Negative impact of Aspergillus galactomannan and DNA detection in the diagnosis of fungal rhinosinusitis.

A proportion of patients with chronic rhinosinusitis, especially if nasal polyps are present, have a diagnosis of fungal rhinosinusitis. The diagnosis is difficult to establish because the symptoms and clinical and radiological signs are non-specific. Also current diagnostic methods, i.e. histology, fungal staining and culture, are insensitive. The performance of the Aspergillus galactomannan (GM) ELISA and real-time PCR for Aspergillus fumigatus mitochondrial DNA was evaluated for the detection of Aspergillus in sinus mucus samples from 25 patients with chronic rhinosinusitis with nasal polyposis. The results were compared with those from nasal lavage fluid from 19 healthy volunteers. Seven patients (28 %) were diagnosed as having fungal rhinosinusitis according to the presence of filaments in histology or direct microscopy using Calcofluor white. All fungal rhinosinusitis patients were negative in the GM ELISA. GM ELISA was positive in five patients whose samples were negative using conventional methods and A. fumigatus PCR. Two out of seven patients with fungal rhinosinusitis were positive by A. fumigatus PCR: one also had a positive A. fumigatus culture, and one had hyphae consistent with Aspergillus in histology. One additional patient had a weak positive PCR result, but other fungal tests were negative. In control subjects, the GM ELISA was positive in 21 %, whereas direct microscopy, culture and A. fumigatus PCR were negative in all samples. Direct microscopy and culture together with histology remain pivotal in defining fungal rhinosinusitis diagnosis. A. fumigatus PCR may have additional value in allowing the diagnosis to be made sooner, whereas the GM ELISA is not reliable in diagnosing Aspergillus infection of the paranasal sinuses.

Association of allergy, asthma and IgE sensitisation to adenoidectomy and infections in children.

OBJECTIVE: To find out whether previous adenoidectomy is associated with asthma, allergic symptoms or allergen-specific IgE antibodies. RECRUITMENT AND METHODS: We recruited 213 paediatric patients admitted for elective tonsillectomy and 155 paediatric controls. Using a structured questionnaire, we recorded their respiratory symptoms, allergies, bronchial asthma and environmental factors. Serum IgE antibodies against respiratory allergens were screened. Patients were divided into those previously adenoidectomised (n = 100) or not adenoidectomised (n = 113). RESULTS: Any allergy (p = 0.007) and non-antibiotic allergy diagnosed by a doctor (p = 0.015), and asthma (p = 0.015) were more common among adenoidectomised than non-adenoidectomised children under the age of seven. Between ages 7 and 11, neither any kind of allergy nor asthma were associated with earlier adenoidectomy. In the oldest age group (12 to 17), only antibiotic allergy was more common in adenoidectomised children. Recurrent otitis media (p < 0.001) and recurrent sinusitis (p = 0.007) were more common in adenoidectomised children. After controlling for recurrent respiratory infections, doctor-diagnosed allergy remained significantly associated with adenoidectomy in the youngest age group. Prevalence of specific IgE did not differ between the patient groups, or between school-aged patients and controls. CONCLUSIONS: Our results suggest that hypersensitivity disorders and infections may share aetiological factors. However, as adenoidectomised children of any age did not have higher levels of specific IgE, it seems possible that allergy is either clinically over-diagnosed or insufficiently detected by serology among young adenoidectomised children.

Snoring is not relieved by nasal surgery despite improvement in nasal resistance.

OBJECTIVES: In the present study, we evaluated the effect of nasal surgery on snoring time, snoring intensity, and sleep-disordered breathing. The role of abnormal cephalometry in treatment outcome was assessed. DESIGN: A cross-sectional prospective study. SETTING: University teaching hospital. PATIENTS: Forty consecutive snoring men who were referred to ENT Hospital because of a snoring problem or suspicion of sleep apnea. INTERVENTIONS: The patients underwent anterior rhinomanometry and polysomnography (PSG) with recording of snoring before and after operative treatment of nasal obstruction. Cephalometric radiographs were obtained before surgery. RESULTS: Nasal resistance decreased significantly in the overall patient group. Snoring time, snoring intensity, nocturnal breathing, and sleep architecture did not change after nasal surgery. Cephalometry did not predict operative outcome in these patients. Snoring intensity was found to be significantly higher during non-rapid eye movement (NREM) sleep than during rapid eye movement sleep. CONCLUSIONS: Operative treatment of mainly structural nasal obstruction did not seem to decrease snoring intensity, snoring time, or sleep-disordered breathing in an objective assessment by PSG performed after surgery. The effect of treating inflammatory nasal changes during nocturnal breathing, as well as the role of cephalometry in the prediction of treatment outcome will need further evaluation. Higher snoring intensity related to NREM sleep may add to the sleep disturbance of a bed partner in the evening.

Patient- and bed partner-reported symptoms, smoking, and nasal resistance in sleep-disordered breathing.

OBJECTIVES: Nocturnal and daytime symptoms are important determinants in clinical decision making in patients suspected of having sleep-disordered breathing (SDB). We compared patients' and bed partners' reporting of symptoms associated with SDB in a clinical sample of snoring men. The bed partners' view on snoring disturbance was assessed. The relationship between sleep parameters, anthropometric data, and selected subjective symptoms was assessed. Additionally, we evaluated the relationship between smoking, nasal resistance, and habitual snoring. DESIGN: A cross-sectional, prospective study. SETTING: University teaching hospital. PATIENTS: Thirty-seven consecutive snoring men referred to ENT Hospital because of a snoring problem or suspicion of sleep apnea, and scheduled for surgical treatment of nasal obstruction. INTERVENTIONS: The patients completed a sleep questionnaire, a questionnaire on nasal history, and the Epworth sleepiness scale. The bed partners were asked to complete a separate sleep questionnaire of the patient's daytime and nocturnal symptoms. Both patients and bed partners evaluated the intensity of snoring on a visual analog scale. The patients underwent polysomnography and anterior rhinomanometry. RESULTS: Agreement of patients' and bed partners' reports on symptoms related to SDB was good in this material. One half of the bed partners were disturbed by snoring every night or almost every night, and one third of the bed partners reported disharmony in the relationship from time to time or repeatedly due to snoring. The combination of current smoking and total nasal resistance in a supine position higher than the median value in this patient sample was associated with history of habitual snoring. CONCLUSIONS: Male patients and their bed partners seem to give congruent reports of snoring and symptoms related to SDB in a clinical population with mild SDB. One half of the bed partners found their sleep constantly disturbed. The combination of current smoking and high nasal resistance was related with habitual snoring.

Esophageal pressure monitoring in detection of sleep-disordered breathing.

OBJECTIVE: The aim was to study the value of esophageal pressure monitoring combined with limited polygraphic recording (oxygen saturation, respiratory and leg movements, airflow, body position, and snoring sound) in diagnosis of sleep-disordered breathing. STUDY DESIGN: A prospective study of consecutive patients with snoring was carried out. METHODS: Sixty-seven patients underwent an overnight study on ward. Patients with normal oxygen desaturation index and any periodic breathing disturbances combined with elevated esophageal pressure were further studied with complete polysomnography. RESULTS: The patient compliance with esophageal catheter was 87%. Esophageal pressure monitoring increased effectively the detection of sleep-disordered breathing with limited polygraphic recording. Sixty-seven percent of the patients with normal oxygen desaturation index and respiratory-related esophageal pressure variation had sleep-disordered breathing on complete polysomnography. Increased esophageal pressure variation was significantly related with oxygen desaturation index and obstructive sleep apnea diagnosis (P <.001). All together, 48% of the mainly nonobese snorers had objective findings of sleep-disordered breathing. Patients with upper airway resistance syndrome were few. Fifteen percent of the patients had periodic leg movements. Neither subjective or objective sleepiness nor snoring or obesity adequately exposed sleep-disordered breathing in this material. CONCLUSION: Esophageal pressure monitoring increases markedly the diagnostic value of limited polygraphic recording as a screening study for sleep-disordered breathing.

Postural cephalometric analysis and nasal resistance in sleep-disordered breathing.

OBJECTIVES: The study was designed to compare upright and supine cephalometric measurements in snorers and to evaluate the effects of mandibular position and nasal resistance on pharyngeal dimensions. Anthropometric, rhinomanometric, and cephalometric measurements were used to investigate predictors of apnea-hypopnea index. STUDY DESIGN: Prospective, cross-sectional. METHODS: Forty consecutive habitually snoring men waiting for nasal surgery (mean age, 44 y; mean body mass index, 28 kg/m2) underwent an overnight polysomnographic, anterior rhinomanometric, and cephalometric analysis in upright and supine positions. RESULTS: Nasal resistance correlated positively with minimal pharyngeal airspace at the level of tongue. The opening of jaws after voluntary relaxation of the mandibular position on lying down correlated with decrease in pharyngeal airway measurements at both velopharyngeal and tongue-base levels. In stepwise multiple regression analysis the overall patient model explained 68% of the variation in apnea-hypopnea index with body mass index as the largest predictor. In the nonobese patients, the model explained 86% of variation in apnea-hypopnea index with change in anteroposterior position of the lower jaw in upright and supine measurements and combined nasal resistance after mucosal decongestion as independent determinants. In selected skeletal subtypes the models predicted 83%, 79%, 61%, and 90% of the variation in apnea-hypopnea index. CONCLUSIONS: In the nonobese patients nasal resistance and change in mandibular position on lying down were found to be independent contributing factors to the apnea-hypopnea index. Further research on supine cephalometry and relaxed mandibular position may improve prediction of sleep-disordered breathing in snorers.

Submucosal bipolar radiofrequency thermal ablation of inferior turbinates: a long-term follow-up with subjective and objective assessment.

OBJECTIVE: To assess the efficacy and morbidity of bipolar radiofrequency thermal ablation of the inferior turbinates in patients with nasal obstruction caused by turbinate hypertrophy. STUDY DESIGN: Prospective, nonrandomized study and outpatient treatment. METHODS: Twenty patients (age range, 23-77 y; median age, 52 y) enrolled in the study. There was one dropout. All the patients had nasal blockage despite medical treatment. Bipolar radiofrequency thermal ablation was delivered to inferior turbinates at 100 kHz with a voltage root mean square value of 168 to 182. The preoperative and postoperative nasal functions were investigated by immediate and long-term visual analogue scale (VAS) scores of symptom parameters, olfactory thresholds, saccharine transit time, rhinomanometry, and acoustic rhinometry. The follow-up was conducted at 1 week and 3, 6, and 12 months. RESULTS: The VAS scores of subjective complaints (nasal discharge, itching, sneezing, crusting) decreased, and the VAS scores of evaluation of the effectiveness (frequency of nasal obstruction, degree of nasal obstruction, and patient satisfaction) increased statistically significantly in the 12-month follow-up without relapses. There were no adverse effects on nasal epithelial clearance time and olfactory functions. In rhinomanometry the changes in total nasal resistance and response to the vasoconstrictor agent were not statistically significant. In acoustic rhinometry the change in the sum of both nasal cavity volumes from nostril to 5 cm was statistically significant 6 and 12 months after the treatments. The difference between the preoperative and postoperative vasoconstrictive effect was not statistically significant. CONCLUSION: The bipolar radiofrequency thermal ablation of inferior turbinates is a promising alternative, which should be considered when planning inferior turbinate interventions.

Correspondence between three olfactory tests and suprathreshold odor intensity ratings.

OBJECTIVES: The capability of three olfactory tests (European Test of Olfactory Capabilities, Sniffin' Sticks and Cross-Cultural Smell Identification Test) to similarly classify subjects as normosmics, hyposmics and anosmics as well as the relation between test performance and suprathreshold ortho- and retronasal odor intensity ratings were examined. MATERIAL AND METHODS: A total of 48 subjects (age range 15-84 years; mean age 49.5 years) completed the 3 olfactory tests, rated aqueous solutions of vanilla (0-0.31%) and lemon aroma (0-0.17%) for odor and flavor intensity and filled in a background questionnaire. Ten subjects had case histories indicating anosmia, with the remainder having subjectively normal olfaction. RESULTS: The test results were highly correlated and differentiated anosmic, hyposmic and normosmic subjects. At an individual level, some discrepancy was seen in the olfactory diagnoses given by the three tests. In principal component analysis, olfactory measurements were loaded on three components: (i) odor detection, discrimination and identification; (ii) suprathreshold intensity ratings; and (iii) threshold for n-butanol. Advanced age was related to impaired olfactory performance. CONCLUSIONS: Although the three olfactory tests diagnosed the individuals slightly differently, all were considered to be valid for clinical evaluation of olfactory capabilities. The tests separated anosmics and normosmics highly significantly, and permitted an assessment of hyposmia. The suprathreshold odor intensity ratings reflected a different dimension of olfaction than the three olfactory tests.

Nasal obstruction and sleep-disordered breathing: the effect of supine body position on nasal measurements in snorers.

OBJECTIVE: Nasal obstruction is considered to be a potential etiological factor in sleep-disordered breathing. However, a significant correlation between nasal measurements and obstructive sleep apnea has not been demonstrated so far. The aim of this study was to investigate the relationships between nasal resistance, nasal volumes and selected sleep parameters using nasal measurements performed in both seated and supine positions. We also investigated whether snoring patients in our clinical sample showed increased positional or decongestive nasal mucosal changes. MATERIAL AND METHODS: Forty-one snoring men on a waiting list for correction of nasal obstruction underwent polysomnography, anterior rhinomanometry and acoustic rhinometry. Nineteen non-snoring control subjects were also recruited. Nasal measurements were performed in a seated position, after lying down in a supine position and, after decongestion of nasal mucosa, in a seated position again. RESULTS: In the overall patient group, nasal volume at a distance 2-4 cm from the nares in the supine position correlated inversely with apnea-hypopnea index (AHI) (r = -0.32, p < 0.05) and oxygen desaturation index (ODI) (r = -0.49, p < 0.05). In the non-obese patients, total nasal resistance measured in a supine position correlated with AHI (r = 0.50, p < 0.05) and ODI (r = 0.58, p < 0.05) and supine nasal volumes were also inversely correlated with ODI. No significant correlations were found between baseline nasal measurements performed in a seated position and sleep parameters. Postural or decongestive changes in nasal measurements were not increased in snoring patients compared with control subjects. CONCLUSION: The relationship found between nasal measurements and sleep parameters suggests that nasal obstruction does augment airway collapse.

Effects of the nasal strip and dilator on nasal breathing--a study with healthy subjects.

OBJECTIVE: To investigate effects of the nose dilating devices on nasal anatomy and breathing in healthy subjects. MATERIALS AND METHODS: 27 healthy subjects were tested when using the Breathe Right nasal strip or the Nozovent dilator. Posterior rhinomanometry, acoustic rhinometry, and a subjective evaluation were used as methods. RESULTS: Both devices significantly increased the minimum cross-sectional area of the nasal valve and decreased nasal resistance. The Nozovent dilator proved to be significantly more effective in reducing nasal resistance than the Breathe Right nasal strip. CONCLUSIONS: Nose dilating devices, the Breathe Right nasal strip and the Nozovent dilator, can be used to reduce nasal resistance. More studies are needed to evaluate the usefulness of the devices for patients with chronic obstruction for any reason in the valve area.

Microbiology of chronic hyperplastic sinusitis.

BACKGROUND: Patients with chronic hyperplastic sinusitis (CHS) form a heterogeneous group with similar symptoms and similar treatment despite of possible different mechanisms behind the disease. In the present study we focused on the microbiological findings in CHS and compared these results to the patient history in order to find out a possible explanation for the aetiology and chronicity of CHS. METHODS: In 30 patients the sinus mucus was collected under endoscopic sinus surgery. Samples from 20 healthy volunteers were collected by nasal lavage. Eosinophil staining, bacterial culturing and fungal staining and culturing were done. Histological samples were obtained from all patients. RESULTS: Bacterial cultures were positive in 93% of the patients compared to 70% in controls. Staphylococcus aureus and coagulase-negative Staphylococci were the two most common findings in both groups. A total of seven patients had positive fungal finding. The only fungal genus found was Aspergillus. In the control group no samples were positive for fungi. CONCLUSIONS: Microbiological findings do not seem to explain the chronic course of CHS, but fungi may play some part in the pathophysiology of the disease. These results may be more a reflection of a change in the environment in the paranasal sinuses and a change in normal flora than the actual cause of CHS.

Rhinoplasty and nasal function in patients with cleft lips.

The purpose of this study was to find out whether harvesting septal grafts and simultaneously doing a septoplasty improves nasal function in patients with clefts who are having a rhinoplasty to correct the external deformity. We studied 14 patients with a unilateral cleft (UCL(P)) and four with bilateral clefts (BCLP). Nasal airflow resistance was measured with active rhinomanometry preoperatively and postoperatively. In nine of the 14 with UCL(P) and in all those with BCLP nasal resistance was normal or near normal both preoperatively and postoperatively. In five with UCL(P) postoperative nasal resistance was highly increased on the cleft side and in three of these patients nasal resistance decreased significantly but still remained abnormal. Only one patient subjectively complained of poor nasal airflow but all sought improvement of their nasal appearance. Harvesting of the graft and simultaneous straightening of the nasal septum during a rhinoplasty in patients with clefts neither improved, nor had a deleterious effect on, nasal function.

Smoking and improvement after nasal surgery in snoring men.

BACKGROUND: The aim of this study was to compare subgroups of smokers and nonsmokers undergoing nasal surgery and to evaluate improvement of nasal stuffiness, snoring, and symptoms related to sleep-disordered breathing after nasal surgery. METHODS: A cross-sectional prospective study was performed. The study population included 40 consecutive snoring men scheduled for surgical treatment of nasal obstruction. The patients completed nasal and sleep questionnaires, an Epworth sleepiness scale, and a visual analog scale of snoring intensity. They underwent polysomnography, anterior rhinomanometry, acoustic rhinometry, and cephalometric analysis. RESULTS: The smokers were younger, they snored longer and louder, and they had higher nasal resistance with decongestion and longer soft palates than the nonsmokers. Nasal stuffiness improved well after surgery, but a decrease of nasal resistance was not related to improvement of subjective snoring. CONCLUSION: Smoking was associated with increased snoring, nasal obstruction, and pharyngeal soft tissue volume. Expectations of patients may influence subjective assessment of snoring after nasal surgery.

Efficacy and safety of orbital decompression in treatment of thyroid-associated ophthalmopathy: long-term follow-up of 78 patients.

OBJECTIVE: To study the long-term results of decompression surgery in patients with thyroid-associated ophthalmopathy (TAO). DESIGN AND METHODS: Retrospective analysis and clinical re-examination of TAO patients with comparison to healthy controls in Helsinki University Central Hospital. PATIENTS: Seventy-eight patients who had undergone orbital decompression due to TAO by transantral or endonasal technique between the years 1985 and 2000 were invited for re-examination. For comparison, 79 healthy age- and sex-matched controls underwent a similar examination. RESULTS: In comparison to the patients' preoperative state, proptosis was reduced by 4.7 (2.6) mm (mean (SD)) in the right and 4.4 (2.9) mm in the left globe (P < 0.0001) but did not reach the level of the controls' globe (P < 0.0001). In the right and left eye of patients, visual acuity improved in 44-55%, remained stable in 27-36% and worsened in 18-20%, but remained significantly worse than in controls (P =0.02-0.001). Prevalence of diplopia was high at the re-examination (N = 39, 50%), but 54% of those patients considered it less difficult than before the surgery. Among patients and controls, maxillary sinusitis and facial neuralgias were equally common. Sensory disturbances were significantly more frequent in patients (P < 0.0001). In assessment of overall satisfaction with present eye status, the median of the visual analogue scale (VAS) was lower for the patients than the controls (P < 0.0001). The majority of the patients considered the operation very helpful regardless of the technique used. CONCLUSION: For patients with TOA, orbital decompression seems to be an effective and safe treatment.

Early treatment of perennial rhinitis with budesonide or cetirizine and its effect on long-term outcome.

BACKGROUND: Perennial rhinitis is a common disease that has many similarities with bronchial asthma. Early treatment with inhaled steroids has improved asthma symptoms, lung function, and bronchial hyperreactivity, but it has not been studied in perennial rhinitis. OBJECTIVE: The main objective was to determine whether early introduction of long-term daily intranasal steroid treatment would have a positive effect on the clinical course and outcome of perennial rhinitis compared with the effect of an antihistamine. A secondary objective was to compare the clinical efficacy of intranasal budesonide and oral cetirizine. METHODS: One hundred forty-three adult patients with newly detected perennial allergic or nonallergic eosinophilic rhinitis of 1 to 3 years' duration were randomized to receive budesonide dry powder, 400 microg (delivered dose of 280 microg) intranasally, or cetirizine, 10 mg orally, once daily for 1 year. At the end of the double-blind treatment period, medication was stopped, and the patients were followed for another year, during which time they could use 14-day courses of intranasal budesonide as needed to control rhinitis relapses. The main outcome measures were the time to first relapse and the number of relapses during the second year. Nasal symptom scores, nasal smear eosinophilia, and nasal peak expiratory flow were used to compare the clinical efficacy of the 2 treatments. RESULTS: During the randomized phase of the study, budesonide was significantly more effective than cetirizine in relieving nasal symptoms. Nasal peak expiratory flow improved significantly in budesonide-treated patients compared with in patients receiving cetirizine. After discontinuation of randomized treatment, 38% of budesonide-treated and 56% of cetirizine-treated patients had a relapse within the first month (P =.04). The median time to first relapse was longer in budesonide-treated patients than in cetirizine-treated patients (62 vs 20 days), although the difference was not significant. Fourteen-day courses of budesonide provided effective control of relapses; the mean number of relapses was 4.0 versus 5.4 in the groups previously treated with budesonide or cetirizine, respectively. Both treatments were well tolerated throughout the study. CONCLUSIONS: Budesonide is significantly more effective than cetirizine in controlling perennial rhinitis. After stopping treatment, budesonide better prevents relapses for 1 to 2 months compared with cetirizine. Periodic therapy with budesonide may be sufficient to control symptoms in most patients who have relapses.

Treatment of acute rhinosinusitis diagnosed by clinical criteria or ultrasound in primary care. A placebo-controlled randomised trial.

OBJECTIVES: To compare antibiotics and placebo in patients with clinically diagnosed acute maxillary sinusitis (AMS). To study whether sinus ultrasound examination would help to detect those patients who benefit from antibiotic therapy. DESIGN: A double-blind, randomised, placebo-controlled multicentre trial. SETTING: Nine primary care sites in Finland. SUBJECTS: 150 adult patients (mean age 39.7 years) with a clinical diagnosis of sinusitis. INTERVENTION: Antibiotics (amoxicillin 750 mg x 2, doxycycline 100 mg x 2 or penicillin V 1500 mg x 2) or placebo twice daily for 7 days; all patients were examined with sinus ultrasound after randomisation. MAIN OUTCOME MEASURE: Clinical success (patients' report of recovery) in telephone interview at 2 weeks. RESULTS: A total of 146 patients completed the 2-week follow-up. Patients receiving antibiotics achieved a slightly higher rate of clinical success than patients receiving placebo (80% vs 66%; p = 0.068). CONCLUSIONS: Antibiotics hasten symptom relief in AMS. Yet many patients recover in 2 weeks without antimicrobial treatment. Only half of patients with a clinical diagnosis of AMS have sinusitis in ultrasound examination.