Osteosarcoma of the foot is not common. A case of osteosarcoma of the calcaneum is presented where a patient had a four months history of  progressive painful swelling of the right hind foot which was initially diagnosed as Madura foot (mycetoma). However after trying both medical and traditional remedies in his rural home town without any significant improvement he decided to go to hospital. Investigations showed that he had osteosarcoma of the right calcaneum. This case illustrates the importance of proper patient investigation

Mulepo, P

Mwaka, ES

English

AJOL - African Journals Online

 ISSN 2073-9990   East Cent. Afr. J. surg  52 COSECSA/ASEA Publication  -East and Central African Journal of Surgery.  March/April 2014 Volume 19 (1)        Calceoneal Osteosarcoma: A case report   E.S. Mwaka, P. Mulepo  Orthopaedics Department, Makerere University School of Medicine - Kampala, Uganda  Correspondence to: E.S. Mwaka, Email: erisamwaka@yahoo.com   Osteosarcoma of the foot is not common. A case of osteosarcoma of the calcaneum is presented where a patient had a four months history of progressive painful swelling of the right hind foot which was initially diagnosed as Madura foot (mycetoma). However after trying both medical and traditional remedies in his rural home town without any significant improvement he decided to go to hospital. Investigations showed that he had osteosarcoma of the right calcaneum. This case illustrates the importance of proper patient investigation.   Introduction Although osteosarcoma is the second most frequent malignant bone tumour, affecting especially children and adolescents, osteosarcomas that involve the bones of the foot are infrequent1. Osteosarcomas may also be misdiagnosed because other types of lesions may mimic their features2, 3. The current prevalence of osteosarcoma in Uganda is unknown because of the paucity of related research however, in a study carried out in between 1964 and 1968 inclusive, osteosarcoma was found to be the commonest primary malignant bone tumour with a peak age of 10 - 19 years4. We present a rare case of osteosarcoma of the calcaneum.   Case report   An 18 year old secondary school student, presented to our hospital with a four-month history of progressive painful swelling of the right heel. The patient first developed pain in the heel without antecedent trauma. Two months later, he developed progressive swelling of the affected foot which prompted him to seek medical help from a local health facility where a diagnosis of Madura foot was made and some analgesics prescribed. Despite the treatment, the condition deteriorated and could no longer walk unsupported. He eventually dropped out of school because of inability to walk the 3 mile journey to school. He then sought the services of a traditional healer but still did not improve. Eventually he was brought to our orthopaedic out-patient clinic.   On examination, he was moderately wasted, ambulated with the aid of a stick and had enlarged right inguinal lymph nodes. He had marked wasting of the right lower limb muscles with a swollen right foot especially at the heel. The swelling was irregular, slightly warm, tender, and firm in consistency. He had no discharging sinuses and the ankle and subtalar joints were stiff (Figure 1).   Radiographs of the right foot showed a mixture of sclerotic and lytic lesions in the calcaneum (Figure 2). Chest radiographs were normal. An incision biopsy done showed tissue with chondroblastic differentiation, infiltration by pleomorphic hyperchromatic cells laying down osteoid bone and chondroblastic lobules surrounded by spindle cells with osteoid bone formation with mitoses. A diagnosis of osteosarcoma of the right calcaneum was then made. The patient was counselled about the different treatment options which included the possibility of a below knee amputation but he declined and opted to be discharged so that he could go back to the traditional healers.    ISSN 2073-9990   East Cent. Afr. J. surg  53 COSECSA/ASEA Publication  -East and Central African Journal of Surgery.  March/April 2014 Volume 19 (1)         Figure 1. The swollen Right Foot   Figure 2. Radiographs of the Right Foot Discussion  Osteosarcomas comprise a family of connective tissue tumours with various degrees of malignant potential. All these tumours share the characteristic ability to produce bone or osteoid directly from neoplastic cells. Osteosarcomas constitute about 20% of all primary bone malignancies 5, 6.  Although, this tumour can occur in any bone, the appendicular skeleton is most frequently involved. Approximately 50% of lesions occur about the knee. In long bones it tends to occur in the metaphysic and multifocal involvement is extremely rare. In contrast to more conventional sites, where the tumour is usually high grade and found in adolescents, osteosarcoma of the small bones is more likely to be low grade and is often seen in older individuals. Occasionally, osteosarcoma of the foot has been reported to be associated with Paget's disease and Werner's syndrome 6, 7.    Extra-skeletal osteosarcoma can also be presented as tarsal tunnel syndrome. In a case series of foot osteosarcomas that was reported by the Mayo Clinic physicians in 1999, osteosarcoma of the calcaneus was the common type7.  Patients present with pain accentuated at night, pain is often mistaken as an injury and is not recognized until the tumour has grown. The initial diagnosis was Madura foot (mycetoma) since the patient was from a rural setting and used to walk barefooted.  ISSN 2073-9990   East Cent. Afr. J. surg  54 COSECSA/ASEA Publication  -East and Central African Journal of Surgery.  March/April 2014 Volume 19 (1)        However, in mycetoma, the spores of the causal agents implanted in the patient incubate for a long period, during which there may be no clinical manifestations except slight pain following the initial injury8. It is characterized by a chronically swollen indurated foot with multiple scars and sinuses discharging grain-filled pus unlike in this case where the history was short, there were no discharging sinuses and the foot was very painful. Other differential diagnoses for osteosarcoma of the foot in our setting are chronic osteomyelitis of the tarsal bones, Kaposi’s sarcoma and Ewing’s sarcoma.   For diagnostic purposes, conventional radiography usually provides adequate information. The findings of bone destruction associated with sclerotic foci of tumour bone formation, an aggressive (sunburst-type, lamellated, or Codman triangle) periosteal reaction, and a soft tissue mass are highly suggestive of osteosarcoma. Further radiographic evaluations for asserting the extent of the disease might be necessary together with computed tomography (CT), magnetic resonance imaging (MRI), and radionuclide bone scan. Definitive diagnosis is usually confirmed by histological examination of tissue biopsy.   Standard treatment for osteosarcoma in Africa has been amputation9.  Increased success of chemotherapy and combined techniques of oncologic reconstruction have allowed the majority of patients with osteosarcoma to undergo limb salvage, and this has improved the survival rate. In Uganda, we usually amputate the affected limb because of unavailability of appropriate adjuvant chemotherapy and tumour prostheses. Sadly though amputations carry some level of stigma in Africa and make the patient disabled, non-productive and a burden to the family.   This case illustrates the importance of thoroughly investigations especially when disease presentation is atypical.   References  1. Campanacci M, Kotz R, Gennari L, Matejovsky Z, Nilsonne U, Salzer-Kuntschik M, et al. Centralized diagnosis and treatment of bone and soft tissue tumors. J Chemother 1989; 1(4):277-8.  2. Spjut HJ, Dorfman HD. Florid reactive periostitis of the tubular bones of the hands and feet. A benign lesion which may simulate osteosarcoma. Am J Surg Pathol 1981; 5(5):423-33.  3. Erseven A, Garti A, Weigl K. Aneurysmal bone cyst of the first metatarsal bone mimicking malignant tumor. Clin Orthop Relat Res 1983(181):171-4.  4. Dodge OG. Tumours of bone and Jaw. Recent Results Cancer Res 1973; 41:222-33.  5. Arndt CA, Crist WM. Common musculoskeletal tumors of childhood and adolescence. N Engl J Med 1999; 341(5):342-52.  6. Tsuji Y, Kusuzaki K, Kanemitsu K, Matsumoto T, Ishikawa Y, Hirasawa Y. Calcaneal osteosarcoma associated with Werner syndrome. A case report with mutation analysis. J Bone Joint Surg Am 2000; 82(9):1308-13.  7. Choong PF, Qureshi AA, Sim FH, Unni KK. Osteosarcoma of the foot: a review of 52 patients at the Mayo Clinic. Acta Orthop Scand 1999; 70(4):361-4.  8. Sharif HS, Clark DC, Aabed MY, Aideyan OA, Mattsson TA, Haddad MC, et al. Mycetoma: comparison of MR imaging with CT. Radiology 1991; 178(3):865-70.  9. Ahuka OL, Lusi KM. Amputations in rural areas of another Zaire: an aetiological and epidemiological study. East and Central J Surg 1995; 1:33-35.  

Calceoneal Osteosarcoma: A case report

Background: Rhinitis may be allergic or non allergic. Allergic rhinitis,  intermittent or persistent is the most common type of rhinitis, affecting approximately 20% of the population while nonallergic rhinitis affects 5-10%. While rhinitis is not a life-threatening condition, complications may occur and the condition can significantly impair quality of life. In order tomeasure the mucociliary clearance time in patients with and without rhinitis a study was conducted in the ENT, H&amp;N, and orthopedic departments at KNH.Methods: 130 cases between the age of 18 and 40 years and matched controls were inducted. The Anderson saccharine test was conducted.Results: The average mucociliary clearance time was significantly different, 12.64 and 7.80minutes in cases and controls respectively (p = &lt;0.01). Nasal crusting as well as the rheology of mucus were significant factors in determining mucociliary clearance time (p&gt;0.01).Conclusion: The normative values of MCT remain debatable with overlap between the cases and controls.Key words: rhinitis, mucociliary clearance time, saccharine tes

Mukara, BK

Mugwe, P

 ISSN 2073-9990   East Cent. Afr. J. surg  30 COSECSA/ASEA Publication  -East and Central African Journal of Surgery.  March/April 2014 Volume 19 (1)        Mucociliary Clearance Time in Patients with and without Rhinitis.  B.K. Mukara¹, P. Mugwe² ¹Department of Otorhinolaryngology, Head and Neck Surgery, University of Rwanda. ²Otorhinolaryngology, Head and Neck Surgery, Department of Surgery University of Nairobi, Kenya Correspondences to: DrMukara B.K, E-mail: kaibat@hotmail.com ABSTRACT Background: Rhinitis may be allergic or non allergic. Allergic rhinitis, intermittent or persistent is the most common type of rhinitis, affecting approximately 20% of the population while nonallergic rhinitis affects 5-10%. While rhinitis is not a life-threatening condition, complications may occur and the condition can significantly impair quality of life. In order to measure the mucociliary clearance time in patients with and without rhinitis a study was conducted in the ENT, H&N, and orthopedic departments at KNH. Methods: 130 cases between the age of 18 and 40 years and matched controls were inducted. The Anderson saccharine test was conducted. Results: The average mucociliary clearance time was significantly different, 12.64 and 7.80minutes in cases and controls respectively (p = <0.01). Nasal crusting as well as the rheology of mucus were significant factors in determining mucociliary clearance time (p>0.01).  Conclusion: The normative values of MCT remain debatable with overlap between the cases and controls. Key words: rhinitis, mucociliary clearance time, saccharine test Introduction Rhinitis is defined as inflammation of the mucous membranes lining the nasal passages. It is characterized by a symptom complex that consists of any combination of the following: sneezing, nasal obstruction, nasal itching, postnasal dripping, rhinorrhea and occasionally nasal pains1,2,3. Rhinitis could be allergic or non allergic. Non-allergic rhinitis is subclassified into Infectious rhinitis, Recumbency rhinitis, Occupational rhinitis, Hormonal rhinitis, Drug-induced rhinitis, gustatory rhinitis, nonallergic rhinitis with eosinophilia syndrome (NARES), non airflow rhinitis and Idiopathic rhinitis. The exact prevalence of nonallergic rhinitis is not known but estimates indicate that up to 50 percent of patients with rhinitis actually have non-allergic causes2. Measurement of cilia beat frequency started in 1844 with Martius who used a stroboscope to estimate frequency beat. This is unreliable at frequencies about 6-20Hz 4. Later, in 1974 the saccharine test was described 5. The defensive function of the nose rests upon the efficiency of the mucociliary mechanism to move mucus from the nose to the pharynx to be swallowed. The vibrissae arrest large       particles5,6,7,8. The mucociliary system of the airway forms a highly efficient defense mechanism that protects the lungs against inhaled particles including living organisms like bacteria, viruses, fungi and mycoplasma as well as chemical irritants. The vital part of this system is an adequate quantity of mucus with appropriate rheological quality and adequately functioning cilia, which allow the continuous exchange of the covering fluid layer and removal of engulfed particles. Any disturbance in this system leads to stagnation of secretions and secondary infection5, 9, 10.   Ciliary activity is affected by drying, temperature, saline solutions, changes in Ph, drugs, viruses and bacteria, allergic rhinitis, chronic rhinosinusitis, nasal polyposis and                aging 5,6,7,8,11,12,13,14,15,16,17,18,19. The nasal cycle is a well-recognized physiological phenomenon exists in order to replenish the water content of nasal mucus, allowing continued humidification of inspired air 20. Some workers have noted asymmetry in mucociliary  ISSN 2073-9990   East Cent. Afr. J. surg  31 COSECSA/ASEA Publication  -East and Central African Journal of Surgery.  March/April 2014 Volume 19 (1)        clearance at the morning peak of the nasal cycle 21 although others have found no significant difference at different times of the day or in different phases of the cycle 22.  Methods used to test nasomucociliary flow Several techniques have been utilized to measure mucociliary clearance; Andersen’s saccharin test, visible dyes or particles, small metal discs (imaged by fluoroscopy) and radiolabled particles (detected by gamma scintigraphy)5,18. Of these, the Andersen’s test has become the most useful screening test in clinical practice and compares well with the imaging studies. The advantages being that it is easy to learn, it is cheap, readily available, lacks toxicity, and has no radioactivity, has a high level of tolerance, results are reproducible and can be performed in a clinical  setting23, 24.   However, the test can be difficult to perform in children and cannot be repeated in a short time since the sweetness takes some time to disappear25. A study curried out on college students in the catchment area of KNH showed that 13% suffered from allergic rhinitis5. But what are the values for mucociliary clearance in patients with rhinitis in our population and what is the effect of rhinitis on mucociliary clearance?  Subjects and Methods After approval by the ethical committee, data was collected over a period of 4 months. A total of 260 subjects aged 18-40 years were seen during the study period, giving an informed consent and meeting the inclusion criteria were recruited consecutively. History was taken then anterior rhinoscopy performed on the subjects to rule out any abnormalities; morphological or pathological. Normal subjects were patients seen in the orthopedic clinics and wards who were under follow up for traumatic conditions. Patients with conditions treated with steroids or oncological conditions were excluded. Eligible patients were entered in the control group while patients under follow up for rhinitis were entered in the cases. These were matched for sex and age.  To perform the Anderson saccharine test, a saccharin particle (1.5-mm diameter) was carefully placed on the floor of nasal cavity about 1 cm behind the anterior end of the inferior turbinate. The subject was asked not to sniff, sneeze, smoke, eat or drink during the test and to avoid deep breathing 5. The subject was also asked to swallow every 30 seconds and to report the first change in their sensation of taste. The time taken by the subjects to perceive sweet taste in the pharynx was taken as MCT in that nose. The test was repeated on each side and the average of two was taken as the NMCT. This was done to exclude the effect of nasal cycle on mucociliary clearance 8, 23.  Reference values were 7-15 minutes in normal subjects 5, 16, 27, 28, 29. Data collected was analyzed by SPSS statistical package. Descriptive statistics such as means, median, frequency and standard deviation were calculated, including comparisons for sex and age. Tests of statistical significance were carried out using the Chi square test and Mann- Whitney test where applicable. The patient evaluation sheet was pre-tested before commencement of the study and necessary modifications made before final data entry was initiated in order to minimize errors.  No incidents of patients sneezing or sniffing in the course of the test were encountered as this was overcome during the pre-testing.  Results  Nearly a third (31.5%) of the subjects was in the 26 – 30 years age group. This had the highest frequency. The median age was 27 years. This applies to the controls since they were  ISSN 2073-9990   East Cent. Afr. J. surg  32 COSECSA/ASEA Publication  -East and Central African Journal of Surgery.  March/April 2014 Volume 19 (1)        matched for sex and age. Females accounted for 65% of the case and matched controls. Both factors did not affect MCT (P<0.01) Majority of the cases presented with sneezing, 96.2%. Other symptoms included runny nose, nasal blockage, post nasal drip, headache and facial pains. On examination 67.7% had hypertrophy of the left inferior turbinate, 60% had hypertrophy of the right inferior turbinate, while 51.6% had rhinorrhoea. Of those with rhinorrhoea, 11.5% reported having thick mucus, 39.2% had watery mucus while 47.7% had no mucus at the time of presentation. It is worth noting that this observation is subjective and patient dependent. The average MCT in cases was 9.67 minutes with a range of 1.34 to 54.07minutes, while the average MCT in the controls was 7.51 minutes with a range of 2.11 to 15.64 minutes. Differences in the MCT in both nostrils could be due to the nasal cycle. Of the 130 cases 55 (42.3%) had normal MCT, 39 (30%) had prolonged MCT while 36(27.7%) had decreased MCT. Table 1. Average MCT in Minutes in Cases and Controls MCTin minutes Cases (n=130) Controls (n=130) Frequency % Frequency % Decreased    (< 7) 36 27.7 56 43.1 Normal (7-15) 55 42.3 73 56.2 Prolonged (>15) 19 30.0 1 0.8 Total 130 100 130 100  Conversely, 73 (56.2%) of the controls had normal MCT; it was accelerated in 56 (43.1%) and prolonged in 1 (0.8%) as summarized in the table above. There was no significant difference in the symptom presentation in relation to the MCT in the cases (p =<0.01). The consistency of mucus was a significant factor that affected the MCT. None of the cases with thick mucus had a decreased MCT. (p<0.01) Presence of nasal crusts affected MCT as resulting in delayed MCT. 6 of the 9 cases that had nasal crusting had delayed MCT. (p>0.01) Discussion There is no consensus on the limits for normal MCT. Some studies quote <20 minutes as being the normal cut off 28 while others propose 7-15 minutes5, 16, 27, 28, 29. In our study, the later was considered the normal range. In their study, Prior et al obtained a mean of 12 minutes in their cases while the controls had a mean of 8 minutes28. The current study agrees with previous workers, obtaining a mean of 12.6 and 7.8 minutes for the cases and controls respectively.   Ultrastructure of cilia has been shown to change beyond the age of 40 years but remains normal below this age. The changes observed were not related to sex19. In our study, only cases under 40 years were included and neither was age or sex found to affect the MCT. Our study demonstrated a difference in the MCT readings between the nostrils, a phenomenon of the nasal cycle, first described in 1885. It has been shown that 70-80% of adults manifest this cycle 21. Anderson demonstrated areas of the turbinate where clearance could be slow hence the inter-individual differences in the MCT 5. This could justify our findings. There were cases where there was complete obstruction of the nasal cavity by a hypertrophied inferior turbinate which impeded proper placement of the saccharine granule as described by Anderson. This could have possibly affected the MCT. In unison with other studies such as  ISSN 2073-9990   East Cent. Afr. J. surg  33 COSECSA/ASEA Publication  -East and Central African Journal of Surgery.  March/April 2014 Volume 19 (1)        that by Lale et al5 and Stanley et al16, our study did not show any detrimental effect after use of topical steroids or antihistamines.  Patients included in our study had intervals when they were not using the antihistamines or nasal steroids. These intervals were not standardized neither were the types of drugs used considered. Patients who had used topical vasoconstrictors for duration longer than 2 weeks were excluded from the study to avoid the confounding condition of rhinitis medicamentosa over the MCT. Nonetheless, studies have showed that ephedrine sulphate (0.5% solution) does not affect ciliary action12, 13, 14.   Prolonged MCT in patients with rhinosinusitis and atrophic rhinitis is attributed to the changes in the rheology of mucus including oedema. Changes in the ultrastructure of cilia have also been reported 5, 17. It has been documented that bacteria release toxins that disrupt epithelial cells resulting in loss of a confluent ciliary field. Also of interest is that neutrophils gather at the site of purulent infection to produce an elastase that is directly toxic to respiratory epithelium thus delaying the MCT 15.  In our study, cases with thick mucus had significantly prolonged MCT some extending even beyond 60 minutes. Immunodeficiency has been shown extensively to be associated with deranged mucociliary transport. Patients with immunodeficiency have slower nasal mucociliary transport and more extensive mucosal damage and rhinitis is a common presentation in this group30. Patients with overt immunosuppression were excluded in our study but no attempts were made to establish the serostatus of the cases or the controls. It is therefore possible that some of the included subjects could have had a degree of immunosuppression.  Conclusion Our study included subjects in the age range of 18 to 40 years. MCT was not affected by age neither was sex showed to affect it. Presence or absence of sneezing, headache, hypertrophy of the turbinates, nasal obstruction or postnasal drip does not affect MCT.  The rheology of mucus significantly affects the MCT. Patients with thick mucus have delayed MCT as compared to those with watery mucus. Patients with nasal crusting have extremely delayed MCT possibly suggestive of atrophic rhinitis. The normative values of MCT remain debatable with overlap between the cases and controls. References 1. Mygind N, Naclerjo R, Definition, classification and terminology. In allergic and non-allergic rhinitis, 2nd ed. Chapter 1,1996, Published by Blackwell science 2. Cummings C W, Fredrickson JM et al, Otolaryngology Head and Neck Surgery, 3rd ed; 1998, Vol 2 Chapter 48, Published by Mosby Inc. 3. Agency for Healthcare Research and Quality, Management of Allergic and Non allergic Rhinitis, Evidence report/ Technology Assessment, New England Medical Center Evidence-Based Practice Center. AHRQ Publication no. 02-E024, May 2002 4. Torremalm NG, Mercke U, A Reimer, The mucociliary activity of the upper respiratory tract. Rhinology, 1975; 13: 113-120 5. Lale AM, Mason JDT, Jones NS, Mucociliary transport and its assessment: a review. Clinic. Otolaryngol. 1998; 23: 388-396 6. Scott-Brown’s Diseases of the Ear Nose and Throat, Basic Sciences, 3rded, 1971, Vol 1, Pg 147-150 7. Mygind N, Nasal allergy, 2nded, Chapter 1 1979, Published by Blackwell science,  8. Stafanger G, In vitro effect of beclomethasonedipropionate and flunisolide on the mobility of human nasal cilia. Allergy, 1987; 42: 507-511  ISSN 2073-9990   East Cent. Afr. J. surg  34 COSECSA/ASEA Publication  -East and Central African Journal of Surgery.  March/April 2014 Volume 19 (1)        9. Petruson B, Hansan H.A, Karlsson G, Structural and functional aspects of cells in the nasal mucociliary system. Arch. Otolaryngol. 110 (1984), pp. 576–581 10. Wig U, Jindal NK, Goe H l, Chawla RK, Nasal mucus clearance in nasal and paranasal sinus disorders. Indian J. Chest. Dis. All. Sci. 30 (1988), pp. 176–180. 11. Clary-Meinesz C, J. Mouroux J, Cosson J et al, Influence of external pH on ciliary beat frequency in human bronchi and bronchioles. Eur. Respiratory Journal, 1998; 11: 330-333 12. O’Callaghan C, AchavaL M, Forsythe I, Barry PW, brain and respiratory cilia: effect of temperature. Biol. Neonate, 1995; 68: 394-397 13. Wong LB, Miller IF, Yeates DB, Stimulation of ciliary beat frequency by autonomic agonists: In vivo. J. Appl. Physiol. 1988; 65: 971-981 14. Wong LB, Miller IF, Yeates DB, Regulation of ciliary beat frequency by autonomic agonists: In vivo. J. Appl. Physiol. 1988; 65:1995-901 15. Wilson R, Roberts D, Cole PJ, Effect of bacterial products on ciliary function in vitro, Thorax. 1985; 40: 125-131 16. Stanley PJ, Wilson R, Greenstone MA et al, Abnormal nasal mucociliary clearance in patients with rhinitis and its relationship to concomitant chest disease. Br, J, Dis. Chest, 1985; 79: 77-82 17. Fontolliet C, Terrier G, Abnormalities of cilia and chronic sinusitis. Rhinology, 1987; 25: 57-62 18. Cauna N, Hinderer KH, Manzetti GW et al, Fine structure of nasal polyps. Ann. Otol. 1972; 81: 41-48 19. Ho JC, Kwok N, Chan et al,The Effect of Aging on Nasal Mucociliary Clearance, Beat Frequency, and Ultrastructure of Respiratory Cilia, Am. J. Respir. Crit. Care Med., Volume 163, Number 4, March 2001, 983-988 20. Ingelstedt S, Humidifying capacity of the nose. Ann Otol. Rhinol. Laryngol. 1970; 79: 474-480-20 21. Soane RJ, Carney AS, Jones NS, The effect of nasal cycle on mucociliary clearance. Clin. Otolaryngol. 2001; 26: 9-15 22. Doyle WJ, Van Cauwenberge PB, Relationship between nasal patency and clearance. Rhinology, 1987; 25: 167-179 23. Andersen, G. Lundquist, P.L. Jensen, K. Philipson and Proctor DF, Nasal clearance in monozygotic twins. Am. Rev. Respir. Dis. 110 (1974), pp. 301–305. 24. Carcianni M, Barlocco EG, Mastella G, The saccharin method for testing mucociliary function in patients suspected to have primary ciliarydiskinesia. Paediatr. Pulmonol. 1988; 5: 210-214 25. Waguespack R, Mucociliary clearance pattern following endoscopic sinus surgery. Laryngoscope. 1995; 105: 1-40 26. Gathiru B, Prevalence of Allergic rhinitis in college students at KMTC, Mmed thesis, KNH, 2006 27. Corbo GM, Foresi A, Bonfitto P et al, Measurement of nasal mucociliary clearance. Arch. Dis. Child, 1989; 64: 546-550 28. Prior MJ, Schofield K, Boivin CM, Assessment of mucociliary transport in patients with chronic mucoid rhinitis. ClinOtolaryngol. 1999; 24: 242-246 29. Schuhl JF, Nasal mucociliary clearance in perennial rhinitis. J. Invest Allergol. Clin. Immunol. 1995; 5: 533-536 30. Karlsson G, Hansson HA, Petruson B et al, The nasal mucosa in immunodeficiency: surface morphology, mucociliary function and bacteriology findings in adult patients with common variable immunodeficiency or selective IgA deficiency. ActaOtolaryngologica, 1985; 100: 456-469 

Mucociliary Clearance Time in Patients with and without Rhinitis

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Calceoneal Osteosarcoma: A case report

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