International Rhinologic Society Rhinology 0300-0729 51 3 2013 9 1 Patient-centered treatment goals 193 194 EN W.J. Fokkens Department of Otorhinolaryngology, Academic Medical Centre, Amsterdam, The Netherlands 1174 10.4193/Rhin We often explain to patients that we do not operate CT scans or MRI's but patients with symptomatic disease. But, how clear are we in discussing the aims of our treatment with our patients? How often is our surgical goal to remove the polyps or open up the sinus, which we may judge to be useful for the patient's disease without directly improving the primary symptom of the patient, and does the patient understand our goal? Are we always sure that our aim is the same as the wishes of our patients? Are we sure that we explain our CRS patient that he/she has an inflammatory disease that most likely will need long term medical treatment also after surgery?

International Rhinologic Society Rhinology 0300-0729 51 3 2013 9 1 Aspirin and salicylate in respiratory disease 195 205 EN J.E. Mitchell Department of Ear Nose and Throat Surgery, Royal Surrey County Hospital NHS Foundation Trust, Guildford, United Kingdom I. Skypala 1159 10.4193/Rhin This article describes the natural history, pathogenesis and diagnosis of Aspirin Exacerbated Respiratory Disease. The evidence base for the role of oral aspirin and nasal L-Lysine-aspirin desensitisation is reviewed. Evidence for the role of dietary salicylic acid and its avoidance is also reviewed.

International Rhinologic Society Rhinology 0300-0729 51 3 2013 9 1 Olfactory loss after head and neck cancer radiation therapy 206 209 EN A. Brämerson Department of Otorhinolaryngology, Central Hospital, Skővde, Sweden J. Nyman S. Nordin M. Bende 1157 10.4193/Rhin BACKGROUND: A reduced sense of smell may be one explanation for why patients with cancer in the ear, nose and throat (ENT) region who are treated with radiation therapy lose weight. The purpose of this study was to investigate whether radiation therapy has a negative effect on olfactory function and, if so, whether this effect is dose-related. METHODOLOGY: Seventy-one patients were tested using odour-detection sensitivity and olfactory identification tests before radiation therapy and 20 months after it. RESULTS: Patients who received radiation close to the olfactory organ showed a reduced sense of smell, in both tests. A multiple regression analysis showed that the radiation dose was related to decline in the olfactory function, while age, sex, chemotherapy and interactions between these variables were not. CONCLUSION: Radiation therapy can damage olfactory cells.

International Rhinologic Society Rhinology 0300-0729 51 3 2013 9 1 Clinical usefulness and feasibility of time-frequency analysis of chemosensory event-related potentials 210 221 EN C. Huart Department of Otorhinolaryngology, Cliniques universitaires Saint-Luc, Brussels, Belgium Ph. Rombaux T. Hummel A. Mouraux 1163 10.4193/Rhin BACKGROUND: The clinical usefulness of olfactory event-related brain potentials (OERPs) to assess olfactory function is limited by the relatively low signal-to-noise ratio of the responses identified using conventional time-domain averaging. Recently, it was shown that time-frequency analysis of the obtained EEG signals can markedly improve the signal-to-noise ratio of OERPs in healthy controls, because it enhances both phase-locked and non phase-locked EEG responses. The aim of the present study was to investigate the clinical usefulness of this approach and evaluate its feasibility in a clinical setting. METHODOLOGY: We retrospectively analysed EEG recordings obtained from 45 patients (15 anosmic, 15 hyposmic and 15 normos- mic). The responses to olfactory stimulation were analysed using conventional time-domain analysis and joint time-frequency analysis. The ability of the two methods to discriminate between anosmic, hyposmic and normosmic patients was assessed using a Receiver Operating Characteristic analysis. RESULTS: The discrimination performance of OERPs identified using conventional time-domain averaging was poor. In contrast, the discrimination performance of the EEG response identified in the time-frequency domain was relatively high. Furthermore, we found a significant correlation between the magnitude of this response and the psychophysical olfactory score. CONCLUSION: Time-frequency analysis of the EEG responses to olfactory stimulation could be used as an effective and reliable diagnostic tool for the objective clinical evaluation of olfactory function in patients.

International Rhinologic Society Rhinology 0300-0729 51 3 2013 9 1 Clinical effects of sinus surgery and adjuvant therapy in cystic fibrosis patients — can chronic lung infections be postponed? 222 230 EN K. Aanaes Department of Otorhinolaryngology, Head & Neck Surgery and Audiology, Rigshospitalet and Faculty of Health and Medical Sciences, University of Copenhagen, Denmark H.K. Johansen M. Skov F.F. Buchvald T. Hjuler T. Pressler N. Høiby K.G. Nielsen C. Von Buchwald 1158 10.4193/Rhin BACKGROUND: The paranasal sinuses can be a bacterial reservoir for pulmonary infections in patients with cystic fibrosis (CF) Methodology: In this prospective, non-randomised, uncontrolled, intervention cohort study, the clinical effect of sinus surgery followed by two weeks' intravenous antibiotics, 6 months' antibiotic nasal irrigations was assessed in 106 CF patients. RESULTS: One year after sinus surgery, the prevalence of intermittently colonised patients had decreased by 38%, while the prevalence of non-colonised patients had increased by 150%. The frequency of pulmonary samples with CF pathogens was reduced after surgery. Specific IgG against P. aeruginosa decreased after six months. Additionally, the self reported symptoms of chronic rhinosinusitis and quality of life improved. CONCLUSION: Combined sinus surgery and postoperative systemic and topical antibiotic treatment significantly reduced the fre- quency of pulmonary samples positive for CF pathogens in the first year after sinus surgery.

International Rhinologic Society Rhinology 0300-0729 51 3 2013 9 1 Do patients with chronic rhinosinusitis with nasal polyps suffer with facial pain? 231 235 EN A.Z. Eweiss Royal National Throat Nose and Ear Hospital, London, United Kingdom. V.J. Lund Royal National Throat Nose and Ear Hospital, London, United Kingdom. J. Barlow G. Rose 1148 10.4193/Rhin BACKGROUND: Many patients attribute their symptoms of facial pain or headache to sinus problems. Facial pain is one of the symptoms of rhinosinusitis according to European and American consensus documents. This symptom, however, has been insufficiently studied in the group of patients with chronic rhinosinusitis with nasal polyps (CRSwNP). The aim of this work is to study the symptom of facial pain in patients with CRSwNP. METHODS: Patients with CRSwNP were prospectively asked to score their facial pain according to the scoring system used in the Sino Nasal Outcome Test 22 (SNOT 22). RESULTS: Fifty patients fulfilled the inclusion criteria. Thirty-one patients had grade II polyps and 19 patients had grade III polyps. Of these patients, 76% had absent or very mild facial pain. Only 16% of patients had moderate or severe facial pain. All patients with severe facial pain had viscid secretions within their sinuses. CONCLUSION: Significant facial pain is uncommon in patients with CRSwNP. It is important to consider this when counselling patients before surgery.

International Rhinologic Society Rhinology 0300-0729 51 3 2013 9 1 Serial blood serotonin levels in a randomized controlled trial comparing the efficacy of low-dose amitriptyline, amitriptyline with pindolol and surrogate placebo in patients with chronic tension-type facial pain 236 242 EN A.M. Agius The Medical School, University of Malta, Msida, Malta N.S. Jones R. Muscat 1165 10.4193/Rhin BACKGROUND: Patients often present with chronic facial pain despite normal nasal endoscopy and sinus computerized tomography. Such 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 headache in the face. Descending serotonergic neuronal projections are known to modulate pain and intra-platelet serotonin levels are an accepted model reflecting central intra-neuronal serotonin. OBJECTIVES: 1.To determine whether low-dose amitriptyline significantly changes whole blood serotonin compared to a surrogate placebo in patients with chronic MFP 2. To determine whether the addition of pindolol, a beta blocker with serotonin receptor blocking properties further alters blood serotonin. METHODOLOGY: Sixty-two patients were randomized to three treatment groups a) amitriptyline , b) amitriptyline with pindolol, and c) loratadine as surrogate placebo. Whole blood serotonin was taken before and after 8 weeks of treatment. Serotonin was also measured in 40 age-matched healthy controls. RESULTS: There was a significant reduction in blood serotonin levels in the amitriptyline with pindolol group. A non-significant reduction was seen in the amitriptyline group, with no change in serotonin levels in the surrogate placebo group. A comparison of change in serotonin with change in pain frequency and intensity scores is presented. Women in the control group had significantly higher serotonin levels than men. Women with tension-type facial pain who failed to respond to treatment had significantly lower blood serotonin than women in the control group. CONCLUSION: When linked to the clinical response this study provides evidence that the serotonergic system is involved in the modulation of chronic MFP. Serotonin levels are sex-dependent and related to treatment response.

International Rhinologic Society Rhinology 0300-0729 51 3 2013 9 1 Does airway integrated nasal packing after septal surgery improve body oxygenation? 243 248 EN S.S. Yu Department of Otolaryngology, Chi Mei Medical Center, Tainan, Taiwan K.D. Mei Y.S. Lin 1166 10.4193/Rhin BACKGROUND: Airway integrated nasal packing reportedly improves body oxygenation after septal surgery. This randomized controlled study examined the effect of airway integrated nasal packing on oxygen saturation. METHODS: Eighty patients with septal deviation and hypertrophic turbinate were randomly divided into two groups: Group 1 patients were postoperatively packed with airway integrated Nasopore, and Group 2 patients were postoperatively packed with Nasopore without airway integration. The haemodynamic parameters and SpO2 (oxyhemoglobin saturation levels when measured using pulse oximetry) were sequentially checked. Nasal pain sensations were recorded using a visual analog scale. RESULTS: SpO2 was not significantly different between Groups 1 and 2. Nasal pain levels were significantly higher in Group 1 than in Group 2 at both 4 (p = 0.034) and 6 (p = 0.001) hours postoperatively. There were no significant differences between the two groups in the incidences of septal haematoma, perforation, or bleeding, or in sequentially checked heart rate, mean blood pressure, or respiration rate. CONCLUSION: It was not evident that integrated airways improved the reduction of SpO2. However, Group 1 patients, with integrated airways, had more pain than did Group 2 patients, without integrated airways. EVIDENCE LEVEL: 1b.

International Rhinologic Society Rhinology 0300-0729 51 3 2013 9 1 Evaluating the relationship between nasal obstruction and Mean Platelet Volume by using acoustic rhinometry in patients with septum deviation 249 252 EN S. Ulu Department of Otorhinolaryngology, Afyon Kocatepe University, Faculty of Medicine, Afyonkarahisar, Turkey M.S. Ulu A. Busak O.K. Kahveci F. Yucedag A. Aycicek 1147 10.4193/Rhin BACKGROUND: Nasal airway obstruction is a common cause of upper airway obstruction. It is associated strongly with obstructive and hypoxic manifestations. Mean platelet volume (MPV) levels increase in hypoxic conditions. MPV is one of the platelet activation indices which re!ects the platelet production rate. We aimed to evaluate the relationship between MPV levels and nasal septal deviation (NSD) by using acoustics rhinometry in patients with septum deviation. METHODS: We performed a retrospective study of 51 patients with NSD and 58 healthy age matched subjects as control group. The diagnosis of patients with NSD was based on anterior rhinoscopy, endoscopic nasal examination and acoustics rhinometry. All the patients underwent Cottle- or Killian-type septoplasty under general anesthesia. Blood samples were collected before nasal septoplasty. RESULTS: MPV and platelet distribution width (PDW) levels were signi"cantly higher and mean platelet count was lower in patients with NSD than the control group. A negative correlation was found between MPV, NDVol2 (volume2 of non-deviated side of the nose) and TNDVol (total volume of non-deviated side of the nose) values. CONCLUSION: MPV values increase in patients with NSD. Moreover, this increase was found in relation with the severity of obstruction.

International Rhinologic Society Rhinology 0300-0729 51 3 2013 9 1 Influence of exposure to tobacco cigarette smoke on the eosinophil count in the nasal mucosa of young patients with perennial allergic rhinitis 253 258 EN B.B. Montaño-Velázquez Unidad de Investigación Médica en Otoneurología, CMN sXXI, Instituto Mexicano del Seguro Social, México, D.F. F.J. García Vázquez R.C. Navarrete M.D.M. Martínez L.F. Gonzalez K. Jáuregui-Renaud 1149 10.4193/Rhin BACKGROUND: To assess the influence of exposure to tobacco cigarette smoke on the eosinophil count and the frequency of apoptosis of eosinophils in the nasal mucosa of teenagers with perennial allergic rhinitis. METHODS: Fifty patients were evaluated (aged 10 to 19 years old): 25 patients with and 25 patients with no recent exposure to tobacco cigarette smoke, by means of The Global Youth Tobacco Survey and cotinine/creatinine ratio. After a clinical evaluati- on, all the patients replied to a validated questionnaire of the severity of nasal symptoms; then, a nasal sample was processed to identify the eosinophil count and the frequency of apoptosis of eosinophils. RESULTS: Patients with active exposure to tobacco cigarette smoke had higher eosinophil counts than patients with no expo- sure to the smoke. In the two groups, apoptosis of eosinophils in the nasal mucosa was scarce and no significant correlation was observed between the frequency/severity of the nasal symptoms and the eosinophil count. CONCLUSION: Teenagers with perennial allergic rhinitis and active exposure to tobacco cigarette smoke may show increased eosinophil counts in the nasal mucosa, which might not be related to apoptosis of eosinophils or to the frequency/severity of nasal symptoms.

International Rhinologic Society Rhinology 0300-0729 51 3 2013 9 1 Premedication with clonidine before TIVA optimizes surgical field visualization and shortens duration of endoscopic sinus surgery - results of a clinical trial 259 264 EN K. Wawrzyniak Chair of Anesthesiology and Intensive Therapy Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University of Torun, Poland K. Kusza J.B. Cywinski P.K. Burduk W. Kazmierczak 1164 10.4193/Rhin BACKGROUND: During functional endoscopic sinus surgery (FESS), intraoperative bleeding can significantly compromise visualization of the surgical field. Clonidine constricts peripheral blood vessels and reduces systemic blood pressure, which in combination decrease nasal mucosa blood flow. This dual effect can potentially reduce bleeding during FESS and stabilize the intraoperative hemodynamic profile of the patient. AIM: The aim of this prospective study was to assess if the quality of the surgical field visualization during FESS was improved when clonidine was used as a premedication agent. METHODOLOGY: A group of 44 patients undergoing FESS for chronic sinusitis and polyp removal were enrolled and randomly assigned to receive either oral clonidine or midazolam as preoperative premedication. During the operation, the quality of the surgical field was assessed and graded by the operating surgeon using the scale proposed by Boezaart. The evaluations were done during surgery at 15 minutes (K1), 30 minutes (K2), 60 minutes (K3) and 120 minutes (K4) after incision. RESULTS: The duration of the surgical procedure was significantly shorter in the clonidine group: mean time of surgery: 80 vs. 96 min in the clonidine and midazolam groups, respectively. Also better quality of surgical field was observed at all time points in the clonidine group. CONCLUSION: Premedication with clonidine before FESS results in shortening of the surgical time and a better quality of the surgical field.

International Rhinologic Society Rhinology 0300-0729 51 3 2013 9 1 Nasal and paranasal involvement in primary Sjőgren's syndrome 265 267 EN R. Midilli Otolaryngology, Ege University School of Medicine, Izmir, Turkey S. Gode G. Oder Y. Kabasakal B. Karci 1160 10.4193/Rhin BACKGROUND: The aim of this study is to investigate nasal and paranasal signs and symptoms of the primary Sjőgren's syndrome patients and compare them with healthy controls. METHODOLOGY: Seventy-seven (7 M, 70 F) primary Sjőgren's syndome patients and 77 healthy controls were included in the study. Anterior rhinoscopy, nasal endoscopy, 5 component smell discrimination test, nasal clearance analysis with saccharin test and electrorhinomanometer were performed. RESULTS: Nasal crusting was present in 31 and 24 individuals in patient and control groups, respectively. Sinusitis was present in 2 and 1 individuals in patient and control groups, respectively. Nasal polyposis was present in 7 and 1 individuals in patient and control groups, respectively. These differences were not statistically different. CONCLUSION: Although there were some findings in a few patients, nasal findings were insignificant and mild even in patients with severe oral or ocular findings. Rhinomanometry, nasal clearance determination or smell discrimination tests have very little value in the diagnosis or management of primary Sjőgren's syndrome. Nasal polyposis was higher in the patient group, though it did not reach a significant level. Nasal glandular involvement is mild and insignificant in primary Sjőgren's syndrome.

International Rhinologic Society Rhinology 0300-0729 51 3 2013 9 1 Optimising outcomes in the management of spontaneous cerebrospinal fluid rhinorrhoea 268 274 EN J.S. Virk Otolaryngology Department, Charing Cross Hospital, Imperial College Healthcare, London, United Kingdom B. Elmiyeh C. Stamatoglou H.A. Saleh 1156 10.4193/Rhin BACKGROUND: To describe our experience of the management of spontaneous cerebrospinal fluid (CSF) rhinorrhoea in a large case series focusing on surgical approach, peri-operative management and outcomes; to evaluate the efficacy of endoscopic CSF leak repairs. METHODOLOGY: Retrospective chart review was performed for all patients with spontaneous CSF rhinorrhoea managed from 2003 to 2011 at a tertiary referral centre. Data regarding demographics, presentation, site of leak, peri-operative management, surgical approach, body mass index (BMI), follow up and success rates was collated. RESULTS: Thirty-six patients were identified: 9 male and 27 female with a mean age of 50.4 years. Eight patients had previous failed repairs in other units. Success rate after first surgery was 89 % and after second surgery was 100 %. Four patients had recurrences, 3 underwent successful revisions and the fourth had complete cessation of the leak after gastric bypass surgery and weight reduction. All failures were before 2004 prior to instigation of an anatomic three-layered repair with no further failures in the following 7 years. Mean follow up was 21.5 months. Mean body mass index was 34.0 kg/m2. Fifty percent of spontaneous leaks were from the cribriform plate, 22 % sphenoid, 14 % ethmoid and 14 % frontal sinus. CONCLUSION: Endoscopic CSF fistula closure has become the gold standard of care. In order to optimise the outcome, we recommend a multidisciplinary approach to manage the associated idiopathic intracranial hypertension and an anatomic three-layered closure technique for recalcitrant cases.

International Rhinologic Society Rhinology 0300-0729 51 3 2013 9 1 Evaluation of inferior turbinate outfracture outcomes using computed tomography 275 279 EN J.Y. Min Department of Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea H.J. Dhong H.J. Cho S.K. Chung H.Y. Kim Department of Otorhinolaryngology - Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea 1161 10.4193/Rhin BACKGROUND: Outfracture of the inferior turbinate (IT) presents numerous advantages, but it is generally believed that the latera- lized IT will resume its original position. The purpose of this study was to evaluate the outcome of IT outfracture objectively using computed tomography (CT). METHODOLOGY: Fifteen patients who underwent bilateral IT outfracture for the removal of pituitary adenomas by the endonasal approach were enrolled. The angles between the lateral wall of the nasal cavity (NC) and IT on both sides were measured from CT scans before and at least 6 months after operation. In addition, we evaluated the effects of variables including age, thickness of IT attachment site and width of the nasal floor, on the angles. RESULTS: Regardless of the side where a Hardy retractor was placed, the angle between the lateral wall of the NC and IT decreased significantly within 6 months after the outfracture compared to preoperative values on both sides. Other variables showed no significant correlations with the angle between the IT and the lateral wall of the NC. CONCLUSION: The outfracture procedure effectively lateralized the IT and it maintained that position for at least 6 months after the operation.

International Rhinologic Society Rhinology 0300-0729 51 3 2013 9 1 A retrospective analysis of 29 isolated sphenoid fungus ball cases from a medical centre in Korea (1999-2012) 280 286 EN T.H. Kim Department of Otorhinolaryngology-Head & Neck Surgery, Daegu Fatima Hospital, Daegu, South Korea K.J. Na J.H. Seok S.J. Heo J.H. Park J.S. Kim 1142 10.4193/Rhin BACKGROUND: Isolated sphenoid sinus disease (ISSD) is rare. Fungus ball (FB) is the third most common ISSD. We analysed the characteristics of isolated sphenoid FB based on demographic data, presenting symptoms, preoperative computed tomography (CT), magnetic resonance imaging (MRI), and treatment outcomes. METHODOLOGY: From 1999 to 2012, 29 patients were identified with isolated sphenoid FB. Demographic data; clinical characteris- tics; endoscopic, CT, and MRI findings and treatment outcomes were retrospectively analysed. RESULTS: The most common symptom was headaches, which were localized in various regions of the brain. Other symptoms were uncommon. The most common CT findings were sclerosis, calcification, enlarged sinus and total opacification. On T2-weighted MRI images, we most commonly observed signal void. Endoscopic transnasal paraseptal sphenoidotomy was performed in all patients, and for most, this was performed under local anaesthesia. No recurrence was observed in any patient. CONCLUSION: Isolated sphenoid FB is predominantly observed in older women, and it is characterised by headaches and sclerosis of the sinus wall observed on CT scans. In cases of isolated sphenoid FB, endoscopic transnasal paraseptal sphenoidotomy can be successfully performed under local anaesthesia, which may facilitate rapid recovery and a low morbidity rate.