The role of ostiomeatal complex obstruction in maxillary fungus ball.

OBJECTIVE: The aim of this study was to clarify the role of ostiomeatal complex obstruction in maxillary fungus ball. STUDY DESIGN AND SETTING: Comparative study in a hospital setting of the mean Lund-Mackay scores for the anterior ethmoid and frontal sinuses of 54 versus 48 patients with maxillary fungus ball versus chronic unilateral rhinosinusitis, respectively. RESULTS: In cases with partial opacification in the maxillary sinus, the anterior ethmoid and frontal sinuses were diseased in the chronic unilateral rhinosinusitis group but not in the maxillary fungus ball group. In cases with total opacification in the maxillary sinuses, all anterior ethmoid and frontal sinuses in both groups were diseased, but the disease condition of the frontal sinuses was significantly less severe in the maxillary fungus ball group (P < 0.001). CONCLUSION AND SIGNIFICANCE: In this era of evidence-based medicine, we provide statistical data supporting the principle that maxillary fungus ball is not associated with osteomeatal complex obstruction and that another as-yet-unexplained mechanism must be responsible. EBM rating: B-3b.     

Computed tomographic and endoscopic analysis of supraorbital ethmoid cells.

OBJECTIVES: The aim of this study is to look at the incidence of supraorbital ethmoid cells (SOEC) in normal Chinese subjects by using spiral computed tomography (CT) scanning. In addition, subjects with chronic rhinosinusitis with SOEC were reviewed for endoscopic analysis. METHODS: A total of 202 normal Chinese subjects underwent spiral CT. Meanwhile, a retrospective review of patients who had undergone endoscopic sinus surgery over a 1-year period was conducted. RESULTS: SOEC showed an incidence of 5.4% (22 sides), and all of them arose from the anterior ethmoid cells. On coronal CT, an SOEC might give the appearance of multiple frontal sinuses, type III frontal cells, suprabullar cells, frontal bullar cells, interfrontal septal cells, or that there was a septation present within the frontal sinus. Meanwhile, 11 chronic rhinosinusitis patients with 12 SOEC were identified. CONCLUSION: A thorough knowledge of endoscopic anatomy and CT of the frontal recess and various fronto-ethmoid cells were required for safe dissection of the SOEC and frontal ostium.     

A case report of surgical resection of secretory carcinoma in the maxillary and ethmoid sinus

IntroductionSecretory Carcinoma is a recently discovered head and neck tumour. Surgical resection is generally the first line of treatment with neck dissection, radiation, and chemotherapy decided based on clinical, radiological, and histological parameters. We present a case of a Secretory Carcinoma presenting in the maxillary and ethmoid sinuses.CaseA 39-year-old male presented with left nasal obstruction and chronic rhinosinusitis beginning after surgical repair of the mandible and maxilla due to facial trauma. A CT scan of the head showed soft tissue density in the left maxillary sinus extending through the ethmoid sinus and posterior nasal cavity. Functional endoscopic sinus surgery (FESS) was performed to remove the obstructing lesion. Biopsy was analysed and the main differential diagnosis was between a non-intestinal type adenocarcinoma of nasal origin and a salivary carcinoma.DiscussionTo our knowledge, there have only been two cases of Secretory Carcinoma reported in the sinuses: one case in the ethmoid sinus and the other in the maxillary sinus. This is the first to report follow up at 1 year.ConclusionBoth MRI and exam showed no evidence of recurrent disease at one year follow up. This report aims to further the understanding of Secretory Carcinoma tumours in the sinuses. Our report could be used to further understand diagnostic criteria for Secretory Carcinoma in the sinuses as well as treatment outcomes for surgical resection without adjuvant treatment.     

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.     

Density of middle turbinate subepithelial mucous glands in patients with chronic rhinosinusitis.

OBJECTIVE: Histologic changes have not been systematically assessed in chronic rhinosinusitis. Quantitative histochemical studies evaluated the extent of sinus disease and gland density in the middle turbinates. STUDY DESIGN AND SETTING: Sinus computed tomography scans of 34 patients with chronic rhinosinusitis were retrospectively graded 0 to IV according to the May classification. Middle turbinates from patients with chronic rhinosinusitis (n = 46) and normal patients (n = 7) were harvested during endoscopic sinus surgery. The areas of Alcian blue-stained glands were assessed in paraffin sections using a computer-assisted microscopy video system. RESULTS: Alcian blue-stained glands occupied 7.94% of normal mucosa. The staining in all grade III rhinosinusitis subjects was increased to 12.94% (P < 0.01). In contrast, grade IV pansinusitis was associated with nasal polyposis (6 of 6) with decreased gland area (3.04%, P < 0.01). When polyp patients were excluded from grade III rhinosinusitis, the Alcian blue-staining area was 17.68% (P < 0.01). CONCLUSIONS: Distinct polypoid and glandular histopathologic patterns are present in chronic rhinosinusitis.     

Released intranasal eosinophilic major basic protein as a diagnostic marker for polypoid chronic rhinosinusitis

Objective

To investigate the hypothesis that eosinophil major basic protein is released in high concentrations in the nasal mucus of patients with polypoid chronic rhinosinusitis.

Study Design

Single center, open, prospective trial.

Setting

Medical University of Graz, Austria.

Subjects and Methods

Patients with polypoid chronic rhinosinusitis (n = 23) were compared to three different control groups: patients with chronic rhinosinusitis-like symptoms but without general mucosal thickening, patients who underwent functional endoscopic sinus surgery for reasons other than chronic rhinosinusitis, and patients without sinus disease (total n = 21). Mucus was harvested from each patient using a standardized technique and analyzed for eosinophil major basic protein with an enzyme-linked immunosorbent assay.

Results

In the patient group with polypoid chronic rhinosinusitis, 20 of 23 (87%) were positive for eosinophil major basic protein. In contrast, only one control patient was positive, whereas the remainder had no detectable amount of eosinophil major basic protein in the mucus (P < 0.001 vs chronic rhinosinusitis).

Conclusion

Toxic eosinophil major basic protein levels are elevated in polypoid chronic rhinosinusitis patients compared to control groups that have similar clinical presentations but upon closer examination turn out not to have chronic rhinosinusitis. In the future, the detection of eosinophil major basic protein in nasal mucus may become a sensitive and specific marker for chronic rhinosinusitis and a helpful diagnostic tool.     

Chronic rhinosinusitis and biofilms.

BACKGROUND AND HYPOTHESIS: Biofilms have been implicated in several head and neck infectious processes such as the following: dental and periodontal disease, otitis media, tympanostomy tube otorrhea, and chronic tonsillitis. We believe that biofilms also are associated with chronic rhinosinusitis. No information is known regarding the presence of biofilms in chronic rhinosinusitis. STUDY DESIGN AND SETTING: With institutional review board approval, tissue was obtained from consenting chronic rhinosinusitis patients who were undergoing functional endoscopic sinus surgery. Specimens were taken bilaterally from the ethmoid and maxillary sinuses. Inclusion criteria consisted of a positive diagnosis with pathologic tissue confirmation of chronic inflammation. Diagnosis was based on patient history, physical exam, and coronal sinus CT findings. Once collected, the specimens were labeled and fixed in formalin. The specimens were subsequently dehydrated, with successive immersions in increasing concentrations of diluted ethanol. The specimens were allowed to air dry and then were affixed to aluminum stubs with colloidal carbon. The sample surface was coated with a gold and palladium layer. The specimens were examined under an electron microscope. Areas of interest were photographed. RESULTS: Specimens from 5 patients were examined. All revealed bacterial biofilms. Invariably, biofilms were seen in the ethmoid, as well as in other samples. Denudation of ciliated and goblet cells was noted in all specimens. Biofilms resembled that of Staphylococcus species. Unidentified biofilms were also seen. CONCLUSIONS: This is the first documentation of biofilms in association with chronic rhinosinusitis. Further investigation is warranted, especially with control research subjects.     

Prospective analysis of sinus symptoms and correlation with paranasal computed tomography scan.

OBJECTIVES: We designed a prospective study to determine whether there is a correlation between the severity of sinus symptoms and the severity of computed tomography (CT) scan evidence of rhinosinusitis. METHODS: Acute and chronic rhinosinusitis patients rated their symptoms and had a CT scan of the sinuses taken the same day. A Likert severity scale and standardized CT scoring system were used. Data were analyzed by nonparametric methods with Kendall's rank correlation coefficient. RESULTS: The severity of 5 symptoms correlated with severity of disease on CT scan. Headache and facial pain or pressure had no correlation. CONCLUSION: The certainty of a clinical diagnosis of rhinosinusitis requiring treatment is enhanced in patients with high symptom severity scores for fatigue, sleep disturbance, nasal discharge, nasal blockage, or decreased sense of smell. Isolated headache and facial pain or pressure are less reliable predictors of CT scan findings supporting the diagnosis rhinosinusitis.     

Correlation between middle turbinate and ipsilateral ethmoid histopathology in chronic rhinosinusitis.

OBJECTIVE: Study the concept of "rhinosinusitis" in patients with inflammatory paranasal sinus disease (IPSD). STUDY DESIGN AND SETTING: Prospective case control series in a tertiary care facility. Twenty-two consecutive patients with IPSD without polyposis were enrolled. A partial middle turbinectomy and ethmoidectomy were performed and the histopathologic findings of the surgical specimens from the 2 sites was studied. The general degree of inflammation, epithelial thickening, and inflammatory cell count were measured. RESULTS: The degree of middle turbinate inflammation correlated with that of the ipsilateral ethmoid sinus (Spearman's rho coefficient = 0.450; P < 0.05). Epithelial thickness was more prominent in the ethmoid sinus. The total inflammatory cell count was comparable. There was a statistically significant correlation among total inflammatory cell count, plasma cell count, and eosinophil count between the 2 sites. CONCLUSION: The ethmoid sinus inflammation in IPSD is accompanied by a commensurate ipsilateral middle turbinate inflammation. SIGNIFICANCE: The data support the use of the term "rhinosinusitis."     

Current concepts in management of sinus disease

All the paranasal sinuses originate embryologically from the lateral nasal wall or ethmoid air cells. This common development also determines the ability of the paranasal sinuses to function normally. Disease affecting the common drainage area of the sinus ostia, the ostiomeatal complex, also affects the function of the closely associated paranasal sinuses. Therapy directed toward any sinus without efforts to identify and correct the pathologic process of the ostiomeatal complex often leads to less-than-satisfactory results. Determination of the etiology of chronic paranasal sinus disease depends on the clinical history, endoscopic rhinoscopy, and computerized imaging. Therapy is directed toward relief of the sinus ostial obstruction and restoration of the normal mucociliary clearance. After medical therapy has failed to reverse the pathophysiology of acute or chronic paranasal sinus disease, surgical intervention may be considered.     

Endosinusal treatment impact and prognostic value of IL-5 in chronic maxillary sinusitis

Objectives: The aim of the study was to evaluate subjective outcomes in patients with chronic maxillary sinusitis after steroid/antibiotic endosinusal treatment. Furthermore, the aim was to test the hypothesis that pretreatment levels of interleukin-5 (IL-5) in sinus fluid could predict response to endosinusal steroid/antibiotic treatment.Methods: Thirty patients with chronic maxillary sinusitis were recruited for the study. Patients were treated endosinusally with 2 mg dexamethasone and 40 mg gentamycine per maxillary sinus for 5 days. Patients rated nasal/CRS disease-specific symptoms and completed a self-administered questionnaire concerning sinusitis symptoms at inclusion and after 30 days. Sinus lavage, collected at inclusion, was analyzed for IL-5 concentration.Results: 56.6% of patients had improvement after endonasal treatment with decrease in symptoms (responders), and 43.4% were unchanged or worsened after treatment (nonresponders). Significant improvement was noted for overall sinusitis symptoms score (P = 0.02) and for obstruction, postnasal drip, headache, sneezing, and cough (P < 0.05). There is positive correlation between baseline IL-5 level in sinus lavage and improvement rate of overall sinusitis symptoms score (P < 0.01) and improvement rate of nasal secretion score (P < 0.01).Conclusions: Steroid-antibiotic endosinusal treatment in patients with chronic maxillary sinusitis was proven effective in reducing subjective sinusitis symptoms. Improvement rate to endosinusal treatment is expected be higher in patients with increased level of IL-5 in maxillary sinus lavage. Increased concentrations of IL-5 in sinus fluid might be used as a predictor of a good response to endosinusal treatment of maxillary chronic sinusitis.     

If functional sinus surgery fails: A radical approach to sinus surgery

Radical surgery of the nose and paranasal sinuses was performed in 56 patients as a last resort for severe recurrent treatment-resistant rhinosinusitis. Surgery consists of removal of all walls between the nasal fossa and the paranasal sinuses, creating one cavity. All patients were permanently relieved of sinusitis and nasal obstruction, and other symptoms were greatly reduced. Morbidity is low in relation to preoperative symptoms. We conclude that radical sinus surgery is an effective last resort if functional sinus surgery repeatedly fails. (Otolaryngol Head Neck Surg 1996;114:745-7.)     

CT of the paranasal sinuses is not a valid indicator for sinus surgery in CF patients

BackgroundNo guidelines comprise when or to what extent sinus surgery should be done in patients with cystic fibrosis (CF) or how a CT scan of the paranasal sinuses should influence the decision. Symptoms of rhinosinusitis and/or eradication of pathogenic bacteria from the sinuses are reasons for sinus surgery.MethodsIn this observational cross sectional study, 55 CF cases had their preoperative CT scans scored according to the Lund Mackay- and the Nair-system. Correlations between the CT scans, symptoms, surgical findings and cultures obtained during sinus surgery were made.ResultsThere was no significant correlation between the CT score and detection of pus, pathogenic bacteria or symptoms. Pus and pathogenic bacteria were found in several cases without sinus opacification on the CT scan. Non pathogenic and sterile cultures were also found in sinuses with opacification.ConclusionsA CT scan is not a valid criterion for sinus surgery in CF patients.     

A method for combined dacryocystorhinostomy with external ethmoidectomy

Severe polypoid rhinosinusitis requiring external ethmoid surgery may be seen in conjunction with partial or complete nasolacrimal obstruction. When this obstruction is associated with persistent, unresolved lacrimal symptoms, it is sometimes appropriate to combine surgical procedures, thereby avoiding separate lacrimal surgery. A method combining dacryocystorhinostomy (DCR) with external ethmoidectomy is described. The anatomy involved in this procedure and the indications for it are discussed.     

Effect of endoscopic sinus surgery on irradiation-induced rhinosinusitis in patients with nasopharyngeal carcinoma

OBJECTIVES: We evaluated the effect of endoscopic sinus surgery on irradiation-induced rhinosinusitis of the maxillary-sinus mucosa among patients with nasopharyngeal carcinoma (NPC). DESIGN: Surgical outcomes were evaluated by changes to the ultrastructure of the antral mucosa and nasomucociliary clearance. METHODS: Twenty-one NPC patients with irradiation-induced chronic sinusitis were enrolled in the study, along with five controls. Specimens were taken from 42 maxillary sinuses during surgery and 1 year after surgery. Saccharin transit time was measured before the initial surgery and 1 year after surgery. RESULTS: In the postoperative cases, we found a decrease in the number of the submucosal gland openings (P < 0.05), the cilia in the antral mucosa regenerated (P < 0.05), and the saccharin transit time reduced (P < 0.05); the number of goblet cells did not change. CONCLUSION: Endoscopic sinus surgery is an effective treatment for irradiation-induced rhinosinusitis in NPC patients, improving ventilation and drainage of the paranasal sinuses, and facilitating regeneration of the sinus mucosa.     

Relationship of the optic nerve to the paranasal sinuses as shown by computed tomography

Restricted exposure and inconsistencies in sinus pneumatization place the optic nerve at risk during operations on the sphenoid sinus and posterior ethmoid cells. In this study, computed tomography was used to examine these relationships. We reviewed 80 patients who underwent high-resolution computed tomographic scanning for ophthalmologic complaints in which the scan was negative. Forty-eight percent of posterior ethmoid cells are separated from the optic nerve by the thin bony lamina of the optic canal. Nearly 90% of sphenoid sinuses contact the ipsilateral optic nerve and 10% contact both nerves. Eight percent of posterior ethmoid cells override the ipsilateral sphenoid sinus and contact the optic nerve on that side. Paraxial reformatted displays allowed estimation of the degree of projection of the optic nerve into adjacent sinus cavities. Three percent of optic nerves have significant projection into the posterior ethmoid cell, and 23% project significantly into the sphenoid sinus. The width of the bony plate that separates the optic nerve from the sinus cavity was the same for sphenoid and ethmoid sinuses. Although sinus pneumatization varies among individuals, right and left sides are generally similar within one person.     

Biofilm and persistent inflammation in endoscopic sinus surgery

Bacterial biofilms have been observed in many patients with chronic rhinosinusitis, but their importance is still being investigated. This study examines the association between biofilms and other clinical findings in chronic rhinosinusitis patients.Twenty-four patients with chronic rhinosinusitis who failed medical management underwent endoscopic sinus surgery (ESS). Tissue was collected from the ethmoid sinus and analyzed for the presence of biofilm by hematoxylin and eosin staining, fluorescent in situ hybridization, and confocal scanning laser microscopy. Biofilms were classified as extensive (> 50% of mucosal surface in sample) or present (< 50% of surface). The surgeon remained blinded to the biofilm status of patients until postoperative follow-up was complete.The presence of bacterial biofilm was strongly associated with persistent mucosal inflammation after ESS (53% of biofilm-positive patients vs 0% of biofilm-negative patients, P = 0.009). The amount of biofilm was not important as there was no significant difference between the extensive and present biofilm classifications with respect to inflammation. The presence of biofilm was not associated with prior ESS, allergies, eosinophils, polyps, or presence of fungal elements.     

Radical surgery: effect on quality of life and pain in chronic rhinosinusitis.

OBJECTIVES: Despite effective medical therapy and repetitive endoscopic sinus surgery in the treatment of chronic rhinosinusitis, there still remains a small group of patients without improvement of symptoms. This study evaluates the effect of radical surgery on quality of life and pain in these patients with recalcitrant disease. STUDY DESIGN: A prospective, questionnaire-based study was conducted in 23 patients who underwent Denker's procedure for refractory chronic rhinosinusitis. Quality of life and pain were evaluated before surgery and 12 months and 2 years after surgery with the SF-36 and McGill Pain Questionnaire. RESULTS: Seven of the eight mean scores of the SF-36 postoperatively improved after surgery, with statistical significance for Role Physical (RP) P=0.048. Bodily pain showed a strong tendency to significance. Results of the McGill Pain Questionnaire show a significant improvement in most of the subscores after surgery implying less pain. CONCLUSION: Radical surgery improves the physical burden of chronic rhinosinusitis and pain experience in patients with therapy resistant chronic rhinosinusitis.     

Sinus-nasal polyposis: one-year outcome after endoscopic sinus surgery followed by topical corticosteroid therapy in 72 patients

Nasal polyposis (NP) is considered as an inflammatory disease for which first line therapy is topical and/or oral corticosteroid. In this paper we attempted to determine the efficacy of endoscopic endonasal surgery followed by topical corticoid in 72 adults suffering from bilateral NP refractory to corticosteroid therapy and to delineate the clinical characteristics of this cohort of patients. NP was confirmed endoscopically and with computed tomography. Visual analog scale for the subjective evaluation and endoscopic examination of the paranasal cavities for the objective evaluation were obtained 3 and 12 months postoperatively. Endoscopic endonasal surgery was based on a radical removal of the NP with wide opening of all the sinuses in the vast majority of the cases. Topical corticoid therapy was started 2 months after surgery. Clinical characteristics of the 72 patients revealed: 29.2% of coexisting allergy; 34.7% of coexisting asthma; 19.4% with food and/or aspirin intolerance. Anterior and posterior ethmoid sinus and maxillary sinus were the most affected sinuses. 53.5% of our patients presented a stage II. One year after surgery we observed that 59.1% of our patients revealed a marked decrease of their symptoms with no polyp on nasal endoscopic evaluation, that 28.8% revealed a marked decrease of their symptoms with recurrence of the NP on nasal endoscopic evaluation and that 12.1% presented moderate to severe symptoms with recurrence of NP on nasal endoscopic evaluation. Based on this experience, we think that endoscopic endonasal surgery will continue to play an important role in the management of NP when the patient becomes refractory to corticoid.