Immunoglobulin G4 related disease is an inflammatory condition characterised by the presence of fibrotic lesions infiltrated by immunoglobulin G4 positive plasma cells. It can arise from almost any region of the body and it is being increasingly recognised in the head and neck. Regardless of the site of involvement, the histopathological resemblance is remarkable. Dense lymphoplasmacytic infiltration, overabundance of immunoglobulin G4 bearing plasma cells and presence of storiform fibrosis are typical findings.

This paper presents two cases of immunoglobulin G4 related disease in which there was involvement of the orbit, the infraorbital nerve and the infratemporal fossa. Diagnosis was established in both cases by biopsying radiologically abnormal tissue in the infratemporal fossa.

An awareness of this condition is required to establish the diagnosis and initiate appropriate therapy. Glucocorticoids are the mainstay of initial treatment. The effectiveness of B-lymphocyte depletion with rituximab has also been reported. Correct diagnosis may spare patients from unnecessarily radical surgery.

To assess nasal morbidity resulting from nasoseptal flap use in the repair of skull base defects in endoscopic anterior skull base surgery.

Thirty-six patients awaiting endoscopic anterior skull base surgery were prospectively recruited. A nasoseptal flap was used for reconstruction in all cases. Patients were assessed pre-operatively and 90 days post-operatively via the Sino-Nasal Outcome Test 20 questionnaire and visual analogue scales for nasal obstruction, pain, secretions and smell; endoscopic examination findings and mucociliary clearance times were also recorded.

Sino-Nasal Outcome Test 20 questionnaire data and visual analogue scale scores for pain, smell and secretions showed no significant differences between pre- and post-operative outcomes, with visual analogue scale scores for nasal obstruction actually showing a significant improvement (p = 0.0007). A significant deterioration for both flap and non-flap sides was demonstrated post-operatively on endoscopic examination (p = 0.002 and p = 0.02 respectively).

Whilst elevation of a nasoseptal flap in endoscopic surgery of the anterior skull base engendered significant clinical deterioration on examination post-operatively, quality of life outcomes showed that no such deterioration was subjectively experienced by the patient. In fact, there was significant nasal airway improvement following nasoseptal flap reconstruction.

To study the presence of bacterial biofilm on the sinus mucosa of healthy individuals (controls) and patients with chronic rhinosinusitis with or without nasal polyposis.

An analytical, prospective and observational study was conducted. Tissue samples were obtained from the sinus mucosa. The bacteria were isolated and typified, and the material was examined for biofilm formation using tissue culture plate, Congo red agar detection and tube methods.

A total of 100 cases were analysed for the presence of biofilm. Bacterial biofilm was present in 26 of 50 disease group cases (52 per cent) and in 4 of 50 control group cases (8 per cent) (p < 0.01).

The presence of biofilm on the mucosa of chronic rhinosinusitis patients offers a possible cause for the persistent inflammation, and for antibiotics resistance and antimicrobial therapy failure. These findings could change the approach to treatment.

Very little up-to-date information is available on the microbiology of complicated acute bacterial rhinosinusitis. Reliable microbiology testing is necessary to inform current empirical antimicrobial treatments. This study was conducted in response to recent US guidelines on antimicrobial treatments for acute bacterial rhinosinusitis. It aimed to describe the pathological micro-organisms involved in complicated acute bacterial rhinosinusitis in the UK and their antimicrobial susceptibility.

This study collected retrospective data on cases of complicated acute bacterial rhinosinusitis with sinogenic orbital and/or intracranial infections from 2007 to 2012. Bacteria identified in paranasal sinus pus were compared with those identified in orbital and/or intracranial infections.

Streptococcus anginosus group bacteria were isolated from 61.3 per cent of paranasal sinus pus samples, 83.3 per cent of orbital infections and 77.8 per cent of intracranial infections. All S anginosus isolates were sensitive to penicillin; no penicillin-resistant organisms were isolated.

S anginosus was the predominant organism isolated from complicated acute bacterial rhinosinusitis samples at our UK centre. S anginosus is sensitive to penicillin, suggesting that penicillin can be used as an appropriate first-line empirical antibiotic for uncomplicated acute bacterial rhinosinusitis.

Low-dose clarithromycin has been recommended for the treatment of chronic rhinosinusitis without nasal polyps. However, it is uncertain whether a high dose of clarithromycin is more effective than a low dose.

Forty-three chronic rhinosinusitis patients were randomised to low-dose or high-dose clarithromycin groups, and clinical efficacy was evaluated. Pre- and post-treatment measures included: nasal symptom assessment, endoscopic inspection (Lund–Kennedy system), a quality of life questionnaire (the Sino-Nasal Outcome Test 20) and examination of cytokine levels (interleukin-5 and -8) in nasal secretions.

The high dose of clarithromycin was significantly better in terms of clinical efficacy than the low dose for the treatment of chronic rhinosinusitis (p < 0.025). Significant differences in nasal cytokine levels (interleukin-5 and -8) were also observed between the low-dose and high-dose groups after short-term clarithromycin treatment (p < 0.025).

Short-term, high-dose clarithromycin appears to be more effective for the treatment of chronic rhinosinusitis than low-dose clarithromycin.

Patients often present with facial pain ascribed to sinusitis, despite normal nasal endoscopy and sinus computed tomography. Facial pain is increasingly recognised to be of neurological origin.

A cohort of 240 patients with chronic facial pain was followed up for 36 months at an otolaryngological practice in Malta. The types of facial pain were classified according to International Headache Classification criteria. The body mass index, occupation and educational level of patients were compared with the general population.

Tension-type mid-facial pain and facial migraine without aura were the most common types of chronic facial pain. The sites of pain, symptoms, treatment and outcomes for these principal pain types are discussed. Patients with mid-facial pain were treated with low-dose amitriptyline for eight weeks. After three years, nearly half of the patients were symptom free, and in a third the pain changed from being chronic to being episodic. The treatment of patients with facial migraine was more varied but the length of time until recurrence of pain was similar.

The most effective long-term treatments for tension-type mid-facial pain and facial migraine were low-dose amitriptyline and low-dose amitriptyline and triptans, respectively.

This study aimed to assess the long-term outcome of functional endoscopic sinus surgery for Samter's triad patients using an objective visual analogue scale and nasal endoscopy.

Using a retrospective database, 33 Samter's triad patients who underwent functional endoscopic sinus surgery were evaluated pre- and post-operatively between 1987 and 2007 in Hospital of La Chaux-de-Fonds, Switzerland.

A total of 33 patients participated in the study, and the mean follow-up period was 11.6 years (range 1.2–20 years). Patients were divided into two groups based on visual analogue scale scores of the five parameters with the greatest difference in intensity of symptoms between the beginning and end of follow up. Group 1 included patients with a mean visual analogue scale score of 6 and below at the end of follow up and group 2 included patients with a mean visual analogue scale score of more than 6. The only statistically significant difference noted between the two groups was the endonasal findings: stage III–IV polyposis was present in 1 out of 24 patients (4 per cent) in group 1 and in 5 out of 9 patients (56 per cent) in group 2.

The results of our study indicate that functional endoscopic sinus surgery helps stabilise disease progression. Stage III–IV polyposis had a significant adverse effect on long-term outcome.

To evaluate if phenylephrine–lignocaine mixture (Cophenylcaine) nasal spray performs better than xylometazoline (Otrivine) spray for the purposes of out-patient rigid nasendoscopy preparation.

Prospective, double-blind, randomised trial comparing visual analogue scores for out-patients receiving either phenylephrine–lignocaine mixture or xylometazoline, prior to undergoing rigid nasendoscopy as part of their assessment.

Seventy-three patients requiring rigid nasendoscopy as part of their assessment were recruited to the study from Raigmore Hospital's out-patient clinic. These patients were randomised to receive a nasal spray comprising either phenylephrine–lignocaine mixture or xylometazoline, 10 minutes prior to rigid nasendoscopy. Double-blinding was adopted. After the procedure, the patient and the doctor independently completed separate visual analogue score-based questionnaires regarding the pain of the procedure and the ease of the examination, respectively.

Analysis of the data using standardised statistical methods demonstrated that the phenylephrine–lignocaine mixture did not perform better than xylometazoline, to any statistically significant extent.

Phenylephrine–lignocaine mixture is considerably more expensive and has potentially more side effects than xylometazoline. These study findings suggest that it is difficult to justify the use of phenylephrine–lignocaine mixture over xylometazoline, for nasal preparation prior to rigid nasendoscopy.

Sinonasal malignancies are rare tumours, which can be resected using an open or endoscopic approach. The current study evaluated the outcome of both approaches.

A total of 160 patients with malignant nasal tumours were evaluated in an academic tertiary care hospital. The patients were allocated to ‘open’ or ‘endoscopic’ surgery groups, based on the surgical approach employed. The following data were evaluated and compared: patient and tumour characteristics; oncological treatments; and oncological outcomes, including complications, surgical margin, recurrence, overall survival and disease-free survival.

The maxillary sinus was the most common tumour location and squamous cell carcinoma was the most common histopathology-based diagnosis. Younger patients had lower grades of tumour. Higher survival rates were significantly related to lower tumour stages in both surgery groups. There were no differences between the two relatively similar groups in terms of surgical margin, the need for adjunctive therapy, and recurrence and survival rates. In addition, multivariate logistical regression analysis indicated no correlations between the type of surgical approach employed and the rates of recurrence and complications.

Endoscopic surgery for sinonasal malignancies is comparable to the conventional open approach in carefully selected patients.

To determine the effect of pterygopalatine fossa injection with xylocaine and adrenaline on: surgical field bleeding and blood loss during functional endoscopic sinus surgery for chronic rhinosinusitis, and the duration of the procedure.

A prospective, single-blinded, controlled trial was performed in a tertiary care academic centre. A total of 45 patients undergoing functional endoscopic sinus surgery for chronic rhinosinusitis, whose disease was symmetrical based on computed tomography grading, were included. A unilateral pterygopalatine fossa injection with 1 per cent xylocaine and 1:100 000 adrenaline was performed after the induction of anaesthesia. The contralateral side served as the control. The operating surgeon, who was blinded to the injected side, assessed the surgical field using a validated six-item grading system. Blood loss, blood pressure, heart rate and end-tidal carbon dioxide were recorded every 15 minutes for each side separately, and duration of surgery was noted.

There was no statistically significant difference in the surgical field grade between the injected and non-injected sides (p = 0.161). There were no differences in blood loss or duration of surgery.

Pterygopalatine fossa injection prior to functional endoscopic sinus surgery did not decrease intra-operative surgical field bleeding, blood loss or duration of surgery.

To evaluate the therapeutic effects of functional endoscopic sinus surgery in patients with chronic rhinosinusitis who were unresponsive to medical treatment.

A total of 232 patients were divided into 2 groups: a functional endoscopic sinus surgery group (n = 162) and a conservative therapy group (n = 70). Efficacy was assessed in terms of Lund–Kennedy endoscopy scores and Sino-Nasal Outcome Test 20 symptom scores.

In the functional endoscopic sinus surgery group, Lund–Kennedy and Sino-Nasal Outcome Test 20 scores were significantly lower at 3, 6 and 12 months post-surgery compared with baseline scores. In the conservative therapy group, both sets of scores were significantly lower at 3 months, but not at 12 months. In this latter group, the Lund–Kennedy scores decreased only slightly and the Sino-Nasal Outcome Test 20 scores significantly decreased at six months compared with initial scores, indicating disparity between the subjective and objective measures. Patient-reported symptom improvement was better in the functional endoscopic sinus surgery group than in the medication group at 12 months (p < 0.001).

These findings suggest that functional endoscopic sinus surgery has better efficacy over a longer period compared with conservative therapy.