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CASE REPORTS
Intravascular papillary endothelial hyperplasia (Masson's tumor) as a nasal mass: a case report and review of the literature
Khalid H Al-Qahtani
January-June 2016, 6(1):33-35
DOI
:10.4103/2090-7540.183731
Intravascular papillary endothelial hyperplasia (Masson's tumor) is a rare non-neoplastic vascular proliferative process in a normal blood vessel or vascular malformation. Nose and paranasal sinuses are extremely rare location for this type of tumor. We report a case of Masson's tumor in a 33-year-old female, presented with an obstructing nasal mass in the right side, repeated epistaxis and rhinorrhea for eight months associated with anosmia, frontal headache and proptosis.
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Bilateral antrochoanal polyps: a case report and literature review
Amnah S.A. Alashoura, Nada A Alshaikh, Samuel Yeak
July-December 2016, 6(2):59-63
DOI
:10.4103/2090-7540.200619
Antrochoanal polyp (ACP) is a common unilateral benign lesion that originates from the maxillary sinus mucosa and protrudes through the choana into the nasopharynx. Patients usually present with progressive unilateral nasal obstruction. Rarely, bilateral ACPs could be encountered in clinical practice. It is important to recognize such unusual entity to spare patients unnecessary investigations and prolonged medical and aggressive surgical treatment. Generally, ACP is managed surgically with complete excision including the mucosa of origin to reduce the risk for recurrence. In this report, we present a rare case of bilateral simultaneous ACPs that was managed successfully with endoscopic excision. Review of the literature as regards the etiology, pathophysiology, different clinical presentations, and management aspects of ACP is also presented.
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HOW I DO IT?
How I do it: direct transnasal endoscopic posterior ethmoidectomy with the intact bulla technique
Reda Kamel, Hesham Mansour
July-December 2016, 6(2):64-66
DOI
:10.4103/2090-7540.200614
In lesions affecting both anterior and posterior ethmoids where surgery is indicated, total ethmoidectomy as part of functional endoscopic sinus surgery is the state of the art. In solo posterior ethmoid lesions, there is still controversy in terms of the most direct and least destructive approach. In these cases, it is not justified to disturb the integrity of the bulla ethmoidalis and/or the middle turbinate. In this article, a novel approach to the posterior ethmoid is presented that does not disrupt the integrity of the ostiomeatal complex.
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ORIGINAL ARTICLES
Endoscopic nasopharyngectomy for nasopharyngeal carcinoma
Reda Hussien Kamel, Mohamed Salah Eldeen Hassan, Ahmed Elfarouk Abdelfattah, Ahmed Selim Fouad, Sameh Medhat Zamzam
January-June 2016, 6(1):5-10
DOI
:10.4103/2090-7540.186904
Background
The radiosensitivity of nasopharyngeal carcinoma has led to effective primary treatment using radiation with or without chemotherapy. Despite modern radiotherapy techniques, recurrent or persistent disease remains challenging.
Materials and Methods
This study included 10 patients who underwent endoscopic nasopharyngectomy: two primary cases of nasopharyngeal carcinoma, five cases recurrent after finishing treatment with chemoradiation by 7–14 months, and three patients showed residual disease just after finishing therapy using chemoradiotherapy confirmed with biopsy. The average age was 43.5 years. Chemoradiotherapy was performed postoperatively for all patients. Margin status and complications were evaluated. Repeated nasopharyngeal endoscopic assessment plus computed tomography and MRI imaging with contrast were carried out, with a mean follow-up period of 17.5 months.
Results
One patient showed recurrence (10%) and was managed with resurgery. No deaths were recorded due to the disease (overall survival rate, 100%) until the end of this study, and there were no major complications.
Conclusion
Endoscopic nasopharyngectomy is a feasible, direct, effective, and safe surgical procedure. Long-term follow-up is necessary for better assessment.
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Effect of middle turbinate intervention on outcomes of middle meatal endoscopic surgery
Khaled M Bofares
January-June 2016, 6(1):27-32
DOI
:10.4103/2090-7540.186905
Background and objective
Middle turbinate position, bulk, and shape play a significant role in the determination of drainage and ventilation at the middle meatus. The middle turbinate constitutes the corner stone for the performance of drainage as well as ventilation functions at the area of the ostiomeatal complex. As one of the major aims of middle meatal endoscopic surgery is providing sufficient drainage and ventilation at the level of this complex, the middle turbinate should be assessed properly before the surgery with regard to its position, size, and shape, which may predispose for sinusitis through the obliteration of the ostiomeatal complex as in cases of paradoxical middle turbinate, concha bullosa of the middle turbinate, hypertrophy of the middle turbinate, and double middle turbinate. These varieties of abnormal middle turbinate need to be interfered accordingly to reduce the risk for recurrence of sinusitis after the surgery. In addition, the normal middle turbinate may lateralize postoperatively and subsequently result in the reobstruction of the drainage and ventilation at the middle meatal area. Therefore, for the purpose of maintenance of sufficient drainage and ventilation after middle meatal endoscopic surgery, it is suggested to interfere with the normal middle turbinate either by means of its partial resection at its lower part, its medialization and further fixation of it to the nasal septum with a stitch, or by creating a synechia with the mucoperiosteal flap over the nasal septum. For this reason the serial analytic coherent clinical study was planned prospectively to postulate as to which technique is the best among the previously mentioned three techniques and compared further with noninterfered middle turbinate cases.
Patients and methods
Sixty patients between 14 and 63 years of age with chronic sinusitis presented with clinical as well as radiological evidence of maxilloethmoidal sinusitis with or without frontal and sphenoidal involvement at ENT OPD, Al-Tarahom Private Center (Elbyda, Libya), during the period between July 2013 and March 2015 and underwent functional endoscopic sinus surgery. The patients were divided into four groups, group A (
n
= 16), group B (
n
= 18), group C (
n
= 6), and group D (
n
= 20), which included those patients who proceeded after middle meatal endoscopic surgery with the medialization of the ipsilateral middle turbinate and creation of a synechia between it and the nasal septum, partial resection of the ipsilateral middle turbinate at its lower third, medialization and further fixation of the ipsilateral middle turbinate to corresponding nasal septal flap using a vicryl stitch material, or just medialization of the ipsilateral middle turbinate without any further fixations, respectively. The four groups were compared in relation to postoperative patency persistence of the ipsilateral middle meatus and correlated with the incidence of sinusitis recurrence after the surgery.
Results and conclusion
An overall 49% of the patients who underwent just medialization of the ipsilateral middle turbinate without any further fixations developed recurrence of sinusitis due to reobliteration of the middle meatus either by means of a synechia between the middle turbinate and the lateral wall or by means of extreme lateralization of the middle turbinate compared with the other groups. All patients in other groups achieved complete improvement without any evidence of recurrence of sinusitis after 1 year of follow-up, apart from 12% of patients in group B who presented with evidence of sinusitis recurrence after 3–6 months postoperatively. Broadly speaking, the intervention with the normal middle turbinate can be considered as one of the important steps during the middle meatal endoscopic surgery that may help significantly toward the improvement of outcomes of this commonly performed procedure.
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CASE REPORTS
Pleomorphic adenoma of the nasal septum: a case report and review of the literature
Ali Al Momen, Abdulrahman Al Khatib
January-June 2016, 6(1):36-38
DOI
:10.4103/2090-7540.183985
Intranasal pleomorphic adenomas are quite rare and are frequently misdiagnosed . We report a nasal septal pleomorphic adenoma in a 60-year-old man. Rigid endoscopy of the nose revealed a large polypoid mass filling the right posterior nasal cavity. Computed tomography scan of the paranasal sinuses demonstrated well-pneumatized paranasal sinuses and a soft tissue mass in the posterior aspect of the right nasal cavity arising from the posterior part of the septum. A submucous resection was used as an approach to the tumor and as a method of excising the mass with the segment of septum attached to it. After 4 years, the patient had experienced no further problems with the nasal airway, and repeated nasal endoscopic examination revealed no recurrence of the disease.
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ORIGINAL ARTICLES
Level of total and specific fungus IgE in allergic fungal sinusitis: how it affects management and follow-up
Nabil Galal, Ahmed Shawky, Mahmoud El-Fouly, Ahmed Kamel, Hisham Lasheen, Mahmoud El-Essawy
July-December 2016, 6(2):45-50
DOI
:10.4103/2090-7540.200617
Objective
The aim of this study was to evaluate the relationship between the level of total serum IgE and the prognosis of allergic fungal sinusitis, possibility of recurrence and level of aggressiveness.
Type of the study
This study was a prospective controlled one.
Patients and methods
Forty patients who were diagnosed as having allergic fungal sinusitis were randomly divided into two equal groups. One group (group A) received postoperative systemic steroids, whereas the other group (group B) received postoperative local steroids only. The patients were followed up for 6 months with endoscopy and IgE level evaluation.
Results
The total number of patients who had recurrence of the disease 6 months postoperatively was 17. Six of them were from group A (systemic steroids) and 11 were from group B (local steroids only).
Conclusion
Allergic fungal sinusitis should be treated with minimal surgical or endoscopic procedures, followed by local and more important systemic steroids for a prolonged period. Patients should be followed up at close intervals postoperatively using nasal endoscopy and more importantly serum IgE (total and if available fungus specific) as it is a good indicator to the future possibility of recurrence and thus the possibility of resurgery or further medical treatment.
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Role of static MRI in assessment of velopharyngeal insufficiency
Tarek M. Y. El Banoby, Fawzy A Hamza, Mahmoud I Elshamy, Amro M. A. Ali, Ahmed A Abdelmonem
January-June 2020, 10(1):21-26
DOI
:10.4103/pajr.pajr_5_19
Aim
The purpose of this study was evaluation of static MRI in assessment of VPI and correlation to auditory perceptual assessment (APA) and nasoendoscopy.
Background
Velopharyngeal insufficiency (VPI) occurs owing to insufficient tissues of the velopharyngeal valve.
Patients and methods
This was a multidisciplinary prospective study conducted at Al-Azhar and Beni-Suef University Hospitals, Egypt. The study group consisted of 20 children with VPI postpalatoplasty, aged from 3 to 9 years. Normal MRI values were obtained from Ruotolo et al, and Perry et al. Patients were evaluated by history taking, Gutzman's and Czermark's tests, APA, nasoendoscopy, and static palatal MRI.
Results
APA revealed that most of the patients had bad speech scales. Nasoendoscopy revealed that most of patients had concave velum, absent posterior pharyngeal wall movement, and circular velopharyngeal gap. MRI revealed that patients' velopharyngeal parameters were significantly lower than normal values, and most of patients had symmetrical muscle limbs. Velar length and thickness had a significant positive linear correlation with degree of velar movement. Effective velar length had a moderate negative correlation with degree of velar movement and degree of open nasality.
Conclusion
Static MRI is an important tool in assessment of VPI but should be accompanied by dynamic tools in cases with relatively normal ranged anatomy.
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Effect of using diluted adrenaline injection on hemodynamical parameters during septoplasty
Naif A Alfattani, Ghaydaa S Hazzazi, Bayan O Besharah, Abdullah S Assalem, Albaraa Y Alsini, Fawziah A Halawani
July-December 2020, 10(2):100-104
DOI
:10.4103/pajr.pajr_13_20
Context
Septoplasty is a common surgical procedure performed to correct the deviated nasal septum. A clear surgical field is imperative for the success rate of the procedure. It can be achieved by improving the visualization of the sinonasal structures by optimizing good hemostasis. Adrenaline local infiltration was commonly used despite its potential risks and complications; it is still controversial and referred to as surgeon preference. We aimed to study and evaluate the effect of diluted adrenaline injection in the submucoperichondrial plane in the nasal septum during nasal surgery in relation to hemodynamic parameters of the patient during the procedure.
Aims
We aimed to study and evaluate the effect of diluted adrenaline injection in the submucoperichondrial plane in the nasal septum during nasal surgery in relation to hemodynamic parameters of the patients during the procedure.
Patients and methods
This retrospective single-?center study included patients who underwent septoplasty under general anesthesia at Al-Noor Specialist Hospital from 2014 till 2018.
Statistical analysis
Statistical analysis was performed using Statistical Package for Social Science software, version 21.0.
Results
This study included 223 patients who underwent septoplasty. Males were more prevalent than females (72.6 vs. 27.4%). The sample included 19.3% patients with diabetes, 17.5% were hypertensive, 3.6% had cardiac disease, 1.8% had hypothyroidism, and 2.2% had renal diseases. The mean ± SD of heart rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, and oxygen saturation at baseline and after injection for 12 min was recorded, reflecting no significant changes regarding increasing in all parameters.
Conclusions
Injection of diluted adrenaline (1: 100 000 or 1: 200 000) during septoplasty in relation to hemodynamic parameters is safe, as there is no increase in heart rate, blood pressure, or mean arterial pressure after the infiltration in the submucoperichondrial plane regardless of the patients' comorbidities.
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Frontal sinus fracture classifications: a review of literature and presenting a new classification
Mohammad W El-Anwar, Ahmed S Elaaser
July-December 2020, 10(2):89-93
DOI
:10.4103/pajr.pajr_7_20
Introduction
Several classifications have been published for the frontal sinus (FS) fractures.
Objectives
To review the literature regarding different classifications of the FS fractures to collect and analyze the most commonly used classification and to present a new easily applicable and therapeutically helpful classification that avoids the disadvantages of the previous classifications.
Data synthesis
Repeated searches were performed in the PubMed, LILACS, MEDLINE, SciELO, databases, and Cochrane Library, and the key words used in the search were FS fractures, FS outflow tract, classification, and frontal bone. Collected studies were read and analyzed, and different FS fractures classifications were described and assessed for advantages, disadvantages, missed data, and pitfalls.
Conclusion
This review would be helpful for surgeons to be familiar with different classifications of the FS fractures. A new classification for the FS fractures was presented and described here to overcome the pitfalls of the already described classification and to update the categorization data to the currently used treatment philosophy and tools to be more applicable and treatment based. Moreover, we precisely provide the supposed appropriate treatment for each FS type.
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Role of lingual splint in prevention of mandibular flaring in management of mandibular fracture
Mohamed El sayed Hassan, Hamada Fadl Hashem, Ayman Abdel Aal Mohamady
January-June 2021, 11(1):14-25
DOI
:10.4103/pajr.pajr_12_20
Introduction
For the past decades, there has been a significant increase in head–maxillofacial traumas, and mandible fracture occupies the second most frequent incidence of facial bone fractures, with incidence of approximately 38%. They are mainly caused by road traffic accidents (RTA).
Aim
The aim was to study the effect of repairing the parasymphyseal mandibular fractures with rigid fixation alone vs usage of lingual splint with rigid fixation regarding occurring of mandibular flaring.
Patients and methods
A prospective randomized clinical study was carried out in Benha University Hospital, and it included 30 patients who had isolated parasymphyseal mandibular fractures. Patients were allocated into two groups: group A (15 patients underwent rigid fixation of parasymphyseal mandibular fracture) and group B (15 patients underwent rigid fixation of parasymphyseal mandibular fracture with usage of lingual splint).
Results
This study showed that in group B the mean bigonial width and bicondylar breadth were lower than that in group A; these differences were statistically significant at 3 months after operation, but there were no significant difference between both groups in the preoperative time and just after operation. Regarding complications, there were no significant differences between the two groups regarding intraoperative and postoperative complications.
Conclusion
Adding lingual splint as adjuvant to rigid fixation will offer more stability and accuracy for reduction, and it will prevent occurrence of lingual splay of fracture fragments and mandibular angle flaring, with subsequent minimizing effect on temporomandibular joint.
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Endoscopic coblation versus cold curettage adenoidectomy
Mohammed Aleem, Amr N Rabie, Amany F S Ibrahim
January-June 2021, 11(1):26-36
DOI
:10.4103/pajr.pajr_20_20
Objective
To compare between endoscopic coblation versus cold curettage adenoidectomy regarding operative time, blood loss, postoperative pain, and complications.
Patients and methods
This systematic review was performed in accordance to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. An electronic search was conducted from 1998 till 2019 using the different keywords (curettage–coblation techniques of adenoidectomy) through the MEDLINE databases.
Results
The search retrieved 163 unique records. We then retained 49 potentially eligible records for screening. Finally, 14 studies were included in the present work. Concerning the operative time, the overall effect estimates favored curettage over coblation [95% confidence interval (CI) −11.1 to −4.41;
P
= 0.001). A smaller amount of blood loss was noted in coblation group (95% CI −14.29 to −15.76;
P
= 0.23). The postoperative pain was less with coblation (95% CI −0.07 to −4.75;
P
= 0.04). One study directly compared the recurrence rate in the two groups. It favored coblation over curettage for reduction of recurrence rate.
Conclusion
Endoscopic coblation is superior to curettage adenoidectomy regarding the intraoperative blood loss and postoperative pain. However, special attention should be paid for operation time with endoscopic coblation. Nevertheless, further studies are still needed to confirm our findings.
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Alterations in serum iron markers in allergic fungal rhinosinusitis
Mohamed M Osman, Mohamed I Seddik, Mohamed O. A. Gad
July-December 2021, 11(2):100-104
DOI
:10.4103/pajr.pajr_4_21
Background
There is a debate concerning serum iron markers in fungal infections in patients with different diseases, and so far, none has assessed their level in fungal rhinosinusitis. Therefore, this study aimed to detect whether allergic fungal rhinosinusitis is associated with alterations in serum iron markers.
Patients and methods
Patients of this study were classified into two groups: group A included 35 patients with allergic nasal polyps, and group B included 31 patients with allergic fungal rhinosinusitis. Computerized tomography of paranasal sinuses was performed for all patients. Serum iron and total iron-binding capacity (TIBC) of all patients were measured, and unsaturated iron-binding capacity (UIBC) and transferrin saturation (TSAT) were calculated.
Results
Both the TIBC and UIBC were significantly higher in the allergic fungal rhinosinusitis group than the nasal polyps group. No significant differences were detected in the levels of serum iron and TSAT between the two groups.
Conclusion
Allergic fungal rhinosinusitis is associated with higher TIBC and UIBC, suggesting a possible role of iron in the pathogenesis of allergic fungal rhinosinusitis.
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72
Evaluation of preoperative naso-alveolar molding in correction of unilateral complete cleft lip and palate associated with nasal deformity
Mahmoud El-Bestar, Mamdouh Aboulhassan, Nermin Z Fahmy, Adel El-Antably
July-December 2021, 11(2):110-117
DOI
:10.4103/pajr.pajr_11_21
Objectives
Complete cleft lip and palate (CLP) is a common congenital middle-third facial defect, which has considerable medical, economic, social, and psychological consequences for the affected individuals and their families. Many surgical techniques had evolved for correction, but the displacement of the lower lateral nasal cartilage is considered a challenge for the surgeon. Preoperative naso-alveolar molding (NAM) aims at alignment of tissues, thus improving the surgical outcome. The aim of the current study was to assess the outcome of the use of NAM as a presurgical orthodontic modality for the treatment of patients with unilateral complete CLP associated with nasal deformity.
Patients and methods
This prospective controlled study was conducted on 16 randomly selected patients with unilateral complete CLP associated with nasal deformity. They were divided randomly into two equal groups. One group included eight patients who underwent presurgical NAM therapy, and the other one included eight patients who underwent surgical repair only as a control.
Results
A statistically significant difference was found regarding the hemicolumellar height ratio. Although alar base width values were slightly smaller in presurgical NAM therapy group, no statistically significant difference was found for the alar base width values or the domal angles.
Conclusion
Presurgical NAM proved superior postsurgical nasal symmetry compared with controls regarding the nostril height. The parents of patients with unilateral complete CLP associated with nasal deformity should be counselled to have presurgical NAM to improve the surgical outcome.
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64
Pterygopalatine fossa: a computed tomography analysis and classification
Mohammad W El-Anwar, Diaa B Eldib, Mohamed S Haggag, Rania M Almolla, Mohammad El-Sayed Abd Elbary, Taha M Abdelaal, Alaa O Khazbak
July-December 2021, 11(2):145-150
DOI
:10.4103/pajr.pajr_25_21
Objective
To find out the various dimensions, measurements, and grading of the pterygopalatine fossa (PPF) that were not antecedently published using computed tomography (CT).
Patients and methods
This study was carried on the included 200 paranasal CT scans (400 sides). Axial images were acquired with multiplanar reformates to obtain delicate details in coronal and sagittal planes for all participants.
Results
Within 200 CTs (400 sides), the mean anteroposterior dimension of the PPF was 7.33±1.3 mm (range=3.8–11.6), the mean PPF transverse diameter was 12.5±2.09 mm (range=7.25–22.1), and the mean PPF height was 16.99±2.83 mm (range=10–22.2), without reported significant differences between both sides in all PPF dimensions.
Conclusion
This study improves surgeons' awareness of PPF variations in the endoscopic field and can be of help to residents in training.
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Strategy of endoscopic skull base reconstruction in endoscopic transsphenoidal approaches
Osama Hassan, Maha Zaki, Aly El Garem, AbdEl Rhman Younes
July-December 2021, 11(2):72-76
DOI
:10.4103/pajr.pajr_13_21
Introduction
Endonasal endoscopic approaches gained acceptance in managing many benign skull base tumors. Cerebrospinal fluid (CSF) leak is a common and serious complication with high risk of morbidities or mortality. Identification and management of intraoperative CSF leak is a critical step in these approaches. Various methods and materials had been described for a skull base reconstruction. The size of arachnoid defect plays a crucial role in selecting the proper method of reconstruction.
Patients and methods
This is a prospective analytical study in which 67 patients with benign skull base lesions who were candidates for endoscopic transnasal transsphenoid surgery were included. All cases were subjected to detailed assessment protocol preoperatively and postoperatively. Intraoperative CSF leak was meticulously observed and graded according to the size of arachnoid defect, and then reconstruction was done according to grade of CSF leak by grafts or flaps or combination of them.
Results
This study included 67 patients with sellar–suprasellar tumors who were managed by endoscopic transsphenoid approach. Intraoperative CSF leak occurred in 23 (34.3%) cases. A total of nine (13.4%) cases had grade 1 CSF leak, and all cases were reconstructed with abdominal fat with success rate of 100%;six (8.9%) cases had grade 2 CSF leaks, and all cases were repaired with pedicled nasal flap with success rate (83%); and grade 3 CSF leak occurred in eight (11.9%) cases, and all were repaired with multilayer technique, with success rate of 75%. The incidence of postoperative CSF leak in this study was 4.5%, that is, three patients.
Conclusion
The strategy of skull base reconstruction depending on grade of intraoperative CSF leak according to size of arachnoid defect produces a promising result in decreasing the incidence of postoperative CSF leak and saving the need of unnecessary flaps.
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Effect of combined septal and turbinate injection of botulinum toxin type A in allergic rhinitis
Mostafa Ismail, Alaa Nabil, Mostafa Nasr, Balegh Abdelhak, Osama G Awad, Khalaf Hamead
July-December 2021, 11(2):95-99
DOI
:10.4103/pajr.pajr_7_21
Objective
Allergic rhinitis (AR) has increased in prevalence recently, and traditional treatment strategies sometimes show limited effectiveness for patients with intractable AR. Botulinum toxin type A (BTX-A) is among the increasingly used alternative treatment options. This study was carried out with the aim of performing a clinical assessment of the effect of combined septal and turbinate injection of BTX-A for the management of uncontrolled AR.
Materials and methods
A single-arm pilot study enrolled 40 patients with moderate to severe uncontrolled AR recruited between October 2018 and August 2019. Each patient received 45 units of BTX-A injected into three fixed points of each side of the nose: inferior turbinate (15 IU), middle turbinate (15 IU), and nasal septum (15 IU). All patients were evaluated in terms of nasal hypersecretions, congestion, and sneezing with a visual analog scale before treatment and at weeks 1, 2, 4, 8, and 12 during the follow-up period.
Results
Throughout the 12-week follow-up period, a significant difference in the degree of nasal hypersecretions could be identified before and after BTX-A injection. Sneezing differed significantly only in the first 4 weeks, while nasal congestion did not differ significantly before and after BTX-A injection. BTX-A was well tolerated by the patients, with no serious adverse or systemic effects.
Conclusion
Combined septal and turbinate injection of BTX-A, in patients with uncontrolled AR, may be a long-lasting therapeutic option for the treatment of nasal hypersecretions, but not as effective as for sneezing and nasal congestion.
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th
April, 2016