Evaluation of the Medical and Surgical Treatment Of Chronic Rhinosinusitis: A Prospective, Randomised, Controlled Trial

Anti-inflammatory effects of macrolides: applications in chronic rhinosinusitis

The anti-inflammatory effects of macrolides are significant. The clinical impact on diffuse panbronchiolitis (DPB) has improved 10-year survival from 12% to more than 90% for these patients. The immunomodulatory activity of macrolides has been a source of mechanistic research as well as clinical research in non-DPB inflammatory airway disease. Suppression of neutrophilic inflammation of the airways has been demonstrated as the most robust immunomodulatory response from 14- and 15-membered ring macrolides. The inhibition of transcription factors, mainly nuclear factor-kB and activator protein 1, from alterations in intracellular cell signaling drives this mechanism. The suppression of interleukin-8 to a range of endogenous and exogenous challenges characterizes the alterations to cytokine production. The inflammatory mechanisms of chronic rhinosinusitis (CRS) have been a major non-DPB focus. Macrolides have been trialed in more than 14 prospective trials and are the focus of numerous research projects. Evidence for a strong clinical effect in CRS is mounting, but results may be tempered by researchers' inability to characterize the disease process. Eosinophilic dominated CRS is unlikely to respond, based on current research understanding and data from clinical trials. This article discusses the current concepts of macrolides and their application in the management of CRS.

The effect of endoscopic sinus surgery on bacterial biofilms in chronic rhinosinusitis

OBJECTIVE

To determine whether or not endoscopic sinus surgery (ESS) alters bacterial biofilms in patients with chronic rhinosinusitis (CRS) after three months of follow-up.

STUDY DESIGN

Prospective study.

SETTING

Department of Otorhinolaryngology-Head and Neck Surgery, University of Queensland.

SUBJECTS AND METHODS

Participants with CRS from the Princess Alexandra Hospital Department of Otorhinolaryngology-Head and Neck Surgery and from Logan Hospital were enrolled in the study (2008-2009). The total number of patients was 28, and the age range was 18 to 65 years. All patients underwent pre- and post-ESS questionnaires, endoscopic scoring, and nasal swabs for bacterial culture. Crystal violet staining was used to assess biofilm formation on a 96-well culture plaque.

RESULTS

ESS resulted in a statistically significant improvement in quality-of-life, subjective, and objective outcome measures after three months. A significant reduction was observed in biofilm density before and after ESS (2.63 versus 1.3, P = 0.043). No correlations between the reduction of bacterial biofilms with any of the subjective, objective, and quality-of-life outcomes were seen in our study.

CONCLUSION

ESS was shown to be capable of reducing the prevalence of bacterial biofilms but did not eliminate them entirely. There was no correlation between altered biofilm formation and improved outcome measures in individual patients.

Reliability and validity assessments of a Japanese version of QOL 20-Item Sino-Nasal Outcome Test for chronic rhinosinusitis

OBJECTIVE

The objective of this study was to assess the reliability and validity of a Japanese version of the 20-Item Sino-Nasal Outcome Test SNOT-20, which is one of the quality-of-life (QOL) evaluation sheets for chronic rhinosinusitis (CRS), and assess its reliability and validity.

METHODS

The SNOT-20 was conducted in patients with CRS and in healthy volunteers. The response rate was evaluated as the feasibility of this test, and reliability and internal consistency were assessed as reliability. In addition, concurrent validity and discriminant validity were assessed as validity.

RESULTS

Regarding the feasibility of this test, the response rate for each question item in the SNOT-20 was nearly 100% for all 20 items. For reliability, test-retest reliability was r=0.890 and the internal consistency was alpha=0.903. For validity, the concurrent validity was r=0.162 when compared with objective findings in the nasal cavity, and was r=0.431 when compared with the score for general physical condition, which evaluate the patient's general condition. Discriminant validity was significantly higher in patients with CRS than in healthy volunteers (p<0.001). Moreover, when the discriminant validity was assessed using an ROC (receiver operating characteristic) curve, it was found that ROC-AUC (the area under the curve)=0.775.

CONCLUSION

The reliability and validity of a Japanese version of the SNOT-20 were assessed in this study. It is thought that the SNOT-20 serves as a useful QOL evaluation sheet for CRS.

Impaired mucosal healing and infection associated with Staphylococcus aureus after endoscopic sinus surgery

BACKGROUND

Differentiating normal nasal discharge and postoperative crust from infection after endoscopic sinus surgery (ESS) can be difficult. We investigated whether bacteria cultured at operation was predictive for postoperative mucosal infection-defined as frank pus, thick mucus, and/or abnormal crusting seen on endoscopic examination associated with positive microbiology.

METHODS

The records of 48 patients with chronic rhinosinusitis (CRS) with infection at the time of ESS were retrospectively reviewed. Results of intraoperative cultures were compared with those taken at the time of postoperative mucosal infection.

RESULTS

Fourteen of 16 patients (87.5%) with intraoperative infection with Staphylococcus aureus progressed to postoperative mucosal infection with S. aureus, whereas patients who cultured "other" bacteria intraoperatively progressed to postoperative mucosal infection in 6/19 cases (31.6%), with S. aureus cultured in only 3/19 cases (15.8%; p=0.0001).

CONCLUSION

S. aureus infection at ESS predicts for abnormal, S. aureus-associated mucosal healing and infection post-ESS. Although a prospective trial is warranted, these findings suggest a future role for aggressive anti-S. aureus therapy peri- and/or postoperatively in patients who culture positive for this organism to improve postsurgical outcomes.

Effects of intranasal steroid spray in bacterial culture of chronic rhinosinusitis

BACKGROUND

We attempted to determine whether use of a topical intranasal corticosteroid (INCS) preoperatively had an effect on bacterial culture and antibiotic sensitivity in chronic rhinosinusitis with nasal polyposis.

METHODS

In a prospective study, patients that were diagnosed with rhinosinusitis with nasal polyposis received INCS for one month before functional endoscopic sinus surgery. Bacterial culture testing, obtained under telescope from a source near the middle meatus, was performed before and after INCS. Antibiotic sensitivity was also performed.

RESULTS

One hundred fifty-six patients were enrolled in the prospective study, and 115 patients completed the procedures. The male-to-female ratio was 83:32 and the age range was 14 approximately 76 years (46.7 +/- 2.1). The positive culture rates were 80.9% and 79.1% pre-INCS treatment and post-INCS treatment, respectively. There was no significant difference between pretreatment and posttreatment samples in bacterial culture rate. The single bacterial culture rates were 66.7% and 65.9% pre-INCS treatment and post-INCS treatment, respectively. The drug sensitivities to oxacillin and cephaxolin showed no significant difference in coagulase negative Staphylococcus and Staphylococcus aureus.

CONCLUSION

INCS did not influence the rate of bacterial culture or antibiotic sensitivity in patients with chronic rhinosinusitis with nasal polyps.

United airways: the impact of chronic rhinosinusitis and nasal polyps in bronchiectasic patient's quality of life

BACKGROUND

The nose and the bronchi belong, in anatomical and physiopathological terms, to the concept of united airways. Associations between upper and lower airways diseases have been demonstrated in allergic rhinitis and asthma, nasal polyposis (NP) and asthma, chronic rhinosinusitis (CRS) and chronic obstructive pulmonary disease, and more recently CRS/NP and bronchiectasis (BQ).

OBJECTIVE

To evaluate the impact of CRS on quality of life (QoL) of patients with BQ, and to correlate these findings with the pulmonary status, nasal symptoms, and general health status.

METHODS

In a prospective study, patients with BQ (n = 80) were evaluated for CRS and NP using EP(3)OS criteria, and severity of BQ using chest high resolution computed tomography (HRCT)-scan. Quality of life was assessed in all patients by using specific [Sinonasal Outcome Test-20 (SNOT-20), St George Respiratory Questionnaire (SGRQ)], and generic (Short Form-36; SF-36) questionnaires.

RESULTS

Using SNOT-20, patients with CRS had worse QoL (2.1 +/- 0.1; P < 0.001) than patients without CRS (0.4 +/- 0.06). Using SGRQ total score, patients with CRS had worse QoL (43.7 +/- 2.2; P < 0.001) than patients without CRS (24.7 +/- 2.5). Using SF-36, patients with CRS had worse QoL, both in the physical summary (64 +/- 3.4; P < 0.05) and the mental summary (65.5 +/- 4.7; P < 0.05), than patients without CRS (physical summary [PS]: 76.2 +/- 3.3; mental summary [MS]: 78.3 +/- 5.3, respectively). Sinonasal Outcome Test-20 was correlated with SGRQ total score (r = 0.72; P < 0.01), and SF-36 physical summary (r = -0.63; P < 0.01). St George Respiratory Questionnaire was correlated with SF-36 on physical summary (r = -0.58; P < 0.05) and with forced expiratory volume in 1 s (r = -0.41; P < 0.05).

CONCLUSION

These results suggested that CRS, measured by both specific and generic questionnaires, has a considerable impact on the QoL of patients with BQ.

Is routine histopathological examination of FESS material useful?

Analysis of the clinical value of histopathological examination of material collected during functional endoscopic sinus surgery. Retrospective analysis of collected data of patients undergoing functional endoscopic sinus surgery over a 7-year period. Data were collected from a pathology database of the Sint Lucas Andreas Hospital, Amsterdam, The Netherlands. All material collected from 1,944 functional endoscopic sinus surgery cases in 1,695 patients (some patients underwent revision surgery) operated between 2000 and 2007 was examined histologically. Patients with a histological outcome different from chronic inflammation or polyposis nasi, were checked on indication of surgery, type of surgery and preoperative clinical suspicion for (pre)malignancy. The impact of the histological diagnosis on the clinical course was evaluated. Thirty-seven unusual diagnoses were reported: 18 cases of inverted papilloma, one squamous cell carcinoma, two malignant lymphomas, one leiomyosarcoma, eight squamous cell papillomas, one Churg Strauss syndrome, one Schneiderian papilloma, two cases of Wegener’s granulomatosis and three cases of sarcoidosis. All other specimens were identified as chronic inflammation and/or nasal polyposis. Only two clinically significant, unexpected diagnoses, both inverted papilloma, have resulted from the histological investigation. We conclude that the close correlation between histopathology outcome and examination on clinical grounds or gross inspection indicates that routine histopathological examination of functional endoscopic sinus surgery material has little clinical value and it is questionable if this should be performed. In patients in whom there is a high degree of suspicion for (pre)malignancy, histopathological examination of functional endoscopic sinsus surgery material remains indicated.

Balloon Sinuplasty: balloon-catheter dilation of paranasal sinus ostia for chronic rhinosinusitis

More than 100 million patients worldwide suffer from chronic rhinosinusitis, and a considerable amount of money has been spent on research and treatments by healthcare providers. In the northern hemisphere, damp, temperate climates, along with higher concentrations of pollen, are associated with a higher prevalence of chronic rhinosinusitis. Owing to its persistent nature, the disease can become a significant cause of morbidity. If untreated, it can reduce quality of life and productivity. When medical treatment is not effective, surgery may offer an excellent outcome. Although functional endoscopic surgery has proven to be effective, many cases could be managed medically. Recent research has suggested that optimal medical treatment is as effective as surgery in patients with chronic rhinosinusitis at the end of 1 year. Balloon Sinuplasty (Acclarent, Inc., CA, USA) is a new technique in the management of sinusitis and is a hotly debated topic. It is a delicate, minimally invasive tool, and early research demonstrates promising outcomes in terms of safety and effectiveness. This novel technique has been approved by the US FDA. Recently, NICE raised no concerns regarding its safety and efficacy but will continue to review this procedure.

Response to medical or surgical therapy in chronic rhinosinusitis: A one year prospective analysis

INTRODUCTION

Chronic rhinosinusitis (CRS) is treated with both surgical and medication options. However, long term data on patient outcomes is rare. In a real world clinical environment, our objective was to identify CRS patients, gather patient characteristics, and follow symptoms over one year.

PATIENTS AND METHODS

This observational study enrolled patients with CRS, primary clinical makers included atopy testing, serum lgE, and complete blood counts. A sinus computerized tomography (CT) scan was performed serially. Patients were enrolled into medical treatment Arm A and into surgical treatment Arm B. Symptom scores were calculated using the chronic sinusitis survey (CSS).

RESULTS

Atopy testing was positive in 67%. lgE levels or atopy did not correlate with CSS scores A 23% decrease in total CSS scores was noted in Arm A at one year (p =.01). Arm B demonstrated a 38% reduction in total CSS scores at 3 months (p =.02) only. CT evidence of CRS was found in 74% of patients. However, CT scores did not change significantly over 12 months.

CONCLUSIONS

No correlation was found between serum lgE levels or atopy versus CSS scores. CT scan scores did not change significantly over 12 months in either treatment group. A reduction of CSS scores was seen in both treatment groups: however a rebound effect was suggest in the surgical arm. Our study demonstrates the disconnection common clinical setting. It exemplifies the need for controlled studies with years of chronic rhinosinusitis outcome analysis.

Endoscopic sinus surgery in the management of nasal obstruction

Nasal obstruction is the leading symptom observed among patients who have chronic rhinosinusitis (CRS) with or without nasal polyposis. After failure of medical therapy, functional endoscopic sinus surgery (FESS) has emerged as the preferred treatment of CRS. Interestingly, although patient-reported outcomes show unequivocal relief of nasal obstruction after FESS, studies measuring nasal airflow and resistance demonstrate more modest improvements. This article provides an overview of the physiology of nasal airflow sensation, the burden of nasal obstruction in patients who have CRS, and the efficacy of FESS in addressing nasal obstruction in this population. Additionally, advances in airflow modeling that may enable improved preoperative planning for the relief of nasal obstruction after FESS are discussed.

Short-term antibiotics treatment in patients with nasal polyps and enterotoxins producing Staphylococcus aureus strains

Enterotoxins produced by Staphylococcus aureus (SA) can act as super-antigens and thus influence the course of chronic rhinosinusitis with nasal polyps (NP). The aim of this study was to determine if antibiotic treatment administered after endoscopic sinus surgery (ESS) for NP can positively influence the course of the disease compared to placebo. After ESS, 23 patients who tested positive, in a perioperative culture, for SA strains producing enterotoxins A-E and TSST-1, were randomized into two groups. Group A which in addition to standard treatment received oral anti-staphylococcal antibiotics for 3 weeks. Group B received a placebo. Both groups were compared preoperatively, and at 3 and 6 months after surgery using a symptom-specific score, an endoscopic score and the SNOT-22 quality of life questionnaire. Slightly better results were achieved in patients who received antibiotic therapy. However, the differences were not statistically significant. Regardless of post-operative treatment, approximately 30% of patients had a SA-negative culture 6 months after surgery.

An evidence-based approach to the management of the adult with nasal obstruction

BACKGROUND

Nasal obstruction is a common presenting symptom to the otolaryngology clinic. A variety of structural and mucosal abnormalities can interrupt the subjective sensation of nasal airflow.

METHODS

This review was based on a literature search last performed on 1 October 2008. Current texts and the MEDLINE, EMBASE and COCHRANE databases were searched using the subject heading nasal obstruction in combination with classification, diagnosis, therapy, drug therapy and surgery. Results were limited to include clinical trials, randomised controlled trials, meta-analyses, systematic reviews and review articles. Relevant references from selected articles were also reviewed.

CONCLUSION

We present an evidence-based approach to history-taking and clinical examination of an adult patient with nasal obstruction and provide an overview of management of the most common causative conditions.

Antimicrobial therapy in chronic rhinosinusitis

Antimicrobial therapy has been a mainstay of treatment for chronic rhinosinusitis (CRS). The roles of bacterial and fungal infection in the primary pathogenesis of CRS recently have been called into question. Although many different bacteria and fungi can be isolated from CRS patients, antimicrobial treatment directed at their eradication has met with mixed clinical results. Overall, macrolide antibiotics hold the most promise before surgery. Topical antibiotics are safe, efficient, and effective for treating acute bacterial exacerbations of CRS after endoscopic sinus surgery and may prevent the development of subsequent bacterial resistance. Topical treatment of CRS with antifungal agents both before and after sinus surgery is of limited benefit and should not be considered as a primary treatment modality before surgery. Further research into the role of bacterial and fungal infection in the pathophysiology of CRS may offer better insights into appropriate antimicrobial choices, dosing, and treatment duration.

Olfactory function and nasal nitric oxide

PURPOSE OF REVIEW

To highlight two often forgotten nasal functions, olfaction and nasal nitric oxide production, which have both received more attention over the last two decades with consequent findings that are now entering the routine clinical setting.

RECENT FINDINGS

Olfactory measurements have been optimized and normative data are available, giving clinicians the possibility of testing olfactory function quickly within a patient's workup. The results can lead to more thorough investigations if necessary. Olfactory disorders concern more than just a few people, and these disorders can be a very early sign of Parkinson's disease. Nasal nitric oxide is hypothesized to play a role as an airborne messenger and as an antiinfectious agent in the nose and sinuses and to contribute to the mucociliary clearance. Evidence is growing that the nasal nitric oxide level is a good parameter for diagnosis of ciliary beat impairments and a suitable parameter to monitor treatment success in chronic rhinosinusitis.

SUMMARY

Both nasal nitric oxide and olfactory function are worth testing routinely in any rhinology workup. Valuable clinical information for diagnostic and follow-up purposes can be gained.

Functional endoscopic sinus surgery improved asthma symptoms as well as PEFR and olfaction in patients with nasal polyposis

BACKGROUND

Nasal polyposis is a disease known to be associated with asthma. The management is anti-inflammatory, with topical and oral corticosteroids as the first-line treatment. The effect of surgical treatment on lower airway inflammation has not been sufficiently studied.

AIM

The aim of this study is to investigate the effects of functional endoscopic sinus surgery (FESS) as well as fluticasone proprionate nasal drops (FPND) 400 microg b.i.d. on nasal and lower airway parameters in asthmatics with nasal polyposis.

METHODS

This was a prospective 21-week study of 68 patients with asthma and nasal polyposis, on the benefits of FESS on nasal '(butanol test, subjective olfaction, peak nasal inspiratory flow, congestion, rhinorrhoea, and polyp score)', and on the lower airway parameters (dyspnea, cough, mean daily peak expiratory flow rate (PEFR), and lung function tests). It also included a randomized, double-blind, placebo-controlled 14 weeks phase on FPND.

RESULTS

Functional endoscopic sinus surgery significantly improved mean asthma symptom scores and daily PEFR and all nasal parameters including subjective and objective olfaction tests. This is the first study that shows the benefits of FESS on butanol tests in patients with nasal polyposis. We found no significant difference between topical treatment with FPND or placebo in the nasal or lower airway variables.

CONCLUSION

Functional endoscopic sinus surgery improved nasal and asthma symptoms in patients with nasal polyposis. Functional endoscopic sinus surgery could be considered early in the natural course of nasal polyposis with concomitant asthma, as well as a second-line treatment in nasal polyposis patients with a reduced sense of smell. The potential benefits of FPND 400 microg b.i.d. were probably overshadowed by FESS.

Evaluation of nasal mucociliary clearance after medical or surgical treatment of chronic rhinosinusitis

An evaluation of mucociliary clearance, with the use of rhinoscintigraphy and other objectives and subjectives measures, in medically and surgically treated patients with chronic rhinosinusitis, as well in patients with or without nasal polyposis, can add to the understanding of ciliary function and its role in the pathogenesis of chronic rhinosinusitis. Thirty-four patients medically treated and 21 surgically treated (FESS) patients evaluated with rhinoscintigraphy, CT-scans, and SNOT-20. Nine of the surgically treated patients had nasal polyps and studied as a separate group. Although the various groups differ on Lund-Mackay scores (H = 11.659, P = 0.003) and SNOT-20 results (F = 26.904, P < 0.001), a statistically significant difference between mucociliary transport velocity (MTV) values could not be found. Moreover, multiple linear regression could not prove a statistically significant correlation between MTV and other variables. The various groups of chronic rhinosinusitis patients cannot be differentiated on the basis of possible nasal mucociliary clearance alternations.

Systematic review of change in bodily pain after sinus surgery

OBJECTIVES

To determine whether bodily pain is increased in patients with chronic rhinosinusitis (CRS) and if bodily pain improves following endoscopic sinus surgery (ESS).

METHODS

All studies reporting results of more than 10 adult patients analyzing the response of bodily pain to ESS were retrieved by searching MEDLINE, EMBASE, Web of Science, Cochrane databases, and additional web-based sources (from January 1, 1980, to May 1, 2008); by examining bibliographies of retrieved articles; and by contacting investigators in the field.

RESULTS

Of 279 ESS symptom outcome studies, only studies measuring results using the 36-Item Short Form Health Survey (SF-36) quality-of-life survey instrument measured bodily pain. Eleven observational ESS studies (1019 patients) reported mean preoperative SF-36 bodily pain scores at 0.89 SD below general population norms (24% more severe bodily pain than general population norms) and significantly below norms for a population 25 years older. Using a repeated-measures design, nine of 11 studies noted significant improvement in SF-36 bodily pain domain scores following ESS, with a moderate-sized combined effect of 0.55 (95% confidence interval, 0.45-0.64; I(2) = 44%) using the fixed-effects model. This pooled effect corresponded to a mean improvement of 11.8 U on the SF-36 bodily pain domain scale.

CONCLUSIONS

Bodily pain is increased in patients with CRS awaiting ESS, exceeding the normative bodily pain scores of a general normative population 25 years older. Using within-subject comparisons, a clinically and statistically significant improvement in bodily pain is noted after ESS, an improvement similar to that previously described for fatigue.

Chronic rhinosinusitis and nasal polyps: the role of generic and specific questionnaires on assessing its impact on patient's quality of life

Chronic rhinosinusitis (CRS) including nasal polyps is a chronic inflammatory disease of the nasal and paranasal sinus mucosa that, despite differing hypotheses of its cause, remains poorly understood. Primary symptoms are nasal blockage, loss of smell, rhinorrhea, and facial pain or pressure. Chronic rhinosinusitis causes significant physical symptoms, has a negative impact on quality of life (QoL), and can substantially impair daily functioning. A global evaluation of patients must include, together with nasal symptoms, nasal endoscopy, and CT scan, the measurement of QoL. To assess QoL in CRS, specific and generic questionnaires may be used. Chronic rhinosinusitis has a considerable impact on a patient's QoL but comorbidities, such as asthma and atopy, have an accumulative negative effect. Both medical and surgical treatments lead to a similar improvement on the QoL of CRS and nasal polyp patients.

Endoscopic sinus surgery as day-case procedure

Objective:

Functional endoscopic sinus surgery is the mainstay of surgical treatment for chronic sinusitis. Day-case surgery has the advantage over in-patient surgery of being cost-effective and resource sparing. The objectives of this study were to assess our results for day-case functional endoscopic sinus surgery.

Methods:

This was a retrospective case note review of day-case functional endoscopic sinus surgery procedures performed at Leeds General Infirmary from February 2004 to February 2007. We recorded patients' demographic data, operative details, post-operative course and follow-up results.

Results:

A total of 105 day-case functional endoscopic sinus surgery procedures were included in the study. Patients' ages ranged from 16 to 93 years; 44 (41.9 per cent) were female and 61 (58.1 per cent) were male. Of these patients, 39 (37.1 per cent) had chronic sinusitis and the rest (66; 62.8 per cent) had nasal polyposis and sinusitis. Sixty-one patients (58.1 per cent) underwent surgery on the morning operating list, while the rest (44; 41.9 per cent) underwent surgery in the afternoon. Of the 105 patients, 24 (22.8 per cent) had undergone previous nasal surgery. The majority of patients (90/105; 85.7 per cent) were discharged on the same day as surgery. The only complication recorded in this study was bleeding, noted in seven patients (6.7 per cent). At the follow-up appointment, 90/105 (85.7 per cent) patients were satisfied with their post-operative results.

Conclusions:

Day-case endoscopic sinus surgery can be performed safely as a day-case procedure. The most important factors for a successful outcome are correct patient selection, in terms of general health and social circumstances, and a dedicated day-case team.

Evidence-based recommendations regarding the differential diagnosis and assessment of nasal congestion: using the new GRADE system

Nasal congestion is an important symptom in nasal pathology and can be defined as an objective restriction of nasal cavity airflow because of mucosal pathology and/or increased mucus secretion (excluding anatomical variants). Using the new Grading Recommendations Assessment, Development and Evaluation system, evidence-based recommendations are made that will encompass different clinical questions regarding diagnostic modalities of nasal congestion: (i) their usefulness in assessment of presence and severity of congestion; (ii) their usefulness in assessment of etiological pathology responsible for congestion; and (iii) their usefulness in follow up and treatment effectiveness evaluation of nasal congestion.

Topical antimicrobials in the management of chronic rhinosinusitis: a systematic review

BACKGROUND

Chronic rhinosinusitis (CRS) is a common disease that can significantly impact health. The mainstay of medical treatment is topical steroids and oral antibiotics, but little is known about the efficacy of topical antibiotics. The purpose of this study was to identify evidence for the use of topical antibiotics in the treatment of CRS and exacerbations of CRS.

METHODS

Systematic review of literature with a search of the MEDLINE, EMBASE, and CINAHL databases; Cochrane Central Register of Controlled Trials (Third Quarter 2007); and Cochrane Database of Systemic Reviews (3rd Quarter 2007) databases were performed. The dates of search were from December 1, 1949 to September 30, 2007.

RESULTS

Fourteen studies that fulfilled the inclusion criteria were identified: seven were controlled trials and of these, five were double blinded and randomized. Only one of the randomized studies showed a positive outcome. Overall, there was low-level corroborative evidence for the use of antibacterials. No definite conclusions could be made regarding the use of antifungals. Currently, there is evidence for the use of nasal irrigation or nebulization rather than delivery by nasal spray. For the antibacterial studies, the highest level of evidence currently exists for studies that have used postsurgical patients and culture-directed therapy. Both stable and acute exacerbations of CRS appear to benefit from topical antimicrobials.

CONCLUSION

Topical antibiotics appear effective in the management of CRS. Given the combination of low-level evidence (level III, with inherent potential confounders of natural progression of disease and placebo effect) and the level IIb evidence being limited to the cystic fibrosis group of patients, topical antibiotics should not be first-line management but may be attempted in patients refractory to the traditional topical steroids and oral antibiotics. Larger and better-designed randomized double-blind placebo-controlled trials are required to more fully evaluate this emerging modality of treatment.

Effects of endoscopic sinus surgery and delivery device on cadaver sinus irrigation

Objective

Assess paranasal sinus distribution of topical solutions following endoscopic sinus surgery (ESS) using various delivery devices.

Study Design

Experimental prospective study.

Subjects and Methods

Ten cadaver sinus systems were irrigated with Gastroview before surgery, after ESS, and after medial maxillectomy. Delivery was via pressurized spray (NasaMist), neti pot (NasaFlo), and squeeze bottle (Sinus Rinse). Scans were performed before and after each delivery with a portable CT machine (Xoran xCAT), and blinded assessments were made for distribution to individual sinuses.

Results

Total sinus distribution was greater post-ESS ( P < 0.001). Additional distribution was gained with medial maxillectomy ( P = 0.02). Influence of delivery device on distribution was significantly higher with neti pot > squeeze bottle > pressurized spray ( P < 0.001). Frontal sinus penetration was greatest after surgery ( P = 0.001).

Conclusion

ESS greatly enhances the delivery of nasal solutions, regardless of delivery device. Pressurized spray solutions in un-operated sinuses provide little more than nasal cavity distribution. Use of squeeze bottle/neti pot post-ESS offers a greatly enhanced ability to deliver solutions to the paranasal sinuses.

Fatigue improvement following endoscopic sinus surgery: a systematic review and meta-analysis

BACKGROUND

Fatigue is a common symptom of chronic rhinosinusitis (CRS), yet the response of fatigue to endoscopic sinus surgery (ESS) has not been systematically evaluated.

METHODS

Studies published in any language were retrieved by searching MEDLINE, EMBASE, Web of Science, Cochrane databases, and additional Web-based sources (from 1980-2007); by examining bibliographies of retrieved articles; and by contacting investigators in the field. Studies consisting of more than 10 adult patients analyzing the response of fatigue, vitality, energy, or malaise following ESS were included. Two authors independently evaluated studies for inclusion, rated the methods, and summarized relevant data using a standardized protocol.

RESULTS

Using within-subject comparisons, 28 identified observational studies noted substantial improvement in fatigue after ESS. A subgroup analysis of 11 studies measuring outcomes using the 36-Item Short Form Health Survey (SF-36) demonstrated a moderate-sized combined effect of 0.47 (95% confidence interval, 0.38-0.56; I = 0%), corresponding to a mean +/- standard deviation improvement of 9.7 +/- 3.4 units on the SF-36 vitality domain scores. In studies measuring outcomes using symptom rating scores, the preoperative severity scores and improvement after surgery for fatigue were similar to the respective values for other pooled CRS symptoms.

CONCLUSIONS

All 28 studies described substantial improvement in fatigue following ESS based on presurgery and postsurgery comparisons. A subgroup analysis of 11 studies reporting results by the SF-36 vitality domain scores demonstrated a moderate-sized combined effect. Preoperative fatigue severity scores and improvement noted after surgery were similar to the respective values for other pooled CRS symptoms.

Sleep impairment in allergic rhinitis, rhinosinusitis, and nasal polyposis

Sleep impairment is a significant problem for patients with inflammatory disorders of the upper respiratory tract, such as allergic rhinitis, rhinosinusitis, and nasal polyposis. Nasal congestion, one of the most common and bothersome symptoms of these conditions, is associated with sleep-disordered breathing and is thought to be a key cause of sleep impairment. This review examines sleep impairment associated with allergic rhinitis, rhinosinusitis, and nasal polyposis. It explores the adverse effects of disturbed sleep on patients' quality of life and how these inflammatory nasal conditions can be reduced by therapies that address the underlying problems affecting sleep. Treatment with intranasal corticosteroids has been shown to reduce nasal congestion in inflammatory disorders of the upper respiratory tract. Data on sleep-related end points from clinical trials of intranasal corticosteroids indicate that this reduction is associated with improved sleep, reduced daytime fatigue, and improved quality of life. Further research using measures of sleep as primary end points is warranted, based on the potential of these agents to improve sleep and quality of life in patients with allergic rhinitis, acute rhinosinusitis, and nasal polyposis. Such trials will help to identify the most effective therapies for sleep impairment in these 3 nasal conditions.

The Lund-Mackay staging system for chronic rhinosinusitis: how is it used and what does it predict?

OBJECTIVES

The Lund-Mackay score is widely used in assessment of chronic rhinosinusitis. We aimed to describe its relationship to other measures of pre- and post-treatment health status.

STUDY DESIGN

Multicenter prospective study of 1840 patients undergoing surgery for chronic rhinosinusitis in the UK.

RESULTS

There was no absolute threshold for surgery, but patients with higher Lund-Mackay scores underwent more extensive surgery. There was no correlation between Lund-Mackay and SNOT-22 scores. The Lund-Mackay increased with increasing grade of polyposis. The Lund-Mackay score was associated with symptom reduction (coefficient = 0.24, P = 0.02) complication rates (odds ratio, 1.08, 95%CI 1.06 to 1.1), and revision rates (odds ratio, 1.03, 95% CI 1.001 to 1.06).

CONCLUSIONS

The Lund-Mackay score measures a different aspect of disease to "subjective" symptom scores. However, it correlates well with other markers of disease severity, the nature of surgery offered, and its outcome.

SIGNIFICANCE

This demonstrates the strengths and limitations of a commonly used staging system.

Objective monitoring of nasal patency and nasal physiology in rhinitis

Nasal obstruction can be monitored objectively by measurement of nasal airflow, as evaluated by nasal peak flow, or as airways resistance/conductance as evaluated by rhinomanometry. Peak flow can be measured during inspiration or expiration. Of these measurements, nasal inspiratory peak flow is the best validated technique for home monitoring in clinical trials. The equipment is portable, relatively inexpensive, and simple to use. One disadvantage, however, is that nasal inspiratory peak flow is influenced by lower airway as well as upper airway function. Rhinomanometry is a more sensitive technique that is specific for nasal measurements. The equipment, however, requires an operator, is more expensive, and is not portable. Thus, it is applicable only for clinic visit measures in clinical trials. Measurements require patient cooperation and coordination, and not all can achieve repeatable results. Thus, this objective measure is best suited to laboratory challenge studies involving smaller numbers of selected volunteers. A nonphysiological measure of nasal patency is acoustic rhinometry. This sonic echo technique measures internal nasal luminal volume and the minimum cross-sectional area. The derivation of these measures from the reflected sound waves requires complex mathematical transformation and makes several theoretical assumptions. Despite this, however, such measures correlate well with the nasal physiological measures, and the nasal volume measures have been shown to relate well to results obtained by imaging techniques such as computed tomography scanning or magnetic resonance imaging. Like rhinomanometry, acoustic rhinometry is not suitable for home monitoring and can be applied only to clinic visit measures or for laboratory nasal challenge monitoring. It has advantages in being easy to use, in requiring little patient cooperation, and in providing repeatable results. In addition to nasal obstruction, allergic rhinitis is recognized to be associated with impaired mucociliary clearance and altered nasal responsiveness. Measures exist for the monitoring of these aspects of nasal dysfunction. Although measures of mucociliary clearance are simple to perform, they have a poor record of reproducibility. Their incorporation into clinical trials is thus questionable, although positive outcomes from therapeutic intervention have been reported. Measures of nasal responsiveness are at present largely confined to research studies investigating disease mechanisms in allergic and nonallergic rhinitis. The techniques are insufficiently standardized to be applied to multicenter clinical trials but could be used in limited-center studies to gain insight into the regulatory effects of different therapeutic modalities.

Influence of Polyps on Outcomes After Endoscopic Sinus Surgery

OBJECTIVE

To determine clinical and comparative outcomes for endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) with polyposis.

METHODS

Two cohorts of adult patients with refractory CRS with and without nasal polyps were prospectively studied before and after ESS (minimum follow-up, 12 months) with the Rhinosinusitis Symptom Inventory (RSI). For the non-polyp and polyp cohorts, RSI symptom domains and medical resource utilization were compared in the preoperative and postoperative states. Corresponding effect sizes were computed and compared between cohorts to determine the effect of polyps on prognosis after ESS.

RESULTS

A total of 165 non-polyp and 86 polyp patients were enrolled. Polyps were more common in female patients (2:1, P = .025); age (mean, 42.9 years) and follow-up (18.5 months) were similar between groups. Lund scores were significantly higher for polyp patients (13.7, SD 4.8) vs. non-polyp patients (8.1, SD 5.3, P < .001). At baseline, polyp patients reported lower symptom scores for facial, oropharyngeal, and systemic RSI symptom domains (all P < .012); nasal and total symptom domains were similar between groups. Both non-polyp and polyp groups obtained significant symptomatic benefit from ESS with effect sizes for RSI symptom domain improvements ranging from 0.89 to 1.38 and 0.43 to 1.19, respectively (all P < .001). There were no significant differences between groups in symptomatic improvement, excepting oropharyngeal symptoms (better improvement in non-polyp group, P = .024). Non-polyp patients decreased medical resource consumption more significantly than did polyp patients.

CONCLUSIONS

Both non-polyp and polyp patients derive similar clinically significant symptomatic improvement after ESS. These similarities suggest that polyp patients do not necessarily have a poorer symptomatic outcome after ESS.

Nitric oxide in the airways

PURPOSE OF REVIEW

This review briefly explains the basic facts about nitric oxide, which is entering clinical practice as a measure of lower airways inflammation and is likely also to be employed in otorhinolaryngological practice.

RECENT FINDINGS

These include the validity of nasal nitric oxide in diagnosing primary ciliary dyskinesia and in monitoring the response to chronic rhinosinusitis therapy. The nasal nitric oxide value combined with a humming manoeuvre, which increases the passage of nitric oxide from the sinuses to the nose if the ostiomeatal complex is patent, could reduce the need for computed tomography scans. The link between nitric oxide production and ciliary beating requires further exploration. Therapeutic adjustments to nitric oxide production are under investigation.

SUMMARY

Nitric oxide is likely to prove highly relevant to airways defence, as well as being an inflammatory mediator. Nasal nitric oxide probably explains some of the benefit of nasal rather than mouth breathing.

Adult chronic rhinosinusitis: surgical outcomes and the role of endoscopic sinus surgery

PURPOSE OF REVIEW

To review the recent literature as to the role of and data supporting endoscopic sinus surgery for the treatment of adult chronic rhinosinusitis.

RECENT FINDINGS

Many studies have been published evaluating patient responses to endoscopic sinus surgery. These responses have included subjective measures such as patient-reported symptoms, and subjective symptoms measured objectively, as seen with quality-of-life instruments. Others have used objective measures such as endoscopy scores, medication use and financial impact to measure responses to surgery. These studies have varying follow-up, with patients followed for up to several years postsurgery. The results are very consistent, with most studies reporting improvement in both subjective and objective findings postoperatively.

SUMMARY

The data in the literature clearly support the use of functional endoscopic sinus surgery in cases of chronic rhinosinusitis refractory to medical therapy. Surgery has been shown to improve patient symptoms, quality of life and intranasal endoscopic exam.

Impact of nasal polyps on quality of life of chronic sinusitis patients

OBJECTIVE

To study the significance of nasal polyps on the symptoms of chronic rhinosinusitis (CRS) and their influence on surgical outcomes.

METHODS

Retrospective analysis of prospectively collected data comparing two groups of patients diagnosed with CRS with and without polyps who underwent surgery with a minimum of 3 month follow up period. Subjective scoring was performed using the Sino-nasal Outcome Test (SNOT-20) questionnaire. Computed tomography (CT) scans were compared using the Lund-Mackay scoring system. Endoscopic findings were graded according to Lanza and Kennedy staging system. The two groups were analyzed for the need of revision surgery.

RESULTS

30 patients underwent surgical management of CRS over a period of one year. 20 were male, 10 were female and the average age was 26 years (range 15-55years). Polyps were present in 15 patients with CRS while, the other 15 did not have polyps. The average CT score was 10.13 for the polyp group and 9.79 for patients without polyp.The Polyp group SNOT-20 preoperative scores averaged 20.27 with improvement to 3.80 at 2 weeks, 2.67 at 1 month and 2.93 at 3 months (86.21% improvement p=0.001). Non-polyp group SNOT-20 scores were 18.80 preoperatively with improvement to 4.67 at 2 weeks, 3.40 at 1 month and 3.27 at 3 months (81.83% improvement). Preop diagnostic endoscopy on polyp group was 5.27 which improved to 2.13 in 2 weeks, 1.33 in 1 month and 1.53 in 3 months (73% improvement). In the non polyp group it was 4.53 pre-operatively which improved to 1.20 in 2 weeks, 0.93 in 1 month and to 1.13 in 3months (69% improvement). 6 patients required revision surgery (20%), 3 (10%) belonging to polyp group and 3 (10%) who did not have polyps.

CONCLUSION

Nasal Polyp has a significant negative impact on the patients with CRS. Patients with polyps have higher symptom scores, worse objective findings compared with patients without polyp, but patients with polyp show more improvement after surgical intervention and need for revision surgery is equal in both groups.

Rhinosinusitis: Developing guidance for clinical trials

The Rhinosinusitis Initiative was developed by 5 national societies. The current guidance document is an expansion of the 2004 publication, "Rhinosinusitis: Establishing definitions for clinical research and patient care" and provides templates for clinical trials in antimicrobial, anti-inflammatory, and symptom-relieving therapies for the following: (1) acute presumed bacterial rhinosinusitis, (2) chronic rhinosinusitis (CRS) without nasal polyps, (3) CRS with nasal polyps, and (4) classic allergic fungal rhinosinusitis. In addition to the templates for clinical trials and proposed study designs, the Rhinosinusitis Initiative has developed 6 appendices, which address (1) health outcomes, (2) nasal endoscopy and staging of CRS, (3) radiologic imaging, (4) microbiology, (5) laboratory measures, and (6) biostatistical methods.

Rhinosinusitis: developing guidance for clinical trials

The Rhinosinusitis Initiative was developed by 5 national societies. The current guidance document is an expansion of the 2004 publication "Rhinosinusitis: Establishing definitions for clinical research and patient care" and provides templates for clinical trials in antimicrobial, anti-inflammatory, and symptom-relieving therapies for the following: (1) acute presumed bacterial rhinosinusitis, (2) chronic rhinosinusitis (CRS) without nasal polyps, (3) CRS with nasal polyps, and (4) classic allergic fungal rhinosinusitis. In addition to the templates for clinical trials and proposed study designs, the Rhinosinusitis Initiative has developed 6 appendices, which address (1) health outcomes, (2) nasal endoscopy and staging of CRS, (3) radiologic imaging, (4) microbiology, (5) laboratory measures, and (6) biostatistical methods.

Evaluation of the combined medical and surgical treatment in nasal polyposis. I: functional results

CONCLUSION

This prospective study is the first in the literature to present long-term results of a combined medical and surgical treatment in patients with nasal polyposis (NP) including strict inclusion criteria, analysis of the results in terms of clinical amelioration, polyp size reduction, and steroid consumption. The results of the present study show that combined surgery and corticosteroid therapy is effective in the treatment of NP.

OBJECTIVE

Most publications on outcome after functional endoscopic sinus surgery (FESS) include patients with various pathologies. The aim of this study was to provide reference information for FESS in patients with NP with strict inclusion and exclusion criteria.

MATERIALS AND METHODS

This was a prospective study involving 194 consecutive patients. Clinical symptoms, polyp size, and steroid consumption were evaluated before and after FESS (mean follow-up, 74 months). An actuarial analysis using the Kaplan Meier life table method was performed with regard to the 3- and 5-year symptoms control rates.

RESULTS

All symptoms were improved after FESS. The 5-year actuarial nasal obstruction control rate was 65.8%. The 5-year actuarial severe posterior rhinorrhea control rate was 82.9%. The 5-year actuarial smell loss and anosmia control rates were 17.7% and 65.8%, respectively. Polyp volume and steroid consumption decreased significantly after FESS.

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

OBJECTIVES

Despite effective medical therapy and repetitive endoscopic sinus surgery in the treatment of chronic rhinosinusitis, there still remains a small group of patients without improvement of symptoms. This study evaluates the effect of radical surgery on quality of life and pain in these patients with recalcitrant disease.

STUDY DESIGN

A prospective, questionnaire-based study was conducted in 23 patients who underwent Denker's procedure for refractory chronic rhinosinusitis. Quality of life and pain were evaluated before surgery and 12 months and 2 years after surgery with the SF-36 and McGill Pain Questionnaire.

RESULTS

Seven of the eight mean scores of the SF-36 postoperatively improved after surgery, with statistical significance for Role Physical (RP) P=0.048. Bodily pain showed a strong tendency to significance. Results of the McGill Pain Questionnaire show a significant improvement in most of the subscores after surgery implying less pain.

CONCLUSION

Radical surgery improves the physical burden of chronic rhinosinusitis and pain experience in patients with therapy resistant chronic rhinosinusitis.

Drug management in chronic rhinosinusitis: identification of the needs

Chronic rhinosinusitis (CRS) is a group of multifactorial diseases characterized by inflammation of the mucosa of the nose and paranasal sinuses with a history of at least 12 weeks of persistent symptoms despite maximal medical therapy. The precise role played by infection and immunoglobin E (IgE)-mediated hypersensitivity remains unclear. Diagnosis of CRS is based upon medical history, nasal endoscopy and computed tomography scan of the sinuses. The CRS with polyps visible in the middle meatus must be distinguished from the CRS without polyps. Based on the current knowledge about the pathogenesis of CRS, it is admitted that an optimal medical treatment must consider all favorizing factors and control efficaciously the inflammation process. In case of failure of medical treatment, endoscopic sinus surgery should be proposed. However, some well-validated data and scientific evidences are missing, even for the most frequently used medications. After a review of the actual definitions and classifications, a short description of the current knowledge about pathogenesis of CRS is provided in order to justify the actual therapeutic rationales and identify the needs for an effective treatment of CRS.

Evolution of medical management of chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a surprisingly common, poorly defined, and notoriously difficult-to-treat disease. It has a complex pathophysiology that often, but not always, involves nasal or paranasal sinus infection. Anatomic variations that predispose the sinuses to obstruction may play a role, but are unusual sole causes of chronic disease. Other possible causative factors include allergic or nonallergic inflammation, mucociliary dysfunction, aspirin intolerance (Samter's triad), immunodeficiency, and cystic fibrosis. Although a majority of patients achieve long-term relief from CRS after successful endoscopic sinus surgery, a significant proportion do not, and are likely to benefit from sustained postsurgical medical therapy. Medical therapy for CRS may include treatment with corticosteroids, antibiotics, antifungal agents, antihistamines, leukotriene modifiers, nasal decongestants, mucolytics, and nasal irrigations. The selection of appropriate medical therapy is based on endoscopic evaluation, sinus cultures, and symptoms. Computed tomography, the imaging standard for evaluation of the sinuses, provides information about the extent and distribution of mucosal disease beyond what is visible endoscopically. Because it fails to provide information on the origin of the mucosal changes, computed tomography provides limited information to guide medical therapy.