多重PCR诊断真菌性鼻-鼻窦炎的实验研究

目的:构建一多重PCR反应体系,并探讨其对真菌性鼻-鼻窦炎(FRS)快速诊断和同时鉴定常见致病菌的临床应用.方法:选择3对引物(真菌通用引物、曲霉特异性引物、毛霉特异性引物)建立多重PCR反应体系,采用曲霉菌、毛霉菌、链格孢菌、白色念珠菌等标准菌株DNA验证体系的适用性和摸索反应条件,同时将多重PCR、真菌培养2种方法用于FRS的鼻窦内容物的真菌检测,比较二者敏感性.结果:3对引物具有较好的通用性和特异性,在适宜的反应条件下均能扩增出目的片段.该反应体系的检测灵敏度为10 μg/L.20例FRS标本,真菌培养检测阳性7例,阳性率35%;多重PCR体系检测阳性15例,阳性率75%,两者差异有统计学意义(P<0.05).结论:该多重PCR体系是一种快速、敏感和特异性诊断方法,可对FRS做出快速诊断并鉴定常见的致病菌属.     

Assessment of quality of life after endoscopic sinus surgery for chronic rhinosinusitis

Chronic rhinosinusitis is a disease of undefined etiology that significantly impacts the quality of life of its patients. Various studies carried out in countries other than Brazil have shown endoscopic sinus surgery as an effective means of treating this condition.ObjectiveThis study aims to analyze, with the aid of SNOT-20, the association between endoscopic sinus surgery and disease-specific quality of life of Brazilian patients treated for chronic rhinosinusitis accompanied or not by nasal polyps.Materials and MethodsThis prospective study enrolled patients submitted to endoscopic sinus surgery after drug therapy failed to improve their symptoms. They were assessed based on questionnaire SNOT-20p before and 12 months after surgery. Improvement on total scores and on the five items deemed more important by each patient were assessed. The study also looked into the correlation between preoperative scores and postoperative improvement and if there were any gender-related improvement differences.ResultsForty-three patients aged 44 (19), md (IQR), 65% of whom (26/43) were males. Statistically significant improvement was seen on SNOT-20 and SNOT-20(5+) and a correlation was established between preoperative scores and postoperative improved scores (p<0.001). No gender-related differences were observed in quality of life.ConclusionEndoscopic sinus surgery in patients with chronic rhinosinusitis is associated with statistically significant improvements in disease-specific quality of life.     

Evaluation of the quality of life of patients with chronic rhinosinusitis by means of the SNOT-22 questionnaire

SNOT-22 is a questionnaire used to assess the quality of life of patients with chronic rhinosinusitis (CRS). It is broadly utilized to assess the surgical treatment of patients with CRS. In Brazil there are no studies utilizing the SNOT-22 in non-surgical patients.ObjectiveTo use the SNOT-22 questionnaire to assess the quality of life of individuals with chronic rhinosinusitis without previous surgery and with indication for clinical treatment.MethodProspective and analytical cohort and cross-sectional controlled clinical trial. We had 2 groups, one made up of patients with CRS and another one with adult individuals without the sinonasal disease, consecutively seen in an otorhinolaryngology clinic in Salvador, Bahia, between August of 2011 and June of 2012. They all filled out the Consent Form, a registration form and the SNOT-22.Results176 patients, 78 with CRS and 98 without the disease, the groups matched as far as gender, medication and respiratory allergies were concerned. Age was 40.7 + 13.5 years in the study group and 37.8 + 12.9 in controls (p = 0.26). The SNOT-22 median value in the study group was 53, compared to 8 in the control group (p = 0.001).ConclusionChronic rhinosinusitis reduces the quality of life of patients, according to the SNOT-22 questionnaire.     

Fungal speciation using quantitative polymerase chain reaction (QPCR) in patients with and without chronic rhinosinusitis

OBJECTIVES/HYPOTHESIS: The objectives of this study were to determine the mycology of the middle meatus using an endoscopically guided brush sampling technique and polymerase chain reaction laboratory processing of nasal mucous; to compare the mycology of the middle meatus in patients with sinus disease with subjects without sinus disease; to compare the responses on two standardized quality-of-life survey forms between patients with and without sinusitis; and to determine whether the presence of fungi in the middle meatus correlates with responses on these data sets. STUDY DESIGN: The authors conducted a single-blind, prospective, cross-sectional study. METHODS: Patients with sinus disease and a control group without sinus disease were enrolled in the study. A disease-specific, validated Sinonasal Outcomes Test survey (SNOT-20) was completed by the subjects and a generalized validated Medical Outcomes Short Form 36 Survey (SF-36) was also completed. An endoscopically guided brush sampling of nasal mucous was obtained from the middle meatus. Fungal specific quantitative polymerase chain reaction (QPCR) was performed on the obtained sample to identify one of 82 different species of fungus in the laboratory. Statistical analysis was used to categorize the recovered fungal DNA and to crossreference this information with the outcomes surveys. RESULTS: The fungal recovery rate in the study was 45.9% in patients with sinus disease and 45.9% in control subjects. Patients with chronic rhinosinusitis had a mean SNOT-20 score of 1.80 versus the control group mean score of 0.77 (P < .0001). SF-36 data similarly showed a statistically significant difference between diseased and control populations with controls scoring a mean of 80.37 and patients with chronic rhinosinusitis scoring a mean of 69.35 for a P value of .02. However, no statistical significance could be ascribed to the presence or absence of fungi recovered, the type of fungi recovered, or the possible impact of fungi on the quality-of-life survey results. CONCLUSION: The recovery rate of fungi from the middle meatus of patients with chronic rhinosinusitis and a control population without chronic rhinosinusitis is 45.9% using QPCR techniques. No direct causation with regard to fungal species or presence was proven; however, a species grouping for future studies is proposed based on trends in this data and other reports. Disease-specific outcomes surveys revealed a statistically significant difference between the two groups.     

真菌性鼻窦炎主观评价与客观检查的相关性研究

目的：通过对真菌性鼻-鼻窦炎（FRS）患者主观评价和客观检查方法的研究,了解FRS对患者生活质量的影响,分析FRS患者主观评价之间,客观检查方法之间以及主观评估与客观检查方法之间的相关性。方法：收集18例FRS患者的鼻腔鼻窦结局测量20条（SNOT-20）及视觉模拟量表（VAS）、Lund-Kennedy鼻内镜评分以及Lund-Mackay CT评分数据,并对这些数据进行相关性分析。结果：在SNOT-20中得分最高的前6项为：头面部疼痛及压迫感;流脓涕;需要擤鼻涕;打喷嚏;疲倦;沮丧、焦躁、易怒。SNOT-20总分与其他主客观评分之间无相关性（P〉0.05）,SNOT-20鼻部症状评分与Lund-Mackay CT评分呈正相关（r=0.536,P〈0.05）,SNOT-20睡眠症状评分与VAS评分呈正相关（r=0.605,P〈0.01）。VAS评分与Lund-Mackay CT评分正相关性（r=0.615 0,P〈0.01）,Lund-Mackay CT评分和Lund-Kennedy鼻内镜检查评分呈正相关（r=0.500 4,P〈0.05）,Lund-Kennedy鼻内镜检查与主观调查量表之间在统计学上无相关性（P〉0.05）。结论：FRS患者的客观评价方法之间有着较好的相关性,Lund-Mackay CT评分与SNOT-20鼻部症状评分以及VAS评分之间有相关性,SNOT-20睡眠症状评分与VAS评分呈正相关。     

Current understanding of allergic fungal rhinosinusitis

Studying the pathophysiology of allergic fungal rhinosinusitis (AFRS) has proved challenging. While this clinical entity is easily distinguishable based on the clinical criteria set forth by Bent and Kuhn twenty-five years ago, studies examining type 2 inflammatory profiles in AFRS can make it seem more alike other CRS subtypes than it is different. Still, evolving research seems to clearly delineate this subtype from others in CRS. This review will critically evaluate the evolution of research examining the pathophysiology of AFRS and will conclude with a summary of the special considerations in the management of this fascinating disease.     

Characterization of fungi in chronic rhinosinusitis using polymerase chain reaction and sequencing

The role of fungi in chronic rhinosinusitis (CRS) remains unknown. Fungi were also determined as one of the responsible agents in the etio-pathogenesis, while several studies found fungi in 6–93% of the cases. The aim of this study is to test the presence of fungi in samples taken from the middle meatus of patients with CRS, using traditional culture methods and polymerase chain reaction (PCR), and to compare the efficacy of these methods. Thirty patients diagnosed with CRS, with or without nasal polyposis, undergoing an operation in the Otorhinolaryngology Clinic, were prospectively included in the study. Nasal mucosa samples from ten patients, who were operated for pathologic evaluation, and without CRS, were used as controls. Nasal samples were taken from each patient by swabbing with a cytology brush. Middle meatus culture samples were taken by using nasal cotton swab, and the polyp and/or sinus mucosa samples were taken during endoscopic sinus surgery. Fungal specific PCR, using 18S rRNA primers and standard cultures, were performed on every sample. All amplicons were sequenced. There was no fungal growth in the Sabouraud dextrose agar (SDA) medium from middle meatus samples and tissue parts. Of 30 tissue and brush samples, 3 and 2 were positive for fungal DNA, respectively. Sequence analysis showed that four amplicons were homologus to Cladosporium herbarum and one to Aspergillus amstelodami. We concluded that fungal etiology is overestimated and fungi rarely play a role in patients with CRS. Large-scale studies should be done using molecular methods.     

Long-term outcomes of endoscopic sinus surgery for chronic rhinosinusitis with and without nasal polyps

Chronic rhinosinusitis (CRS) significantly affects patient quality of life. Medical and surgical treatments aim to clinically manage the condition.ObjectiveTo assess the long-term quality of life and clinical management of CRS in patients submitted to endoscopic sinus surgery.MethodThis prospective cross-sectional cohort study enrolled 38 patients and looked into the follow-up data of subjects diagnosed with CRS before surgery, three months after surgery, and at least two years after surgery. The Sinonasal Outcome Test 22 (SNOT-22) was used to assess response to treatment and long-term clinical management of the disease.ResultsSignificant improvements in the SNOT-22 scores were seen between the preoperative (61.3) and postoperative assessments with three (16.9) and 24 (32.3) months. No statistically significant differences were seen when patients with polyps were compared to polyp-free subjects. Few patients were controlled in both groups, and 7.89% of the subjects had revision surgery during the study.ConclusionEndoscopic sinus surgery significantly improved the quality of life of patients with chronic rhinosinusitis. Clinical control of the condition was acceptable, with few patients requiring re-operation within two years of the first surgery.     

Outpatient intravenous antibiotics for chronic rhinosinusitis

OBJECTIVE/HYPOTHESIS: Peripherally inserted central catheter (PICC) lines have greatly facilitated the use of intravenous antibiotics in outpatient medical practice. Otolaryngologic applications for home intravenous therapy through PICC lines have not been well characterized to date. The purpose of the study is to describe indications and complications related to outpatient intravenous antibiotic therapy in patients with chronic rhinosinusitis. STUDY DESIGN: Retrospective cohort study. METHODS: Chart review of patients with chronic rhinosinusitis who were treated at an academic rhinology practice with outpatient intravenous antibiotics over a 3-year period.RESULTS Fourteen patients receiving, in all, 16 courses of intravenous antibiotic therapy through PICC line were identified. The average patient age was 51 years (age range, 36-74 y). The primary indication for intravenous antibiotic use was the treatment of resistant pathogens (50%). The most common organisms treated were, and. Other indications included gastrointestinal intolerance of oral antibiotics and extranasal complications of sinusitis. Eighty-eight percent of patients (14 of 16) were able to complete the entire prescribed course of therapy. Three (19%) catheter-related complications occurred, including thrombophlebitis and deep venous thrombosis. All three complications required removal of the PICC line; one of these patients underwent successful reinsertion of a second catheter and completion of treatment. CONCLUSIONS: Peripherally inserted central catheter line delivery of home intravenous antibiotics can be a well-tolerated adjunct to surgery in the outpatient treatment of chronic rhinosinusitis. Resistant infections, intolerance to oral antimicrobials, and extranasal complications of sinusitis are indications for PICC line therapy. Catheter-related complications can be significant and must be considered in patient selection.     

Detection of fungal DNA in effusion associated with acute and serous otitis media

OBJECTIVES/HYPOTHESIS: Routine bacterial and viral cultures of middle ear fluid are often negative, suggesting that other infectious agents may be involved. Because of the similarities between the paranasal sinuses and middle ear space and the recent recognition of fungi as important pathogens in inflammation of the paranasal sinuses, we investigated the potential role of fungi in acute otitis media and serous otitis media using culture and polymerase chain reaction techniques. STUDY DESIGN: Prospective study. METHODS: Middle ear effusions of 29 patients who underwent myringotomy and pressure equalization tube placement for persistent serous otitis media or recurrent acute otitis media were collected. Fungal culture of the effusion samples was performed on potato flake agar. DNA from the effusion was isolated using standard techniques. Polymerase chain reaction, using radiolabeled universal fungus primer for internal transcribed spacer of 5.8s ribosomal DNA, was performed to detect the presence of any fungal DNA in the samples. RESULTS: Culture of middle ear effusions showed no evidence of fungal growth. Polymerase chain reaction analysis was able to detect the constituent ribosomal DNA of a single fungal genome. Fungal DNA was present in 34% of middle ear effusion samples. CONCLUSIONS: Fungal DNA is present in recurrent acute otitis media and serous otitis media suggesting that it may play an etiological role in serous otitis media and acute otitis media. However, additional studies are necessary to delineate the role of fungi in the pathogenesis of otitis media.     

Isolation of fungi by standard laboratory methods in patients with chronic rhinosinusitis

OBJECTIVES/HYPOTHESIS: Allergic fungal sinusitis and the role of fungi in the pathogenesis of chronic rhinosinusitis are topics of interest and controversy in rhinology. The classification of chronic rhinosinusitis as either a bacterial infection or an allergic (eosinophilic) reaction to fungi has significant implications for treatment of this disease process. We designed a study to determine whether standard isolation techniques, as employed in a university hospital mycology laboratory, could isolate and identify fungi in the intraoperative specimens from patients undergoing functional endoscopic sinus surgery for chronic rhinosinusitis. STUDY DESIGN: Forty-five random patients with a diagnosis of chronic rhinosinusitis by clinical and computed tomography criteria underwent endoscopic sinus surgery during 2001, performed by two senior surgeons (J.B.J., R.A.L.). Specimens of mucin, sinus secretions, and/or tissue were obtained intraoperatively and sent to the New York University Medical Center (New York, NY) mycology laboratory for isolation and identification of fungi. METHODS: Specimens were treated with Sputolysin and chloramphenicol; plated on Sabouraud, ChromAgar/Candida, Mycosel, and Niger seed agar plates; and incubated at 30 degrees C (or 37 degrees C) for up to 1 month. RESULTS: We were able to demonstrate the presence of fungi in 56% of intraoperative specimens obtained from patients undergoing surgery for chronic rhinosinusitis. CONCLUSIONS: Using a standard hospital mycology laboratory protocol, which is relatively inexpensive and readily available, fungus can be isolated from a majority of patients undergoing functional endoscopic sinus surgery for chronic rhinosinusitis. Educational statement: Discuss the possible role of fungus in chronic rhinosinusitis and evaluate the efficacy of documenting the presence of fungus in a routine fashion to encourage clinically relevant directed treatments.)