ORL 1990;52:311-315
© 1990 S. Karger AG. Basel 0301-1569/90/0525-0311S2.75/0
Nasal Mucociliary Clearance in Patients with Nasal Polyposis J. Coromina J. Sauretb a,
aENT Department and bPneumology Department, Hospital de la Santa Cruz y San Pablo, Barcelona, Spain
Key Words. Nasal mucociliary clearance • Nasal polyposis • Saccharin test Abstract. We have studied 30 patients (13 males and 17 females) with nasal polyposis, measuring the nasal mucociliary clearance using the saccharin test. The results have been compared with those obtained in a control group of 20 healthy subjects. The values obtained in the group with nasal polyposis (X ± SD = 31.7 ± 13.4 min) were significantly higher than those of the healthy subjects (X ± SD = 12 ± 6 min; p < 0.002). These results suggest that there is a significant decrease in the nasal mucociliary clearance of patients with nasal poly posis.
The measurement of the mucociliary clearance is an important parameter which facilitates the study and understanding of many nasal and bronchopulmonary dis eases. The most common method of this mea surement consists of the inhalation of an aerosol with radio-active isotope and the follow-up, using a gamma camera, of the pulmonary radio-activity [1], Nevertheless, the clearance can equally be evaluated in the nose using a radio-active colloid or by
simple, less costly and equally effective methods which measure the time of trans port of colouring or sweetening substances. This last system, proposed by Andersen et al. [2], uses a non-invasive and easy to carry out procedure, known as the sac charin test. The purpose of this study is to present our experience and the results of this test in patients suffering from nasal polyposis. We compare these results with those obtained in a control group of 20 healthy subjects.
Downloaded by: King's College London 137.73.144.138 - 11/20/2017 3:49:59 PM
Introduction
Coromina/Sauret
312
Materials and Methods We have studied 30 subjects (13 males and 17 females) with nasal polyps (25 bilateral and 5 unilat eral), ranging in age from 19 to 45 years (X = 34); they volunteered for this study. None of them was a ciga
rette smoker. Three had asthma and 2 had aspirin intolerance. A second group of 20 healthy non-smokers (10 males and 10 females), (without history of nasal or pulmonary illness and aged between 20 and 30 years (X = 27), were studied.
Table 1. Saccharin test in patients with nasal polyps
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Age years
33 32 43 35 30 22 21 39 34 45 26 28 37 37 30 24 38 41 45 31 45 45 43 28 31 24 43 36 47 19
Sex
F F F F M F M M M M F M F M M M M M M M F F F F F F F F F F
TS years
5 8 6 12 6 5 7 6 19 6 4 12 22 3 6 6 10 9 10 4 15 7 10 7 10 8 21 7 28 4
Loc.
2 2 2 2 2 1 2 1 2 2 1 2 2 2 2 1 2 2 2 1 2 2 2 2 2 2 2 2 2 2
Rad. ext.
MS MS-EtS MS-EtS MS-EtS MS-EtS MS MS-EtS MS MS MS MS MS-EtS MS MS MS MS MS-EtS MS MS-EtS MS MS-EtS MS-EtS MS-EtS-FS MS-EtS MS-EtS MS-EtS MS-EtS MS MS-EtS MS
Asp int.
Asthma
Triad
_
_
_
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
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-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
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-
-
-
-
-
-
-
-
-
-
-
+
-
-
-
-
-
-
-
-
+
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
+ +
+ +
+ +
Saccharin, min A
B
54 60 23 25 31 29 26 34 27 26 12 29 8 15 28 35 20 38 32 22 60 30 31 29 25 36 57 19 36 54
48 50 21 19 28 20 28 26 21 26 10 21 12 14 15 29 16 30 26 18 52 28 29 23 19 30 51 12 30 49
TS = Time of symptomatology; Loc. = location: 1 = unilateral nasal polyp, 2 = bilateral nasal polyps; Rad. ext. = radiological extension: MS = maxillary sinus, EtS = ethmoidal sinus; Asp. int. = aspirin intolerance; Triad = nasal polyps, asthma and aspirin intolerance; A = saccharin test before surgery; B = saccharin test after surgery'.
Downloaded by: King's College London 137.73.144.138 - 11/20/2017 3:49:59 PM
Case
Nasal Mucociliary Clearance in Patients with Nasal Polyposis
Table 2. Saccharin test in healthy subjects Case
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Age
23 30 25 25 30 30 31 27 28 20 22 33 28 30 28 26 22 22 25 25
Sex
M M M M M M M M M M F F F F F F F F F F
Saccharin, min A
B
10 6 6 30 15 8 8 11 10 6 8 12 13 14 13 24 6 20 15 11
11 8 8 28 13 7 8 12 10 6 8 12 14 13 17 20 8 18 13 10
A - First determination; B = second determination.
Results The results of our study are presented in tables 1 and 2. The values obtained in the control group of healthy subjects (X ± SD = 12 ± 6 min) were similar to those reported in previous studies, without observing signif icant differences between men and women [4-6], In the patients with nasal polyposis we found values of 31.7 ± 13.4 min (X ± SD), being significantly higher than those ob served in normal subjects (p < 0.002 accord ing to the non-parametric test of MannWhitney U/Wilcoxon). These results show that the group of patients with nasal polyps studied had a significant delay in the muco ciliary nasal clearance. After the surgical procedure, new determinations were per formed, resulting in values of 16 ±12.1 min (X ± SD).
Discussion Two different possibilities have been sug gested to explain these significant alterations in the nasal mucociliary clearance in patients with nasal polyposis: histological modifica tions of the nasal epithelium and hypersecre tion of mucus. Perhaps the most important factors are the histological modifications of the nasal epithelium. Friedrich, in 1843 [7] was one of the first to observe these alterations which consist of: ( 1) pseudostratified columnar epi thelium, in which only some cells are cil iated; (2) transitional epithelium (polystratified epithelium in which the cells that are on the surface contain microvilli); (3) squamous epithelium, and (4) ulcerations. Andersen [8]
Downloaded by: King's College London 137.73.144.138 - 11/20/2017 3:49:59 PM
The saccharin test was carried out on all these sub jects by the usual technique, which consists of putting a 1-mm-diameter particle of saccharin on the surface of the inferior nasal turbinate, 1 cm behind its head. Then, the subject is instructed to remain seated, with out sneezing or blowing his nose, and we register the time which passes until he notices a sweet taste. This happens when the saccharin arrives by the effect of the ciliary beat to the oral cavity. The test was stopped if sweetness was not tasted after 1 h. None of the patients had taken medication for at least 24 h before the day of the experiment; all trials were car ried out in the same room, under similar conditions relative to the atmospheric temperature and relative humidity. In every case, as Puchelle et al. [3] suggested, two determinations were performed: one at 12 a.m. (20 ° C) and the other at 7 p.m. (10 0C).
313
314
A third mechanism of ciliary dysfunction in patients with nasal polyposis is the rhinorrhoea of these patients, usually intermit tent and serous. This rhinorrhoea, due to the important increase in number and size of the goblet cells, which produce mucus, cause a compression of the ciliated cells. This com pression would be bigger in the large polyps, because the cilia come into contact with nasal walls, decreasing their movement. The improvement of the mucociliary clearance after surgery is probably due to the disappearance of the rhinorrhoea. However, nasal epithelium modifications persisting in these patients would explain that the sac charin test does not return to normal.
References 1 Camner, P.: The production and use of test aero sol for studies of human tracheobronchial clear ance. Environ. Physiol. Biochem. 1: 137-154 (1971). 2 Andersen, I.; Camner, P.; Jensen, PL; Philipson, K.; Proctor, DF.: Nasal clearance in monozygotic twins. Am. Rev. resp. Dis. 110: 301-305 (1974). 3 Puchelle, E.; Aug, F.; Pham, Q.T.; Bertrand, A.: Comparison of three methods for measuring nasal mucociliary clearance in man. Acta oto-lar. 91: 297-303 (1981). 4 Rutland. J.: Griffin, WN.; Cole. PJ.: Human cil iary frequency in epithelium from intrathoracic and extrathoracic airways. Am. Rev. resp. Dis. 126: 100-105 (1982). 5 Stanley, P.; MacWilliams, L.; Greenstone, M.; Mackay, I.; Cole, P.: Efficacy of a saccharin test for screening to detect abnormal mucociliary' clearance. Br. J. Dis. Chest 78: 62-65 (1984). 6 Duchatau, GS.; Gramans, K.; Ludera. J.; Merkus. S.: Correlations between nasal ciliary beat fre quency and mucous transport beat in volunteers. Laryngoscope 95: 854-859 (1985). 7 Friedrich, FT.: De polyporum structura peniture. Ed. Leeral 53-56 (1843).
Downloaded by: King's College London 137.73.144.138 - 11/20/2017 3:49:59 PM
observed nests of squamous metaplasia in 20% of the surface epithelia of the polyps, especially in the deepest part of the nose. In 1943, Andersen [8] studied the epithelium of 115 nasal polyps and observed that only in 7 cases was the epithelium exclusively ciliated or respiratory; in 30 cases this epithelium was not unique, but predominant; in 43 cases an epithelial hyperplasia prevailed, and in 11 polyps a monostratified epithe lium was prevalent; this was formed by a layer of small, irregular and polygonal cells, resembling a basement membrane, being the result of desquamation of the cells of the sur face. Finally, in 15 polyps a squamous epi thelium was found [8], Many changes have been detected in the ciliary structure by electron microscopy. We must remember that a normal cilium is com posed of a sheath of microtubules called an axoneme. The microtubules are in a 9 + 2 pattern, which is constant for all the cilia in the body. The 9 outer doublet microtubules are composed of 2 subfibres, A and B. The cilium is a complex motor, and defects in any one of these many essential components can lead to motor failure or to inadequate functioning [9], Thus, Herzon [10] has de scribed in nasal polyposis: extra microtu bules, ‘compound’ cilia (multiple axonemes within a common cell membrane; they seem to arise by the fusion of several cilia), and missing B subfibres. Chao et al. [11] ob served the lack of the subfibre A arms; with this defect, some desorientation of doublet microtubules may occur, affecting the nor mal symmetrical disposition of the ciliary axonemes [11], Finally, it is interesting to remember that Afzelius, in 1979 [12], noted that patients with the immotile cilium syndrome fre quently developed nasal polyps.
Coromina/Sauret
Nasal Mucociliary Clearance in Patients with Nasal Polyposis
8 Andersen, HA.: Nasal polyps and hyperplastic si nusitis (Thaning, Copenhagen 1943). 9 Afzelius , BA.: Immotile cilia syndrome and cilia abnormalities induced by infection and injury. Am. Rev. resp. Dis. 124: 107-109 (1981). 10 Herzon, F.: Upper respiratory tract ciliary ultrastructural pathology. Ann. Otol. Rhinol. Lar. 90: suppl. 83, pp. 1-12 (1981). 11 Chao, J.; Turner, JA.; Sturgess, JM.: Genetic heterogenicity of dynein deficiency in cilia from pa tients with respiratory disease. Am. Rev. resp. Dis. 126:302-303 (1982).
315
12 Afzelius. BA.: The immotile cilia syndrome and other ciliary diseases. Int. Rev. exp. Path. 19: 143 (1979).
Received: December 21, 1988 Accepted: February' 15, 1990 J. Coromina, MD c/ Ganduxer 80 E-08021 Barcelona (Spain)
Announcement
The international ‘winter Meeting’ will be held in Flims-Laax/Switzerland (Hotel Panorama Vallarosa, Laax-Murschetg). March 3-10, 1991. The topic of the meeting is: Plastic and Reconstructive Surgery for Facial and Neck Rehabilitation. Members and guests are invited to submit ‘free papers’ until December 15, 1990.
Further information and details can be obtained from the course organizers: Prof. Dr. C. Walter, Klinik am Rosenberg. CH-9410 Heiden, Switzerland, or Prof. Dr. H. Jung, HNO-Klinik. Krankenhaus Marienhof, Rudolf-Virchow-Str. 7, D-5400 Koblenz, FRG.
Downloaded by: King's College London 137.73.144.138 - 11/20/2017 3:49:59 PM
European Academy of Facial Surgery (The Joseph Society)
© 1990 S. Karger AG. Basel 0301-1569/90/0525-0311S2.75/0
Nasal Mucociliary Clearance in Patients with Nasal Polyposis J. Coromina J. Sauretb a,
aENT Department and bPneumology Department, Hospital de la Santa Cruz y San Pablo, Barcelona, Spain
Key Words. Nasal mucociliary clearance • Nasal polyposis • Saccharin test Abstract. We have studied 30 patients (13 males and 17 females) with nasal polyposis, measuring the nasal mucociliary clearance using the saccharin test. The results have been compared with those obtained in a control group of 20 healthy subjects. The values obtained in the group with nasal polyposis (X ± SD = 31.7 ± 13.4 min) were significantly higher than those of the healthy subjects (X ± SD = 12 ± 6 min; p < 0.002). These results suggest that there is a significant decrease in the nasal mucociliary clearance of patients with nasal poly posis.
The measurement of the mucociliary clearance is an important parameter which facilitates the study and understanding of many nasal and bronchopulmonary dis eases. The most common method of this mea surement consists of the inhalation of an aerosol with radio-active isotope and the follow-up, using a gamma camera, of the pulmonary radio-activity [1], Nevertheless, the clearance can equally be evaluated in the nose using a radio-active colloid or by
simple, less costly and equally effective methods which measure the time of trans port of colouring or sweetening substances. This last system, proposed by Andersen et al. [2], uses a non-invasive and easy to carry out procedure, known as the sac charin test. The purpose of this study is to present our experience and the results of this test in patients suffering from nasal polyposis. We compare these results with those obtained in a control group of 20 healthy subjects.
Downloaded by: King's College London 137.73.144.138 - 11/20/2017 3:49:59 PM
Introduction
Coromina/Sauret
312
Materials and Methods We have studied 30 subjects (13 males and 17 females) with nasal polyps (25 bilateral and 5 unilat eral), ranging in age from 19 to 45 years (X = 34); they volunteered for this study. None of them was a ciga
rette smoker. Three had asthma and 2 had aspirin intolerance. A second group of 20 healthy non-smokers (10 males and 10 females), (without history of nasal or pulmonary illness and aged between 20 and 30 years (X = 27), were studied.
Table 1. Saccharin test in patients with nasal polyps
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Age years
33 32 43 35 30 22 21 39 34 45 26 28 37 37 30 24 38 41 45 31 45 45 43 28 31 24 43 36 47 19
Sex
F F F F M F M M M M F M F M M M M M M M F F F F F F F F F F
TS years
5 8 6 12 6 5 7 6 19 6 4 12 22 3 6 6 10 9 10 4 15 7 10 7 10 8 21 7 28 4
Loc.
2 2 2 2 2 1 2 1 2 2 1 2 2 2 2 1 2 2 2 1 2 2 2 2 2 2 2 2 2 2
Rad. ext.
MS MS-EtS MS-EtS MS-EtS MS-EtS MS MS-EtS MS MS MS MS MS-EtS MS MS MS MS MS-EtS MS MS-EtS MS MS-EtS MS-EtS MS-EtS-FS MS-EtS MS-EtS MS-EtS MS-EtS MS MS-EtS MS
Asp int.
Asthma
Triad
_
_
_
-
-
-
-
-
-
-
-
-
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+
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+ +
+ +
+ +
Saccharin, min A
B
54 60 23 25 31 29 26 34 27 26 12 29 8 15 28 35 20 38 32 22 60 30 31 29 25 36 57 19 36 54
48 50 21 19 28 20 28 26 21 26 10 21 12 14 15 29 16 30 26 18 52 28 29 23 19 30 51 12 30 49
TS = Time of symptomatology; Loc. = location: 1 = unilateral nasal polyp, 2 = bilateral nasal polyps; Rad. ext. = radiological extension: MS = maxillary sinus, EtS = ethmoidal sinus; Asp. int. = aspirin intolerance; Triad = nasal polyps, asthma and aspirin intolerance; A = saccharin test before surgery; B = saccharin test after surgery'.
Downloaded by: King's College London 137.73.144.138 - 11/20/2017 3:49:59 PM
Case
Nasal Mucociliary Clearance in Patients with Nasal Polyposis
Table 2. Saccharin test in healthy subjects Case
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Age
23 30 25 25 30 30 31 27 28 20 22 33 28 30 28 26 22 22 25 25
Sex
M M M M M M M M M M F F F F F F F F F F
Saccharin, min A
B
10 6 6 30 15 8 8 11 10 6 8 12 13 14 13 24 6 20 15 11
11 8 8 28 13 7 8 12 10 6 8 12 14 13 17 20 8 18 13 10
A - First determination; B = second determination.
Results The results of our study are presented in tables 1 and 2. The values obtained in the control group of healthy subjects (X ± SD = 12 ± 6 min) were similar to those reported in previous studies, without observing signif icant differences between men and women [4-6], In the patients with nasal polyposis we found values of 31.7 ± 13.4 min (X ± SD), being significantly higher than those ob served in normal subjects (p < 0.002 accord ing to the non-parametric test of MannWhitney U/Wilcoxon). These results show that the group of patients with nasal polyps studied had a significant delay in the muco ciliary nasal clearance. After the surgical procedure, new determinations were per formed, resulting in values of 16 ±12.1 min (X ± SD).
Discussion Two different possibilities have been sug gested to explain these significant alterations in the nasal mucociliary clearance in patients with nasal polyposis: histological modifica tions of the nasal epithelium and hypersecre tion of mucus. Perhaps the most important factors are the histological modifications of the nasal epithelium. Friedrich, in 1843 [7] was one of the first to observe these alterations which consist of: ( 1) pseudostratified columnar epi thelium, in which only some cells are cil iated; (2) transitional epithelium (polystratified epithelium in which the cells that are on the surface contain microvilli); (3) squamous epithelium, and (4) ulcerations. Andersen [8]
Downloaded by: King's College London 137.73.144.138 - 11/20/2017 3:49:59 PM
The saccharin test was carried out on all these sub jects by the usual technique, which consists of putting a 1-mm-diameter particle of saccharin on the surface of the inferior nasal turbinate, 1 cm behind its head. Then, the subject is instructed to remain seated, with out sneezing or blowing his nose, and we register the time which passes until he notices a sweet taste. This happens when the saccharin arrives by the effect of the ciliary beat to the oral cavity. The test was stopped if sweetness was not tasted after 1 h. None of the patients had taken medication for at least 24 h before the day of the experiment; all trials were car ried out in the same room, under similar conditions relative to the atmospheric temperature and relative humidity. In every case, as Puchelle et al. [3] suggested, two determinations were performed: one at 12 a.m. (20 ° C) and the other at 7 p.m. (10 0C).
313
314
A third mechanism of ciliary dysfunction in patients with nasal polyposis is the rhinorrhoea of these patients, usually intermit tent and serous. This rhinorrhoea, due to the important increase in number and size of the goblet cells, which produce mucus, cause a compression of the ciliated cells. This com pression would be bigger in the large polyps, because the cilia come into contact with nasal walls, decreasing their movement. The improvement of the mucociliary clearance after surgery is probably due to the disappearance of the rhinorrhoea. However, nasal epithelium modifications persisting in these patients would explain that the sac charin test does not return to normal.
References 1 Camner, P.: The production and use of test aero sol for studies of human tracheobronchial clear ance. Environ. Physiol. Biochem. 1: 137-154 (1971). 2 Andersen, I.; Camner, P.; Jensen, PL; Philipson, K.; Proctor, DF.: Nasal clearance in monozygotic twins. Am. Rev. resp. Dis. 110: 301-305 (1974). 3 Puchelle, E.; Aug, F.; Pham, Q.T.; Bertrand, A.: Comparison of three methods for measuring nasal mucociliary clearance in man. Acta oto-lar. 91: 297-303 (1981). 4 Rutland. J.: Griffin, WN.; Cole. PJ.: Human cil iary frequency in epithelium from intrathoracic and extrathoracic airways. Am. Rev. resp. Dis. 126: 100-105 (1982). 5 Stanley, P.; MacWilliams, L.; Greenstone, M.; Mackay, I.; Cole, P.: Efficacy of a saccharin test for screening to detect abnormal mucociliary' clearance. Br. J. Dis. Chest 78: 62-65 (1984). 6 Duchatau, GS.; Gramans, K.; Ludera. J.; Merkus. S.: Correlations between nasal ciliary beat fre quency and mucous transport beat in volunteers. Laryngoscope 95: 854-859 (1985). 7 Friedrich, FT.: De polyporum structura peniture. Ed. Leeral 53-56 (1843).
Downloaded by: King's College London 137.73.144.138 - 11/20/2017 3:49:59 PM
observed nests of squamous metaplasia in 20% of the surface epithelia of the polyps, especially in the deepest part of the nose. In 1943, Andersen [8] studied the epithelium of 115 nasal polyps and observed that only in 7 cases was the epithelium exclusively ciliated or respiratory; in 30 cases this epithelium was not unique, but predominant; in 43 cases an epithelial hyperplasia prevailed, and in 11 polyps a monostratified epithe lium was prevalent; this was formed by a layer of small, irregular and polygonal cells, resembling a basement membrane, being the result of desquamation of the cells of the sur face. Finally, in 15 polyps a squamous epi thelium was found [8], Many changes have been detected in the ciliary structure by electron microscopy. We must remember that a normal cilium is com posed of a sheath of microtubules called an axoneme. The microtubules are in a 9 + 2 pattern, which is constant for all the cilia in the body. The 9 outer doublet microtubules are composed of 2 subfibres, A and B. The cilium is a complex motor, and defects in any one of these many essential components can lead to motor failure or to inadequate functioning [9], Thus, Herzon [10] has de scribed in nasal polyposis: extra microtu bules, ‘compound’ cilia (multiple axonemes within a common cell membrane; they seem to arise by the fusion of several cilia), and missing B subfibres. Chao et al. [11] ob served the lack of the subfibre A arms; with this defect, some desorientation of doublet microtubules may occur, affecting the nor mal symmetrical disposition of the ciliary axonemes [11], Finally, it is interesting to remember that Afzelius, in 1979 [12], noted that patients with the immotile cilium syndrome fre quently developed nasal polyps.
Coromina/Sauret
Nasal Mucociliary Clearance in Patients with Nasal Polyposis
8 Andersen, HA.: Nasal polyps and hyperplastic si nusitis (Thaning, Copenhagen 1943). 9 Afzelius , BA.: Immotile cilia syndrome and cilia abnormalities induced by infection and injury. Am. Rev. resp. Dis. 124: 107-109 (1981). 10 Herzon, F.: Upper respiratory tract ciliary ultrastructural pathology. Ann. Otol. Rhinol. Lar. 90: suppl. 83, pp. 1-12 (1981). 11 Chao, J.; Turner, JA.; Sturgess, JM.: Genetic heterogenicity of dynein deficiency in cilia from pa tients with respiratory disease. Am. Rev. resp. Dis. 126:302-303 (1982).
315
12 Afzelius. BA.: The immotile cilia syndrome and other ciliary diseases. Int. Rev. exp. Path. 19: 143 (1979).
Received: December 21, 1988 Accepted: February' 15, 1990 J. Coromina, MD c/ Ganduxer 80 E-08021 Barcelona (Spain)
Announcement
The international ‘winter Meeting’ will be held in Flims-Laax/Switzerland (Hotel Panorama Vallarosa, Laax-Murschetg). March 3-10, 1991. The topic of the meeting is: Plastic and Reconstructive Surgery for Facial and Neck Rehabilitation. Members and guests are invited to submit ‘free papers’ until December 15, 1990.
Further information and details can be obtained from the course organizers: Prof. Dr. C. Walter, Klinik am Rosenberg. CH-9410 Heiden, Switzerland, or Prof. Dr. H. Jung, HNO-Klinik. Krankenhaus Marienhof, Rudolf-Virchow-Str. 7, D-5400 Koblenz, FRG.
Downloaded by: King's College London 137.73.144.138 - 11/20/2017 3:49:59 PM
European Academy of Facial Surgery (The Joseph Society)
