Pólipo solitario con inserción en techo de fosa nasal / Solitary polyp with insertion into the roof of the nostril

Pólipo coanal es el término utilizado para una masa de tejido blando, solitaria y benigna que se extiende hacia la unión de la cavidad nasal y la nasofaringe; es decir, la coana. Los pólipos coanales nasales se presentan típicamente en tres formas diferentes: pólipos antrocoanales, esfenocoanales y etmoidocoanales. Sitios atípicos de origen han sido reportados en la literatura; por ejemplo, el tabique nasal y el cornete inferior. El conocimiento de los médicos sobre la existencia de pólipos coanales de sitios inusuales puede ayudar en el diagnóstico de los mismos, considerando crucial descartar previamente otros potenciales diagnósticos para estos casos de presentación atípica. A continuación reportamos el caso de un pólipo inflamatorio de inserción en techo de fosa nasal en un paciente de 65 años diagnosticado y tratado en nuestro servicio, cuyo caso es el primero reportado en la literatura.

Coanal polyp is the term used for a solitary, benign soft tissue mass extending into the junction of the nasal cavity and nasopharynx, i.e., the choana. Nasal coanal polyps typically present in three different forms: antrochoanal, sphenocoanal, and ethmoidocoanal polyps. Atypical sites of origin have been reported in the literature; these include the nasal septum and inferior turbinate. Physicians' awareness of the existence of coanal polyps from unusual sites may help in the diagnosis of coanal polyps considering it crucial to previously rule out other potential diagnoses for these cases of atypical presentation. Here we report the case of an inflammatory polyp of insertion in the roof of the nostril in a 65-year-old patient diagnosed and treated in our department, which is the first case reported in the literature.

Una nueva perspectiva en rinosinusitis: EPOS 2020 / A new perspective on rhinosinusitis: EPOS 2020

Resumen EPOS 2020 (European Position Paper on Rhinosinusitis and Nasal Polyps 2020) es una guía clínica desarrollada por un grupo profesionales expertos en el área rinosinusal de la Sociedad Europea de Rinología, que corresponde a la última actualización de sus versiones anteriores (2005, 2007 y 2012). El objetivo principal del documento es entregar recomendaciones claras basadas en la mejor evidencia disponible y algoritmos de manejo concisos para las patologías de rinosinusitis aguda y crónica tanto en adultos como en pacientes pediátricos. Algunas de las novedades más importantes de esta guía, son: nueva clasificación de rinosinusitis crónica en primarias y secundarias, rinosinusitis crónica en pediatría, nuevos conceptos en cirugía sinusal, entre otros. También enfatiza la importancia de manejo multidisciplinario de la patología, incluyendo el autocuidado del paciente, inclusive promoviendo el uso de medicamentos de venta libre, antes del manejo médico en niveles escalonados de atención. El objetivo de esta revisión es dar a conocer de manera resumida el manejo de rinosinusitis aguda y crónica en adultos propuesta en esta guía.

Abstract EPOS 2020 (European Position Paper on Rhinosinusitis and Nasal Polyps 2020) is a clinical guide developed by a group of professional experts in the rhinosinusal area of the European Society of Rhinology, which corresponds to the latest update of its previous versions (2005, 2007 and 2012). The main objective of the document is to bring clear recommendations based on the best available evidence and concise management algorithms for the pathologies of acute and chronic rhinosinusitis in both adults and pediatric patients. Some of the most important novelties of this guide are: new classification of chronic rhinosinusitis in primary and secondary, chronic rhinosinusitis in pediatrics, new concepts in sinus surgery, among others. It also emphasizes the importance of multidisciplinary management of the pathology, including self-care of the patient, promoting the use of over-the-counter medications, before medical management at tiered levels of care. The objective of this review is to present in a summarized way the management of acute and chronic rhinosinusitis in adults proposed in this guide.

Predictive diagnostic value of serum 25-hydroxyvitamin D3 in eosinophilic chronic rhinosinusitis with nasal polyps / 中华耳鼻咽喉头颈外科杂志

Objective: To compare the value of 25-hydroxyvitamin D3 (25-(OH)D3) with other clinical parameters in the prediction and diagnosis of eosinophilic chronic rhinosinusitis with nasal polyps (ECRSwNP). Methods: Eligible chronic rhinosinusitis with nasal polyps (CRSwNP) patients and healthy subjects in the Affiliated Hospital of Guizhou Medical University from January to April of 2021 were included for this study. The age, gender, past history and other basic characteristics of all subjects were recorded. The CRSwNP patients were classified into ECRSwNP and non-eosinophilic chronic rhinosinusitis with nasal polyps (nECRSwNP) endotypes by the percentage of tissue eosinophils. Serum 25-(OH)D3 levels measurements were performed in all subjects. Paranasal sinus CT scans, blood eosinophil counts, and determination of total immunoglobulin E (total IgE), Th1/Th2 plasma cytokines and nasal nitric oxide (nNO) levels were performed before surgery. Logistic regression analysis was used to evaluate the related factors of ECRSwNP. Receiver operating characteristic (ROC) curves was used to evaluate the predictive potential of the clinical parameters. Results: One hundred and twenty-seven CRSwNP patients and 40 healthy subjects were recruited, including 74 males and 93 females of the patients, with the age of (38.73±13.05) years. In patients with ECRSwNP, serum 25-(OH)D3 levels were significantly lower than those in nECRSwNP patients ((26.14±4.58) ng/ml vs (35.71±7.86) ng/ml, t=-8.564, P<0.01). The prevalence of asthma, prevalence of allergic rhinitis, peripheral blood eosinophil counts, total IgE levels, nNO levels and CT scores ratio for ethmoid sinus and maxillary sinus (E/M ratio) of ECRSwNP patients were significantly higher than those in nECRSwNP patients (all P<0.05). However, there was no significant difference in Th1/Th2 cytokines levels between the histological types of CRSwNP (all P>0.05). Among the predictive indicators, 25-(OH)D3 had the highest predictive value, with ROC area under curve (AUC) value of 0.882. The best cut-off point of 28.5 ng/ml for 25-(OH)D3 demonstrated a sensitivity of 0.871 and a specificity of 0.762 for ECRSwNP. Conclusion: Measurement of serum 25-(OH)D3 level may be used as an effective method to distinguish between ECRSwNP and nECRSwNP.

Poliposis nasosinusal / Nasosinusal Polyposis

La poliposis nasosinusal, es una entidad caracterizada por un proceso inflamatorio de la mucosa nasosinusal, con sintomatología obstructiva, para su diagnóstico es necesario la exploración endoscópica y la tomografía computarizada, siendo la cirugía endoscópica nasosinusal, el tratamiento recomendado. Objetivo:recopilar información actualizada acerca de la poliposis nasosinusal con respecto a su fisiopatología, diagnóstico y tratamiento. Material y Métodos: se realizó la búsqueda de artículos en las bases de datos como HINARI, SciELO, Biblioteca Cochrane, PubMed, con las palabras clave rinosinusitis polipoide y poliposis nasosinusal, en inglés y español; se encontraron varios artículos, de los cuales se seleccionaron 20, de revistas biomédicas publicadas en los últimos 5 años y según su importancia de los conceptos básicos de esta entidad. Conclusión: existe debate en la fisiopatología de la poliposis nasosinusal, aunque se acepta la teoría alérgica y la reacción inflamatoria como las causas. Además, el manejo medicamentoso, no es un tratamiento definitivo, teniendo que recurrir al tratamiento quirúrgico para mejorar la sintomatología, donde el tratamiento recae principalmente, en la cirugía endoscópica nasosinusal...(AU)

Síndrome de Pai: dos nuevos casos con manifestaciones inusuales / Pai syndrome: Two new cases with unusual manifestations

El síndrome de Pai se describe como la presencia de 3 anomalías congénitas: fisura de labio medial, pólipos cutáneos nasales y faciales, y lipoma pericallosal. La expresión clínica es variable. El desarrollo neuromadurativo suele ser normal. Existen 42 casos descritos en la literatura. Se proponen distintos tipos de herencia, pero, hasta la actualidad, no existe un gen asignado para esta patología. Se presentan dos pacientes con síndrome de Pai, uno de ellos con hallazgos clínicos aún no descritos (defectos de segmentación vertebral y osteoma coroideo).

Pai syndrome is a very rare congenital disorder characterized by medial cleft lip, nasal and facial cutaneous polyps, and pericallosal lipoma. Broad phenotypic variability exists in this condition. Neurodevelopment is usually normal. Up to date 42 cases have been reported in the literature. Different types of inheritance have been proposed, but most cases are sporadic. No gene has been identified. We report two cases with Pai syndrome, one of them with novel clinical findings as vertebral segmentation defects and choroidal osteoma.

Rhinosinusal polyposis and inverted papilloma: a morphometric comparative study

Introduction Nasal obstruction is one of the main rhinologic complaints, and two diseases must be investigated as differential diagnosis: rhinosinusal polyposis and inverted papilloma. Using traditionalmethods, the differential diagnosis between these diseases may be difficult. The morphometric study may be a useful tool for differential diagnosis and to define prognosis. Objective Calculate the morphometric values of rhinosinusal polyposis and inverted papilloma and compare the average of variables obtained between the groups. Methods The nasal mucus of 10 patients who had surgery in the Department of Otorhinolaryngology and Surgery of Head and Neck was studied; 5 had rhinosinusal polyposis and 5 had inverted papilloma. After the capture and print of corresponding data of each slide, the largest and smallest diameters of the nuclei were measured and the morphometric variables were calculated: average diameter, perimeter, ratio between largest and smallest diameter, volume, area, ratio of volume to area, form coefficient, contour index, and eccentricity. Results We found a significant difference (p < 0.05) between the two groups in the following morphometric variables: largest diameter, smallest diameter, average diameter, volume, area, perimeter, and ratio of volume to area, indicating that these parameters can be useful in diagnostic differentiation between these diseases. Conclusion We founded morphometric variables higher in patients with inverted papilloma, which can be related to the neoplastic origin of the inverted papilloma. The analysis of nuclear parameters is an instrument of great value in the differential diagnosis between rhinosinusal polyposis and inverted papilloma.

Evaluation of an alternative technique to optimize direct bonding of orthodontic brackets to temporary crowns

OBJECTIVE: To compare shear bond strength of different direct bonding techniques of orthodontic brackets to acrylic resin surfaces.METHODS: The sample comprised 64 discs of chemically activated acrylic resin (CAAR) randomly divided into four groups: discs in group 1 were bonded by means of light-cured composite resin (conventional adhesive); discs in group 2 had surfaces roughened with a diamond bur followed by conventional direct bonding by means of light-cured composite resin; discs in group 3 were bonded by means of CAAR (alternative adhesive); and discs in group 4 had surfaces roughened with a diamond bur followed by direct bonding by means of CAAR. Shear bond strength values were determined after 24 hours by means of a universal testing machine at a speed of 0.5 mm/min, and compared by analysis of variance followed by post-hoc Tukey test. Adhesive remnant index (ARI) was measured and compared among groups by means of Kruskal-Wallis and Dunn tests.RESULTS: Groups 3 and 4 had significantly greater shear bond strength values in comparison to groups 1 and 2. Groups 3 and 4 yielded similar results. Group 2 showed better results when compared to group 1. In ARI analyses, groups 1 and 2 predominantly exhibited a score equal to 0, whereas groups 3 and 4 predominantly exhibited a score equal to 3.CONCLUSIONS: Direct bonding of brackets to acrylic resin surfaces using CAAR yielded better results than light-cured composite resin. Surface preparation with diamond bur only increased shear bond strength in group 2.

OBJETIVO: comparar a resistência ao cisalhamento de diferentes técnicas para colagem direta de braquetes ortodônticos em superfície de resina acrílica.MÉTODOS: sessenta e quatro (64) discos de resina acrílica ativada quimicamente (RAAQ) foram divididos aleatoriamente em qautro grupos: grupo 1 = colagem com resina composta fotopolimerizável (adesivo convencional); grupo 2 = superfície abrasionada com broca diamantada e colagem com resina composta fotopolimerizável; grupo 3 = colagem com RAAQ (adesivo alternativo); grupo 4 = superfície abrasionada com broca diamantada e colagem com RAAQ. A resistência ao cisalhamento foi avaliada 24h após a colagem, utilizando-se uma máquina universal de ensaios, operando a uma velocidade de 0,5mm/min, e comparada por meio da análise de variância, seguida pelo teste post-hoc de Tukey. O índice de adesivo remanescente (IAR) foi mensurado e comparado entre os grupos por meio dos testes Kruskal-Wallis e Dunn.RESULTADOS: os grupos 3 e 4 demonstraram resistência ao cisalhamento significativamente maior do que os grupos 1 e 2. Os grupos 3 e 4 apresentaram resultados similares. O grupo 2 apresentou melhores resultados do que o grupo 1. Na análise do IAR, observou-se predominância do escore 0 para os grupos 1 e 2 e do escore 3 para os grupos 3 e 4.CONCLUSÕES: a colagem do braquete em superfície de resina acrílica utilizando-se a RAAQ apresentou melhores resultados do que a colagem com resina composta fotopolimerizável. A abrasão da superfície com broca diamantada apenas aumentou a resistência ao cisalhamento no grupo 2.

Chronic rhinosinusitis and nasal polyposis in cystic fibrosis: update on diagnosis and treatment / Rinossinusite crônica e polipose nasossinusal na fibrose cística: atualização sobre diagnóstico e tratamento

Although cystic fibrosis (CF) is an irreversible genetic disease, advances in treatment have increased the life expectancy of CF patients. Upper airway involvement, which is mainly due to pathological changes in the paranasal sinuses, is prevalent in CF patients, although many are only mildly symptomatic (with few symptoms). The objective of this literature review was to discuss the pathophysiology and current therapeutic management of chronic rhinosinusitis (CRS) in CF patients. The review was based on current evidence, which was classified in accordance with the Oxford Centre for Evidence-Based Medicine criteria. When symptomatic, CRS with nasal polyps can affect quality of life and can lead to pulmonary exacerbations, given that the paranasal sinuses can be colonized with pathogenic bacteria, especially Pseudomonas aeruginosa. Infection with P. aeruginosa plays a crucial role in morbidity and mortality after lung transplantation in CF patients. Although clinical treatment of the upper airways is recommended as initial management, this recommendation is often extrapolated from studies of CRS in the general population. When sinonasal disease is refractory to noninvasive therapy, surgery is indicated. Further studies are needed in order to gain a better understanding of upper airway involvement and improve the management of CRS in CF patients, with the objective of preserving lung function and avoiding unnecessary invasive procedures.

A fibrose cística (FC) é uma doença genética irreversível, mas os avanços no tratamento têm aumentado a expectativa de vida dos pacientes. O acometimento das vias aéreas superiores, principalmente por alterações patológicas dos seios paranasais, é prevalente nesses pacientes, embora muitos apresentem poucos sintomas. O objetivo desta revisão é discutir a fisiopatologia e o manejo terapêutico atual da rinossinusite crônica (RSC) na FC. A revisão fundamentou-se nas evidências mais recentes, classificadas em conformidade com os critérios do Oxford Centre for Evidence-Based Medicine. Quando sintomática, a RSC com pólipos nasais pode afetar a qualidade de vida e as exacerbações pulmonares, já que os seios paranasais podem ser colonizados por bactérias patogênicas, principalmente a Pseudomonas aeruginosa. Essa bactéria tem papel crucial na morbidade e mortalidade após o transplante pulmonar em pacientes com FC. Embora o tratamento clínico das vias aéreas superiores seja indicado no manejo inicial, a indicação é muitas vezes extrapolada de estudos sobre RSC na população geral. A cirurgia é a alternativa quando o quadro nasossinusal é refratário à terapia não invasiva. Mais estudos são necessários para compreender melhor o acometimento das vias aéreas superiores e melhorar o manejo da RSC na FC, a fim de preservar a função pulmonar e evitar procedimentos invasivos desnecessários.

Obstrucción nasal unilateral en niños: Síndrome de Pai / Unilateral nasal obstruction in children: Pai syndrome

La obstrucción unilateral de las fosas nasales en niños es causada principalmente por la introducción de cuerpos extraños, se manifiesta con rinorrea y olor fétido. Con menor frecuencia, puede ser de origen traumático, neoplásico, malformativo congénito o iatrogénico. Los síntomas de una masa intranasal congénita pueden manifestarse desde el nacimiento, o pasar desapercibidos y ser un hallazgo en un examen pediátrico de rutina. La evaluación del paciente debe incluir estudios por imágenes para orientar al diagnóstico y descartar una extensión intracraneal. Un síndrome asociado al tumor nasal congénito debe sospecharse cuando existen otras anomalías. El síndrome de Pai es un trastorno genético raro. Sus manifestaciones son craneofaciales y su marcador principal es el pólipo nasal congénito. Presentamos un paciente con insuficiencia ventilatoria nasal unilateral secundaria a un lipoma nasal congénito, junto a anomalías craneofaciales del síndrome de Pai. La obstrucción nasal fue resuelta quirúrgicamente en forma exitosa.

Unilateral obstruction of the nasal cavity in children is mainly caused by the introduction of foreign bodies further stated with rhinorrhea and fetid odor. Less commonly, it can be traumatic, neoplastic, due to congenital malformation or iatrogenic. Symptoms of congenital intranasal mass may present at birth, or go unnoticed and be a finding in a routine pediatric examination. Patient evaluation should include imaging studies to guide the diagnosis and rule out intracranial extension. A syndrome associated with congenital nasal tumor should be suspected when other abnormalities are present. Pai syndrome is a rare genetic disorder. Its manifestations are craniofacial being congenital nasal polyp his main marker. We present a patient with unilateral nasal respiratory failure secondary to congenital nasal lipoma, with craniofacial anomalies belonging to Pai syndrome. Nasal obstruction was successfully surgically resolved.

Avaliação endoscópica nasal de crianças e adolescentes com fibrose cística / Nasal endoscopic evaluation of children and adolescents with cystic fibrosis

As principais manifestações otorrinolaringológicas da Fibrose Cística são a rinossinusite crônica e a polipose nasossinusal, com diferentes apresentações clínicas. Objetivo: Caracterizar, do ponto de vista nasossinusal, as crianças e adolescentes com fibrose cística por meio de um questionário, do exame clínico e da endoscopia nasal. Forma de estudo: Clínico descritivo transversal. Material e método: Avaliação de 100 crianças e adolescentes com fibrose cística por meio de um questionário específico, exame físico otorrinolaringológico, endoscopia nasal e estadiamento endoscópico dos pólipos nasais. Resultados: Os sintomas mais frequentes foram: tosse (45 por cento), respiração oral (44 por cento), distúrbios do sono (42 por cento) e obstrução nasal (37 por cento). Vinte e oito pacientes (28 por cento) apresentaram secreção mucopurulenta nasal e 41 por cento apresentaram abaulamento medial da parede lateral do nariz. Os pólipos nasais foram identificados em apenas 14 por cento dos casos, nenhum deles era obliterante. Conclusão: O questionário, o exame clínico e especialmente a endoscopia nasal permitiram uma avaliação detalhada das características nasais das crianças e adolescentes com fibrose cística. Alguns achados foram discordantes da literatura, principalmente a baixa prevalência encontrada de pólipos nasais, e parecem estar relacionados com características próprias da população estudada. A melhor caracterização desse grupo de pacientes, do ponto de vista otorrinolaringológico, contribui para uma adequada abordagem multidisciplinar.

The main otorhinolaryngological manifestations of CF are chronic rhinosinusitis and nasal polyposis, with different clinical presentations. AIM: To characterize children and adolescents with cystic fibrosis through a questionnaire, an ENT clinical examination and nasal endoscopy. Study design: Cross-sectional clinical descriptive. Material and method: Assessment of 100 children and adolescents with cystic fibrosis through a specific questionnaire, ENT physical examination, nasal endoscopy and endoscopic staging of nasal polyps. Results: The most frequent symptoms were: cough (45 percent), oral breathing (44 percent), sleep disorders (42 percent) and nasal obstruction (37 percent). Twenty-eight patients (28 percent) had purulent nasal discharge, and 41 percent had medial bulging of the nasal lateral wall. Nasal polyps were identified in only 14 percent of cases, none were obstructing. Conclusion:The questionnaire, clinical examination and especially nasal endoscopy lead to a detailed assessment of the nasal characteristics of children and adolescents with cystic fibrosis. Some findings were discordant with the literature, particularly the low prevalence of nasal polyps, and appear to be related to specific characteristics of the population studied. The best characterization of this group of patients, from the ENT standpoint, contributes to an appropriate multidisciplinary approach.

Clinicopathological study of non-neoplastic lesions of nasal cavity and paranasal sinuses.

An analysis of cases presenting as mass in nasal cavity (NC), paranasal sinuses (PNS), and nasopharynx (NP) was done over a period of 7 years in Jawaharlal Nehru Medical College, Aligarh. A provisional diagnosis was made after clinical assessment and radiological investigations, but final diagnosis was made after histopathological examination. The incidence of masses in NC, PNS, and NP was 34.3 cases per year, non-neoplastic lesions constituted 60% of these cases and their incidence was 20.7 cases per year. All the cases were carefully examined histopathologically and it was found that the region was affected by a variety of non-neoplastic lesions. Among 240 cases, 145 were non-neoplastic and 95 were neoplastic The lesions in the decreasing order of frequency were - nasal polyp, rhinoscleroma, tuberculosis, fungal infection, fibrous dysplasia, ossifying fibroma, cysts, nasal glioma, and cemento-ossifying fibroma. NP was involved by a range of neoplastic lesions; however, no non-neoplastic lesion was seen in this region.

Poliposis nasal en niños / Nasal polyposis in children

Las molestias atribuidas a obstrucción nasal son causa frecuente de consulta, los pediatras deben pensar primero en las etiologías más frecuentes como infección respiratoria alta y alergias, pero no olvidar considerar patologías menos frecuentes como poliposis nasal. En este artículo se realiza una revisión del tema para orientar su correcta sospecha y diagnóstico.

Nasal glioma: a case report.

Here we describe a rare case of nasal glioma in a 14 year old boy who presented with history of right nasal obstruction and nasal discharge since 6 months. On examination a pale mass was seen filling the right nasal cavity and extending down in the oropharynx. Clinical impression was antrochoanal polyp. Excision of the mass was carried out and sent for histopathology which showed presence of glial tissue and the diagnosis was made as nasal glioma.

Prognostic factors for the olfactory outcome after endoscopic sinus surgery: age and gender

Gender and age have been shown to influence the function and the regenerative processes in the peripheral and central olfactory pathways. However, the potential predictive value of either age or gender, for the recovery of olfaction after surgery has not been determined yet. The aim of this study was to objectively evaluate the prognostic value of age and gender for the postoperative olfactory performance of patients with extensive nasal polyposis who have been treated with endoscopic sinus surgery. This study involves 116 patients who have been evaluated before and 6 months after surgery with Sniffin' Sticks, a combined test battery for olfactory threshold, identification and discrimination. After statistical adjustment for baseline scores and potential confounders [duration of symptoms, smoking, previous surgery, allergic rhinitis, aspirin-exacerbated respiratory disease and gustatory impairment] gender was found to have no significant influence on the recovery of all olfactory indices. On the contrary, patients older than 55 years were found to recover significantly slower and less efficiently than patients who were less than 35 years old or patients 36-55 years old. Moreover patients older than 55 years seemed to have significantly less possibilities to regain normosmia than patients whose age was less than 55 years. Gender does not seem to have any prognostic value with regard to the postoperative olfactory performance. Old age, however, seems to represent a strong independent negative predictor for the recovery of olfaction and the achievement of normosmia

Chronic rhinosinusitis and recurrent nasal polyps in two children with IgG subclass deficiency and review of the literature.

Chronic rhinosinusitis (CRS) is a chronic inflammatory disorder of mucosa of the nose and the paranasal sinuses. Two major forms of CRS can be differentiated; CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). The pathophysiology and etiology of nasal polyps (NPs) are partly understood. IgG subclass deficiency was shown to be associated with an increased susceptibility to infections. However the association between NPs and IgG subclass deficiency has never been reported. OBJECTIVES: To report two cases of recalcitrant CRS and recurrent NPs with IgG subclass deficiency. CASE REPORT: Two children (6 and 8 year-old boys) were referred to the Pediatric Allergy/Immunology Clinic, Siriraj Hospital due to a prolonged history of CRS and recurrent NPs. Both of them were treated with aggressive medical (topical and systemic corticosteroids, antibiotics, leukotriene antagonist, nasal irrigation) as well as surgical therapy, without significant improvement. Immunologic investigation in both patients showed that IgG, IgA, and IgM level were normal. IgG subclasses level in patient No. 1 were IgG1 1,235 (280-1120) mg/dl (79%), IgG2 235 (30-630) mg/dl (23.5%), IgG3 27.3 (40-250) mg/dl (1.74%), and IgG4 92.4 (11-620) mg/dl (5.9%). IgG subclasses level in patient No. 2 were IgG1 1,139 (280-1120) mg/dl (82.5%), IgG2 170 (30-630) mg/dl (12.3%), IgG3 5.6 (40-250) mg/dl (0.4%), IgG4 65.7 (11-620) mg/dl (4.8%). The diagnosis of CRS and recurrent NPs with IgG3 subclass deficiency in the first patient and IgG2/IgG3 subclass deficiency in the second patient were made. Patient No. 1 was given monthly IVIG therapy for the total of 7 courses and medications were gradually tapered. Currently, the patient is doing well after the cessation of IVIG therapy for 3 months. Patient No. 2 denied the IVIG treatment and was lost to follow up. CONCLUSION: We reported two cases of recalcitrant CRS and recurrent NPs in children. Immunologic work up revealed IgG subclass deficiency. The treatment with monthly IVIG improved CRS and NPs in treated patient which brought up the possibility of association between NPs and IgG subclass deficiency. Further study on the direct role of IVIG in NPs will be needed in the future.