Purpose SARS-CoV-2 is a new pandemic influenza caused by a coronavirus which main route of transmission is through exhaled droplets that primarily infect the nose and the nasopharynx. The aim of this paper is to evaluate the effect of acetic acid, the active component of vinegar, as a potential disinfectant agent for upper airways. Methods Twenty-nine patients were enrolled and divided into two groups: group 1 (14 patients) was composed of patients treated with off-label hydroxychloroquine and lopinavir/ritonavir, whereas group 2 (15 patients) was composed of patients treated with hydroxychloroquine only, combined with the inhalation of acetic acid disinfectant at a 0.34% concentration. A questionnaire-based evaluation of symptoms was performed after 15 days in both groups. Results It appears that the number of patients treated with acetic acid (group 2) that experienced improvement in individual symptoms was double that of the other group of patients (group 1), although numbers are too small for robust statistical analysis. Conclusions Considering its potential benefits and high availability, acetic acid disinfection appears to be a promising adjunctive therapy in cases of non-severe COVID-19 and deserves further investigation.

Expansion Sphincter Pharyngoplasty (ESP) was introduced in 2007 and represents a promising surgical technique to treat patients with oropharyngeal walls collapse with reduced morbidity and high success rates. Between December 2012 and January 2015 17 patients underwent ESP at the department of Otorhinolaryngology of the University of Brescia (Italy), using barbed knotless sutures to improve the biomechanical effect of sutures on tissue collapse (BESP). Patients with moderate to severe OSAS and BMI < 30 kg/m2, who did not tolerate or refused ventilation therapy, were selected for BESP based on the presence of oropharyngeal collapse, as determined by upper airway examination and drug-induced sleep endoscopy. Overall success of BESP was 94,1%. Postoperative oxygen desaturation index (ODI) showed significant improvement (P<0.01). Likewise, Epworth Sleepiness Scale score was significantly reduced (P<0.05). No patient complained of uncontrolled pain after the procedure and/or reported unsatisfactory analgesia at follow-up visits. Albeit limited by the sample size and duration of follow-up, our experience confirms the validity of BESP in this selected patient population. This article is protected by copyright. All rights reserved.

BACKGROUND:Extended endoscopic maxillectomy (Sturmann-Canfield procedure) allows full visualization of the maxillary sinus by sectioning the lacrimal duct and removing the medial part of the anterior maxillary wall. The aim of this study is to evaluate the morbidity of Sturmann-Canfield procedure in patients treated for inverted papilloma.METHODOLOGY:The clinical records of all patients treated with a Sturmann-Canfield procedure for inverted papilloma from October 2000 to September 2015 at two teaching hospitals were reviewed. All patients were evaluated by nasal endoscopy and lacrimal system patency was assessed. Pre-maxillary cutaneous sensitivity was tested with a Semmes-Weinstein aesthesiometer and thermic stimulation. The SNOT-22 questionnaire was administered. Patients were also asked to report any other post-surgical complaints.RESULTS:Fifty-nine patients were identified. Mean follow-up after surgery was 66.3 months. Mean SNOT-22 score was 5.94 (range 0-20); the majority of patients (86%) had a SNOT-22 symptom score of 3 or lower. Mucocoele occurred in 3 (5%) cases. Lacrimal pathway obstruction was observed in 7 (12%) patients. Fourteen (24%) patients complained of paraesthesia in the malar area; hypoesthesia was present in only 5 (8%) cases. Hypoesthesia in the region innervated by the anterior superior alveolar nerve was detected in 17 (29%) patients. One patient reported a slight depression of paralateronasal soft tissues.CONCLUSIONS:Although nasal function outcomes and the results from SNOT-22 questionnaires were favourable, a high rate of neurologic and lacrimal complications was observed. Potential morbidity of the intervention, including the possibility of negative aesthetic sequelae, should be discussed during preoperative counselling.

The anterior wall of the maxillary sinus represents a blind spot in maxillary sinus endoscopic surgery because of the absence of proper visualisation and instrumentation to reach it. The aim of this study was to validate a new approach through the oral cavity into the nose with a flexible video endoscope (oro-nasal endoscopic approach; ONEA) to visualise the entire anterior maxillary wall including the anteromedial angle. We started from a dried bone cadaver model, and then dissected fresh-frozen cadavers. The maxillary sinus was explored with a rigid and a flexible endoscope entering from the nose. Next, a flexible endoscope was introduced through the mouth and back up through the choana, it accessed the maxillary middle antrostomy, entering inside the sinus and looking at the anterior wall. A small ruler inserted inside the sinus demonstrated all the angles visualised. The new ONEA technique allows complete visualisation of the anterior wall of the maxillary sinus with inspection of all blind spots. It is therefore possible to detect lesions that would normally not be visible with a normal rigid endoscope. We demonstrate the validity of a novel technique that allows visualisation of the infero-medial angle of the anterior wall of the maxillary sinus.

Background Granulomatosis with polyangiitis, former Wegener9s (GPA) is a systemic vasculitis characterized by necrotizing granulomatous inflammation and necrotizing vasculitis classically affecting the ear, nose and throat (ENT) district, the lower respiratory tract, and kidneys [1]. Otorhinolaryngological symptoms can be the first localized expression of the disease in a vast majority of patients (73-93%) [2]. NBI endoscopy allows for real-time visualization of mucosal and submucosal vascular patterns and it is used to distinguish precancerous and cancerous lesions of the head and neck [3]. Objectives To investigate the role of NBI in GPA and to evaluated whether disease-specific mucosal vascular pattern alterations could be present. Methods Endoscopic evaluation of upper airways with NBI was performed in 4 groups of patients: 1) 14 patients already diagnosed with GPA; 2) 9 patients with signs and symptoms of EGPA who needed to undergo nasal biopsy to confirm their diagnosis 3) 21 patients affected by chronic rhinosinusits with nasal polyps 4) 25 healthy controls. The presence of NBI vascular alterations and histological results in patients in group 1 and 2 were matched with the final diagnosis in a cross tabulation. Sensibility (SE), specificity (SP), positive predictive value (PPV) and negative predictive value (NPV) were calculated. Results 11 areas with vascular abnormalities were identified in nasal and sinonasal mucosa of 10 patients (8 pts in group 1 and 2 pts in group 2). The anomalous patterns differed substantially from one patient to another. Patients in group 3 and group 4 showed a normal pattern. SE, SP, PPV and NPV of NBI compared with final diagnosis of GPA in group 2 were 0.40, 1, 1 and 0.57 respectively. SE, SP, PPV and NPV of histology compared with final diagnosis of GPA in group 2 were 0.60, 1, 1 and 0.67 respectively. SE, SP, PPV and NPV of NBI compared with final diagnosis of GPA in group 1 + group 2 were 0.53, 1, 1 and 0.31 respectively. SE, SP, PPV and NPV of histology compared with final diagnosis of GPA in group 1 + group 2 were 0.43, 1, 1 and 0.33 respectively. Conclusions Compared to nasal biopsy, NBI endoscopy is a less invasive and time-demanding technique. In our cohort of patients NBI nasal endoscopy offered diagnostic sensitivity and specificity similar to histology. This novel technique, combined with other tests, could help clinicians to reach sufficient diagnostic evidence of GPA and could be used to direct tissue sampling. We consider NBI a promising rapid technique that, on the basis of future studies, could become a supplementary diagnostic tool in the complex workup of GPA. References Hoffman GS, Kerr GS, Leavitt RY et al. Wegener granulomatosis: an analysis of 158 patients. Ann Intern Med 1992;116:488-98. Srouji IA, Andrews P, Edwards C, Lund VJ. Patterns of presentation and diagnosis of patients with Wegener9s granulomatosis: ENT aspects. J Laryngol Otol. 2007;121:653-8. Watanabe A, Taniguchi M, Tsujie H, Hosokawa M, Fujita M, Sasaki S. The value of narrow band imaging for early detection of laryngeal cancer. Eur Arch Oto-rhinolaryngol. 2009;266:1017–23. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.4452

Purpose: Review of the literature concerning cocaine induced midline destructive lesions (CIMDL). Methods: We reviewed the English literature regarding CIMDL involving the nose and its surrounding structures. The review is based on a search of the US National Library of Medicine (PubMed) online database from January 1st, 1982 to March 31st, 2013. Results: CIMDL is a pathology that mimics systemic diseases with positive anti-neutrophil cytoplasmic antibodies (ANCA). The prevalence of CIMDL is considered to be about 4.8% among cocaine users. Clinical manifestations include hyposmia, facial pain, crusting, ulcers, nasal septal perforation, palatal perforation, sinus wall destruction, orbital erosion and damage of the anterior skull base. The presence of ANCA directed against human neutrophil elastase (HNE) is the most distinguishing feature of CIMDL. Toxicological tests, indirect immunofluorescence microscopy, antigen specific solid assay testing, histopathological analysis, apoptosis assay and MRI imaging concur in the clinical identification of CIMDL. The pathogenesis of CIMDL is poorly understood and implicates inflammatory, infective, proapoptotic and autoimmune mechanisms. Conclusion: CIMDL must be readily recognized by clinicians to provide appropriate treatment. Immunosuppressive therapy has no role in the treatment of CIMDL. Only abstinence can interrupt the progression of the disease.

To describe a new and useful criterion to identify endoscopically approachable lateral frontal sinus mucoceles. We retrospectively reviewed all patients diagnosed with frontal mucocele with lateral extension who underwent endoscopic sinus surgery (ESS) at the Department of Otorhinolaryngology, San Raffaele Scientific Institute over a 4 year period, from January 2008 to March 2012. We analyzed patient charts, pre- and post-operative imaging, operative reports, postoperative periods, and follow-up records. Our series is composed of seven patients, four males and three females, with a mean age of 56 years. Symptoms at presentation varied depending on the extent of mucocele growth and orbital and intracranial invasion. Mucocele extension medially to a virtual sagittal plane tangential to the medial side of the ocular globe was also evaluated with computed tomography, to determine the appropriateness and feasibility of an ESS procedure. After pre-operative investigations, patients underwent marsupialization of the mucocele with ESS. Postoperative follow-up ranged from 1 to 4 years. At present, all patients remain free of disease, as documented by radiological imaging. In defining endoscopically approachable lesions, it is essential to determine their extension beyond a virtual sagittal plane tangential to the medial side of the ocular globe. The success of the endoscopic procedures described was undoubtedly linked to the localization of the mucocele medial wall. This criterion is more important than the size of the mucocele, and accurate computed tomography evaluation can identify those mucoceles approachable with ESS, even if laterally extended.

Malignant melanoma is particularly resistant to conventional chemotherapy and radiotherapy. For this reason in the past years a huge variety of new compounds has been developed with potential chemotherapeutic activity which needs to be tested in vitro and in vivo. We investigated the in vitro action of three new experimental antifolate substances (MR7, MR21 and MR36) with a critical target for thymidylate synthase (TS), an essential enzyme for DNA synthesis. The response of two melanoma cell lines (SK-MEL-2 derived from malignant melanoma metastasis and SK-MEL-28 derived from primary malignant melanoma) was examined after treatment with these substances. The antifolate agents induced apoptosis in SK-MEL-2 and SK-MEL-28 cells as confirmed by the TUNEL technique and Comet Assay. Western-blot analysis showed a down-regulation of Bcl-2 protein level and PARP cleavage, otherwise p53 and Bax expressions were not modulated. Moreover, these antifolate-induced apoptosis was accompanied by both pro-caspase-9 and -8 activations. These results were supported by the use of the pan-caspases inhibitor Z-VAD-FMK that almost completely decreased the amount of apoptosis in both the melanoma cell lines treated with antifolate. In conclusion our results show that TS inhibitors are able to induce apoptosis through a caspase-mediated pathway, but without the involvement of the p53/Bax signalling.

BACKGROUND:It is generally accepted that sunlight may contribute to the development of melanoma.OBJECTIVES:To analyse gene expression of melanocytes obtained from clinically unaffected skin of patients with melanoma and healthy controls before and after exposure to ultraviolet B radiation.METHODS:Using GeneChip array technology, the gene expression of melanocytes obtained from the two donor groups was profiled, in order to identify transcriptional differences affecting susceptibility to melanoma.RESULTS:The data collected did not show any difference between the expression profiles of melanocytes purified from normal donors and from patients with melanoma that was able to give a statistically significant class separation. However, by means of unsupervised clustering our data could be divided into two main classes. The first class included the transcriptome profiles of melanocytes obtained from skin samples of patients with a vertical growth phase (VGP) melanoma, while the second class included the transcriptome profiles of melanocytes obtained from skin samples of patients with a radial growth phase (RGP) melanoma.CONCLUSIONS:These data suggest that melanocytes in patients with VGP and RGP melanomas show significant differences in gene expression profiles, which allow us to classify patients with melanoma also from clinically unaffected skin.

The sphingomyelin pathway is an ubiquitous, evolutionary conserved signaling system which transduces an extracellular signal into the cell. During the past few years increasing evidence has shown that the sphingolipid ceramide may play a role as a second messenger in intracellular signal transduction. The ceramide generation via sphingomyelinase (SMase) is followed by three major cellular responses: cell growth arrest, induction of cell differentiation and/or induction of programmed cell death or apoptosis. The aim of this study is to investigate whether activation of SMases and generation of ceramide can be induced by UVB radiation in normal human keratinocytes. The present data show that exposure to UVB radiation results in rapid generation of ceramide. The ceramide accumulation starts 15 min after UV exposure and progressively increases up to 24 h. In vitro measurement of SMase activity following exposure to UVB evidences an activation of both neutral and acidic SMases. Moreover, UVB induces apoptosis in normal human keratinocytes as shown by TUNEL technique and FACS analysis. These data indicate that UVB induced ceramide generation and activation of both neutral and acidic SMases, suggesting that sphingolipids metabolism may be involved in the UVB signaling pathway.