Angelika May

Immunoglobulin deficiency and determination of pneumococcal antibody titers in patients with therapy-refractory recurrent rhinosinusitis

Abstract We examined 245 patients with chronic rhinosinusitis not responding to prolonged antibiotic treatment and tested each patient for humoral antibody deficiencies. Low immunoglobulin levels were found in 22 patients. Five of them had defects of two or more immunoglobulin isotypes that were diagnosed as common variable immunodeficiency (CVI). Seventeen had an IgG-subclass deficiency. Before and after immunization with pneumococcal vaccine, serotype-specific pneumococcal antibody levels were determined to further evaluate the relevance of the underlying deficiency. Significantly reduced antibody titers of pneumococcal serotypes were found in CVI patients (n = 5), while immunization of 17 patients with IgG-subclass deficiency gave different results. Three of the 17 patients responded poorly to pneumococcal immunization and were prone to a polysaccharide specific immunodeficiency. Patients with CVI or IgG-subclass deficiency failing to produce protective antibody levels in more than five serotypes were chosen for antibiotic and/or immunoglobulin substitution therapy. Since recurrent sinusitis in these patients did not resolve with adequate conservative therapy, endonasal microsurgery was then performed and was seen to be a valuable therapeutic option. Our study suggests that an IgG-subclass deficiency may be the first sign of a basic immunological change, resulting in persisting sinus infections.

Labyrinth anesthesia: A forgotten but practical treatment option in Ménière's disease

The aim of this study was to determine the efficiency of labyrinth anesthesia – the intratympanic instillation of lidocaine – in the treatment of Ménière’s disease and to recall a forgotten method. Twenty-four patients (15 male, 9 female), aged from 19.7 to 80.6 years (mean: 47.8 years) with the clinical diagnosis of unilateral Ménière’s disease who underwent labyrinth anesthesia in our department were included in this retrospective study. After local anesthesia of the tympanic membrane, a solution of 4% lidocaine and furfuryladenine (Kinetin) was instilled into the tympanic cavity. Patient records, a questionnaire and a physical examination were used to evaluate vertigo control, hearing loss, tinnitus, and quality of life according to the AAO-HNS criteria before and after surgery. Postoperatively, 87.5% of patients reported at least a noticeable decrease of vestibular symptoms, 66.7% of these patients were free of attacks for an average of 26.5 months. Postoperative hearing was the same or even improved in 87.5% of our patients. Tinnitus was not affected in any individual. Based on the findings presented herein, we consider labyrinth anesthesia a practicable and, due to its safety, highly recommendable therapeutic option for patients suffering from Ménière’s disease.

Familienuntersuchung bei Patienten mit ASS-Intoleranz und Rhinosinusitis

ZusammenfassungHintergrund und Fragestellung. Eine Aspirin-(ASS-)Intoleranz kommt bei Asthmatikern in 8–20% und bei Patienten mit Nasenpolypen in 6–15% der Fälle vor. Diese Assoziation und Berichte über das Betroffensein von Familienmitgliedern lassen eine genetische Disposition vermuten. Ziel unserer Studie war es, durch eine Familienuntersuchung Hinweise auf Erblichkeit zu erhalten.Material und Methode. 33 unausgelesene Patienten mit ASS-Intoleranz aus 28 Familien nahmen an der Studie teil. Eltern, Geschwister und Kinder wurden nach Krankheiten des Respirationstraktes sowie Allergien gefragt. Durch Pricktests und IgE-Bestimmung wurde eine Typ-I-Allergie abgeklärt mittels Provokationstests wurde eine ASS-Intoleranz verifiziert. Zur Kontrolle wurden Personen ausgewählt, die in der HNO-Klinik wegen einer anderen Erkrankung behandelt wurden (n=52). Das Manifestationsalter für eine ASS-Intoleranz mit Rhinosinusitis liegt bei unseren Probanden zwischen dem 20. bis 55. Lebensjahr.Ergebnisse. ASS-Intoleranz wurde bei Eltern, Geschwistern und Kindern ASS-intoleranter Probanden gefunden, und Kinder der ASS-Probanden hatten signifikant häufiger Nasenpolypen bzw. Rhinosinusitis als Kinder von Kontrollpersonen.Schlussfolgerung. Bei betroffenen Patienten sollte durch eine gezielte Familienanamnese die Risikogruppe eingegrenzt werden und die entsprechende Diagnostik und Prävention vorrangig sein.AbstractBackground and objective. The high prevalence of aspirin intolerance in asthmatics and patients with nasal polyps as well as reports of familial clustering suggest a genetic disposition of this disease. Our study aimed at obtaining further evidence of hereditary factors in this disease. We included 33 unselected patients from 28 families with aspirin intolerance and rhinosinusitis in this study. Controls were recruited from individuals treated in our ENT clinic for diseases other than aspirin intolerance (n=52).Patients and methods. A questionnaire focused on family histories as well as reports on diseases of the upper respiratory tract or allergies. ASS intolerance was verified either by bronchial or nasal provocation tests.Results. We found cases of aspirin intolerance among parents, siblings, and children of ASS intolerant probands. The children of probands had nasal polyps and rhinosinusitis more often than the children of controls.Conclusions. We propose that ASS intolerance with nasal polyps and asthma represents a complex phenotype, with genetic and environmental factors contributing to its manifestation.

Eosinophilic cationic protein as a marker of nasal inflammation in patients with cystic fibrosis.

Objectives: Evaluation was made of eosinophilic cationic protein (ECP) in nasal secretion for measuring the degree of nasal inflammation and monitoring response to therapy in cystic fibrosis (CF) patients with chronic rhinosinusitis. Symptoms and findings in regard to ECP levels before and after treatment were described.

Bone replacement by ionomer cement in osteoplastic frontal sinus operations

Ionomer-based cement is a new bone replacement material. After promising results in middle ear and skull base surgery, we started to use Ionocap as an alternative to metal osteosynthesis material. Between 1992 and 1995, 20 men and 9 women were treated with an osteoplastic approach for complicated frontal sinus diseases at Johann Wolfgang Goethe University. Ionocap as bonding material for bone was used in 22 of the patients. The indications for osteoplastic surgery were recurrent frontal rhinosinusitis, mucoceles, skull base fractures, osteomas and meningocele. The surgical procedure using bone cement was found to be much easier and shorter, the functional stability achieved was at least equal and the cosmetic outcome was clearly superior when compared to cases done with metal osteosynthesis. No rejection of the material or osteonecrosis was observed. In no case was the cement placed in direct contact to dura mater. Our findings show that ionomer-based cement can be recommened in osteoplastic frontal sinus surgery, but Ionocap should only be used strictly according to the guidelines of the supplier.

Indication and technique of transnasal microscopic orbital decompression for endocrine ophthalmopathy.

If endocrine ophthalmopathy progresses despite conservative treatment then indications for surgical decompression are: loss of visual acuity, increasing strabism, and severe keratopathy. Endonasal microsurgery ensures a binocular view onto the intranasal landmarks of the orbital walls and allows simultaneous decompression of the medial and inferior wall as well as a good relief of pressure at the orbital apex. Surgical decompressions were performed on 29 orbits in 19 patients, 16 by using the endonasal microsurgical, 3 via external approach. The microscopic approach was entirely comparable with regard to the reduction of proptosis with a mean improvement of 4.2 mm against a mean of 4.7 mm by external approach and a mean 0.2 of better visual acuity in both procedures. The microsurgical technique is considered superior to an external approach avoiding external scars, neural pain, and reportedly less diplopia. The healing phase and the hospitalization time are shorter.

Mikrochirurgisch bedeutsame Varianten der Nasennebenhöhlen im Computertomogramm

Die Weiterentwicklung der endonasalen Mikrochirurgie und die Hinwendung zur minimal invasiven Chirurgie wird durch die exzellente Darstellung der lateralen Nasenwand und NasennebenhOhlen im CT unterstUtzt. Von 1990 bis 1994 wurden 547 Patienten wegen chronischer Rhinosinusitis und akuter therapieresistenter Rhinosinusitis an unserer Klinik behandelt und eine hochauflOsende CT in zwei Ebenen durchgefUhrt. Eine der hAufigsten Varianten ist die Septumdeviation. Diese trat in 48% auf. Eine Concha bullosa ist eine belUftete mittlere Muschel, die bei 30% der Patienten vorlag. Sie geht mit einer guten Pneumatisation des Siebbeins einher und nimmt eine Sonderstellung ein. Bei 23% aller Patienten fanden wir eine Bulla frontalis, aber bei 63% der Patienten mit komplizierter persistierender Rhinosinusitis fanden wir eine prominente Bulla frontalis. Hallersche Zellen, zumeist vom vorderen Siebbein ausgehende Zellen, die sich unter dem Orbitadach in die KieferhOhle vorschieben, fanden wir in 7%. Durch die Einengung des KieferhOhlenostiums prAdisponieren sie zu chronischen EntzUndungen. Hallersche Zellen sind aber auch intraoperativ zu beachten, da sie den Operateur falsch leiten kOnnen. Pneumatisationsvarianten wie Onodi-Zellen oder ausgedehnte Pneumatisation im Keilbein mit Vorspringen der Arteria carotis sind deshalb von Bedeutung, weil hier bei iatrogener Manipulation fatale Komplikationen hervorgerufen werden kOnnen. Die Kenntnis der speziellen Anatomie der NasennebenhOhlen und ihrer Varianten sowie das Erkennen dieser anatomischen Strukturen im CT sind von fundamentaler Bedeutung fUr einen erfolgreichen und risikoarmen rhinochirurgischen Eingriff.

Ancillary procedures in microscopic endonasal orbital decompression for thyroid-associated ophthalmopathy

In 35 patients with thyroid-associated orbitopathy, nonresponsive to conservative treatment, an endonasal microscopic approach with bimural osteotomy was performed for decompression in two ways. While in group A the periorbita was resected, and fat septa were cut, in group B periorbital strips were left, and fat septa were respected. In accordance with other authors, resection of the periorbital and cutting fat septa will improve vision and proptosis, but in up to 30% of the patients de novo diplopia occurs. Our data favor the assumption that a more conservative endonasal microscopic decompression of the orbita leaving periorbital strips and fat septa achieves similar good results for reduction of proptosis and visual gain but creates less often de novo diplopia in primary gaze. Based on our experience, rehabilitation for thyroid-associated arbitopathy comprises as a first step orbital endonasal decompression with cooperation of the ophthalmologist, then if necessary as a second step strabismus surgery, and thirdly eyelid repair for scleral show.

Endoillumination-Guided Intranasal Microscopic Dacryocystorhinostomy for Difficult Cases

Purpose: This prospective study explores the efficacy of a combined approach by intranasal microsurgical dacryocystorhinostomy and fiberglass endoillumination of the tear passage for difficult cases of lacrimal sac or nasolacrimal duct obstruction. Methods: Microscopic dacryocystorhinostomy was performed in 67 patients with lacrimal obstruction and for revision of external dacryocystorhinostomy. Improved endonasal visualization by microscope and combination with endoillumination of the tear passage allows instant identification and opening of the lacrimal nasal sac without skin incision. Silicon tubes were used for bicanalicular intubation. The patients were prospectively observed for at least 1 year. Results: The operation was well tolerated by all patients. In 95%, a persistently open tear passage was successfully established. No serious complications were observed. Conclusion: Endoillumination of the lacrimal sac is useful for locating the sac precisely and refining the endonasal operation technique.

Chloridleitfähigkeit nasaler Fibroblasten von Polyposis-Patienten mit zystischer Fibrose und Patienten ohne zystische Fibrose Relevanz für den HNO-Arzt

ZusammenfassungZum komplexen Krankheitsbild der zystischen Fibrose (CF) gehören überdurchschnittlich häufig auftretende Rhinosinusitiden und Nasenpolypenbildung. Der Basisdefekt dieser Erkrankung ist im cAMP-abhängigen Chloridkanal lokalisiert. Elektrophysiologische Untersuchungen zur Chloridleitfähigkeit am nasalen Fibroblasten liegen noch nicht vor. Da der Fibroblast das Grundgerüst des Nasenpolypen bildet, erscheint es wichtig zu untersuchen, ob eine cAMP-abhängige Chloridleitfähigkeit auch im nasalen Fibroblasten nachzuweisen ist, und ob diese Leitfähigkeit bei CF-Fibroblasten defekt ist. Wir haben deshalb mit Hilfe konventioneller Mikroelektroden Potentialmessungen an Fibroblasten aus Primärkulturen von Nasenpolypen durchgeführt. Unsere Untersuchungen zeigen, daß der Nicht-CF-Fibroblast eine cAMP-regulierte Chloridleitfähigkeit besitzt, die bei CF-Fibroblasten fehlt. Die cAMP-regulierte Chloridleitfähigkeit, die in der Epithelzelle für den transepithelialen Chloridtransport und somit für die Atemwegsbefeuchtung erforderlich ist, hat im Fibroblasten offenbar eine andere Bedeutung. Sie ist wahrscheinlich an der Regulation der Zellproliferation beteiligt und könnte auf diese Weise in die Polypengenese eingreifen.SummaryCystic fibrosis (CF) is a complex systemic disease that has pathological alterations in the upper airways, including the recurrent formation of nasal polyps. Although the fibroblast is the predominant cell type in nasal stroma and nasal polyps, little is known about the electrophysiological properties of nasal fibroblasts. We investigated whether fibroblasts possess a cAMP-regulated chloride conductance which is impaired in patients with CF. Thus far the few studies concerning conductance in fibroblasts have been performed on skin fibroblasts using indirect methods and have yielded conflicting results. Therefore we studied chloride conductance in fused nasal fibroblasts by employing conventional microelectrodes. We have demonstrated that a cAMP-regulated chloride conductance is present in fibroblasts. However, this chloride conductance cannot be activated in fibroblasts from CF-patients. Thus, we present direct evidence that the impairment of the cAMP-regulated chloride conductance in CF is not confined to epithelial cells but also affects the fibroblast. We discuss how this conductance might modulate fibroblast proliferation to produce polyp formation.