Summary Background Addition of H 1 antagonists to intranasal corticosteroid treatment of allergic rhinitis (AR) is common in clinical practice and recommended by guidelines, despite some evidence that the additive benefits are negligible. Objective To assess additional benefits of 5 mg levocetirizine dihydrochloride in seasonal AR patients using 200 mcg fluticasone propionate nasal spray once daily. Methods In a double‐blind placebo‐controlled crossover study of 27 patients, following 2 weeks without treatment, subjects used fluticasone with levocetirizine or identical placebo for 2 weeks each. Assessments were the Juniper mini Rhinoconjunctivitis Quality‐of‐Life Questionnaire (mini‐RQLQ), domiciliary peak nasal inspiratory flow (PNIF), total nasal symptoms (TNS) scores and nasal nitric oxide concentrations. Effects were interpreted and tested against minimal clinically important differences. Results Add‐on effects for levocetirizine vs. placebo excluded any clinically significant benefits: mean effects (one sided 95% confidence intervals) were mini‐RQLQ −0.11 (−0.34), PNIF +0.57 (+5.23), and TNS −0.11 (−0.60). Numbers needed to treat (95% confidence intervals) by outcome were mini‐RQLQ 14 (5 to 49), PNIF 4 (3–7), and TNS 3 (2–6). No significant within or between treatment effects were seen for nasal nitric oxide. Conclusion Contrary to current practice, the present results demonstrate that for the majority of patients, antihistamine add‐on to effective nasal steroid treatment is inappropriate. Further work is required to confirm that this is also true in the most severe cases, and the available evidence needs to be put into guidelines and implemented.
Abstract Objectives: To investigate rates of septorhinoplasty and rhinoplasty in Scotland between 2006 and 2010, and to establish the impact of government legislation. Methods: Data on the rates of rhinoplasty and septorhinoplasty were collected and analysed according to specialty, region and year. Results: In 2006, 754 septorhinoplasty and rhinoplasty cases were recorded (147 per million population), rising to 893 (171 per million population) in 2010. Mean annual rates per million population were 152 (87 per cent of procedures) in ENT, 13.9 (8 per cent) in plastic surgery and 8.7 (8 per cent) in oromaxillofacial surgery. After 2009, there was a 43 per cent reduction in the rhinoplasty rate ( p < 0.0001), although the oromaxillofacial surgery rate increased by 68 per cent ( p < 0.05). Over the same period, the septorhinoplasty rate increased in ENT (46 per cent, p < 0.0001), and declined in plastic surgery (24 per cent, p = 0.49) and oromaxillofacial surgery (45 per cent, p = 0.05). Overall, the rate for rhinoplasty plus septorhinoplasty only declined by 1 per cent. There was significant regional variation. Conclusion: Overall, septorhinoplasty rates have increased and rhinoplasty rates have decreased. There was only a 1 per cent decrease in the overall rate following the 2009 legislation. Practice differs between regions.
Background: Asthma and allergic rhinitis are manifestations of a single unified allergic airway, for which the best treatment is uncertain. Objective: To compare the anti‐inflammatory efficacy in the unified allergic airway of combined oral mediator antagonism and combined topical steroid. Methods: Subjects with asthma and perennial allergic rhinitis entered a randomized double blind crossover study comparing montelukast 10 mg and cetirizine 10 mg to extra‐fine inhaled beclomethasone 400 mcg/day and intranasal beclomethasone 200 mcg/day, each taken once daily for 2 months, after 2‐week placebo washouts. Measurements were made after each washout and randomized treatment, comprising: methacholine PC 20 , exhaled and nasal nitric oxide, blood eosinophils and eosinophilic cationic protein, symptoms, lung and nasal function tests. Results: Seventeen patients completed per protocol. For PC 20 and exhaled nitric oxide, only combined topical steroid produced improvements ( P < 0.005) from placebo baseline. Combined steroid was superior by a 0.93 (95% CI 0.14–0.93, P < 0.05) doubling dilution difference for PC 20 and a 0.99 (95% CI 0.9–15.1, P < 0.01) doubling difference for exhaled nitric oxide. Both treatments attenuated eosinophils and eosinophilic cationic protein, and reduced nasal symptoms ( P < 0.05). Only steroid improved nasal nitric oxide ( P = 0.05) and asthma symptoms ( P < 0.05). Neither treatment affected lung or nasal function tests. Conclusion: Combined topical steroid and combined mediator antagonism both attenuated systemic inflammation in the unified allergic airway, but only the former reduced bronchial and nasal inflammatory markers. The relevance of this to exacerbations and airway remodelling needs to be defined.
Background Because the principle behind functional endoscopic sinus surgery (FESS) recognizes the middle meatus as essential for the control of the disease, the effect of the operation in the distribution of drugs in the same area should be of similar importance. This study was designed to clarify whether nasal drug delivery is improved in patients after FESS. The study involved a prospective assessment within subject comparison. The subjects were 20 adult (>18 years old) patients on the waiting list for FESS. It was conducted within two teaching hospitals in the East of Scotland. Methods A novel method was used, positioning a neurosurgical patty in the middle meatus and assessing blue dye nasal spray absorption on a 4-point scale. Results A significant improvement was observed in the distribution of the indicator in the middle meatus postoperatively. Seventy percent of the patients showed improvement in the drug distribution after FESS. The median result for absorption score was 2 preoperatively (<50%) and 3 postoperatively (>50%). The difference was statistically significant (p < 0.001). Conclusion The distribution of nasal drugs is improved in the middle meatus after FESS. This can have important clinical applications that can benefit patients in otolaryngology as well as other disciplines.
To evaluate the management of patients with malignant tumors of the ear and temporal bone.Retrospective analysis of data.Radcliffe Infirmary, Oxford, United Kingdom.Twenty-seven patients were classified into two groups according to the site of origin of the tumor: (1) superficial (17 tumors): tumors arising from the skin of the pinna, parotid, and temporomandibular joint area; (2) deep (10 tumors): tumors arising in the ear canal and temporal bone.Treatment modality, complications, recurrence rate, disease-free interval, and survival.The mean follow-up period was 25 months (0 to 60), and the median overall survival 46 months (0 to 102). Complications occurred in 6 patients (22%). The 3-year survival was 38% (95% confidence interval [CI], 19 to 58%), and the 5-year survival 19% (95% CI, 3 to 35%).There were insufficient data to demonstrate any difference in survival or disease-free interval related to the site of tumor origin (superficial versus deep tumors). There were independent differences in survival in favor of both performing parotidectomy and using postoperative radiotherapy, but neither reached significance at the 0.05 level.
Abstract Objectives: To establish the safety and effectiveness of nurse-led triage of otolaryngology out-patient referrals. Method: One hundred consecutive general practitioner referrals were reviewed by two consultants, two specialist registrars, two foundation year two senior house officers and two otolaryngology nurses. One of the nurses had received triage training. All referrals were triaged as ‘urgent’, ‘soon’ or ‘routine’ by each rater. Results: The triage-trained nurse's results demonstrated good agreement with those of the senior consultant (80 per cent). This agreement was similar to that with the other consultant (77 per cent) and the specialist registrars (79 and 82 per cent). Weighted κ statistics (correcting for chance agreement) showed that the triage-trained nurse had the second closest agreement to the senior consultant (0.66). After the actual out-patient appointments, retrospective review of the patients' case notes revealed that none had been triaged inappropriately by the trained nurse, and no urgent cases had been missed. Conclusions: Triage of out-patient referrals by trained ENT nurses is safe and effective, and is an acceptable alternative to traditional consultant vetting of referrals.
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