International Rhinologic Society Rhinology 0300-0729 51 4 2013 12 1 Anatomy, anatomy, anatomy...... 289 290 EN V.J. Lund Royal National Throat Nose and Ear Hospital, London, United Kingdom. 1194 10.4193/Rhin This end of year issue is the usual blend of basic science and medical or surgical treatments, but with a strong anatomical flavour. It would seem there is little new to say about topographical anatomy and yet from a surgical perspective there is still much to be learnt, as evidenced by the in-depth investigation by Liu et al. of the Vidian canal. Although vidian neurectomy is clearly still fashionable in Taiwan, the canal itself has assu- med greater importance with the demonstration that this is the principle route for sphenoid invasion by juvenile angiofibroma (JAF) and thus the site of 'recurrence' if not adequately explored. Drilling out the canal and the surrounding basi-sphenoid is now recognised as a key determinant in the complete removal of JAF whatever surgical approach is employed. 3-D imaging reconstruction elegantly demonstrates the range of anatomical variation related principally to increased sphenoid pneumatisa- tion and consequent prominence of adjacent structures such as the vidian canal itself and the foramen rotundum. A better appreciation of this anatomy might even lead to a resurgence of international interest in vidian neurectomy for the treatment of excessive watery rhinorrhoea if the associated complications from the procedure could be minimised.

International Rhinologic Society Rhinology 0300-0729 51 4 2013 12 1 Role of tranexamic acid in endoscopic sinus surgery - A systematic review and meta-analysis 291 297 EN V. Pundir Department of Otorhinolaryngology, East Sussex Healthcare NHS Trust, Conquest Hospital, United Kingdom J. Pundir C. Georgalas W.J. Fokkens Department of Otorhinolaryngology, Academic Medical Centre, Amsterdam, The Netherlands 1175 10.4193/Rhin BACKGROUND: The role of tranexamic acid in patients undergoing endoscopic sinus surgery (ESS) is not clearly defined. The aim of our study is to systematically review the existing evidence on the role of tranexamic acid in patients undergoing ESS. METHODOLOGY: Systematic search of MEDLINE (1950 - 2013), EMBASE (1980 - 2013), metaRegister, Cochrane Library and ISI conference proceedings was carried out. RESULTS: Five randomised controlled trials with 192 patients receiving tranexamic acid and 196 controls were included. Meta-analysis demonstrated that mean estimated blood loss was significantly lower, and surgical field quality was significantly better in tranexamic acid group. There was no significant difference in mean operative time between the two groups. No significant adverse effects were noted in either of the groups. CONCLUSION: Intra-operative use of local and systemic tranexamic acid in ESS, results in significantly reduced estimated blood loss and improved surgical field quality. There is no statistically significant difference seen in operative time and incidence of side effects. Well-conducted larger RCTs using validated objective outcome measures and reporting on minor and major complications are required.

International Rhinologic Society Rhinology 0300-0729 51 4 2013 12 1 Bleeding control in endoscopic sinus surgery: a systematic review of the literature 298 305 EN A. Rodríguez Valiente Department of Otorhinolaryngology, University Hospital Puerta de Hierro, Madrid, Spain A. RoldÃˇn Fidalgo D. Laguna Ortega 1177 10.4193/Rhin In the literature various methods are described to reduce bleeding in endoscopic sinus surgery. Scientific evidence and results were gathered and analysed to determine the effectiveness of the various methods used. A total of 20 articles fulfilled the inclusion criteria. Two retrospective articles studied the differences between local and general anaesthesia. Three articles analysed the use of local methods to control bleeding. The majority of the articles analysed the use of different systemic drugs to control intraoperative bleeding. Certain procedures, such as the reverse Trendelenburg position, the use of high doses of epinephrine, the infiltration of phenylephrine and lidocaine into the pterygopalatine fossa, the preoperative use of prednisone, and the control of the heart rate (with dexmedetomidine or remifentanil), appear to reduce the intraoperative blood loss and/or improve the visualisation of the surgical field. However, the evidence supporting these conclusions is poor. The benefits of other procedures, such as the preoperative use of β-blockers, antihypertensive agents, and surgical pledgets with oxymetazoline, phenylephrine, or cocaine, for bleeding control are not evidenced in the literature. In addition, the literature does not present any evidence on the benefits of local anaesthesia compared with general anaesthesia or the use of propofol compared to inhaled analgesics in terms of intraoperative bleeding or complication rates.

International Rhinologic Society Rhinology 0300-0729 51 4 2013 12 1 Three-dimensional bone CT reconstruction anatomy of the vidian canal 306 314 EN S.C. Liu Department of Otolaryngology-Head and Neck Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China H.W. Wang Department of Otolaryngology-Head and Neck Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan H.L. Kao P.C. Hsiao W.F. Su 1162 10.4193/Rhin OBJECTIVES: To examine the anatomical features of the anterior opening of the vidian canal using three-dimensional (3D) computed tomography (CT) images of the bone. METHODS: We reviewed 62 patients who had undergone bilateral vidian neurectomies. One hundred and twenty-four vidian canals and their surrounding anatomies were analyzed. 3D images were reconstructed using algorithms and compared with conventional two-dimensional (2D) CT images. RESULTS: A bony prominence that overlaid the vidian canal along the sphenoid sinus floor was found in 60 (48.39 %) canals. Pneumatization of the pterygoid process was observed in 45 sides (36.29%). No significant discrepancy was found in detecting these variances between the 2D and the 3D images. The presence of a surgically favorable gap between the palatine and the sphenoid bone was seen in 25 sides (20.16%) without significant association with pterygoid process pneumatization or vidian canal protrusion. This gap was not identified on the 2D CT scans. CONCLUSION: 3D CT reconstruction images of bone provide superior delineation of the gap between the palatine and the sphenoid bone, which is a critical variation for vidian neurectomy. This useful method may contribute to better prediction and guidance of the surgical approach to the vidian canal and pterygopalatine fossa.

International Rhinologic Society Rhinology 0300-0729 51 4 2013 12 1 Inflammasome gene expression alterations in Staphylococcus aureus biofilm-associated chronic rhinosinusitis 315 322 EN C. Jardeleza Department of Surgery-Otorhinolaryngology, Head and Neck Surgery, University of Adelaide, Adelaide, Australia D. Miljkovic L. Baker S. Boase N.C.W. Tan S.A. Koblar P. Zalewski M. Rischmueller S. Lester A. Drilling D. Jones L.W. Tan P.J. Wormald S. Vreugde 1170 10.4193/Rhin BACKGROUND: The role of inflammasomes in chronic inflammation has been the subject of intense research in recent years. Chronic rhinosinusitis (CRS), a persistent inflammatory disease, continues to be investigated hoping that a clearer pathophysiologic description will guide discovery of future treatment modalities. This study investigates the role of inflammasome complexes in CRS patients with Staphylococcus aureus biofilm infection, a key culprit associated with disease severity and recalcitrance. METHODOLOGY: Sinonasal tissue samples were collected from CRS patients with (P+) and without (P-) polyps and controls. S. aureus biofilm status was obtained using fluorescence in situ hybridization and classified as biofilm positive (B+) or negative (B-). RNA was analysed using a Human Inflammasome PCR array, profiling the expression of 84 genes involved in inflammasome function. RESULTS: Sixteen samples were obtained: 5 B+P+, 5 B-P- and 6 controls. Comparing B+P+ vs. controls showed the greatest number of differentially expressed genes. In particular, Absent in Melanoma 2 (AIM2) was consistently and significantly up-regulated in the B+P+ vs. B-P- and controls. In contrast, when comparing the B-P- vs. controls, no genes showed significant changes. CONCLUSION: Our results indicate the involvement of inflammasome complexes and their signalling pathways in CRS patients with polyps and S. aureus biofilms. In particular, AIM2, activated by intracellular double-stranded DNA, is up-regulated in this group, implying that S. aureus may play a role in intracellular triggering of the inflammasome response. Studies with further patient stratification and assessing corresponding protein expression are needed to further characterize the role of inflammasomes in CRS.

International Rhinologic Society Rhinology 0300-0729 51 4 2013 12 1 Efficacy and safety of erdosteine in the treatment of chronic rhinosinusitis with nasal polyposis - a pilot study 323 327 EN J. Hoza Department of Otorhinolaryngology and Head&Neck Surgery, University Hospital Olomouc, Palacky University Olomouc, Olomouc, Czech Republic R. Salzman I. StÃˇrek P. Schalek R. KellnerovÃˇ 1171 10.4193/Rhin BACKGROUND: Erdosteine was originally developed as a mucolytic agent. It is a multimechanism substance with anti-bacterial, anti-oxidant, and most importantly anti-inflammatory effects. Given similar mechanisms of action (suppression of cytokines, including tumor necrosis factor α), it could become a reasonable alternative to currently used treatments with macrolides or steroids. OBJECTIVE: To assess efficacy and safety of erdosteine in the treatment of chronic rhinosinusitis with nasal polyposis (CRSwNP). METHODOLOGY: A prospective non-interventional post-authorisation study comparing patients treated with erdosteine only or the combination of erdosteine and nasal corticosteroid spray for CRSwNP. The end-points were pre- and post-treatment changes in endoscopic score and subjective evaluation of CRSwNP related symptoms using a 22-item Sinonasal Outcome Test questionnaire. Patients underwent nasal endoscopy and filled the questionnaire before and after the treatment. RESULTS: No patient experienced any adverse effect during the study. A comparison of pre- and post-treatment endoscopic findings and questionnaire values revealed significant reduction in both patient groups, with a significantly better response in the erdosteine only group. CONCLUSION: Based on this pilot study, erdosteine seems effective in the treatment of CRSwNP and might become a reasonable alternative to currently used medication. The therapeutical role of erdosteine needs to be further assessed.

International Rhinologic Society Rhinology 0300-0729 51 4 2013 12 1 Long-term results of functional endoscopic sinus surgery in children with chronic rhinosinusitis with nasal polyps 328 334 EN M.E. Cornet Department of Otorhinolaryngology, Academic Medical Centre Amsterdam, Amsterdam, the Netherlands C. Georgalas S.M. Reinartz W.J. Fokkens Department of Otorhinolaryngology, Academic Medical Centre, Amsterdam, The Netherlands 1179 10.4193/Rhin BACKGROUND: Chronic rhinosinusitis with nasal polyps (CRSwNP) is rare in children and has a major impact on Quality of Life (QoL). Functional endoscopic sinus surgery (FESS) has proven to be an effective treatment, but it is still unclear what long-term outcomes are in children with CRSwNP. The objective of this study was to assess long-term results of FESS in children with CRSwNP. METHODOLOGY: We performed a combined prospective and retrospective study. A QoL questionnaire was send to all children with CRSwNP who received FESS between the year 2000-2010. Almost half of these children also filled in this questionnaire preoperatively. RESULTS: Forty-four Children underwent FESS. From 18 patients, we also prospectively collected preoperative QoL questionnaires. The mean follow-up period was 4.0 years (± 2.9). The mean age at surgery was 13 years (±2.9). Of these children, 9 had CF and 10 children asthma. R-SOM scores showed a significant improvement both in general symptoms as well as several different domains when comparing pre- and postoperative questionnaires. Only 5 of 44 patients needed a subsequent intervention. In children with CF this was 3 of 9. CONCLUSION: This study demonstrates that long-term results of FESS in children with CRSwNP are good. QoL has improved significantly, especially in nasal symptoms, showing that FESS is a good treatment in children with CRSwNP. Furthermore, even children with CF show good results.

International Rhinologic Society Rhinology 0300-0729 51 4 2013 12 1 Algorithm for navigated ESS 335 342 EN T. Baudoin Department of Otorhinolaryngology & Head and Neck Surgery, Sisters of Mercy University Medical Center, Zagreb University School of Medicine, Zagreb, Croatia M.V. Grgić D. Zadravec G. Geber D. Tomljenović L. Kalogjera 1167 10.4193/Rhin ENT navigation has given new opportunities in performing Endoscopic Sinus Surgery (ESS) and improving surgical outcome of the patients' treatment. ESS assisted by a navigation system could be called Navigated Endoscopic Sinus Surgery (NESS). As it is generally accepted that the NESS should be performed only in cases of complex anatomy and pathology, it has not yet been established as a state-of-the-art procedure and thus not used on a daily basis. This paper presents an algorithm for use of a navigation system for basic ESS in the treatment of chronic rhinosinusitis (CRS). The algorithm includes five units that should be highlighted using a navigation system. They are as follows: 1) nasal vestibule unit, 2) OMC unit, 3) anterior ethmoid unit, 4) posterior ethmoid unit, and 5) sphenoid unit. Each unit has a shape of a triangular pyramid and consists of at least four reference points or landmarks. As many landmarks as possible should be marked when determining one of the five units. Navigated orientation in each unit should always precede any surgical intervention. The algorithm should improve the learning curve of trainees and enable surgeons to use the navigation system routinely and systematically.

International Rhinologic Society Rhinology 0300-0729 51 4 2013 12 1 Three-dimensional analysis of the surface registration accuracy of electromagnetic navigation systems in live endoscopic sinus surgery 343 348 EN C.M. Chang Department of Otolaryngology, Far Eastern Memorial Hospital, Taipei, Taiwan K.M. Fang T.W. Huang C.T. Wang P.W. Cheng 1173 10.4193/Rhin BACKGROUND: Studies on the performance of surface registration with electromagnetic tracking systems are lacking in both live surgery and the laboratory setting. This study presents the efficiency in time of the system preparation as well as the navigational accuracy of surface registration using electromagnetic tracking systems. METHODOLOGY: Forty patients with bilateral chronic paranasal pansinusitis underwent endoscopic sinus surgery after undergoing sinus computed tomography scans. The surgeries were performed under electromagnetic navigation guidance after the surface registration had been carried out on all of the patients. The intraoperative measurements indicate the time taken for equipment set-up, surface registration and surgical procedure, as well as the degree of navigation error along 3 axes. RESULTS: The time taken for equipment set-up, surface registration and the surgical procedure was 179 ± 23 seconds, 39 ± 4.8 seconds and 114 ± 36 minutes, respectively. A comparison of the navigation error along the 3 axes showed that the deviation in the medial-lateral direction was significantly less than that in the anterior-posterior and cranial-caudal directions. CONCLUSION: The procedures of equipment set-up and surface registration in electromagnetic navigation tracking are efficient, convenient and easy to manipulate. The system accuracy is within the acceptable ranges, especially on the medial-lateral axis.

International Rhinologic Society Rhinology 0300-0729 51 4 2013 12 1 Transitional cell tumours of the lacrimal drainage apparatus 349 354 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. A. Jay G. Rose 1169 10.4193/Rhin BACKGROUND: Tumours of the lacrimal drainage apparatus (LDA) are very rare, but can be life-threatening. Seventy percent of lacrimal sac tumours are of epithelial origin, and transitional cell tumours represent an interesting sub-group of these epithelial tumours. METHODS: A retrospective review of cases of LDA transitional cell tumours co-managed at the Royal National Throat Nose and Ear Hospital and Moorfields Eye Hospital, London. RESULTS: Twenty cases of transitional cell tumours of the LDA were identified, comprising 10 transitional cell papillomas (TCPs) and 10 transitional cell carcinomas (TCCs). All cases were resected through a modified lateral rhinotomy approach. Limited resection of orbital fat with preservation of orbital functions was required for 2 cases of TCC. Fractionated external beam radiotherapy was administered in 7 cases of TCC. The mean follow up was 80 months (range 11 months-16 years). Recurrences were detected in 4 cases, which were managed by further surgery. Two cases have been lost to follow-up, but the 18 other patients are currently alive and disease free. CONCLUSION: A favourable outcome can be achieved with transitional cell tumours of the LDA when an optimum management plan is followed.

International Rhinologic Society Rhinology 0300-0729 51 4 2013 12 1 Pilot study of submucosal radiofrequency for epistaxis in hereditary hemorrhagic telangiectasia 355 360 EN G. Mortuaire Department of Otorhinolaryngology and Head and Neck surgery, Huriez Hospital, University of Lille, France O. Boute P.Y. Hatron D. Chevalier 1180 10.4193/Rhin OBJECTIVE: To assess the safety and efficacy of submucosal radiofrequency (RF) treatment for hereditary hemorrhagic telangiectasia (HHT) with mild or moderate epistaxis. METHODOLOGY: We carried out a prospective pilot study of 16 consecutive patients with HHT-related epistaxis from June 2010 to April 2012. Under local anesthesia, RF was applied to one or both sides of the nose from the columella beneath the septal mucosal (50 joules per puncture). Patients were sent a questionnaire at least six months after the procedure. RESULTS: RF under local anesthesia was well tolerated, according to visual analog scale scores. Neither crusting nor pain was reported one week after the intervention. The frequency of epistaxis per day and per month was significantly lower after RF. The duration of bleeding also decreased from more than 10 minutes to less than 5 minutes in two thirds of patients. Thirteen of the 16 patients were satisfied with the technique and would request it for subsequent procedures to treat repeated bleeding. CONCLUSION: Submucosal RF treatment for HHT is a safe, well tolerated procedure with significant efficacy in the short term. It should be considered as an alternative technique for managing HHT-related epistaxis, although long-term results remain to be evaluated.

International Rhinologic Society Rhinology 0300-0729 51 4 2013 12 1 Patients' evaluation for the surgical management of nasal obstruction 361 367 EN D. Akduman Bursa Sevket Yilmaz Training and Research Hospital, Department of Otorhinolaryngology, Bursa, Turkey M. Yanılmaz M. Haksever F. Döner Z. Sayar 1172 10.4193/Rhin STATEMENT OF PROBLEM: Surgery for nasal obstruction is performed to give a subjective benefit. We aimed to evaluate the surgical management of the nasal obstruction in the patient's perception. METHODS OF STUDY: The study was performed prospectively with 134 patients over the age of 18. They were allotted to three groups according to the level of nasal obstruction by clinical examination. The G1 group had only a deviated nasal septum (DNS), G2 had DNS and hypertrophy of inferior turbinates, and G3 had nasal valve problems in conjunction with DNS. All the patients had surgery focused on obstructive pathologies. The study was conducted using three different scoring systems to determine the patients' evaluation of the surgical procedures. RESULTS: The study included more man than woman, with a mean age around 28 (wide range). Twenty six patients were in G1, 73 patients in G2 and 35 patients in G3. Total and general Glasgow Benefit Inventory (GBI) scores for each group showed improve- ment postoperatively. There was a significant difference between the groups for general GBI score, and Post-hoc test showed that the improvement of G1 was greater than of G3. The influence of the surgery on physical health, psycho-social function and social interaction scores for each group showed no changes postoperatively. There was a significant improvement in all Nasal Obstruction Septoplasty Effectiveness (NOSE) scores and Likert Scale scores for each group. The improvement of G1 and G2 were greater than G3 on the Likert Scale. CONCLUSION: Surgical management targeted to the region of obstruction improves symptoms and benefit in the patient's percep- tion.

International Rhinologic Society Rhinology 0300-0729 51 4 2013 12 1 Respecting nasal mucosa during turbinate surgery: end of the dogma? 368 375 EN G. Neri Department of Neuroscience and Imaging, Faculty of Medicine, University "G. d'Annunzio" of Chieti-Pescara, Italy V. Mastronardi T. Traini F. D’Orazio M. Pugliese F. Cazzato 1181 10.4193/Rhin BACKGROUND: Chronic rhinitis with inferior turbinate hypertrophy is the most common cause of chronic nasal obstruction. Pharmacological treatment, mainly consisting of corticosteroids, is largely inadequate and, therefore, in the last few years several surgical techniques have been proposed (emptying, radiofrequency, cryotherapy, etc...). The aim of our work is to demonstrate that surgical removal of the inferior turbinate mucosa with the microdebrider, along with the submucosal chorion, results in a full restoration of mucosal physiological structure and function. METHODOLOGY: Thirteen symptomatic adult patients were subjected to bilateral inferior partial turbinoplasty with the microdebrider. All patients underwent endoscopic examination, functional nasal tests and nasal mucosa biopsy before and after surgery. RESULTS: The sensitivity in open airspaces improved after nasal surgery, and the results of functional tests returned to within a normal range. SEM examination confirmed that complete mucosal regeneration was within 4 months. CONCLUSION: Total removal of the inferior turbinate mucosa with the microdebrider in patients suffering from hypertrophic chronic rhinitis allows the perfect regeneration of physiological respiratory tissue and doesn't have a negative impact on healing time and offsets any adverse postoperative event.

International Rhinologic Society Rhinology 0300-0729 51 4 2013 12 1 Efficacy of fexofenadine in isolated rat tracheas 376 380 EN W.S. Lai Department of Otolaryngology-Head and Neck Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan Y.Y. Lin Department of Otolaryngology-Head and Neck Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan Y.H. Chu Department of Otolaryngology-Head and Neck Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan C.H. Wang Department of Otolaryngology-Head and Neck Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan H.W. Wang Department of Otolaryngology-Head and Neck Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan C.H. Wang Department of Otolaryngology-Head and Neck Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan H.W. Wang Department of Otolaryngology-Head and Neck Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan C.P. Shih Department of Otolaryngology-Head and Neck Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan 1168 10.4193/Rhin OBJECTIVES: Histamine is an important chemical mediator in both nasal and bronchial inflammation in patients with allergic rhinitis and asthma. The effect of histamine receptor-1 antagonists on nasal mucosa in vivo is well known, however, the effect on tracheal smooth muscle has rarely been explored. The purpose of this study was to determine the effects of fexofenadine on isolated tracheal smooth muscle in vitro. METHODS: Six tracheal strips were used for each experiment, and one untreated strip served as a control. We examined the effectiveness of fexofenadine on isolated rat tracheal smooth muscle by testing the effect on: 1) tracheal smooth muscle resting tension; 2) contraction caused by 10E−6 M methacholine as a parasympathetic mimetic; and 3) electrically induced tracheal smooth muscle contractions. RESULTS: The results indicated that addition of methacholine caused the trachea to contract in a dose-dependent manner. The addition of fexofenadine at a dose of 10E−4 M elicited a significant relaxation response compared to 10E−6 M methacholine-induced contraction. There were no detectable changes in the peak tension of electrical field stimulation-induced contractions in the fexofenadine group. CONCLUSION: High concentrations of fexofenadine had an anti-cholinergic effect. In addition to diminishing histamine-mediated allergic symptoms, fexofenadine may have a potentially therapeutic implication in alleviating asthma-related symptoms due to reducing methacholine-induced contractions of tracheal smooth muscle though these aspects were not studied.

International Rhinologic Society Rhinology 0300-0729 51 4 2013 12 1 ERS-FELLOWSHIPS 2014 383 383 EN 1195 10.4193/Rhin ERS-FELLOWSHIPS 2014 Sponsored by THE EUROPEAN RHINOLOGIC SOCIETY Available to junior members of ERS (under 35 years) One place available on each of the following Courses in 2014