Assessing Cut-off Points of Eosinophils, Nasal Polyp, and Lund-Mackay Scores to Predict Surgery in Nasal Polyposis: A Real-World Study.

BACKGROUND: Developing tools to identify chronic rhinosinusitis with nasal polyps (CRSwNP) patients requiring surgical treatment would help clinicians treat patients more effectively. The aim of this retrospective cross-sectional study was to identify cut-off values ​​for eosinophil percentage, nasal polyps (NP), and Lund-Mackay (LM) scores that may predict the need for surgical treatment in Finnish CRSwNP patients. METHODS: Data of CRSwNP patients (N = 378) undergoing consultation for ESS in 2001-19 were used. Data was collected from patient records and Lund-Mackay scores were determined from sinus computed tomography scans. The percentage of eosinophils was microscopically evaluated from the polyp samples available (n = 81). Associations were analyzed by Mann Whitney U test, and cut-off values by the area under the receiver operating characteristic curve (AUROC). RESULTS: ESS was performed to 293 (77.5%) of patients. Polyp eosinophilia was associated significantly with ESS (p = 0.001), whereas peripheral blood eosinophil count, LM- score and endoscopic NP- score were not (p > 0.05). AUROC values (95% CI) for detecting those needing ESS were for polyp eosinophilia 0.71 (0.60-0.83), p = 0.001, for LM score 0.59 (0.50-0.67), p = 0.054; for NP score 0.56 (0.48-0.64), p = 0.17, and for blood eosinophil count 0.68 (0.46-0.90), p = 0.08. With the threshold value of polyp eosinophilia (>25%), the sensitivity and specificity were optimal for detecting the group needing ESS from the group not undergoing ESS. The cut-off value of blood eosinophil count (>0.26 × 109/L) had relatively good, yet statistically insignificant (underpowered), predictive potential. Moderate cut-off values were found for endoscopic LM score (≥14/24) and NP score (≥4/8). CONCLUSIONS: Polyp eosinophilia (>25%) predicted ESS among Finnish hospital-level CRSwNP patients. A future challenge would be to find less invasive and cost-effective clinical factors predicting uncontrolled CRSwNP.

Similar survival outcome after endoscopic and open approaches for sinonasal mucosal melanoma.

BACKGROUND: To describe a cohort of sinonasal mucosal melanoma (SNMM) patients, and to assess if choice of surgical approach (open versus endoscopic) has impact on survival. METHODOLOGY: Adequate data on clinical presentation, treatment, and recurrence pattern were available for 58 consecutive patients treated for SNMM at the Helsinki University Hospital (HUH) between 1983 and 2016. RESULTS: The 5-year disease-specific survival (DSS) was 27% and overall survival 25% for the whole cohort. The 3-year DSS for patients treated with curative intent with endoscopic surgery was comparable to open surgery (56% and 51%, respectively). Patients with tumours arising from the paranasal sinuses and patients with Stage IV disease had significantly worse prognosis compared with other locations and Stage III patients. All patients who had disease persistence at three months after primary treatment succumbed to SNMM. Post-operative radiotherapy did not affect survival significantly, but a trend towards improved local control was observed. CONCLUSIONS: Local control after endoscopic surgery was comparable to open surgery. Small tumours without local or locoregional spread had improved prognosis, independent of surgical approach. Disease persistence after treatment with curative intent led to death invariably.

Pleomorphic adenoma in the nasal cavity: a clinicopathological study of ten cases in Finland.

The objective of the study was to investigate the nationwide occurrence of sinonasal pleomorphic adenoma in Finland. A retrospective study was conducted at The Departments of Otorhinolaryngology-Head and Neck Surgery, and Pathology at the five university hospitals in Finland. Data were obtained by searching for sinonasal pleomorphic adenoma cases in the clinical and histopathological registries at these institutions for the past two to four decades. All patients who had had a histologically proven pleomorphic adenoma in the sinonasal area were included as participants. Ten cases with pleomorphic adenoma of the nasal cavity were found. The majority of these tumours originated in the septum, and there were no malignant transformations. Pleomorphic adenomas of the nasal cavity were found to be extremely rare in this nationwide investigation.

Application of the European Test of Olfactory Capabilities in patients with olfactory impairment.

A central issue in olfaction concerns the characterization of loss of olfactory function: partial (hyposmia) or total (anosmia). This paper reports the application in a clinical setting of the European Test of Olfactory Capabilities (ETOC), combining odor detection and identification. The study included three phases. In phase 1, anosmics, hyposmics and controls were tested with the 16-items version of the ETOC. In phase 2, a short version of the ETOC was developed: patients with and controls without olfactory impairment were tested on a 6-items ETOC. In phase 3, to predict olfactory impairments in new individuals, the 16-items ETOC was administered on samples of young and older adults, and the 6-items version was applied in samples of young, elderly participants and Alzheimer patients. In phase 1, linear discriminant analysis (LDA) of ETOC scores classified patients and controls with 87.5 % accuracy. In phase 2, LDA provided 84 % correct classification. Results of phase 3 revealed: (1) 16-items ETOC: whereas in young adults, 10 % were classified as hyposmic and 90 % as normosmic, in elderly, 1 % were classified as anosmic, 39 % hyposmic and 60 % normosmic; (2) 6-items ETOC: 15 % of the young adults were classified as having olfactory impairment, compared to 28 % in the older group and 83 % in Alzheimer patients. In conclusion, the ETOC enables characterizing the prevalence of olfactory impairment in young subjects and in normal and pathological aging. Whereas the 16-items ETOC is more discriminant, the short ETOC may provide a fast (5-10 min) tool to assess olfaction in clinical settings.

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.

Lack of efficacy of long-term, low-dose azithromycin in chronic rhinosinusitis: a randomized controlled trial.

BACKGROUND: In persistent chronic rhinosinusitis (CRS), conventional treatment is often insufficient. Long-term, low-dose administration of macrolides has been suggested as a treatment option. The MACS (Macrolides in chronic rhinosinusitis) study is a randomized placebo-controlled trial evaluating the efficacy of azithromycin (AZM) in CRS. METHODS: We describe a group of patients with recalcitrant CRS with and without nasal polyps unresponsive to optimal medical and (in 92% also) surgical treatment. Patients were treated with AZM or placebo. AZM was given for 3 days at 500 mg during the first week, followed by 500 mg per week for the next 11 weeks. Patients were monitored until 3 months post-therapy. The assessments included Sino-Nasal Outcome Test-22 (SNOT-22), a Patient Response Rating Scale, Visual Analogue Scale (VAS), Short Form-36 (SF-36), rigid nasal endoscopy, peak nasal inspiratory flow (PNIF), Sniffin' Sticks smell tests and endoscopically guided middle meatus cultures. RESULTS: Sixty patients with a median age of 49 years were included. Fifty per cent had asthma and 58% had undergone revision sinus surgery. In the SNOT-22, Patient Response Rating Scale, VAS scores and SF-36, no significant difference between the AZM and the placebo groups was demonstrated. Nasal endoscopic findings, PNIF results, smell tests and microbiology showed no relevant significant differences between the groups either. CONCLUSION: At the investigated dose of AZM over 3 months, no significant benefit was found over placebo. Possible reasons could be disease severity in the investigated group, under-dosage of AZM and under-powering of the study. Therefore, more research is urgently required.

Sense of smell in long-standing nasal polyposis.

An impaired sense of smell is a common complaint in patients with nasal polyposis, and hyposmia is usually attributed to obstruction of the nasal airways. The duration of nasal polyposis and nasal surgery may also affect olfaction. It has been shown that aging and chronic rhinitis both impair olfaction. The aim of our study was to evaluate the sense of smell in patients who had had nasal polyposisfor at least 20 years. The olfactory threshold was assessed with a commercially available odor detection threshold test. The threshold of 19 (46%) of 41 patients was greater than the age-related upper 95% reference limit. In a forward stepwise multiple regression analysis of all the polyposis patients, the degree of opacity of ethmoidal sinuses seen in computed tomography (CT), polyposis visible in anterior rhinoscopy, total nasal resistance, and gender had a significant association with olfactory threshold.

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 polyposis: clinical course during 20 years.

BACKGROUND: The etiology of nasal polyposis is mainly unknown although it has been connected with many clinical conditions. The long-term clinical course of nasal polyposis is largely unknown, because long-term followup studies on the recurrence of nasal polyposis have rarely been reported. OBJECTIVE: The aim of the study was to find out the clinical course of nasal polyposis over a long period of time. PATIENTS AND METHODS: Our report describes a 20-year follow-up study of 41 patients with nasal polyps. These patients had surgery for nasal polyp disease 20 years previously and they were initially grouped according to occurrence of (1) acetylsalicylic acid (ASA) intolerance, (2) atopic allergy (AT), and (3) intrinsic allergy-like disease (INTR). Patients were now re-examined, sinus computed tomography (CT) scanning was made, and a biopsy from polyp or from mucosa of the middle turbinate was taken. RESULTS: Anterior rhinoscopy revealed polyps in 35 of 41 patients. Thus nasal polyposis was still active in 85% of patients after 20 years. Mucosal changes in paranasal sinuses were found in every patient. Anosmia or hyposmia was found in 61% (25/41) of the patients. Eight patients had had 11 or more surgical operations during the 20-year period. Of these, 88% (7/8) belonged to the ASA group. Bronchial asthma was found in all ASA intolerance patients (11/11), and in 36% (4/11) of AT and in 16% (3/19) of INTR patients, respectively. CONCLUSION: Because of the high recurrence tendency and insidious symptoms of nasal polyposis, patients will require followup for the rest of their lives.

Vascular permeability factor/vascular endothelial growth factor in nasal polyps.

Although the aetiology of polyps is still, for the most part, unknown, the disease is known to involve tissue oedema. Vascular permeability/vascular endothelial growth factor (VPF/VEGF) is a major inducer of angiogenesis and capillary permeability. This study investigated VPF/VEGF expression in biopsies of nasal polyps from 39 patients and in healthy nasal mucosa from 10 patients by immunohistochemical staining. Staining for VPF/VEGF in the mucosal surface and in the glandular epithelium of nasal polyps was weaker than in normal controls. In two patients, strong staining for VPF/VEGF was found in a granular pattern in mast cells, while the mast cells in other polyposis patients appeared to be largely degranulated. VPF/VEGF was not seen in the mast cells of control patients. Although expression of VPF/VEGF was not increased in the epithelium of the nasal polyps, VPF/VEGF secreted from mast cells may take part in nasal polyp formation.

A-mode ultrasound in the diagnosis of chronic polypous sinusitis.

A-mode ultrasound (A-US) is a simple, non-invasive and non-ionizing method for detecting fluid or even mucosal swelling in inflamed maxillary and frontal sinuses. A-US has been shown to be a quite reliable tool in the diagnosis of acute maxillary sinusitis. However, controversy still exists over the reliability of A-US in detecting fluid retention or mucosal swelling in patients suffering from chronic polypous rhinosinusitis or in transantrally operated maxillary sinuses. We have compared the results of maxillary sinus A-US with computed tomography (CT) images in a selected series of chronic polypous rhinosinusitis comprising 40 patients. Fluid retention was seen in 20 of 79 maxillary sinuses on CT scanning. Only 6 of these 20 retentions were detected with A-US. There were 11 false positive findings. In six of these cases a back-wall echo was received through polypoid masses in the sinus. Mucosal swelling was also difficult to diagnose. The results of A-US were not easily reproduced; only in 50% of cases were identical results obtained by two investigators. We do not recommend the use of A-US to diagnose fluid retention or mucosal swelling in a patient with chronic mucosal changes in the maxillary sinus or if surgery has been performed on the anterior wall of the maxillary sinus.