 3.81 mg/l (baseline) to 15.27 +/- 2.21 mg/l (nCPAP alone). With attachment of a NML, aH decreased from 15.27 mg/l not significantly (p = 0.058) to 13.77 +/- 2.28 mg/l (nCPAP and NML) compared to nCPAP alone. After addition of heated humidification to nCPAP, aH increased again from 13.77 mg/l significantly (p = 0.042) to 15.29 +/- 3.51 mg/l (nCPAP and HH) compared to aH (nCPAP+NML). No difference was found between aH (nCPAP and HH) and aH (nCPAP alone). Airway temperature did not change significantly after application of nCPAP alone, nCPAP and NML, and nCPAP and HH. These data indicate that nCPAP therapy with NML tends to have more remarkable reduction of the nasal humidity than nCPAP therapy without NML. nCPAP with heated humidifier is able to compensate the dehydration effects induced by nCPAP therapy with NML by increasing the aH at the anterior turbinate area to the levels observed during breathing with nCPAP alone.

Nasal conditioning after endonasal surgery in chronic rhinosinusitis with nasal polyps.

BACKGROUND: Endoscopic sinus surgery (ESS) is a frequently performed operation for chronic rhinosinusitis (CRS). The aim of this study was to investigate nasal conditioning after ESS with/without septoplasty and turbinoplasty in patients with CRS with nasal polyps and to determine its relation to nasal patency and geometry. METHODS: Twenty-one patients were enrolled into this study. Nasal conditioning, AAR, and acoustic rhinometry were measured before and 4-8 months after endonasal surgery. RESULTS: The temperature and humidity gradient across the nose increased significantly after operation. High nasal volumes and patency were positively correlated with elevated nasal conditioning. No correlation between preoperative and postoperative changes in nasal geometry and nasal airflow with changes in conditioning values was found. CONCLUSION: Patients with CRS with nasal polyps seem to profit from ESS with/without septoplasty and turbinoplasty because nasal conditioning is improved postoperatively. Properly performed ESS has its importance within the variety of nasal surgical procedures ensuring improved nasal function.

Lower airway humidification in spontaneously breathing tracheostomized patients: comparative study of trachea spray versus heated humidifier.

BACKGROUND: Our aim was to compare inhalation with molecular water (vaporizing humidifier) and particulate water (trachea spray) in spontaneously breathing tracheostomized patients. METHODS: We performed a randomized, 2-way crossover study and a prospective, comparative, nonblinded study. Tracheal humidity and temperature were measured before and after use of a humidifier and spray for 1 week. RESULTS: After both inhalation and spray, the tracheal temperature and total water content increased significantly (study 1). The temperature gradient between ambient and tracheal air was significantly higher after spray, but not after inhalation (study 2). The water gradient increased nonsignificantly after spray and inhalation. The water gradient after inhalation or spray did not differ significantly. CONCLUSIONS: Molecular water is not superior to particulate water because of temperature and humidity increase after both forms of water delivery. Because of its easy use, portability, and moisturizing effect, a trachea spray may offer additional options in postoperative tracheostomy care.

The impact of septorhinoplasty and anterior turbinoplasty on nasal conditioning.

BACKGROUND: Septorhinoplasty and turbinoplasty is a frequently performed operation in facial plastic surgery. The aim of this study was to investigate nasal conditioning after septorhinoplasty and inferior turbinoplasty in patients with internal and external nasal deformities and hypertrophy of the inferior turbinates and to determine its relation to nasal patency. METHODS: Ten patients and 10 volunteers as controls were enrolled into this study. Measurement of nasal conditioning and active anterior rhinomanometry were performed before and 4-6 months after functional-esthetic septorhinoplasty and inferior turbinoplasty. RESULTS: Nasal airflow was significantly higher postoperatively than preoperatively. The preoperative nasal temperature (TEMP) and heat increase (HI) was lower in the patients compared with the controls. The postoperative TEMP, HI, total water content, and water gradient were significantly higher than the preoperative values. CONCLUSION: Based on this relatively small series, functional-esthetic septorhinoplasty in combination with inferior turbinoplasty may be associated with improved nasal conditioning.

Medium-term symptom outcomes after paranasal sinus surgery in children and young adults with cystic fibrosis.

OBJECTIVE: To determine the effectiveness of paranasal sinus surgery (PSS) for individual symptoms and recurrence of nasal polyposis in children and young adults with cystic fibrosis and chronic rhinosinusitis (CRS). DESIGN: Nonrandomized, prospective, clinical trial. INTERVENTION: Children and young adults with medically refractory CRS were examined before and after PSS. The extend of nasal polyposis was graded endoscopically and on computed tomography images. The severity of symptoms of CRS was recorded on a 6-point Likert scale by the investigator. RESULTS: In 26 patients, a complete rhinosinusitis symptom score (RSS) before and after surgery was available. The mean follow-up time after surgery was 23 months. Postoperatively, no polyp recurrence was seen in eight patients (of 26 patients). An improved polyp score was found in 14 patients. In four patients, polyp recurrence to the same extent as before surgery was seen. The mean RSS was significantly improved after surgery. Before surgery, "nasal obstruction" was the most common complaint. "Headache" was the second most common complaint before PSS. After PSS, although improved, "headache" was the most common complaint. During further follow-up, in two patients, endocranial complications caused by recurrent frontal mucopyoceles (1 frontal abscess, 1 subacute meningitis) were observed. After transfrontal revision surgery, both patients recovered without neurologic damage. CONCLUSIONS: Even in cases of polyp recurrence, PSS provides significant symptom relief for nasal and facial symptoms associated with CRS. The symptom "headache" requires special attention because it improves least after surgery and may indicate recurrence of frontoethmoidal mucopyoceles or endocranial complication of CRS.

Delivery of molecular versus particulate water in spontaneously breathing tracheotomized patients.

BACKGROUND: Adequate humidification of inspired gas with active or passive humidifiers is a standard of care for tracheotomized patients. In this study, a comparison is made between the tracheal climate after tracheobronchial humidification either with molecular water (via a vaporizing humidifier) or particulate water (via spray) in spontaneously breathing tracheotomized patients. METHODS: We performed a randomized, 2-way crossover study on 10 tracheotomized patients. Tracheal humidity and temperature were measured prior to and after use of a vaporizing humidifier and aerosol spray, respectively. RESULTS: After use of both the vaporizing humidifier and the aerosol spray, the end-inspiratory total water content and water gradient in the upper trachea increased significantly, compared with baseline values before application. After end of use of the vaporizing humidifier, the total water content and the water gradient decreased significantly faster than after application of the aerosol spray. CONCLUSIONS: Delivery of both molecular and particulate water significantly increases the tracheal climate and conditioning in the tracheal airways. Because the tracheal humidity remained on a higher level after aerosol spray, we speculate that particulate water may be efficient on tracheal humidification for longer. However, the positive effect on tracheal humidity after prolonged application of the aerosol spray remains to be proven.

Influence of nasal sponges on patients' complaints after nasal and sinus surgery.

BACKGROUND: The goal of this study was to investigate the effect of nasal sponges on the subjective nasal well-being after nasal and sinus surgery. METHODS: The study was designed as a randomized prospective clinical trial comparing four different types of sponges used as nasal passive humidifiers (NPHs). The 40 participants were blinded to the size and pore structure of the NPHs. The NPHs were applied in both nostrils for 1 hour on the 2nd postoperative day. Subjective nasal sensations were evaluated on a visual analog scale. RESULTS: Wearing comfort was rated as satisfactory. Intranasal humidity and feeling of a dry nose were rated as improved after wearing the NPHs. CONCLUSION: The use of NPHs may have a positive effect on the patients' perception of nasal obstruction and intranasal humidity. Additional investigations in patients with intranasal dryness are planned to improve patients' complaints.

Influence of passive humidification on nasal conditioning.

BACKGROUND: Passive humidifiers (PH) have been beneficial to upper and lower airway humidity, especially in patients who are in a long-time ventilated intensive care unit. The goal of this pilot study was to provide nasal conditioning data and measure the benefit of a nasal PH to spontaneously breathing, conscious subjects. METHODS: Eleven healthy volunteers had to wear a PH for 1 hour, which was introduced into both nasal vestibules. The PH had a heat and moisture restoring body of polyurethane foam with an open-pore structure. Before and after application of the nasal PH, nasal conditioning was measured and nasal symptoms were assessed by the participants. RESULTS: Ten minutes after removal of the PH a significant increase was observed for the scores for nasal patency and nasal humidity. CONCLUSION: We hypothesize that the nasal PH could provide a valuable contribution to the supportive therapy of diseases that accompany nasal mucosal dryness.

Radiofrequency-induced thermotherapy on nasal polyps: preliminary results.

BACKGROUND: The aim of this study was to determine the effects of radiofrequency-induced thermotherapy (RFITT) in patients with nasal polyps. METHODS: A retrospective analysis was performed of prospectively collected data from 17 consecutive patients (11 men and 6 women; mean age, 51.7 +/- 16.9 years) treated with RFITT from 2002 to 2003. The postoperative outcome was assessed using active anterior rhinomanometry, "sniffin' stick" test, and endoscopic nasal examination preoperatively and 4 weeks postoperatively. Subjective complaints were assessed with Likert scales. RESULTS: Transnasal airflow increased by 40.3% 4 weeks postoperatively (p = 0.029). Endoscopic appearance of nasal polyps indicated a nonsignificant reduction of 37.1%. Subjective complaints such as impaired nasal ventilation (p = 0.014), nasal discharge (p = 0.0007), postnasal drip (p = 0.0002), and hyposmia (p = 0.048) improved significantly 4 weeks after surgery. CONCLUSION: RFITT is well tolerated as a day case procedure under local anesthesia and might be a procedure for treating recurrence of NP after sinus surgery. It remains unclear at this point whether RFITT for nasal polyps results in a permanent reduction.

Acoustic rhinometry in nasal provocation test in perennial allergic rhinitis.

Acoustic rhinometry is one method to evaluate nasal geometry by an acoustic reflection technique. The aim of this study was to investigate the changes in acoustic rhinometry after nasal provocation in patients with exclusively perennial allergic rhinitis. In 19 patients, acoustic rhinometry and active anterior rhinomanometry were performed before and after nasal provocation test. There was a statistically significant nasal flow reduction measured by active anterior rhinomanometry after nasal provocation (p < 0.05) and a median symptom score of four points, both indicating a positive response to nasal provocation. On the other hand, there was no statistically significant change in the values of acoustic rhinometry after nasal provocation (p > 0.05). In patients with exclusively perennial allergic rhinitis, acoustic rhinometry does not seem to significantly change after nasal provocation. In contrast, active anterior rhinomanometry values decreased significantly after nasal provocation. The presented results indicate that acoustic rhinometry does not seem to be a diagnostic method superior to active anterior rhinomanometry in this context.

Video-endoscopy and digital image analysis of the nasal valve area.

The aim of this study was to evaluate the benefit of digital image analysis of video-endoscopic images of the valve area to study changes in cross-sections of the nasal valve area before and after nasal surgery. Fifty patients scheduled for septoplasty or septorhinoplasty were included. Successful recordings of the valve area and digitally calculated cross-sections of the nasal valve area served as main outcome measures. First, various endoscopes (rigid 0 degrees - and 25 degrees -endoscopes and fibreoptic 0 degrees -endoscope) were tested and video-endoscopy was standardised in 39 patients. Second, preoperative and postoperative images of the nasal valve area in 11 patients with obstruction of the nasal valve area were digitally analysed and compared. In these patients, a significant widening of the valve area could be shown postoperatively. We conclude that digital image analysis of the nasal valve area can be helpful in the measurement of cross-sections of the nasal valve area before and after nasal surgical procedures in selected patients.

Influence of passive humidification on respiratory heat loss in tracheotomized patients.

BACKGROUND: The aim of this study was to evaluate changes in total respiratory heat loss during use of a heat and moisture exchanger (HME) in tracheotomized patients. METHODS: Tracheal humidity and temperature were measured before the application and during use of the HME (plastic foam impregnated with CaCl2), and total respiratory heat loss was calculated. RESULTS: No significant difference was found between the convective heat exchange before and after use of the HME for a 10-minute period. When the HME was placed on the tracheal opening, the evaporative heat exchange and the total respiratory heat loss decreased significantly. CONCLUSIONS: The results indicate that passive airway humidification is effective in tracheotomized patients even after a 10-minute period. However, the positive effect on the energy balance of the tracheal mucosa after prolonged use of the HME remains to be proven.

Prolonged diplopia following sinus vein thrombosis mimicking Gradenigo's syndrome.

We report about a boy with the symptoms of Gradenigo's syndrome (abducens nerve palsy, acute otitis media, unilateral headache). The MR imaging showed a sinus vein thrombosis instead of the expected petroapicitis. After 2 weeks of conservative therapy with antibiotics and anticoagulation, without any clinical effort the boy underwent a mastoidectomy. Headache and otitis media recovered quickly but the diplopia still remained after 25 months.

Measurement of tracheal humidity and temperature.

BACKGROUND: After tracheostomy, patients often present with chest complaints. Measurement of objective parameters of the tracheal climate is important to evaluate 'artificial noses' or humidifying devices. OBJECTIVES: The purpose of this study was to present an experimental setup for measurement of tracheal temperature and humidity for possible use in clinical studies in tracheotomized patients. METHODS: The study design was a prospective study. Patients with tracheal stoma were chosen as study participants. Tracheal temperature and humidity during the respiratory cycle were measured using a miniaturized thermocouple and a humidity sensor connected to a suction system. RESULTS: Accurate measurement of tracheal temperature and humidity was feasible in patients with tracheal stoma. Tracheal humidity and temperature values measured in this study were similar to values reported earlier by other working groups. CONCLUSIONS: The experimental setup presented may reliably be used in the evaluation of 'artificial noses' or other passive humidifiers in tracheotomized patients.