Slide agglutination test for the diagnosis of pulmonary and extra-pulmonary tuberculosis

Nasal polyposis can be defined as a chronic inflammatory disease of the paranasal sinus mucosa, leading to a protrusion of benign edematous polyps from the meatus into the nasal cavities. Nasal polyps are histologically characterized by massive edema and accumulation of eosinophils. IgE-mediated allergy seems to play only a minor role in eosinophil accumulation, leaving the place for a new concept of non-allergic rhinitis with eosinophilia. The central question still remains, however, why eosinophils accumulate into nasal polyposis tissue. Some initial data show that tissue structural cells, i.e. epithelial cells or fibroblasts, could produce cytokines (GM-CSF) and play a role in eosinophil accumulation (micro-environmental theory). However, further studies showed, that GM-CSF was mainly produced by eosinophils themselves (autocrine theory), leading to the hypothesis of an intrinsic eosinophilic inflammatory process. Eosinophils may contribute to nasal polyp formation and growth not only through inflammation but also by exerting their effects on extracellular matrix including stimulation of collagen synthesis. Another feature associated with nasal polyposis is aspirin sensitivity. Some preliminary data indicate that eosinophils could also be involved in aspirin-sensitivity mechanisms.     

Nasal polyps in children

The inflammatory nasal polyp is the most common benign or malignant nasal mass seen in children. Nasal polyps in the pediatric population appear to occur as inflammatory responses to bacterial infections. In 33% of the patients with polyps whom we studied, antral choanal polyps were noted, and in 20% of the patients the polyps were unilateral but not antral choanal. In 18% of the patients the polyps were bilateral and in an additional 29% they occurred bilaterally in association with cystic fibrosis. History of an allergy is infrequently associated with nasal polyps; allergies are potentially major contributing factors to nasal polyps only in patients without cystic fibrosis whose nasal polyps are bilateral. Patients with antral choanal polyps are most successfully managed by simultaneous Caldwell-Luc antrostomy and polypectomy. Sixty percent of patients with nasal polyps and cystic fibrosis are adequately managed with a single intranasal polypectomy. Simultaneous sinus surgery and polypectomy should be considered for all patients with recurrent polyps and for all patients with clinical or radiographic evidence of significant sinusitis. Complications, including epistaxis and intranasal synechia, occurred in 3% of the 170 surgical procedures performed.     

Medical treatment of paranasal sinus polyposis: a prospective study in 181 patients

Treatment of naso-sinus polyposis has been the subject of much controversy. The large number of reports in the literature suggest that role of surgical treatment is on the uprise. There is however general agreement that medical treatment is fundamental although an insufficient number of studies have evaluated its efficacy. The aim of this prospective study was to evaluate results 6 months, 12 months and 2 years after medical treatment of polyposis in 181 patients. Despite a well-coduced information protocol, nearly 19% of the patients were lost to follow-up. Less than 32% of the patients have been operated. Patients treated medically were given a standard regimen according to a protocol combining short-term oral corticosteroids (prednisolone) and steroid nasal spray (beclometasone). Treatment was successful in 68% of the patients given medical treatment alone. Mean symptom intensity declined by 35 to 80% at 6 months then remained unchanged to the end of the study (2 years follow-up). Mean doses of prednisolone and beclomethasone were evaluated. Doses could be tapered off progressively allowing satisfactory nasal comfort. Medical treatment should be the first line therapy for nasal polyposis. Surgery should not be proposed until corticosteroid therapy has been found to be unsuccessful over a mean 6 months of a well-conducted treatment and good patient compliance.     

Estradiol receptors expression in nasal polyps and its significance

Nasal polyps are generally considered as a result of extreme nasal mucosal edema induced by long-term recurrent inflammation of the respiratory mucosa. The estradiol (E2) has been demonstrated to play a facilitating role in nasal inflammation. To evaluate the effect of estradiol on the pathogenesis of nasal polyps, the expression of E2 receptors in paraffin section from patients with nasal polyps (84 cases), chronic hypertrophic rhinitis (6 cases) and healthy control subjects were investigated by means of immunohistochemistry for E2 receptors and toluidine blue staining for mast cells. It was shown that there was high expression of E2 receptors in 61 out of 84 cases (male 40, female 44) of nasal polyps and the expression distributed equally among both sexes. Low expression of E2 receptors presents in 2 out of 6 cases of chronic rhinitis and 1 out of 4 healthy subjects. Noteworthily, the E2 receptor expressing cells are similar with the mast cells in shape and distribution. The authors speculate that they may be identical cells. E2 receptor expression in nasal polyps suggests that estradiol plays certain role in the development of nasal polyps.     

Frequency specificity of acoustic evoked potentials of early and intermediate latency with high-pass noise masking

OBJECTIVES: To investigate the effect of intranasal corticosteroids in the treatment of polyps in patients with severe polyposis listed for surgical treatment and to determine the treatment effect on the progression of the disease. DESIGN: A double-blind, randomized, parallel-group, placebo-controlled, 12-week study at a single center. SETTING: A tertiary referral center in London, England. PATIENTS: Thirty-four patients with severe polyposis listed for endoscopic surgical treatment. INTERVENTION: By random allocation, fluticasone propionate aqueous nasal spray (FPANS), 200 microg twice a day; beclomethasone dipropionate aqueous nasal spray, 200 microg twice a day; or placebo nasal spray twice a day was administered. Patients received 2 actuations to each nostril in the morning and in the evening. MAIN OUTCOME MEASURES: Efficacy end points were the need for polypectomy at the end of treatment, the results of acoustic rhinometry, the polyp score, the peak nasal inspiratory flow rate, and an assessment of symptoms. RESULTS: The polyp score was significantly decreased in the FPANS-treated group (P < or = .01). The nasal cavity volume was significantly increased in both the FPANS-treated group and the group receiving beclomethasone compared with placebo (P < or = .01) at the end of treatment. The percentage change in the mean morning peak nasal inspiratory flow rate was greater in the FPANS-treated group, with a significant effect observed at week 2 (P = .01). Nasal blockage was significantly decreased in both active groups compared with the group receiving placebo. No significant difference was observed between the treatment groups in the number of patients requiring polypectomy. CONCLUSIONS: Fluticasone and beclomethasone aqueous nasal sprays are effective in treating the symptoms of severe nasal polyps. There was some evidence that the group treated with FPANS responded more quickly to intervention and that the magnitude of the response was greater than in the group receiving beclomethasone.     

Mixed lipid-protein films of bacterial photosynthetic reaction centres. II. Mixed multilayers on solid supports

The cytokine interleukin 8 (IL-8) has been shown to be a potent mediator of leukocyte recruitment and neovascularization in inflammatory and neoplastic diseases. In this study we hypothesize that IL-8 produced in the nasal polyp microenvironment is responsible for the leukocyte recruitment seen in nasal polyposis. To test this hypothesis we evaluated nasal polyps for distribution and content of IL-8 antigen with immunohistochemical techniques and radioimmunoassay to determine tissue levels of IL-8. The immunohistochemical results demonstrated that IL-8 antigen staining occurred predominantly within inflammatory cells and epithelium. IL-8 was detected in all nasal polyp tissue homogenates (a mean value of 1767 +/- 1633 pg/mg total protein (TP) with a range of 134 to 3668 pg/mg TP vs control specimens with a mean value of 77 pg/mg TP with a range of 0.09 to 255 pg/mg TP). These data demonstrate the presence and distribution and levels of IL-8 antigen in nasal polyps in vivo, supporting our hypothesis that local production of IL-8 could be an important factor in the sustained recruitment of leukocytes in nasal polyposis. Thus IL-8 likely plays a significant role in the pathogenesis of this disease process and therefore is a potential target for therapeutic intervention.     

Reconstruction of posterior mandibular defects with soft tissue using the rectus abdominis free flap

Nitric oxide (NO) plays an important regulatory role in airway function and seems to be implicated in the pathophysiology of several airway diseases. We studied the presence of NO synthase activity in human nasal mucosa and nasal polyp tissues obtained from patients undergoing septoplasty or polypectomy, respectively. NO synthase activity was quantified in tissue homogenates using citrulline release assay and was located in tissue sections using NADPH-diaphorase histochemistry. The results indicated that nasal polyps contain higher levels of total NO synthase activity than nasal mucosa tissue. In addition, nasal polyps contained mainly inducible NO synthase activity whereas all NO synthase activity detected in the nasal mucosa was in constitutive form. In both cases, NO synthase activity was localized in epithelial cells. In view of these results, we conclude that NO may be an important inflammatory mediator in the respiratory system and that the epithelium may be a source of NO production.     

Effect of indomethacin suppositories on rectal polyposis in patients with familial adenomatous polyposis

BACKGROUND: Oral sulindac is known to reduce polyps in patients with familial adenomatous polyposis (FAP). The authors speculated that rectal administration of indomethacin would be effective therapy for adenomas in the rectal remnant of FAP. METHODS: Eight patients with FAP who had been treated by total colectomy with ileorectal anastomosis were administered an indomethacin suppository (50 mg) once or twice daily during a period of 4 or 8 weeks. The number of polyps at the same site within the rectum was counted under proctoscopy prior to, at the end of, and after the treatment. In four patients, proliferative activity of the rectal mucosa was assessed by immunohistochemical staining for MIB-1. RESULTS: In six of the eight patients who initially had ten or more polyps, the number of polyps decreased to fewer than five, whereas such a decrease could not be observed in the remaining two patients. In the six patients, the number of polyps increased after indomethacin was discontinued. The proliferative activity of the rectal mucosa was higher at the end of treatment than it was prior to indomethacin administration. CONCLUSIONS: Indomethacin suppositories may be effective in the management of rectal adenomatosis in patients with FAP.     

Nasal obstruction

When we talk about nasal obstruction, we should define this notion by differentiating between a nasal obstruction, linked to the presence of a physical or inflammatory obstacle on the level of the nasal passages, and the feeling of a nasal obstruction or breathing discomfort described by the patient. The ear, nose and throat explanation will have to take an interest in all the possible causes. The methods of investigation associate anamnesis and clinical examination, helped by endoscopes or fibroscopes, immunological and allergological examinations, computed tomography and magnetic resonance imaging, rhinomanometry and less often use examinations such as muco-ciliary examinations, nasal cellular examinations or the examination of the sense of smell. Nasal obstruction can also be caused by anomalies in the structure of the nasal passages or paranasal cavities, or by anomalies in the mucosa in the nasal passages, or by tumours. Subjective nasal obstruction or nasal discomfort is a pathology at the limit of the conscious and subconscious whose working bases are still not fully explained. Treatment of nasal obstruction can be medical or surgical, but it must absolutely take into account the aetiology and not just the symptoms.     

Colorectal lesions predisposing to cancer

Precursors of colorectal carcinoma are adenomatous polyps, sporadic or arising in familial adenomatous polyposis and Lynch syndrome and chronic inflammatory lesions related to ulcerative colitis and Crohn's disease. The adenoma-carcinoma sequence is well established and early detection and removal of colorectal adenomas is thought to prevent colorectal cancer in high risk asymptomatic persons, i.e. subjects over 45 years, with personal or familial history of adenomas and colorectal cancers. The precancerous potential of adenomatous polyps varies according to tissue type, with increased risk with the extent of the villous component, high grade of dysplasia, large size greater than 1 cm and multiple adenomas. The development of de novo colorectal cancer from normal mucosa with flat adenomas has been recently emphasized. The risk of colonic cancer in patients with ulcerative colitis and Crohn's disease is controversed.     

Recent advances in surgery for colon and rectal cancer

Surgery is the mainstay of therapy for colon and rectal cancer. Over the past several decades, there have been important advances both in the understanding of the biology of colon and rectal cancer and in the preoperative and operative techniques for treating this disease. Although it appears in some studies that we have made a difference in the survival rates in the treatment of colon and rectal cancer, in actual fact, this phenomenon may only be secondary to better staging and, therefore, a greater ability to prognosticate a particular patient's chance of cure. What has been learned in the past 20 to 30 years is that most colon and rectal carcinomas start as polyps of the colon and rectum. Most often, polyps are sporadic, but there are certain high-risk groups that produce polyps and, consequently, colon and rectal cancer at a much higher rate. The goal of a practicing physician is to identify these high-risk individuals and to recommend frequent screenings so as to intervene before a polyp has had a chance to become a deeply invasive cancer. These high-risk groups are best typified by familial adenomatous polyposis, which if left untreated will, in 100% of cases, lead to the death of a patient from colon or rectal cancer. Other diseases that lead to an increase in colon and rectal cancer but may not go through the usual adenoma-to-carcinoma sequence include inflammatory bowel disease such as Crohn's colitis and ulcerative colitis. Most patients with colorectal carcinoma are asymptomatic at the time of diagnosis. This phenomenon has led to efforts to screen the general population for polyps and for cancer. Screening techniques such as the detection of occult blood in the stool and endoscopic procedures are currently the most popular. It is unclear at this time exactly what the efficacy of these techniques is in improving the survival of the general population from colorectal carcinoma. The surgical techniques to remove colon and rectal carcinomas have recently expanded to include a more aggressive local excision policy for small tumors of the rectum and the application of laparoscopic techniques, new stapling techniques, and new anastomosing techniques for tumors of the colon and rectum. These techniques have become possible in part through advances in surgical instrumentation and also in part from our increasing understanding of the biology of the disease. Both have allowed for more creative approaches to diagnosing and treating colon and rectal cancer.(ABSTRACT TRUNCATED AT 400 WORDS)     

Airway reactivity of nose and bronchi in patients with nasal polyps

The aim of the study was to determine whether patients with nasal polyps have a hyperreactive nasal mucosa and/or bronchi and whether there is any correlation between nasal and bronchial hyperreactivity. Twenty-six healthy volunteers and 10 consecutive patients with nasal polyps participated in the study. They were challenged with increasing concentrations of histamine. The nasal mucosa response was studied with rhinostereometry and the bronchial response was estimated by peak flow. One of the patients was mildly hyperreactive in the nose and 6 patients were hyperreactive in the bronchi. There was no correlation between nasal and bronchial hyperreactivity. Patients with nasal polyps do not have a hyperreactive nasal mucosa but there seems to be a high incidence of bronchial hyperreactivity in patients with nasal polyps.     

Unusual metastasis of renal cell carcinoma. A case report with review of the literature

BACKGROUND: The occurrence of metastasis of renal cell carcinomas in the head and neck region is extremely rare. Metastasis in the larynx, hypopharynx, and the nasal sinuses has been reported. We report here about a 55-year-old female with metastasis in the soft palate and tonsil, which occurred 10 years following tumor nephrectomy. RESULTS AND CONCLUSIONS: The incidence of metastasis in renal cell carcinomas can be observed even many years following initial curative treatment of the primary tumor. Although rare in the region of the head and neck, they can often be mistaken for benign tumors such as hemangiomas or inflammatory tissue. The treatment of choice is radical surgical resection.     

Algorithm analysis of lectin glycohistochemistry and Feulgen cytometry for a new classification of nasal polyposis

The aim of this study is to present a new classification of nasal polyps. This classification is based both on morphologic criteria relating to morphonuclear features from isolated Feulgen-stained nuclei and on glycohistochemical characteristics from histologic slides submitted to three lectins (peanut, wheat germ, and gorse seed agglutinins) and one neoglycoconjugate glycohistochemical stain. While the morphonuclear features (including 30 variables) relate essentially to chromatin pattern, the glycohistochemical stains (including 16 variables) are linked to the presence of specific carbohydrate moieties in cell membranes and cytoplasm. Forty-nine nasal polyps, including single polyps, diffuse polyposis, cystic fibrosis-related polyposis, and aspirin idiosyncracy-related polyposis associated with asthma, were thus characterized. All the variables were obtained quantitatively by means of computer-assisted microscopy. Two complementary methods of data classification were used to determine the actual diagnostic value contributed by each quantitative variable, namely, discriminant analysis, which forms part of multifactorial statistical analysis, and the decision tree technique, which is an artificial intelligence-related algorithm. The data so obtained show that our morphologic classification of nasal polyps fits in with the classification of nasal polyps defined on the basis of clinical criteria.     

The role of powered instrumentation in the surgical treatment of allergic fungal sinusitis

Allergic fungal sinusitis is a chronic disorder that is being more frequently recognized by otolaryngologists. It is a recurrent illness characterized by frequent exacerbations, and requires aggressive medical and surgical treatment. When surgical therapy is employed, it is necessary to ensure adequate debridement and removal of edematous tissue. We have been using powered dissection as our primary method in sinus surgery over the past three year. We have treated 11 patients with allergic fungal sinusitis, and find powered instrumentation to be very effective in removing the polypoid tissue from the nose and sinuses, and in providing a clear surgical field. The procedure can be performed safely with minimal trauma to normal tissue. We believe that the use of powered dissection greatly enhances the comprehensive treatment of allergic fungal sinusitis.     

Verrucous squamous cell carcinoma of the larynx: diagnostic and therapeutic considerations

Certain prostaglandins acting as inflammatory mediators have been implicated in the aetiology of perennial allergic rhinitis (PAR). Inhibition of prostaglandin synthesis in the nasal mucosa might therefore influence the symptoms associated with PAR. A randomised, doubleblind, placebo-controlled cross-over trial using 0.1% Diclofenac eye-drops has been conducted to investigate this hypothesis. Diclofenac, a non-steroidal anti-inflammatory drug (NSAID), reduces prostaglandin synthesis through the inhibition of the cyclo-oxygenase pathway. Twenty-five patients with significant PAR and positive skin tests to relevant perennial allergens were recruited and two drops of the given preparation were administered bilaterally q.d.s.. Thirteen patients completed the study. Nasal symptom score (itch, rhinorrhoea, sneezing, and blockage), smell test score, saccharin transit time, total nasal airflow resistance, and nasal inspiratory peak flow measurements were obtained at each of three study visits. No significant treatment effects were found. The daily nasal symptom score over the entire study period showed no significant variation. Adverse effects such as local invitation, dry nose or throat were rare. No untoward changes in haematological, biochemical profiles and urinalysis occurred. In conclusion, topical 0.1% Diclofenac eye-drops applied nasally have no significant effect on PAR. Prostaglandins alone may not play a major role in mediation of symptoms in this condition.     

Chronic sinusitis refractory to standard management in patients with humoral immunodeficiencies

Chronic refractory sinusitis is a common feature in patients with primary immunodeficiencies. The efficacy of standard therapeutic strategies is questionable. In an open trial we evaluated the efficacy of azithromycin, N-acetylcysteine and topical intranasal beclomethasone (100 microg twice daily for 6 weeks) in 16 patients with primary immunodeficiencies (median age 13.5 years, range 5-32 years). All patients suffered from chronic sinusitis despite regular immunoglobulin replacement therapy every 3 weeks. Magnetic resonance imaging (MRI) scans were performed before and after 6 weeks of treatment to evaluate morphological changes in the paranasal sinuses. Nasal swabs and washings were taken for microbial analysis and measurement of inflammatory mediators (IL-8, tumour necrosis factor-alpha (TNF-alpha), eosinophilic cationic protein (ECP)) before and post therapy. Inflammatory mediators in nasal secretions were significantly elevated in patients: IL-8 median 2436 pg/ml (range 441-5435 pg/ml), TNF-alpha 37.3 pg/ml (3.75-524 pg/ml) and ECP 33 ng/ml (1.5-250 ng/ml) versus age-matched healthy controls: IL-8 median 212 pg/ml (99-825 pg/ml), TNF-alpha 3.77 pg/ml (2.8-10.2 pg/ml) and ECP 1.5 ng/ml (1.5-14.8 ng/ml) (P < 0.0001). Inflammation of the maxillary sinuses was confirmed by MRI scans in all patients, additionally infection of the ethmoidal and frontal sinuses was recorded in five patients. Bacterial growth appeared in 11 out of 16 cultures. In spite of therapy, no improvement in sinal inflammation visualized by MRI was achieved. Moreover, no significant decrease in pathogens and levels of inflammatory mediators could be detected (IL-8 1141 pg/ml, 426-4556 pg/ml; TNF-alpha 13.9 pg/ml, 4.1-291.6 pg/ml; ECP 32.3 ng/ml, 3.7-58.4 ng/ml). Our results demonstrate that conventional management of sinusitis is of little benefit in patients with chronic refractory sinusitis with an underlying immunodeficiency. More studies are needed to test antibiotic regimens, probably combined with surgical drainage and anti-inflammatory agents.     

Chronic rhinosinusitis in cystic fibrosis (mucoviscidosis)

The authors present two clinical studies performed in the ENT departments of two Belgian Universities. A total of 248 patients with mucoviscidosis (cystic fibrosis, CF) were assessed by means of nasal endoscopy. One hundred eighteen underwent computed tomography of the paranasal sinuses (CT) and 55 were endoscopically operated. This allowed the observation of different clinical patterns of rhinosinusitis: mucopyosinusitis (pseudomucocele) of the maxillary antrum with bulging of the lateral nasal wall (LNW), nasal polyposis with erosion of the LNW, and chronic purulent rhinosinusitis with an isolated prominent uncinate process. The treatment of those patients could be tailored to the individual clinical pattern. Medical therapy consisted of systemic antibiotics and topical drugs delivered by sprays or by lavages with a nose can. Surgery was mainly aimed at removing the massive polyposis when it interfered with the daily life activities. The use of the endoscope enabled to perform safely more extensive procedures resulting in a lower recurrence rate. In patients with chronic rhinosinusitis without polyposis, yet presenting ostiomeatal obstruction, a limited and more functional endoscopic surgery was indicated in order to restore some drainage and to improve the penetration of topical drugs into the affected sinus. A short addendum presents two studies: one about genetics and the other about prevalence of middle ear disease in CF. The first concluded that no clear correlation was found between DF508 (the most common CF mutation) and nasal polyposis. The second revealed that in contrast with the extremely high prevalence of sinus problems, there was no clear evidence of an increased prevalence of middle ear disease in CF.     

Chronic rhinosinusitis in children: evolution of concepts

The concept of chronic rhinosinusitis in children has been recently individualized. The diagnosis is based upon the clinical history. It may be part of a diffuse inflammatory disease of the respiratory tract. Allergic and environmental polluting factors are possibly involved and must be looked for. Drainage of the rhinopharynx and local steroids are usually the first line treatment. In case of failure, a CT-scan of the sinuses should be performed looking for an obstructive anomaly of the sinuses requiring functional endoscopic sinus surgery.