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Yun-Chen Chang,1 Ta-Jen Lee,1 Chi-Che Huang,1,2 Po-Hung Chang,1,2 Yi-Wei Chen,1 Chia-Hsiang Fu1,2 1Department of Otolaryngology-Head and Neck Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, 333, Taiwan; 2Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan City, 333, TaiwanCorrespondence: Chia-Hsiang FuDivision of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Linkou Chang Gung Memorial Hospital and Chang Gung University, No. 5 Fu-Shin Street, Guishan District, Taoyuan City, 333, TaiwanTel +886-3-3281200, ext.: 8465Fax +886-3-3979361Email fufamily@adm.cgmh.org.twBackground: Screening for the existence of aeroallergens in patients with possible allergic rhinitis using venous blood samples has become more popular, with advantages of increased convenience and less consumption of time.Objective: The aim of this study was to investigate the sensitivities and specificities of Phadiatop tests and total immunoglobulin E (IgE) levels in both adults and children.Methods: This study was conducted prospectively in a tertiary center. The process of recruitment took place from Jan 2015 to Dec 2019, and patients with clinical symptoms that suggested persistent allergic rhinitis were recruited and their serum samples collected. The results of the total IgE and Phadiatop tests as well as the positive items in the ImmunoCAP assay were recorded and analyzed.Results: A total of 9174 cases with complete data were enrolled, including 576 children and 8598 adults. A positive result in the ImmunoCAP assay was considered a positive atopic status towards aeroallergens. While using the total IgE levels to predict positive aeroallergens, the sensitivities and specificities were 65.7% and 85.7%, respectively, for adults and 86.3% and 77.4%, respectively, for children. When we used Phadiatop tests for allergy screening, the sensitivities and specificities was 94.5% and 98.2%, respectively, for the adult group and 98.5% and 96.8%, respectively, for the pediatric group.Conclusion: The Phadiatop test had better diagnostic power for aeroallergen detection than the serum total IgE levels, or even the dual test, for both the adult and pediatric groups in this hospital-based study. We suggest that the Phadiatop test is more cost-effective in aeroallergen screening for patients with suspected atopic airway diseases.Keywords: Phadiatop test, ImmunoCAP, total immunoglobulin E, IgE, aeroallergens

Introduction Most patients with asthma, either allergic or non-allergic, usually exhibit some level of concurrent rhinitis. Treatments for rhinitis and asthma can affect both conditions. Objective The present study aimed to examine asthma-specific outcomes in patients with chronic rhinitis (CR) and asthma after surgery for nasal obstruction, and to identify the patient group most likely to experience improved asthma control after surgery. Methods Asthmatic patients with CR and nasal obstruction were prospectively recruited for evaluations of nasal and asthma-specific outcomes before and after surgery for nasal obstruction. Results Twenty-eight participants were enrolled. There was a significant association between the Asthma Control Test (ACT) and the Sino-Nasal Outcome Test-22 scores, both at the preoperative and 3-month postoperative assessments. Patients demonstrating ACT improvement after nasal surgery had worse preoperative ACT scores and predicted forced expiratory volume in 1 s. Conclusion Nasal symptom severity was closely associated with the extent of asthma control in asthmatic patients with CR and nasal obstruction. Assessment of CR and nasal obstruction in patients with poorly controlled asthma should be considered an essential approach to improve the response to treatment and patients' quality of life.

Purpose A near-infrared spectroscopy system was developed to evaluate peripheral arterial occlusive disease (PAOD). The wireless device can take measurements when patients are doing rehabilitation exercise. Methods Two LED modules with wavelengths of 740 nm, 808 nm and 850 nm were placed over 32 mm away from the photodiode to detect the deep backscattering from muscle tissue. The absorbance difference from the extent of tissue oxygenation was extracted using a modified Beer’s law. Measurements taken on different muscle groups were applied to determine which branch of artery is occluded. Results The changes in oxygenation of gastrocnemius and tibialis anterior muscle were recorded when PAOD patients were riding a stationary bicycle. The drop in oxygenation with exercise generally should recover within 15 min of continuing exercise. Otherwise, the artery is not capable to provide enough blood supply to the exercising muscles. Since gastrocnemius is the primary muscle used in biking exercise, the compensatory vasodilation in gastrocnemius leads to hypoperfusion in tibialis anterior muscle. Conclusion This NIRS system is helpful for detecting the changes in tissue oxygenation during exercise. Muscle hypoxia was more obvious during exercise when the artery had some degree of occlusion.

With the broad indications for dental implantation, complications rates have increased. Dental implant displacement into the maxillary sinus, although rare, can occur during the restoration of maxillary posterior teeth. We performed a 6-year retrospective review and found 3 cases with displaced implants in the maxillary sinus. Detailed information, including surgical indications and dental implant removal methods, is provided. Dental implants can be dislocated to the maxillary sinus perioperatively or postoperatively. Endoscopic sinus surgery can be performed to remove the implant and restore sinus patency. If the implant is displaced to deeper areas (commonly anterior and inferior) of the maxillary sinus, a prelacrimal recess approach can provide a panoramic view of the maxillary sinus and is a good alternative to the Caldwell-Luc operation in terms of mucosal preservation and postoperative complications.

Background: Empty nose syndrome (ENS) is a syndrome of paradoxical nasal obstruction that is thought to be mostly caused by inappropriate turbinate procedures. This study aimed to investigate depression- and anxiety-associated psychological symptoms in patients with ENS before and after surgical reconstruction, and to compare them with those of control subjects. Methods: Patients with ENS were prospectively enrolled. The Sino-Nasal Outcome Test-25 (SNOT-25), Empty Nose Syndrome 6-item questionnaire (ENS6Q), Beck Depression Inventory-II (BDI-II), and Beck Anxiety Inventory (BAI) were used to evaluate the participants before and after reconstruction surgery with submucosal Medpor implantation (Stryker, Kalamazoo, MI), as well as control subjects at enrollment. Results: Forty patients with ENS and forty age- and sex-matched controls were recruited. Patients with ENS experienced significant improvement in SNOT-25, ENS6Q, BDI-II, and BAI scores after surgery, but all were significantly greater than those in the control group. Nine patients with ENS (22.5%) had postoperative residual psychological symptoms. Preoperative BDI-II and BAI scores were significant predictors of postoperative residual psychological symptoms. The optimal cut-off value was BDI-II > 28.5 (sensitivity, 77.8%; specificity, 77.4%) in receiver operating characteristic curve analysis. Conclusions: The nasal and psychological evaluations in patients with ENS significantly improved after nasal reconstruction surgery, but both were significantly greater than those in the control group. Identifying individuals who may experience postoperative residual symptoms and providing a multimodal approach, including surgical reconstruction and psychiatric treatment, are suggested.

Simple Summary Chronic rhinosinusitis (CRS) is a common treatment complication in patients with nasopharyngeal carcinoma (NPC) after radiotherapy. In this study, we aimed to investigate the incidence and severity of CRS in NPC patients who underwent intensity-modulated proton therapy (IMPT) by evaluating the sinus mucosa change in imaging studies, and we compared these patients with those who underwent volume-modulated arc therapy (VMAT). This was a retrospective case–control study in which 53 and 54 patients were treated with IMPT and VMAT, respectively. We noted that patients in the IMPT group had a significantly lower incidence and decreased severity of sinus mucosa abnormality than those with VMAT. Better and faster recovery of sinonasal function after radiotherapy in the IMPT group was also observed. IMPT techniques deposit the bulk of their radiation doses in highly confined areas, allowing lower exposure of non-target organs during irradiation, which results in more sinonasal mucosa being retained. Abstract In the past decade, patients with nasopharyngeal cancer (NPC) have been deemed candidates for proton radiotherapy, due to the large and comprehensive target volumes and the necessity for the retention of the surrounding healthy tissues. In this study, we aimed to compare the incidence and severity of post-irradiation sinusitis by detecting sinus mucosa diseases (SMDs) via the magnetic resonance imaging (MRI) of patients with NPC after intensity-modulated proton therapy (IMPT) and volume-modulated arc therapy (VMAT). A total of 53 patients in the IMPT group and 54 patients in the VMAT group were enrolled in this study. There were significantly lower endoscopic scores and Lund–Mackay staging scores determined from MRI scans in the IMPT group during different follow-up periods. For the most vulnerable sinuses, the incidence and severity of SMD were the highest during the third post-radiotherapy month in both groups. These decreased steadily, and there was no significant increase in the incidence and severity of SMD during the second post-radiotherapy year in the IMPT group. Our data show that NPC patients with IMPT have a significantly lower incidence and decreased severity of SMD than those with VMAT. A better and faster recovery of sinonasal function after radiotherapy in the IMPT group was also observed.

Although cases of empty nose syndrome (ENS) are not very common, the suffering that ENS causes patient is immense and could be very difficult to imagine. Nasal nitric oxide (nNO) is an airway disease biomarker, and its levels increase after endoscopic sinus surgery. The trend of nNO levels in ENS before and after surgical treatment remains unknown. This study aimed to evaluate the role of nNO in ENS.Patients with ENS who received surgical implantation and with chronic hypertrophic rhinitis (CHR) who underwent turbinoplasty and completed at least 1 year of follow-up were prospectively enrolled. nNO measurements and subjective assessments [SinoNasal Outcome Test (SNOT)-22, Beck Depression Inventory (BDI)-II, and Beck Anxiety Inventory (BAI)] were performed preoperatively and at 3, 6, and 12 months postoperatively.We enrolled 19 ENS and 12 CHR patients. nNO levels were significantly lower in the ENS than in the CHR patients before surgical treatment (p 0.001). nNO levels in the ENS patients significantly increased 3 months after implantation and remained plateaued (p = 0.015). BDI-II and BAI scores significantly improved after surgical treatment for the ENS patients but not for the CHR patients; changes in nNO levels correlated well with improvements in BDI-II and BAI scores (p = 0.025 and 0.035, respectively).nNO significantly increased at third month after surgical treatment and remained plateaued in ENS patients. This increase correlated with improvements in BDI-II and BAI scores. Therefore, nNO may be important in assessing the psychiatric status of empty nose syndrome.

Background: To screen the existence of aeroallergens in patients with possible allergic rhinitis by venous blood becomes more popular, with advantages of more convenient and less consumption of time. The aim of this study is to investigate the sensitivity and specificity of Phadiatop test and total immunoglobulin E (IgE) level examination in both adults and children groups.Methods: This study was conducted prospectively in a tertiary center. The process of recruitment took place from Jan 2015 to Dec 2019, and patients with clinical symptoms suggesting of persistent allergic rhinitis were recruited and their serum samples were collected. The results of total IgE levels, Phadiatop tests, and the positive items in the ImmunoCAP assay were recorded and analyzed.Results: Total 9174 cases with complete data were enrolled, including 576 children and 8598 adults. A positive result in the ImmunoCAP assay was defined to confirm a positive atopic status towards aeroallergens. While using the total IgE level to predict positive aeroallergens, the sensitivity and specificity were 65.7% and 85.7% for adults and 86.3% and 77.4% for children, respectively. If we applied Phadiatop test for allergy screening, the sensitivity and specificity was 94.5%, 98.2% and 98.5%, 96.8% for the adult and the pediatric group, respectively.Conclusions: Phadiatop test had a better diagnostic power for aeroallergen detection than the serum total IgE level, or even the dual test, for both the adult and pediatric groups in this hospital-based study. We suggest that the Phadiatop test is more cost-effective in aeroallergen screening for patients suspected of atopic airway diseases.

OBJECTIVES /HYPOTHESIS Empty nose syndrome (ENS) is a complicated condition currently thought to be caused by excessive surgical resection of turbinate tissue. Patients with ENS experienced significant psychological symptoms, such as depression and anxiety. This study aimed to evaluate the impact of the psychological burden on the surgical outcome of ENS. STUDY DESIGN Prospective case series in a tertiary medical center. METHODS Patients with ENS were prospectively recruited between 2015 and 2018. Validated instruments including the Sinonasal Outcome Test-25 (SNOT-25), Beck Depression Inventory-II (BDI-II), and Beck Anxiety Inventory (BAI) were used to evaluate patients with ENS prior to and 3, 6, and 12 months after nasal reconstruction surgery with submucosal Medpor implantation. RESULTS A total of 54 ENS patients were enrolled during the study period. All three evaluations revealed significant improvement, and symptoms stabilized 3 months after surgery. Six months post-operatively, SNOT-25 scores were significantly associated with the pre-operative BDI-II and BAI scores (β = 0.64 and 0.87; P = .006 and

Objectives To determine a paradigm for evaluating and managing maxillary sinus conditions before dental implantation via preoperative sinonasal assessment. Study Design Prospective cohort study. Methods Eighty-four patients who underwent dental implantation with or without sinus augmentation were included. Maxillary sinus conditions were classified into groups 1 to 6 according to cone-beam computed tomography (CT) findings: 1) nonspecific findings, 2) solitary polyp or cyst, 3) mucosal thickening, 4) air–fluid level or fluid accumulation, 5) near-total opacification of the maxillary or other paranasal sinus, and 6) calcification spots in the maxillary sinus. Dental implantation with or without sinus augmentation was suggested with postoperative sinus observation (groups 1–3), after medication for acute sinusitis (group 4), and after comprehensive treatment of chronic or fungal sinusitis (groups 5–6). Intraoperative and postoperative sinus-related complications were recorded. Results Two patients (groups 1 and 3) developed acute rhinosinusitis after sinus augmentation; both recovered completely with medical treatment. Schneiderian membrane perforation occurred during sinus lift surgery in six patients (group 1): five recovered after conservative medical therapy and close observation, whereas one required endoscopic sinus surgery and recovered well. No chronic rhinosinusitis developed after dental implantation. Conclusion Craniofacial CT is crucial for pre-dental implantation sinonasal evaluation. The risk of dental implant-related chronic rhinosinusitis is low for patients with cysts, polyps, or mucosal thickening in the maxillary sinus. However, preventive endoscopic sinus surgery is recommended for patients with incurable chronic rhinosinusitis, fungal sinusitis, and large polyps or cysts. Level of Evidence 4. Laryngoscope, 2017

Objective/Hypothesis Endonasal submucosal implantation has been confirmed to be beneficial for patients with empty nose syndrome (ENS). However, the optimal implantation site has not been defined. This study aimed to evaluate whether lateral nasal wall implantation is superior to inferior nasal wall implantation in terms of clinical benefits and improvements in quality of life. Study Design Retrospective study in a tertiary medical center. Methods Consecutive ENS patients between 2010 and 2015 with operative histories of inferior turbinectomies and indicated for surgical implantation were enrolled, with at least 1-year follow-up. Patients were divided into lateral and inferior nasal wall groups. SinoNasal Outcome Test (SNOT)-22, Beck Depression Inventory (BDI)-II, and Beck Anxiety Inventory (BAI) were applied before and 1 year after implantation. Results Of the total 30 ENS patients analyzed, 14 were in the inferior nasal wall group and 16 were in the lateral nasal wall group. There were no significant intergroup differences in demographic data and preoperative SNOT-22, BDI-II, and BAI scores. Postoperative assessment revealed that the lateral nasal wall group had significantly better SNOT-22 score improvements than the inferior nasal wall group, particularly regarding rhinological symptoms and sleep function. Conclusion Lateral nasal wall implantation may provide significantly better clinical outcomes than inferior nasal wall implantation, and thus may be the preferred, more optimal site for implant placement in ENS patients. Level of Evidence 4. Laryngoscope, 2017

Peripheral arterial occlusive disease has a high risk to occur in the lower extremity which causes low oxygen saturation level in muscle tissue, especially after exercise. A muscle tissue oxygen saturation measurement system was developed to detect the insufficient blood supply to lower limb.

In recent years, the prevalence of peripheral arterial disease (PAD) has increased. This disease is related to arterial occlusion in the heart and brain. Many researches mentioned, measurement of muscle tissue oxygen saturation by near-infrared spectroscopy (NIRS) has a different phenomenon for normal people and patients. In order to quantify the muscle oxygen saturation measured by near-infrared spectroscopy. In this research, we use a in-house made multi-wavelength and two light-detector distances to measure the liquid phantom with adjustable oxygen saturation. LED polarizer wavelength is 740 nm, 808 nm and 850 nm. Two light-detector distances are 32 mm and 40 mm. Liquid phantom using purified red blood cell from pig blood and intralipid to mix the blood cell solution. The liquid phantom simulated lower limbs muscles optical properties. Use yeast and oxygen to change oxygen saturation in the liquid phantom and continuous measurement at the same time. Measurement result show, absorbance at 740 nm and 850 nm will change with oxygen saturation, but absorbance at 808 nm will not. In the other side, between two light-detector distances the trend of change is small. This result is consistent with the absorption spectrum of hemoglobin to calculate a calibration curve for muscle oxygen saturation quantification in a in-house made machine. In the future, it will be embedded in the signal of clinical measurement to help PAD patient’s classification. This classification will become one of the indicators for doctor diagnosis.

A potential mechanism underlying cigarette smoke-induced airway disease is insufficient tissue repair via altered production of matrix metalloproteinases (MMPs). Osteitis is a signature feature of recalcitrant chronic rhinosinusitis (CRS) and often results in revision surgery. The present study aimed to investigate MMP expression in the nasal tissues of asthmatic patients with CRS and any association with cigarette smoking and osteitis. Thirteen smokers with CRS and asthma, 16 non-smokers with CRS and asthma, and seven non-smoker asthmatic patients without CRS were prospectively recruited. The expression of MMPs and associated immunological factors in surgically-obtained nasal tissues was evaluated via real-time PCR and western blotting. Maximal bone thickness of the anterior ethmoid (AE) partition was measured in axial sinus computed tomography (CT) sections. MMP-1 and MMP-9 expression was increased in the nasal tissues of smokers with asthma and CRS via real-time PCR and western blot. Maximal AE partition bone thickness was greater in smokers with CRS and asthma than in non-smokers with CRS and asthma. MMP-1 and MMP-9 levels were correlated with maximal AE bone thickness. Cigarette smoking was associated with the up-regulation of MMP-1 and MMP-9 in the nasal tissues of patients with airway inflammatory diseases, and with AE osteitis, and with therapeutic resistence.

Objectives In the past two decades, endoscopic sinus surgery (ESS) has been performed frequently in children with medically recalcitrant chronic rhinosinusitis (CRS). However, surgical success rates vary according to age. The causes of failure and prognostic factors for revision ESS remain unclear. The aims of the present study were to evaluate prognostic factors related to revision surgery after ESS, and to determine the most optimal timing for surgery in the pediatric population. Methods This was a retrospective review in a tertiary medical center. Children who underwent ESS for CRS between 2004 and 2017 were enrolled. Demographics, sinonasal examination findings, previous operation history, laboratory data, comorbidities, and computed tomography (CT) results were collected from medical records. Prognostic factors for revision surgery were analyzed. Results A total of 188 pediatric patients were enrolled in this study. Twenty-four patients (12.8%) required revision surgery. Multivariate logistic regression analysis identified patients with nasal allergy (OR = 6.258; P = .010) and higher Lund-Mackay score on preoperative sinus CT (OR = 1.658; P = .043) had worse outcomes, while older age was a positive prognostic factor (OR = 0.702; P = .018). A cut-off point of 15.68 years of age and mean Lund-Mackay score of 10.5 showed the best predictive power for revision surgery. Conclusion Because ESS is performed with increasing frequency in children, knowledge of prognostic factors for revision surgery is important. In this study, patients with younger age, nasal allergy, and higher Lund-Mackay score on preoperative sinus CT had worse outcomes. Level of evidence 4 Laryngoscope, 130:1051-1055, 2020.

(1) Background: We compared the outcomes of patients with nasopharyngeal carcinoma treated with IMPT and VMAT. (2) Methods: We performed a retrospective propensity score matching analysis (1:1) of patients treated with IMPT (years: 2016–2018) and VMAT (2014–2018). Survival was estimated using the Kaplan–Meier method. Multivariate Cox proportional hazards regression analysis was used to identify the independent predictors of survival. Binary toxicity endpoint analyses were performed using a Cox model and logistic regression. (3) Results: Eighty patients who received IMPT and VMAT were included. The median follow-up time was 24.1 months in the IMPT group. Progression-free survival (PFS) and overall survival (OS) were not statistically different between the two groups but potentially better in IMPT group. In multivariate analysis, advanced N-stage and body weight loss (BWL, &gt, 7%) during radiotherapy were associated with decreased PFS. The IMPT group had significantly less requirement for nasogastric (NG) tube placement and BWL during treatment. The mean oral cavity dose was the only predictive factor in stepwise regression analysis, and IMPT required a significantly lower mean dose. However, IMPT increased the grade 3 radiation dermatitis. (4) Conclusions: IMPT is associated with reduced rates of NG tube insertion and BWL through reducing oral mean dose, potentially producing better oncologic outcomes.

Background Chronic rhinosinusitis with nasal polyposis (CRSwNP) remains a difficult-to-cure disease. The aim of this study was to determine the potential long-term predictors of revision sinus surgery for CRSwNP. Methods Prospectively gathered patients with bilateral CRSwNP who received primary endoscopic sinus surgery were enrolled. Clinical variables, including the preoperative Lund-Mackay score (LMS), were collected to clarify possible risk factors for revision surgery within a 5-year follow-up. The symptomatic burden was measured using a 10-cm visual analog scale (VAS) before and 1 year after surgery. Further survival analysis was performed to present the revision-free survival in Kaplan−Meier plotting. Results Eighty four qualified patients were identified and all of them experienced significant improvement in VAS after primary surgery. The 5-year revision rate was 19.05%, and the mean time of revision surgery was 25.31 ± 17.11 months postoperatively. Nasal allergy (OR = 9.287; p = 0.011) and LMS (OR = 1.29; p = 0.06) were found to be the independent risk factors for revision surgery. The discriminatory power of LMS for revision surgery was acceptable (AUC = 0.79) with the best cutoff point located at LMS > 13.5. Patients with both nasal allergy and LMS≧14 had only half of revision-free survival in comparison to overall survival (38.1% vs. 80.95%, p Conclusions In patients with CRSwNP who have concurrent nasal allergy and higher preoperative LMS may indicate an advanced disease status and eventually be in a high risk of revision surgery after a long-term follow-up. An outcome-based staging system will be helpful in the future to improve the prognosis for CRSwNP.

Objectives/hypothesis Maxillary sinus fungus ball (MSFB) is the most common type of noninvasive fungal rhinosinusitis. Surgical removal of the ball achieves good outcomes. Making a rapid and accurate diagnosis is important to avoid unnecessary medical therapy. Intralesional hyperdensity (IH) on computed tomography (CT) is reportedly a good indicator. The aim of this study was to evaluate the diagnostic features of MSFB without IH on preoperative CT images. Study design Retrospective database review. Methods Two hundred fifty-eight patients with histopathological evidence of a sinus fungal ball were retrospectively investigated. Forty-seven of 222 patients with MSFB did not show IH on preoperative CT images and were enrolled in the MSFB group. Forty-one patients with unilateral nonfungal chronic rhinosinusitis were enrolled in a control group. CT features previously reported to have diagnostic significance were evaluated. Results Sclerosis of the lateral sinus wall, erosion of the inner sinus wall, and irregular surface of the material were significantly more common in the MSFB group than in the control group. In the subgroup of patients with total opacification in the maxillary sinus, the sensitivity, specificity, and positive and negative predictive values for erosion of the inner sinus wall were more than 90%. In the subgroup with partial opacification, the sensitivity, specificity, and positive predictive value of an irregular surface of the material were more than 80%. Conclusions We have devised an algorithm to help diagnose MSFB without IH on preoperative CT images. Use of this algorithm would improve the diagnostic accuracy and ensure appropriate treatment. Level of evidence 4 Laryngoscope, 129:1041-1045, 2019.

Objectives/Hypothesis Empty nose syndrome (ENS) is often associated with psychological symptoms. With the absence of psychiatric instruments utilized in the current literature, the assessment of psychological disorder is limited, and the effectiveness of surgical intervention in improving such disorders in ENS are not well understood. The aim of this study was to evaluate the change in depression and anxiety before and after surgical treatment for ENS Study Design Prospective cohort study in a tertiary medical center. Methods ENS patients indicated for surgical treatment were enrolled. The Beck Depression Inventory II (BDI-II) and Beck Anxiety Inventory (BAI) questionnaires were completed by these patients before and after surgery to assess the level of depression and anxiety. Results A total of 20 patients completed the BDI-II and BAI before and after surgical treatment. A majority of patients developed depression and anxiety prior to surgical treatment. The severity of depression and anxiety were significantly decreased following the surgery; the mean scores of both the BDI-II and BAI improved from moderate severity to normal (both P < .001). The preoperative total score was found to be a powerful predictor for the postoperative improvement in both BDI-II and BAI (P < .001). Female patients had significantly worse preoperative scores (P = .005) and greater postoperative improvement (P = .012) in the BDI-II. Conclusions Depression and anxiety are psychological disorders prevalent among ENS patients. Surgical treatment for ENS is effective in improving depression and anxiety. Patients with worse preoperative BDI-II and BAI scores as well as female patients may be better candidates for surgical intervention. Level of Evidence 4 Laryngoscope, 2015

Recent evidence has indicated that osteoporosis is a risk factor for benign paroxysmal positional vertigo (BPPV). This large population-based study demonstrated that patients with osteoporosis had a 1.82-fold higher risk of developing BPPV than those without osteoporosis through the use of the Taiwan National Health Insurance Research Database. Benign paroxysmal positional vertigo (BPPV) is one of the most frequent causes of vertigo. Osteoporosis reflects a homeostatic imbalance in the rate of bone turnover, with the rate of bone resorption exceeding that of bone formation. Recent evidence has indicated that osteoporosis is a risk factor for BPPV. We aimed to validate the risk of BPPV in osteoporotic patients through a nationwide, population-based, cohort study. Patients treated for osteoporosis were identified from entries made in the Taiwan National Health Insurance Research Database (NHIRD) between 2000 and 2013. Each osteoporosis patient was age- and sex-matched with four randomly selected subjects without osteoporosis. We compared the incidence rates of BPPV in the two cohorts (with and without osteoporosis) and identified risk factors. We identified 6649 osteoporosis patients and 26,596 match controls. According to the incidence of BPPV among the two groups, patients with osteoporosis were found to have a 1.82-fold higher risk of developing BPPV than those without osteoporosis. The incidence rate ratio (IRR) between osteoporotic patients and the control cohort was 2.0 (p

Endonasal submucosal implantation has been confirmed to be beneficial for patients with empty nose syndrome (ENS). However, the optimal implantation site has not been defined. This study aimed to evaluate whether lateral nasal wall implantation is superior to inferior nasal wall implantation in terms of clinical benefits and improvements in quality of life.Retrospective study in a tertiary medical center.Consecutive ENS patients between 2010 and 2015 with operative histories of inferior turbinectomies and indicated for surgical implantation were enrolled, with at least 1-year follow-up. Patients were divided into lateral and inferior nasal wall groups. SinoNasal Outcome Test (SNOT)-22, Beck Depression Inventory (BDI)-II, and Beck Anxiety Inventory (BAI) were applied before and 1 year after implantation.Of the total 30 ENS patients analyzed, 14 were in the inferior nasal wall group and 16 were in the lateral nasal wall group. There were no significant intergroup differences in demographic data and preoperative SNOT-22, BDI-II, and BAI scores. Postoperative assessment revealed that the lateral nasal wall group had significantly better SNOT-22 score improvements than the inferior nasal wall group, particularly regarding rhinological symptoms and sleep function.Lateral nasal wall implantation may provide significantly better clinical outcomes than inferior nasal wall implantation, and thus may be the preferred, more optimal site for implant placement in ENS patients.4. Laryngoscope, 128:554-559, 2018.

Eosinophils and their granular proteins are crucial for combating allergic airway diseases. Eosinophils derived from HL-60 clone 15 (HC15) cells have been established as a feasible alternative cell model for human primary eosinophils. Simvastatin, a cholesterol-lowering agent, has been shown to exhibit anti-inflammatory and anti-allergic effects. Among the granular eosinophil proteins, eosinophil cationic protein (ECP) is the one best recognised in allergic airway diseases. The aim of our study is to investigate the effect and regulatory mechanisms of simvastatin on ECP levels derived from eosinophils. Both HC15 cell counts and ECP levels decreased after simvastatin treatment in the animal and cell models; however, after a cell count adjustment, simvastatin was not observed to exert a significantly inhibitory effect on ECP expression. Real-time polymerase chain reaction and Western blotting analyses demonstrated that simvastatin did not inhibit the intracellular formation or release of ECP. Cell cycle analysis showed that the percentage of HC15 cells in the G1 and S phases significantly increased and decreased, respectively, after simvastatin treatment. Simvastatin inhibited the proliferation of HC15-derived eosinophils by inducing G1/S cell cycle arrest in a dose-dependent manner. Its effect on the cell cycle involved the downregulation of cyclin A but without the presence of mevalonate; therefore, total ECP expression from eosinophils decreased, not by suppressing the actual formation or release of ECP but by arresting the G1/S cell cycle phase and inhibiting subsequent cell proliferation through the mevalonate pathway.

Background Empty nose syndrome (ENS) describes symptomatology and radiographic findings after surgeries on turbinates.The treatment of ENS is still debatable. Purpose To analyse clinical outcomes of submucosal Medpor® implantation for ENS. Methods A total of 18 patients underwent submucosal Medpor® implantation from 2006 to 2011. We applied SNOT-22 (SinoNasalOutcome Test) for statistical survey of the patients' symptoms before and after surgery. Results Two patients were lost to follow up after the surgery. Most of the patients developed ENS-related symptoms gradually within 2 years to 16 years after the previous nasal surgery or treatment. The sites of submucosal implantation are mainly septum and nasal floor, unilaterally or bilaterally. There is a significant improvement of SNOT-22 pre-operatively to one year post-operatively. Conclusions The symptomatolgy remains the most important point when dealing with patients with ENS. Submucosal implantation of Medpor® is a feasible surgical treatment to ENS. A positive cotton test is suggested for the surgical indication and planning.

The united airways concept suggests that patients with asthma typically exhibit parallel inflammation in the upper airway. The resulting nasal symptoms should reduce quality of life and substantially affect the evaluation of asthma control among these patients. This study aimed to assess the association of nasal symptoms with the evaluation of asthma control. Fifty-eight patients with asthma and persistent nasal symptoms were prospectively recruited for evaluations of their sinonasal symptoms and asthma control in a cross-sectional study from August 2013 to June 2016. Participants underwent thorough nasal endoscopy, sinus computed tomography, pulmonary function testing, the asthma control test (ACT), and the Sino-Nasal Outcome Test-22 (SNOT-22) questionnaires to evaluate their asthma control and sinonasal symptoms. There was a significant association between ACT and SNOT-22 scores. Among patients with asthma and chronic rhinosinusitis, ACT scores were closely related to the symptoms of cough, post-nasal discharge, dizziness, waking up at night, absence of a good night's sleep, and waking up tired. Among patients with asthma and chronic rhinitis, the forced expiratory volume in 1 second was closely related to the symptoms of needing to blow nose, runny nose, and cough. Patients with emergency clinic visits during the previous 3 months had relatively high SNOT-22 scores, especially for the symptoms of sneezing, runny nose, nasal blockage, cough, and dizziness. Sinonasal symptom severity was closely associated with measured asthma control status among patients with asthma and persistent nasal symptoms. Therefore, upper and lower airway inflammations should be considered and treated simultaneously.

Unilateral sinus disease (USD) can sometimes be difficult to accurately diagnose before surgery. The application of nasal nitric oxide (nNO) for USD diagnosis and its surgical outcome in USD has not been reported in the literature. We prospectively enrolled sixty-six USD patients who underwent endoscopic sinus surgery for fungal rhinosinusitis (n = 19), chronic rhinosinusitis (CRS) without nasal polyps (n = 13), CRS with nasal polyps (n = 12) and sinonasal mass lesions (n = 22). nNO levels were measured preoperatively and at three and six months postoperatively. Correlations between nNO levels and potential clinical parameters, type of disease, disease severity, and disease-related quality of life (QOL) were assessed. Unlike bilateral CRS, in USD, nNO levels did not correlate with disease severity or postoperative QOL improvements. Except for fungus group, there were no differences in nNO levels between lesion and non-lesion sides in all the other groups. nNO levels on both sides were significantly elevated six months postoperatively in all groups. Fungal rhinosinusitis patients had the lowest preoperative nNO levels, and a cutoff of 239.3 ppb had the best sensitivity (79.0%) and specificity (87.2%) for preoperative diagnosis. While preoperative nNO levels cannot serve as an alternative marker for disease severity of USD, they were lower in fungal rhinosinusitis patients than in other USD patients and may be useful for more accurate diagnosis prior to surgery.

Coexistence of chronic rhinosinusitis (CRS) with asthma appears to impair asthma control. Type-2 innate lymphoid cells (ILC2s) respond to the cytokines of thymic stromal lymphopoietin (TSLP), interleukin (IL)-25 and IL-33, thus contributing to airway diseases such as CRS and asthma. We investigate whether the augmented Th2-cytokines in CRS might be related to sinonasal tract ILC2s corresponding to enhanced IL-25, IL-33 and TSLP release in severe asthmatics, and be involved in asthma control. Twenty-eight asthmatics (12 non-severe and 16 severe) with CRS receiving nasal surgery were enrolled. The predicted FEV1 inversely associated with CRS severity of CT or endoscopy scores. Higher expression of Th2-driven cytokines (IL-4, IL-5, IL-9, and IL-13), TSLP, IL-25 and IL-33 in nasal tissues was observed in severe asthma. Severe asthmatics had higher ILC2 cell counts in their nasal tissues. ILC2 counts were positively correlated with Th2-cytokines. Nasal surgery significantly improved asthma control and lung function decline in severe asthma and CRS. The higher expression of IL-33/ILC2 axis-directed type 2 immune responses in nasal tissue of CRS brought the greater decline of lung function in severe asthma. ILC2-induced the upregulated activity of Th2-related cytokines in asthmatics with CRS may contribute to a recalcitrant status of asthma control.

Treatments for chronic rhinosinusitis (CRS) and asthma can affect both conditions, based on the united airway concept. This study aimed to evaluate the link between CRS and asthma, based on disease-specific quality of life measures. We performed a prospective cohort study to investigate the correlations between results from CRS- and asthma-specific questionnaires. Thirty-two patients with asthma and CRS were evaluated before and after undergoing nasal surgery at a tertiary medical center. There were significant correlations between the results from the Asthma Control Test (ACT) and the Sino-Nasal Outcome Test-22, as well as between the results of the ACT and Rhinoconjunctivitis Quality of Life Questionnaire, at both the preoperative and 3-month postoperative evaluations (P

Objectives/Hypothesis: In patients with nasal natural killer/T-cell lymphoma (NKTL), it is commonly without an obvious mass found in the nasal cavity by clinical or computed tomography (CT) findings. As a result, it takes longer to make a definite diagnosis when compared with other nasal malignancy. This study was designed to investigate clinical and CT findings of nasal NKTL. Study Design: Forty-three patients with nasal NKTL were enrolled. The patients' data were collected retrospectively. Methods: All patients underwent contrast-enhanced CT scans and endoscopic examinations. Symptoms were noted and recorded in detail. Results: Patients with lymphoma limited to their nasal cavity or paranasal sinus (N/PN) presented symptoms similar to chronic rhinosinusitis, such as nasal obstruction and purulent nasal discharge. Patients with lymphoma of the nasopharynx or oropharynx (NPx/OPx) tended to present more frequently with epistaxis or blood-tinged sputum. On CT, NKTL was usually nonenhanced (79.1%), homogenous (100%), unilateral (61.9%), infiltrative (67.4%), and without central necrosis. Only 30.2% of the patients presented with a prominent mass. One disease-specific sign, different from patients with chronic rhinosinusitis, was that the mucosa of the nasal cavity was thickened without involvement of the mucosa of the paranasal sinus (40.6%). Conclusions: The thickening of the mucosa of the nasal cavity without similar involvement of the paranasal sinuses is easily overlooked in patients with NKTL. In addition, the imaging findings of thickened mucosa of the nasal floor and/or nasal septum near the inferior meatus, a prominent mass, and bony destruction should raise suspicion of this diagnosis. Laryngoscope, 2012

The aim of this study was to evaluate the efficacy of transnasal endoscopic marsupialization as a treatment modality in patients with postoperative maxillary mucoceles and to compare the efficacy of marsupialization via middle meatal antrostomy with that of marsupialization via inferior meatal antrostomy. The study design was a retrospective clinical series and the setting was a tertiary referral center. After obtaining approval from the local ethics committee, we reviewed the medical records of 39 consecutive patients with postoperative maxillary mucoceles who were diagnosed and treated at the Department of Otolaryngology, Chang Gung Memorial Hospital, Taiwan, from 2004 to 2009. Transnasal endoscopic marsupialization was performed on 32 patients (34 sides) with postoperative maxillary mucoceles. All patients were followed for more than 12 months after surgery, and recurrence was noted in five patients (14.9%). Recurrence was experienced by five patients who underwent inferior meatal antrostomy and zero patients who underwent middle meatal antrostomy; thus, a statistically significant difference (p = 0.04) was observed. Transnasal endoscopic marsupialization is an effective modality for postoperative maxillary mucoceles and results in reduced morbidity. The use of middle meatal antrostomy in particular is preferred.

Background: Dysregulation of cysteinyl cathepsins and their inhibitors, cystatins (stefins), were implied in progression of tumorgenesis; nevertheless, their role in sinonasal inverted papilloma (IP) is still unrecognized. Methods: The differential expression of cathepsins and stefins in IP and normal tissues were revealed by data of human Affymetrix U133A gene chips, real-time polymerase chain reaction (PCR) and immunohistochemistry. Results: Among the cathepsins and stefins family, expression of cathepsin S and stefin A were most differentially expressed (down- and up-regulated, respectively) in IP tissue as compared with normal tissues. Their expression levels were validated by real-time PCR, which showed the expression level of cathepsin S was significantly down-regulated, whereas the expression of stefin A was significantly up-regulated in IP tissue compared to normal sinus mucosa. Using immunohistochemistry, expression of cathepsin S was observed in stromal and epithelial area macrophages of normal sinus mucosa, but no obvious expression of cathepsin S was found in IP tissue. In contrast, over-expression of stefin A was present in nearly all layers of the proliferative squamous cells of IP, but expression of stefin A was only detected in a scattered area of normal sinus mucosa. Conclusion: Down-regulation of cathepsin S and up-regulation of its endogenous inhibitor, stefin A, were found in IP tissues as compared with their expression level in normal sinus mucosa tissues. The biological significance of inverse expression of both stefin A and cathepsin S in sinonasal IP need further investigation in the future.