Microbiology of middle meatus in chronic rhinosinusitis

BACKGROUND: Nasal endoscopy allows the collection of middle meatus secretion samples and is an alternative method for determining microorganisms in rhinosinusitis. This study assessed endoscopically collected middle meatus secretions in patients with chronic rhinosinusitis (CRS) and compared those findings with ipsilateral maxillary sinus aspirates and microbiological data of healthy individuals. METHODS: Middle meatus samples were collected from 114 CRS patients for aerobic, anaerobic, and fungal cultures; maxillary sinus secretions were collected from 13 of these patients. Twenty-three healthy volunteers served as controls. RESULTS: Aerobes were isolated in 86% of CRS patients, anaerobes were isolated in 8% of CRS patients, and fungi were isolated in 11% of CRS patients; the most frequent microorganisms were Staphylococcus aureus (36%), coagulase-negative Staphylococcus (20%), and Streptococcus pneumoniae (17%). Middle meatus and maxillary sinus cultures presented the same pathogens in 80% of cases. In healthy individuals, coagulase-negative Staphylococcus (56%), S. aureus (39%), and S. pneumoniae (9%) were the most frequent isolates. CONCLUSION: The culture of endoscopically collected middle meatus secretions is effective in identifying microorganisms in CRS patients.     

Comparing different methods used to collect material for a microbiological evaluation of patients with chronic rhinosinusitis

There is still controversy on which is the best method to collect the secretion directly from the middle meatus or maxillary sinus in patients with chronic rhinosinusitis.Aim: To evaluate the prevalence of bacteria in patients with chronic rhinosinusitis and compare the suction trap collector to direct aspiration attached to a syringe for the microbiological analysis of these secretions.Materials and Methods: Prospective study involving 31 patients who underwent endoscopically guided maxillary secretion aspiration by two different methods (aspiration with the collector tube “suction trap” and aspiration with the use of a catheter connected to a syringe), to determine the microbiological diagnosis and to compare the two methods used.Results: microorganisms grew samples collected from 55% of the 31 patients. The most frequent bacteria were S. aureus, Pseudomonas aeruginosa and other aerobic Gram-negative bacteria. The results from cultures were similar between the two methods in 71% of patients.Conclusion: S. aureus, Pseudomonas aeruginosa and other aerobic Gram-negative bacteria make up the main flora in the maxillary sinus of the patients. There was good correlation between the microbiological results obtained by using a catheter attached to a syringe and the “suction trap” nasal collector.     

Nasal mycology of chronic rhinosinusitis

BACKGROUND: Ponikau used a novel collection and culturing method to recover fungi from nasal secretion in patients with chronic rhinosinusitis. The same method had been used previously in Europe with a similar result. However, the use of Ponikau's method has not been reported in Asia. METHODS: Fifty-one patients with chronic rhinosinusitis who were scheduled for functional endoscopic sinus surgery were enrolled in this study. One day before functional endoscopic sinus surgery, swab specimens were obtained from middle meatuses and were sent to the microbiology laboratory for routine bacterial and fungal cultures. Then, the same nasal cavity was lavaged with 20 mL of sterile water. The exhaled fluid was collected and processed using the Ponikau method. Skin testing with Candida extract was done also in all patients. The results obtained by different culture methods were compared. RESULTS: Bacteria grew from 45 of 51 swab specimens. The culture rate was 88.2%. Fungi were cultured from 6 of 51 swab specimens (11.8%) and from 25 of 51 lavage specimens (49%). The fungal culture rates were significantly different between swab and lavage specimens (p < 0.001). Candida was the most common cultured fungi in the lavaged specimens. CONCLUSION: The study showed that Ponikau's method resulted in a higher fungal culture rate than that obtained with the swab method, but the culture rate was lower than the bacterial culture rate. Additional study is needed to investigate the role of fungi in the pathogenesis of chronic rhinosinusitis.     

Bacterial infection in chronic rhinosinusitis: a controlled paired analysis

BACKGROUND: The aim of this study was to determine if pathogenic bacteria are involved in the pathogenesis of chronic rhinosinusitis (CRS). METHODS: A consecutive series of adult patients with unilateral sinus disease determined by unilateral radiographic involvement or unilateral purulent secretions was microbiologically studied. Aerobic and anaerobic bacterial and fungal cultures were obtained during endoscopic sinus surgery from purulent secretions or tissue culture. Positive culture rates were compared between the diseased sinus and the contralateral nondiseased (control) sinus to determine if pathogenic bacteria were more commonly recovered from the diseased sinuses. RESULTS: Forty-nine adult patients completed the study with appropriate microbiological data. Coagulase-negative staphylococci were the most commonly recovered bacteria followed by Staphylococcus aureus from the diseased side of the sinuses with similar findings for the control sinus. Bacterial species were recovered from 87.8% of the diseased side of the sinuses versus 85.7% from the control sinuses (p = 0.50). Reanalysis with coagulase-negative staphylococci considered as nonpathogen showed a 46.9 and 49.0% positive bacterial culture rate in diseased and control groups, respectively (p = 0.50). No significant difference in positive anaerobic culture rates were identified between groups (59.1% diseased versus 55.1% control, respectively, p = 0.61). Antibiotic resistance rates were no different between bacteria cultured from diseased sinuses versus control (p = 0.115). CONCLUSION: Both aerobic and anaerobic bacterial species may be recovered from both diseased and nondiseased sinuses in patients with CRS. These findings cast some doubt on the exact etiologic role of bacteria in CRS, suggesting other factors or other agents also may be responsible in CRS pathogenesis.     

Bacterial infection after endoscopic sinus surgery: a controlled prospective study

OBJECTIVES/HYPOTHESIS: The objective was to determine whether infections occurring after endoscopic sinus surgery represent overgrowth of sinonasal flora versus de novo bacterial infection. STUDY DESIGN: Prospective controlled cohort study. METHODS: A cohort of adult patients was prospectively followed after endoscopic sinus surgery. Baseline postoperative control cultures of the ethmoid sinus were obtained. Patients with acute infectious exacerbations of chronic rhinosinusitis had endoscopic culture, and these results were compared with baseline culture data. RESULTS: One hundred thirteen patients were followed for a mean period of 14.5 months after endoscopic sinus surgery. Baseline postoperative culture data revealed that the ethmoid labyrinth was sterile in 23% of cases, carried oral flora in 18% of cases, and was colonized in 60% of cases. Gram-positive cocci, particularly staphylococcal species, were the most common colonizing organisms (41% of cases). Twenty acute exacerbations were cultured in 17 patients during the follow-up period. All infectious cultures recovered bacteria; one culture recovered only oral flora. Gram-positive cocci predominated (56% of isolates) with Staphylococcus aureus being the most common isolate (28%). Of the 36 isolates, only 9 isolates (25%) corresponded to bacteria identified at the time of baseline culture. CONCLUSION: Although the postoperative sinonasal cavity may be colonized by bacteria after endoscopic sinus surgery, infections arising postoperatively most commonly represent de novo infections by bacteria other than colonizing bacteria. Empirical therapy based on baseline data may be misleading; acute exacerbations of chronic rhinosinusitis after endoscopic sinus surgery should be cultured to guide optimal antibiotic therapy.     

鼻内镜术后病情迁延的细菌学分析

目的:探讨慢性鼻-鼻窦炎(CRS)鼻内镜术后迁延不愈者鼻腔分泌物的细菌学特征。方法:选取单纯鼻中隔偏曲患者20例(对照组),取其中鼻道分泌物;选取首次接受鼻内镜手术的CRS患者30例(手术组),术中取中鼻道分泌物;取FESS术后随访3个月以上未达治愈标准的患者20例(迁延组),在鼻内镜下取中鼻道分泌物,分别做细菌培养和药物敏感试验,3组结果进行比较分析。结果:对照组检出细菌13株,手术组检出15株,迁延组检出15株,其检出阳性率差异无统计学意义;迁延组G-菌检出率明显高于对照组和手术组;对常用抗生素耐药的菌株比例迁延组显著高于手术组。结论:需氧菌可存在于正常鼻腔内;CRS术后迁延不愈者,G-杆菌的感染和细菌的耐药性明显增加。因此,强调要合理应用抗生素,对术后迁延性鼻窦炎的抗生素治疗,应建立在细菌培养和药敏试验的基础上。     

Endoscopically guided aerobic cultures in postsurgical patients with chronic rhinosinusitis

BACKGROUND: There is considerable amount of debate in the literature regarding the microbial flora of normal, acutely infected, and chronically infected paranasal sinuses. Few studies have specifically looked at the microbial flora of healthy and infected sinus cavities after functional endoscopic sinus surgery. METHODS: One hundred thirty-four cultures were studied. All cultures were obtained using a standard technique. The nasal cavities were decongested and anesthetized, and nasal endoscopy was performed. When purulent secretions were identified, specimens of purulent secretions were obtained for incubation. Sensitivities were tested according to microorganisms identified. Empiric therapy generally consisted of afluoroquinolone, amoxicillin/clavulanate, or a later-generation cephalosporin, and adjustment in individual instances when appropriate. RESULTS: Twelve cultures showed no growth, 86 grew a single microorganism, and 35 grew two or more microorganisms for a total of 151 microorganisms identified. The most common microorganisms were Staphylococcus aureus, coagulase-negative staphylococci, and Pseudomonas aeruginosa. Other organisms that were cultured <5% of the time included Streptococcus pneumoniae, Haemophilus influenza, Moraxella catarrhalis, Serratia liquefaciens, Stenotrophomonas (Xanthomonas) maltophilia, alcaligenes, Fusobacterium, Escherichia coli, diphtheroids, Acinetobacter species, Klebsiella species, skin flora, and mixed Gram-negative and Gram-positives. CONCLUSION: Endoscopically guided aerobic cultures in postsurgical patients with acute exacerbations of chronic rhinosinusitis most commonly grew S. aureus, coagulase-negative staphylococci, and pseudomonal species. These cultures altered antibiotic treatment management decisions in a significant number of cases regardless of patients' clinical characteristics or history of previous culture.     

Microbiology of chronic ethmoid sinusitis: is this a bacterial disease?

PURPOSE: Review the microbiology of chronic rhinosinusitis and test the hypothesis that bacterial infections are not the predominant etiology for chronic rhinosinusitis. MATERIALS AND METHODS: Tissue cultures were prospectively collected from the ethmoid mucosa of 179 patients (94 had chronic rhinosinusitis and 85 had chronic rhinosinusitis with polyposis) at the time of endoscopic sinus surgery. All patients were off antibiotics for at least 1 week at the time of surgery. Both aerobic and anaerobic cultures were obtained for each specimen. RESULTS: A total of 263 isolates were identified (average: 1.5 isolates per specimen). Coagulase-negative Staphylococcus, a likely contaminant, was the most common isolate and was identified in 51% of patients. Forty percent of patients (72/179) grew pathogenic aerobic bacteria, the most common was Staphylococcus aureus (18%). Six percent of patients (10/179) grew pathogenic anaerobic bacteria. The microbiology of patients with and without nasal polyposis was not significantly different. CONCLUSION: These findings suggest that factors other than bacterial infection may play an integral role in the pathogenesis of chronic rhinosinusitis.     

Comparison of maxillary sinus puncture with endoscopic middle meatal culture in pediatric rhinosinusitis

BACKGROUND: Although maxillary sinus puncture is considered the gold standard for obtaining bacterial cultures, there is an increasing field of evidence indicating that results of endoscopic middle meatal culture correlate well with those of maxillary sinus punctures. However, the subjects of these studies were adults and there was no prior study comparing endoscopic middle meatal culture with maxillary sinus punctures in children with rhinosinusitis. The aims of this study were to compare the results obtained by endoscopic middle meatal culture and maxillary sinus punctures in children with rhinosinusitis. METHODS: A prospective study of children with community-acquired rhinosinusitis was conducted. Results obtained by endoscopic culture were compared with those of maxillary sinus puncture, and the correlation of these 2 techniques was investigated. RESULTS: There were 41 specimen sets sent for aerobic cultivation. Correlation obtained from the middle meatus with those from the maxillary sinus puncture was demonstrated in 32 of 41 specimens (78.0%). When looking at the diagnostic usefulness of endoscopic middle meatus sampling versus maxillary sinus puncture, endoscopic sampling provided a sensitivity of 75.0%, a specificity of 88.9%, a predictive value of a positive result of 96.0%, a predictive value of a negative result of 50.0%, and an accuracy of 78.0%. CONCLUSION: We demonstrated that, when performed in pediatric patients, the correlation between endoscopic middle meatal culture and maxillary sinus puncture was not as favorable as in the case of adult patients.     

Bacterial cultures of the middle meatus and bronchoalveolar lavage in chronic rhinosinusitis

The role of bacteria in chronic rhinosinusitis (CRS) is still debated and their effect on the lower airways is less known. The aim of this study was to identify the individual bacterial species in CRS and to correlate these microbiological data with the clinical findings and associated bacterial cultures of the lower airways. This prospective study included 25 CRS patients scheduled for functional endoscopic sinus surgery. Preoperatively, pulmonary function and CT examinations were performed together with endoscopic and clinical assessment. Under aseptic conditions, with the patient under general anesthesia, 25 bronchoalveolar lavages (BALs) via the endotracheal tube and 50 endoscopically guided middle meatal specimens were obtained. All the specimens were examined for aerobic and anaerobic bacteria and correlated to the associated neutrophilic cellular changes. Positive bacterial cultures were obtained in 71% of the middle meatal specimens and 8% of the BAL specimens. Three subgroups of lower airway involvement were identified, i.e. asthma, small airway disease (SAD) and normal lower airways. In SAD only, there was a significant correlation between the cultured bacteria of the left (p = 0.04) and the right (p = 0.04) middle meatus and the presence of local neutrophilia. In asthma, middle meatal bacterial cultures correlated with nasal blockage (p = 0.04) and CT Lund-Mackay score (p = 0.04). CONCLUSION: Middle meatal cultures were frequently positive, mainly aerobic Gram-positive bacteria. In SAD, a mixed flora of Gram-positive aerobic bacteria and anaerobic bacteria was observed that correlated with neutrophilic inflammation. BAL cultures do not show infection or colonization of the lower airways, despite functional abnormalities in 60% of the patients.     

Bacteriologic findings from the nose, ethmoid, and bloodstream during endoscopic surgery for chronic rhinosinusitis: implications for antibiotic therapy

This study addresses the bacterial flora of chronic rhinosinusitis at the time of endoscopic sinus surgery. We used the consensus definition of chronic rhinosinusitis as the presence of paranasal sinus inflammation present for greater than 12 weeks. In our patient study group, all cases of chronic rhinosinusitis had failed to respond to antibiotic therapy and had not been treated previously with surgery. By microscopic examination, chronic inflammatory changes were confirmed in the resected sinus lining of all study patients. Intraoperative cultures were obtained from the nasal vestibule, the middle meatus, ethmoid lining, and peripheral blood during and after the endoscopic procedure. We found approximately 30% of the patients with sterile sinuses, 50% with coagulase-negative staphylococci, and the remainder with a mixed group of "nonpathogenic" organisms. Anaerobes were conspicuously rare. The blood cultures were positive in 7% of cases and were consistent with an organism of the operative site. This is the first time bacteremia has been reported in association with endoscopic sinus surgery. The results suggest that chronic rhinosinusitis is not a bacterial disease, but rather the result of chronic inflammation produced by a previous acute inflammation. The incidence of positive blood cultures, while relatively low and cleared quickly, should alert the physician for the possible need for prophylactic antibiotics in patients with cardiac, prosthetic, or systemic conditions that could lead to metastatic infection.     

Resistant bacteria in the adenoids: a preliminary report

OBJECTIVE: To determine the incidence of resistant bacteria in adenoid cultures from children with and without middle ear disease and rhinosinusitis symptoms. DESIGN: Children meeting the requirement for tympanostomy tube placement underwent an adjuvant adenoidectomy for symptoms of adenoid hypertrophy or recurrent rhinosinusitis. Adenoid tissue and coexisting middle ear fluid, if present, were cultured. SETTING: Tertiary referral children's hospital with community-based satellite clinics. PATIENTS: Forty-six patients ranging in age from 1 to 11 years (68% <3 years) with recurrent or persistent otitis media and symptoms of adenoid hypertrophy or rhinosinusitis (study patients) underwent tympanostomy tube placement and adenoidectomy with culture of the adenoids and middle ear effusions. Eighteen patients with adenoid hypertrophy without ear disease or rhinosinusitis were used as controls. INTERVENTIONS: Tympanostomy tube placement and adenoidectomy. MAIN OUTCOME MEASURES: Presence or absence of resistant bacteria. RESULTS: Resistant bacteria were found in cultures of the adenoids in 56% (26/46) of the study group compared with 22% (4/18) of the control patients (P<.02). Also, strains of Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis were found in cultures from 78% (36/ 46) of the study group, compared with 44% (8/18) of those from the control group (P<.01). Resistant isolates were found in 65% (23/35) of the S. pneumoniae, 37% (18/49) of the H. influenzae, and 100% (19/19) of the M. catarrhalis cultures from the adenoids or middle ear spaces. CONCLUSION: Resistant bacteria are present in significant amounts in the adenoids of children with middle ear disease and rhinosinusitis symptoms compared with patients without those diseases or symptoms.     

Intracellular residency is frequently associated with recurrent Staphylococcus aureus rhinosinusitis

AIM: The prevalence of intracellular Staphylococcus aureus organisms in the nasal mucosa of patients with recurrent infectious rhinosinusitis episodes was studied. METHOD: Twenty-seven consecutive adult patients who failed medical management of chronic rhinosinusitis (CRS) of multiple origins, associated or not with nasal polyposis, were consecutively enrolled for endonasal sinus surgery (including partial middle turbinectomy, middle antrostomy, ethmoidectomy, sphenoidotomy) and followed for a 12-month post-operative period. RESULTS: Seventeen of these patients showed the presence of intracellular S. aureus as detected by confocal laser scan immunofluorescence microscopy in epithelial cells of surgical intranasal biopsy specimens. Nine of the patients with and two without intracellular bacteria yielded S. aureus in endoscopically guided cultures of middle meatus secretions, despite the recent administration of prophylactic antibiotics. Eleven of the 17 patients with intracellular S. aureus relapsed for rhinosinusitis within the 12-month follow-up period. Molecular typing of sequential S. aureus isolates demonstrated the persistence of unique patient-specific S. aureus clonotypes in nine of the patients with intracellular bacteria during the 12-month follow-up. CONCLUSION: The presence of intracellular S. aureus in epithelial cells of the nasal mucosa is a significant risk factor for recurrent episodes of rhinosinusitis due to persistent bacterial clonotypes, which appear refractory to antimicrobial and surgical therapy.     

Role of Middle Meatus Aspiration Culture in the Diagnosis of Chronic Sinusitis

Although empiric antibiotic therapy is often used for sinusitis, the emergence of antibiotic resistance has increased the failure rate of this approach. Culture-directed therapy usually increases treatment success, but traditional antral puncture is often accompanied by poor patient and physician acceptance. Endoscopically directed middle meatal aspiration culture is increasingly used in this setting, but studies have not convincingly demonstrated the validity of this technique. Both endoscopic middle meatal and direct antral cultures were performed during endoscopic sinus surgery. Cytologic examination was performed to confirm the presence of inflammatory cells. When culture results were compared in 21 specimen pairs, exact correlation was found in 18 (85.7%). Based on this study, endoscopically directed middle meatus aspiration culture appears to be a valuable alternative to antral puncture for guiding organism-specific antibiotic therapy in sinusitis.     

Is pyogenic ethmoidal osteitis the cause of complicated rhinosinusitis with subperiosteal orbital abscess?

Multiple theories were described concerning the pathogenesis of orbital infection in rhinosinusitis, but no theory was proved. Understanding the cause of complication can allow its proper management. We speculate that subperiosteal orbital abscess (SPOA) secondary to rhinosinusitis is similar to subperiosteal abscess associated with osteomyelitis of bone all over the body. The objective was to evaluate bony changes of the ethmoidal sinuses in complicated rhinosinusitis patients with SPOA. This prospective controlled study was performed on eight patients undergoing endoscopic sinus surgery drainage for rhinosinusitis complicated with SPOA. Age, radiographic bony characteristics, and histopathological findings were all documented. Ethmoidal bone specimens were examined and assessed histopathologically. Purulence of SPOA was collected and sent for cultures. The authors evaluated normal ethmoidal bone specimens taken endoscopically from the medial wall of obstructing concha bullosa in ten control patients. The analysis revealed CT and histopathologic changes consistent with high grades of ethmoidal bone pyogenic osteitic changes. Coagulase-positive staphylococci were the predominant cultured bacteria (62.5%) in SPOA. These findings suggest that orbital subperiosteal abscess in rhinosinusitis patients is attributed to diffuse higher grades of ethmoidal sinus bony pyogenic osteitis. Staphylococcus aureus is the most commonly involved cultured bacteria. Bony osteitis in rhinosinusitis patients with SPOA is similar clinically and histopathologically in its character and behavior to osteomyelitis of bone all over the body with associated subperiosteal abscess.     

The microbiology and antimicrobial resistance patterns in chronic rhinosinusitis

OBJECTIVES: The purpose of this study was to review the microbiology of chronic rhinosinusitis (CRS) in patients undergoing endoscopic sinus surgery (ESS) and comment on antimicrobial resistance trends. METHODS: A retrospective review of 101 patients undergoing ESS during the period of 1997 to 2001 was performed. Patients were divided into groups based on their surgical history. Fifty-five patients without prior ESS history were placed in the primary group; 46 patients who had undergone prior ESS were placed in the revision group. Intraoperative microbiology culture data were reviewed and antimicrobial resistance data analyzed. RESULTS: Data on 101 patients were analyzed. There were 182 total cultures sent, yielding 257 isolates. The most common isolates were coagulase-negative Staphylococcus (SCN) (45% of cultures), gram-negative rods (25% of cultures), and Staphylococcus aureus (24% of cultures). Pseudomonas aeruginosa was isolated in 9% of cultures. When comparing the 2 patient groups, we did not find consistent trends in the differences in the prevalence of these isolates. Antimicrobial resistance for SCN (P = .01) and S aureus (P < .001) was greater in the revision surgery. Overall, 62% of patients were found to have at least 1 isolate with decreased antibiotic sensitivity. CONCLUSION: The most prevalent microorganisms in patients with CRS are SCN, S aureus, and gram-negative rods. Perhaps more importantly, the antimicrobial sensitivities of these microorganisms appear to be a growing problem. These findings suggest increased antimicrobial resistance in patients undergoing revision ESS when compared with patients undergoing surgery for the first time.     

Clinical value of bacteriological examinations of nasal and paranasal mucosa in patients with chronic rhinosinusitis

Introduction. In the literature, contradictory statements regarding the physiological flora of the nose and paranasal sinuses, the role of aerobic and anaerobic ‘pathogenic’ bacteria, and the influence of the sample technique and location can be found. The aim of this study was to examine the reliability of bacteriological examinations of the nasal and paranasal mucosa in patients with chronic rhinosinusitis. Methods. Patients with and without chronic rhinosinusitis undergoing a functional endoscopic sinus surgery (FESS) or a septoplasty were examined. Nasal brushes of the inferior turbinate and mucosal biopsies of the middle turbinate were taken in both groups. Mucosal biopsies of the ethmoidal bulla and maxillary sinus were taken in only the chronic rhinosinusitis group. Results. In both groups, coagulase‐negative Staphylococci were found in all samples. Staphylococcus aureus was found in 22% (middle turbinate) and 33% (inferior turbinate) of all samples in the control group and in 33% (maxillary sinus) and 50% (inferior turbinate) in the patient group. Other aerobic bacteria were found in low percentages in both groups. No strictly anaerobic bacteria and no significant differences between both groups and the different samples were found. Conclusions. A differentiation between patients with and without chronic sinusitis was not possible.     

Fungal cultures of different parts of the upper and lower airways in chronic rhinosinusitis

The relation between fungi, upper and lower airways in chronic rhinosinusitis (CRS) patients are not clear yet. So the aim of this study was to identify the different cultured fungi in various sub-sites of the nasal cavity and lower airways in adult (CRS) patients and to correlate the cultured fungi to the associated cellular inflammatory changes. In the outpatient clinic a control group of 10 normal subjects was subjected to total nasal lavages to validate our mycological culture technique. Twenty-five adult CRS patients were enrolled in this prospective study. Under general anaesthesia before functional endoscopic sinus surgery (FESS) operation 50 nasal vestibular swabs, 25 bronchoalveolar lavages (BALs), 50 middle meatal lavages (MMLs) and 50 nasal cavity lavages (NCLs) were obtained in the operating room. These samples were processed for fungal culture and eosinophilic cellular counts. The intraoperative pathological specimens were examined using Haematoxylin and Eosin (H&E) and Gomori methanamine silver (GMS) staining. In the normal control group total nasal lavages showed 100% positive fungal cultures. In the CRS patient group the BALs showed positive fungal cultures in 28%. Nasal vestibule cultures were positive in 8%. Positive middle meatal cultures were obtained in 44% of the 25 CRS patients. Two cases (8%) with maxillary fungal ball showed a positive maxillary sinus culture but a negative middle meatal culture. Nasal cavity lavages were positive in 36%. Middle meatal eosinophilia was identified in 33.6% of the positive middle meatal fungal culture. Following the deShazo's criteria of diagnosis of allergic fungal rhinosinusits (AFRS), only 16% of the subjects in this study fulfilled the criteria. No correlation existed between fungal culture, cellular and other clinical parameters. Also no correlation existed between upper and lower airway positive cultures. In conclusion fungi seemed to be present in different percentages and types in different sub sites of the airways but without associated eosinophilia. There were no significant correlations between the fungal culture and clinical parameters of CRS nor were there significant correlations between fungal culture and objective lower airway involvement.     

Comparison of antral tap with endoscopically directed nasal culture

OBJECTIVES/HYPOTHESIS: The diagnosis of acute bacterial rhinosinusitis continues to generate controversy in critically ill patients. The efficacy of endoscopically directed cultures in these patients is unknown. We compared antral tap (AT) with endoscopic tissue culture (ETC) of the osteomeatal complex in an intensive care unit (ICU) setting. METHODS: Twenty patients admitted to a surgical/trauma ICU were evaluated by AT and ENB for the presence of rhinosinusitis. All patients had 1) a fever of unknown origin without resolution on empiric antibiotic therapy for > or =48 hrs; 2) other sources of fever ruled out; 3) computed tomography scan evidence of mucoperiosteal thickening +/- sinus air/fluid levels; and 4) attempt at conservative treatment with topical decongestants and removal of all nasal intubation. Microbiologic data were collected and analyzed for any statistical difference between groups. RESULTS: A total of 29 sides underwent simultaneous tap and endoscopically directed tissue culture. The mean age was 40 years (range, 23-77 y) with 85% being males. Fifteen of 20 (75%) patients in the AT group were culture-positive. Of the 49 isolates from the AT, 55% yielded Gram-negative bacilli (Acinetobacter sp. 37%) and 45% yielded Gram-positive cocci. The ETC group was culture-positive in 18 of 20 (90%) patients. Of the 52 isolates from the ETC, Gram-negative bacilli were found in 58% (Acinetobacter sp. 33%) and 42% yielded Gram-positive cocci. The ETCs were culture-positive in all but 1 patient with positive taps. There appeared to be a concordance between AT and ETC in 60% of the patients. In five instances (25%), results of the AT or ETC changed ICU management. Two patients ultimately required sinus surgery. CONCLUSIONS: Sinus taps and/or endoscopically directed tissue cultures led to a change in ICU care in 25% of ICU patients studied. In patients with fever of unknown origin and computed tomography evidence of sinusitis, an antral tap continues to provide important information concerning maxillary sinusitis. However, ETC may give as good a representation of the microbiology and secondary inflammatory changes responsible for bacterial ICU rhinosinusitis causing fever of unknown origin. Further study on a larger group of patients is needed.     

Identification of bacteria isolated from nasal polyps and their ability to produce superantigens and biofilms in Lebanese patients

Staphylococcus aureus superantigens and bacterial biofilms have been implicated in the development of chronic rhinosinusitis and nasal polyps. We conducted a study of 32 Lebanese patients-21 males and 11 females, aged 15 to 71 years (mean: 39)-to identify bacteria isolated from nasal polyps and to determine if these bacteria produced superantigens and biofilms. Polyps were surgically removed, homogenized, and subjected to bacteriologic studies. The presence or absence of S aureus enterotoxin A, B, C, and D (superantigen) genes was determined in all isolates by polymerase chain reaction. Biofilm production by coagulase-negative staphylococci and Pseudomonas aeruginosa was assessed by tissue culture plate assay. A total of 34 bacterial species/groups were isolated from the nasal polyps. Of these, only 3 (8.8%) were S aureus, and only 1 possessed an enterotoxin-coding gene (enterotoxin B). Moreover, of the 21 coagulase-negative staphylococci isolates that were found, none possessed the investigated genes, and only 1 had a strong biofilm-formation property. Our results could not confirm that S aureus enterotoxins (superantigens) or biofilm-producing bacteria play a role in the development of nasal polyps in the Lebanese group studied.