International Rhinologic Society Rhinology 0300-0729 51 2 2013 6 1 Proving the point 97 98 EN V.J. Lund Royal National Throat Nose and Ear Hospital, London, United Kingdom. 1153 10.4193/Rhin In the United Kingdom, we are about to be subjected to a process of commissioning of secondary services by the primary care doctors who are now effectively in charge of the NHS. This means that contracts for everything from hearing aid provision to head and neck or major skull base surgery have to be 'bid' for with the inevitable problems of balancing quality and expertise against cost. At the same time, surgeons are being made to publish individual raw data on their outcomes in the public domain, potentially without risk-level adjustment or taking into account the influence of other members of the multi-disciplinary team. Although many of us would welcome the opportunity to publicise the quality of the care that our patients receive, the potential ambiguities in the system lead to a natural nervousness and a need for even more robust outcome measures and studies to demonstrate the value of what we do. A number of the papers in this issue of the journal address these areas but also highlight some of the difficulties in undertaking these studies.

International Rhinologic Society Rhinology 0300-0729 51 2 2013 6 1 Allergen immunotherapy for allergic rhinitis 99 110 EN K. Petalas Department of Allergy and Clinical Immunology, 251 General Air Force Hospital, Athens, Greece S.R. Durham 1150 10.4193/Rhin Allergic rhinitis, a risk factor for bronchial asthma, is a global health problem that impairs patients' physical and social activity and consequently their quality of life. Specific Immunotherapy (SIT) involves the administration, subcutaneously or sublin- gually, of increasing doses of the causative allergen, in order to induce clinical and immunologic tolerance. SIT has been shown to be effective in those with a poor response to conventional drug therapy. Immunotherapy has been shown to have disease-modifying effects and result in long term remission of allergic symptoms and reduces the risk of progression from rhinitis to asthma, as well as the chances of developing new sensitizations to allergens. Injection immunotherapy is a safe tre- atment for allergic rhinitis with/without mild controlled asthma, provided that it is performed in the context of a harmonious interaction between trained medical personnel and appropriately selected patients. Immunotherapy suppresses early and late responses to allergen exposure by modifying both T-cell and B-cell responses to inhaled allergens. Immune deviation of allergen-specific T cell responses in favour of Th1 and/or the induction of regulatory T cells is crucial in achieving immune to- lerance. Increased understanding of the mechanisms of immunotherapy has identified potential biomarkers of the response to treatment and highlighted new therapeutic pathways with potential for even more effective future standardized vaccines.

International Rhinologic Society Rhinology 0300-0729 51 2 2013 6 1 Pregnancy-induced rhinitis 111 119 EN N. Orban Department of Otolaryngology and Head & Neck Surgery, Wexham Park Hospital, Wexham, Slough, Berkshire, United Kingsdom E. Maughan N. Bleach 1139 10.4193/Rhin BACKGROUND: Pregnancy-induced rhinitis (PIR) is often misclassified and under-diagnosed. There is currently no cure or opti- mum symptomatic treatment. OBJECTIVE: To summarize current knowledge of PIR and assess evidence supporting treatment options. TYPE OF REVIEW: Structured literature search. SEARCH STRATEGY AND EVALUATION METHOD: Review of English-language articles addressing evidence for aetiology, classifica- tion, differential diagnosis or treatment options for PIR. Comparisons to management of other types of rhinitis in pregnancy are also considered. RESULTS: Incidence and prevalence of PIR vary widely between studies. Hormonal changes have a presumed aetiological role, although present evidence is scanty. Smoking appears to be the only agreed identifiable risk factor. Distinction between PIR and other types of rhinitis in pregnancy, especially allergic rhinitis, is important as effective treatments differ. Management of PIR focuses on minimal intervention required for symptom relief. CONCLUSIONS: Although PIR is temporary, its impact on patients' quality of life can be profound. Advice and conservative treatment provide the mainstay of clinical management. None of the currently available medical options offer an ideal solu- tion. Any potential benefit gained should be balanced against risks to the foetus. Clarifying the definition of this separate category of rhinitis will lead to better recognition, with prompt and appropriate treatment.

International Rhinologic Society Rhinology 0300-0729 51 2 2013 6 1 Feasibility of balloon sinuplasty in patients with chronic rhinosinusitis: the Graz experience 120 127 EN P.V. Tomazic Department of General ORL, H&NS, Medical University Graz, Graz, Austria H. Stammberger H. Braun W. Habermann C. Schmid G.P. Hammer W. Koele 1138 10.4193/Rhin BACKGROUND: Balloon sinuplasty (BSP) is a catheter-based technique to dilate sinus ostia and drainage pathways to create ventilation and drainage. The aim of this study was to evaluate the feasibility of BSP in routine treatment of patients suffering from chronic rhinosinusitis (CRS). METHODOLOGY: Patients with CRS refractory to medical therapy who had been scheduled for endoscopic sinus surgery between 2009 and 2011 were included in this study. RESULTS: Forty-five consecutive patients were included in this study, in whom 112 sinuses were approached by BSP. Of the 112 sinuses, 68 (60%) were planned as a "Balloon-Only" procedure and 44 (40%) were planned as a "Hybrid" procedure. Of the 68 sinuses in the "Balloon-Only" group, in 44 sinuses BSP failed, equating to a failure rate of 65%. Forty-four sinuses were planned for "Hybrid" procedures. In 29 of these sinuses BSP failed, giving a failure rate of 66%. CONCLUSION: According to literature, BSP can be a useful adjunct technique to standard FESS. In our experience, however, a failure rate of 65% for "Balloon-Only" and of 66% for "Hybrid" procedures occurred, which was regarded as unacceptable by the study group. Therefore, the study initially scheduled for 200 consecutive patients, was abandoned.

International Rhinologic Society Rhinology 0300-0729 51 2 2013 6 1 Diagnosing chronic rhinosinusitis: comparing questionnaire-based and clinical-based diagnosis 128 136 EN B. Lange Department of Otorhinolaryngology, Odense University Hospital, University of Southern Denmark, Odense, Denmark T. Thilsing J. Baelum R. Holst A. Kjeldsen 1146 10.4193/Rhin BACKGROUND: The European Position Paper on Rhinosinusitis and Nasal Polyps (EP3OS) incorporates symptomatic and endo- scopic criteria in the clinical diagnosis of chronic rhinosinusitis (CRS), while in epidemiological studies the definition is based on symptoms only. The aim of this study was to evaluate the correlation between questionnaire-based and clinical-based CRS. METHODS: Based on the GA2LEN postal survey data a total of 366 persons participated at the follow-up at the Danish centre and provided information on questionnaire-based CRS. At the same occasion the 366 participants underwent clinical inter- view and examination by an otorhinolaryngologist to provide information for a clinical-based CRS diagnosis. The association between questionnaire-based and clinical-based CRS diagnosis was determined using logistic regression models and kappa statistics. RESULTS: Mean age of respondents to the postal questionnaire was 45.3 years and 52.9% were female. Persons with asthma were 8.4 % and 26.2 % were actual smokers. There was moderate agreement between questionnaire-based and clinical- based CRS. Sensitivity and specificity were low comparing questionnaire-based CRS with clinical-based CRS. Incorporation of self reported CRS and medical history in diagnosing CRS by questionnaire increased the agreement, sensitivity, and specifi- city. CONCLUSION: Evaluating the correlation between questionnaire-based and clinical-based CRS showed only moderate agree- ment and questions whether they evaluate the same disease. It brings into consideration that adjustments are needed to justify correlation between questionnaire-based and clinical-based diagnosis of CRS.

International Rhinologic Society Rhinology 0300-0729 51 2 2013 6 1 Comparison of polyvinyl alcohol coated nasal packing with non-absorbable nasal packing 137 142 EN J.H. Seol Department of Otorhinolaryngology-Head & Neck Surgery, Konkuk University School of Medicine, Seoul, Korea J.M. Kim S.S. Kim B.R. Na H. Jung J.H. Cho J.K. Kim 1137 10.4193/Rhin BACKGROUND: A number of different nasal packing materials are available for prevention of nasal bleeding after endoscopic sinus surgery. Polyvinyl alcohol (PVA) coated nasal packing is an expandable packing for use in rhinological surgery. This innovative surf- ace treatment helps to reduce the possibility of adherence to tissue and of blood clotting within the sponge. The present study investigated the effects of PVA coated packing and non-absorbable packing with respect to pain, healing site and postoperative bleeding following endoscopic sinus surgery. METHODOLOGY: Patients between 18-80 years of age undergoing sinus surgery were enrolled. Each patient's ethmoid cavities were randomised to receive PVA coated packing material or the standard non-absorbable sinus packs. The remaining nasal packing material was removed on the 2nd day in the clinic. We determined visual analog scale score, bleeding time and wound healing status. A single rhinologist graded postoperative endoscopic appearance. Length of follow-up was 3 months. RESULTS: Thirty three patients were recruited. There was a significant difference in the bleeding time between the two groups, but pain and wound healing were not significantly different between the two groups. CONCLUSION: PVA-coated nasal packing presents comparable characteristics with traditional nasal packing.

International Rhinologic Society Rhinology 0300-0729 51 2 2013 6 1 A Randomized Controlled Trial comparing the efficacy of low-dose amitriptyline, amitriptyline with pindolol and surrogate placebo in the treatment of chronic tension-type facial pain 143 153 EN A.M. Agius The Medical School, University of Malta, Msida, Malta N.S. Jones R. Muscat 1144 10.4193/Rhin BACKGROUND: Patients often present to otolaryngologists with chronic facial pain, presumed to be of sinus origin despite normal nasal endoscopy and sinus CT. This pain has increasingly been recognized as being of neurological origin with one of the commonest underlying causes being mid-facial segmental tension-type pain (MFP) which is a version of tension-type headache affecting the midface. OBJECTIVES: Primary outcome measures: 1. To determine whether low-dose amitriptyline reduces pain scores compared to surrogate placebo in patients with chronic MFP. 2. To determine whether the addition of pindolol, a beta blocker with serotonin receptor blocking properties hastens onset of action or improves efficacy of amitriptyline. Secondary outcome measure: to determine whether amitriptyline or amitriptyline with pindolol significantly reduces analgesic consumption. METHODOLOGY: Sixty two patients were randomized to three treatment groups (a) amitriptyline 10mg daily (b) amitriptyline 10mg daily with pindolol 5mg twice daily and (c) loratadine 10mg daily. Daily pain scores using a facial pain diary were recorded over eight weeks. RESULTS: At 8 weeks, pain frequency and intensity were significantly reduced in patients treated with amitriptyline and in those receiving amitriptyline with pindolol compared to surrogate placebo. Patients on the combination therapy showed significantly improved clinical outcome and significantly reduced analgesic intake compared to those on amitriptyline alone. CONCLUSION: Low dose amitriptyline is effective in the management of MFP and is enhanced by the addition of pindolol.

International Rhinologic Society Rhinology 0300-0729 51 2 2013 6 1 Immunohistochemical studies of wound healing after monopolar electrocautery and ultrasound submucosal inferior nasal turbinate reduction in sheep 154 161 EN C.S. Nousia Department of Otorhinolaryngology, Faculty of Medicine, Democritus University of Thrace, Alexandroupolis, Greece H. Gouveris A. Giatromanolaki M. Katotomichelakis P. Ypsilantis M. Riga E. Sivridis J.B. Watelet P. van Cauwenberge V. Danielides 1154 10.4193/Rhin BACKGROUND: Extracellular matrix (ECM) proteins such as fibronectin and collagen III, enzymes such as matrix metalloproteinases and macrophages have been demonstrated to intervene in nasal and paranasal sinuses wound healing. AIM OF THE STUDY: To compare concentration of ECM proteins, enzymes and the recruitment of macrophages during wound repair after monopolar electrocautery in contrast with ultrasound submucosal surgical tissue reduction of inferior nasal turbinate (INT) tested in sheep. MATERIALS AND METHODS: Prospective controlled study in sheep. Immunostaining for collagen III, fibronectin, CD68 and matrix metalloproteinase-9 (MMP9) was applied in tissue specimens of INT mucosa after monopolar electrocoagulation (MEC) and ultrasound tissue reduction (UTR). Twelve INTs were studied 1, 3 and 8 weeks post-operatively in each interventional group (MEC and UTR) and 5 INTs were studied in animals of the control group (without surgery). The immunoreactivity was quantitatively graded between 0% to 100% immunoreactivity by a blinded senior pathologist. RESULTS: At the end of the study period collagen III, fibronectin and MMP9 were increased in both groups compared to the levels of the control group. When compared to control group, CD68 immunoreactivity was found higher in MEC group but not in UTR group. Fibronectin subepithelial immunoreactivity exhibited a substantial negative correlation with mucosal epithelial cell necrosis, a substantial positive correlation with fibrosis in MEC-treated specimens and a significant positive correlation with sinusoid engorgement in UTR-treated specimens. Collagen III tissue immunoreactivity showed a particularly significant negative correlation with sinusoid engorgement in MEC-treated specimens. CONCLUSION: Correlation of fibronectin and collagen III immunoreactivity to histopathologic findings suggests different ECM repair processes between MEC and UTR turbinate tissue reduction. The use of CD68 and MMP9 provides additional clues to the mode of actions of these techniques and to the molecular and cellular events of the nasal mucosa wound healing process.

International Rhinologic Society Rhinology 0300-0729 51 2 2013 6 1 Clinical-radiological correlation after functional endoscopic sinus surgery in patients with chronic rhinosinusitis: interest of a sinonasal aerial volumetry 162 170 EN M. Garetier Department of Radiology, Military Teaching Hospital Clermont-Tonnerre, Brest, France C. Barberot S. Chinellato D. Commandeur T. Le Bivic L. Bonne R. Marianowski M. Nonent J. Rousset 1155 10.4193/Rhin BACKGROUND: Although a CT scan is often performed after functional endoscopic sinonasal surgery (FESS) in patients with chronic rhinosinusitis, its role hasn't been firmly established. The goal of this study is to investigate the correlation between symptoms and CT findings before and after FESS for chronic rhinosinusitis. In addition, the interobserver agreement for both sinonasal aerial volumetry and CT score is assessed. METHODS: Thirty-three patients surgically treated for chronic rhinosinusitis were included in this prospective study. Conventional and modified Lund-Mackay scores and sinonasal volumetry were determined by two radiologists before (M0), at 3 months (M3) and 1 year (M12) after surgery. The symptoms were evaluated by the 22-item SinoNasal Outcome Test (SNOT-22). RESULTS: Change of SNOT-22 and air volume were significantly correlated between M0 and M12, but not between M0 and M3, for both readers. Compared to other scores, volume had the best intraclass correlation coefficient and reproducibility, according to the Bland-Altman analysis. No correlation was found between SNOT-22 and CT scores before and after surgery, except between M12 and M0 for one reader. CONCLUSION: The correlation between CT scan and symptoms is low or absent. The measurement of sinonasal air volume is best correlated with the symptoms after surgery, with the best inter-observer agreement.

International Rhinologic Society Rhinology 0300-0729 51 2 2013 6 1 Postoperative improvement in acoustic rhinometry measurements after septoplasty correlates with long-term satisfaction 171 175 EN N.M. Toyserkani Department of Otolaryngology, Head and Neck Surgery, Rigshospitalet and Faculty of Health Sciences, University of Copenhagen, Denmark T. Frisch C. Von Buchwald 1141 10.4193/Rhin BACKGROUND: Not much is known about long-term satisfaction of septoplasty. Our goal was to compare pre- and postoperative acoustic rhinometry measurements with satisfaction 11 years after surgery. METHODOLOGY: Acoustic rhinometry measurements were performed preoperatively and 3 months postoperatively. Satisfaction was evaluated with semi-structured interviews by telephone 11 years after surgery. Symptoms were evaluated using the NOSE score. RESULTS: In total, 222 patients were interviewed and eligible to enter the study. Of these, 213 had preoperative acoustic rhinometry and 159 had postoperative acoustic rhinometry. In total, 157 patients had a complete data set. Mean follow-up time was 11.3 years. Patients satisfied with surgery had a bigger improvement in total minimum cross-sectional area before decongestion and total nasal cavity volume after decongestion. NOSE scores were not correlated with acoustic rhinometry measurements. CONCLUSION: Acoustic rhinometry could be a valuable tool for evaluating the results of septoplasty. Satisfaction at 11 years follow-up was associated with 3 months postoperative acoustic rhinometry improvements. Acoustic rhinometry did not show preoperative patient selection potential.

International Rhinologic Society Rhinology 0300-0729 51 2 2013 6 1 Asymmetrical nostril axis angle in the post traumatic nose 176 180 EN I. Smillie Department of Otolaryngology, Head & Neck Surgery, Southern General, Glasgow, Scotland, United Kingdom A. Sil R. Haddock N. Balaji 1145 10.4193/Rhin BACKGROUND: Nasal tip reconstruction is a challenging part of septorhinoplasty in post-traumatic patients. Aesthetic appearance of the nose is dependent on adequate tip definition, projection and rotation. Our aim is to establish if caudal septal dislocation (secondary to fracture or subluxation) is a significant factor in causing asymmetry in nostril axis angle (NAA) to effect surgical intervention. In addition, to assess if there is an association between the side of dislocation and the magnitude of NAA. METHODOLOGY: Photographic assessment of NAA was measured in a study group of 26 patients with caudal dislocation of the septum and a control group of 26 patients without caudal septal dislocation. All 52 patients were awaiting a septorhinoplasty procedure due to nasal trauma. RESULTS: Caudal septal dislocation causes a mean difference in NAA of 7.95o compared to 1.38o difference in the control group. We also found there is a greater degree of upward tip rotation on the side of the dislocation resulting in a larger NAA. CONCLUSION: Caudal dislocation of the septum causes a significant asymmetry in NAA, with a greater degree of rotation on the side of the dislocation. We should be aware of this fallacy prior to surgery.

International Rhinologic Society Rhinology 0300-0729 51 2 2013 6 1 Sphenoid sinus fungall ball: a retrospective study over a 10- year period 181 188 EN Ph. Eloy ENT Department CHU UCL Mont-Godinne 5530 Yvoir, Belgium J. Grenier A. Pirlet A.L. Poirrier The Royal National Throat Nose and Ear Hospital, 330 Grays Inn Road, London, WC1X 8DA, United Kingdom J.S. Stephens Ph. Rombaux 1143 10.4193/Rhin A fungal ball consists of a dense conglomerate of fungal hyphae growing at the surface of the sinus mucosa without tissue infiltration. The maxillary sinus is by far the most commonly involved paranasal sinus cavity followed by the sphenoid sinus. The present study is a retrospective study of 25 consecutive cases treated during the last 10 years in the two hospitals be- longing to the Catholic University of Louvain (CHU Mont-Godinne and UCL Saint Luc). We report the symptomatology, the imaging and discuss the different surgical managements. We conclude that the clinician must have a high index of suspicion when dealing with a unilateral rhinosinusitis persisting despite a maximal and well conducted medical treatment. This is particularly so in elderly women when associated with facial pain and post nasal drip, particularly when the computed tomography shows an unilateral opacity of the sphenoid sinus with or without a sclerosis or an erosion of the bony walls, a polyp in the sphenoethmoidal recess or a hyperdensity mimicking a foreign body. An endonasal endoscopic sphenoidotomy is the treatment of choice in most cases, allowing good ventilation of the sinus and radical removal of all the fungal concretion. A biopsy of the sinus mucosa adjacent to fungal elements is of upmost important to confirm the non- invasiveness of the fungi within the tissue. Antifungal medication is not required in uncompli- cated forms. All host factors producing some degree of immunosuppression must be corrected when present and must alert the clinician to rule out any forms of invasive disease.