Optical rhinometry - new challenges and possibilities of rhinitis diagnostics and not only.

Optical rhinometry is the only diagnostic tool in rhinitis for assessing real-time changes in nasal occlusion. It illustrates lumen changes of nasal mucosa vessels in response nonspecific/specific factors and not only. The first attempts to standardize the method conducted by German researchers show the potential of optical rhinometry not only as regards challenge tests, but also vice versa, in respect of the anemization of the mucosa it evaluates the extent of the oedema which occurred in the pathomechanism of non-allergic rhinitis. The relatively small number of publications in the domain of interest demonstrates there is a need to conduct further research on the suitability of the above-mentioned technique for the evaluation of nasal patency in the field of rhinological diagnostics.

Evaluation of maxillary arch dimensions and palatal morphology in mouth-breathing children by using digital dental casts.

OBJECTIVE: The aim of the present study was to analyze the variations of maxillary arch size and of palatal morphology in subjects with prolonged mouth-breathing due to allergic rhinitis when compared with a control group with normal breathing pattern by using a three-dimensional analysis on digital casts. METHODS: 26 Caucasian children (19 females and 7 males) with a mean age of 8.5 years (SD 1.6 years) were selected according to the following criteria: mouth-breathing pattern due to allergic rhinitis, early mixed dentition, skeletal Class I relationship and prepubertal stage of cervical vertebral maturation. The study group was compared with a control group of 17 nasal breathing subjects (9 females; 8 males, mean age 8.5 years SD 1.7 years). For each subject an initial dental cast was taken and the upper arch was scanned by using a tridimensional scanner. On each digital model linear measurements were performed to analyze maxillary arch dimensions and palatal morphology. Significant between-group differences were tested with the Student t-test (p<0.05). RESULTS: the transverse dimension of the upper arch was significantly smaller in subjects of the study group thus confirming the influence of oral breathing on skeletal development with a significant constriction of the whole palate. The study group showed a higher and sharper palatal vault at the level of second deciduous molars and of first permanent molars. CONCLUSIONS: Children with mouth-breathing pattern showed a significant constriction of the maxillary arch and an increased palatal height when compared with subjects with normal breathing pattern.

Three-dimensional bone CT reconstruction anatomy of the vidian canal.

OBJECTIVES: To examine the anatomical features of the anterior opening of the vidian canal using three-dimensional (3D) computed tomography (CT) images of the bone. METHODS: We reviewed 62 patients who had undergone bilateral vidian neurectomies. One hundred and twenty-four vidian canals and their surrounding anatomies were analyzed. 3D images were reconstructed using algorithms and compared with conventional two-dimensional (2D) CT images. RESULTS: A bony prominence that overlaid the vidian canal along the sphenoid sinus floor was found in 60 (48.39 %) canals. Pneumatization of the pterygoid process was observed in 45 sides (36.29%). No significant discrepancy was found in detecting these variances between the 2D and the 3D images. The presence of a surgically favorable gap between the palatine and the sphenoid bone was seen in 25 sides (20.16%) without significant association with pterygoid process pneumatization or vidian canal protrusion. This gap was not identified on the 2D CT scans. CONCLUSION: 3D CT reconstruction images of bone provide superior delineation of the gap between the palatine and the sphenoid bone, which is a critical variation for vidian neurectomy. This useful method may contribute to better prediction and guidance of the surgical approach to the vidian canal and pterygopalatine fossa.

Effect of accessory ostia on maxillary sinus ventilation: a computational fluid dynamics (CFD) study.

We evaluated, by CFD simulation, effects of accessory ostium (AO) on maxillary sinus ventilation. A three-dimensional nasal model was constructed from an adult CT scan with two left maxillary AOs (sinus I) and one right AO (sinus II), then compared to an identical control model with all AOs sealed (sinuses III and IV). Transient simulations of quiet inspiration and expiration at 15 L/min, and nasal blow at 48 L/min, were calculated for both models using low-Reynolds-number turbulent analysis. At low flows, ventilation rates in sinuses with AOs (I ≈ 0.46 L/min, II ≈ 0.54 L/min), were both more than a magnitude higher than sinuses without AOs (II I ≈ 0.019 L/min, IV ≈ 0.020 L/min). Absence of AO almost completely prevented sinus ventilation. Increased ventilation of sinuses with AOs is complex. Under high flow conditions mimicking nose blowing, in sinuses II, III, and IV, the sinus flow rate increased. In contrast, the airflow direction through sinus I reversed between inspiration and expiration, while it remained almost constant throughout the respiration cycle in sinus II. CFD simulation demonstrated that AOs markedly increase maxillary sinus airflow rates and alter sinus air circulation patterns. Whether these airflow changes impact maxillary sinus physiology or pathophysiology is unknown.

Long-term results of bilateral endoscopic vidian neurectomy in the management of moderate to severe persistent allergic rhinitis.

OBJECTIVE: To evaluate the long-term efficacy of bilateral endoscopic vidian neurectomy in the management of moderate to severe persistent allergic rhinitis. DESIGN: A prospective reassessment of the postoperative long-term results of bilateral endoscopic vidian neurectomy using the Rhinoconjunctivitis Quality of Life Questionnaire and visual analog scale for patients with moderate to severe persistent allergic rhinitis. SETTING: University hospital. PATIENTS: A total of 236 patients with moderate to severe persistent allergic rhinitis were divided into the following 3 treatment groups: those who underwent bilateral endoscopic vidian neurectomy (group 1, n = 93), those who underwent partial inferior turbinectomy and/or septoplasty (group 2, n = 51), and those who received conservative therapy (controls, n = 92). MAIN OUTCOME MEASURE: The patients' quality of life was assessed at 6 months, 1 year, and 3 years after undergoing the initial selected treatments for moderate to severe persistent allergic rhinitis. The complications were observed after treatment. RESULTS: Data from 199 of 236 patients who had complete follow-up documents were statistically analyzed. The average posttreatment bilateral endoscopic vidian neurectomy scores of the Rhinoconjunctivitis Quality of Life Questionnaire and visual analog scale were significantly improved at 6 months, 1 year, and 3 years compared with pretreatment scores for group 1 (P < .00) and for those in groups 2 and 3 during the same period. By the patient's self-evaluation posttreatment, the percentages of much improved, improved, and not improved was 64.7% (55 cases), 24.7% (21 cases), and 10.6% (9 cases), respectively. The percentages were significantly higher for those in group 1 than for those in group 2 (P < .05). No severe complication occurred in all 3 patient groups. CONCLUSION: In the hands of a well-trained surgeon bilateral endoscopic vidian neurectomy is an effective and safe technique in the management of moderate to severe persistent allergic rhinitis.

High sensitivity C-reactive protein levels in chronic rhinosinusitis and allergic rhinitis.

OBJECTIVES: In this study we evaluated the relationship between peripheral blood high sensitivity C-reactive protein (hs-CRP) levels with allergic rhinitis and chronic rhinosinusitis (CRS) with or without nasal polyps. PATIENTS AND METHODS: The study included 100 patients who were divided into four groups each 25 patients; as follows: allergic rhinitis (group 1), CRS with nasal polyps (group 2), CRS without nasal polyps (group 3), and controls (group 4) who were non-smokers. All patients underwent a detailed symptom enquiry, physical examination, and investigations including a complete blood count and radiograph of the paranasal sinuses. The hs-CRP was measured in all the patients by a semi quantitative assay using the latex enhanced immunonephelometric test. RESULTS: There was no statistically significant difference in the levels of hs-CRP between the group 1, group 2, and group 3 by the control group respectively (p=0.861, p=0.7196, and p=0.127). CONCLUSION: Allergic rhinitis, CRS with nasal polyps and CRS without nasal polyp groups compared with the control group were statistically not significant differences in the hs-CRP levels with peripheral blood.

Lack of bone metabolism side effects after 3 years of nasal topical steroids in children with allergic rhinitis.

This study evaluated the effects on bone mineral status of long-term treatment with intranasal budesonide (INB) spray, using the recommended dose, in pediatric patients with allergic rhinitis (AR). This retrospective, case-control study of 230 prepubertal children with perennial AR, who had used nasal budesonide at a mean daily dose of 100 µg (range, 89-132 µg) for at least 3 years intermittently, was conducted from May 2007 through May 2010. The bone mineral density (BMD) of the lumbar spine was measured by dual-energy X-ray absorptiometry. Levels of serum calcium, phosphorus, alkaline phosphatase (ALP), parathyroid hormone, and osteocalcin were also assessed. The results were compared to sex- and age-matched controls (n = 140), who were newly diagnosed children with AR without any corticosteroid treatment. The 230 study patients (145 boys) were aged from 7 to 11 years. The average age (± SEM) was 8.7 ± 0.7 years; the mean (± SEM) steroid dosage used was 73.5 ± 7.0 µg daily, with 65.2 ± 5.2 g total steroid use during treatment. The 140 control patients (90 boys) were aged from 6 to 11 years. No significant differences were observed in BMD (P > 0.05) between the study and the control groups. Although mean serum ALP level was higher, and cortisol, phosphorus, and osteocalcin levels were lower, in the treatment group, these differences were not statistically significant. The findings suggest that long-term intermittent treatment for 3 years with INB spray, 50 µg twice daily, for children with perennial rhinitis revealed no negative effect on BMD and associated parameters.

One-year evaluation of combined treatment with an intranasal corticosteroid and montelukast for chronic rhinosinusitis associated with asthma.

OBJECTIVES: Chronic rhinosinusitis associated with asthma is often difficult to treat effectively with intranasal corticosteroids alone. Thus, the aim of this study was to evaluate the effectiveness of combination treatment with an intranasal corticosteroid and a leukotriene-receptor antagonist (montelukast) in reducing the size of nasal polyps. METHODS: The subjects of this study were 20 patients with chronic rhinosinusitis associated with adult-onset asthma, which was being treated with inhaled corticosteroids. All patients were treated with intranasal fluticasone propionate, 200 microg/day, and montelukast, 10 mg/day, for 1 year. The size of nasal polyps and the score of sinus shadows were assessed with nasal endoscopy and computed tomography (CT), respectively, before and after treatment. The peripheral blood eosinophil counts were also evaluated before and after treatment. RESULTS: Nasal polyps were significantly smaller after both 6 months (p<0.01) and 12 months of treatment (p<0.01) than before treatment. The decrease in the shadow score was statistically significant after both 6 months (p<0.01) and 12 months of treatment (p<0.01). Significant reductions in peripheral blood eosinophil counts were also seen after both 6 months (p<0.05) and 12 months of treatment (p<0.01). A significant correlation was found between the rate of change in the peripheral blood eosinophil count and that in the CT score after both 6 months (r=0.578, p=0.012) and 12 months (r=0.625, p=0.007). CONCLUSION: Combined treatment with intranasal fluticasone propionate and montelukast, for at least 1 year, is effective for chronic rhinosinusitis associated with adult-onset asthma.

Olfactory dysfunction in allergic rhinitis.

BACKGROUND: Olfactory dysfunction in patients with allergic rhinitis has long been thought to be secondary to coexisting chronic rhinosinusitis and polyposis with obstruction of airflow over the olfactory epithelium. Recent evidence suggests that the allergic inflammatory infiltrate may itself affect olfaction in the absence of mucosal hypertrophy. OBJECTIVE: We undertook a study to determine olfactory function in patients with allergic rhinitis in the presence and absence of chronic sinusitis. METHODS: Fifty-one subjects with symptoms of rhinitis who presented for allergy testing were administered the University of Pennsylvania Smell Identification Test. In addition each patient underwent computed tomography (CT) scanning of the sinuses. RESULTS: Eighty percent of subjects were allergic. Subjects with allergic rhinitis and no evidence of sinusitis scored on average in the 30th percentile (95% CI 20-40th percentile) on objective olfactory testing compared to age- and gender-specific norms. Half the allergic patients were classified as normosmic, while half had some degree of hyposmia. CONCLUSIONS: Our study demonstrates that even in the absence of mucosal disease on CT scan, a significant subset of patients with allergic rhinitis will exhibit hyposmia, mostly to a mild or moderate degree. The pathophysiology and potential treatments for olfactory loss in these patients should be further explored.

Radiologic staging system for allergic fungal rhinosinusitis (AFRS).

OBJECTIVES: 1) Develop an objective method for quantifying radiologic bone erosion in allergic fungal rhinosinusitis (AFRS); and 2) assess the utility of the new CT scan staging system in differentiating AFRS patient groups. METHODS: Patients from two tertiary care rhinology practices with AFRS and available CT scans (1999-2007) were included for review by trained graders. The following novel assessment scale was used: Each paranasal sinus wall with expansion/erosion was scored 1 point, with maximum 3 points possible for each frontal sinus, 2 points for each ethmoid complex, 3 points for each sphenoid sinus, 3 points for each maxillary sinus, and 1 point each for the frontal and sphenoid intersinus septae, yielding maximum of 24 possible points. RESULTS: A total of 111 CT scans were reviewed. Mean score was 7.8 (range, 0-24). Males scored significantly higher than females (mean, 9.3 vs 5.6, P = 0.001). African Americans scored significantly higher than Caucasians (mean, 9.6 vs 5.0, P < 0.001). CONCLUSIONS: A scoring system for bone remodeling in AFRS is presented. Males and African-Americans with AFRS demonstrate significantly more bone erosion. Additional analysis of disease course will assess the utility of this staging system in predicting outcomes.

Long-term frontal sinus patency after endoscopic frontal sinusotomy.

BACKGROUND: The frontal recess is the drainage pathway that connects the frontal sinus to the anterior ethmoid sinus. Mechanical obstruction is the primary cause of chronic frontal sinusitis with or without a secondary inflammatory process. Eosinophilic inflammation is one of the underlying causes for chronic rhinosinusitis. OBJECTIVES/HYPHOTHESIS: To evaluate long-term frontal sinus patency after endoscopic frontal sinusotomy in chronic rhinosinusitis patients and to assess the effect of eosinophilic inflammation on frontal sinus patency. STUDY DESIGN: Retrospective chart review. Symptom assessment and archived endoscopic photographs were prospectively collected on patients who underwent frontal sinusotomy between 7-1-1999 and 12-31-2000. Subjective symptom improvements were evaluated using the SNOT-20 = 20-item Sino-Nasal Outcome Test. Objective findings of endoscopic frontal sinus patency were documented by archived digital photography. RESULTS: A total of 161 patients with 294 frontal sinuses who underwent endoscopic frontal sinus surgery in the 18 months had an average follow-up of 45.9 months. The patient population was divided into two groups: 58 patients had eosinophilic CRS (ECRS), and 103 patients had CRS without eosinophils (non-ECRS). The mean follow-up for patients with ECRS is 61.6 months and 37.0 months for non-ECRS patients. The non-ECRS patients had a documented endoscopic frontal sinus patency of 90%, and the ECRS patients had an endoscopic frontal sinus patency of 85%. The overall frontal ostium patency rate for all patients was 88.0%. CONCLUSIONS: Long-term endoscopic confirmation of frontal ostium patency demonstrates that endoscopic frontal sinusotomy can yield high quality, durable results. There was no significant difference in patency results between ECRS and non-ECRS patients. Laryngoscope, 2009.

[Allergic rhinitis in childhood]. / La rhinite allergique de l'enfant.

Prevalence of allergic rhinitis has increased in the past years. The determination of the aeroallergens involved is important. Children with persistent rhinitis must be evaluated for asthma. Early treatment of allergic rhinitis may avoid asthma onset. The management of allergic rhinitis must include allergen avoidance, pharmacological treatment and immunotherapy. Sublingual swallow immunotherapy is a safe and effective method of treatment.

[Allergic fungal sinusitis: ten cases]. / La Sinusite Fongique Allergique (SFA). A propos de 10 cas.

OBJECTIVES: Diagnosis, nosological individualization, and treatment of allergic fungal sinusitis remain difficult and controversial despite the increasing number of publications. We present ten cases of allergic fungal sinusitis and review the literature to highlight the main clinical, radiological, biological, immunoallergological, mycological, and therapeutics features. MATERIAL AND METHODS: This retrospective study included ten patients (six men and four women, mean age 45 years) with allergic fungal sinusitis diagnosed on the basis of all diagnostic criteria reported in the literature. RESULTS: Six patients had isolated allergic fungal sinusitis which was associated with allergic bronchopulmonary aspergillosis in the four others. Treatment combined endoscopic sinus surgery and corticosteroids, which provided good results in six patients and average results in three. Treatment failure was observed in one patient. CONCLUSION: As in the case of allergic bronchopulmonary aspergillosis, a set of clinical, radiological, histopathological, immunoallergological and mycological criteria is necessary for precise diagnosis and to avoid fungal drift. The most appropriate endoscopic sinus surgery and the best corticosteroid regimen remain to be determined.

[Computed tomography stage in patients with allergic rhinitis and nonallergic rhinitis with eosinophilia syndrome]. / Alerjik rinit ve nonalerjik rinit eozinofilik sendromlu hastalarda bilgisayarli tomografi evresi.

OBJECTIVES: To compare computed tomography (CT) scores and nasal eosinophilia between patients with allergic rhinitis and nonallergic rhinitis with eosinophilia syndrome (NARES) and to evaluate the effect of the number of responsible allergens on the CT scores. PATIENTS AND METHODS: Sixty-three patients with a positive skin prick test, 11 patients with NARES and 15 healthy volunteers were included in this study. Allergic rhinitis patients were divided into three groups according to sensitivity to one allergen, two allergens, and more than two allergens. All the patients were examined by paranasal CT scans. The mean CT scores were determined by using the Lund-Mackay grading system and the results were compared. RESULTS: The mean CT scores were 5.4+/-5.8, 15.6+/-6.2, and 1.0+/-0.6 in patients with allergic rhinitis and NARES and in the control group, respectively. The mean CT score and eosinophilia in nasal smears were significantly higher in NARES patients compared to those with allergic rhinitis (p<0.05). No significant differences were found between the three groups of allergic rhinitis in this respect (p>0.05). CONCLUSION: Although the paranasal sinuses are affected by both allergic rhinitis and NARES, this effect is greater in NARES. The number of allergens causing sensitivity does not influence the CT score.

Subjects with allergic rhinitis show signs of more severely impaired paranasal sinus functioning during viral colds than nonallergic subjects.

BACKGROUND: Viral cold is thought to be the major contributing factor in the pathogenesis of sinusitis, as it causes ostiomeatal obstruction. The aim was to evaluate whether paranasal sinus functioning during viral colds is similar in subjects with and without allergic rhinitis. METHODS: Forty-eight volunteers were examined during an early (2-4 days) natural cold and again 3 weeks later. The examinations included computed tomography (CT) scans, nasal mucosal biopsies, and viral and bacterial specimens. Subjects with positive skin prick tests and persistent or intermittent rhinitis were considered to have allergic immunoglobulin E (IgE)-mediated rhinitis. In addition, specific IgE antibodies to staphylococcal enterotoxin B (SEB) were measured. RESULTS: Nine subjects (19%) had allergic rhinitis. The allergic subjects were significantly more often IgE sensitized to SEB than the nonallergic subjects (33%vs 3%, P = 0.02). Viral etiology of the cold was identified in 32 (67%) subjects. The subjects with allergic rhinitis had significantly higher CT scores compared with nonallergic subjects during the colds (median (range) scores 16 (6-22) vs 6 (0-17), P = 0.004). In both groups, the median scores declined markedly during convalescence, but the difference remained significant (P = 0.009). Among the allergic subjects, those who were IgE sensitized to SEB tended to have the highest CT scores [median (range) 16 (16-22)]. Total serum IgE and the nasal subepithelial eosinophil counts correlated with the CT scores during the cold (rs = 0.38, P = 0.008 and rs = 0.46, P = 0.001, respectively). CONCLUSIONS: Subjects with allergic IgE-mediated rhinitis had more severe paranasal sinus changes in CT scans than nonallergic subjects during viral colds. These changes indicate impaired sinus functioning and may increase the risk of bacterial sinusitis.

Hypoxia in paranasal sinuses of patients with chronic sinusitis with or without the complication of nasal allergy.

OBJECTIVE: In order to elucidate the pathogenesis of the radiologic opacity of the sinuses frequently observed in patients with allergic rhinitis, the mechanisms underlying their sinus mucosal swelling were studied clinically. MATERIAL AND METHODS: We confirmed the presence of hypoxia in inflamed sinuses and obstruction of the sinus ostium in operated patients with chronic sinusitis by digitally monitoring the oxygen tension. The possibility of radiologic sinus shadow was also investigated after transient obstruction of the natural ostium. RESULTS: The oxygen tension was significantly lower in inflamed than non-inflamed sinuses (p < 0.01), irrespective of the presence or absence of allergic rhinitis. In 54.5% of patients without sinusitis, transient obstruction of the middle meatus by gauze packing resulted in the appearance of a pathologic sinus shadow on radiograms obtained after septoplasty and turbinotomy. In both allergic and non-allergic rhinitis, thick opacity was the most frequently encountered pattern (p < 0.01). CONCLUSION: Our study revealed that in the absence of a primary allergic reaction in the sinus mucosa, blocking of the middle meatus and ostium by allergic swelling of the nasal mucosa may induce hypoxia and secondary mucosal swelling in the sinuses.