Ultra-low-dose CBCT scan: rational map for ear surgery.

PURPOSE: This study will evaluate the clinical quality and usability of peripheral image data from the temporal bone area obtained using a sinonasal ultra-low-dose (ULD) cone-beam computed tomography (CBCT) scan and compare them to those obtained using a high-resolution (HR) CBCT. METHODS: The population consisted of 66 anatomical sites (ears of 33 subjects) imaged using two modalities: an HR CBCT (Scanora 3Dx scanner; Soredex, Tuusula, Finland) and a ULD CBCT (Promax 3D Mid scanner; Plandent, Helsinki, Finland). The image quality (IQ) for every anatomical site in each image was rated using a Likert scale from 0 to 5. RESULTS: The quality of ULD CBCT scans was clinically sufficient in over 95% of the assessed images of the sigmoid sinus, jugular bulb, epitympanum and mastoid antrum as well as external acoustic meatus (all p > 0.05 compared to HR CBCT). The IQ was clinically sufficient in 75-94% of the assessed images of the scutum, mastoid segment of the facial nerve, cochlea and semicircular canals (all p < 0.05 compared to HR CBCT). The overall IQ of the HR CBCT scans was good or excellent. CONCLUSION: CBCT imaging and the data at image margins are underutilized. CBCT can produce excellent structural resolution with conventional imaging parameters, even with off-focus images. Using ultra-low doses of radiation, the produced IQ is clinically sufficient. We encourage ear surgeons to check the patients' imaging history and to consider the use of imaging modalities that involve lower radiation doses especially when conducting repetitive investigations and with children.

The effect of inferior turbinate surgery on nasal symptoms and inferior turbinate contractility.

OBJECTIVES: The aim of this study was to compare radiofrequency ablation (RFA), diode laser, and microdebrider-assisted inferior turbinoplasty (MAIT) in the treatment of chronic nasal obstruction in a one-year follow-up, and to pay special attention to the effect of the procedures on the contractility capacity of the inferior turbinates. METHODS: The patients filled a Visual Analogue Scale (VAS) questionnaire regarding nasal symptoms pre- and postoperatively. Saccharin transit time (STT) evaluation and acoustic rhinometry were also performed. A total of 77 patients attended the one-year control visit and had technically reliable acoustic rhinometry results. RESULTS: All the examined techniques decreased the VAS score for the severity of nasal obstruction statistically significantly. There was no deterioration found in the symptoms of crusting, nasal discharge, and sneezing, nor in mucociliary function in any of the groups. All the three techniques increased the non-decongested total V2-5 cm values and decreased the decongested total V2-5 cm values statistically significantly. The V2-5 cm change (%) values decreased statistically significantly in the RFA, diode laser, and the MAIT groups following the operations, the mean changes being -57 percentage points (pp), -53 pp, and -73 pp respectively. CONCLUSION: All three techniques decreased the severity of nasal obstruction significantly in the one-year follow-up. Although submucosal fibrosis seemed to increase, all the techniques increased the anterior nasal cavity volume significantly. Inferior turbinate contractility decreased to the normal level from the preoperative congested state following the surgery with every examined technique.

Eosinophilia, asthma, NERD and the use of oral corticosteroids predict uncontrolled chronic rhinosinusitis with nasal polyps after surgery.

BACKGROUND: Severe uncontrolled chronic rhinosinusitis with nasal polyps (CRSwNP) is a challenging condition to treat. The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 (EPOS2020) has the following criteria when considering biological therapy for severe uncontrolled CRSwNP: eosinophilia, need for oral corticosteroids (OCS), symptom score, loss of sense of smell and co-morbid asthma. OBJECTIVE: This study aimed at finding associations of baseline factors with uncontrolled CRSwNP after endoscopic sinus surgery (ESS). METHODS: Electronic health record data of CRSwNP patients (N = 137) undergoing ESS in 2002-17 were used. Endpoints of uncontrolled CRSwNP were revision ESS, purchased OCS and antibiotic courses during follow up. Baseline factors were chosen based on EPOS2020 and the data available: nasal polyp (NP) eosinophilia, peripheral blood eosinophilia, co-existing asthma and/or non-steroidal anti-inflammatory drug exacerbated respiratory disease (NERD), need for OCS during the previous year, previous ESS, endoscopic NP score, and Lund-Mackay score of sinus computed tomography scans. RESULTS: During the follow-up of 10.1 ± 3.1 (mean ± standard deviation) years, 35 (25.5%) individuals underwent revision ESS. The best predictive model was obtained by a sum of baseline (1) blood eosinophilia ≥ 250 cells/≥l and/or NP eosinophilia ≥ 30% (Eos), (2) asthma/NERD, and (3) ≥ 1 OCS/year. It was significantly associated with revision ESS, purchased doctor-prescribed OCS and antibiotic courses during follow-up. CONCLUSIONS: We identified similar predictive variables for uncontrolled CRSwNP that are used in the EPOS2020 indications of biological therapy, thus suggesting that these estimates are usable in clinical practice.

Hierarchical clustering in evaluating inflammatory upper airway phenotypes; increased symptoms in adults with allergic multimorbidity.

BACKGROUND: Inflammatory upper airway diseases cause significant morbidity. They include phenotypes with different treatment; allergic or non-allergic rhinitis (AR, nAR), and chronic rhinosinusitis with or without nasal polyps (CRSwNP, CRSsNP). In clinical practice, these phenotypes are often difficult to distinguish and may overlap. OBJECTIVE: To evaluate if hierarchical clustering can be used to distinguish these phenotypes based on the presence of nasal polyps, off-seasonal allergic symptoms, and self-reported background characteristics - e.g. atopic dermatitis (AD); and to further analyse the obtained clusters. METHODS: We studied a random sample of 74 CRS (chronic rhinosinusitis) patients, and a control group of 80 subjects without CRS with/without AR (tertiary hospitals, 2006-2012). All underwent interview and nasal examination, and filled a questionnaire. Variables regarding demographics, off-seasonal symptoms, and clinical findings were collected. Hierarchical clustering was performed, the obtained clusters were cross-tabulated and analysed. RESULTS: Four clusters were identified; 1: "Severe symptoms and CRSwNP" (n = 29), 2: "Asymptomatic AR and controls" (n = 39), 3: "Moderate symptoms and CRSsNP" (n = 36), and 4: "Symptomatic and AD" (n = 50). Cluster 1 had most sinonasal symptoms, cluster 3 had a high prevalence of facial pain. The presence of AR did not distinguish CRS groups. Of the AR subjects, 51 % belonged to cluster 4, where AR with off-seasonal airway symptoms and AD predominated. CONCLUSIONS: Hierarchical clustering can be used to distinguish inflammatory upper airway disease phenotypes. The AR phenotype was subdivided by the presence of AD. Adult AR+ AD patients could benefit from active clinical care of the upper airways also off-season.

Ethmoidal drug-eluting stent therapy is not superior to nasal corticosteroid spray in the prevention of endoscopic sinus surgery: Results from a randomised, clinical trial.

OBJECTIVES: To evaluate whether an ethmoidal drug-eluting stent (DES) (the Relieva Stratus™ MicroFlow Spacer) could better prevent endoscopic sinus surgery (ESS) than standard non-invasive therapy using corticosteroid nasal spray in patients suffering from chronic rhinosinusitis (CRS). DESIGN: Prospective, randomised clinical trial. SETTING: Tertiary referral centre. PARTICIPANTS: Sixty-three adult patients with ethmoidal involvement in cone beam computerised tomography (CBCT) whose first-line medical treatment with topical corticosteroids had failed and who were candidates for ESS were randomised either to a DES group, which received triamcinolone acetonide stents (n = 34), or to a topical intranasal corticosteroid group (n = 29) that used optimally dosed triamcinolone acetonide nasal spray. OUTCOME MEASURES: Patients were followed up prospectively for 6 months and at 36 months. Freedom from ESS was the primary endpoint. Further, we identified those factors predicting ESS. RESULTS: At 6 months, ESS could be prevented in almost half of the patients in both groups (DES 13/28, 46.4%, nasal spray 14/29, 48.3%). At 36 months, 20/28 (71.4%) patients in the DES group and 18/29 (62.1%) in the nasal spray group had been operated. The differences were not statistically significant at either timepoint. Patients who smoked (14/19, 73.7% vs 16/38, 42.1%) were more likely to be operated at 6 months. CONCLUSION: Endoscopic sinus surgery can be prevented using both therapies in the medium term in almost half of cases with neither therapy being statistically superior. This effect was somewhat diminished in the long term with a trend towards more patients being operated in the DES group. Considering the additional costs, the need for general anaesthesia and the potential side effects associated with DES, its potential clinical role appears to be limited. Smoking was significantly associated with ESS.

In vitro detection of common rhinosinusitis bacteria by the eNose utilising differential mobility spectrometry.

Acute rhinosinusitis (ARS) is a sudden, symptomatic inflammation of the nasal and paranasal mucosa. It is usually caused by respiratory virus infection, but bacteria complicate for a small number of ARS patients. The differential diagnostics between viral and bacterial pathogens is difficult and currently no rapid methodology exists, so antibiotics are overprescribed. The electronic nose (eNose) has shown the ability to detect diseases from gas mixtures. Differential mobility spectrometry (DMS) is a next-generation device that can separate ions based on their different mobility in high and low electric fields. Five common rhinosinusitis bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Staphylococcus aureus, and Pseudomonas aeruginosa) were analysed in vitro with DMS. Classification was done using linear discriminant analysis (LDA) and k-nearest neighbour (KNN). The results were validated using leave-one-out cross-validation and separate train and test sets. With the latter, 77% of the bacteria were classified correctly with LDA. The comparative figure with KNN was 79%. In one train-test set, P. aeruginosa was excluded and the four most common ARS bacteria were analysed with LDA and KNN; the correct classification rate was 83 and 85%, respectively. DMS has shown its potential in detecting rhinosinusitis bacteria in vitro. The applicability of DMS needs to be studied with rhinosinusitis patients.

Allergic rhinitis.

There have been no major changes in the pharmacological treatment of allergic rhinitis in recent years. Treatment is symptomatic and tailored individually, taking into account the type and severity of symptoms. Few new products have entered the market, and treatment is still largely based on antihistamines and nasally administered glucocorticoids. However, the general strategies for treating allergic rhinitis have developed over the last decade due to the introduction of the Finnish National Allergy Program. The treatment should aim at improving tolerance. Avoiding allergens is not necessary but it may help in controlling the symptoms. Hyposensitization, the only disease-modifying therapy, is a recommended, effective and safe form of treatment. New, practical sublingual hyposensitization products have facilitated treatment implementation and moved it from outpatient clinics into homes, which is a more patient-oriented approach and also cost-effective in the long term. However, the unit costs of treatment are relatively high for the patients.

Image-guided, navigation-assisted Relieva Stratus MicroFlow Spacer insertion into the ethmoid sinus.

Anatomical complexity presents the main challenge in the administration of topical corticosteroid therapy to the paranasal sinus mucosa. This often leads to suboptimal drug delivery due to low concentrations of the therapeutic agent to the intended target area. The Relieva Stratus™ MicroFlow Spacer (Relieva Stratus) is a drug-eluting stent that is temporarily implanted into the ethmoid sinus. The reservoir of the stent is filled with triamcinolone acetonide, which is then slowly released from the device into the ethmoid sinus mucosa. The Relieva Stratus provides local and targeted delivery of the anti-inflammatory agent to the diseased mucosa. This minimally invasive implant is an option when treating ethmoid sinusitis. From January 2011 to November 2013, a total of 52 Relieva Stratus implantations into the ethmoidal cells were performed at the Department of Ear and Oral Diseases at Tampere University Hospital, Finland. C-arm fluoroscopy guidance was employed for 26 sinuses (13 patients) and optical image-guided surgery (IGS)-assisted insertions were performed on another 26 sinuses (13 patients). The accuracy of fluoroscopic insertion is not optimal, but this method is accurate enough to prevent the violation of the skull base and lamina papyracea. IGS enables the precise treatment of the diseased cells. From a technical perspective, IGS-guided insertion is a faster, safer and more exact procedure that guarantees the optimal positioning and efficacy of the implant. Moreover, IGS guidance does not entail the use of ionizing radiation.

The Experience of Treating Drooling with Repeated Botulinum Toxin Injections.

Botulinum toxin A (BTX-A) injections to the salivary glands are effective in the treatment of drooling, and complications are rare. However, there are only a few previous reports on the long-term use of BTX-A injections. This study retrospectively analyzes our experience of treating drooling with repeated BTX-A injections in patients with neurodegenerative diseases. All patients who received repeated BTX-A injections to the submandibular glands at Tampere University Hospital in 2004-2013 were included in the analysis. Six patients, aged from 6 to 21 years, were included in the study, and a total of 41 bilateral BTX-A injections were administered to their submandibular glands. The average number of injections per patient was 6 (range: 3-11). The average interval between the injections was 9.8 months (range: 4-18), and 95% (39/41) of the injections were performed with good response. The complication rate of the BTX-A injections was 2.4% (1/41), since one of the patients had swallowing problems after an injection. BTX-A injections to the submandibular glands are effective and have a low morbidity rate, and repeated injections can be recommended as long-term treatment of drooling.

Retrospective analysis of a combined endoscopic and transcutaneous technique for the management of parotid salivary gland stones.

Sialendoscopy is used in the diagnosis and treatment of various symptoms relating to the salivary gland, e.g. chronic swelling or obstruction and inflammation of the salivary duct. Small intraductal stones can be removed with various instruments during sialendoscopy, whereas larger ones can be fragmented with extracorporeal shockwave lithotripsy or laser. However, 5-10% of the patients with parotid stones cannot be treated with these methods. In patients with large impacted stones or stones in a hilus area, a combined endoscopic and transcutaneous technique can be employed. The stone is approached endoscopically, a skin flap is raised over or a small incision is made through the illuminated area, and the stone is removed by an external route with minimal morbidity. This retrospective study analysed the cases of 8 patients treated using the combined technique, 6 of whom became symptom free. Superficial parotidectomy was performed in 1 patient. No complications were observed, and ductal stents were not used. The average diameter of the stones was 7.6 mm (range 7.0-10.2). The combined technique is recommended for the removal of large and impacted intraductal stones in the parotid gland. No major complications have been reported.

[Combined technique in the removal of parotid gland stones]. / Yhdistelmätekniikka korvasylkirauhasen kivien poistossa.

Sialendoscopy is used in the diagnostics and treatment of salivary gland swelling. Small intraductal stones can be removed with various instruments during sialendoscopy. In cases with larger fixed stones a combined technique can be applied. The stone is approached endoscopically, skin flap is raised or a small incision is made through the illuminated area and the stone is removed via the external route with minimal morbidity. In this series five out of seven patients treated by the combined technique became symptomless. Superficial parotidectomy was performed on one patient. The combined technique is recommended in the removal of stones that are large, fixed in the duct or located in the gland's hilus.

[Airways dysfunction syndromes RADS and RUDS]. / Hengitysteiden reaktiiviset toimintahäiriöt RADS ja RUDS äkillisen työperäisen kemikaalialtistuksen seurauksena.

RADS is an airways dysfunction syndrome caused by a sudden, massive exposure to an irritative chemical. RADS is considered a subtype of occupational asthma. RADS patient may cure within months, but RADS may also become a permanent disability. RUDS is a dysfunction syndrome in upper airways caused by exposure to an irritative chemical. It seems that in RUDS there are problems in olfactory function in addition to inflammation of upper airways. We present a patient, who was suddenly exposed to chemical vapours in her workplace. She had RADS-like symptoms and was diagnosed with RUDS.

[Update on Current Care Guideline: Sinusitis]. / Sivuontelotulehdus.

Patients with common cold have often symptoms similar to sinusitis. These symptoms often resolve in time, but symptomatic treatment (e.g. analgesics, decongestants) may be used. If symptoms continue for over 10 days, or severe symptoms continue for over 3 days, or symptoms turn worse in the course of the disease, bacterial sinusitis should be suspected. Diagnosis is based on clinical findings, and can be confirmed with ultrasound examination. Amoxicillin, penicillin or doxicyclin are recommended for bacterial sinusitis. Patients with chronic or recurrent sinusitis should be referred to specialist care.

The Detection of Bacteria in the Maxillary Sinus Secretion of Patients With Acute Rhinosinusitis Using an Electronic Nose: A Pilot Study.

OBJECTIVE: Detecting bacteria as a causative pathogen of acute rhinosinusitis (ARS) is a challenging task. Electronic nose technology is a novel method for detecting volatile organic compounds (VOCs) that has also been studied in association with the detection of several diseases. The aim of this pilot study was to analyze maxillary sinus secretion with differential mobility spectrometry (DMS) and to determine whether the secretion demonstrates a different VOC profile when bacteria are present. METHODS: Adult patients with ARS symptoms were examined. Maxillary sinus contents were aspirated for bacterial culture and DMS analysis. k-Nearest neighbor and linear discriminant analysis were used to classify samples as positive or negative, using bacterial cultures as a reference. RESULTS: A total of 26 samples from 15 patients were obtained. After leave-one-out cross-validation, k-nearest neighbor produced accuracy of 85%, sensitivity of 67%, specificity of 94%, positive predictive value of 86%, and negative predictive value of 84%. CONCLUSIONS: The results of this pilot study suggest that bacterial positive and bacterial negative sinus secretion release different VOCs and that DMS has the potential to detect them. However, as the results are based on limited data, further conclusions cannot be made. DMS is a novel method in disease diagnostics and future studies should examine whether the method can detect bacterial ARS by analyzing exhaled air.

Laboratory Test Results in Patients with Workplace Moisture Damage Associated Symptoms-The SAMDAW Study.

The mechanisms of health effects of moisture damage (MD) are unclear, but inflammatory responses have been suspected. The usefulness of laboratory and allergy tests among patients in secondary healthcare with symptoms associated with workplace MD were examined. Full blood count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), total serum immunoglobulin E (IgE), fractional exhaled nitric oxide (FeNO), and skin prick testing were assessed and analyzed in relation to multiple chemical sensitivity (MCS) and perceived stress in 99 patients and 48 controls. In analysis, t-tests, Mann-Whitney tests, and chi-squared tests were used. Minor clinically insignificant differences in blood counts were seen in patients and controls, but among patients with asthma an elevated neutrophil count was found in 19% with and only in 2% of patients without asthma (p = 0.003). CRP levels and ESR were low, and the study patients' FeNO, total IgE, or allergic sensitization were not increased compared to controls. The level of stress was high among 26% of patients and 6% of controls (p = 0.005), and MCS was more common among patients (39% vs. 10%, p < 0.001). Stress or MCS were not significantly associated with laboratory test results. In conclusion, no basic laboratory or allergy test results were characteristic of this patient group, and neither inflammatory processes nor allergic sensitization were found to explain the symptoms among these patients. While the value of basic laboratory tests should not be ignored, the use of allergy tests does not seem necessary when symptoms are indicated to be workplace-related.

[Osler's disease or hereditary hemorrhagic telangiectasia]. / Oslerin tauti eli hereditaarinen hemorraginen telangiektasia.

According to current knowledge, Osler's disease may be caused by gene defects of several distinct genes, causing vascular fragility and lack of contractility. The most typical symptoms are recurrent spontaneous nose bleedings. Other target organs of the disease include skin, lungs, intestinal tract, brain and liver, but symptoms in these organs are less common. The diagnosis is based on clinical findings, family history and can, if necessary, be confirmed by a gene test. Osler's disease is treated symptomatically. There is no curative treatment.

[Pott's puffy tumor--a rare complication of frontal sinusitis]. / "Pott's puffy"-tuumori--otsaontelotulehduksen harvinainen komplikaatio.

Pott's puffy tumor is an extremely rare complication of frontal sinusitis. It is most typically found in young men. Streptococci, staphylococci or anaerobic bacteria are usually the causative agents. In our patients the inflammation was caused by Streptococcus milleri and Streptococcus pneumoniae. The treatment should be started with broad-spectrum antibiotics. The antibiotics are administered intravenously for 1 to 2 weeks and thereafter orally for at least four weeks. Paranasal sinuses must be operated, and if necessary, intracranial abscesses are treated neurosurgically.

Factors Predictive of Outcome in Inferior Turbinate Surgery.

OBJECTIVES: The purpose of the study was to examine the various preoperative predictive factors of inferior turbinate surgery and to find possible factors that predict an optimal subjective response using 3 common surgical techniques-radiofrequency ablation (RFA), diode laser, and microdebrider-assisted inferior turbinoplasty (MAIT)-in a randomized, prospective study with a 1-year follow-up. METHODS: The patients filled a visual analogue scale (VAS) questionnaire regarding the severity of nasal obstruction prior to and 1 year after surgery. A VAS score improvement of 3 points or more was chosen as an optimal subjective response. Univariate and multivariate regressions were used to evaluate the effect of the predictive factors. In total, 80 patients attended a 1-year control visit. RESULTS: In the multivariate analysis, patients without anterior septal deviation had a statistically significantly higher odds ratio of a satisfactory subjective response compared to patients with anterior septal deviation (5.6; 95% CI: 1.4-23.1; P = .02). Patients treated with RFA had a statistically significantly higher odds ratio of an optimal subjective response compared to patients treated with MAIT (9.0; 95% CI: 1.5-54.2; P = .02). CONCLUSIONS: Anterior septal deviation seems to decrease the likelihood of an optimal subjective response to inferior turbinate surgery, which supports the consideration of concomitant septoplasty at least in clear cases to optimize the subjective response. Radiofrequency ablation had a significantly higher likelihood of an optimal subjective response compared to MAIT. Further investigations regarding the findings are needed.

The Long-term Effect of Inferior Turbinate Surgery Techniques on Nasal Obstruction and Quality of Life.

OBJECTIVE: The aim of the study was to compare the long-term effects of radiofrequency ablation (RFA), microdebrider-assisted inferior turbinoplasty (MAIT), and diode laser techniques on the severity of nasal obstruction and quality of life (QOL) in a 3-year follow-up. METHODS: The patients filled a Visual Analog Scale (VAS) regarding the severity of nasal obstruction and the Glasgow Health Status Inventory (GHSI) questionnaire preoperatively and during the control visits at 3 months and 3 years. Acoustic rhinometry was also performed. A total of 78 patients attended both control visits. RESULTS: All 3 techniques improved the VAS score for the severity of nasal obstruction and the GHSI total score significantly compared to the preoperative values at both 3 months and 3 years. Compared to the preoperative values, all 3 techniques increased the V2 to 5 cm values significantly at 3 months. After 3 years, compared to the preoperative values, the MAIT (P = .005) and diode laser (P < .001) still had a statistically significant volume increase in V2 to 5 cm, whereas the RFA (P = .06) did not achieve a statistically significant effect. CONCLUSION: The RFA, MAIT, and diode laser all improved both the patients' subjective sensation of the severity of nasal obstruction and QOL significantly. The response was sustained during the 3-year follow-up period with all 3 techniques. A weakening in the objective treatment response to RFA was found in the longer follow-up, but that did not cause a weakening of the patients' subjective treatment response.

Identifying chronic rhinosinusitis without nasal polyps by analyzing aspirated nasal air with an electronic nose based on differential mobility spectrometry.

BACKGROUND: The diagnosis of chronic rhinosinusitis (CRS) is a complicated procedure. An electronic nose (eNose) is a novel method that detects disease from gas-phase mixtures, such as human breath. AIMS/OBJECTIVES: To determine whether an eNose based on differential mobility spectrometry (DMS) can detect chronic rhinosinusitis without nasal polyps (CRSsNP) by analyzing aspirated nasal air. MATERIALS AND METHODS: Adult patients with CRSsNP were examined. The control group consisted of patients with septal deviation. Nasal air was aspirated into a collection bag and analyzed with DMS. The DMS data were classified using regularized linear discriminant analysis (LDA) models with 10-fold cross-validation. RESULTS: The accuracy of the DMS to distinguish CRSsNP from patients with septal deviation was 69%. Sensitivity and specificity were 67 and 70%, respectively. Bonferroni-corrected statistical differences were clearly noted. When a subgroup with more severe inflammatory disease was compared to controls, the classification accuracy increased to 82%. CONCLUSIONS: The results of this feasibility study demonstrate that CRSsNP can potentially be differentiated distinguished from patients with similar nasal symptoms by analyzing the aspirated nasal air using DMS. Further research is warranted to evaluate the ability of this novel method in the differential diagnostics of CRS.