Position paper on nasal obstruction: evaluation and treatment.

Nasal obstruction (NO) is defined as the subjective perception of discomfort or difficulty in the passage of air through the nostrils. It is a common reason for consultation in primary and specialized care and may affect up to 30%-40% of the population. It affects quality of life (especially sleep) and lowers work efficiency. The aim of this document is to agree on how to treat NO, establish a methodology for evaluating and diagnosing it, and define an individualized approach to its treatment. NO can be unilateral or bilateral, intermittent or persistent and may be caused by local or systemic factors, which may be anatomical, inflammatory, neurological, hormonal, functional, environmental, or pharmacological in origin. Directed study of the medical history and physical examination are key for diagnosing the specific cause. NO may be evaluated using subjective assessment tools (visual analog scale, symptom score, standardized questionnaires) or by objective estimation (active anterior rhinomanometry, acoustic rhinometry, peak nasal inspiratory flow). Although there is little correlation between the results, they may be considered complementary and not exclusive. Assessing the impact on quality of life through questionnaires standardized according to the underlying disease is also advisable. NO is treated according to its cause. Treatment is fundamentally pharmacological (topical and/or systemic) when the etiology is inflammatory or functional. Surgery may be necessary when medical treatment fails to complement or improve medical treatment or when other therapeutic approaches are not possible. Combinations of surgical techniques and medical treatment may be necessary.

[Primary meningioma of the nose and the paranasal sinus]. / Méningiome primitif nasosinusien.

Primary extracranial and extraspinal meningiomas are not very common, less than 1% out of meningiomas and with a pathogeny not well defined. Less than 60 cases have been described so far. The histopathological diagnosis can be really difficult. All the cases published were diagnosed after an anatomopathological study. We reviewed all publications about these tumors, which belong to the group of those rare neoplasms the otorhinolaryngologist must have in mind whenever he faces a paranasal sinus neoformation.

[Why evidence-based medicine? 20 years of meta-analysis]. / Por qué la medicina basada en la evidencia? 20 años de metaanálisis.

BACKGROUND: Meta-analysis, described within evidence-based medicine, has become a frequent issue in recent medical literature. An exhaustive search of reported meta-analysis from any medical specialty is described. MATERIAL AND METHODS: Search of papers included in Medline or Embase between 1973-1998. A study of intra and inter-reviewers liability about selection and classification have been performed. A descriptive analysis of the reported papers (frequency tables and graphics) is described, including differences of mean of reported meta-analysis papers by medical specialty and year. RESULTS: 1,518 papers were selected and classified. Most frequently found (45.91%) were: methodology (15.7%), psychiatry (11.79%), cardiology (10.01%) and oncology (8.36%). Inter personal agreement was 0.93 in selecting papers and 0.72 in classifying them. Between 1977-1987 overall mean of reported studies of meta-analysis (1.67 + 4.10) was significatively inferior to the 1988-1998 (49.54 + 56.55) (p < 0.001). Global number of meta-analysis was positively correlated (p < 0.05) with the number of studies about fundamentals and methodology during the study period. CONCLUSIONS: The method used to identify meta-analysis reports can be considered to be adequate; however, the agreement in classifying them in medical specialties was inferior. A progressive increase in the number of reported meta-analysis since 1977 can be demonstrated. Specialties with a greater number of meta-analysis published in the literature were: psychiatry, oncology and cardiology. Diffusion of knowledge about fundamentals and methodology of meta-analysis seems to have drawn and increase in performing and reporting this kind of analysis.

[Ethmoidofrontal mucoceles. Their clinical picture, diagnosis and differential diagnosis]. / Mucoceles etmoidofrontales. Clínica, diagnóstico y diagnóstico diferencial.

Anterior sitting is the most frequent localisation of frontal or ethmoidal mucocele. Generally its evolution is slow, but some times they evolve as acute inflammatory processes. The AA. report 2 paradigmatic cases of each course. The CAT shows the thinning out of the bone and the spreading of the disease. Comments on the symptomatology, exploratory means and differential diagnosis with other sinusal or orbital conditions.

[Retropharyngeal abscess due to atypical mycobacteria. Case report]. / Absceso retrofaríngeo por micobacterias atípicas. Estudio de un caso.

It is a rare clinico-pathological infection located in the retropharyngeal space. Our contribution refer to a young man suffering this complaint caused by atypical mycobacteria, being the aim of the paper to underline the exceptional placement. The difficulties encountered in establishing the bacteriological diagnosis as well the excellent response to a combined treatment with tuberculostatics and surgery.

[Our experience in chondrosarcoma. Three case reports]. / Nuestra experiencia en condrosarcomas de laringe. A propósito de 3 casos.

Sarcoma of the larynx are extremely rare neoplasms that account for approximately 1% of all tumors of this organ. Less than 0.1% correspond to chondrosarcomas. Three cases of laryngeal chondromas are described. The patient's age ranged between 65 and 75 years, and all they were men. Two of the tumors arose in the cricoid cartilage, and the other one, in the left wing of the thyroid cartilage. Two of the cases corresponded to high-grade, indifferentiated chondrosarcoma. Two of the patients were alive and free of recurrence of metastases 5 years after surgery.

[Adenoid cystic carcinoma of the larynx. Case report and literature review]. / Carcinoma adenoide quístico de laringe. Aportación de un caso y revisión de la literatura.

Adenoid cystic carcinoma is a rare neoplasm that comprise approximately 0.25% of all laryngeal malignancies. The rarity of these lesions has prohibited clarification of definitive therapy. Traditionally, radical surgery is performed because of the usually high stage at presentation. A case of larynx ACC is reported. The literature on this topic has been reviewed, in order to describe the natural course and the different treatments of this tumor.

[Biopsy cannula as diagnostic alternative to puncture-aspiration biopsy with fine needle in head and neck tumors]. / La cánula de biopsia: alternativa diagnóstica de la punción-aspiración con aguja fina en tumores de cabeza y cuello.

Biopsy cannula is a diagnostic tool allowing anatomopathological examination of tissue samples, achieved through a percutaneous perforation. Unlike puncture-aspiration with fine needle method that only permits a cytologic study, this technique eases the removal of pieces big enough to provide the knowledge of the whole architecture of the lesion. At length in other specialities in our has been forgotten perhaps for the great efficiency of PAFN on neck masses or as complement of traditional surgery. We present one case in which the biopsy-cannula showed its diagnostic usefulness. We also discuss on the technique and made a bibliographic perusal about the published literature.

[Tumor of the mouth floor: submucosal schwannoma]. / Tumoración del suelo de la boca: schwannoma submucoso.

We report a 77 years old patient with a tumour of the floor of the mouth. The long clinical evolution and its big size--longest diameter: 7.5 cm.--, are the most stringling clinical characteristics of this case. The pathologic study showed a schwannoma, a very unusual neoplasm in this situation. We focus our discussion in pathological aspects and differential diagnosis.

[Report of a case of pneumocephalus secondary to otologic surgery]. / Presentación de un caso de neumoencéfalo secundario a cirugía otológica.

Non-traumatic pneumocephalus of otic etiology, secondary to colesteatoma or the otologic surgery is extremely rare, and very few cases are described in the worldwide literature. The existence of air in the intracranial spaces/tracts is known as pneumocephalus. Symptoms are due to the increased intracranial pressure, therefore, a differential diagnosis should be made in order to rule out other expansive processes. Surgical treatment, with closure of the existing fistula, is conclusive. We present a case of tension pneumocephalus secondary to otologic surgery and review the literature existing on the topic.

[Mastoid osteoma]. / Osteoma de mastoides.

Extra-canalicular osteomas of the temporal bones are rare benign tumours. We report a retroauricular osteoma in a 18 years old patient. Usually symptomless, they may present for cosmetic reasons. We briefly comment this type of tumours.

[Hypernephroma metastasis in frontal sinus]. / Metástasis de hipernefroma en seno frontal.

PURPOSE: We present a case of metastatic neoplasia in the right frontal sinus derived from and hypernephroma, with a clinical picture that initially was interpreted as a mucocele. PATIENTS AND METHODS: Sixty years old male. Personal history: prostatectomy and left nephrectomy because of hypernephroma three years before. In december 92 the patient reported a protrusion in the right frontal sinus. CT scans and NMR revealed a breakage of the external and internal walls of the right frontal sinus and the right orbital roof. In february 93 a surgical exploration of the frontal sinus revealed the metastatic nature of the lesion. DISCUSSION: Metastatic tumors in paranasal sinuses are infrequent since most of the tumors in this localization are primary. Metastatic affectation of the frontal sinus is extremely rare. We recommend the systematic exploration of paranasal sinuses in patients affected by hypernephroma.

[Cerebral abscess as a complication of the chronic otitis]. / Absceso cerebral como complicación de la otitis crónica.

Otogenic intracranial complications are now rare. Meningitis is the most frequent, followed by cerebral abscess. In spite of diagnostic and therapeutic advances, cerebral abscess has a high mortality. We report four cases seen in our service over the last five years and their treatment. The subject is reviewed.

[Cervical chordoma]. / Cordoma cervical.

Chordoma is an uncommon neoplasia with very aggressive behavior and very high local recurrence rate. It remains a difficult problem for the surgeon. A case of cervical chordoma in a 30 years old woman is reported. The patient had a retropharyngeal mass and changes in the quality of speech. A transoral approach was used to obtain complete removal. The biological, clinical and diagnostic characteristic of cervical chordomas are reviewed.

[An outpatient study in ENT (otorhinolaryngology) emergencies at a general hospital]. / Estudio de las urgencias externas otorrinolaringológicas en un hospital terciario.

ORL emergencies attended at in a general hospital for a year were studied from 1-7-1990 to 30-6-1991. 168,145 emergencies were received of which 3,101 (1.8%) were attended by an otorhinolaringologist. The age, sex, arrival time, aetiology, treatment, admissions and the admissions where AEP (Appropriateness Evaluation Protocol) criteria was applied were thoroughly examined. The most numerous pathologies presented were infectious inflammations (41%), hemorrhages (21%), and foreign bodies (18.5%). But the most frequent aetiologies were epistaxis (16.3%), otitis media (14.8%) and otitis externa (14.8%). Most patients arrived generally between 9-12 hrs. (21.3%), and 17-20 hrs. (25.4%). The average age was 38.8 years old, though there was a significant difference depending on the pathology presented. Infectious inflammations emergencies were usually the youngest age group (average age 32) and tumoral processes the eldest (average age 60), 5% of the cases were admitted. These admissions accounted for only 17.9% of total admissions. Because AEP criteria was employed 97.5% of admissions presented inclusion criteria.

[Examination of the patient with supraglottic carcinoma at the medical office. Contribution of the rigid optical devices and the fiberscope]. / La exploración en la consulta del paciente con carcinoma supraglótico. Aportación de la óptica rígida y de la fibroscopia.

Seventy one patients afflicted of supraglottic carcinoma were included in a prospective study whose purpose was to determine which of three optical tools available at the medical office--indirect mirror laryngoscopy, laryngotelescopy and fiberscopic examination--is the most suitable to examine the larynx of patients with this disease. No significant differences were found among these explorations in the easily observable regions, as the hypopharyngeal areas and the epilarynx. The examination of the pericommisural region--the most difficult area to see--was easier with the flexible fiberscope. The laryngotelescope provided better visualization than the mirror laryngoscopy. Exploration with the new optical devices did not correct the errors in the interpretation of images made with the mirror laryngoscopy. We conclude that flexible fiberoptic laryngoscopy provides better information than other diagnostic tools for the assessment of patients with supraglottic carcinoma at the medical office.

[Cancer of the nasopharynx: our experience with 34 cases]. / Cáncer de nasofaringe: nuestra experiencia con 34 casos.

Thirty four cases of patients with nasopharyngeal cancer, all white people, are reviewed. The more frequent clinical signs are, in order of frequency: nasal obstruction, which is presented in 65% of patients, transmission deafness, in 59%; adenomegalies in 44%; epistaxis in 26% and migraine in 21% of cases. The mean time evolution between the first clinical symptom and the treatment was four and a half months. The pathologic study was: epidermoid carcinoma in 31 cases (91.9% and non-Hodgkin lymphoma in 3 cases 8.9%). The 31 cases of epidermoid carcinoma were treated with radiotherapy and the 5 years survival was 38%. In 62% of cases, the tumor recurred locally, in lymph nodes or were distant metastasis.

[Congenital cholesteatoma of the petrous process and mastoid: a report of two cases]. / Colesteatoma congénito de peñasco y mastoides. A propósito de dos casos.

Congenital cholesteatoma are unusual. They may arise in different sites of the temporal bone: petrous process, middle ear and mastoid. Primary cholesteatomas originate from embryonary ectodermal inclusions but the pathogenesis is not clear and many different hypotheses regarding its origin have been suggested. The clinical diagnosis is not easy if the tympanic membrane is normal, and computerized tomography and magnetic resonance imaging are useful. We report two cases of congenital cholesteatoma: One located in the petrous process and the other in the mastoid without affection of the tympanic cavity.

[Mucoepidermoid carcinoma of the larynx. A case report]. / Carcinoma mucoepidermoide de laringe. A propósito de un caso.

We report a case of laryngeal mucoepidermoid carcinoma that was diagnosed in the Hospital Miguel Servet of Zaragoza. The unusual tumor site and difficult diagnosis were notable and, above all the fatal outcome after local recurrence and metastasis in spite of good overall prognosis.

[Laryngeal histoplasmosis]. / Histoplasmosis laríngea.

A case of laryngeal histoplasmosis is reported. This laryngeal mycosis was diagnosed by histological identification of intracellular hyphae of Histoplasma capsulatum. Laryngoscopy revealed edema, erythema and leukoplakia of the righ vocal cord. Itrakonazole treatment was successful. The relevant literature is reviewed.