Microbiology of chronic sinusitis in children

To better understand the factors involved in chronic sinusitis in childhood, we cultured the sinuses, middle meatus, and nasopharynx in 39 children requiring surgical intervention. Sixty-nine percent of these patients had other medical problems, including asthma (49%) and immunologic compromise (18%). We cultured coagulase-negative staphylococcus in 18 patients, Streptococcus viridans in 14 patients, normal flora in 10 patients, Staphylococcus aureus in nine patients, group D streptococcus in five patients, Corynebacterium in five patients, Haemophilus influenzae in three patients, Neisseria in three patients, and Streptococcus pneumoniae, group A streptococcus, Escherichia coli, Pseudomonas aeruginosa, Klebsiella oxytoca, Propionibacterium acnes, Actinomyces, and an anaerobic gram-negative bacillus in one patient each. Cultures yielded no growth in nine patients. A strong association between cultures of the middle meatus obtained ipsilaterally and cultures of the maxillary (83%) and ethmoid sinuses (80%) occurred. A poor correlation was found between cultures of the nasopharynx and maxillary (45%) and ethmoid sinuses (49%). All seven patients who had both maxillary and ethmoid sinus cultures showed the same organisms in both sinuses. Only 41% of organisms were found on both sides when procedures were performed bilaterally. Cultures of the middle meatus appear to be sensitive and specific for organisms within sinuses. The presence of predominantly nonvirulent organisms in low titers suggests that additional factors other than bacterial overgrowth contribute to the pathogenesis of chronic sinusitis in children.     

Endoscopically guided aerobic cultures in postsurgical patients with chronic rhinosinusitis

BACKGROUND: There is considerable amount of debate in the literature regarding the microbial flora of normal, acutely infected, and chronically infected paranasal sinuses. Few studies have specifically looked at the microbial flora of healthy and infected sinus cavities after functional endoscopic sinus surgery. METHODS: One hundred thirty-four cultures were studied. All cultures were obtained using a standard technique. The nasal cavities were decongested and anesthetized, and nasal endoscopy was performed. When purulent secretions were identified, specimens of purulent secretions were obtained for incubation. Sensitivities were tested according to microorganisms identified. Empiric therapy generally consisted of afluoroquinolone, amoxicillin/clavulanate, or a later-generation cephalosporin, and adjustment in individual instances when appropriate. RESULTS: Twelve cultures showed no growth, 86 grew a single microorganism, and 35 grew two or more microorganisms for a total of 151 microorganisms identified. The most common microorganisms were Staphylococcus aureus, coagulase-negative staphylococci, and Pseudomonas aeruginosa. Other organisms that were cultured <5% of the time included Streptococcus pneumoniae, Haemophilus influenza, Moraxella catarrhalis, Serratia liquefaciens, Stenotrophomonas (Xanthomonas) maltophilia, alcaligenes, Fusobacterium, Escherichia coli, diphtheroids, Acinetobacter species, Klebsiella species, skin flora, and mixed Gram-negative and Gram-positives. CONCLUSION: Endoscopically guided aerobic cultures in postsurgical patients with acute exacerbations of chronic rhinosinusitis most commonly grew S. aureus, coagulase-negative staphylococci, and pseudomonal species. These cultures altered antibiotic treatment management decisions in a significant number of cases regardless of patients' clinical characteristics or history of previous culture.     

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.     

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.     

Presence of fungus in sinus cultures of cystic fibrosis patients

BACKGROUND: Sinonasal pathology is nearly universal in the cystic fibrosis (CF) population. The bacteriology of sinus cultures from CF patients and the implications of sinus bacterial pathogens in this group have been studied; however, sinus fungal isolates from CF patients have not been examined in the literature. METHODS: We reviewed 30 consecutive CF patients undergoing endoscopic sinus surgery at our institution for the presence of fungal isolates obtained from the sinuses at the time of surgery. RESULTS: Thirty-three percent of fungal cultures were positive in this sample; in addition, two patients were newly diagnosed with allergic fungal sinusitis. CONCLUSION: We examine the possible implications of positive fungal sinus cultures in the CF population.     

Effectiveness of intraoperative mitomycin C in maintaining the patency of a frontal sinusotomy: a preliminary report of a double-blind randomized placebo-controlled trial

BACKGROUND: Postoperative scarring in the frontal recess is the most common cause of iatrogenic frontal sinusitis. Topical mitomycin-C (MMC) is an antifibroblastic agent that has been shown to reduce clinical scarring. This is a preliminary report of a double-blind, randomized, placebo-controlled trial using MMC to determine its effectiveness in reducing frontal recess stenosis after frontal sinusotomy. METHODS: All patients with chronic rhinosinusitis undergoing primary or revision bilateral image-guided endoscopic sinus surgery were enrolled. Patients requiring frontal sinus stents and those with allergic fungal sinusitis were excluded. After completion of the frontal sinusotomy, dimensions of the frontal recess were measured using curved Frazer suction diameters. A neuropattie soaked in 0.5 mg/mL of MMC was then placed into one frontal recess for 4 minutes in a randomized manner. A saline control was used for the other side. The primary surgeon was blinded to the medicated side intraoperatively and throughout the follow-up period. Measurements of the frontal recess were repeated at 1, 3, and 6 months. RESULTS: There was no difference in the degree of frontal recess stenosis between the MMC and control sides at 1, 3, and 6 months postoperatively for both primary and revision cases. CONCLUSION: One-time intraoperative topical MMC is not effective in reducing postoperative frontal recess stenosis in both primary and revision cases.     

Assessment of symptomatic patients after endoscopic sinus surgery with special reference to the frontal sinus: comparative radiologic analysis

PURPOSE: To reveal the role of potential risk factors in frontal recess dissection (FRD), middle turbinate resection (MTR), sinonasal polyposis, and extension of disease in postoperative frontal sinus opacification by determining radiologic changes after endoscopic sinus surgery (ESS) in symptomatic cases using computed tomography (CT). STUDY DESIGN: Retrospective analysis of prospectively collected data from symptomatic patients after ESS. METHODS: Postoperative CT scans were taken in all symptomatic patients during their least symptomatic period or after maximal medical therapy. The radiologic findings of each sinus were compared, and the outcome of ESS was statistically evaluated. Furthermore, FRD, MTR, sinonasal polyposis, and extension of disease were analyzed for postoperative frontal sinus opacification. RESULTS: In our study, 101 sinuses of 61 symptomatic patients were examined. A significant improvement in opacification in all sinuses was detected postoperatively. Multivariate analysis of all potential risk factors revealed that postoperative frontal sinus opacification was affected only by sinonasal polyposis (odds ratio [OR] 3.32; 95% confidence interval [CI] 1.04-10.58) and extension of disease (OR 16.93; 95% CI 4.33-66.23). CONCLUSIONS: Our study revealed that surgical procedures such as FRD and/or MTR may not directly affect postoperative frontal sinus opacification. On the contrary, sinonasal polyposis and extension of disease seemed to be the main risk factors of this issue.     

鼻内镜手术在额窦病变中的应用

目的 探讨鼻内镜下开放额窦口治疗额窦病变的适应证、方法和疗效。方法 76例患者术前常规行鼻窦CT证实有额窦病变,包括额窦囊肿9例,孤立性额窦炎7例,霉菌性额窦炎5例,额窦炎伴鼻息肉及其他鼻窦炎症55例。根据CT扫描行DrafⅠ型、Ⅱa/b型和Ⅲ型额窦引流术。结果 术后随访6个月, Ⅰ型引流治愈38侧, 有效18侧, 总有效率为90.3%;Ⅱa型引流治愈21侧, 有效11侧, 总有效率为91.4%;Ⅱb型引流治愈17侧, 有效10侧, 总有效率为93.1%;Ⅲ型引流治愈2侧, 有效1侧, 总有效率为100.0%。结论 经鼻内镜手术治疗额窦病变应密切参考CT扫描影像, 准确定位额窦口。鼻内镜下开放额隐窝,去除额隐窝处病变的关键是充分额窦口引流。     

Comparative evaluation of cefuroxime axetil and cefaclor for treatment of acute bacterial maxillary sinusitis

Cefuroxime axetil, a new beta-lactamase-stable cephalosporin, was compared with cefaclor for the treatment of acute bacterial maxillary sinusitis in 106 adult patients. Direct sinus aspirations for quantitative bacterial culture were done for all patients before treatment; aspiration was repeated for most patients after treatment. Pretreatment sinus aspirates were positive for 63 of 134 sampled sinuses. Of specimens yielding at least 10(4) CFU/mL, Haemophilus influenzae (38%) and Streptococcus pneumoniae (37%) were the most common pathogens. Ten (42%) of 24 strains of H influenzae, 2 (40%) of 5 Haemophilus parainfluenzae, and all 3 isolates (60%) of Branhamella catarrhalis produced beta-lactamase. Cefuroxime axetil, 250 mg twice a day, was compared with cefaclor, 500 mg three times a day. Among culture-positive sinuses, bacteriologic cure was achieved in 36 (95%) of 38 sinuses and 15 (71%) of 21 sinuses treated with cefuroxime axetil and cefaclor, respectively. The overall frequencies of adverse events were similar between drugs, although cefuroxime axetil was associated with more frequent diarrhea. Cefuroxime axetil was an effective therapy for the treatment of acute bacterial maxillary sinusitis in adults.     

Microbiology of intracranial abscesses and their associated sinusitis

OBJECTIVE: To evaluate the organisms recovered from infected sinuses and associated intracranial abscesses (IAs). DESIGN: Retrospective review of findings from aspirate of pus from 10 infected sinuses and their corresponding IAs. SETTING: Academic medical center. PATIENTS: Ten patients diagnosed as having sinusitis (age range, 7-58 years). MAIN OUTCOME MEASURE: Aerobic and anaerobic bacteria findings from infected sinuses and IAs. RESULTS: Polymicrobial flora was found in 9 sinuses and 8 IAs. Anaerobes were isolated from all sinuses and 9 IAs. A total of 26 isolates (2.6 isolates per specimen) were recovered from the sinuses: 19 anaerobic, 6 aerobic or facultative, and 1 microaerophilic; 17 isolates were found in the IAs (1.7 isolates per site): 13 anaerobic, 2 aerobic or facultative, and 2 microaerophilic. The predominant anaerobes were Fusobacterium species (in 5 corresponding sinuses and abscesses, 1 in a sinus only, and 1 in an IA only), Prevotella species (in 3 corresponding sinuses and abscesses), Peptostreptococcus species (in 2 corresponding sinuses and abscesses, and 4 in a sinus only), Staphylococcus aureus, Haemophilus influenzae type b, microaerophilic streptococci, and Bacteroides ureolyticus (in 1 corresponding sinus and abscess each). Streptococcus pneumoniae was recovered 2 times, only from a sinus. Alpha-hemolytic streptococci and beta-hemolytic streptococci group F were each isolated once from the sinus. Concordance in the microbiological findings between the sinus and the IA was found in all instances. However, certain organisms were present at only one or the other site. CONCLUSION: These data illustrate the concordance in the recovery of organisms from infected sinuses and their associated IA and confirm the importance of anaerobic bacteria in sinusitis and IA.     

Preoperative CT scanning for endoscopic sinus surgery: a rational approach.

Recent research on inflammatory sinus disease has implicated a central role for the ethmoid labyrinth, which may influence changes in the maxillary and frontal sinuses. CT can provide excellent definition of the paranasal sinuses and particularly the ethmoids, which is a prerequisite for endoscopic surgery. We describe a prospective series of 110 coronal CT scans performed on patients with a clinical diagnosis of sinusitis who had undergone diagnostic nasal endoscopies and medical treatment prior to surgery. 86% of the scans showed abnormal mucosal thickening. The ethmoids were affected in 73% and the maxillary sinus in 64%. Pneumatization of the middle turbinate was a common variant and when present was associated with anterior ethmoid disease in 60% of patients. Anterior ethmoid inflammatory changes were demonstrable in 95% of patients with maxillary sinus disease. Direct coronal CT can readily demonstrate disease in the infundibulum, frontal recess and posterior ethmoids in the same orientation confronting the endoscopist, and helps in the planning of ethmoidal surgery. Following surgery the sinuses can be directly inspected in outpatients which reduces the need for any further plain radiographs. It is important that the diagnosis of sinusitis is not based on CT findings alone as isolated areas of mucosal thickening are common in the normal population.     

Preoperative CT scanning for endoscopic sinus surgery: a rational approach

Recent research on inflammatory sinus disease has implicated a central role for the ethmoid labyrinth, which may influence changes in the maxillary and frontal sinuses. CT can provide excellent definition of the paranasal sinuses and particularly the ethmoids, which is a prerequisite for endoscopic surgery. We describe a prospective series of 110 coronal CT scans performed on patients with a clinical diagnosis of sinusitis who had undergone diagnostic nasal endoscopies and medical treatment prior to surgery. 86% of the scans showed abnormal mucosal thickening. The ethmoids were affected in 73% and the maxillary sinus in 64%. Pneumatization of the middle turbinate was a common variant and when present was associated with anterior ethmoid disease in 60% of patients. Anterior ethmoid inflammatory changes were demonstrable in 95% of patients with maxillary sinus disease. Direct coronal CT can readily demonstrate disease in the infundibulum, frontal recess and posterior ethmoids in the same orientation confronting the endoscopist, and helps in the planning of ethmoidal surgery. Following surgery the sinuses can be directly inspected in outpatients which reduces the need for any further plain radiographs. It is important that the diagnosis of sinusitis is not based on CT findings alone as isolated areas of mucosal thickening are common in the normal population.     

The pathogenicity and antibiotic resistance of coagulase-negative Staphylococci isolated from the maxillary and ethmoid sinuses

AIM OF THE STUDY: To investigate the pathogenicity and antibiotic resistance of coagulase-negative staphylococci (CNS) isolated from the maxillary and ethmoid sinuses of patients undergoing endoscopic sinus surgery for chronic sinusitis. PATIENTS AND METHODS: Ninety-three patients (63 males, 30 females) aged between 19 - 68 years, who had undergone functional endoscopic sinus surgery (FESS) for chronic sinusitis, were included in the study. Nasal mucosa, skin and adjacent structures were cleansed with povidone-iodine solution before surgery to prevent a probable contamination. In all patients, nasal swabs were taken before and after the application of povidone-iodine solution. Colonies isolated and identified as Staphylococci in cultures were further investigated for pathogenicity and antibiotic susceptibility. Slime test was used to determine the pathogenicity of CNS. The relationship between antibiotic resistance of pathogenic and non-pathogenic CNS was compared by chi2 analysis. RESULTS: While bacterial growth rate was 62.3% in nasal swab cultures taken before the application of povidone-iodine solution, it decreased to 12.9% after the application of solution. Microorganisms were isolated in 95.6% of cultures taken from maxillary sinuses and in 91.3% of cultures obtained from ethmoid sinuses during the FESS. The most frequently isolated microorganism in each of the sinuses was CNS. Slime test was carried out in 30 CNS isolated. Twelve of these were slime positive and 18 were slime negative. While 83.3% of CNS isolated was resistant to penicilin, all of CNS were sensitive to vancomycin and teikoplanine. The difference between slime positive and slime negative CNS for gentamicin and ciprofloxacin resistance was statistically significant (p<0.05). CONCLUSION: We consider that the pathogenicity tests like slime production and antimicrobial susceptibilities of CNS frequently isolated from the patients with chronic sinusitis should be investigated and also these microorganisms should be kept in mind in the selection of empiric treatment.     

Long-term results of the Lothrop operation

With continued surgical instrument advancement, endoscopic sinus surgery techniques continue to evolve with an overall improvement of our ability to offer surgical treatment for a variety of surgical disorders of the sinuses and anterior skull base. Frontal sinusitis and the extent of surgery performed in the frontal recess once medical management fails are constantly debated in the literature. It seems that even though instrumentation has greatly improved, surgical management of frontal sinusitis remains a frustrating endeavor for otolaryngologists. Open approaches to the frontal sinus, including the osteoplastic flap with frontal sinus obliteration using adipose tissue, have been the gold standard, but require external incisions and complete removal of sinus mucosa with destruction of the frontal sinus. The endoscopic modified Lothrop technique involves removal of the frontal sinus floor bilaterally with frontal septectomy and resection of the nasal septum to create a large nasofrontal communication. Recent postoperative results of this technique rival the results after frontal sinus obliteration in selected patients while avoiding the morbidity associated with the open destructive approach.     

Association of radiological evidence of frontal sinus disease with the presence of frontal pain

BACKGROUND: Rhinosinusitis is a common cause of frontal pain. We evaluated the relationship between frontal pain and the type and degree of frontal sinus disease in chronic rhinosinusitis (CRS) patients. METHODS: Inclusion criteria were presence of frontal sinusitis or frontal recess obstruction on computed tomography scan. Office notes and operative reports were reviewed to determine the presence and location of frontal pain and categorization of sinus disease. RESULTS: Two-hundred seven patients were identified with frontal recess obstruction and/or frontal sinus disease. Thirty-one of 37 frontal mucocele patients (84%) had frontal pain. Twenty of 70 polyp patients (29%) had frontal pain, with only 7 of 38 patients (18%) with complete frontal opacification having pain. In patients with CRS without polyps or mucocele, 59 of 100 (59%) had frontal pain, with 21 of 38 (55%) with complete opacification having pain. This difference between the distribution of frontal pain was significant (p < 0.005) among the mucocele, polyp, and nonpolypoid CRS groups. Additionally, among nonmucocele CRS groups exhibiting complete opacification, there was a significant difference in proportion of patients exhibiting frontal pain (p < 0.005). When the nonmucocele groups (i.e., polypoid and nonpolypoid CRS patients) were combined and stratified for disease extent, a difference in the distribution of frontal pain was found (p < 0.025), with the mild-to-moderate thickening group showing the highest proportion of pain. CONCLUSION: Frontal pain was more common in nonpolypoid CRS patients than in polyp patients. Furthermore, in nonmucocele CRS, patients with mild-to-moderate thickening exhibited more frontal pain.     

Microbiology of chronic hyperplastic sinusitis

BACKGROUND: Patients with chronic hyperplastic sinusitis (CHS) form a heterogeneous group with similar symptoms and similar treatment despite of possible different mechanisms behind the disease. In the present study we focused on the microbiological findings in CHS and compared these results to the patient history in order to find out a possible explanation for the aetiology and chronicity of CHS. METHODS: In 30 patients the sinus mucus was collected under endoscopic sinus surgery. Samples from 20 healthy volunteers were collected by nasal lavage. Eosinophil staining, bacterial culturing and fungal staining and culturing were done. Histological samples were obtained from all patients. RESULTS: Bacterial cultures were positive in 93% of the patients compared to 70% in controls. Staphylococcus aureus and coagulase-negative Staphylococci were the two most common findings in both groups. A total of seven patients had positive fungal finding. The only fungal genus found was Aspergillus. In the control group no samples were positive for fungi. CONCLUSIONS: Microbiological findings do not seem to explain the chronic course of CHS, but fungi may play some part in the pathophysiology of the disease. These results may be more a reflection of a change in the environment in the paranasal sinuses and a change in normal flora than the actual cause of CHS.     

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

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

Salvage frontal sinus surgery: the endoscopic modified Lothrop procedure

OBJECTIVES/HYPOTHESIS: Until recent years, the osteoplastic flap with frontal sinus obliteration has been the gold standard for recalcitrant frontal sinusitis. The present series evaluated the role of the endoscopic modified Lothrop procedure, which has recently been advocated as an alternative. STUDY DESIGN: Prospective non-randomized interventional case series. METHODS: The study prospectively assessed 83 consecutive patients who underwent endoscopic modified Lothrop procedure. The mean age was 52.4 years (SD = 13.6 y) with a male-to-female ratio of 3:1. Patients had a mean of six previous sinus surgical procedures with 17 patients having undergone previous frontal sinus obliteration with mucocele formation. Seventy-six patients (91%) had frontal pain or headache as their primary presenting symptom, with 72 having nasal discharge. There were 14 patients who presented with 17 complications of frontal sinus disease. There were eight erosions of the posterior table of the frontal sinus with extension of the mucocele intracranially, seven orbital complications, and one cerebrospinal fluid leak. Twenty-four patients (30%) had fungus cultured from their sinuses at the time of surgery. RESULTS: Six of the 83 patients (7%) developed frontal ostium stenosis resulting in a 93% primary success rate after an average follow-up of 21.9 months (SD = 6.1 mo). These patients all underwent a revision modified Lothrop procedure and had a patent frontal ostium at their last review. Twenty-one patients (25%) developed recurrent symptoms, which were managed medically. Of these 21 patients, 9 with previously diagnosed fungal sinusitis developed mucosal changes again in their frontal sinuses, but their ostia have remained patent. Four patients have had recurrent infections in the frontal sinuses, and three patients with aspirin-sensitive asthma and polyps have developed polyps again in their frontal sinuses. Five patients continued to have frontal pain without radiological evidence of further frontal disease. No patients required an osteoplastic flap procedure. CONCLUSION: The endoscopic Lothrop procedure is a successful short-term management option for recalcitrant and complicated frontal sinusitis caused by a wide range of diseases.     

The axillary flap approach to the frontal recess

OBJECTIVES: To evaluate the access to the frontal recess using the axillary flap approach by identifying the frontal ostium during endoscopic sinus surgery. STUDY DESIGN: Prospective review of 64 consecutive patients (118 sides) undergoing axillary flap exposure of the frontal recess between November 1998 and July 1999. METHODS: Demographic data, identification of the frontal ostium, findings at surgery, use of nasal packing, the presence of postoperative symptoms, revision surgery, and the endoscopic appearance of the frontal recess were collected. The operative technique is presented. RESULTS: The frontal sinus ostium was identified in 96% of patients (104 of the 118 sides). Eight sides had Kuhn type 3 cells that required removal for clearance of the frontal ostium. Eighty-two percent of sides (97 sides) had endoscopically healed sinuses without symptoms after an average follow-up of 15.4 months. Six sides had middle meatal adhesions requiring division under local anesthetic. One patient has required revision surgery. CONCLUSION: The axillary flap approach to the frontal recess provides excellent access to the frontal recess and allows clearance of cells in the recess with identification of the frontal ostium in the vast majority of cases.     

Bacteriology of nontraumatic maxillary sinus mucoceles versus chronic sinusitis

OBJECTIVE: To compare the bacteriology of maxillary sinus mucoceles to chronic sinusitis and understand the pathogenesis of nontraumatic maxillary sinus mucoceles (NTMSM). STUDY DESIGN: Retrospective review. METHODS: Review of intraoperative bacteriology culture results obtained in patients with NTMSM. Patients with history of facial trauma or previous paranasal sinus surgery were not included in the study. The results were compared to intraoperative cultures obtained from patients with chronic sinusitis (CS). RESULTS: The study groups consisted of 16 patients with NTMSM (9 male and 7 female patients) and 211 patients with CS (86 male and 125 female patients). Cultures in the NTMSM group were positive in 7 of 16 patients (44%) (four cultures had more than one isolate). There was no growth in cultures of 9 patients (56%). On the other hand, cultures in 176 patients with CS (83%) grew organisms (42 cultures had more than one isolate); there was no growth in 35 of 211 patients (17%) (P = .0007). The cultures grew aerobic bacteria in 7 of 16 (44%) and 160 of 211 (76%) patients of the NTMSM and CS groups, respectively. Anaerobic bacteria were detected in cultures of 2 of 16 patients (12.5%) with NTMSM compared with 13 of 211 patients (6.2%) in the CS group (P = .286). The most common pathogenic aerobe in the NTMSM group was alpha-hemolytic Streptococcus, while Staphylococcus aureus was the most common in the CS group. CONCLUSION: The bacteriology of maxillary sinus mucoceles is different from that of CS. The majority of patients with mucoceles have sterile intraoperative cultures. The data do not support infection as the main origin of NTMSM.