Tomislav Baudoin

Histopathologic Parameters as Predictors of Response to Endoscopic Sinus Surgery in Nonallergic Patients with Chronic Rhinosinusitis

OBJECTIVE: To estimate the predictable value of histopathologic parameters in chronic rhinosinusitis (CRS) for response to endoscopic sinus surgery (ESS). STUDY DESIGN: Symptomatology was rated in 100 patients prior to as well as 12 and 24 months after surgery. Specimens taken during the procedure were examined and scored for goblet cells, subepithelial thickening, mast cells, and eosinophils. Multiple regression analysis was performed to predict the total score of subjective symptoms before treatment by histopathologic parameters. The correlation between histopathologic parameters and postoperative symptoms was then evaluated. RESULTS: Goblet cells were the best predictor correlating with 5 symptoms. Subepithelial thickening correlated with 4 symptoms. Mast cell infiltration correlated with 3 symptoms. Eosinophilic infiltration correlated with only one symptom (P < 0.05). CONCLUSION: Certain histopathologic parameters in CRS are predictive of favorable response to ESS. SIGNIFICANCE: Pathologic evaluation may help the ENT surgeon to predict the persistence of certain CRS symptoms after ESS, even in patients at low risk for surgical failure. EBM rating: C-4

Dose-dependent protective effect of BPC 157 on capsaicin-induced rhinitis in rats

Protection of BPC 157 on capsaicin-induced rhinitis was studied in Wistar rats for its effect on mastocyte infiltration, degranulation and inflammatory cell infiltration. Animals were pretreated with 10 μg/kg, 10 ng/kg or 2 ml saline i.p. and capsaicin (0.05 ml/nostril of 1750 nmol/l sol.) was applied intranasally. They were then euthanized at 1, 3 and 12 h after capsaicin provocation. Nasal mucosa was analyzed and scored for mastocyte infiltration, degranulation and inflammatory cell infiltration. BPC 157 pretreatment significantly prevented mastocyte infiltration at 1 h. Polymorphonuclear leukocyte infiltration was significantly reduced in rats pretreated with 10 μg/kg BPC 157. A dose-dependent effect of BPC 157 pretreatment was demonstrated only for polymorphonuclear leukocyte infiltration at 12 h.

Effect of Endosinusal Treatment on Cellular Markers in Mild and Moderate Asthmatics

Objective—To determine the efficacy of topical endosinusal treatment in terms of reduction in activation of inflammatory cells and asthma/rhinosinusitis symptoms in patients with asthma and chronic rhinosinusitis (CRS). Material and Methods—Eighteen mild-to-moderate asthmatics with CRS were subjected to antral sinoscopy and endosinusal treatment with 2 mg of dexamethasone and 40 mg of gentamicin per maxillary sinus for 7 days. Sinus lavage and serum samples were taken before and after the treatment and bacteriological swabs from the sinuses were taken at the time of inclusion in the study. Subjective scores for CRS symptoms and forced expiratory volume in 1 s (FEV1) were tested at inclusion and after 30 days. Levels of eosinophil cationic protein (ECP), tryptase and myeloperoxidase (MPO) were analyzed in serum and sinus fluid before and after the treatment. Results—ECP and tryptase levels were significantly reduced in both serum and sinus fluid, but serum MPO did not show significant changes after the treatment. MPO in sinus lavage was reduced only in moderate asthmatics. Subjective scores for CRS and FEV1 were significantly improved for the whole group. ECP, usually used as a parameter for asthma staging, was mostly affected at the systemic level, whilst tryptase was more markedly reduced at the local level. Conclusion—The topical endosinusal treatment used in this clinical study significantly reduced activation of eosinophils and mastocytes, improved FEV1 and reduced symptoms of CRS in mild-to-moderate asthmatics.

Distilled water nasal provocation in hyperreactive patients.

Nonisotonic aerosol may act as a provocation agent in the upper and lower airways of hyperreactive individuals. The purpose of the study was to compare the results of nasal challenge with distilled water in patients with allergic rhinitis to those with noninfective nonallergic rhinitis (NINAR), with respect to the potential clinical use of the obtained data. A group of 68 ambulatory patients with allergic rhinitis or NINAR (39 perennial allergic, 6 seasonal, 23 NINAR) were challenged with 10 mL of distilled water aerosol after the baseline active anterior rhinomanometry. Patients with nasal polyposis at endoscopy, significant unilateral septal deviation, positive bacteriologic swab, recent nasal surgery, and uncertain anamnestic data about the medication taken 6 weeks before the provocation were excluded from the study. After 10 minutes of nasal provocation, rhinomanometry was repeated to assess the response. In 15 patients of the perennial allergic group, the same measurements were performed after a 2-week oral antihistamine and topical steroid therapy. Nasal resistance was significantly increased on the more patent side of the nose after nasal provocation with distilled water aerosol in allergic patients in comparison to the nasal resistance before provocation. In the patients with NINAR, the provocation resulted in a significant rise on the more patent side, but the total nasal airway resistance (NAR) levels were also significantly increased. The systemic antihistamine and topical steroid 2-week therapy in patients with perennial allergic rhinitis significantly reduced the response to nasal distilled water provocation. Nasal provocation with distilled water aerosol is a cheap, simple, and acceptable method that provides useful clinical data on the level of nonspecific nasal hyperreactivity and the therapy success.

Modified alar swing procedure in saddle nose correction.

Reconstruction of the saddle nose may involve the use of different augmentation materials, from autogenous bone and cartilage to alloplastic materials. The most important problems when considering the choice of reconstructive technique, besides underlying pathology and expected result, include: long-term stability, donor morbidity, tendency of the implant to infection, extrusion, and resorption. The use of the lateral crura of the lower lateral cartilages as dorsal onlay was reserved for the corrections of minor supratip depressions (flying wing and alar swing procedure). The authors suggest the use of pedicled flaps of cephalic portions of lateral crura as dorsal septal strut, which may increase the profile line more than dorsal onlay. Reconstruction is performed using open rhinoplasty approach. Pedicled flaps of the cephalic portions of lateral crura are transfixed in the sagittal plane and, following separation of upper lateral cartilages and medial crura, placed on the dorsum of nasal septum. Upper laterals are sutured to newly formed cartilaginous dorsum, or a new bridge is created using conchal cartilage. Columellar strut may be formed of the septal cartilage. Authors have performed such corrections in 15 patients with good long-term functional and aesthetic results.

Nasal and ocular responses after specific and nonspecific nasal challenges in seasonal allergic rhinitis

BACKGROUND Different nasal challenges induce neural and immune response leading to nasal and ocular symptoms in patients with seasonal allergic rhinitis (SAR). The release of neural mediators from nasal mucosa and conjunctiva after no-specific challenges in patients with SAR remains unknown. OBJECTIVES To compare the release of mediators from the nose and conjunctiva with symptoms after different nasal challenges in patients with SAR. METHODS Three types of consecutive nasal challenges were performed outside the pollen season in 25 patients with SAR. Challenges consisted of 500 biological units (BU) of allergen, 80 μg of histamine, and 1 mL of 2% hypertonic saline per nostril, within 24-hour and 72-hour intervals, respectively. Before and 15 minutes after challenges, evaluation of symptoms was performed with a visual analog scale. Concentrations of tryptase, eosinophil cationic protein in nasal lavages after 15 minutes, and substance P in tears after 5 minutes were measured with enzyme immunoassays. RESULTS Concentrations of substance P in tears were significantly higher after nonspecific challenges. Substance P concentration in tears significantly correlated with eye itchiness after histamine and hypertonic saline and with tearing after allergen. Ocular symptoms correlated significantly with tryptase concentration in nasal lavage collected 15 minutes after allergen challenge. There is a significant correlation in tear volume comparing different nasal challenges. CONCLUSIONS Nasal challenges with allergen, histamine, or irritants outside the pollen season induce a significant increase in nasal and ocular symptoms in patients with SAR. Interaction of the early-phase response and neurogenic inflammation define the pattern and severity of eye symptoms.

Local IgE and inflammation in chronic rhinosinusitis of asthmatics and non-asthmatics.

The aim of the study was to show the difference in the pattern of inflammation, and Th1/Th2 polarization between asthmatic and non-asthmatic patients with CRS, specifically eosinophil activation, local IgE levels in the sinus fluid and tissue, and the severity of inflammation were measured. The maxillary sinus lavages, mucosal biopsies and bacteriological swabs were taken in 17 asthmatic and 36 non-asthmatic adult patients with CRS. The concentrations of IgE, eosinophil cationic protein (ECP), myeloperoxidase (MPO), and tryptase were analyzed and IgE+ cells, eosinophils, lymphocytes and plasma cells were counted. The granulocyte activation markers and IgE in sinus lavages, and the inflammatory and IgE+ cells counts were significantly higher in the asthmatics with the greatest difference in ECP and IgE concentrations. The tryptase concentrations did not differ, but only in the asthmatics they correlated significantly with the IgE concentrations and IgE+ cells count. Asthmatic patients present a distinct subgroup among the patients with chronic rhinosinusitis (CRS). The levels of the cellular markers and IgE in the sinus fluid differ from those of non-asthmatic patients with CRS. The activation of granulocytes (especially eosinophils), local IgE concentrations and the inflammatory cells infiltration are significantly higher in the asthmatics.

Association between computed tomography findings and clinical symptoms in chronic rhinosinusitis with and without nasal polyps

Objective of this study was to test whether there is a difference between chronic rhinosinusitis patients with (CRSwNP) and without (CRSsNP) nasal polyps in the association of extent of disease on CT scans with symptom severity and health-related quality-of-life (HRQL) impairment. Data sets from 271 chronic rhinosinusitis (CRS) patients who completed the Sino-Nasal Outcome Test 22 (SNOT-22) and visual analog scale (VAS) scores were subjected to principal component analysis (PCA) to identify a symptom components related to CRS. After controlling for demographics, medical therapy, and comorbidities, the association between symptom components/items excluded from PCA and Lund–Mackay score (LMS) was evaluated. No association was found between the total SNOT-22 score and LMS in CRS patients. There was an independent association between a higher “nasal” symptom component derived from SNOT-22 PCA and LMS in patients with CRSwNP (p < 0.001), but not in CRSsNP patients, with a statistically significant difference between two patient subsets (p = 0.003). In patients with CRSsNP, higher (worse) SNOT-22 “facial pain” was associated with lower LMS (p = 0.022), although the estimated change in LMS was modest. Considering VAS PCA components, higher “nasal” symptoms were associated with higher LMS in CRSwNP patients (p < 0.001) but not in CRSsNP, with a statistically significant difference between CRS groups (p = 0.024). A higher “pain” PCA component was associated with lower LMS in CRSsNP patients (p = 0.019). This study found significant differences in the relationship between symptom burden and CT scores between CRS phenotypes and no association between HRQL impairment and CT scores.

Subglottic laryngitis – Changes in therapy approach over the past 20 years

OBJECTIVE To show changes in the management of subglottic laryngitis over the last twenty years in Croatia. METHODS We sent questionnaires to paediatricians and otolaryngologists (ENT) in 9 Croatian hospitals in 1993, 2003 and 2013. In the questionnaire we presented a case of a child with moderately difficult subglottic laryngitis, after which they had to answer questions about the management of this kind of a patient and common therapy practice in their hospitals. All data were categorical, described in absolute frequencies and with relative percentages. The Cochran-Armitage test for trend was used in the analysis of different treatments over the years among ENT and paediatricians. Associations were statistically significant if p<0.05. RESULTS During a twenty-year period main novelties included the introduction of racemic epinephrine use (ENT from 3.3% in 1993 to 92.3% in 2013; paediatricians from 17.2% in 1993 to 100.0% in 2013) and downfall of humidification (ENT from 60.0% to 23.3%; paediatricians from 60.0% to 12.0%), antibiotic (ENT from 53.0% to 2.3%; paediatricians from 21.0% to 0.0%) and antihistaminic use (ENT from 67.7% to 0%; paediatricians from 43.2% to 2%), while corticosteroids (both parenteral and nebulized form) remained the cornerstone in treatment of moderately severe subglottic laryngitis. CONCLUSION Main novelties included the use of racemic epinephrine and downfall of antibiotic, antihistaminic and humidification therapy use, while corticosteroids remained the cornerstone in the treatment of moderately severe subglottic laryngitis. Differences between approaches among specialities are minimized during 20-year period.

Algorithm for navigated ESS.

ENT navigation has given new opportunities in performing Endoscopic Sinus Surgery (ESS) and improving surgical outcome of the patients` treatment. ESS assisted by a navigation system could be called Navigated Endoscopic Sinus Surgery (NESS). As it is generally accepted that the NESS should be performed only in cases of complex anatomy and pathology, it has not yet been established as a state-of-the-art procedure and thus not used on a daily basis. This paper presents an algorithm for use of a navigation system for basic ESS in the treatment of chronic rhinosinusitis (CRS). The algorithm includes five units that should be highlighted using a navigation system. They are as follows: 1) nasal vestibule unit, 2) OMC unit, 3) anterior ethmoid unit, 4) posterior ethmoid unit, and 5) sphenoid unit. Each unit has a shape of a triangular pyramid and consists of at least four reference points or landmarks. As many landmarks as possible should be marked when determining one of the five units. Navigated orientation in each unit should always precede any surgical intervention. The algorithm should improve the learning curve of trainees and enable surgeons to use the navigation system routinely and systematically.