Bhaskar Ram

Montelukast as an adjunct to oral and inhaled steroid therapy in chronic nasal polyposis

Objective To examine the potential of montelukast, a leukotriene receptor antagonist, as an adjunct to oral and inhaled steroid in subjects with chronic nasal polyps. Study Design Prospective, randomized controlled trial. Subjects and Methods Thirty-eight consecutive adult patients with bilateral nasal polyps were randomized into two groups. Eighteen subjects were treated with oral prednisolone for 14 days and budenoside nasal spray for 8 weeks. Twenty subjects received similar treatment with additional oral montelukast for 8 weeks. Subjects completed a modified nasal ICSD symptom score at 8 and 12 weeks after beginning treatment and the SF-36 quality of life questionnaire at 12 weeks. Results Symptom scores improved in both groups after treatment. Subjects treated with montelukast reported significantly less headache (P = 0.013), facial pain (P = 0.048) and sneezing (P = 0.03) than controls. Four weeks after completing treatment, no significant differences were recorded. Conclusion Montelukast therapy may have clinical benefit as an adjunct to oral and inhaled steroid in chronic nasal polyposis, but effects are not maintained after cessation of treatment.

Incidental magnetic resonance image sinus abnormalities in asymptomatic Australian children.

Plain X-rays, computed tomography (CT) and magnetic resonance imaging (MRI) scans performed for non-ENT reasons often reveal incidental sinus mucosal changes. These changes need to be correlated clinically before diagnosing rhinosinusitis. This study examined the prevalence of such changes in MRI scans in children up to age 16. Scans were scored using an adapted Lund-Mackay classification and were positive when one or more sinuses showed abnormalities. Randomly selected scans in the retrospective arm revealed a prevalence of 20 of 62 (32.3 per cent). In the prospective arm 45 of 60 children were defined as truly asymptomatic, of which 14 scans (31 per cent) were positive. Other studies in adults and children using CT and MRI report a prevalence range of roughly 30 to 45 per cent. This variability may be attributed to differences of study design, definitions of population age, definitions of asymptomatic and definition of abnormal sinus. Other plausible factors to explain regional differences are climate and frequency of upper respiratory tract infections.

Use of complementary and alternative medicine by patients attending a rhinology outpatient clinic.

Background There are 50,000 practitioners of complementary and alternative medicine (CAM) within the United Kingdom. The current U.K. prevalence of CAM use is reported to be 25% and is rising. The national expenditure on CAM is an estimated £1.6 billion. The aim of this study was to explore the pattern of CAM use in patients attending a rhinology outpatient clinic in Aberdeen. Methods Questionnaires were provided to 100 patients over a 2-month period. The questionnaire consisted of demographic sections and whether they had ever used CAM from a list of 49 herbal and nonherbal alternative therapies. Subjects were also asked why they used CAM, where they learned of CAM, whether they found it efficacious, and whether their general practitioner was aware they were using it. Results One hundred subjects completed questionnaires. Patients attending the clinic were suffering from the most common rhinological complaints including rhinosinusitis and nasal polyps. Sixty-five percent of patients had ever used CAM. Women were statistically significantly more likely to use CAM than men (p = 0.012). Patients who were employed were more likely to use CAM, but there was no significant difference in CAM usage depending on marital status, social class, and age. Only 6% of patients felt CAM use was definitely ineffective. Only 43% of users of CAM had informed their doctor about its use. Conclusion CAM usage is growing in popularity. All health care professionals should be aware of this and of the potential for adverse drug reactions occurring. The dangers of noncompliance with conventional medications should be emphasized to CAM users.

Combined risk factors contributing to cerebral venous thrombosis in a young woman.

Cerebral venous thrombosis is a rare condition affecting predominantly adolescents or young adults. The presentation is often non-specific, and delay in diagnosis is common. The otolaryngologist may be consulted about the radiological findings of lateral sinus thrombosis and mastoid changes. The association of congenital thrombophilia with unusual presentations of venous thrombosis, especially in young individuals is now well documented. We present a case of lateral and sagittal sinus thrombosis complicated by cerebral venous infarction in a girl with protein C deficiency and masked mastoiditis. Unusual forms of venous thrombosis, including cerebral venous thrombosis may develop in association with a single risk factor for thrombosis, but additional risk factors should be sought especially when thrombosis presents in very young individuals. This case draws attention to the multi-causal nature of cerebral venous thrombosis in young adults, and highlights the issue of masked mastoiditis. A coordinated approach by otolaryngological and haematological teams is recommended in such cases.

An algorithm recommendation for the pharmacological management of allergic rhinitis in the UK: A consensus statement from an expert panel

Allergic rhinitis is a frequent presenting problem in primary care in the UK, and has increased in prevalence over the last 30 years. When symptomatic, patients report significant reduction in their quality of life and impairment in school and work performance. Achieving adequate symptom control is pivotal to successful allergic rhinitis management, and relies mostly on pharmacotherapy. While it is recognised that most mild-moderate allergic rhinitis symptoms can be managed successfully in primary care, important gaps in general practitioner training in relation to allergic rhinitis have been identified. With the availability of new effective combination therapies, such as the novel intranasal formulation of azelastine hydrochloride and fluticasone propionate in a single device (Dymista®; Meda), the majority of allergic rhinitis symptoms can be treated in the primary care setting. The primary objective of this consensus statement is to improve diagnosis and treatment of allergic rhinitis in primary care, and offer guidance on appropriate referral of difficult-to-treat patients into secondary care. The guidance provided herein outlines a sequential treatment pathway for allergic rhinitis in primary care that incorporates a considered approach to improve the management of allergic rhinitis symptoms and improve compliance and patient satisfaction with therapy. Adherence with this care pathway has the potential to limit the cost of providing effective allergic rhinitis management in the UK by avoiding unnecessary treatments and investigations, and avoiding the need for costly referrals to secondary care in the majority of allergic rhinitis cases. The fundamentals presented in this consensus article should apply in most health-care settings.

Laser-Assisted Endonasal Dacryocystorhinostomy

This chapter is focussed on the surgical description of laser-assisted endonasal DCR surgery. A step-by-step guide of the surgical technique is detailed in the chapter. The technique is a modification of the endolaser techniques described in the literature.