Critical evaluation of different objective techniques of nasal airway assessment: a clinical review.

Objective tests for the nasal volume flow are needed for the assessment of nasal patency for diagnosis, documentation and medicolegal purposes. Three main techniques are nowadays established: active anterior rhinomanometry (AAR), 4-phase rhinomanometry (4PR) and acoustic rhinometry (AR). Several guidelines and consensus reports and the International Committee on Standardization have clarified the field of interest and the limitations of this technology. In the meantime, technical progress and the development of seemingly new methods have brought up many new facts which necessitate the re-evaluation of the test available. From our method of critical analysis we can conclude that AAR can be still considered as the standard technique for the objective assessment of the nasal airway. AR is a valid technique with limitations and cannot replace AAR because it measures different parameters thus forming a complementary technique. 4PR might provide supplementary information although not yet all open technical and mathematical inconsistencies conjoint with this technique have been clarified. Still the individual subjective sensations of the patient do not always match the objective measurements. In conclusion, a combination of information given by the patient, the rhinoscopic findings and the carefully interpreted results of AAR and AR will increase considerably the success of surgical interventions and the feeling of satisfaction by the patient after surgery, when matched thoughtfully.

First Report of Plum pox virus on Plum in New York State.

Plum pox, also known as Sharka, is one of the more significant viral diseases of stone fruit trees such as plum, peach, and apricot. It was first reported in Europe in the early 1900s and more recently in Chile in 1992, the United States (Pennsylvania) in 1999, Canada (Ontario and Nova Scotia) in 2000, China in 2001, and Argentina in 2004. Plum pox virus (PPV) was recently detected in two plum (Prunus domestica) trees in an orchard in Niagara County, NY, located within 5 miles from a Canadian plum pox eradication zone. Typical symptoms of chlorotic rings and spots were observed on some of the leaves from these trees. No symptoms were reported prior to the survey collection in July 2006. Survey samples were screened for the presence of PPV by ELISA using the Agdia PPV (Agdia, Elkhart, IN) specific kit that recognizes all strains but C of PPV. Approximately 5% of the survey samples were additionally analyzed by a validated immunocapture reverse transcription (IC-RT)-PCR TaqMan assay in a Cepheid SmartCycler (Cepheid, Sunnyvale, CA). Both replicates of the two New York plum trees produced a positive ELISA reaction in two consecutive tests. The ELISA-positive samples also produced positive results when subjected to the real-time IC-RT-PCR test. The PPV-positive trees were sampled again and an additional 53 samples were collected from trees in the surrounding area. Suspect trees again tested positive, while all the trees in the surrounding area tested negative. The methods used for confirmation included two ELISA tests (Durviz [Valencia, Spain] DAS indirect monoclonal ELISA and Agdia DAS polyclonal ELISA). Confirmatory real-time IC-RT-PCR was performed using universal 3' nontranslated region (NTR) primers (2,3) in a SYBR Green assay format and a coat protein (CP) primers/probe TaqMan assay (3,4). Further, the New York PPV isolate was identified as PPV D group using a subgroup specific conventional IC-RT-PCR (1). A 1.4-kb sequence fragment from the 3' end of the New York PPV was sequenced (GenBank Accession No. DG 883816). Comparison of the sequence with the database confirmed this isolate as subgroup D and exhibited a high degree of identity with other PPV D accessions (PPV D Teycheney [Accession No. X16415]; Penn4 [Accession No. DQ465243] Cnd 123-1 [Accession No. AY9553267]; and Cnd 3 [Accession No. AY953262]). To our knowledge, this is the first report of PPV in New York. References: (1) T. Candresse et al. Phytopathology. 88:198, 1998. (2) L. Levy et al. J. Virol. Methods. 49:295, 1994. (3) V. Mavrodieva and L. Levy. Acta Hortic. 657:141, 2004. (4) T. Wetzel et al. J.Virol. Methods 33:355, 1991.

Influence of extensive functional endoscopic sinus surgery (FESS) on facial growth in children with cystic fibrosis. Comparison of 10 cephalometric parameters of the midface for three study groups.

OBJECTIVES: To determine the impact of FESS after the first and before the second growth spurt on facial growth and in particular of the maxilla. DESIGN: Prospective study of 23 patients with cystic fibrosis, 13 patients requiring extensive endoscopic spheno-ethmoidectomy (FESS) because of massive nasal polyposis, with a follow-up of at least 10 years. SETTING: A cystic fibrosis referral centre in an academic tertiary pediatric hospital. PATIENTS: At the time the standard cephalometric measurements were performed all patients were adults with cystic fibrosis. One group of patients underwent FESS during facial growth (N=9), a second group of patients had no previous surgery (N=9), and in a third group FESS has been performed after the second growth spurt (N=5). RESULTS: No statistically significant differences (Kruskall-Wallis test) were found in the cephalometric measurements of these three patient groups. CONCLUSIONS: Extensive FESS after the first and before the second growth spurt has no impact on the outcome of facial growth.

Consensus report on acoustic rhinometry and rhinomanometry.

With respect to acoustic rhinometry, new elements concern the problems related to the interpretation of the minimal cross-sectional area, and the presentation of a protocol for a multinational study, which aims to define a normal nose. Also, the previously issued recommendations for standardisation for technical specifications and standard operating procedures are briefly reviewed. For rhinomanometry, new insights into the field of fluid dynamics are highlighted, as well as their repercussion on more recent graphical representations for active anterior rhinomanometry such as four phases rhinomanometry and resistometry. For acoustic rhinometry as well as rhinomanometry, a more stringent standardisation of decongestive procedures is suggested.

Comparison of five new antihistamines (H1-receptor antagonists) in patients with allergic rhinitis using nasal provocation studies and skin tests.

BACKGROUND: It was the aim of the authors to compare all of the latest second-generation antihistamines and to see if there were significant differences in their efficacy. It is important for ENT specialists to know if these differences exist, as it is for general practitioners trying to choose between these drugs. METHODS: In 12 confirmed grass pollen allergic patients the authors performed nasal smears to asses eosinophilia, histamine/grass pollen skin tests, and grass pollen nasal provocation tests. All tests were performed before and after administration of one of five different antihistamines (cetirizine, loratadine, ebastine, fexofenadine, mizolastine) or placebo. The order of administration of antihistamines and placebo was randomised, and patients were not aware of which drug they were given. A decrease in nasal eosinophilia (nasal smear), or nasal or skin reactivity (provocation tests) was looked for. RESULTS: A significant decrease in nasal eosinophilia was observed for all antihistamines but not for placebo. For the grass pollen nasal provocation tests, the decrease was significant for nasal blockage and sneezing; for rhinorrhea there was an insignificant decrease that was true for all antihistamines. A significant reduction in histamine/grass pollen skin test reactivity was also observed for all antihistamines, during an 8 h observation period. A significant difference in efficacy between the different antihistamines could not be found with any of the tests performed. CONCLUSIONS: For the newer nonsedating H1-antagonists there appears to be no clinically relevant differences in activities--at least not in our study. Preference of the patient may be the most important factor in making a choice between these drugs.

Endoscopic endonasal surgery in choanal atresia.

Twenty-seven cases of choanal atresia operated between 1979 and 2000 have been reported from 4 different institutions (19 females, 8 males, age of first surgical procedure ranging from 2 days to 35 years). Of these 27 cases, 22 were previously untreated. The outcomes for 19 of these new cases were available for the present report. Bilateral atresias were somewhat more frequent (15 versus 12) and associated anomalies were present in 10 out of 27 patients. Details about the types of atresia, associated anomalies, surgical techniques, duration of stenting and outcomes are given together with a theoretical review on choanal atresia.

Reference data for DPOAE in healthy newborns.

Distortion Product Otoacoustic Emissions (DPOAE) can be used as an alternative to Transient Evoked Otoacoustic Emissions (TEOAE). This study aims to establish normal values for DPOAE in healthy newborns. DPOAE were determined with the Madsen Celesta 503 at 0.5, 1, 2, 4 and 8 kHz with an unequal stimulus level of the primaries (L1 = 65 dB SPL, L2 = 50 dB SPL). DPOAE were present in 92.4% of the ears of the 185 babies tested at 4 days after birth. The 5% quantile and the median of the DPOAE of the right and left ears were calculated for the five frequencies tested. At 4 kHz there was a significant sex effect (mean amplitude of DPOAE was higher in female than in male babies) and at 2 kHz a significant interaction effect was found between sex and side. The calculated reference limits are open to comparison with data obtained using other commercial equipment.

Microbiology of the middle meatus: a comparison between normal adults and children.

Middle meatal samples were obtained from 52 carefully selected healthy adults. In 75 per cent of the test subjects bacterial organisms were cultured. However, growth was often poor and the predominant species suggest a commensal flora: coagulase-negative staphylococci were retrieved from 35 per cent, Corynebacterium sp. from 23 per cent and Staphyloccus aureus from eight per cent of the adults. These data are very different from those previously obtained among children where--even in the absence of obvious ENT pathology--the most frequently cultured organisms were typical sinusitis pathogens: Haemophilus influenzae present in 40 per cent, Moraxella catarrhalis in 34 per cent and Streptococcus pneumoniae in 50 per cent of children. Furthermore, Streptococcus viridans and Neisseria sp., both organisms that might be able to inhibit colonization by some of the pathogens and found commonly among children, are virtually absent in healthy adults.

Management of rhinosinusitis in children.

The authors provide definitions for the different forms of pediatric rhinosinusitis, with an enumeration of the main symptoms and signs. They also provide the indications for CT scan examination and microbiological investigations. In addition, they emphasize the importance of concomitant systemic disease, such as allergy and immunological disorders. The adequate medical management, which is mandatory before any surgery, is considered and discussed, and the indications for surgery are provided.

Epidemiology and prevalence of aspecific chronic sinusitis.

The problems inherent in the gathering of epidemiologic and prevalence data for aspecific chronic sinusitis are outlined. The need for a better understanding of the natural history of chronic sinusitis in children is stressed.

Distortion product oto-acoustic emissions as objective audiometry in a group of children with ventilation tubes.

The aim of this study was to evaluate distortion product oto-acoustic emissions (DPOAEs) as a means of objective audiometry in a population of children with ventilation tubes. We measured DPOAEs at two different stimulus levels--recorded transient evoked oto-acoustic emissions (TEOAEs) and obtained pure-tone audiometry (PTA). DPOAEs were compared with the normal range proposed by the Madsen company: the CELESTA 503 provides a 'normalized' distortion-product-gram which we compared with the pure-tone threshold of the test group. DPOAEs at 60 dBSPL were more easily obtained in the test group than TEOAEs and PTA. Correlation between 'normalized' DPOAEs and pure-tone thresholds was the strongest at 2 and 4 kHz. Surprisingly, DPOAEs at 60 dBSPL showed significant differences also at 2 and 4 kHz compared with the Madsen data. DPOAEs at 60 dBSPL might be an easy, objective test for evaluating auditory function and for determining hearing threshold at 2 and 4 kHz.

Bacteriology of the middle meatus in children.

Little is known about the bacteriology of the middle meatus in children. Therefore, middle meatal samples were obtained from 50 children who underwent adenoidectomy or adenotonsillectomy, while a group of 50 children submitted to minor non-ENT surgical procedures, were used as a control group. Haemophilus influenzae, Moraxella catarrhalis and Streptococcus pneumoniae were the most frequent cultured organisms, not only in the ENT group (in 68, 50 and 60% of the children respectively) but also in the control group (40, 34 and 50%). These three potential pathogens were more frequently seen among the children of the ENT group but only for H. influenzae was the observed difference statistically significant (P = 0.009). On semiquantitative analysis, there seemed to be more negative cultures or cultures with only a few colonies in the control group, while the richer cultures were obtained from the ENT group. Again, only for H. influenzae, these differences reached a statistical significance (P = 0.003). Streptococcus viridans and Neisseria species, both organisms that might be able to inhibit colonisation by some of the pathogens, were more frequently cultured in the control than in the ENT group: Strep. viridans 30 vs. 10% (P = 0.025) and Neisseria species 14 vs. 2% (P = 0.069).

Microbiology of the middle meatus in children requiring adenotonsillectomy.

Middle meatus samples were cultured in 120 children undergoing adenotonsillectomy with, or without, insertion of ventilation tubes. Every child (except one) had positive cultures. Haemophilus influenzae (62 per cent of the children), Moraxella catarrhalis (53 per cent) and Streptococcus pneumoniae (48 per cent) were the most commonly isolated bacteria. The presence of Moraxella catarrhalis and (to a lesser extent) Streptococcus pneumoniae was higher in younger children, while Haemophilus influenzae was cultured independently of age. Culture results of these middle meatal samples, carefully taken in order to avoid any contamination, probably reflect some ongoing sinus infection in these children requiring adenotonsillectomy. The problems inherent in the interpretation of surface cultures are addressed.

Acoustic rhinometry and rhinomanometry in the evaluation of nasal patency of patients with nasal septal deviation.

The aim of the present study was to assess the clinical utility of acoustic rhinometry (AR) compared with active anterior rhinomanometry (AAR) in the evaluation of nasal patency in subjects with nasal septal deviation. Fifty patients were divided into three groups based upon the part of the nasal cavity where the septal deviation was situated (anterior: up to 2.5 cm; middle: between 2.5 and 4.5 cm; posterior: between 4.5 and 8 cm measured from the columella). The control group consisted of 15 subjects with no nasal complaints and no history of nasal disease. Inspiratory and expiratory nasal airway resistance (NAR) at 75 Pa and at 150 Pa before and after decongestion were measured by AAR. Minimal Cross-sectional Area (MCA), distance of MCA, and nasal volume (Vol) were measured before and after decongestion by AR (Rhino 2000). Subjective nasal patency was assessed by Visual Analogue Score (VAS). In the statistical analysis the deviated unilateral nasal cavities were compared with the randomly chosen unilateral nasal cavities of normal subjects. Both techniques AR and AAR were sufficiently sensitive to reveal severe deviations in the anterior nasal cavity (MCA, Volant, NAR75, NAR150, p < 0.05). The techniques were less sensitive in cases of middle and posterior deviations (MCA, Volmid, Volpost, MCAmid, MCApost, NAR75, p > 0.05). The nondecongested inspiratory and expiratory NAR at 150 Pa were the only parameter that differed from normal in cases of posterior deviations. The VAS correlated better with NAR than with MCA. MCA correlated more frequently with expiratory than with inspiratory NAR.

A comparison of the efficacy, tolerability and safety of azithromycin and co-amoxiclav in the treatment of sinusitis in adults.

The efficacy, tolerability and safety of azithromycin and co-amoxiclav in the treatment of non-severe acute maxillary/ethmoidal sinusitis were compared in a randomized, open clinical trial in 254 adult patients. The predominant pathogens were Streptococcus pneumoniae and Haemophilus influenzae (83 patients). Azithromycin was administered orally to 165 patients at a single daily dose of 500 mg for 3 days, and co-amoxiclav (4:1) to 89 patients, at a dose of 500 mg three times daily for 10 days. The overall clinical response rates were 87.5% for azithromycin and 83.7% for co-amoxiclav at follow-up (day 21-28). Microbiological responses to both drugs were good, with only five patients in each group having a persistent infection after treatment. Both drugs were well tolerated and produced similar incidences of adverse events, which were mostly gastrointestinal. Azithromycin was as effective, and as well tolerated as co-amoxiclav, and its shorter simpler dosing regime may offer advantages in compliance and cost.

Nasal mucosal sarcoidosis: a case report.

The authors present a case of nasal mucosal sarcoidosis. Its low incidence may be due to unawareness of this sometimes forgotten entity. Crusting and nasal obstruction may be the first symptoms of this multisystemic disease. With the nasal endoscope, today's most helpful tool for examining the nose and its adjacent structures, the otolaryngologist can diagnose this disease at an early stage.

Management of rhinosinusitis in children: consensus meeting, Brussels, Belgium, September 13, 1996.

OBJECTIVES: To (1) provide definitions for the different forms of pediatric rhinosinusitis, with an enumeration of the main symptoms and signs; (2) provide indications for microbiological, allergic, and immunologic assessment as well as for imaging studies; (3) suggest standard medical management with judicious use of antimicrobial agents; and (4) discuss indications for surgery. DATA SOURCES: Clinical studies and literature data relevant to the different topics of pediatric rhinosinusitis. CONCLUSIONS: Rhinosinusitis in children is a multifactorial disease in which the importance of several predisposing factors changes with increasing age. Continued study to obtain a better understanding of the disease and carefully controlled comparative evaluations of medical and surgical therapies are suggested.

Peroperative findings of the middle turbinate in 50 patients with chronic sinusitis who underwent total spheno-ethmoidectomy.

This study describes the peroperative endoscopic findings about the size, shape and mucosal changes of the middle turbinate in patients with chronic sinusitis who underwent total spheno-ethmoidectomy. Results confirmed the middle turbinate to be a useful landmark in performing extensive sinus surgery. The most frequent change due to chronic inflammation seems to be polypous degeneration followed by hyperplastic mucosa. Anatomical variations, being paradoxically bent turbinate and concha bullosa, are not seen frequently.