International Rhinologic Society Rhinology 0300-0729 51 1 2013 3 1 Sinonasal neoplasms again 1 2 EN W.J. Fokkens Department of Otorhinolaryngology, Academic Medical Centre, Amsterdam, The Netherlands 1140 10.4193/Rhin Sinonasal neoplasms are uncommon neoplasms, accounting for only 1% of all malignancies and only 3% to 5% of all head and neck malignancies. In 2010 Rhinology published the European position paper on endoscopic management of tumours of the nose, paranasal sinuses and skull base (1). This issue of Rhinology again contains interesting new data on tumours in the nose and sinuses and raised my interest in potential role of external (occupational) factors that may influence the pathophysiology of sinonasal disease.

International Rhinologic Society Rhinology 0300-0729 51 1 2013 3 1 Is the common cold a clinical entity or a cultural concept? 3 8 EN R. Eccles Common Cold Centre and Healthcare Clinical Trials, Cardiff School of Biosciences, Cardiff University, United Kingdom 1127 10.4193/Rhin Common cold is the most common infectious disease of mankind and the term is widely used in the clinical literature as though it were a defined clinical syndrome. Clinical studies on this syndrome often use elaborate symptom scoring systems to diagnose a common cold. The symptom scores are based on a study conducted over 50 years ago to retrospectively diagnose experimental cold and this method cannot be applied to diagnosis of common cold in the community. Diagnosis of the common cold by virology is not feasible because of the number of viruses and the variability in the disease states caused by the viruses. Because of the familiarity of subjects with common cold and the variability in symptomatology it seems a more reasonable approach to use self-diagnosis of common cold for clinical research studies and accept that the common cold is a cultural concept and not a clinical entity.

International Rhinologic Society Rhinology 0300-0729 51 1 2013 3 1 Sublingual immunotherapy in allergic rhinitis: indications, efficacy and safety 9 17 EN H.H. Kariyawasam Royal National Throat Nose Ear Hospital London, University College London, London, United Kingdom G. Rotiroti D.S. Robinson 1131 10.4193/Rhin Sublingual immunotherapy (SLIT) is now an established treatment for allergic rhinitis. Whilst several systematic reviews have now confirmed clinical efficacy and safety, recent analysis also confirms that therapeutic benefit persists for several years after the com- pletion of SLIT. Such findings, along with the obvious ease of administration of sublingual preparations, have clearly promoted SLIT as an attractive option for treatment of allergic rhinitis resistant to medical treatment. This article reviews the development, efficacy and safety of SLIT in allergic rhinitis and the current indications for its use.

International Rhinologic Society Rhinology 0300-0729 51 1 2013 3 1 The golden ratio in facial symmetry 18 21 EN E.P. Prokopakis Department of Otorhinolaryngology, University of Crete School of Medicine, Heraklio, Crete, Greece I.M. Vlastos V.A. Picavet G. Nolst Trenité R. Thomas C. Cingi ENT Department, Medical Faculty, Eskisehir Osmangazi University, Eskisehir, Turkey 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 1128 10.4193/Rhin Symmetry is believed to be a hallmark of appealing faces. However, this does not imply that the most aesthetically pleasing proportions are necessary those that arise from the simple division of the face into thirds or fifths. Based on the etymology of the word symmetry, as well as on specific examples and theories of beauty, we conclude that φ-value, a ratio also known as the golden ratio or the divine proportion, can also characterize symmetrical forms. Therefore, we propose the utilization of this ratio in facial aesthetics.

International Rhinologic Society Rhinology 0300-0729 51 1 2013 3 1 Primary sinonasal malignant melanoma: a nationwide study of the Swedish population, 1960-2000 22 30 EN M. Jangard Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden J. Hansson B. Ragnarsson-Olding 1130 10.4193/Rhin OBJECTIVE: To establish population-based trends for sinonasal mucosal melanoma (SNMM) in Sweden. METHODS: We identified 186 patients from the Swedish National Cancer Registry diagnosed with primary melanomas arising from the nasal cavity, paranasal sinuses, or both, during the period 1960 through 2000. Incidence, gender and age, primary anatomical sites, geographic distribution, treatment and survival were investigated. RESULTS: The age-standardized incidence of SNMM increased significantly during the 41-year-period, with a higher overall incidence for females than males, but with a more rapid increase for males than for females. The incidence increased with age, peaking after the eightieth year in both genders. About 70 % of the cases were clinically amelanotic. The most common primary treatment was surgery. Five-year, disease-specific survival rates were poor for all these patients, but women had a significantly better survival time than men. For both genders the survival rate lengthened during the study period, irrespective of therapeutic strategy. CONCLUSION: SNMM is a rare disease, but the incidence in Sweden has increased significantly from 1960 through 2000, although not at the same pace as that of cutaneous malignant melanoma. Both the incidence and the survival were significantly higher in females than in males, but the reason for these gender differences is unknown.

International Rhinologic Society Rhinology 0300-0729 51 1 2013 3 1 Prevalence of occupational hazards in patients with different types of epithelial sinonasal cancers 31 36 EN M. Bonzini Epidemiology and Preventive Medicine Research Centre, University of Insubria, Varese, Italy P. Battaglia D. Parassoni M. Casà N. Facchinetti M. Turri-Zanoni R. Borchini P. Castelnuovo M.M. Ferrario 1129 10.4193/Rhin BACKGROUND: Occupational exposure to carcinogens contributes greatly to the etiology of sinonasal cancer (SNC), but the role of different risk factors in determining different histological subtypes is disputed. METHODOLOGY: All consecutive surgical epithelial SNC cases (case-series study) underwent a systematic occupational medicine examination to determine previous exposure to a wide range of work-related chemical hazards. RESULTS: We investigated 65 SNC cases including intestinal-type adenocarcinoma [ITAC] squamous-cell carcinoma [SCC], and others. Occupational exposure was recognized for 39 cases. Occupational exposures were sensibly more frequent among ITAC than among SCC or other histotypes. Occupational exposure in ITAC cases was to leather or wood dust only, while among non-ITAC cases, we recognised exposure to formaldehyde, solvents and metal fumes. A high proportion of SNC with occupational exposure originated in the ethmoidal epithelium. CONCLUSION: In our case-series of SNC, a very high frequency of previous occupational exposure to carcinogens was detected, suggesting that occupational hazards may be associated to the aetiopathogenesis, primarily for ITAC, but also for other histotypes. Besides leather or wood, other chemical agents must be recognized as occupational risk factors.

International Rhinologic Society Rhinology 0300-0729 51 1 2013 3 1 Endoscopic endonasal surgery for skull base tumours: technique and preliminary results in a consecutive case series report 37 46 EN J. Enseñat Division of Neurosurgery, Hospital Clinic de Barcelona, Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain M. de Notaris Department of Neuroscience, Division of Neurosurgery, "G. Rummo" Hospital, Benevento, Italy M. SÃˇnchez C. FernÃˇndez E. Ferrer M. Bernal-Sprekelsen Department of Otorhinolaryngology, Rhinology Unit, Hospital Clinic de Barcelona, Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain I. Alobid Department of Otorhinolaryngology, Rhinology Unit, Hospital Clinic de Barcelona, Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain 1125 10.4193/Rhin BACKGROUND: The introduction of the endoscope in transsphenoidal surgery has allowed access to lesions located in complex regions of the skull base under direct visual control. With the application of this technique, our group started treating pituitary tumours and from 2009 onwards began treating skull base lesions through extended endoscopic endonasal approaches. The AIM OF THE PRESENT STUDY is to report our experience with extended endoscopic approaches. Indications, results, limitations and complications of this new technique are also discussed. MATERIAL AND METHODS: From January 2007 to January 2012, the endonasal approach was used in 40 patients with different cancerous lesions. RESULTS: Total tumour removal, as assessed by postoperative magnetic resonance imaging, occurred in 30/ 40 patients (75%), but in 10 patients only partial removal was possible. Major complications, including cerebrospinal fluid leak, were observed in 5/40 patients (8%). One patient died 3 months after surgery due to a severe systemic sepsis. CONCLUSION: The extended endoscopic endonasal approach could be used as a minimally invasive and innovative technique for the removal of selected skull base lesions.

International Rhinologic Society Rhinology 0300-0729 51 1 2013 3 1 Access to the crista galli and the foramen caecum in nasal dermal sinus cysts - lessons learned in a single tertiary care centre 47 53 EN D. Vital Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital of Zurich, Switzerland N. Krayenbühl O. Bozinov D. Holzmann 1133 10.4193/Rhin OBJECTIVE: Several surgical techniques have been suggested for the treatment of nasal dermal sinus cysts (NDSC). We have used several different techniques and have developed a minimally invasive approach. The aim of this study is to describe the evolution to this approach and compare the results with those achieved with our experience of more traditional techniques. METHODOLOGY/PRINCIPAL: A retrospective data collection of patients with NDSC presenting to our clinic between 1998 and 2012 was performed. We initially performed external approaches as outlined elsewhere. With an increasing number of young children requiring surgery, the technique was modified to a less invasive form. This new approach starts with mobilisation of the pit via a tiny skin incision. An open rhinoplasty approach is used to follow the fistula on the nasal bone. Once the fistula passes underneath the nasal bone, an endoscopic endonasal approach is used. Following the fistula cranially, the area of the foramen caecum can be identified. RESULTS: Twelve out of 15 patients (80%) were treated surgically. The transfacial, coronal subcranial and minimally invasive ap- proach was used in 3 (25%), 4 (33%) and 5 patients (42%), respectively. Radical resection was achieved in all patients. Cosmetic problems were present in all patients undergoing a transfacial and in half of the patients after the coronal subcranial approach. Patients treated by the minimally invasive technique remained without sequelae. CONCLUSION: The minimally invasive approach enables a perfect exposure of the fistula up to the crista galli and provides less morbidity and better cosmetic results than the transfacial and subcranial approach.

International Rhinologic Society Rhinology 0300-0729 51 1 2013 3 1 Paranasal sinus osteoma: is there any association with anatomical variations? 54 60 EN A. Janovic Department of Radiology, School of Dentistry, University of Belgrade, Belgrade, Serbia S. Antic Z. Rakocevic M. Djuric 1126 10.4193/Rhin BACKGROUND: Developmental disturbances of the paranasal sinuses are proposed as the cause of osteoma. We examined whether such disturbances may result in the frequent presence of anatomical variations of the paranasal sinuses in patients with osteoma. METHODOLOGY/PRINCIPAL: The study was performed retrospectively on 2,820 patients subjected to CT examination during 2005 - 2011. Demographic and CT characteristics of osteoma, and associated pathological findings were evaluated for 104 patients with diagnosed osteoma. The presence of anatomical variations was assessed for 51 osteoma patients with a complete medical history, and for 1,233 patients from a control group. RESULTS: The prevalence of osteomas was found to be 3.69%, with male to female ratio 1.08:1. The frontal sinus was most commonly affected. The presence of anatomical variations was more frequent in patients with osteoma than in controls, with significant differences confirmed for the sphenomaxillary plate, infraorbital cell, and crista galli pneumatization. CONCLUSIONS: The paranasal sinus osteoma is associated with higher prevalence of anatomical variations. This can be explained either by the stronger influence of genetic and/or environmental factors on the development of the paranasal sinuses in patients with osteoma, or by their higher susceptibility to above mentioned factors.

International Rhinologic Society Rhinology 0300-0729 51 1 2013 3 1 Eicosanoid imbalance correlates in vitro with the pattern of clinical symptoms of Samter ́s triad 61 69 EN U. Förster Department of Otorhinolaryngology, Campus Virchow, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany S. Strathmann D. Schäfer A.J. Szczepek H. Olze 1134 10.4193/Rhin BACKGROUND: Hypersensitivity to non-steroidal anti-inflammatory drugs (NSAIDs) is often associated with chronic rhinosinusitis (CRS), nasal polyps (CRSwNP) and asthma, together known as Samters triad. The disease is characterised by eicosanoid imbalan- ce. In our study, we determined clinical and laboratory parameters in respect of three groups of patients: 1) CRSwNP, 2) CRSwNP and asthma (CRSwNP-A), and 3) CRSwNP with asthma and NSAID-triggered hypersensitivity (CRSwNP-AA). Our main goal was to improve the characterisation of the stages of development in Samter ́s triad, pointing to the homogeneous or heterogeneous course of disease. METHODOLOGY: Forty-three patients (10 CRSwNP, 14 CRSwNP-A, 19 CRSwNP-AA) and 10 control subjects were included in the study. Nasal assessment using the CRS visual analogue score, endoscopy- and computer tomography scores, allergy tests, analysis of sinus surgeries, asthma severity and in vitro functional eicosanoid tests (FET) with peripheral blood leucocytes were performed. RESULTS: The scores reflecting CRS symptoms such as nasal congestion, nasal discharge and smell impairment differed between the patients groups reflecting the severity of disease (CRSwNP-AA > CRSwNP-A > CRSwNP). Eicosanoid imbalance correlated with nasal congestion, nasal discharge and loss of smell. CONCLUSION: The data presented support the hypothesis of the continuous development of NSAID-triggered hypersensitivity, culminating in Samter's triad.

International Rhinologic Society Rhinology 0300-0729 51 1 2013 3 1 Interleukin-6 -174 G/C promoter gene polymorphism in nasal polyposis and asthma 70 76 EN E.M. Kosugi Department of Otorhinolaryngology - Head and Neck Surgery, Sao Paulo Federal University, Sao Paulo - SP, Brazil C.M. de Camargo-Kosugi E.R. Hirai J.A. Mendes-Neto L.C. Gregorio Department of Otolaryngology-Head and Neck Surgery, Federal University of São Paulo, Brazil I.D.C. Guerreiro-da-Silva L.L.M. Weckx 1135 10.4193/Rhin BACKGROUND: Interleukin-6 (IL-6) is an inflammatory mediator linked to nasal polyposis and asthma, with a single nucleotide poly- morphism -174 G/C that seems to promote an inflammatory status. We aimed to analyze the relationship between this polymor- phism and asthmatic nasal polyposis patients. METHODOLOGY: Cross-sectional study to investigate IL-6 - 174 G/C genotypes of 45 nasal polyposis with asthma patients, 63 nasal polyposis-only patients, 45 asthma-only patients and 81 subjects without both diseases. Aspirin intolerance and atopy were main exclusion criteria. IL-6 genotyping was performed using the PCR method with specific primers followed by restriction enzyme analysis, classifying patients in GG, GC or CC genotype. RESULTS: The GG genotype was the most frequent in all inflammatory groups. Less than 40% of controls presented with the GG ge- notype. There were significant differences between inflammatory groups and control group. No significant differences were seen when comparing inflammatory groups to each other, other than between nasal polyposis-only group and asthma-only group. CONCLUSION: The IL-6 74 GG genotype was found more frequently in all inflammatory groups than in controls. This genotype could influence nasal polyposis and asthma, and seems to be more important in the latter.

International Rhinologic Society Rhinology 0300-0729 51 1 2013 3 1 Septorhinoplasty by disarticulation: early assessment of a new technique for morphological correction of crooked noses 77 87 EN N. Boulanger Service d'ORL et de chirurgie cervico-faciale, CHU NANCY Hôpital Central, Nancy, France C. Baumann R. Beurton H. Elueque P. Gallet R. Grosjean P. Lindas C. Lorentz R. Jankowski 1132 10.4193/Rhin OBJECTIVE: This study was aimed to assess the early morphological results of a new septorhinoplasty technique based on disarti- culation (SRD) between bony and cartilaginous nose structures. METHODOLOGY: A retrospective, multi-judge, blind comparison of pre- and post-operative photographs displayed on Google documents© was designed. A nasal morphology analysis grid based on 10 items was fulfilled independently by 6 judges to assess pre- and post-operatively, two times with a 15 day interval, the severity of each deformity by a score between 0 and 2. The sum of all deformities in a single patient produced the individual global score of nasal deformity, which was set between 0 and 20 for each patient. Pre- and post-operative individual global scores were compared using Student's t test on paired samples. Percenta- ges of post-operative improvement and deterioration were calculated for each item. RESULTS: Thirty-five SRD were analyzed. Before surgery, 80% of noses were humped and 86% were crooked; three months after surgery, 64% of noses had a rectilinear nasal crest on profile and 57% on facial view. The mean global score of deformities drop- ped from 11.1 before surgery to 5.8 after surgery, an improvement of 47% . Improvement rates of 82% and 74.3% were obtained, respectively, for hump profiles and orbitonasal lines. DISCUSSION: The early morphological results of SRD allow to propose this technique as a possible solution to correct crooked noses with humps.

International Rhinologic Society Rhinology 0300-0729 51 1 2013 3 1 Audit: Patient reported outcomes of extracorporeal septorhinoplasty 88 92 EN D. Mendis Department of ENT Surgery, New Cross Hospital NHS Trust, Wolverhampton, United Kingdom P.P. Cheang L.P. Glossop 1136 10.4193/Rhin BACKGROUND: Extracorporeal septorhinoplasty (ECS) presents an important option in the surgical correction of the markedly deformed and twisted nose. However, there is a paucity of literature on the qualitative outcomes of ECS. METHODOLOGY: Retrospective telephone and postal questionnaire study of operations performed over 2 years (2008-2009) under the care of a senior rhinologist at two linked hospitals in the United Kingdom. Questionnaires were designed (i) relating to the procedure and (ii) patient perceptions of surgical success, improvements in physi- cal health, psychosocial functioning and social interactions. For succinctness a shortened version of the Glasgow Benefit Inventory was used. RESULTS: Forty-six cases were analysed eight of which were revision cases. Two cases required revision surgery and two minor complications occurred, managed conservatively. The patients had a minimum of two to three follow-ups from seven days to one year. Questionnaire scores suggested high satisfaction in response to surgical success, with notable improvements in physical health (sleep disturbance) and in general health and well-being. Regarding psychosocial functions patients reported feeling either moderately less self-conscious or not self-conscious at all post-surgery. Improvements in social interactions were less well-defined. CONCLUSION: In this audit of cases with significant deformities, ECS appears to confer high levels of satisfaction.