International Rhinologic Society Rhinology 0300-0729 49 4 2011 10 1 Epistaxis management: evaluation of old tricks and new treatment options 385 386 EN W.J. Fokkens Department of Otorhinolaryngology, Academic Medical Centre, Amsterdam, The Netherlands 1040 10.4193/Rhin Although epistaxis is a very common and usually mild problem that is experienced by the majority of the population somewhere in life, it can be a very serious and life threatening event. Fighting with a patient with epistaxis usually in the middle of the night with not enough help around is an experience that most of us came across and usually it does not bring sweet memories. We tend to think that certain weather conditions increases the change of a busy duty with lots of patients with epistaxis but this has been shown to be hardly the case. Otorhinolaryngologists with a special interest in hereditary telangiectasia also recognize the significant reduction of quality of life the disease is giving to the patients (and of course to a lesser extent to the doctor). For that reason we are all always interested in "the best" way to manage epistaxis.

International Rhinologic Society Rhinology 0300-0729 49 4 2011 10 1 Catarrh - The patient experience 387 391 EN R.A. Cathcart Department of Otorhinolaryngology, Freeman Hospital, Newcastle upon Tyne, United Kingdom J.A. Wilson School of Surgical and Reproductive Sciences, University of Newcastle, Newcastle upon Tyne, United Kingdom 1033 10.4193/Rhin BACKGROUND: No study to date has looked at the symptoms of chronic catarrh as defined by the patients themselves. We looked to explore the catarrh experience through the eyes of patients using a qualitative approach. METHODOLOGY/PRINCIPAL: Forty-eight patients referred to Secondary Care with chronic catarrh, postnasal drip or persistent throat clearing completed an open-ended questionnaire from which a comprehensive symptom list was generated. Nineteen of these patients undertook semi-structured interviews to explore symptomatic themes relating to their catarrh using grounded theory analysis. RESULTS: A standardised list of 38 catarrh-related symptoms was generated covering a wide topography. A common theme amongst interviewees was the frustration of being unable to expectorate mucus rather than expelling too much. CONCLUSIONS: Difficulties exist in establishing whether the extensive list of symptoms associated with catarrh is a result of differing experiences for patients or simply differing lexicon describing the same experience. Many of these symptoms are not included in the most commonly used nose/throat symptom instruments. Furthermore a distinction should be made between patients with true rhinitis who expel mucus and those who present with apparent postnasal drip or throat clearing but who cannot expectorate, whose management ought be focused more on symptom-coping strategies rather than medication or investigation.

International Rhinologic Society Rhinology 0300-0729 49 4 2011 10 1 Mucosal eosinophilia and recurrence of nasal polyps - new classification of chronic rhinosinusitis 392 396 EN T. Nakayama Department of Otorhinolaryngology, Jikei University School of Medicine, Tokyo, Japan M. Yoshikawa Department of Otorhinolaryngology, Jikei University School of Medicine, Tokyo, Japan D. Asaka Department of Otorhinolaryngology, Jikei University School of Medicine, Tokyo, Japan T. Okushi Department of Otorhinolaryngology, Jikei University School of Medicine, Tokyo, Japan Y. Matsuwaki Department of Otorhinolaryngology, Jikei University School of Medicine, Tokyo, Japan N. Otori Department of Otorhinolaryngology, Jikei University School of Medicine, Tokyo, Japan T. Hama Department of Otorhinolaryngology, Jikei University School of Medicine, Tokyo, Japan H. Moriyama Department of Otorhinolaryngology, Jikei University School of Medicine, Tokyo, Japan 1023 10.4193/Rhin BACKGROUND: Eosinophils and nasal polyps are believed to affect the surgical outcome of chronic rhinosinusitis (CRS). CRS is classified based on the presence of nasal polyps in western countries. The majority of patients with CRS with nasal polyps (CRS with NP) are characterized by predominantly eosinophilic inflammation. However, Asian patients with CRS with NP show characteristics indicative of neutrophilic inflammation. Therefore, are eosinophils or nasal polyps more important for the classification of CRS? METHODS: A prospective cohort study conducted from April 2007 to March 2008 classified patients with CRS based on the presence of nasal polyps and mucosal eosinophilia. The recurrence rate of nasal polyps was compared between the groups. Recurrence rate was analysed as a time-dependent variable by the Kaplan-Meier method. RESULTS: Eosinophilic inflammation was found in 59.6% of patients with CRS with NP. Patients with mucosal eosinophilia had higher polyp recurrence rate than patients without mucosal eosinophilia, whereas patients with nasal polyps did not have higher polyp recurrence rate than patients without nasal polyps. CONCLUSIONS: Presence of mucosal eosinophilia is a more important factor than nasal polyps for classifying CRS in terms of the surgical outcome.

International Rhinologic Society Rhinology 0300-0729 49 4 2011 10 1 Impairment of nasal mucociliary clearance in former smokers with stable chronic obstructive pulmonary disease relates to the presence of a chronic bronchitis phenotype 397 406 EN V. Koblizek Pulmonary Department, Faculty of Medicine and University Hospital Hradec Kralove, Charles University in Prague, Czech Republic M. Tomsova Fingerland Department of Pathology, Faculty of Medicine and University Hospital Hradec Kralove, Charles University in Prague, Czech Republic E. Cermakova Computer Technology Centre, Faculty of Medicine Hradec Kralove, Charles University in Prague, Czech Republic P. Papousek Pulmonary Department, Faculty of Medicine and University Hospital Hradec Kralove, Charles University in Prague, Czech Republic S. Pracharova Pulmonary Department, Faculty of Medicine and University Hospital Hradec Kralove, Charles University in Prague, Czech Republic R.A.A. Mandalia Pulmonary Department, Faculty of Medicine and University Hospital Hradec Kralove, Charles University in Prague, Czech Republic J. Ceral First Department of Internal Medicine, Faculty of Medicine and University Hospital Hradec Kralove, Charles University in Prague, Czech Republic J. Novosad Department of Clinical Immunology and Allergology, Faculty of Medicine and University Hospital, Charles University in Prague, Czech Republic L. Fila Pulmonary Department, Faculty of Medicine and University Hospital Motol, Charles University in Prague, Czech Republic V. Sedlak Pulmonary Department, Faculty of Medicine and University Hospital Hradec Kralove, Charles University in Prague, Czech Republic J. Ruta Pulmonary Department, Faculty of Medicine and University Hospital Hradec Kralove, Charles University in Prague, Czech Republic V. Bartos Pulmonary Department, Faculty of Medicine and University Hospital Hradec Kralove, Charles University in Prague, Czech Republic F. Salajka Pulmonary Department, Faculty of Medicine and University Hospital Hradec Kralove, Charles University in Prague, Czech Republic M. Hrnciarik Pulmonary Department, Faculty of Medicine and University Hospital Hradec Kralove, Charles University in Prague, Czech Republic 1032 10.4193/Rhin BACKGROUND: Associations between nasal and bronchial impairment have been repeatedly described in chronic obstructive pulmonary disease (COPD), whereas nasal mucociliary clearance (MCC) in COPD patients is not yet fully understood. We studied nasal MCC parameters in COPD patients and compared them with healthy adults (HA) and with cystic fibrosis (CF) patients with compromised MCC. METHODOLOGY: An observational study of 98 COPD ex-smokers and subjects from control groups evaluated for nasal MCC time (NMCCt) and by digital video microscopy of nasal mucosa recording ciliary beat frequency (CBF) and ciliary beat pattern. RESULTS: The NMCCt was decreased in HA compared to those with COPD and decreased in those with COPD compared to those with CF. CBF in COPD was lower compared to HA. The index of ciliary dyskinesia in COPD patients differed from HA. We detected higher NMCCt and lower nasal CBF in patients with chronic bronchitis phenotype (CB) compared to non-CB patients. CONCLUSIONS: We confirmed the presence of impaired nasal MCC in COPD ex-smokers. These impairments were apparent predominantly in the CB phenotype.

International Rhinologic Society Rhinology 0300-0729 49 4 2011 10 1 Ciliary function of the nose in patients with Osler's disease and the effect of topically applied estrogens as a nose ointment 407 412 EN J.U. Sommer Department of Otorhinolaryngology Head and Neck Surgery, University Hospital Mannheim, Germany B.A. Stuck Department of Otorhinolaryngology Head and Neck Surgery, University Hospital Mannheim, Germany C. Heiser Department of Otorhinolaryngology Head and Neck Surgery, University Hospital Mannheim, Germany S.S. Kassner Department of Otorhinolaryngology Head and Neck Surgery, University Hospital Mannheim, Germany K. HÃśrmann H. Sadick Department of Otorhinolaryngology Head and Neck Surgery, University Hospital Mannheim, Germany 1026 10.4193/Rhin BACKGROUND: In recent years, the positive effect of topically applied estriol nose ointment in the adjuvant therapy of Morbus-Rendu-Osler (HHT) has been proven. Due to the induced metaplasia, a complete destruction of the ciliated cells may be expected. However, data regarding the ciliary function of HHT patients with and without the use of topical estriol application are currently lacking. METHODOLOGY/PRINCIPAL: Ciliated samples were obtained by gently brushing the inferior nasal turbinate of 19 healthy volunteers and 15 patients with known HHT (8 of them regularly using 0.1% estriol nose ointment for 2 years (HHTwE) and 7 of them not using the ointment in the last 12 months (HHTwoE)). Analysis was done with an inverted phase contrast microscope connected to a high-speed digital camera. Recorded parameters were the visual integrity (VI) of the ciliary beat and its frequency (CBF) in Hz. RESULTS: The VI index of all samples showed an undisrupted, even beating pattern with a difference between the three groups. The mean CBF in all HHT patients was reduced compared to the control group's mean CBF. Within the HHT group itself, the mean CBF was reduced in the HHTwE group compared to the HHTwoE group. CONCLUSIONS: The ciliary beat frequency of HHT patients is impaired compared to the control group and even more so if the HHT patients topically apply estriol more than 6 months. An undisrupted beating pattern is found in the HHTwE group despite the fact that estrogens induce a transformation of the ciliated columnar into a keratinizing squamous epithelium. This data may justify the adjuvant application of estriol as a nose ointment in the treatment of epistaxis in HHT patients without the fear of damage to the nose's mucus clearance.

International Rhinologic Society Rhinology 0300-0729 49 4 2011 10 1 Predictors of post-operative response to treatment: a double blind placebo controlled study in chronic rhinosinusitis patients 413 419 EN F.A. Ebbens Department of Otorhinolaryngology, Academic Medical Center, Amsterdam, the Netherlands S. Toppila-Salmi Department of Eye, Ear and Oral Diseases, Tampere University Hospital and University of Tampere, Tampere, Finland E.J.J. de Groot Department of Otorhinolaryngology, Academic Medical Center, Amsterdam, the Netherlands J. Renkonen Transplantation Laboratory & Infection Biology Research Program, Haartman Institute, University of Helsinki and HUSLAB, Helsinki University Central Hospital, Helsinki, Finland R. Renkonen Transplantation Laboratory & Infection Biology Research Program, Haartman Institute, University of Helsinki and HUSLAB, Helsinki University Central Hospital, Helsinki, Finland C.M. van Drunen M.G.W. Dijkgraaf Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, Amsterdam, the Netherlands W.J. Fokkens Department of Otorhinolaryngology, Academic Medical Centre, Amsterdam, The Netherlands 1041 10.4193/Rhin Background: In the majority of CRS patients suffering from primary or recurrent CRS, topical glucocorticoids are highly effective. A subset of CRS patients, however, does not respond to (topical) glucocorticoids and requires surgical intervention. Although surgery is highly effective in those individuals, recurrence of disease is observed in some. In this study we describe our search for one or more predictors predicting the response to surgery in combination with peri-operative oral glucocorticoids in CRS patients. Methods: Thirty-five inferior turbinate specimens were randomly selected from a larger group of CRS patients requiring FESS for persistent disease that either responded favorably or demonstrated recurrent disease. Tissue biopsies were taken at the time of surgery and compared for inflammatory markers, endothelial cell markers, and various leukocyte subsets using immunohistochemistry. Results: Compared to non-responders, the baseline level of lamina propria activated eosinophils is significantly increased in CRS patients responding to surgery in combination with peri-operative oral glucocorticoids treated or not treated post-operatively with topical glucocorticoids. No significant differences were observed for all other studied parameters. Post-operative treatment with FPANS 100 μg q.i.d. was significantly associated with response to treatment. A trend towards association was observed for increased numbers of eosinophils at baseline. Conclusion: Our data suggest that CRS patients with higher levels of eosinophils are less likely to suffer from post-operative recurrent sinonasal disease when treated post-operatively with FPANS 100 μg q.i.d.

International Rhinologic Society Rhinology 0300-0729 49 4 2011 10 1 A multi-centre study on quality of life and absenteeism in patients with CRS referred for endoscopic surgery 420 428 EN P. Sahlstrand-Johnson Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, Lund University, Skåne University Hospital, Malmő, Sweden B. Ohlsson Department of Clinical Sciences, Division of Gastroenterology, Faculty of Medicine, Lund University, Skåne University Hospital, Malmő, Sweden C. Von Buchwald M. Jannert Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, Lund University, Skåne University Hospital, Malmő, Sweden Marianne Ahlner-Elmqvist Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden 1031 10.4193/Rhin AIMS: This study summarises the health-related quality of life (HRQOL) scores and absenteeism caused by sinus problems in patients awaiting surgery with the diagnoses recurrent acute rhinosinusitis (RARS), chronic rhinosinusitis with nasal polyps (CRS+NP) or CRS without nasal polyps (CRS-NP), in a prospective multi-centre study. METHODOLOGY: Two hundred and seven patients with RARS, CRS+NP or CRS-NP were enrolled. EP3OS definitions of CRS and NP were used. The patients completed the 22 Sinonasal Outcome Test (SNOT-22), the short-form 36-item questionnaire (SF-36), the Hospital Anxiety and Depression Scale (HAD) and a total Visual Analogue Scale (VAS) regarding rhinosinusitis symptoms. RESULTS: SNOT-22 and VAS scores indicated severe disease. Comparison of the HRQOL scores in the three rhinosinusitis subgroups showed statistical differences in nine of the SNOT-22 items and in the SF-36 subscale of bodily pain. Mean scores of SF-36 were significantly lower than that of the normal Swedish population. According to the HAD scores, 28% of the patients had probable or possible anxiety or depression disorder. Fifty-seven percent of the patients reported absenteeism from work due to sinus problems. CONCLUSIONS: RARS, CRS+NP and CRS-NP significantly decrease HRQOL. Some statistically significant differences in HRQOL were found between the three rhinosinusitis subgroups. Absenteeism due to chronic sinus conditions is considerable.

International Rhinologic Society Rhinology 0300-0729 49 4 2011 10 1 Evaluation of an image-guided navigation system in the training of functional endoscopic sinus surgeons. A prospective, randomised clinical study 429 437 EN K. Stelter Department of ORLHNS, Munich University Hospital, Munich, Germany B. Ertl-Wagner Institute for Clinical Radiology, University of Munich, Germany M. Luz Specialist group for Industrial, Engineering and Organisational Psychology of the Technical University, Berlin, Germany S. Müller Innovation Centre Computer Assisted Surgery (ICCAS), Leipzig, Germany G. Ledderose Department of Otorhinolaryngology at the Ludwig Maximilian University, Munich, Germany V. Siedek Department of Otorhinolaryngology at the Ludwig Maximilian University, Munich, Germany A. Berghaus Department of Otorhinolaryngology, Head and Neck Surgery, Ludwig Maximilian University, Munich, Germany S. Arpe Department of Otorhinolaryngology at the Ludwig Maximilian University, Munich, Germany A. Leunig Department of Otorhinolaryngology, Head and Neck Surgery, Ludwig Maximilian University, Munich, Germany 1034 10.4193/Rhin INTRODUCTION: Many sinus surgeons report improved spatial orientation after using a navigation system. This study investigates the surgical, ergonomic and economic aspects of using a navigation system in training and teaching. MATERIALS AND METHODS: Eight rhino-surgeons in training and 32 patients with bilateral diseases of the paranasal sinus system were included. After randomisation, one patient´s side was operated on with a navigation system while the other side was operated on without navigation. It was monitored how often the surgeon used the navigation pointer and then changed the procedures. A standardised and validated interview recorded the cognitive load when using the navigation system and the application efficiency. RESULTS: The operations lasted on average 16 minutes longer with the navigation. Five paranasal sinuses could not be found in the control group without navigation. In only 10-13% of cases did the surgical procedure change after the use of the pointer. Most of the surgeons admitted that particular steps of the operation were more reliable and safer to carry out with the navigation system. The general trust in the system rose in proportion to intraoperative accuracy and repeated use. CONCLUSION: Overall, there was an overwhelming level of trust in the navigation system. Trainee sinus surgeons seeing their more experienced colleagues using a navigation device tend to overestimate the possibilities of the system and to underestimate the risks. The assistance system was used particularly effectively in the group of slightly more experienced surgeons. In this group, the additional expenditure of time was less and the navigation substantially contributed to reinforcing the anatomical sense of direction.

International Rhinologic Society Rhinology 0300-0729 49 4 2011 10 1 Computed tomography findings after endoscopic sinus surgery with preserving or enlarging maxillary sinus ostium surgery 438 444 EN J. Myller Department of Otorhinolaryngology, University of Tampere, Tampere, Finland P. Dastidar Department of Otorhinolaryngology, University of Tampere, Tampere, Finland T. Torkkeli Department of Otorhinolaryngoly, Mikkeli Central Hospital, Mikkeli, Finland M. Rautiainen Department of Otorhinolaryngology, University of Tampere, Tampere, Finland S. Toppila-Salmi Department of Eye, Ear and Oral Diseases, Tampere University Hospital and University of Tampere, Tampere, Finland 1021 10.4193/Rhin Endoscopic sinus surgery (ESS) is the main surgical approach in the treatment of chronic rhinosinusitis (CRS) after failure of medical treatment. ESS is based on the theory that obstruction of the maxillary sinus ostium is mainly behind the pathogenesis of CRS. Controversy remains concerning the enlargement of the natural maxillary sinus ostium. The aim of this study was to compare computed tomography (CT) findings after preservation or enlargement of the maxillary sinus ostium. Thirty patients with non-polypous CRS underwent randomized endoscopic sinus surgery with uncinectomy on one side and additional middle meatal antrostomy on the other side. Lund-Mackay (LM) scores and the ostium diameters were analysed from CT scans taken preoperatively and nine months postoperatively, and were used for comparison of the two operative techniques. In addition, the correlation between CT findings and subjective outcomes was studied. Comparison of the preoperative and postoperative CT scans revealed that significant reduction of LM score was achieved on both sides, regardless of the type of procedure performed. The postoperative area of the ostium remained significantly larger on the antrostomy side compared to the uncinectomy side. A large maxillary sinus ostium size seems to associate with lower postoperative LM score, but does not seem to provide superior symptom relief.

International Rhinologic Society Rhinology 0300-0729 49 4 2011 10 1 Carbon nanotubes have a deleterious effect on the nose: the first in vitro data 445 452 EN L. de Gabory Inserm, U577, Bordeaux, F-33076 France; Univ Victor Segalen Bordeaux 2, F33076 France R. Bareille Inserm, U577, Bordeaux, F-33076 France; Univ Victor Segalen Bordeaux 2, F33076 France R. Daculsi Inserm, U577, Bordeaux, F-33076 France; Univ Victor Segalen Bordeaux 2, F33076 France R. Daculsi Inserm, U577, Bordeaux, F-33076 France; Univ Victor Segalen Bordeaux 2, F33076 France B.J. L Azou Laboratoire Biologie Cellulaire, Univ Victor Segalen Bordeaux 2, F33076 France E. Flahaut Université de Toulouse, UPS, INP, Institut Carnot Cirimat, 118, route de Narbonne, F-31062 Toulouse cedex 9, France L. Bordenave Inserm, U577, Bordeaux, F-33076 France; Univ Victor Segalen Bordeaux 2, F33076 France 1022 10.4193/Rhin Background: The information currently available concerning carbon nanotubes toxicity is disturbing and conflicting. Moreover, little is known about their effect on the nasal cavities, which are the first target for nanoparticles. Material and method: We investigated the cytotoxicity (50 to 0.5 #181;g/mL) of double-walled carbon nanotube with two independent tests (MTT, Wst-1) on normal human nasal epithelial cells after 12-day exposure (control untreated nasal cells and A549). Nasal cell differentiation function, oxidative stress, the morphological features of cells in contact with DWCNTs and the localizations of the latter were also investigated. Results: Exposure revealed a dose-dependent decrease in cell metabolic activity and cell growth. In nearly all conditions, normal human nasal epithelial cells were more sensitive than malignant ones. Even with both tests, the cytotoxic threshold dose could not be accurately determined because of dye adsorption by DWCNTs. Nasal cells showed stronger cytokeratin 7 and persistent UEA-I immunostaining. Cytokeratin 19 production was increased at 25 #181;g/mL and mucus production was stimulated from 0.5 #181;g/mL. A significant increase in Reactive Oxygen Species was observed from 25 #181;g/mL. The cell plasma membrane showed several holes and DWCNTs were present in the cytoplasm. Conclusion: DWCNTs seem to have a deleterious effect on nasal cells after 12-day exposure.

International Rhinologic Society Rhinology 0300-0729 49 4 2011 10 1 The menthol and cold sensation receptor TRPM8 in normal human nasal mucosa and rhinitis 453 457 EN S.M. Keh Peripheral Neuropathy Unit, Hammersmith Hospital, Faculty of Medicine, Imperial College London, London, United Kingdom P. Facer Peripheral Neuropathy Unit, Hammersmith Hospital, Faculty of Medicine, Imperial College London, London, United Kingdom A. Yehia Department of Ear, Nose and Throat Surgery, Charing Cross Hospital, Hammersmith, United Kingdom G. Sandhu Department of Ear, Nose and Throat Surgery, Charing Cross Hospital, Hammersmith, United Kingdom H.A. Saleh P. Anand Peripheral Neuropathy Unit, Hammersmith Hospital, Faculty of Medicine, Imperial College London, London, United Kingdom 1028 10.4193/Rhin BACKGROUND: Menthol and cold sensation trigger symptoms and reflex responses in the upper airway, but the underlying molecular mechanisms are unknown. We have therefore studied nerve fibres expressing the menthol and cold receptor TRPM8 in normal human mucosa, and in rhinitis. TRPM8 nerve fibres were compared with those expressing other TRP receptors including TRPV1 (capsaicin and heat receptor), and TRPA1 (mechano-cold receptor). METHODS: Immunohistology and image-analysis were used to study TRP receptors in biopsies of nasal turbinate from control subjects, patients with allergic rhinitis, and non-allergic rhinitis. RESULTS: TRPM8-immunoreactive nerve fibres were observed in the sub-epithelium, and were profuse around blood vessels in deeper regions, where they were markedly greater in number than TRPV1+ fibers. Image analysis of TRPM8 in sub-epithelial and vascular regions showed no significant differences between control and the rhinitis patient groups. TRPA1-immunoreactivity was weak and seen rarely in nerve fibres. CONCLUSION: We show that TRPM8 nerve fibres are abundant in nasal mucosa particularly around blood vessels, and may mediate neurovascular reflexes. TRPM8 antagonists deserve consideration for therapeutic trial in rhinitis.

International Rhinologic Society Rhinology 0300-0729 49 4 2011 10 1 Differences in anosmic and normosmic group in bimodal odorant perception: a functional- MRI study 458 463 EN E. Iannilli Smell & Taste Clinic, Department of Otorhinolaryngology, University of Dresden Medical School, Dresden, Germany T. Bitter Department of Otorhinolaryngology, University of Jena, Jena, Germany H. Gudziol Department of Otorhinolaryngology, University of Jena, Jena, Germany H.P. Burmeister Department of Radiology, University of Jena, Jena, Germany H.J. Mentzel Department of Radiology, University of Jena, Jena, Germany A.P.S. Chopra Unilever R&D Port Sunlight, Merseyside, United Kingdom T. Hummel 1029 10.4193/Rhin So-called bimodal odorants are able to stimulate the intranasal trigeminal system at relatively low concentrations. Using them as stimuli, the current study focused on the interaction between the olfactory and trigeminal systems at a cerebral level. In the experiment, menthol was used at two concentrations, low and high, and these were delivered to two groups of subjects, a healthy control group and an anosmic group who were unable to perceive smells. A computer-controlled olfactometer based on principles of air-dilution was used to deliver the stimuli, while the brain functions were assessed by a functional magnetic resonance imaging (fMRI) technique. SPM5 was used for data analysis. The results showed that normosmic subjects exhibited activation in the anterior cingulate cortex (ACC) and posterior cingulate cortex (PCC), prefrontal cortex (PFC), and cerebellum. Whilst anosmic subjects activated the same area inside the anterior cingulate; moreover a cluster of activation was found in the left parahippocampal gyrus. In controls, an effect of stimulus intensity was localized between the anterior cingulated, the medial frontal gyrus and the cerebellum; such areas could not be found in anosmic subjects. These results suggest that the olfactory system modifies trigeminally mediated information causing an evident effect in the differentiation between stimulus intensities.

International Rhinologic Society Rhinology 0300-0729 49 4 2011 10 1 Role of cAMP-PKA/CREB pathway in regulation of AQP 5 production in rat nasal epithelium 464 469 EN W. Wang Department of Anatomy, Fujian Medical University, Fuzhou City, Fujian, China M. Zheng Department of Anatomy, Fujian Medical University, Fuzhou City, Fujian, China 1001 10.4193/Rhin OBJECTIVES: Aquaporin 5 (AQP5) is a water-specific channel protein. In this study, we investigated the possible role of the cyclic adenosine monophosphate-protein kinase A/cyclic adenosine monophosphate response element binding protein (cAMP-PKA/CREB) pathway in the regulation of AQP5 in nasal epithelial cells. METHODS: Rat nasal epithelial cells were cultured and treated with the PKA inhibitor H89 or cAMP inducing medicine forskolin for 12 or 24 hours in vitro. AQP5 and phosphorylated CREB (p-CREB) at serine133 (Ser133) were detected by immunocytochemistry, Western blotting or real-time PCR. Experiments were repeated 10 times. RESULTS: After treatment with H89 for 12 or 24 hours, the number of cells positive for AQP5 and p-CREB (Ser133) were decreased, p-CREB (Ser133) and AQP5 protein decreased, and AQP5 mRNA decreased. After treatment with forskolin for 12 or 24 hours, the number of p-CREB (Ser133) and AQP5 positive cells increased, p-CREB (Ser133) and AQP5 protein increased, and AQP5 mRNA was increased. CONCLUSION: Both H89 (PKA inhibitor) and forskolin (cAMP inducing medicine) regulate AQP5 production through the cAMP-PKA/CREB pathway, which could influence the secretary function of the submucosal glands in nasal epithelium.

International Rhinologic Society Rhinology 0300-0729 49 4 2011 10 1 The relationship between pressure and volume when using Rapid Rhino® packs in the management of epistaxis 470 473 EN S. Mackeith Milton Keynes General Hospital, Milton Keynes, United Kingdom R. Hettige Milton Keynes General Hospital, Milton Keynes, United Kingdom A. Falzon Milton Keynes General Hospital, Milton Keynes, United Kingdom M. Draper Milton Keynes General Hospital, Milton Keynes, United Kingdom 1025 10.4193/Rhin Despite the popularity of Rapid Rhino packs, there are no clear guidelines regarding the volume of air to be inflated when used in the management of epistaxis. The manufacturers suggest that subjective assessment by pilot cuff palpation is used to guide inflation. However, studies have clearly demonstrated that clinicians are poor at judging balloon pressure by pilot cuff palpation when used in other settings. Our objective was to investigate the relationship between the volume of air inflated and the resultant intra-nasal pressure generated by nasal balloon packing. Twelve healthy subjects were packed with 5.5 cm Rapid Rhino packs, which were connected to a manometer and 20 ml syringe via a 3-way tap in a closed circuit. Increments of 2.5 mls of air were inflated and the resultant intra-nasal pack pressure was measured. There appeared to be a linear relationship between increasing volume and pack pressure. However, between individuals, there was a large variation in the intra-nasal pack pressure produced for a given fixed volume of air inflated. This is presumably due to variations in nasal anatomy. It may be that a manometer-measured, pressure guided nasal pack inflation technique would represent best practice, especially for less experienced staff.

International Rhinologic Society Rhinology 0300-0729 49 4 2011 10 1 On the effectiveness of treatment options in epistaxis: an analysis of 678 interventions 474 478 EN M.B. Soyka G. Nikolaou epartment of Otorhinolaryngology, Head and Neck Surgery, University Hospital of Zurich, Switzerland K. Rufibach D. Holzmann 1030 10.4193/Rhin BACKGROUND: Epistaxis represents one of the most common emergencies in ENT clinics around the world. It creates great physical and emotional stress to the patient as well as a financial burden on health-care systems. A lot of research has been performed with regard to aetiology and possible treatment, however, not much effort has been put into analysing the effectiveness of common treatment forms. It is the objective of this study to clarify which of these treatment forms is reliable. STUDY DESIGN: Retrospective cohort study. Level of Evidence: 2b. METHODS: Between 03/2007 and 04/2008, all epistaxis therapies including relapses and treatment failures at the University Hospital of Zurich have been documented using a computerised questionnaire. Different treatments were compared to each other. RESULTS: An analysis of 678 interventions in 537 patients was performed with emphasis on failure proportions and time to occurrence. The estimated failure proportions of coagulation in anterior epistaxis accounts for 14%. Successful treatment of epistaxis in posterior bleedings could be achieved in 62% by packing and in 97% by surgery with a statistically significant difference between the respective groups. CONCLUSION: Using our treatment options, anterior epistaxis can be cured reliably by cauterisation. Surgical therapies in posterior bleedings are able to successfully salvage failed packing therapies.

International Rhinologic Society Rhinology 0300-0729 49 4 2011 10 1 Altered expression of E-cadherin and β-catenin in malignant transformation of sinonasal inverted papillomas 479 485 EN B.S. Koo Department of Otolaryngology-Head and Neck Surgery, Cancer Research Institute, Research Institute for Medical Sciences, Chungnam National University College of Medicine, Daejeon, Korea B.J. Jung Department of Otolaryngology-Head and Neck Surgery, Cancer Research Institute, Research Institute for Medical Sciences, Chungnam National University College of Medicine, Daejeon, Korea S.G. Kim Department of Otolaryngology-Head and Neck Surgery, Cancer Research Institute, Research Institute for Medical Sciences, Chungnam National University College of Medicine, Daejeon, Korea Z.L. Liang Department of Pathology, Chungnam National University College of Medicine, Daejeon, Korea J.M. Kim M.K. Yeo Department of Pathology, Chungnam National University College of Medicine, Daejeon, Korea K.S. Rha Department of Otolaryngology-Head and Neck Surgery, Cancer Research Institute, Research Institute for Medical Sciences, Chungnam National University College of Medicine, Daejeon, Korea 1019 10.4193/Rhin BACKGROUND: E-cadherin and β-catenin are molecules that mediate cell-cell adhesion in normal epithelium. Aberrant expression of these adhesion molecules results in the loss of intercellular adhesion, with possible cell transformation and tumour progression. We determined the role of E-cadherin and β-catenin in the pathogenesis of sinonasal inverted papilloma (IP) and its malignant transformation. METHODS: We determined the expression of E-cadherin and β-catenin by immunohistochemistry in paraffin-embedded tissue of 21 subjects with nasal polyps, 56 with IPs, 7 IPs with dysplasia and 18 IPs with squamous cell carcinoma (SCC). The clinicopathological variables of the IPs with SCC correlated with the degree of expression of E-cadherin and β-catenin. RESULTS: The degree of expression of E-cadherin and β-catenin in the cell membrane was significantly lower in IPs with SCC than in nasal polyps and IPs. The degree of expression of β-catenin was significantly lower in IPs with SCC with a malignant proportion > 50% compared to a malignant proportion ≤ 50%. However, there was no significant association between the degree of expression of E-cadherin and β-catenin and clinicopathological variables, such as age, gender, T stage, tumour differentiation, or SCC type (metachronous vs. synchronous). In addition, there was no significant relationship between recurrence or survival rate in IPs with SCC and the degree of expression of E-cadherin or β-catenin in the cell membrane or nuclear β-catenin. CONCLUSION: Decreased expression of E-cadherin and β-catenin in the cell membrane may be associated with carcinogenesis of IPs and help predict malignant transformation in sinonasal IPs.

International Rhinologic Society Rhinology 0300-0729 49 4 2011 10 1 Surgical closure of nasal septal perforation. Early and long term observations 486 491 EN L.K. Døsen Department of Oto-rhino-laryngology, Lovisenberg Diakonale Hospital, Oslo, Norway R. Haye Department of Oto-rhino-laryngology, Lovisenberg Diakonale Hospital, Oslo, Norway 1020 10.4193/Rhin BACKGROUND: Results of surgical treatment of nasal septal perforation are usually evaluated using closure of the perforation as criterion of success. Patients, however, may still have symptoms. AIM: To assess the long-term results of surgical treatment of nasal septal perforation with bilateral, posterior based mucoperichondrial septal flaps using a four-point symptom score to ultimately improve treatment and selection criteria. METHODOLOGY: Patients were seen 6 months postoperatively. Questionnaires were sent to 116 surviving patients in 2008-2009. The response was 104. Patients reporting moderate or severe symptoms were seen as outpatients. RESULTS: Between 1987 and 2004, 126 patients were surgically treated using posterior based bilateral mucoperichondrial septal flaps. Sixteen patients had a reperforation during the first 3 months, and another 3 several years later. There was no correlation between early outcome and diagnosis, preoperative size of the perforation, gender or severity of preoperative crusting. There was an increased rate of reperforation with increasing age. Complications seen at the 6 months' follow-up of patients with closed perforations were lachrymal duct stenosis, partial vestibular stenosis, hypoesthesia, crusting and septal deviation, most of which were treatable. Long-term observation mean 10 years) of the same patients showed the following moderate or severe symptoms: crusting, obstruction and bleeding, mainly in men. Obstruction was often due to various forms of perennial rhinitis, sometimes to crusting and more rarely to septal deviation. Crusting was the only independent symptom. There was no correlation between crusting and diagnosis, preoperative size of the perforation, age or severity of preoperative crusting. CONCLUSIONS: Results of the surgical technique using posterior based bilateral mucoperichondrial septal flaps for treatment of nasal septal perforations were good, but depend on surgical expertise and age of the patient. Long-term results from other studies will be a guide to choose the proper surgical procedure to minimize the number of late symptoms. Prosthetic treatment cans be an alternative. Patients with return of symptoms should seek further advice.