Concordance of middle meatal swab and maxillary sinus aspirate in acute and chronic sinusitis: a meta-analysis

BACKGROUND: The medical management of acute and chronic sinusitis is a therapeutic challenge. The use of endoscopic middle meatal cultures as a noninvasive method to determine the bacteriology of the maxillary sinus has not accurately been established. The aim of this study was to review the literature that compares cultures obtained by endoscopic middle meatal swabs with those obtained from maxillary sinus aspirates (MSAs). METHODS: We reviewed studies published between January 1966 and October 2003 that were identified from searches of multiple databases, bibliographies, and original articles. Studies were included for analysis if they compared the results of endoscopic middle meatal cultures to aspirate cultures. All clinical variables and test performances were independently extracted by two reviewers. RESULTS: Middle meatal culture had a per isolate accuracy of 82% (95% confidence interval, 0.64, 0.92) compared with MSA (excluding coagulase negative staphylococcus and fungal cultures). CONCLUSION: Endoscopic middle meatal cultures have a high concordance with MSAs.     

Comparison of maxillary sinus puncture with endoscopic middle meatal culture in pediatric rhinosinusitis

BACKGROUND: Although maxillary sinus puncture is considered the gold standard for obtaining bacterial cultures, there is an increasing field of evidence indicating that results of endoscopic middle meatal culture correlate well with those of maxillary sinus punctures. However, the subjects of these studies were adults and there was no prior study comparing endoscopic middle meatal culture with maxillary sinus punctures in children with rhinosinusitis. The aims of this study were to compare the results obtained by endoscopic middle meatal culture and maxillary sinus punctures in children with rhinosinusitis. METHODS: A prospective study of children with community-acquired rhinosinusitis was conducted. Results obtained by endoscopic culture were compared with those of maxillary sinus puncture, and the correlation of these 2 techniques was investigated. RESULTS: There were 41 specimen sets sent for aerobic cultivation. Correlation obtained from the middle meatus with those from the maxillary sinus puncture was demonstrated in 32 of 41 specimens (78.0%). When looking at the diagnostic usefulness of endoscopic middle meatus sampling versus maxillary sinus puncture, endoscopic sampling provided a sensitivity of 75.0%, a specificity of 88.9%, a predictive value of a positive result of 96.0%, a predictive value of a negative result of 50.0%, and an accuracy of 78.0%. CONCLUSION: We demonstrated that, when performed in pediatric patients, the correlation between endoscopic middle meatal culture and maxillary sinus puncture was not as favorable as in the case of adult patients.     

Correlation between bacteriology of the middle meatus and ethmoid sinus in chronic sinusitis

In this study we report on the correlation between the bacteriology of the middle meatus and ethmoid sinus in chronic sinusitis. When patients with chronic sinusitis underwent functional endoscopic sinus surgery (FESS), swab specimens were taken from the middle meati before surgery. After removing the ethmoid bullae, swab specimens were taken from the ethmoid sinuses. Between November 1998 and February 2001, 186 pairs of middle meatal and ethmoid sinus specimens were collected from 186 patients. No bacteria were cultured from either specimen in 32 patients. The same bacteria were cultured from both specimens in another 60 patients. The culture results differed between the middle meatal and ethmoid sinus specimens in the remaining 94 patients. There was a significant difference between culture rates of 63.4 per cent for middle meatal specimens and 76.3 per cent for the ethmoid sinus specimens. In analysing bacterial species, significantly more aerobic gram negative bacteria were cultured from the ethmoid sinus specimens than from the middle meatal specimens. This study shows that the bacteriology of the middle meatus was different from that of the ethmoid sinus. Therefore, the bacteriological findings in the middle meati may not reflect the real bacteriology in chronic sinusitis.     

内窥镜鼻窦手术治疗儿童慢性鼻窦炎

儿童鼻窦的解剖特点决定了在儿童的慢性鼻窦炎中，上颌窦炎最常见，自１９９０年以来，我院对５１例（９７侧）经药物和上颌窦穿刺冲洗失败患儿行内窥镜下鼻窦手术。其中大部分（５０例）有慢性上颌窦炎，１０冽有中鼻甲水肿和息肉样变，６例有筛窦炎。行上颌窦中鼻道开窗术１００侧次，筛窦开放术１２侧次，中鼻甲部分或全部切除术３２侧次，手术后２０例头痛消失，４３例鼻呼吸通畅，３７例黄脓涕消失，疗效满意，故内窥镜鼻窦手术是目前治疗儿童慢性上颌窦炎较为理想的方法。     

Normalization of maxillary sinus mucosa after functional endoscopic sinus surgery in pediatric chronic sinusitis

OBJECTIVES: To observe the recovery of maxillary sinus mucosa after endoscopic sinus surgery in children with chronic maxillary sinusitis. Functional endoscopic sinus surgery (FESS) was used to perform a middle meatal antrostomy, leaving the antral mucosa intact for later observation. METHODS: Between January 1998 and December 2003, 43 children with chronic sinusitis were enrolled in the study. Pre-operative patient profiles, including a history of symptoms, signs and allergies, were collected. Phidiatap test was used to check allergy. Saccharine transit time tests were performed for each side of the nasal cavity. Under endoscopic observation, the antral mucosa was macroscopically divided into edematous and polypoid types. RESULTS: Sixty-four (76.2%) of the 84 antrums had edematous type mucosa in which 73.4% (48/64) of cases were found to have returned to normal within 8 weeks. The polypoid antral mucosa exhibited a slower recovery with 80% (16/20) returning to normal within 4 months. The preoperative saccharine transit time significantly correlated with recovery of the antral mucosa (p < 0.05), but allergy did not (p > 0.05). CONCLUSION: The antral mucosa in children with chronic maxillary sinusitis was predominantly of the edematous type. Most recovered within 2 months of having FESS. The prolonged saccharine transit time and polypoid type antral mucosa were associated with delayed mucosal recovery, warranting follow-up of more than 4 months.     

Modified endoscopic medial maxillectomy for chronic maxillary sinusitis

BACKGROUND: Recently, modified endoscopic medial maxillectomy (MEMM) has been described as an alternative technique to open maxillectomy for benign sinonasal neoplasms. However, few reports discuss the efficacy of MEMM for treatment of inflammatory disease of the maxillary sinus. We evaluate the efficacy of MEMM in treating chronic maxillary sinusitis. METHODS: A retrospective review of patients who underwent MEMM for refractory inflammatory disease between December 2002 and September 2004 was performed. All patients were treated with MEMM alone or as part of an endoscopic sinus surgery procedure. Standard demographic data, operative technique, and postoperative follow-up times were collected. RESULTS: Nineteen patients (average age, 57 years) underwent 24 EMMs for chronic maxillary sinusitis refractory to middle meatal antrostomy. All patients failed prior sinus surgery, including 14 Caldwell-Luc procedures. Average follow-up was 19.5 months (range, 10-27 months). One patient has persistent hyperplastic sinusitis that currently requires monthly follow-up and medical treatment. Our only complication was one nasolacrimal duct injury. CONCLUSION: MEMM is both a safe and an effective treatment for chronic maxillary sinusitis refractory to standard medical and endoscopic surgical management.     

Endoscopic transnasal surgery in chronic maxillary sinusitis

The treatment of chronic maxillary sinusitis aims at the re-establishment of proper aeration and drainage of the antrum. Middle meatal antrostomy offers ventilation and clearance of the antrum and has anatomical, physiological, physical and pathological basis. This work included 66 cases of chronic maxillary sinusitis, for whom 94 operations of endoscopic middle meatal antrostomy were performed (38 unilateral and 28 bilateral procedures). Any associated anatomical variations and/or pathological abnormalities at the ostiomeatal area were dealt with. Follow-up of these cases for periods ranging from four to 12 months showed that 95.5 per cent of the cases experienced subjective improvement. Endoscopically 96.8 per cent of the antrostomies were patent and 94.7 per cent of the maxillary sinuses were clear and regained healthy mucosa. The author concluded that middle meatal antrostomy, when done endoscopically, is a safe procedure with good results.     

Evaluation of telescopes and forceps for endoscopic transnasal surgery on the maxillary sinus

BACKGROUND: Contemporary endonasal surgical treatment of chronic hyperplastic paranasal sinusitis strives for microsurgical excision of all spots of irreversibly diseased hyperplastic mucosa. However, anatomy of the maxillary sinus reveals distinct hidden areas and niches that pose problems to optical and instrumental control. METHODS: The specific range of view of common telescopes (30, 45, and 70 degrees) inside the maxillary sinus after generous middle meatal antrostomy is analyzed in three different-sized anatomic specimens. The examinations are paralleled by investigations on the range of action of 14 surgical instruments. The results are visualized by means of a three-dimensional computed tomograph of all specimens. RESULTS: The different telescopes and surgical tools that are introduced via the middle meatal antrostomy reveal a specific overlap in the range of view and in the range of action, respectively. Anatomic areas that are difficult to reach e.g., are the medial and anterior parts of the sinus and the alveolar recess. An additional inferior antrostomy offers minor benefits with respect to control of the prelacrimal recess. CONCLUSIONS: Routine surgery on the maxillary sinus in case of chronic hyperplastic pansinusitis via middle meatal antrostomy does not cover all hidden niches of the sinus. The most important area that is out of sight and control is the prelacrimal recess.     

Mucosal healing and mucociliary transport change after endoscopic sinus surgery in children with chronic maxillary sinusitis

OBJECTIVES: The aim of the study was to evaluate the effects of endoscopic sinus surgery for chronic maxillary sinusitis in children by investigating ultrastructure element changes in the sinus mucosa and nasal mucociliary clearance before and after operation. METHODS: Twenty-five children with chronic maxillary sinusitis scheduled to undergo functional endoscopic sinus surgery and another five controls were enrolled. A saccharin transit test was performed before and after the operation for each subject. Forty specimens of diseased maxillary sinus mucosa were classified into edematous and polypoid types, with 20 specimens in each type. The mucosal specimens were taken from the superolateral wall of each maxillary sinus during surgery and at post-operative follow-up when the mucosal recovery had begun and the symptoms had subsided. The specimens were examined with a scanning electron microscope. RESULTS: A significant increase in number of the submucosal gland openings (GO) was noted for the sinusitis group, of both edematous and polypoid types. In post-operative cases, the number of gland openings decreased, however, it remained higher than for the control group. The number of goblet cells (GC) decreased in the sinusitis cases, and significant difference was not demonstrated compared to postoperative and control groups. After endoscopic sinus surgery, the cilia in both types of antral mucosa were significantly regenerated compared to preoperative variants. Significant differences in postoperative saccharin transit time were demonstrated for both types of antral mucosa compared to the preoperative values. CONCLUSION: After endoscopic sinus surgery for chronic pediatric sinusitis, the antral mucosa recovered and mucociliary clearance improved for both types of antral mucosa, with improved ventilation and drainage demonstrated for our patients. Based on our specimens, the edematous mucosa appear to regenerate sooner than the polypoid variant, with close post-operative follow-up for more than 2 and 4 months for the edematous and polypoid types of antral mucosa, respectively, necessary to prevent sinusitis relapse.     

A comparative study between endoscopic middle meatal antrostomy and caldwell-luc surgery in the treatment of chronic maxillary sinusitis

Functional endoscopic sinus surgery (FESS) has almost completely replaced the radical Caldwell-Luc approach. About 20?years after its origin of FESS a comparative study with Caldwell-Luc Surgery (C-L) definitely should be on cards to validate the previous results. To compare the effectiveness of endoscopic middle meatal antrostomy and Caldwell-Luc's surgery in the management of Chronic Maxillary Sinusitis. This is a prospective randomized comparative study based on the analysis of eighty patients who were diagnosed to have chronic, unilateral, maxillary sinusitis and underwent surgery, after a failed trial of conservative management. One year after surgery 44% of the C-L patients and 89% of the FESS patients reported distinct improvement of their symptoms. Both are effective in the management of chronic sinusitis. Endoscopic middle meatal antrostomy is superior to Caldwell-Luc in intraoperative and postoperative parameters.     

Chronic Maxillary Sinusitis of Dental Origin: Is External Surgical Approach Mandatory?

OBJECTIVE: The study evaluated a minimally invasive endoscopic shaver-assisted technique for treatment of chronic maxillary sinusitis of dental origin. STUDY DESIGN: A retrospective multicenter chart review was performed at two clinics of all patients who had a diagnosis of chronic maxillary sinusitis of dental origin and were treated using the technique. METHODS: The patients were divided into two main groups: patients with and without chronic oral antral fistula. Data from the patients were collected and analyzed. RESULTS: Seventy patients aged 16 to 62 years had surgery using the endoscopic technique. Thirty-nine patients presented with oral antral fistula of different locations, the most common being third molar fistula (26 cases). Foreign bodies were found in 21 sinuses, among them teeth roots (in 11), dental fillings (in 7), and packs (in 3). Fungal ball was found in six sinuses. The surgical technique included retrograde resection of the uncinate process, enlargement of the natural maxillary ostium posteriorly, and removal of the polyps and foreign bodies from the sinus through the middle meatal antrostomy window. Approach through the oral antral fistula facilitated additional access to the alveolar recess. Removal of polyps from the alveolar recess was performed using the microdebrider, which was introduced through the fistula under endoscopic control through the nasoantral window. The fistula was closed in two layers. Good results were obtained in all but four patients in terms up to 3 years. No complications occurred. Overall recovery rate after primary surgery was 94.7%. CONCLUSION: Endoscopic approach to chronic maxillary sinusitis of dental origin is a new, reliable method associated with less morbidity and lower incidence of complications.     

Bilateral antrochoanal polyps originated from inferior meatal antrostomies

We present the first reported case of simultaneously occurring bilateral antrochoanal polyps in a 49-year-old female patient, originated from previously performed inferior antrostomies as a treatment for chronic maxillary sinusitis. The antrochoanal polyps were removed by endoscopic surgery with combined approach through the inferior and middle meatal antrostomies. Microscopic analysis of the specimens showed benign inflammatory antrochoanal polyps. Follow-up appointment 6 months postoperatively showed patent antrostomies and no recurrence of the disease. Endoscopic treatment with middle meatal antrostomy is the recommended technique in most cases of antrochoanal polyps as the greater portion of the antral part of the polyp can be removed with the healthy antral mucosa left intact promoting epithelialization and mucociliary clearance of the antrum. Inferior antrostomy can be an additional part of the operation in selected cases.     

Canine fossa puncture and clearance of the maxillary sinus for the severely diseased maxillary sinus

OBJECTIVES: To assess the impact of canine fossa puncture (CFP) with clearance of the maxillary sinus during endoscopic sinus surgery on the subjective and objective outcomes as defined by quality of life questionnaires, endoscopic findings, endoscopic aspirate for culture and sensitivity, and magnetic resonance imaging (MRI) evaluation. STUDY DESIGN: Retrospective, cross-sectional study. METHODS: Twenty-five patients who had undergone canine fossa were compared to 12 patients who had undergone routine endoscopic middle meatal clearance of the maxillary sinus. At an average postoperative time point of 19.9 months, all patients were administered the chronic sinusitis survey (CSS) and a visual analogue scale (VAS). At this visit, patients underwent nasendoscopy, sampling of the ostial region for bacterial and fungal cultures, and MRI of the sinuses. RESULTS: There were 42 sides for analysis from 25 patients on the study arm; the control arm comprised 12 patients with completely opacified maxillary sinuses and 17 sides for analysis. The CSS symptom subscore was better in the CFP group (Mann-Whitney test, P = .02). The overall VAS score was less in the CFP group (Mann-Whitney test, P = .01), indicating better symptom control. No opacification was evident in 61.9% of patients in the CFP group compared with 11.8% in the control arm (chi, P < .001). CONCLUSION: CFP is a useful technique to address the severely diseased maxillary sinus and is associated with significantly better symptom control compared with the transnasal middle meatal antrostomy clearance of the maxillary sinus.     

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.     

Nasal antrostomy

With chronic maxillary sinusitis the pathological changes in the diseased mucosa used to be considered irreversible, thus necessitating its radical removal, which is only possible with the Caldwell-Luc operation. The discovery of the reversibility of the pathology caused a shift from the Caldwell-Luc towards endonasal procedures, of which the inferior meatal antrostomy became the most widely used. Nasendoscopy, later combined with computed tomography, led to the development of the concept of the osteomeatal unit, and hence the functional endoscopic sinus surgery, which is concentrated round the infundibulum region. In view of possible risks and complications of that method it is propagated here to differentiate between these two techniques: When the focus of chronic sinusitis appears to be situated in the infundibulum/anterior ethmoid region, the functional endoscopic surgery seems preferable; For cases where the inflammatory process was restricted largely to the maxillary sinus a modified inferior meatal antrostomy technique proved to have a 92% success rate in 378 sinuses.     

Bacteriological findings and antimicrobial susceptibility in chronic sinusitis with nasal polyp

CONCLUSIONS: We recommend amoxacillin/clavulanate, cephalosporins and macrolides rather than penicillin as the first-line drug in chronic sinusitis with nasal polyps. In cases where there is no improvement of symptoms, cultures should be taken from the middle meatus, followed by appropriate selection of second-line antibiotics according to the sensitivity test results. OBJECTIVE: To investigate the causative bacteria and the antimicrobial susceptibility in patients with chronic sinusitis and nasal polyps in Korea. MATERIALS AND METHODS: The bacteriology and antimicrobial susceptibility of maxillary sinus aspirates from 81 patients were evaluated. RESULTS: Aerobes were isolated from 58.0% of the cultures from the middle meatus and from 48.1% of those from the maxillary sinus. Staphylococcus aureus, Haemophilus influenzae, and Streptococcus pneumoniae were the most prevalent aerobic pathogens. Anaerobes were isolated from 8.6% of the cultures from the middle meatus and from 18.5% of the cultures from the maxillary sinus. The predominant anaerobic organisms were Prevotella and Peptostreptococcus in adults but none of them were cultured in children. A high rate of concordance of the middle meatus and maxillary sinus was noted. Monomicrobial infection was most commonly observed. Ampicillin-resistant H. influenzae isolates were cultured in 46% of the cases. Penicillin resistance rates were 93% for Staph. aureus; 25% of Strep. pneumoniae were intermediate and 25% were resistant.     

Bacteriology of chronic sinusitis in relation to middle meatal secretion

BACKGROUND: The bacteriology of chronic sinusitis has been studied widely, but some factors may affect the results, such as sample sources and sampling techniques. However, whether the presence of secretion in the middle meatus affects the culture result has been studied rarely. METHODS: When patients with chronic sinusitis underwent functional endoscopic sinus surgery, swab specimens were taken from the ipsilateral middle meatuses and ethmoid sinuses under endoscopic guidance. While taking specimens from the middle meatuses, we observed the presence of secretions in the middle meatuses. The severity of chronic sinusitis was evaluated by preoperative computed tomography, which was scored by the Lund-Mackay system. The scores of the frontal, anterior ethmoid, maxillary sinus, and ostiomeatal complex were cumulated. RESULTS: Between March 2001 and February 2004, 210 pairs of specimens were collected. The secretion was present in 82 middle meatuses and was absent in the other 128 middle meatuses. The culture rates of middle meatus and ethmoid sinus specimens were 70.7 and 51.2%, respectively, for patients with secretions in the middle meatuses and 53.1 and 44.5%, respectively, for patients without secretions in the middle meatuses. The culture rate was significantly different for middle meatus specimens (p = 0.011) and the mean cumulated computed tomography score also was significantly higher in patients with secretions in the middle meatuses than in patients without secretions in the middle meatuses (p < 0.001). CONCLUSION: The results of this study suggest that the presence of secretion in the middle meatus indicates more severe disease in the anterior group of paranasal sinuses.     

鼻内镜手术中扩大上颌窦自然口的意义

目的：探讨鼻内镜手术中扩大上颌窦自然口对上颌窦炎转归的影响。方法：将慢性上颌窦炎218例随机均分为两组，A组的手术范围是切除钩突、筛泡，开放前、中、后组筛窦，扩大上颌窦自然开口，切除部分肥厚明显的中鼻甲；B组手术范围是切除钩突、筛泡，开放前、中组筛窦，不处理上颌窦自然开口，尽量保留中鼻甲,特别肥厚者也行部分切除。结果：218例均随访1年以上。按海口1997年疗效评定标准，A组治愈100例,治愈率92%，B组治愈99例,治愈率91%；A组好转9例,好转率8%，B组好转10例,好转率9%。结论：鼻内镜手术范围的关键是切除窦口鼻道复合体的解剖变异，是否扩大上颌窦口并不十分重要。     

Treatment of chronic maxillary sinusitis in children

In the present study 141 children aged between 3 and 10 years and suffering from chronic maxillary sinusitis were treated non-selectively in one of 4 ways: amoxicillin combined with decongestive nose drops, drainage of the maxillary sinus, a combination of the two, or a placebo. The duration of the follow-up period was 6 months. The therapeutic effects of the 4 forms of treatment did not differ significantly. Haemophilus influenzae and streptococcus pneumoniae were the micro-organisms encountered most often in these children. The results are discussed.     

鼻内镜下中鼻道联合泪前隐窝入路治疗真菌性上颌窦炎

目的 探讨鼻内镜下经中鼻道上颌窦自然口扩大联合泪前隐窝入路治疗真菌性上颌窦炎的适应证及疗效。 方法 回顾分析2008年6月至2014年6月行鼻内镜下经中鼻道上颌窦自然口扩大联合泪前隐窝入路治疗真菌性上颌窦炎32例患者的临床资料,分析联合入路的适应证、疗效及并发症。 结果 患者均完整彻底清除病变,无并发症发生。随访1年半以上,均无复发。 结论 鼻内镜下经中鼻道上颌窦自然口扩大联合泪前隐窝入路视野清晰,对上颌窦暴露充分,上颌窦霉菌清除彻底,创伤小,疗效确切,可作为鼻内镜下经中鼻道行上颌窦扩大或辅助下鼻道开窗仍无法彻底清除窦内霉菌的首选方法。