Clinical Practice Guideline: Nasal Irrigation for Chronic Rhinosinusitis in Adults

The Korean Society of Otorhinolaryngology-Head and Neck Surgery and Korean Rhinologic Society appointed a guideline development group (GDG) to establish a clinical practice guideline, and the GDG developed a guideline for nasal irrigation for adult patients with chronic rhinosinusitis (CRS). The guideline focuses on knowledge gaps, practice variations, and clinical concerns associated with nasal irrigation. Nasal irrigation has been recommended as the first-line treatment for CRS in various guidelines, and its clinical effectiveness has been demonstrated through a number of studies with robust evidence. However, no guidelines have presented a consistent nasal irrigation method. Several databases, including OVID Medline, Embase, the Cochrane Library, and KoreaMed, were searched to identify all relevant papers using a predefined search strategy. When insufficient evidence was found, the GDG sought expert opinions and attempted to fill the evidence gap. Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. The committee developed 11 evidence-based recommendations. This guideline focuses on the evidence-based quality improvement opportunities deemed the most important by the GDG. Moreover, the guideline addresses whether nasal lavage helps treat CRS, what type of rinsing solution should be used, and the effectiveness of using additional medications to increase the therapeutic effect.

Age Differences in Pet Sensitization by Pet Ownership

Objectives@#. The association between pet sensitization and pet ownership remains unclear. Therefore, we aimed to elucidate the association between pet sensitization and pet ownership by age. @*Methods@#. We retrospectively reviewed 2,883 patients who visited our allergy clinic for nasal symptoms from January 2003 to December 2014, of whom 1,957 patients with data on skin-prick tests and questionnaire responses were included and divided into adults (age >19 years) and children (age ≤19 years). The association between pet sensitization and pet ownership was evaluated in both groups. @*Results@#. Among children, dog and cat sensitization showed no associations with dog and cat ownership, respectively. However, among adults, dog sensitization was significantly associated with dog ownership (odds ratio [OR], 3.283; P<0.001), and cat sensitization with cat ownership (OR, 13.732; P<0.001). After adjustment for age, sex, familial history of allergy, sinusitis, diabetes mellitus, other pet ownership, and non-pet sensitization, significant associations remained between dog sensitization and dog ownership (adjusted OR [aOR], 3.881; P<0.001), and between cat sensitization and cat ownership (aOR, 10.804; P<0.001) among adults. Dog ownership did not show any association with allergic rhinitis, asthma, or atopic dermatitis, whereas atopic dermatitis had a significant association with cat ownership in adults (aOR, 4.840; P<0.001). @*Conclusion@#. Pet ownership in adulthood increased the risk of pet sensitization. However, pet ownership was not associated with the prevalence of atopic disorders, regardless of age, except for atopic dermatitis and cat ownership in adults.

Complications After Inadequate Treatment of Nasal Bone Fracture Combined With Septal Fracture: A Case Report

In treating a nasal bone, an incomplete nasal bone reduction can result in nasal deformity, both aesthetic and functional, requiring a secondary operation. A 60-year-old female with a traumatic comminuted nasal bone fracture with septal fracture was initially treated with closed reduction, which later resulted in a saddle nose and a completely occluded nasal cavity. Later, the patient underwent a revision operation of extracorporeal septorhinoplasty with rib cartilage graft, and the postoperative course was uneventful. Herein, we present a case of complications occurring after inadequate treatment of septal fracture. Physicians should thoroughly evaluate the extent of the nasal bone fracture, including the integrity of the nasal septum, and manage accordingly.

Age Differences in Pet Sensitization by Pet Ownership

Objectives@#. The association between pet sensitization and pet ownership remains unclear. Therefore, we aimed to elucidate the association between pet sensitization and pet ownership by age. @*Methods@#. We retrospectively reviewed 2,883 patients who visited our allergy clinic for nasal symptoms from January 2003 to December 2014, of whom 1,957 patients with data on skin-prick tests and questionnaire responses were included and divided into adults (age >19 years) and children (age ≤19 years). The association between pet sensitization and pet ownership was evaluated in both groups. @*Results@#. Among children, dog and cat sensitization showed no associations with dog and cat ownership, respectively. However, among adults, dog sensitization was significantly associated with dog ownership (odds ratio [OR], 3.283; P<0.001), and cat sensitization with cat ownership (OR, 13.732; P<0.001). After adjustment for age, sex, familial history of allergy, sinusitis, diabetes mellitus, other pet ownership, and non-pet sensitization, significant associations remained between dog sensitization and dog ownership (adjusted OR [aOR], 3.881; P<0.001), and between cat sensitization and cat ownership (aOR, 10.804; P<0.001) among adults. Dog ownership did not show any association with allergic rhinitis, asthma, or atopic dermatitis, whereas atopic dermatitis had a significant association with cat ownership in adults (aOR, 4.840; P<0.001). @*Conclusion@#. Pet ownership in adulthood increased the risk of pet sensitization. However, pet ownership was not associated with the prevalence of atopic disorders, regardless of age, except for atopic dermatitis and cat ownership in adults.

What is the Optimal Method for Steroid Delivery in the Treatment of Chronic Rhinosinusitis With Nasal Polyps?

No abstract available.

The Impact of Nasal Polyposis on Olfactory Dysfunction in Chronic Rhinosinusitis

BACKGROUND AND OBJECTIVES: Olfactory disturbance is a major sinonasal symptom of chronic rhinosinusitis (CRS) with nasal polyps (NP). The aim of this study was to investigate the relationship between the severity of nasal polyposis and olfactory dysfunction in CRS. SUBJECTS AND METHOD: A total of 277 subjects with CRS were included in this study. All participants were divided into four groups according to the size and degree of the nasal polyposis: the control group (no polyp; n=79); NP (nasal polyp) group I (both or unilateral simple polyposis; n=85); NP group II (unilateral diffuse polyposis; n=66); and NP group III (bilateral diffuse polyposis; n=47). We analyzed the relationships between the severity of nasal polyposis and olfactory dysfunction using both the Korean Version of the “Sniffin'Sticks” test (KVSS Test) II and the Questionnaire of Olfactory Disorders (QOD). RESULTS: The KVSS Test II TDI score was significantly decreased in the bilateral diffuse polyposis group (NP group III=15.62±13.39) compared to the other polyp groups [control group=25.04±9.67 (p<0.001); NP group I=21.67±11.18 (p=0.005); NP group II=21.51±10.85 (p=0.008)]. However, there were no significant differences in the KVSS Test II TDI score between the control group and NP groups I and II. For the QOD_NS score, only NP group III (11.51±9.87) had significantly increased values compared to the control group [8.42±12.27 (p=0.015)]. CONCLUSION: These results suggest that bilateral diffuse nasal polyposis is related to significant olfactory dysfunction in CRS.

Two Cases of Pediatric Obstructive Hypoventilation Managed with Upper Airway Surgery

Sleep-disordered breathing in children can include habitual snoring, obstructive hypoventilation, upper airway resistance syndrome, and obstructive sleep apnea. Obstructive hypoventilation in children is characterized by CO₂ retention caused by prolonged partial upper airway obstruction during sleep. To date, there have been few studies regarding the clinical significance and management strategies in pediatric obstructive hypoventilation, although it is a unique feature of pediatric sleep-disordered breathing. In this report, we describe two cases of obstructive hypoventilation that demonstrated improvement following upper airway surgery. These results suggest that upper airway surgery could be an additional treatment modality in obstructive hypoventilation.

Clinical Features and Outcomes of a Rare Nasal Cavity Tumor Glomangiopericytoma / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Glomangiopericytoma falls within the category of borderline low-malignant-potential soft tissue tumors of the nose and paranasal sinuses. It is a rare tumor arising from the pericytes surrounding capillaries, and accounts for less than 0.5% of all sinonasal tumors. The aim of this study was to analyze the clinical manifestation and surgical outcomes of the glomangiopericytoma in the nasal cavity. SUBJECTS AND METHOD: Medical records of eight patients who were surgically managed for glomangiopericytoma of the nose and paranasal sinuses from 2000 to 2015 were retrospectively reviewed. Clinical features, size, Immunohistochemical staining, extent of surgery, adjuvant treatment, and recurrence were evaluated. RESULTS: Eight patients, 3 males and 5 females, were enrolled, with the mean age of 54.7 years old. The most common symptom of glomangiopericytoma was ipsilateral nasal obstruction. All patients got surgical treatment, and one patient received radiation to the surgical site, whose margin of resection was positive. The mean follow-up period was 39.5 months (3-176 months). During the follow-up period, one patient was found to have a positive resection margin. CONCLUSION: The surgical outcome shows that complete initial excision is important to prevent recurrence. Furthermore, adjuvant radiation therapy may also be a reasonable option for some patients with margin involvement.

The Relationship between Obstructive Sleep Apnea and Metabolic Syndrome in Adult

BACKGROUND AND OBJECTIVES: The prevalence of obstructive sleep apnea (OSA) and metabolic syndrome (MS) is increasing and those have been recognized as potential risk factors for cardiovascular disease in adults. The aim of this study is to investigate the association between obstructive sleep apnea syndrome and metabolic syndrome. MATERIALS AND METHODS: We enrolled 127 adults who were evaluated as having OSA. Each subject underwent overnight polysomnography to identify OSA based on the apnea-hypopnea index (AHI); OSA was diagnosed when AHI≥5, and subjects with AHI<5 were classified as the control group. MS was defined according to the Adult Treatment Panel (ATP) III criteria. RESULTS: Among 127 participants, 105 subjects were diagnosed with OSA. The mean age and smoker percentage showed differences between the OSA and control group. The prevalence of MS was significantly higher in the OSA group compared to the control group. As the severity of OSA increases, the prevalence of MS also increase. CONCLUSIONS: The MS is significantly related to the OSA in adults. Therefore, we suggest that patient with OSA should be screened to identify the presence of MS.

In Reply: Dominance of Ossicular Route in Sound Transmission

No abstract available.

Microbiome of the upper airway focusing on chronic rhinosinusitis and allergic rhinitis

The human microbiome is a collection of microbial species and their associated genomes that live on and in the body. Recent advances in molecular biology methods have revolutionized microbiome analysis techniques. Studies of the airway microbiome have illustrated that the paranasal sinuses are not sterile in the healthy state. Because human airways are in constant contact with the external environment and their mucosal surfaces are colonized with microorganisms, it is assumed that the local microbiota might influence immune homeostasis as well. Chronic rhinosinusitis and allergic rhinitis are the most common chronic airway diseases that yield a significant amount of socioeconomic burden. Despite the problematic nature of the diseases, a thorough understanding of their cause and pathogenesis is still lacking. At present, bacteria are believed to play a pathogenetic role in the propagation of inflammation and it is necessary to establish the relationship between the microbiome and inflammatory patterns to find their clinical reflections and also their possible causal relationship. Such investigations may elucidate the path to therapeutic approaches in correcting an imbalanced microbiome. In this review, we summarized recent typical studies dealing with the upper airway microbiome and discuss their clinical significance focusing on chronic rhinosinusitis and allergic rhinitis.

A Case of Bariatric Surgery for an OSAS Patient with Severe Obesity / 수면정신생리

Obstructive sleep apnea syndrome (OSAS) has negative effects on health, including increased mortality, risk of cardiovascular disease, and neurocognitive difficulties. OSAS is common in obese patients and obesity is an important risk factor of OSAS. A 41-year-old female OSAS patient with severe obesity (body mass index [BMI] ≥ 35) who failed dietary weight loss underwent bariatric surgery. After surgery, there were improvements in BMI (from 36.9 to 31.7 kg/m2) and polysomnographic data, including the apnea-hypopnea index (from 25.1 to 11.2 events/hr) and minimum SaO2 (from 69 to 82%). This case demonstrates that bariatric surgery may be an effective therapeutic option to reduce sleep-disordered breathing in severely obese patients with moderate OSAS. Bariatric surgery as a treatment option for OSAS should be considered in OSAS patients with severe obesity who failed dietary weight loss.

A Case of Nasal Surgery for a Positive Airway Pressure-Intolerant OSAS Patient Due to Nasal Obstruction / 수면정신생리

Positive airway pressure (PAP) is currently recommended as a primary treatment for obstructive sleep apnea syndrome (OSAS) and positively affects various subjective and objective parameters related to OSAS, such as the apnea-hypopnea index, excessive daytime sleepiness, and blood pressure. However, PAP also exhibits various adverse effects, including skin breakdown, pressure intolerance, claustrophobia, unintentional mask removal, mouth leaks, and dryness. Especially, unintentional mask removal due to nasal obstruction may result in poor PAP compliance. A 47-year-old male patient with severe OSAS who had low PAP compliance due to nasal obstruction underwent nasal surgery. After the surgery, nasal obstruction was corrected and the patient experienced improved PAP compliance (from 30.4% to 86.7%). This case demonstrates that nasal surgery may be useful for improving PAP compliance in OSAS patients with nasal obstruction.

Reactive Oxygen Species, Interferon and Antiviral Innate Immune Response in Nasal Mucosa / 대한이비인후과학회지

The regulated production of reactive oxygen species (ROS) has been considered a unique property of phagocytic cells which use this ROS system to induce innate defense system that enables it to successfully combat the pathogens. However, the mechanisms for how respiratory mucosa might produce ROS against respiratory viral infection still need to be completely defined. Respiratory mucosa and nasal epithelium has been known as the first defense site of human respiratory tract which is highly exposed and vulnerable to environmental pathogens, including air-bone microbes, viruses and allergens. We are especially interested in the innate immune response to respiratory virus infection in nasal epithelium and how this response might be influenced by ROS generation after viral infection. The interferon (IFN) signaling system is perhaps the most critical pathway for antiviral defense and protective actions of IFNs rely on signaling through IFN receptors, transcription factors and IFN-stimulated genes or antiviral cytokines requiring for virus degradation and suppression of viral transcription or translation. We verified that both type I and type III IFN genes expression and secreted proteins were more highly induced after influenza A virus infection in nasal epithelium. We also propose that type III IFNs are the primary IFNs to mediate an anti-viral defense in nasal epithelium and more sensitively reacted with ROS which were produced after respiratory virus infection. We estimate that ROS are necessary for the innate immune response and trigger the induction of IFN-related innate immune response to resist respiratory virus infection in human respiratory mucosa.

Medical treatment according to phenotypes of chronic rhinosinusitis

Chronic rhinosinusitis is generally divided into 2 types. One is chronic rhinosinusitis with nasal polyps and the other is chronic rhinosinusitis without nasal polyps. However, this classification has the drawbacks no consideration of various immunologic characters of chronic rhinosinusitis and too simple grouping. To compensate for these drawbacks, 1 recent classification has utilized histologic and immunologic parameters to subdivide chronic rhinosinusitis with nasal polyps into that with eosinophilic polyps and that with noneosinophilic nasal polyps. Moreover, phenotyping of chronic rhinosinusitis by using various clinical parameters such as biopsy, computed tomography, and endoscopic findings is very important for the appropriate medical treatment. In this review, before discussing the overall medical treatment of chronic rhinosinusitis, we describe not only clinical characters of chronic rhinosinusitis without nasal polyps but also the immunologic and histologic differentiation of chronic rhinosinusitis cases with eosinophilic and noneosinophilic nasal polyps closely related to the phenotype of chronic rhinosinusitis.

Determinants of Conductive Hearing Loss in Tympanic Membrane Perforation

OBJECTIVES: Tympanic membrane perforations are common, but there have been few studies of the factors determining the extent of the resulting conductive hearing loss. The aims of this study were to determine whether the size of tympanic membrane perforation, pneumatization of middle ear & mastoid cavity, and location of perforation were correlated with air-bone gap (ABG) of patients. METHODS: Forty-two patients who underwent tympanoplasty type I or myringoplasty were included and preoperative audiometry were analyzed. Digital image processing was applied in computed tomography for the estimation of middle ear & mastoid pneumatization volume and tympanic membrane photograph for the evaluation of perforation size and location. RESULTS: Preoperative mean ABG increased with perforation size (P=0.018), and correlated inversely with the middle ear & mastoid volume (P=0.005). However, perforations in anterior versus posterior locations showed no significant differences in mean ABG (P=0.924). CONCLUSION: The degree of conductive hearing loss resulting from a tympanic membrane perforation would be expected with the size of perforation and pneumatization of middle ear and mastoid.

Erratum: Determinants of Conductive Hearing Loss in Tympanic Membrane Perforation: Correction of the Sixth Author Name

The sixth author's name should have been given as Myung-Whan Suh.

A Case of Acute Mastoiditis Complicated with Epidural Abscess / 대한이비인후과학회지

Epidural abscess is the most common intracranial complication of acute mastoiditis and may lead to a life-threatening condition if an appropriate treatment is not performed. The treatment of choice is a surgical eradication of lesion, drainage of the abscess, and intravenous antibiotic therapy. We report a case of acute mastoiditis followed by an epidural abscess in the posterior cranial fossa in a 32-month male patient.