International Rhinologic Society Rhinology 0300-0729 50 4 2012 12 1 Diagnosis is not the end 337 338 EN V.J. Lund Royal National Throat Nose and Ear Hospital, London, United Kingdom. 1122 10.4193/Rhin This December issue is wide-reaching in its content but has a strong emphasis on diagnosis. Following hard on the heels of EPOS2012 (1), we have the Executive Summary of the Euro- pean Task Force on Diagnostic Tools in Rhinology, authored by some of the 'usual suspects' but with an additional allergic perspective (2). The importance of an accurate history however, is correctly emphasised with the use of a wide range of quality of life instruments to quantify and qualify the impact of the symptoms. The increasing emphasis on QoL by clinicians, pa- tients and politicians is to be commended and allows everyone to engage in sequential assessment of outcomes without re- course to expensive and/or complex instrumentation. However, there is also a range of simple tests that can be undertaken in most clinics such as nasal inspiratory peak flow (NIPF), a wide range of smell tests and saccharine transit time to consider mu- cociliary clearance which have been available for a long time.

International Rhinologic Society Rhinology 0300-0729 50 4 2012 12 1 Executive summary of European Task Force document on diagnostic tools in rhinology 339 352 EN P.W. Hellings Department of Otorhinolaryngology, Head and Neck surgery, University Hospitals Leuven, Leuven, Belgium, Department of Otorhinolaryngology, Academic Medical Centre Amsterdam, Amsterdam, the Netherlands G. Scadding I. Alobid Department of Otorhinolaryngology, Rhinology Unit, Hospital Clinic de Barcelona, Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain C. Bachert W.J. Fokkens Department of Otorhinolaryngology, Academic Medical Centre, Amsterdam, The Netherlands R. Gerth van Wijk P. Gevaerts J. Guilemany L. Kalogjera J. Mullol G. Passalacqua E. Toskala C.M. van Drunen 1115 10.4193/Rhin This Executive Summary of the EAACI Task Force document on Diagnostic Tools in Rhinology provides the readers with an over- view of the currently available tools for diagnosis of nasal and sino-nasal disease, published in full version in the first issue of Clini- cal and Translational Allergy. A panel of European experts in the field of Rhinology have contributed to this consensus document on Diagnostic Tools in Rhinology. Important issues related to history taking, clinical examination and additional investigative tools for evaluation of the severity of nasal and sinonasal disease are briefly highlighted in this executive summary.

International Rhinologic Society Rhinology 0300-0729 50 4 2012 12 1 Congenital problems of mucociliary clearance: primary ciliary dyskinesia 353 359 EN J. Rimmer Department of Otolaryngology, Royal National Throat Nose & Ear Hospital, London, United Kingdom 1124 10.4193/Rhin Mucociliary clearance is a primary defence mechanism of the airway that can be altered in congenital diseases such as primary ciliary dyskinesia and cystic fibrosis, as well as acquired conditions. This article focuses on primary ciliary dyskinesia and the diag- nostic approach to it, which is still evolving.

International Rhinologic Society Rhinology 0300-0729 50 4 2012 12 1 Endoscopic sinus surgery in patients with cystic fibrosis: A systematic review and meta-analysis of pulmonary function 360 369 EN K.I. Macdonald Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada A. Gipsman A. Magit M. Fandino E. Massoud I.J. Witterick P. Hong 1114 10.4193/Rhin INTRODUCTION: The role of endoscopic sinus surgery (ESS) in patients with cystic fibrosis (CF) is not clearly defined. OBJECTIVE: TO perform a systematic review of subjective and objective outcomes of ESS in CF. METHODS: A systematic review was performed using the keywords'sinusitis,''sinus surgery,''nasal polyps'and'cystic fibrosis.'The quality of papers was assessed using the NICE scoring scale. Outcomes included safety, subjective symptoms, objective endo- scopy scores, days spent in hospital, courses of antibiotics, and pulmonary function tests (PFTs). RESULTS: Nineteen studies involving 586 patients were included in the review. There were four prospective cohort trials, and three were rated as good quality. There were no major complications attributable to ESS. There was consistent evidence in four cohort studies of improved sinonasal symptoms, including nasal obstruction, facial pain, headaches, rhinorrhea and olfaction. Three studies reported conflicting results in post-operative endoscopy scores. Three studies showed a decrease in days spent in hospital, and two showed a significant decrease in courses of intravenous antibiotics. A recent study, however, did not show a difference in either days spent in hospital or courses of antibiotics. Pulmonary function tests were not improved by ESS in six cohort trials, and one small study found significant improvement. A meta-analysis of FEV1 scores confirmed no significant difference. CONCLUSION: THE most consistent findings of this review were that ESS in patients with CF is safe, produces symptomatic benefit, and does not consistently improve PFTs. There were more conflicting results with regards to endoscopy scores, days spent in hos- pital, and courses of intravenous antibiotics. Future prospective studies, utilizing validated quality of life, symptom and endoscopy scales, are needed to further elucidate the role of ESS in the management of chronic rhinosinusitis in CF patients.

International Rhinologic Society Rhinology 0300-0729 50 4 2012 12 1 Effects of oxymetazoline nasal spray on the nasal cycle assessed by long-term rhinoflowmetry 370 375 EN T. Braun Department of Otorhinolaryngology, Head and Neck Surgery, Ludwig Maximilian University, Munich, Germany M. Rich Department of Otorhinolaryngology, Head and Neck Surgery, Ludwig Maximilian University, Munich, Germany A. Berghaus Department of Otorhinolaryngology, Head and Neck Surgery, Ludwig Maximilian University, Munich, Germany M.F. Kramer Department of Otorhinolaryngology, Head and Neck Surgery, Ludwig Maximilian University, Munich, Germany 1110 10.4193/Rhin BACKGROUND: Long-term rhinoflowmetry assesses bilateral nasal flow over 24 hours. In the present study, we evaluated the effects of a standard dose of oxymetazoline topical nasal spray, a widely used over-the-counter drug, on the nasal cycle, since the exact long-term effects, such as the duration of the decongestive effect, are not yet reported. METHODOLOGY/PRINCIPAL: Thirty healthy volunteers received a portable long-term rhinoflowmetry device and applied 22.5 μg oxymetazoline in each nostril. RESULTS: In 90 % of the probands, effects of the nasal spray application could be seen as changes in nasal flow. A decongestive effect could be seen after 18 minutes on average. We found a mean duration of the maximal decongestive effect of four hours. However, it took more than six hours on average until the nasal cycle resumed its normal condition. We did not find significant differences of the effect between probands with a 'classic,''in concert' or impaired nasal cycle. In contrast to a substantial interindi- vidual variability, repeated measurements showed that intraindividual variability of the effect of decongestive nasal spray seems to be rather small. CONCLUSION: Long-term rhinoflowmetry, yielding reliable results, is a valuable tool in the assessment of the effects of nasal drugs on the nasal cycle.

International Rhinologic Society Rhinology 0300-0729 50 4 2012 12 1 Using dynamic analysis of Laser-Doppler blood flowmetry to measure nasal mucosa bloody flow in postural changes 376 380 EN K.-K. Tsai Department of Otolaryngology-Head and Neck Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C. C.-F. Yen Y.-H. Chu H.-W. Wang 1104 10.4193/Rhin BACKGROUND: The regulation of nasal mucosa blood flow (NMBF) is affected by multiple factors, such as the autonomic nervous system, medications, temperature, humidity, endocrine, even emotional stress and vision. The effects of postural changes on NMBF have been described in numerous studies. However, the results are far from consistent due to different experimental designs. OBJECTIVE: Dynamic analysis of Laser-Doppler blood flowmetry (LDBF) is employed to recognize the effect of postural changes on NMBF. METHODS: NMBF was continuously measured by LDBF in 14 participants with changing postures (sitting and supine). NMBF was measured in Blood Perfusion Unit (BPU), equivalent to the number of red blood cells multiplied by their mean velocity in a measured volume. RESULTS: NMBF increases significantly in a supine posture compared with that in a sitting posture. CONCLUSION: Our study demonstrates that NMBF is significantly influenced after initial postural change, suggesting that changes in posture may be regarded as an important factor regulating NMBF.

International Rhinologic Society Rhinology 0300-0729 50 4 2012 12 1 Correlation between peak nasal inspiratory flow and peak expiratory flow in children and adolescents 381 385 EN C. Chaves Paediatric Pulmonology Unit, University Hospital, Federal University of Minas Gerais, Belo Horizonte, Brazil C. Ibiapina C.R. Andrade R. Godinho C.G. Alvim A.A. Cruz 1116 10.4193/Rhin BACKGROUND: PEAK nasal inspiratory flow (PNIF) has been proposed as a simple method to evaluate nasal patency. Asthma and allergic rhinitis are commonly associated, and lower airway assessment can provide information concerning an objective interpre- tation of nasal function. AIMS: TO determine whether the PNIF is correlated with peak expiratory flow (PEF) in children and adolescents. METHODS AND RESULTS: Cross-sectional study carried out in healthy students randomly chosen in 14 public schools of the city of Belo Horizonte. PNIF and PEF were assessed for each subject as the following characteristics: gender, height, weight and age. We created a linear regression model to explain the PNIF, in which we included all the variables with a p value ≤ 0.25 in a univariate analysis, and to calculate the relationship between the maximum PNIF and maximum PEF by the Spearman correlation coef- ficient. In total, 297 healthy subjects, aged between six and eighteen years were evaluated. A positive and significant correlation between PNIF and PEF was found. CONCLUSIONS: PEF is predictive of PNIF. However, these measures evaluate two distinct segments of the airways and should be both obtained for a more precise assessment of airflow limitation.

International Rhinologic Society Rhinology 0300-0729 50 4 2012 12 1 Unilateral peak nasal inspiratory flow, normal values in adult population 386 392 EN G. Ottaviano Department of Neurosciences, Otolaryngology Section, University of Padova, Padova, Italy G.K. Scadding ENT and Allergy Department, Royal National Throat, Nose and Ear Hospital, London, United Kingdom B. Scarpa D. Accordi A. Staffieri V.J. Lund Royal National Throat Nose and Ear Hospital, London, United Kingdom. 1119 10.4193/Rhin AIMS: Measurement of Peak Nasal Inspiratory Flow (PNIF) is a cheap, simple, easily performed method to assess nasal patency and it is suitable for serial measurements and for home use. The purpose of this study was to establish normative unilateral PNIF data for a healthy adult population and provide charts relating unilateral PNIF normal values with various explanatory variables. METHODS AND RESULTS: Repeated measurements of PNIF and unilateral PNIF were performed in 109 volunteers. Ninety seven of these fulfilled the study criteria and all of them were non-smokers, non-asthmatic, without nose and paranasal sinus problems, with ages ranging from 13 to 80 years. Data were statistically analysed and tables were produced relating unilateral PNIF to height which was the only studied variable that correlated statistically with unilateral PNIF. CONCLUSIONS: The measurement of unilateral PNIF, providing the present data are confirmed in a larger series, could be a useful method to study single nostril patency to aid diagnosis of nasal disease, especially when it is necessary to assess the functional effects of unilateral nasal septal deviations or in all cases where there is a suspicion of a unilateral nasal occlusion. This pilot study provides initial normative unilateral PNIF data.

International Rhinologic Society Rhinology 0300-0729 50 4 2012 12 1 Different types of tissue composition in inflammatory or reparative upper airway disorders 393 401 EN L. De Coster Department of Otorhinolaryngology, Ghent University, Ghent, Belgium Ph. Eloy ENT Department CHU UCL Mont-Godinne 5530 Yvoir, Belgium L. Ferdinande J. Taildeman C.A. Cuvelier J.-B. Watelet 1113 10.4193/Rhin BACKGROUND: Composition changes of extracellular matrix (ECM) can lead to functional disorders of the upper airways (UA). The aim of this study was to systematically measure both the association patterns and the correlation degree between tissue compo- sition parameters in UA inflammatory diseases. METHODOLOGY: Nasal samples were obtained from patients with chronic rhinosinusitis with (CRS+NP), without nasal polyps (CRS), with post-operative adhesions (S) and normal nasal mucosa (NM). A reproducible semi-quantitative method, which takes epi- thelial and lamina propria damages into account was applied for haematoxylin and eosin, alpha-smooth muscle actin, reticulin, elastin, laminin and collagen type IV stainings. RESULTS: The most severe cases of epithelial shedding have been found in a significant higher amount in CRS+NP when compared with NM. The most severe cases of inflammatory reaction were mainly found in CRS+NP. CRS+NP had significantly more severe cases of oedema than NM. Excluding elastin, networks in other ECM proteins were found modified in fibrotic fields but to a lesser extend in oedematous regions in all conditions. CONCLUSION: Although non specific, oedema in the lamina propria is a key-feature of CRS+NP, while fibrosis, massively present in CRS and S, affects profoundly the distribution of ECM proteins in these areas.

International Rhinologic Society Rhinology 0300-0729 50 4 2012 12 1 Does the maxillary sinus have a triggering role in nasal nitric oxide synthesis? 402 407 EN O. Güçlü Department of Otorhinolaryngology, Canakkale Onsekiz Mart University Faculty of Medicine, Çanakkale, Turkey A. Uludağ A. Akçalı K. Tekin H. Erdoğan F. Sılan F.S. Dereköy 1117 10.4193/Rhin OBJECTIVES: We investigated whether the maxillary sinus plays a stimulatory role in nasal nitric oxide (NO) synthesis. Research on sinusitis and nasal polyps has found low NO levels in exhaled air and linked this to obstruction of the ostium. However, the major source of NO in exhaled air is thought to be the nasal mucosa. In this study, Streptococcus pneumoniae was applied to the maxil- lary sinus to investigate changes in NO synthesis of the nasal mucosa. METHODS: An experimental study was performed with New Zealand white rabbits. Three groups, pneumococcus, control and sham, were created. The maxillary sinus of the pneumococcal group was exposed to Streptococcus pneumoniae suspension. Before and after the exposure, bilateral biopsy specimens were taken from the inferior turbinate. Specimens were examined by RT-PCR for expressions of endothelial nitric oxide synthase (e-NOS) and inducible nitric oxide synthase (i-NOS). Physiological saline solution was administered to the maxillary sinus in the control group and biopsies were obtained. The sham group underwent only biopsy. RESULTS: A significant increase in i-NOS expression of tissue samples from the pneumococcal group on the same and opposite sides were detected. There was no increase in e-NOS expression in this group. The control and sham groups had no significant change in i-NOS or e-NOS expression. CONCLUSION: In the acute period after the maxillary sinus is exposed to a pathogen, i-NOS expression increases in the nasal mucosa, but endothelial NOS expression is not affected. Consequently, a combined response in the maxillary sinus and the nasal mucosa for nitric oxide synthesis is shown in the present study.

International Rhinologic Society Rhinology 0300-0729 50 4 2012 12 1 Expression of Trefoil factor family peptides in the nasal allergic mucosa 408 416 EN N. Miyahara Department of Otorhinolaryngology, Head and Neck Surgery, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan T. Ishino T. Kono K. Go S. Takeno M. Takumida K. Hirakawa 1118 10.4193/Rhin OBJECTIVE: Trefoil factor family peptides (TFFs) are the secretory products of mucous cells and are closely associated with mucins. TFFs appear to be important in mucosal healing processes. Although TFF1/3 are expressed in the human respiratory tract, their role in the nasal mucosa is not thoroughly understood. We investigated the association between TFFs and mucins and the role TFFs in the human nasal mucosa. MATERIAL AND METHODS: Patients undergoing turbinectomy were included and it was determined whether patients had nasal al- lergies or not. The localization of TFF1/3, MUC5AC/5B expression was investigated using immunohistochemistry. The levels of the mRNA transcripts were examined using quantitative real-time PCR. RESULTS: TFF1/3 had a similar pattern of localization in epithelial goblet cells and submucosal glandular cells. TFF1/3 co-localized with MUC5AC in the epithelium, and co-localized with MUC5B in the epithelium and the submucosal glandular cells. The levels of TFF1/3 and MUC5B mRNA in allergic patients were significantly increased. CONCLUSION: Our results suggest that TFF1/3 may associate with MUC5AC and MUC5B in the nasal mucosa, and that up-regulation of TFF1/3 and MUC5B may play an important role in the clinical condition of the nasal allergic mucosa.

International Rhinologic Society Rhinology 0300-0729 50 4 2012 12 1 Clinical efficacy of a dry extract of five herbal drugs in acute viral rhinosinusitis 417 426 EN R. Jund Puchheim, Germany M. Mondliger H. Steindl H. Stammer P. Stierna C. Bachert on behalf of the ARhiSi II study group 1120 10.4193/Rhin OBJECTIVE: A herbal drug combination (Dry Extract BNO 1016) has been assessed for efficacy and tolerability in patients with acute viral rhinosinusitis. METHODOLOGY: In this randomised, controlled trial patients with symptom duration of ≤3 days, mild to moderate facial pain and a Major Symptom Score (MSS) of ≥ 8 and ≤ 12 were treated for 15 days with BNO 1016 or placebo (coated tablets administered orally). Primary efficacy endpoint was mean MSS at end of treatment. Secondary outcome measures included treatment response and changes in paranasal sinuses assessed by ultrasonography. RESULTS: Treatment resulted in clinically relevant, significant differences in mean MSS for BNO 1016 versus placebo. BNO 1016 provided symptom relief two days earlier than placebo. The number needed to treat for healing is 8. BNO 1016 was superior regarding responder rates at Day 10 and Day 14 and percentage of patients without signs of acute viral rhinosinusitis assessed by ultrasonography at end of treatment. BNO 1016 was well tolerated; no serious adverse events were reported. CONCLUSION: The herbal dry extract BNO 1016 is efficacious and well tolerated in patients with acute viral rhinosinusitis. Trial registration: ClinicalTrials.gov (ClinicalTrials.gov Identifier: NCT01146860; EudraCT: 2009-016682-28).

International Rhinologic Society Rhinology 0300-0729 50 4 2012 12 1 Steroid resistance in nasal polyposis: role of glucocorticoid receptor and TGF-β1 427 435 EN S. Aversa Otorhinolaryngology, Department of Clinical and Biological Sciences, University of Torino, San Luigi Hospital, Orbassano, Torino, Italy C. Ondolo G. Abbadessa F. Piccione V. Carriero A. Fulcheri A. Lauria S. De Francia S. Racca 1093 10.4193/Rhin BACKGROUND: Glucocorticoids (GCs) are considered drugs of choice for treating nasal polyps (NPs). However, a subset of patients shows a limited clinical response even to high doses of GCs. Altered expression of glucocorticoid receptors (GRs), namely GR-α and GR-β, is a potential mechanism underlying GC insensitivity. GCs modulate the expression of several cytokines, including transforming growth factor-β (TGF-β), which may contribute to cellular proliferation in NPs. The study investigates some biomolecular features of GC-resistant NPs, and examines possible differences from normal mucosa (NM). METHODOLOGY: Radioligand binding assay (binding) was used to determine GR-α binding capacity; Western blotting was used to evaluate GR-α, GR-β, and TGF-β expression and GR-α subcellular distribution. NPs were sampled in 32 patients during ethmoidectomy; NM was taken from 15 healthy patients during rhinoplasty. RESULTS: GR-α was present in NPs and NM, with lower affinity for the ligand in NPs. GR-α was prevalent in the cytosol of NPs that were GR-α-negative to the binding assay. GR-β was expressed in NPs and absent in the majority of NM. TGF-β1 expression was higher in NPs than in NM. CONCLUSIONS: GR-β and TGF-β1 might be involved in NP pathogenesis, but their role in modulating GC sensitivity is still unclear.

International Rhinologic Society Rhinology 0300-0729 50 4 2012 12 1 Cystic dilation of the distal end of the nasolacrimal duct: underrated cause of epiphora in adults and its endoscopic treatment 436 441 EN P. Eloy HNS & ENT Department, CHU-Mont-Godinne, UCL, Yvoir, Belgium A.L. Poirrier The Royal National Throat Nose and Ear Hospital, 330 Grays Inn Road, London, WC1X 8DA, United Kingdom C. Marlair HNS & ENT Department, CHU-Mont-Godinne, UCL, Yvoir, Belgium G. Delahaut HNS & ENT Department, CHU-Mont-Godinne, UCL, Yvoir, Belgium E. Leruth HNS & ENT Department, CHU-Mont-Godinne, UCL, Yvoir, Belgium P. Rombaux HNS & ENT Department, CHU-Mont-Godinne, UCL, Yvoir, Belgium 1111 10.4193/Rhin Epiphora is a frequent reason for ophthalmologic consultation. Among the multiple causes, obstructions of the lacrimal excretory system are common. Sacal and postsacal obstructions are much more frequent than presacal obstructions. Obstruction at the level of the Hasner's valve is rare and likely underestimated. The authors report the clinical history and the imaging of 3 patients with a cystic dilation of the distal end of the nasolacrimal duct (NLD). These patients were easily managed by an ENT surgeon. In one case, the surgery consisted of an endonasal DCR where in the 2 other cases, a marsupialisation of the cystic expansion of the nasolacrimal duct was successfully performed with the micro- debrider. The authors review the world literature on this specific topic. They conclude that a coronal sinus CT scan and an inferior meatus endoscopy should be included in the ophthalmologic work-up performed in all cases of low obstruction of the lacrimal system. When there is a dilation of the distal end of the NLD the marsupialisation of the cystic expansion in the inferior meatus is the option of treatment instead of performing a DCR. ENTs must play a role in the assessment and treatment of low obstructions of the lacrimal excretory system.

International Rhinologic Society Rhinology 0300-0729 50 4 2012 12 1 Audit of CT scanning of paranasal sinuses in patients referred with facial pain 442 446 EN I. Amir Department of Otolaryngology and Head and Neck Surgery, Aberdeen Royal Infirmary, Aberdeen, Scotland, United Kingdom J.C.L. Yeo B. Ram 1121 10.4193/Rhin Background: Computed tomography (CT) scans are performed by some clinicians in the belief that they are a useful primary investigation in patients with facial pain. Objective: To assess the appropriateness and outcome of sinuses CT scans in patients with facial pain based on the European Position Paper on Chronic Rhinosinusitis and Nasal Polyps (EPOS) 2007 guideline and International Headache Society (IHS) criteria for diagnosing and investigating rhinosinusitis. Methodology: The first cycle of audit was performed on 50 patients with facial pain who underwent CT scanning. The findings on nasal endoscopy, Lund-Mackay scores (LMS) of the scans and management of these patients were analysed. Following implemen- tation of the IHS and EPOS criteria, 50 consecutive patients were re-audited. Results: In the first cycle, 16% of patients had positive nasal endoscopic findings. Thirty patients had LMS of 0 and only 9 showed significant changes (LMS ≥ 8) on their scans. In the second cycle, only 10 patients underwent CT imaging as per EPOS guideline and 4 of them showed significant changes. The remaining 80% of patients in this cycle were diagnosed and treated for non-sino- genic causes. Conclusion: Applying the IHS and EPOS criteria has reduced the number of inappropriate CT scans requests and allowed consideration of non-sinogenic aetiologies.