Diagnosis and management of laryngopharyngeal reflux disease

PURPOSE OF REVIEW

A practical approach for the evaluation and management of laryngopharyngeal reflux is provided.

RECENT FINDINGS

In the absence of definite diagnostic criteria, laryngopharyngeal reflux disease remains a subjective entity. The development and validation of various assessment instruments (the reflux symptom index and reflux finding score) are beginning to remedy this problem. A diagnosis of laryngopharyngeal reflux disease is usually based on response of symptoms to empirical treatment. Investigative modalities such as pH monitoring and, more recently, impedance studies are generally reserved for treatment failures. In contrast to gastroesophageal reflux disease, laryngopharyngeal reflux disease rarely responds to behavior modification alone, or in combination with low-dose histamine-2 receptor antagonists. Laryngopharyngeal reflux disease usually requires more aggressive and prolonged treatment to achieve regression of both symptoms and laryngeal findings. Surgical intervention may play a useful role in selected patients with persistent acid or nonacid reflux.

SUMMARY

Laryngopharyngeal reflux is suspected when the history and laryngoscopy findings are suggestive of the diagnosis. Failure to respond to an empiric treatment suggests the need for confirmatory studies and consideration of alternative diagnoses. pH monitoring and multichannel impedance studies are the most useful modalities for directing further investigations or therapy.

The cytology and microbiology of persistent paranasal sinus secretions after endoscopic sinus surgery: a controlled study

OBJECTIVE

To determine the cellular composition and influence of microbiology on persistent paranasal sinus secretions after endoscopic sinus surgery (ESS).

METHODS

Persistent sinus secretions from a consecutive series of patients after ESS were studied with cytopathology and cultures for aerobic, anaerobic, and fungal organisms. A control group consisting of patients without persistent secretions after ESS was also studied. Epithelial, neutrophil, and eosinophil cell presence was semiquantitatively assessed on a 4-point scale and compared between control and diseased groups. Cellular composition was then stratified and analyzed according to the presence of microorganisms.

RESULTS

A total of 50 diseased and 24 control patients were studied. Both diseased and control patients demonstrated sloughed epithelial cells in secretions (53.1% and 66.7%, respectively, P = .131). The diseased group exhibited significantly higher eosinophilic or eosinophilic/neutrophilic cellularity than the controls (P = .048). The average neutrophil infiltration score was 0.82 versus 0.54 for the controls (P = .104). For the diseased group, the mean eosinophil score was 1.56 versus 0.96 in the control group (P = .035). Pathogenic bacteria were identified in 64% of the diseased group patients versus 54.2% in controls (P = .454). Only two fungal cultures were positive (diseased group). Microbiological analysis indicated that in the absence of bacteria, diseased group patients mainly manifested an eosinophilic presence, whereas in the presence of bacteria, the neutrophil response was enhanced in diseased patients and eosinophil response was enhanced in controls.

CONCLUSIONS

Persistent sinus secretions after ESS are primarily driven by an eosinophilic presence. Patients without inflammatory exudate after ESS respond to bacteria with increased eosinophilia, whereas hypersecretory patients demonstrate both increased neutrophil and eosinophil presence.

[Acute rhinoethmoiditis with periorbital cellulitis in a newborn]

Rhinoethmoiditis at newborn is rare. Possible complications include orbital abscess, orbital cellulitis, intracranial complications. Inflammation with orbital and periorbital acute onset at newborn present to clinician as therapeutical dilemma. Pathogenic links which involve this process began from cellulitis to orbital abscess, cavernous sinus thrombosis, cerebral abscess, meningitis. We present 2 cases of rhinoethmoiditis at newborn with orbital cellulitis, with the main differential diagnostic problems and therapeutical options.

The role of biofilms in otolaryngologic infections: update 2007

PURPOSE OF REVIEW

Biofilms have been shown to play a role in otitis media, sinusitis, cholesteatoma, tonsillitis, adenoiditis, and device infections. This article is written to review recent advances in the field.

RECENT FINDINGS

The role of biofilms in the persistence of chronic, mucosal-based ENT-related infections was first recognized in otitis media. Definitive proof was lacking until the demonstration of bacterial biofilms on the middle-ear mucosa of children, not only with chronic otitis media with effusion, but also with recurrent otitis media. Strains of Pseudomonas aeruginosa isolated from cholesteatoma are avid biofilm formers. Biofilms have been reported in the adenoids of children with chronic rhinosinusitis, helping to explain the clinical observation that adenoidectomy can be beneficial to children with chronic otitis or chronic rhinosinusiti. Additional studies have confirmed the presence of biofilms in chronic tonsillitis. Biofilms have also been shown to be involved in infected cochlear implants and tracheotomy tubes.

SUMMARY

The recognition that chronic otolaryngologic bacterial infections are biofilm related has been the impetus for the development of new technologies for the study of biofilms and their prevention and treatment. Understanding that chronic bacterial infections are biofilm related is fundamental to developing rationale strategies for treatment and prevention.

Negative impact of Aspergillus galactomannan and DNA detection in the diagnosis of fungal rhinosinusitis

A proportion of patients with chronic rhinosinusitis, especially if nasal polyps are present, have a diagnosis of fungal rhinosinusitis. The diagnosis is difficult to establish because the symptoms and clinical and radiological signs are non-specific. Also current diagnostic methods, i.e. histology, fungal staining and culture, are insensitive. The performance of the Aspergillus galactomannan (GM) ELISA and real-time PCR for Aspergillus fumigatus mitochondrial DNA was evaluated for the detection of Aspergillus in sinus mucus samples from 25 patients with chronic rhinosinusitis with nasal polyposis. The results were compared with those from nasal lavage fluid from 19 healthy volunteers. Seven patients (28 %) were diagnosed as having fungal rhinosinusitis according to the presence of filaments in histology or direct microscopy using Calcofluor white. All fungal rhinosinusitis patients were negative in the GM ELISA. GM ELISA was positive in five patients whose samples were negative using conventional methods and A. fumigatus PCR. Two out of seven patients with fungal rhinosinusitis were positive by A. fumigatus PCR: one also had a positive A. fumigatus culture, and one had hyphae consistent with Aspergillus in histology. One additional patient had a weak positive PCR result, but other fungal tests were negative. In control subjects, the GM ELISA was positive in 21 %, whereas direct microscopy, culture and A. fumigatus PCR were negative in all samples. Direct microscopy and culture together with histology remain pivotal in defining fungal rhinosinusitis diagnosis. A. fumigatus PCR may have additional value in allowing the diagnosis to be made sooner, whereas the GM ELISA is not reliable in diagnosing Aspergillus infection of the paranasal sinuses.

[Bacteriological study on adult chronic sinusitis operated after endoscopic sinus surgery]

OBJECTIVE

To explore the bacteria isolated from middle nasal meatus, maxillary sinus, ethmoid sinus and postoperative cavity of patients with chronic rhinosinusitis and their characteristics of antibiotic resistance.

METHODS

Eighty-seven patients with chronic rhinosinusitis were operated on by ESS to obtain the pus specimen for bacterial culture and antibiotic susceptibility test, before and 1 month, 3 months and 6 months after operation.

RESULTS

Totally 645 strains (26 species) of bacteria were detected in 464 specimens [total positive rate was 78.9% (366/464)], in which aerobic bacteria was 95.3% (615/645). Gram negative bacteria and gram positive bacteria were 51.2% (330/645) and 48.8% (315/645), respectively. There was supernumerary tendency in detectable rate of gram negative bacteria isolated from postoperative groups. The main pathogens of postoperative patients were gram negative bacteria, with Enterobacter aerogenes, Pseudomonas aeruginosa and Hemophilus influenza occupying the first 3 places. The detectable rate of multiple drug resistance bacteria in postoperative group was much higher than preoperative groups, in which gram negative bacteria was the most, especially for Pseudomonas aeruginosa. There was significant difference in beta-lactamase detectable rate of the bacteria isolated from the delayed recovery group and the preoperative group (chi2 = 4.85, P < 0.05), Enterobacteriaceae occupied the first place among the beta-lactamase detectable bacteria isolated from the delayed recovery group. There was no significant difference in detectable rate of kinds of bacteria isolated from recovery group and control group.

CONCLUSIONS

The main pathogens of patients with chronic rhinosinusitis are multiple drug resistance gram negative bacteria after operation, in which Pseudomonas aeruginosa occupies the first place. Gram negative bacteria are becoming the main opportunity pathogenic bacteria, which shows antibiotic resistance. microbial population of postoperative cavity from recovery group are becoming balanced.

Eosinophilic Bacterial Chronic Rhinosinusitis

BACKGROUND

A subset of Chronic Rhinosinusitis (CRS) patients are those with eosinophilic CRS (ECRS). These patients remain the most refractory to medical and surgical intervention, and are thought to reflect an inflammatory process arising from a variety of causes. Recently the role of fungus in ECRS, defined as the presence of fungi in the eosinophilic mucin of CRS, has been proposed as causal in many cases. Other proposed causes of ECRS include bacterial superantigen induction of inflammation and aspirin sensitivity.

DESIGN

Retrospective review.

METHODS

Histopathology from patients with previously diagnosed ECRS was prospectively re-reviewed for bacterial and fungal presence and correlated with patients' demographic data. The study population was comprised of 55 specimens with ECRS from 34 patients, over a 3-year period from a single investigator at the University of Pittsburgh Medical Center.

RESULTS

Histologic presence of bacteria was shown in 34 of 55 (62%) of all ECRS specimens. Specimens with fungal colonization were more often associated with bacterial presence than without bacteria (17 of 22 [77%] vs. 5 of 22 [23%], P < .02).

CONCLUSION

Bacteria were present in almost two-thirds of all specimens, and most cases of fungal presence were accompanied by bacterial presence, potentially providing support for bacteria as a source of superantigen. Other possible reasons for the high rate of bacterial and fungal colonization of ECRS include increased pathogen exposure, or failure to eliminate pathogens.

New insights into pediatric rhinosinusitis

Rhinosinusitis is a common children's disease. Most cases are acute, follow an episode of common cold, and are the consequence of a superimposed bacterial infection. If mild, they are characterized by the persistence of signs and symptoms of upper respiratory tract disease for more than 10 days; if severe, they involve fever and a purulent nasal discharge, and can cause a substantial decline in general health. Recurrent acute or chronic cases are usually diagnosed in children with predisposing factors, such as recurrent respiratory tract infections, allergic rhinitis, cystic fibrosis, immunodeficiency, ciliary dyskinesia, anatomic abnormalities or reflux. Therapy is based on antibiotics, administered orally in mild, and intravenously in severe cases. On the basis of recently highlighted antibiotic resistances and the possibility of spontaneous resolution, experts agree in considering amoxicillin the drug of choice for mild cases, and an antibiotic capable of overcoming all possible resistance for severe cases.

Topical treatment of rhinosinusitis

We reviewed current clinical evidence for the use of topical treatments in pediatric rhinosinusitis. Repeated Entrez PubMed searches were done using the template algorithm [rhinosinusitis AND (...)] with the settings: [Humans; English; All Child 0-18; Clinical trial; Last 10 yr] for the following comparators: steroid, irrigation, saline, antihistamine, decongestant, antibiotic, antimycotic, fungicide. The authors' clinical experience in the pediatric allergy unit of a university hospital was also drawn upon. Pediatric studies were retrieved but only one satisfied current evidence-based medicine standards for reporting clinical trials. Studies could not be systematized because of methodological, analytical, and interpretation biases. While saline irrigation, nasal decongestants, steroids, antibiotics, antihistamines and fungicides are all in widespread pediatric use, comparing studies from the literature for evidence of efficacy implied subjective appraisal, except in the case of topical steroids. Evidence for the efficacy of topical treatment for pediatric rhinosinusitis is narrative albeit this modality cannot be excluded from individualized patient protocols on the basis of the clinical literature alone. With the exception of topical steroids, no weighable evidence of effectiveness supports the premise that topical treatments actually serve the purpose for which they are widely prescribed in pediatrics.

Invasive fungal rhinosinusitis in Maharaj Nakorn Chiang Mai Hospital

BACKGROUND

Invasive fungal rhinosinusitis, a rare infection, is a life threatening disease. Delay in diagnosis may consequently lead to high morbidity and mortality.

OBJECTIVE

Encourage early detection and proper management of invasive fungal rhinosinusitis.

MATERIAL AND METHOD

Medical records, radiological, and pathological reports of five patients who were diagnosed as invasive fungal rhinosinusitis were reviewed retrospectively.

RESULTS

Four in five cases of invasive fungal rhinosinusitis, confirmed by pathological study, had successful treatment. One patient had intracerebral hemorrhage that may be associated with the disease spreading. Disease extension was evaluated by CT paranasal sinus in all cases, but it usually did not have classic bony erosion.

CONCLUSION

Curing infection, correcting underlying conditions, and working up fungal infection should be carried out as early as possible, because morbidity and mortality depend on disease extension and host status.

From clinical practice to guidelines: how to recognize rhinosinusitis in children

Rhinosinusitis is a common childhood respiratory infection. Children have approximately six to eight viral infections of the upper respiratory tract each year, 5-13% of which may be complicated by a secondary bacterial infection of the paranasal sinuses. The diagnosis of acute bacterial rhinosinusitis in children is established by the persistence of purulent nasal or post-nasal draining lasting at least 10 days, especially if accompanied by supporting symptoms and signs, at which point antibiotic treatment has to be recommended. Appropriate antibacterial therapy should also be recommended if the draining has been present for less time, but is concomitantly associated with significant fever and localized signs of sinus inflammation in a child who appears ill. Imaging studies are not necessary to confirm the diagnosis of clinical rhinosinusitis for the purposes of treatment, but should be reserved for cases in which the diagnosis is in doubt or a complication is suspected, and for patients with recurrent or chronic rhinosinusitis. Under these circumstances, computed tomography is the preferred evaluation. Together with their clinical judgment, these suggestions may be useful for pediatricians in diagnosing this common condition.

Systemic treatment of rhinosinusitis in children

Systemic acute rhinosinusitis therapy consists mostly of antibiotic treatment because pathogens play a major role. Amoxicillin is the drug of choice for treatment of acute rhinosinusitis, with second- and third- generation cephalosporins, azythromycin, clarithromycin, and telithromycin as possible options, especially in the case of allergy to amoxicillin. If the clinical course suggests that an anaerobic pathogen is more likely, clindamycin or metronidazole can be considered in combination with a broad-spectrum drug. In antimicrobial treatment of chronic sinusitis there is no consensus on treatment length, organism coverage, or which antibiotics are most effective because the bacteriology is variable with polymicrobial anaerobic and aerobic organisms present. Adjuvant therapies need to be proven by additional studies. Chronic rhinosinusitis is heterogeneous and treatment should vary according to the causative factor involved. Short courses of systemic steroids have been found very useful to decrease mucosal swelling and inflammation in chronic rhinosinusitis. However, no randomized controlled studies have been performed to validate their efficacy in children. A variety of other agents are used in the treatment of chronic rhinosinusitis including antihistamines, decongestants, and leukotriene modifiers. To date, there is no good evidence from randomized controlled studies to support the use of any of these agents in the treatment of this disease in either children or adults.

[Acute rhinosinusitis in children]

Rhinosinusitis in children is mainly caused by virus. After medical examination and according to the evolution, two clinical situations are defined: sub acute and persisting rhinosinusitis or acute and severe rhinosinusitis. Due to the development of sinus cavities, location of rhinosinusitis varies with age, ethmoïditis being the first location in young child. Imaging is recommended in cases of severe symptomatology or extra maxillary locations or for complications. Antibiotherapy is recommended in severe cases or complications. The choice of drugs is supported by the bacterial epidemiology of these infections and the level of resistance in France of the different microorganisms involved. In other cases, management includes symptomatic treatment and obvious informations on the different modalities of evolution.

PAR-2 activation regulates IL-8 and GRO-alpha synthesis by NF-kappaB, but not RANTES, IL-6, eotaxin or TARC expression in nasal epithelium

BACKGROUND

The effects of protease-activated receptor-2 (PAR-2) stimulation on inflammation mechanisms of chronic rhinosinusitis (CRS) are still unknown.

METHODS

PAR-2 receptor expression was investigated by immunohistochemistry and Taqman mRNA analysis in the mucosa of different rhinosinusitis entities. In primary nasal epithelial cell cultures, the function of PAR-2 and its ability to produce CXC, CC chemokines, and IL-6 were measured by calcium mobilization and stimulation tests. Inhibition tests were performed using cortisone, serine protease inhibitors, cysteine protease inhibitors, Pertussis toxin (PTX) and nuclear transcription factor (NF-kappaB) inhibition (BAY 11-7085). Signal transduction pathways were analysed by electromobility shift assays (EMSA) and NF-kappaB binding studies.

RESULTS

The expression of PAR-2 was found to be increased in CRS specimens. The activation of PAR by trypsin or PAR-2-specific activating peptide (AP) caused an increase in cytosolic calcium, as well as the release of the CXC chemokines IL-8 and growth-related oncogene (GRO)-alpha, but not the release of CC chemokines or IL-6. AP-induced CXC chemokine was sensitive to PTX and activation of NF-kappaB was inhibited by BAY11-7085. Furthermore, a serine protease inhibitor significantly inhibited chemokine synthesis stimulated by trypsin and culture supernatants of staphylococci, whereas steroids and cysteine protease inhibitors had little effect.

CONCLUSION

PAR-2 plays a role in serine protease-mediated regulation - staphylococcal and non-staphylococcal origin - of IL-8 and GRO-alpha in nasal epithelial cells, but not in the regulation of CC chemokines. PAR-2 may therefore be involved in the pathophysiology of CRS and NP at different sites of activation, namely (i) proteases, (ii) the PAR-2 receptor itself or (iii) the application of novel agents that block NF-kappaB/IkappaB-alpha signalling.

Fungal allergens induce cathelicidin LL-37 expression in chronic rhinosinusitis patients in a nasal explant model

BACKGROUND

Fungus is thought to play an important role in some subgroups of chronic rhinosinusitis (CRS) patients with eosinophilic mucus (EMCRS). The cathelicidin LL-37 is an important innate defense peptide with antimicrobial activity but its responses in CRS and EMCRS patients have not been established. We investigated the innate immune responses of LL-37 in nasal tissue from CRS and EMCRS patients to fungal allergen challenge.

METHODS

The levels of LL-37 produced by nasal tissue and secreted in response to fungal allergen challenge were determined by a nasal tissue explant in vitro model. LL-37 mRNA and protein levels were quantified by real-time reverse-transcriptase-polymerase chain reaction and immunoassay methods.

RESULTS

LL-37 mRNA expression in CRS, but not EMCRS patients, is significantly upregulated by Aspergillus (mean fourfold increase) and Alternaria (mean sixfold increase) extracts in a dose-response manner (p < 0.001). LL-37 peptide levels in the nasal tissue from CRS patients are increased in response to Alternaria (p < 0.05). In contrast, with EMCRS patients, the expression of LL-37 peptide in nasal tissue is increased with Aspergillus (p < 0.001) but is reduced with Alternaria. We also observed a trend where levels of secreted LL-37 were decreased with higher doses of Alternaria and Aspergillus extracts.

CONCLUSION

LL-37 is significantly up-regulated at the mRNA and protein level in CRS patients in response to fungal allergens. However, EMCRS patients do not show increased LL-37 at either the mRNA or the protein level in response to Alternaria.

The fungal debate: where do we stand today?

Chronic rhinosinusitis (CRS) is an inflammatory disorder affecting the nose and paranasal sinuses. Although bacteria have long been implicated as pathogens in most forms of CRS, it has been recognized that fungi may be responsible for some forms of CRS. Recent studies have shown that under optimal conditions, fungi can be identified within the nose and paranasal sinuses of nearly every individual. Considerable controversy exists concerning the proper diagnosis of and potential overlap between 'allergic fungal rhinosinusitis' and 'chronic rhinosinusitis'. Although the disease name 'allergic fungal rhinosinusitis' is suggestive of an immunoglobulin E (IgE) mediated reaction to fungi, recent studies demonstrate the presence of elevated serum IgE levels to one fungus while another fungus is present in CRS mucin of the same individual, questioning the role of type I hypersensitivity. Several mechanisms explaining the role of fungi in the pathogenesis of CRS, all requiring additional investigations with adequate controls, have been suggested and will be reviewed. Although preliminary trials suggest a beneficial effect of topical and oral antifungal agents in the treatment of CRS patients, several double-blind placebo controlled trials do not. Presently, in the absence of convincing immunological data and evidence of clinical improvement of CRS upon therapy with antifungal agents, the case against the fungus remains unproven.

Proinflammatory impact of Staphylococcus epidermidis on the nasal epithelium quantified by IL-8 and GRO-alpha responses in primary human nasal epithelial cells

BACKGROUND

Bacterial etiology of chronic rhinosinusitis (CRS) still remains controversial. Whereas Staphylococcus aureus enterotoxins have been detected in CRS, the impact of Staphylococcus epidermidis, a major commensal inhabitant of the nose, has not been studied. Among others, serine and cysteine proteases have been identified as factors of virulence in S. epidermidis.

METHODS

S. epidermidis was examined in tissue biopsies of 30 CRS patients (16 with nasal polyposis) using standard procedures. Primary human nasal epithelial cells from inferior nasal turbinates (HNECs), from nasal polyps (NPECs) and A549 airway epithelial cells were stimulated with S. epidermidis supernatants DSM20044 or ATCC35984 and the IL-8 and GRO-alpha response was quantified by ELISA. Protease-triggered chemokine responses and involvement of NF-kappaB were investigated by addition of protease or NF-kappaB inhibitors. Activation of NF-kappaB was demonstrated by quantitative DNA binding assay.

RESULTS

S. epidermidis was the most frequently isolated bacteria in the majority of CRS patients. HNECs and NPECs revealed no different IL-6 and IL-8 synthesis following stimulation with DSM20044 or ATCC35984. Stimulation of HNECs and A549 cells with S. epidermidis supernatants resulted in increased IL-8 and GRO-alpha expression which could be suppressed by the serine protease inhibitor AEBSF and the NF-kappaB inhibitor BAY 11 but not by the cysteine protease inhibitor E64. Results obtained for A549 cells were similar to HNECs.

CONCLUSION

S. epidermidis was present in the majority of CRS specimens. Proinflammatory impact of S. epidermidis supernatants on nasal epithelial cells was demonstrated by serine protease-triggered and NF-kappaB-dependent chemokine responses.

A randomized prospective double blind controlled trial on effects of long-term consumption of fermented milk containing Lactobacillus casei in pre-school children with allergic asthma and/or rhinitis

To examine whether long-term consumption of fermented milk containing a specific Lactobacillus casei may improve the health status of preschool children suffering from allergic asthma and/or rhinitis a randomized, prospective, double blind, controlled trial was conducted in 187 children 2-5 y of age. The children received for 12 mo either fermented milk (100 mL) containing Lactobacillus casei (10(8) cfu/mL) or placebo. The time free from and the number of episodes of asthma/rhinitis after starting intervention were the outcome measures. The number of fever or diarrhea episodes and the change in serum immunoglobulin were further assessed. No statistical difference between intervention and control group occurred in asthmatic children. In children with rhinitis, the annual number of rhinitis episodes was lower in the intervention group, mean difference (95% CI), -1.6 (-3.15 to -0.05); the mean duration of an episode of diarrhea was lower in the intervention group, mean difference -0.81 (-1.52 to -0.10) days. While long-term consumption of fermented milk containing Lactobacillus casei may improve the health status of children with allergic rhinitis no effect was found in asthmatic children.

Significance of Streptococcus milleri in acute rhinosinusitis with complications

Objectives:

To assess the significance of Streptococcus milleri in acute rhinosinusitis with complications.

Methods:

A retrospective case note review was undertaken of in-patients at both the Red Cross Children's Hopital and the Groote Schuur Hospital (for adults), Cape Town, South Africa, between 1999 and 2003, with a diagnosis of acute rhinosinusitis with complications. The following were documented: age, gender, complications, organisms cultured and their sensitivity, type and number of operations, and length of hospital stay.

Results:

Seventy-one case notes were reviewed, for 30 female and 41 male patients, representing 38 adults and 33 children. Streptococcus milleri was the most commonly implicated organism (52.1 per cent; 37/71). Patients from whom this organism was isolated tended to require more than one operative procedure, and had a protracted hospital stay.

Isolation of Aspergillus nidulans from a case of fungal rhinosinusitis: a case report

A rare species i.e. A. nidulans is reported as a causative agent of allergic fungal rhinosinusitis in this study. It is an increasingly recognized type of chronic recurring hypertrophic sinus disease. There are more than 185 species of aspergillus and over 95% of all infections are caused by A. fumigatus, A. flavus and A. niger. A. fumigatus alone accounts for the large majority of cases of both invasive and non invasive aspergillosis. A young immunocompetent lady presented with bilateral nasal obstruction due to multiple polypoid mass at Sheth Vadilal Sarabhai General Hospital, Ahmedabad. Provisional diagnosis of sinonasal polyposis possibly due to fungal cause with infiltration in to nasal cavity was made. Bilateral functional endoscopic sinus surgery with polypectomy was done. The specimen was examined by standard methods and the fungus was identified as A. nidulans by slide culture.

Activity of nasal amphotericin B irrigation against fungal organisms in vitro

BACKGROUND

The role of fungi in chronic rhinosinusitis has been described in recent reports. Controversy exists on the use of topical amphotericin B therapy as a treatment modality for this condition. The effect of various concentrations of amphotericin B nasal irrigation on actively growing fungi was studied in vitro.

METHODS

Ten species of fungi commonly found in the nasal cavity were grown on growth media plates. Each fungi was exposed to 20 mL of amphotericin B nasal irrigation at concentrations of either 100, 200, or 300 microg/mL or sterile water two times daily for 6 weeks. Each plate was subcultured on a weekly basis to examine for any viable fungi.

RESULTS

Fungi growth was not arrested in the 100-microg/mL amphotericin B and sterile water groups at the end of 6 weeks. Use of the 300-and 200-microg/mL amphotericin B solutions showed failure of the subcultured fungi to grow at 5 and 6 weeks, respectively.

CONCLUSION

Nasal amphotericin B irrigation is ineffective in killing fungi in vitro at a concentration of 100 microg/mL over a 6-week period. Concentrations of 200 and 300 lig/mL successfully prevented fungi growth at the conclusion of the study. The current concentration of commercially available topical amphotericin B (100 microg/mL) seems ineffective in eradicating fungi in vitro.

Intranasal corticosteroid use is associated with lower rates of bacterial recovery in chronic rhinosinusitis

OBJECTIVE

To determine whether use of a topical intranasal corticosteroid (INCS) preoperatively had an effect on the bacterial recovery rate and flora recovered at endoscopic sinus surgery (ESS).

STUDY DESIGN AND SETTING

A prospective, multicenter, observational study from academic-based rhinology practices. Consecutive, unselected patients undergoing ESS had protected sinus cultures done at the time of ESS.

RESULTS

157 patients were assessed. Overall growth rate was 45.5%. INCS users had a positive culture rate of 35.4% vs 61.7% in nonusers (P = 0.0001). This effect was most pronounced in the subgroup undergoing revision surgeries (bacterial recovery rate INCS: 40.0%, no INCS: 82.6%, P = 0.001) and most marked for S. aureus (INCS: 12.5%, no INCS: 40.0%, P = 0.04) and CNS (INCS: 12.5%, no INCS: 30.4%, P = 0.05). While the rate of nasal polyposis was higher in both revision and the INCS-treated groups, rate of bacterial recovery was not influenced by a diagnosis of nasal polyposis.

CONCLUSION

INCS use preoperatively is associated with a lesser rate of bacterial recovery at the time of ESS, especially in individuals with previous ESS.

SIGNIFICANCE

The results suggest a possible role of INCS in the management of post-ESS disease.

Intranasal Helicobacter pylori colonization does not correlate with the severity of chronic rhinosinusitis

OBJECTIVE

To investigate the prevalence of Helicobacter pylori (HP) in the nasal cavity of patients with chronic rhinosinusitis (CRS) and to correlate it with the severity of CRS.

STUDY DESIGN AND SETTING

Intranasal HP was investigated using rapid urease (CLO) testing and immunohistochemical (IHC) analysis and confirmed with transmission electron microscopy. To evaluate the severity of sinusitis, CT scans were graded according to the Lund-MacKay scoring system, and CRS symptom scores were recorded.

RESULTS

Twelve of 48 patients (25.0%) were positive, but only 1 of 29 (3.4%) controls was positive for both CLO testing and IHC analysis (P = 0.025). The mean preoperative CT grade (P = 0.439) and symptom scores (P = 0.515) were not related to the severity of CRS.

CONCLUSIONS

Intranasal HP was more prevalent in patients with CRS than healthy controls. However, there was no significant correlation observed between the severity of sinusitis and intranasal HP colonization.

SIGNIFICANCE

HP has a limited role in pathogenesis of CRS.