Prevalence of allergy in patients with chronic rhinosinusitis.

OBJECTIVES: The purpose of this study was to provide further evidence that allergic rhinitis is an important factor in chronic and recurrent acute rhinosinusitis. Specifically, this study shows that perennial allergens play a more significant role than seasonal allergens. STUDY DESIGN AND SETTING: Census by chart review of patients with chronic and recurrent acute rhinosinusitis presenting to the Department of Otolaryngology at the MetroHealth Medical Center, Cleveland, OH. METHODS: All participants had allergy testing done either by RAST or intradermal skin endpoint titration utilizing a battery of seasonal and perennial antigens. RESULTS: Of the 48 voluntary participants analyzed in this study, 57.4% had a positive allergy test. Most patients in the study were sensitive to more than one allergen. Of the patients with a positive allergy test, 92% demonstrated sensitivity to one or more perennial allergens-most prominently, molds and dust mites. CONCLUSIONS: Perennial allergy has a statistically significant association with chronic and recurrent acute rhinosinusitis. SIGNIFICANCE: The diagnosis and management of perennial allergies may be beneficial when treating chronic sinus disease.     

Prevalence of hypersensitivity to specific fungal allergens as determined by intradermal dilutional testing.

OBJECTIVE: To determine fungal allergen reactivity prevalence by intradermal dilutional testing in patients with and without chronic rhinitis or rhinosinusitis symptoms. STUDY DESIGN: Prospective comparison of fungal allergen reactivity prevalence in symptomatic and asymptomatic patients. SETTING: University medical center. METHODS: Group I (chronic rhinitis and/or rhinosinusitis symptoms) and Group II (asymptomatic) patients underwent intradermal dilutional testing with usual and fungal allergens. RESULTS: Fungal reactivity occurred in 65% (13/20) of Group I, and 13% (4/30) of Group II (P < 0.0002 by chi(2) testing). Group I was more reactive to non-fungal allergens (85% vs. 33%, p < 0.0004), and to all allergens considered together (95% vs. 40%, p < 0.0001). CONCLUSIONS: Patients with chronic rhinitis and rhinosinusitis symptoms were more reactive to fungal and nonfungal allergens. Fungal allergens were as likely as nonfungal to elicit reactivity. SIGNIFICANCE: These findings suggest a role for fungal hypersensitivity in chronic rhinitis and chronic rhinosinusitis.     

Allergy testing and immunotherapy in an academic otolaryngology practice: a 20-year review.

OBJECTIVE: Allergic disease plays a central role in the clinical practice of otolaryngology. The purpose of this study was to review the 20-year experience of an allergy clinic integrated within an otolaryngology practice at a major academic institution. STUDY DESIGN: We performed a retrospective database review of over 3300 otolaryngology patients referred for allergy skin testing between 1979 and 1999. RESULTS: Approximately 80% of patients referred for allergy testing in our clinic had positive test results, of which 75.7% went on to undergo desensitization. The most common allergen was house dust, with allergies to mites, ragweed, and grass also prevalent. Among current allergy immunotherapy patients, 30.8% have undergone nasal septal, turbinate, and/or endoscopic sinus procedures in addition to allergy management. Nasal obstruction was the symptom most frequently persistent despite immunotherapy and the one most frequently reported to be improved by surgery. CONCLUSIONS: The otolaryngologist-head and neck surgeon is uniquely qualified to perform comprehensive medical and surgical management for patients with complex disease processes involving a component of allergy. We believe that an integrated approach to allergy within an otolaryngology practice optimizes the treatment of such patients.     

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.     

The role of agger nasi air cells in patients requiring revision endoscopic frontal sinus surgery.

OBJECTIVES: To determine the association of agger nasi air cell disease with frontal rhinosinusitis, assessed by computed tomography (CT), in patients who require revision functional endoscopic sinus surgery (FESS). METHODS: We prospectively collected data on patients undergoing revision FESS at a tertiary care medical center over an 18-month period. Sinus CT scans were graded as per Lund-Mackay. Frontal sinus findings on CT scan were correlated with the presence or absence of disease in agger nasi air cells. RESULTS: Eighty patients underwent revision FESS in an 18-month period. A total of 160 sides were evaluated by sinus CT scan with agger nasi being present in all but 11 sides (93%). One patient did not have a pneumatized frontal sinus on 1 side and so 148 sides were available for study. Frontal sinus disease was present in 119 and absent in 29 sides. The average CT grade of patients with frontal rhinosinusitis was 8.4 while it was only 3.0 in patients without frontal rhinosinusitis (P = 0.000). Agger nasi air cell disease was present in only 3 of 29 (10%) sides in patients without frontal rhinosinusitis and was present in all 119 (100%) sides of patients with frontal rhinosinusitis (P = 0.0000). CONCLUSION: Agger nasi air cells are a common anatomic feature, present in 93% of our patients. Agger nasi air cell disease correlates strongly with frontal sinus disease as assessed by sinus CT scan in patients undergoing revision FESS. In addition, frontal sinus disease correlates with the severity of overall sinus disease as determined by sinus CT scan.     

Computed tomographic and endoscopic analysis of supraorbital ethmoid cells.

OBJECTIVES: The aim of this study is to look at the incidence of supraorbital ethmoid cells (SOEC) in normal Chinese subjects by using spiral computed tomography (CT) scanning. In addition, subjects with chronic rhinosinusitis with SOEC were reviewed for endoscopic analysis. METHODS: A total of 202 normal Chinese subjects underwent spiral CT. Meanwhile, a retrospective review of patients who had undergone endoscopic sinus surgery over a 1-year period was conducted. RESULTS: SOEC showed an incidence of 5.4% (22 sides), and all of them arose from the anterior ethmoid cells. On coronal CT, an SOEC might give the appearance of multiple frontal sinuses, type III frontal cells, suprabullar cells, frontal bullar cells, interfrontal septal cells, or that there was a septation present within the frontal sinus. Meanwhile, 11 chronic rhinosinusitis patients with 12 SOEC were identified. CONCLUSION: A thorough knowledge of endoscopic anatomy and CT of the frontal recess and various fronto-ethmoid cells were required for safe dissection of the SOEC and frontal ostium.     

Miniseminar: Chronic rhinosinusitis: The impact of allergic rhinitis management

Chronic rhinosinusitis is a common medical condition encountered throughout the world. Allergic rhinitis has a high prevalence in the general population and is a condition that affects up to half of patients with chronic rhinosinusitis. As the recognized experts in the care of medical problems affecting the nose, otolaryngologists spend a significant portion of their professional time evaluating and managing chronic rhinosinusitis.The current miniseminar will investigate the impact of allergic rhinitis on the pathophysiology and optimal management of chronic rhinosinusitis. A variety of teaching methods, including lectures, slide presentations, interactive discussions, and reviews of recent literature will be utilized to help the attendee develop a science-based approach to incorporate the management of allergic rhinitis into the treatment of patients with chronic rhinosinusitis. First, the updated definition of chronic rhinosinusitis, as recently reported by the Chronic Rhinosinusitis Task Force, will be reviewed, emphasizing the clinical and research applications of the definition. The epidemiologies of the 2 conditions will then be discussed, exploring the role of allergic rhinitis in the development and propagation of chronic rhinosinusitis. Information will also be presented about possible etiologies of the increasing incidence of allergic rhinitis. After focusing on the relationship of allergic rhinitis and chronic rhinosinusitis, the miniseminar will progress to a discussion on the role of evaluation and management of allergic rhinitis in the treatment of chronic sinusitis. Particular attention will be given to the timing of allergic rhinitis management for patients approaching the need for surgical intervention. This portion will discuss the use of optimal allergy identification and treatment to help avoid the need for primary or repeat surgery, and to improve the long-term outcomes in patients who undergo surgical treatment. The treatments discussed will include allergen avoidance, the latest topical and systemic pharmacotherapy options, and immunotherapy. The last portion of the miniseminar will review the outcomes data published in the recent literature to investigate the value of allergic rhinitis management in the treatment of chronic rhinosinusitis. At the conclusion of the miniseminar, the attendee will have received a thorough explanation of the impact of allergic rhinitis on the pathogenesis and treatment of chronic rhinosinusitis.     

Systemic corticosteroids for allergic fungal rhinosinusitis and chronic rhinosinusitis with nasal polyposis: a comparative study.

OBJECTIVES: To compare the effect of preoperative high-dose systemic corticosteroids on the radiographic and endoscopic appearance of allergic fungal rhinosinusitis (AFRS) and chronic rhinosinusitis with nasal polyposis (CRSwNP). STUDY DESIGN AND SETTING: Eight AFRS and 10 CRSwNP patients underwent computed tomographic (CT) scans and then received preoperative 1 mg/kg prednisone for 10 days. CT scans were repeated 1 day before surgery and compared with pretreatment scans (Lund-MacKay radiologic scoring system). The endoscopic appearance was recorded intraoperatively. RESULTS: The score dropped from 16 (66.4%) to 4.75 in the AFRS group and from 18.4 (23%) to 14.1 in the CRSwNP group (P=0.0064). Intraoperatively, most sinus mucosal surfaces appeared normal in the AFRS patients but were markedly edematous in the CRSwNP patients. CONCLUSION: Radiographic response of AFRS to systemic corticosteroids is significantly greater compared with CRSwNP. This finding is supported by endoscopic observation.     

Biofilm and persistent inflammation in endoscopic sinus surgery

Bacterial biofilms have been observed in many patients with chronic rhinosinusitis, but their importance is still being investigated. This study examines the association between biofilms and other clinical findings in chronic rhinosinusitis patients.Twenty-four patients with chronic rhinosinusitis who failed medical management underwent endoscopic sinus surgery (ESS). Tissue was collected from the ethmoid sinus and analyzed for the presence of biofilm by hematoxylin and eosin staining, fluorescent in situ hybridization, and confocal scanning laser microscopy. Biofilms were classified as extensive (> 50% of mucosal surface in sample) or present (< 50% of surface). The surgeon remained blinded to the biofilm status of patients until postoperative follow-up was complete.The presence of bacterial biofilm was strongly associated with persistent mucosal inflammation after ESS (53% of biofilm-positive patients vs 0% of biofilm-negative patients, P = 0.009). The amount of biofilm was not important as there was no significant difference between the extensive and present biofilm classifications with respect to inflammation. The presence of biofilm was not associated with prior ESS, allergies, eosinophils, polyps, or presence of fungal elements.     

Nasal endoscopy and the definition and diagnosis of chronic rhinosinusitis

OBJECTIVES: Although endoscopy has been shown by a few authors to be a valuable tool for the diagnosis of chronic rhinosinusitis, its true role in the evaluation of the patient with chronic rhinosinusitis has not been elucidated. The current definition of chronic rhinosinusitis is a symptom-based definition, and objective testing such as endoscopy or computed tomography (CT) is not included. However, the current treatment paradigm for chronic rhinosinusitis is dependent on the definition for diagnosis. Patients are treated with 4 weeks of antibiotics and decongestant/antihistamines/steroids based on the definition. This study aims to evaluate in a prospective fashion the place of endoscopy in the diagnosis of chronic rhinosinusitis. STUDY DESIGN: A group of 78 patients meeting the definition of chronic rhinosinusitis were subjected to same-day endoscopy and CT scanning. RESULTS: Seventeen (22%) of 78 patients had positive endoscopic and CT results. There were 20 (26%) of 78 patients with negative endoscopic and positive CT results. Six (8%) patients had positive endoscopic and negative CT results, and 35 (45%) had negative endoscopic and negative CT results. Overall, 37 (47%) patients had positive CT results, and 41 (53%) patients had negative CT results. Endoscopy showing the presence of purulence, nasal polyps, or watery congested mucosa correlated well with CT results. Negative endoscopy correlated with CT results in 65% of patients. CONCLUSION: The use of endoscopy to corroborate the diagnosis in nonpolypoid or nonpurulent rhinosinusitis in previously unoperated patients is questioned. Patients who meet the subjective definition of chronic rhinosinusitis should have a high degree of sensitivity and specificity with endoscopy or CT. The fact this is not the case questions the accuracy of the definition and the treatment paradigm. SIGNIFICANCE: According to this study, positive endoscopic results correlated well with CT, and negative endoscopic results correlated in 71% of patients with negative CT results.     

Concomitant Transsphenoidal Approach to the Anterior Skull Base and Endoscopic Sinus Surgery in Patients with Chronic Rhinosinusitis

Objectives To describe outcomes of endoscopic resection of sellar tumors with concomitant endoscopic sinus surgery for patients with chronic rhinosinusitis (CRS).Design Retrospective chart review.Setting Tertiary care medical center.Participants Patients who underwent endoscopic transsphenoidal surgery for excision of anterior skull base lesions and simultaneous functional endoscopic sinus surgery (FESS) for CRS between January 2006 and January 2011 by senior authors (MRR and JJE).Main Outcomes Measured Short- and long-term postoperative complications.Results Fourteen patients were identified. Average follow-up was 27 months. All patients had preoperative symptoms consistent with CRS. No patients were treated with preoperative antibiotics. Surgical pathology revealed chronic sinusitis in all specimens. Pathology of the intracranial lesions included 11 pituitary macroadenomas, one craniopharyngioma, one chondrosarcoma, and one cholesterol granuloma. Short-term postoperative morbidities included a sphenoid polyp, one adhesion, and one case of pharyngitis. Long-term outcomes included one frontoethmoidal mucocele, one recurrence of nasal polyps, and three cases of acute sinusitis. There were no intracranial complications for the entire follow-up period.Conclusions Transsphenoidal surgery can safely be performed in the setting of CRS without increased risk of intracranial complications.     

Clinical predictors of long-term success after endoscopic sinus surgery.

OBJECTIVE: Determining the clinical predictors of long-term success after endoscopic sinus surgery (ESS) would better guide the management of patients. METHODS: One hundred-thirty chronic rhinosinusitis (CRS) patients were evaluated retrospectively. Overall subjective improvement was 83% with a mean follow-up of 60 months. Eighty percent had anatomic variations; 36.2%, allergy; 55.4%, nasal polyps; and 26.9%, history of previous operation. The improvement was 100%, 94%, 79.5%, and 69.7% in stages 0, I, II, and III, respectively. With other parameters, the success rates were 68.1% and 91.6% with and without allergy, 73.6% and 94.8% with and without polyps, 54.3% and 93.7% with and without previous history of surgery, 84.4% and 82.7% with and without anatomic variations, and 23.8% and 94.4% with and without recurrent polyps. CONCLUSION: In multivariate Cox regression analysis, allergy (P < 0.05; relative risk, 4.6) and previous polypectomy (P < 0.05; relative risk, 9.9) were found to be predictors of poor prognosis in the long-term follow-up.     

Image-guided functional endoscopic sinus surgery.

INTRODUCTION: Computer-aided surgery (CAS) technology in functional endoscopic sinus surgery (FESS) has engendered considerable discussion. OBJECTIVE: The goals of this study were to describe CAS preoperative planning (software-based CT image analysis) and to develop intraoperative CAS strategies for endoscopic sinus surgery. Study Design: Between October 1, 1997, and December 31, 1998, the StealthStation (Sofamor Danek, Memphis, TN) was used in 61 FESS cases, and a retrospective review of the findings was performed. The indication for surgery in all instances was chronic rhinosinusitis refractory to medical management. The StealthStation was used to review all CT scans before surgery. Anatomic fiducial registration supplemented by contour mapping was used. RESULTS: Localization accuracy was estimated to be within 2 mm or better. The StealthStation was used for both CT image review and intraoperative localization. CAS was useful in the frontal recess, sphenoethmoid region, posterior ethmoid system, and skull base area. CAS was deemed helpful in situations where the surgical anatomy was altered by previous surgery and extensive inflammatory disease (polyposis, fungal sinusitis, and pansinusitis). CONCLUSION: The paradigm of image-guided FESS surgery, which integrates CAS into FESS, will serve to increase surgical effectiveness and decrease surgical morbidity.     

Chronic rhinosinusitis and biofilms.

BACKGROUND AND HYPOTHESIS: Biofilms have been implicated in several head and neck infectious processes such as the following: dental and periodontal disease, otitis media, tympanostomy tube otorrhea, and chronic tonsillitis. We believe that biofilms also are associated with chronic rhinosinusitis. No information is known regarding the presence of biofilms in chronic rhinosinusitis. STUDY DESIGN AND SETTING: With institutional review board approval, tissue was obtained from consenting chronic rhinosinusitis patients who were undergoing functional endoscopic sinus surgery. Specimens were taken bilaterally from the ethmoid and maxillary sinuses. Inclusion criteria consisted of a positive diagnosis with pathologic tissue confirmation of chronic inflammation. Diagnosis was based on patient history, physical exam, and coronal sinus CT findings. Once collected, the specimens were labeled and fixed in formalin. The specimens were subsequently dehydrated, with successive immersions in increasing concentrations of diluted ethanol. The specimens were allowed to air dry and then were affixed to aluminum stubs with colloidal carbon. The sample surface was coated with a gold and palladium layer. The specimens were examined under an electron microscope. Areas of interest were photographed. RESULTS: Specimens from 5 patients were examined. All revealed bacterial biofilms. Invariably, biofilms were seen in the ethmoid, as well as in other samples. Denudation of ciliated and goblet cells was noted in all specimens. Biofilms resembled that of Staphylococcus species. Unidentified biofilms were also seen. CONCLUSIONS: This is the first documentation of biofilms in association with chronic rhinosinusitis. Further investigation is warranted, especially with control research subjects.     

Refractory chronic sinusitis: evaluation of symptom improvement after Denker's procedure.

OBJECTIVES: Although there is ample literature describing various aspects of functional endoscopic sinus surgery (FESS) in relationship to its success rates, very little has been reported regarding possibilities in case of recurrent failure. We investigated subjective results of Denker's procedure used as a last resort for refractory chronic rhinosinusitis/polyposis. STUDY DESIGN AND SETTING: A retrospective questionnaire-based study of 82 patients who underwent Denker's procedure between 1986 and 1997 at the Erasmus University Medical Center, The Netherlands, was conducted. RESULTS: Eighty-four percent of patients reported reduction of overall symptomatology. A significant reduction of nasal obstruction, headache, feeling of fullness, post-nasal drip, rhinorrhoea, facial pain, dental pain, and coughing was reported. In addition, symptoms of lower airway inflammation did improve significantly in asthmatic patients. CONCLUSIONS: These data suggest that radical surgery using Denker's approach should be considered in selected cases after recurrent failure of functional sinus surgery. SIGNIFICANCE: A prospective study is warranted to validate this approach for refractory chronic rhinosinusitis.     

CT analysis and histopathology of bone remodeling in patients with chronic rhinosinusitis.

OBJECTIVE: To evaluate the findings of computed tomography (CT) and histopathology of the bulla ethmoidalis as objective markers of bone remodeling in chronic rhinosinusitis (CRS). METHODS: Preoperative ostiomeatal unit (OMU) scans and histopathologic findings of the bulla ethmoidalis were performed on 23 patients (39 sides) undergoing endoscopic sinus surgery for CRS. Lund-Mackay scores and Hounsfield units (HU) of the bulla were checked in coronal CT scans. The pathologist graded the severities of the mucosal and bony changes in histopathology. Statistical analysis was performed using Mann-Whitney U test and Spearman correlation coefficient (r). RESULTS: The HU values of the bulla were significantly increased with higher Lund-Mackay scores in OMU CT (r = 0.405, P = 0.01). The bony grades in histopathology were significantly increased with higher mucosal grades (r = 0.821, P = 0.0001). These findings in CT scans and histopathology were well correlated with each other (r > 0.3, P < 0.05). CONCLUSION: HU may be a useful objective marker of bone remodeling in chronic rhinosinusitis.     

Radical surgery: effect on quality of life and pain in chronic rhinosinusitis.

OBJECTIVES: Despite effective medical therapy and repetitive endoscopic sinus surgery in the treatment of chronic rhinosinusitis, there still remains a small group of patients without improvement of symptoms. This study evaluates the effect of radical surgery on quality of life and pain in these patients with recalcitrant disease. STUDY DESIGN: A prospective, questionnaire-based study was conducted in 23 patients who underwent Denker's procedure for refractory chronic rhinosinusitis. Quality of life and pain were evaluated before surgery and 12 months and 2 years after surgery with the SF-36 and McGill Pain Questionnaire. RESULTS: Seven of the eight mean scores of the SF-36 postoperatively improved after surgery, with statistical significance for Role Physical (RP) P=0.048. Bodily pain showed a strong tendency to significance. Results of the McGill Pain Questionnaire show a significant improvement in most of the subscores after surgery implying less pain. CONCLUSION: Radical surgery improves the physical burden of chronic rhinosinusitis and pain experience in patients with therapy resistant chronic rhinosinusitis.     

Long-term impact of functional endoscopic sinus surgery on asthma.

Using objective and subjective criteria, we performed a study to assess the long-term impact of functional endoscopic sinus surgery (FESS) in patients with chronic rhinosinusitis and asthma at an average follow-up of 6.5 years. One hundred twenty patients who underwent FESS for chronic rhinosinusitis were followed up for an average of 6.5 years (range 6.0 to 10.6 years). Seventy-two (60%) patients responded to a follow-up questionnaire, and 30 (42%) of them reported a history of asthma. Subjective levels of improvement and assessments of medication need were evaluated and statistically assessed with parametric and nonparametric methods. Of these 30 patients, 27 (90%) reported that their asthma was better than it had been before FESS, 6.5 years ago. Average reported improvement increased from 49% at 1.1 years after surgery to 65% at 6.5 years after surgery. Asthma attacks declined in 20 of 27 (74.1%). Medication use for asthma showed similar improvement, with approximately half reporting less inhaler usage and nearly two thirds reporting less oral steroid use. This study demonstrates that a combination of FESS, careful postoperative care, and appropriate medical therapy for chronic rhinosinusitis has a favorable long-term effect on asthma in patients with symptomatic chronic sinusitis. In this study asthma severity, frequency of attacks, and medication need were all improved.     

Pediatric alternating allergic fungal rhinosinusitis: A case report and literature review

Objectivesto report the alternating nature of allergic fungal rhinosinusitis in children in the Eastern part of Saudi Arabia and to review the experience of King Fahad Specialist Hospital in the diagnosis and management of alternating allergic fungal rhinosinusitis in children.An 8 years old Saudi girl with alternating allergic fungal rhinosinusitis was diagnosed and managed. The patient was diagnosed to have unilateral left allergic fungal rhinosinusitis and underwent endoscopic sinus surgery and cleaning of the left sinuses from polyps, mud and mucin. One year postoperatively the patient developed AFRS in the contralateral right side.Conclusioninvolvement of the contralateral sinuses in children with AFRS is uncommon. The normal uninvolved sinus should be involved in the routine endoscopic examination and the post-operative treatment in order to minimize the risk of disease recurrence.