PROGRAMandABSTRACTeBOOK

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PROGRAM

Theme Speaker

14.00 -

15.00 Registration

15.00 -

15.45 Opening Ceremony

15.45 -

16.30Welcome Drink

16.30 -

18.00

Advances in RhinologyChairperson: Wytske Fokkens (Amsterdam, The Netherlands)Moderators: Nicolas Busaba (Boston, USA), Rajko Jović (Novi Sad, Serbia)

The future of rhinologyWytske Fokkens, Amsterdam, The Netherlands

Advances in the medical management of chronic rhinosinusitis

Nicolas Busaba,Boston, USA

Learning from mine and other people mistakes in skull base reconstruction and CSF leak management

Christos Georgalas,Athens, Greece

State of the art in cleft lip rhinoplasty Marc Scheithauer,Ulm, Germany

Therapeutic approach and results of the treatment of malignant tumors of the sinonasal region

Rajko Jović,Novi Sad, Serbia

Thursday, 04 April 2019

Theme Speaker

08.00 - 09.00 Registration

09.00 - 10.30

Endoscopic and Skull Base Surgery (Session 1)Chairperson: Sergei Karpischenko (Saint Petersburg, Russia)Moderators: John DelGaudio (Atlanta, USA),Timoleon Terzis (Athens, Greece)

Cystic fibrosis in children - what is the role of FESS?

Dilyana Vicheva,Plovdiv, Bulgaria

Isolated sphenoid sinusitisSergei Karpischenko,Saint Petersburg, Russia

Endoscopic treatment of the middle turbinate

John DelGaudio,Atlanta, USA

Complications of endoscopic sinus surgery

Timoleon Terzis,Athens, Greece

Interstitial brachytherapy for the management of nose vestibule malignancy

Francesco Bussu,Sassari, Italy

10.30 - 11.15 Satellite Symposium

The role of Cinnabsin® in treatmentof acute and chronic rhinosinusitis

Dyliana Vicheva(Alpen Pharma)

Friday, 05 April 2019

Respimer® - tsunami in the nose

Aleksandar Ugrinović(Emi Pharm)

The role of Nasaleze® spray in treatment of allergic rhinitis

Slobodan Savović (Lifemedic)

11.15 - 11.45 Coffee Break

11.45 - 13.15

Rhinitis/Rhinosinusitis (Session 1)Chairperson: Sarah K. Wise (Atlanta, USA)Moderators: Tomislav Baudoin (Zagreb, Croatia), Aleksandra Barać (Belgrade, Serbia)

Highlights from the International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis - What we know and what we don’t?

Sarah K. Wise,Atlanta, USA

Upper respiratory tract diseases: host-microbe interactions in chronic rhinosinusitis

Aleksandra Barać,Belgrade, Serbia

Gender associated differences in neuroallergic response to nasal challenges

Livije Kalogjera,Zagreb, Croatia

Does treatment of laryngopharyngeal reflux improve symptoms of chronic rhinosinusitis?

Tomislav Baudoin,Zagreb, Croatia

Rhinitis in athletes Pavol Surda, London, UK

13.15 - 14.00 Satellite Symposium

Therapeutic options for the outpatienttreatment of acute upper airway infections

Aleksandra Barać (Hemofarm Stada)

Dymista® - the winning combination, 2018 study

Bojan Pavlović (Mylan)

The use of Sinomarin® Allergy Relief intreatment of allergic rhinitis

Vesna Tomić Spirić(Oktal Pharma)

14.00 - 15.00 Lunch/E-Poster Session 1

15.00 - 16.15

Rhinitis/Rhinosinusitis (Session 2)Chairperson: Aleksandar Perić (Belgrade, Serbia)Moderators: Ljiljana Jovančevič (Novi Sad, Serbia), Tanja Soklič Košak (Ljubljana, Slovenia)

Transcription factors gene expression in CRS with and without nasal polyps

Tanja Soklič Košak, Ljubljana, Slovenia

Is there an otologic manifestation of Samter’s triad?

Ljiljana Čvorović,Belgrade, Serbia

Olfaction in neurodegenerative disease

Ljiljana Jovančević,Novi Sad, Serbia

Effects of intranasal corticosteroid treatment on parameters of eosinophilic inflammation in patients with perennial allergic rhinitis and nasal polyposis

Aleksandar Perić,Belgrade, Serbia

16.15 - 16.45 Coffee Break

16.45 - 18.15

Rhinoplasty and Septal SurgeryChairperson: Gabriela Kopacheva Barsova (Skopje, Republic of North Macedonia)Moderators: Željka Roje (Split, Croatia), Slobodan Savović (Novi Sad, Serbia)

The pillars of the nose-crura shortening for overprojection nose

Gabriela Kopacheva Barsova, Skopje, Republic of North Macedonia

Management of rhinophyma with coblation

Željka Roje,Split, Croatia

Rhinoplasty - personal view and evolution

Jane Netkovski,Skopje, Republic of North Macedonia

Influence of septoplasty on the course of chronic rhinosinusitis

Slobodan Savović,Novi Sad, Serbia

Cartilage and temporal fascia graft for nasal dorsal contouring in revision rhinoplasty

Roven Sinani,Tirana, Albania

20.00 - 23.00 Gala Dinner / BRF party

Saturday, 06 April 2019

Theme Speaker

08.00 - 09.00 Registration

09.00 - 10.45

Endoscopic and Skull Base Surgery (Session 2)Chairperson: Boštjan Lanišnik (Maribor, Slovenia)Moderators: Ivana Pajić Matić (Slavonski Brod, Croatia), Milanko Milojević (Belgrade, Serbia)

Nasal douching after endoscopic sinus surgery

Ivana Pajić Matić,Slavonski Brod, Croatia

Surgical treatment of inverted papilloma: 10-year experience

Maja Buljčik Čupić,Novi Sad, Serbia

Endoscopic surgery for benign and malignant tumors of the nose and paransal sinuses

Boštjan Lanišnik,Ljubljana, Slovenia

Management of paranasal sinus mucoceles

Milanko Milojević,Belgrade, Serbia

Endoscopic skull base surgery: 10-year experience

Aleksandar Trivić,Belgrade, Serbia

Endoscopic repair of cerebrospinal fluid fistulas in nasal liquorrhea

Vladimir Kljajić,Novi Sad, Serbia

Paranasal sinus and anterior skull base malignant tumors. Surgery and decision making

Milan Stanković,Niš, Serbia

10.45 - 11.15 Coffee Break

11.15 - 12.30

Pediatric Rhinology Chairperson: Jannis Constantinidis (Thessaloniki, Greece)Moderators: Aleksandra Aleksić (Banja Luka, Bosnia & Herzegovina),Šekib Umihanić (Tuzla, Bosnia & Herzegovina)

Relationship between chronic nasal obstruction and craniofacial deformities

Aleksandra Aleksić, Banja Luka, Bosnia & Herzegovina

Choanal polyps in children: 10-year experience from a tertiary care hospital

Milica Labus,Belgrade, Serbia

Endoscopic pediatric skull base surgery

Jannis Constantinidis, Thessaloniki, Greece

Significance of adenochoanal ratio in sleep apnea syndrome in children

Šekib Umihanić,Tuzla, Bosnia & Herzegovina

12.30 - 13.00 Satellite Symposium

The nose experts –Nosko Hemo® and Nosko Oil®

Ljiljana Jovančević (Ceumed)

The role of Beta-glukan in treatmentof atopic diseases

Jasna Jovićević (Esensa)

13.00 - 14.00 Lunch /E-poster session 2

14.00 - 15.15

Rhinitis/Rhinosinusitis (Session 3)Chairperson: Boris Jelavić (Mostar, Bosnia & Herzegovina)Moderators: Jetmira Fejza Bulaj (Tirana, Albania), Snežana Sanković Babić (Belgrade, Serbia)

Safety profile of allergen-specific immunotherapy of allergic rhinitis

Katarina Mitrović,Podgorica, Montenegro

Cone Beam Computed Tomography (CBCT) imaging in preoperative assessment of patients with chronic sinus diseases

Snežana Sanković Babić, Belgrade, Serbia

Fungal rhinosinusitis: our experience in treatment

Jetmira Fejza Bulaj,Tirana, Albania

Bacterium Helicobacter pylori in chronic rhinosinusitis: cause or bystander

Boris Jelavić, Mostar, Bosnia & Herzegovina

15.15 - 16.15

ERS Juniors Session “How I do it?”Chairperson: Aleksandra Barać (Belgrade, Serbia)Moderators: Pavol Surda (London, UK), Puya Dehgani Mobaraki (Perugia, Italy)

Turbinoplasty: endoscopic reduction and minimizing the risk of bleeding

Pavol Surda,London, UK

Endoscopic assisted coblation turbinoplasty

Puya Dehgani Mobaraki, Perugia, Italy

ERS juniors: history and activities Aleksandra Barać,Belgrade, Serbia

Awardee of “The best Junor’s Abstract Award”

Awarded ERS Junior Member E-poster presentation

16.15 Farewell and awarding certificates of attendance

ePOSTER SESSIONS

Theme Speaker

14.30 -

15.00

ePOSTER SESSION 1 05 April 2019Chairs: Ljiljana Jovančević (Novi Sad, Serbia),Tomislav Baudoin (Zagreb, Croatia)

ePoster 1: Sinonasal undifferentiated carcinoma - case report

Miroljub Todorović (Montenegro)

ePoster 2: Reconstructive surgery of the frontal sinus via external approach in different clinical cases

Jegors Safronovs (Latvia)

ePoster 3: Antibiotic treatment of acute sinusitis in primary health care in Novi Sad, Serbia

Tamara Tešić(Serbia)

ePoster 4: Sinonasal mucosal melanoma: retrospective analysis of 17 patients

Bruno Domingues (Portugal)

ePoster 5: Primary nasopgaryngeal tuberculosis as a rare case for non-pulmonary tuberculosis

Ana Trimoska-Radevska(North Macedonia)

ePoster 6: Nasopgaryngeal presentation of second branchial cleft cyst: case report of a 29-year-old female patient

Vladan Stanojković (Slovenia)

ePOSTER SESSIONS

Theme Speaker

13.30 -

14.00

ePOSTER SESSION 2 06 April 2019Chairs: Gabriela Kopacheva Barsova (Skopje, North Macedonia), Aleksandar Perić (Belgrade, Serbia)

ePoster 7: Comparative study between jodoform-vaseline nasal packing and Merocel Hemox 10 cm after the septo-turbinoplasty or rhinoseptoplasty procedure

Marjan Marolov (North Macedonia)

ePoster 8: Pharmaceutical excipients associated with nasal preparations side effects

Tamara Tešić (Serbia)

ePoster 9: Rare sinonasal tumours

José Ferreira Penêda (Portugal)

ePoster 10: Epithelial squamous metaplasia and dysplasia in inflammatory nasal polyps: a 10-year observational study

Marko Stoiljkov (Montenegro)

ePoster 11: Exposure to tobacco smoke and allergic rhinitis in preschool children

Slađana Simović (Serbia)

ePoster 12: The role of granulocyte-macrophage colony-stimulating factor in pathogenesis of chronic non-allergic rhinitis

Danijela Đokić (Serbia)

Editors:

Aleksandar Perić, MD, PhD, Assistant Professor of Otorhinolaryngology, Military Medical Academy Faculty of Medicine, Belgrade, Serbia

Jelena Sotirović, MD, PhD, Assistant of Otorhinolaryngology, Military Medical Academy Faculty of Medicine, Belgrade, Serbia

ABSTRACT eBOOK

FACULTY ABSTRACTS

RELATIONSHIP BETWEEN CHRONIC NASAL OBSTRUCTION AND CRANIOFACIAL DEFORMITIES

Aleksandra Aleksić1, Zorica Novaković1, Željko Markić1, Nataša Dragović2, Dragana Knežević2, Mirjana Gnjatić1

1Department of Ear, Throat and Nose, University Clinical Centre, Banja Luka, Bosnia and Herzegovina2Institute of stomatology. Banja Luka, Bosnia and Herzegovina.Background. Chronic nasal obstruction can cause craniofacial malformations and abnormal craniofacial formation can lead to impaired nasal breathing, sleep disorders and airway obstruction.

Methods. The etiology and management of nasal obstruction in children with craniofacial malformations is widely discussed.

Results. Mouth breathing due to an inadequate nasal airway, could affect craniocervical posture and maxilla-mandibular relationship and cause changes in dentofacial growth and positions of the teeth. Several different factors may act simultaneously and influence changes in craniofacial growth. Cephalometric analysis should be used in order to better recognize mouth breathing caused dento-skeletal dysmorphism. Recognition of nasal incompetence in children, early and proper orthodontic stability are important steps for treatment.

Conclusions. Objective evaluation of mouth breathing is important and treatment of patients with a diagnosis of mouth breathing needs to be a conjunct effort between otolaryngologist, pediatrician, and orthodontist.

UPPER-RESPIRATORY TRACT DISEASES: HOST-MICROBE INTERACTIONS IN CHRONIC RHINOSINUSITIS

Aleksandra Barać

Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade

Background. There has been considerable investigation of host-microbial interactions in patients with chronic rhinosinusitis (CRS) in hopes of elucidating mechanisms of disease and better treatment.

Methods. Inadequate immune responses, as well as a dysbiosis of the sinonasal microbiota, have been put forward as aetiological factors of the disease. Most attention has been paid to bacterial infection and potential underlying defects in innate immunity. Bacterial biofilm is present in most patients with CRS undergoing surgical intervention, and its presence is associated with more severe disease and worse surgical outcomes. A role for viral or fungal infection in patients with CRS is less clear.

Results. There is no evidence for a primary defect in mucociliary clearance in most patients with CRS. Decreased levels of certain antimicrobial proteins, most notably lactoferrin, have been found in sinus secretions, whereas levels of other antimicrobial proteins have been found to be normal. No primary defects in Toll-like receptors have been found in patients with CRS, although a 50% reduced expression of Toll-like receptor 9 was reported in patients with recalcitrant nasal polyps. A polymorphism in a bitter taste receptor was recently associated with refractory CRS and persistent Pseudomonas aeruginosa infection. A downregulation of innate immunity by maladaptive TH2 tissue inflammation has also been described in patients with recalcitrant nasal polyps, suggesting a link to persistent infection.

Conclusions. To date, an effective means of restoring host-microbial balance and mitigating disease in patients with CRS remains elusive. Further research requires in vitro models mimicking the healthy and diseased host environment along with the sinonasal microbiota.

DOES TREATMENT OF LARYNGOPHARYNGEAL REFLUX IMPROVE SYMPTOMS OF CHRONIC RHINOSINUSITIS?

Tomislav BaudoinDepartment of ENT & HNS, Sestre Milosrdnice University Hospital Center, Zagreb, Croatia

Background: Laryngopharyngeal reflux (LPR) is a relatively new clinical diagnosis. According to recent epidemiological data it is a common disorder characterized by regurgitation of gastric contents into larynx, pharynx, nose and paranasal sinuses. It has a very wide spectrum of comorbidities. Most comorbid diseases are those of the respiratory system such as asthma, laryngitis, allergic rhinitis and rhinosinusitis. There are some evidences that LPR has an impact on clinical symptoms and findings in these diseases. The impact is due to respiratory mucosa lesion caused by gastric acid and pepsin. The aim of this lecture is to present data from the literature and our studies which show relationship between chronic rhinosinusitis (CRS) and LPR.

Methods: Review of the literature.

Results: LPR was present with a significantly greater difference in patients with CRS compared to the group of patients without CRS. There are studies which show the presence of pepsin in nasal lavage and Helicobacter pylori in sinonasal mucosa. On the other hand, LPR can mimic CRS symptoms such as postnasal drip.

Available studies suggest that there is a relationship between LPR and recalcitrant CRS refractory to conservative and surgical treatment.Some studies show anti-reflux therapy to be efficient in the treatment of patients with CRS and LPR. The most efficient medical treatment is PPIs long-term treatment.Conclusion: There appears to be a relative prevalence of LPR in patients with CRS. Treatment of LPR could improve symptoms in patients with CRS.

The relationship between LPR and CRS is still a controversial issue.

SURGICAL TREATMENT OF INVERTED PAPILLOMA: 10 YEARS EXPERIENCE

Maja Buljčik Čupić¹², Slobodan Savović¹², Ljiljana Jovančević¹², Nemanja Pejaković¹², Tamara Tešić¹²

¹Faculty of Medicine, University of Novi Sad

²ENT and Head and Neck Surgery Clinic, Clinical Center of Vojvodina

Background. Inverted papilloma (IP) are primary, benign tumors that originate from respiratory mucous membrane epithel cells, grow inside it, infiltrating themselves into stroma hence the name – inverted.

Methods. Retrospective-prospective study encircled the patients in the period of ten years, surgically treated at the ENT Clinic, Clinical Centre of Vojvodina.   

Results. The total number of patients was 31, which places IP in rare tumors of nasal cavity and sinuses. They most commonly occur in middle-aged patients 56.68 ± 13.57 (34-83). Men are more susceptible to the disorder than women (74.20%). The development of IP was preceded by a chronic inflammation in 83.87% of the cases, and long-term smoking in 67.73% of the cases. The prevailing symptom was nasal breathing difficulty diagnosed on the VAS scale 8.77± 1.80, while the least significant symptom was pain (38.71%), which was located in the facial region with an average grade of 6.58 ± 2.23. The most common localization of IP is in the region of the lateral wall of the nose (51.61%), while the rarest one (3.22%) was in the region of the maxillary sinus. The most frequently diseased sinus was the anterior ethmoid sinus 27/31 (87.1%), while the least frequently diseased sinuses were frontal sinuses 9/31 (29.03%) as well as sphenoid sinus 7/31 (22.08%). Most patients 25/31 (80.64%) underwent FESS, in cases when anterior ethmoidectomy was performed, 4/31 (12.9%) underwent open surgical techniques, and the most common procedure was medial maxillectomy in 75% of the cases. The tumor was diagnosed in the T3 stage in most patients in 17/31 (54.83%), according to Krousse. In the period of ten years, recidive occurred in one third of the patients after estimated 4.67 years after the primary surgical treatment.  Malignant transformation of the papilloma into planocellular carcinoma in the observation period was diagnosed in two patients (6.45%).

ADVANCES IN THE CLINICAL MANAGEMENT OF CHRONIC RHINOSINUSITIS

Nicolas Busaba, MD, FACS

Department of Otorhinolaryngology, Harvard Medical School, Boston, Massachusetts, USA

Background. Chronic rhinosinusitis (CRS) with or without polyposis is a prevalent inflammatory disorder with high disease-specific, general health, and economic burden. Surgery is frequently performed to treat CRS, but with high rate of recidivism. Advances leading to the development of more targeted and effective medical therapy is paramount.

Methods. Double-blind, placebo-controlled medical trial comparing the efficacy of oral verapamil to placebo in treating patients diagnosed with CRS with nasal polyposis (CRScNP). The primary end point is change in Sinonasal Outcome Test (SNOT-22) scores. The secondary end points are changes in Lund-Mackay score (LMS) and Lund-Kennedy endoscopic score (LKS).

Results. A total of 18 patients completed the study. The least squares mean (LSM) change between baseline and week 8 SNOT-22 score was −27.3 in the verapamil group and 0.4 in the placebo group, resulting in LSM difference of −27.7 between groups (p=0.03). Similarly, there was a significant reduction in total LKS in the verapamil group compared with placebo at week 4, with an LSM difference of −2.8 between groups (P  =  .003) and the trend continued through week 8; however, the LSM difference between groups was no longer significant at −1.05 (P = .25). The role of ASA-desensitization, anti-IgE (Omalizumab), anti-Interleukin 5 (Mepolizumab), and anti-Interleukin 4 and 13 (Dupilumab) was discussed as it pertains to specific CRS with polyposis phenotypes – inflammatory pathways.

Conclusions. Newer medical therapies for CRScNP based on disease phenotype are promising. Oral Verapamil improved SNOT-22, LKS, and LSM scores and can be offered to patients with recalcitrant CRScNP. Mepolizumab and Dupilumab are reasonable for CRScNPassociated with systemic and /or tissue eosinophilia and failed conventional therapies. Severe IgE-mediated inflammation can benefit from Omalizumab. ASA-desensitization can be added to the treatment algorithm of AERD patients.

INTERSTITIAL BRACHYTHERAPY FOR THE MANAGEMENT OF NOSE VESTIBULE MALIGNANCIES

Francesco Bussu1, 2, Luca Tagliaferri3, Davide Rizzo1, Claudio Parrilla4, Caterina Kihlgren1, Vincenzo Valentini3

1Azienda Ospedaliero Universitaria, Otolaryngology Division, Sassari, Italy2Università Cattolica del Sacro Cuore, Istituto di Otorinolaringoiatria, Roma, Italia3Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC di Radioterapia, Dipartimento di Scienze Radiologiche, Radioterapicheed Ematologiche, Roma, Italia4Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC di Otorinolaringoiatria, Dipartimento di Scienzedell’invecchiamento, Neurologiche, Ortopediche e dellaTesta-Collo, Roma, Italia

Background. The NV is the anterior part of the nasal cavity lined by squamous epithelium up to the limen nasi, the muco-cutaneous junction. Squamous cell carcinoma (SCC) of the nasal vestibule (NV) is a relatively rare condition with clear clinical peculiarities, for which a standard treatment has still to be defined.We evaluated the oncological, cosmetic and functional results of exclusive brachytherapy.Methods. Twenty-nine (n=29) patients, treated with exclusive brachytherapy between 2010 and 2016, were consecutively enrolled in a university hospital in Italy. 23 (79,31%) were primary tumors and 6 (20,69%) were recurrences. Fifteen (n=15) out of the 21 patients free of disease since at least 9 months underwent functional evaluation (endoscopy, nose cytology, rhinomanometry, olfactometry and saccharin test), and were compared to a group of 15 healthy subjects and to another group of patients previously irradiated through external beam (EB) on the nose mucosa. Results. The disease specific survival of the 29 patients was 71% at 5 years. Such figure dramatically increases to 92% when only primary cases are considered (excluding recurrences). No interruptions of the IRT schedule for acute toxicity were recorded. The cosmetic late toxicity was extremely low. As for the functional study no differences emerged between BRT patients and healthy subjects. On the other hand, EB patients always presented crusting, lower Threshold Discrimination Identification (TDI) score at olfactometry and markedly impaired mucociliary clearance at saccharin test.Conclusions. Interstitial brachytherapy on T (we treat the neck by surgery when indicated) is associated to excellent oncological results in primary nose vestibule SCCs, at least comparable with surgery. Also brachytherapy is associated to clearly better cosmetic results than surgery and to clearly better functional results than EB.These findings lead us to conclude that brachytherapy is the new standard for the treatment of the primary lesion in nose vestibule SCCs.

ENDOSCOPIC PEDIATRIC SKULL BASE SURGERY

Jannis Constantinidis

Thessaloniki University Hospital, Department of Otorhinolaryngology, Thessaloniki, Greece

Background. Endoscopic endonasal surgery (EES) for skull base pathologies in the pediatric population presents unique challenges. Pediatric sinonasal and cranial base anatomy is much more restricted than in adults and endoscopic surgery more difficult. Specially adapted instruments permit passage through narrow sinonasal pathway to access the entire midline skull base. Methods. A retrospective review of 39 pediatric patients who underwent EES at our institution from 2004 to 2018 was performed.Results. Twenty patients were male, and the mean age at the time of surgery was 13.7 years (range 2.3-18.0 years). Seven patients had anmeningoencephalocele. Skull base tumors included angiofibromas (n = 14), craniopharyngiomas (n = 3), Rathke cleft cysts (n = 2), pituitary adenomas (n = 4), chordomas/chondrosarcomas (n = 2), olfactory neuroblastomas (n = 2) and five other pathologies. The mean follow-up time was 22.7 months (range 1-114 months). Overall, complications included CSF leak in 4 cases (10.2%), meningitis in 2 (5.1%) and transient diabetes insipidus in 1 patient (2.56%). Two patients (5.1%) had transient cranial nerve palsies. Conclusions. Endoscopic endonasal surgery has proved to be a safe and feasible approach for the management of pediatric skull base pathologies. When appropriately indicated, EES may achieve optimal outcomes in the pediatric population.

IS THERE AN OTOLOGIC MANIFESTATION OF SAMTER’S TRIAD?

Ljiljana Čvorović1, Aleksandar Trivić1, Zoran Dudvarski1, Ana Jotić1, Miljan Folić1, Uglješa Grgurević2, Danilo Vojvodić3, Aleksandar Perić2

1School of Medicine, University of Belgrade, Clinic for Otorhinolaryngology and Maxillofacial Surgery, Clinical Centre Serbia, Belgrade, Serbia2 Department of Otorhinolaryngology, Military Medical Academy Faculty of medicine, Belgrade, Serbia3 Institute for Medical Research, Division of Clinical & Experimental Immunology, Military Medical Academy Faculty of Medicine, Belgrade, Serbia.

Background. Samter’s triad (ST) is a well-described condition manifesting as eosinophilic nasal polyps, aspirin intolerance and non-atopic asthma. The risk for OME in ST patients was estimated to be five times higher than the risk in patients with only nasal polyps. OME associated with ST is a difficult entity to treat. The aim of study was an investigation of middle ear and nasal production of cytokines and chemokines in patients with ST and analyzing differences between them and controls. Methods. Prospective cohort two-years study. Fifteen patients with OME (8 without allergic rhinitis, 5 with allergic rhinitis and 2 with ST) and 15 healthy participants were included. IL-β, IFN-α2, IFN-γ, TNF-α, MCP-1, IL-6, IL-8, IL-10, IL-12p70, IL-17A, IL-18, IL-23 and IL-33 concentrations were measured in nasal and middle ear secretions. We showed medians for concentration of cytokines and chemokines of all group of patients, their differences and correlation with some clinical parameters. Results. There were positive correlations between concentrations of IL-β, IFN-α2, IFN-γ, MCP-1, IL-6, IL17A, IL-18, IL-23 in nasal and middle ear secretions (p<0.001, p<0.001, p=0.005, p=0.002, p=0.050, p=0.001, p=0.003, p=0.314, p=0.001, respectively). There was no connection between the type of middle ear secretion (serous or mucous) and the levels of cytokines or chemokines. There was a positive correlation between the symptom duration and concentration of MCP-1 in middle ear (p=0.030). There was negative correlation between the middle ear concentrations of IL-β and IL-8 and air- bone gap in conductive hearing loss (p=0.070 and p=0.018, respectively). Conclusions. This preliminary report showed uniformity of inflammatory mediator production in the nasal and middle ear mucosa and few differences between middle ear mediators and symptom duration and air- bone gap in conductive hearing loss. More patients with ST and OME are needed to understand OME associated with ST, their possible treatment and outcome.

ENDOSCOPIC ASSISTED COBLATION TURBINOPLASTY: HOW I DO IT?

Puya Dehgani-Mobaraki1,2

1Department of Otolaryngology-Head & Neck Surgery at the Gubbio-Gualdo Tadino Hospital, Perugia, Italy2Association “Naso Sano” Onlus, Umbria Regional Registry of volunteer activities, Corciano,Italy

Background: Coblation technology, used for years in the neurosurgical, gynecological and urological fields, has recently seen wide expansion also in the otorhinolaryngology but controversy remains linked to the costs.This technology offer the best results in turbinoplasty, where radiofrequency energy is delivered through a molecular bond that causes extensive tissue fibrosis associated with reduction in submucosal glands and venous sinusoids, while maintaining an intact respiratory basal membrane.We describe our endoscopic technique for an effective and safe coblation turbinoplasty.Methods: A retrospective analysis was carried on 50 patients.Standard clinical examination, nasal endoscopy and prick tests wereperformed in every patients in order to evaluate the nasal cavities, turbinates hypertrophy and allergic sensibility.Candidates for a coblation turbinoplastywere those suffering from nasal obstruction due to mucosal hypertrophy of the inferior turbinates and failure of specific and non-specific medical treatments. Local topical anesthesia was achieved by placing endoscopically cotonoids soaked with xylocaine, for 20 minutes medially and inferiorly to the inferior turbinates. Every procedure was performed counting 40 second from the insertion of the tip of the instrument and the withdraw. Patients weredischarged generally 30 minutes after the operation and Nasal douches with sodium hyaluronate 0.3 % solution, were prescribed for two weeeks post-operatively.Results: Endoscopic coblation turbinoplasty was performed in 50 patients for a total of 100 procedures. Patients were evaluated endoscopically (objective evaluation) and by using the Nasal Obstruction Symptoms Evaluation (NOSE) scale (subjective evaluation) every 2 weeks for the first month and then after 3 months. A total of 45 patients(95%) reported a score between 0 and 20, while other 5 patients (5%) reported a higher score due to the concomitant allergic rhinitis exacerbation.Conclusions: The endoscopic assisted coblation turbinoplasty is a precise and minimal invasiveness technique with low epithelial damage, making it repeatable over time.

ENDOSCOPIC TREATMENT OF THE MIDDLE TURBINATE

John M. DelGaudio

Department of Otolaryngology, Emory University, Atlanta, GA, USA

Background: The middle turbinate is an important structure in endoscopic sinus and skull base surgery. It serves as a landmark for orientation during endoscopic surgery, is increasingly being recognized as an important structure in the nasal filter and allergic process, and can be involved in the disease process. Anatomic variants and disease involvement in the middle turbinate need to be recognized and sometimes addressed during the endoscopic procedure.

Methods: The literature on middle turbinate preservation vs. resection will be reviewed. Recent reports on isolated polypoid changes in the middle turbinate related to allergy, and the newly described entity of central compartment atopic disease will be reviewed, including how to address the middle turbinates in these cases. Various anatomic conditions and pathologies involving the middle turbinate will be presented with surgical videos.

Results: Representative cases of middle turbinate pathology, including middle turbinate polyps, central compartment atopic disease, concha bullosa, paradoxical middle turbinates, and resection for disease involvement and for improved delivery of topical medication will be presented. Complications of middle turbinate resection will be discussed.

Conclusions: The middle turbinates are important structures that can be involved in inflammatory disease processes as both protective structures or as part of the disease process. It is important to recognize when best to preserve or resect the middle turbinate, conservatively or more completely.

FUNGAL RHINOSINUSITIS: OUR EXPERIENCE IN DIAGNOSIS AND TREATMENT

Jetmira Fejza Bulaj, Roven Sinani

ENT Department, University Hospital Center “Mother Teresa”, Tirana, Albania

Background. “Fungal rhinosinusitis” is the most appropriate term to describe fungal infection of the paranasal sinuses because concomitant involvement of the nasal cavity is seen in most cases. Fungal infections are causing factors in many cases of chronic rhinosinusitis. Most fungal sinus infections are noninvasive, except when they occur in individuals who are immunocompromised. Noninvasive disease has 2 types of presentations (fungus ball and allergic fungal sinusitis), while invasive disease has 3 types of presentations (acute fulminant type, chronic and granulomatous type). Fungus ball is the most common condition. Diagnosis is made by clinical, radiological and histopathological findings. Treatment depends on type of fungal rhinosinusitis and includes, surgical and medical treatment. Methods. We present here our 5-year experience (2013-2018) in diagnosis and treatment of fungal rhinosinusitis. There were 57 patients diagnosed with fungal rhinosinusitis. The diagnosis was established by history, clinical examination, endoscopic nasal examination and CT scan. All patients underwent Functional endoscopic sinus surgery (FESS).Results. All patients had fungus ball. The diagnosis was supported by histopathological examinations. No other allergic or invasive fungal infections were presented at our clinic. All patients were treated with FESS. We didn’t have recidives or complications of fungal infections.Conclusions. Fungus ball is the most common type of fungal infections. It is unilateral and mostly located in maxillary sinus. Metallic densities in CT scan can be frequently seen. Treatment is surgery (FESS), usually no drugs treatment is required. Follow up is necessary.

THE FUTURE OF RHINOLOGY

Wytske Fokkens

Department of Otorhinolaryngology, Amsterdam University Medical Centres, Location AMCAmsterdam, The Netherlands Background: We live in a time of very interesting progress in rhinology. Since the introduction of the nasal corticosteroids in the 1970ies, developments have not been so intense. It can well be envisioned that in a decade we prevent/treat allergic rhinitis in a way that it will no more have an impact on quality of life of our patients. We will be able to treat the mother with probiotics and/or re-engineer the microbiome in at-risk infants to prevent allergy from developing. And if we are too late for that, effective immunotherapy will not only treat the symptoms but prevent new sensitisation and the development of asthma to occur. Immunotherapy will also be the treatment of choice in head and neck malignancies with genetic profiling and mapping the immune landscape of the tumour being integrated into a precision approach. The precision approach will also be the standard in the treatment of Chronic Rhinosinusitis (CRS). Here, we can expect most of our patients to be treated effectively in the office with high dose local corticosteroid devices and if that is insufficient with monoclonal antibodies. Surgery will only be left for very few patients. Or maybe in a bit further future: a simple microbiome transplant will cure the CRS. Patients with CF will not suffer a life of upper and lower airway disease ending in lungtransplant but will receive effective restoration of their underlying CFTR defect with normalisation of the homoeostasis of the airway surface liquid layer in the airways by genetherapy of small molecule treatment. In Granulomatosis with Polyangitis (former M. Wegener) and other small- and large-vessel systemic vasculitis will be treated with cheap and effective biological with minimal side effects.Also on the technical aspects of surgery a lot will have changed: easy and cheap 3D navigation will be the standard of care in surgery. In patients with CRS with occlusion of ostia and limited mucosal disease balloons will help us to open up the sinuses. With more mucosal disease, high dose local corticosteroids implants will solve the remaining problem. Instruments will easily be malleable and steered to the proper place with memory of shape and way of movements. Especially in skull base surgery, robots will enable us to go to places we never visited before.If you think that many of the above sounds too good to be true, many things are already there or on the brink of being there.Although the evidence is not yet conclusive, recent guidelines from the World Allergy Organization recommend the use of probiotics for the primary prevention of eczema in pregnant and breastfeeding mothers of infants at high risk for developing allergy and in high-risk infants. Immunotherapy for melanoma that were untreatable 10 years ago now lead to two-year survival rates over 50%.

New devices to install high dose local corticosteroids in the ethmoid are developed and some are brought on the market already. The exact place of these new treatments in treatment algorithms has to be established, but we can dream of treating many of our CRSwNP patients by simply placing a drug-eluting device in between their polyps that is as effective as systemic corticosteroids.Treatment with monoclonal antibodies against mediators and cytokines playing a role in Th2 eosinophilic inflammation is now established in daily practice in the treatment of patients with severe asthma. In the last years studies a number of randomized trials with monoclonal antibodies such as Dupilumab, Mepolizumab, and Omaliumab have been shown to be effective in patients with CRSwNP. Moreover, some large phase 3 trials are ongoing. However, at this moment, we do not have registration/licencing for monoclonal antibodies for CRSwNP. The ability to predict which patients will respond favourably to a certain monoclonal antibody will be a key issue in achieving costs-effectiveness and potential registration for the indication CRSwNP.The first treatments containing correctors (lumacaftor) and/or potentiators (ivacaftor) of the cystic fibrosis transmembrane conductance regulator (CFTR) are on the market and bring significant improvement of quality of life and hope to our CF patients.Finally, the technological development in our field are breathtaking. From drug-eluting stents via 3D endoscopes to new robotic systems dedicated to endoscopic paranasal sinuses and skull base surgery have been developed to overcome the technical challenges in our field.Many of the developments in our field aim at developing new medical treatments for diseases that now are often treated surgically. Not all otorhinolaryngologist take an optimistic approach to these developments. However, taking together all the developments in our field we can face our (surgical) future with confidence.

Figure 1. The integrated OR in the AMC in Amsterdam

CSF LEAK AND RECONSTRUCTION: LEARNING FROM MINE AND OTHER PEOPLE’S MISTAKES

Christos Georgalas

Hygeia Hospital, Department of Otorhinolaryngology, Athens, Greece Background. Although endoscopic trans nasal reconstruction of skull base defects and closure of CSF leaks has a high success rate, there are still a number of failures. 

Methods. Drawing from our experience of revision cases and cases that have been managed via endoscopic or open approaches previously, we try to present in a structured way the ways to avoid recurrence of CSF rhinorrhea.

Results and Conclusion. In this presentation we aim to highlight the commonest reasons for failure, focusing on the predisposing factors for CSF rhino rheas, the diagnosis, the imaging and technique of reconstruction and postoperative management.

BACTERIUM HELICOBACTER PYLORI IN CHRONIC RHINOSINUSITIS: CAUSE OR BYSTANDER?

Boris Jelavić

Department of Otorhinolaryngology of University Hospital; School of Medicine of University of Mostar; Mostar, Bosnia and Herzegovina

Background. The bacteria Helicobacterpylori (H. pylori) have been identified in extragastric tissues in the nasal cavity and paranasal sinuses. The origin and pathogenicity of these bacteria in the nose and sinuses are not known. This review examines the evidence for a possible relationship of H. pylori with chronic rhinosinusitis.

Methods. A review of literature was conducted using keywords related to H. pylori and rhinosinusitisand included studies published in English.

Results. The bacteria H. pylori colonise the nose and sinuses. The possible modes of spread are gastric reflux, a nasal or oral route. No connection between H. pylori in the stomach and H. pylori, found in the nose and sinuses, was proved. There is no evidence of an active role of H. pylori in chronic rhinosinusitis and a cause-effect correlation was not established. There is a lack of evidence to perform H. pylori testing for rhinosinusitis. The results of the previous studies on this topic are conflicting.

Conclusions. The clinical significance of H. pylorisinonasal colonization is debatable. The suggestion that sinonasal cavities may serve as a reservoir for H. pylori and that re-infection of the stomach occurs after eradication therapy awaits further studies for confirmation. These bacteria, found in the nose and sinuses, may be accidental or innocent bystanders which do not affect the pathways of rhinosinusitis disease. More research on the bacterium’s infectious and immunological properties should test the hypothesis that H. pylori may cause nose and sinus diseases even far from the primary site of infection in the stomach by interfering with different biologic processes.Future studies should determine the modes of spread of the bacteria into the nose and sinuses and whether colonization isoccasional or persistent. More information about H. pylori activities in patients with sinonasal carcinogenesis are warranted.

OLFACTION IN NEURODEGENERATIVE DISEASES

Ljiljana Jovančević 1,2, Slobodan Savović1,2, Maja Buljčik-Čupić1,2

University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia1

Clinical Centre of Vojvodina, Clinic for Otorhinolaryngology and Head and Neck Surgery, Novi Sad, Serbia2

Background: It is not latest news that there is a link between olfactory dysfunction and neurological disease. However, olfactory disfunction is usually neglected by physicians at large.

Methods: Review of the literature.Results: Olfactory dysfunction is most commonly seen in neurodegenerative conditions

such as Parkinson’s disease (PD) and Alzheimer’s disease (AD), but also has been associated with epilepsy, schizophrenia, Parkinson–dementia complex of Guam, multiple sclerosis (MS), myasthenia gravis, Huntington disease, multi-infract dementia, amyotrophic lateral sclerosis and stroke. There is considerable variation in the prevalence and magnitude of olfactory dysfunction among neurodegenerative diseases. In AD, PD, and Parkinson–dementia complex of Guam, olfactory dysfunction is severe, whereas is more moderate in other disorders. Olfactory dysfunction in PD is more com mon than the resting tremor and predates motor symptoms by many years. Patients with olfactory dysfunction secondary to PD commonly describe a gradual onset, do not often report parosmia and are unli kely to see any improvement over time. In the case of AD, smell problems occur in the beginning of the disease and this pattern can reflect an “preclinical” period of disease development by preceding the onset of classic symptoms. Olfactory dysfunction in AD is associated with disease progression, can be helpful in the differential diagnosis of major depression and AD, and may have clinical value as an early diagnostic marker in predicting incident AD in high-risk individuals. Surprisingly, most patients with AD and PD are unaware of their olfactory loss although 85 to 90% of them in the early stages present olfactory impairment. Where a neurological aetiology is suspected, a full cranial nerve and peripheral nervous system examination should be under taken. Tests of memory and cognition should be performed by the appropriate neurological specialists.

Conclusion: Rhinologists especially, but also otolaryngologists in general and neurologists should include olfactory tests in the screening of patients at higher risk of dementia.

THERAPEUTIC APPROACH AND RESULTS OT THE TREATMENT OF MALIGNANT TUMORS OF THE SINONASAL REGION

Rajko Jović, Karol Čanji, Vladimir Kljajić, Danijela Dragičević

Clinic for Otorhinolaryngology and Head and Neck Surgery, Clinical Center of Vojvodina, Faculty of Medicine, University in Novi Sad, Serbia

Introduction: Size and localization of malignant tumors of the nose and paranasal sinus, proximity of the endocrani, orbit, and other vital structures determines the approach to treatment and limits the extent of resection in surgical interventions. The endoscopic treatment approach is widely accepted, but extensive resections of advanced tumors are reserved for large centers, while classical surgery by external access is still maintained in smaller environments. The aim is to present the results of the treatment of patients with malignant tumors of the nasal cavity and paranasal sinuses, to analyze and compare the different modalities of the applied therapy.

Methods: A retrospective study analyzed the results of treatment of 56 patients with a malignant tumor of the nasal cavity and / or paranasal sinuses in the period 2002-2012 in a tertiary health institution. With primary surgery was treated 37 patients, chemioradiotherapy was applied in 4 patients, only polychemotherapy in 8 and only irradiation in 5 patients. Results: According to localization, the malignant process in the nasal cavity present in 13 (23.2%), the nasal cavity with enlargement to the maxillary sinus 17 (30.36%), maxillary sinus 9 (16.07%), nasal vestibulum and nosal cavity 15 (26.78% frontal sinus in 2 (3.57%). In two patients, there was metastasis of melanoma in one and ductal breast cancer at the other. Patohystologically diagnosed with adenocarcinoma in 3 (5.6%), adenoid cystic carcinoma in 3 (5.6%), anaplastic carcinoma 3 (5.6%), planocellular carcinoma in 30 (55.6%), transiocellular carcinoma 6 (11.1%), melanoma 5 %), osteosarcoma one (1.8%), rhabdomyosarcoma one (1.8%), plasmocyte one (1.8%), malignant Swan one (1.8%). Regional metastases of sino nasal carcinoma registered in 4 (7.4%) patients. Overall 3 years survival is 55.7% and overall 5 years survival is 38%. Overall survival of surgicaly tretaed patients: 3 year survival is 61.2%, 5 year survival is 41.3%. Overall 3 years survival of patients with chemoradiotherapy is 39.1%, while no one in this category has survived for 5 years. Conclusion: Treatment of sinonasal malignancy based on surgery, endoscoopic in early and open surgery in advanced. In combination with hemoradiotherapy it gives significantly better results

GENDER ASSOCIATED DIFFERENCES IN NEUROALLERGIC RESPONSE TO NASAL CHALLENGES

Livije Kalogjera

University Hospital Centre „Sestre milosrdnice“, Department of Otorhinolaryngology and Head & Neck Surgery, Zagreb School of Medicine, Croatia

Background. Female predominance in the prevalence of idiopathic and local allergic rhinitis (LAR) was found in recent epidemiological studies. Female patients with allergic rhinitis (AR) show higher sensitivity to irritants and hyperresponsiveness than males. Asthma shows female predominance in post-puberty patients, and different gender interaction in 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. 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.

Methods. We have performed allergen and non-specific nasal challenges (histamine and hypertonic saline - HTS) 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.

Results. Female allergic subjects have higher substance P (SP) concentrations both before and after non-specific challenges, however, this difference was statistically significant only after HTS challenges It indicated that female patients with SAR have stronger neurokinin release after non-specific challenge than male. 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.

Conclusions. The results indicate significant difference in the interaction between inflammatory cells, presumably mast cells, and the neurogenic response, which is gender- related, and which may affect symptom profiles after challenges.

ISOLATED SPHENOID SINUSITIS

Sergei Karpischenko, Olga Stancheva

Department of Otorhinolaryngology, First Pavlov State Medical University, Saint Petersburg, Russia

Background: Isolate sphenoid sinus disease (ISSD) is a rare pathology that occurs an inflammation of the sphenoid sinus mucous membrane. Among patients with acute and chronic inflammation pathology of the sinuses, ISSD is diagnosed in 1-3% of cases. Nonspecific symptoms as headache and diplopia make it difficult to diagnose this pathology earlier. Therefore, patients are often observed by ophthalmologists, neurologists etc. The CT-scan examination has the high specificity and sensitivity as the method of ISSD diagnosis. There are many surgical approaches for the treatment the sphenoid sinus disease, among them endonasal sphenoidotomy is preferable.

Methods: A retrospective analysis of the patients who were treated in ENT Department with a diagnosis of isolated sphenoid sinusitis from 2015 to 2018 was conducted. History, symptoms, endoscopic examination of the nasal cavity and CT examinations were analysed. The opening of the sphenoid sinus in all cases was carried out through the endonasal approach under general anaesthesia. All removed tissues of the sphenoid sinus were sent for histological examination to confirm the diagnosis.

Results: More than 2000 FESS were completed during the period from 2015 to 2018. There are 41 cases of acute and chronic inflammation process isolated in the sphenoid sinus. In 7 cases medical therapy helped to prevent the complications and lead to recovery. In 34 cases there are necessary to open the sphenoid sinus. Fungal ball was detected as the most common pathology in the sinus cavity.

Conclusion: Cone-beam and multispiral computed tomography allows to verify the kind of pathological changes in the sphenoid sinus with a high specificity. It helped to determine the optimal surgical approach according to the anatomical variants of the intranasal structures. If there are not significant indications for sphenoetmoidal recess hypoventilation and no signs of complications due to inflammatory process, surgical intervention should wait for 7-14 days.

ENDOSCOPIC REPAIR OF CEREBROSPINAL FLUID FISTULAS IN NASAL LIQUORRHEA

Vladimir Kljajić, Slobodan Savović, Ljiljana Vlaški, Maja Buljčik Čupić, Danijela Dragičević

Ear, Nose and Throat Clinic, Clinical Center of Vojvodina, Faculty of Medicine, University of Novi Sad, Serbia

Background. Cerebrospinal fluid rhinorrhea is a leakage of cerebrospinal fluid from the nasal cavity. Patients mostly complain of clear fluid leaking from the nose when bending forward. Patient medical histories show that in most patients it occurs following head injury, nasal surgical intervention, or neurosurgery. Only a small number of patients reported spontaneous cerebrospinal fluid leakage.

The aim of this paper is to examine the results of endoscopic diagnosis and closure of cerebrospinal fluid fistulas.

Methods. The study included 30 patients undergoing endoscopic diagnosis and closure of cerebrospinal fluid fistulas, in the period from 2007 to 2018, at the Clinical Center of Vojvodina. Diagnostic nasal endoscopy was performed after intrathecal injection of 5% sodium fluorescein, and after precise localization of the leak, it was endoscopically repaired in a single-step procedure.

Results. Of the total number of patients, successful primary closure of cerebrospinal fluid fistulas was accomplished in 97% of patients. Due to unsuccessful leak closure, one patient underwent cerebrospinal fluid leak repair using trnascranial dural repair.

There were no intraoperative complications. Complications occurred in three patients: one patient presented with acute hydrocephalus, one with reversible encephalopathy syndrome on the fifth postoperative day with bilateral loss of vision, and one patient was diagnosed with hydrocephalus two years after the repair of cerebrospinal fluid fistula.

Conclusion. Endoscopic closure of cerebrospinal fluid fistulas is a relatively safe and effective procedure providing high patient comfort.

THE PILLARS OF THE NOSE- CRURA SHORTENING FOR OVERPROJECTION NOSE

Gabriela Kopacheva – Barsova

ENT University Hospital, University Campus “St. Mother Theresa”, Skopje, Republic of North Macedonia

Background. The overprojected nose presents a significant challenge to the surgeon performing rhinoplasty. The rhinoplasty surgeon must understand the concepts of nasal projection and with pre-operative analyses to determine the ideal position for the nasal tip after having understood and defined the ideal position for the nasion. The aim of surgery should be to achieve an ideal landmarks position and to set the dorsal line between them.

Method. A review of surgical techniques and results of rhinoplasty performed by author.

Results. The crural anatomy of the nasal tip relates to the size and shape of the lower lateral cartilages (LLCs) and their relationship with the caudal septum and upper lateral cartilages (ULCs). Modification of nasal tip rotation and projection should attempt to preserve or reconstruct major tip mechanisms and also eliminating postoperative changes caused by scar contracture.

Conclusions. Modern rhinoplasty techniques have increased the surgeon’s ability to control tip projection, without disruption of the domes and medial crura. With loss of tip support, scar contracture has led to an increased incidence of post-operative ptosis, pinch nose, alar insufficiencies, bossa nose and other tip deformities.

CHOANAL POLYPS IN CHILDREN AND ADULTS: 10-YEAR EXPERIENCE FROM A TERTIARY CARE HOSPITAL

Milica Labus1, Aleksandar Perić1, Tijana Vukadinović1,2, Tarik Kujundžić1,3, Marko Stoiljkov1,4, Biserka Vukomanović Đurđević1,5

1Department of Otorhinolaryngology, Military Medical Academy Faculty of Medicine, Belgrade, Serbia2Department of Otorhinolaryngology, Clinical Centre of Montenegro, Podgorica, Montenegro3ENT Unit, General Hospital Plevlja, Pljevlja, Montenegro4ENT Unit, General Hospital Bar, Bar, Montenegro 5Institute for Pathology, Military Medical Academy Faculty of Medicine, Belgrade, Serbia

Background. Choanal polyps (CPs) are benign, solitary, soft-tissue lesions extending towards the junction between the nasal cavity and the nasopharynx through the choana. The aim of this retrospective study was to evaluate clinical and histological characteristics of CPs in children comparing to adult patients.

Methods. Characteristics of CPs treated in our hospital (demography, main complaints, side, localization, surgical approach, histological characteristics, accompanying paranasal sinus diseases, association with allergic rhinitis, postoperative follow-up period, and recurrence rates) were retrospectively reviewed.

Results. Seventy-eight patients with CPs were included, 22 (28%) patients in children and 56 (72%) patients in adults. We found no differences in the prevalence of main nasal complaints (nasal obstruction, rhinorrhea, snoring and epistaxis) between the child and adult. In 27% children and in 7% adults, we found the oropharyngeal extension of CPs (p<0.01). In 18% children and in 5.3% adults, we found the histological characteristics of an angiomatous CP (p<0.05). The association with allergic rhinitis was more frequent in children (32%) than in adults (18%) (p<0.05). In 32% pediatric patients and in 14% adult patients, we found the association with ipsilateral chronic maxillary rhinosinusitis without nasal polyps (CRSsNP) (p<0.05). After the surgical treatment, we found the recurrence in 3 (14%) pediatric and in 5 (8%) adult patients, without the significant difference.

Conclusion. Our results suggest some specificities of CPs in children comparing to adults. Oropharyngeal extension, association with allergic rhinitis and ipsilateral CRS, and the presence of angiomatous histological type of CPs are more frequent in the pediatric population.

ENDOSCOPIC SURGERY FOR BENIGN AND MALIGNANT TUMORS OF THE PARANASAL SINUSES

Boštjan Lanišnik, Matic Glavan

Department of Otolaryngology-Head and Neck Surgery, University Medical Center Maribor, Slovenia

Background: Endoscopic endonasal surgery (EES) for sinonasal malignancy is still controversial and is often compared to open craniofacial resection as the golden standard. Nevertheless, EES offers relative lower morbidity for selected patients and may be used with curative or palliative intent. EES has limited value in patients with soft tissue invasion and in cases where orbital clearance is indicated for oncological reasons.

Methods: Patients with advanced sinonasal malignancy that were managed in a tertiary University hospital from 2008 to 2017 were analysed. We managed 48 patients with sinonasal malignancy (20 adenocarcinomas, 8 melanomas, 2 olfactory neuroblastomas, 12 squamous cell carcinomas, 2 SNUCs, 1 high-grade mucoepidermoid carcinoma, 1 adenoid cystic carcinoma, 1 malignant schwannoma, 1 plasmocytoma). All patients had advanced T3 or T4 tumors. Patients were treated with EES alone in 38/48 (80%), combined in 2/40 (5%) and craniofacial resection with/without orbital clearance in 8/48 (15%). All patients received adjuvant therapy, either radiotherapy alone (44 patients) or combination with chemotherapy (4 patients). We also manged 54 benign tumors (45 inverted papillomas, 5 osteomas, 2 hemangiomas, 1 pelomorphic adenoma). All patients were managed with endoscopic resection. Results: Overall survival for malignant tumors was 80%. Six patients died from disease progression, 2 patients are alive with disease and distant metastasis. Locoregional control was achieved in 40/48 patients (83%). Control for inverted papilloma was achived in 42/45 (93%).

Conclusions: Patients with advanced sinonasal malignancy can be successfully managed with EES or combined approach. Endoscopic surgery has a limited value in patients that need orbital clearance or soft tissue involvement. Endoscopic resection of the inverted papilloma has a high control rate.

MANAGEMENT OF PARANASAL SINUS MUCOCELES

Milanko Milojevic

Department of Otorhinolaryngology, Military Medical Academy Faculty of Medicine, Belgrade, Serbia

Background. The first description of mucoceles was given by Langenbeck in the early nineteenth century. He named these lesions as hydatid cysts. Rollet was the first author who used the term mucocele. They are defined as pseudocystic formations whose wall is composed of a respiratory epithelium, filled with mucosal, sterile content that completely fulfill some of the paranasal cavities. Mucoceles occur as a result of repeated inflammation, trauma, and previous sinus surgery or are formed secondary due to the neoplastic process. The frontal sinus and the ethmoid cells are the most common site of origin, whereas the sphenoid sinus is infrequently involved. Due to their long developmentthey often remain asymptomatic for a long period of time. The most frequent presenting symptoms are orbital i.e. diplopia and neurologic manifestations like increasing of the intracranial pressure.

Methods. Review of the literature and retrospective study of surgically treated patients with paranasal sinus mucocele in a tertiary care hospital.

Results. The treatment of choice is endoscopic sinus surgery. Precise diagnostic and a detailed access plan are very important for a positive outcome. When there is need to restitute the anatomy of paranasal sinuses, the endoscopic and external approach are combined. Rare cases of exclusive external approach are usually reserved for recurrent cases and cases of endocranial propagation when a multidisciplinary approach is recommended with the participation of a neurosurgeon. The recurrence rates of each surgical technique are not frequent. In our series of patients, for the 10 years of follow-up, they are only 5.6%.

Conclusions. The benefits of endoscopic approach for paranasal mucocele are reflected in precise intraoperative management, low operative trauma and faster postoperative recovery.

SAFETY PROFILE OD ALLERGEN SPECIFIC IMUNOTHERAPY OF ALLERGIC RHINITIS

Katarina Mitrović1, Vesna Tomić Spirić2

1Department of Otorhinolaryngology, Clinical Center of Montenegro, Podgorica, Montenegro

2Clinic for Allergy and Clinical Immunology, Clinical Center of Serbia, Belgrade, Serbia

Background. The aim of the presentation is to determine the safety profile of allergen specific immunotherapy, the frequency of local and/or systemic reactions, including subcutaneous (SCIT) and sublingual (SLIT) administrations.

Methods. Our research was carried out in the diagnostic polyclinic section of the Clinic for Allergy and Clinical Immunology of the Clinical Center of Serbia in Belgrade. We looked at retrospective insights into medical documentation, and all statistics was processed in the SPSS software.

Results. Allergen specific immunotherapy (ASIT) is an effective treatment in IgE mediated allergic diseases: a) allergic rhinitis, with or without conjunctivitis, b) allergic asthma and c) hypersensitivity to venomas, with range of patients from very good tolerance of AIT (no local, no systemic reactions 67,5 %) to the patients with very poor tolerance of AIT (there was no one case with anaphylactic shock, 0 %).

Conclusions. Its advantage as immunomodulatory treatment versus conventional pharmacological is that alleviates the clinical picture, prevents the development of new symptoms, sensitizations and progression of rhinitis in asthma or the more severe disease. The quality of life is remarkable improved and also exhibits long term effects after discontinuation of therapy.

RHINOPLASTY- PERSONAL VIEW AND EVOLUTION

Jane Netkovski

University Clinic of Otorhinolaryngology, University Campus “St. Mother Theresa” Skopje, Republic of North Macedonia

Background. Rhinoplasty remains one of the most requested surgical procedure for both men and womenand still presents the most challenging and difficult surgical procedure in facial plastic surgery. It is indisputable that rhinoplasty patients benefit aesthetically, physiologicaly and emotionally and overall present a positive experience for the vast majority of patients.

Methods. Approximately 75%of rhinoplasties were performed using closed approach. Delivery approach was reserved for patients with boxy nose and those that require only tip correction, 10%. About 15% of all patients were operated with open approach. The last cases were dominantly revision surgeries and patients with severe trauma of the nose.

Results. The evaluation of final outcome was realized by surgeon and patient’s groups, approximately one year after surgery. Excellent results were presented in 52%, good results in 39%. 9% were unsatisfied patients, but in the surgeon’s opinion it is a group of overespected patients. According to surgeon only 4% of last group of patients needed revision surgery. While some surgeons tend to consider all rhinoplasties as simple and usualprocedures, others view them as technically challenging, complex and unpredictable. I consider this surgery to be not only technical challenge but even more very subtle thing and one’s ability to respect and predict the features of the external nose. There are always limitations to rhinoplasty procedure, therefore it is important for the patients to have realistic desires and expectations for the outcome.

Conclusion. Excellent rhinoplasty outcome depends of exact pre-op assessment, excellent surgical execution while respecting and preserving normal anatomic structures and correct post op care. The end-result in rhinoplasty is never exactly predictable but it must be well balanced job between function-improving and shape-corrective nasal surgery. To achieve optimal and natural result, surgeons must acknowledge their skill level, willingness to learn and individualize the operative plan.

NASAL DOUCHING AFTER ENDOSCOPIC SINUS SURGERY

Ivana Pajić Matić1, Dino Damjanović1, Alen Sekelj1, Ivo Matić2

1ENT Department, General hospital „ dr Josip Benčević“ Slavonski Brod, Croatia2Department of Anestesiology and Reanimatology, General hospital“ Dr Josip Benčević“, Slavonski Brod, Croatia

Background. Functional endoscopic sinus surgery is a minimally invasive procedure used to restore sinus ventilation and normal function. It is recommended for the patients who have reccurent acute or chronic infective sinusitis, nasal polyposis, fungal sinusitis, tumors and others. Postoperative nasal mucosa healing is highly coordinate procedure which involves coagulation phase, blood clot formation, inflammation, tissue creation and remodeling. Duration of a certain healing phase can be shortened, or prolonged depending on postoperative care. Disorder of sinonasal respiratory mucosa healing causes the development of infection or scar formation. Infection with additional mucosal destruction, excessive granulation and connective tissue hyperplasia can slow down the epithelization. Crusts or clots can capture the mucus and cause reinfection. Old blood can be a bacterial growth medium. This is the reason why the local toilette of the postoperative wound is important.

Methods. Regular wound cleaning prevents propagation of pathogenic bacteria thus preventing infection of the wound. In this presentation we follow patients postoperative wound healing after nasal douching.

Results. Postoperative nasdal douching makes mechanical effect of washing and creates a physiological environment.

Conclusion. Proper postoperative non-suppresive care is important in healing of the mucous membrane so that it is part of the endoscopic sinus surgery.

EFFECTS OF INTRANASAL CORTICOSTEROID TREATMENT ON PARAMETERS OF EOSINOPHILIC INFLAMMATION IN PATIENTS WITH PERENNIAL ALLERGIC RHINITIS AND NASAL POLYPOSIS

Aleksandar Perić1, Cveta Špadijer Mirković1, Biserka Vukomanović Đurđević2, Danilo Vojvodić3

1Department of Otorhinolaryngology, Military Medical Academy Faculty of Medicine, Belgrade, Serbia2Institute for Pathology, Military Medical Academy Faculty of Medicine, Belgrade, Serbia3Institute for Medical Research, Division of Clinical and Experimental Immunology, Military Medical Academy Faculty of Medicine, Belgrade, Serbia

Background: The pathogenesis of mucosal hypereosinophilia in patients with allergic rhinitis and nasal polyposis is not well known. Previous investigations showed an increased migration of eosinophils guided by chemokines in all chronic upper airway eosinophilic inflammatory disorders. Eotaxin-2 and ‘Regulated on Activation Normal T Cell Expressed and Secreted’ (RANTES) have been postulated to be responsible for eosinophilia in the tissue of chronically inflamed nasal mucosa. The aim of this study was to assess mucosal production of eotaxin-2 and RANTES in patients with perennial allergic rhinitis (PAR), non-allergic and allergic patients with chronic rhinosinusitis with nasal polyps (CRSwNP), before and after nasal corticosteroid treatment. Methods: Twenty patients with PAR, 20 non-allergic and 20 allergic CRSwNP patients and 20 healthy controls were included. Eotaxin-2 and RANTES concentrations were measured in the nasal secretion samples. The patients with chronic inflammation were treated with fluticasone furoate nasal spray (220 μg daily) for two weeks. Nasal symptoms assessment, cytological examination and measurement of eotaxin-2 and RANTES in nasal fluid samples were performed before and after the administration of corticosteroid. Results: The levels of RANTES in nasal secretions were significantly higher in patients with PAR (p<0.05), non-allergic (p<0.01) and allergic CRSwNP patients (p<0.001) compared to controls. We found significantly higher eotaxin-2 levels in patients with PAR (p<0.001) and in non-allergic (p<0.001) and allergic CRSwNP patients (p<0.001) in comparison to healthy participants. After the therapy, we found a significant decrease of RANTES and eotaxin-2 concentrations (p<0.001) in all three groups of patients. Conclusion: The levels of eotaxin-2 and RANTES in nasal fluid may reflect the degree of local eosinophilic inflammation and could be reliable markers for assessment of the therapeutical outcome during corticosteroid therapy.

MANAGEMENT OF RHINOPHYMA WITH COBLATION: HOW I DO IT?

Željka Roje

Private ENT and H&N Surgery Practice, Split, Croatia

Background: Rhinophyma is an uncommon, progressive, disfiguring condition of the nasal region. It is considered to be the most severe expression of the final stage of acne rosacea, which is characterized by a progressive, painless hyperplasia of the sebaceous glands and connective tissue. Depending on the extent of the disease, patients with rhinophyma may seek medical attention because of nasal airway compromise or cosmetic deformity.Surgery remains the mainstay in treating patients with rhinophyma. A wide range of surgical approaches has been described. Cosmetic results and postoperative morbidity were similar for each of the various techniques, but the major problems reported being hemostasis, uncontrolled tissue destruction, a high scarring rate, and prolonged wound healing times. Having a lot of experience with coblation in ENT soft-tissue surgery we decided to use it for rhinophyma treatment.Methods: Retrospective evaluation of using coblation for rhinophyma treatment.Results: Thermal damage to the surrounding tissues is minimal because of the relatively low temperatures involved in the procedure and the continuous irrigation of the operative field with cold saline. The shorter depth of thermal damage incurred with this radiofrequency technique than with conventional electrosurgery offers less postoperative morbidity and good control of tissue destruction. The lower intraoperative blood loss resulting from the possibility of simultaneous hemostasis makes the procedure much more comfortable for the surgeon and the patient. Our goal was: removal of excess tissue to achieve an acceptable cosmetic result in terms of color, texture, and symmetry with minnimal discomfort for the patient. We perform a coblation surgery under general anesthesia using the Evac 70 Wand (Smith& Nephew, London, UK), with the power control dial set at 7W. The hypertrophied nasal tissue is debulked down to the level of normal-looking skin, preserving the pilosebaceousunits. Postoperative wound care includes the application of a thin layer of petroleum jelly and petroleum jelly gauze to prevent desiccation. There is no need for postoperative antibiotics or analgesics. Reepithelization occurrs in approximately 2 weeks.Conclusion: Coblation is safe, quick, and effective as a surgical modality for the treatment of rhinophyma. It can achieve good cosmetic results and with lower postoperative morbidity than other methods.

CONE BEAM COMPUTED TOMOGRAPHY (CBCT) IMAGING IN PREOPERATIVE ASSESSMENT OF THE PATIENTS WITH CHRONIC SINUS DISEASES

Snezana Sanković Babić

ENT Clinic, Clinical Hospital Centre “Zvezdara”, Belgrade, Serbia

Background. Cone beam computed tomography (CBCT) is imaging technique currently in use in dental and maxillofacial practice and it is relatively new tool in diagnosis of ear, nose and throat diseases. This imaging method is localized low dose radiation of craniofacial region. The aim of this study was to analyse the usefulness of cone beam computed tomographic (CBCT) images using Scanora 3dx System in patients with chronic sinus diseases.

Methods. Observational clinical study included 60 patients with the clinical diagnosis of chronic sinusitis and sinonasal polyposis. In preoperative assessment CBCT of the paranasal sinuses as imaging method was performed. Experienced ENT surgeons evaluated visualization of important radiologic landmarks as a part of preoperative assessment of endoscopic sinus surgery(ESS). Imaging process was conducted by CBCT Scanora 3dx system, Finland.

Results. In independent evaluations, surgeons concluded that preoperative CBCT showed well defined extent of disease in 91.7%, and 95% of analysed CBCT images. Anatomic variations were well defined in 95% and 96.7% respectively. In analysis of bone structures and borders of the sinus walls, well defined scores were up to 983%. When surgeons evaluated visualization of scar tissue CBCT images were poorly-defined in 71.4% and 85.1% respectively.

Conclusion. The advantage of the CBCT is good quality of radiologic images generated at low radiation doses and reasonably low costs. The disadvantage of the method is the limited soft tissue differentiation. CB CT scanning of paranasal sinuses can be included in regular preoperative assessment of patients with sinonasal diseases. In patients with suspected sinusogenous complications MSCT imaging method is superior than CBCT.

INFLUENCE OF SEPTOPLASTY ON THE COURSE OF CHRONIC RHINOSINUSITIS

Slobodan Savović, Vladimir Kljajić, Ljiljana Jovančević, Maja Buljčik Čupić, Danijela Dragičević, Slobodanka Lemajić Komazec

University of Novi Sad, Faculty of Medicine, Clinical Center of Vojvodina, Clinic of Otorhinolaryngology, Head and Neck Surgery, Novi Sad, Serbia

Background. Chronic rhinosinusitis is a disorder that is characterized with the presence of two or several following symptoms: nasalcongestion, nasal discharge (anterior/posterior nasal drip), and/or facial pain/pressure and reduction or loss of smell. Among numerous causes that can lead to this disorder, mechanical factors are very frequent.

Methods. The research involved ninety patients that were, according to the degree of the nasal septum deformity, divided into three groups. All the patients were pre-surgically subjected to a subjective estimation of the symptoms of chronic rhinosinusitis by using VAS, clinical and endoscopycal examination of the nose, CT nose examination and paranasal sinuses. According to CT findings and paranasal sinuses, we determined the degree of nasal septum deformity and Lund-Mackay score. The breathing function of the nose was examined in all the patients by using objective methods- rhinomanometry. All of them undergone septoplasty. As early as six month post-surgery, all the patients were undergone again to a subjective estimation of the disorder symptoms, clinical and endoscopical nose examination as well as an objective examination of the breathing function of the nose.

Results. Only in patients whose pre-surgical degree of nasal septum deformity was minimum 10, septoplasty leads to a significant improvement of subjective nasal breathing (Z=3.075; p=0.002) and at the same time it diminishes the sensation of the facial pain/pressure (Z=3.246; p=0.001). A relevant post-surgical nasal secretion decrease was not found, nor was the olfactory function improved. Septoplasty leads to a significant decrease of the proportion of nasal secretion (Z=2.612; p=0.009), while it has no impact on nasal mucosa. Septoplasty leads to a significant decrease in nasal air flow resistance (t=7.553; p=0.000).

Conclusions. Septoplasty causes a significant decrease of the majority of subjective symptoms in patients with chronic rhinosinusitis, influences the decrease of the quantity of nasal secretion and leads to an objective improvement of nasal breathing. 

STATE OF THE ART IN CLEFT LIP RHINOPLASTY

Marc Scheithauer

ENT Deptartment, University Hospital of Ulm, Germany

Background. Due to numerous scars resulting from previous operations in early childhood, not only the soft tissue but also cartilage and bone show severe deformations. In many cases there is even a present lack of tissue.

Methods. The presentation includes the description of the specific pathological nasal anatomy followed by a clear analysis which then leads to the choice of an appropriate operational technique.

Results. The latest and most versatile techniques are shown in details on the one hand for a thorough understanding of the underlying pathology and on the other hand to demonstrate how good functional and aesthetic results can be achieved.

Conclusions. Cleft lip rhinoplasty truly is the most challenging task when we deal with septorhinoplasty.

CARTILAGE AND FASCIA TEMPORAL GRAFT FOR NASAL DORSAL COUNTOURING IN REVISION RHINOPLASTY

Roven Sinani

University Hospital Center “Mother Thereza”, Department of Otorhinolaryngology, Tirana, Albania

Background. Rhinoplasty is one of the most difficult aesthetic procedures with high revision rate up to 22%. In revision rhinoplasty dorsal irregularities are troublesome in patient with thin nasal skin. In our experience the use of autogenous grafts represents the first choice in rhinoplasty.

Methods. Twenty-five (n=25) underwent revision rhinoplasty between 2011 and 2015: 6 male and 19 female.Temporal fascia graft was used to cover the crush cartilage graft.Open rhinoplasty performed in all patient.

Results. Postoperative follow up was between 1-12 months. All patient had satisfactory aesthetic results and no irregularities observed over the nasal dorsum.

Conclusion. This study shows that temporal fascia is reliable for camouflaging any post-op irregularities in revision rhinoplasty in patients with thin nasal skin.

TRANSCRIPTION FACTORS GENE EXPRESSION IN CHRONIC RHINOSINUSITIS WITH AND WITHOUT NASAL POLYPS

Tanja Soklič Košak1,2, Matija Rijavec3, Mira Silar3, Ana Koren3, Izidor Kern3 and Peter Korošec3

1Department of Otorhinolaryngology and Head & Neck Surgery, University Medical Centre Ljubljana, Slovenia2Faculty of Medicine, University of Ljubljana, Slovenia3University Clinic of Respiratory and Allergic Diseases Golnik, Slovenia

Background: Chronic rhinosinusitis (CRS) current therapeutic approaches still fail in some patients with severe persistent symptoms and recurrences after surgery. We aimed to evaluate the master transcription factors gene expression levelsof T cell subtypes in chronic rhinosinusitis with nasal polyps (CRSwNP) and chronic rhinosinusitis without nasal polyps (CRSsNP) that could represent new, up-stream targets for topical DNAzyme treatment.

Methods: Twenty-two (n=22) newly diagnosed CRS patients (14 CRSwNP and 8 CRSsNP) were prospectively biopsied and examined histopathologically. Gene expression levels ofT-box transcription factor (T-bet, TBX21), GATA binding protein 3 (GATA3), Retinoic acid-related orphan receptor C (RORC) and Forkhead box P3 (FOXP3) were analyzed by real-timequantitative polymerase chain reaction (RT-qPCR).

Results: Eosinophilic CRSwNP was characterized by a higher level of GATA3gene expression compared to noneosinophilic CRSwNP, whereas there was no difference in T-bet, RORC and FOXP3 expression between eosinophilic and noneosinophilic CRSwNP. In CRSsNP, we found simultaneous upregulation of T-bet, GATA3 and RORCgene expression levels in comparison to CRSwNP; meanwhile, there was no difference in FOXP3gene expression between CRSwNP and CRSsNP.

Conclusions: In eosinophilic CRSwNP, we confirmed the type 2 inflammation by elevated GATA3 gene expression level. In CRSsNP, we unexpectedly found upregulated T-bet (related to the type 1 inflammation), GATA3(related to the type 2 inflammation) and RORC (related to Th17 cells) transcription factors gene expression levels. The simultaneous upregulation of T-bet and GATA3 in CRSsNP is currently unexplained; however, it might originate from activated CD8+ cells in CRSsNP. The RORC upregulation (related to Th17 cells) in CRSsNP could be part of normal homeostatic nasal mucosa immune responsethatmight be better preserved in CRSsNP patients compared to CRSwNP. Further data on transcription factors expression rates in CRS phenotypes are needed.

PARANASAL SINUS AND ANTERIOR SKULL BASE MALIGNANT TUMORS. SURGERY AND DECISION MAKING

Milan Stanković

University ENT Clinic, Clinical Center Nis, Serbia

Background: Anterior skull base malignant tumors have different histology, propagation, symptoms, and the outcome. They were considered inoperable because of damage of vital structures. Recently, improved survival is achieved thanks to better diagnostics, antibiotics, microscope, and reconstruction of defect. Early diagnosis is essential for the treatment. Contraindications for a purely endoscopic approach are reported. Indications for Combined Microscopic and Endoscopic Technique (COMET) and for exclusive external approach are documented.

Methods: Surgical experience with 25 malignat tumors affecting paranasal sinus and anterior skull base is presented.

Results: Tumors predominantly started in ethmoid (10), nasal cavum (6), from thesurroundings with secondry ingrowth (5), or from maxilla (4). Squamocellular carcinoma was the most frequent (16), followed by adenocarcinoma, malignant melanoma, and other histologic types. Subtotal ethmoidomaxillectomy was performed in 10, radical ethmoidomastoidectomy in 9, and partial ethmoidomaxillectomy in 6 patients. Dural reconstruction was needed in 5 patients. After five years of follow up local control of the disease was achieved in 15 patients, three had local recidive, and 7 patients died during this period.

Conclusion: Both traditional CFR and the endonasal endoscopic approach have advantages and disadvantages. Adequate patient selection, knowledge of location and the extent of tumor enable achieving gross total resection with microscopic negative margin.

RHINITIS IN ATHLETES

Pavol Surda1,4, Matus Putala2, Pavel Siarnik3, Abigail Walker1, Wytske Fokkens4

1Department of Otorhinolaryngology, Guy’s and St Thomas’ University Hospital, London, United Kingdom

2Department of Physical Education and Sports, Comenius University, Bratislava, Slovakia

3Department of Neurology, Faculty of Medicine, Comenius University, Bratislava, Slovakia

4Department of Otorhinolaryngology, Academic Medical Center, Amsterdam, The Netherlands

Background. Limited data suggest that swimmers might be affected by rhinitis significantly more often than the general population. This can have impact on quality of life but also on performance. The aim of the present study was to determine the prevalence and impact of QOL of rhinitis in swimming compared to non-swimming athletes and controls.

Methods. This was an observational case control, questionnaire based study involving elite (n=101) and non-elite swimming athletes (n=107), non-swimming athletes (n = 38) and sex and age-matched controls (n = 50). The survey instrument consisted of a general and the miniRQLQ questionnaire. Main question used to assess the prevalence of rhinitis was from the ISAAC study.

Results. Rhinitis was reported significantly more often by the elite swimmers (45%) than non-elite swimmers (31%), non-swimming athletes (32%) and controls (24%). Allergic rhinitis prevalence was similar in all groups (12-18%). The prevalence of non-allergic rhinitis was significantly higher in elite swimmers (33%) and non-elite swimmers (22%) compared to non-swimming athlethes and controls. Overall mean miniRQLQ score and all subdomains except the “eye” domain showed significantly reduced QOL in elite and non-elite swimmers compared to non-swimming athletes and controls. Regular nasal medication was used significantly less by elite swimmers (18%) compared to controls (67%) and non-swimming athletes (42%).

Conclusions. This study revealed a high prevalence of non-allergic rhinitis in swimmers and related impact on QoL. These findings highlight the importance to increase the awareness toward upper airway disorders in the swimming athletes and to ensure adequate management.

COMPLICATIONS OF ENDOSCOPIC SINUS SURGERY

Timoleon F. Terzis

Athens Rhinology Center, Athens Medical Center, Athens, Greece

Background. Since the early 1990’s, when Harris Mosher stated that “Intranasal Ethmoidectomy is the easiest way to kill a patient”, intranasal surgery has gone through a miraculous evolution, with corresponding major improvements in effectiveness and safety.

Methods. Personal view and review of the literature.

Results. Minor common complications, such as scarring and adhesions, often leading to occlusion of the sinus cavities, can be prevented by preservation of mucosa, when possible. Lateralization of the middle turbinate can be avoided by means of a conchopexy suture. Lacrimal injury leading to obstruction of the lacrimal apparatus is treated with a DCR procedure. Traumatized anterior ethmoidal artery can retract into the orbit and cause a retrobulbar hematoma. In this case, lateral canthotomy and inferior cantholysis should be performed immediately, before increased intraorbital pressure results in ischemic damage to the optic nerve. Severe posterior intraoperative or postoperative hemorrhage is treated with ligation/cautery of the sphenopalatine artery. Superficial lamina papyracea penetration is a common minor complication with no consequences, if recognised immediately, apart from possible minor eyelid ecchymosis. Penetration into the orbit, on the other hand, is a severe complication, as it can cause severe occulomotor muscle injury, which is rarely reversible, or trauma to the optic nerve, leading to blindness. As extended endoscopic procedures have evolved, intranasal skull base or brain surgery has put in danger sensitive anatomical structures, such as the internal carotid arteries. According to current literature, trauma to major vessels can occur in up to 9 % of the skull base surgery cases. Disaster protocol, as suggested by late H. Stammberger, and immediate action plan for major vessel injury, are discussed. Finally, intraoperative Cerebrospinal Fluid Leak management is discussed, with various treatment and repair material options.

Conclusion. Complications do occur in endoscopic sinus surgery, and the surgeon should be aware of their prevention and management.

ENDOSCOPIC SKULL BASE SURGERY – 10 YEAR EXPERIENCE

Aleksandar Trivić

Clinic of ENT and MFS, Clinical Center of Serbia, University of Belgrade Faculty of Medicine, Belgrade, Serbia

Background: At the Clinic for Otorhinolaryngology and Maxillofacial surgery, endoscopic sinus surgery has been in place since 2000. At the end of 10 years, approximately 1800 patients were treated at the clinic. In this period, different pathology was present.

Results: Nasal polyposis and chronic rhinosinusitis are the most common pathology. Additionally, 103 patients had inverted papillomas, 54 patients with antrohoanal polyps. Considering that there is a very high oncology surgery at the Clinic, 43 patients have been treated in the previous period due to the malignant tumor of the paranasal sinuses and the base of the skull. All are operated endoscopic. The right challenge for every surgeon is juvenile angiofibromas, which we had 12 boys, the youngest was 9 years old. In cooperation with the Institute of Microbiology we isolated isolated rare chronic granulomatous fungal rhinosinusitis, such as Madurella. In addition, 24 patients were isolated from aspergillus, fungus ball and zigomycet. Together with neurosurgeons, we had extensive tumor operations of the skull base, chondrosarcoma, and angio sarcoma. Two surgical procedures were combined, endoscopic and craniotomy.

Conclusions: The fact that access to tumor base of the skull is a major challenge in endoscopic sinus surgery and often requires a multidisciplinary approach, i.e. cooperation with neurosurgeons.

SIGNIFICANCE OF ADENOCHOANAL RATIO IN SLEEP APNEA SYNDROME IN CHILDREN

Šekib Umihanić, Hasan Altumbabić

ENT Clinic, University Clinical Centre Tuzla, Bosnia and Herzegovina Background. Enlargement of tonsils and/or  adenoids  is considered the most common cause of pediatric obstructive sleep apnea syndrome (OSAS). This study is aimed to evaluate the relationships between adenochoanal ratio, parameters of polygraphy (portabille monitoring), and sleep apnea symptoms.

Methods. A 4-point grading method adenochoanal ratio and paramethers of polygraphy (portabile monitoring- Philips-Alice NightOne): apnea (max, average), hypopnea (max, average), apnea/hypopnea index (AHI), PO2, pulse, and clinical score pre and postoperation were performed.

Results. There were 10 male and 3 female patients between the ages of 5 and 13 years (mean age 8.9+/-2.6; med 9). Adeno choanal ratio (AHR) preoperative had high obstruction values (mod 4, med3), Apnea/hypopnea index (AHI) preoperative was moderate (25.64±21.63; med 20.30; mod 12.20), and AHI postoperative was improved to mild form (6.54 ±5.21; med 3.50, mod 3.30). Clinical score sleep apnea symptoms is postoperatively statistically significantly improved.

Conclusions. Adeno/tonsillectomy with correction adenochoanal ratio statistically significantly reduces sleep apnea syndrome measured with a polygraph (Apnea-av. and max; Hypopnea-av. and max; AHI, pulse, PO2 and symptoms clinical score (p<0.01, Sperman correlation).

CYSTIC FIBROSIS IN CHILDREN - WHAT IS THE ROLE OF FESS?

Dilyana Vicheva

Department of Otorhinolaryngology, Medical Faculty, Medical University, Plovdiv, Bulgaria

Background: Cystic fibrosis (CF) is an autosomal recessive disorder with estimated incidence overall 1 in 30 000 people. Chromosome 7q31 encodes a protein product, specifically a chloride channel otherwise known as CFTR.

Method: Literature search using key words related to cystic fibrosis.

Results: Medical Management of PCRS with CF is limited: Topical CS; AB – aminoglycosides, tobramycin, nasal irrigation; Dornase alfa (recombinant human deoxyribonuclease); Nasal saline irrigations; Lumacaftor/Ivacaftor; Ibuprofen; Inhaled Nitric Oxide; Bronchodilatators; Mannitol; Influenza and Pneumococcal Vaccines; IV Gama globulin; Hydration; Physical Therapy. Surgical recommendations are always made following interdisciplinary discussion and consideration of risks and benefits! Surgery varied from minimal functional procedure to eliminate obstructions caused at the OMC to total spheno-ethmoidectomy and enlargement of all natural ostia. А number of studies supporting more aggressive surgical strategies in CF patients due to the high rate of revision surgery and the ability to achieve better control of sinonasal bacteria.

Conclusion: While there are NO ‘GOLD STANDARTS’ in the treatment of CF-related sinus disease, it often includes combination therapy with medical and surgical intervention.

HIGHLIGHTS FROM THE INTERNATIONAL CONSENSUS STATEMENT ON ALLERGY AND RHINOLOGY: ALLERGIC RHINITIS – WHAT WE KNOW AND WHAT WE DON’T

Sarah K. Wise, MD, MSCR

Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, Georgia, USA

Background. In order to fully understand the currently available allergic rhinitis (AR) literature, critical examination of the quality and validity of the evidence is necessary. This also forms a basis for translation of published evidence to the individual clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).

Methods. Using previously described methodology, specific AR topics were developed. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.

Results. The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR. This presentation will summarize the strongest and weakest evidence relating to AR treatment, knowledge gaps, and interesting treatment modalities that are not mainstream or commonplace.

Conclusion. The ICAR document is a critical review of the AR literature. It has identified several strengths, where providers can be confident that treatment decisions are supported by rigorous studies. There are also substantial gaps in the AR literature, which should be viewed as opportunities for improvement and additional research. This presentation will highlight the strengths and weaknesses of AR treatment according to current literature. It will offer a glimpse into some interesting, less common, AR treatment ideas as well.

ePOSTER ABSTRACT

THE ROLE OF GRANULOCYTE-MACROPHAGE COLONY-STIMULATING FACTOR IN PATHOGENESIS OF CHRONIC NON-ALLERGIC RHINITIS

Danijela Đokić1, Aleksandar Perić2, Biserka Vukomanović Đurđević2, Danilo Vojvodić3

1Department of Otorhinolaryngology, 2Institute for Pathology, 3Institute for Medical Research

Military Medical Academy Faculty of Medicine, Belgrade, Serbia

Background: Granulocyte-macrophage colony-stimulating factor (GM-CSF) is a strong proinflammatory cytokine that takes part in allergic nasal inflammation as an eosinophil colony-stimulating factor. However, the role of GM-CSF in non-allergic rhinitis has not been fully explored. The aim of this investigation was to assess the concentration of GM-CSF in nasal secretions in patients with non-allergic rhinitis with eosinophilia syndrome (NARES) in comparison to patients with perennial allergic rhinitis (PAR) and healthy subjects, and to assess the realationship with the degree of eosinophilic inflammation and clinical characteristics of the patients.

Methods: Fourteen patients with diagnosis of NARES, 14 PAR patients, and 14 healthy subjects were included in this cross-sectional study. All patients underwent symptom score assessment, nasal endoscopy, allergy testing, and cytological evaluation. The concentration of GM-CSF in nasal secretions of all participants was measured by enzyme-linked immunosorbent assay (ELISA).

Results: We found significantly higher levels of GM-CSF in patients with NARES than in the control group (p=0.035). The percent of eosinophils in nasal mucosa was higher in NARES patients in comparison to patients with PAR (p<0.001) and control patients (p<0.0001). We found positive correlations between GM-CSF levels and eosinophil counts only in NARES patients.

Conclusion: The concentrations of GM-CSF in nasal secretions correlate well with eosinophil counts in the nasal mucosa of NARES patients. These facts idicate a possible role of GM-CSF as a favorable marker for assessment of nasal disease severity and the degree of chronic eosinophilic inflammation in the nasal mucosa.

SINONASAL MUCOSAL MELANOMA: RETROSPECTIVE ANALYSIS OF 17 PATIENTS

Bruno Domingues, Eduardo Breda, Eurico Monteiro

Instituto Português de Oncologia, Porto, Portugal

Background: The present study aimed at reporting on the characteristics, treatment outcomes and failure paterns of 17 cases of nasosinusal mucosa melanoma.

Methods: between 1997 and 2018, 17 patients diagnosed with nasosinusal mucosa melanoma were managed in our institution. We reviewed the literature in PubMed in order to find the main series from studies associated with this topic.

Results: we found 7 men and 10 women, with age at presentation between 42 and 82 years (median of 67 years). Fourteen of these patients were submitted to surgical excision followed by radiotherapy with or without chemotherapy. One patient refused any treatment and 2 were considered with irresecable disease and submitted to palliative support. The survival median was 48 months. Four patients are still alive.

Conclusion: Sinonasal melanoma is a rare and aggressive tumor, with high loco-regional and distant failure rates, and poor treatment outcomes. New target directed therapies are necessary for better survival outcomes.

RARE SINONASAL TUMOURS

José Ferreira Penêda*, Joana Vilela Silva*, Francisco Monteiro*, João Fernandes**, Eurico Monteiro**

* Otorhinolaryngology department, Centro Hospitalar Vila Nova de Gaia/Espinho, Portugal

** Otorhinolaryngology department, Instituto Português de Oncologia do Porto, Francisco Gentil, Portugal

Background: Sinonasal malignant tumours are rare neoplasms, accounting for only 0,2-0,8% of all malignancies. Squamous cell carcinoma (SCC), adenocarcinoma and adenoid cystic carcinoma (ACC) are the most frequent types, representing more than 90% of all sinonasal malignant tumours. Aesthesioneuroblastoma (AENB), sinonasal undifferentiated carcinoma (SNUC), small cell neuroendocrine carcinoma (SCNEC), melanoma and hemangiopericytoma are other sinonasal malignancies very seldomly encountered. Due to their low frequency, little is known about disease behaviour and optimal treating protocols are still lacking

Methods: A retrospective analysis was conducted; all cases with histologic confirmation of sinonasal malignancies were included. SCC, adenocarcinoma and ACC were excluded; melanoma cases were analysed separately and results are presented elsewhere.

Results: 22 cases were included – 11 AENB, 8 SCNEC and 2 SNUC. AENB affected both genders equally and mean age at presentation was 47 years old. Most cases presented in advanced stages. Surgery was the preferred treatment in the majority of AENB. Chemo and radiotherapy were used as adjuvant treatment in most advanced cases. Most patients dealt well and survival was above 80%. Patients with SCNEC and SNUC were mostly male and mean age at presentation was 50 years old. Surgery was an option in half of the cases. Outcome was considerably worse when compared to AENB, with only 3 patients being alive at time of data analysis.

Conclusions: AENB, SNUC and SCNEC are rare sinonasal malignancies whose best treatment is still unknown. On our series, a combination of surgery with or without adjuvant radiotherapy achieved good results in most patients with AENB despite high stage on presentation. SNUC and SNEC show much more dismal prognosis. Due to the low incidence of disease, large multicentric analysis are required for further conclusions.

COMPARATIVE STUDY BETWEEN JODOFORM-VASELINE NASAL PACKING AND MEROCEL HEMOX 10

cm AFTER THE SEPTO-TURBINOPLASTY OR RHINOSEPTOPLASTY PROCEDURE

Marjan Marolov, Gabriela Kopacheva Barsova, Marija Dokoska

University Clinic for ENT “Mother Theresa”, Skopje, Republic of North Macedonia

Background: The purpose of our study was to compare Merocel (Merocel Hemox 10 cm) and

Jodoform-Vaseline cotton tampons (JVT) after a rhinoseptoplasty procedure in efficiency and

patient comfort.

Methods: We carried out a prospective study of 53 patients who had undergone surgery between

01/2018 and 01/2019. GroupA, packed with Merocel was composed of 29 patients, and GroupB

packed with JVT was composed of 24 patients. A standard scale ranging from zero (no symptoms)

to 5 (most severe symptoms) was used to assess subjective symptoms. To compare the usefulness

of materials we evaluated the after-surgery bleeding and bleeding after nasal pack removing,

discomfort of the patient at 12h and after 72h, discomfort during removing nasal pack. Secretions

and crusts were evaluated 1 week and 2 weeks after surgery in both groups.

Results: A total of 53 patients were enrolled in the study, 37 women and 16 men; age range 15-42

with a mean age of 34 years. After removing of the nasal pack in the GroupA, in 27 cases no bleeding

was present, and in 2 cases there was present bleeding. In the GroupB in 19 cases no bleeding was

present, and in 5 cases there was present bleeding. In the GroupA overall average discomfort score

was 2, and in the GroupB overall average discomfort was 3. We noticed statistically significance

reduction of nasal secretions and crusts at 1 week after surgery. The difference is not statistically

significant 2 weeks after surgery. Difference in discomfort related to nasal packing is statistically

significant (p < 0.05) regarding the pain during packing removal, the general satisfaction and the

pressure.

Conclusions: Merocel Hemox 10 cm was easily implanted and removed, causing patients less

discomfort during the first days after surgery. The nasal mucosa was better preserved with Merocel

than with JVT. This type of material can be used in rhino-septoplasty or septoturbinoplasty.

RECONSTRUCTIVE SURGERY OF THE FRONTAL SINUS VIA EXTERNAL APPROACH IN DIFFERENT CLINICAL CASES.

Jegors Safronovs1,2, Tatjana Bogdanova1, Karina Rapsa2, Eduards Jurshevičs1, Kirils Jursevičs2.

1“LIPEX” Clinic of Aesthetic Medicine of Medical Doctor Edward Jurshevich, Riga, Latvia.2Riga Stradinsh University, Faculty of Medicine, Department of Otolaryngology

In the era of advanced endoscopic sinus surgery, the majority of the frontal sinus diseases can be treated via minimally invasive endoscopic approach with great cosmetic result and most physiological and natural drainage repair. However, 5-10% cases should still be treated via external approach with simultaneous sinus reconstruction. Frontal sinus is anatomically most diverse of all paranasal sinuses. This sinus diseases and postoperative complications usually present with chronic frontal headache and poor forehead skin cosmetic outcomes. Good surgical outcomes depend on adequate pre-operative investigations (including CT evaluation of patient-specific anatomy, choice of the best surgical approach and technique) and surgical training and skills. Unique anatomy must be studied to work out the plan of surgery. The most frequent cases demanding external approach and reconstruction are: frontal bone trauma/fracture, tumours, mucocele, chronic inflammatory processes and postoperative complications. Four challenging clinical cases from Riga’s private clinic “LIPEX” will be presented including: titanium clamp extrusion after neurosurgical osteosynthesis, chronic frontoethmoiditis with skin fistula, lateral mucocele of the frontal sinus, and chronic headache due to small osteoma. Structures and possible pathology. Based on the CT findings, complaints and local status the most appropriate approach and surgical technique are chosen.

EXPOSURE TO TOBACCO SMOKE AND ALLERGIC RHINITIS IN PRESCHOOL CHILDREN

Sladjana Simovic 1, Sandra Zivanovic 2, Tatjana Sarenac Vulovic 2,3, Vesna Velickovic 3, Mladen Koravovic 5, Natasa Mihailovic 6

1 Department of Otorhinolaryngology, Health Centre Kragujevac, Serbia2 Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia3 Clinic of Ophthalmology, Clinical Centre Kragujevac, Serbia4 Pediatric Clinic, Clinical Centre Kragujevac, Serbia5 Faculty of Pharmacy, University of Belgrade, Belgrade, Serbia 6 Institute of public health Kragujevac, Serbia

Background: Exposure to tobacco smoke (ETS) is a potential risk factor for adverse effect on health. Parental smoking may increase the prevalence of allergic rhinitis (AR) of their children. The objective of this study was to examine the Ets and AR in preschool children.

Methods: Preschool children, who conducted to routine systemic examination for admission to school in to the ENT Department of Health Centre Kragujevac were examined. We performed detailed history especially for ETS, AR symptoms, clinical ENT examination, positive skin prick test and/or serum specific IgE. Data was statistically analysed with descriptive statistical methods, Chi square test and Spearman's rank correlation coefficient using by SPSS for Windows, version 19.0.

Results and Conclusions: In the study sample ETS were 44% children. There not exist statistical significance between ETS among boys and girls (χ2=0,01, df=1, p>0,05). Among our participant two thirds fathers (74.7%), one third mathers (28.3%) and both parents in 11.8% cases were smokers. Every fifth mother were smoked during pregnancy. Each fourth child have AR and each tirth child living in the rural area (29.7%).The application of chi square test was not revealed a significant difference of ETS and AR. There is the statistically significant difference with place of life and AR (χ2=16,35, df=1, p<0,01), there were statistical significance children's living in the rural area were less ETS opposite urban area(χ2=12,07, df=1, p<0,01).The Spearman's rank correlation coefficient was not revealed a significant correlation between ETS and AR in study sample (rs=0,006, p>0,05); father smoking and AR in children (rs=0,004, p>0,05); mother smoking and AR in children (rs =0,02, p>0,05); both parents smoking and AR in children (rs =0,006, p>0,05) and mothers smoking during pregnancy and AR in children (rs =0,08, p>0,05). In the study sample was not revealed statistically significant difference or correlation between ETS and AR in preschool children.

NASOPHARYNGEAL PRESENTATION OF SECOND BRANCHIAL CLEFT CYST: CASE REPORT OF A 29-YEAR-OLD FEMALE PATIENT

Vladan Stanojković

ENT Department, Hospital Izola, Izola, Slovenia

Branchial cleft fistulae are rare congenital abnormalities that arise from the abnormal persistence of branchial apparatus remnants. Second branchial cleft fistulae pass deep to second arch structures and over third arch structures, in a direction extending from the anterior border of sternocleidomastoid (SCM) muscle to the upper pole of the ipsilateral tonsil fossa. Because of this anatomical route, these long tubular structures are intimately associated with major neuro-vascular structures in the neck. Treatment is complete surgical excision and extirpation in toto.

However, there is a very rare case where second branchial cleft cyst appears in the form of cystic mass that is located in parapharyngeal or pharyngeal space. Rare location in the pharyngeal presence shown only three cases in the world.

We report one case of nasopharyngeal branchial cleft cyst in adults. We present the clinical presentation and surgical management of a sized cystic structures (40 x 25 x 9 mm) second branchial cleft cyst, pharyngeal presentation located from the epipharyngeal space to the hyoid bone in a 29-year-old female patient with main complaints of swelling sensation of pharynx, dysphagia and throat pain that had continued 2 days before otorhinolaringologist-examining. Preoperative CT scans of the neck clearly demonstrated the cysta. Biopsy revealed a squamous lined epithelial wall with lymphoid aggregation, which is characteristic of branchial cleft cyst.

We recommend a operation intra-oral to allow safe and complete extirpation per via naturale under general anesthesia.. The author completely removed cysts in transoral approach for cystic mass in pharyngeal space without any surgical complications- one day surgery.

EPITHELIAL SQUAMOUS METAPLASIA AND DYSPLASIA IN INFLAMMATORY NASAL POLYPS: A 10-YEAR OBSERVATIONAL STUDY

Marko Stoiljkov1,2, Danijela Đokić2, Biserka Vukomanović Đurđević3

1General Hospital Bar, ENT Unit, Bar, Montenegro2Department of Otorhinolaryngology, Military Medical Academy Faculty of Medicine, Belgrade, Serbia3Institute for Pathology, Military Medical Academy Faculty of Medicine, Belgrade, Serbia

Background: Nasal polyposis (NP) is characterized by polypoid outgrowths of chronically inflamed respiratory mucosa. The presence of squamous metaplasia and dysplasia on the mucosal surface of nasal polyps (NPs) represents different manifestations of epithelial atypia. The aim of this investigation was to evaluate the presence of epithelial squamous metaplasia and dysplasia in ethmoidal NPs.

Methods: This prospective analysis of retrospectively collected data enrolled 212 patients with NP undergoing endoscopic ethmoidectomy. To evaluate possible etiological factors for epithelia atypia, the patients in whom we histopathologically detected the presence of epithelial atypia were compared with patients with ‘normal’ NPs in accordance with their characteristics found in medical data: gender, age, main symptoms, preoperative extent of sinus disease on computed tomography, atopic status, aspirin sensitivity, cigarette smoking, occupational exposure to different noxious factors.

Results: The histopathological findings of epithelial atypia were detected in 44 (20.7%) NP patients, but the features of ‘true’ dysplasia we found in only one patient (0.5%). The presence of atypia was more frequent in male than in female population (p<0.01). The association with aspirin-exacerbated respiratory disease (AERD) and with long-term occupational exposure to different noxious chemicals, especially in workers exposed to salts of heavy metals, were more frequent in NP patients with epithelial atypia than in patients without atypia (p<0.05; p<0.01, respectively).

Conclusions: Our results suggest the possible association of epithelial atypia in NPs with the aspirin sensitivity and occupational exposure to different noxious chemicals. Although extremely rare, epithelial dysplasia may occasionally be noted in NPs, a fact that both rhinologist and pathologist should keep in mind.

ANTIBIOTIC TREATMENT OF ACUTE SINUSITIS IN PRIMARY HEALTH CARE IN NOVI SAD, SERBIA

Nemanja Todorović1, Tamara Tešić2,3, Maja Buljčik-Čupić2,3, Nataša Milošević1, Boris Milijašević4, Mladena Lalić-Popović1

1University of Novi Sad, Faculty of Medicine Novi Sad,Department of Pharmacy, Novi Sad, Republic of Serbia

2Clinical Centre of Vojvodina, Clinic for Ear, Nose and Throath Diseases, Novi Sad, Republic of Serbia

3University of Novi Sad, Faculty of Medicine Novi Sad, Department of Otorhinolaryngology, Novi Sad, Republic of Serbia

4University of Novi Sad, Faculty of Medicine Novi Sad, Department of Pharmacology and Toxicology, Novi Sad, Republic of Serbia

Background: Reducing bacterial resistance to antibiotics requires the creation of and adherence to detailed guidelines.The aim of this study was to examine the adherence of prescribed antibiotics for the treatment of acute sinusitis to guidelines that existed at the time of prescribing the drugs.

Methods: Data were collected during January 2018 in seven pharmacies (Health Institution Pharmacy “Cvejić“) on the territory of Novi Sad.Realized antibiotic prescription were analyzed, and data of interest were: gender, age, diagnosis and prescribed therapy.The adherence of the prescribing practice to the guidelines given by the Republic Health Insurance Fund from 2014 was verified. Data analysis was performed using the Microsoft Excel software for Windows.

Results: In the observed period, 13115prescriptions were realized, of which 734 (5.60 %) were antibiotic.Acute sinusitis was the fifth most common diagnosis for which antibiotics were prescribed and a total of 34 patients were diagnosed with this infection: 25 women with the average age of 47.64±14.44 years (range 14-69 years), eight men with the average age of 38.75±19.20 years (range 14-68 years) and one child seven years old.Eighteen prescriptions (52.94 %) were in accordance with the guidelines.In 11 recipes (35.35 %)drugs that were not listed in the guidelines (levofloxacine, doxycycline, clyndamicine and co-trimoxazole) were identified. In five prescriptions (14.70 %) the prescribed dose was not adequate: four prescriptions (11.76 %) prescribed subminimal doses of the drug, and in one prescription (2.94 %) the dose exceeded the maximum prescribed dose for the overall treatment of the infection.

Conclusions: The study shows low adherence to the guidelines when prescribing antibiotics for the treatment of acute sinusitis.Although following the guidelines when prescribing drugs is not obligatory, it can contribute to reducing the resistance of bacteria to antibiotics.

PHARMACEUTICAL EXCIPIENTS ASSOCIATED WITH NASAL PREPARATIONS SIDE EFFECTS

Nemanja Todorović1, Tamara Tešić2,3, Ljiljana Jovančević2,3, Svetlana Goločorbin-Kon1, Nebojša Pavlović1, Mladena Lalić-Popović1

1University of Novi Sad, Faculty of Medicine Novi Sad, Department of Pharmacy, Novi Sad, Republic of Serbia

2Clinical Centre of Vojvodina, Clinic for Ear, Nose and Throath Diseases, Novi Sad, Republic of Serbia

3University of Novi Sad, Faculty of Medicine Novi Sad, Department of Otorhinolaryngology, Novi Sad, Republic of Serbia

Background: Generally pharmaceutical excipients are pharmacologically inactive medicine constituents. However, there are many effects that some of them can cause.The aim of this study was to determine the presence of excipients with known effects (EKE) in registered nasal preparations (ATC groups R01).

Methods: The data of excipientswere taken from the online available Summary of Product Characteristics (SmPC), at the web-sites of national medicines agencies of Serbia, Croatia and Slovenia.Further consideration of excipients was done in accordance with the recommendations of European Medicines Agency.

Results: Fifty-three medicines from Serbia, 46 from Croatia and 38 from Slovenia were processed.The highest percentage of medicines with EKE was among Serbian medicines (75.47 %) and they had the highest average number of EKE per medicine (1.40). The percentage of medicines that did not have the mentioned (all) EKE in section two of SmPC was also the highest here (37.50 %). Among the Slovenian medicines, 68.42 % contained EKE with an average number of 1.38 per medicine. 15.38 % of these medicines did not emphasise the presence of EKE in section two of the SmPC.Croatian medicines had the lowest percentage of medicines with EKE (54.35 %), as well as the smallest average number of EKE per medicine (1.08). Only 12 % of medicines with EKE did not have their content mentioned in the section two of the SmPC.The most common EKE in all three countries was benzalkonium chloride, which can cause irritation and swelling of mucosa in nasal use.

Conclusions: National regulations are largely aligned with EU regulations, but they are not fully respected in terms of EKE labeling. The presence, characteristics and labeling of EKE in the analyzed medicines require additional caution when prescribing and issuing this group of medicines.

SINONASAL UNDIFFERENTIATED CARCINOMA - CASE REPORT

Miroljub Todorović1, Tanja Boljević2

1Department for Ear, General hospital Danilo I, Cetinje, Montenegro

2Clinic of Otorhinolarynology and Maxillofacial Surgery, Clinical Center of Montenegro, Podgorica, Montenegro

Introduction: Sino-nasal non-differentiated tumors in the maxillary sinus is very uncommon. Patients usually come to doctor with complains of nosebleed, difficulty breathing through nose or facial pain.

Methods: Case presentation.

Results: A sixty-four years old male patient presented with a pain on the right side of face and occasional bleeding from the nose. Clinical examination showed vegetative formation that narrowed the right nasal corridor. After the radiographic diagnosis, maxillary sinus and nose tumor surgery was performed. The pathohistological verification of undifferentiated sino-nasal cancer was followed by the radiation therapy and chemotherapy.

Conclusion: Synonyms non-differentiated carcinoma is a rare tumor that requires aggressive therapy. These patients require timely surgical treatment, with postoperative chemotherapy and radiation therapy. Due to its poor prognosis, this malignant tumor should be kept in mind in case of the patient suspected of malignancy in maxillary sinuses.

PRIMARY NASOPHARYNGEAL TUBERCULOSIS AS A RARE CASE FOR NON- PULMONARY TUBERCULOSIS

Ana Trimoska-Radevska, Jane Bushev, Zoran Karatashev, Rade Filipovski, Irena Mihajlovska- Shulevska, Violeta Jovanova Minova

Department of ENT, City Hospital 8th of September, Skopje, Rep. of Macedonia Department of Pathology, City Hospital 8th of September, Skopje, Rep. of Macedonia

Background. Tuberculosis is an infectious disease, which is common worldwide. Mostly lungs are affected, although other organs can be affected also. But the involvement of nasopharynx is extremely rare (0,1%).

Methods. We present you case with primary nasopharyngeal tuberculosislocated in the epipharynx.

Results/Case report. A 50 Year female came to us with history of nasal secretion and obstruction, headaches for 1 year. When endoscopy was performed, a pink mass was obstructing the whole nasopharynx and choana, There was a secretion stagnation, without bleeding when touched.

CT scan was performed, and it showed a mass that extend from posterior pharynx, obstructing both of choanas, especially from the right.

Than we made MRI – that showed soft tissue mass, that was extending to the pterygoid mussels and prevertebral space, but does not invades it. On a 2nd and 3th level a noticeable enlarged lymph nodes in both sides were seen, with reactive signal response. Other compartments of the head and neck were not involved.

Than we performed biopsy, that had no specific histopathologycal finding, except of lymph reactive tissue. We decided for surgical extirpation of pathological tissue, and performing recanalisation of the choana.Under general anesthesia endoscopicaly, we tried to perform recanalisation of the choana, the tissue was very adherent, sowe reduced a part of it, and succeeded in releasing the choana from the left side. The tissue was send to histopathological investigation and it revealed – Tuberculosis, with multiple granulomata with caseos necrosis and also Langhans type giant cell. The patient was put on chemotherapy with tuberculostatics for 6 months. In the follow up after 2 months she had improvement in to the clinical finding.

Conclusion. When you see a pathological mass in the nasopharynx, that doesn’t associate you to anything, you should think of tuberculosis!

NIKOLA TESLA ON NOSES

»Dear colleagues, what would we know about the world without noses?I assure you that we would not know anything! Our noses connect us with the invisible world. They inform us about healthy and unhealthy things. They say that the bed is clean and whether the soup is boiling hot. They give us the smell of mornings and the coming storms. They unite us with the nature. Namely, noses are often compared with plants: we know about »bell pepper, chilli pepper or potato like« noses. Human noses are like a bridge to the animal world. You have heard about »eagle, duck, and trunk like« noses.

Many unfortunate young men are called »toucan, unicorn, rhinoceros«.Our nose also connects us with the seasons. It brings us the scent of February frost and linden trees in June. The smell of peppers on the stove burner is a heraldic symbol of August. It is a type of tool. People are wondering: Could it be used to open a can? It is often compared to the shovel, ax, and cutter. It is also a musical instrument similar to the trumpet, bassoon, thrombone. It is a notorious snoring resonator and therefore hated among the roommates.A nose determines the color of a voice, it is the blessing of a singer and the curse of a nasal voice owner. People even feel the smell of social relationships. I know about the »smell of money« and »the smell of the poor«. It illustrates the face of the mother Earth, reminding us of the bitter mountain cliffs as well as of the speleological pits. The nose is a labyrinth, where the light and air meet the darkness of the throat. It provides a life. Do not forget that our nose gives us breath before giving us scent. As a topic, a nose has always inspired the wise. Pascal believed that the face of the world would have been different if Cleopatra’s nose had been smaller. No matter for how long we have been crying, we always need to blow our nose - Heine joked. Volter said that all people were born with ten fingers and a nose, and no one with the knowledge of God. Nose-pick-ing is a sign of immaturity and it demasks the attempt of politeness. Tycho de Brahe had a golden nose. Like an ear, it can be decorated with an earring. Dear colleagues, you’ve all seen a walker pulling a dog unsuccessfully, and a dog who does not move until it completes listening to a story that is preached to it by a scent of a nearby road. A nose tells stories. This supreme memory alarm clock still remembers the scent of the attic and cellar of the parent’s house.

A nose is a throne for glasses. Parisian and Cologne perfume manufacturers are great friends of a human soul. A nose gives us the smell of basil, coffee and lemon peel. The Greeks, Jews and other ancient nations believed that the gods, like us, liked the scent of barbecue. These ancient gods received by their noses - undoubtedly beautiful – the smell of burnt sacrifices. Beggars try to satisfy their craving in front of a restaurant, by nervously inhaling the scents of soups, goulash, and roasted meat.Eskimos kiss using their noses. It is fragile and sensitive and boys like to break that nice little ting.- Hit him in the nose – they shout - his eyes will be filled with blood. After that, he will be uselles.The legend says that Napoleon’s cannoneer rejected the Sphinx’s nose because it was too perfect. Many people are not satisfied with their noses. Visionaries dream of a noses swap. Or, even a noses stock market that would be controlled by the East India Company with its headquarters in London and Amsterdam.Every face has a nose – nice - my grandfather used to say.What is said for horses, can also be applied to noses: a good nose, a thousand defects. A bad nose, only one – it is bad.Dear colleagues, inspired colleagues - TRUST YOUR NOSE!«

Nikola Tesla to students of the Polytechnic School in GrazDecember 23, 1875

Source: book, »Tesla, The portrait among masks«, by Vladimir Pistalo