Dose-dependent relationship between nocturnal gastroesophageal reflux and chronic rhinosinusitis in a middle-aged population: results from the SCAPIS pilot.

BACKGROUND: Gastroesophageal reflux (GER) has been associated with several upper- and lower-airway diseases. It would be plausible if nightly occurring reflux via laryngopharyngeal reflux (LPR) might affect the upper airways. Still, the role of nocturnal gastroesophageal reflux (nGER) in chronic rhinosinusitis (CRS) is not fully established. The aim of this population-based study was to investigate the association between nGER and CRS. METHODOLOGY: This cross-sectional population-based study comprises 1,111 randomly selected subjects from Gothenburg, Sweden, aged 50-64 years. The study is based on self-reported validated questionnaires. CRS was defined according to EPOS criteria. nGER was reported in relation to frequency. RESULTS: CRS was more common among subjects with nGER than in those without (13 vs. 4.8%). There was a dose-response association between the frequency of nGER episodes and the risk of having CRS. In the logistic regression adjusted for (age, sex, BMI, educational level, smoking, and asthma). CRS was associated with nGER, OR 1.43 and the odds ratio increased if episodes were reported 'almost every night' OR 4.6. CONCLUSIONS: The study shows an association between nocturnal GER and CRS in a middle-aged population. The revealed dose dependency supports, though does not prove causality.

Unmet challenges in septoplasty-nordic studies from a uniform healthcare and geographical area.

Purpose: Nasal septoplasty is one of the most common surgical procedures in otorhinolaryngology and optimising both patient selection and the surgery is a challenge. The Nordic countries have similar public healthcare systems and comparable populations in terms of size. Methods: This is a review of studies of outcome and predictors related to septoplasty from Denmark, Finland, Norway and Sweden, published during the last decade. The aim of this review was to identify areas in need of further research to meet the challenges of septoplasty in the Nordic countries with reference to international data. Results: Postoperative patient satisfaction at 6-12 months was reported in around 2/3 of the patients and well in line with international data. Patients with more severe symptoms had a higher chance of improvement. Lack of standardisation in patient selection, surgical methods and skills, and follow up procedures, still makes it difficult to explain the 25% failure rate in septoplasty surgery. Conclusion: This review of the Nordic studies from the last decade shows that septoplasty in general is effective in relieving nasal obstruction. There is a need for studies addressing the standardisation of diagnostic tools and algorithms and the systematic and continuous implementation of follow-up of the surgical results at both departmental and personal level. This includes an awareness of how surgical skills in septoplasty are obtained and maintained.

Surgery to relieve nasal obstruction: outcome for 366 patients operated on by one senior surgeon.

BACKGROUND: Studies of patient-rated outcome in septoplasty and turbinoplasty most frequently involve several surgeons with varying surgical skills, techniques and experience. The aim of the present study was to evaluate outcome based on one experienced surgeon. METHODS: Three hundred and sixty-six consecutive patients referred for nasal obstruction were included. All the patients were examined with nasal endoscopy before and after decongestion, they filled out a nose VAS and rated their overall general health before and three to six months after surgery. The patients underwent septoplasty, septoplasty plus turbinoplasty or turbinoplasty. RESULTS: The mean nose VAS for nasal obstruction (0-100) preoperatively was 64.7 for all patients. Patients undergoing septoplasty (n = 159) were younger than patients undergoing septoplasty + turbinoplasty (n = 79) or patients undergoing turbinoplasty alone (n = 128). The nose VAS for nasal obstruction improved significantly in all three groups and 25% had a normal nose VAS after surgery in the septoplasty and septoplasty + turbinoplasty groups compared to only 8% in the turbinoplasty alone group. There was no significant difference in the improvement in nasal obstruction between septoplasty and septoplasty + turbinoplasty, but the septoplasty + turbinoplasty group experienced a significantly greater improvement in general health. CONCLUSIONS: In 366 patients operated on by one experienced surgeon, septoplasty and septoplasty + turbinoplasty were more effective at relieving nasal obstruction than turbinoplasty alone. Septoplasty + turbinoplasty resulted in a greater improvement in general health than septoplasty alone, despite the same improvement in nasal obstruction, indicating a beneficial effect of additional turbinoplasty in septoplasty.

Total nasal airway resistance while sitting predicts airway collapse when lying down.

BACKGROUND: Nasal obstruction when lying down is a common complaint in patients with chronic nasal obstruction, but rhinomanometry is typically performed in the sitting position. This study aimed to analyse whether adding rhinomanometry in a supine position is a useful examination. METHOD: A total of 41 patients with chronic nasal obstruction underwent rhinomanometry and acoustic rhinometry, sitting and supine, before and after decongestion, as well as an over-night polygraphy. RESULTS: Total airway resistance was measurable in a supine position in 48 per cent (14 of 29) of the patients with total airway resistance of equal to or less than 0.3 Pa/cm3/second when sitting and in none (0 of 12) of the patients with total nasal airway resistance of more than 0.3 Pa/cm3/second when sitting. After decongestion, this increased to 83 per cent and 58 per cent, respectively. CONCLUSION: Increased nasal resistance when sitting predicts nasal breathing problems when supine. Rhinomanometry in a supine position should be performed to diagnose upper airway collapse when supine.

Occupational exposure and the risk of new-onset chronic rhinosinusitis â€" a prospective study 2013-2018.

BACKGROUND: The aetiology behind chronic rhinosinusitis (CRS) is still poorly understood. The aim of this study was to investigate the association between the onset of CRS and several common occupational exposures over time. METHODOLOGY: An adult random population from Telemark, Norway, comprising 7,952 subjects, who answered a comprehensive respiratory questionnaire including questions on CRS and occupational exposure first in 2013 and again in 2018. RESULTS: New-onset CRS during the five-year follow-up was independently associated with occupational exposure to hair-care products, cleaning agents among women, super glue, strong acids, cooking fumes and wood dust. CONCLUSION: In this random population cohort from Norway, exposure to several common occupational agents, such as hair-care products, super glue and wood dust, was associated with the onset of CRS. It is important that physicians who see patients with CRS inquire about workplace exposure.

Prognostic factors for outcome after septoplasty in 888 patients from the Swedish National Septoplasty Register.

BACKGROUND: The aim of this study was to identify predictors of outcome after septoplasty in 888 patients from the Swedish National Septoplasty Register. METHODOLOGY: This is an observational register study analysing data from patients undergoing septoplasty in Sweden between 2015 and 2016. The patients reported severity of nasal obstruction (mild, moderate, severe) pre- and again 12 months postoperatively (none, mild, moderate, severe), unplanned visits within 30 days after surgery. The examining doctor reported co-morbidities such as allergic rhinitis and snoring. The primary end-point was one level improvement of the nasal obstruction 12 months after surgery. RESULTS: Nasal obstruction had improved in 63% 12 months after surgery. Twelve months after surgery, 81% with severe nasal obstruction and 31% with mild nasal obstruction before surgery had improved. Only 56% reported that the results of the surgery were as they had expected. Higher patient age at surgery, no unplanned visits within 1 month of surgery and activity limitation before surgery were associated with improvements in nasal breathing in the logistic regression model. CONCLUSION: Septoplasty should be offered to patients with severe nasal obstruction and surgery should be avoided in mild nasal obstruction confirmed by both an improvement in nasal obstruction and patient expectations in this study.

Indirect costs related to caregivers' absence from work after paediatric tonsil surgery.

Tonsillotomy has gradually replaced tonsillectomy as the surgical method of choice in children with upper airway obstruction during sleep, because of less postoperative pain and a shorter recovery time. The aim of this study was to examine the costs related to caregivers' absenteeism from work after tonsillectomy (TE) and tonsillotomy (TT). All tonsillectomies and tonsillotomies in Sweden due to upper airway obstruction during 1 year, reported to the National Tonsil Surgery Register in children aged 1-11 were included, n = 4534. The number of days the child needed analgesics after surgery was used as a proxy to estimate the number of work days lost for the caregiver. Data from the Social Insurance Agency (Försäkringskassan) regarding the days the parents received temporary parental benefits in the month following surgery were also analysed. The indirect costs due to the caregivers' absenteeism after tonsillectomy vs tonsillotomy were calculated, using the human capital method. The patient-reported use of postoperative analgesic use was 77% (n = 3510). Data from the Social Insurance Agency were gathered for all 4534 children. The mean duration of analgesic treatment was 4.6 days (indirect cost of EUR 747). The mean number of days with parental benefits was 2.9 (EUR 667). The indirect cost of tonsillectomy was 61% higher than that of tonsillotomy (EUR 1010 vs EUR 629). The results show that the choice of surgical method affects the indirect costs, favouring the use of tonsillotomy over tonsillectomy for the treatment of children with SDB, due to less postoperative pain.

Healthcare provider contact for children with symptoms of sleep-disordered breathing: a population survey.

BACKGROUND: Symptoms of sleep-disordered breathing in children, such as frequent snoring, apnoea and choking, may lead to health problems if untreated. The caregiver's level of awareness of these symptoms has been poorly studied. This study aimed to study healthcare provider contact related to sleep-disordered breathing symptoms in a population of children aged 0-11 years. METHODS: A total of 1320 children were randomly selected from a national database that included all children living in Sweden. Caregivers answered a questionnaire about sleep-disordered breathing symptoms during the last month and healthcare provider contact related to these symptoms. RESULTS: A total of 754 answers were received. The prevalence of sleep-disordered breathing symptoms was 4.8 per cent. Of this subgroup, 69 per cent had not been in contact with a healthcare provider regarding their symptoms. CONCLUSION: This study shows that sleep-disordered breathing in children is underestimated and that there is a need to increase caregiver and healthcare provider awareness of sleep-disordered breathing in children.

Simulated postnasal mucus fails to reproduce the symptoms of postnasal drip in rhinitics but only in healthy subjects.

BACKGROUND: Post nasal drip (PND) is a very common symptom associated with upper respiratory tract disorders. While easy to visualize, the concept of PND due to an increased volume of secretions which move from the posterior nasal choanae into the posterior nasopharynx/oropharynx may be overly simplistic. PND could also be associated with altered viscosity of nasal secretions. An alternative hypothesis is that the sensation of PND is due to mucosal inflammation resulting in heightened cough or irritant throat sensory dysfunction. The impact of viscous secretions on the symptoms of PND is assessed. METHODS: Healthy subjects and rhinitis patients were recruited. Patients were asked about PND symptoms with a 9 item PNDSS questionnaire at baseline and after the insertion of two different viscosities of artificial mucus utilizing hydroxypropyl methylcellulose at 1% and 4%. RESULTS: Sixty six patients were recruited. As expected, rhinitics had an increased sense of PND compared to healthy subjects at baseline. However, only healthy subjects could detect the increased viscosity of secretions and where rhinitics failed to respond. Cough was not induced in either group. CONCLUSION: The mechanisms of PND in chronic patients and those with rhinitis are likely to have other aetiologies other than simply increased or more viscous secretions.

Nocturnal GERD - a risk factor for rhinitis/rhinosinusitis: the RHINE study.

BACKGROUND: It has been suggested that gastroesophageal reflux disease (GERD) is a risk factor for developing rhinitis/rhinosinusitis, but data are lacking. This is a prospective 10-year follow-up study of a large multicenter cohort from Northern Europe, evaluating the relationship between nocturnal GERD and noninfectious rhinitis (NIR). METHODS: The study comprised 5417 subjects born between 1945 and 1973, who answered a questionnaire in 1999-2001 and again in 2010-2012. Noninfectious rhinitis was defined as having nasal obstruction, secretion, and/or sneezing without having the common cold. Odds ratios for developing NIR in relation to age, gender, BMI, smoking, asthma, and nocturnal GERD were calculated. RESULTS: During the 10-year observation period, 1034 subjects (19.1%) developed NIR. Subjects reporting nocturnal gastroesophageal reflux in both 1999 and 2010 had more NIR in 2010 (2.8% vs 1.2%, P < 0.001). There was a significant dose-response relationship between the number of reflux episodes/week in 1999 and the risk of having NIR in 2010, P = 0.02. In the multiple regression adjusted for age, gender, BMI, tobacco smoke, and asthma, those with nocturnal GERD in 1999 (≥3 episodes of nocturnal gastroesophageal reflux symptoms per week) had an OR of 1.6 (95% CI 1.0-2.5, P = 0.03) to develop NIR in 2010. Smoking was associated both with an increased risk of developing NIR (30.7% vs 24.0%, P < 0.001) and with the development of nocturnal GERD. CONCLUSION: This large, population-based, 10-year study indicates that nocturnal GERD was a risk factor for noninfectious rhinitis/rhinosinusitis. GERD should therefore be considered in patients with rhinitis of known and unknown origin.

Allergic rhinitis and the common cold--high cost to society.

UNLABELLED: The common cold and allergic rhinitis constitute a global health problem that affects social life, sleep, school and work performance and is likely to impose a substantial economic burden on society because of absence from work and reduced working capacity. This study assesses the loss of productivity as a result of both allergic rhinitis and the common cold in the Swedish working population. METHODS: Four thousand questionnaires were sent to a randomized adult population, aged 18-65 years, in Sweden, stratified by gender and area of residence (metropolitan area vs rest of the country). The human capital approach was used to assign monetary value to lost productivity in terms of absenteeism (absence from work), presenteeism (reduced working capacity while at work) and caregiver absenteeism (absence from work to take care of a sick child). RESULTS: Thousand two hundred and thirteen individuals responded, response rate 32%. The mean productivity loss was estimated at 5.1 days or euro 653 per worker and year, yielding a total productivity loss in Sweden of euro 2.7 billion a year. Of the total costs, absenteeism (44%) was the dominant factor, followed by presenteeism (37%) and caregiver absenteeism (19%). Poisson regression analyses revealed that women, people in the 18-29 year age group, and respondents with 'doctor-diagnosed asthma' reported more lost days than the rest of the group. CONCLUSION: In Sweden, the cost of rhinitis is euro 2.7 billion a year in terms of lost productivity. A reduction in lost productivity of 1 day per individual and year would potentially save euro 528 million.

Genes regulating molecular and cellular functions in noninfectious nonallergic rhinitis.

BACKGROUND: Chronic noninfectious, nonallergic rhinitis (NINAR) is a complex syndrome with a principally unknown pathophysiology. New technology has made it possible to examine differentially expressed genes and according to network theory, genes connected by their function that might have key roles in the disease. METHODS: Connectivity analysis was used to identify NINAR key genes. mRNA was extracted from nasal biopsies from 12 NINAR patients and 12 healthy volunteers. Microarrays were performed using Affymetrix chips with 54 613 genes. Data were analysed with the Ingenuity Pathway System for organization of genes into annotated biological functions and, thereafter, linking genes into networks due to their connectivity. The regulation of key genes was confirmed with reverse transcription-polymerase chain reaction (RT-PCR). RESULTS: In all, 43 genes were differentially expressed. The functional analysis showed that these genes were primarily involved in cellular movement, haematological system development and immune response. Merging these functions, 10 genes were found to be shared. Network analysis generated three networks and two of these 'shared genes' in key positions, c-fos and cell division cycle 42 (Cdc42). These genes were upregulated in both the array and the RT-PCR analysis. CONCLUSION: Ten genes were found to be of pathophysiological interest for NINAR and of these, c-fos and Cdc42 seemed to be of specific interest due to their ability to interact with other genes of interest within this context. Although the role of c-fos and Cdc42 in upper airway inflammation remains unknown, they might be used as potential disease markers.

Rhinitis increase the risk for adult-onset asthma--a Swedish population-based case-control study (MAP-study).

The aim of the study was to examine certain predictors, especially non-infectious rhinitis, and the risk for adult-onset asthma. A nested case-control study of adult-onset asthma was performed in a random sample from the general population (n = 15,813), aged 21 to 51 years. Cases for the study included subjects reporting physician-diagnosed asthma (n = 235) and controls (n = 2044) were randomly selected from the whole population sample. The case-control sample was investigated with a comprehensive respiratory questionnaire. Odds ratios were calculated stratified for sex, year of diagnosis and birth-year. Adult-onset physician-diagnosed asthma was associated with occurrence of non-infectious rhinitis before asthma onset (OR = 5.4, 95% CI 4.0-7.2), especially among smoking non-atopics (OR = 9.1, 95% CI 5.3-15.4). Smoking before asthma onset increased the risk for asthma (OR = 1.5, 95% CI 1.1-2.1). In conclusion, this population-based case-control study indicate that non-infectious rhinitis and current smoking, especially among non-atopics, are associated with increased risk for adult-onset asthma.

Increased nasal mucosal swelling in subjects with asthma.

OBJECTIVE: The objective of this study was to evaluate nasal mucosal swelling with acoustic rhinometry in subjects with asthma and in healthy controls. METHODS: We examined 184 individuals with asthma and compared with 156 randomly selected controls outside the pollen season, where 144 subjects in the asthma group and 80 controls had a previous history of non-infectious rhinitis (NIR). Nasal mucosal swelling was assessed with acoustic rhinometry before and after nasal decongestion with oxymetazoline and was analysed for the crosssectional area (4cm from the nostril) and the volume between 3.3 and 4cm from the nostril. Symptom scores for nasal blockage, secretion, itching and sneezing were assessed on a 0-10 visual analogue scale as well as peak nasal inspiratory flow and spirometry. RESULTS: Before decongestion there was a decrease in the cross-sectional area at 4 cm (1.32 cm2 vs. 1.59 cm2, mean left + right P = 0.04) and in the volume (1.70 vs. 1.91 cm3 P = 0.03) in the asthma group compared with healthy controls. After decongestion there were no significant differences in cross-sectional area at 4cm (1.66 vs. 1.73cm2 P=0.32) or volume (2.12 vs. 2.24cm3 P=0.32). Combined nasal symptom scores were higher in the asthma group (1.8 vs. 0.8, P=0.0001) and peak nasal inspiratory flow was lower (119 vs. 124 L/min, P = 0.38) than the healthy controls. FEV1 (% predicted) was also lower in asthma group (84 vs. 93% P < 0.0001). CONCLUSION: We have been able to demonstrate an increased nasal mucosal swelling in a population sample of persons with asthma compared to healthy controls. These data support previous reports of a generalized airway inflammation in patients with asthma and suggest that acoustic rhinometry can be used to monitor the nasal mucosal swelling in these patients.

Nasal symptoms among workers exposed to soft paper dust.

OBJECTIVES: To clarify whether occupational exposure to paper-dust is associated with an increased risk of non-infectious rhinitis. METHODS: Thirty-seven workers exposed to paper-dust in a soft-paper mill were compared with 36 unexposed controls. The study was performed under normal working conditions during the non-pollen season. Medical and occupational history was taken down in a comprehensive questionnaire and nasal symptoms were scored on a visual analogue scale (VAS). Pulmonary and nasal function was assessed by spirometry, acoustic rhinometry and peak nasal inspiratory flow. Nasal lavage was analysed for interleukin-8 (IL-8) and nasal transit time was monitored with the saccharine test. Concentrations of inhalable dust for each exposed subject during the day of the clinical study were measured with personal sampling devices. RESULTS: There was an increased prevalence of nasal blockage and crust formation among the exposed workers. However, there was no difference with regard to acoustic rhinometry, nasal transit time or nasal peak inspiratory flow. In the whole population, IL-8 in nasal lavage was higher among men than among women, 193 ng/l vs 132 ng/l, P = 0.006. There was also a positive trend (P = 0.01) with increasing nasal IL-8 going from non-smokers (122 ng/l), ex-smokers (126 ng/l) to current smokers (235 ng/l). CONCLUSIONS: We have found that occupational exposure to paper-dust is associated with symptoms of nasal blockage and nasal crusting. We find no objective signs of nasal inflammation, even among the subgroup with the highest current exposure.

Variations in the feedback of hearing aids.

Variations in the loop response of hearing aids caused by jaw movements, variations in acoustics outside the ear, and variations of vent size have been identified. Behind The Ear (BTE) and In The Ear Canal (ITEC) hearing aids were considered. The largest variations among the variations of the acoustics outside the ear, except when the hearing aid was partly removed, were found with the ITEC when a telephone set was placed by the ear. The variations of the loop response caused by changes in vent size were compared with the variations of a theoretical model of the feedback path. The theoretical model was also used to compare the feedback of different designs of the vent that gives the same acoustic impedance at low frequencies. The calculated feedback was less with the short vents (12 mm) than the long vents (24 mm).

System identification of feedback in hearing aids.

The feedback problems of behind the ear (BTE), in the ear (ITE), and in the ear canal (ITEC) hearing aid categories have been investigated. All possible feedback paths (acoustical via vent, via tubing wall, mechanical, etc.) were converted to a single transfer function from the ear canal to the hearing aid microphone, here called the acoustic feedback equivalent (AFE). The attenuation of the AFE represents the maximum gain that can be used without the hearing aid starting to howl. Magnitude and phase responses of the AFE were identified on ten human subjects and on a Knowles ear manikin (KEMAR). The acoustic feedback via vent and leak between earmould and ear canal dominated the AFE. The transfer function from a reference point under the ear to the position of microphone of the different hearing aid categories was identified and used together with the AFE to calculate the maximum real ear aided gain (REAG) for the hearing aid categories. A model of the AFE, consisting of a fourth-order filter together with a delay, showed good agreement with the measured data.

Nasal nitric oxide and its relationship to nasal symptoms, smoking and nasal nitrate.

Nitric oxide (NO) is produced in the nasal mucosa and in the paranasal sinuses. Increased nasal NO concentrations have been found in patients with asthma and/or rhinitis, and nasal NO has been suggested to be a marker of nasal inflammation. Measuring the stable end products of NO, nitrate and nitrite in nasal lavage fluid have been proposed as an indirect method for measuring NO concentration. The aim of this study was to measure nasal NO concentration, and to find out its relationship to nasal nitrate concentration and clinical parameters. 73 paper-mill workers were investigated with nasal and exhaled NO, nitrate in nasal lavage fluid and were given a respiratory questionnaire. Nasal air was sampled directly from a nasal mask and NO concentration was measured with a chemiluminescence analyser. Exhaled NO was measured with the subjects breathing tidal volumes and wearing nose clips. The nitric oxide metabolites were analysed as nitrate, after reduction of nitrite to nitrate. Smokers had lower nasal NO concentration (264 ppb) as compared to NO concentrations of 340 ppb among non-smokers (p = 0.02). There was no statistically significant relationship between nasal NO concentration and nitrate in nasal lavage fluid or nasal symptoms. Nasal NO concentration was significantly related to FVC (p = 0.047) and there was a relationship with borderline statistical significance (p = 0.06) to FEV1. In conclusion, we found no relationship between nitrate in nasal lavage and nasal NO, and neither of these were correlated to nasal symptoms or to nasal PIF. Nasal NO was significantly lower among smokers. Further controlled studies on subjects with rhinitis are needed, to evaluate the relation between nasal NO and nasal inflammation. In addition, there is also a need to develop methods for measuring nasal NO that minimise contamination from sinuses.

Clinical trial of a digital hearing aid.

A clinical trial of Oticon DigiFocus hearing aid was performed. The test aid was evaluated on 33 subjects with several years' experience as users of modern analog hearing aids. These aids were used as reference for the 1-month-long trial. The Abbreviated Profile of Hearing Aid Benefit (APHAB) showed a mean difference in benefit with superior ratings for the test aid concerning ease of communication, speech in reverberation and speech in background noise. The subjects' own aids were rated somewhat better concerning aversiveness of sounds, but this difference was not statistically significant. The Gothenburg Profile showed a statistically significant difference between the test aid and the reference aids in favour of the test aid. The difference was not most evident with regard to speech communication and the effects of hearing loss on social interactions. Sound quality ratings concerning clearness were significantly higher for the test aid. Speech recognition thresholds in noise were on average 0.7 dB better for the test aids when tested at speech levels 60 and 75 dB. The difference was statistically significant only at 75 dB. There was significant interaction between general preference and hearing aid type, indicating that overall sound quality was an important factor affecting the general preference for either the test aid or the reference aid. Twenty-three subjects generally preferred the test aid, six preferred their own aid and four stated no difference.