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Background Pregnancy-induced rhinitis (PIR) is a form of chronic non-allergic rhinitis not present before pregnancy that manifests itself during pregnancy with complete resolution of symptoms after delivery. Objective The objective of this ambidirectional longitudinal cohort study is to evaluate the prevalence of PIR and to investigate the appearance and character of its symptoms, and its impact on the quality of life. Methodology: Six hundred eighty-one (681) women were recruited in the study. They completed questionnaires about nasal symptoms a day after delivery and each woman with nasal symptoms was interviewed 30 days later and data on symptom duration and quality were recorded. Results The prevalence of PIR was 31.86% (N = 217), 47.14% (N = 321) women had no nasal symptoms and 21% (N = 143) of participants had prior sinonasal disease. The clinical presentation of pregnancy rhinitis included nasal obstruction as the most common symptom, followed by rhinorrhea, postnasal secretion, nose itching, sneezing, and hyposmia. The median duration of PIR was 4 months with their complete resolution of symptoms between 2th and 16th day after delivery in the majority of respondents. PIR was diagnosed significantly more often if the women carried a female child. PIR affected their quality of life during pregnancy in 53,9% women (N = 117), with an average VAS score of 8. It seems that pregnancy may affect the course of previously present sinonasal disease (allergic rhinitis, chronic rhinosinusitis, nonallergic rhinitis, or non-infectious rhinitis prior to the pregnancy). Conclusions PIR is a common clinical entity with a wide range of symptoms with a direct impact on the quality of life in pregnancy. We propose a new definition of pregnancy-induced rhinitis.

Foreign body aspiration is an important emergency and cause of morbidity and mortality in children. We present a 17-month-old boy who developed pneumonia and atelectasis a few weeks after unnoticed peanut inhalation. Despite prompt foreign body removal atelectasis persisted for three months. This case highlights the importance of timely diagnosis and treatment of foreign body aspiration.

Objective: This study aims to evaluate how asthma influences clinical symptoms, imaging scores and health related quality of life (HRQL) in patients with chronic rhinosinusitis (CRS). Methods:The study enrolled 256 CRS patients and collected data about asthma status, clinical symptoms, allergic sensitization, computed tomography (CT) and 22- item SinoNasal Outcome questionnaire (SNOT-22). Matching pairs of asthmatic and non-asthmatic CRS patients were defined based on age, gender and nasal polyp presence. The difference between pairs in clinical symptoms, CT, and SNOT-22 was then analyzed. The study enrolled mild to moderate asthma patients. Results: Out of 256 patients asthma status was unknown in 6 patients and they were excluded. From 250 CRS patients 65 (26%) have had asthma. We found 60 CRS asthma and CRS non- asthma pairs based on age, gender and nasal polyp presence. There was no difference in total SNOT-22 score between asthma(46.45) and non-asthma(43.52) CRS groups(p

Uvod: Meningeomi su najčešći primarni tumori središnjeg živčanog sustava kod odraslih, te čine preko 30% svih intrakranijalnih tumora. Prema Svjetskoj zdravstvenoj organizaciji (World Health Organization - WHO) klasificiraju se kao benigni (WHO gradus I), atipični (WHO gradus II), te maligni/anaplastični (WHO gradus III). Ekstrakranijalni meningeomi, bez intrakranijalne komponente, vrlo su rijetki, te čine samo 1-2% slučajeva svih meningeoma. Prikaz slučaja: Šezdesetjednogodišnjem muškarcu s recidivom tumora etmoidnog sinusa lijevo, učinjena je endoskopska resekcija. Bolesniku je prije 7 godina (2015. g.) učinjena prva endoskopska operacija tumora etmoida lijevo. Patohistološki nalaz tada je pokazao da se radi o metastazi karcinoma bubrega. Bolesniku je prije 17 godina (2005. g.) učinjena desnostrana nefrektomija radi primarnog karcinoma bubrega. Rezultati opsežne imunohistokemijske analize reseciranog recidiva tumora upućuju na to da se radi o atipičnom meningeomu. S obzirom na dvije različite patohistološke dijagnoze, učinjena je revizija materijala prve endoskopske operacije, odnosno dodatna imunohistokemijska analiza. U spomenutoj naknadnoj imunohistokemijskoj analizi upotrijebljeni su, ranije nedostupni, specifični markeri potencijalnog metastatskog karcinoma bubrežnih stanica. Pokazalo se da su spomenuti specifični markeri negativni u oba uzorka, odnosno da se nije radilo o metastazi karcinoma bubrega, već o atipičnom meningeomu. Zaključak: Atipični meningeomi paranazalnih šupljina vrlo su rijetka stanja nerazjašnjene etiologije. Radikalna kirurška ekscizija bi trebala biti glavni cilj, kako bi se smanjila pojava recidiva. S obzirom na to da su atipični meningeomi skloni recidiviranju, potrebno je redovito praćenje takvih bolesnika.

Purpose SARS-CoV-2 vaccines are a key step in fighting the pandemic. Nevertheless, their rapid development did not allow for testing among specific population subgroups such as pregnant and breastfeeding women, or elaborating specific guidelines for healthcare personnel working in high infection risk specialties, such as otolaryngology (ORL). This clinical consensus statement (CCS) aims to offer guidance for SARS-CoV-2 vaccination to this high-risk population based on the best evidence available. Methods A multidisciplinary international panel of 33 specialists judged statements through a two-round modified Delphi method survey. Statements were designed to encompass the following topics: risk of SARS-Cov-2 infection and use of protective equipment in ORL; SARS-Cov-2 infection and vaccines and respective risks for the mother/child dyad; and counseling for SARS-CoV-2 vaccination in pregnant, breastfeeding, or fertile healthcare workers (PBFHW). All ORL PBFHW were considered as the target audience. Results Of the 13 statements, 7 reached consensus or strong consensus, 2 reached no consensus, and 2 reached near-consensus. According to the statements with strong consensus otorhinolaryngologists—head and neck surgeons who are pregnant, breastfeeding, or with childbearing potential should have the opportunity to receive SARS-Cov-2 vaccination. Moreover, personal protective equipment (PPE) should still be used even after the vaccination. Conclusion Until prospective evaluations on these topics are available, ORL-HNS must be considered a high infection risk specialty. While the use of PPE remains pivotal, ORL PBFHW should be allowed access to SARS-CoV-2 vaccination provided they receive up-to-date information., info:eu-repo/semantics/published

Medicina se kontinuirano razvija i usavršava. Promjene se ne vide na mjesečnoj ili godišnjoj osnovi, no već kada se pogleda malo dulje razdoblje – desetljeće ili dva – vidimo značajne razlike u stavovima, smjernicama, tehnikama operiranja, mogućnostima liječenja i rezultatima. Najznačajnije promjene u zadnja dva desetljeća sigurno su se dogodile u endoskopskoj kirurgiji sinusa i baze lubanje, i to prvenstveno zahvaljujući razvoju tehnoloških mogućnosti vizualizacije, orjentacije i manipuliranja unutar ovoga anatomski uskog i zahtjevnog područja. Kao posljedica toga promijenili su se i stavovi i smjernice u operativnim pristupima. Najradikalnija promjena očituje se u tome da je prije 20 godina endoskopski pristup na zloćudne tumore nosa i baze lubanje bio kontraindiciran i tretirao se doista kao vitium artis. Danas je ovaj pristup standardan i u većini slučajeva čak superioran u odnosu na vanjski pristup. Promijenile su se i metode liječenja upalnih bolesti paranazalnih sinusa. Iako je osnove funkcionalne endoskopske kirurgije postavio Messerklinger prije 40 godina, nije sve što se radilo u tom razdoblju bilo „funkcionalno“. U estetskoj kirurgiji također se primjećuju promjene, no kako je ova grana u većini zemalja izvan pokrivanja zdravstvenih osiguranja, parametri koji utječu na promjene u estetskoj kirurgiji više su u ekonomskoj domeni. Cilj ove prezentacije je pokazati neke od navedenih promjena, te osvijestiti mlađe kolege da kritički usvajaju znanja koja im se prezentiraju, jer kao što mi danas gledamo na neke zastarjele metode i tehnike koje su naši učitelji primjenjivali, ne tako davno, vjerojatno će i drugi u skoroj budućnosti gledati na neke od naših današnjih tehnika i metoda liječenja.

Tonzilarni problem je skup pitanja koja si postavljamo kod pravilnog odlučivanja o indikaciji za tonzilektomiju. Ta su pitanja izrazito važna, budući da je tonzilektomija globalno najčešće izvođen kirurški zahvat. Tri su osnovna pitanja u rješavanju toga problema: 1. Koja je uloga tonzila u zdravlju djeteta (fiziološka uloga) ; 2. koja je uloga u bolesti djeteta (patološka uloga) i 3. Na koji način liječnici trebaju pristupati djetetu s bolesnim tonzilama. Postoje ISKRA smjernice na kojima se temelje naše smjernice. Medikamentozno liječenje koje dijelimo na simptomatsko i antimikrobno, ovisno o uzroku, te kirurško liječenje koje dogovaramo s pedijatrima i roditeljima. U pristupu problemu s tonzilama važna je multidisciplinarnost, odnosno zajedničko djelovanje, u prvom redu pedijatara i otorinolaringologa, ali i drugih struka, kao što su infektolozi, internisti, dermatolozi, klinički mikrobiolozi i neki drugi. Da bi se problem s tonzilama što učinkovitije rješavao, potrebno je držati se smjernica za dijagnostiku i terapiju grlobolje i postavljanje indikacije za tonzilektomiju.

ENT navigation has given new opportunities in performing endoscopic sinus surgery (ESS), and improving the surgical outcome of patient treatment. The generally accepted statement that navigated endoscopic sinus surgery (NESS) should be performed only in cases of complex anatomy and pathology has been changing gradually. In this way, NESS will be established as a state-of-the-art procedure, and used on a daily basis. Many surgeons have access to the navigation system but they do not use it on a daily basis. The approach to frontal sinus is one of the most challenging tasks within endoscopic sinus surgery even in cases with normal anatomy and average pathology. In cases of distorted anatomy and extensive pathology, a successful approach to frontal sinus can be a nightmare. Due to this, failure in frontal sinus surgery is the most frequent cause of revision surgery in the entire endoscopic sinus surgery. The use of the navigation system increases the surgeon's confidence and ability to perform a more complete dissection in frontal sinuses. We have created a simplified algorithm for the use of a navigation system for basic ESS in the treatment of chronic rhinosinusitis with and without nasal polyps. The simplified NESS algorithm consists of seven landmarks in four navigation units, which could be called seven must landmarks as they should always be recognised during basic ESS. These landmarks are as follows: 1) maxillary sinus ostium, 2) frontal recess, 3) ground lamella, 4) fovea posterior, 5) sphenoid sinus ostium, 6) orbital wall – anywhere, 7) skull base – anywhere. In using this algorithm, surgeons would become familiar with the navigation system and would receive all facilities which the navigation system offers in its approach to frontal sinus.

Objective: The aim of the study was to test whether asthma per se is a factor influencing subjective and objective outcomes in patients with chronic rhinosinusitis (CRS). Materials and methods: This was a cross-sectional study which enrolled CRS patients for 2 years. Patients were asked to score the severity of their rhinosinusitis symptoms on a visual analog scale (VAS), and to fill out a questionnaire on the health-related quality of life– Sinonasal Outcome Test 22 (SNOT-22). CRS was confirmed by symptoms, endoscopy and CT findings. We have defined matching pairs of asthmatic and non-asthmatic patients based on nasal polyp presence, gender, age and allergic sensitization and analysed the difference in symptom scores, HRQL impairment and imaging scores. Results: We observed pairs from 250 patients with CRS, from which 65 (26%) had asthma and 185 (74%) did not have asthma. There was a higher proportion of CRS with nasal polyps (64.2% vs. 29.7%) in the asthma group and positive history of allergy (67.2% vs. 28.2%). Lund-Mackay (LM) scores were higher in asthma patients (13.06 vs. 8.83). We found 60 matching asthma and non-asthma CRS pairs. There was no difference in the SNOT-22 total score (46.45 for asthma and 43.52 for non-asthma group, p

Epistaksa je čest problem koji se javlja kod, do 60% opće populacije. Iako je većina epizoda benigna, epistaksu je povremeno teško kontrolirati. Podaci iz studija pokazuju da samo 10% njih, ili manje, zatraži medicinsku pomoć. Epidemiološkom analizom brojnih studija primijećeno je da se epistaksa javlja najčešće kod djece ili kod starijih pojedinaca, s nešto većom prevalencijom u muškaraca. Uzroci epistakse mogu biti lokalni ili sistemski, te se, ovisno o tome, pristupa liječenju. Liječenje epistakse temelji se na lokalnom zaustavljanju krvarenja, te je stoga poznavanje osnovne anatomije nosa i nazofarinksa, te nekoliko hemostatskih strategija nužno u tretiranju akutnog krvarenja.

Introduction Current practice guidelines in gastroesophageal reflux disease (GERD) often require invasive diagnostic testing. Objective The aim of the present study was to evaluate the significance of extra-esophageal symptoms and reliability of a screening risk score that is simple to use. Methods A longitudinal retrospective single-institution cohort study. Setting: A university clinical hospital tertiary referral center. The present study enrolled pediatric patients with symptoms suggestive of GERD: epigastric pain, occasional nausea, regurgitation, tasting acid in the oral cavity, chronic cough, hoarseness of voice, frequent throat clearing. The patients underwent 24-hour esophageal pH monitoring and fiber-optic laryngoscopy. The correlations between the local findings, anamnestic and objective measurement data were analyzed. Results The present study evaluated 89 pediatric patients. Patients with asthma presented significantly more often with adjoining gastrointestinal symptoms (p = 0.0472). Patients that were obese were linked to a higher rate of reports of gastrointestinal symptoms (p = 0.0495). After the patients had been assigned to newly developed risk groups, obesity showed to be significantly more frequent in patients placed in higher risk groups (p Conclusion Patients with leading symptoms of asthma presented significantly more often with adjoining gastrointestinal symptoms. Obesity showed to be significantly more frequent in patients placed in higher risk groups for a positive GERD diagnosis.

Cilj: Prikazati slučaj neuobičajenog kliničkog tijeka prirođenog laringealnog stridora i razmotriti indikacije za endoskopskim pregledom u takvim slučajevima. Prikaz slučaja: Terminsko eutrofično muško novorođenče je po porodu radi akutnog skrotuma te respiratornih teškoća u vidu tahipneje i hipoksemije primljeno u Kliniku za pedijatriju. Neposredno nakon kirurškog zahvata dijete je rutinski ekstubirano. Međutim, vrlo brzo nakon odvajanja od tubusa ponovno je naglo razvilo respiratorne teškoće obilježene stridorom i hipoksemijom. Dijete je ponovno intubirano i vraćeno na strojnu ventilaciju. U daljnjem tijeku se u više navrata pokušavao provesti postupak ekstubacije. Isti nije bilo moguće učiniti jer bi se nakon odvajanja od tubusa vrlo brzo vratili znakovi respiratornih teškoća pod kliničkom slikom akutnog laringotraheobronhitisa. S obzirom na probleme otežane ekstubacije i ovisnosti o tubusu te na perzistentne atipične simptome krupa i neučinkovitost farmakoterapije, dijete je u dobi od mjesec dana podvrgnuto endoskopskom pregledu dišnih putova. Vizualizirana je koncentrična subglotična stenoza membranskog tipa. U pripremama za liječenje endoskopskom laserskom ablacijom stridor je bivao sve manje izražen. Dva tjedna nakon prvog endoskopskog pregleda učinjen je kontrolni na kojem je vizualni nalaz sugerirao značajnu regresiju subglotičnog membranskog suženja. Odustalo se stoga od planirane intervencije laserom, a stridor se u dojenčeta spontano povukao. Zaključak: Iako je laringomalacija daleko najčešća etiološka podloga prirođenog stridora, i ne predstavlja apsolutnu indikaciju za endoskopijom dišnog puta, isti može biti izazvan nizom drugih rijetkih stanja uključujući prirođenu subglotičnu stenozu. U prikazanom slučaju zabilježena je neuobičajena spontana regresija subglotične stenoze membranskog tipa., Aim: To report an unusual clinical course of an infant with congenital laryngeal stridor. Indications for endoscopic examination of airways in such cases have also been discussed. Case report: A full-term male newborn was admitted to the Department of Paediatrics because of the symptoms of acute scrotum as well as because of breathing difficulties and severe hypoxemia. Soon after surgery the child was extubated but breathing difficulties persisted. A loud inspiratory stridor together with rapid respiratory deterioration occurred. The infant was intubated and underwent mechanical ventilation again. In the following period several trials of extubation were repeatedly unsuccessful despite favourable weaning parameters. Just few hours after each trial of extubation symptoms of acute laryngotracheobronchitis were apparent. Because of extubation failure, tube dependency and persistent atypical symptoms of croup unresponsive to standard pharmacotherapy, endoscopic assessment was performed at the age of one month. Concentric central membranous subglottic stenosis was visualized. While preparing for the endoscopic laser ablation treatment, stridor was getting less pronounced. Two weeks later patient underwent endoscopy again and significant regression of subglottic membrane narrowing was documented. Planned laser intervention was canceled. At the age of four months stridor disappeared. Conclusion: Laryngomalacia is the most common cause of congenital laryngeal stridor and endoscopic evaluation is usually not indicated in such cases. However, there are other causes of congenital stridor which are not so common, including congenital subglotttic stenosis. In this case an unusual spontaneous regression of congenital membranous subglottic stenosis was reported.

OBJECTIVE: To show changes in the management of subglottic laryngitis over the last twenty years in Croatia. ----- METHODS: We sent questionnaires to paediatricians and otolaryngologists (ENT) in 9 Croatian hospitals in 1993, 2003 and 2013. In the questionnaire we presented a case of a child with moderately difficult subglottic laryngitis, after which they had to answer questions about the management of this kind of a patient and common therapy practice in their hospitals. All data were categorical, described in absolute frequencies and with relative percentages. The Cochran-Armitage test for trend was used in the analysis of different treatments over the years among ENT and paediatricians. Associations were statistically significant if p

The objective of this study was to evaluate the interaction of nasal septal deformity (NSD), including the contribution of septal spurs, with the severity of subjective symptoms, impairment of health-related quality of life (HRQoL) and sinus mucosal hyperplasia in patients with chronic rhinosinusitis (CRS). One hundred seventeen patients with CRS were assigned to three groups with mild, moderate or severe NSD, according to the measured nasal septal angle, including the presence of contact septal spurs. All CRS patients completed the visual analog scale (VAS) symptom severity score and the Sino-Nasal Outcome Test (SNOT-22) questionnaire. Symptoms scores, SNOT-22 and Lund-Mackay (LM) scores among the three NSD groups were compared. Related anatomy from the study group was compared with 100 control patients. VAS score for postnasal discharge in CRS patients was significantly higher in patients with mild NSD. There was a significantly higher LM score in CRS patients with severe NSD, compared to those with mild (P = 0.001) or moderate NSD (P = 0.005). CRS patients with a contact spur demonstrated a significantly higher LM score (P = 0.006) compared to those without a contact spur, and no differences in VAS symptom scores or HRQoL scores. There was a similar prevalence of septal deformities in CRS patients and in the non-ENT population. Our results support the conclusion that in patients with CRS, associated NSD or contact septal spur do not contribute significantly to CRS symptom severity or HRQoL impairment, but may have an impact on sinus mucosal hyperplasia.

Purpose: We aimed to evaluate the interaction between the overall severity of chronic rhinosinusitis (CRS) before treatment and subjective improvement following surgical or medical treatment. Procedures: A group of 97 patients with CRS completed the visual analog scale (VAS) symptom score and the Sino-Nasal Outcome Test 22 (SNOT-22) questionnaire in the moment of their sinus computerized tomography (CT) scan. Data were analyzed via a 2-step cluster analysis based on gender, polyp presence, CT scan, and VAS scores for symptoms. Results: There were 3 clusters: the first cluster comprised 37 female patients with CRS without nasal polyps (CRSsNP), the second cluster comprised 30 patients with CRS and NP (CRSwNP; 15 males and 15 females); and third cluster had 30 male patients with CRS without NP (CRSsNP). Different symptom patterns between clusters were identified. After adjustment for polyp presence, gender, eosinophilia (p = 0.021), and the SNOT-22 score (p = 0.005) were found to be better outcome predictors than the CT score (p = 0.26). Conclusion: Long-term patient satisfaction is significantly associated with the subjective symptom severity prior to treatment, i.e., postnasal drip and overall disease severity (SNOT-22 score), but not with the objective severity of the disease (CT score and inflammation).

Epidemiological studies show female predominance in the prevalence of non- allergic rhinitis (NAR) and local allergic rhinitis (LAR). Experimental studies show female patients with allergic rhinitis (AR) demonstrate higher levels of sensitivity to irritants and airway hyperresponsiveness than males. Bronchial asthma shows female predominance in post-puberty patients, and gender interaction with severe asthma endotypes. Fibromyalgia, chronic fatigue syndrome, migraine and chronic cough, syndromes, which are commonly related to neurokinin substance P (SP) in the literature, also show strong female predominance. Studies have demonstrated that sex hormones, primarily oestrogens, affect mast cell activation. Mast cell proteases can amplify neurogenic inflammatory responses including the release of SP. Based on human epidemiological data and animal experimental data we hypothesized that female patients have different interaction between mast cell activation and neurogenic inflammation, i.e. substance P release, resulting in a different nasal symptom profile. To test the hypothesis we performed allergen and non-specific nasal challenges in patients with seasonal allergic rhinitis (SAR) out of season and looked for gender differences in subjective and objective responses. The interaction between subjective and objective reactivity was evaluated through the comparison of subjective symptom scores, concentrations of neurokinin substance P (SP) and cellular markers in nasal lavages after low doses of nasal allergen challenges. Female allergic subjects tended to have higher substance P (SP) concentrations both before and after non-specific challenges. The difference between post-allergen and post - hypertonic saline (HTS) challenge was highly significant in female patients (p = 0.001), while insignificant in male subjects (p = 0.14). Female patients had significantly stronger burning sensation after HTS challenge than male. These data indicate difference in the interaction between inflammatory cells and the neurogenic response, which is gender- related, and which may affect symptom profiles after challenges. Different regulation of neurogenic inflammation in females may have impact on symptoms and endotyping in respiratory disorders, not only in allergic rhinitis, but also asthma, chronic rhinosinusitis and irritant -induced cough.

Objectives Gastroesophageal reflux recommended treatment (dose and duration) with proton pump inhibitor (PPI) compared to placebo significantly reduces the signs and symptoms of laryngopharyngeal reflux (LPR) and comorbid chronic rhinosinusitis (CRS). Design Double blind randomized placebo controlled trial. Setting Eight weeks of treatment with omeprazole 20 mg once daily (OD). Participants 60 patients (28 women, aged 19-87 years) with diagnosed LPR and comorbid CRS. Main outcome measures Significant reduction of signs and symptoms (reflux symptom index (RSI) score as subjective, and reflux finding score (RFS) as objective measure) of LPR after 8 weeks of treatment with omeprazole 20 mg OD when compared to placebo. Secondary objectives were significant reduction of signs and symptoms of comorbid CRS after 8 weeks of treatment with omeprazole 20 mg OD when compared to placebo; and the association of the severity of signs and symptoms of LPR with the ones of CRS. Results RSI and RFS decreased significantly more in the active treatment group after 8 weeks compared to placebo (p

Retropharyngeal abscess is acute suppurative infection of the retropharyngeal space. Most commonly it occurs in children younger than four years of age having history of streptoccocal pharyngitis. Clinical presentation similar to epiglottitis or foreign body aspiration makes distinguishing issues so the diagnosis of retropharyngeal abscess can initially be missled. Here we are illustrating four month old female infant with incipient presentation that clinically resembles epiglottitis. After the initial management in the intensive care unit clinical work-up was continued with multidysciplinary collaboration and the diagnosis of retropharyngeal abscess was given, treated both surgically and conservatively. Postoperative intensive care was then continued with subsequent clinical and biochemical improvement. This case demonstrates the need for broad thinking when dealing with affebrile child being respiratory distressed and during diagnostic work-up of a patient having fever of unknown origin.

Haemangiomas of the nasal cavity are rare benign tumours which usually arise in the Kiesselbach triangle of the septum. Mostly they are seen in young population with peak age 20 years. Epistaxis is the most common symptom in these patients. We present a case of a 62-year-old woman with recurrent epistaxis. On examination she had had an obstruction of both nasal cavities. Computed tomography imaging demonstrated a well-defined tumour originating from the posterior tip of the right inferior turbinate, passing into the nasopharynx. The tumour was managed via endoscopic endonasal approach. The histological analysis revealed a tumour tissue with the appearance of a cavernous haemangioma as well as capillary haemangioma. A focus of intravascular endothelial papillary hyperplasia was also observed. In patients with endonasal benign tumours choice of surgical approach depends on the exact location of the tumour and suspected pathology. The transnasal endoscopic approach and bipolar cautery resection enable adequate exposure and visualization of the tumour, control of bleeding and complete removal of the tumour.

The ORL Section and Board of Otorhinolaryngology-Head and Neck Surgery of the European Union of Medical Specialists (UEMS) developed pediatric ORL subspecialty program. The program was created with support and consultation of the European Society of Pediatric Otorhinolaryngology. It is divided into four sections: Pediatric Otology, Pediatric Rhinology and Facial Plastic Surgery, Pediatric Laryngology and Phoniatrics and Pediatric Head and Neck Surgery. After completion of the program, the trainee is supposed to achieve an advanced level of competency. The aim of the program is to serve as a guideline for training centers, enabling them to meet the European Standard as set out by the European Board of UEMS through competency based assessments.

Objective of this study was to test whether there is a difference between chronic rhinosinusitis patients with (CRSwNP) and without (CRSsNP) nasal polyps in the association of extent of disease on CT scans with symptom severity and health-related quality-of-life (HRQL) impairment. Data sets from 271 chronic rhinosinusitis (CRS) patients who completed the Sino-Nasal Outcome Test 22 (SNOT-22) and visual analog scale (VAS) scores were subjected to principal component analysis (PCA) to identify a symptom components related to CRS. After controlling for demographics, medical therapy, and comorbidities, the association between symptom components/items excluded from PCA and Lund-Mackay score (LMS) was evaluated. No association was found between the total SNOT-22 score and LMS in CRS patients. There was an independent association between a higher "nasal" symptom component derived from SNOT-22 PCA and LMS in patients with CRSwNP (p

Otitis media with effusion (OME) is a common disease in childhood. There is no consensus on the optimal therapeutic option for OME. Considering the known efficacy of acetylcysteine (AC) and azithromycin (AZ) in the treatment of middle ear mucosa, the aim of the study was to assess their efficacy in the management of chronic OME. The study included 90 children with OME, both ears. They are divided into three groups of 30 children. Group 1 (AC) patients were treated with acetylcysteine per os, 3 × 100 mg, for 3 weeks; group 2 (AZ) with body weight adjusted dose of azithromycin for 3 days; and group 3 (AC + AZ) with a combination of acetylcysteine and azithromycin at doses described above. Three measurements were performed. On second measurement, tympanogram improvement was recorded in 45% of 60 ears in group I, 53.3% of 60 ears in group II, and 61.7% of 60 ears in group III. The percentage of improvement was highest in group III. Although between-group differences did not reach statistical significance, the results obtained appear to be clinically relevant. In conclusion, conservative therapy for chronic OME is reasonable. Although study results don’t have a strong statistical differences and may not refer clinical improvement results suggest that this combination of drugs (antibiotics, bronchosecretolytics) can be useful in the treatment of OME.

BackgroundChronic rhinosinusitis (CRS) with and without polyps has a high impact on health-related quality of life (HRQL), but the difference in HRQL and symptom presentation between two clinical phenotypes of CRS has not been specifically evaluated before now.ObjectiveTo evaluate patterns of symptoms and HRQL disease-specific domains affected in patients with CRS by comparing differences between two clinical phenotypes, adjusted for demographics, major risk factors, comorbidities, current medical treatment, and previous surgery.MethodsA group of 251 patients with CRS completed the visual analog scale (VAS) symptom severity score and the Sino-Nasal Outcome Test 22 (SNOT-22) questionnaire. Data sets were analyzed by using principal component analysis (PCA) to identify a set of symptom components, together with the items excluded from PCA, which were then analyzed for differences between patients with CRS with nasal polyps (CRSwNP) and patients with CRS without nasal polyps (CRSsNP).ResultsPCA of SNOT-22 items identified six components, three referred to CRS-specific symptoms termed “nasal”; “extranasal, rhinologic”; and “olfactory/cough”; and three referred to HRQL impairment termed “sleep disturbance,” “functional disturbance,” and “emotional disturbance.” Nasal obstruction, ear pain, ear fullness, and fatigue were excluded from PCA and treated as separate outcomes. Patients with CRSwNP had significantly worse nasal symptoms, olfactory/cough symptoms, and nasal obstruction. Patients with CRSsNP scored significantly worse with regard to fatigue and to sleep and functional disturbances. The PCA results for VAS scores identified three symptom components: pain, nasal symptoms, and pharyngeal symptoms. Patients with CRSwNP had significantly worse VAS nasal symptoms but less pronounced VAS pain symptoms than patients with CRSsNP. The total SNOT-22 score between the groups was not significantly different.ConclusionWith controlling of covariates that may influence the severity of the disease, this study showed significant differences in symptom patterns and different aspects of HRQL impairment between patients with CRSwNP and patients with CRSsNP, however, with no difference in the total HRQL score.

Background Different nasal challenges induce neural and immune response leading to nasal and ocular symptoms in patients with seasonal allergic rhinitis (SAR). The release of neural mediators from nasal mucosa and conjunctiva after no-specific challenges in patients with SAR remains unknown. Objectives To compare the release of mediators from the nose and conjunctiva with symptoms after different nasal challenges in patients with SAR. Methods Three types of consecutive nasal challenges were performed outside the pollen season in 25 patients with SAR. Challenges consisted of 500 biological units (BU) of allergen, 80 μg of histamine, and 1 mL of 2% hypertonic saline per nostril, within 24-hour and 72-hour intervals, respectively. Before and 15 minutes after challenges, evaluation of symptoms was performed with a visual analog scale. Concentrations of tryptase, eosinophil cationic protein in nasal lavages after 15 minutes, and substance P in tears after 5 minutes were measured with enzyme immunoassays. Results Concentrations of substance P in tears were significantly higher after nonspecific challenges. Substance P concentration in tears significantly correlated with eye itchiness after histamine and hypertonic saline and with tearing after allergen. Ocular symptoms correlated significantly with tryptase concentration in nasal lavage collected 15 minutes after allergen challenge. There is a significant correlation in tear volume comparing different nasal challenges. Conclusions Nasal challenges with allergen, histamine, or irritants outside the pollen season induce a significant increase in nasal and ocular symptoms in patients with SAR. Interaction of the early-phase response and neurogenic inflammation define the pattern and severity of eye symptoms.

The efficacy of topical nasal furosemide treatment has been shown in the protection of nasal polyp recurrence. The aim of the study was to compare the effect of oral steroid, as standard preoperative treatment, and inhaled furosemide, as alternative treatment, for 7 days preoperatively in terms of subjective improvement of nasal symptoms, polyp size reduction, inflammation in the polyp tissue, and intraoperative blood loss. A group of 40 patients with nasal polyposis entered the study and they were randomly allocated to 7-day preoperative treatment with either oral methylprednisolon (1 mg/kg/day) or topical furosemide by inhalation (6.6 mmol/l solution). Subjective scores of rhinosinusitis symptoms, polyp scores at endoscopy, and biopsy of the most superficial polyp were taken at inclusion. All procedures were repeated on day 7. Intraoperative blood loss was estimated (scores 0-10) by the surgeon at the operation. Eosinophils, mastocytes, and oedema were quantified by histomorphometry. Subjective symptoms and endoscopy scores did not differ significantly between the groups after the treatment although improvement of olfaction was insignificantly better in the steroid group. Steroid treatment significantly reduced eosinophil count, with no effect on mastocytes and oedema. Furosemide treatment did not affect inflammatory cells count significantly, but it has significantly reduced oedema in previously unoperated patients. No difference in intraoperative bleeding was observed between the groups.

Nasal polyps recur in approximately one-third of patients after surgical treatment. It would be beneficial to be able to predict the patients in whom we might expect recurrence and to predict the clinical outcome after surgery. The study included 30 patients operated for nasal polyps. Removed polyps were analyzed by immunohistochemical analysis for IL-5, IgE, vascular endothelial growth factor and eosinophilic infiltration. These parameters together with preoperative CT score were used as independent variables, and subjective score improvement after 2 years was used as a dependent variable in multiple linear regression analysis. Furthermore, the patients were divided into two groups: low and high polyp tissue immunoreactivity. The Chi-squared test was used to determine whether polyp immunoreactivity influences polyp recurrence and subjective score. Preoperative CT score had a slightly positive correlation with subjective score after 2 years. High eosinophil infiltration significantly predicted a higher risk for polyp recurrence. High IL-5 positivity was related to greater risk for polyp recurrence than low IL-5 reactivity but not significantly. IgE and VEGF reactivity in polyp specimens did not have any effect on polyp recurrence. High eosinophilic infiltration in polyps can predict worse outcome after surgical treatment of chronic rhinosinusitis with nasal polyposis. IgE and VEGF do not have prognostic significance to polyp recurrence after surgery. The preoperative extent of disease measured by CT score had a slightly positive correlation with worse outcome after surgery.

OBJECTIVE: The aim of this study was to assess the validity of current diagnostic approaches in pediatric laryngopharyngeal reflux (PLPR). Clinical status findings and 24h double probe oesophageal pH monitoring results in children with suspected PLPR and/or GERD were analyzed and a clinically useful probability score was developed. ----- METHODS: This is a retrospective longitudinal cohort study including 89 pediatric patients who underwent preliminary oropharyngoscopy, and then nasal fibre optic laryngoscopy and ambulatory 24h oesophageal pH monitoring in a tertiary pediatric and otorhinolaryngology hospital center. The patients' parents gave written informed consent for diagnostic testing. Statistical analysis was performed using standard descriptive statistics. Associations between variables were assessed using Fisher's exact test, Mann-Whitney test and Kruskal-Wallis test for non-parametric paired samples. ----- RESULTS: Patients' age spanned 1-18 years with a median of 11.2. Out of the 89 patients, 56 were girls, and 33 were boys. All of the patients underwent nasal fibre optic laryngoscopy and 24h double probe pH monitoring. Out of 89 examined children, 50 had PLPR. Out of the 50 positive for PLPR, 46 had a positive clinical finding, with a sensitivity of 92% (95% CI: 80.75-97.73%) and specificity of 10.26% (95% CI: 2.93-24.24%). Boys have GERD significantly more often than girls (p

ENT navigation has given new opportunities in performing Endoscopic Sinus Surgery (ESS) and improving surgical outcome of the patients` treatment. ESS assisted by a navigation system could be called Navigated Endoscopic Sinus Surgery (NESS). As it is generally accepted that the NESS should be performed only in cases of complex anatomy and pathology, it has not yet been established as a state-of-the-art procedure and thus not used on a daily basis. This paper presents an algorithm for use of a navigation system for basic ESS in the treatment of chronic rhinosinusitis (CRS). The algorithm includes five units that should be highlighted using a navigation system. They are as follows: 1) nasal vestibule unit, 2) OMC unit, 3) anterior ethmoid unit, 4) posterior ethmoid unit, and 5) sphenoid unit. Each unit has a shape of a triangular pyramid and consists of at least four reference points or landmarks. As many landmarks as possible should be marked when determining one of the five units. Navigated orientation in each unit should always precede any surgical intervention. The algorithm should improve the learning curve of trainees and enable surgeons to use the navigation system routinely and systematically.

The aim of this study is to present five surgical cases of recurrent sinonasal melanoma. We report the clinical course of this highly malignant disease and give a brief overview of the relevant literature. For the purpose of our presentation, inclusion criteria for all patients were initally negative surgical margins, surgery with curative intent without implementation of radiotherapy, and absence of distant metastatic spread at presentation (MO). They were diagnosed and treated at the same ENT/Head and Neck Surgery department and had clear surgical margins following first resection. The majority of five cases had local recurrences (average two) which were all amenable to at least one salvage operation. In conclusion, despite extensive disease at presentation, we recommend repeated attempts at local surgical salvage. However, this decision must be carefully considered, respecting postoperative quality of life, the estimated life expectancy as well as general socioeconomic issues in each particular case.

Ear, nose, and throat problems comprise a significant portion of patient visits to the primary care physicians' offices, urgent care facilities, emergency rooms, and children's hospitals. Since its beginnings in the 1970s, the specialty of pediatric otolaryngology has developed significantly and even more so in the last five to ten years. The aim of this special issue is to offer our pediatrician colleagues an opportunity to learn about recent advances in both diagnostic methods and therapeutic procedures that are now available to assist in the care of children with ear, nose, and throat disorders. This special issue is comprised of both original clinical research and review articles from all areas of pediatric otolaryngology such as otologic disease and hearing loss, sinonasal disorders, airway issues, and head and neck masses. These papers emphasize how methods of diagnosis have improved for certain conditions, how existing surgical procedures have been modified to be less invasive and better tolerated, and finally, how new technology and operations allow clinicians to treat otolaryngologic disorders that were without treatment in the past. The paper “Troublesome tinnitus in children: epidemiology, audiological profile, and preliminary Results of Treatment” by G. Bartnik et al. offers a very readable and practical approach to a common otologic problem in children while most pediatric textbooks often have no information on this subject. This group offers their experience with a treatment called “Tinnitus Retraining Therapy.” A. Koravand, B. Jutras, and M. Lassonde present their original research using the diagnostic tools of cortical auditory evoked potentials and mismatch responses (MMRs) to identify patterns of neural activity in the central auditory system of children with hearing loss. The care of patients with nose and sinus complaints can be frustrating to the primary care physician. H. Ramadan's paper “Chronic rhinosinusitis in children” provides a simple, straightforward approach to the pediatric patient with these symptoms including the use of “real-life” examples to illustrate the important aspects of the history and physical exam that are necessary in the care of these patients. After reading this article, any health care practitioner will feel more confident about their decision-making in patients with sinus disease. Although juvenile angiofibroma is a rare clinical problem, P. Nicolai, A. Schreiber, and A. B. Villaret describe new, less invasive approaches to treatment of this sinonasal mass. This is in addition to a succinct review of the pathophysiology and recommended work-up including the relative advantages and disadvantages of various radiographic imaging techniques. The airway section of this special issue will be of great value to the primary care practitioner. Included are three papers on stridor in the infant, one dedicated entirely to laryngomalacia, and lastly, a paper on a new diagnostic tool called “sleep endoscopy.” M. Daniel and A. Cheng discuss the approach to an infant with noisy breathing or stridor; separating the material into three sections that allow for easy recall and use by the pediatrician. Novel approaches such as the EXIT procedure to treat disorders of the fetal airway are presented. A. M. Landry and D. M. Thompson's review article on laryngomalacia will be equally relevant. The reader will find it to be complete yet easily digestible. Finally, any health care practitioner will be familiar with the frustration of seeing patients for persistent difficulty breathing at night after adenotonsillectomy for upper airway obstruction or obstructive sleep apnea. Although polysomnography can determine the presence and severity of any degree of obstruction, it cannot identify the location of obstruction. The paper by A. C. Lin and P. J. Koltai describe a new diagnostic tool called “sleep endoscopy” that will allow otolaryngologists the opportunity to identify such areas of obstruction and perhaps offer treatment options which were not obvious in the past. The approach to a patient with a vascular malformation can be confusing. G. T. Richter's review article on this clinical entity will be very helpful to the primary care practitioner. Nomenclature, relevant parts of the history and physical exam, diagnostic tools including radiographic imaging studies, and medical and surgical therapies are discussed. D. Dzepina's paper on papillary thyroid carcinoma in children describes their approach and results with total thyroidectomy including neck dissection for lymphatic dissemination which is common in this type of thyroid cancer. The editors of this special issue have worked hard with the authors to provide primary care practitioners with information that is relevant to their practice and, at the same time, very easy to read and understand. We hope the papers in this special issue will be of great help to primary care practitioners as they see pediatric patients with ear, nose, and throat problems. Jeffrey A. Koempel Tomislav Baudoin Alan T. L. Cheng Debra M. Don Ajoy M. Varghese

Compared with rhinologic patients without chronic rhinosinusitis (CRS), a higher prevalence of sinonasal Helicobacter pylori (HP) in patients with CRS was found. This study investigated if HP sinonasal colonization has a prognostic value for efficacy of functional endoscopic sinus surgery (FESS). Nasal polyps of 40 patients with CRS, undergoing FESS, were analyzed for presence of HP using immunohistochemistry (IHC). Patients were categorized as to whether the IHC was positive (HP+ group) or negative (HP- group). HP+ group and HP- group were compared according to the nasal polyp eosinophil density, and to the improvement (difference between pre- and post-operative scores) of the subjective symptom scores, and the nasal endoscopic scores. Nasal polyps in 28 (70%) patients were positive for HP. There were no significant differences between HP+ group and HP- group comparing the eosinophils, and the improvement of the single symptom and the total symptom scores. HP+ group had significantly greater improvement of the nasal endoscopic scores (F[1.38] = 6.212 ; P = 0.017). There is no influence of sinonasal HP on tissue eosinophilia and on CRS symptoms. There is a prognostic value for endonasal findings: CRS patients with HP have statistically significant greater improvement of the postoperative endoscopic scores.

Sore throat is most commonly caused by viruses, but when caused by bacteria, the most important is group A streptococcus (GAS). The aim of these guidelines is to determine optimal treatment for streptococcal sore throat and reasonable indications for tonsillectomy, as well as recommend how to differentiate streptococcal infection for which antibiotics are justified, from numerous other sore throats where antibiotics wont have a significant effect on disease course, but might contribute to bacterial resistance to antibiotics. The development of the guidelines was initiated by the Interdisciplinary Section for Antibiotic Resistance Control (ISKRA) of the Croatian Ministry of Health and Social Welfare in accordance with the principles of AGREE (Appraisal of Guidelines for Research and Evaluation) methodology which means that the guidelines are the result of consensus between all interested professional societies and institutions. For streptococcal sore throat diagnostics, the Working Group recommends evaluation of clinical presentation according to Centor criteria and for patients with Centor score 0-1, antibiotic therapy is not recommended nor bacteriological testing, while for patients with Centor score 2-4 bacteriological testing is recommended (rapid test or culture) as well as antibiotic therapy in case of positive result. The drug of choice for the treatment of streptococcal tonsillopharyngitis is oral penicillin taken for ten days (penicillin V) or in case of poor patient compliance benzathine penicillin G can be administered parenterally in a single dose. Other antibiotics (macrolides, clindamycin, cephalosporins, co-amoxiclav) are administered only in case of hypersensitivity to penicillin or in recurrent infections. Tonsillectomy is a widely accepted surgical procedure that decreases the number of sore throats in children and should be performed only if indications for this procedure are established. Absolute indications include five or more streptococcal infections per year, tonsillitis complications, permanent respiratory tract obstruction, obstructive sleep apnea syndrome and suspected tonsillar malignancy. Relative indications include chronic tonsillitis and occlusion disturbances.

To study frequency and type of indications for tonsillectomy in ENT Department of "Sestre milosrdnice" Clinical Hospital, distribution of operations according to the age and sex of the patients. To present history of tonsillectomies.Retrospective study, information collected by clinical documentation review (anamnesis, physical findings).In the nine-year period 1995 - 2003 the total number of operations was 4704, 2527 male, 2177 female patients. There were 2692 tonsillectomies, 2011 adenotomies and 1 tonsillectomy "a chaud". The most frequent indication for tonsillectomy was recurrent tonsillitis (72%), followed by adenotonsillar hypertrophy (13%), chronic tonsillitis (12%), focaloses (1%) and peritonsillar abscess (2%). Distribution according to the surgeon: 80% of the operations were performed by specialists, 20% by residents. According to the age of patient: operations were most often performed at the age of 4 (800 patients).According to this study the most frequent indication for tonsillectomy was recurrent tonsillitis. Indications for tonsillectomy are clearly defined and as such should be followed.