Diagnosing allergic rhinitis: effectiveness of the physical examination in comparison to conventional skin testing.

OBJECTIVE: To evaluate the effectiveness of physical examination alone in diagnosing nasal allergic patients. DESIGN: A cross-sectional study of 15 consecutive evaluable patients. SETTING: A tertiary care otolaryngology clinic at the Jewish General Hospital, McGill University, Montreal. METHODS: All patients were assessed by three physicians in random order. Each conducted a specific examination, made a clinical impression, and then took a directed history to make a second impression. Both impressions were compared to skin testing. Multivariate regression analyses assessed the linear relationships of both examination and history variables to impressions and skin testing results. Fleiss kappa tests assessed interrater reliabilities. MAIN OUTCOME MEASURES: Accuracy in diagnosing allergic rhinitis by examination alone and inter-rater reliability in this diagnosis. RESULTS: When comparing physical examination variables to history variables relative to the second impression, history variables had a stronger relationship (R²  =  .90 vs .52). This was also true when comparing both sets of variables to skin testing (R²  =  .81 vs .60). The interrater reliability of physical examination variables was poorer than that of the history variables (.377 and .494, respectively). Taking all physicians, the average sensitivity, specificity, positive predictive value, and negative predictive value of the history impression were all higher than those of the examination impression. CONCLUSION: Physical examination alone yields unreliable and inconsistent results in diagnosing allergic rhinitis. This is likely secondary to the relative subjectivity involved in evaluating the nasal cavity. Adding a history to the examination is essential to increase diagnostic accuracy.

Retrospective comparison of an endoscopic assisted versus a purely endoscopic approach to sellar tumour resection.

INTRODUCTION: The purely endoscopic approach to sellar tumors is thought to offer improved visualization and decreased complications compared to the endoscopic assisted approach. METHODS: This retrospective study was approved by the Research Ethics Board (REB) of McMaster University. Seventy-one consecutive patients who underwent sellar surgery at our institution from January 2003 to October 2005 were reviewed. 40 patients underwent an endoscopic assisted (microscope) approach, while 31 underwent a purely endoscopic approach. Populations were compared for differences in demographics, OR times, outcome measures, and complication rates. RESULTS: The groups were demographically equivalent. The pathology was similar across both groups. Both groups had a reduction of volume and invasion post operatively. There was a trend toward greater reduction in tumour volume and a significant decrease in tumour invasion in the purely endoscopic group. Both groups demonstrated similar improvements in visual fields. The purely endoscopic group had an improvement of 0.33 axes (p<0.05) in pituitary function. Overall, complications were reduced in the purely endoscopic group. A trend toward shorter operative times (128 minutes vs 135 minutes) and length of hospital stay (3.6 days (p<0.05) vs 5.4 days) in the purely endoscopic group. CONCLUSION: Our purely endoscopic group demonstrated a trend, as skill and confidence increased so did the size and invasiveness of the tumours being resected. Overall, the purely endoscopic technique showed improved total tumour resection, improved pituitary function, similar visual field outcomes, less post operative complications, decreased operative times and reduced hospital stay when compared to the endoscopic assisted technique.

Site of attachment of inverted papilloma predicted by CT findings of osteitis.

BACKGROUND: The treatment of choice for sinonasal inverted papilloma (IP) is surgical resection, which typically includes identification of the site of origin with appropriate inclusion or management of this site in the surgical resection. Appropriate preoperative planning is thus of significant importance and will routinely include CT imaging and nasal endoscopy. The aim of this study was to determine whether findings of osteitis in the patients' preoperative CT images could predict the site of attachment. METHODS: This bipartite study contained both retrospective and prospective arms. For the retrospective arm, preoperative CT images of all cases were reviewed electronically in a blinded fashion by the senior author and a prediction was made for the site of attachment. The actual site of attachment as documented in the operative note was then compared with the predicted site. A similar process was followed for the prospectively acquired patients except that the site of attachment was predicted preoperatively. RESULTS: Twenty-eight retrospective and six prospective patients were identified as eligible for the study. Six retrospective patients were excluded because of incomplete data. In patients that were reviewed retrospectively, osteitis was seen in 20/22 patients and was used to correctly predict the site of attachment in 18/20 times. Of the prospectively acquired patients osteitis was seen in 5/6 patients with the site of attachment predicted in 4/5 patients. CONCLUSION: In patients in whom osteitis is detectable on the preoperative CT scan, the site of origin of the IP can be predicted with a high degree of accuracy.

Brain metastases from papillary adenocarcinoma of the thyroid.

BACKGROUND: Papillary thyroid adenocarcinoma (PTA) is the most common type of thyroid malignancy. Distant metastatic spread is relatively rare, most commonly affecting the lungs and bone. Brain metastases are very uncommon. We present a series of four patients with this development and review their diagnosis and treatment. METHODS: A retrospective chart review analysis of patients diagnosed with PTA between 1983 and 2003 at St. Joseph's Healthcare Centre in Hamilton, Ontario, was conducted. RESULTS: Four patients with brain metastasis from their PTA were identified. Three were female and one was male. Their ages at the initial presentation ranged from 20 to 67 years (mean 48 years). The time between the initial treatment and presentation of distant metastasis ranged from 15 to 167 months (mean 89 months). Thyroglobulin data were followed on all four patients. Thyroglobulin results rose with the development of brain and other distant metastasis for two patients but never increased in the other two patients despite distant metastases at multiple sites. Treatment of brain metastasis was with a combination of surgery, external beam radiation, and radioactive iodine. All patients eventually died of their disease, and the overall survival after the diagnosis of brain metastases was 15.3 months in the four patients. CONCLUSION: This study shows that brain metastasis may or may not be the first site of distant metastasis in patients with PTA. The distant metastasis cannot always be predicted from thyroglobulin data. Once brain metastases are diagnosed, palliation with preservation of quality of life becomes the goal of therapy.