The impact of sinus computed tomography on treatment decisions for chronic sinusitis

OBJECTIVES: To determine the impact of sinus computed tomography (CT) on treatment decisions by otolaryngologists and to explore the factors leading to choice of surgical treatment for patients suspected of having chronic sinusitis. DESIGN: Prospective cohort study. SETTING: A tertiary academic medical center. PATIENTS: Questionnaires were administered to 3 otolaryngologists in a tertiary academic institution regarding diagnosis and treatment decisions in 27 patients suspected of having chronic sinusitis, before and after they reviewed sinus CT scans. MAIN OUTCOME MEASURES: The dichotomous decisions regarding surgical or nonsurgical treatment and the agreement of treatment decisions among surgeons were evaluated. The factors strongly influencing surgeons' treatment decisions regarding patients selected for surgery were also determined. RESULTS: The dichotomous treatment decisions were changed in one third of patients (9 of 27) after the sinus CT scans were reviewed. The agreement of treatment decisions among the 3 surgeons was markedly improved after they reviewed sinus CT scans. The factors favorably influencing surgical treatment were obstruction of the ostiomeatal complex on CT and concordance of CT abnormality with a patient's symptoms. Lund-Mackay stage, symptoms, and corticosteroid or antibiotic use were not significant predictors. CONCLUSIONS: Despite the common belief that treatment decisions for chronic sinusitis should be solely based on clinical grounds, with sinus CT providing only anatomic detail before surgery, our study indicates that the decision to perform surgery was altered by CT in a substantial portion of the patients. In our preliminary study, CT increased the tendency to elect surgical treatment by all 3 surgeons.     

Allergic fungal sinusitis

Allergic fungal sinusitis is a recently described clinical entity that has gained increased attention as a cause of chronic sinusitis. Consist in a benign noninvasive sinus disease related to a hypersensitivity reaction to fungal antigens. It should be suspected in any atopic patient with refractory nasal polyps. Computed tomography (CT) findings are characteristics, but not diagnostic. Diagnosis requires show allergic mucin in the histopathologic examination and hiphae in special fungal stains. The suitable treatment includes the allergic mucin removal and sinus aeration accomplished endoscopically, perioperative systemic steroids and immunotherapy with fungal antigens. We present a case of this kind of chronic sinusitis describing the characteristic histopathologic and radiologic findings, the pathogenic theories and recent advances in immunotherapy.     

Clinical impact of ectopic teeth in the maxillary sinus

OBJECTIVE: To evaluate the clinical features, aetiologic factors, challenging properties (such as radio opacity in Water's view in a patient with no sinusitis), signs and symptoms of the ectopic teeth in the maxillary sinus. STUDY DESIGN: Clinical symptoms and radiographic findings of 14 patients with ectopic teeth in the maxillary sinus were evaluated. Computed tomography (CT) and conventional radiographic images of maxillary sinus and clinical findings were compared with each other with regard to the final diagnosis. RESULTS: Water's view is inadequate to diagnose ectopic tooth in the maxillary sinus in some cases. Panoramic radiographs may be preferred before CT to evaluate the ectopic tooth in the maxillary sinus as structure of a tooth can be clearly detected on panoramic radiographs. Crowding was the most common aetiologic factor among the 14 cases. CONCLUSION AND SIGNIFICANCE: The patients with ectopic tooth in the maxillary sinus should be evaluated thoroughly by complete otorhinolaryngologic, intraoral examinations and proper diagnostic imaging procedures in order to avoid misdiagnosis of maxillary sinusitis. As the opacity of the maxillary sinus in Water's view due to ectopic tooth can be misinterpreted as maxillary sinusitis, patients who have sinusitis-like complaints and opacity of maxillary sinus in Water's view who are resistant to medical treatment should be evaluated with respect to the presence of ectopic tooth.     

真菌球型蝶窦炎临床分析

目的 提高对孤立性真菌球型蝶窦炎的认识,有利于早期诊断和治疗.方法 回顾性分析10例孤立性真菌球型蝶窦炎的临床表现、影像学特点、鼻内镜手术方法及疗效.结果 10例患者最主要的临床表现为头痛或/和涕中带血,主要影像学特征为单侧蝶窦内软组织影,骨壁增厚,中央常可见高密度钙化斑.全部患者鼻内镜下行蝶窦开放术,定期换药,随访3～18个月,全部治愈.结论 孤立性真菌球型蝶窦炎临床表现无特异性,早期不易发现,CT扫描及鼻内镜检查有利于早期诊断,病理学检查可确诊,采用鼻内镜下蝶窦开放术具有创伤小、并发症少和术后恢复快等优点,值得推广.     

Ultrasound and antral lavage in the examination of maxillary sinuses

Two hundred and ninety maxillary sinuses in 206 patients, suspected of having acute or prolonged maxillary sinusitis, were examined using ultrasound (US) and then irrigated with isotonic saline. The results of the antral lavage and the US were compared and various US recording variables were analyzed. The sensitivity of US examination to find maxillary sinus secretion was 77% and the specificity 49%. The distance from the initial echo to the back wall echo (BWE) and the ratio of the echo-free area to the distance from the initial echo to the BWE were sensitive indicators of the presence of maxillary sinus secretion. The results suggest that US is a relatively sensitive method also in the diagnosis of prolonged maxillary sinus inflammations. However, its low specificity weakens its value in clinical work. The usability of US in the diagnosis of maxillary sinusitis can be increased by intermittently controlling US findings by sinus puncture. This is of particular importance for general practitioners, but also for specialists.     

Subdurales Empyem und Zerebritis als Folge einer dentogenen, eitrigen Pansinusitis

BACKGROUND: Complications and local extension of dentogenous and paranasal sinus infections most often involve the periorbit and frontal cranium. Because of the widespread use of antibiotics, intracranial extension of maxillofacial sinusitis is rarely seen today. Nevertheless, the clinician must be aware of the potential for these complications, because late recognition of this condition and delay in treatment can increase morbidity and mortality rates. CASE REPORT: A case report of sinogenic intracranial complications is presented, with sinogenic empyema, cerebritis, and subdural empyema. The mechanisms and potential for intracranial spread of infection from the frontal, sphenoid, and ethmoid sinuses are discussed. The management of complications is outlined, including the use of computed tomography and the role of surgical drainage.     

Relevance of the conventional Waters' view in evaluating chronic bacterial maxillary sinusitis

Considerable controversy exists as to whether X-ray examination of the sinuses is a reliable diagnostic guide or not, in cases of chronic bacterial maxillary sinusitis, as many factors apart from infection in the sinuses may produce radiographic signs on the X-ray film. With those facts in mind, it was decided to investigate the diagnostic reliability of Waters' view in these cases. The present work showed that radiographic signs of chronic maxillary sinusitis have different diagnostic and predictive reliabilities ranging from the almost complete inaccuracy of reduced translucency or 'veiling' of the sinus to the perfect validity of 'fluid levels' or polyps within the sinus. In general, while Waters' view undoubtedly yields valuable information regarding maxillary sinus pathology, nevertheless the presence of various sources of error while exposing and reading the film should make one appreciate that radiographic diagnosis is not absolute and should only be considered in the light of the clinical findings and possibly other investigations.     

Preoperative diagnosis of allergic fungal sinusitis

OBJECTIVES/HYPOTHESIS: Although the diagnosis of allergic fungal sinusitis is mainly based on characteristic histopathological findings, certain preoperative diagnostic criteria have been proposed. However, their usefulness in differentiating allergic fungal sinusitis from other sinus diseases is unknown. The objective of the study was to identify accurate preoperative diagnostic parameters for allergic fungal sinusitis. STUDY DESIGN: Prospective, comparative study. METHODS: Twenty consecutive cases of allergic fungal sinusitis were evaluated prospectively and compared with 16 cases of ethmoidal polyposis and 5 cases of invasive sinus aspergillosis, with regard to various clinical, radiological, and immunological parameters. All patients were categorized based on histopathological findings. RESULTS: Nasal polyps were seen in all 20 cases of allergic fungal sinusitis, all 16 cases of ethmoidal polyposis, and 2 of 5 cases of invasive sinus aspergillosis. Computed tomography (CT) scan hyper-attenuation was seen in all 20 cases of allergic fungal sinusitis but also in 2 (13%) cases of ethmoidal polyposis and 2 (40%) cases of invasive sinus aspergillosis. Serum levels of specific anti-Aspergillus immunoglobulin E were elevated in 14 (70%) cases of allergic fungal sinusitis, 2 (13%) cases of ethmoidal polyposis, and 3 (60%) cases of invasive sinus aspergillosis. The combination of all three (ie, nasal polyps, CT scan hyper-attenuation, and elevated titers of anti-Aspergillus immunoglobulin) was not found in any case of ethmoidal polyposis or invasive sinus aspergillosis. This triad demonstrated a sensitivity of 70% and a specificity of 100% for the preoperative diagnosis of allergic fungal sinusitis. CONCLUSIONS: Nasal polyps, CT scan, and specific immunoglobulin E titers, when considered in combination, have a high preoperative diagnostic value in allergic fungal sinusitis. However, they should not be considered in isolation because considerable overlap occurs with invasive sinus aspergillosis and ethmoidal polyposis.     

Acute bacterial sinusitis in adults: management in the primary care setting

Sinus disease is inherently associated with viral upper respiratory tract infections and occurs in 90% of individuals with the common cold. Acute bacterial sinusitis occurs in 0.5 to 2% of these individuals. Although the diagnosis of acute bacterial sinusitis is usually based on physical findings, no one sign or symptom is either sensitive or specific for sinusitis. The predictive power can be significantly improved when all signs and symptoms are combined into a clinical impression. Imaging studies have not been shown to be cost effective in the initial assessment and treatment of patients in the primary care setting. Simple plain films may be indicated to resolve the diagnosis in patients with an equivocal history or to follow patients admitted to hospital with severe sinus disease. The initial management of acute sinusitis should be directed toward the relief of symptoms with a 7-day course of decongestants and mucoevacuents. For patients who fail to improve with symptomatic treatment, a 10-day course of amoxicillin is recommended. Second line antibiotics should be initiated if improvement is not seen within 72 to 96 hours.     

霉菌性鼻窦炎临床诊治分析

目的探讨霉菌性鼻窦炎的诊断分型和治疗方法。方法回顾性分析21例霉菌性鼻窦炎病人临床资料，全组病例均行手术治疗，其中功能性鼻窦内镜手术(FESS)13例、柯陆氏5例、鼻内镜下单纯蝶窦开放术1例、FESS加蝶窦开放术2例。结果21例病人均治愈，且均经术后病理证实。结论霉菌性鼻窦炎以上颌窦多发，蝶窦、筛窦次之、额窦最少，分型以非侵袭性霉菌性鼻窦炎最常见，CT检查是早期诊断的有效途径。疗效预后关键在于鼻窦开放程度、引流通畅与否。     

Intracranial Complications of Sinusitis

Intracranial suppurative complications of sinusitis remain a challenging and contemporary topic. To determine the prevalence of sinogenic sources in intracranial infectious complications, we reviewed the records at a large public hospital between 1985 and 1995. There were 203 patients with 212 suppurative intracranial infections. Sinogenic sources were identified in 12 patients with 19 infections. Most patients had ethmoid or frontal sinusitis. We discuss the presentation, microbiology, diagnosis, treatment, and clinical course of these 12 cases. The diagnosis of intracranial complications of sinusitis requires a high index of suspicion and radiographic imaging of the head and paranasal sinuses. The mean hospital stay was 31.4 days and all 12 patients survived, although three patients had significant neurologic sequelae.     

Progressive swelling and radiopaque mass in maxillary sinus: formation of stone

Although radiopaque lesions located in the maxillary sinus are rare, differential diagnosis should include a number of pathologies. Formation of stone, namely "antrolith" in the paranasal sinuses is a very rare phenomenon and it should be considered in the differential diagnosis, as it is usually located in the maxillary sinus. In this article, we present a 47-year-old male case with unilateral chronic sinusitis for a long time and calcification in maxillary sinus in the light of clinical/radiographic findings of the lesion and treatment strategy.     

Endoscopic Endonasal Treatment of a Pott's Puffy Tumor

Pott's puffy tumor is an infrequent entity characterized by a subperiosteal abscess associated with frontal bone osteomyelitis. It has become rare due to the development of antibiotics and is usually seen as a complication of frontal sinusitis. Although Pott's puffy tumor is more commonly described in children, it should also be included in the differential diagnosis of swelling on the forehead in adults. Once the diagnosis is suspected, appropriate imaging should be performed to evaluate the possible complications. The treatment of Pott's puffy tumor combines medical and surgical approaches in order to prevent further complications. The goal of surgery is to drain the sinus and to excise the infected bone if necessary. The endoscopic endonasal approach is a safe and effective alternative to the external approach. This report describes the case of a 25-year-old man with Pott's puffy tumor resulting from frontal sinusitis.     

Endoscopic sinus surgery for unilateral chronic sinusitis]

Functional endoscopic sinus surgery has become an increasingly popular treatment for chronic sinusitis. This approach is aimed at re-establishment of ventilation and mucociliary clearance of the sinuses. However, some otolaryngologists believe that the Caldwell-Luc procedure should be routinely used for unilateral chronic sinusitis, because it is often associated with the maxillary sinus carcinomas. To evaluate the state of endoscopic sinus surgery for the diagnosis and treatment of unilateral chronic sinusitis, we analyzed the cases of 39 patients with unilateral chronic sinusitis who underwent endoscopic sinus procedures. These patients were unresponsive to appropriate antibiotic management for more than 6 months. Generally, endoscopic ethmoidectomy and antrostomy were performed with preservation of the middle turbinate. After the ostium was enlarged, the maxillary sinus was cleaned and carefully inspected for the presence of associated neoplasms using 30 and 70 degree endoscopes. Preoperative computed tomography (CT), postoperatve pathologic diagnosis, fiberscopic findings of the maxillary sinus, and symptomatic improvement were evaluated. Three patients had CT evidence of bone destruction of the lateral nasal wall. Pathological diagnosis demonstrated that three patients had maxillary sinus mycoses caused by Aspergillus species, one patient had inverted papilloma, and the other 35 patients had chronic sinusits. No associated malignancy was found. Eighty-one percent of the patients had almost normal endoscopic findings of the maxillary sinus by postoperative fiberscopic examination 4 to 8 months following surgery. With an average follow-up of 26 months, 88% of the patients were judged as having significantly improved in their presenting complaints of mucopurulent rhinorrhea, nasal obstruction, and facial pain. The results of this series suggest that endoscopic sinus surgery is an effective procedure for the diagnosis and treatment of unilateral chronic sinusitis.     

Maxillary sinus disease of odontogenic origin

Odontogenic sinusitis is a well-recognized condition and accounts for approximately 10% to 12% of cases of maxillary sinusitis. An odontogenic source should be considered in patients with symptoms of maxillary sinusitis who give a history positive for odontogenic infection or dentoalveolar surgery or who are resistant to standard sinusitis therapy. Diagnosis usually requires a thorough dental and clinical evaluation with appropriate radiographs. Common causes of odontogenic sinusitis include dental abscesses and periodontal disease perforating the Schneidarian membrane, sinus perforations during tooth extraction, or irritation and secondary infection caused by intra-antral foreign bodies. The typical odontogenic infection is now considered to be a mixed aerobic-anaerobic infection, with the latter outnumbering the aerobic species involved. Most common organisms include anaerobic streptococci, Bacteroides, Proteus, and Coliform bacilli. Typical treatment of atraumatic odontogenic sinusitis is a 3- to 4- week trial of antibiotic therapy with adequate oral and sinus flora coverage. When indicated, surgical removal of the offending odontogenic foreign body (primary or delayed) or treatment of the odontogenic pathologic conditions combined with medical therapy is usually sufficient to cause resolution of symptoms. If an oroantral communication is suspected, prompt surgical management is recommended to reduce the likelihood of causing chronic sinus disease.     

蝶窦恶性肿瘤的诊断与治疗

目的进一步认识蝶窦恶性肿瘤的临床特点、鼻内镜及影像学表现、误诊疾病及治疗效果,以提高诊断与治疗水平。方法对9例蝶窦肿瘤患者的临床资料进行回顾性分析。临床表现为头痛8例,视力下降3例,涕中带血、鼻塞3例,脑神经麻痹2例。误诊为蝶窦炎3例,鼻咽癌2例,脑梗塞、脑积水各1例。手术加术后放射治疗7例,单纯放射治疗1例。结果1例内翻性乳头状瘤恶变随访6年无复发;1例神经内分泌癌随访3年生存;4例治疗后2～3年内死亡,其中1例恶性黑色素瘤治疗后3年死于心肌梗塞,1例腺样囊性癌治疗后3年死亡,2例鳞状细胞癌治疗后2年内死亡:1例低分化鳞状细胞癌和1例恶性黑色素瘤随访1年生存;1例低分化腺癌失访。结论蝶窦恶性肿瘤早期无特殊症状,临床容易误诊和漏诊。对不明原因头痛、视力下降、涕中带血的患者应及早行鼻内镜和鼻窦CT、MRI检查,鼻内镜检查发现蝶筛隐窝小息肉,应及时活检以明确诊断。     

变应性真菌性鼻窦炎

目的　通过总结 3例变应性真菌性鼻窦炎 (allergicfungalsinusitis,AFS)的诊断、治疗过程 ,结合复习文献中关于本病的病理、生理过程的探讨 ,提示本病的诊断、治疗特点。方法　通过对 3例病史、鼻窦CT检查、鼻窦分泌物及鼻腔检查 ,对临床怀疑变应性真菌性鼻窦炎的 3例患者进行鼻窦内镜手术。通过分泌物真菌涂片、培养 ,组织病理学检查以及放射免疫吸附试验 (radioallergosorbenttest,RAST)结果 ,明确AFS诊断。术后口服强的松 ,局部雷诺考特喷鼻及大扶康冲洗鼻腔。结果　通过上述系统治疗 ,2例术后分别随访 2 5个月和 15个月症状完全缓解 ,1例术后 6个月症状复发 ,变应性黏蛋白再次出现 ,经术腔清理及大扶康冲洗后局部症状及分泌物完全消失 ,随访 2个月无复发。结论　变应性真菌性鼻窦炎有其独特的临床发生、发展过程。慢性鼻窦炎、鼻息肉中存在着一定比例的AFS ,应对其做出及时的诊断和进行合理、完善的综合治疗 ,以降低本病的并发症和复发率。     

Short and long-term treatment results in chronic maxillary sinusitis

The diagnostic criteria and the length of the observation period are essential factors influencing the results of treatment of maxillary sinusitis. In 198 patients (244 sinuses) with chronic maxillary sinusitis of either rhinogenous or dental etiology all patients were judged as cured or improved at the short-term control 1-3 months after completion of therapy. The long-term observation (mean 3.5 years) revealed different figures of healing. Satisfactory results after conservative therapy were seen in only 34% while the Caldwell-Luc operation gave good results in 80%. In sinusitis of dental origin, dental treatment combined with local sinus surgery was successful in 90%. In 78 sinuses investigated by sinoscopy, discrepancy between the symptoms and the endoscopic findings was seen in 14 cases (18%). Information obtained by questionnaire is therefore unreliable. In 30 sinuses operated upon with the Caldwell-Luc procedure, discrepancy between radiographic and endoscopic findings was seen in 3 cases (10%). Contributory factors, e.g. nasal polyps, dental infections and nasal allergy were found in 48 out of 84 sinuses not completely healed at the long-term control. Patients treated for chronic maxillary sinusitis must be followed up over a long period. A clinical control after 1-2 years, including sinoscopy or sinus radiographs, is recommended even in patients free from symptoms of sinusitis. Sinoscopy seems to be more reliable than sinus radiography and should be performed if the sinus radiographs show any pathology. The patients are also recommended to visit their dentists regularly, due to the close relationship between dental infections and chronic maxillary sinus diseases.     

Sinogenic brain abscess.

The otolaryngological contribution to the combined treatment of intracranial suppuration secondary to sinusitis can vary from observation to external approach sinus exploration. Limited surgical intervention using the endoscopic approach, in conjunction with neurosurgical drainage, has recently been adopted at our department as the initial therapeutic strategy in the management of such cases. A retrospective analysis of the otolaryngological input into the treatment of 16 patients with sinogenic brain abscess at the Department of Otolaryngology/Head and Neck Surgery, Beaumont Hospital, Dublin, Ireland is presented. This study reveals that it is generally a disease of young adult males without an antecedent history of sinus disease and that Strep. Milleri is the most common causative organism. It is demonstrated that there is a lack of a consistent approach to the management in the acute phase and that there is an inadequate initial radiologic evaluation of the paranasal sinuses. There are two forms of presentation: 1) an ENT complaint with development of an abscess, and 2) an idiopathic abscess with subsequent identification of a paranasal sinus infective source. Extensive initial intervention seems to be associated with an increased incidence of revision surgery, thus suggesting that a limited endoscopic approach combined with neurosurgical drainage is the optimal course in the first-line management of sinogenic abscess.     

Hals-Nasen-Ohren-Befunde bei Arteriitis temporalis Horton Literaturübersicht und Falldarstellung

Otorhinolaryngological findings of a temporal arteritis frequently occur in the beginning and/or course of the disease. A purulent sinusitis can be a sign of recurrence of the arteritis and was diagnosed in a 77-year-old woman with known disease that had been biopsied 6 years earlier. Puncture of the maxillary sinus was considered necessary, but no bacteria were found in purulent sinus discharge. When antibiotic treatment failed to bring about a resolution of the inflammatory condition, steroid therapy was begun and the patient recovered within a few days in response to this treatment. The clinical findings in this case show that early diagnosis and treatment by the otorhinolaryngologist are necessary in order to prevent severe complications of the disease.