Chronic rhinosinusitis in young children differs from adults: a histopathology study

OBJECTIVE

A histopathologic study of children with chronic rhinosinusitis (CRS) was undertaken to compare the sinus mucosa in pediatric and adult CRS.

STUDY DESIGN

CRS has been defined as persistent or recurrent sinusitis symptoms for >or=12 weeks despite conventional medical therapy, with abnormal computed tomography of the maxillary sinuses. Maxillary mucosal biopsies were obtained from pediatric CRS subjects for inflammatory cell and morphologic studies. Archival sinus mucosal tissues from adults with CRS were used as histologic controls. Sinus lavages were performed on children with and without CRS for microbiologic studies.

RESULTS

Sinus mucosal biopsies were obtained from 19 children with CRS (median age, 3.0 years; range 1.4-8.2 years). Pediatric CRS biopsies, as compared with adult CRS controls, had a higher density of submucosal lymphocytes (median 469 versus 294 cells/mm(2) per 5 high-power fields [HPF]; P=.02), lower density of submucosal eosinophils (medians 13 versus 82 cells/mm(2) per 5 HPF; P=.01), thinner and more intact epithelium (P=.01 and.07, respectively), thinner basement membranes (P=.002), and fewer submucosal mucous glands (P=.004).

CONCLUSION

The sinus mucosa of young children with CRS has less eosinophilic inflammation, basement membrane thickening, and mucus gland hyperplasia characteristic of adult CRS.

Electron microscopy assessment of the recovery of sinus mucosa after sinus surgery

OBJECTIVES

To determine the level of injury to the maxillary sinus mucosa due to chronic infection and the capacity of sinus mucosa to recover after sinus surgery.

MATERIAL AND METHODS

Scanning and transmission electron microscopy (SEM and TEM, respectively) were used for examination of maxillary sinus mucosa at the time of endoscopic sinus surgery and 6 months postoperatively.

RESULTS

SEM showed non-ciliated cells, metaplasia, ciliary disorientation, abundant goblet cells, microvilli and compound cilia perioperatively. Six months postoperatively the numbers of non-ciliated cells and microvilli had increased but the degree of metaplasia and disorientation and the number of compound cilia had decreased. Perioperative TEM revealed metaplasia, disorientation, tubulus anomalies, compound cilia and one patient with short dynein arms.

CONCLUSIONS

As a result of this study we conclude that sinus mucosa repairs slowly after surgery. There are still many pathological findings in the mucosa 6 months postoperatively and some of these findings may even be irreversible. Patients need frequent follow-up after their operation and we suggest that a follow-up time for sinus surgery patients of at least 1 year should be allowed before final evaluation of the operation and its outcomes is made.

Detection of Helicobacter pylori in nasal and maxillary sinus specimens from patients with chronic sinusitis

OBJECTIVES

In patients with chronic sinusitis, the colonization of nasal and maxillary sinus tissues by Helicobacter pylori (HP) was investigated using polymerase chain reaction, urease test (CLO test), culture, and immunohistochemical analysis.

STUDY DESIGN

A prospective clinical study.

METHODS

The subjects were 11 patients aged 20 to 72 years with chronic sinusitis who had undergone sinus surgery under local anesthesia. In 7 of 11 patients, the HP status of the stomach was also studied. Nasal and maxillary sinus tissues were studied using polymerase chain reaction, urease test, culture, and immunohistochemical analysis. Helicobacter pylori infection of nasal and maxillary sinus tissues was defined by at least two positive results of different tests.

RESULTS

Three (16%) of 19 nasal and maxillary sinus specimens from two patients were shown to be HP-positive (positive by polymerase chain reaction and immunohistochemical analysis and weakly positive by the CLO test). In one of these two patients, HP infection of the stomach was confirmed. In the other, a positive findings on immunohistochemical analysis suggested HP infection of the stomach. Immunoreactive structures were seen by immunohistochemical analysis in the nasal, maxillary sinus, and gastric specimens of these two patients but were partially degraded.

CONCLUSION

Helicobacter pylori may exist in the nasal and maxillary sinus tissue specimens of some patients with chronic sinusitis with gastric HP infection.

Reduced nitric oxide in sinus epithelium of patients with radiologic maxillary sinusitis and sepsis

Radiologic maxillary sinusitis is an important risk factor for development of bronchopneumonia in mechanically ventilated patients. Nitric oxide produced within the paranasal sinuses is considered to provide an antibacterial environment and to modulate mucociliary clearance function. We hypothesized that a reduced formation of nitric oxide might contribute to the compromised local host defense in radiologic maxillary sinusitis and measured nitric oxide levels directly within maxillary sinuses of septic patients with radiologic maxillary sinusitis (n = 11), whose sinuses were fenestrated to eliminate a possible septic focus. Data were compared with those of patients without airway inflammation (n = 11, control subjects). Despite local inflammation and infection, we found considerably lower maxillary nitric oxide levels than in control subjects (31 +/- 10 versus 2554 +/- 385 parts per billion, mean +/- standard error of the mean, p < 0.001). Consistently, immunohistochemical and in situ hybridization investigations revealed strongly reduced expression of inducible nitric oxide synthase. By applying ultrastructural immunolocalization, we identified cilia and microvilli of the maxillary sinus epithelium as the major nitric oxide production site in control subjects. Our findings provide evidence of markedly reduced nitric oxide production in maxillary sinuses of patients with radiologic maxillary sinusitis and sepsis, implicating impaired local host defense and an increased risk for secondary infections.

Allergic fungal rhinosinusitis--a case report

Allergic fungal rhinosinusitis is a unique disorder characterised by specific immunological hypersensitivity to certain fungal antigens usually presenting with nasal polyps and characteristic CT findings. It is a noninvasive disease and on histopathology shows formation of allergic mucin containing numerous eosinophils, charcot leyden crystals and scattered fungal hyphae. Many cases have been reported in western journals but it has been rarely reported in Indian literature. This case is probably the first case in India. It is presented here for its rarity.

[Video-assisted endoscopic sinus revision for treatment of chronic, unilateral odontogenic maxillary sinusitis]

BACKGROUND

The proportion of dental causes of maxillary sinusitis is estimated between 10% and 40%. The mechanisms are manifold and originate from the close relation of the side teeth and the maxillary sinus. In the past, the transantral approach was commonly used by maxillofacial surgeons as their first choice.

PATIENTS AND METHODS

Between 01/1999 and 10/2001 38 patients underwent endoscopic surgery controlled via the fossa canina. Apart from the mandatory treatment of the dental focus and the mucosal pathologies, a fenestration to the middle meatus of the nose was performed in 7 cases.

RESULTS AND CONCLUSION

The dental medical history, OPG, CT scans in coronary plane, endoscopic findings, and histology showed the commonly "silent" course of dental sinusitis. Typical findings in CT scans are unilateral basal maxillary opacities adjacent to the molar and premolar teeth. In 20% of the cases there was also a blockade of the infundibulum. All patients were reexamined 6-12 months postoperatively. The patients are free of symptoms, but sometimes suffer from headaches. An exact diagnosis and the clear separation of rhinogenic causes are vital points for the therapy of dental sinusitis. In cases of unilateral sinusitis, a comprehensive investigation by the maxillofacial surgeon should be recommended. Video-assisted endoscopic sinus revision is preferable to the transantral approach and is especially suitable for the treatment of mucosal retention cysts, the removal of foreign bodies, endoscopically controlled resections of apical roots, elevations of the sinus floor, and dental implants. If the ethmoidal infundibulum and maxillary ostium are open, no fenestration is needed. In cases of blockade, fenestration to the middle nose canal is indicated.

Molecular analysis of bacterial flora associated with chronically inflamed maxillary sinuses

Chronic maxillary sinusitis is a chronic inflammatory condition in which the role of microbial infection remains undefined. Bacteria have been isolated from chronically inflamed sinuses; however, their role in the chronicity of inflammation is unknown. The objective of this study was to determine whether bacteria are present in clinical samples from chronic maxillary sinusitis and to assess the diversity of the flora present. Washes and/or tissue samples from endoscopic sinus surgery on 11 patients with chronic maxillary sinusitis were subjected to PCR amplification of bacterial 16S rDNA using three universal primer pairs, followed by cloning and sequencing. The samples were also assessed for the presence of bacteria and fungi by conventional culture methods. Viable bacteria and/or bacterial 16S rDNA were detected from maxillary sinus samples of five of the 11 patients examined (45 %). Three sinus samples were positive by both PCR and culture methods, one was positive only by PCR, and one only by culture. Thirteen bacterial species were identified: Abiotrophia defectiva, Enterococcus avium, Eubacterium sp., Granulicatella elegans, Neisseria sp., Prevotella sp., Pseudomonas aeruginosa, Serratia marcescens, Staphylococcus aureus, Stenotrophomonas maltophilia, Streptococcus gordonii, Streptococcus mitis/Streptococcus oralis and Streptococcus sp. Fungi were not detected. In one patient Streptococcus mitis/Streptococcus oralis, and in another patient Pseudomonas aeruginosa, were detected from both the sinus and the oral cavity using species-specific PCR primers. These results suggest that both aerobic and anaerobic bacteria can be detected in nearly half of chronic maxillary sinusitis cases.

Serum and mucosal nitric oxide levels and efficacy of sodium nitroprussid in experimentally induced acute sinusitis

Experimental acute sinusitis was induced in 21 New Zealand hybrid rabbits by occluding the ostium and inoculating them with Streptococcus pneumonia. While a group of rabbits with sinusitis was left untreated, two other groups were administered parenteral sodium nitroprussid (SNP) and oral levofloxacin for ten days. While staphylococci species, non-hemolytic streptococcus and contaminated flora were isolated from the sinuses of controls, Streptococcus pneumonia was re-isolated in two of six untreated rabbits, in one of six SNP administered rabbits and none of the levofloxacin treated rabbits. Serum and maxillary sinus mucosal nitric oxide (NO) levels were correlated. While the mean maxillary sinus NO level of controls was significantly higher than that of untreated rabbits, the mean maxillary sinus and serum NO levels were significantly higher in SNP administered rabbits than in the others. Although goblet cell hyperplasia and squamous cell metaplasia were detected in some slides, edema and neutrophil infiltration were the prominent findings. The most severe inflammatory changes were found in the untreated sinusitis group on the third and fifth days. The earliest improvement was observed in the levofloxacin treated rabbits. It was concluded that NO level is decreased during acute sinusitis and that SNP administration hastens the bacteriological and histological recovery.

Cross-sectional survey of paranasal sinus magnetic resonance imaging findings in schoolchildren

AIM

Sinus image abnormalities are common among children examined for indications other than sinus disease. The purpose of this study was to determine the frequency of sinus abnormalities among otherwise healthy children attending school.

METHODS

Magnetic resonance imaging (MRI) was performed on 24 children aged 8-9 y, 18 of whom were re-examined after 6-7 mo.

RESULTS

Sinus abnormalities were common. An abnormality was seen in 12 of the children [50%, 95% confidence interval (95% CI) 29-71%], and 9 (38%, 95% CI 19-59%) had abnormalities in the maxillary sinuses. As many as 8 (42%, 95% CI 20-67%) of the asymptomatic children (lacking clinical symptoms or findings) had abnormalities in the maxillary or ethmoidal sinuses. The follow-up examination showed that about half of the abnormal sinus MRI findings had resolved or improved without any intervention.

CONCLUSION

Abnormal sinus MRI findings are common both among otherwise healthy children attending school and in totally asymptomatic children. As incidental findings, these should be interpreted as normal and do not indicate any need for treatment in children imaged for purposes other than sinus disease.

Maxillary sinus floor elevation surgery. A clinical, radiographic and endoscopic evaluation

Although augmentation of the maxillary sinus floor with autogenous bone grafts has become a well established preimplantology procedure, its effect on the function of the maxillary sinus has not been the subject of prospective human studies. In this prospective study the effects of sinus floor augmentation on maxillary sinus performance were evaluated. Seventeen consecutive patients who were to undergo augmentation of the maxillary sinus floor with an iliac crest autogenous bone graft agreed to participate in this study. All patients were subject to (i) extensive anamnestic and clinical investigation on sinusitis, (ii) conventional radiography (Waters' projection) and (iii) unilateral endoscopic inspection of the maxillary sinus. This triad of evaluations was performed preoperatively, immediately preceding the augmentation procedure (the maxillary sinus to be inspected endoscopically was randomly selected), and at 3 (at insertion of the implants) and 9 months (at uncovering of implants) postaugmentation. None of the 17 patients showed clinical or radiological signs of actual sinus pathology preoperatively, though 5 patients had a history of an impeded sinus clearance. By contrast, unilateral endoscopic evaluation revealed pre-existing subclinical mucosal pathology in two out of five patients with a history of sinus clearance impairment and in one out of the other 12 patients. At 3 months' postaugmentation, clinical and radiographical examination showed chronic maxillary sinusitis in one non-compromised patient. Moreover, serial unilateral endoscopic evaluation revealed subclinical maxillary mucosal pathology in four other patients (two of whom had a history of an impeded sinus clearance), confirmed by Waters' projection in three of these four patients. At 9 months' postaugmentation, only subclinical maxillary mucosal pathology was detected endoscopically in two patients (one compromised, one non-compromised patient), confirmed by Waters' projection in this last patient. Five implants were lost during the 9-month observation period. As is obvious from this prospective evaluation, the effects of the augmentation procedure on maxillary sinus performance in patients without signs of maxillary sinusitis are of no clinical significance.

Ultrastructural ciliary changes of maxillary sinus mucosa following functional endoscopic sinus surgery: an image analysis quantitative study

This was a study of the effect of functional endoscopic sinus surgery (FESS) on the ciliary regeneration of maxillary sinus mucosa in patients with chronic maxillary sinusitis, using objective quantitative methods. Twenty specimens from the mucosa of both the superolateral wall and the ostium of the maxillary sinus were sampled during FESS and then six to 12 months later. They were light examined first by light microscopy and then by scanning electron microscopy in combination with image analysis software in order to study the cilia under higher magnification and to calculate proportion of the field that was ciliated. Samples were taken and studied at Cairo University hospital. This study showed that the maxillary sinus mucosa in chronic sinusitis is capable of regeneration and could return towards normal with the improvement of ventilation and drainage of the maxillary sinus following FESS. There were no significant changes in the degree of glandular hyperplasia, goblet cells or pathological glands after surgery.

Expression of epidermal growth factor receptor and its ligands in chronic sinusitis

The epidermal growth factor receptor (EGF-R) system plays a crucial role in mucus production in vitro and in rats. However, the role of the EGF-R system in humans is not known. We compared the localization of EGF-R and its ligands (epidermal growth factor and transforming growth factor alpha) in the epithelia of sinuses with chronic sinusitis and in those of healthy controls. Immunohistochemical techniques were employed to identify the presence of EGF-R and its ligands in the sinus mucosa. We found EGF-R in goblet cells, basal cells, and submucosal gland cells, but not in ciliated cells. Immunoreactivity for both epidermal growth factor and transforming growth factor alpha was found in the epithelial cells and inflammatory cells and in some submucosal gland cells. There was stronger staining of EGF-R and its ligand proteins in chronic sinusitis specimens than in controls. The interrelated localization of EGF-R and its ligands suggests a role in mucus production in the epithelium of the sinus mucosa.

[The course of repair processes in the maxillary sinuses after radical surgery]

87 patients with chronic purulent hyperplastic and cystic maxillary ethmoiditis have undergone a radical surgical treatment with Caldwell-Luc operation as a surgical approach. Histopathological parameters of maxillary mucosa before and after surgery were compared. Mucociliary clearance, formation of postoperative anastomosis, changes in sinus microflora were followed up. Causes of recurrent postoperative chronic processes in the paranasal sinuses were analysed.

The treatment duration of acute maxillary sinusitis: how long should it be? A nasal smear controlled study

The aim of this study was to determine the most appropriate duration of treatment in acute maxillary sinusitis. The study was performed prospectively on 40 adult patients with acute maxillary sinusitis diagnosed by sinus puncture. Patients were randomized as to several treatment periods and treated by various antibiotics according to culture-sensitivity results. Patients in group 1 received treatment for 7 days; groups 2, 3, and 4 received 14, 21, and 28 days, respectively. The patients were followed up with nasal smear findings on certain intervals during the 56-day follow-up period. Statistically significant differences were found beginning from the 21st day between group 1 and the other groups. However, there were no statistical differences among groups 2, 3 and 4. These findings show that the most appropriate duration of treatment in acute maxillary sinusitis should be at least 14 days according to nasal smear results.

The role of bone in chronic rhinosinusitis

OBJECTIVES

To evaluate and confirm the histological inflammatory changes that occur in bone and in the overlying mucosa in experimentally induced chronic rhinosinusitis and to evaluate differences in the inflammatory patterns that may occur with different organisms.

STUDY DESIGN

Histological study of induced maxillary rhinosinusitis in 29 New Zealand White rabbits (15 with, 14 with ) 7 to 9 weeks after infection.

METHODS

Following maxillary sinus ostial infection, unilateral chronic bacterial rhinosinusitis was induced in 29 New Zealand White Rabbits, using (n = 15) and (n = 14). The pathogenic organism was confirmed by culture, and the rabbits were sacrificed at predetermined time intervals (7, 8, and 9 wk) from the time of infection. Following harvest, en bloc sinus sections were mounted, stained, and analyzed. Specific attention was given to identifying histological changes in paranasal sinus bones on both sides.

RESULTS

All animals (29 of 29) demonstrated histological evidence of operative occlusion on the side of the original inoculum, and all were culture-positive for the inoculated organism at death. Histological evidence of chronic rhinosinusitis in the inoculated sinus was demonstrated in 86% of animals (25 of 29). Evidence of chronic osteomyelitis in the noninfected side was seen in 15 of 29 animals (52%) overall, or 9 of 15 animals (60%) infected with pseudomonas and 6 of 14 (43%) animals infected with staphylococcus organisms.

CONCLUSIONS

The study provides further evidence that bacterial rhinosinusitis can involve bone at a distance from the site of primary infection, thereby suggesting that infectious agents may spread through bony structures in the pathogenesis of chronic rhinosinusitis.

Experimentally induced rhinosinusitis in rabbits

OBJECTIVE

The purpose of this study was to develop an experimental rhinosinusitis model by using bacteria-added absorbable material for temporary ostial obstruction.

METHOD

Absorbable gelatin sponge was inserted between the endoturbinals and the ostium of the sinus. In the first group, the effects of surgical procedure and Gelfoam on ostial mucosa were examined macroscopically. In the second group Gelfoam was moistened with Staphylococcus aureus (ATCC 25923). The sinuses of rabbits were examined by coronal com puted tomography before each surgical procedure and sacrifice. The animals were sacrificed at the first, second, fourth eighth, and tenth weeks. Histologic and microbiologic examinations were performed.

RESULTS

In the first group, fibrotic bands and adhesions were observed between the ostium of the maxillary sinus and the endoturbinals in the first and second week. In the second group, a thick purulent discharge that invariably filled the sinuses of the inoculated side was seen after the first week of induction, and opacity, which was determined radiologically, did not disappear until the end of the study.

CONCLUSION

In this study, an experimental rhinosinusitis model was accomplished. It is currently believed that obstruction of the ostium with mucosal edema, polyps, or tumour leads to maxillary sinusitis. In this model, the pathogenesis of human sinusitis was imitated by temporary occlusion of the ostium with bacteria-added Gelfoam. This model can be used in further studies to explore the role of the ostium in the pathogenesis of sinusitis.

Experimental sinusitis in nasally catheterised rabbits

AIM

The aim of the study was to create an experimental rabbit model for investigating the effects of nasal catheterization on rhinosinus mucosa, bacterial flora and observing the development of bacterial sinusitis.

METHODS

Healthy adult white rabbits of either sex and with body weights of 2.5-3 kg were used. Rabbits were randomly separated into two groups; the first group was catheterized by 12 French and the second group was catheterized by 8 French catheters blindly and the non-catheterized left sides were accepted as control. Three randomly chosen rabbits from each group were examined by computerized tomography scans (CT) and sacrified in the first, second and the fourth week of the study. Microbiological and histopathological examinations were performed.

RESULTS

In both study groups after the first week of nasal catheterization, opacity or air-fluid level was detected in maxillary sinuses by CT scans, which was significant in group 1. Inflammation spread by the prolongation of nasal catheterization and rapidly development of sinusitis was observed by thicker catheters' usage.

CONCLUSION

In this study, the role of nasal catheterization as a predisposing factor in the development of sinusitis and the increase of sinusitis development risk in relation with the catheterization period and the catheters' thickness was shown.

Evaluation of the pathophysiology of odontogenic maxillary sinusitis using bone scintigraphy

The inflammatory changes in the maxillary sinus mucosa and wall (mucosal and bony lesions) were evaluated to identify the pathophysiology of odontogenic maxillary sinusitis. Out of 80 patients who underwent CT, 32 patients were examined using single photon emission computerized tomography (SPECT) bone scintigraphy (bone SPECT) with 99mTc-hydroxymethylene-diphosphonate. Mucosal and bony lesions were evaluated morphologically on both images. SPECT data were used to assess the bone activity by calculating the count ratios of the causative alveolar process over the cervical vertebrae. The relationships with clinical symptoms, mucosal changes around the maxillary ostium (ostial lesions), and radiolucencies around the causal teeth (periapical lesions) were assessed. Bone SPECT showing the causal site was valuable for aiding a definitive diagnosis. Mucosal lesions tended to exceed bony lesions horizontally and vertically. Bony lesions tended to extend posteriorly and then anteriorly. The vertical extent of mucosal lesions and the horizontal and vertical extent of bony lesions were correlated with the presence of facial symptoms, ostial lesions, and periapical lesions. Bone activity was significantly correlated with the horizontal and vertical extent of mucosal lesions, horizontal extent of bony lesions, and presence of infraorbital symptoms, ostial lesions, and periapical lesions. Bone activity caused by alveolitis affects the pathophysiology of this disease.

[The relationship between ostial patency and medical treatment in acute maxillary sinusitis: an experimental study]

OBJECTIVES

We investigated the relationship between ostial patency and medical treatment in an experimental model of acute maxillary sinusitis.

DESIGN AND METHODS

Forty healthy New Zealand white rabbits were assigned to two groups. The left maxillary sinus ostia were filled with absorbable gelatin sponge in one group (n=20). In the other group, half of the ostuim was blocked by bone particles and tissue adhesive (Histoacryl). Following induction of acute maxillary sinusitis, each group was divided into four subgroups, one of which was left untreated. The other subgroups received systemic antibiotic therapy plus topical administration of physiological saline solution, a decongestant, and a steroid, respectively, for 10 days. All rabbits were monitored for four weeks. Each week nasal smear samples were obtained for neutrophil and leucocyte counts. In the end, maxillary sinus biopsies were obtained to determine the extent of healing.

RESULTS

There were no significant differences between subgroups having the same ostium patency. However, compared to the subgroups with patent ostia, corresponding subgroups with semi-patent ostia exhibited significantly increased nasal smear and nasal biopsy scores starting from the second week.

CONCLUSION

The degree of ostial patency seems to have a significant role in the treatment of acute maxillary sinusitis.

A fatal case of necrotizing sinusitis due to toxigenic Corynebacterium ulcerans

A 77-year-old farmer developed cough with sputum production, fever, bloody nasal discharge and a mass in his right maxillary sinus leading to necrotic ulceration of the sinus. Corynebacterium ulcerans, carrying the beta-phage for the diphtheria toxin and secreting the toxin, was detected microscopically and by culture from the sinusoidal and ulcer discharge. Despite immediate antimicrobial chemotherapy the patient died of pulmonary failure associated with the production of large amounts of very viscous sputum. Identification of the causative agent, pathophysiological aspects and risk factors of this unusal infection are discussed.

Efficacy and tolerability of once-daily therapy with telithromycin for 5 or 10 days for the treatment of acute maxillary sinusitis

BACKGROUND

The efficacy and tolerability of oral telithromycin 800 mg once daily for 5 vs. 10 days were assessed in patients with acute maxillary sinusitis (AMS).

METHODS

Adults (n = 341) with confirmed AMS diagnosed on clinical signs and symptoms and sinus X-ray showing total opacity or air-fluid level were randomized to receive oral telithromycin for 5 days (followed by placebo for 5 days; n = 170) or 10 days (n = 171). Causative pathogens were isolated by pretreatment sinus puncture (day 1). Clinical and bacteriologic outcomes, and safety and tolerability endpoints were assessed.

RESULTS

Clinical cure rates post-therapy (per-protocol; days 17-21) were comparable (91.1% in the 5-day group, n = 123; 91.0% in the 10-day group, n = 133). Bacteriologic eradication rates (per-protocol) were also similar (90.7 vs. 91.3%). Both regimens were well tolerated.

CONCLUSIONS

A 5-day course of telithromycin 800 mg once daily is an effective, well-tolerated treatment for adults with AMS, comparable to a 10-day regimen.

[Silent sinus syndrome: a rare case of enophthalmia]

INTRODUCTION

The causes of spontaneous enophthalmos, without trauma, surgical factors, or systemic illness, which can be found are rare. A particular entity called silent sinus syndrome in the Anglo-Saxon literature, which concerns the long-term effect of hypoventilation of the maxillary sinus responsible for an attraction of the sinus walls, resulting in sagging of the orbital floor, itself responsible for the enophthalmos.

CASE REPORT

We report the case about a 29-year-old woman, presenting a left-side spontaneous enophthalmos, with sinus-type pains for 2 months. The clinical examination revealed a horizontal diplopia when looking leftwards. Computed tomography showed a maxillary homolateral sinusitis with characteristic attraction of the sinus walls. The draining of the sinus collection by inferior endoscopic enlargement of the maxillary ostium led to pain resolution. The enophthalmos and diplopia were stabilized.

CONCLUSION

After eradicating the orbital causes of enophthalmos, the sinus causes were sought more precisely, the pauci-symptomatic causes such as the silent sinus syndrome. The recognition of this syndrome stopped the progression of enophthalmos by making the maxillary sinus permeable again. A surgical reconstruction of the orbital floor can be proposed in order to correct the motility of the eyes and esthetic considerations.

Sinusitis in the hypoplastic maxillary antrum: the crucial role of radiology in diagnosis and management

Maxillary sinus hypoplasia (MSH) is occasionally encountered in otorhinolaryngological practice. The hypoplastic sinus is liable to mucus retention, and cases of MSH usually present as a persistent maxillary sinusitis. Endoscopic surgery has been recommended as an effective treatment for the sinus infection. However, MSH is associated with anomalies of the lateral nasal wall which, if not recognized pre-operatively, can lead to inadvertent surgical damage to the orbit. Although some of these abnormalities can be evident endoscopically, the role of imaging in diagnosis and identification of important surgical landmarks is paramount. A posteriorly placed middle meatal antrostomy is recommended as the surgical treatment of choice.

[Pathology of recent odontogenic maxillary sinusitis and the usefulness of endoscopic sinus surgery]

A Clinicopathological investigation of 34 patients with surgery-requiring odontogenic maxillary sinusitis was conducted. 1) Eighty-nine percent of the causative teeth leading to odontogenic maxillary sinusitis were teeth that had received a root canal treatment. The root canals of most of these teeth were incompletely filled with the filling material. 2) The pathological findings for the causative teeth showed pulpal necrosis and apical lesions after the root canal treatment. 3) Apical lesions in incorrectly treated teeth caused ostitis and odontogenic maxillary sinusitis. 4) The cause of odontogenic maxillary sinusitis should be questioned, even if a dental procedure has been performed. 5) All cases of sinusitis treated with endoscopic sinus surgery improved remarkably. Endoscopic sinus surgery is highly indicated for odontogenic maxillary sinusitis. 6) If the ventilation and drainage of the maxillary sinus is successful after surgery, most of the causative teeth (root canal-treated teeth with apical lesions) can be preserved only by treatment with antibiotics.

The silent sinus syndrome: a case series and literature review

PURPOSE

The purpose of this study is to describe the clinical and pathologic features of a form of chronic maxillary atelectasis referred to as the silent sinus syndrome, which is characterized by progressive enophthalmos secondary to maxillary collapse resulting from maxillary sinus hypoventilation.

METHODS

A retrospective medical record analysis was carried out to identify patients with enophthalmos secondary to maxillary collapse. Clinical records, including ophthalmology and otolaryngology evaluations as well as computed tomography scans and operative reports, were carefully examined. A complete literature review for relevant studies was performed to examine possible pathophysiology and similar cases.

RESULTS

Four patients with enophthalmos and asymptomatic maxillary sinus disease were identified. On computed tomography, all four of the patients had opacified, partially collapsed maxillary sinuses with osteopenia of the sinus walls and orbital floor displacement resulting in enophthalmos. All four underwent successful functional endoscopic sinus surgery and transconjunctival orbital floor repair.

CONCLUSION

In some instances, chronic maxillary atelectasis can present with enophthalmos secondary to collapse of the maxillary sinus. For reasons that are unclear, the sinus component of the disease remains asymptomatic and is discovered only after thorough evaluation of the enophthalmos.

Morphological and clinical characteristics of antrochoanal polyps: comparison with chronic inflammation-associated polyps of the maxillary sinus

OBJECTIVES

to compare morphological and clinical features of antrochoanal polyps and chronic inflammation-associated polyps of the maxillary sinus.

STUDY DESIGN

histological and scanning electron microscopic examination of ten antrochoanal polyps and ten chronic inflammation-associated polyps of the maxillary sinus; comparison of clinical data in both groups of patients.

METHODS

following surgical removal, the polyps were halved, the halves being processed for routine light microscopy (formalin fixation, paraffin embedding, HE staining) and scanning electron microscopy (formaldehyde/glutaraldehyde fixation, critical point drying, gold coating), respectively. Clinical data were retrospectively reviewed, tabulated and compared.

RESULTS

the antrochoanal polyps differed from chronic inflammation-associated polyps of the maxillary sinus only in a few minor features; slightly longer duration of the process, lower incidence of maxillary ostial obstruction, higher incidence of frequent headaches, persistent nasal obstruction, presence of cysts in the polyp stroma, thickened basement membrane, lower incidence of squamous cell metaplasia, and higher proportion of migratory cells in nasal smears. In two cases, allergy was diagnosed but it seemed not to influence the polyps, which did not show morphological features typical of allergy-associated (eosinophilic) polyps.

CONCLUSIONS

In spite of minor differences, antrochoanal polyps can be regarded as chronic inflammation-associated polyps with cystic origin and peculiar localization.

Anti-inflammatory activity of clarithromycin in adults with chronically inflamed sinus mucosa

In a phase IV, open-label study, 25 patients with clinically stable chronic sinusitis and persistent maxillary sinus inflammation were treated for 14 days with clarithromycin 500 mg twice daily. Biopsy specimens of the maxillary sinus mucosa were obtained pretreatment and evaluated for macrophages (CD68), eosinophils (MBP), elastase, interleukin-6 (IL-6), IL-8, tumor necrosis factor-alpha (TNF-alpha), and activity of eosinophils (EG2), as well as edema score. Clinical signs and symptoms were assessed pretreatment, at the end of treatment, and 1 and 2 weeks later. Statistically significant reductions (P < or = .05) from pretreatment were observed for all markers of sinus mucosal inflammation, including CD68, EG2, elastase, IL-6, IL-8, TNF-alpha, and edema score, with a trend to decreased total eosinophil count. Improvement was observed for all clinical signs and symptoms of chronic sinusitis--sinus pain, sinus headache, nasal congestion, nasal discharge, and mucopurulent discharge--up to 14 days after the end of treatment. Cultures to evaluate persistent infection with Chlamydia pneumoniae showed negative results. Significant reductions in various markers of sinus mucosal inflammation support the role of clarithromycin in modulating immunologic responses. Improvement of clinical signs and symptoms in patients with chronic inflammatory sinusitis not meeting criteria for known or presumed bacterial infection was also noted up to 2 weeks after completion of a 14-day course of clarithromycin.

Cholesterol granuloma and aspergilloma of the maxillary sinus

Cholesterol granuloma (CG) of the paranasal sinuses is rare. The proposed mechanisms of initiation are haemorrhage, impaired drainage and obstruction of ventilation. To the best of our knowledge, association of CG with a specific infection has not been described before. We have recently observed CG and aspergilloma of Aspergillus flavus type from the left maxillary sinus of a 58-year-old male patient presenting with nasal obstruction, headache and postnasal discharge. Any causative relationship between the two findings is obscure. The suspected mechanisms underlying aspergilloma and CG of the paranasal sinuses seems similar, since there is obstruction of ventilation and drainage. The cholesterol accumulation cannot be attributed to cellular components or breakdown products of the aspergillus as the major sterol of the plasma membranes of fungi is ergosterol, not cholesterol.

Leukotriene B4 levels in rabbit maxillary sinusitis: limitations of the current model

Since the late 1980s, the rabbit model for sinusitis has been widely used for experimental studies on sinusitis; however, the clinical relevance of these experimental data has been questioned. To elucidate the role of leukotrienes in the pathogenesis of sinusitis, leukotriene B4 (LTB4) levels were determined in acute Streptococcus pneumoniae sinusitis in this model. The rabbit model for acute maxillary sinusitis was utilized. Briefly, the right maxillary ostium of each New Zealand white rabbit was occluded with cyanoacrylate under general anesthesia. Twenty-four hours after occlusion, the occluded sinus received an inoculation of 10(8) Streptococcus pneumoniae (ATCC 10813) or a sham inoculation of saline alone. Rabbits were then sacrificed one week later, and the maxillary sinus mucosae were harvested. Leukotriene B4 levels were determined by ELISA assay. LTB4 levels in the sinuses inoculated with bacteria tended to be higher; however, statistical analysis did not reveal significant differences between the experimental and control groups. It is possible to reliably assess leukotriene B4 levels in this model of sinusitis. Although the data suggest a trend for elevated LTB4 levels, statistical analysis did not support this conclusion. The study also demonstrated significant limitations in the current rabbit model for sinusitis; that is, the standard human sinus bacterial pathogens are minimally pathogenic in rabbit sinuses and the small size of the sinus limits the material available for assay. Further modifications of the model are necessary. After such adjustments, the role of leukotrienes in sinusitis may be further explored.

Substance P immunoreactive sensory axons as a subset of the total axonal population in the maxillary sinus of the rabbit: a characterization of normal and infected mucosa

Substance P (SP), one of the neuropeptides released from sensory nerves, is thought to mediate neurogenic inflammation. Although SP immunoreactive axons have been described in the sinus mucosa, no attempt has been made to characterize SP fibers as a subset of all axons present in the sinus mucosa. In addition, no study to date has characterized the changes in infected sinus mucosa. The maxillary sinus mucosa of New Zealand white rabbits was harvested from control animals and in animals with induced maxillary sinusitis. Immunohistochemical staining of the sinus mucosa for both Protein Gene Product 9.5 (PGP), a nonspecific marker for all nerves, and for SP was performed on 11 animals: 3 controls and 8 infected. In sinus mucosa from the control rabbits, <50% of all axons labeled by PGP were immunoreactive for SP. In infected mucosa, the absolute number of axons found by PGP staining decreased and nearly all of these remaining fibers were also immunoreactive for SP. We conclude that the phenotypical labeling of nerve fibers seen in normal mucosa is altered by bacterial-induced infection.

Bone involvement in sinusitis: an apparent pathway for the spread of disease

OBJECTIVES/HYPOTHESIS

To study the effects of bone involvement in experimentally induced sinusitis and the effect of involved bone on the overlying mucosa.

STUDY DESIGN

Animal study.

METHODS

Sinusitis was induced unilaterally with Pseudomonas aeruginosa in the maxillary sinus of 19 New Zealand white rabbits. At 6 weeks, the pathogenic organism was confirmed by culture, and a segment of the bone from the medial wall of the sinus implanted in a submucosal pocket in the opposite sinus. The rabbits were killed at predetermined time intervals up to 13 weeks from sinusitis induction, and en bloc sinus sections were decalcified and stained.

RESULTS

The implanted bone reabsorbed partially or totally in all specimens. However, the study revealed clear histological evidence of bone involvement adjacent to the infected sinuses and the bony changes extended to the noninfected side in all specimens. The histological findings were identical to those seen in chronic osteomyelitis.

CONCLUSIONS

This study demonstrates the ability for pseudomonal sinusitis, at least in the presence of surgical intervention, to involve bone at a distance from the site of primary infection in the absence of intervening mucosal disease. If confirmed with additional organisms and models, these findings have significant implications for the therapeutic management of chronic sinus disease.

[Immunohistochemical study of the sinus mucosa during chronic maxillary sinusitis]

OBJECTIVE

To study the protective role of some immunocompetent cells and some humoral immune factors in the local mucosa during chronic sinusitis.

METHOD

Using immunohistochemical streptavidinbiotin peroxide complex (SABC) method to investigate the distribution and the numbers about the T-lymphocytes and subsets, B-cells, macrophages, NK cells, mast cells eosinophils, HLA-DR antigen and IgA, IgG, complement C3, lysozyme in the local mucosa of two type chronic sinusitis.

RESULT

The numbers of T-lymphocytes, T helper/inducer cells, B-cells and macrophages in the mucosa of chronic sinusitis type 1 was significantly more than these in the healthy control (P < 0.01). The number of T-lymphocytes, T suppressor cells, B cells, mast cells and eosinophils in the type 2 was significantly more than these in the healthy control (P < 0.01). The ratio of the helper cells to T suppressor cells significant different in the two type chronic sinusitis.

CONCLUSION

The study showed that the infiltrating of immunocompetent cells was different between the two type chronic sinusitis.

Sinusitis-induced enophthalmos: the silent sinus syndrome

Enophthalmos caused by inadequate maxillary sinus function was first reported in 1964. Since this initial report, scattered case reports and, more recently, reviews have appeared in the literature detailing the pathophysiology, clinical findings, and management of this process. We present a classic case of the asymptomatic development of enophthalmos caused by maxillary sinus hypoventilation: the silent sinus syndrome. In addition, this case included findings in the ethmoid sinuses that suggested their contribution to this disorder, which by our review of the literature has not been well described.

Computed tomography evidence of dental restoration as aetiological factor for maxillary sinusitis

Maxillary sinusitis due to dental causes is usually secondary to periodontal disease or periapical infection and is commonly associated with mucosal thickening of the floor of the maxillary antrum. Computed tomography (CT) is currently the modality of choice for evaluating the extent of disease and any predisposing factors in patients with symptoms of chronic maxillary sinusitis, but it is unable to diagnose dental disease reliably. The presence of restorative dentistry is, however, easily seen at CT and is associated with both periapical and periodontal disease. We aimed to determine whether its presence at CT may predispose to maxillary sinusitis, and in particular to focal mucosal thickening of the sinus floor characteristic of dental origin. Three hundred and thirty maxillary sinus CT images in 165 patients were reviewed for the presence of restorative dentistry in the adjacent teeth, focal maxillary sinus floor mucosal thickening, any maxillary sinus disease (including complete opacification, air fluid levels, diffuse mucosal thickening, focal mucosal thickening) and evidence of a rhinogenic aetiology (osteomeatal complex pathology, mucosal thickening in other sinuses). One hundred and ninety two sinuses adjacent to restorative dentistry and 178 sinuses not adjacent to restorative dentistry were analysed. Focal floor thickening both with, and without, evidence of a rhinogenic aetiology, was significantly more common adjacent to restorative dentistry. Maxillary sinus disease overall was no more common adjacent to restorative dentistry. This work demonstrated that the presence of restorative dentistry predisposes to focal mucosal thickening in the floor of the maxillary sinus and its presence should prompt clinical and radiographical assessment to exclude dental disease as a source of chronic maxillary sinusitis.

A histochemical study of inflammatory lesions of the maxillary sinus mucosa using biotinylated lectins

The distribution of glycoconjugates in normal maxillary sinus tissues, in cases of maxillary sinusitis and in postoperative maxillary cysts (POMC), was examined using seven different lectins as probes. The results showed that wheatgerm agglutinin (WGA), peanut agglutinin (PNA), Ulex europaeus agglutinin-1 (UEA-1), Ricinus communis agglutinin-1 (RCA-1), and concanavalin A (ConA) strongly react with the cilia and goblet cells. The binding of WGA, PNA, UEA-1, and RCA-1 was increased in maxillary sinusitis and POMC compared with normal maxillary sinus epithelium, whereas that of ConA was decreased. The decreased binding of ConA suggested that there were fewer mannoside residues in the maxillary sinus epithelium in the inflammatory lesion. The PNA bound to the cilia, goblet cells and mucous glandular cells in maxillary sinusitis and POMC, but not in normal, uninflamed cells, indicating that D-galactose was produced by the inflammatory condition. Similar binding patterns of PNA and RCA-1 were found in the cilia and on the surface of the epithelium and in the goblet cells. It is assumed that the carbohydrate moiety in the sinus mucosa is altered in inflammatory conditions.

Prognosis and prediction of response to surgery in allergic patients with chronic sinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) occurs frequently in patients with atopy, but little is known of the prognosis after surgery and of factors that may predict a poor outcome.

OBJECTIVE

Our purpose was to assess the long-term prognosis in atopic patients with CRS who undergo surgery and whether certain immune markers could predict a worse prognosis in this setting.

METHODS

Fifteen patients with diffuse involvement of the sinuses on computed tomographic (CT) scan but without nasal polyposis underwent ethmoidectomy with middle meatotomy for CRS when it was clinically indicated. All patients had a biopsy of the inferior turbinate and of the most inflamed areas of the maxillary and ethmoid sinuses at the time of surgery. Follow-up was performed by video endoscopy and by assessment of 2 chronic sinusitis questionnaires at 0, 6, and 24 months postoperatively. The number of lymphocyte subsets (CD3, CD4, CD8), mast cells and eosinophils, and cells expressing IL-4 and IL-5 messenger RNA (mRNA) in all 3 biopsy sites at the time of surgery were compared with the clinical response after surgery.

RESULTS

Seven patients had persistent improvement after surgery, with a decrease in pain, rhinorrhea, or nasal obstruction and a decrease in the need for medication. Eight patients were unchanged or worsened after surgery with disabling rhinorrhea and repeated sinusitis. We found no difference in the number of inflammatory cells, lymphocyte subsets, or IL-4 mRNA-positive cells in the sinus mucosa between responders and nonresponders. However, an increased number of cells expressing IL-5 mRNA was found in the ethmoid sinus at the time of surgery in patients who did not respond to the surgical intervention (P =.007).

CONCLUSION

More than 50% of patients with perennial rhinitis and CRS do not improve after surgery, a response that may be predicted by more cells expressing IL-5 mRNA in the ethmoid sinuses. The increased number of cells expressing IL-5 mRNA may have the potential to be used as a marker for prediction of the response to surgery. The worsening of symptoms in some patients with CRS after sinus surgery could be a result of the disturbance of the anatomy of the sinuses and exposure to the environmental allergens.

Correlation of plain radiological diagnostic features with antral lavage results in chronic maxillary sinusitis

To justify the continued relevance of plain radiography of maxillary sinus in establishing diagnosis and planning treatment of chronic maxillary sinusitis, its specificity and predictive values must have a high degree of confidence. The objective of this study was to examine different plain radiographic features and correlate them with antral lavage results in patients suffering from chronic maxillary sinusitis. Air-fluid level and antral opacity have specificity of 92.3% each and positive predictive value of 87.5% and 96.0% respectively. Gross mucosal thickening and haziness showed low specificity and predictive values of 36.7% and 29.4% respectively. Normality of radiographs was reliable in predicting clear antral lavage effluent. Plain radiograph of the maxillary sinus is still relevant in establishing diagnosis and planning treatment in chronic maxillary sinusitis.

Immunohistochemical localization of cytokines and cell adhesion molecules in maxillary sinus mucosa in chronic sinusitis

OBJECTIVE

Chronic sinusitis is a common disease characterized by persistent inflammation of the nasal and paranasal sinus mucosa. Accumulating evidence supports the importance of proinflammatory cytokines and endothelial cell adhesion molecule (CAM) expression as an initiating process in tissue inflammation. This study was conducted to investigate the localization of major cytokines and CAMs in the maxillary sinus mucosa from patients with chronic sinusitis and from normal subjects.

METHODS

Maxillary sinus mucosal specimens from patients with chronic sinusitis (n = 10) and from normal subjects (n = 6) were immunostained with specific antibodies directed against the cytokines (IL-1alpha, IL-1beta, IL-6, IL-8 and TNF-alpha) and the CAMs (intercellular adhesion molecule-1, ICAM-1 and vascular CAM-1, VCAM-1).

RESULTS

The number of immunoreactive cells for IL-1alpha, IL-1beta, IL-6, IL-8, and TNF-alpha was increased significantly in patients with chronic sinusitis compared with normal controls. Immunoreactivity for ICAM-1 was also increased significantly in patients with chronic sinusitis compared with normal controls, whereas VCAM-1 is only minimally expressed or is absent in both groups.

CONCLUSION

These findings indicate that bacterial and/or viral infection may induce functional and morphologic changes in the maxillary sinus mucosa in chronic sinusitis through enhanced generation of specific cytokines in conjunction with CAMs.

Malondialdehyde levels and superoxide dismutase activity in experimental maxillary sinusitis

OBJECTIVE

Acute maxillary sinusitis is one of the most common diseases in human. Reactive oxygen metabolites (ROMs) produced also physiologically in the body, are normally neutralised by antioxidative enzymes such as superoxide dismutase (SOD). Infection is one of the causes of increased ROMs production. The most important mechanism of tissue damage produced by ROMs is the peroxidation of lipids found in cell membranes and it may be estimated by malondialdehyde (MDA) levels. The purpose of this study, is to investigate tissue damage caused by ROMs in maxillary sinusitis in 24 rabbits.

METHODS

Experimental sinusitis was induced by blocking the right nose and inoculating Staphylococcus aureus into the right maxillary sinuses. Left maxillary sinuses were the control group. Animals were divided into three groups and killed at 3, 5 and 7 days. Mucosas of each maxillary sinus were examined histopathologically and MDA levels were determined. Blood samples were obtained preoperatively (control blood) and on killing days (experimental blood). Serum MDA levels and erythrocyte SOD activities were determined.

RESULTS

All the infected sinuses displayed signs of the inflammation. MDA levels and SOD activities in the experimental blood samples were significantly higher than those of the control group (P < 0.05). Mucosal MDA levels in the experimental group were significantly higher than the controls (P < 0.01).

CONCLUSIONS

In maxillary sinusitis caused by S. aureus an increased ROMs production was observed and it may contribute to tissue damage of sinusitis.

Calcification in chronic maxillary sinusitis: comparison of CT findings with histopathologic results

BACKGROUND AND PURPOSE

It is important to differentiate fungal from nonfungal sinusitis in order to determine the optimal treatment for chronic sinusitis. The purpose of this study was to describe the CT findings of calcifications in chronic fungal and nonfungal maxillary sinusitis.

METHODS

Five hundred ten patients with pathologically proved chronic maxillary sinusitis were studied with unenhanced CT before undergoing sinonasal surgery. In 36 patients, the CT scans were reviewed retrospectively to ascertain the shape and location of intrasinus calcifications.

RESULTS

Calcifications were found in 20 (51%) of 39 patients with fungal sinusitis and in 16 (3%) of 471 patients with nonfungal sinusitis. Direct histopathologic correlation was performed in two of 16 patients with nonfungal sinusitis who had intrasinus calcification. The location of intrasinus calcification was central in 95% of the patients with fungal sinusitis and peripheral in 81% of those with nonfungal sinusitis. Although calcifications with a nodular or linear shape were seen in both fungal and nonfungal sinusitis, fine punctate type calcifications were seen only in those with fungal sinusitis (50%) and round or eggshell type calcifications only in those with nonfungal sinusitis (19%).

CONCLUSION

Intrasinus calcifications are different in location and shape between fungal and nonfungal maxillary sinusitis. Although intrasinus calcification is uncommon in nonfungal sinusitis, the CT finding of intrasinus calcification may be helpful for differentiating fungal from nonfungal maxillary sinusitis.

Middle ear pathologic changes associated with chronic anaerobic sinusitis in rabbits

OBJECTIVE/HYPOTHESIS

To study the histopathologic changes in association with the inflammatory/immune response present in the middle ears of a rabbit model of unilateral chronic anaerobic sinusitis.

STUDY DESIGN

New Zealand white rabbits, two at each experimental time point. Normal rabbits and sham-operated animals served as controls.

METHODS

Left maxillary sinusitis was induced by inoculating Bacteroides fragilis surgically after closure of the ostium. Cultures, lavages, and mucosa were harvested from bilateral middle ear and sinus cavities at 1, 2, 3, and 4 weeks following inoculation. Parameters analyzed include tissue for histopathologic study, immunoglobulin G antibody (IgG Ab) against B fragilis, and lactate dehydrogenase (LDH) levels in lavage samples, interferon gamma (IFN gamma) messenger RNA (mRNA) expression in mucosal tissue, and bacterial culture.

RESULTS

Despite closure of the ostium of the left sinus, mild to moderate dissemination of B fragilis into the right sinus and left and right ears were observed in some but not all rabbits (2/8, 5/7, and 2/8, respectively). Histopathologic changes in the right sinus and middle ears were much less severe in contrast to the severe inflammatory changes in the left sinus. An immune response against B fragilis appeared to occur in the sinuses and ears bilaterally independent of bacterial dissemination, as evidenced by a rise of IgG Ab in lavage fluid and detection of IFNg mRNA. Neither control nor sham-operated animals had detectable levels of IFNg mRNA or IgG Ab. In B fragilis-inoculated rabbits, the magnitude of IgG Ab responses was equivalent in the right and left ear, independent of B fragilis dissemination; IgG Ab levels in the middle ear positively correlated to each other (P < .01) and to the levels in the sinuses (P < .01 and P < .01). LDH levels were closely associated with bacterial growth and degree of tissue inflammation.

CONCLUSION

This reproducible model of chronic sinusitis provides an opportunity to study the middle ear infection and inflammatory/immune responses occurring with sinusitis. Our results indicate bilateral middle ear mucosal immune responses to an elicited sinus infection, independent of B fragilis dissemination.

[Atelectasis of the maxillary sinus. Analysis of progression stages. Apropos of 4 cases]

We analyzed atelectasic processes occurring in the maxillary sinus. Several publications in the literature have tempted to analyze the pathogenesis. Clinically the processes are often silent and only revealed when the major opthalmological complication, enophthalmia, becomes patent. In other cases there is a long history of chronic sinusitis. There is a spectacular retraction of the maxillary sinus walls leading to collapse of the orbital floor and enophthalmia. We report four cases of maxillary sinusitis with atelectasia of the sinus walls at different stages of progression. These observations and data in the literature emphasize the importance, whatever the state of development, of endoscopic osteal decompression to avoid ophthalmological complications.

The "sinusogram", a real-time ultrasound sign of maxillary sinusitis

OBJECTIVE

To describe a real-time ultrasound sign, the visualization of the cavity and the walls of the maxillary sinus ("sinusogram"), and to assess its correlation with total opacity of the sinus.

DESIGN

Prospective clinical study.

SETTING

The medical ICU of a university-affiliated hospital.

PATIENTS

The significance of this sign was assessed in 50 critically ill supine patients (100 maxillary sinuses) who underwent paranasal CT.

MEASUREMENTS AND RESULTS

The "sinusogram" was defined as complete when the internal, external and posterior walls were frankly visible, and incomplete in the case of partial visualization of the walls. The "sinusogram" was present in all 21 cases of total opacity, in 2 of 12 cases of air-fluid level, in 8 of 14 cases of mucosal thickening, in one giant polyp, and in none of 52 normal sinuses. The "sinusogram" was complete in 10 of 21 cases of total opacity. It was incomplete in 11 of 21 cases of total opacity and in all 8 cases of mucosal thickening with positive ultrasound. For the diagnosis of radiologic maxillary sinusitis (total opacity or air-fluid level within the maxillary cavity), the sensitivity was 67 % and the specificity 87 %. For the diagnosis of total opacity (versus absence of total opacity, which includes fluid level), the sensitivity was 100% and the specificity 86%. When the "sinusogram" was complete, the specificity was 100% for the diagnosis of total opacity.

CONCLUSIONS

Ultrasound may be proposed in first-line diagnosis of radiologic maxillary sinusitis.

The correlation between ciliary ultrastructure and ciliary beat frequency in experimental chronic sinusitis

Ciliary ultrastructural abnormalities secondary to chronic sinusitis may cause abnormal mucociliary transport clearance. We examined the relationship between anatomic abnormalities of ciliary ultrastructure secondary to chronic sinusitis and ciliary beat frequency (CBF) before and after middle meatal antrostomy (MMA) in rabbits. Ultrastructural abnormalities of cilia included absence of axoneme membrane, blebs of the axoneme membrane, compound cilia, and ciliary orientation. Two groups of rabbits were studied: Uninfected (group A control, n = 3) and infected (group B, n = 10); 10(8) CFU S. pneumoniae were used to infect the animals in group B after sinus ostial occlusion and chronic sinusitis developed. After 6 weeks with infection, 6 of 10 group B animals underwent MMA and were restudied 6 weeks later. Uninfected animals had mean CBF = 11.75 Hz. Animals with chronic sinusitis had mean CBF = 8.5 Hz (p < 0.05). Six weeks after MMA, mean CBF = 11.82 Hz. This was not different from control. There were significant changes in ciliary ultrastructure when uninfected and infected rabbits were compared. These changes were reversed with MMA. Changes in ciliary ultrastructure correlated significantly with changes in CBF for all animals. Abnormalities in ciliary ultrastructure may account for the abnormal mucociliary transport clearance seen in chronic sinusitis in rabbits.

[Cluster epithelial cells in nasal secretions of allergic rhinitis and its relation to eosinophils]

The cytology of nasal secretions in 20 patients with allergic rhinitis and 15 patients with chronic maxillary sinusitis was investigated with transmission electron microscope to study the ultrastructure of the cluster epithelial cells in nasal secretions of allergic rhinitis. The results showed that the cluster epithelial cells were predominant cellular element in allergic nasal secretions. The number of cluster cells correlated positively with the number of eosinophils and the levels of eosinophilic cationic protein. It is suggested that the exfoliation of cluster nasal epithelial cellular elements may be caused by eosinophic cationic protein with resultant hyperreactivity of nasal mucosa.

Comparison of inflammatory cell profile and Th2 cytokine expression in the ethmoid sinuses, maxillary sinuses, and turbinates of atopic subjects with chronic sinusitis

Chronic sinusitis is a common disease characterized by persistent inflammation of the sinus mucosa. This study was undertaken to investigate immunopathologic findings in biopsy specimens from the ethmoid sinuses, maxillary sinuses, and inferior nasal turbinates of 14 allergic subjects with chronic sinusitis. The composition of the inflammatory infiltrate in the three tissue sites was examined by immunocytochemistry with anti-CD3 (total T cells), anti-CD4 (helper T cells), anti-CD8 (suppressor T cells), anti-MBP (eosinophils), antitryptase (mast cells), and antichymase (mast cells) antibodies. These revealed a significant increase in the T-cell helper/suppressor ratio and eosinophils in the ethmoid sinus mucosa compared with those in the maxillary sinus mucosa and the inferior turbinate. Eosinophil numbers were also higher in the maxillary sinus than in the inferior turbinate. Mast cells were present in significantly higher numbers in the ethmoid sinus and inferior turbinate biopsy sections than in the maxillary sinus. With antisense, radiolabeled riboprobes, we used in situ hybridization to examine the expression of interleukin-4 and interleukin-5 transcripts. The density of cells expressing interleukin-4 transcripts was significantly higher in the inferior turbinate biopsy sections than in those from the ethmoid and maxillary sinuses. In addition, the number of interleukin-4 mRNA-positive cells was higher in the ethmoid than in the maxillary sinus mucosa. The density of interleukin-5 mRNA-positive cells was significantly higher in the ethmoid and maxillary sinuses than in the inferior turbinate. The results of this study indicate (1) a more intense inflammatory response in the ethmoid sinus than in the maxillary sinus and inferior turbinate in allergic chronic sinusitis and (2) different inflammatory responses in the upper airways that are dependent on the anatomic site. These findings have potential implications in the design of new therapeutic interventions for allergic chronic sinusitis.

A comparative study of the ciliary area of the maxillary sinus mucosa and computed tomographic images

The ciliary area of the maxillary sinus mucosa and coronal sinus computed tomographic (CT) scans were studied in 36 maxillary sinuses of 28 patients with chronic sinusitis. Tissue specimens allowed ciliary surfaces to be observed under scanning electron microscopy, allowing surfaces to be expressed in terms of ciliary area (CA) as the percentage of mucosal surface occupied by cilia. The opacity produced by mucosal swelling and secretion in the maxillary sinus on CT was assessed by two methods: Min's and modified van der Veken's methods. Both techniques indicated an inverse correlation between opacity of the maxillary sinus and CA. Our findings suggest that the opacity of maxillary sinus on CT could be a significant parameter for predicting the surface conditions of ciliated maxillary mucosa prior to sinus surgery.