Bacteriology of chronic sinusitis after amoxicillin-clavulanate potassium therapy

The bacteriology of chronic sinusitis was studied after amoxicillin-clavulanate potassium therapy. Patients with chronic sinusitis were randomly divided into 2 groups. In the study group, 90 patients were given a 2-week course of amoxicillin-clavulanate potassium before functional endoscopic sinus surgery. In the control group, 113 patients did not take any antibiotics within 2 weeks before the surgery. Swab specimens were taken from the maxillary and ethmoid sinuses during surgery and sent for aerobic and anaerobic culture. In the study group, the culture rates of maxillary and ethmoid sinuses were 45.6% and 28.9%, respectively. In the control group, the culture rates of maxillary and ethmoid sinuses were 53.1% and 34.5%, respectively. The culture rates between the control group and the study group were not significantly different, either for the maxillary sinus or the ethmoid sinus. This showed that treatment with amoxicillin-clavulanate potassium did not change the bacteriology of chronic sinusitis.     

Treatment of chronic rhinosinusitis refractory to other treatments with topical antibiotic therapy delivered by means of a large-particle nebulizer: results of a controlled trial.

OBJECTIVE: To study the efficacy of nebulized topical saline-tobramycin solution in patients with chronic rhinosinusitis refractory to medical and surgical therapy. STUDY DESIGN AND SETTING: Twenty patients in whom endoscopic sinus surgery failed to relieve symptoms entered a randomized, double-blind trial of tobramycin-saline solution or saline-only solution administered thrice daily to the nasal passages by means of a large-particle nebulizer apparatus for 4 weeks, followed by a 4-week observation period. Outcome measures of symptoms, quality of life, and endoscopic aspect of sinus mucosa were assessed. RESULTS: Both treatments were well tolerated and produced equivalent improvement in symptoms, quality of life, and mucosal aspect. Treatment with the tobramycin-saline solution gave more rapid improvement of pain, but led to the development of nasal congestion. CONCLUSION: Therapy with a 4-week course of large-particle nebulized aerosol therapy improves symptomatology and objective parameters of rhinosinusitis in patients refractory to surgical and medical therapies. Addition of tobramycin appears of minimal benefit. The mechanism of this effect is unexplained. SIGNIFICANCE: Large-particle nebulized aerosol therapy may offer a safe and effective management alternative for patients with refractory rhinosinusitis.     

The endoscopic modified Lothrop procedure for salvage of chronic frontal sinusitis after osteoplastic flap failure

OBJECTIVE: While reported results utilizing the osteoplastic flap procedure are very good, some patients fail the surgery due to recurrent or persistent frontal sinus disease. This study was performed to evaluate the utility of the endoscopic modified Lothrop sinus surgery for osteoplastic flap failure. STUDY DESIGN AND SETTING: A retrospective chart analysis and telephone survey of 10 patients from outside our institution for whom an osteoplastic flap with fat obliteration failed were salvaged using a computerized endoscopic modified Lothrop procedure. RESULTS: The main complaints were headache/pressure and recurrent infection. The usual pathology was chronic sinusitis and/or mucocele. The frontal recess and floor of the frontal sinus were the most common areas of persistent disease. Symptomatic clinical improvement was noted in more than 90% of patients. CONCLUSION: Salvage endoscopic modified Lothrop sinus surgery is recommended for a limited number of traditional osteoplastic flap failures. Computerized surgical navigation may help avoid complications in situations with abnormal anatomy and previous dissection. SIGNIFICANCE: The endoscopic modified Lothrop procedure should be considered to salvage failed osteoplastic flap sinus obliteration.     

鼻内镜下经鼻丘径路治疗慢性额窦炎

目的探讨鼻内镜下鼻丘径路治疗慢性额窦炎的疗效。方法对慢性额窦炎27例在鼻内镜下通过切除鼻丘气房暴露额窦开口,开放额窦。结果27例全部开放成功。除3侧眶周青紫外,无并发症发生。鼻内镜检查额窦口引流良好。27例术后随访6个月,18例额窦炎症状全部消失,7例明显改善,2例无明显改善。结论鼻内镜下经鼻丘径路微创治疗慢性额窦炎手术安全有效,值得在临床推广。     

Routine histopathology in uncomplicated sinus surgery: is it necessary?

OBJECTIVE: To evaluate the incidence of occult pathology in routine, uncomplicated endoscopic sinus surgery, and to suggest guidelines for when to send specimens for histopathologic exam. STUDY DESIGN AND SETTING: Retrospective analysis of case records of 790 patients who underwent 868 endoscopic sinus surgeries at a tertiary care center from 1986 to 2003. Indications were chronic sinusitis, recurrent acute sinusitis, nasal polyposis, or combinations of these diagnoses. All cases were considered routine and did not involve preoperative suspicion of neoplasm or other complicating factors. Charts were reviewed for surgical indication, patient age, laterality of disease, history of prior sinus surgery, intraoperative suspicion of tumor, and final histopathology. RESULTS: In 868 cases of endoscopic sinus surgery, occult neoplasm was diagnosed in 2 patients (0.23%). In one patient, the initial surgery cured the lesion. Final histopathology of the remaining 866 (99.8%) specimens was consistent with inflammation and/or nasal polyposis. In 121 cases of unilateral sinusitis, none was positive for neoplasm. In 277 cases involving bilateral nasal polyposis and 13 involving unilateral polyposis, no neoplasms were found. Intraoperative suspicion of neoplasm occurred in 12 cases, with all specimens read as consistent with sinusitis and/or polyposis. CONCLUSIONS: Histopathologic review of every specimen obtained in routine sinus surgery for sinusitis and/or nasal polyposis is not indicated. Submission of specimen is indicated in routine cases when: 1) there is intraoperative suspicion of tumor, 2) unilateral nasal polyposis is present, 3) unilateral sinus opacification is present, and 4) additional diagnostic information is needed (eg, presence of eosinophils, fungal forms, etc.). SIGNIFICANCE: Establishes a safe and reasonable standard of care, with potential cost savings and medico-legal ramifications.     

A targeted endoscopic approach to chronic isolated frontal sinusitis.

OBJECTIVE: Chronic isolated frontal sinusitis occurs infrequently. In this condition, most of the ethmoid cells are well aerated and the frontal sinus is involved secondary to anatomical obstruction or inflammatory changes confined to the frontal recess. The purpose of this study was to evaluate a targeted endoscopic technique where standard anterior ethmoidectomy is unnecessary in the treatment of chronic isolated frontal sinusitis. STUDY DESIGN AND SETTING: This retrospective study was conducted in a large university-affiliated hospital and included 11 patients with chronic isolated frontal sinusitis who underwent endoscopic sinus surgery limited to the frontal sinus outflow. The ethmoid bulla was untouched in all cases. Follow-up continued for 19 to 40 months (mean 28.6 months). RESULTS: Frontal sinus outflow patency was verified in 9 patients (81.8%). Nine patients, including one with an apparent nonpatent frontal ostium, reported improvement. Two patients-one of whom had a patent frontal ostium-reported no improvement. There were no complications. CONCLUSION: Chronic isolated frontal sinusitis can be effectively treated in selected cases by a targeted endoscopic procedure, limited to reestablishment of frontal sinus outflow. EBM rating: C-4.     

Management of acute complicated sinusitis: a 5-year review.

Acute sinusitis is a relatively common problem; however, sinusitis associated with a complication is less frequent. Currently there is debate as to whether acute complicated sinusitis should be managed by frontal sinus trephine and sinus washout or by immediate frontoethmoidectomy/functional endoscopic sinus surgery. To assess the effectiveness of frontal sinus trephine in the management of acute complicated frontal sinusitis, we reviewed all patients admitted to Groote Schuur Hospital with acute pansinusitis (includes frontal, maxillary, and ethmoid) from 1989 to 1993. Eighty-seven patients were admitted, of whom 43 were treated medically and 44 were treated surgically. Of the surgical patients 38 had frontal trephines and management of associated complications. Thirty (80%) of the patients who received frontal trephines recovered without further surgery, and 8 required further sinus surgery for persistent disease. Frontal trephine with management of associated complications is an acceptable management option for patients with acute complicated pansinusitis. Frontoethmoidectomy or functional endoscopic sinus surgery can be held in reserve for those patients with persistent disease that does not resolve after the initial frontal trephine.     

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.     

Outcome of reflux therapy on pediatric chronic sinusitis.

OBJECTIVE: The cause of pediatric chronic sinusitis is multifactorial, but nasal edema appears to be the initial pathologic step. The objective of this study is to evaluate gastronasal reflux as a possible cause of pediatric sinusitis. METHODS: Thirty children with chronic sinusitis were believed to be appropriate candidates for functional endoscopic sinus surgery. Children were evaluated retrospectively for their response to reflux therapy with regard to their sinus symptoms and avoidance of sinus surgery. RESULTS: Two of the 30 children were eventually excluded because they were taken to surgery for the specific purpose of contact point release. Chart review at 24-month follow-up indicated that 25 of the 28 children (89%) avoided sinus surgery. CONCLUSION: After reflux treatment, the number of children requiring sinus surgery was dramatically reduced. The results of this preliminary pediatric study indicate that gastronasal reflux should be evaluated and treated before sinus surgical intervention.     

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.     

Osteoplastic flap for obliteration of the frontal sinus: Five years’ experience

The objective of this retrospective study was to evaluate the osteoplastic flap (OPF) for the obliteration of the frontal sinus in this current era of endoscopic management of frontal sinus disease. A review of consecutive OPF procedures (n = 43) performed by the senior author (J.A.D.) from 1992 to 1997 was carried out. Data were gathered regarding chief symptom, medical history, previous sinus surgery, endoscopic findings in the office and at surgery, CT scan findings, and follow-up results (mean 19.4 months). Previous endoscopic management of frontal sinus disease had failed in 24% of patients; 97% had eventual resolution of frontal sinusitis with OPF. After OPF, 63% also had improvement or resolution of disease in other paranasal sinuses. Statistically significant, positive correlations (P < 0.05) were noted between the resolution of frontal sinusitis and improved or resolved pain, as well as the resolution of frontal sinusitis and improved or resolved infections in other paranasal sinuses. In 1998 OPF remains the standard for treating frontal sinus disease refractory to other methods. OPF can decrease the pain associated with frontal sinus infections and has a positive impact on inflammatory disease in other paranasal sinuses. (Otolaryngol Head Neck Surg 1999;121:731-5.)     

Small and large middle meatus antrostomies in the treatment of chronic maxillary sinusitis.

OBJECTIVE: The study goal was to compare the postoperative endoscopic appearance of the middle meatus antrostomy with symptomatic relief in patients undergoing endoscopic endonasal sinus surgery for chronic maxillary sinusitis. STUDY DESIGN: We conducted a prospective randomized study encompassing 133 patients with chronic rhinogenic maxillary sinusitis who underwent endoscopic ethmoid surgery and middle meatal antrostomies. One of the tasks was to compare small-sized (less than 6 mm) antrostomies with large-sized (more than 16 mm) antrostomies in relieving the symptoms of chronic maxillary sinusitis. During follow-up an attempt was made to correlate endoscopic findings with symptomatic failure. RESULTS: We could not demonstrate a statistically significant correlation between the degree of improvement of the main sinusitis symptoms (obstruction, headache, and nasal discharge) and the postoperative size of the antrostomy. Nevertheless, persistent accessory maxillary ostia, scarring within the ethmoid were statistically significant predictors of poor surgical outcome. CONCLUSION: We conclude from this study that the size of the middle meatal antrostomy has no influence on the outcome of endonasal surgery for chronic rhinogenic maxillary sinusitis.     

Osteoplastic flap for obliteration of the frontal sinus: five years' experience.

The objective of this retrospective study was to evaluate the osteoplastic flap (OPF) for the obliteration of the frontal sinus in this current era of endoscopic management of frontal sinus disease. A review of consecutive OPF procedures (n = 43) performed by the senior author (J.A.D.) from 1992 to 1997 was carried out. Data were gathered regarding chief symptom, medical history, previous sinus surgery, endoscopic findings in the office and at surgery, CT scan findings, and follow-up results (mean 19.4 months). Previous endoscopic management of frontal sinus disease had failed in 24% of patients; 97% had eventual resolution of frontal sinusitis with OPF. After OPF, 63% also had improvement or resolution of disease in other paranasal sinuses. Statistically significant, positive correlations (P < 0.05) were noted between the resolution of frontal sinusitis and improved or resolved pain, as well as the resolution of frontal sinusitis and improved or resolved infections in other paranasal sinuses. In 1998 OPF remains the standard for treating frontal sinus disease refractory to other methods. OPF can decrease the pain associated with frontal sinus infections and has a positive impact on inflammatory disease in other paranasal sinuses.     

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.     

Predictive and monitoring value of matrix metalloproteinase-9 for healing quality after sinus surgery

Functional endoscopic sinus surgery is considered the standard therapeutic procedure for chronic rhinosinusitis and nasal polyposis after failure of medical treatment. We tested the hypothesis that the healing outcome after surgery was correlated to the secretion profile of gelatinase-B (matrix metalloproteinase-9 [MMP-9]) and transforming growth factor-beta1 (TGF-beta1) in nasal fluid. We performed a prospective study in 36 patients bilaterally operated for chronic rhinosinusitits or nasal polyposis and the healing quality was evaluated until 6 months after surgery by standardized nasal endoscopy, using a visual analog scale. Before functional endoscopic sinus surgery and during the postoperative period, TGF-beta1 and MMP-9 in nasal secretions were measured by enzyme-linked immunosorbent assay. Both MMP-9 and TGF-beta1 showed a significant increase initially after surgery. The healing quality after 6 months was significantly and independently correlated to preoperative MMP-9 concentrations in nasal secretions (p = 0.03), initial disease (p = 0.03), and previous sinus surgery (p = 0.004). Furthermore, concentrations of MMP-9 were significantly lower in patients with good healing (visual analog scale < 3) from week 3 to month 6 compared to patients with poor healing. MMP-9 is the first objective factor suitable to predict and monitor the healing quality after sinus surgery, indicating MMP-9 as a possible therapeutic target.     

Characteristics of sinus-related pain

OBJECTIVES: The goal of this study was to determine possible distinctive features of facial pain when caused by chronic sinusitis and to validate the pain characteristics previously described in the literature. METHODS: Included were 82 patients with radiographic and endoscopic evidence of chronic sinusitis and significant facial pain who underwent functional endoscopic sinus surgery and were available for 1-year follow-up. A modified McGill pain questionnaire was filled out before surgery, and follow-up data were obtained at 1 year. RESULTS: At 1 year 38% of patients had persistent facial pain despite the lack of any evidence of persistent sinusitis. A consistent use of pain adjectives and other distinctive features was noted in patients reporting improvement of headache. There was no correlation between the severity of pain and the extent or location of mucosal disease. The site of pain did not correlate with the site of disease. CONCLUSIONS: Sinusitis-related pain has distinctive features that set it apart from primary headache disorders and other causes of facial pain. Nonsinus causes account for the headache in 1 of 3 patients undergoing sinus surgery.     

Thickening of sphenoid sinus mucosa during the acute stage of pituitary apoplexy.

The authors treated two patients with pituitary apoplexy in whom magnetic resonance (MR) images were obtained before and after the episode. Two days after the apoplectic episodes, MR imaging demonstrated marked thickening of the mucosa of the sphenoid sinus that was absent in the previous studies. The relevance of this change in the sphenoid sinus was investigated. Retrospective evaluations were performed using MR images obtained in 14 consecutive patients with classic pituitary apoplexy characterized by acute onset of severe headache. The mucosa of the sphenoid sinus had thickened predominantly in the compartment just beneath the sella turcica, in nine of 11 patients, as ascertained on MR images obtained within 7 days after the onset of apoplectic symptoms. This condition improved spontaneously in all four patients who did not undergo transsphenoidal surgery. The sphenoid sinus mucosa appeared to be normal on MR images obtained from three patients at the chronic stage (> 3 months after onset). The incidence of sphenoid sinus mucosal thickening during the acute stage was significantly higher in the patients with apoplexy than that in the 100 patients without apoplexy. A histological study conducted in four patients who underwent transsphenoidal surgery during the early stage showed that the subepithelial layer of the sphenoid sinus mucous membrane was obviously swollen. The sphenoid sinus mucosa thickens during the acute stage of pituitary apoplexy. This thickening neither indicates infectious sinusitis nor rules out the choice of the transsphenoidal route for surgery.     

Role of anaerobes in chronic sinusitis: Will polymerase chain reaction solve the debate.

BACKGROUND: Bacteriology of chronic sinusitis continues to be a matter of debate, particularly the role of anaerobes. Some authors suggest that anaerobes play a significant role whereas others suggest a minimal role. Those who suggest a significant role argue that standard culture techniques are the culprits. OBJECTIVE: The purpose of this study was to use polymerase chain reaction (PCR) on sinus specimens for the presence of anaerobes and to compare them with standard culture techniques. METHODS: Sixty-four samples were obtained in a sterile fashion during sinus surgery and were sent for standard anaerobic cultures as well as anaerobic PCR analysis. RESULTS: Anaerobic bacteria were demonstrated in 5% of culture specimens, which is similar to recently published data. PCR identified anaerobic bacteria in 19% of the specimens (P = 0.01). CONCLUSION: PCR analysis of surgical samples obtained during endoscopic sinus surgery for chronic sinusitis identified a significantly higher incidence of anaerobes (x4) compared with standard anaerobic culture technique.     

Cost-utility analysis for endoscopic sinus surgery.

OBJECTIVE: To undertake cost-utility analysis for endoscopic sinus surgery (ESS) in order to analyze the cost-effectiveness of different chronic sinusitis severity groups. METHODS: One hundred ninety-two patients with chronic sinusitis were evaluated with a Chronic Sinusitis Survey (CSS) before and 1-year after ESS. Direct health care cost data during the first year after operation were retrieved. The utility gain is defined as change in the CSS total score. The cost-utility ratio was defined as cost per utility gain. Patients are stratified by disease severity using the Harvard Staging System. RESULTS: The average total direct cost attributable to ESS is 40,829 NT dollars in the first postoperative year and the average cost-utility ratio is 2194.42 NT dollars. The high cost-utility ratio of 3246.45 NT dollars for pansinusitis cases is due to the higher cost and limited utility gain. CONCLUSIONS: Treating mild and moderate chronic sinusitis are most cost-effective because of their favorable utility gain and relatively reasonable cost. However, there is no proportional linear relationship between disease severity and cost-utility ratio.     

Single-stage strategy for management of anterior table frontal sinus fractures involving the frontal sinus outflow tract

Treatment of frontal sinus fractures has been controversial for years. The aim of treatment, besides cosmetic restoration, is to create a “safe” sinus especially in those with evidence of injury to the frontal sinus outflow tract. Early and late complications include acute and chronic sinusitis, mucocoele and mucopyocoele formation, brain abscess and osteomyelitis. Osteoplastic flap with frontal sinus obliteration or cranialisation is most commonly performed. With the advent of modern endoscopic and advanced imaging techniques, endoscopic sinus surgery for treatment of diseases of the frontal sinus is ever increasing. In this paper, we describe our successful experience using a single-stage, combined open and transnasal endoscopic technique in management of patients with anterior table frontal sinus fractures involving the frontal sinus outflow tract.