Adult chronic rhinosinusitis: definitions, diagnosis, epidemiology, and pathophysiology

Allergic rhinitis and rhinosinusitis

A relationship between allergic rhinitis and acute and chronic rhinosinusitis has been postulated for many years. Epidemiologic evidence suggests that such a relationship is likely. In addition, evidence of a common pathophysiologic mechanism linking these diseases is compelling and continues to evolve. Although a clear and definitive causal relationship remains to be elucidated, an increasing number of studies support the plausibility of this link. The current paradigm of the "unified airway" and evidence to support this model further strengthen this link. This article reviews the literature relating allergic rhinitis and acute and chronic rhinosinusitis.

Chronic rhinosinusitis and asthma

Based on considerations of the underlying epidemiology, pathophysiology, histopathology, clinical relationships and treatment outcomes, the links between rhinosinusitis and asthma become evident supporting the unified airway concept.

Fluoroquinolones compared with beta-lactam antibiotics for the treatment of acute bacterial sinusitis: a meta-analysis of randomized controlled trials

BACKGROUND

The presumed superiority of newer fluoroquinolones for the treatment of acute bacterial sinusitis is based on laboratory data but has not yet been established on clinical grounds.

METHODS

We performed a meta-analysis of randomized controlled trials comparing the effectiveness and safety of fluoroquinolones and beta-lactams in acute bacterial sinusitis.

RESULTS

We identified 8 randomized controlled trials investigating the newer "respiratory" fluoroquinolones moxifloxacin, levofloxacin and gatifloxacin. In the primary effectiveness analysis involving 2133 intention-to-treat patients from 5 randomized controlled trials, the extent of clinical cure and improvement did not differ between fluoroquinolones and beta-lactams (odds ratio [OR] 1.09, 95% confidence interval [CI] 0.85-1.39) at the test-of-cure assessment, which varied from 10 to 31 days after the start of treatment. Fluoroquinolones were associated with an increased chance of clinical success among the clinically evaluable patients in all of the randomized controlled trials (OR 1.29, 95% CI 1.03-1.63) and in 4 blinded randomized controlled trials (OR 1.45, 95% CI 1.05-2.00). There was no statistically significant difference between fluoroquinolones and amoxicillin-clavulanate (OR 1.24, 95% CI 0.93-1.65). Eradication or presumed eradication of the pathogens isolated before treatment was more likely with fluoroquinolone treatment than with beta-lactam treatment (OR 2.11, 95% CI 1.09-4.08). In the primary safety analysis, adverse events did not differ between treatments (OR 1.17, 95% CI 0.86-1.59). However, more adverse events occurred with fluoroquinolone use than with beta-lactam use in 2 blinded randomized controlled trials. The associations described here were generally consistent when we included 3 additional studies involving other fluoroquinolones (ciprofloxacin and sparfloxacin) in the analysis.

INTERPRETATION

In the treatment of acute bacterial sinusitis, newer fluoroquinolones conferred no benefit over beta-lactam antibiotics. The use of fluoroquinolones as first-line therapy cannot be endorsed.

Acute bacterial rhinosinusitis and otitis media: changes in pathogenicity following widespread use of pneumococcal conjugate vaccine

OBJECTIVE

Acute bacterial rhinosinusitis and acute otitis media are two of the most common respiratory tract infections. The common pathogenic bacteria associated with these infections are Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Staphylococcus aureus. With the recent widespread use of pneumococcal conjugate vaccine, there is evidence that there is a shift of both the pneumococcal serotypes and the distribution of pathogenic bacteria. The purpose of this article was to investigate whether the literature supports changes in pathogenicity of acute bacterial rhinosinusitis and otitis media after widespread use of conjugate pneumococcal vaccine.

DATA SOURCES

MEDLINE search of the literature was performed between 1995 and 2007.

REVIEW METHODS

Literature review of changes in distribution of pathogens, resistance rates, and pneumococcal serotype changes before and after widespread use of conjugate pneumococcal vaccine.

RESULTS

There is evidence that the distribution of pneumococcal serotypes has changed after the widespread use of conjugate pneumococcal vaccine. There appears to be both less invasive and noninvasive pneumococcal disease and with childhood immunization there also appears to be a protective effect on adults (herd immunity). Increases in nonvaccine serotypes, some with high levels of resistance are being identified in some communities. There is also growing evidence that there may be an increasing prevalence of Haemophilus influenzae in these infections.

CONCLUSIONS

Widespread use of conjugate pneumococcal vaccine has led to decreasing incidence of pneumococcal otitis media and likely also acute bacterial rhinosinusitis, which may have implications for treatment recommendations for these infections.

Evaluation of combined medical and surgical treatment in nasal polyposis - III. Correlation between symptoms and CT scores before and after surgery for nasal polyposis

CONCLUSION

Computed tomography (CT) in nasal polyposis (NP) patients has three functions before any treatment. CT provides objective evidence of the disease and precise topography of the disease, and is an indicator of the disease severity. After functional endoscopic sinus surgery (FESS), CT is an indicator of the residual disease severity and permits detection of asymptomatic mucoceles.

OBJECTIVE

NP affects nearly 4% of the population. CT has become the examination of choice for the exploration of NP. FESS is accepted for NP treatment in the setting of failure of medical management. The aim of this study was to find out whether any correlation exists between symptom severity and CT scan score before and after FESS.

PATIENTS AND METHODS

A total of 114 CT scans were performed in NP patients without contrast medium before and after FESS (mean follow-up 5 years), and were scored according to the Lund-MacKay system.

RESULTS

Lund-MacKay scores before treatment ranged from 8 to 24. There was a correlation between symptom and CT scores before any treatment. Postoperative Lund-MacKay scores ranged from 0 to 24. There was a correlation between symptom and CT scores after surgery. There was no correlation between postoperative symptom and baseline CT scores. Eleven asymptomatic mucoceles were found.

The analysis of clinical characteristics of the chronic rhinosinusitis: complicated and uncomplicated form

The objective of our study was to analyze the intensity of subjective symptoms and objective findings of endoscopy and CT scanning in chronic rhinosinusitis, in the groups with and without nasal polyps. To evaluate the intensity of subjective symptoms visual analogue scale (VAS) was used, while scores were obtained by adding grades. Endoscopic finding was given in scores recommended by Lanza and Kennedy and CT results were presented by Lund-Mackay scoring system. The study included 90 consecutive adult patients, 47 males (52%) and 43 females (48%), mean age 45 years. The group with chronic rhinosinusitis without nasal polyps (uncomplicated form) consisted of 30 patients, while the group with polyps (complicated form) included 60 patients. Comparing mean intensity values of all subjective symptoms between these two groups we found out that nasal obstruction, nasal secretion and hyposmia were significantly more manifested in the polyp group (P<0.01). Facial congestion was also more manifested in the polyp group (P<0.05). Mean score value of major symptoms was 35.55 in the polyp group, and 23.13 in the group without polyps (P<0.01). Mean value of total symptom scores was 48.68 in the polyp group, and 35.00 in the group without polyps (P<0.01). Endoscopic score was approximately 9.03 in the polyp group, and 2.43 in the group without polyps (P<0.01). CT score was 16.05 on an average in the polyp group, and 4.37 in the group without polyps (P<0.01). Chronic rhinosinusitis complicated by nasal polyposis is characterized by higher degree of nasal obstruction, nasal secretion, hyposmia and facial congestion, which results in higher score of major and total score of symptoms, respectively. This form is also characterized by worse objective findings, which is reflected in higher endoscopic and CT scores.

Influence of allergy in patients with nasal polyposis after endoscopic sinus surgery

CONCLUSION

Allergy does not modify the symptoms and steroid consumption (oral and local) of nasal polyposis (NP) patients after functional endoscopic sinus surgery (FESS).

OBJECTIVES

To assess the role of allergy in the evolution after FESS of patients presenting with the diagnosis of NP.

PATIENTS AND METHODS

This was a prospective study of 63 consecutive patients with NP (57% males, mean age 45.8 years), who were analyzed to detect whether the results of a surgical treatment of NP were influenced by the presence of positive allergic tests (Phadiatop). Three nasal criteria were scored: nasal obstruction, posterior rhinorrhea, and the loss of smell. The frequency of asthma was evaluated. Medical treatment of NP after FESS consisted of washing of the nasal cavities, steroid spray, and oral steroid administration. The amount of consumption of steroids (prednisolone and beclomethasone) was studied.

RESULTS

Decrease of all nasal symptoms was not statistically different in the two groups of patients with and without allergy. Cumulative consumption of prednisolone and beclomethasone after surgery was similar in the two groups.

Olfactory cilia: our direct neuronal connection to the external world

An organism's awareness of its surroundings is dependent on sensory function. As antennas to our external environment, cilia are involved in fundamental biological processes such as olfaction, photoreception, and touch. The olfactory system has adapted this organelle for its unique sensory function and optimized it for detection of external stimuli. The elongated and tapering structure of olfactory cilia and their organization into an overlapping meshwork bathed by the nasal mucosa is optimized to enhance odor absorption and detection. As many as 15-30 nonmotile, sensory cilia on dendritic endings of single olfactory sensory neurons (OSNs) compartmentalize signaling molecules necessary for odor detection allowing for efficient and spatially confined responses to sensory stimuli. Although the loss of olfactory cilia or deletion of selected components of the olfactory signaling cascade leads to anosmia, the mechanisms of ciliogenesis and the selected enrichment of signaling molecules remain poorly understood. Much of our current knowledge is the result of elegant electron microscopy studies describing the structure and organization of the olfactory epithelium and cilia. New genetic and cell biological approaches, which compliment these early studies, show promise in elucidating the mechanisms of olfactory cilia assembly, maintenance, and compartmentalization. Importantly, emerging evidence suggests that olfactory dysfunction represents a previously unrecognized clinical manifestation of multiple ciliary disorders. Future work investigating the mechanisms of olfactory dysfunction combining both clinical studies with basic science research will provide us important new information regarding the pathogenesis of human sensory perception diseases.

Clinical practice guideline: adult sinusitis

OBJECTIVE

This guideline provides evidence-based recommendations on managing sinusitis, defined as symptomatic inflammation of the paranasal sinuses. Sinusitis affects 1 in 7 adults in the United States, resulting in about 31 million individuals diagnosed each year. Since sinusitis almost always involves the nasal cavity, the term rhinosinusitis is preferred. The guideline target patient is aged 18 years or older with uncomplicated rhinosinusitis, evaluated in any setting in which an adult with rhinosinusitis would be identified, monitored, or managed. This guideline is intended for all clinicians who are likely to diagnose and manage adults with sinusitis.

PURPOSE

The primary purpose of this guideline is to improve diagnostic accuracy for adult rhinosinusitis, reduce inappropriate antibiotic use, reduce inappropriate use of radiographic imaging, and promote appropriate use of ancillary tests that include nasal endoscopy, computed tomography, and testing for allergy and immune function. In creating this guideline the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of allergy, emergency medicine, family medicine, health insurance, immunology, infectious disease, internal medicine, medical informatics, nursing, otolaryngology-head and neck surgery, pulmonology, and radiology.

RESULTS

The panel made strong recommendations that 1) clinicians should distinguish presumed acute bacterial rhinosinusitis (ABRS) from acute rhinosinusitis caused by viral upper respiratory infections and noninfectious conditions, and a clinician should diagnose ABRS when (a) symptoms or signs of acute rhinosinusitis are present 10 days or more beyond the onset of upper respiratory symptoms, or (b) symptoms or signs of acute rhinosinusitis worsen within 10 days after an initial improvement (double worsening), and 2) the management of ABRS should include an assessment of pain, with analgesic treatment based on the severity of pain. The panel made a recommendation against radiographic imaging for patients who meet diagnostic criteria for acute rhinosinusitis, unless a complication or alternative diagnosis is suspected. The panel made recommendations that 1) if a decision is made to treat ABRS with an antibiotic agent, the clinician should prescribe amoxicillin as first-line therapy for most adults, 2) if the patient worsens or fails to improve with the initial management option by 7 days, the clinician should reassess the patient to confirm ABRS, exclude other causes of illness, and detect complications, 3) clinicians should distinguish chronic rhinosinusitis (CRS) and recurrent acute rhinosinusitis from isolated episodes of ABRS and other causes of sinonasal symptoms, 4) clinicians should assess the patient with CRS or recurrent acute rhinosinusitis for factors that modify management, such as allergic rhinitis, cystic fibrosis, immunocompromised state, ciliary dyskinesia, and anatomic variation, 5) the clinician should corroborate a diagnosis and/or investigate for underlying causes of CRS and recurrent acute rhinosinusitis, 6) the clinician should obtain computed tomography of the paranasal sinuses in diagnosing or evaluating a patient with CRS or recurrent acute rhinosinusitis, and 7) clinicians should educate/counsel patients with CRS or recurrent acute rhinosinusitis regarding control measures. The panel offered as options that 1) clinicians may prescribe symptomatic relief in managing viral rhinosinusitis, 2) clinicians may prescribe symptomatic relief in managing ABRS, 3) observation without use of antibiotics is an option for selected adults with uncomplicated ABRS who have mild illness (mild pain and temperature <38.3 degrees C or 101 degrees F) and assurance of follow-up, 4) the clinician may obtain nasal endoscopy in diagnosing or evaluating a patient with CRS or recurrent acute rhinosinusitis, and 5) the clinician may obtain testing for allergy and immune function in evaluating a patient with CRS or recurrent acute rhinosinusitis.

DISCLAIMER

This clinical practice guideline is not intended as a sole source of guidance for managing adults with rhinosinusitis. Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. It is not intended to replace clinical judgment or establish a protocol for all individuals with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem.

Rate of allergic fungal etiology of chronic rhinosinusitis in Turkish population

The aim of this study is to investigate intranasal fungal incidence in Turkish patients with chronic rhinosinusitis (CRS). One hundred patients with CRS and 40 healthy subjects as a control group were included in the prospective study. Nasal lavage samples were investigated for the presence of fungus, using new culture techniques and histopathologic examination. Epidermal and intradermal hypersensitivity tests were used to find out fungal atopy. Levels of serum eosinophils, total IgE and presence of fungus-specific IgE were investigated in the blood samples. Quantitative parameters were analyzed using Pearson chi(2) test. Allergic fungal sinusitis (AFS) was diagnosed in 13 (13%) patients. There was no fungal growth in the control group. Eosinophilic mucin was detected in 94% of patients. Clinical and laboratory parameters of CRS were not significantly different in patient groups with or without intranasal fungi. As a result, fungal incidence was not as high as expected in Turkish patients with CRS. Furthermore, no significant correlation could be found between presence of intranasal fungus and type-1 hypersensitivity in patients with CRS.

Evaluation of the surgical treatment of nasal polyposis. II: Influence of a non-specific bronchial hyperresponsiveness

CONCLUSION

Bronchial hyperresponsiveness (BHR) is not a risk factor for surgery in patients with nasal polyposis (NP).

OBJECTIVE

Management of NP should be primarily medical, and surgery should not be envisaged before a trial of dual steroid therapy. In patients with severe NP resistant to a strict medical treatment, endoscopic sinus surgery is performed, but no prognostic factor for efficacy of surgery is obvious. Some authors suggest that asthma could be a major risk for ineffectiveness of surgery. The aim of this study was to evaluate whether the presence of BHR can be considered a risk factor for ineffectiveness of surgery.

SUBJECTS AND METHODS

Surgery (with associated medical treatment) was evaluated over a mean follow-up period of 74 months. A total of 63 subjects without and 131 subjects with BHR were operated according to a standardized protocol.

RESULTS

The present study shows that combined surgery and corticosteroid therapy is effective in the treatment of severe NP, producing significant and long-term improvements in symptoms and in the size of nasal polyps. BHR did not influence the outcome. Moreover, the mean amount of prednisolone and beclomethasone necessary after surgery was similar in the two groups.

A preliminary study into the effect of low-intensity pulsed ultrasound on chronic maxillary and frontal sinusitis

Sinusitis is a very common acute or chronic illness that affects a significant percentage of individuals. Recently, therapeutic ultrasound was reported as a treatment for chronic sinusitis. The purpose of this study was twofold: 1) to evaluate the effectiveness of low-intensity pulsed ultrasound (US) in chronic sinusitis using a pretest-posttest research design and 2) to determine the level of association between the independent variables of initial presence of symptoms, age, gender, and duration of disease and the dependent variable of improvement of symptoms. Patients with chronic sinusitis were treated with low-intensity pulsed US, 3 days per week for 15 sessions. Fifty-seven patients (18 females and 39 males; mean age, 35 years) were included in the study. The results of the McNemar test showed a significant change in proportions of post nasal drip and nasal obstruction, two common leading symptoms of patients with chronic sinusitis (p < 0.001). Most of the major and minor symptoms showed significant changes after US therapy (p < 0.05). The total improvement of symptoms was 81.3%. The greatest improvement in symptoms was observed in nasal discharge (100%), followed by facial pain (95.4%) and postnasal drip (82.7%), three major factors in sinusitis. There was a significant, low association between the initial presence of symptoms and the improvement of symptoms after US therapy (chi(2) = 30.352; df = 12; p = 0.002; phi value = 0.356). A significant, low association was also noted between the age and the improvement of symptoms after intervention (chi(2) = 17.548; df = 6; p = 0.007; phi value = 0.270). It may be concluded that low-intensity pulsed US has a significant effect on chronic sinusitis and improves patient symptoms in our study group.

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.

Invasive aspergillosis of the paranasal sinuses and the skull base

Invasive aspergillosis (IA) originating from the paranasal sinuses can cause an intracranial growth mainly along the skull base and larger vessels. This study reports our experience in the diagnosis and treatment of a series of patients with IA. A retrospective chart review of four patients with chronic invasive intracranial aspergillosis was performed. Clinical signs, physical examinations, radiographs, histological samples, and outcome were demonstrated. The patients demonstrated different symptoms like exophthalmus, ophthalmoplegia, loss of vision, and hypaesthesia of the ophthalmic and maxillary nerve. Computed tomography and MRI revealed extensive sino-orbital and skull base lesions. The patients were treated with aggressive endonasal debridement, intravenous antifungal agents and daily irrigations with antimycotic suspensions. Furthermore, we applied hyperbaric oxygenation. Two patients died from complications due to subarachnoidal hemorrhage and accompanied complications respectively. Despite the high mortality rate patients with an invasive aspergillosis can be effectively treated in some cases by an early and rigorous treatment schedule using all surgical and conservative therapeutic options.

Role of prostaglandin D2 and E2 terminal synthases in chronic rhinosinusitis

BACKGROUND

Prostaglandin (PG)D(2) and E(2), two major cyclooxygenase (COX) products, are generated by PGD(2) synthase (PGDS) and PGE(2) synthase (PGES), respectively, and appear to mediate airway inflammation.

OBJECTIVE

We sought to determine the role of PGDS and PGES in the pathophysiology of chronic rhinosinusitis (CRS).

METHODS

The study examined the expression of PGDS and PGES in nasal polyps of 22 CRS patients. As controls, uncinate process mucosae were obtained from 12 CRS patients not having nasal polyps and five subjects without sinusitis. Immunohistochemistry and quantitative real-time PCR were used to evaluate the expression.

RESULTS

Both PGDS and PGES were detected in nasal polyps by immunohistochemistry. Significantly greater levels of PGDS mRNA and lesser levels of PGES mRNA were observed in the nasal polyps as compared with uncinate process mucosae, and an inverse correlation between PGDS and PGES expression was observed. Levels of PGDS mRNA in nasal polyps were positively correlated with degree of infiltration by EG2+ eosinophils, whereas the levels of PGES were inversely correlated. Significantly increased levels of PGDS and conversely decreased levels of PGES were observed in asthmatics as compared with non-asthmatics. In addition, PGDS and PGES levels were positively and inversely correlated with the radiological severity of sinusitis, respectively.

CONCLUSIONS

These results suggest that PGDS and PGES display an opposite and important role in the pathophysiology of CRS such as polyp formation, and more specifically, a biased expression of these synthases might contribute to the development of CRS by affecting eosinophilic inflammation.

The role of interleukin-16 in eosinophilic chronic rhinosinusitis

Eosinophilic granulocytes (Eos) are found in great numbers both in the tissue and in the mucus of patients suffering from chronic rhinosinusitis with polyposis (ECRS). Interleukin-16 (IL-16) is known as a highly potent chemotactic and chemoattractant molecule (ED 10-11) for Eos. In an open, explorative, controlled study we examined the presence of IL-16 in mucosa tissue, mucus and serum in patients suffering from ECRS and its association to Eos activation. Tissue and nasal mucus specimen from 10 previously untreated, non allergic ECRS-patients undergoing paranasal sinus surgery and from 10 healthy non sinusitis subjects, undergoing nasal surgery because of anatomic nasal obstruction were investigated by real-time (RT-) PCR targeting human IL-16 mRNA. Haematoxylin-eosin (HE) staining and immunohistochemistry of formalin embedded tissue and mucus were applied for detection and determination of the proportion of activated Eos (aEos) and IL-16. Serum IL-16 was analyzed by enzyme-linked-immunosorbent assay (ELISA). IL-16 mRNA and IL-16 protein levels were elevated in nasal mucus, polyp tissue and in the serum of ECRS patients compared to healthy controls. There was a high proportion of aEos in ECRS patients compared to healthy subjects. Serum IL-16, IL-16 mRNA expression and IL-16 protein in mucus and tissue specimens were significantly associated with the presence of aEos in polyps of ECRS patients. Immunohistochemically IL-16 protein was mainly expressed in aEos, mast cells, lymphocytes and epithelial cells. In conclusion our data indicate that IL-16 may stimulate the migration and persistence of activated Eos in ECRS. IL-16 production in ECRS patients is not mediated by Immunglobuline-E (IgE).

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.

New bone formation in unilateral rhinosinusitis

BACKGROUND

Computed tomography (CT) frequently shows abnormal bone thickening in patients with chronic rhinosinusitis. The sinus bone may be not in a static state, and remodeling occurs in response to chronic inflammation.

METHODS

Ostiomeatal unit CT scans were reviewed in 29 patients with unilateral rhinosinusitis (URS) undergoing endoscopic sinus surgery. We defined new bone formation (NBF) as a remarkable bone thickening or hyperostosis of the intrinsic sinus walls in comparison with the normal side. Bony CT scores of sinus walls were expressed by the Hounsfield unit (HU) and soft tissue CT scores were measured by the Lund-Mackay system.

RESULTS

Almost all of the NBF was located at the maxillary and anterior ethmoid sinuses (83.7%), and it was significantly increased in patients with higher Lund-Mackay scores (p = 0.043). The HU values were significantly different between NBF and non-NBF contralateral sides (p < 0.05).

CONCLUSION

The HU may be helpful to diagnose and quantify the bone remodeling in URS.

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.

The significance of MRI findings for non-rhinological disease

OBJECTIVES

Mucosal changes in the paranasal sinuses are detected in 30-50% of scans for non-rhinological disease. This study assesses the relationship between symptoms of rhinosinusitis and radiological evidence of sinus pathology in patients undergoing magnetic resonance imaging (MRI) scans for unrelated pathology.

DESIGN

Prospective observational study, evaluating symptoms of rhinosinusitis in patients undergoing MRI scanning of the internal acoustic meati. A visual analogue scale (VAS) of rhinological symptoms was completed immediately before scanning, specifying symptoms present at the time of completing the questionnaire. Symptom scores were recorded by one of the investigators, blinded to the MRI images. Two investigators independently rated sinus mucosal thickening for each scan, both of whom were blinded to the symptom scores. Lund and Mackay scoring systems were used for both symptom and radiological scores, which were then compared.

SETTING

Otolaryngology and Radiology Departments in a large teaching hospital.

PARTICIPANTS

Fifty consecutive patients were recruited over a 2-month period.

MAIN OUTCOME MEASURES

Visual analogue scale symptom scores were compared with radiological scores for sinus mucosal thickening.

RESULTS

No statistically significant relationship was demonstrated between rhinological symptoms and radiological features suggestive of rhinosinusitis in patients undergoing MRI scanning for non-rhinological disease.

CONCLUSIONS

The relationship between rhinological symptoms and MRI findings of sinus pathology is not straightforward. Management decisions should be made on the basis of nasal history and endoscopy, rather than radiological findings. This is the first study assessing this relationship by documenting symptoms on the day of scanning, using a validated scoring system.

Herbal medicines for the treatment of rhinosinusitis: a systematic review

OBJECTIVES

To assess the efficacy of herbal medicines for treating rhinosinusitis.

DATA SOURCE

Five electronic databases, bibliographies of located papers, manufacturers, and experts in the field.

REVIEW METHODS

Inclusion of randomized clinical trials (RCT) testing any herbal medicine in rhinosinusitis, as sole or adjunctive treatment. Data were extracted independently by two reviewers following a predetermined protocol.

RESULTS

Ten RCTs, testing six different herbal products against placebo (8 RCTs) or "no additional treatment" (2 RCTs) were included. Four RCTs tested Sinupret as adjunctive treatment for either acute (3 RCTs) or chronic (1 RCT) rhinosinusitis. The quality of these studies varied, but two in acute sinusitis, including the largest and best quality study, and one in chronic sinusitis reported significant positive findings. Three RCTs tested bromelain in either acute sinusitis (2 RCTs) or patients of mixed diagnosis (chronic and acute sinusitis), and all reported some positive findings. Metanalysis of the two RCTs in acute sinusitis suggested that adjunctive use of bromelain significantly improves some symptoms of acute rhinosinusitis. Single RCTs were identified for 4 other herbal products (Esberitox, Myrtol, Cineole, and Bi Yuan Shu) as treatments for sinusitis, all reported some positive results. The median methodological quality score was 3 of 5.

CONCLUSION

Evidence that any herbal medicines are beneficial in the treatment of rhinosinusitis is limited, particularly in chronic rhinosinusitis. There is encouraging evidence that Sinupret and bromelain may be effective adjunctive treatments in acute rhinosinusitis. Positive results from isolated RCTs of four other herbal products require independent replication.

Endoscopic treatment of maxillary sinus disease before grafting

We present our experience of the treatment of four patients with maxillary sinus disease by endoscopic sinus surgery to restore the normal physiology of the sinus before grafting.

Differential diagnosis of eosinophilic chronic rhinosinusitis

Eosinophilic chronic rhinosinusitis (ECRS) encompasses a wide variety of etiologies. To date, a unifying pathophysiologic mechanism remains elusive. Eosinophilia is frequently, but not exclusively, caused by immunoglobulin (Ig)E-mediated hypersensitivity and is dominated by the associated cytokine milieu of Th2 inflammation. The provisional subcategories of ECRS include superantigen-induced eosinophilic chronic rhinosinusitis, allergic fungal sinusitis, nonallergic fungal eosinophilic chronic rhinosinusitis, and aspirin-exacerbated eosinophilic chronic rhinosinusitis. Within each subcategory, recent findings supporting distinct mechanisms that promote eosinophilic infiltration are presented, and, therefore, targeted therapeutic interventions with specific antibacterial, antifungal, or immune modulation may be indicated.

Distinct features of chronic rhinosinusitis with and without nasal polyps

BACKGROUND

Based on the presence of nasal polyps on endoscopy, chronic rhinosinusitis (CRS) may be clinically divided in CRS with nasal polyps and CRS without nasal polyps. It is unclear, whether CRS with nasal polyps and CRS without nasal polyps represent different disease entities or just different stages of one single disease. In case of one disease, only minor histopathological differences between CRS with small early-stage polyps (CRSNP((+))) and CRS without nasal polyps (CRSNP(-)) were expected.

METHODS

Patients with CRSNP((+)) confined to the infundibular region or CRSNP(-) were selected. Histochemical and immunohistochemical characterization of ethmoidal mucosa was performed on formalin-fixed and paraffin-embedded tissue specimens. Frequency and distribution of eosinophils, neutrophils, mast cells, IgE(+) cells, macrophages, B- and T-cell subsets, natural killer cells, plasma cells and goblet cells were assessed. In addition, the thickness of the basal membrane was evaluated.

RESULTS

Nine CRS patients without detectable polyps, and 11 patients with small early-stage polyps confined to the infundibular region were selected. Despite adjacent polyp stage, the amount of round cell infiltration (P < 0.05), number of eosinophils (P < 0.05), and plasma cells (P < 0.01) significantly differed in the ethmoidal specimens from patients of the two groups.

CONCLUSION

Substantial histopathological differences were observed in ethmoidal mucosa of CRSNP((+)) and CRSNP(-) patients. Thus, the results of this investigation support the concept that CRS with nasal polyps and CRS without nasal polyps are two different disease entities rather than different stages of one single disease, but may also be interpreted as a higher degree of inflammation.

Imaging for functional endoscopic sinus surgery

Radiologic imaging is an essential part of the presurgical evaluation of patients with sinusitis and of the monitoring of difficult-to-treat,recurrent, and postsurgical disease. In patients with noninflammatory sinus pathology and those who "baffle" clinical diagnosis, ima-ging is extremely helpful in differentiating the various pathological entities and determining the extent of disease. Computerized tomography (CT), when deemed clinically necessary, is the current modality of choice to evaluate sinusitis. CT's ability to display bone,mucosa, and air makes it a perfect tool for imaging of the paranasal sinuses. The fine bony architecture of the nasal cavity and the para-nasal sinus drainage pathways are depicted accurately with CT examination.

Primary role of growth-related oncogene-alpha and granulocyte chemotactic protein-2 as neutrophil chemoattractants in chronic rhinosinusitis

BACKGROUND

The aetiology of chronic rhinosinusitis (CRS) remains unclear. The purpose of this study was to investigate neutrophil-attracting chemokine patterns in CRS without nasal polyposis.

METHODS

The biological activity of the chemokines was identified using a two-step high-performance liquid chromatography (HPLC) technique combined with a bioassay in extracts from 55 CRS patients, and in the turbinate mucosa (TM) of patients (N=51) undergoing septumplasty. The biologic activity of each chemokine was assessed using blocking antibodies to chemokines. Immunolocalization of detected neutrophil chemokines was performed by quantitative evaluation of immunohistochemistry. Besides, PCR analysis was performed to quantify neutrophil chemokine mRNA.

RESULTS

In CRS, the chemokines primarily detected by two-step HPLC were growth-related oncogene-alpha (GRO-alpha) and the granulocyte chemotactic protein-2 (GCP-2). Blocking of GCP-2 and GRO-alphad each resulted in chemotaxis inhibition rates of 43.3% and 35.9%, respectively, whereas anti-IL-8 and anti-ENA-78 had no effect. Both GCP-2 and GRO-alphad were generally synthesized by the surface epithelium and mucosal glands while GRO-alpha in particular was synthesized by endothelial cells, as shown by immunohistochemistry. The concentrations of the chemokines IL-8 and epithelial cell-derived neutrophil attractant-78 (ENA-78) were low in CRS and TM.

CONCLUSION

It appears that both GRO-alpha and GCP-2 contribute to neutrophil chemotaxis in CRS, whereas IL-8 and ENA-78 appear to be of secondary importance for the chemotaxis of neutrophils in this condition. The expression of chemokines in mucosal gland cells is the main phenomenon involved in constitutive neutrophil chemotaxis in the TM.

Fungal speciation using quantitative polymerase chain reaction (QPCR) in patients with and without chronic rhinosinusitis

OBJECTIVES/HYPOTHESIS

The objectives of this study were to determine the mycology of the middle meatus using an endoscopically guided brush sampling technique and polymerase chain reaction laboratory processing of nasal mucous; to compare the mycology of the middle meatus in patients with sinus disease with subjects without sinus disease; to compare the responses on two standardized quality-of-life survey forms between patients with and without sinusitis; and to determine whether the presence of fungi in the middle meatus correlates with responses on these data sets.

STUDY DESIGN

The authors conducted a single-blind, prospective, cross-sectional study.

METHODS

Patients with sinus disease and a control group without sinus disease were enrolled in the study. A disease-specific, validated Sinonasal Outcomes Test survey (SNOT-20) was completed by the subjects and a generalized validated Medical Outcomes Short Form 36 Survey (SF-36) was also completed. An endoscopically guided brush sampling of nasal mucous was obtained from the middle meatus. Fungal specific quantitative polymerase chain reaction (QPCR) was performed on the obtained sample to identify one of 82 different species of fungus in the laboratory. Statistical analysis was used to categorize the recovered fungal DNA and to crossreference this information with the outcomes surveys.

RESULTS

The fungal recovery rate in the study was 45.9% in patients with sinus disease and 45.9% in control subjects. Patients with chronic rhinosinusitis had a mean SNOT-20 score of 1.80 versus the control group mean score of 0.77 (P < .0001). SF-36 data similarly showed a statistically significant difference between diseased and control populations with controls scoring a mean of 80.37 and patients with chronic rhinosinusitis scoring a mean of 69.35 for a P value of .02. However, no statistical significance could be ascribed to the presence or absence of fungi recovered, the type of fungi recovered, or the possible impact of fungi on the quality-of-life survey results.

CONCLUSION

The recovery rate of fungi from the middle meatus of patients with chronic rhinosinusitis and a control population without chronic rhinosinusitis is 45.9% using QPCR techniques. No direct causation with regard to fungal species or presence was proven; however, a species grouping for future studies is proposed based on trends in this data and other reports. Disease-specific outcomes surveys revealed a statistically significant difference between the two groups.

Chlamydophila pneumoniae in chronic rhinosinusitis

CONCLUSIONS

The intracellular bacterium Chlamydophila pneumoniae (Cp) was infrequently found in nasopharynx and lacking in biopsies from the middle turbinate in chronic rhinosinusitis (CRS) patients. Compared with healthy controls, patients suffering from CRS had significantly higher and more prevalent antibody titers to Cp. However, an association between CRS and Cp could not be established.

OBJECTIVES

To study the prevalence of Cp in CRS patients and in healthy controls to determine if an association exists between Cp and CRS.

MATERIALS AND METHODS

PCR against Cp was run on middle turbinate biopsies and on throat and nasopharyngeal swabs from 25 CRS patients and from 10 healthy controls. Serum samples were tested for Cp-specific antibodies by the microimmunofluorescence method. Patients that tested positive for Cp or had high antibody titers were treated with antibiotics.

RESULTS

Cp was found in nasopharyngeal samples from two patients but from none of the controls. Neither patients nor controls had Cp in biopsies from the middle turbinate. Antibody titers against Cp were significantly higher and more prevalent in patients than in controls. Seventeen patients were treated with antibiotics but only four of them recovered from sinusitis symptoms during the 2-year follow-up.

Development of a murine model of chronic rhinosinusitis

OBJECTIVE

The aim of this study was to develop a mouse model of chronic eosinophilic rhinosinusitis.

STUDY DESIGN

Mice were sensitized to Aspergillis fumigatus (Af) extract by intraperitoneal injection. The animals subsequently received nasal challenges with Af extract 3 times per week for 12 weeks. Sinonasal complexes were studied histologically by the study otolaryngologists and pathologists to characterize the inflammatory response.

SETTING

Animal care facility at an academic institution.

RESULTS

A chronic eosinophilic inflammatory response was evoked in all study animals. Statistical analysis was performed for inflammation, secretory cell hyperplasia, mast cells, and eosinophils. There were very significant differences (P<0.0005) between control and study mice in all categories.

CONCLUSION

Prolonged nasal challenge of Af extract creates an inflammatory response in murine nasal mucosa that mimics human chronic eosinophilic rhinosinusitis.

SIGNIFICANCE

A murine model for chronic rhinosinusitis is reported that may facilitate future investigations into disease pathophysiology.

EBM RATING

B-2.

Much ado about functional endoscopic sinus surgery

BACKGROUND

Reported success rates in endoscopic sinus surgery vary from 74 to 97%. However, the methods of evaluation and the functional endoscopic sinus surgery (FESS) techniques are not standard in these series. In our practice, some patients failed to attend the 3-monthly follow up claiming all was well. With this experience, the aim of this study is to document a standard minimal technique with minimal follow up, which may be applicable to selected patients.

METHODS

An open prospective clinical trial was conducted. A total of 102 selected patients were subjected to minimal FESS surgery and discharged after a 3-month follow up with instructions to return if problems re-ensued.

RESULTS

In a telephone follow up ranging from 28 to 40 months postoperatively, 12 patients could not be traced. All of the other patients expressed satisfaction with the results. There were no patients who were dissatisfied with the outcome. However, two patients have persisted with postoperative check-up visits on their own accord.

CONCLUSION

It is possible in selected patients to resort to minimal FESS surgery with expectation of a good clinical outcome. It is stressed that, 'rigid selection criteria' apply.

Classification and management of rhinosinusitis and its complications

A stepwise evaluation of patients who have CRS allows a management approach that is tailored to each individual patient and to the specific type of disease.

Chronic rhinosinusitis and superantigens

This article discusses the potential role of bacterial superantigens (SAgs) in chronic rhinosinusitis with nasal polyposis (CRS/NP). First, it briefly describes SAgs, focusing on how they interact with the immune system by binding to T-cell receptors (TCR) and major histocompatibility complex (MHC) class II molecules. Second, it discusses the role of SAgs in other chronic inflammatory diseases.Finally, it presents evidence for the role of SAgs in the pathogenesis and maintenance of CRS/NP focusing on current research and future considerations.

Role of MR and CT in the paranasal sinuses

This article discusses the benefits and drawbacks of MR imaging and computed tomography as they relate to sinus disease.

Viral infections and susceptibility to recurrent sinusitis

Viral respiratory infection is thought to be the major contributing factor in the pathogenesis of bacterial sinusitis. It is still not clear why some patients suffer from recurrent sinusitis episodes, as information on the exact pathomechanism of how bacterial sinusitis develops as a complication of viral colds is still scarce. In this review, different mechanisms of how a viral infection may predispose some patients to recurrent bacterial sinusitis episodes are presented. Awareness of the fact that different mechanisms may exist behind this single diagnosis of recurrent sinusitis may be of help when diagnostic measures and treatments are planned for these patients.

The role of ubiquitous airborne fungi in chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a confusing disease for both allergists and otorhinolaryngologists, partially due to its poorly understood pathophysiology and partially due to its limited treatment options. Several recent reports now provide evidence for a better understanding of the etiology and the relationship of CRS to airborne fungi, especially to Alternaria. First, the development of novel methods enables detection of certain fungi in mucus from the nasal and paranasal sinus cavities. Second, a non-immunoglobulin E-mediated immunologic mechanism for reactivity of CRS patients to certain common fungi has been described. Third, these fungi are surrounded by eosinophils in vivo, suggesting that they are targeted by eosinophils. Fourth, the preliminary results of studies using antifungal agents to treat patients with CRS are promising. Overall, these recent discoveries provide a logical mechanism for the pathophysiology of CRS, and they also suggest promising avenues for treatment of CRS with antifungal agents.

Treatment of chronic rhinosinusitis with low-dose, long-term macrolide antibiotics: an evolving paradigm

The 14-membered and 15-membered ring macrolide antibiotics express immunomodulatory effects in chronic respiratory disorders in humans that are distinct from their antimicrobial properties. These drugs downregulate the excessive immune and inflammatory responses observed in these conditions while promoting tissue repair. To this end, chronic rhinosinusitis is characterized by mucosal inflammation of nasal and sinus mucosa for more than 3 months and accounts for significant health care resource allocation due to difficulties in treatment. Clinical efficacy of macrolide antibiotics as biologic response modifiers in patients with chronic rhinosinusitis is suggested by compelling basic research and small, uncontrolled clinical studies. Hence, long-term, prospective double-blind placebo-controlled clinical studies are indicated to establish the utility of these drugs in the treatment of patients with chronic rhinosinusitis.

Sinusitis in HIV: microbiology and therapy

Rhinosinusitis in the HIV-infected population is an increasingly common finding as HIV infection has transitioned toward becoming a chronic medical condition. In this patient population, rhinosinusitis may be challenging to diagnose and treat effectively. However, adequate diagnostic tools are available, microbial identity can be reasonably anticipated based on the CD4 count, and effective management strategies can be implemented. In this article, we discuss the diagnostic and therapeutic options for HIV-infected patients with rhinosinusitis.

Radiological imaging of inflammatory lesions in the nasal cavity and paranasal sinuses

Paranasal sinus development and pneumatisation variants are described, and rhinosinusitis and different patterns of inflammatory sinonasal diseases are reviewed. Other inflammatory sinonasal diseases, e.g., fungal sinusitis, mucocele, pyocele and sinonasal manifestations in systemic diseases, are briefly described. Computed tomography (CT) is the primary modality in diagnosing and mapping suspected inflammatory sinonasal disease. Magnetic resonance (MR) imaging is complementary to CT if fungal sinusitis, pyocele or malignancy are suspected.

Bacterial Biofilms: Do They Play a Role in Chronic Sinusitis?

Although medical and surgical strategies for chronic sinusitis have been greatly refined during the last 2 decades, many patients continue to suffer. Bacterial biofilms are three-dimensional aggregates of bacteria that recently have been shown to play a major role in many chronic infections. There is growing evidence that bacterial biofilms may play a role in some forms of recalcitrant chronic sinusitis that persists despite surgically opened sinus cavities and what seems to be appropriate, culture-directed antibiotic therapy. New directions in therapy aimed at biofilms may provide some success in treatment for patients with chronic sinusitis.

Allergy and Chronic Rhinosinusitis

The association between chronic rhinosinusitis (CRS) and allergy of the upper respiratory system has been discussed for many years,but much of this discussion has been anecdotal. Although epidemiologic evidence supports the increased prevalence of CRS among patients who have allergic rhinitis, and treatment of upper airway inflammation and allergy has been shown to decrease morbidity in patients who have CRS, but pathophysiologic mechanisms linking the two disease states have not been well elucidated. This article examines data supporting the link between upper airway allergic disease and CRS. It proposes a frame work for the treatment of CRS, with consideration of managing the allergic inflammation commonly noted in this disease. Finally, it discusses avenues for potential future research in evaluating the comorbidities of allergic inflammation and CRS.

Diagnóstico de rinossinusite crônica em pacientes com fibrose cística: correlação entre anamnese, nasofibroscopia e tomografia computadorizada

O comprometimento nasossinusal é uma das principais manifestações otorrinolaringológicas da fibrose cística. Na literatura, é descrita a alta incidência de rinossinusite crônica nesses pacientes. Apesar de mais de 90% dos casos apresentarem panopacificação dos seios da face em exames de imagem, tais achados são raramente acompanhados de sintomas. Por isso, o profissional tem dificuldade de diagnosticar a doença nasossinusal em pacientes com fibrose cística. Dentre os métodos disponíveis para essa avaliação, o questionário (sintomas), a nasofibroscopia (sinais) e a tomografia computadorizada têm grande importância. OBJETIVO: Avaliar o diagnóstico de rinossinusite crônica em pacientes portadores de fibrose cística por meio de questionário (anamnese); nasofibroscopia e tomografia computadorizada de seios da face e comparar os seus achados. FORMA DE ESTUDO: Clínico prospectivo transversal. MATERIAL E MÉTODO: Avaliação de 34 pacientes - maiores de 6 anos de idade e portadores de fibrose cística - por meio de questionário, nasofibroscopia (escore de Lund-Kennedy) e tomografia computadorizada de seios da face (escore de Lund-Mackay). RESULTADOS: Observou-se que o diagnóstico de rinossinusite crônica foi positivo em: 20,58% dos casos pelo questionário; 73,52% dos casos pela nasofibroscopia e 93,54% dos casos pela tomografia computadorizada. A diferença entre os resultados foi estatisticamente significante. Verificou-se uma correlação de 55,1% entre as estratificações dos escores de nasofibroscopia e de tomografia computadorizada. CONCLUSÃO: O diagnóstico positivo da rinossinusite crônica foi predominantemente observado pela tomografia computadorizada. O diagnóstico negativo foi predominante na avaliação pelo questionário. Houve diferença estatisticamente significante entre os meios de avaliação. A nasofibroscopia é um excelente recurso que deve ser utilizado na avaliação de rinossinusite crônica em fibrose cística.

Sinogenic Facial Pain: Diagnosis and Management

Most patients who present to an otorhinolaryngology clinic with facial pain and headaches believe they have sinusitis. There is an increasing awareness that neurologic causes are responsible for a large proportion of patients with headache and facial pain. If facial pain and pressure is the primary symptom, it is unlikely to be caused by sinus disease in the absence of any nasal symptoms or signs. Patients with facial pain who have no objective evidence of sinus disease are unlikely to be helped by surgery. Most patients with pain caused by sinusitis respond to medical therapy.

Superantigens and chronic rhinosinusitis: detection of staphylococcal exotoxins in nasal polyps

OBJECTIVE/HYPOTHESIS

The role of infectious agents in the etiology of chronic rhinosinusitis with nasal polyposis (CRSwNP) remains unclear. Recent studies have provided indirect evidence of exposure to staphylococcal exotoxins in the blood and polyp tissue of patients with CRSwNP. These exotoxins have the capacity to act as superantigens, bypassing normal antigen processing and directly stimulating a massive inflammatory response. The objective of the study was to analyze mucus and polyp tissue samples from patients with CRSwNP for the presence of staphylococcal exotoxins.

STUDY DESIGN

Prospective study.

METHODS

Tissue and mucus samples were obtained from 42 patients undergoing endoscopic sinus surgery for chronic rhinosinusitis and 11 normal control patients. Twenty-nine of 42 patients had chronic rhinosinusitis with bilateral nasal polyposis, 2 had antrochoanal polyps, and 11 had chronic rhinosinusitis without nasal polyps. Eleven patients without chronic rhinosinusitis or polyps served as normal control patients. Specimens were analyzed for the presence of five staphylococcal exotoxins (SEA, SEB, SEC, SED, and toxic shock syndrome toxin type 1 [TSST-1]) using enzyme-linked immunosorbent assay (ELISA). Histological analysis of specimens and mean eosinophil counts were correlated with the presence of toxin.

RESULTS

At least one toxin was detected in 14 of 29 patients with bilateral nasal polyposis. Nine of the 14 patients also had positive findings for additional toxins. The dominant histological pattern in the CRSwNP patient group was polypoid mucosa with edema, which was found in both ELISA-positive and ELISA-negative patients. Mean eosinophil counts tended to be higher in ELISA-positive patients with polyps compared with patients without toxin detection. No toxin was detected in the 11 specimens taken from normal control patients. Only 1 of the 13 patients with CRS without polyps had positive ELISA results for toxin.

CONCLUSION

The current study demonstrates the presence of superantigen toxins in 14 of 29 patients with CRSwNP, with SEB and TSST-1 being the most common. Further studies are necessary to correlate the presence of toxin with the pathological changes present in polyp tissue.