Occupational rhinitis caused by hypersensitivity to black pepper.

Black pepper (Piper nigrum) rarely leads to allergic inflammation of the nasal mucosa. This is a presentation of a 52-year-old female worker exposed to black pepper dust for 10 years suffering from allergic rhinitis and chronic rhinosinusitis. She complained of nasal obstruction, rhinorrhoea, and a weakened sense of smell. Clinical examination showed the bilateral presence of polypoid lesions arising from the middle turbinate. After surgery, histopathological examination confirmed the diagnosis of inflammatory nasal polyps. Duration of exposure to black pepper and serum concentration of specific immunoglobulin E antibodies indicating work-related exposure would support a causal link between exposure to these factors and the development of chronic inflammation in the nasal mucosa. Inflammatory nasal polyps may be noted in the nasal cavity in workers exposed to black pepper dust. The absence of exposure to black pepper resulted in no detectable circulating antibodies one year after the change of workplace.

INTRANASAL PLEOMORPHIC ADENOMA ARISING FROM THE LATERAL NASAL WALL.

Pleomorphic adenoma is very rare in the sinonasal region, with the most common localization on the nasal septum, followed by lateral nasal wall. In the case presented, a 72-year-old woman was complaining of the right sided nasal obstruction without any other symptoms. The symptom started a year before and increased progressively. Anterior rhinoscopy revealed a mucosa-covered, smooth-surfaced, soft, polypoid, pale, grayish-pink in color mass in the right nasal cavity, approximately 2x2 cm in size. Nasal endoscopy showed the mass to have a broad base on the lateral nasal wall. Computerized tomography scan showed a homogeneous, solid soft tissue mass, 25x18x12 mm in size, which was attached to the lateral nasal wall, behind the nasal vestibule, just in front of the inferior turbinate. Endonasal endoscopic complete tumor excision was performed, during which some spillage of the tumor occurred. Histology diagnosis was pleomorphic adenoma of minor salivary glands. The patient was followed up on regular basis and had no tumor recurrence in the 6th postoperative year. Intranasal pleomorphic adenoma arising from the lateral nasal wall in front of the inferior turbinate is extremely rare, so the presented case is probably the first ever published.

The influence of standardized dry ivy leaf extract on the proportion of nasal secretion after post-septoplasty nasal packing removal.

INTRODUCTION: After post-septoplasty nasal packing removal, a certain proportion of nasal secretion occurs, leading to local and sometimes systemic infections. OBJECTIVE: The aim was to determine if standardized dry ivy leaf extract application after nasal packing removal influences the reduction of nasal secretion and diminish the occurrence of local infections. METHODS: The study included 70 post-septoplasty patients (divided into two equal groups) whose nasal packing was removed on the third day after the procedure. Group I was treated with standardized dry ivy leaf extract syrup along with regular nasal irrigation for the five days after the nasal packing removal whereas the Group II had only nasal lavage. On the sixth day after nasal packing removal, the quantity of nasal secretion was determined using a visual analog scale and nasal endoscopic examination. RESULTS: The group treated with standardized dry ivy leaf extract syrup had significantly lesser nasal secretion both by subjective patients' assessment (p<0.001) and by nasal endoscopic examination (p=0.003). The post-surgical follow up examination on the sixth day after nasal packing removal showed no development of local infection in the Group I, while in the Group II a local infection was evident in five patients (14.29%) and antibiotic therapy was required. CONCLUSION: The use of the standardized dry ivy leaf extract after nasal packing removal significantly lowers the proportion of nasal secretion.

Fungi-Induced Upper and Lower Respiratory Tract Allergic Diseases: One Entity.

Introduction:Aspergillus can cause different allergic diseases including allergic bronchopulmonary aspergillosis (ABPA) and allergic fungal rhinosinusitis (AFRS). ABPA is allergic pulmonary disease against Aspergillus antigens. AFRS is a type of chronic rhinosinusitis (CRS) presented as hypersensitivity reactions to the fungal presence in sinuses. The aim of the present study was to clarify if ABPA and AFRS could be considered as a common disease entity. Methodology: The prospective cohort study included 75 patients with ABPA. Patients were divided into two groups and compared with each other: (i) patients with CT confirmation of rhinosinusitis and presence of fungi in sinuses (ABPA+AFRS group) and (ii) patients without CT or without mycological evidence of AFRS (ABPA group). Results: Findings of this study were: (i) AFRS was confirmed in 80% of patients with ABPA; (ii) all ABPA+AFRS patients had allergic mucin while fungal hyphae were present in 60% sinonasal aspirate; (iii) ABPA+AFRS patients had more often complicated CRS with (nasal polyps) NP (p < 0.001) and more severe forms of CRS; (iv) culture of sinonasal aspirate revealed fungal presence in 97% patients with ABPA+AFRS; (v) patients with ABPA+AFRS had more common positive skin prick test (SPT) for A. fumigatus (p = 0.037), while patients without AFRS had more common positive SPT for Alternaria alternata and Penicillium notatum (p = 0.04 and p = 0.03, respectively); (vi) 67% of ABPA patients had Aspergillus induced AFRS; (vii) larger number of fungi was isolated from the air-samples obtained from homes of patients with ABPA+AFRS than from the homes of patients without AFRS, while the most predominant species were A. fumigatus and A. niger isolated from almost 50% of the air-samples. Conclusion: The pathogenesis of ABPA and AFRS is similar, and AFRS can be considered as the upper airway counterpart of ABPA. Fungi-induced upper and lower respiratory tract allergic diseases present common entity. Next studies should clarify the mechanism by which fungi turn from "normal flora" into trigger of immunological reactions, resulting in ABPA or AFRS as well as to find new approaches for its' diagnosis and treatment.

Granulocyte-Macrophage Colony-Stimulating Factor Production and Tissue Eosinophilia in Chronic Rhinitis

Abstract Introduction Granulocyte-macrophage colony-stimulating factor (GM-CSF) is a strong proinflammatory cytokine that takes part in allergic nasal inflammation as an eosinophil colony-stimulating factor. However, the role of GM-CSF in non-allergic rhinitis has not been fully explored. Objectives The aim of this investigation was to assess the concentration of GM-CSF in nasal secretions of patients with non-allergic rhinitis with eosinophilia syndrome (NARES) in comparison to patients with perennial allergic rhinitis (PAR) and healthy subjects, as well as to assess the relationship with the degree of eosinophilic inflammation and clinical characteristics of the patients. Methods Fourteen patients with diagnosis of NARES, 14 PAR patients, and 14 healthy subjects were included in this cross-sectional study. All patients underwent symptom score assessment, nasal endoscopy, allergy testing, and cytological evaluation. The concentration of GM-CSF in nasal secretions of all participants was measured by enzyme-linked immunosorbent assay ( ELISA ). Results We found significantly higher levels of GM-CSF in patients with NARES than in the control group (p= 0.035). The percent of eosinophils in nasal mucosa was higher in NARES patients in comparison to patients with PAR (p< 0.001) and control patients (p< 0.0001). We found positive correlations between GM-CSF levels and eosinophil counts only in NARES patients. Conclusion The concentrations of GM-CSF in nasal secretions correlate well with eosinophil counts in the nasal mucosa of NARES patients. These facts indicate a possible role of GM-CSF as a favorable marker for assessment of nasal disease severity and the degree of chronic eosinophilic inflammation in the nasal mucosa.

Granulocyte-Macrophage Colony-Stimulating Factor Production and Tissue Eosinophilia in Chronic Rhinitis.

Introduction Granulocyte-macrophage colony-stimulating factor (GM-CSF) is a strong proinflammatory cytokine that takes part in allergic nasal inflammation as an eosinophil colony-stimulating factor. However, the role of GM-CSF in non-allergic rhinitis has not been fully explored. Objectives The aim of this investigation was to assess the concentration of GM-CSF in nasal secretions of patients with non-allergic rhinitis with eosinophilia syndrome (NARES) in comparison to patients with perennial allergic rhinitis (PAR) and healthy subjects, as well as to assess the relationship with the degree of eosinophilic inflammation and clinical characteristics of the patients. Methods Fourteen patients with diagnosis of NARES, 14 PAR patients, and 14 healthy subjects were included in this cross-sectional study. All patients underwent symptom score assessment, nasal endoscopy, allergy testing, and cytological evaluation. The concentration of GM-CSF in nasal secretions of all participants was measured by enzyme-linked immunosorbent assay (ELISA). Results We found significantly higher levels of GM-CSF in patients with NARES than in the control group (p = 0.035). The percent of eosinophils in nasal mucosa was higher in NARES patients in comparison to patients with PAR (p < 0.001) and control patients (p < 0.0001). We found positive correlations between GM-CSF levels and eosinophil counts only in NARES patients. Conclusion The concentrations of GM-CSF in nasal secretions correlate well with eosinophil counts in the nasal mucosa of NARES patients. These facts indicate a possible role of GM-CSF as a favorable marker for assessment of nasal disease severity and the degree of chronic eosinophilic inflammation in the nasal mucosa.

Correlation between subjective and objective nasal breathing assessments in examinees with nasal septum deformities.

BACKGROUND/AIM: Nasal obstruction is one of the most frequent disorders because of which patients see their Ear, Nose and Throath (ENT) doctors. Impaired nose breath ing is a subjective symptom and it often does not coincide with clinical nose findings and functional tests of breath ing function. Therefore, the aim of this study was to es tablish if there is an accordance between a subjective nose breathing assessment and objective methods (rhinoma nometry and acoustic rhinometry) in assessing nose breathing function in patients with diverse nasal septum deformity degrees, as well as to establish an accordance between these two objective methods. METHODS: This study involved the total of 90 examinees divided into three groups. The group I consisted of examinees with nasal septum deformities less than 10 degrees. The group II consisted of examinees with nasal septum deformities ranged from 10 degrees to 15 degrees. The group III involved examinees with nasal septum deformities over 15 degrees. Each examinee had subjec tively graded his/her nasal breathing on the side of the nose septum deformity from 0 to 10, and afterwards the whole noses. Rhinomanometry and acoustic rhinometry were done on the side of the nasal septum deformities and after that on the other side of the nose using the Interacoustics SRE 2000 device. RESULTS: In the groups II and III there was a positive correlation between a subjective nose breathing assessment and rhinomanometric values both on the side of the nasal septum deformities and the nose as a whole, (p < 0.05), and no correlation between these traits in the group I (p > 0.05). In none of the exam ined groups correlation was found between a subjective nose breathing assessment and rhinometric values, both minimum cross-sectional area (MCA) and volume (VOL), both on the side of the nasal septum deformities and the nose as a whole (p > 0.05). There was no correlation found between rhinomanometric and rhinometric MCA and VOL values in either on the sides of nasal septum deformities or the nose as a whole in any of the examined groups (p > 0.05). CONCLUSION: Rhinomanometry significantly correlates with the subjective nose breathing assessment and it can be used as a reliable and objective indicator of nose breathing in everyday clinical practice. Acoustic rhinometry, on the other hand, which does not correlate with a subjective nose breathing assessment could have a greater significance in a scientific sense than in clinical applying.

Gustatory rhinitis.

PURPOSE OF REVIEW: This review aims to characterize gustatory rhinitis using recent advances in pathophysiology and novel surgical and medical management strategies. RECENT FINDINGS: A significant amount of research has recently focused on the role of capsaicin and its receptors (TRPV1 and VR1), which can be found on sensory c-fibers in human nasal mucosa and play a critical role in the development of nasal hyperresponsiveness to environmental factors. Blocking the nasal sensory nerve stimulation (via the use of capsaicin desensitization) or outgoing parasympathetic innervation (via endoscopic Vidian neurectomy) may control nasal hyperresponsiveness and therefore prevent the induction of rhinitis symptoms. SUMMARY: Gustatory rhinitis is a conspicuous type of food-associated rhinorrhea, which can occasionally be associated with significant quality-of-life impairment. It results from an abnormal gustatory reflex associated with a hyperactive, nonadrenergic, noncholinergic, or peptidergic neural system. The use of nasal ipratropium bromide may be effective, if avoidance is not possible or successful. We have had excellent results with the use of intranasal capsaicin or endoscopic vidian neurectomy (including removal of 4-5 mm of the nerve between pterygopalatine fossa and the sphenoid floor) in patients with nonallergic rhinitis, and these could potentially be used as a last resort in patients with intractable gustatory rhinitis.

Comparison between auditory steady-state responses and pure-tone audiometry.

BACKGROUND/AIM: A more recent method, the auditory steady-state response (ASSR), has become more and more important test method due to difference that was found in previous investigations between hearing thresholds determined by the ASSR and the pure-tone audiometry (PTA). The aim of this study was to evaluate the reliability of the ASSR in determining the frequency specific hearing thresholds by establishing a correlation between the thresholds determined by PTA, as well as to evaluate the reliability of ASSR in determining the hearing threshold with respect to the level of hearing loss and the configuration of the PTA findings. METHODS: The prospective study included 46 subjects (92 ears) which were assigned to groups based on their level of hearing loss and audiometric configuration. All the subjects underwent determination of hearing thresholds by PTA and ASSR without insight into their previously obtained PTA results. RESULTS: The overall sample differences between the ASSR and PTA thresholds were 4.1, 2.5, 4.4, and 4.2 dB at 0.5, 1, 2, and 4 kHz, respectively. A high level of correlation was achieved in groups with different configurations of PTA findings. The correlation coefficients between the hearing thresholds determined by ASSR and PTA were significant in subjects with all levels of hearing loss. The differences between hearing thresholds determined by ASSR and PTA were less than 10 dB in 85% of subjects (ranging from 4 dB for moderately severe hearing loss to 7.2 dB for normal hearing). CONCLUSION: The ASSR is an excellent complementary method for the determination of hearing thresholds at the 4 carrier frequencies, as well as determination of the level of hearing loss and the audiometric configuration.

Gustatory rhinitis.

Gustatory rhinitis is characterized by watery, uni- or bilateral rhinorrhea occurring after ingestion of solid or liquid foods, most often hot and spicy. It usually begins within a few minutes of ingestion of the implicated food, and is not associated with pruritus, sneezing, nasal congestion or facial pain. It is considered to be a non-immunological reaction. Immunohistological and pharmacological observations suggest that this disease is most likely caused by stimulation of trigeminal sensory nerve endings located at the upper aerodigestive track. Recent evidence suggests that sensory nerve stimulations could be associated with a parasympathetic reflex and activation of cholinergic muscarinic receptors, sensitive to atropine. There are various types of gustatory rhinitis, including age-related, posttraumatic, postsurgical and associated with cranial nerve neuropathy. Avoidance of the implicated foods, is the first treatment option, but it is rarely sufficient. The intranasal topical administration of anticholinergic agents such as atropine, either prophylactically or therapeutically has been shown effective. Surgical therapy in the form of posterior nasal nerve resection or vidian nerve neurectomy is not recommended because of its short lasting result and frequent unpleasant side effects.

[Corrosive substance ingestions management].

Acute poisonings with corrosive substances make 15-20% of all acute poisonings in our country. They are on the second place, after drug poisonings, which are far more often. After the ingestion of corrosives, corrosive lesions of the gastrointestinal tract appear. The oesophagus has lesions mostly in cases of ingestion of alkali, and the stomach (gaster) is damaged when an acid is ingested The first steps in the management of the patients having ingested a corrosive substance are to stabilise all vital parameters of the patient (reanimation) and to dilute the substance. The dilution can be done within 60 minutes, with water or milk. After the stabilisation of all vital parameters, the further treatment should start, meaning diagnostics and therapeutic measures. The best diagnostic procedure to determine the presence and severity of corrosive oesophageal lesions is oesophagoscopy. Basic therapeutic principles in the management of patients after corrosive substance ingestion must be applied. According to these principles, it is contraindicated to induce vomiting, diarrhoea and do corrosive substance neutralisation or gastric lavage. Charcoal has no effect, and is not indicated. It is important to identify the kind and quantity of ingested substance, as well as to withhold all oral feedings, and to assess fluid and electrolyte balance carefully and to watch for development of complications. This paper presents the complete treatment protocol of ENT Clinic, Clinical Center of Vojvodina, Serbia. This protocol has been in use since the year 2000 and the results are excellent.

Complicated hypopharyngeal perforation caused by a foreign body.

The paper describes a patient who ingested a piece of bone during his meal. A Jbreign body was suspected and admission to the hospital was recommended as well as esophagoscopy, which he refused. Approximately 48 hours after the meal, the patient was admitted to the hospital for increased temperature, neck pain, and swollen right side of neck. Assuming that the condition was a result of hypopharyngeal perforation cased by a foreign body, computed tomography was performed A collection oJ'pus was found in the lateral and anterior neck compartments with subcutaneous tissue edema, and a foreign body was found in the projection of the hypopharynx. A wide incision was made under general anesthesia and drainage was performed using surgical drains and nasogastric tube. Antibacterial therapy was also applied. The patient was dismissed from the hospital in good general condition. Complications involving a foreign body in the hypopharynx and/or esophagus require urgent attention and adequate diagnosis and therapy. A correct indication, good choice of surgical procedure and intensive antibacterial therapy increase the chance of cure in such patients.

[Epistaxis in patients with hereditary hemorrhagic teleangiectasia].

INTRODUCTION: Spontaneous recurrent epistaxis is the most common clinical manifestation of hereditary hemorrhagic teleangiectasia (HHT). It occurs in more than 90% of HHT patients and is the most distressing symptom. Nasal teleangiectasias tend to increase with age both in size and number, so epistaxis is heavier and more frequent. For patients with mild to moderate disease, there are many adequate treatment options. For those with severe disease, most treatments offer just a hemorrhage-free interval. Experienced otorhinolaryngologists who treat epistaxis in these patients often use the adage "to do as little as possible for as long as possible". MANAGEMENT OF ACUTE EPISTAXIS: The recommendations for the management of acute epistaxis include: compression, use of topical antifibrinolytics, laser therapy, argon plasma coagulation therapy, fibrin sealant spray or gelatin sponge soaked in adrenaline. In cases of heavy acute epistaxis, an epistaxis balloon combined with artery ligation and/or embolization is the most effective treatment. Nasal packing and electrocauterisation should be avoided to prevent further trauma to the blood vessels. TREATMENT OF RECURRENT EPISTAXIS: Management of recurrent epistaxis includes topical application of laser energy (argon, Nd:YAG, KTP/532 and diode, not CO2), argon plasma coagulation in combination with 0.1% estriol ointment, caustics, antifibrinolytics, bleomycin and sclerosing substances. Systemic estrogen-progesterone at doses used for oral contraception may eliminate bleeding in women with heavy epistaxis. Systemic antifibrinolitics (used with extreme precaution) and septal dermoplasty give good results. The only method which successfully and permanently solves the problem of severe refractory epistaxis in hereditary hemorrhagic teleangiectasia is closure of the nasal cavities.

[Dysphagia aortica--case report].

INTRODUCTION: Dysphagia aortica is a swallowing condition caused by external compression of the esophagus due to aortic aneurysm or atherosclerotic changes affecting the aorta. The case report on this rare cause of dysphagia should contribute to better diagnosis of dysphagia aortica and swallowing difficulties in general. CASE REPORT: A 63-year-old male patient was hospitalized duo to a four month history of intermittent swallowing difficulties. Chest radiography showed a widened mediastinum and an enlarged aortic arch. Rigid esophagus endoscopy was done in general endotracheal anesthesia. At 28 cm from the upper incisors, a difficulty in passing the endoscope appeared, revealing an external compression as a probable cause, since the whole esophagus had no intraluminal pathological changes. Contrast esophagography revealed an aortic aneurysm. The esophagus had a normal lumen width, wall tension and elasticity, and smooth contours. After cardiovascular examination and magnetic resonance imaging, a giant aneurysm of the aortic arch was diagnosed. DISCUSSION: Patients with dysphagia aortica as well as patients with any other swallowing difficulties should be managed by multidisciplinary "dysphagia team". The team should include an otorhinolaryngologist, neurologist, radiologist, gastroenterologist, surgeon, dietitian, speech and language therapist and specially trained nurses. CONCLUSION: Aneurysm of the thoracic aorta is a very rare cause of dysphagia. Mild to moderate symptoms can be in great disproportion with the severe condition which causes them.

[Use of antibiotics in otorhinolaryngologic practice]. / Upotreba antibiotika u otorinolaringoloskoj praksi.

INTRODUCTION: This study investigated utilization of antibacterial agents at the Ear, Nose and Throat Department of the Outpatient Service of the Health Center Novi Sad-Liman and at the Ear, Nose and Throat Clinic of the Clinical Center Novi Sad, in the period February-March 2001. MATERIAL AND METHODS: All antibacterial agents were classified as group J, regarding Anatomic-Therapeutic-Chemical Classification. Data on drug utilization were presented in Defined Daily Doses (DDD). Patients who were under observation were all treated with antibiotics. RESULTS: In regard to prescribed treatment in the Ear, Nose and Throat Department of the Outpatient Service of the Health Center Novi Sad-Liman, most outpatients were treated with macrolide antibiotics--in 26.21%; combination of penicillin and beta-lactamase inhibitors in 20.83% and pyranosides in 16.12%. At the Ear, Nose and Throat Clinic of the Clinical Center Novi Sad, macrolides and lincosamines were most frequently used--in 20.46%; cephalosporins in 19.87% and penicillins susceptible to beta-lactamase in 18.85%. It is extremely positive and in agreement with current pharmacotherapeutic principles that in both institutions peroral ampicillins have not been prescribed. Aminoglycosides have been prescribed in less than 1% of patients of the Ear, Nose and Throat Department of the Outpatient Service of the Health Center Novi Sad-Liman, whereas they were much more frequently prescribed at the Ear, Nose and Throat Clinic of the Clinical Center Novi Sad--in 11.25%. Although there is a positive postantibiotic effect in regard to these antibiotics and it is recommended to use them once a day, in both examined institutions aminoglycosides were given twice a day. In regard to bacterial identification it was done in 80.76% of patients of the Ear, Nose and Throat Department of the Outpatient Service of the Health Center Novi Sad-Liman, while in the Ear, Nose and Throat Clinic of the Clinical Center Novi Sad it was done only in 32.42%. CONCLUSIONS: Although treatment performed on empirical basis and clinical findings is usually correct, a greater percentage of antibiotic prescriptions should be confirmed by antibiograms providing optimal therapy and decreased degree of resistance.