Juvenile nasopharyngeal angiofibroma: a single centre's 11-year experience.

OBJECTIVE: This study aimed to present the clinical features and surgical outcomes of juvenile nasopharyngeal angiofibroma patients who were surgically treated. METHODS: The medical records of 48 male patients histologically confirmed as having juvenile nasopharyngeal angiofibroma, who underwent transnasal endoscopic surgery between 2005 and 2016, were retrospectively reviewed. RESULTS: The overall recurrence rate was 20.8 per cent; however, the recurrence rate differed significantly between patients diagnosed aged less than 14 years (34.7 per cent) and more than 14 years (8 per cent) (p < 0.05). Advanced-stage tumours (Radkowski stage of IIC or more, and Önerci stage of III or more) were more aggressive than earlier stage tumours (p < 0.05 and p < 0.01, respectively). Pre-operative embolisation significantly prolonged mean hospitalisation duration, but had no effect on intra-operative blood loss in patients with advanced-stage tumours (p < 0.001 and p = 0.09, respectively). CONCLUSION: The findings show that transnasal endoscopic surgery could be considered the treatment of choice for juvenile nasopharyngeal angiofibroma. Patients diagnosed when aged less than 14 years and those with advanced-stage tumours are at risk of recurrence, and should be monitored with extreme care.

mySinusitisCoach: patient empowerment in chronic rhinosinusitis using mobile technology.

Mobile health technology is emerging to take a prominent position in the management of chronic diseases. These technologies aim at enhancing patient empowerment via education and self-management. To date, of all the different apps available for patients with sinus disease, none were developed by medical experts dealing with chronic rhinosinusitis (CRS). The European Forum for Research and Education in Allergy and Airway diseases (EUFOREA) has undertaken a multi-stakeholder approach for designing, developing and implementing a tool to support CRS patients in monitoring their symptoms and to provide patients with a digital support platform containing reliable medical information about their disease and treatment options. mySinusitisCoach has been developed by medical experts dealing with CRS in close collaboration with patients, primary care physicians and community pharmacists, meeting the needs of both patients and health care providers. From a research perspective, the generation of real life data will help to validate clinical studies, patient stratification and improve understanding of the socio-economic impact of CRS, thereby paving the way for better treatment strategies.

Prospective multicentre study on barbed reposition pharyngoplasty standing alone or as a part of multilevel surgery for sleep apnoea.

OBJECTIVES: The aim of this study was to demonstrate in a prospective multicentre study that Barbed Reposition Pharyngoplasty (BRP) procedure is safe and effective in management of obstructive sleep apnoea/hypopnea syndrome (OSAHS) patients. DESIGN: Prospective study. SETTING: Multicentre study. PARTICIPANTS: Patients suffering from obstructive sleep apnoea. MAIN OUTCOMES MEASURES: Values of postoperative apnoea-hypopnea index (AHI), oxygen desaturation index (ODI), epworth sleepiness scale (ESS). RESULTS: 111 Barbed Reposition Pharyngoplasty procedures standing alone or as a part of multilevel surgery for OSAHS, performed between January and September 2016, were analysed in 15 different centres. The average hospitalisation period was 2.5 ± 0.5 days. The mean patient age was 46.3 ± 10.5 years. The average body mass index at the time of the procedure was 27.9 ± 3.2, and the majority of the patients were men (83%). The mean preoperative and postoperative apnoea/hypopnea index was 33.4 ± 19.5 and 13.5 ± 10.3, respectively (P < .001). The mean preoperative and postoperative ESS score was 10.2 ± 4.5 and 6.1 ± 3.6, respectively (P < .001). The mean preoperative and postoperative ODI were 29.6 ± 20.7 and 12.7 ± 10.8, respectively (P < .001). CONCLUSIONS: Patients undergoing BRP standing alone or as part of a multilevel approach for the treatment of OSAHS have a reasonable expectation for success with minimal morbidity.

Rhinology Future Debates, an EUFOREA Report.

The first Rhinology Future Debates was held in Brussels in December 2016, organized by EUFOREA (European Forum for Research and Education in Allergy and Airways diseases). The purpose of these debates is to bring novel developments in the field of Rhinology to the attention of the medical, paramedical and patient community, in a highly credible and balanced context. For the first time in Rhinology, a peer to peer scientific exchange with key experts in the field of rhinology and key medical colleagues from leading industries let to a brainstorming and discussion event on a number of hot issues in Rhinology. Novel developments are presented by key experts from industry and/or key thought leaders in Rhinology, and then followed by a lively debate on the potential positioning of new developments in care pathways, the strengths and weaknesses of the novel development(s), and comparisons with existing and/or competing products, devices, and/or molecules. As all debates are recorded and distributed on-line with limited editing (www.rhinology-future.com), EUFOREA aims at maximizing the education of the target groups on novel developments, allowing a critical appraisal of the future and a more rapid implementation of promising novel tools, techniques and/or molecules in clinical practise in Europe. The next Rhinology Future debate will be held in Brussels in December 2017.

Positioning the principles of precision medicine in care pathways for allergic rhinitis and chronic rhinosinusitis - A EUFOREA-ARIA-EPOS-AIRWAYS ICP statement.

Precision medicine (PM) is increasingly recognized as the way forward for optimizing patient care. Introduced in the field of oncology, it is now considered of major interest in other medical domains like allergy and chronic airway diseases, which face an urgent need to improve the level of disease control, enhance patient satisfaction and increase effectiveness of preventive interventions. The combination of personalized care, prediction of treatment success, prevention of disease and patient participation in the elaboration of the treatment plan is expected to substantially improve the therapeutic approach for individuals suffering from chronic disabling conditions. Given the emerging data on the impact of patient stratification on treatment outcomes, European and American regulatory bodies support the principles of PM and its potential advantage over current treatment strategies. The aim of the current document was to propose a consensus on the position and gradual implementation of the principles of PM within existing adult treatment algorithms for allergic rhinitis (AR) and chronic rhinosinusitis (CRS). At the time of diagnosis, prediction of success of the initiated treatment and patient participation in the decision of the treatment plan can be implemented. The second-level approach ideally involves strategies to prevent progression of disease, in addition to prediction of success of therapy, and patient participation in the long-term therapeutic strategy. Endotype-driven treatment is part of a personalized approach and should be positioned at the tertiary level of care, given the efforts needed for its implementation and the high cost of molecular diagnosis and biological treatment.

The comparison of the quality of life and intranasal edema between the patients with or without nasal packing after septoplasty.

Septoplasty is one of the most common operations performed in otolaryngology and anterior nasal packing is done routinely to prevent postoperative bleeding, septal hematoma or nasal synechia. Currently, transseptal sutures have gained a broader application area, not only for preventing the complications such as septal hematoma and bleeding but also closing any accidental tears of septal mucosa and providing additional support for the cartilage pieces retained in septoplasty. We evaluated the quality of life of the patients in early postoperative period (in the first postoperative week), intranasal edema with endoscopic examination and the intranasal changes with acoustic rhinometry. We performed a prospective and randomized study with patients undergoing septoplasty without inferior turbinectomy. As packing material, there were two groups: in group A, gauze in a glove finger and in group B, Doyle splint were used, and in the additional group C, only transseptal suture with 4/0 vicryl among the cartilaginous septum was performed. The patients were invited to control examinations on the postoperative 2nd, 4th and 7th days to evaluate the scores from 1 to 5 on the questionnaire for the pain, nasal fullness, sneezing, epiphora, difficulty in swallowing and sleep disturbances. The patients were also administered an endoscopic nasal examination for the purpose of detecting the intranasal edema, and acoustic rhinometry was performed during the control examinations to detect the intranasal changes. Total occluding packing was found to cause much more frequent and higher scores of epiphora, sneezing, difficulty in swallowing, but mainly, the pain compared to in silicone packing with airway and transseptal suture only. Although the silicone packing with airway was found to be much more comfortable, it also led to sneezing and epiphora. The patients without nasal packing had more comfortable period especially in the early postoperative days (the first 4 days). However, 1 week after surgery, groups with and without nasal packing were found to be equalized on behalf of the objective and subjective parameters. As any complication was not observed due to not using nasal packing, it is thought that nasal packing usage following septoplasty is not a necessity.

Aspirin 300 mg/day is effective for treating aspirin-exacerbated respiratory disease.

BACKGROUND: Aspirin desensitization (AD) treatment at doses of up to 1300 mg/day improves outcomes in aspirin-exacerbated respiratory disease (AERD). The aim of this study was to investigate the efficacy of aspirin 300 mg/day in the treatment of patients with AERD. METHODS: The study included 40 patients diagnosed in our clinic as AERD that were desensitized and treated with aspirin 300 mg/day between December 2005 and December 2012. Changes from the baseline status were analyzed at 1 year and at 3 years of follow-up. RESULTS: Of the 40 patients included, 24 (60%) were female and median (interquartile range [IQR]) age was 45 (40-51) years. Median (IQR) duration of AD was 31.5 (10.5-48.5) months. In total, 29 patients continued treatment for at least 1 year and 18 patients for at least 3 years. The annual rate of use of systemic corticosteroid regimens, episodes of sinusitis, and surgery was significantly lower both at 1 year (P = 0.002, P = 0.01, and P < 0.001, respectively) and at 3 years (P = 0.001, P = 0.03, and P = 0.002, respectively). Significant improvement was observed in the nasal congestion score (P = 0.01) and sense of smell score (P = 0.05) at 1 year and in the postnasal drainage score (P = 0.01) at 3 years. CONCLUSION: Daily treatment with aspirin 300 mg had beneficial effects in patients with AERD, especially for the control of upper airway disease.

Dacryocystorhinostomy. Diagnosis and treatment of nasolacrimal canal obstructions.

Since Toti's original description of the dacryocystorhinostomy (CDR) in 1904, most surgery for relief of lacrimal obstruction has been performed through an external incision. Although the endonasal approach was for the first time introduced by Caldwell in 1893, its use stayed limited due to difficulties in visualizing the endonasal structures during the operation. The advance of the operating microscope and later a rigid endoscope into the surgery awakened interest for the endonasal approach. Endonasal DCR surgery has the advantages of preventing a scar on the skin and preserving the pump function of the naslacrimal sac. If the surgeon is experienced in endoscopic or microscopic surgery, correct localization of the window and addressing possible other nasal pathologies is possible in the same session. The endonasal laser DCR is not the first operation to be preferred due to the high cost, longer operation time, and less satisfactory results. It may be an alternative in cases with a tendency to bleeding. Endonasal surgery can not help canalicular problems. In these cases external surgery should be preferred. In revision cases, the endonasal approach is preferred by almost all authors. Even in external surgery, endoscopy may accompany the external approach to check the site of the fistula. Silicone intubation may be used routinely for two months to have better results, but no longer than 3 months to avoid complications. Silicone intubation is especially recommended in canalicular stenosis, small scarred lacrimal sacs and in reoperations. In this review article, diagnostic tests and various surgical methods, the advantages and disadvantages, were compared. Reasons for failure after surgery are also discussed.

Conventional or endoscopic probing for congenital nasolacrimal duct obstruction.

PURPOSE: To compare conventional and endoscopic probing for congenital nasolacrimal duct obstruction in infants. METHODS: Conventional probing was performed in 22 eyes of 18 patients, age range 7-14 months (mean 11.4 months). Probing was done with intranasal endoscopic visualization in 18 eyes of 14 patients, age range 7-13 months (mean 11.2 months). All were primary probing cases. RESULTS: After conventional probing 2 of the 22 cases required reprobing. After endoscopic probing only 1 of the 18 cases required reprobing. CONCLUSIONS: In most cases of congenital nasolacrimal duct obstruction endoscopy is not required; however, in failed cases direct visualization of the inferior meatus with endoscopic guidance may be helpful.

Positive surgical margins in cancer of the larynx.

In order to determine what should be done for laryngeal cancer patients when surgical margins are positive, and to evaluate their prognosis, a retrospective review of 21 laryngeal cancer patients with positive surgical margins out of 714 surgically treated cases (2.9%) was carried out. Nineteen patients were treated with postoperative radiation therapy. Two patients who had had endolaryngeal partial laryngectomy were treated with vertical partial laryngectomy. Two patients were lost to follow-up. Ten patients (10/19; 53%) were recurrence-free. Four patients had local, two had regional, and two had locoregional recurrences. Only one patient with a local recurrence could be salvaged with total laryngectomy and is disease-free. One patient developed liver metastasis. Nineteen patients had a mean and median disease-free survival of 48 and 36 months, respectively. Nine out of fourteen patients (64%) treated curatively were recurrence-free. The patients with positive margins developed significantly more locoregional recurrences than those with free margins (P < 0.05). We conclude that surgical margins must be checked peroperatively with frozen sections to make sure that they are free. The margins of every laryngectomy specimen must be diligently examined. If positive, re-excision, postoperative radiotherapy and chemotherapy are treatment alternatives. They should not just be managed with close follow-up. However, whatever treatment is applied, the prognosis for patients with positive margins is significantly worse than for those with free margins.

Pulmonary metastasectomy in the treatment of recurrent ameloblastoma of the maxilla and mandible: a case report.

Ameloblastoma is an aggressive benign tumor with frequent local recurrences. Although histologically benign, it occasionally metastasizes to many organs, most commonly to the lungs. The metastasis develops after multiple recurrences and many unsuccessful attempts at removal of the tumor. When distant metastasis occurs, the prognosis is poor and there is no effective treatment. A case of metastatic ameloblastoma of the mandible and maxilla is reported which was treated with pulmonary metastasectomy. The treatment options are discussed in relation to the literature.

Reappraisal of probing of the congenital obstruction of the nasolacrimal system: is nasal endoscopy essential?

OBJECTIVE: The rate of false passages during probing for congenital nasolacrimal system obstruction (CNLO) is a major limiting factor for a successful outcome. This shortcoming may be decreased with the use of a nasal endoscope during probing. This approach is particularly important in the probing training of ophthalmology residents. METHODS: An experienced pediatric ophthalmologist performed probings on 11 eyes, and a group of ophthalmology residents under his supervision performed probings on another 11 eyes for CNLO. Their claims of a successful or unsuccessful procedure were evaluated with nasal endoscopy by an ear--nose--throat (ENT) surgeon. The age range of the patients was 8-23 months. RESULTS: The ophthalmologist made two false passages, one of which he was aware, out of 11 eyes. The residents had five false passages, two of which were unclear to them, out of another 11 eyes. No false passages occurred in obstructions at the level of the Hasner valve. None of the successful probings required more than a 30 mm probe introduction into the nasolacrimal canal from the inferior punctum. CONCLUSION: It seems justified to have a nasal endoscopic evaluation, performed by an ENT surgeon, for probings during the training program of ophthalmology residents. Difficult cases with stenosis proximal to the inferior meatus, prior false passage experience on a particular case, and any indication for silicone tube implantation will benefit from the use of an endoscope during the procedure. In order to achieve the best results in CNLO, the collaborative teamwork of an ophthalmologist and an ENT specialist is necessary.

Long-term results and reasons for failure of intranasal endoscopic dacryocystorhinostomy.

The aim of this study was to evaluate the long-term results and the factors influencing the success in patients with nasolacrimal duct obstruction treated with intranasal endoscopic dacryocystorhinostomy (DCR) and silicone tube intubation (STI). We prospectively investigated 158 patients with lacrimal obstruction in two groups, one of which comprised 108 patients treated primarily with intranasal endoscopic DCR by experienced surgeons and the other comprised 50 patients who were operated on by inexperienced surgeons. In a mean follow-up time of 49 months the surgical success was 94.4% in experienced hands and 58.0% in inexperienced hands. The endoscopic examination of six patients with failure in the first group revealed granulation tissue around the tube in four, atonic sac in one and persistence of bone that was supposed to have been excised in the nasal cavity in one. There were 21 failures out of 50 patients in the second group: granulation tissue in 2 cases, fenestration to the nasolacrimal duct instead of the sac in 6 cases, synechia between the lateral nasal wall and the middle turbinate in 2 cases, bony spicles causing obstruction in 5 cases and fenestration anterior to the sac in 2 cases. In 4 cases no reasons were found for failure, but perhaps the small fenestration and failure to remove the medial half of the membranous sac wall was the reason. DCR and STI can be performed for primary treatment in lacrimal obstruction. There is a learning curve for the operation. False localization of the lacrimal sac, granulation tissue formation around the tubes, retained bony spicles, inadequate removal of the medial wall of the sac and the synechia between the lateral wall and the middle turbinate are the most common causes of failure.

Hamartoma of the larynx: a case of unusual bleeding after microlaryngoscopy.

We report on a rare complication of surgery in a 36-year-old man who had undergone removal of a hamartoma of the larynx. The patient had developed a submucosal lesion in the left ventricular fold, which was removed by surgical microlaryngoscopy. Following the excision, the patient began to experience an excessive amount of bleeding at the surgical site. Before hemostasis was achieved, the patient had lost almost 1,000 ml of blood. Although the occurrence of hemorrhage during surgical laryngoscopy is rare, surgeons should be aware of and prepared for this possibility.

Necrotizing otitis externa, otitis media, peripheral facial paralysis, and brain abscess in a thalassemic child after allogeneic BMT.

Severe infection is one of the major complications in the early and late post-bone marrow transplantation period. The authors report a thalassemic child who developed necrotizing otitis externa and otitis media, a very rare complication after bone marrow transplantation, and then peripheral facial nerve paralysis and brain abscess in the early period of bone marrow transplantation despite antibacterial and antifungal prophylaxis. Necrotizing otitis media is characterized by necrosis and sloughing of considerable areas in the middle ear and adjacent tissues and is an unusual disorder because of today's antibiotics. Granulocytopenia and background ear tissue exposed to previous repeated otitis media attacks may be the predisposing factors in this case. The authors conclude that the children with previous histories of recurrent otitis media should be prepared and monitored very carefully during bone marrow transplantation because of the risk of necrotizing otitis media, especially in the granulocytopenic period.