European position paper on diagnostic tools in rhinology.

The accurate diagnosis of rhinologic disease depends on the clinical history, examination findings and, in many cases, further investigations. There are a wide variety of diagnostic tests available, the choice of which depends upon the condition being assessed. This position paper is intended to provide an up-to-date comprehensive description of the diagnostic tools available to rhinologists, allergists, general otolaryngologists and other physicians with an interest in sinonasal disease. The literature has been reviewed and evidence-based recommendations are included. The relevant history and examination techniques are described, including endoscopic assessment of the nose. General and disease-specific quality of life instruments are an important tool in assessing the impact of rhinologic disease and the response to treatment. Relevant blood tests are discussed, as well as the various methods of allergy testing. Techniques for collecting microbiological and tissue samples are described, as well as the use of more specialised tests such as nasal nitric oxide and those evaluating ciliary structure and function. Imaging techniques and their indications are included. Chemosensory (smell and taste) testing is explained, and the available techniques for objective measurement of nasal airflow and patency are reviewed. Prompt and accurate diagnosis allows appropriate management to be initiated; an understanding of the currently available diagnostic tools is a vital part of the assessment of rhinologic disease.

EAACI Position paper on the standardization of nasal allergen challenges.

Nasal allergen challenge (NAC) is an important tool to diagnose allergic rhinitis. In daily clinical routine, experimentally, or when measuring therapeutic success clinically, nasal allergen challenge is fundamental. It is further one of the key diagnostic tools when initiating specific allergen immunotherapy. So far, national recommendations offered guidance on its execution; however, international divergence left many questions unanswered. These differences in the literature caused EAACI to initiate a task force to answer unmet needs and find a consensus in executing nasal allergen challenge. On the basis of a systematic review containing nasal allergen challenges of the past years, task force members reviewed evidence, discussed open issues, and studied variations of several subjective and objective assessment parameters to propose a standardized way of a nasal allergen challenge procedure in clinical practice. Besides an update on indications, contraindications, and preparations for the test procedure, main recommendations are a bilaterally challenge with standardized allergens, with a spray device offering 0.1 mL per nostril. A systematic catalogue for positivity criteria is given for the variety of established subjective and objective assessment methods as well as a schedule for the challenge procedure. The task force recommends a unified protocol for NAC for daily clinical practice, aiming at eliminating the previous difficulty of comparing NAC results due to unmet needs.

Extranasopharyngeal angiofibroma revisited.

BACKGROUND: Angiofibromas in the head and neck region usually arise in the nasopharynx, but may also occur elsewhere. This study aims at evaluating the incidence and clinical features of extranasopharyngeal angiofibroma (ENA). MATERIAL AND METHODS: Systematic review of the literature (Medline® and Google™ ) up to 31 December 2015. RESULTS: 174 cases of ENA were retrieved from a total of 170 publications. In contrast to former publications and previous understanding, the nasal septum was by far the most common site of the disease. Four patients had a congenital lesion, the oldest patient was 87 years old (mean: 28.7 years; median: 23 years). Male gender was predominantly affected, but the sex ratio was more balanced (2.13:1) than in previous reports in the literature until 12/2015. The majority of patients presented with nasal obstruction, either in combination with epistaxis (25.8%) or other symptoms (12.6%). Symptoms had developed within 13.1 months on average (median: 4 months). Brisk bleeding resulted in 11 of 43 biopsy procedures. Surgical resection as first-line therapy was performed in 170 patients. A tumour regrowth within 12 months was registered in four patients. CONCLUSION: The increasing awareness of ENA and the willingness to publish case reports-not only in Medline-listed journals-resulted in a significant increase of published case reports lately. Although extremely rare, ENAs have to be taken into account in the differential diagnosis of unclear masses, particularly in adult patients presenting with a rapidly developing nasal obstruction resulting from a nasal septum tumour. Female gender or normal vascularity does not exclude the diagnosis. Transnasal resection is sufficient in most cases, and recurrences are rare. Pathologists as well as clinicians should consider ENA in their differential diagnosis of any mass of the upper airway.

[Treatment of nasal valve stenosis]. / Therapie der Nasenklappenstenose.

Nasal valve dysfunction is one of the most common causes of obstructed nasal ventilation. In most cases the cause is congenital, but iatrogenic occurrence after functional-aesthetic rhinoplasty is not infrequent. To diagnose nasal valve dysfunction, a thorough anamnesis, inspection, endoscopy, and palpation is required. If conservative therapy using rhinologic substances, as well as outer and inner stenting do not achieve the desired outcome, and the dysfunctional site can be localized, surgical procedures are indicated to improve nasal valve function. Numerous procedures and techniques are available, amongst which the most important ones shall be elucidated and discussed in the present article. These include septoplasty, septorhinoplasty, and enlargement of pyriform aperture stenosis, as well as corrections of the upper and lower lateral cartilages.

[Position paper "Chemosensory testing for expert opinion in smell disorders"]. / Positionspapier "Die chemosensorische Testung bei der gutachterlichen Abklärung von Riechstörungen"

Providing expert opinion in the context of smell disorders is often challenging, not only with regard to general aspects of providing an expert opinion but particularly with regard to chemosensory testing. Currently there is no consensus which chemosensory test should be selected and how they should be executed. This positions paper from Committee on Olfaction and Gustation of the German Society of Otorhinolaryngology, Head and Neck Surgery aims to give concrete recommendations for chemosensory testing for providing expert opinion for smell disorders with regard to the selection and execution of these test.

Influence of formalin fixation on tissue dimensions in palatal tonsils.

AIM: To investigate the change of tissue dimensions after formalin fixation, and to determine the optimal time of fixation. HYPOTHESIS: Formalin fixation may lead to shrinkage in tissue dimensions and may thus alter tumor stages. BACKGROUND: It is often observed in tumor surgery that the dimensions in vivo seem larger than after resection, and tissue appears to shrink further after formalin fixation. This might alter dimensions and assessment of spread of the tumor and thus lead to a lesser tumor classification and stage. In cases where the decision for adjuvant chemoradiation is based upon the stage, it may thus be of relevance for the patient to evaluate the pathologic and not the in vivo dimensions of the tumor. MATERIAL AND METHODS: In order to obtain comparable tissues, we investigated 100 palatal tonsils after cold steel dissection tonsillectomy for chronic tonsillitis. There were four time points investigated: directly after excision in the operating room and after four, 24 and 72 h of fixation in formaldehyde (4% Formaldehyde in phosphate buffer pH 7.4). The tissue was measured in the following dimensions: volume (ml), weight (g) and length, broadness and width (mm). RESULTS: The tissue size did not change significantly in dimensions except for an increase in length. The time of fixation did not influence the size. DISCUSSION: Formalin fixation does not significantly influence the tissue dimensions of palatal tonsils in comparison to direct ex vivo measurements. A minimal time of fixation of 20 h is required in order to stop all degenerative processes; however, longer fixation does not change the dimensions of the specimen. CONCLUSION: The null hypothesis has to be withdrawn that tissue dimensions are altered by formalin fixation. Thus, the histopathological measurements do not influence TNM staging.

Efficacy and safety of mometasone furoate nasal spray in the treatment of chronic rhinosinusitis.

INTRODUCTION: This study evaluated the efficacy and safety of mometasone furoate nasal spray (MFNS) in patients with chronic sinusitis. METHODS: In this double-blind, placebocontrolled, multicenter, parallel-group study, 60 patients with persistent sinusitis symptoms were randomized to receive either MFNS 200 µg twice daily or placebo, for 16 weeks (112 days). Eventually, 53 patients terminated the study in regular course. RESULTS: Total Symptom Scores (TSS) in patients receiving MFNS changed by a mean of -7.27 (95% CI -9.71, -4.84), versus -5.35 (95% CI -6.73, -3.96) in the placebo group (P=0.51). MFNS reduced nasal congestion and discharge scores, and improved patients' olfactory function. There were few side effects. Considerably more patients in the MFNS group were satisfied with the treatment than those who had received placebo (P<0.05). Also, more patients would take the medication again in the event of symptoms, compared with those who had taken placebo (P<0.05). Furthermore, the MFNS patients would recommend it to others. CONCLUSION: The positive patient assessment and few side effects are reflected in the efficacy evaluation performed by the physicians. The endoscopic results under MFNS were always numerically more favorable than those under placebo, and the overall difference reached statistical significance (P<0.01). MFNS offers an effective and safe treatment for chronic rhinosinusitis.

[Survey of sensory perception and patients' subjective assessment of the application of nasal sprays - the nasal-spray-sensoric-scale]. / Erhebung der sensorischen Wahrnehmung und subjektiven Patienteneinschätzung bei der Verabreichung von Nasenspray - Die Nasen-Spray-Sensorik-Skala.

AIM: The Nasal Spray Evaluation Questionnaire is a standardized means to evaluate hedonicity of nasal sprays in the English speaking countries. To date, there is no such questionnaire for German speaking patients. The here presented study aimed at evaluating the translated questionnaire. Three nasal sprays were tested and the questionnaire was used to estimate sensory hedonicity. Finally, the questionnaire was improved and can now serve as a standardized means to measure nasal sensory perceptions. MATERIAL AND METHODS: The questionnaire was literally translated from English to German. There were three groups of 60 patients each presenting with the sensation of a 'dry nose' to a secondary medical center with a board certified otolaryngologist. The ingredients of the three different nasal sprays varied only in one phytotherapeutic addition. The first evaluation of the nasal spray was conducted immediately after application of the nasal spray, and two minutes after application. A third and optional telephone survey was performed several days later after continuous use of the spray. RESULTS: The different evaluations of nasal sprays were already lined out after the first questionnaire. It could serve as a new, reliable and reproduceable tool for the evaluation of nasal sensory perceptions. DISCUSSION: The questionnaire served as an adequate tool to estimate hedonicity of nasal sprays. First results of the German version show, however, that it could facilitate the evaluation by restructuring the questionnaire. Continuously marking good grades with high points (maximum 100) and negative answers with low points (minimum 0 points) will unify and simplify the questionnaire. CONCLUSION: The translation of the Nasal Spray Evaluation Questionnaire into a German version can serve as a new standard tool for measuring nasal sensation.

[Dysphagia as a presenting symptom of a cervical neurofibroma]. / Zervikales Neurofibrom als Ursache von Globusgefühl.

A 33-year-old, otherwise healthy female nursing student presented to the ear-, nose-, and throat- (ENT) outpatient clinic with a globus sensation that had been progressing for 6 months. Tomographic imaging revealed a neck mass extending from the 4th vertebrum to the subclavicular region and apex of the left lung. A surgical resection with histopathological examination exposed a neurofibroma. Management and differential diagnoses of globus sensation are herein discussed. This case underlines the importance of tomographic imaging, even in common but persisting symptoms such as globus sensation.

Topical therapy in anosmia: relevance of steroid-responsiveness.

OBJECTIVES/HYPOTHESIS: The use of steroids either systemically or topically is known as a common therapy in patients with anosmia. Nevertheless, investigations giving proof for the benefit of a topical therapy are very rare, and no prognostic factors are known. In our study, we for the first time evaluated the additional effect of a topical therapy not only with steroids but also with antibiotics after conventional pretreatment with oral steroids and propose the steroid-responsiveness of an anosmia as a prognostic factor. STUDY DESIGN: Retrospective design. METHODS: We analyzed the data of 299 patients with olfactory dysfunction. Eighty-nine underwent initial pretreatment with systemic steroids and presented data over a sufficient follow-up time. In a second step all these patients were given a topical treatment in a head down forward position, namely either budesonid alone or in combination with neomycin. Primary outcome parameter was the threshold, discrimination and identification (TDI) score. RESULTS: Initial therapy with oral steroids changed the TDI from 15.5 to 18.7 in the means (P < .001). In general, leaving away systemic steroids while applying local therapy did not led to a reduction of the TDI (P < .001). Dividing up the patients into those suffering from a steroid-responsive anosmia (SRA) and those without benefit from initial systemic steroids (non-SRA), the topical treatment led to a significant difference between the two groups with benefit toward the non-SRA group (P < .001). Regarding only the nonchronic rhinosinusitis anosmics, these findings became even more apparent. Furthermore, in non-SRA patients we found even better results with steroids in combination with neomycin as a topical therapy. In this group, the combined topical therapy elevated the TDI for +2.1 points whereas topical steroids alone raised it only for +1.0 point. CONCLUSIONS: The steroid-responsiveness of anosmia seems to be a relevant prognostic indicator for a significant benefit of a topical therapy in general. Within all patients, the effect of an initial systemic therapy could be maintained by the adjacent topical treatment whereas in non-SRA patients a topical therapy has a significant greater impact. Furthermore, antibiotics even seem to have an additional effect in this group. Different reasons, first of all an overwhelmed steroid resistance by additional antiinflammatory effects of antibiotics, e.g., the inhibition of apoptosis might play a role and are discussed.

[Reversible hypogeusia during bilateral thalamic stimulation for essential tremor]. / Geschmacksstörung unter tiefer Hirnstimulation des Thalamus bei essenziellem Tremor.

Deep brain stimulation of ventral intermediate nucleus (VIM-DBS) has become an established therapy for severe essential tremor (ET). The technique is however limited in some ET patients by relevant side effects such as paresthesia, dysarthria, and gait disturbances. To our knowledge, this is the first report of VIM-DBS-induced reversible hypogeusia along with retroinsular cortical deactivation under effective VIM stimulation measured with 18-fluorodexoglucose positron emission tomography. This case demonstrates that gustatory dysfunction should be considered in the pre- and postsurgical management of patients with VIM-DBS. Moreover it provides direct evidence that the thalamus acts as an important relay station in the human cerebral gustatory pathway.

Pathology of the olfactory epithelium: smoking and ethanol exposure.

OBJECTIVE: To investigate the effects of tobacco smoke on the olfactory epithelium. Cigarette smoking has been associated with hyposmia; however, the pathophysiology is poorly understood. The sense of smell is mediated by olfactory sensory neurons (OSNs) exposed to the nasal airway, rendering them vulnerable to environmental injury and death. As a consequence, a baseline level of apoptotic OSN death has been demonstrated even in the absence of obvious disease. Dead OSNs are replaced by the mitosis and maturation of progenitors to maintain sufficient numbers of neurons into adult life. Disruption of this balance has been suggested as a common cause for clinical smell loss. This current study will evaluate the effects of tobacco smoke on the olfactory mucosa, with emphasis on changes in the degree of OSN apoptosis. STUDY DESIGN: A rat model was used to assess the olfactory epithelium after exposure to tobacco smoke. METHODS: Rats were exposed to tobacco smoke alone (for 12 weeks), smoke plus dietary ethanol (for the final 5 weeks), or to neither (control). Immunohistochemical analysis of the olfactory epithelium was performed using an antibody to the active form of caspase-3. Positive staining for this form of the caspase-3 enzyme indicates a cell undergoing apoptotic proteolysis. RESULTS: Control rats demonstrated a low baseline level of caspase-3 activity in the olfactory epithelium. In contrast, tobacco smoke exposure triggered a dramatic increase in the degree of OSN apoptosis that affected all stages of the neuronal lineage. CONCLUSIONS: These results support the following hypothesis: smell loss in smokers is triggered by increased OSN death, which eventually overwhelms the regenerative capacity of the epithelium.

[Prospective randomised study on influencing complaints following lumbar discotomy by intraoperative application of cortisone via intrathecal and peridural injection (author's transl)]. / Eine prospektive randomisierte Studie zur Beeinflussung der Beschwerden nach lumbaler Diskotomie durch intraoperative Cortison- applikation in die Wurzeltaschen sowie in den Periduralraum.

In a prospective, randomised study 35 patients suffering from lumbar vertebral disc herniation were given an intrathecal and peridural injection of 0.5 ml (= 10 mg) Triamcinolone hexacetonide. The postoperative course of the disorder was compared with that of 35 patients operated on the same manner, however, without medication. It was established that the intraoperative administration of Triamcinolonhexacetonid had no statistically significant influence on the results of the operations.

[The trace-element zinc in medial fractures of the collum femoris and in coxarthrosis (author's transl)]. / Das Spurenelement Zink bei der medialen Schenkelhalsfraktur und Koxarthrose.

In a comparative study among two groups of patients--persons with a medial fracture of the collum femoris and persons with advanced coxarthrosis--the zinc-content of the femur was measured. For this analysis a bone-biopsy was performed when an endoprothesis was implanted. In some of the patients the zinc-levels in the blood were determined on several occasions. If the zinc-content of the blood was low, similarly the zinc-content of the bone was reduced, especially in patients with medial fractures. In patients with severe coxarthrosis the zinc-content is reduced by 50%.

[Mezlocillin concentrations in human bone tissue]. / Mezlocillin-Konzentrationen im menschlichen Knochen.

20 patients undergoing extended hip surgery received a single i.v. injection of 2 g 6-[(R)-2-[3-methylsulfonyl-2-oxo-imidazolidine-1-carboxamido]-2-phenyl-acetamido]-penicillanic acid sodium salt (mezlocillin, Baypen). At different times after the infections but simultaneously 31 samples of blood and bone (spongiosa) were collected for determination of mezlocillin concentrations. On an average, maximum concentrations of approximately 20 microgram/g bone were demonstrated 30 min after injection, these being within the clinico-therapeutical range. The concentration of azlocillin--another acylureido-penicillin--was comparatively higher.

[Postoperative complications of wound healing in orthopaedic surgery (author's transl)]. / Zur Beeinflussung der Wundheilungsstörungen in der operativen Orthopädie.

From 1. 1. 1971--30. 6. 1977 (6.5 years) 4,169 aseptic orthopaedic operations were performed in the Orthopädische Universitätsklinik Düsseldorf. 42 complications of wound healing have been observed (1%)9 Without an ultrasteril operationbox it is also possible to reduce the complications of wound healing in orthopaedic surgery. It is important to know the principles of asepsis and antisepsis, the method of our preoperative preparation of patients is described; the indication of prophylaxis of chemotherapeutic agents should be severe.