Bacteriology in patients with chronic sinusitis who have been medically and surgically treated

Chronic sinusitis is a disease that afflicts a significant percentage of the population and causes considerable long-term morbidity. The common use of multiple broad-spectrum oral antibiotics and endoscopic sinus surgery to treat this condition may alter the pathogenes that promote persistence of chronic sinusitis. Forty-eight culture-positive patients with chronic sinusitis who had been medically treated for at least 3 months and had undergone sinus surgery were bacteriologically evaluated. Swab specimens of the middle meatus and sphenoethmoid recess were aseptically obtained endoscopically and cultured for aerobes. Coagulase-negative staphylococci were the most common isolates (45.8%), followed by Streptococcus pneumoniae (16.7%), Enterobacteriaceae (16.7%), Staphylococcus aureus (10.4%), and Pseudomonas aeruginosa (10.4%). Coagulase-negative staphylococci were the most frequently isolated organisms in our study, as in many other studies. Despite the significant predominance of these organisms, they have always been assumed to be contaminants, and their presence in culture has been discounted. Coagulase-negative S aureus may be a pathogen in the chronic sinusitis process, and sensitivities of this isolate should be obtained for evaluation and possible treatment of the disease.     

Paranasal sinus etiology of headaches and facial pain

The otolaryngologist is obliged to consider chronic headache attacks because it is probable that people afflicted with chronic headache claim to have "sinusitis" more than any other related chief complaint. While only a small percentage of these patients actually have headaches of sinus etiology, sinusitis must be differentiated from all other forms of headache. Otolaryngologists who are primarily interested in headache may require less consultation with neurologic and neurosurgical colleagues than otolaryngologists who are primarily interested in sinus surgery and the treatment of sinusitis. In any case, all otolaryngologists should be conversant with the causes of headache and well trained in the treatment of headaches, particularly those related to the paranasal sinuses.     

An immunological approach to chronic and recurrent sinusitis

PURPOSE OF REVIEW: Sinusitis is an illness that is often successfully treated by primary care physicians. Recurrent or chronic rhinosinusitis, however, can be frustrating for patients as well as primary care and subspecialty providers. The present review details the approach to recurrent or chronic sinusitis. We give a broad overview of the workup of chronic rhinosinusitis, focusing on immune deficiency, an often overlooked but clinically important aspect of the sinusitis workup. RECENT FINDINGS: Immune deficiency is prevalent in patients with recurrent or chronic sinus disease. An immunologic workup, as well as a workup for other chronic treatable diseases, should be undertaken before sinus surgery or in patients who have been unresponsive to surgery. This approach can enhance visualization during surgery, minimize postoperative complications, improve surgical outcomes, and possibly obviate the need for surgery altogether. SUMMARY: Elucidating the cause of recurrent or refractory sinus disease can be challenging. Allergic disease should be evaluated and treated early in the process. An immunologic evaluation should be performed and uncommon causes of sinus inflammation should be addressed later in the course to reduce inflammation either to avoid surgery or improve surgical outcomes.     

Incidence and presentation of fungal sinusitis in patient diagnosed with chronic rhinosinusitis

Significant number of patients diagnosed with chronic rhino sinusitis often tend to have a final diagnosis of fungal sinusitis. We wanted to find out (a) The incidence of patients with fungal sinusitis in those patients who were initially diagnosed as chronic rhinosinusitis. (b) The presentation of fungal sinusitis patients who were initially diagnosed as CRS. Retrospective chart review of 242 patients diagnosed as CRS from May 2006 to April 2009. The various symptoms and signs of those diagnosed initially as CRS, who were then diagnosed as fungal sinusitis were tabulated. Radiological and serological investigations were then analyzed. The microbiology of various species that were cultured in those identified as fungal sinusitis were also presented. Out of 242 patients diagnosed with CRS, 67 patients had clinical and radiological evidence of fungal sinusitis but only 24 of these patients had fungal organisms identified. Majority of them were Aspergillus fumigatus. Clinical suspicion of fungal sinusitis should be made in those patients presenting with CRS with the following signs and symptoms of nasal obstruction, discharge and polyps. Most of those fungus were Aspergillus fumigatus and responded well to treatment.     

慢性鼻窦炎骨炎患者病情程度的危险因素

目的 探讨慢性鼻窦炎骨炎患者病情程度的危险因素及预防对策.方法 对2011年4月～2014年4月期间本院收治的120例慢性鼻窦炎患者的手术治疗及临床资料进行回顾性分析,对影响患者病情程度的危险因素进行Logistic回归分析.结果 本组慢性鼻窦炎病例中,有65例（54.17％）合并骨炎,与未合并骨炎患者比较,其慢性鼻窦炎病程、合并哮喘比例、伴发鼻息肉比例、手术次数、Lund Kennedy评分、Lund Mackay评分、GOSS评分等指标差异有统计学意义（P＜0.05）,尤其慢性鼻窦炎病程、Lund Kennedy评分、LundMackay评分及手术次数等,均是影响慢性鼻窦炎骨炎患者全球骨炎评分（GOSS）的独立危险因素（P＜0.05）.结论 慢性鼻窦炎患者骨炎的发生与手术次数、慢性鼻窦炎病程、Lund-Kennedy评分、Lund-Mackay评分等因素密切相关,应规范鼻窦手术操作,预防骨炎的发生。     

Comparison of sinusitis with and without allergic rhinitis: characteristics of paranasal sinus effusion and mucosa.

PURPOSE: The relationship between chronic sinusitis and allergy has been discussed for many years. Type I allergies are believed to be involved in chronic sinusitis. However, there is not enough evidence to allow allergic sinusitis to be distinguished as an exact entity. This study was designed to examine the role of immunoglobulin E-mediated allergic reactions in allergic sinusitis. PATIENTS AND METHODS: We investigated the differences between 31 patients with allergic rhinitis and chronic sinusitis (allergic sinusitis) and 48 control subjects with nonallergic chronic sinusitis (chronic sinusitis). The pathological features of paranasal sinus effusion and mucosa were examined and compared in these two groups. RESULTS: The number of eosinophils, activated eosinophils, and neutrophils was higher in paranasal sinus effusion from patients with allergic sinusitis. The concentration of interleukin-5 was higher in the effusion of allergic sinusitis patients. In addition, more eosinophils and activated eosinophils infiltrated into the sinus mucosa of patients with allergic sinusitis. CONCLUSION: The type I allergic reaction has a significant role in the pathogenesis of sinusitis arising in patients with allergic rhinitis.     

Haemolytic streptococcus infection of chronic maxillary sinusitis. An immunological study using the skin window test

The SWT was performed on 30 patients with chronic haemolytic streptococcus maxillary sinusitis, and 5 controls with no streptococcus in their nose and throat. Foreign and patient's own organism were used as antigen. The lymphoblastic transformation was higher in control streptococcus free patients than in chronic maxillary sinusitis, more when using foreign than patient's own organism. The failure of cellular immune response as a contributory factor to chronicity of maxillary sinusitis is discussed. The possible value of prepared foreign streptococcus vaccine in prevention and treatment is mentioned.     

Prevalence of noninvasive fungal sinusitis in South Australia

BACKGROUND: The aim of this study was to document the prevalence of noninvasive fungal sinusitis in patients with chronic sinusitis and thick viscous secretions in South Australia. METHODS: We studied of 349 patients with chronic rhinosinusitis undergoing endoscopic sinus surgery in a specialized rhinology practice. Patients with nasal polyposis and thick fungal-like sinus mucin had operative samples sent for microscopy and fungal culture. Evidence of atopy was taken as positive radioallergosorbent or skin-prick tests to fungi. RESULTS: One hundred and thirty-four (38%) patients were noted to have thick, viscid sinus mucin, raising suspicion of fungal disease. Ninety-three patients had positive fungal cultures or microscopy (26.6%). It was possible to classify 95.5% of the patients into subgroups of noninvasive fungal sinusitis or nonfungal sinusitis: 8.6% of patients with allergic fungal sinusitis, 1.7% of patients with allergic fungal sinusitis-like sinusitis, 15.2% of patients with chronic fungal sinusitis, one patient with a fungal ball, and the remaining 69% of patients with nonfungal chronic sinusitis. CONCLUSION: This is the first prospective study to evaluate the prevalence of these increasingly widely recognized conditions. It highlights the need for otolaryngologists to be alert to these not uncommon diagnoses in order for early, appropriate medical and surgical management to be instituted.     

600例难治性咽异感症患者病因分析

目的：探讨难治性咽异感症的病因。方法：除耳鼻咽喉常规检查外,行鼻咽纤维喉镜、纤维食管胃镜、鼻窦CT、茎突X线摄片、颈部和甲状腺B超等检查以及相关治疗。结果：600例咽异感症患者中,患胃食管炎229例（38．2％）,鼻窦炎113例（18．8％）,更年期综合征57例（9．5％）,慢性扁桃体炎40例（6．7%）,疑癌症22例（3．7％）,亚急性甲状腺炎和甲状腺肿瘤13例（2．2％）,茎突过长综合征9例（1．5％）,其他117例（19．5％）。所有患者根据检查的相关病因治疗,随访6个月,有效率达84．2％。结论：咽异感症的病因较多,要重视胃食管炎、鼻窦炎等,特别是返流性胃食管病与咽异感症的关系。     

12 minute consultation: Evidence based management of a patient with facial pain

Clin. Otolaryngol. 2012, 37 , 207–212 Background: There is a common misconception that facial pain and headache are mainly caused by sinusitis. The findings of nasal endoscopy, computer tomography (CT) and the results of observational studies reveal that this is not the case. Moreover, when sinus surgery is performed in patients where headache/facial pain has been a feature, it has been found that these symptoms persist after sinus surgery, particularly where there had been no nasal symptoms or endoscopic signs of paranasal sinusitis. Methods: This review was based on a literature search performed on 30 November 2011. The MEDLINE, EMBASE and Cochrane databases were searched using the subject heading of facial pain, that is, rhinosinusitis, migraine, cluster headaches, midsegment facial pain, trigeminal neuralgia, paroxysmal hemicrania, hemicrania continua and drug‐dependent headache. The search was limited to English language articles. Relevant references from selected articles were reviewed after reading the abstract. Results: A review of the literature shows that headaches are rarely caused by sinusitis. Similarly, only a small proportion of patients with facial pain have sinusitis, and these patients have either acute sinusitis or an acute exacerbation of chronic purulent sinusitis. Importantly, most patients with chronic rhinosinusitis rarely have facial pain unless they develop an acute infection or suffer barotrauma. CT scans should not routinely be performed for facial pain because of the prevalence of incidental changes in asymptomatic patients. Surgery is very rarely indicated in the treatment for chronic facial pain. Conclusion: A structured history of the pain and its associated symptoms, nasendoscopy and relevant targeted investigations should lead to a correct diagnosis and the appropriate treatment.     

197例鼻窦炎螺旋CT扫描结果分析及临床意义

目的：用高分辨率CT对鼻窦炎进行影像学分析,探讨窦口鼻道复合体（OMC）的解剖变异与鼻窦炎发生的关系。方法：选取197例有明显症状、初诊为鼻窦炎的患者（鼻窦炎组）,年龄4～74岁;选取无鼻部疾病史的654例为对照组,年龄4～76岁;两组均行鼻窦冠、轴状位CT扫描,对OMC的几种常见的解剖变异进行评估,并统计解剖变异与年龄的关系。结果：存在OMC区解剖变异的患者在11～20岁;慢性鼻窦炎患者的年龄11～20岁;鼻中隔偏曲、钩突变异和下鼻甲肥大的发生在鼻窦炎组和对照组之间差异有统计学意义（P〈0．05）。结论：OMC解剖变异常见,且与慢性鼻窦炎密切相关,特别是鼻中隔偏曲、钩突变异及下鼻甲肥大,纠正这三处的异常对鼻窦炎的预防和治疗有重大意义。     

Gastroesophageal reflux disease and chronic sinusitis

BACKGROUND: It is increasingly suggested that there may be a connection between gastrooesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR) and chronic sinusitis. We therefore wished to establish whether the literature contains sufficient evidence to support this assumption. MATERIAL AND METHODS: We performed a search in Medline (PubMed) and EMBASE with the key words "GERD, GER, reflux, sinusitis, chronic sinusitis". The literature obtained was assessed with regard to the reported results and their evidence levels. The level of evidence was classified according to the usual levels I - IV, only levels Ia or Ib being considered sufficient evidence for a knowledge gain confirmed by therapeutic trials. RESULTS: A total of 77 references were found in Medline and 142 in EMBASE. A large number of these were narrative review articles addressing the connection between GERD or sinusitis and asthma or GERD or sinusitis and chronic cough. Only 12 papers and one case report dealt more or less directly with the question of a connection between chronic sinusitis and reflux. None of the studies could be classed as evidence level I (randomised controlled trials), ten were classed as level III studies, one as level IIb and one as level IV. DISCUSSION AND CONCLUSIONS: The existing studies do not allow us to pinpoint LPR (and even less so GERD) as a clear-cut factor in the aetiopathogenesis of chronic sinusitis. However, despite all their deficiencies and limitations the studies nevertheless do show that reflux into the pharynx and nasopharynx is possible. This reflux (= LPR) can lead to chronic inflammation which can be successfully treated with antireflux therapy with proton pump inhibitors. Quantification of the association is not currently possible. An above-average proportion of the patients with chronic rhinosinusitis appear to have GERD/LPR. However the prevalence of GERD in the population is generally high. It has not yet been established with sufficient certainty whether the LPR must be regarded as a causative factor, whether it exacerbates or chronifies the disease or whether it is merely an epi-phenomenon which does not require specific treatment. To answer this important question we need prospective randomised controlled studies which will provide evidence of sufficient quality. These should be conducted with the help of standardised documentation.     

鼻内镜与CT扫描对慢性鼻窦炎诊断的协同作用

目的探讨鼻内镜与CT扫描对慢性鼻窦炎诊断的协同作用.方法回顾分析164例慢性鼻窦炎患者的临床资料,总结鼻内镜与CT扫描对本病诊断的协同作用.结果164例慢性鼻窦炎中,31例CT扫描窦口鼻道复合体基本正常,但鼻内镜检查却发现窦口鼻道复合体存在黏膜病变.CT漏诊率为18.9%.其中19例行功能性鼻内镜手术,治愈率为89.4%;其余12例行保守治疗,治愈率为33.3%,差异有显著性意义(P＜0.05).结论在慢性鼻窦炎诊断中鼻内镜与CT扫描有着重要的协同作用.鼻内镜对窦口鼻道复合体黏膜病变的诊断具有更优越的价值.     

Sinusitis and fever of unknown origin

It is relatively uncommon to document sinusitis as a cause of fever with much certainty. Therefore, investigation for sinusitis should be undertaken only after more likely causes have been excluded. and the actions taken should reflect the individual patient's circumstances. Aggressive evaluation and treatment should be geared to minimizing the patient's overall morbidity and to identifying the more aggressive forms of sinusitis and their potential complications.     

Indications for the surgical treatment of osteomas of the frontal and ethmoid sinuses

Sixty-one patients with an osteoma of the frontal or ethmoid sinuses have been studied. The following indications for surgical removal of these osteomas are suggested: osteomas extending beyond the boundaries of the frontal sinus, if enlarging, if localized in the region adjacent to the nasofrontal duct, if signs of chronic sinusitis are present, osteomas of the ethmoid sinuses, irrespective of their size and if patients with osteomas complain of headache and other causes of headache have been excluded. The operation of choice is the osteoplastic flap operation.     

Infectious diseases of the sphenoid sinus

Thirty-one patients with sphenoid sinusitis were treated from 1978-1982. Twenty patients had infections contiguous with other paranasal sinus disease. Five of these patients had fungal sinusitis. Eleven patients were seen with isolated sphenoid sinusitis; 3 were secondary to trauma and 8 were due to nontraumatic causes. Possible etiologies include upper respiratory infections, developmental abnormalities, and water forced into the nasal cavity during swimming. The immunocompromised patient is more likely to present with minimal symptoms with a fungal infection, and aggressive diagnostic and therapeutic measures should be undertaken. Because the symptoms of headache, nasal stuffiness, proptosis, ptosis and decreased visual acuity may be interpreted as an intracranial, neurological, or vascular problem, a misdiagnosis may be made. A high index of suspicion for sphenoiditis should be maintained. Therapy involves a combination of medical (antimicrobial agent) and surgical (sinus drainage and marsupialization) management.     

Different types of fungal sinusitis occurring concurrently: implications for therapy

The purpose of this study is to describe the clinical and histopathological features, management and outcome of a series of patients with simultaneous occurrence of invasive and non-invasive fungal sinusitis (mixed fungal sinusitis). The histopathological records of patients with fungal sinusitis seen over the last 6 years were reviewed. The clinical, histopathological, treatment and follow up details of all cases with mixed fungal sinusitis were noted. Six cases of mixed fungal sinusitis with concurrent occurrence of chronic granulomatous fungal sinusitis and allergic fungal sinusitis (AFS) were seen during the study period. Most (83.3 %) had bilateral disease. All patients had undergone prior endoscopic sinus surgery at least once within the previous 2 years. Histopathological features showed predominance of invasive disease in half the patients. Except for one patient who did not report for follow up, all patients with predominant chronic granulomatous fungal sinusitis received systemic antifungal therapy and inhaled steroids. Those with predominant features of AFS received oral and inhaled steroids. Five patients with mixed fungal sinusitis who had follow up ranging from 6 months to 5 years were disease free following treatment. Mixed fungal sinusitis should be recognized by the surgeon and pathologist as a separate category of fungal sinusitis whose treatment depends on accurate histological diagnosis. A good outcome may be expected with appropriate therapy.     

慢性鼻窦炎对中耳听阈的影响

目的 探讨慢性鼻窦炎对中耳听阈的影响。方法 对53例慢性鼻窦炎病人、10例健康成人行纯音测听。采用多状态Logistic回归模型，对慢性鼻窦炎可能影响听阈的因素进行评价。结果 ①53例中，正常听阈35例（66．04％），轻度聋16例（30．19％），中度聋2例（3．77％）。②各频率鼻窦炎组与对照组、鼻窦炎各分型之间听阈比较，有统计学意义（P〈0．05）。③慢性鼻窦炎对中耳听阈的影响因素中，经过多状态Logistic回归模型的逐步筛选，显示2项因素可能影响听阈，即筛窦CT分型呈硬化型，鼻窦炎分型分期较重时。结论 ①慢性鼻窦炎可影响听阈，随慢性鼻窦炎分型分期加重，听力损伤加重。②筛窦呈硬化型、鼻窦炎分型分期重时，可能影响最大。     

Conversion to Chronic Invasive Fungal Sinusitis From Allergic Fungal Sinusitis in Immunocompetence

A review of the treatment of allergic and invasive fungal sinusitis, as well as a presentation of the first recorded case of a conversion from allergic fungal sinusitis (AFS) to chronic granulomatous invasive sinusitis and the fourth case of invasive fungal sinusitis associated with Curvularia. This immunocompetent patient suffering from chronic AFS converted after repeated high‐dose steroid tapers and noncompliance. AFS may present atypically and should be suspected even in immunocompetent patients with sinus disease who report new onset pain and neurologic symptoms. Clinicians should consider the potential complications associated with repeated systemic steroid administration. Laryngoscope, 129:2447–2450, 2019     

Tympanometric findings in patients with adenoid hyperplasia, chronic sinusitis and tonsillitis

Tympanograms were done on 120 patients with adenoid hyperplasia, chronic sinusitis and chronic tonsillitis to measure the middle-ear pressure as a parameter to eustachian tube function. The results were compared with those obtained in 50 normal subjects. The statistical significance of the mean values of middle-ear pressure is very highly significant in patients with adenoid hyperplasia, significant in chronic sinusitis group and insignificant in patients with chronic tonsillitis, as compared to the normal control group. Hence, eustachian tube dysfunction is maximum in patients with obstructing adenoids, less in chronic sinusitis and least in chronic tonsillitis.