Search

International audience; The allergenic content of the atmosphere varies according to climate, geography and vegetation. Data on the presence and prevalence of allergenic airborne pollens, obtained from both aerobiological studies and allergological investigations, make it possible to design pollen calendars with the approximate flowering period of the plants in the sampling area. In this way, even though pollen production and dispersal from year to year depend on the patterns of preseason weather and on the conditions prevailing at the time of anthesis, it is usually possible to forecast the chances of encountering high atmospheric allergenic pollen concentrations in different areas. Aerobiological and allergological studies show that the pollen map of Europe is changing also as a result of cultural factors (for example, importation of plants such as birch and cypress for urban parklands), greater international travel (e.g. colonization by ragweed in France, northern Italy, Austria, Hungary etc.) and climate change. In this regard, the higher frequency of weather extremes, like thunderstorms, and increasing episodes of long range transport of allergenic pollen represent new challenges for researchers. Furthermore, in the last few years, experimental data on pollen and subpollen-particles structure, the pathogenetic role of pollen and the interaction between pollen and air pollutants, gave new insights into the mechanisms of respiratory allergic diseases.

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.

SummaryBackground A distinct set of inflammatory and remodelling factors have been found elevated in chronic rhinosinusitis. Objective The investigation of their expression in early stage disease may reveal early events in this common disease. Methods Sinonasal mucosal samples from nine patients with early stage CRSsNP were taken from the inferior and middle turbinates, the uncinate process, maxillary sinus, anterior ethmoid, bulla ethmoidalis and the posterior ethmoid and measured for TGF-beta 1 and it's receptors, MPO protein as well as pro-inflammatory cytokines (TNF-alpha and IL-1beta) and the Th1 cell signature (IFN-gamma and T-bet). As outcome parameter for TGF-beta signalling collagen deposition was analysed. Inferior turbinates from patients undergoing (rhino-) septoplasty were collected as controls. Results TGF-beta 1 protein concentrations were significantly increased in the maxillary sinuses (P = 0.006), the uncinate process (P = 0.01), the anterior ethmoid including the bulla ethmoidalis (P = 0.005) and the posterior ethmoid (P = 0.037) when compared to the inferior and middle turbinates. Collagen deposition was significantly increased in the maxillary sinus when compared to the inferior turbinates (P = 0.008). In contrast, mRNA for TGF-beta receptors, Th1 related markers (IFN-gamma and T-bet), pro-inflammatory cytokines (IL-1 beta and TNF-alpha), and MPO protein as neutrophil marker were expressed at all locations but showed no significant differences between the various locations. TGF-beta 1 mRNA expression in inferior turbinates of CRSsNP was significantly higher when compared to inferior turbinates of controls (P = 0.017). The pro-inflammatory cytokines and Th1-related cytokines did not show an upregulation in inferior turbinates of CRSsNP when compared to controls. Conclusions In early stage chronic sinus disease, TGF-beta protein is expressed in significantly higher concentrations within the paranasal sinuses when compared to turbinates, whereas pro-inflammatory, neutrophilic and Th1 markers did not show any difference. These findings suggest that TGF-beta plays a central role in the initiation of CRSsNP, and represents a major target for further research and future intervention.

The origin of the epidemic of IgE-associated (allergic) diseases is unclear. MeDALL (Mechanisms of the Development of ALLergy), an FP7 European Union project (No. 264357), aims to generate novel knowledge on the mechanisms of initiation of allergy and to propose early diagnosis, prevention, and targets for therapy. A novel phenotype definition and an integrative translational approach are needed to understand how a network of molecular and environmental factors can lead to complex allergic diseases. A novel, stepwise, large-scale, and integrative approach will be led by a network of complementary experts in allergy, epidemiology, allergen biochemistry, immunology, molecular biology, epigenetics, functional genomics, bioinformatics, computational and systems biology. The following steps are proposed: (i) Identification of 'classical' and 'novel' phenotypes in existing birth cohorts; (ii) Building discovery of the relevant mechanisms in IgE-associated allergic diseases in existing longitudinal birth cohorts and Karelian children; (iii) Validation and redefinition of classical and novel phenotypes of IgE-associated allergic diseases; and (iv) Translational integration of systems biology outcomes into health care, including societal aspects. MeDALL will lead to: (i) A better understanding of allergic phenotypes, thus expanding current knowledge of the genomic and environmental determinants of allergic diseases in an integrative way; (ii) Novel diagnostic tools for the early diagnosis of allergy, targets for the development of novel treatment modalities, and prevention of allergic diseases; (iii) Improving the health of European citizens as well as increasing the competitiveness and boosting the innovative capacity of Europe, while addressing global health issues and ethical issues.

A major part of the burden of asthma is caused by acute exacerbations. Exacerbations have been strongly and consistently associated with respiratory infections. Respiratory viruses and bacteria are therefore possible treatment targets. To have a reasonable estimate of the burden of disease induced by such infectious agents on asthmatic patients, it is necessary to understand their nature and be able to identify them in clinical samples by employing accurate and sensitive methodologies. This systematic review summarizes current knowledge and developments in infection epidemiology of acute asthma in children and adults, describing the known impact for each individual agent and highlighting knowledge gaps. Among infectious agents, human rhinoviruses are the most prevalent in regard to asthma exacerbations. The newly identified type-C rhinoviruses may prove to be particularly relevant. Respiratory syncytial virus and metapneumovirus are important in infants, while influenza viruses seem to induce severe exacerbations mostly in adults. Other agents are relatively less or not clearly associated. Mycoplasma and Chlamydophila pneumoniae seem to be involved more with asthma persistence rather than with disease exacerbations. Recent data suggest that common bacteria may also be involved, but this should be confirmed. Although current information is considerable, improvements in detection methodologies, as well as the wide variation in respect to location, time and populations, underline the need for additional studies that should also take into account interacting factors.

The links between asthma and rhinitis are well characterized. The Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines stress the importance of these links and provide guidance for their prevention and treatment. Despite effective treatments being available, too few patients receive appropriate medical care for both diseases. Most patients with rhinitis and asthma consult primary care physicians and therefore these physicians are encouraged to understand and use ARIA guidelines. Patients should also be informed about these guidelines to raise their awareness of optimal care and increase control of the two related diseases. To apply these guidelines, clinicians and patients need to understand how and why the recommendations were made. The goal of the ARIA guidelines is to provide recommendations about the best management options for most patients in most situations. These recommendations should be based on the best available evidence. Making recommendations requires the assessment of the quality of available evidence, deciding on the balance between benefits and downsides, consideration of patients’ values and preferences, and, if applicable, resource implications. Guidelines must be updated as new management options become available or important new evidence emerges. Transparent reporting of guidelines facilitates understanding and acceptance, but implementation strategies need to be improved.

Cite this as: C. A. Perez Novo, M. Jedrzejczak-Czechowicz, A. Lewandowska-Polak, C. Claeys, G. Holtappels, P. Van Cauwenberge, M. L. Kowalski and C. Bachert, Clinical & Experimental Allergy, 2010 (40) 1323–1332. Summary Background Staphylococcal superantigens may modulate airway inflammatory disease. Objective We assessed the effect of Staphylococcus aureus enterotoxin B (SEB) on T cell activation in patients with nasal polyps and asthma, and its possible link to aspirin hypersensitivity. Methods Leucocytes were isolated from five healthy subjects (controls), five asthmatics with nasal polyps without (NP-ATA) and five with aspirin-induced asthma (NP-AIA). Cells were incubated with increasing concentrations of SEB for 4 and 18 h. Release of TH1/TH2 cytokines was assessed by Cytometric Bead-Array. Foxp3 and TNFRS18-L expression were analysed by qPCR and flow cytometry. Results After 4 and 18 h, SEB significantly increased IFN-gamma, IL-4, TNF-alpha, IL-5 and IL-2 concentrations in supernatants of both NP polyp groups compared with controls. Baseline Foxp3 was significantly decreased in both NP-asthma groups. Incubation with SEB for 4 h induced a limited up-regulation of Foxp3 in NP-AIA patients, which was switched off consecutively. Foxp3 was significantly up-regulated in the control group after 18 h, but not in the NP-asthmatic groups. In parallel, TNFRS18-L mRNA significantly increased after 18 h in the NP-asthma groups compared with control subjects. This molecule was highly expressed in CD11c+CD14+ cells and its levels increased after 18 and 24 h culture in the NP-asthma patients. Conclusion SEB induces both TH1 and TH2 pro-inflammatory responses in patients with nasal polyps and asthma regardless of the presence of aspirin hypersensitivity. The nature of this response may be linked to a basal deficiency of Foxp3 observed in the NP-asthmatic patients and/or to the up-regulation of TNFRS18-L on monocytes/dendritic cell precursors.

Udgivelsesdato: 2010-Apr BACKGROUND: First-generation H(1)-antihistamines obtained without prescription are the most frequent form of self-medication for allergic diseases, coughs and colds and insomnia even though they have potentially dangerous unwanted effects which are not recognized by the general public. AIMS: To increase consumer protection by bringing to the attention of regulatory authorities, physicians and the general public the potential dangers of the indiscriminate use first-generation H(1)-antihistamines purchased over-the counter in the absence of appropriate medical supervision. METHODS: A GA(2)LEN (Global Allergy and Asthma European Network) task force assessed the unwanted side-effects and potential dangers of first-generation H1-antihistamines by reviewing the literature (Medline and Embase) and performing a media audit of US coverage from 1996 to 2008 of accidents and fatal adverse events in which these drugs were implicated. RESULTS: First-generation H(1)-antihistamines, all of which are sedating, are generally regarded as safe by laypersons and healthcare professionals because of their long-standing use. However, they reduce rapid eye movement (REM)-sleep, impair learning and reduce work efficiency. They are implicated in civil aviation, motor vehicle and boating accidents, deaths as a result of accidental or intentional overdosing in infants and young children and suicide in teenagers and adults. Some exhibit cardiotoxicity in overdose. CONCLUSIONS: This review raises the issue of better consumer protection by recommending that older first-generation H(1)-antihistamines should no longer be available over-the-counter as prescription- free drugs for self-medication of allergic and other diseases now that newer second- generation nonsedating H(1)-antihistamines with superior risk/benefit ratios are widely available at competitive prices.

Summary Background Staphylococcus aureus Enterotoxin B (SEB) has immunomodulatory effects in allergic airway disease. The potential contribution of SEB to the sensitization process to allergens remains obscure. Objective In order to study the effects of staphylococcal-derived toxins on the sensitization to ovalbumin (OVA) and induction of allergic airway inflammation, we have combined the nasal application of OVA with different toxins. Methods Nasal applications of OVA and saline, SEA, SEB, toxic shock syndrome toxin (TSST)-1, protein A or lipopolysaccharide (LPS) were performed on alternate days from day 0 till 12. On day 14, mice were killed for the evaluation of OVA-specific IgE, cytokine production by mediastinal lymph node (MLN) cells and bronchial hyperreactivity (BHR) to inhaled metacholine. The effect of SEB on dendritic cell (DC) migration and maturation, and on T cell proliferation was evaluated. Results Concomitant endonasal application of OVA and SEB resulted in OVA-specific IgE production, whereas this was not found with SEA, TSST-1, protein A, LPS or OVA alone. Increased DC maturation and migration to the draining lymph nodes were observed in OVA/SEB mice, as well as an increased T cell proliferation. Bronchial inflammation with an influx of eosinophils and lymphocytes was demonstrated in OVA/SEB mice, together with hyperresponsiveness and the production of IL-4, IL-5, IL-10 and IL-13 by MLN stimulated with OVA. Conclusions Our data demonstrate that SEB facilitates sensitization to OVA and consecutive bronchial inflammation with features of allergic asthma. This is likely due to augmentation of DC migration and maturation, as well as the allergen-specific T cell proliferation upon concomitant OVA and SEB application. Cite this as: W. Huvenne, I. Callebaut, M. Plantinga, J. A. J. Vanoirbeek, O. Krysko, D. M. A. Bullens, P.Gevaert, P. Van Cauwenberge, B. N. Lambrecht, J. L. Ceuppens, C. Bachert and P. W. Hellings, Clinical & Experimental Allergy, 2010 (40) 1079–1080.

Background Quality management is increasingly important in clinical practice. The Global Allergy and Asthma European Network (GA(2)LEN) is a network of clinical and scientific excellence with originally 25 allergy centres in 16 European countries, a scientific society (European Academy of Allergology and Clinical Immunology), and a patient organization (European Federation of Allergy and Airways Diseases Patients' Associations). Although some allergy centres adhere to internal quality criteria, the implementation of a standardized quality management system for allergy centres across Europe was lacking. Objectives To implement standardized quality criteria among allergy centres organized within GA(2)LEN and thus ensure equal standards of diagnosis and care as well as to establish a culture of continuous quality improvement. Methods Quality criteria covering, e.g., diagnostic and therapeutic procedures, and emergency preparedness to assure patient safety were developed and agreed upon by all 25 participating centres. To assure implementation of quality criteria, centres were audited to check quality indicators and document deviations. A follow-up survey was used to assess the usefulness of the project. Results Deviations were documented mainly in the areas of emergency care/patient safety (27.3% lacked regular emergency training of doctors and nurses; 22.7% inadequate emergency intervention equipment; 22.7% lacked critical incidence reporting/root cause analyses) and handling of extracts/pharmaceuticals (31.8% lacked temperature logs of fridges; 4.5% inadequate check of expiration dates). Quality improvement was initiated as shown by findings of re-audits. Usefulness of the project was rated high. Conclusion The establishment of a quality management system with joint standards of care and harmonized procedures can be achieved in an international health network and ensures quality of care.

Allergic diseases represent a major health problem in Europe. They are increasing in prevalence, severity and costs. GA2LEN (Global Allergy and Asthma European Network), an FP6 Network of Excellence, was created in 2005 as a vehicle to ensure excellence in research bringing together research and clinical institutions to combat fragmentation in the European research area and to tackle Allergy in its globality. GA2LEN benefited greatly from the voluntary efforts of researchers who are strongly committed to this model of pan-European collaboration. The network was organized in order to increase networking for scientific projects in allergy and asthma around Europe and to make GA2LEN the world leader in the field. Besides these activities, research has been jointly made and the first papers are being published. GA2LEN achievements in general can be grouped as those for a durable infrastructure built up during the project phase those which are project-related work based on these novel infrastructures, and the development and implementations of guidelines. The major achievements of GA2LEN are reported in this paper.

Chronic rhinosinusitis is one of the most common health care challenges, with significant direct medical costs and severe impact on lower airway disease and general health outcomes. The diagnosis of chronic rhinosinusitis (CRS) currently is based on clinical signs, nasal endoscopy and CT scanning, and therapeutic recommendations are focussing on 2 classes of drugs, corticosteroids and antibiotics. A better understanding of the pathogenesis and the factors amplifying mucosal inflammation therefore seems to be crucial for the development of new diagnostic and therapeutic tools. In an effort to extend knowledge in this area, the WP 2.7.2 of the GA(2)LEN network of excellence currently collects data and samples of 1000 CRS patients and 250 control subjects. The main objective of this project is to characterize patients with upper airway disease on the basis of clinical parameters, infectious agents, inflammatory mechanisms and remodeling processes. This collaborative research will result in better knowledge on patient phenotypes, pathomechanisms, and subtypes in chronic rhinosinusitis. This review summarizes the state of the art on chronic rhinosinusitis and nasal polyposis in different aspects of the disease. It defines potential gaps in the current research, and points to future research perspectives and targets.

BACKGROUND: There is evidence that selenium levels are relatively low in Europe and may be falling. Low levels of selenium or low activity of some of the enzymes dependent on selenium have been associated with asthma. METHODS: The GA(2)LEN network has organized a multicentre case-control study in Europe to assess the relation of plasma selenium to asthma. The network compared 569 cases in 14 European centres with a diagnosis of asthma and reporting asthma symptoms in the last 12 months with 576 controls from the same centres with no diagnosis of asthma and no asthmatic symptoms in the last 12 months. RESULTS: All cases and controls were selected from the same population defined by age and place of residence. Mean plasma selenium concentrations among the controls ranged from 116.3 microg/l in Palermo to 67.7 microg/l in Vienna and 56.1 microg/l among the children in Oslo. Random effects meta-analysis of the results from the centres showed no overall association between asthma and plasma selenium [odds ratio (OR)/10 microg/l increase in plasma selenium: 1.04; 95% confidence interval (CI): 0.89-1.21] though there was a significantly protective effect in Lodz (OR: 0.48; 95% CI: 0.29-0.78) and a marginally significant adverse effect in Amsterdam (OR: 1.68; 95% CI: 0.98-2.90) and Ghent (OR: 1.35; 95% CI: 1.03-1.77). CONCLUSION: This study does not support a role for selenium in protection against asthma, but effect modification and confounding cannot be ruled out.

Background Recent findings indicate that Staphylococcus aureus and its products may be involved in the modification of nasal polyposis. The purpose of this study was to investigate the presence of S. aureus enterotoxin genes and the agr subtype in bacterial DNA of S. aureus strains isolated from the middle meatus of nasal polyp and control patients. Methods S. aureus strains were isolated from nasal polyp patients and controls. The strains were screened using PCR for their agr subtype, classic superantigens (SEA, SEB, SEC, SED or TSST-1), the egc cluster (SEG, SEI, SEM, SEN, and SEO and other enterotoxins (SEE, SEH, SEJ, SEK, and SEL) distinct from the egc locus. Results Seventy-five percent of S. aureus strains had at least one enterotoxin in their DNA. The egc gene cluster was identified in 27 (67.5%) strains. At least one classic enterotoxin gene was present in 42.5% of the strains. Interestingly, there were no differences in enterotoxin genes between S. aureus strains isolated from controls compared with nasal polyposis patients. In controls, an equal distribution among the four agr groups was found, while 73% of the NPs strains belonged to agr groups I and II. Conclusion In this study we found no significant difference between strains from nasal polyp patients and controls in the presence of enterotoxin genes. However, in NPs, a higher number of strains belonged to agr I or II, which are associated with strains causing enterotoxin-mediated disease.

Histamine is the primary mediator involved the pathophysiology of allergic rhinitis and chronic urticaria, and this explains the prominent role that histamine H(1)-receptor antagonists have in the treatment of these disorders. However, histamine is clearly not the only mediator involved in the inflammatory cascade. There is an emerging view that drugs which can inhibit a broader range of inflammatory processes may prove to be more effective in providing symptomatic relief in both allergic rhinitis and chronic urticaria. This is an important consideration of the Allergic Rhinitis and its Impact on Asthma (ARIA) initiative which provides a scientific basis for defining what are the desirable properties of an 'ideal' antihistamine. In this review of rupatadine, a newer dual inhibitor of histamine H(1)- and PAF-receptors, we evaluate the evidence for a mechanism of action which includes anti-inflammatory effects in addition to a powerful inhibition of H(1)- and PAF-receptors. We assess this in relation to the clinical efficacy (particularly the speed of onset of action) and safety of rupatadine, and importantly its longer term utility in everyday life. In clinical trials, rupatadine has been shown to be an effective and well-tolerated treatment for allergic rhinitis and chronic idiopathic urticaria (CIU). It has a fast onset of action, producing rapid symptomatic relief, and it also has an extended duration of clinical activity which allows once-daily administration. In comparative clinical trials rupatadine was shown to be at least as effective as drugs such as loratadine, cetirizine, desloratadine and ebastine in reducing allergic symptoms in adult/adolescent patients with seasonal, perennial or persistent allergic rhinitis. Importantly, rupatadine demonstrated no adverse cardiovascular effects in preclinical or extensive clinical testing, nor negative significant effects on cognition or psychomotor performance (including a practical driving study). It improved the overall well-being of patients with allergic rhinitis or CIU based on findings from quality of life questionnaires and patient global rating scores in clinical trials. Thus, rupatadine is a recently introduced dual inhibitor of histamine H(1)- and PAF-receptors, which has been shown to be an effective and generally well-tolerated treatment for allergic rhinitis and chronic urticaria. It possesses a broader profile of anti-inflammatory properties inhibiting both inflammatory cells and a range of mediators involved in the early- and late-phase inflammatory response, but the clinical relevance of these effects remain to be clarified.

Allergic rhinitis is a symptomatic disorder of the nose induced after allergen exposure by an IgE-mediated inflammation of the membranes lining the nose. It is a global health problem that causes major illness and disability worldwide. Over 600 million patients from all countries, all ethnic groups and of all ages suffer from allergic rhinitis. It affects social life, sleep, school and work and its economic impact is substantial. Risk factors for allergic rhinitis are well identified. Indoor and outdoor allergens as well as occupational agents cause rhinitis and other allergic diseases. The role of indoor and outdoor pollution is probably very important, but has yet to be fully understood both for the occurrence of the disease and its manifestations. In 1999, during the Allergic Rhinitis and its Impact on Asthma (ARIA) WHO workshop, the expert panel proposed a new classification for allergic rhinitis which was subdivided into 'intermittent' or 'persistent' disease. This classification is now validated. The diagnosis of allergic rhinitis is often quite easy, but in some cases it may cause problems and many patients are still under-diagnosed, often because they do not perceive the symptoms of rhinitis as a disease impairing their social life, school and work. The management of allergic rhinitis is well established and the ARIA expert panel based its recommendations on evidence using an extensive review of the literature available up to December 1999. The statements of evidence for the development of these guidelines followed WHO rules and were based on those of Shekelle et al. A large number of papers have been published since 2000 and are extensively reviewed in the 2008 Update using the same evidence-based system. Recommendations for the management of allergic rhinitis are similar in both the ARIA workshop report and the 2008 Update. In the future, the GRADE approach will be used, but is not yet available. Another important aspect of the ARIA guidelines was to consider co-morbidities. Both allergic rhinitis and asthma are systemic inflammatory conditions and often co-exist in the same patients. In the 2008 Update, these links have been confirmed. The ARIA document is not intended to be a standard-of-care document for individual countries. It is provided as a basis for physicians, health care professionals and organizations involved in the treatment of allergic rhinitis and asthma in various countries to facilitate the development of relevant local standard-of-care documents for patients.

By definition, allergy is a multifactorial disease (1), whichcan no longer be studied by single research groups.Networks are therefore essential to achieve optimalresearch outcome. However, the results of this researchneed to be translated for physicians, patients, the publicand policy makers. The networks should, therefore,include all experts, researchers, physicians of differentspecialties, general practitioners, other health care pro-fessionals and patients to accomplish these tasks. In thesenetworks, dissemination of research is the key to theirsuccess.The European Union, having been at the forefront ofallergy research for more than a decade, has led severalnetworks, concerted actions and integrated projects.Projects commenced before 2002 have been reviewed inprevious papers of the journal (2, 3). The EuropeanCommunity Respiratory Health Survey was one of thefirst and most successful assignments (4). Some projectslike European Network For Understanding MechanismsJ. Bousquet

Objective: The main purpose of this study is to determine the treatment effectiveness of pharyngeal flap surgery by measuring speech outcome 1 year after surgery. The authors hypothesized that flap surgery is an effective technique for velopharyngeal inadequacy resulting in improved intelligibility, decreased hypernasality and nasalance scores and normal voice characteristics. Patients and Methods: Objective (Nasometer, Dysphonia Severity Index) as well as subjective (perceptual evaluations) assessment techniques were performed in 7 subjects. Speech evaluations were performed 1 year after flap surgery and comparison was made between the speech results of the preoperative condition (1 week before surgery) and the first postoperative condition (6 weeks after surgery). Results: After pharyngeal flap surgery there was improved though still slightly impaired intelligibility, with normal nasality, normal nasalance values for standard Flemish speech and normal voice characteristics. The normal nasality and nasalance values were not present in the preoperative condition. Persistence of the incorrect production of the thrill sound /r/ and the fricatives /s/ and /sch/ were observed. Conclusion: It is likely that the slightly impaired speech intelligibility is determined by the presence of persistent articulation disorders.

In allergic rhinitis, cross linking of IgE molecules upon allergen contact induces degranulation of mast cells and basophils within the mucosal tissue, and results in the release of typical mediators, which consecutively induce the well-known symptoms. Omalizumab counteracts these interactions by a reduction in serum levels of free IgE. Therapy targeted against IgE also interferes with its binding to the high- as well as the low-affinity receptors, inhibiting the amplification of the Th2-type response. Treatment of allergic rhinitis with anti-IgE has been shown to be safe and to reduce specific symptoms. Furthermore, the combination ofomalizumab with specific immunotherapy (SIT) may offer not only an increase in efficacy, but also in safety in appropriate patients. The currently available studies with omalizumab in allergic rhinitis, as monotherapy or in combination with immunotherapy, are summarized. In nasal polyp disease, a local polyclonal IgE response has recently been described, initiated by Staphylococcus aureus-derived enterotoxins, which at least modifies the inflammatory reaction within the tissue. Evidence accumulates that these enterotoxins act as superantigens resulting in a polyclonal T- and B cell activation with massive IgE formation within the airways. Because of the polyclonality, a range of allergens could possibly maintain a constant degranulation of mast cells present in polyp tissue, which may contribute to the disease severity. We here discuss a proof-of-concept treatment trial with omalizumab in nasal polyposis, which in case of a positive therapeutic response, also would open the door for anti-IgE treatment approaches for severe nonatopic lower airway disease.

Viral infections of the respiratory tract are the most common precipitants of acute asthma exacerbations. Exacerbations are only poorly responsive to current asthma therapies and new approaches to therapy are needed. Viruses, most frequently human rhinoviruses (RV), infect the airway epithelium, generate local and systemic immune responses, as well as neural responses, inducing inflammation and airway hyperresponsiveness. Using in vitro and in vivo experimental models the role of various proinflammatory or anti-inflammatory mediators, antiviral responses and molecular pathways that lead from infection to symptoms has been partly unravelled. In particular, mechanisms of susceptibility to viral infection have been identified and the bronchial epithelium appeared to be a key player. Nevertheless, additional understanding of the integration between the diverse elements of the antiviral response, especially in the context of allergic airway inflammation, as well as the interactions between viral infections and other stimuli that affect airway inflammation and responsiveness may lead to novel strategies in treating and/or preventing asthma exacerbations. This review presents the current knowledge and highlights areas in need of further research.

Background: Chronic rhinosinusitis (CRS) clinically is a heterogeneous group of sinus diseases, which may cover different disease entities, or may represent a disease continuum. Studying inflammatory cells and mediators in clearly defined disease subgroups may lead to a better differentiation of chronic sinus diseases. Methods: Sinonasal mucosal tissue from 10 nasal polyp (NP) patients, 13 cystic fibrosis patients (CF-NP), eight CRS subjects without polyps, and nine control patients were stained for CD3, CD25, CD68, CD20, myeloperoxidase (MPO), CD138 and tissue homogenates were assayed for eotaxin, interleukin (IL)-1 beta, IL-2sR alpha, IL-5, interferon (IFN)-gamma, IL-8, transforming growth factor (TGF)-beta 1, tumor necrosis factor-alpha, and MPO by enzyme-linked immunosorbent assay or UNICAP system. Results: Nasal polyp and CF-NP showed increased numbers and activation of T cells, while only NP displayed an increase in plasma cells. Nasal polyp had significantly higher levels of eosinophilic markers [eosinophils, eotaxin, and eosinophil cationic protein (ECP)] compared with CRS, controls and CF-NP. Chronic rhinosinusitis was characterized by a Th1 polarization with high levels of IFN-gamma and TGF-beta, while NP showed a Th2 polarization with high IL-5 and immunoglobulin (Ig) E concentrations. Nasal polyp and CF-NP were discriminated by edema from CRS and controls, with CF-NP displaying a very prominent neutrophilic inflammation. Conclusions: Based on cellular and mediator profiles, we suggest that CRS, NP, and CF-NP are distinct disease entities within the group of chronic sinus diseases.

Background: Allergic rhinitis (AR) and noninfectious, nonallergic rhinitis (NINA) are common disorders, which may prompt patients to seek medical help. Methods: We performed a survey in a representative sample of the Belgian population (n = 4959) with an overall prevalence of self-declared recent rhinitis symptoms of 39.3%. Detailed information on patients having experienced nasal symptoms over the past year was then obtained from a random sample of respondents (n = 743). Results: The adjusted prevalence was 29.8% for AR and 9.6% for NINA, respectively. According to the ARIA classification, there was significantly more ‘persistent’ symptomatology in the AR group (40.8%) than in NINA (23.5%) (P

Tissue remodelling reported in upper airways include epithelial hyperplasia, increased matrix deposition in the nasal or paranasal lining, matrix degradation and accumulation of plasma proteins. Genetic influences, foetal exposures and early life events may contribute to structural changes such as subepithelial fibrosis from an early age. Other structural alterations are related to duration of the disease and long-term uncontrolled inflammation. Structural changes may increase alteration of the protective functions of the upper airways namely by affecting mucociliary clearance and conditioning of inspired air. The sequences of tissue changes during wound repair of upper airway mucosa after surgery are illustrative of the complexicity of tissue modelling and remodelling and could be considered as an important source of information for a better understanding of the complex relationship between inflammatory reaction, of the subsequent tissue damages and fibroblast metabolism of upper airways.

Allergic rhinitis, rhinosinusitis, and otitis media are among the most common health problems encountered in general practice. Although frequently trivialized, they affect the quality of life, represent a significant socioeconomic burden, and are associated with some serious complications. In addition, allergic rhinitis, rhinosinusitis, and otitis media are often considered as comorbidities. These disorders involve an inflammatory process of the respiratory mucosa of the nose, paranasal sinuses, or middle ear. Because of their well-known anti-inflammatory effects, the role of glucocorticosteroids in the management of these three disorders has been questioned, evaluated, and, in some cases, established.

Summary Epidemiological studies show that the prevalence of asthma and allergic rhinitis (AR) has increased progressively over the past two to three decades. Similarly, there is increasing evidence that asthma and rhinitis frequently co-exist in the same patients and that rhinitis is a risk factor for asthma. Although several guidelines are currently available for the diagnosis and management of AR, the earlier guidelines and their successors were not evidence based, and were developed primarily on the basis of expert opinion, but of course based on the available literature. More recently, the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines were published in co-operation with the World Health Organization. These guidelines are evidence based and directed towards managing co-morbid rhinitis and asthma as different manifestations of a single airway disease, rather than as two separate diseases of the nose and the lung. They recommend treatment of AR in a step-wise manner (using a combination of allergen avoidance, pharmacotherapy and immunotherapy), based on the duration and severity of disease, rather than on the basis of type of exposure (i.e seasonal, perennial, occupational), as recommended by previous guidelines. The ARIA guidelines recognize that both the availability and the cost of a particular intervention are likely to determine patient compliance, and therefore recommends a flexible approach based on availability and cost of specific interventions in different countries. Despite the availability of treatment guidelines, there is evidence that the severity of disease is often diagnosed and treated inappropriately by general practitioners (GPs), who frequently do not use a guided treatment strategy, leading to low patient satisfaction and compliance. This suggests a clear need to implement the guidelines among GPs, especially since the vast majority of patients generally trust their GPs to provide appropriate information and optimal medication for the management of their disease.

Allergic diseases and asthma pose an important and increasing problem for populations and health care systems around the world (1). European research groups have been at the forefront of investigations into the early life influences on the causes of these conditions and management of allergy and asthma (2, 3). Moreover, initiatives from the European Commission have led to a greater collaboration between the European countries and beyond in tackling these problems. It has been shown to be both practical and rewarding to exploit the wide variations in culture, environment and health care systems within Europe to study these issues (4). Collaborative projects such as the European Community Respiratory Health Survey (ECRHS), the International Study of Asthma and Allergy in Childhood (ISAAC), and many other, funded by the European Commission, have clearly demonstrated the ability and advantages of European groups working together (1, 5, 6). Although allergy and asthma represent a burden in all countries and regions in Europe there is still a lack of permanent structures to support this type of work. The collaboration between European groups so far has often had a relatively narrow methodological focus and has therefore produced only short-term collaborations without a formal enduring structure. The basic idea of the European Research Area (ERA) is that the aims and goals of future research cannot be met without much greater integration of Europe’s research efforts and capacities. The sixth framework programme is a key instrument of ERA with a budget of 17 500 million. For this reason the sixth framework programme introduces new instruments like networks of excellence from which joint strategies can be developed. These networks have clearly defined thematic objectives and will be directed towards advancing scientific and technological knowledge, within mediumto long-term time-frames (7, 8). P. Van Cauwenberge, J. B. Watelet, T. Van Zele, J. Bousquet, P. Burney, T. Zuberbier, on behalf of the GALEN partners* Department of Otorhinolaryngology, Ghent University Hospital, Ghent, Belgium; University Hospital and INSERM U454, Montpellier, Institut Pasteur Paris, France; Department of Public Health Sciences, Guy's, King's and St Thomas School of Medicine, King's College, London, UK; Department of Dermatology and Allergy, Charit , Berlin, Germany *GALEN partners are given in Appendix.

Clinical guidelines are 'systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances'. They may offer concise instructions on which diagnostic or screening tests to order, stipulate how medical services should be provided, how long patients should stay in hospital, or many other details relevant to clinical practice. This paper argues that guidelines should be simple, adapted to the clinical setting they inform and to treatment availability in their respective geographic context and that they should not be viewed as a yardstick but as support for physicians. The benefits of evidence-based-medicine (EBM), which defines the value of medical interventions in terms of empiric evidence from clinical trials, are growing in many contexts and are well described. Not sufficiently acknowledged, however, are the limits of EBM. A gap still exists between clinical research and clinical practice which should be better recognized and assessed.

Staphylococcus aureus is a frequent germ in the upper airways, and, under appropriate conditions, may produce enterotoxins with superantigenic activities. The classical enterotoxins SEA-E and TSST-l activate B- and T cells, eosinophils, epithelial and other cells, and are able to induce a polyclonal immune response including IgE synthesis and eosinophilic inflammation. We have shown that nasal polyps frequently are colonized with Staphylococcus aureus, inducing a local immune reaction, which aggravates the eosinophilic inflammatory response. IgE antibodies in nasal polyp tissue may be used as diagnostic means for this immune reaction. We consider it probable that enterotoxines from Staphylococcus aureus are crucially contributing to this often difficult to treat disease of the upper airways. Furthermore, recent studies in severe, steroid-dependent asthmatics have shown that IgE-antibodies to enterotoxins are also found in the sera of these patients and similar pathomechanisms as in polyps may apply for the lower airways. To summarize, enterotoxins from Staphylococcus aureus most probably play an at least modulating role in severe upper and lower airway disease.

Objectives/Hypothesis: After failure of medical treatment, chronic rhinosinusitis and nasal polyposis require surgical management. However, little is known about the predictive factors for objective outcome after sinus surgery. The aims of the study were to correlate preoperative, intraoperative, and postoperative clinical factors to healing outcome and to establish their respective predictive values. Study Design: Prospective study. Methods: Eighteen patients who had surgery for chronic rhinosinusitis and 18 who had surgery for nasal polyposis at the Ghent University Hospital (Ghent, Belgium) were followed for a 6-month period. In all, 76 operated sides were independently considered. The healing quality was evaluated by endoscopy weekly and then monthly for a period of 6 months. A logistic regression analysis with healing quality at month 6 as outcome was performed on preoperative, intraoperative, and postoperative factors. Results: Previous sinus surgery (P = .0006) and initial disease (P = .0430) were found to be highly predictive for the healing outcome at month 6, patients with nasal polyposis or previous surgery showing significantly worse objective outcome (P = .0034 and P < .0001, respectively). The preoperative computed tomography scan had no predictive value with respect to the extent of surgery (P = .0281). Postoperative parameters had less predictive value. Conclusion: Initial disease and its severity as reflected by the extent of surgery and surgical antecedents were the best predictors for the objective outcome at 6 months after sinus surgery. Whereas the first postoperative phase showed similar characteristics for all patients, the healing course differed between patients from month 1 to the end point.

Allergic diseases and asthma represent one of the mostcommon chronic pathological conditions throughoutthe world (1, 2). They usually start early in infancy orchildhood and often persist throughout life (3). Theyare extremely common in developed countries. It isestimated that 2–15% of the European populationsuffers from asthma, and that, in some countries,allergy may affect over 50% of children. Moreover,the prevalence of allergic diseases and asthma hasactuallyincreasedduringthepastthreetofourdecades.More recently a similar increase has been noted indeveloping countries, and these diseases now representanimportantproblem(4).IntheEuropeanUnion(EU)theprevalenceandseverityofallergicdiseasesincludingasthma present a serious challenge both to health caresystems and to society as a whole. Specific problemsinclude the continuing increase in the prevalence offood allergy, which is a particular concern because itmay be life-threatening, and it has a major impact onpatient’s lives (7). This problem affects mainly children(5, 6) but also an increasing number of adult pollenallergic patients. Occupational allergy is anotherimportant medical and economic problem which isunder recognized and needs a more careful evaluation(1, 8). The interaction between the indoor and outdoorenvironment is critical for the development of thesediseases (9).Allergic diseases and asthma also seriously affect thesocial life of the patients. Asthma is still a leadingconditionofschoolabsenteeismaswellasamajorcauseof work absenteeism (10) but even more importantlygood investigations regarding the impact of allergies oncognitive functions and the reduced performance ineducation and work are hardly available. Finally, directand indirect costs for allergic diseases and asthma havesharplyrisenwithinthepast10years(11–13).Although the use of asthma guidelines has reducedmorbidity and mortality, the burden of asthma is stillhigh and both the knowledge of better treatmentoptions and their implementation need to be improved(1)asdoesthedevelopmentofmoreeffectivepreventivestrategies. Knowledge of the causes of the atopicresponse and of asthma have greatly increased overthe last decade with major advances in our knowledgeof the effects of infection, diet and the environment.There remains, however, a major gap between thisknowledge and the ability to mount effective preventivecampaigns.J.Bousquet

Background: Nasal polyps (NP) are characterized by pseudocyst formation, whereas the mucosa in chronic sinusitis (CS) only shows a limited oedema. Matrix metalloproteinases (MMPs) are a family of endopeptidases able to degrade the extracellular matrix. Differences in histological features between CS and NP might be related to the respective expression of MMPs and their tissue inhibitors (TIMPs). Objective: The aim of this study was to investigate MMP-7, MMP-9 and TIMP-1 proteins in NP and CS in comparison with normal mucosa. Methods: Nasal samples, obtained from controls (n = 10), from NP (n = 8) and from CS (n = 10), were analysed by immunohistochemistry and enzyme-linked immunosorbent assay (ELISA). Results: In NP, compared with controls, staining for MMP-9 and MMP-7 appeared in blood vessels. Matrix metalloproteinase-9-positive inflammatory cells could be detected in increased numbers in pseudocyst formations. Concentrations of MMP-9 protein was found significantly increased in both CS and NP compared with controls, while MMP-7 was significantly increased in NP compared with controls and CS. Tissue inhibitors of metalloproteinase-1 protein was significantly increased in CS and NP when compared with controls. Conclusions: Chronic sinusitis and NP show different pattern of MMP-7/-9 and TIMP-1 expression. We suggest that this difference in regulation of enzymes is related to the respective tissue remodelling observed in both diseases.

Background: Allergic rhinitis is a common disease altering quality of life. Its treatment is well established and guidelines have been proposed. However, their efficacy has never been tested. The aim of the study was to validate the guidelines of the International Consensus on Rhinitis in the treatment of seasonal allergic rhinitis. Methods: A multicenter, multinational, open label, parallel, randomized study compared two therapeutic strategies in seasonal allergic rhinitis during a 3-week treatment. General practitioners were randomized into two groups. In the first group of 224 patients, doctors followed guidelines from the International Consensus on Rhinitis. Depending on the severity of nasal and ocular symptoms defined using visual analogue scales, patients received ebastine (an oral antihistamine), triamcinolone acetonide (a topical corticosteroid) and/or ophthalmic nedocromil sodium (a topical ocular cromone). In the second group of 241 patients, general practitioners had a free choice of treatment. The primary efficacy end points were quality of life measured using the standardized rhinoconjunctivitis quality of life questionnaire (RQLQ) and the symptom-medication scores assessed daily with an electronic dairy system. Results: Adjusted mean total symptom scores over 21 days were 4.93 in the guidelines strategy group compared with 7.48 in the free-choice treatment group (P = 0.0001). Mean total scores in the RQLQ decreased by 2.19 in the guidelines group compared with a decrease of 1.79 in the free-choice treatment group (P = 0.0001). At 21 days, the least square mean difference in improvement in overall scores for RQLQ in the guidelines group compared with the free-choice treatment group was 0.53, which was greater than the minimal important difference. Conclusions: Patients with seasonal allergic rhinitis often present severe symptoms which are not well recognized or controlled by physicians using their own criteria of severity and treatment. Using a simple method for the evaluation of the severity and a simple therapeutic scheme based on International Guidelines, patients with seasonal allergic rhinitis presented a significant improvement by comparison with those receiving a non-standardized treatment.

Summary Allergic rhinitis is a common disease, affecting 25–35% of the population. Allergic rhinitis is still increasing in prevalence. It is characterized by rhinorrhoea, itching, sneezing and nasal obstruction. Allergic rhinitis is classically classified into three groups: seasonal (intermittent), perennial (persistent) and occupational allergic rhinitis. In the ARIA document allergic rhinitis is classified into intermittent and persistent. There is a known relationship between allergic rhinitis and asthma, sinusitis, otitis media with effusion, nasal polyposis and upper respiratory tract infections. Allergic rhinitis results from IgE-mediated allergy, associated with cellular inflammation of the nasal mucosa. The diagnosis of allergic rhinitis is confirmed by a clinical history of typical allergic symptoms and in vivo or in vitro tests for detection of free or cell-bound IgE. Treatment of allergic rhinitis comprises avoidance of the allergens, oral/nasal antihistamines, decongestants, chromones, ipratropium bromide and intranasal/oral corticosteroids. It is advised to follow the international guidelines, ‘a stepwise approach’. Allergic conjunctivitis is the most common ocular allergic disorder, affecting 5–22% of the population. Ocular allergy involves typical symptoms (itching, watery, stringy or ropey discharge and redness), recurrent/intermittent/persistent episodes, a strong personal and/or family history of atopy and an early age of onset. Treatment of allergic conjunctivitis includes oral/intraocular antihistamines, cromones or topical corticosteroids.

Our understanding of the pathophysiology of allergy has moved to the molecular level, while study of epidemiology and genetics has revealed risks of developing allergies based on environmental and genetic profiles, and pharmacoeconomic data have enabled accurate measurement of the immense burden of allergic disease. These advances in allergy research have affected its management, particularly the search for new antiallergy therapies. New therapies should intervene in the systemic allergy inflammatory cascade and provide clinical efficacy that extends to multiple allergic disease states. In addition, these new therapies should present no additional safety issues, offer improvements over existing therapies, and have an impact on disease-impaired quality of life. In vitro studies show that desloratadine, a new, once-daily, nonsedating, selective histamine H1-receptor antagonist, blocks the systemic allergy cascade at multiple points. Desloratadine 5 mg once daily relieves the symptoms of chronic idiopathic urticaria and of both seasonal (SAR) and perennial allergic rhinitis. In patients with concomitant asthma and SAR, asthma symptoms are relieved and beta2-agonist medication use is decreased by desloratadine. Unlike many other second-generation histamine H1-receptor antagonists, desloratadine provides the added benefit of efficacy against nasal obstruction in SAR. Desloratadine improves quality of life by decreasing the impact of allergic symptoms on sleep and on daily activities.

Background: This paper reports a study on the concentrations of the pro-inflammatory cytokines IL-18 and IL-1β in nasal secretions of allergic rhinitis patients in relation to ECP and nasal symptoms. Methods: We measured IL-18 and IL-1β concentrations using ELISA, and eosinophilic cationic protein (ECP) using the CAP system, in nasal secretions of 15 seasonal allergic rhinitis (SAR) patients at six visits throughout the pollen season. Pollen exposure, nasal and ocular symptoms were monitored daily. Furthermore, we measured IL-18, IL-1β and ECP concentrations in nasal secretions of 19 controls and 20 symptomatic persistent allergic rhinitis (PAR) patients with house dust mite allergy. Results: In SAR, the increase of IL-18, IL-1β and ECP paralleled the pollen flight with a time delay. IL-18 and IL-1β significantly increased during the pollen season compared to baseline, and differently from ECP, remained elevated until 4 weeks after the season. In PAR, the concentrations of IL-18 and ECP, but not IL-1β, were significantly higher compared to controls, with IL-18 concentrations also being significantly higher than in SAR. Conclusion: This is the first study to demonstrate the up-regulation of IL-18 in nasal secretions in allergic rhinitis. The persistence of elevated IL-18 concentrations until after the season and the high concentrations in PAR compared to SAR suggests its role in persistent allergic inflammation.

Staphylococcus aureus (S. aureus), one of three pathogenic species of the Gram-positive cocci, is often found as part of the normal microflora of the human skin, the upper respiratory tract, especially the vestibulum nasi, and the intestinal tract. Transmission of the organism is frequently achieved by direct contact with an infected individual, although it may also be airborne or infect via fomites. It is thought that about 25% of the population are permanent carriers of S. aureus and whilst approximately 20% of all human staphylococcal infections are autogenous, several factors have been identified that predispose the host to increased susceptibility to infection by S. aureus (1). These include injury to skin or mucous membrane, abnormal leukocyte function, viral infections (e.g., influenza), metabolic abnormalities (e.g., diabetes mellitus and uraemia) and miscellaneous conditions (e.g., malnutrition, old age, malignancies, etc.). Under appropriate conditions, the organism leads to a variety of clinical conditions, affecting the skin, lungs, heart, central nervous system (CNS), bones and joints, gastrointestinal tract and the blood system (1). Skin infections, lung abscesses, pneumonia, osteomyelitis, food poisoning, fever, scalded skin syndrome and toxic shock syndrome are among the most common conditions. Although the pathogenicity of S. aureus is closely correlated with the production of coagulase enzymes, and many conditions result as a consequence of invasion by the bacterium, these organisms also contain a number of cellular antigens and produce a variety of toxins with superantigenic properties (2, 3). Recent studies of these staphylococcal superantigens have demonstrated that they can influence the activity of both immunomodulatory and pro-inflammatory effector cell types, and therefore may have a potentially important role in the pathogenesis of chronic inflammatory disease.

Resume Les glucocorticosteroides sont de loin les anti-inflammatoires les plus puissants de la pharmacopee en allergologie, et, depuis le debut des annees 1970, leurs preparations locales sont devenues un element therapeutique essentiel dans le traitement de la rhinite allergique. Grâce a une augmentation de leurs proprietes actives, grâce a leur moindre biodisponibilite et a leur meilleure tolerance, les molecules glucocorticosteroides modernes sont, non seulement de plus en plus utilisees en premier choix chez l’adulte mais elles trouvent aussi leur place dans la prise en charge de la rhinite allergique chez l’enfant. Neanmoins, compte tenu de certains rapports scientifiques recents, quelques precisions doivent etre apportees quant a leur utilisation en clinique quotidienne. Enfin, une proposition de lignes directrices pour un traitement raisonne a ete recemment publiee afin de standardiser la prise en charge de la rhinite allergique et de specifier la place de chaque possibilite therapeutique.

Imaging of the semicircular canals specifically is part of the imaging process of the temporal bone in general. The semicircular canals are easily seen on CT images and 3DFT-CISS-weighted MR images, both performed with 1.0-mm-thick slices, or even thinner slices. In selected cases, the T1-weighted images give unique information on the semicircular canals. This article briefly reviews the variety of semicircular canal anomalies that are most frequently present and can be routinely seen on CT and MR examinations of the temporal bone. It also provides a list that can be used by the radiologist in clinical practice to decide which technique, CT or MR, should be used to detect specific anomalies at the level of the semicircular canals.

Objective To evaluate the use of maxillary sinus puncture as a routine diagnostic procedure to exclude or confirm purulent sinusitis in intensive care unit (ICU) patients presenting with fever or a septic state of unknown origin. Study Design Retrospective. Methods All patients admitted to the ICU at the University Hospital Ghent who required ENT examination to exclude acute sinusitis as possible cause of their otherwise inexplicable fever or septic state underwent maxillary sinus puncture via the inferior meatus. The results of clinical examination and the relation between the presence of foreign bodies (e.g., nasogastric tubes) and culture results from the middle meatus and sinuses were analyzed. Results One hundred five punctures were performed in 53 patients. Macroscopic purulent effusions were obtained from 25 and nonpurulent effusions from 19 sinuses. The presence of a nasogastric tube did not influence puncture results but significantly increased colonization of the middle meatus. Staphylococcus aureus and Gram-negative agents were frequently cultured from sinus aspirates. Although purulent secretions often reveal no growth, most patients present with a multibacterial (40%) or monobacterial (28%) infection. Simple anterior rhinoscopy reduces the need for antral puncture. Only 8% of punctures in patients with a normal clinical examination were positive. Conclusions Antral puncture proves to be a simple, fast, safe, inexpensive, and effective procedure for immediate diagnosis of acute nosocomial sinusitis in ICU patients and is therefore recommended as first procedure in these patients, even when only minor clinical abnormalities are present.

BACKGROUND: As there have been no previously published studies, this multinational, double-blind, randomized, placebo-controlled, parallel group study compared the efficacy, safety and impact on quality of life (QoL) in seasonal allergic rhinitis patients (SAR) of fexofenadine and loratadine (with placebo), when administered once daily. METHODS: Six hundred and eighty-eight SAR patients were randomized to receive fexofenadine HCl 120 mg, loratadine 10 mg or placebo, once daily for 2 weeks. The key parameters were the change from baseline in: mean 24-h reflective total symptom scores (TSS); sum of four individual symptom scores, excluding nasal congestion; instantaneous TSS; individual symptom scores including nasal congestion; and Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ). Adverse events were recorded. RESULTS: Mean 24-h reflective and instantaneous TSS were significantly reduced by both fexofenadine HCl (both P

Résumé Beaucoup de controverses existent toujours quant au rôle tenu par les virus, bactéries et champignons dans les affections rhino-sinusiennes. Une rhinite virale ne semble pas pouvoir à elle seule induire une sinusite aiguë clinique. Les bactéries déterminent l'image clinique et le devenir de la sinusite. Il n'y a pas trop de controverses quant au rôle des bactéries dans la sinusite aiguë, S. pneumoniae, H. influenzae and M. catarrhalis étant les bactéries les plus souvent retrouvées. Beaucoup plus de rapports contradictoires sont publiés concernant la flore normale des cavités sinusiennes, le rôle des anaérobies et la microbiologie de la sinusite chronique. Les liens entre pathologies infectieuses et allergiques sont plus compliqués à démontrer. Il semble que les virus, en particulier, peuvent influencer la libération de médiateurs inflammatoires et modifier l'évolution de la réaction inflammatoire. De même, leur rôle dans la destruction épithéliale, la mise à nu des terminaisons nerveuses, la sensibilisation de certaines cellules inflammatoires et par-delà, dans l'hyperréactivité des voies respiratoires en général, a été évoqué. Enfin dans le cadre des sinusites, diverses hypothèses ont été émises afin d'expliquer les liens possibles avec l'hyperréactivité bronchique.