Effects of systemic steroid treatment in chronic polypoid rhinosinusitis evaluated with magnetic resonance imaging.

BACKGROUND: The aim of this prospective study was to evaluate the efficacy of a combined (local and systemic) steroid therapy on the extent of chronic polypoid rhinosinusitis and patient symptoms. METHODS AND PATIENTS: Subjects of this study were 20 patients with severe chronic polypoid rhinosinusitis with total or subtotal narrowing of the all sinuses. A nasal budesonide spray (2 x 0.1 mg/day) and an oral fluocortolone medication with a daily reduction during a 12-day period (total dose: 560 mg = group 1) and a 20-day period (total dose: 715 mg = group 2), respectively, were administered. Before and after the steroid treatment we evaluated the extent of the sinusitis with MRI and patient symptoms with symptom-related questionnaires. RESULTS: A significant reduction (> 30%) of the chronic polypoid rhinosinusitis was observed in 50% of MRI findings. The steroid effect on polypoid masses was heterogeneous in different anatomic areas (maxillary sinus 40%, anterior ethmoid 19%, posterior ethmoid 33%, sphenoidal sinus 61%, frontal sinus 46%). Most sinusitis-related symptoms were distinctly diminished in most patients (80%). No major side effects were observed. CONCLUSIONS: A combined short-term steroid therapy is highly effective in chronic polypoid rhinosinusitis, reducing the mucosal inflammation mainly in the large sinuses and reducing the incidence of symptoms significantly. However, this therapy was insufficient in the anterior ethmoid and cannot replace the current surgical treatment concept of the osteomeatal complex in CPR. The indication for such a short-term steroid therapy is the preoperative treatment. It facilitates functional endoscopic sinus surgery by reducing the extent of surgical procedures, the time, and thereby the risks of sinus surgery.     

The role of ostiomeatal complex obstruction in maxillary fungus ball.

OBJECTIVE: The aim of this study was to clarify the role of ostiomeatal complex obstruction in maxillary fungus ball. STUDY DESIGN AND SETTING: Comparative study in a hospital setting of the mean Lund-Mackay scores for the anterior ethmoid and frontal sinuses of 54 versus 48 patients with maxillary fungus ball versus chronic unilateral rhinosinusitis, respectively. RESULTS: In cases with partial opacification in the maxillary sinus, the anterior ethmoid and frontal sinuses were diseased in the chronic unilateral rhinosinusitis group but not in the maxillary fungus ball group. In cases with total opacification in the maxillary sinuses, all anterior ethmoid and frontal sinuses in both groups were diseased, but the disease condition of the frontal sinuses was significantly less severe in the maxillary fungus ball group (P < 0.001). CONCLUSION AND SIGNIFICANCE: In this era of evidence-based medicine, we provide statistical data supporting the principle that maxillary fungus ball is not associated with osteomeatal complex obstruction and that another as-yet-unexplained mechanism must be responsible. EBM rating: B-3b.     

Small and large middle meatus antrostomies in the treatment of chronic maxillary sinusitis.

OBJECTIVE: The study goal was to compare the postoperative endoscopic appearance of the middle meatus antrostomy with symptomatic relief in patients undergoing endoscopic endonasal sinus surgery for chronic maxillary sinusitis. STUDY DESIGN: We conducted a prospective randomized study encompassing 133 patients with chronic rhinogenic maxillary sinusitis who underwent endoscopic ethmoid surgery and middle meatal antrostomies. One of the tasks was to compare small-sized (less than 6 mm) antrostomies with large-sized (more than 16 mm) antrostomies in relieving the symptoms of chronic maxillary sinusitis. During follow-up an attempt was made to correlate endoscopic findings with symptomatic failure. RESULTS: We could not demonstrate a statistically significant correlation between the degree of improvement of the main sinusitis symptoms (obstruction, headache, and nasal discharge) and the postoperative size of the antrostomy. Nevertheless, persistent accessory maxillary ostia, scarring within the ethmoid were statistically significant predictors of poor surgical outcome. CONCLUSION: We conclude from this study that the size of the middle meatal antrostomy has no influence on the outcome of endonasal surgery for chronic rhinogenic maxillary sinusitis.     

Effect of endoscopic sinus surgery on irradiation-induced rhinosinusitis in patients with nasopharyngeal carcinoma

OBJECTIVES: We evaluated the effect of endoscopic sinus surgery on irradiation-induced rhinosinusitis of the maxillary-sinus mucosa among patients with nasopharyngeal carcinoma (NPC). DESIGN: Surgical outcomes were evaluated by changes to the ultrastructure of the antral mucosa and nasomucociliary clearance. METHODS: Twenty-one NPC patients with irradiation-induced chronic sinusitis were enrolled in the study, along with five controls. Specimens were taken from 42 maxillary sinuses during surgery and 1 year after surgery. Saccharin transit time was measured before the initial surgery and 1 year after surgery. RESULTS: In the postoperative cases, we found a decrease in the number of the submucosal gland openings (P < 0.05), the cilia in the antral mucosa regenerated (P < 0.05), and the saccharin transit time reduced (P < 0.05); the number of goblet cells did not change. CONCLUSION: Endoscopic sinus surgery is an effective treatment for irradiation-induced rhinosinusitis in NPC patients, improving ventilation and drainage of the paranasal sinuses, and facilitating regeneration of the sinus mucosa.     

Prevalence of pus in radiologically diseased sinuses in patients undergoing surgery for chronic rhinosinusitis.

OBJECTIVE: To establish the prevalence of pus in radiologically diseased sinuses in patients undergoing sinus surgery and to correlate this with the bacterial load in the sinuses. STUDY DESIGN AND SETTING: A prospective study performed on adult patients with the diagnosis of chronic sinusitis undergoing endoscopic sinus surgery at an Adelaide group of academic hospitals. In 45 consecutive and unselected patients, a radiologically diseased sinus was surgically opened, and a specially designed suction aspirator was placed into the sinus under endoscopic control. These aspirates were Gram stained and cultured to quantify the polymorphonuclear neutrophil count, bacterial flora, and bacterial colony count. The CT scans of all patients were graded by using the Lund-Mackay scoring system. RESULTS: A variety of bacteria, most commonly staphylococci, were cultured from a radiologically diseased sinus in 88% of patients. There was no correlation between the bacterial colony count and presence of pus, and only 11% of patients had microscopic evidence of inflammation in sinus aspirates. There was no correlation between the Lund-Mackay CT score and the presence of pus in the sinus. CONCLUSIONS: The majority of patients undergoing surgery for chronic sinusitis did not have a purulent exudate, and there was no correlation with the bacterial load. The usefulness of antibiotics in the treatment of chronic rhinosinusitis, in the absence of macroscopic pus, is questionable.     

Prolonged nasotracheal intubation and its association with inflammation of paranasal sinuses

Sixteen critically ill patients whose tracheas were intubated through the nasal route were examined for paranasal sinusitis between the 2nd and 3rd day and again on the 8th day after intubation. Between the 2nd and 3rd days, 6 of the 16 patients developed either maxillary sinusitis alone (3 of them) or sphenoid sinusitis (in the other 3). By the 8th day, all patients had developed sinusitis involving at least one sinus. The most commonly affected sinuses were the maxillary (87%) and the sphenoid (87%) followed by the ethmoid (50%) and frontal (12.5%). On the day 8 after intubation, the nasotracheal tubes were removed and replaced by orotracheal tubes, or tracheostomies were performed. On day 8 after extubation, 10 of the 16 patients were reexamined. Computer tomographic (CT) scan at this time revealed persistent sinusitis in two. Long-term nasotracheal intubation is associated with sinusitis.     

Endoscopically guided sinonasal cultures: a direct comparison with maxillary sinus aspirate cultures.

Sinusitis is a common medical problem that can at times be challenging to treat. Although most cases respond to empiric therapy, success is not achieved universally. If empiric therapy fails, it is important to identify the causative bacterial pathogen. Antral puncture is the traditional diagnostic method to recover and identify pathogens in sinusitis; however, it remains a painful, invasive test with potential complications. In contrast, rigid sinonasal endoscopy permits recovery of mucopus emanating from the sinus ostia with little pain and few possible complications. Endoscopy also affords important visual information that can confirm or refute a historical/clinical diagnosis of sinusitis. Although previous studies have shown poor correlation between nasal cavity swab cultures and maxillary sinus aspiration cultures, few investigations have compared endoscopically guided middle meatal cultures with cultures obtained from maxillary sinus aspiration. Thirteen patients with maxillary sinusitis in one or both sinuses underwent endoscopically guided culture of the middle meatus and maxillary sinus puncture with aspiration and culture (16 total study samples). Results from the microbiologic analysis were compared. Endoscopically guided middle meatal cultures accurately identified the predominant bacterial pathogen and correlated with the cultures from maxillary sinus aspiration in more than 90% of infections. These preliminary results suggest that endoscopically guided sinonasal cultures hold promise as a viable alternative to maxillary sinus aspiration. Endoscopically guided cultures appear to be an effective, noninvasive diagnostic tool for otolaryngologists managing sinusitis.     

A case report of surgical resection of secretory carcinoma in the maxillary and ethmoid sinus

IntroductionSecretory Carcinoma is a recently discovered head and neck tumour. Surgical resection is generally the first line of treatment with neck dissection, radiation, and chemotherapy decided based on clinical, radiological, and histological parameters. We present a case of a Secretory Carcinoma presenting in the maxillary and ethmoid sinuses.CaseA 39-year-old male presented with left nasal obstruction and chronic rhinosinusitis beginning after surgical repair of the mandible and maxilla due to facial trauma. A CT scan of the head showed soft tissue density in the left maxillary sinus extending through the ethmoid sinus and posterior nasal cavity. Functional endoscopic sinus surgery (FESS) was performed to remove the obstructing lesion. Biopsy was analysed and the main differential diagnosis was between a non-intestinal type adenocarcinoma of nasal origin and a salivary carcinoma.DiscussionTo our knowledge, there have only been two cases of Secretory Carcinoma reported in the sinuses: one case in the ethmoid sinus and the other in the maxillary sinus. This is the first to report follow up at 1 year.ConclusionBoth MRI and exam showed no evidence of recurrent disease at one year follow up. This report aims to further the understanding of Secretory Carcinoma tumours in the sinuses. Our report could be used to further understand diagnostic criteria for Secretory Carcinoma in the sinuses as well as treatment outcomes for surgical resection without adjuvant treatment.     

Management of acute complicated sinusitis: a 5-year review.

Acute sinusitis is a relatively common problem; however, sinusitis associated with a complication is less frequent. Currently there is debate as to whether acute complicated sinusitis should be managed by frontal sinus trephine and sinus washout or by immediate frontoethmoidectomy/functional endoscopic sinus surgery. To assess the effectiveness of frontal sinus trephine in the management of acute complicated frontal sinusitis, we reviewed all patients admitted to Groote Schuur Hospital with acute pansinusitis (includes frontal, maxillary, and ethmoid) from 1989 to 1993. Eighty-seven patients were admitted, of whom 43 were treated medically and 44 were treated surgically. Of the surgical patients 38 had frontal trephines and management of associated complications. Thirty (80%) of the patients who received frontal trephines recovered without further surgery, and 8 required further sinus surgery for persistent disease. Frontal trephine with management of associated complications is an acceptable management option for patients with acute complicated pansinusitis. Frontoethmoidectomy or functional endoscopic sinus surgery can be held in reserve for those patients with persistent disease that does not resolve after the initial frontal trephine.     

Computed tomography imaging of the maxillary and ethmoid sinuses in children with short-duration purulent rhinorrhea.

INTRODUCTION: Adults with a common cold often have paranasal sinus effusions detected by computed tomographic (CT) scans. There are no comparable data for children. The purpose of this study was to document the sinus CT findings in children with short-duration purulent rhinorrhea. DESIGN: Thirty children, 3 to 12 years of age (median age, 7 years), with purulent rhinorrhea for a mean duration of 5 days (and always less than 9 days) were enrolled in the study. The children were otherwise well. Institutional Review Board (IRB)-approval was obtained before enrollment of the first patient. Informed written consent was obtained from each child's parent. CT imaging of the maxillary and ethmoid sinuses was obtained on the day of the initial visit (occasionally, the following day). Follow-up CT scans were obtained from cooperative children/parents, 3 to 4 weeks later. RESULTS: Opacification or an air/fluid level in the maxillary sinuses was seen in 27 (90%) of 30 study children at study entry. Ethmoid sinuses were not opacified without opacification of a maxillary sinus. Three weeks later, 24 of 27 study children, who had positive CT scans on study entry, improved clinically. Of 17 follow-up CT scans, 10 (58%) normalized, 4 had improvement of bilateral disease, and 3 improved with unilateral disease. None appeared worse than baseline. CONCLUSIONS: Pansinus opacification (ethmoid and maxillary sinuses), on CT scans in children with short-duration purulent nasal drainage was seen in 70% of children. An additional 20% had isolated maxillary sinus effusions (10% had no effusion). Three-week follow-up CT scans on 17 children were normal in 60% and improved (partial clearance) in 40%. In this patient population, the decision to treat with antibiotics should be made on clinical grounds alone.     

A targeted endoscopic approach to chronic isolated frontal sinusitis.

OBJECTIVE: Chronic isolated frontal sinusitis occurs infrequently. In this condition, most of the ethmoid cells are well aerated and the frontal sinus is involved secondary to anatomical obstruction or inflammatory changes confined to the frontal recess. The purpose of this study was to evaluate a targeted endoscopic technique where standard anterior ethmoidectomy is unnecessary in the treatment of chronic isolated frontal sinusitis. STUDY DESIGN AND SETTING: This retrospective study was conducted in a large university-affiliated hospital and included 11 patients with chronic isolated frontal sinusitis who underwent endoscopic sinus surgery limited to the frontal sinus outflow. The ethmoid bulla was untouched in all cases. Follow-up continued for 19 to 40 months (mean 28.6 months). RESULTS: Frontal sinus outflow patency was verified in 9 patients (81.8%). Nine patients, including one with an apparent nonpatent frontal ostium, reported improvement. Two patients-one of whom had a patent frontal ostium-reported no improvement. There were no complications. CONCLUSION: Chronic isolated frontal sinusitis can be effectively treated in selected cases by a targeted endoscopic procedure, limited to reestablishment of frontal sinus outflow. EBM rating: C-4.     

Endoscopic endonasal surgery--concepts in treatment of recurring rhinosinusitis. Part I. Anatomic and pathophysiologic considerations

Many years of endoscopic investigation and observation proved that most infections of the paranasal sinus are rhinogenic, spreading from the nose into the sinuses. The common focus of infection in cases of recurring sinusitis is the stenotic areas of the anterior ethmoid, with infection recurring in the larger sinuses. The anterior ethmoid, especially its infundibulum, is thus a key location for infection or cure, and maxillary as well as frontal sinuses are fully dependent on the pathophysiologic conditions there. Histologic examination demonstrates that massive changes of the nasal glands are the reason for permanent mucosal thickening. Retention cysts, highly viscous mucus, mucus extravasations, and metaplastic epithelial changes add to the vicious cycle of blockage of the ostium-meatus unit.     

Squamous carcinoma of the nasal cavity and paranasal sinuses

This study retrospectively analyzed 105 patients with squamous carcinoma of the nasal cavity and paranasal sinuses. The primary tumor was located in the maxillary sinus in 65 patients (62 percent), the nasal cavity in 27 (26 percent), the ethmoid sinus in 11 (10 percent), and the sphenoid sinus in 2 (2 percent). Over half of the patients with antral cancer were treated with surgery and radiotherapy, whereas one-third of the remaining patients received combination therapy. Most procedures were radical, including sacrifice of the orbital contents in half of the surgically treated patients. The 5-year determinate cure rate was 45 percent for patients with nasal cavity tumors, 38 percent for those with maxillary sinus lesions, and 13 percent for those with ethmoid tumors. Local recurrence remains a major problem despite aggressive surgery and increased use of adjunctive radiotherapy.     

Clinical study of routes of onset of inflammatory diseases in the maxillary sinuses

Pathways of the maxillary sinus diseases is an interesting issue investigated by many authors during the past decades. The goal of this research was to study the pathways of infection spreading into the maxillary sinuses and to compare them in relation to their frequency, underlying causes and general epidemiologic characteristics of the involved population. A total number of 150 adult patients of both gender suffering different diseases of maxillary sinuses were included into the study. Pathways rising maxillary sinuses diseases were diagnosed on the basis of standard clinical procedures including CT scean and MRI of the region. We found inflammatory processes to dominate the tumorous ones (107:43 patients). Rhinogenic type of sinusitis was the most frequent disease (72 patients) while odontogenic sinusitis (35 patients) was significantly less frequent. No case of traumatic or hematogenic maxillary sinusitis was found. Rhinogenic maxillary sinusitis is characterised by spontaneous onset while odontogenic one is mostly of arteficial origin after surgical procedures in the oral cavity (88% of patients). In contrast to rhinogenic type, odontogenic maxillary sinusitis is far more frequent in younger patients.     

Sinusitis in long-term intubated, intensive care patients: nasal versus oral intubation

Discussion of paranasal sinusitis as a nosocomial infection in the mechanically ventilated intensive care (ICU) patient has recently been intensified. Some authors have emphasized nasotracheal intubation as a possible pathogenetic pathway. The aim of this study was to investigate the impact of nasotracheal or orotracheal intubation on the development of sinusitis in ICU patients. METHODS. In a prospective study, we followed 44 patients who required mechanical ventilation (greater than 24 h) in the ICU because of prolonged recovery from abdominal, thoracic, or posttraumatic surgery. Twenty patients were intubated nasotracheally and 24 orotracheally. Assignment to the groups was random. All were provided with a nasogastric tube and initially treated with systemic antibiotics. They received local antimicrobial prophylaxis of the nose, oropharynx, and stomach. Daily a-scan examinations of the maxillary sinuses were performed from the day of admission to the ICU until extubation, tracheotomy, death, or transfer. The average observation period was 6.9 days in the oral group and 7.1 days in the nasal group. In the case of a pathologic finding, aspiration of the antral sinus was carried out. In this study sinusitis indicated a sonographic finding; it did not necessarily imply a bacterial infection. RESULTS. At the beginning of the observation period, 6 patients in the oral group and 4 in the nasal group already had a pathologic maxillary sinus finding. At the end, in 15 of 24 in the oral group and 19 of 20 in the nasal group unilateral or bilateral sinusitis could be demonstrated. Development of bilateral sinusitis (13/20 in the nasotracheal group, 8/24 in the orotracheal group) was mainly observed after the appearance of unilateral sinusitis. The site corresponded to the site of the nasal tube in 65%. Unilateral paranasal infection was observed in nasotracheally and orotracheally intubated patients after an average of 2.8 and 2.6 days, respectively, whereas bilateral sinusitis had an average time delay of 4.5 and 5.7 days. Aspiration of the maxillary sinus was performed in 22 of 34 cases with sinusitis. Pathogenic organisms could be demonstrated in 7 of 13 nasotracheally intubated patients but only 2 of 9 with orotracheal tubes. CONCLUSION. We found that patients intubated orotracheally developed significantly less sinusitis than those intubated nasotracheally. Edema, local infection of the nasal mucosa, or mechanical obstruction of sinus drainage pathways by the tube are possible explanations. The fact that 63% of orally intubated patients had a pathologic maxillary sinus finding as well suggests that in addition to other reasons, an increased central venous pressure, positive pressure ventilation, and the supine position must be regarded as predisposing factors that increase the incidence of sinusitis. We conclude that the conditions of critically ill patients predispose to the development of sinusitis. Nasotracheal intubation is to be regarded as an additional risk, and therefore oral intubation should be preferred.     

Maxillary sinusitis in patients ventilated for a severe head injury and with nostrils free of any foreign body

Background

This study aims to determine the frequency of maxillary sinusitis in the patients with traumatic head injury and nostrils free of any foreign body. In addition, the sensitivity and specificity of ultrasonography (US) for the detection of the presence of fluid in maxillary sinuses were evaluated.

Patients and methods

Forty patients with severe traumatic head injury were included in the study. The patients who had displaced maxillary sinus fracture at the medial wall and naso-tracheal and/or naso-gastric tube were excluded. Paranasal computed tomography (CT) was performed along with the routine cranial CT scanning or in case of unknown source of infection and compared with the results of ultrasonographic examination of maxillary sinuses performed by a single radiologist who was unaware of the CT results. In the patients, who had clinical and radiological signs of sinusitis, a trans-nasal puncture was performed using sinoject (SinoJect^®, ATOS Medical, Sweden), a spring-activated puncture instrument, to take a sample for microbiologic examination and to drain maxillary sinuses.

Results

Eighty-five percent of the patients were tracheotomised on the fifth day (on average) of their intensive care unit (ICU) stay. The frequency of sinusitis in the study group was found to be 32.5% (13 patients). The most frequently isolated species were Pseudomonas spp. (37.5%), Escherichia coli (20.8%) and Peptostreptococcus (16.7%). Five of the aspirates were polymicrobial. The sensitivity, specificity, positive predictive value and negative predictive value of B-mode US, compared with CT for the detection of fluid presence in maxillary sinuses in a 100 maxillary sinus examinations, were 92.2%, 81.6%, 83.9% and 90.9%, respectively.

Conclusion

Maxillary sinusitis should be considered as a source of infection or sepsis in patients with traumatic head injury because of its high frequency. US is likely to be used as the first-line diagnostic tool for the determination of fluid in maxillary sinuses, especially in patients who do not require CT or cannot be transported to a radiology unit for CT.     

鼻内镜辅助下上颌窦根治术治疗真菌性上颌窦炎的临床研究

目的探讨鼻内镜辅助下上颌窦根治术治疗真菌性上颌窦炎的临床价值。方法选择40例患者在鼻内镜辅助下上颌窦根治术治疗真菌性上颌窦炎，并与常规开放上颌窦根治术的患者比较，观察两组手术时间、术中出血以及总住院时间，并统计两组术后发生的并发症。结果观察组术中出血显著少于对照组（P〈0．05），总住院时间显著短于对照组（P〈0．05），观察组术后出现引流不畅、上唇麻木以及术后出血的比率均显著低于对照组（P〈0．05）。结论鼻内镜辅助下上颌窦根治术治疗真菌性上颌窦炎其手术创伤小，术后恢复快，并发症少，值得临床推广。     

Therapie odontogener Kieferhöhlenerkrankungen

In contrast to rhinogenic sinusitis, the management of acute and chronic maxillary sinusitis of dental origin requires treatment of the odontogenetic source, e.g. chronic oroantral fistulae, apical infections, foreign bodies and aspergillosis. The modern concept of functional endoscopic sinus surgery (FESS) facilitates a minimally invasive approach and a reduction of morbidity for the patient. Using these techniques we use a refined algorithm in the management of chronic maxillary sinusitis of dental origin. In cases that require an osteoplastic approach via the anterior maxillary wall for treatment of the odontogenetic source of infection, drainage of the maxillary sinus is performed via the inferior meatus or via the middle meatus using an infundibulotomy depending on the patency of the ostiomeatal complex. In cases with no necessity for an external osteoplastic approach via the anterior maxillary wall, the odontogenetic source of infection is managed locally and the drainage of the maxillary sinus is performed via the inferior meatus or via an infundibulotomy.     

Die Kieferhöhle und die laterale Nasenwand

Modern concepts in the therapy of odontogenic maxillary sinusitis take the function of the paranasal sinuses into account. Besides the knowledge of pathological conditions within the maxillary sinus, a profound knowledge of the anatomy, especially of the ostiomeatal complex and the physiology of the maxillary sinus is essential. Anatomical variations in the area of the natural ostium and impairments of mucociliary clearance promote the development of maxillary sinusitis.