New clinical diagnostic criteria for eosinophilic chronic rhinosinusitis

Objective

Chronic rhinosinusitis is a heterogeneous disease. Most cases of chronic rhinosinusitis with nasal polyp(s) (CRSwNP) in Western countries show a strong tendency for recurrence after surgery and pronounced eosinophil infiltration in the nasal polyps. The prevalence of CRSwNP with pronounced eosinophilic inflammation is steadily increasing and is classified as eosinophilic chronic rhinosinusitis (ECRS) in Japan. However, less than 50% of CRSwNP patients in Japan and East Asia show such features. Since the treatment strategy of ECRS differs from that of non-ECRS, clinical diagnostic criteria that distinguish ECRS from non-ECRS are needed.

Methods

A total of 124 patients with CRSwNP patients who underwent endonasal sinus surgery were classified as ECRS or non-ECRS according to their clinical characteristics and the clinical features of the two groups were compared. Computed tomography (CT) images of the sinuses were graded according to the Lund-Mackay system. We also graded CT images of the olfactory cleft. Blood examination findings, sinus CT images and asthma complications were analyzed by multivariate logistic regression. Clinical findings that were significantly different between ECRS and non-ECRS were analyzed by receiver operating characteristic curves to determine optimal predictors of ECRS.

Results

Blood eosinophilia, asthma complications and CT image scores were significantly different between ECRS and non-ECRS. In particular, increased blood eosinophil percentage and CT image scores for the posterior ethmoid and the olfactory cleft showed good accuracy as predictors of ECRS. A combination of the cut-off values for three predictors (increased blood eosinophil percentage above the normal range, olfactory cleft score ≥1 and posterior ethmoid score ≥1) indicated high accurate diagnostic ability (sensitivity, 84.6%; specificity, 92.3%).

Conclusion

A set of three clinical findings can differentiate ECRS from non-ECRS with high accuracy, even when these findings are assessed in regular outpatient clinics.     

Increased exhaled nitric oxide and its oxidation metabolism in eosinophilic chronic rhinosinusitis

Objective

Monitoring of fractional concentrations of exhaled nitric oxide (FeNO) has become a reliable marker of inflammation in human nose and paranasal sinuses. However, it is still unknown to what extent nasal NO levels contribute to the pathology of chronic rhinosinusitis (CRS). In the present study, we aimed to examine FeNO levels and the underlying mechanism of NO production and metabolism in patients with eosinophilic chronic rhinosinusitis (ECRS) and non-ECRS.

Methods

Thirty-three untreated ECRS patients, 16 non-ECRS patients, and 38 normal subjects were enrolled in this cross-sectional study of FeNO levels. Oral and nasal FeNO levels were measured before treatment using an electrochemical NO analyzer (NObreath^®) with a nose adaptor. The mRNA expression of three nitric oxide synthase (NOS) isoforms, interleukin-5 (IL-5), and transforming growth factor-beta (TGF-β) in the ethmoid sinus mucosa and nasal polyps were analyzed by real-time PCR. Immunohistological localization of inducible NOS (iNOS) and nitrotyrosine (NT), a marker for oxidized NO metabolites, was also examined.

Results

ECRS patients showed significantly higher oral FeNO levels compared to non-ECRS patients and normal subjects (mean values, 47.6, 13.5, and 15.3 ppb, respectively). Nasal FeNO levels of the non-ECRS patients (30.5 ppb) were significantly lower than those of the ECRS patients (53.9 ppb) and normal subjects (45.5 ppb). Positive correlations existed between the blood eosinophil percentage and FeNO levels in ECRS patients. Histologically, ECRS patients showed higher eosinophil accumulation in the ethmoid mucosa than non-ECRS patients (103.1 vs. 16.3 cells/HPF). Real-time PCR analysis showed significant upregulation of iNOS and IL-5 mRNA expression in the ethmoid mucosa of the ECRS patients compared to those of non-ECRS patients. Positive iNOS immunoreactivity was observed in ciliated epithelial cells, submucosal glands and associated inflammatory cells in both groups. NT immunoreactivity was detected in the epithelium and around inflammatory cells. Intense NT staining was co-localized with eosinophil accumulation and ECRS patients showed significantly higher rates of NT-positive cells than non-ECRS patients.

Conclusion

A combination of oral and nasal FeNO measurement is a valid marker for the classification and definition of different CRS subtypes in Japan. Higher levels of oral and nasal FeNO in ECRS patients may reflect the persistence of eosinophilic inflammation in sinus mucosa with concomitant iNOS upregulation and accompanying deposition of oxidized NO metabolites.     

Postoperative evaluation of olfactory dysfunction in eosinophilic chronic rhinosinusitis – comparison of histopathological and clinical findings

Abstract

Background: Olfactory dysfunction in eosinophilic chronic rhinosinusitis (ECRS) is poorly understood.

Objective: To compare olfactory mucosal injury due to eosinophil infiltration in ECRS with postoperative olfactory function.

Methods: Seventeen ECRS patients (ECRS group) and 18 bilateral rhinosinusitis (non-ECRS group) patients were compared. At 3 and 12 months post-endoscopic sinus surgery (ESS), all patients were evaluated for subjective symptoms (nasal obstruction, nasal discharge and olfactory dysfunction), endoscopic nasal findings, CT score and T&T olfactometer recognition threshold test. The eosinophil count, OMP-positive cells and epithelial erosion in olfactory mucosa collected during ESS were compared with the postoperative olfactory function.

Results: The non-ECRS group showed significant improvement in all clinical findings at 3 and 12 months, but the ECRS group showed worsening of the olfactory dysfunction symptoms and T&T olfactometer recognition threshold at 12 months because of recurrence of sinusitis. The groups differed significantly in the ΔT&T value (i.e. pre-ESS T&T recognition threshold – post-ESS T&T recognition threshold) at both 3 and 12 months, and the degree of olfactory improvement differed. Histologically, the ECRS group showed significantly more eosinophils, fewer OMP-positive cells and greater epithelial erosion than the non-ECRS group.

Conclusions: Eosinophilic inflammation was thought to cause olfactory mucosal injury/dysfunction.     

Expression and distribution of glucocorticoid receptor isoforms in eosinophilic chronic rhinosinusitis

Objective

Patients with eosinophilic chronic rhinosinusitis (ECRS) show a high percentage of eosinophilic infiltration in the paranasal sinus mucosa. It is well documented that topical steroids have a beneficial effect in ECRS with nasal polyposis. We investigated mucosal distribution and cellular localization of glucocorticoid receptor (GR) isoform expression in human paranasal sinuses in relation to the clinical characteristics of eosinophilic chronic rhinosinusitis (ECRS) patients.

Methods

Mucosal specimens were obtained from 20 sinusitis patients by endoscopic sinus surgery (ESS). Quantitative fluorescence immunohistochemical analysis was employed to examine the degree of glucocorticoid receptor (GR) isoform expression in sinus mucosa specimens. An RT-PCR procedure was performed to determine the relative quantities of mRNA for the human GRα and GRβ genes.

Results

Patients in the ECRS group showed significant increases in peripheral blood eosinophils as compared to the non-ECRS group (16.98% vs. 2.31%). Positive immunoreactivity of GRβ expression was predominantly found to be positive in inflammatory cells. The absolute number of GRβ-positive cells in the ECRS group was increased in comparison with that in the non-ECRS group. The difference was statistically significant both in the maxillary (179.7 cells/mm² vs. 82.5 cells/mm²) and ethmoid sinus (302.0 cells/mm² vs. 61.5 cells/mm²) mucosa. The GRβ/GRα cell ratio in the ECRS group was elevated when compared with that in the non-ECRS group both in the maxillary and the ethmoid sinus mucosa, with the latter difference being significant.

Conclusions

The presence of high peripheral eosinophilia indicates a high likelihood of ECRS disease. Our results support the association of GRβ expression with ECRS. The expression of GRβ immunoreactivity, an endogenous inhibitor of steroid action previously associated with steroid insensitivity, may be one of major contributing factors in ECRS.     

Delayed type of allergic skin reaction to Candida albicans in eosinophilic rhinosinusitis cases

Objective

Eosinophilic chronic rhinosinusitis (ECRS) is frequently complicated by asthma, and recognized as refractory and persistent rhinosinusitis. However, the detailed pathophysiology of ECRS has not been elucidated yet. In this study, we investigated the association between recurrent ECRS and intradermal testing to multi-antigens including Candida albicans.

Olfactory changes after endoscopic sinus surgery in patients with chronic rhinosinusitis

Objective

To address the controversy over whether olfactory function is improved or not after endoscopic sinus surgery (ESS) in patients with eosinophilic (ECRS) and non-eosinophilic chronic rhinosinusitis (non-ECRS).

Methods

Between June 2006 and March 2012, 89 adult patients with CRS underwent ESS at Hyogo College of Medicine. There were 55 men and 34 women with a mean age of 53 years old, ranging from 23 to 79 years. The average follow-up period was 10.7 months (3–24) after ESS. Peripheral blood examination, sinonasal CT imaging, and four kinds of olfaction tests [self-administered olfaction test (SAOQ), visual analog scale (VAS), T&T recognition threshold tests (T&T) and intravenous olfaction test using prosultiamine] were performed. We diagnosed ECRS when (i) symptoms of nasal congestion and olfactory disorder, (ii) bilateral chronic rhinosinusitis with nasal polyps (CRSwNPs), (iii) peripheral blood eosinophilia (>7.0%), and (iv) ethmoid sinus dominant opacification in preoperative CT findings (i.e. ethmoid sinuses (E) were more bilaterally occupied than those of maxillary sinuses (M), E/M ≥ 1), were completely fulfilled. We divided the patients into two groups of ECRS (group A) and non-ECRS (group B). Olfaction tests before operation, and at the 3rd, 6th, 12th, and 24th month postoperation were analyzed. The severity and therapeutic evaluation of olfaction were based on criteria of T&T recognition thresholds.

Results

The mean SAOQ and VAS scores showed significant improvement within 6 months after ESS in both group A and group B. In total, the improvement rates were 52.0% (26/50) at 3 months, 58.5% (24/41) at 6 months, 40.5% (15/37) at 12 months, and 41.2% (7/17) at 24 months. The significant improvement of T&T recognition thresholds in group B was maintained for 24 months, whereas those in group A, showing transient improvement, deteriorated after 12 months or more. A significant difference in postoperative T&T recognition between groups A and B was found at the 12th postoperative month. In both A and B, 84% of patients had a response to prosultiamine (positive group) in the preoperative stage. T&T thresholds in the positive group were significantly better that those in the negative groups in the postoperative stage.

Conclusion

Olfactory disorders due to ECRS showed transient improvement that deteriorated as time passed after surgery. The olfaction in the non-ECRS patients recovered comparatively well. Postoperative olfactory results were unfavorable in patients without a preoperative reaction to prosultiamine.     

Searching for the cheese: does ethmoid pneumatization affect the location of the anterior ethmoid artery?

Endoscopic sinus surgery is a widely used technique in otolaryngologic practice. To avoid complications, the locations of important anatomical structures, such as the anterior ethmoid artery (AEA), should be determined preoperatively. We want to evaluate the effect of ethmoid cavity pneumatization on the location of the AEA and to determine consistent landmark(s) for locating the AEA. 524 consecutive patients undergoing sinus CT scans between February and October 2012 were reviewed retrospectively. After the exclusion criteria were applied, 150 CT scans (300 sides) were selected for the study. A statistically significant positive correlation was found between ethmoid pneumatization and the distance of the AEA to the attachment of the inferior turbinate to the lateral nasal wall (Spearman’s rho = 0.305; p < 0.001). Likewise, a statistically significant positive correlation was found between ethmoid pneumatization and the distance between the AEA and the frontonasal junction (Spearman’s rho = 0.219; p < 0.001). We found that the artery was located mostly between the second and third lamellae [n 211 (71 %) cases]. There was no statistically significant correlation between ethmoid pneumatization and AEA location in terms of the lamellae. Increased ethmoid volume increases the distance of the AEA from the frontonasal junction and the lateral attachment of the inferior turbinate. However, increased pneumatization of the ethmoid cavity did not affect AEA localization in terms of the lamellae. Based on our findings, we suggest that using the lamellae to locate the AEA is reliable.     

PORP vs. TORP: a meta-analysis

After the surgical procedure of ossicular chain reconstruction, the effectiveness and/or stability of partial ossicular replacement prosthesis (PORP) or total ossicular replacement prosthesis (TORP) were systematically compared and evaluated using meta-analysis. A total of 40 eligible investigations with 4,311 subjects were included in our study. There was a significant difference in the effectiveness of the reconstruction of the ossicular chain between PORP and TORP; the data showed a combined risk ratio (RR) of 1.28 (95 % CI 1.17–1.41, p < 0.00001), but no notable difference was obtained in staged procedures subgroup and cholesteatoma subgroup, with a combined RR of 1.13 (95 % CI 0.60–2.11, p = 0.70) in staged procedures subgroup and RR of 2.60 (95 % CI 0.20–36.21, p = 0.59 in cholesteatoma subgroup). There was a statistically significant difference in the stability of the prostheses in long-term follow-up, with a combined RR of 0.37 (95 % CI 0.16–0.85, p = 0.02), but no significant difference was observed in the total sample, with a combined RR of 0.64 (95 % CI 0.40–1.03, p = 0.06). Our overall results suggest that the effectiveness of PORP was higher than TORP, except within staged procedures subgroup and cholesteatoma subgroup. In addition, the stability of PORP was significantly superior to TORP in long-term follow-ups, but no significant effect was detected in the general study.     

Osteitis in chronic rhinosinusitis with nasal polyps: a comparative study between primary and recurrent cases

Reports in rhinology suggest that operated cases of chronic hypertrophic rhinitis with nasal polyps are more prone to further recurrence. This study was designed to find out if recurrence rate after surgery is related to a possible increase in the incidence and degree of osteitis. A prospective study of 82 patients with nasal polyps was carried out. They were divided into two groups: group A 50 patients, undergoing FESS for the first time, group B 32 patients, undergoing revision surgery. Histopathological examination was performed for specimens taken from the bony septa of the ethmoid with the overlying mucosa. Bony changes were seen in only 30% of the patients in group A, compared to 87.5% in group B; this difference was statistically highly significant (p = 0.001). Failure was seen in five patients (10%) in group A, 26.6% had osteitis. In contrast, failure was seen in 53% of group B, and constituted 60.7% of patients with osteitis in this group. Surgery plays a major role in increasing the incidence of osteitis in patients with nasal polyps. The increase recurrence rate in revision cases is not only related to osteitis. There are other factors than osteitis which needs further studies.     

The relationship between pneumatized middle turbinate and the anterior ethmoid roof dimensions: a radiologic study

The development of pneumatized middle turbinate may affect anterior ethmoid roof formation. The aim of this study was to investigate the relationship between the pneumatized middle turbinate and the dimensions of the anterior skull base structures using computed tomography scans. The coronal reconstructed images of the computed tomography scans were evaluated retrospectively. The lateral and medial ethmoid roof points, the width of the cribriform plate (CP), and the anterior ethmoid roof were identified at the first coronal cut, which was determined by the infraorbital nerve. The pneumatized middle turbinates were measured on the axial, vertical, and sagittal planes. The images of 101 patients were evaluated. The mean axial diameters of the pneumatized middle turbinate on the right and left sides were between 6.93 and 4.95 mm, respectively. The correlation between the axial diameters of the pneumatized middle turbinate and the width of the anterior ethmoid roof (termed AER width) was significant for both sides and gender (p < 0.05). There was a higher correlation on the right side where the pneumatized middle turbinate was observed more frequently (r = 0.357). The relationship between CP width and the diameters of the pneumatized middle turbinate was not significant (p > 0.05) for both sides. Iatrogenic lesions of the skull base occur predominantly in the lateral lamella of the CP. The risk of this complication may decrease with increasing of the AER width. Pneumatized middle turbinate may cause an increase in the width of the anterior ethmoid roof and provide more reliable endoscopic intervention of the anterior skull base and frontal sinus.     

患者术前临床特征对嗜酸性粒细胞型慢性鼻窦炎伴鼻息肉的预测价值

目的 探讨患者的术前临床特征对嗜酸性粒细胞型慢性鼻窦炎伴鼻息肉(ECRSwNP)的预测价值,并构建用于临床实践的诺模图。方法 选取2019年9月—2020年9月就诊于新乡医学院第一附属医院并行功能性鼻内镜手术治疗的慢性鼻窦炎伴鼻息肉(CRSwNP)患者97例,根据术后病理结果嗜酸性粒细胞(EOS)浸润程度将其分为ECRSwNP组和非嗜酸性粒细胞型慢性鼻窦炎伴鼻息肉(nonECRSwNP)组,收集并比较两组患者的临床特征资料,采用单因素及多因素二元Logistic回归分析筛选对ECRSwNP有预测价值的术前特征资料,并构建用于临床实践的诺模图。采用SPSS 26.0和R语言软件4.1.2对数据进行分析。结果 两组患者在是否合并哮喘史、外周血嗜酸性粒细胞(EOS)计数、外周血嗜碱性粒细胞(Baso)计数、日本难治性嗜酸性慢性鼻窦炎流行病学调查(JESREC)评分、上颌窦评分、前后组筛窦评分、CT总分、E/M(筛窦与上颌窦的Lund-Mackay评分比值)上差异具有统计学意义(P<0.05)。单因素及多因素二元Logistic回归分析并构建的诺模图显示,基于哮喘史、外周血EOS、外周血...     

Clinical effects of submucosal middle turbinectomy for eosinophilic chronic rhinosinusitis

Objective

The preservation or resection of the middle turbinate (MT) during endoscopic sinus surgery (ESS) currently remains a matter of debate. The present study aimed to investigate the effects of submucosal middle turbinectomy (SMT) in ESS for eosinophilic chronic rhinosinusitis (ECRS).

Risk factors for olfactory dysfunction in chronic rhinosinusitis

Objective

Although risk factors for olfactory dysfunction in patients with chronic rhinosinusitis (CRS) have been examined, most studies did not distinguish between classified eosinophilic chronic rhinosinusitis (ECRS) and noneosinophilic chronic rhinosinusitis (NECRS). The incidence of eosinophilic disease in Japan differs from that in the West. Thus, when olfaction in CRS is investigated, ECRS and NECRS should be examined separately. In the present study, we examined the clinical characteristics associated with olfactory dysfunction in Japanese patients with ECRS and NECRS enrolled in a large multicenter, prospective cohort study.

Methods

Olfactory examination results, demographic data, clinical factors, and comorbidity data were analyzed for 418 patients with CRS at 3 tertiary care centers. We used T&T olfactometry, intravenous olfactory test (the Alinamin test) and Likert scale to assess subjects’ olfactory function. Data were analyzed with univariate and multivariate analyses.

Results

Olfactory dysfunction was more severe and more prevalent in ECRS than in NECRS. We found that olfactory cleft polyps (odds ratio [OR], 3.24), ethmoid opacification (OR, 2.64), asthma (OR, 2.29), current smoking (OR, 1.74) and age ≥50 years (OR, 1.66) were associated with olfactory dysfunction in CRS. Ethmoid opacification (OR, 3.09) and olfactory cleft polyps (OR, 3.05) were associated with olfactory dysfunction in NECRS. Olfactory cleft polyps (OR, 3.98), current smoking (OR, 2.67), IgE ≥400 IU/ml (OR, 2.65), ethmoid opacification (OR, 2.51), and asthma (OR, 2.34) were associated with olfactory dysfunction in ECRS.

Conclusions

Olfactory dysfunction was more severe and prevalent in ECRS than in NECRS. Physician should pay attention to these clinical findings to diagnose olfactory dysfunction, especially in ECRS, and should provide appropriate explanation, guidance, and care. In addition, smokers should be advised to stop smoking to help prevent olfactory dysfunction.     

Comparison of olfactory and taste functions between eosinophilic and non-eosinophilic chronic rhinosinusitis

ObjectiveMost patients with chronic rhinosinusitis (CRS) complain of olfactory and/or taste dysfunctions. However, olfactory and taste dysfunctions depending on the subtype of CRS, classified as eosinophilic CRS (ECRS) and non-eosinophilic CRS (NCRS), have not been clearly reported. Therefore, the purpose of this study was to investigate the clinical features in olfactory and taste functions according to the subtype classified as ECRS and NCRS.MethodsWe retrospectively analyzed the electronic medical records of patients who underwent endoscopic sinus surgery and were diagnosed with CRS. The patients were divided into ECRS and NCRS groups, according to their Japanese Epidemiological Survey of Refractory Eosinophilic Chronic Rhinosinusitis (JESREC) scores. We analyzed demographic characteristics, Sino-Nasal Outcome Test findings, Lund-Mackay score, and the results of previously-validated tests, including the Korean Version of Sniffin' Stick test and chemical gustatory function test.ResultsPatients with ECRS and NCRS had decreased olfactory and taste functions compared to the control group. In particular, the olfactory score of ECRS patients was lower than that of NCRS patients (18.1 ± 9.5 vs 23.7 ± 8.5, respectively, p <0.001). On the other hand, taste scores of ECRS patients were not statistically different compared to NCRS patients (19.1 ± 4.7 vs. 18.3 ± 4.7, respectively, p = 0.166). Olfactory score decreased with increase in JESREC score (r=-0.203, p = 0.002), but it had no correlation with taste score (r = 0.072, p = 0.276).ConclusionWe found a difference in olfactory function but no difference in taste function between patients in ECRS and NCRS groups. These results may provide valuable clinical features in terms of olfactory and taste functions according to the subtypes of CRS.     

Multiple chemical sensitivity worsens quality of life and cognitive and sensorial features of sense of smell

Multiple chemical sensitivity (MCS) is characterized by a loss of tolerance to a variety of environmental chemicals. Multiple chemical sensitivity is frequently triggered by exposure to chemical agents, especially insecticides. The aim of the study was to measure the sense of smell and quality of life in patients with MCS compared to the control group. We studied the sense of smell, both sensitive and sensorial characteristics, in female patients with MCS (n = 58, mean 50.5 ± 8.5 years) and healthy female volunteers without rhinosinusal pathologies (n = 60, mean age 46 ± 10.2 years). Olfactometry (Barcelona Smell Test 24/BAST-24), sinonasal symptoms (visual analogue scale/VAS 0–100 mm), and quality of life (Quick Environmental Exposure and Sensitivity Inventory/QEESI) were assessed. Multiple chemical sensitivity patients showed a significant impairment in smell identification (19 ± 12 %; p > 0.05) and forced choice (62 ± 18 %; p > 0.05), but not in smell detection (96 ± 4 %) compared to the control group. Multiple chemical sensitivity patients reported more odours as being intense and irritating and less fresh and pleasant when compared with the control group. Patients scored a high level (40–100) on QEESI questionnaire (symptom severity, chemical intolerances, other intolerances, life impact). In MCS patients, total symptom intensity (VAS/0–700 mm) score was 202 ± 135, while disease severity score was 80 ± 23. The most frequent symptoms were itching and posterior rhinorrhea. Multiple chemical sensitivity patients have an impairment in smell cognitive abilities (odour identification and forced choice, but not for detection) with increased smell hypersensitivity and poor quality of life.     

Association of metabolic factors with high-sensitivity C-reactive protein in patients with sleep-disordered breathing

Sleep-disordered breathing (SDB) such as snoring or obstructive sleep apnea and metabolic syndrome are both related to cardiovascular diseases. Being a surrogate marker of high risk for cardiovascular disorder, the high-sensitivity C-reactive protein (hs-CRP) level is thought to be elevated in patients with both SDB and metabolic syndrome. To understand better the development of cardiovascular disease in patients with SDB, we examined the association of metabolic variables with hs-CRP levels in adult patients with symptoms of SDB and without any previous treatment, who were selected to participate in the study. Metabolic parameters including fasting blood glucose, lipid profile and hs-CRP were measured following an overnight polysomnography. Laboratory and polysomnographic data were analyzed to identify variables related to high hs-CRP levels. A total of 309 patients with SDB participated in this study. Of these, 139 presented with hs-CRP <1 mg/L and 52 presented with hs-CRP >3 mg/L. Patients with high hs-CRP showed a higher apnea-hypopnea index (AHI), body mass index (BMI), fasting glucose, and triglyceride level, and a lower mean and minimal oxygen saturation and HDL-cholesterol level. However, ordinal regression analysis demonstrated that only a higher BMI and fasting glucose level and a lower HDL-cholesterol level were independent risk factors for cardiovascular diseases (OR = 1.076, 95 % CI = 1.009–1.147, p = 0.005; OR = 1.011, 95 % CI = 1.004–1.019, p = 0.008; OR = 0.966, 95 % CI = 0.947–0.984, p < 0.001, respectively). The results showed that elevated hs-CRP is common in patients with SDB but is not independently associated with the severity of SDB. Metabolic factors such as a higher BMI and fasting blood glucose and a lower HDL-cholesterol level were more strongly associated with elevated hs-CRP rather than with SDB severity, suggesting that metabolic parameters are important contributors to cardiovascular diseases and should be corrected in patients with SDB.     

Reduced impact of nodal metastases as a prognostic factor for tonsil cancer in the HPV era

Metastatic lymph nodes (LN) are an adverse prognostic factor in head and neck squamous cell carcinoma (SCC). In this study, we tested the hypothesis that nodal metastases have reduced impact on survival in tonsil cancer in the HPV-predominant era. Incidence and mortality data of tonsil and oral cavity SCC between 1988 and 2007 were obtained from the SEER database. Based on published literature, we considered cases of tonsil cancer from 1988 to 1997 as the pre-HPV cohort (N = 752), and 1998–2007 as the HPV-predominant cohort (N = 2,755). Comparing the two cohorts, Kaplan–Meier 5-year overall survival (OS) for tonsil SCC improved from 54.0 to 74.3 % (p < 0.0001), and cancer-specific survival (CSS) improved from 66.0 to 82.9 % (p < 0.0001). Stratifying by LN involvement showed improved OS in the HPV-predominant cohort with one (63.6 vs. 79.7 %, p < 0.0001), two to three (54.2 vs. 75.9 %, p < 0.0001), four to eight (40.3 vs. 68.9 %, p < 0.0001), and greater than eight positive nodes (25.5 vs. 41.9 %, p < 0.0001). While metastatic LNs still negatively affect prognosis, their impact on OPC survival has diminished in the HPV-predominant era. This finding provides a rationale for additional studies of the prognostic significance of LN metastases in OPC cohorts of defined HPV status, and supports the concept that HPV-related OPC is a disease distinct from “classical” OPC, with unique prognostic features.     

Comparison of three techniques in adult tonsillectomy

This study aimed at investigating the thermal welding (TW), classic dissection (CD) and bipolar cautery dissection (BCD) tonsillectomy in adults. 120 adults with chronic tonsillitis, who were scheduled for elective tonsillectomy between January 2009 and April 2012, were randomized to tonsillectomy with the TW, CD and BCD methods. Operation time, intraoperative blood loss, post-operative haemorrhage rate and especially post-operative pain were evaluated. The difference between operative time of the TW and BCD groups against CD group was statistically significant (p < 0.05). The difference between intraoperative blood loss of the TW and BCD groups against CD group was statistically significant (p < 0.05). No significant difference was found in the incidence of post-tonsillectomy haemorrhage between the three groups (p > 0.05). The difference between post-operative pain score between CD and TW was not statistically significant (p > 0.05). The difference between post-operative pain score of the two groups against BCD group was statistically significant (p < 0.05). TW technique is a relatively safe and reliable method with significantly less post-operative morbidity than CD and BCD tonsillectomy. When we compared TW with the CD and BCD tonsillectomy, we found significant reduction in the surgical time and the intraoperative blood loss without any increase in the post-operative pain.     

The European positional paper on rhinosinusitis and nasal polyps: has the introduction of guidance on the management of sinus disease affected uptake of surgery and acute admissions for sinusitis?

Rhinosinusitis is a common condition with adults experiencing 2–5 episodes per year. The European Positional Paper on Rhinosinusitis and Nasal Polyps (EP3OS) published in 2005 and updated in 2007 provided evidence-based guidelines on the management of sinus disease promoting a conservative approach to treatment. This study examines the effect of EP3OS on sinus surgery uptake and acute admissions for sinusitis in England and Wales. A retrospective study using the national electronic health databases of England (Hospital Episodes Statistics, HES online) and Wales (Patient Episodes Database of Wales, PEDW) was undertaken from 2000 to 2010 using the OPCS-4 codes E12–E17 (sinus surgery) and ICD10 code J01 (acute admission for sinusitis). Data were analysed for effect following the introduction of the EP3OS in 2005 using linear regression and Chi squared analysis. 116,370 sinus procedures and 10,916 acute admissions for sinusitis were made during the study period. No significant decrease in sinus surgery procedures occurred following the introduction of the EP3OS as may have been expected (p > 0.05), although subgroup analysis suggested a significant increase in Wales (p < 0.05). In addition, significant increases in acute admissions for sinusitis were observed following the introduction of EP3OS (p < 0.05). However, subgroup analysis suggested this was not the case in Wales (p > 0.05). The EP3OS appears to have had little impact on the rates of sinus surgery but more conservative approaches to managing of sinus disease may have led to an increase in acute admissions. Further research is required to investigate whether changes in practice were adopted.     

Mental health and quality of life in patients with chronic otitis media

The present study focused on the comparison of mental health and quality of life (QoL) between chronic otitis media (COM) patients and the hearing population. The patients with chronic otitis media and healthy control group were enrolled in the study. The duration and severity of the auditory impairment were recorded. In addition to hearing loss (HL), the findings of each patient’s other ear disorders (ear discharge and tinnitus) were also recorded. In both the groups, psychological symptom profile and health-related QoL were evaluated and compared using a sociodemographic questionnaire, the Symptom Check List 90-Revised Form (SCL-90-R), and the Short Form-36 (SF-36). According to SCL-90-R, somatization (p < 0.001), interpersonal sensitivity (p < 0.001), depression (p < 0.001), phobic anxiety (p < 0.001), and other subscores, and also global severity index score (p < 0.001) were significantly high in patient group when compared to the control group. The patients with COM reported significantly lower levels of QoL in terms of physical role difficulty (p < 0.001), general health perception (p < 0.004), social functioning (p < 0.001), and mental health (p < 0.017) than those of control subjects. Our results indicated that COM patients with mild or moderate HL have poorer life quality and higher psychological problems. Psychological well being should be also considered in assessment of COM patients in addition to the clinical evaluation and audiological tests.