Facial pain: sinus or not?

Facial pain remains a diagnostic and therapeutic challenge for both clinicians and patients. In clinical practice, patients suffering from facial pain generally undergo multiple repeated consultations with different specialists and receive various treatments, including surgery. Many patients, as well as their primary care physicians, mistakenly attribute their pain as being due to rhinosinusitis when this is not the case. It is important to exclude non-sinus-related causes of facial pain before considering sinus surgery to avoid inappropriate treatment. Unfortunately, a significant proportion of patients have persistent facial pain after endoscopic sinus surgery (ESS) due to erroneous considerations on aetiology of facial pain by physicians. It should be taken into account that neurological and sinus diseases may share overlapping symptoms, but they frequently co-exist as comorbidities. The aim of this review was to clarify the diagnostic criteria of facial pain in order to improve discrimination between sinogenic and non-sinogenic facial pain and provide some clinical and diagnostic criteria that may help clinicians in addressing differential diagnosis.

Can curcumin modulate allergic rhinitis in rats?

OBJECTIVES: This study aimed to explore the effects of curcumin on experimental allergic rhinitis in rats. METHODS: Twenty-eight male Wistar albino rats were randomly divided into four groups: a control group; a group in which allergic rhinitis was induced and no treatment given; a group in which allergic rhinitis was induced followed by treatment with azelastine hydrochloride on days 21-28; and a group in which allergic rhinitis was induced followed by treatment with curcumin on days 21-28. Allergy symptoms and histopathological features of the nasal mucosa were examined. RESULTS: The sneezing and nasal congestion scores were higher in the azelastine and curcumin treatment groups than in the control group. Histopathological examination showed focal goblet cell metaplasia on the epithelial surface in the azelastine group. In the curcumin group, there was a decrease in goblet cell metaplasia in the epithelium, decreased inflammatory cell infiltration and vascular proliferation in the lamina propria. CONCLUSION: Curcumin is an effective treatment for experimentally induced allergic rhinitis in rats.

The role of endothelial nitric oxide synthase (eNOS) in the pathogenesis of sinonasal polyps.

OBJECTIVE: The pathogenesis of sinonasal polyps has not been known completely. We investigated the role of endothelial Nitric Oxide Synthase (eNOS) in the pathogenesis of sinonasal polyps. PATIENTS AND METHODS: Study group (Groups 1-3) consisted of nasal polyp samples of patients with sinonasal polyps; and control group consisted of inferior turbinate samples of patients without nasal polyp. In Group 1: 14 specimens from ethmoid sinus; in Group 2: 10 specimens from nasal cavity; in Group 3: 10 specimens from maxillary sinus; and in Group 4 (Control): 9 specimens from inferior turbinate were included. By immunohistochemical staining technique, eNOS Positivity Index in mucosal layers; and in the inflammatory cells were assessed. RESULTS: eNOS Positivity Index was higher at apical layer of epithelium; and perivascular and glandular parts of subepithelial layer. As a rate of mononuclear cells increased, eNOS positivity increased at basal part of epithelium. In eNOS Positivity Index of mononuclear cells increased ones, eNOS values also increased at glands of subepithelial layer. In nasal cavity, eNOS positivity index of all cells was significantly higher than that of the control group. Increased eNOS all cells positivity index values were seen with decreased glandular and endothelial eNOS values. In all cells group, fibroblasts were seen beside the mononuclear cells. It was observed that eNOS was not expressed in PMNC (mainly neutrophils), growing more in acute inflammatory process; and was expressed in MNCs and all cells group with fibroblasts which were the cells of chronic inflammatory process. Especially MNCs and fibroblasts may play a role in the polyp formation process. In males and in patients with longer polyp duration, eNOS values decreased. CONCLUSIONS: We concluded that eNOS Positivity Index was higher at apical layer of epithelium; and perivascular and glandular parts of subepithelial layer. eNOS plays role in vascular dilatation, increases in vascular permeability; increases in nasal secretion due to glandular secretion; and edema in subepithelial and deep layers of the mucosa by affecting glands. Irritant agents in the breathing air and environment may cause increase in eNOS values at apical part of epithelium and may promote polyp formation by vasodilatation and increased glandular secretion due to increased nitric oxide values. In elderly patients and in long standing polyps, eNOS values decreased causing more fibrotic polyps.

Inducible nitric oxide synthase (iNOS) in sinonasal polyp pathogenesis.

OBJECTIVES: We investigated the role of inducible nitric oxide synthase (iNOS) in the pathogenesis of sinonasal polyps. METHODS: Adult patients (21 men, 3 women) with nasal polyposis underwent functional endoscopic sinus surgery. Nine adults without polyps (6 men) who underwent septoplasty and/or rhinoplasty served as controls. Polyp specimens came from three regions: the maxillary sinus (10), ethmoid sinus (14), and nasal cavity (10). Control group samples (9) came from the inferior turbinate. Specimens were evaluated in eight mucosal layers for count and distribution of inflammatory cells and iNOS expression. An iNOS positivity index (PI) was determined for the epithelium (E), subepithelial layer of the lamina propria (SE), and deep paraglandular layer of the mucosa (D). RESULTS: Polymorphonuclear cell (PMNC) % values of the ethmoid and maxillary sinus and overall ethmoid sinus PI were significantly higher in the polyp group. Patients with longer polyp duration, D-perivascular (D-pv), and a higher Brinkmann index had decreased ethmoid sinus D PIs. However, in older patients and patients with longer polyp duration, perivascular PIs increased in maxillary sinus SE and D, respectively. Furthermore, as PMNC % and iNOS-PMNC PI increased, SE_glandular and epithelial_apical iNOS values decreased. In the ethmoid and maxillary sinuses, iNOS_D_. endothelial values increased but decreased in the nasal cavity. CONCLUSIONS: iNOS may play a role in sinonasal polyp pathogenesis, especially in mucosal SE and D layers. Increased vascular permeability, stromal edema, inflammatory cell migration into the stroma of the mucosa, and increased mucosal gland secretion may result in polyp formation.

Time-dependent middle ear pressure changes under general anaesthesia in children: N2O-O2 mixture versus air-oxygen mixture.

OBJECTIVES: The aim of this study was to investigate the effects of N2O-O2 mixture (Inspired O2 30%) on middle ear pressure (MEP) in children compared with the effects of an air-oxygen mixture (Inspired O2 50%). METHOD: The study included thirty child patients who underwent general anaesthesia for different reasons, with the exception of ENT problems and ear interventions. They were randomly divided into two groups. Group 1 (15 children: 10 male and 5 female) received a N2O-O2 mixture (Inspired O2 30%); and group 2 (15 children: 10 male and 5 female) were given an air-oxygen mixture (Inspired O2 50%). MEP was measured using a portable impedance analyser before the operation (PreO),10 minutes after intubation (10AEn), 30 minutes after intubation (30AEn), 10 minutes before extubation (10BEx), 15 minutes after the operation (PO15), 30 minutes after the operation (PO30), 1 hour after the operation (PO1h) and 6 hours after the operation (PO6h). RESULTS: The pressure and compliance values were the same in groups 1 and 2. The pressure-time graphs for the two groups were different: in Group 2, MEP rose quickly at 10AEn and positive pressure values were seen in the middle ear. MEP then fell rapidly until the end of the surgery and lower and negative pressures (Mean -50 daPa) were observed at PO6h. In Group 1, MEP was elevated at 10AEn and positive pressure was found (but not as high as in Group 2). MEP then fell more slowly. In other words, positive pressure in the middle ear persisted longer and the middle ear was subjected to positive pressure and nitrogen over a longer period. Separate analyses were made in Groups 1 and 2 of pressure differences and of compliance values at eight measurement points using the Friedman test. Differences in pressure values were found to be statistically significant in both Group 1 (p = 0.000) and Group 2 (p = 0.000). In Group 1, all the 10AEn and 30AEn values were significantly higher than the PreO, PO30, PO1h and PO6h values. The 10BEx value was significantly higher than the PreO and PO1h values. The PO15 value was significantly higher than the PreO value. In Group 2, the PO6h value was significantly lower than the 10BEx, 10AEn and 30AEn values. The PO1h value was significantly lower than the 30AEn values. The MEP values increased in Group 1 in younger and taller children and in children receiving anaesthesia for shorter periods. MEP values increased in Group 2 in younger and taller children, and in heavier children. MEP values fell with the length of anaesthesia. CONCLUSION: In brief anaesthesia, nitrogen was not removed from the middle ear quickly in Group 1: middle ear pressure values were higher. The nitrous oxide remained in the middle ear longer and so the possibility of ear toxicity may increase. In Group 2, 50% O2 was rapidly absorbed and removed from the middle ear and so middle ear pressure was not as high. It may be concluded that air-oxygen mixture (Inspired O2 50%) anaesthesia should be recommended as being more reliable in tympanoplasties and other middle ear interventions than a N2O-O2 mixture (Inspired O2 30%).