Herpesvirus type 1-8 in sinus aspirates from HIV-infected patients and immunocompetent individuals

Sinusitis is frequently occurring in HIV-infected patients, but in a substantial number of cases the etiology is unknown. The purpose of this study was by PCR 1) to determine the prevalence of the eight human herpesviruses in sinus aspirates from 24 HIV-positive/AIDS patients with sinusitis 2) to relate the presence of herpesvirus DNA to clinical and immunological parameters and 3) to compare the prevalence of herpesvirus DNA in sinus aspirates from HIV-infected patients with the prevalence observed in 50 immunocompetent patients with sinusitis. DNA from HSV-1, EBV, CMV and HHV-8 was detected in 8 (33%) of the sinus aspirates from HIV-infected patients. In the immunocompetent patients, one of the herpesviruses, HHV-6, was found in one sinus aspirate. These data indicate that herpesviruses are frequently found in sinus aspirates from HIV-infected patients with sinusitis, whereas they do not seem to be related to clinical signs of sinusitis in immunocompetent individuals. The cause of these discrepancies may be due to uncontrolled reactivation of herpesviruses, which is known to occur in immunocompromised individuals. It remains to be established whether the herpesviruses play a pathogenic role in the development of sinusitis in HIV-infected patients.     

Differential diagnosis of purulent and non-purulent acute maxillary sinusitis in young adults

In acute maxillary sinusitis, purulence could best be assessed from sinus washings, but evaluation based on aspirates was also reliable, provided that the amount of secretion was adequate. Injection-aspirates were of negligible diagnostic value in this respect. Sinus washings and aspirates which were clinically defined as purulent were almost invariably indicative of bacterial infection. The bacterial etiology was most accurately obtained by sinus aspiration. Only 14.5% of cultured specimens were negative for pathogenic bacteria. In maxillary sinusitis, judged to be non-purulent, 52.5% of cultures grew a pathogen. The most common pathogen was Haemophilus influenzae, which accounted for 90% of these isolations. There was a clear correlation between occurrence of many PMNs and pathogen positive culture in non-purulent cases. Thus, antimicrobial therapy which is effective against Haemophilus influenzae seems indicated in most cases of non-purulent maxillary sinusitis.     

Value of Antral Puncture in the Intensive Care Patient With Fever of Unknown Origin

Objective To evaluate the use of maxillary sinus puncture as a routine diagnostic procedure to exclude or confirm purulent sinusitis in intensive care unit (ICU) patients presenting with fever or a septic state of unknown origin. Study Design Retrospective. Methods All patients admitted to the ICU at the University Hospital Ghent who required ENT examination to exclude acute sinusitis as possible cause of their otherwise inexplicable fever or septic state underwent maxillary sinus puncture via the inferior meatus. The results of clinical examination and the relation between the presence of foreign bodies (e.g., nasogastric tubes) and culture results from the middle meatus and sinuses were analyzed. Results One hundred five punctures were performed in 53 patients. Macroscopic purulent effusions were obtained from 25 and nonpurulent effusions from 19 sinuses. The presence of a nasogastric tube did not influence puncture results but significantly increased colonization of the middle meatus. Staphylococcus aureus and Gram‐negative agents were frequently cultured from sinus aspirates. Although purulent secretions often reveal no growth, most patients present with a multibacterial (40%) or monobacterial (28%) infection. Simple anterior rhinoscopy reduces the need for antral puncture. Only 8% of punctures in patients with a normal clinical examination were positive. Conclusions Antral puncture proves to be a simple, fast, safe, inexpensive, and effective procedure for immediate diagnosis of acute nosocomial sinusitis in ICU patients and is therefore recommended as first procedure in these patients, even when only minor clinical abnormalities are present.     

Microbial flora of nose and paranasal sinuses in chronic maxillary sinusitis

Nasal secretions, maxillary sinus aspirates and specimens of the maxillary sinus mucosa were collected in 44 patients aged between 25 and 60 affected by mono- or bilateral chronic maxillary sinusitis, in order to establish the best sampling technique for microbiological purposes, the most frequently involved bacteria and the physiopathological mechanism underlying chronic maxillary disease. The sinusal mucosa resulted to be the most reliable sample as it reduces contamination and microbial variability. Anaerobic bacteria were isolated in nasal swab (15.6%), in maxillary sinus aspirates (30.4%) and in maxillary sinus mucosa (36.4%) of maxillary sinusitis patients. In controls anaerobic bacteria were isolated only in one nasal swab (2.3%), while they could not be isolated in maxillary sinus aspirates and in maxillary sinus mucosa. The presence of anaerobic bacteria in chronic maxillary sinusitis patients and their absence in controls seem to confirm that anaerobic microorganisms represent the main pathogenetic agents of chronic maxillary sinusitis. The possible physiopathological mechanisms underlying chronic maxillary sinus disease are finally discussed.     

Non-Hodgkin's lymphoma of the maxillary sinus in a patient with acquired immunodeficiency syndrome

Non-Hodgkin's lymphoma (NHL) is one of the most common malignancies in patients infected with human immunodeficiency virus (HIV): it occurs 25-60 times more frequently in HIV-infected patients than in the general population. This neoplasm in acquired immunodeficiency syndrome (AIDS) patients is a highly aggressive tumour with a poor prognosis and tends to develop in extranodal sites, such as the central nervous system, digestive tract and bone marrow. NHL involving the paranasal sinuses is rare in HIV-infected patients, and is likely to be confused clinically and radiographically with sinusitis; moreover, its optimal treatment is currently uncertain. We present a case of NHL involving the left maxillary sinus in a patient with AIDS. The patient was treated with systemic chemotherapy (low dose-CHOP), but the malignancy did not respond. Subsequently, he was treated with local maxillary sinus irradiation which resulted in partial regression of the neoplasm and in decrease of local symptoms.     

Microsporidian Sinusitis in Patients with the Acquired Immunodeficiency Syndrome

Sinusitis in patients with human immunodeficiency virus (HIV) infection usually arises from the same organisms that are infective in the nonimmunosuppressed population. The authors of this article report that optimal antimicrobial treatment and functional endoscopic sinus surgery failed to eradicate sinonasal disease in three of five patients with acquired immunodeficiency syndrome (AIDS) and refractory sinusitis. The sinonasal disease was manifested by congested, edematous, and polypoid mucosa, often with a superimposed bacterial infection from ostial obstruction. After tissue was sent for electron microscopy (EM), the patients were eventually diagnosed with microsporidiosis of the sinonasal cavities. Microsporidia are obligate intracellular protozoans that have been seen in AIDS patients with diarrhea. These protozoans have only recently been identified in sinonasal tissue. Microsporidia are often missed on routine histopathology. The authors present case reports on their five AIDS patients with refractory sinusitis. The management of refractory sinusitis in the HIV-infected population, including mandatory EM of sinonasal tissue, is also discussed.     

暗色真菌致侵袭性鼻窦炎1例报告并文献复习

目的:探讨暗色真菌致侵袭性鼻窦炎的临床特征、诊断及治疗原则。方法:回顾收治的1例较典型的暗色真菌致侵袭性鼻窦炎患者的诊断和治疗过程。结合全身疾病病史,头痛伴眼部及鼻部症状,影像学,鼻内镜及鼻腔分泌物真菌培养检查,明确临床诊断。治疗包括鼻内镜下彻底清除病变,术后进行全身抗真菌治疗、基础疾病治疗以及对症支持治疗。结果:患者经病理和真菌培养证实为鼻窦黏膜侵袭性真菌感染,致病菌为暗色真菌链格孢属。经上述治疗后随访1年无复发。结论:在免疫低下人群,暗色真菌可导致侵袭性鼻窦炎的发生。结合病史、症状、影像学及微生物学检查可以明确诊断。及时彻底的根治性清创,足量抗真菌治疗,严格控制原发病以及足够的全身支持治疗,是治疗成功的关键。     

The prevalence and significance of incidental paranasal sinus abnormalities on MRI

Morphological changes in the paranasal sinuses are regularly noted on MRI, but little is known about the incidence and significance of these changes in the general population. The purpose of this study was 1) to classify the morphological changes in the paranasal sinuses seen on MRI 2) to investigate the prevalence, site and type of paranasal abnormalities and 3) to evaluate the significance of the findings by relating them to the presence of sinusitis symptoms, allergy, smoking habits and seasonal variations. In a one-year period, 404 patients referred to MRI for suspected intracranial neurological pathology were prospectively investigated. Before undergoing the scan the patients completed a questionnaire. The observed morphological conditions were classified so that mucous thickening < 5 mm was recorded as normal; > or = 5 mm, total sinus opacification or fluid and polyps as pathological. According to this classification 31.7% of the patients had pathological findings in the sinuses. A significantly higher incidence was found in the winter period and in patients with symptoms associated to sinusitis. "Blocked nose" was the only symptom occurring significantly more often in patients with pathological changes. There was no significant relationship between paranasal sinus abnormalities and sex, age, allergy, smoking habits, previous events of sinusitis or frequent events of colds. Criteria for pathological MRI findings in the paranasal sinuses are desirable and might improve the basis for a decision on the correct medical or surgical treatment.     

The role of endoscopic sinus surgery in patients with acquired immune deficiency syndrome

Purpose: Increasingly, otolaryngologists are treating patients with acquired immunodeficiency syndrome (AIDS) who suffer from associated sinusitis refractory to medical therapy. Despite this trend, few reports in the literature detail the mode of surgical therapy, pathogens, and outcome in this patient population. Our aim in this study was to describe our experience in treating these patients, with particular attention to surgical outcome and pathogens.Patients and Methods: We reviewed our experience with performing sinus surgery in 33 AIDS patients. Endoscopic sinus procedures were performed in 24 patients, while the remaining nine patients underwent nasal antral windows and/or Caldwell-Luc operations. Follow-up information was obtained in 16 of the 24 patients who underwent endoscopic sinus surgery.Results: At an average follow-up time of 16 months, 14 of the endoscopic sinus surgery patients reported improvement from their preoperative condition. Thirty-seven pathogens were identified in 23 patients. A larger percentage of nontraditional pathogens was found in these patients, which suggests a larger role for microbiologic diagnosis and treatment versus empiric therapy.Conclusion: Patients with AIDS and chronic sinusitis may benefit from endoscopic sinus procedures.     

Correlation between upper airway tract and lower airway tract in the break down of sinobronchiectasis

A retrospective study of 44 patients who were involved in combination with chronic sinusitis and bronchiectasis provided better understanding of the etiology in the relationship between upper air ways tract and lower air way tract. The incidence of bronchictasis was found in 5%, 3 out of 60 cases with chronic sinusitis and that of chronic sinusitis in 45%, 44 out of 98 cases with idiopathic bronchiectasis. Both side involvements of the paranasal sinus and the lung were statistically high in sinobronchiectasis compared to chronic sinusitis or bronchiectasis involved alone. The past history of the patients with sinobronchiectasis showed high occurrence of bronchial asthma or allergic rhinitis, habitual angina of the throat, acute otitis media and pneumonia. A chest X. Ray evaluation of 70 patients with chronic sinusitis alone revealed relatively high incidence of abnormal fibro-nodular shadow in the lung compared to 70 patients without chronic sinusitis. It was thought that weakness of air-way tract to infection in the patients with sinobronchiectasis might play some role on break down of sino-bronchial syndrome, a combination disease of chronic sinusitis and chronic bronchitis.     

Ostial and nasal patency in chronic maxillary sinusitis. A long-term post-treatment study

In a long-term follow-up study (mean 3.5 years) after treatment of chronic maxillary sinusitis of either rhinogenous or dental origin, 72 sinuses in 66 patients were examined with respect to maxillo-ostial and nasal resistance. In sinusitis of rhinogenous etiology, the mean equivalent ostial diameter was pathologically narrowed (0.89 mm, in patients treated conservatively) whereas it was normal (2.51 mm) in sinusitis of dental etiology (dental treatment in combination with local sinus surgery). In the former group, all sinuses were diseased, compared with 3 out of 23 in the dental group. In order to distinguish between functional and organic ostial stenosis, the patients were also tested after physical exercise. The functional ostial diameter in healthy sinuses was significantly increased in contrast to the diseased sinuses. In one patient the narrow ostium was due to mucosal swelling only, but in the other cases was caused mainly by an organic stenosis. In sinusitis of rhinogenous etiology, a pathologically increased nasal resistance was found in 14.3%, while the corresponding figure in the dental group was 4.3%. Improved sinusal and nasal ventilation, achieved either pharmacologically or, preferably by surgical intervention, seems necessary for successful treatment of chronic maxillary sinusitis.     

43例真菌球型鼻窦炎诊疗分析

摘要：目的探讨真菌球型鼻窦炎的病因、临床特点、手术方式及疗效。方法回顾分析北京仁和医院耳鼻咽喉头颈外科2013年11月~2017年4月收治的43例真菌球型鼻窦炎患者的临床资料。全部患者均在全身麻醉下行鼻内镜手术治疗。结果术后随访6个月至1年，1例真菌球型蝶窦炎患者术后6个月复发，再次手术后随访6个月未见无复发。结论真菌球型鼻窦炎根据临床表现，结合鼻窦CT检查可初步诊断，鼻内镜手术是治疗的主要方法，预后良好。     

蝶窦和筛窦真菌球性病变急性发作的诊断及治疗

目的:分析蝶窦和筛窦真菌球性病变急性发作时的特征,提高诊断的准确性和治疗的及时性。方法:回顾分析18例真菌球性蝶窦炎和筛窦炎患者资料,急性发作时症状以头痛、发热为主,鼻内镜检查、鼻窦CT与MRI可以协助诊断。13例患者药物抗炎治疗后行鼻内镜下鼻窦开放手术;5例患者拒绝手术,随访观察。结果:13例患者病理证实为真菌病变,完全去除病变后患者恢复良好。术前CT与MRI显示结果与术中所见一致。1例未手术者2.5个月后发生头痛,应用抗生素及鼻腔药物后症状改善。结论:临床特征和影像学检查有助于蝶窦和筛窦真菌球性病变急性发作的鉴别诊断,并采取针对性治疗。     

Microbiology of acute exacerbation chronic sinusitis in adults

The bacterial flora taken by sinus puncture from 115 patients with uni and bilateral acute exacerbation of chronic maxillary sinusitis was analyzed. Germ-free culture was obtained in 49 cases (40%) and in 69 cases (60%) bacteria were isolated from all sinus aspirates. Microbiological evaluation shows, that in majority of cases (90%) of acute exacerbation of chronic sinusitis there were pathogenic bacteria namely aerobic and anaerobic. The most frequent pathogens isolated from the aspirates were; Staphylococcus aureus, Haemophilus influenzae, Escherichia coli, Streptococcus pneumoniae, Staphylococcus hominis, Propionibacterium acnes i Candida albicans. The culture analysis proves that one or more pathogens can be the etiological factor. In the majority of cases (64%) the sinusitis is caused by monoculture.     

Paranasal sinusitis associated with nasotracheal and orotracheal long-term intubation.

The impact of nasotracheal and orotracheal long-term intubation on the development of sinusitis paranasalis was investigated in a prospective study. Daily A-scan ultrasound examinations of the maxillary sinuses were performed on 44 intensive care unit patients (20 nasally, 24 orally intubated) who required prolonged intubation (greater than 24 hours). At the end of the investigation period 19 (95%) of 20 nasotracheally and 15 (63%) of 24 orotracheally intubated patients showed pathologic antral sinus findings. In nasally intubated patients the incidence of bilateral sinusitis was significantly higher and its onset sooner. Pathologic organisms were found in the sinus aspirates in seven of 13 nasotracheally intubated patients, but only in two of nine patients with an oral tube. Thus, the nasotracheal tube can be seen as an adding factor in the development of sinusitis paranasalis.     

Sinusitis in patients with the acquired immunodeficiency syndrome

AIDS patients suffer from multiple immunologic deficits involving humoral and cell-mediated immunity. The humoral deficits place the patient at a higher risk for recurrent bacterial infection than the general population. Sinusitis has been recognized to be a more common problem in AIDS patients than was previously appreciated. A high level of clinical suspicion is important, especially in patients with fever, headaches, or symptoms referrable to the upper respiratory tract. Should sinusitis be demonstrated, aggressive medical management is indicated. Surgical drainage is indicated in patients who worsen in spite of appropriate medical therapy, patients who have signs of systemic toxicity from the sinusitis that do not rapidly improve, and patients with recurrent sinusitis. Further studies are indicated to determine the true incidence of sinusitis in the AIDS population and to elucidate further the immunologic defects involved.     

Sinusitis complicated by meningitis: current management

OBJECTIVES: Meningitis is the most common intracranial complication of sinusitis. We review the incidence, current management, outcomes, and complications of this serious infection. Our study also examines the evolving roles of endoscopic sinus surgery and other new therapeutic and diagnostic modalities in our armamentarium. STUDY DESIGN: A retrospective chart review was performed at a tertiary academic medical center of all patients diagnosed with sinusitis with complications between January 1985 and December 1999. METHODS: The patients were divided into two main groups: intracranial versus orbital complications. Meningitis was the most common intracranial complication. Data on patients with sinusitis and meningitis were collected and analyzed. RESULTS: Intracranial complications were present in 39 of 82 patients whereas orbital complications were noted in 43 patients. Twenty-one of the 39 intracranial complications were meningitis. The most common computed tomography finding in adults (54%) was sphenoid sinusitis. All patients with AIDS (6 of 21) had unique cryptococcus meningitis. In patients without AIDS, the most common organism was Streptococcus pneumoniae (10 of 21). The most common sequela was seizure disorder (4 of 21). Endoscopic sinus surgery was performed on 7 of 21 patients. One patient with AIDS who had sinusitis and meningitis died. CONCLUSIONS: Meningitis as a complication of sinusitis may still pose a serious threat. Although outcomes are encouraging, sequelae such as seizure disorders and hearing loss are common complications. The introduction of high-resolution computed tomography scans and magnetic resonance imaging and the availability of wide-spectrum antibiotics have improved our management significantly.     

Paranasal sinus computed tomographic findings of children with chronic cough

Objective: Chronic cough is a frequent problem in the practice of clinical pediatrics, and sinusitis is a common etiologic factor. In this study, our aim was to determine the prevalence of sinus abnormalities in pediatric patients presenting with chronic cough. Methods: Forty-two patients, ranging from 3 to 16 years of age from both sexes completed the study. Paranasal sinuses were examined by coronal paranasal sinus limited computed tomographic scan. The CT scan findings were categorized as no disease, minimal, moderate and severe sinusitis. Results: The most frequent symptoms after cough were rhinorrhea, sniffling, and halitosis. We found sinus abnormalities in 66.6% and no abnormality in 33.3% of the children. Age and sex were not important factors in sinus disease. There was no correlation between sinus findings and any of symptoms. The most common anatomical abnormalities were concha bullosa, paradoxical middle turbinate, Haller's cells, and deviated nasal septum. These abnormalities were not correlated with sinus disease. Conclusion: Paranasal sinus abnormalities are common among pediatric patients with chronic cough and imaging studies of the sinuses should be considered in these children.     

Causes of headache in patients with a primary diagnosis of sinus headache

Headache is a common occurrence among the general population. Although the pain could be a symptom of acute sinusitis, chronic sinusitis is not considered as a usual cause of headache. In addition, autonomic-related symptoms in the sinonasal region may be associated with vascular pain. Confusion regarding these symptoms could lead to an incorrect diagnosis of sinusitis. A prospective cross-sectional study was conducted at two tertiary referral centers with residency programs in otorhinolaryngology, head and neck surgery and neurology. The study included 58 patients with a diagnosis of “sinus headache” made by a primary care physician. Exclusion criteria were as follows: previous diagnosis of migraine or tension-type headache; evidence of sinus infection during the past 6 months; and the presence of mucopurulent secretions. After comprehensive otorhinolaryngologic and neurologic evaluation, appropriate treatment was started according to the final diagnosis and the patient was assessed monthly for 6 months. The final diagnoses were migraine, tension-type headache and chronic sinusitis with recurrent acute episodes in 68, 27 and 5% of the patients, respectively. Recurrent antibiotic therapy was received by 73% of patients with tension-type headache and 66% with migraine. Sinus endoscopy was performed in 26% of the patients. Therapeutic nasal septoplasty was performed in 16% of the patients with a final diagnosis of migraine, and 13% with tension-type headache. Many patients with self-described or primary care physician labeled “sinus headache” have no sinonasal abnormalities. Instead, most of them meet the IHS criteria for migraine or tension-type headache.     

Sinusitis in the nasotracheally intubated patient

Maxillary sinusitis as a complication of nasotracheal intubation has long been recognized as difficult to diagnose and equally difficult to treat. To better define this problem from a diagnostic and therapeutic standpoint, we studied patients admitted to the surgical intensive care unit at the University of Texas Health Science Center at Houston-Hermann Hospital over a six-month period. During this time, we identified 19 cases of maxillary sinusitis. Diagnostic criteria included fever, leukocytosis, purulent rhinorrhea, and maxillary sinus opacification or air fluid level noted on sinus roentgenograms. Patients who met these criteria underwent maxillary sinus aspiration. Sixteen patients were receiving antibiotic therapy when sinusitis was diagnosed. All patients had their endotracheal tubes replaced orally, had diseased maxillary antra lavaged, and underwent appropriate antibiotic therapy guided by culture and sensitivity studies. Four of 19 patients required more than one sinus lavage, but all patients had their sinus disease resolve. These data suggest an aggressive approach to diagnosing sinusitis in the nasotracheally intubated patient is needed. A maxillary sinus aspiration and lavage should be an integral part of the diagnosis and treatment of these patients.