The Completely Opacified Frontal or Sphenoid Sinus: A Marker of More Severe Disease in Chronic Rhinosinusitis?

OBJECTIVE: Determine whether complete opacification of the sphenoid or frontal sinus is associated with increased clinical severity of chronic rhinosinusitis (CRS). METHODS: Adult patients undergoing evaluation for CRS prospectively completed the rhinosinusitis symptom inventory (RSI) and underwent computed tomography of the paranasal sinuses. A cohort with at least one completely opacified frontal sinus was identified. To each patient in this opacified cohort, a control patient without complete frontal sinus opacification was matched with corresponding Lund score. Symptom scores for headache, facial pressure, RSI symptom domains, and medical resource consumption were statistically compared. Similar analysis was conducted for patients with complete sphenoid sinus opacification. RESULTS: Fifty-four patients with at least one completely opacified frontal sinus were matched for Lund score to the control group (mean Lund score 17.1). There was no statistically significant difference in headache (2.1 vs. 2.8) or pressure scores (2.0 vs. 2.3) or in the RSI symptom domains between those patients with completely opacified frontal sinuses and controls, respectively. Although completely opacified patients received more antibiotic treatment and missed more workdays, only the increased numbers of physicians visits (4.0 vs. 2.1, P = .02) was significant. Thirty-four of 35 completely opacified sphenoid patients were matched to control patients (mean Lund score 16.7). Again, differences in symptom scores for headache (2.5 vs. 2.5), facial pressure (2.3 vs. 2.3), and RSI symptom domains were not statistically significant. Increased use of antibiotics (9.6 vs. 3.9, P = .036) and physician visits (5.8 vs. 1.8, P = .024) for sphenoid opacification patients was statistically significant. CONCLUSIONS: Patients with a completely opacified sphenoid or frontal sinus do not necessarily manifest more severe clinical symptoms of CRS. Thus, a higher radiographic stage should not be automatically assigned to patients with a completely opacified sphenoid of frontal sinus in CRS.     

What is the evidence for non-antibiotic drug therapy of Rhinosinusitis?

The German AWMF-guideline for rhinosinusitis and nasal polyps is to be reassessed. By searching the literature for the reevaluation we investigate in this systematic review to what extent existing recommendations can be affirmed, have to be changed or if there are new recommendations to give.We searched PUBMED, MEDLINE and other databases via MEDPILOT, and the Cochrane Central Register of Controlled Trials without limiting the publication date range. Relevant clinical trials identified by 2 reviewers out of the search results were assessed for their methodical quality using an extended Jadad scale. Datas were extracted and study design, therapy/application, control group and results were analysed. Furthermore, levels of evidence for the different therapeutics have been determined.Out of 1?346 search results 227 potentially eligible trials were identified; for this review we considered only the 47 trials published since 01/2006. Former recommendations are mainly supported by the identified relevant publications and several Cochrane reviews published in the last years.Levels of evidence are Ia for topical and systemic corticosteroid therapy for acute and chronic rhinosinusitis. Additionally, there is evidence that the application of saline solutions is useful not only for chronic but also for acute rhinosinusitis. New therapy options are under examination, but there is not enough evidence for adding them to actual recommendations.     

Significance of Pseudo-Conductive Hearing Loss and Positional Nystagmus for Perilymphatic Fistula: Are They Related to Third-Window Effects?

ObjectivesPatients’ clinical presentation is critical for identifying suspected perilymphatic fistula (PLF). The involvement of third-window lesions in the pathomechanism of PLF has been hypothesized. This study investigated the clinical features of PLF and the relationship of the third-window effect with PLF. MethodsSixty patients underwent surgical exploration for suspected PLF and the oval and round windows were reinforced. Clinical features including demographics, pure-tone audiometry (PTA), and videonystagmography were evaluated preoperatively and 1 month postoperatively. Surgical outcomes were analyzed according to the improvement of hearing and vestibular symptoms and signs. The conductive components of PTA (air-bone gap [ABG]) were measured, and the relationship between ABG closure after surgery and hearing improvement was analyzed. In addition, postoperative subjective dizziness was assessed by clinical interviews. Changes in positional nystagmus were analyzed according to ABG closure and hearing improvement.ResultsABG at lower frequencies (LFABG; 250 Hz, 500 Hz, 1,000 Hz) was present in 27 patients (45%). Postoperatively, PTA significantly improved after surgical repair. Among the patients with preoperative LFABG (n=27), 15 (55.5%) showed postoperative ABG closure and significant improvement in PTA at all frequencies compared with the patients without ABG closure (P=0.012). Subjective dizziness improved in 57 patients (93.3%). Positional nystagmus was found in 45 of 49 patients. Multiple canal involvement was more common than single canal involvement (67% vs. 33%). The horizontal semicircular canal was most commonly involved, followed by the posterior and anterior canals. Postoperatively, positional nystagmus disappeared, or the number of involved canals decreased in 22 of 34 patients (64.7%). ConclusionPseudo-conductive hearing loss at lower frequencies and positional nystagmus originating from multiple semicircular canals were common findings in PLF. Surgical reinforcement of the oval and round windows improved the hearing threshold accompanied by closure of ABG. A third-window lesion might explain these clinical features of PLF.     

Behavior and Obstructive Sleep Apnea in Children: Is Obesity a Factor?

OBJECTIVES: Children with obstructive sleep apnea (OSA) frequently exhibit behavioral and neurocognitive problems. There is a high prevalence of OSA among obese children. This study aims to evaluate the relationship between OSA and behavioral problems in obese children as compared with normal-weight children (controls). STUDY DESIGN: Prospective, nonrandomized, controlled study of obese and normal-weight children with OSA presenting to a tertiary medical center for adenotonsillectomy. METHODS: All study participants underwent preoperative polysomnography to document OSA. Obesity was defined as age- and sex-adjusted body mass index at the 95th percentile or higher. Behavior was evaluated using the Behavior Assessment System for Children (BASC). Preoperatively, the Behavioral Symptoms Index (BSI), a global measure of behavior, and BASC scores for obese and normal-weight children were compared using an unpaired t test. RESULTS: The study population included 52 children, 18 (35%) of whom were obese. The mean age of obese children was 8.6 (range, 2.0-14.9) years. The mean age of normal-weight children was 6.4 (range, 2.1-12.9) years. Demographics were otherwise similar. The mean apnea-hypopnea index for obese children was 17.2 (5.0-38.0) and for normal-weight children was 15.7 (5.3-88.0). The BSI score was 55.3 (SD, 15.9) for obese and 55.9 (SD, 15.0) for normal-weight children. Seven (38.9%) obese and 12 (35.3%) normal-weight children had clinically significant or abnormal behavior. Similar results were seen for the BASC scales of atypicality, depression, hyperactivity, and somatization in both groups. CONCLUSIONS: Behavioral problems are highly prevalent in children with OSA. However, these problems exist independently of whether children are obese or normal weight.     

Biofilms in Ear,Nose, and Throat Infections: How Important are They?

BACKGROUND: Biofilms present a new challenging concept in sustaining chronic, common antibiotic-resistant ear, nose, and throat (ENT) infections. They are communities of sessile bacteria embedded in a matrix of extracellular polymeric substances of their own synthesis that adhere to a foreign body or a mucosal surface with impaired host defense. The aim of this paper is to review the literature on ENT diseases that can be attributed to biofilm formation and to discuss options for future treatment. MATERIALS AND METHODS: Literature review from Medline and database sources. Electronic links and related books were also included. STUDY SELECTION: Controlled clinical trials, animal models, ex vivo models, laboratory studies, retrospective studies, and systematic reviews. DATA SYNTHESIS: Biofilm formation is a dynamic five-step process guided by interbacterial communicating systems. Bacteria in biofilms express different genes and have markedly different phenotypes from their planktonic counterparts. Detachment of cells, production of endotoxin, increased resistance to the host immune system, and provision of a niche for the generation of resistant organisms are biofilm processes that could initiate the infection process. Effective prevention and management strategies include interruption of quorum sensing, inhibition of related genes, disruption of the protective extrapolymer matrix, macrolides (clarithromycin and erythromycin), and mechanical debridement of the biofilm-bearing tissues. With regard to medical indwelling devices, surface treatment of fluoroplastic grommets and redesign of cochlear implants could minimize initial microbial colonization. CONCLUSION: As the role of biofilms in human infection becomes better defined, ENT surgeons should be prepared to deal with their unique and tenacious nature.     

Timing of Endoscopic Sinus Surgery in Children: Is There an Impact on Outcome?

OBJECTIVES/HYPOTHESIS: Endoscopic sinus surgery in children continues to be a controversial issue. Major factors in determining when to operate are the duration of the disease and duration of medical treatment. STUDY DESIGN: Prospective study of children referred to a tertiary center. PATIENTS AND METHODS: Eighty-three patients underwent endoscopic sinus surgery for refractory chronic sinusitis. All patients were followed prospectively to evaluate their response to surgery for a mean follow-up period of at least 1 year. A chi2 analysis and logistic regression analysis were performed to determine statistical difference between duration of symptoms and outcome. RESULTS: The overall success rate of endoscopic sinus surgery was 80%. Children who had surgery between 6 and 12 months of symptoms despite continued medical therapy had an 84% success rate, those who had surgery between 12 and 18 months had a 74% success rate, and those with more than 18 months of treatment for symptoms had an 81% success rate (P > .05). CONCLUSIONS: Duration of the symptoms of chronic sinusitis in children of more than 6 months was not a predictor of success of endoscopic sinus surgery in these children. Although there seemed to be a trend toward having a more successful procedure in children who had surgery between 6 and 12 months of medical treatment versus those who had surgery after more than 12 months of medical treatment, this did not reach statistical significance. A prospective study with more patients may shed more light on this subject.     

Assessing Penetration and Aspiration: How Do Videofluoroscopy and Fiberoptic Endoscopic Evaluation of Swallowing Compare?

OBJECTIVES/HYPOTHESIS: We aimed to investigate whether the type of dysphagia examination (fiberoptic endoscopic evaluation of swallowing [FEES] or videofluoroscopy) influences the scoring of penetration and aspiration. STUDY DESIGN: Prospective, single-blind study. METHODS: Fifteen dysphagic participants were recruited and underwent one FEES and one videofluoroscopy examination, performed and recorded simultaneously. Fifteen independent raters from 12 centers scored penetration and aspiration from recordings using the Penetration Aspiration Scale. Raters were blind to participant details, the pairing of the FEES and videofluoroscopy recordings, and the other raters' scores. Interrater and intrarater reliability were analyzed using weighted kappa. RESULTS: The Penetration Aspiration Scale scores were significantly higher for the FEES recordings than for the videofluoroscopy recordings (ANOVA P < .001). The mean difference between the FEES and videofluoroscopy penetration aspiration scores for the same swallows was 1.15 points. Interrater and intrarater reliability ranged from 0.64 to 0.79 (weighted kappa). CONCLUSIONS: Penetration aspiration is perceived to be greater (more severe) from FEES than videofluoroscopy images. The clinical implications are discussed.     

Intratympanic steroids: Do they acutely improve hearing in cases of cochlear hydrops?

OBJECTIVE: To study the acute effects on hearing of intratympanic dexamethasone in patients with cochlear hydrops. STUDY DESIGN: Retrospective review. METHODS: Patients who met established criteria for the diagnosis of Ménière's disease or had a history of fluctuating hearing loss and met hearing loss criteria for Ménière's disease, indicating cochlear hydrops, underwent a series of one to three intratympanic injections of dexamethasone in the affected ear. Follow-up audiograms were obtained 1 week after each injection and, in many patients, several months after injection. RESULTS: Fifty patients met inclusion criteria and were studied. Using the American Academy of Otolaryngology-Head and Neck Surgery reporting guidelines, hearing improved acutely in 20 of the 50 patients (40%), was worse in 2 (4%), and did not change in 28 (56%). For those who improved, the average decrease in threshold was 14.2 dB. Whether the patient had typical Ménière's disease or cochlear hydrops did not affect the response to therapy. There were no significant complications from the injections. CONCLUSIONS: Intratympanic administration of dexamethasone may acutely affect sensorineural hearing loss associated with endolymphatic hydrops. A prospective, controlled study is required.     

Petrous bone fractures in children: risk of meningitis, and indication for early Cochlear implant?

The case of a 5 year old boy who had a right petrous bone fracture with right CSF otorrhea and deafness is reported. This child presented, three years after the trauma, a right side otitis media, complicated by meningitis and pneumococcal sepsis, which might have as consequence a left side deafness. The bilateral deafness and the early possibility for cochlear ossification made us decide rapidly on a cochlear implant. Benjamin was then operated for a left side cochlear implant 40 days after contracting meningitis. Two months later, this boy was able to understand a speech without lip reading. Current concepts in the management of petrous bone fractures with CSF otorrhea are reviewed in this report. We also discussed prophylactic attitudes to adopt to reduce the risk of post temporal bone fracture meningitis.     

When is a biopsy justified in a case of relapsing polychondritis?

Relapsing polychondritis (RP) is a relatively rare rheumatic condition of unknown aetiology. It is characterized by recurrent episodic inflammation of cartilaginous structures (nose, ear and trachea). The clinical diagnosis of polychondritis can frequently be made with confidence in the absence of histological confirmation. A 61-year-old diabetic man, with bilateral relapsing aural inflammation, left ear deafness with tinnitus and pain at the sternocostal junctions is reported. After clinical diagnosis of relapsing polychondritis steroid therapy was started. An ear cartilage biopsy was performed confirming the clinical diagnosis. Subsequently soft tissue infection occurred at the operation site. The abscess was drained and oral ciprofloxacin was given with complete resolution of the infection over 30 days. As the infection is the main cause of death in these patients, we analyse whether biopsy is absolutely necessary for the diagnosis of RP in some patients.     

Connexin 32 and 43 mutations: Do they play a role in chronic rhinosinusitis?

Objective

Dysfunction of the sinonasal epithelium may contribute to the pathogenesis of chronic rhinosinusitis (CRS) including recurrent acute rhinosinusitis (RARS). Mutations in connexin 32 and 43 proteins have been associated with a number of human diseases. The objective of this study is to investigate the role of mutations in connexin 32 or connexin 43 genes in CRS and RARS.

Methods

Prospective case series of 19 patients with CRS and /or RARS. Clinical and demographic factors were noted and buccal swabs were collected for DNA sequencing of connexin 32 and connexin 43 genes.

Results

One patient was found to have a conservative V193I mutation in the connexin 32 gene. Connexin 43 mutations were found in two patients – a silent R239R mutation and an AAA insertion after the stop codon in the 3′ UTR. None of these mutations are associated with any known diseases or predicted to lead to protein dysfunction.

Conclusion

Mutations in connexin 32 or 43 genes in patients with CRS, including RARS, appear to be rare. The etiologic role of connexin mutations in chromic rhinosinusitis is suspect, and routine sequencing for connexin mutations in patients with RARS or CRS is not cost effective.     

Tracheal and laryngeal rupture in neonates: complication of delivery or of intubation?

Neonatal tracheal or laryngeal rupture is a rare but life-threatening condition that is attributable to traumatic endotracheal intubation or traumatic delivery. We present a review of the literature and 6 new cases of laryngeal or tracheal rupture following complicated delivery. High-risk groups were identified as 1) low-birth weight neonates, for intubation trauma, and 2) extremely high-birth weight neonates with shoulder dystocia, for trauma due to delivery. Two specific types of ruptures can be distinguished. The less-rare type involves a partial anterior rupture in the subglottic area, which can occur after traumatic intubation or traumatic delivery. The rarer type involves a distal circumferential tracheal rupture that gives rise to ventilatory problems, usually after a delay of several days. This type of rupture was only observed following traumatic delivery. Early diagnosis, optically guided orotracheal intubation, and timely treatment can reduce the risks of mortality and morbidity.