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Background The Nasal Obstruction Symptom Evaluation (NOSE) scale has been developed and validated in English to overcome the controversies concerning other methods of evaluation of nasal obstruction. The scale is currently used worldwide and has been translated into several languages. The purpose of the present work was to translate the English (NOSE) scale into Arabic (A-NOSE) and to assess its validity and reliability in Arabic-speaking patients. Results The internal consistency and test-to-test reliability of the Arabic scale were statistically good. The differences between the scores of the patients and control subjects were statistically significant. Postoperative scores of the patients were significantly higher than preoperative scores. All participants completed the Arabic questionnaire easily and few of them required slight assistance. Conclusions The translated NOSE scale is easy to administer and can be a robust and usable outcome measure for patients with nasal obstruction. The translated scale is sensitive to changes in nasal airway patency and can be used in clinical practice and outcome research.

Smoking, whether active or passive, has proven deleterious effects on the nasal mucosa. There is also a link between smoking and development and/or maintenance of chronic rhinosinusitis (CRS). Reversal of smoking-induced mucosal changes after quitting smoking is still unconfirmed and controversial. The present study investigated the possibility of reversal of smoking-related nasal mucosal changes back to normal after completely quitting smoking. The study was performed on 32 smokers whose nasal mucosa was previously biopsied for electron microscopic examination and then they completely quit smoking. Smoking history of the participants and duration of cessation of smoking were recorded. A tiny 1-mm3 biopsy was taken from the inferior turbinate 1 cm behind its anterior end and processed for electron microscopy. The specimens were processed for electron microscopy and the sections were examined by a pathologist who was blinded to the identity and smoking status of the participant. The results of electron microscopic examination of the nasal mucosa before and after quitting smoking were compared. The mean duration of quitting smoking was 30.75 months (± 8.26). Examination of the electron microscopic sections before quitting smoking showed variable degrees of loss of cilia and columnar cells, edema between the epithelial cells, few goblet cells, hyperplasia of seromucinous acini, and vascular congestion. The pathologic changes correlated positively with the smoking index of the participant. On the other hand, the sections after quitting smoking showed variable degrees of regeneration of the ciliated cells and decreased vascular congestion. Numerous goblet cells and seromucinous acini were seen. Less pathologic changes were observed with longer durations of cessation of smoking. The present study showed an association between smoking and the nasal mucosa. Smoking has several injurious effects on the nasal mucosa. However, the nasal mucosa has excellent regeneration potentials and quitting smoking for sufficient periods of time may reverse these deleterious changes. Considering the established link between smoking and CRS, quitting smoking may help smokers to overcome their recalcitrant disease. This should be further investigated.

BackgroundOdontogenic sinusitis is an underdiagnosed entity and is one cause of failure of conventional treatments of sinusitis. Unfortunately, there is no consensus so far on the best management protocol. This retrospective study aimed to suggest a practical management protocol that can reduce misdiagnosis and improve treatment outcomes.MethodsThe study included 74 patients with confirmed odontogenic sinusitis who were diagnosed and treated over 10 years (2010–2019). The patient data were recorded and analysed.ResultsDental pain was reported in only 31.1 per cent of patients. Fifty-six patients (75.7 per cent) had received dental treatment during the last year, but only 13 (23.1 per cent) reported it. Dental pathology was missed on initial computed tomography evaluation in 24 patients (32.4 per cent). Forty-one patients (55.4 per cent) were successfully treated by dental procedures and antibiotics. Fourteen patients needed functional endoscopic sinus surgery in addition to dental procedures.ConclusionSuccessful management of odontogenic sinusitis requires good communication between rhinologists, radiologists and dentists. Dental treatment should be the logical first step in the treatment protocol, unless otherwise indicated.

To prospectively study a series of scleroma patients with a focus on socioeconomic status, clinical presentation, pathology, microbiology, and treatment. A total of 52 patients diagnosed with scleroma were included in the study. Demographic data of the patients were collected and clinical, radiographic, and histopathologic findings were analyzed. Biopsies from atypical patients were sent for electron microscopic examination. Patients were treated both medically and surgically with clinical follow-up to determine outcomes and the incidence of recurrence. Fifty-two patients were included in the study. There were 23 males (44.2%) and 29 females (55.8%). The highest incidence of scleroma was identified in individuals from poor, rural areas in the third to fourth decades of life. The nose was affected in all cases. Other affected sites included the nasopharynx, soft and hard palate, larynx and trachea, lacrimal passages, skin, and gingiva. Some patients had atypical presentations. Complete follow-up of all patients was hindered by non-compliance with clinic visits and the long duration of medical treatment. Recurrence or relapse of the granulomatous lesions after initial improvement occurred in 11 patients (21.2%) within 1 to 3 years. Scleroma is a stubborn, chronic, granulomatous bacterial disease. The diverse presentations may mimic neoplasms and other granulomatous conditions. We present cases with unusual presentations and demonstrate the transmission electron microscopic features of these lesions. Furthermore, we confirm the importance of achieving full eradication of the etiologic bacilli to prevent recurrent disease.

Objectives Passive exposure of children to cigarette smoke has been implicated in several recalcitrant respiratory childhood disorders. However, to our knowledge, no information is available regarding the connection between passive exposure to tobacco smoke and the formation of nasal biofilms in children. The present study was therefore geared at investigating the hypothesis that exposure of children to household passive smoking may induce the formation of nasal biofilms. Methods The study included 20 children between the ages of 6 and 12 years with a positive history of prolonged exposure to household passive smoke, and who required inferior turbinate reduction together with other procedures. Another 20 children who required similar surgeries but with negative history of exposure to household smoking formed the control group. None of children, in the study and control groups, had evidence of adenoids or infective rhinosinusitis. At the time of surgery, a tiny biopsy was taken from the lower border of the inferior turbinate. The specimens were processed for scanning and transmission electron microscopy. Results The nasal mucosa of 11 out of 20 children with positive history of exposure to passive smoking showed biofilm formation. Ten of these biofilms grew S. aureus. On the other hand, only one child in the control group showed nasal biofilm. Longer exposure to tobacco smoke and higher urinary cotinine levels were associated with more frequent biofilm formation. Likewise, children of heavy smokers developed biofilms more frequently than other children. On the other hand, the age of the children and nasal allergy had no effect on the chances of biofilm formation. Conclusions This is a preliminary report showing that children exposed to household passive cigarette smoking may develop nasal biofilms. Development of these biofilms may increase susceptibility of affected children to persistent sinonasal and possibly other respiratory infections.

Background The physiological functions of the paranasal sinuses are as yet unclear, and it is often assumed that these empty air-filled spaces have no vital function in our body. Recently, nitric oxide has been reported to be synthetized in high concentration by the paranasal sinuses which seems to be the main function of these air-filled empty spaces. Body of abstract The functional role of the paranasal sinuses is still ambiguous despite the several hypotheses that have been put forward to justify their existence. Although it has been recently demonstrated that the paranasal sinuses produce large amounts of nitric oxide (NO), otolaryngologists overwhelmed by attempting to unravel the enigmatic etiology underlying chronic rhinosinusitis have interpreted the high NO output in this context. Nevertheless, NO prime function is vasodilation and has long been recognized to be produced by the endothelial cells. In this review, evidence in the literature is piled and pieces of the puzzle are put together to show that NO synthesized in the paranasal sinuses functions as an airborne messenger that induces pulmonary vasodilation and thereby decreases the workload on the heart. Recognition that the paranasal sinuses are in fact an organ with known function is likely to foster further research and has an impact on our current surgical philosophy. Conclusion The paranasal sinuses seem to play a vital physiological role in our body rather than being evolutionary remnants as initially thought. They are likely responsible for regulating the pulmonary blood pressure thereby preventing pulmonary hypertension.

Objective The present study aimed to evaluate the long-term results of combining spreader grafts with lateral suspension techniques for management of narrow internal nasal valves. Methods This prospective study included 79 patients who underwent surgical interference for dysfunctional nasal valve. The surgical intervention was a combination of two commonly used techniques for management of internal nasal valve dysfunction: spreader graft insertion and lateral suspension of the upper lateral cartilages. The patients were assessed using the nasal obstruction symptom evaluation (NOSE) tool, computed tomography (CT) scans, and endoscopic examinations. Results All patients reported initial improvement and satisfaction in nasal breathing. Seventy-two patients (91%) reported sustained relief of nasal breathing for at least 3 years postoperatively. The mean NOSE scores decreased from 69.8 to 20.65 postoperatively. The internal nasal valve angle, as measured endoscopically, increased from 7.23° to 13.05° on the right side and from 6.75° to 11.98° on the left side; the increase was statistically significant. The angle, as measured on axial CT scans, increased from 8.11° to 14.15° on the right side and from 6.98° to 12.13° on the left side' this increase, too, was statistically significant. Conclusion Combining spreader grafts with lateral suspension sutures provide good, stable, and sustained repair of dysfunctional narrowed internal nasal valves.

Inverted papilloma (IP) is a benign tumor with a local aggressive nature and has a tendency to recur after excision. Despite the evolution of endoscopic techniques in the management of IP, external approaches still play a crucial role in frontal sinus involvement. Objective The present study aimed at planning a strategy for managing IP arising in or involving the frontal recess and/or frontal sinus. Patients and methods Ten patients with frontal sinus IP were enrolled in the present study. The type of surgical procedure was tailored according to the site of origin and extent of the tumor. Results Five combined surgeries and five extended endoscopic surgeries were performed in 1 year and 4 months with a follow up period of 2 years. Complete resection of the tumor was achieved in all the cases and no recurrences were reported at the end of the follow up period. Conclusions The exact approach to frontal sinus IP differ from one case to the other. Endoscopic frontal surgery is the mainstay in treatment of frontal sinus IP. External or combined approaches still remain a valid option for lesions affecting the mucosa of the frontal sinus extensively or extending far lateral.

ObjectiveTo study the cluster of differentiation 8 population in the laryngeal mucosa of patients with laryngeal carcinoma. To our knowledge this is the first paper to address this issue.MethodsThe study group included 40 patients with known laryngeal cancer who were scheduled for laryngectomy. The control groups included 10 smokers and 10 non-smokers who were scheduled for microlaryngeal surgery. Specimens from the three groups were processed for histopathological and histochemical evaluation.ResultsIn patients without cancer of the larynx, the number of cluster of differentiation 8 lymphocytes was greater in smokers than non-smokers. The number of cluster of differentiation 8 lymphocytes was greatest in smokers with laryngeal cancer, and the difference between this group and the two control groups was statistically significant.ConclusionThe study showed that smoking increased the number of cluster of differentiation 8 T-lymphocytes in the laryngeal mucosa. The increase was greatest in patients who had developed laryngeal cancer.

Importance & objective Rhinoplasty for reconstruction of crooked nose continues to update over time to achieve the best results. It is not uncommon for surgeons to perform rhinoplasty in patients with facial asymmetry. The aim of the present study was to introduce a new method of assessment of crooked nose deformities and to evaluate the surgical outcomes of the corrective procedures through the assessment of deviation angles and the utilization of the quality of life (QoL) questionnaire by comparing patient satisfaction in both symmetric and asymmetric faces. Methods Patients were divided into 2 groups; the first group had rhinoplasty to correct crooked nose in patients without facial asymmetry, and patients in group 2 had rhinoplasty for crooked nose in patients with facial asymmetry. Preoperative and post operative analyses of the angles of deviation of the nose were performed. Visual Numerical Scale scores were performed using statistical analysis to assess changes of the quality of life as patient satisfaction for all patients. Results Survey responses were received from 50 patients. Group one included 30 patients and group two included 20 patients. Each group was further subdivided according to the type of deformity into C-shaped nasal deviations and I-shaped linear deviations. Data from all groups were obtained and statistically analyzed. Conclusions All patients in this study who had rhinoplasty for crooked nose either with or without facial asymmetry reported improvement in their disease-specific quality of life and a significant improvement of the nasal axis deviation.

The incidence of traumatic CSF has increased in recent years due to increased incidence of road traffic accidents (RTA) as well the increasing number of endoscopic sinus surgeries (ESS). The objective of this study is to present our experience in management of traumatic CSF leaks using the endoscopic multilayer repair technique. Forty-two patients (aged 10-75 years, 30 males and 12 females) presenting with confirmed post-traumatic CSF rhinorrhea were operated upon between January 2007 and December 2013. The endoscopic multilayer technique was used in all cases. Electromagnetic navigation was used in some cases. All cases presented with intermittent watery rhinorrhea. The duration of the rhinorrhea ranged from 3 days to 1 year before repair. One case presented after 10 years from the causative trauma. Ten cases had a history of meningitis. Nine cases had more than one defect. Iatrogenic defects were larger than defects following accidental trauma. Two cases, following RTA, developed pseudo-aneurysm of internal carotid artery. Ten cases had associated pneumocephalus. The mean duration of postoperative hospitalization was 6 days (range 4-8 days). The mean follow-up duration was 31.2 +/- 11.4 months (range 16-48 months). None of our patient developed serious intra- or postoperative complications. Only one case required another surgery to repair a missed second defect. Post-traumatic CSF leaks can be successfully managed via the endonasal endoscopic route using the multilayer repair technique. It is important to look for multiple defects in these cases. CT angiography is recommended for traumatic leaks involving the lateral wall of the sphenoid sinus to diagnose or exclude the development of pseudo-aneurysm of the internal carotid artery.

The current management options of congenital pyriform aperture stenosis (CNPAS) are either conservative measures awaiting further growth of the bony nasal framework or surgical intervention that focuses on bone removal from the margin of the pyriform aperture (PA) without exposure of the nasolacrimal duct (NLD) followed by stenting. Recently, CT measurements of the nasal cavity in CNPAS have shed light that the site of maximal bony obstruction corresponds to the bony buttress encasing the NLD rather than the margin of the PA as initially thought. Herein, we present an extramucosal pyriplasty technique that can be used without stenting to enlarge the PA and achieve immediate and sustained relief of nasal obstruction. Retrospective chart review of 4 patients with radiologically confirmed CNPAS who had undergone extramucosal pyriplasty without stenting during the period from 2012 to 2016. Three patients were full term without any clinically detectable congenital anomaly. The fourth patient was preterm infant who needed ICU management. On computerized tomography scan, the PA width ranged from 5.8 to 7.1 mm with a mean of 6.4 mm while site of maximal stenosis ranged from 5.4 to 6.8 with a mean of 6 mm. Extramucosal pyriplasty relieved nasal obstruction and restored normal oral feeding in all patients. Postoperative follow-up endoscopy revealed an adequately patent airway with no scarring, granulation or restenosis. Extramucosal pyriplasty with decompression of the NLD without stenting is a treatment modality for CNPAS that provides prompt sustainable relief of nasal obstruction and avoids the drawbacks of stenting and shortcomings of the current conservative methods.

Nasal valve dysfunction has a role in up to 13 % of adults complaining of chronic nasal obstruction yet it is overlooked by many physicians. In rhinoplasty and other nasal surgeries, preserving nasal function is the most significant issue. The autospreader flap has proved to be an effective spreader graft alternative. Adding the spring effect proposed in this study to the autospreader flap increases the width of the internal nasal valve, thus gaining two factors supporting the internal nasal valve. The modified autospreader flap technique is described in detail. Patients in this study were classified into two groups. The first group had no obstructive complaints and the second group had nasal obstructive complaints. Quantitative analysis of NOSE scale scores, endoscopic evaluation, and tomographic evaluation before and after the surgery were performed using statistical analysis. Survey responses were received from 22 patients. Significant improvement in the nasal valve angle width was found in both groups by the endoscopic and tomographic evaluation. Subjective evaluation using NOSE scale scores showed improvement in both groups. The greatest advantage of this technique is that it adds to the autospreader flap a spring action that widens the valve area. We found this technique to be reliable and simple to be performed with fairly good results and patient satisfaction.

Objectives/Hypothesis: Passive exposure to cigarette smoke has been implicated in a number of respiratory childhood disorders. Most studies concerning smoking were directed to its carcinogenic effect on the lungs. However, the effects of smoking on nasal respiratory mucosa have not been widely studied. The aim of the present study was, therefore, to study the ultrastructural changes in the nasal mucosa of a pediatric population exposed to passive smoking. Study Design: The study included 20 children between the ages of 5 and 11 years, who were scheduled for tonsillectomy and at the same time had a positive history of prolonged exposure to household passive smoke. Another 10 children with a negative household smoking history were included as a control group. All children were nonatopic and with a negative family history of allergy. None of them had adenoids or infective rhinosinusitis. Methods: At the time of surgery, a 1-mm3 biopsy was taken was taken from the lower border of the inferior turbinate. The specimens were processed and examined with electron microscopy Results: Examination of the nasal mucosa showed several ultrastructural changes. These included patchy loss of cilia, generalized loss of cilia, squamous metaplasia, hyperplasia of goblet cells and seromucinous acini, and vascular congestion. More severe changes were observed with longer passive exposures to cigarette smoke. The study did not disclose any evidence of ongoing allergic reaction or neoplastic transformations. Conclusions: Children exposed to passive cigarette smoke may develop several structural changes in the respiratory nasal mucosa with subsequent negative effects on its ciliary activity and mucociliary function. As a result of these effects, defense mechanisms of the nose may be ruined or lost, and those children may develop persistent sinonasal infections. Exposure of these children to passive smoking for longer periods of time may also induce other significant changes that were not detected in the present study.

Background The reported incidence of inverted papilloma of the sinonasal areas is 0.5–4% of all primary nasal tumours. Aggressive surgical approaches and endoscopic sinus techniques have been used as the main line of management. Study design To evaluate 30 cases of inverted papilloma as regarding their clinical and radiological findings, as well as the use of the extended sublabial vestibulotomy (ESV) approach in their management. Results The age average was 56.13 years with male prevalence. The lateral nasal wall and nasal cavity were involved in all the cases. The individual sinuses were involved to a variable extent. All patients treated by extended sublabial vestibulotomy with endoscopic assistance whenever indicated with no significant complications or recurrence. Conclusion ESV approach is ideally for extensive benign lesions in the sinonasal areas; as well, it enables the access to the nasopharynx. It can be considered as a feasible approach.

Background Scleroma is a chronic granulomatous condition that particularly affects the nose in all patients and the larynx in fewer patients, and less often the trachea and bronchi. Study design Analysing the clinical and imaging data of 48 patients’ scleroma. Results Forty-eight scleroma patients were included. Their age ranged from 17 to 60 years. There was female predominance. Patients presented with laryngeal and tracheal symptomatologies were more common than nasal symptomatology. Combined nasal with laryngeal affection exhibited the most frequent occurrence. Radiologically, a new pattern of involvement of the trachea fits the description of cribriform tracheitis. The commonest naked eye appearance was fibrosis, granuloma and to a lesser extent atrophy and crusting. Conclusion A change in the pattern of presentation and regional involvement in scleroma dictated the need for a change of its name and our awareness.

Endoscopic coagulation of the sphenopalatine artery (SPA) is indicated in patients with recurrent or severe posterior epistaxis. The present work aimed at studying the effects of the sphenopalatine artery coagulation on the nasal seromucinous glands. The study was carried out on 30 patients who were scheduled for endoscopic SPA coagulation. All patients signed informed consents that were approved by the Committee of Medical Ethics. Minute punch biopsies were taken from the inferior turbinates, under local anesthesia, just before the procedure as well as 12 weeks and 1 year postoperatively. The biopsies were stained with hematoxylin and eosin and PAS Alcian blue. Histochemical examination was done for the activity of the succinic dehydrogenase, alkaline phosphatase and cholinesterase enzymes. Morphometric analysis as well as analysis of the histological and histochemical results showed that SPA coagulation was followed by an early decrease in the size, number and secretory activity of the nasal seromucinous glands, which was associated with decreased activity of the alkaline phosphatase enzyme in the endothelial cells of the nasal blood vessels and decreased activity of the cholinesterase enzyme in the cholinergic nerve fibers. These changes, however, were temporary and reversible since examination of the late postoperative biopsies, at 1 year, showed normalization of the number, appearance, and histochemical activity of the glandular acini as well as the surrounding blood vessels and cholinergic nerve fibers.

Introduction:The term septal body refers to a thickened area of the nasal septum which is located superior to the inferior turbinate and anterior to the middle turbinate. Despite its important role in changing nasal airflow resistance, it has received little attention. Clinically, a well developed septal body may be misdiagnosed as high septal deviation.Aim:The aim of the present study was to reassess the histological characteristics of the septal body mucosa and the morphometric differences between it and the adjacent septal mucosa. This information was then used to determine the exact location and surface area of the septal body.Materials and methods:The study was performed on 30 cadaveric specimens (60 sides). Serial numbered sections of the whole septal mucosa were stained with haematoxylin and eosin as well as periodic acid Schiff – Alcian blue. Morphometric analysis was performed to determine the histological differences between the septal body mucosa, the anterior septal mucosa and the inferior septal mucosa. The precise boundaries of the septal body area were then defined in a manner similar to the Mohs micrographic surgical technique.Results:The histological characteristics of the septal body mucosa included thick (more than 60 µm), pseudostratified, ciliated respiratory epithelium with goblet cells, abundant seromucinous glands and many blood sinusoids. Morphometric analysis showed that the septal body mucosa had thicker epithelium and more glandular acini and blood sinusoids than the rest of the septal mucosa. Mapping of the septal body area showed that its anterior end was 2.2 ± 0.3 cm (mean ± standard deviation) behind the caudal edge of the septal cartilage, and its inferior border was 1.1 ± 0.2 cm above the floor of the nose. The mean horizontal diameter of the septal body was 2.0 ± 0.15 cm, and the mean vertical diameter was 1.5 ± 0.11 cm.Conclusions:The present study determined the morphometric characteristics of the septal body as well as its location and surface area. The intimate relationship of the septal body to the internal nasal valve and the histological characteristics of its mucosa should stimulate research into its potential role in modifying nasal airflow pattern and resistance, and its role in changing the humidity and temperature of the inspiratory air stream.

Introduction:Coblation tonsillectomy is a relatively recently introduced surgical technique which attempts to bridge the gap between ‘hot’ and ‘cold’ tonsillectomy methods.Aim:To compare coblation tonsillectomy with three commonly used surgical techniques: cold dissection–ligation, monopolar electrocautery and CO2 laser.Materials and methods:A prospective, randomised, double-blinded clinical trial was undertaken of 60 adult patients divided into three equal study groups. Patients in each group were randomly assigned to have one tonsil removed with coblation and the second with one of the other three tonsillectomy techniques. Ten randomly selected tonsils resected by each method were sent for histopathological evaluation.Results:Coblation was significantly faster to perform than laser and produced significantly less intra-operative blood loss than both the dissection–ligation and laser techniques. Subjective visual analogue scale comparisons showed a non-significant pain score difference between coblation and dissection–ligation on most post-operative days. Coblation produced consistently highly significantly (p p = 0.001) or laser (p = 0.003).Conclusions:In adult patients, coblation tonsillectomy offers some significant advantages in terms of post-operative pain and healing, compared with other tonsillectomy techniques.

In our previous studies on nasal conditioning, we observed a large variability among individuals to condition inspired air. Although we previously investigated various physiological parameters (age, sex, nasal mucosal temperature, heart rate, blood pressure, and nasal volume) that might underlie these differences, we have been unable to explain this variability. Many proteins and molecules, which are under genetic control and could affect nasal conditioning, are involved in water transport,. In this study, we hypothesized that familial factors may contribute to the differences in nasal conditioning capacity (NCC). We performed a prospective study of 47 sibling pairs. Cold dry air was delivered to the nose, and the total water gradient (TWG) was calculated to determine the NCC. We found a highly significant intraclass correlation of 0.53 ( P < 0.0001) between sibling pairs for the TWG. These results suggest that there is a familial basis for nasal conditioning and a large enough genetic component to search for genes explaining the observed correlation.

The anatomy of the sphenoid sinus, as it relates to endoscopic sinus surgery, was studied in 93 cadaver heads (186 sphenoid sinuses) using endoscopic dissections as well as sagittal sections. The relationship of the sphenoid sinuses to the carotid artery, optic nerve, floor of sella turcica, as well as other important structures, were verified and discussed. The recesses of the sinus as well as its ostium and accessory septa and crests were described and their clinical importance was discussed. Pertinent measurements were included wherever appropriate.

Endoscopic Repair of Nasal Septal Perforations Using Modified Pedicled Inferior Turbinate Flap Background: Septal perforations are usually difficult to treat. Surgery is indicated if the perforation is symptomatic. Our aim is to evaluate endoscopic closure of nasal septal perforation using pedicled inferior turbinate flap. Patients and Methods: Endoscopic closure of nasal septum perforations were performed in 31 patients using unilateral pedicled inferior turbinate flap. Results: Twenty-three patients (74%) had complete closure of their perforations. Six other patients (19.5%) had incomplete closure with a small residual perforation< 1cm in diameter posteriorly. Two patients (6.5%), who had previous submucosal diathermy of the inferior turbinate, had flap necrosis with complete failure of the repair. There was a significant inverse relationship between the diameter of the perforation and the success of the repair. Conclusions: Endoscopic repair of nasal septal perforations, up to 2 cm in diameter, using a modified pedicled inferior turbinate flap, is a feasible technique that offers acceptable success rates due to the remarkable vascularity and thickness of the flap. The use of endoscopes allowed more precise a traumatic elevation of the flap posteriorly. The present technique differs from other previously described flap procedures in that it extends the posterior dissection to include a part of the mucosa of the inferior meatus in order to allow more free un-constrained rotation of the flap, and decrease the thickness of the pedicle so that we may not need to divide it in a second stage. This step would have been more difficult and less precise without the use of the endoscope. Previously operated turbinates are not suitable for this technique. Also the procedure may not be suitable if the perforation is very anterior or larger than 2 cm in diameter.

Ten patients with chronic non-allergic rhinitis and presenting mainly with nasal obstruction due to hypertrophied inferior turbinates were subjected to laser turbinectomy using CO2. Tiny biopsies were taken, at the time of surgery as well as one monthlater, and were processed for transmission electron microscopy. The ultrastructural observations included: early epithelial loss which wasfollowed by prompt regeneration of healthy epithelium, decreased number and activity of the seromucinous glands, fibrosis of the connective tissue stroma, as well as diminished number and congestion of the cavernous blood spaces. These observations were discussed in view of the excellent clinical response of the patients.

Obstruction of the nasal valve is an important cause of chronic nasal obstruction in adults. In a series of 500 patients, obstruction at the level of the nasal valve was diagnosed in 65 of them (13 per cent). The obstruction was unilateral in 57 patients (88 per cent). Forty-seven patients (72 per cent) had history of previous nasal surgery of accidental trauma. Causes of obstruction of the nasal valve included high septal deviations, a weak or deformed upper lateral cartilage, adhesions, and alar collapse. All patients underwent corrective nasal surgery and the surgical procedures were tailored according to the existing pathology. Post-operatively, the mean nasal patency score increased from 2.9 to 8.6, the mean nasal airflow increased from 579.5 to 727 cm/sec (at 150 Pa), and the mean nasal resistance decreased from 0.31 to 0.23 Pa/cm3sec-1.

Introduction: The New Zealand White (NZW) rabbit model is commonly used for the research of posterolateral intertransverse lumbar arthrodesis. The standard approach reported by many researchers are a muscle splitting approach through the intermuscular plane between multifidus and longissimus muscles. Methods: In this research the fusion bed was exposed by retracting the three groups of paraspinal muscles (multifidus, longissimus and iliocostalis) medially. Results: This alternative method showed good exposure of the transverse processes and intertransverse membrane with less bleeding from the muscles observed. No death due to surgical complication was observed out of twenty-four rabbits operated. Conclusion: An easy and safe method for performing posterolateral intertransverse lumbar arthrodesis was demonstrated and recommended as an alternative approach for surgery on New Zealand White rabbits.

Purpose The objective of the study was to evaluate the accuracy of endoscopically directed middle meatal cultures in the diagnosis of bacterial sinusitis in intensive care unit (ICU) patients in comparison with computed tomographic (CT) scans. Patients and Methods The study was conducted at Alexandria University Hospitals on 51 ICU patients with occult fever and clinical signs suggestive of sinusitis. Sinus CT scans were done for all patients, and Calgi swabs were obtained from the middle meatus bilaterally under endoscopic vision using sterile endoscopes with avoidance of any contamination of the swabs. The results of middle meatal cultures were compared with the results of CT scans. Results Radiologic signs of sinusitis were bilateral in 10 patients (19.6%), unilateral in 31 patients (60.8%), and negative in 10 patients (19.6%). Middle meatal swabs yielded positive cultures on both sides in 13 patients (25.5%) and on one side in 27 patients (52.9%). On the other hand, the cultures were negative in 11 patients (21.6%). Middle meatal cultures had a sensitivity of 92.8%, a specificity of 80.0%, and an accuracy of 90.2% in comparison with CT scans. Polymicrobial colonization was more frequent than monomicrobial colonization. The organisms isolated most frequently were coagulase-negative staphylococci, Staphylococcus aureus, and Pseudomonas aeurginosa. Of 47 patients with actual or previous intubation, 38 (80.9%) had positive cultures. In addition, 92.3% of patients with unilateral positive cultures acquired sinusitis on the same side of previous intubation. Conclusions The data of the present study indicated that endoscopically directed middle meatal cultures had high positive and negative predictive values and accurately diagnosed bacterial sinusitis and identified the causative bacteria with high sensitivity and specificity in comparison with the criterion standard CT scans. The procedure is simple, noninvasive, and can be easily performed at the bedside without discomfort or morbidity. Based on our data, the procedure can be considered as a trustworthy substitute to sinus CT scans in ICU patients especially when it is difficult to transport the patients for imaging. Computed tomographic scans can, therefore, be reserved for patients who do not respond to culture-specific antibiotherapy. A further advantage of this approach is avoidance of the cumulative effect of unnecessary radiation. The study also confirmed the role of nasogastric and nasotracheal intubation in the pathogenesis of ICU sinusitis.

Objective:To assess the correlation between bacterial pathogens in the adenoid core and the middle meatus, in children with hypertrophied adenoids and chronic or recurrent sinusitis.Design:The study was conducted at Alexandria University Hospitals. We included 103 children aged four to 12 years who were scheduled for adenoidectomy and who had clinical and/or radiological evidence of chronic or recurrent sinusitis. Adenoid core specimens and middle meatal swabs were obtained from every patient and were sent for bacteriological evaluation using standard qualitative and quantitative microbiological techniques. The results were statistically analysed.Results:The bacterial species isolated most frequently from the adenoid core were coagulase-negative staphylococci (40.8 per cent),Staphylococcus aureus(22.3 per cent),Streptococcus pneumoniae(18.4 per cent),Haemophilus influenzae(16.5 per cent) and group A streptococci (15.5 per cent). The bacterial species isolated most frequently from the middle meatus were coagulase-negative staphylococci (41.7 per cent),S aureus(32 per cent),S pneumoniae(28.1 per cent),H influenzae(21.6 per cent) and group A streptococci (19.4 per cent). The adenoid core and middle meatal cultures were both positive for at least one bacterial species in 63 cases, and were both negative in 25 cases. In six cases, a positive adenoid core culture was associated with a negative middle meatal culture. In five cases, a negative adenoid core culture was associated with a positive middle meatal culture (for one or more pathogenic species). Thus, adenoid core culture had a positive predictive value of 91.5 in forecasting the middle meatal culture result, and a negative predictive value of 84.3.Conclusion:Apart from its effect on nasal airway patency, adenoidal tissue may function as a bacterial reservoir initiating and maintaining sinus infection in children. These study findings support a potential role for adenoidectomy in the treatment of chronic or recurrent paediatric sinusitis.

Objective:To establish normative dimensions for the depth of the olfactory fossa, the length and angulation of the lateral lamella of the cribriform plate, and the height of the ethmoid roof, in adult males and females.Design:The study assessed 300 high resolution, multislice computed tomography scans of the paranasal sinuses, which were evaluated using Merge Efilm software (version 2.0.0, build 37).Results:According to the original Keros classification, the type II olfactory fossa was the commonest type in men (66.7 per cent), while the type I fossa was commonest in women (53 per cent). A difference of 3 mm or more between the depths of the right and left olfactory fossae was present in 11 per cent of men and 2 per cent of women. The lateral lamella of the cribriform plate was significantly shorter and less oblique in men than in women. The length of the lateral lamella was greater anteriorly than posteriorly in both sexes. There was a statistically significant difference between the angle of the lateral lamellae, comparing right and left sides. The ethmoid roof was lower in women than men.Conclusion:The observed differences between men and women and between the right and left sides are of surgical importance, and should alert surgeons to the need for thorough, systematic pre-operative evaluation of computed tomography scans.

As yet, there is no totally satisfactory means for treating hypertrophied turbinates and the proper management of turbinate dysfunction remains in question. In the present series, four of the widely practiced surgical procedures for the reduction of the size of the inferior turbinates were evaluated and compared. In all cases turbinectomy was performed as an isolated procedure. Eighty patients with chronic non-allergic rhinitis and hypertrophied inferior turbinates were selected, randomly divided into four groups, and followed up post-operatively for one year. Study of the results indicated that the beneficial effect of the operation is mainly mechanical by reduction of the resistance to nasal airflow. The post-operative improvement in smell acuity correlated positively with the increased patency of the nasal airway. None of the procedures had a deleterious effect on olfactory acuity. In contrast, the operation failed to enhance the mucociliary clearance rate or significantly decrease nasal drainage. Partial inferior turbinectomy and laser turbinectomy improved nasal breathing in 77 per cent of patients, and enhanced olfactory acuity in 78 per cent of patients who had pre-operative hyposmia. The results of turbinoplasty and cryoturbinectomy were less favourable. The surgical technique, advantages, and drawbacks of each of these procedures are discussed.

The goal of the present work was to investigate possible risk factors for the poor response of some cases of chronic sinusitis to endoscopic sinus surgery in spite of the precision of the surgical technique. Eleven adult patients who were scheduled for revision endoscopic sinus surgery underwent a complete allergy workup. At the time of surgery, a tiny biopsy was taken from the maxillary sinus mucosa close to the middle turbinate. The specimens were processed for histochemical and transmission electron microscopic examination. Six patients (55 per cent) proved to be allergic. Their sinus mucosa showed eosinophilic infiltration (6.1 cells/mm(2)), and mast cell degranulation. This proves that allergens can reach the sinus mucosa and have a direct impact on it. Another three patients (27 per cent) were non-allergic but exhibited mucosal eosinophilia (5.0 cells/mm(2)), and two of them showed mast cell degranulation. These patients were diagnosed as having nonallergic rhinosinusitis with eosinophilia (NARSE). The nasal mucosa of the remaining two patients did not reveal any characteristic pathological findings, and no pathologic diagnosis could be established for them. None of the patients showed electron microscopic evidence of purulent inflammatory changes, and the bacterial cultures recovered normal respiratory flora in nine patients (82 per cent). The present research spotlights the importance of allergy and nonallergic eosinophilic infiltration of the mucosa as possible risk factors that may degrade the results of endoscopic sinus procedures and discusses some pertinent pathological and clinical aspects.

The ultrastructure of the mucosa of the eustachian tube was studied in four temporal bones showing tympanosclerosis, cholesteatoma, otitic meningitis and a grafted tympanic membrane (tympanoplasty). The mucosa of tube was abnormal in the four cases confirming the relationship between the state of the eustachian tube and the inflammatory process in the middle ear. The observed abnormalities included: ciliary loss, abnormal ciliary morphology and motility, oedema of the microvilli, hyperplasia of the goblet cells and the seromucinous acini, desquamation of the non-ciliated cells and appearance of mast cells in the lamina propria of the tube. Ciliary changes were the most frequent abnormalities and the morphological changes, in general, were fewest in the case of healed tympanoplasty. The pathophysiology of the morphological changes was discussed and correlated with the disease in the middle ear.

The fine structure of the human tertiary syphilitic nasal mucosa was studied in 5 patients. The epithelium showed variations in thickness, loss of cilia, irregular cell contours, widened intercellular spaces, rare goblet cells. The seromucinous glands were in three forms. The arterioles and capillaries varied in relation to the pathology of the surrounding tissue. The venules were least affected. The stroma was infiltrated by macrophages, plasma cells with some areas having excessive fibrosis and others partially necrotic. These findings were correlated to the histochemical reactions. Scattered Treponema pallidum were seen, demonstrating the blood-borne dissemination and the infective nasal secretions.

Partial surgical closure of the nostril was performed in 20 patients suffering from primary atrophic rhinitis, and the effect of the operation on the ultrastructure of the nasal mucosa was studied and analyzed. It was concluded that the operation has a beneficial effect on the nasal mucosa and reverses the basic pathologic alterations in its microanatomy.

The authors present their experience with pneumatic nasal catheters in cases of epistaxis. Among the advantages of this method over tamponade with petroleum jelly-covered gauze are: Effective tamponade without causing hypoxia, carbon dioxide retention or additional loading of the cardiopulmonary system; Less need for sedation; and Easy application and removal. Conversely, its most important adverse effect is the possibility of pressure necrosis of the nasal mucosa and nasal septum. This can be greatly reduced by considering a few technical recommendations.

The ultrastructure of the respiratory nasal mucosa of patients suffering from vasomotor rhinitis was studied and compared with the reported ultrastructural findings in cases of chronic perennial allergic rhinitis. The principal ultrastructural differences were the absence of interendothelial gap junctions, the scarcity of eosinophils and plasma cells, and the absence of immunologically stimulated or degranulated mast cells in vasomotor rhinitis. These differences were discussed in the light of the known pathophysiologic facts.

The larynges of 30 unmated, mature female albino mice were examined histologically and histochemically after injecting them with 19-nandrolone phenylpropionate. Permanent irreversible changes, in the form of parakeratosis and squamous metaplasia of the epithelium, and hypertrophy of the muscle fibers, were observed together with persistence of increased alkaline phosphatase enzyme intensity in the endothelium of capillaries and increased activity of nonspecific esterase in the muscles. Similar changes may be responsible for the alteration in the human female's voice after prolonged treatment with anabolic steroids.

• We studied the effects of topical dinoprostone on the nasal blood vessels of patients with allergic rhinitis. The outstanding changes noted were constriction of the arterioles and capillaries (to a lesser extent) and tight closure of the interendothelial junctions. These changes caused a diminution of nasal blood flow and edema fluid formation, a reduction in the size of the turbinates, and consequently, an increase in nasal patency. However, dinoprostone had no effect on the nasal venules. ( Arch Otolaryngol 1983;109:815-817)

The present investigation examines the effects of sickle cell crisis on peripheral auditory function and auditory brainstem response (ABR). The study includes 10 homozygous sickle cell anemia patients with documented sickle cell (SS) hemoglobin. Testing was performed during the crisis and 1 month after it subsided. Unilateral high frequency hearing loss was found in three patients but persisted in only one of them. Abnormal ABR tracings occurred in four patients but reversed to normal in one of them. The study suggests a trend toward increased incidence of sensorineural hearing loss (SNHL) and ABR changes as frequency and severity of crisis episodes increases. The relationship between SNHL and ABR is analyzed and discussed.

(Al Khobar, Saudi Arabia)IntroductionWaters' view was developed by Waters and Waldron in 1915 as a modification of theoccipito-frontal projection. It was essentially designed to provide a view of themaxillary sinus unobstructed by the petrous bone, and it has been regarded as thebest single view for the maxillary sinuses (Merriel, 1959; Yanagisawa and Smith,1976; Dodd and Jing, 1977). Since that time Waters' view has been the subject ofconflicting opinions, and few investigations have been carried out to assess itsdiagnostic capabilities. Almost all of the previous investigations consisted of com-paring the results of roentgen examination and antral lavage, ultrasonic examin-ation or sinoscopy (Vuorinen et al., 1962; Axelsson et al., 1970; Ilium et al., 1972;Revonta, 1980 Janner; t et al., 1982; Kay etal., 1984). On the other hand, no one hasyet compared the predictive accuracy of Waters' view with the operative findings inthese cases.The aim of the present investigation is to establish the relevance of the differentradiographic signs displayed on Waters' view in diagnosing chronic bacterial maxill-ary sinusitis and to determine to what degree these signs can reflect real sinusdisease. The shortcomings of the view will be exposed, and factors affecting thecorrectness of the radiographic evaluation of the disease will be demonstrated anddiscussed.Material and Methods research project; and second by strictly adopt-I—The first part of this work was aimed at ing an optimal technique that gives highstudying the normal radiographic appearance quality Waters' view radiographs. This tech-of the maxillary sinus in Waters' view, identi- nique consisted of taking the Waters' projec-fying the limits of normal, and finding out the tion (occipito-mental projection) in the sittingpossible causes of a false positive radiographic position with the orbitomeatal line at an anglediagnosis of chronic maxillary sinusitis. of 40° to the plane of the film. The centreThe material of this part consisted of 100 beam was directed perpendicularly throughnormal asymptomatic subjects, who kindly the junction of the nose and upper lip. Theaccepted participation in the present radiographic tube had a fine focal spot andresearch, having a mean age of 25 years (range a rotating anode. Film-target distance was10-52 years). All of them underwent 90 cm. and the Potter-Bucky diaphragm withradiologic examination twice: first by random a small cone was used for all cases. The tworadiologists who were given no clues about the radiographs of each patient were compared.This work has been done in Dr. Fakhry Hospital, Al Khobar, Saudi Arabia.1233

Histochemical examination of lactic dehydrogenase enzyme activity was used to detect the effect of certain factors on the viability of cartilage autografts in the middle ear. The study shows that the presence of perichondrium on both sides of the strut and placing the lateral end of the strut increase the chance of survival of chondrocytes. On the other hand, middle ear infection has a very bad effect on the viability of chondrocytes. The length of the strut and the presence of silastic film in the middle ear have been found to be unimportant as far as the survival of the graft is concerned.

The respiratory nasal mucosa of patients with scleroderma showed several ultrastructural and histochemical changes. These included initial goblet cell hyperplasia, loss of cilia and microvilli, exfoliation of the superficial epithelial layers, increased glandular activity in cases with squamous metaplasia and fibrous tissue deposition in the lamina propria. These changes seem to be related to the duration of the disease, whose nature and pathogenesis are still uncertain.

The irradiation-induced changes in the middle ear mucosa of six patients were described and discussed. The epithelium showed marked reduction of the cytoplasmic mass, variable degrees of ciliary loss and widening of the intercellular spaces with disruption of some of the maculae adherentes. The connective tissue stroma showed increased production of collagenous fibrous tissue and increased number of synthetically active fibroblasts. New gland formation has been observed and the glands exhibited reduced activity. The endothelial cells of some blood capillaries were swollen and the basal lamina was duplicated. The lumina of other capillaries were completely obliterated and replaced by a cord of fibrous tissue.