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Xu Z, Yan J, Wen W, Zhang N, Bachert C. Pathophysiology and management of Staphylococcus aureus in nasal polyp disease. Expert Rev Clin Immunol 2023; 19:981-992. [PMID: 37409375 DOI: 10.1080/1744666x.2023.2233700] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 07/03/2023] [Indexed: 07/07/2023]
Abstract
INTRODUCTION Staphylococcus aureus (S. aureus) is a common pathogen that frequently colonizes the sinonasal cavity. Recent studies demonstrated the essential role of Staphylococcus aureus in the pathophysiology of uncontrolled severe chronic rhinosinusitis with nasal polyps (NP) by initiating an immune response to the germ and its products, resulting in type 2 inflammation. AREAS COVERED This review aims to summarize the evidence for the role of S. aureus in the development of NP disease including S. aureus-related virulence factors, the pathophysiologic mechanisms used by S. aureus, and the synergistic effects of S. aureus and other pathogens. It also describes the current management of S. aureus associated with NPs as well as potential therapeutic strategies that are used in clinical practice. EXPERT OPINION S. aureus is able to damage the nasal mucosal epithelial barrier, impair the clearance of the host immune system, and trigger adaptive and innate immune reactions which lead to the formation of inflammation and nasal polyp growth. Further studies should focus on the development of novel therapeutic strategies, such as biologics, bacteriophages, probiotics, and nanomedicine, which could be used to treat S. aureus and its immunological consequences in the future.
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Affiliation(s)
- Zhaofeng Xu
- Department of Otorhinolaryngology, The First Affiliated Hospital of Sun Yat-Sen University, Sun Yat-Sen University, Guangzhou, China
| | - Jieying Yan
- Department of Otorhinolaryngology, The First Affiliated Hospital of Sun Yat-Sen University, Sun Yat-Sen University, Guangzhou, China
- Upper Airway Research Laboratory, Ghent University, Ghent, Belgium
| | - Weiping Wen
- Department of Otorhinolaryngology, The First Affiliated Hospital of Sun Yat-Sen University, Sun Yat-Sen University, Guangzhou, China
- Upper Airway Research Laboratory, Ghent University, Ghent, Belgium
| | - Nan Zhang
- Department of Otorhinolaryngology, The First Affiliated Hospital of Sun Yat-Sen University, Sun Yat-Sen University, Guangzhou, China
- Upper Airway Research Laboratory, Ghent University, Ghent, Belgium
| | - Claus Bachert
- Department of Otorhinolaryngology, The First Affiliated Hospital of Sun Yat-Sen University, Sun Yat-Sen University, Guangzhou, China
- Upper Airway Research Laboratory, Ghent University, Ghent, Belgium
- Division of ENT Diseases, Stockholm, Sweden
- Clinic for ENT Diseases and Head and Neck Surgery, University Clinic Münster, Münster, Germany
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Popper C, Martin H, Shah R, Sicard R, Hodges K, Frank-Ito DO. Intranasal Spray Characteristics for Best Drug Delivery in Patients With Chronic Rhinosinusitis. Laryngoscope 2023; 133:1036-1043. [PMID: 35560998 PMCID: PMC9653517 DOI: 10.1002/lary.30155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 04/05/2022] [Accepted: 04/22/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To determine parameter combinations for effective drug delivery of intranasal spray steroids to the ostiomeatal complex (OMC) and maxillary sinus (MS) in patients with chronic rhinosinusitis (CRS). METHODS Each patient's sinonasal cavity was reconstructed from computed tomography scans. Intranasal airflow and drug particle transport were simulated using computational fluid dynamic modeling. Airflow simulations were performed at 15 Pascal inhalation pressure. Intranasal spray particles of 1-100 μm were simulated at release speeds of 1, 5, and 10 m/s from 6 release locations (Bottom, Center, Top, Lateral, Lateral-Bottom, and Lateral-Top) at a nozzle insertion depth of 15 mm. Drug delivery simulations were performed in the head tilted forward position. RESULTS Maximal OMC deposition was 0.78%-12.44%, while maximal MS deposition was 0.02%-1.03% across all simulations. In general, particles between 6 and 10 μm had the best OMC (at 1 m/s particle velocity) and MS (at 10 m/s particle velocity) deposition. Particles ranging from 21 to 30 μm also had superior OMC deposition. The lateral and lateral-top spray release locations produced maximum OMC deposition, but no one release location demonstrated an increase in MS deposition. CONCLUSION This preliminary study suggests that it is challenging to determine a common set of intranasal spray parameter combinations for effective drug delivery to the OMC and MSs. Although drug particle size and spray particle velocity seem to impact particle deposition patterns, spray release location appears to vary with anatomical differences between subjects, particularly when the MS is the target location for particle deposition. Laryngoscope, 133:1036-1043, 2023.
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Affiliation(s)
- Carson Popper
- Campbell University School of Osteopathic Medicine, Buies Creek, North Carolina, USA
- Department of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Hannah Martin
- Department of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Reanna Shah
- Department of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Ryan Sicard
- Department of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Katrina Hodges
- Department of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, North Carolina, USA
- Pre-Health Post-Baccalaureate Program, Meredith College, Raleigh, North Carolina, USA
| | - Dennis Onyeka Frank-Ito
- Department of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, North Carolina, USA
- Computational Biology and Bioinformatics PhD Program, Duke University, Durham, North Carolina, USA
- Department of Mechanical Engineering and Materials Science, Duke University, Durham, North Carolina, USA
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Martinez-Paredes JF, Donaldson AM, Marino M, Choby G, Olomu O, Alfakir R, Stokken JK, O'Brien E, Lal D. Sinonasal Outcomes Using Oral Corticosteroids in Patients with Chronic Rhinosinusitis with Nasal Polyps and Positive Sinonasal Cultures. Int Arch Otorhinolaryngol 2022; 27:e286-e295. [PMID: 37125375 PMCID: PMC10147476 DOI: 10.1055/s-0042-1743275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 12/21/2021] [Indexed: 12/24/2022] Open
Abstract
Abstract
Introduction Patients with chronic rhinosinusitis with nasal polyps (CRSwNP) and positive sinonasal bacterial cultures may be recalcitrant to topical therapy alone due to the additional local inflammatory burden associated with bacterial infection/colonization.
Objective To evaluate sinonasal outcomes in CRSwNP patients with a positive perioperative bacterial culture, who were treated with postoperative intranasal corticosteroids (INCS) alone versus INCS in combination with a short-term course of oral corticosteroids (OCS).
Methods This is a retrospective chart review of CRSwNP patients. A total of 59 patients met inclusion criteria, including positive perioperative bacterial culture and treatment with INCS with or without concomitant use of OCS. Two cohorts were formed based on the chosen postoperative medical treatment; 32 patients underwent postoperative INCS alone, while 27 underwent INCS plus a ≤ 2-week course of OCS. The 22-item sinonasal outcome test (SNOT-22) scores and Lund-Kennedy scores (LKS) were assessed preoperatively, and at 2-week, 4-week, and 4 to 6 months after endoscopic sinus surgery (ESS).
Results There were no statistically significant differences in postoperative sinonasal symptoms or endoscopic scores between the cohorts treated with INCS plus OCS versus those prescribed INCS alone (p > 0.05). Our regression model failed to demonstrate a relationship between the use of OCS and better sinonasal outcomes at 2-week, 4-week, and 4 to 6 months after ESS (p > 0.05).
Conclusion Our study suggests that in a cohort of CRSwNP patients with recent bacterial infections, the postoperative use of combined OCS and INCS did not result in a statistical improvement of endoscopic and symptomatic outcomes over INCS irrigation alone. However, both treatment groups had a clinically significant improvement based on the Minimal Clinically Important Difference.
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Affiliation(s)
- Jhon F. Martinez-Paredes
- Department of Otolaryngology – Head and Neck Surgery, Mayo Clinic, Jacksonville, Florida, United States
- Department of Surgery, University of Texas – Rio Grande Valley, Edinburg, Texas, United States
| | - Angela M. Donaldson
- Department of Otolaryngology – Head and Neck Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Michael Marino
- Department of Otolaryngology – Head and Neck Surgery, Mayo Clinic, Phoenix, Arizona, United States
| | - Garret Choby
- Department of Otolaryngology – Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Osarenoma Olomu
- Department of Otolaryngology – Head and Neck Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Razan Alfakir
- Department of Speech, Language & Hearing Sciences, Auburn University, Alabama, United States
| | - Janalee K. Stokken
- Department of Otolaryngology – Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Erin O'Brien
- Department of Otolaryngology – Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Devyani Lal
- Department of Otolaryngology – Head and Neck Surgery, Mayo Clinic, Phoenix, Arizona, United States
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Tseng FH, Newman M, Song CH. Chronic and Recurrent Sinusitis in Children, as Manifestation of Immune Dysfunction and Atopic Background. Adv Pediatr 2022; 69:75-93. [PMID: 35985718 DOI: 10.1016/j.yapd.2022.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Rhinosinusitis in children, as in adults, can be classified by duration (acute, recurrent, and chronic) and by cause (viral, bacterial, and inflammatory) and needs to be treated accordingly after careful investigation which include through clinical history, laboratory tests, and, if necessary, nasal endoscopy and imaging studies.
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Affiliation(s)
- Farn-Hsuan Tseng
- Harbor-University of California, Los Angeles, Torrance, CA 90509, USA
| | - Marissa Newman
- University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Charles H Song
- Harbor-University of California, Los Angeles, Torrance, CA 90509, USA.
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Martinez-Paredes JF, Choby G, Marino M, Lal D, Olomu O, Alfakir R, Stokken JK, O’Brien E, Donaldson AM. Endoscopic outcomes in patients with AERD treated with topical antibiotics and intranasal corticosteroids. Front Cell Infect Microbiol 2022; 12:812215. [PMID: 35959364 PMCID: PMC9358357 DOI: 10.3389/fcimb.2022.812215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 06/29/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundIdentifying effective therapy for recalcitrant chronic rhinosinusitis with nasal polyposis (CRSwNP) is a major challenge; and subtypes such as aspirin-exacerbated respiratory disease (AERD) are even more difficult to treat. Evidence on topical antibiotics use in (CRSwNP) is lacking. Current consensus guidelines recommend against its routine use, but recent reviews show some benefit when managing recalcitrant disease after endoscopic sinus surgery (ESS).ObjectiveEvaluate the effect of culture-directed topical antibiotics on sinonasal outcomes in AERD patients with a positive perioperative sinonasal bacterial culture who have undergone ESS.MethodsA retrospective cohort study of AERD patients with positive sinonasal culture, who underwent ESS from 2016 to 2021 was performed. Forty-four patients were identified and stratified based on their postoperative medical treatment. Twenty-six underwent postoperative intranasal corticosteroids (INCS) alone, while eighteen underwent INCS plus a 4-weeks treatment with topical antibiotics. SNOT-22 and Lund-Kennedy score (LKS) were assessed preoperatively and at 4-weeks and 4-6 months after ESS.ResultsA statistically significant improvement in the 4-weeks and 4-6 months postoperative SNOT-22 and LKS were noted within both groups (p<0.05). However, only a statistically significant difference was found in the 4-weeks postoperative LKS when comparing between treatment groups (p=0.01). Our linear regression model demonstrated a relationship between the use of combined therapy with INCS and topical antibiotics and the LKS 4-weeks post ESS (p=0.015).ConclusionIn AERD patients with a confirmed sinus infection, the combination of culture-directed topical antibiotics and intranasal corticosteroid irrigations in the postoperative period can provide a short-term improvement in endoscopic scores.
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Affiliation(s)
- Jhon F. Martinez-Paredes
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic in Florida, Jacksonville, FL, United States
- Department of Surgery, University of Texas Rio Grande Valley, Edinburg, TX, United States
| | - Garret Choby
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic in Rochester, Rochester, MN, United States
| | - Michael Marino
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic in Arizona, Phoenix, AZ, United States
| | - Devyani Lal
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic in Arizona, Phoenix, AZ, United States
| | - Osarenoma Olomu
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic in Florida, Jacksonville, FL, United States
| | - Razan Alfakir
- Department of Speech-Language & Hearing Sciences, Auburn University, Auburn, AL, United States
| | - Janalee K. Stokken
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic in Rochester, Rochester, MN, United States
| | - Erin O’Brien
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic in Rochester, Rochester, MN, United States
| | - Angela M. Donaldson
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic in Florida, Jacksonville, FL, United States
- *Correspondence: Angela M. Donaldson,
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Smith SS, Kim R, Douglas R. Is there a role for antibiotics in the treatment of chronic rhinosinusitis? J Allergy Clin Immunol 2022; 149:1504-1512. [PMID: 35217148 PMCID: PMC11185277 DOI: 10.1016/j.jaci.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 02/14/2022] [Accepted: 02/14/2022] [Indexed: 11/15/2022]
Abstract
Rhinosinusitis is one of the most common reasons for adult outpatient antibiotic prescriptions, though there is little clinical evidence to support this practice, especially for chronic rhinosinusitis. Despite considerable research, the etiology of chronic rhinosinusitis, including the pathogenic role of microbes, remains poorly understood. Rigorous studies of the efficacy of antibiotic treatment of chronic sinusitis are surprisingly few in number and the results are somewhat conflicting. This review article will review the rationales for and against the treatment of chronic rhinosinusitis with antibiotics, based on current evidence and understanding of pathophysiology, and will also summarize the current guidelines.
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Affiliation(s)
- Stephanie Shintani Smith
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill; Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill.
| | - Raymond Kim
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Richard Douglas
- Department of Surgery, The University of Auckland, Auckland, New Zealand
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Hon K, Liu S, Cooksley C, Vreugde S, Psaltis A. Low pH nasal rinse solution enhances mupirocin antimicrobial efficacy. Rhinology 2022. [DOI: 10.4193/rhin21.459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Background: Chronic rhinosinusitis (CRS) is a common condition negatively impacting a patient’s quality of life. It has been hypothesized that bacterial biofilms are involved in the pathogenesis of CRS due to their persistence and difficulty to eradicate with conventional antibiotic therapy. Hence, the topical delivery of antibiotics via nasal rinse solution has gained a lot of attention due to the ability to deliver higher local concentrations, with less systemic absorption and side effects. This study investigates the efficacy of mupirocin dissolved in the 3 most commonly used sinus rinses in Australia Neilmed (isotonic saline), Flo Sinus Care (sodium chloride, sodium bicarbonate, potassium chloride, glucose anhydrous and calcium lactate and Pentahydrate) and FloCRS (sodium chloride, potassium chloride and xylitol). Methods: Planktonic and biofilm cultures of S. aureus (ATCC25923, 2 methicillin-resistant S. aureus (MRSA) (C222 and C263), and 2 methicillin-susceptible S. aureus (MSSS) (C311 and C349) clinical isolates) were treated with mupirocin dissolved in three sinus rinses (Neilmed, Flo Sinus Care and FloCRS with different pH). To establish whether pH was a significant factor in determining antibiotic activity, experiments with Flo CRS were performed both at pH 5.64 and elevated pH 7.7. The minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) were determined for planktonic cells. The biofilm biomass and metabolic activity were assessed by using crystal violet assay and alamarBlue assay respectively. Results: The combination of mupirocin in low pH (pH 5.64) sinus rinse (FloCRS) had the highest efficacy in reducing the growth of S. aureus in both the planktonic and biofilm forms. Mupirocin diluted in FloCRS (pH 5.64) showed a significantly higher reduction in both biomass and metabolic activity than that was observed when mupirocin was diluted in Neilmed, Flo Sinus Care or FloCRS (pH 7.7). Conclusion: The choice of irrigant solution for topical mupirocin delivery appears to be important for antimicrobial activity. The delivery of mupirocin via low pH FloCRS could be useful in eliminating S. aureus biofilms present on the sinus mucosa of patients with CRS.
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Park DY, Choi JH, Kim DK, Jung YG, Mun SJ, Min HJ, Park SK, Shin JM, Yang HC, Hong SN, Mo JH. Clinical Practice Guideline: Nasal Irrigation for Chronic Rhinosinusitis in Adults. Clin Exp Otorhinolaryngol 2022; 15:5-23. [PMID: 35158420 PMCID: PMC8901942 DOI: 10.21053/ceo.2021.00654] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 06/17/2021] [Indexed: 11/22/2022] Open
Abstract
The Korean Society of Otorhinolaryngology-Head and Neck Surgery and Korean Rhinologic Society appointed a guideline development group (GDG) to establish a clinical practice guideline, and the GDG developed a guideline for nasal irrigation for adult patients with chronic rhinosinusitis (CRS). The guideline focuses on knowledge gaps, practice variations, and clinical concerns associated with nasal irrigation. Nasal irrigation has been recommended as the first-line treatment for CRS in various guidelines, and its clinical effectiveness has been demonstrated through a number of studies with robust evidence. However, no guidelines have presented a consistent nasal irrigation method. Several databases, including OVID Medline, Embase, the Cochrane Library, and KoreaMed, were searched to identify all relevant papers using a predefined search strategy. When insufficient evidence was found, the GDG sought expert opinions and attempted to fill the evidence gap. Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. The committee developed 11 evidence-based recommendations. This guideline focuses on the evidence-based quality improvement opportunities deemed the most important by the GDG. Moreover, the guideline addresses whether nasal lavage helps treat CRS, what type of rinsing solution should be used, and the effectiveness of using additional medications to increase the therapeutic effect.
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Affiliation(s)
- Do-Yang Park
- Department of Otolaryngology, Ajou University School of Medicine, Suwon, Korea
| | - Ji Ho Choi
- Department of Otorhinolaryngology-Head and Neck Surgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Dong-Kyu Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
| | - Yong Gi Jung
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sue Jean Mun
- Department of Otorhinolaryngology-Head and Neck Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hyun Jin Min
- Department of Otorhinolaryngology-Head and Neck Surgery, Chung-Ang University College of Medicine, Seoul, Korea
| | - Soo Kyoung Park
- Department of Otorhinolaryngology-Head and Neck Surgery, Chungnam National University College of Medicine, Daejeon, Korea
| | - Jae-Min Shin
- Department of Otorhinolaryngology-Head and Neck Surgery, Korea University College of Medicine, Seoul, Korea
| | - Hyung Chae Yang
- Department of Otolaryngology-Head and Neck Surgery, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, Korea
| | - Seung-No Hong
- Department of Otorhinolaryngology-Head and Neck Surgery, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Ji-Hun Mo
- Department of Otorhinolaryngology-Head and Neck Surgery, Dankook University College of Medicine, Cheonan, Korea
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Petersen IS, Zeuthen AB, Christensen JM, Bartels MD, Johansen HHN, Johansen SP, Jarløv JO, Mogensen D, Pedersen J. Rhinopharynx irrigations and mouthwash with dissolved mupirocin in treatment of MRSA throat colonization - proof-of-concept study. J Hosp Infect 2021; 119:16-21. [PMID: 34699965 DOI: 10.1016/j.jhin.2021.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 08/20/2021] [Accepted: 09/01/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND To prevent transmission of, and infection with, meticillin-resistant Staphylococcus aureus (MRSA), eradication treatment of colonized individuals is recommended. Throat colonization is a well-known risk factor for eradication failure. Staphylococcus aureus throat colonization is associated with colonization of the rhinopharynx, but in the currently recommended Danish MRSA eradication strategies, rhinopharynx colonization is not directly targeted. Rhinopharynx colonization could therefore be an important risk factor for prolonged MRSA throat carriage. AIM To determine whether irrigation and wash of the rhinopharynx and mouth with dissolved mupirocin is a feasible and potentially efficacious supplementary strategy against treatment-resistant MRSA throat carriage. METHODS The patient study was an open, non-blinded, trial including 20 treatment-resistant MRSA throat carriers. In the study, the patients received a supplementary treatment besides the standard treatment according to the Danish MRSA eradication strategy. The supplementary treatment consisted of rhinopharyngeal irrigation and mouth-gurgling twice a day for 14 days with a mupirocin ointment (22 g 2% ointment per litre of isotonic sterile saline solution) in a 37°C solution. FINDINGS Eighteen patients (90%) complied with the treatment protocol and none ex-perienced any major adverse events. Out of the 18 patients who finished the study per protocol, 15 (83%) and seven (39%) patients had negative MRSA sampling results one and six months after end of treatment, respectively. CONCLUSION This study demonstrates the feasibility and clinical potential of also targeting the rhinopharynx and oropharynx in non-systemic throat MRSA eradication strategies.
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Affiliation(s)
- I S Petersen
- Department of Clinical Microbiology and MRSA Unit, Slagelse Hospital, Zealand, Denmark.
| | - A B Zeuthen
- Department of Clinical Microbiology and MRSA Unit, Slagelse Hospital, Zealand, Denmark
| | - J M Christensen
- Department of Clinical Microbiology and MRSA Unit, Slagelse Hospital, Zealand, Denmark
| | - M D Bartels
- Department of Clinical Microbiology and MRSA Knowledge Center, Copenhagen University Hospital - Amager and Hvidovre, Copenhagen, Denmark
| | - H H N Johansen
- Department of Clinical Microbiology and MRSA Knowledge Center, Copenhagen University Hospital - Amager and Hvidovre, Copenhagen, Denmark
| | - S P Johansen
- Department of Clinical Microbiology and MRSA Knowledge Center, Copenhagen University Hospital - Amager and Hvidovre, Copenhagen, Denmark
| | - J O Jarløv
- Department of Clinical Microbiology and MRSA Unit, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - D Mogensen
- Department of Clinical Microbiology and MRSA Unit, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - J Pedersen
- Department of Clinical Microbiology and MRSA Unit, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
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Ulhaq ZS, Putri ASK, Atmaja WPS, Santosaningsih D. The 40-kDa protein of Lumbricus rubellus eradicates methicillin-resistant Staphylococcusaureus in an long-term nasal carriage model. ACTA ACUST UNITED AC 2021; 39:310-311. [PMID: 34088458 DOI: 10.1016/j.eimce.2020.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 08/18/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Zulvikar Syambani Ulhaq
- Department of Biochemistry, Faculty of Medicine and Health Sciences, Maulana Malik Ibrahim State Islamic University of Malang, Batu, East Java, Indonesia; Department of Clinical Microbiology, Faculty of Medicine, Brawijaya University/Dr. Saiful Anwar Hospital, Malang, East Java, Indonesia.
| | - Anggi Sasmita Kharisma Putri
- Department of Clinical Microbiology, Faculty of Medicine, Brawijaya University/Dr. Saiful Anwar Hospital, Malang, East Java, Indonesia
| | - Wahyu Picesa Sila Atmaja
- Department of Clinical Microbiology, Faculty of Medicine, Brawijaya University/Dr. Saiful Anwar Hospital, Malang, East Java, Indonesia
| | - Dewi Santosaningsih
- Department of Clinical Microbiology, Faculty of Medicine, Brawijaya University/Dr. Saiful Anwar Hospital, Malang, East Java, Indonesia
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Kühnel TS, Hosemann WG, Weber R. [Postoperative treatment following paranasal sinus surgery]. HNO 2021; 69:517-528. [PMID: 33942126 DOI: 10.1007/s00106-021-01057-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
Postoperative care is a crucial aspect for the success of paranasal sinus interventions. Basic procedures include saline nasal wash, which should be started on the first postoperative day, topical steroids, and antibiotics in cases of infection. Medical treatment involves aspiration of secretion in the inferior meatus during the first week. Removal of scabs in the surgical field should be carried out under endoscopic control beginning at the second week. Intervals are scheduled individually. Occlusion of the nose for the time of epithelium regeneration provides a moist space in the ethmoid, which improves wound healing.
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Affiliation(s)
- Thomas S Kühnel
- Klinik und Poliklinik für Hals-Nasen-Ohren-Heilkunde, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland.
| | - Werner G Hosemann
- Fachbereich HNO, Helios Hanseklinikum Stralsund, Große Parower Straße 47, 18435, Stralsund, Deutschland
| | - Rainer Weber
- HNO-Klinik, Städtisches Klinikum Karlsruhe, Moltkestraße 90, 76133, Karlsruhe, Deutschland
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Orlandi RR, Kingdom TT, Smith TL, Bleier B, DeConde A, Luong AU, Poetker DM, Soler Z, Welch KC, Wise SK, Adappa N, Alt JA, Anselmo-Lima WT, Bachert C, Baroody FM, Batra PS, Bernal-Sprekelsen M, Beswick D, Bhattacharyya N, Chandra RK, Chang EH, Chiu A, Chowdhury N, Citardi MJ, Cohen NA, Conley DB, DelGaudio J, Desrosiers M, Douglas R, Eloy JA, Fokkens WJ, Gray ST, Gudis DA, Hamilos DL, Han JK, Harvey R, Hellings P, Holbrook EH, Hopkins C, Hwang P, Javer AR, Jiang RS, Kennedy D, Kern R, Laidlaw T, Lal D, Lane A, Lee HM, Lee JT, Levy JM, Lin SY, Lund V, McMains KC, Metson R, Mullol J, Naclerio R, Oakley G, Otori N, Palmer JN, Parikh SR, Passali D, Patel Z, Peters A, Philpott C, Psaltis AJ, Ramakrishnan VR, Ramanathan M, Roh HJ, Rudmik L, Sacks R, Schlosser RJ, Sedaghat AR, Senior BA, Sindwani R, Smith K, Snidvongs K, Stewart M, Suh JD, Tan BK, Turner JH, van Drunen CM, Voegels R, Wang DY, Woodworth BA, Wormald PJ, Wright ED, Yan C, Zhang L, Zhou B. International consensus statement on allergy and rhinology: rhinosinusitis 2021. Int Forum Allergy Rhinol 2021; 11:213-739. [PMID: 33236525 DOI: 10.1002/alr.22741] [Citation(s) in RCA: 413] [Impact Index Per Article: 137.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/09/2020] [Indexed: 02/06/2023]
Abstract
I. EXECUTIVE SUMMARY BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document. METHODS ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary. RESULTS ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided. CONCLUSION This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.
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Affiliation(s)
| | | | | | | | | | - Amber U Luong
- University of Texas Medical School at Houston, Houston, TX
| | | | - Zachary Soler
- Medical University of South Carolina, Charleston, SC
| | - Kevin C Welch
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | | | | | | | - Claus Bachert
- Ghent University, Ghent, Belgium.,Karolinska Institute, Stockholm, Sweden.,Sun Yatsen University, Gangzhou, China
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - David A Gudis
- Columbia University Irving Medical Center, New York, NY
| | - Daniel L Hamilos
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Richard Harvey
- University of New South Wales and Macquarie University, Sydney, New South Wales, Australia
| | | | | | | | | | - Amin R Javer
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | | | | | | | | | | | | | - Valerie Lund
- Royal National Throat Nose and Ear Hospital, UCLH, London, UK
| | - Kevin C McMains
- Uniformed Services University of Health Sciences, San Antonio, TX
| | | | - Joaquim Mullol
- IDIBAPS Hospital Clinic, University of Barcelona, Barcelona, Spain
| | | | | | | | | | | | | | | | | | | | - Alkis J Psaltis
- University of Adelaide, Adelaide, South Australia, Australia
| | | | | | | | - Luke Rudmik
- University of Calgary, Calgary, Alberta, Canada
| | - Raymond Sacks
- University of New South Wales, Sydney, New South Wales, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | - De Yun Wang
- National University of Singapore, Singapore, Singapore
| | | | | | | | - Carol Yan
- University of California San Diego, La Jolla, CA
| | - Luo Zhang
- Capital Medical University, Beijing, China
| | - Bing Zhou
- Capital Medical University, Beijing, China
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Swords CE, Wong JJ, Stevens KN, Psaltis AJ, Wormald PJ, Tan NCW. The Use of Postoperative Antibiotics Following Endoscopic Sinus Surgery for Chronic Rhinosinusitis: A Systematic Review and Meta-analysis. Am J Rhinol Allergy 2021; 35:700-712. [PMID: 33487001 DOI: 10.1177/1945892421989142] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Endoscopic sinus surgery is performed for medically recalcitrant chronic rhinosinusitis. There is no universally accepted strategy regarding post-operative antibiotics despite the high rates of usage worldwide. The aim of this study was to analyse patient-reported and objective outcomes behind antibiotic use following endoscopic sinus surgery. METHODS A search of electronic databases was performed. Eligible randomised controlled trials (RCTs) and observational trials were included. The primary outcome was patient reported outcome measures. Secondary outcomes were local infections, endoscopy scores and adverse events. Meta-analysis was performed. RESULTS Of 1045 publications identified, 7 were included in the qualitative synthesis and 5 RCTs were included in meta-analysis. Antibiotic regimens varied between studies in terms of antibiotic selection, timing commenced and duration of use. Meta-analysis suggested no significant difference between placebo and antibiotics in patient reported outcome measures (standardised mean difference (SMD) -0.215, 95% confidence interval (CI) -0.637 to 0.207) or endoscopic scores (SMD -2.86, 95% CI -0.846 to 0.273). There was no consistent definition in reporting of infection; therefore, this outcome cannot be comprehensively considered. No severe adverse events were attributable to antibiotics. CONCLUSIONS From the studies analysed, there is no level 1 evidence to suggest that antibiotics improved patient outcomes following sinus surgery. However, there was significant heterogeneity in outcome measures and no clear data exists regarding the effects of antibiotics on postoperative infections. The available evidence at present is not enough to make a recommendation in either direction. Further designed larger RCTs are required to investigate these questions in more detail.
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Affiliation(s)
- Chloe E Swords
- Department of Otolaryngology, West Suffolk Hospital, Bury St Edmunds, UK
| | - Jeremy J Wong
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Kara N Stevens
- Medical Statistics, University of Plymouth, Plymouth, UK
| | - Alkis J Psaltis
- Department of Otolaryngology, University of Adelaide, Adelaide, Australia
| | - Peter J Wormald
- College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Neil C-W Tan
- College of Medicine and Health, University of Exeter Medical School, Exeter, UK.,Department of Otolaryngology, Royal Cornwall Hospital, Truro, UK
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Kim K, Otto BA, Farag AA, Zhao K. Topical irrigation against gravity may lead to better sinus penetration. Int Forum Allergy Rhinol 2020; 11:198-200. [PMID: 33145957 DOI: 10.1002/alr.22711] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/30/2020] [Accepted: 10/02/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Kanghyun Kim
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, OH.,Department of Biomedical Engineering, The Ohio State University, Columbus, OH
| | - Bradley A Otto
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, OH
| | - Alexander A Farag
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, OH
| | - Kai Zhao
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, OH.,Department of Biomedical Engineering, The Ohio State University, Columbus, OH
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Zhao K, Kim K, Craig JR, Palmer JN. Using 3D printed sinonasal models to visualize and optimize personalized sinonasal sinus irrigation strategies. Rhinology 2020; 58:266-272. [PMID: 32441708 DOI: 10.4193/rhin19.314] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Topical sinus irrigations (neti-pot, squeeze bottles) play a critical role in the management of sinonasal disease. However, due to intricate nasal anatomy, penetration of topical irrigations to targeted sinus regions may be highly variable, and difficult to objectively predict. Variables, including head positions, injection angles, flow rates, etc. may vary significantly depending on the individual's anatomy. OBJECTIVE The purpose of this study was to propose a novel idea: using a 3D printed model of sinonasal cavities to visualize and develop a patient-specific irrigation strategy. METHODS As a proof of concept, 3D replicas of one patient's sinonasal cavities pre- and post-surgery were printed with a Form2 SLA 3D printer based on their CT scans. The setup included rubber/silicon seals attached to the model's nostrils to create a watertight seal with the irrigation device and food color dye added for better visualization of irrigation results. RESULTS Irrigations were performed on the 3D models with various head positions, injection angles, and flow rates, and were successful to determine the optimal strategy to targeted sinuses. Significant differences were observed between different targeted sinuses and between pre and post-surgery models. CONCLUSION With more affordable 3D printing, this technology may potentially improve patient care and patient education, allowing clinicians and patients to develop a personalized irrigation strategy and have visual confirmation.
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Affiliation(s)
- K Zhao
- Department of Otolaryngology- Head and Neck Surgery, The Ohio State University, Columbus, OH, USA
| | - K Kim
- Department of Otolaryngology- Head and Neck Surgery, The Ohio State University, Columbus, OH, USA
| | - J R Craig
- Department of Otolaryngology- Head and Neck Surgery, Henry Ford Health System, Detroit, MI, USA
| | - J N Palmer
- Department of Otolaryngology- Head and Neck Surgery, Perelmann School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
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Ulhaq ZS, Putri ASK, Atmaja WPS, Santosaningsih D. The 40-kDa protein of Lumbricus rubellus eradicates methicillin-resistant Staphylococcusaureus in an long-term nasal carriage model. Enferm Infecc Microbiol Clin 2020. [PMID: 33070991 DOI: 10.1016/j.eimc.2020.08.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Zulvikar Syambani Ulhaq
- Department of Biochemistry, Faculty of Medicine and Health Sciences, Maulana Malik Ibrahim State Islamic University of Malang, Batu, East Java, Indonesia; Department of Clinical Microbiology, Faculty of Medicine, Brawijaya University/Dr. Saiful Anwar Hospital, Malang, East Java, Indonesia.
| | - Anggi Sasmita Kharisma Putri
- Department of Clinical Microbiology, Faculty of Medicine, Brawijaya University/Dr. Saiful Anwar Hospital, Malang, East Java, Indonesia
| | - Wahyu Picesa Sila Atmaja
- Department of Clinical Microbiology, Faculty of Medicine, Brawijaya University/Dr. Saiful Anwar Hospital, Malang, East Java, Indonesia
| | - Dewi Santosaningsih
- Department of Clinical Microbiology, Faculty of Medicine, Brawijaya University/Dr. Saiful Anwar Hospital, Malang, East Java, Indonesia
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Local immunoglobulin production in nasal tissues: A key to pathogenesis in chronic rhinosinusitis with nasal polyps and aspirin-exacerbated respiratory disease. Ann Allergy Asthma Immunol 2020; 126:127-134. [PMID: 33065294 DOI: 10.1016/j.anai.2020.09.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/11/2020] [Accepted: 09/16/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Local activation of B cells and antibody production are important for protective and pathogenic immune responses. Furthermore, there is evidence that local activation of B cells and antibody production are important for pathogenesis of chronic rhinosinusitis with nasal polyps (CRSwNP) and a severe subset of CRSwNP, aspirin-exacerbated respiratory disease (AERD). This review summarizes these findings and the potential role of B cells and antibodies in disease pathogenesis. DATA SOURCES Published literature from PubMed searches. STUDY SELECTIONS Studies relevant to B cell development and the roles of B cells and antibodies in the pathogenesis of CRSwNP and AERD. RESULTS Formation of tertiary lymphoid structures plays a key role in the local activation of B cells and antibody production. This process is important for fighting infections, but it also contributes to autoimmune disease. Furthermore, there is evidence to support a role for local B cell activation and antibody production in a variety of allergic diseases. Nasal polyp tissues from patients with CRSwNP and AERD have elevated levels of activated B cell subsets and locally produced antibodies. These locally produced antibodies may contribute to disease pathogenesis in a variety of ways, including activation of innate effector cells, whereas locally activated B cells may contribute to pathogenesis through the activation of T cells. CONCLUSION More studies are needed to determine the role of B cells and antibodies in driving disease in these patients. However, targeting the processes that drive local B cell activation and antibody production may provide new therapeutic approaches and could help to reduce chronic inflammation.
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Lee VS, Pottinger PS, Davis GE. Tolerability and effectiveness of povidone-iodine or mupirocin versus saline sinus irrigations for chronic rhinosinusitis. Am J Otolaryngol 2020; 41:102604. [PMID: 32563787 PMCID: PMC7484091 DOI: 10.1016/j.amjoto.2020.102604] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 05/31/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The role of topical anti-infectives in acute exacerbations of chronic rhinosinusitis is controversial. Povidone-iodine is an anti-bacterial and anti-viral that is affordable and available over-the-counter and may demonstrate advantages over mupirocin as a sinus irrigation therapy. The objective was to compare povidone-iodine or mupirocin versus saline sinus irrigations for sinusitis exacerbations in post-surgery subjects as well as to assess tolerability of povidone-iodine sinus irrigations. MATERIALS AND METHODS This was a prospective single-blinded (clinician only) randomized controlled trial. Subjects were post-surgery with acute exacerbations of chronic rhinosinusitis and gram-positive bacteria on culture. They received povidone-iodine, mupirocin, or saline sinus irrigations, twice daily for 30 days. Outcomes were post-treatment culture negativity (primary) and Sinonasal Outcome Test-20 and Lund-Kennedy endoscopic score change (secondary). RESULTS Of the 62 subjects analyzed, post-treatment culture negativity rate was higher in the MUP (14/20, 70%) group compared to the PI (9/21, 43%) and SAL (9/19, 47%) groups, although this was not significant (p = 0.29). Povidone-iodine sinus irrigations at the 1% concentration were very well-tolerated, similar to saline irrigations. There were no significant differences in Sinonasal Outcome Test-20 score (povidone-iodine -0.3 [-0.6, 0.05] vs. mupirocin -0.3 [-0.7, 0.05] vs. saline -0.4 [-0.8, 0.05]; p = 0.86) or Lund-Kennedy endoscopic score (povidone-iodine -3.5 [-7, -0.5] vs. mupirocin -2 [-4, 2] vs. saline -3 [-5, 0]; p = 0.45) change. No serious adverse effects were reported. CONCLUSIONS In patients who have had prior sinus surgery with acute exacerbations of CRS and gram-positive bacteria on culture, mupirocin sinus irrigations achieved a better post-treatment culture "control" rate compared to saline and povidone-iodine. In addition, 1% povidone-iodine solution was well-tolerated as a sinus irrigation and may represent a feasible method for temporarily disinfecting the sinonasal cavity of bacteria and viruses such as COVID-19.
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Affiliation(s)
- Victoria S Lee
- Department of Otolaryngology - Head and Neck Surgery, University of Washington, Box 356515, Seattle, WA 98195, United States of America.
| | - Paul S Pottinger
- Department of Medicine, Division of Allergy & Infectious Diseases, University of Washington, 1959 NE Pacific St, PO Box 356130, Courier BB-302, Seattle, WA 98195, United States of America
| | - Greg E Davis
- Department of Otolaryngology - Head and Neck Surgery, University of Washington, Box 356515, Seattle, WA 98195, United States of America
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Riley CA, Zheng Z, Williams N, Smith TL, Orlandi RR, Tabaee A. Concordance of self‐reported practice patterns of American Rhinologic Society members with the International Consensus Statement of Allergy and Rhinology: Rhinosinusitis. Int Forum Allergy Rhinol 2020; 10:665-672. [DOI: 10.1002/alr.22533] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 11/29/2019] [Accepted: 01/09/2020] [Indexed: 11/08/2022]
Affiliation(s)
- Charles A. Riley
- Department of Otolaryngology–Head and Neck SurgeryFort Belvoir Community Hospital and Walter Reed National Military Medical Center Fort Belvoir VA
| | - Zhong Zheng
- Department of Otolaryngology–Head and Neck SurgeryNew York Presbyterian Hospital‒Weill Cornell Medicine New York NY
| | - Nicholas Williams
- Division of Biostatistics and EpidemiologyDepartment of Healthcare Policy and ResearchWeill Cornell Medicine New York NY
| | - Timothy L. Smith
- Division of Rhinology and Sinus Surgery, Oregon Sinus CenterDepartment of Otolaryngology–Head and Neck SurgeryOregon Health and Science University Portland OR
| | - Richard R. Orlandi
- Division of Otolaryngology–Head and Neck SurgeryUniversity of Utah Salt Lake City UT
| | - Abtin Tabaee
- Department of Otolaryngology–Head and Neck SurgeryNew York Presbyterian Hospital‒Weill Cornell Medicine New York NY
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Latest developments on topical therapies in chronic rhinosinusitis. Curr Opin Otolaryngol Head Neck Surg 2020; 28:25-30. [DOI: 10.1097/moo.0000000000000598] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Abstract
As the understanding of the primary cause of chronic rhinosinusitis has shifted away from infection toward inflammation, topical corticosteroid sprays and saline irrigations have become mainstays of treatment. Topical corticosteroid irrigations are recommended particularly in the postoperative setting, but further research on their effect and possible hypothalamic-pituitary-adrenal axis suppression is needed. The popularity of topical antibiotics has subsequently waned with their use reserved for recalcitrant cases. Further research is needed on the effect of topical antifungals in allergic fungal rhinosinusitis. Topical alternative therapies that target biofilms have gained increasing recognition, and investigations on topical probiotics are on the horizon.
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Affiliation(s)
- Victoria S Lee
- Department of Otolaryngology-Head and Neck Surgery, University of Illinois at Chicago, 1855 West Taylor Street, MC 648, Room 3.87, Chicago, IL 60611, USA.
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Carlton DA, Beahm DD, Chiu AG. Topical antibiotic therapy in chronic rhinosinusitis: an update. Int Forum Allergy Rhinol 2020; 9:S27-S31. [PMID: 31087634 DOI: 10.1002/alr.22338] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 02/28/2019] [Accepted: 03/12/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Topical antibiotic therapies have been investigated for their use in chronic rhinosinusitis (CRS). However, society guidelines and evidence-based medicine reviews have recommended against the use of topical antibiotic therapy based on randomized controlled trials (RCTs). The purpose of this article is to review recent clinical research published since the aforementioned guidelines were published. METHODS A structured literature review was performed on clinical studies published in the last 5 years investigating the use of topical antibiotic therapies. RESULTS One double-blinded, randomized controlled trial (DB-RCT) supported the use of tobramycin using a vibrating aerosolizer; 1 non-blinded non-randomized controlled prospective trial lent support to use of topical ofloxacin for its anti-biofilm properties; and 1 meta-analysis found mupirocin irrigations to be beneficial in the short term. One Cochrane Review was unable to make a recommendation as no trial met the inclusion criteria. An additional systematic review found limited evidence to support the use of topical antibiotics with the exception of mupirocin irrigations that may be considered in Staphylococcus aureus infections. Two retrospective studies found that topical antibiotics change bacterial cultures of the sinuses. CONCLUSION There is additional evidence to support continuing investigation of topical antibiotic therapies. Further, larger RCTs are required to establish the efficacy of topical antibiotic therapies.
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Affiliation(s)
- Daniel A Carlton
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, KS
| | - D David Beahm
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Alexander G Chiu
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, KS
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Effects of nasal lavage with and without mupirocin after endoscopic endonasal skull base surgery: a randomised, controlled study. The Journal of Laryngology & Otology 2019; 133:1059-1063. [DOI: 10.1017/s0022215119002329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractBackgroundNasal lavage with mupirocin has the potential to reduce sinonasal morbidity in endoscopic endonasal approaches for skull base surgery.ObjectiveTo evaluate the effects of nasal lavage with and without mupirocin after endoscopic endonasal skull base surgery.MethodsA pilot randomised, controlled trial was conducted on 20 adult patients who had undergone endoscopic endonasal approaches for skull base lesions. These patients were randomly assigned to cohorts using nasal lavages with mupirocin or without mupirocin. Patients were assessed in the out-patient clinic, one week and one month after surgery, using the 22-item Sino-Nasal Outcome Test questionnaire and nasal endoscopy.ResultsPatients in the mupirocin nasal lavage group had lower nasal endoscopy scores post-operatively, and a statistically significant larger difference in nasal endoscopy scores at one month compared to one week. The mupirocin nasal lavage group also showed better Sino-Nasal Outcome Test scores at one month compared to the group without mupirocin.ConclusionNasal lavage with mupirocin seems to yield better outcomes regarding patients’ symptoms and endoscopic findings.
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Ooi ML, Jothin A, Bennett C, Ooi EH, Vreugde S, Psaltis AJ, Wormald P. Manuka honey sinus irrigations in recalcitrant chronic rhinosinusitis: phase 1 randomized, single‐blinded, placebo‐controlled trial. Int Forum Allergy Rhinol 2019; 9:1470-1477. [DOI: 10.1002/alr.22423] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 07/24/2019] [Accepted: 08/06/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Mian Li Ooi
- Department of Surgery–Otolaryngology, Head and Neck SurgeryBasil Hetzel Institute for Translational Health Research, The University of Adelaide Adelaide SA Australia
| | - Arvind Jothin
- Department of Surgery–Otolaryngology, Head and Neck SurgeryBasil Hetzel Institute for Translational Health Research, The University of Adelaide Adelaide SA Australia
| | - Catherine Bennett
- Department of Surgery–Otolaryngology, Head and Neck SurgeryBasil Hetzel Institute for Translational Health Research, The University of Adelaide Adelaide SA Australia
| | - Eng H. Ooi
- Department of Otolaryngology–Head and Neck SurgeryFlinders Medical Centre and Flinders University Bedford Park Adelaide SA Australia
| | - Sarah Vreugde
- Department of Surgery–Otolaryngology, Head and Neck SurgeryBasil Hetzel Institute for Translational Health Research, The University of Adelaide Adelaide SA Australia
| | - Alkis J. Psaltis
- Department of Surgery–Otolaryngology, Head and Neck SurgeryBasil Hetzel Institute for Translational Health Research, The University of Adelaide Adelaide SA Australia
| | - Peter‐John Wormald
- Department of Surgery–Otolaryngology, Head and Neck SurgeryBasil Hetzel Institute for Translational Health Research, The University of Adelaide Adelaide SA Australia
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[Guideline for "rhinosinusitis"-long version : S2k guideline of the German College of General Practitioners and Family Physicians and the German Society for Oto-Rhino-Laryngology, Head and Neck Surgery]. HNO 2019; 66:38-74. [PMID: 28861645 DOI: 10.1007/s00106-017-0401-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Vickery TW, Ramakrishnan VR, Suh JD. The Role of Staphylococcus aureus in Patients with Chronic Sinusitis and Nasal Polyposis. Curr Allergy Asthma Rep 2019; 19:21. [PMID: 30859336 DOI: 10.1007/s11882-019-0853-7] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Staphylococcus aureus (S. aureus) is correlated with the development of persistent severe inflammatory disease of the upper airway including chronic rhinosinusitis with nasal polyps (CRSwNP). The presence of S. aureus is associated with atopic disease including allergic rhinitis and atopic dermatitis and is associated with poor outcomes. RECENT FINDINGS Several different strains of S. aureus generate different toxins and gene products that can account for organism pathogenicity. S. aureus bacteria and its antigens shape the bacterial and fungal microbiome and the mucosal niche which generates host responses that can account for inflammation. The multiple disease phenotypes and molecular endotypes seen in CRSwNP can be characterized by T-helper cell environment within the inflammatory milieu, the presence of epithelial barrier dysfunction, aberrant eicosanoid metabolism, poor wound healing, and dysfunctional host-bacteria interactions which lead to recalcitrant disease and worse surgical outcomes. Understanding the pathomechanisms that S. aureus utilizes to promote nasal polyp formation, prolonged tissue inflammation, and bacterial dysbiosis are essential in our efforts to identify new therapeutic approaches to resolve this chronic inflammatory process.
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Affiliation(s)
- Thad W Vickery
- Department of Head and Neck Surgery, David Geffen School of Medicine, University of California Los Angeles, 10833 Le Conte Ave., CHS 62-132, Los Angeles, CA, 90095-1624, USA
| | - Vijay R Ramakrishnan
- Department of Otolaryngology-Head and Neck Surgery, University of Colorado, 12631 E 17th Ave., B205, Aurora, CO, 80045, USA
| | - Jeffrey D Suh
- Department of Head and Neck Surgery, David Geffen School of Medicine, University of California Los Angeles, 10833 Le Conte Ave., CHS 62-132, Los Angeles, CA, 90095-1624, USA.
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Griggs ZH, M Williams A, Craig JR. Head and Bottle Angles Achieved by Patients During High-Volume Sinonasal Irrigations. Am J Rhinol Allergy 2019; 33:302-309. [PMID: 30674198 DOI: 10.1177/1945892419825612] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Certain head positions can optimize topical irrigation distribution to specific sinuses. No studies have assessed whether patients attain these positions when irrigating. OBJECTIVE The purpose of this study was to assess head and bottle angles achieved when patients irrigate based on instructions from an irrigation device or from a Rhinologist. METHODS Study approval was obtained from Henry Ford Health System's Institutional Review Board (10604). Forty-two patients with various rhinologic conditions were equally divided into groups based on irrigation instruction type: pictoral instructions from an irrigation device or written/verbal instructions from a Rhinologist. Both groups' instructions directed nose-to-floor head positioning. Simulating home irrigations, patients irrigated 120 mL of saline into each naris using 240 mL squeeze bottles. Frontal and lateral views were captured using video cameras. On frontal view, angles were measured between (1) nasal dorsum (ND) and bottle tip (BT; n = 84) and (2) ND and vertical (V; n = 84). On lateral view, angles were measured between (1) line from nasion-to-pogonion (NTP) and horizontal (H) (n = 73) and (2) NTP and BT (n = 73). RESULTS On lateral view, average angle between NTP and H was 20.0° (standard deviation [SD] = 13.1, 95% confidence interval [CI] = 17.0-23.0) and between NTP and BT was 59.4° (SD = 15.8, 95% CI = 55.8-63.1). On frontal view, average angle between ND and V was 9.5° (SD = 19.5, 95% CI = 5.3-13.6) and between ND and BT was 24.5° (SD = 12.0, 95% CI = 21.9-27.0). There were no significant angle differences between sides or instruction types. CONCLUSION When instructed to irrigate in the nose-to-floor head position, patients achieved a head position uprotated 20° on lateral view and vertex rotated 10° away from the side of irrigation on frontal view.
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Affiliation(s)
- Zachary H Griggs
- 1 Department of Otolaryngology, Henry Ford Health System, Detroit, Michigan
| | - Amy M Williams
- 1 Department of Otolaryngology, Henry Ford Health System, Detroit, Michigan
| | - John R Craig
- 1 Department of Otolaryngology, Henry Ford Health System, Detroit, Michigan
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Beswick DM, Gray ST, Smith TL. Pharmacological Management of Chronic Rhinosinusitis: Current and Evolving Treatments. Drugs 2018; 77:1713-1721. [PMID: 28853058 DOI: 10.1007/s40265-017-0803-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Chronic rhinosinusitis (CRS) is an inflammatory sinonasal condition with multiple etiologic factors that is associated with a vast economic cost. Treatment is most frequently pharmacologic and has centered on agents that ameliorate inflammation, decrease bacterial or pathogen load, and facilitate egress of mucus or purulence from the sinonasal cavity. Nasal saline irrigations, topical nasal steroids, certain antibiotics, and systemic steroids have shown some efficacy in the management of CRS. Recently, biologic therapeutics that target specific inflammatory pathways associated with subsets of CRS have been developed and evaluated. Early data evaluating these biologic treatments suggest a potential role in treating a subset of CRS with refractory, poorly controlled disease. Additional studies are necessary to identify which patients would benefit most from biologic therapies and to assess the cost of these therapies compared with the benefit they provide. This review describes the pathophysiology of CRS and summarizes both established and novel biologic pharmacologic treatments.
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Affiliation(s)
- Daniel M Beswick
- Department of Otolaryngology, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Stacey T Gray
- Department of Otolaryngology, Harvard Medical School, Boston, MA, USA.,Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Timothy L Smith
- Department of Otolaryngology, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA.
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Heath J, Hartzell L, Putt C, Kennedy JL. Chronic Rhinosinusitis in Children: Pathophysiology, Evaluation, and Medical Management. Curr Allergy Asthma Rep 2018; 18:37. [PMID: 29845321 DOI: 10.1007/s11882-018-0792-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
PURPOSE OF REVIEW Pediatric chronic rhinosinusitis (CRS) is a common disorder that carries significant morbidity. The diagnosis requires sinus symptoms that persist despite standard medical therapy greater than 3 months. Viral infections, allergies, and anatomic differences in children lead to chronic obstruction of the osteomeatal complex. RECENT FINDINGS Chronic rhinosinusitis as a diagnosis is a conglomeration of multiple phenotypes and endotypes. As such, the diagnosis and management are complex. New survey studies provide some consensus on prevalence and management of this disease in children. In this review, we highlight the differential diagnosis of pediatric CRS, including non-eosinophilic/infectious variants, eosinophilic variants with and without nasal polyps, allergic fungal sinusitis, aspirin-exacerbated respiratory disease, primary immunodeficiency, and disorders of mucociliary clearance. Further, we detail treatment options that should be considered. Finally, we feature emerging potential treatment options of CRS, including anti-immunoglobulin E, interleukin-5, and interleukin-4 receptor alpha subunit.
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Affiliation(s)
| | - Larry Hartzell
- Department of Otolaryngology, Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Claire Putt
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA.,Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Joshua L Kennedy
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA. .,Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA. .,Arkansas Children's Research Institute, 13 Children's Way, Slot 512-13, Little Rock, AR, 72202, USA.
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30
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Ooi ML, Richter K, Bennett C, Macias-Valle L, Vreugde S, Psaltis AJ, Wormald PJ. Topical Colloidal Silver for the Treatment of Recalcitrant Chronic Rhinosinusitis. Front Microbiol 2018; 9:720. [PMID: 29696011 PMCID: PMC5905234 DOI: 10.3389/fmicb.2018.00720] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 03/27/2018] [Indexed: 11/20/2022] Open
Abstract
Background: The management of recalcitrant chronic rhinosinusitis (CRS) is challenged by difficult-to-treat polymicrobial biofilms and multidrug resistant bacteria. This has led to the search for broad-spectrum non-antibiotic antimicrobial therapies. Colloidal silver (CS) has significant antibiofilm activity in vitro and in vivo against S. aureus, MRSA, and P. aeruginosa. However, due to the lack of scientific efficacy, it is only currently used as an alternative medicine. This is the first study looking at the safety and efficacy of CS in recalcitrant CRS. Methods: Patients were included when they had previously undergone endoscopic sinus surgery and presented with signs and symptoms of sinus infection with positive bacterial cultures. Twenty-two patients completed the study. Patients were allocated to 10–14 days of culture directed oral antibiotics with twice daily saline rinses (n = 11) or 10 days of twice daily 0.015 mg/mL CS rinses (n = 11). Safety observations included pre- and post-treatment serum silver levels, University of Pennsylvania Smell Identification Test (UPSIT) and adverse event (AE) reporting. Efficacy was assessed comparing microbiology results, Lund Kennedy Scores (LKS) and symptom scores using Visual Analog Scale (VAS) and Sino-Nasal Outcome Test (SNOT-22). Results: CS demonstrated good safety profile with no major adverse events, no changes in UPSIT and transient serum silver level changes in 4 patients. CS patients had 1/11 (9.09%) negative cultures, compared to 2/11 (18.18%) in the control group upon completion of the study. Whilst not statistically significant, both groups showed similar improvement in symptoms and endoscopic scores. Conclusion: This study concludes that twice daily CS (0.015 mg/mL) sinonasal rinses for 10 days is safe but not superior to culture-directed oral antibiotics. Further studies including more patients and looking at longer treatment or improving the tonicity of the solution for better tolerability should be explored.
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Affiliation(s)
- Mian L Ooi
- Department of Surgery-Otolaryngology, Head and Neck Surgery, Basil Hetzel Institute for Translational Health Research, The University of Adelaide, Adelaide, SA, Australia
| | - Katharina Richter
- Department of Surgery-Otolaryngology, Head and Neck Surgery, Basil Hetzel Institute for Translational Health Research, The University of Adelaide, Adelaide, SA, Australia.,Adelaide Biofilm Test Facility, Sansom Institute for Health Research, University of South Australia, Adelaide, SA, Australia
| | - Catherine Bennett
- Department of Surgery-Otolaryngology, Head and Neck Surgery, Basil Hetzel Institute for Translational Health Research, The University of Adelaide, Adelaide, SA, Australia
| | - Luis Macias-Valle
- Department of Surgery-Otolaryngology, Head and Neck Surgery, Basil Hetzel Institute for Translational Health Research, The University of Adelaide, Adelaide, SA, Australia.,Facultad Mexicana de Medicina Universidad La Salle, Department of Otolaryngology Head and Neck Surgery, Spanish Hospital of Mexico, Granada, Mexico
| | - Sarah Vreugde
- Department of Surgery-Otolaryngology, Head and Neck Surgery, Basil Hetzel Institute for Translational Health Research, The University of Adelaide, Adelaide, SA, Australia
| | - Alkis J Psaltis
- Department of Surgery-Otolaryngology, Head and Neck Surgery, Basil Hetzel Institute for Translational Health Research, The University of Adelaide, Adelaide, SA, Australia
| | - Peter-John Wormald
- Department of Surgery-Otolaryngology, Head and Neck Surgery, Basil Hetzel Institute for Translational Health Research, The University of Adelaide, Adelaide, SA, Australia
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31
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Jain R, Hoggard M, Zoing M, Jiang Y, Biswas K, Taylor MW, Douglas RG. The effect of medical treatments on the bacterial microbiome in patients with chronic rhinosinusitis: a pilot study. Int Forum Allergy Rhinol 2018; 8:890-899. [PMID: 29517178 DOI: 10.1002/alr.22110] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 01/16/2018] [Accepted: 02/01/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Antibiotics and corticosteroids are prescribed to patients with chronic rhinosinusitis (CRS) to reduce bacterial burden and mucosal inflammation. Unfortunately, clinical improvement is often short-lived and symptoms frequently recur following cessation of treatment. The impact of these systemic therapies on bacterial communities is not well understood. Improved knowledge of how medical therapies influence the intranasal ecosystem may allow for more effective prescribing and the development of more targeted treatments. METHODS Twenty patients with CRS were randomized to receive either doxycycline 100 mg twice daily or prednisone 30 mg once daily for 7 days. A further 6 patients with CRS were recruited as untreated controls. Swabs were taken immediately before and after the study period. Symptom scores (22-item Sino-Nasal Outcome Test [SNOT-22]) were recorded. Bacterial communities were characterized using 16S ribosomal RNA (rRNA) gene-targeted amplicon sequencing. Bacterial abundance was estimated using quantitative polymerase chain reaction (PCR) of 16S rRNA gene copies. RESULTS Bacterial profiles were dominated by members of the genera Corynebacterium and Staphylococcus. Patients treated with either doxycycline or prednisone had variable and unpredictable changes in communities. The average relative abundance of Propionibacterium increased after treatment in the doxycycline treatment group, and Corynebacterium reduced in the prednisone group. Significant differences in clinical scores, bacterial community richness, diversity, and bacterial abundance were not seen after treatment. CONCLUSION The short-term response of bacterial communities to antibiotic or corticosteroid therapy is unpredictable. This study suggests that the use of systemic therapy in patients with stable CRS should be rationalized to minimize antibiotic-associated morbidity and bacterial dysbiosis.
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Affiliation(s)
- Ravi Jain
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Michael Hoggard
- School of Biological Sciences, The University of Auckland, Auckland, New Zealand
| | - Melissa Zoing
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Yannan Jiang
- Department of Statistics, The University of Auckland, Auckland, New Zealand
| | - Kristi Biswas
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Michael W Taylor
- School of Biological Sciences, The University of Auckland, Auckland, New Zealand
- Maurice Wilkins Centre for Molecular Biodiscovery, Auckland, New Zealand
| | - Richard G Douglas
- Department of Surgery, The University of Auckland, Auckland, New Zealand
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Shikani AH, Khoueir N, Jabra-Rizk MA, Shikani HJ, Basaraba RJ, Leid JG. Topical therapy for refractory rhinosinusitis caused by methicillin-resistant Staphylococcus aureus: First report in a prospective series. Auris Nasus Larynx 2018; 45:994-999. [PMID: 29426723 DOI: 10.1016/j.anl.2018.01.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Revised: 01/09/2018] [Accepted: 01/21/2018] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The incidence of refractory chronic rhinosinusitis (CRS) associated with methicillin-resistant Staphylococcus aureus (MRSA) is rising and remains a therapeutic challenge. The goal of this study is to demonstrate the efficacy of a non-invasive topical therapy against MRSA in these patients. METHODS Seventeen patients with refractory CRS caused by MRSA were treated with a topical therapy protocol. Treatment consisted of weekly endoscopic sinus debridement followed by intra-sinus installation of a hydroxyl-ethylcellulose gel that releases mometasone and a culture-directed antibiotic for a period of 6 weeks, along with daily nasal nebulization of mometasone with the same antibiotic and saline rinses. Clinical outcome was assessed using the Lund-Kennedy (LK) symptom and endoscopic appearance scores. Sinus mucosal tissue was homogenized and cultured, and microbial biofilm burden was assessed based on colony forming units (CFUs) counts. RESULTS Rhinotopic therapy resulted in clearance of MRSA in 13 of 16 patients (81.2%). Treated patients also demonstrated significant improvement clinically as measured by the LK scores. In addition, a significant decrease in mucosal CFUs was observed post-therapy. CONCLUSION Our findings demonstrate that topical therapy is an effective method for treating MRSA-associated refractory CRS.
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Affiliation(s)
- Alan H Shikani
- Department of Otolaryngology Head and Neck Surgery/Maryland Nose & Sinus Center at MedStar Union Memorial Hospital, Baltimore, MD, United States
| | - Nadim Khoueir
- Department of Otolaryngology Head and Neck Surgery/Maryland Nose & Sinus Center at MedStar Union Memorial Hospital, Baltimore, MD, United States.
| | - Mary Ann Jabra-Rizk
- Department of Oncology and Diagnostic Sciences, Dental School, Department of Pathology, School of Medicine, University of Maryland, Baltimore, United States
| | - Henry J Shikani
- Department of Pathology, Sue Golding Graduate Division, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Randall J Basaraba
- Department of Microbiology Immunology and Pathology, Colorado State University, Fort Collins, United States
| | - Jeff G Leid
- Center for Microbial Genetics and Genomics, Northern Arizona University, Flagstaff, United States
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Snidvongs K, Thanaviratananich S. Update on Intranasal Medications in Rhinosinusitis. Curr Allergy Asthma Rep 2017; 17:47. [PMID: 28602009 DOI: 10.1007/s11882-017-0720-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This review describes beneficial effects and adverse events of various intranasal medications in treating rhinosinusitis. Application of intranasal steroids has been described in treating all subtypes of adult rhinosinusitis, but reports are limited in pediatrics and mostly in acute pediatric subgroups resulted in benefits While saline irrigation is effective for patients with chronic rhinosinusitis without polyps and in pediatric acute rhinosinusitis, there is no evidence yet for saline drips and sprays. Application of intranasal antifungals and nasal irrigation with surfactant brings more harm than benefits. There is no evidence supporting the use of intranasal antibiotics. We also review influence of devices, methods, and patient head position on nasal and paranasal sinus drug delivery.
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Affiliation(s)
- Kornkiat Snidvongs
- Department of Otolaryngology, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand.
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34
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Szaleniec J, Górski A, Szaleniec M, Międzybrodzki R, Weber-Dąbrowska B, Stręk P, Składzień J. Can phage therapy solve the problem of recalcitrant chronic rhinosinusitis? Future Microbiol 2017; 12:1427-1442. [PMID: 29027819 DOI: 10.2217/fmb-2017-0073] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Chronic rhinosinusitis (CRS) affects 5-15% of the global population. In some patients, the infectious exacerbations of the disease are recalcitrant to medical treatment and surgery. These cases are probably associated with the presence of bacterial biofilms. Bacteriophage (phage) therapy seems to be a promising antibiofilm strategy. The efficacy of phage therapy in sinonasal infections has been demonstrated both in vitro and in animal models. In the past, phage preparations were also administered to humans with CRS with favorable outcomes and no significant side effects. Very recently, the safety and efficacy of phage therapy in otolaryngological infections has been demonstrated in pioneer Phase I/II clinical trials. This review addresses the potential of phage therapy to treat CRS. We also discuss issues that require further research.
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Affiliation(s)
- Joanna Szaleniec
- Department of Otolaryngology, Jagiellonian University Medical College, Sniadeckich 2, 31-531 Krakow, Poland
| | - Andrzej Górski
- Institute of Immunology & Experimental Therapy, Polish Academy of Sciences, Weigla 12, 53-114 Wroclaw, Poland.,Transplantation Institute, Medical University of Warsaw, Nowogrodzka 59, 02-006 Warsaw, Poland
| | - Maciej Szaleniec
- Jerzy Haber Institute of Catalysis & Surface Chemistry, Polish Academy of Sciences, Niezapominajek 8, 30-239 Krakow, Poland
| | - Ryszard Międzybrodzki
- Institute of Immunology & Experimental Therapy, Polish Academy of Sciences, Weigla 12, 53-114 Wroclaw, Poland.,Transplantation Institute, Medical University of Warsaw, Nowogrodzka 59, 02-006 Warsaw, Poland
| | - Beata Weber-Dąbrowska
- Institute of Immunology & Experimental Therapy, Polish Academy of Sciences, Weigla 12, 53-114 Wroclaw, Poland
| | - Paweł Stręk
- Department of Otolaryngology, Jagiellonian University Medical College, Sniadeckich 2, 31-531 Krakow, Poland
| | - Jacek Składzień
- Department of Otolaryngology, Jagiellonian University Medical College, Sniadeckich 2, 31-531 Krakow, Poland
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Talesh KT, Gargary RM, Arta SA, Yazdani J, Roshandel M, Ghanizadeh M, Kafil HS, Mousavi MNS. Effect of 2% Nasal Mupirocin Ointment on Decreasing Complications of Nasotracheal Intubation: A Randomized Controlled Trial. J Clin Diagn Res 2017; 11:PC08-PC12. [PMID: 28969192 DOI: 10.7860/jcdr/2017/29575.10396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 07/06/2017] [Indexed: 11/24/2022]
Abstract
INTRODUCTION In oral and maxillofacial surgeries, nasotracheal intubation is carried out to increase the surgeon's access to the oral cavity. During nasotracheal intubation the risk of trauma is higher than that in orotracheal intubation as there is passage of the tube through the mucosa of the nasal tract due to which bacteria might get transported into the trachea. AIM To evaluate the effect of 2% nasal mupirocin ointment before and after nasotracheal intubation on decreasing the complications of intubation for oral and maxillofacial surgeries. MATERIALS AND METHODS In the present single blinded randomised controlled clinical trial, 44 patients were randomly assigned to two equal groups. A sterile swab was used, eight to 10 hours before nasotracheal intubation, to take a sample for culturing from the vestibule of nostrils and the anterior septum of the patients. In Group 1, 2% nasal mupirocin ointment was applied to the vestibules of both nostrils and the anterior septum. In Group 2, no intervention was carried out. After general anaesthesia and extubation, microbial cultures were prepared from the 4 cm distal end of the tube and antibiogram test was carried out. Also, the patients were compared in terms of the severity of nasal bleeding, the ease of breathing through the nose after nasotracheal intubation. Data were analysed with suitable statistical tests. RESULTS In the mupirocin group, 27.2% of the subjects were carriers of Staphylococcus aureus in the nasal cavity but no S. aureus was detected at the distal end of nasotracheal tube after extubation. In the control group, 18.2% of the subjects were carriers of Staphylococcus aureus in the nasal cavity but there was no change in the number of S. aureus counts at the distal end of nasotracheal tube (p-value<0.001). After extubation, in the mupirocin and control groups, 18.2% and 22.7% of the subjects, respectively, exhibited severe bleeding (p-value=0.001). In the mupirocin and control groups, 86.4% and 59.1% of the subjects had easy extubation, respectively (p-value=0.044). In the mupirocin and control groups, 9.1% and 63.7% of the subjects immediately after regaining consciousness and 9.1% and 54.6% three hours after extubation had difficulty in breathing, respectively (p-value=0.001). CONCLUSION Use of mupirocin before nasotracheal intubation decreased the complications of nasal intubation in addition to decreasing the risk of colonization of S. aureus and other gram-negative bacteria.
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Affiliation(s)
- Kourosh Taheri Talesh
- Professor, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Reza Movassaghi Gargary
- Assistant Professor, Department of Anesthesiology, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Seyed Ahmad Arta
- Assistant Professor, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Javad Yazdani
- Associate Professor, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Monireh Roshandel
- Postgraduate Student, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Milad Ghanizadeh
- Postgraduate Student, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hossein Samadi Kafil
- Assistant Professor, Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mir Naser Seyyed Mousavi
- Assistant Professor, Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Ciofu O, Rojo-Molinero E, Macià MD, Oliver A. Antibiotic treatment of biofilm infections. APMIS 2017; 125:304-319. [PMID: 28407419 DOI: 10.1111/apm.12673] [Citation(s) in RCA: 244] [Impact Index Per Article: 34.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Accepted: 01/10/2017] [Indexed: 12/24/2022]
Abstract
Bacterial biofilms are associated with a wide range of infections, from those related to exogenous devices, such as catheters or prosthetic joints, to chronic tissue infections such as those occurring in the lungs of cystic fibrosis patients. Biofilms are recalcitrant to antibiotic treatment due to multiple tolerance mechanisms (phenotypic resistance). This causes persistence of biofilm infections in spite of antibiotic exposure which predisposes to antibiotic resistance development (genetic resistance). Understanding the interplay between phenotypic and genetic resistance mechanisms acting on biofilms, as well as appreciating the diversity of environmental conditions of biofilm infections which influence the effect of antibiotics are required in order to optimize the antibiotic treatment of biofilm infections. Here, we review the current knowledge on phenotypic and genetic resistance in biofilms and describe the potential strategies for the antibiotic treatment of biofilm infections. Of note is the optimization of PK/PD parameters in biofilms, high-dose topical treatments, combined and sequential/alternate therapies or the use antibiotic adjuvants.
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Affiliation(s)
- Oana Ciofu
- Department of Immunology and Microbiology, Faculty of Health and Medical Sciences, Costerton Biofilm Center, University of Copenhagen, Copenhagen, Denmark
| | - Estrella Rojo-Molinero
- Servicio de Microbiología, Hospital Son Espases, Instituto de Investigación Sanitaria de Palma (IdISPa), Palma de Mallorca, Spain
| | - María D Macià
- Servicio de Microbiología, Hospital Son Espases, Instituto de Investigación Sanitaria de Palma (IdISPa), Palma de Mallorca, Spain
| | - Antonio Oliver
- Servicio de Microbiología, Hospital Son Espases, Instituto de Investigación Sanitaria de Palma (IdISPa), Palma de Mallorca, Spain
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37
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Lee VS, Davis GE. Culture-directed topical antibiotic treatment for chronic rhinosinusitis. Am J Rhinol Allergy 2017; 30:414-417. [PMID: 28124652 DOI: 10.2500/ajra.2016.30.4380] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Topical antibiotics, delivered optimally as high-volume culture-directed sinus irrigations, are being increasingly used for recalcitrant chronic rhinosinusitis (CRS). Their impact on subjective and objective outcome measures, however, is still unclear. OBJECTIVE To assess if the use of topical antibiotics in recalcitrant CRS is associated with improved 20-Item Sino-Nasal Outcome Test and Lund-Kennedy endoscopic scores, and to determine the negative posttreatment culture "control" rate. METHODS Patients were included in the study if they met diagnostic criteria for CRS, received high-volume topical antibiotic sinus irrigations twice daily for 1 month, between December 2009 and May 2015, and had undergone endoscopic sinus surgery. The primary outcome was the 20-Item Sino-Nasal Outcome Test score. Secondary outcomes were the Lund-Kennedy endoscopic score and a negative posttreatment culture "control" rate. Paired t-tests were used to compare pre- and posttreatment scores. Patients with cystic fibrosis were analyzed separately. RESULTS Of the 58 patients included, 47% had nasal polyposis, 57% had asthma, 16% had aspirin sensitivity, and 55% had environmental allergies. The median Lund-Mackay computed tomography score was 11 (interquartile range, 6-16), and the median time to follow-up was 8 weeks (interquartile range, 6-10 weeks). The 20-Item Sino-Nasal Outcome Test scores improved from pre- to posttreatment period, although this was not significant mean 1.5 [confidence interval {CI} 1.3, 1.7] to mean 1.3 [CI 1.1, 1.6]; p = 0.16). Lund-Kennedy endoscopic scores, however, significantly improved from pre- to posttreatment (mean 4.9 [CI 4.3, 5.6] to mean 4.1 [CI 3.5, 4.7]; p = 0.05). Of the 47 patients with complete culture data, 72% had negative posttreatment culture results, defined as "controlled." Only one patient discontinued treatment, related to discomfort from irrigations. CONCLUSION In patients with recalcitrant CRS, the use of topical antibiotics trended toward improvement in symptom severity and significantly improved endoscopic appearance. Furthermore, 72% had negative posttreatment culture results, meaning microbiological "control." The results of this study support the use of high-volume culture-directed topical antibiotics, and, in the future, more rigorous prospective studies are warranted.
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Affiliation(s)
- Victoria S Lee
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
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Abstract
Our understanding of chronic rhinosinusitis (CRS) show biofilm and osteitis play a role in the disease's pathogenesis and refractory. Studies point to its role in pathogenesis and poor prognosis. Outside the research laboratory, biofilm detection remains difficult and specific treatment remains elusive. It is believed that osteitis is a nidus of inflammation and occurs more commonly in patients with refractory CRS. However, osteitis may be exacerbated by surgery and a marker of refractory disease, not a causative agent. Surgery remains the mainstay treatment for biofilm and osteitis with mechanical disruption and removal of disease load providing the most effective treatment.
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Affiliation(s)
- Yi Chen Zhao
- Department of Surgery - Otolaryngology Head & Neck Surgery, The University of Adelaide, Adelaide, Queen Elizabeth Hospital 28 Woodville Rd, Woodville South, South Australia 5011, Australia
| | - Peter-John Wormald
- Department of Surgery - Otolaryngology Head & Neck Surgery, The University of Adelaide, Adelaide, Queen Elizabeth Hospital 28 Woodville Rd, Woodville South, South Australia 5011, Australia.
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39
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Barshak MB, Durand ML. The role of infection and antibiotics in chronic rhinosinusitis. Laryngoscope Investig Otolaryngol 2017; 2:36-42. [PMID: 28894821 PMCID: PMC5510277 DOI: 10.1002/lio2.61] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2016] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE To review the current understanding of the role of infection and antibiotics in chronic rhinosinusitis. REVIEW METHODS PubMed literature search. RESULTS Chronic rhinosinusitis (CRS) in adults is an inflammatory condition and the role of infection is unclear. Biofilms are present in both CRS and normal patients so their role in CRS is unknown. Sinus cultures in CRS demonstrate a mixture of aerobic and anaerobic bacteria but may be hard to interpret due to contaminating nasal flora. Staphylococcus aureus is common in CRS patients but also present in 20-30% of nasal cultures in the normal population; eradicating this organism did not lead to symptom improvement versus placebo in a randomized controlled trial (RCT). In CRS patients who develop an episode of acute rhinosinusitis (ARS), bacteria typical of ARS can generally be cultured and require short-course treatment. For CRS, topical antibacterial or antifungal agents have shown no benefit over placebo in RCTs, although RCTs of topical antibacterial agents have been small. Oral macrolides and doxycycline, antibiotics with anti-inflammatory properties, are the only systemic antibiotics that have been evaluated in RCTs. One RCT found 3 weeks of doxycycline beneficial in patients with polyps but follow up was short (<3 months); RCTs of prolonged macrolide therapy have produced mixed results, and most show no benefit after cessation of therapy. Long-term antibiotic therapy may produce side effects and select increasingly resistant flora. The American Academy of Otolaryngology-Head and Neck Surgery guidelines recommend against treatment of CRS with antifungal agents but do not comment on the role of antibacterial treatment. CONCLUSION The role of infection in CRS is unknown, and the only well-defined role for antibiotics is for treatment of ARS episodes or their infectious complications. LEVEL OF EVIDENCE N/A.
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Affiliation(s)
- Miriam Baron Barshak
- Massachusetts General Hospital and Massachusetts Eye and Ear InfirmaryBostonMassachusetts
| | - Marlene L. Durand
- Massachusetts General Hospital and Massachusetts Eye and Ear InfirmaryBostonMassachusetts
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Sinonasal methicillin-resistant Staphylococcus aureus: updates on treatment. Curr Opin Otolaryngol Head Neck Surg 2017; 25:19-23. [DOI: 10.1097/moo.0000000000000324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lee VS, Humphreys IM, Purcell PL, Davis GE. Manuka honey sinus irrigation for the treatment of chronic rhinosinusitis: a randomized controlled trial. Int Forum Allergy Rhinol 2016; 7:365-372. [PMID: 27935259 DOI: 10.1002/alr.21898] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 11/04/2016] [Accepted: 11/15/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND Manuka honey (MH) has been shown in vitro to be effective against biofilm-producing bacteria. This study assessed the effectiveness of MH for patients with active chronic rhinosinusitis (CRS) and prior sinus surgery. METHODS This prospective single-blinded (clinician only) randomized controlled trial recruited patients with active CRS and prior sinus surgery. Patients received either MH or saline (SAL) sinus irrigations twice daily for 30 days and were offered oral antibiotics and/or oral/topical steroids as indicated. Outcomes were 22-item Sino-Nasal Outcome Test (SNOT-22) change score (primary), culture negativity, and Lund-Kennedy endoscopic change score. RESULTS Forty-two patients were analyzed (MH, n = 20; SAL, n = 22). The SNOT-22 change score achieved a clinically significant improvement in both groups but was similar between MH (median [interquartile range]: -12 [-20, -1]) and SAL (-12.5 [-22, -6]) (p = 0.57). Culture negativity was better on MH (8/19, 42%) compared to SAL (4/21, 19%), nearing statistical significance (p = 0.11). Lund-Kennedy endoscopic change score improved in both groups but was not statistically better on MH (-3 [-5, 0]) compared to SAL (-1 [-2, 0]) (p = 0.20). For patients not receiving oral antibiotics/steroids, culture negativity was statistically better on MH (5/10, 50%) compared to SAL (0/6, 0%) (p = 0.04). MH was well-tolerated. No adverse events were reported. CONCLUSION In patients with active CRS and prior sinus surgery, both MH and SAL improved outcomes, but there was no statistically significant difference between these groups. However, in the subset that did not receive oral antibiotics/steroids, culture negativity was statistically better on MH, suggesting that MH alone may be effective for acute exacerbations of CRS.
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Affiliation(s)
- Victoria S Lee
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA
| | - Ian M Humphreys
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA
| | - Patricia L Purcell
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA
| | - Greg E Davis
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA
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Kim JS, Kwon SH. Mupirocin in the Treatment of Staphylococcal Infections in Chronic Rhinosinusitis: A Meta-Analysis. PLoS One 2016; 11:e0167369. [PMID: 27907108 PMCID: PMC5132234 DOI: 10.1371/journal.pone.0167369] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 11/12/2016] [Indexed: 12/15/2022] Open
Abstract
Background Saline irrigation of the nasal cavity is a classic and effective treatment for acute or chronic rhinosinusitis. Topical antibiotics such as mupirocin have been widely used for recalcitrant chronic rhinosinusitis. Therefore, the purpose of this study was to evaluate the effect of saline irrigation using mupirocin. Methods A systematic literature review and meta-analysis of mupirocin saline irrigation were performed using EMBASE, MEDLINE, and Cochrane library through December 2015. Data were analyzed with R 3.2.2 software. A random effects model was used because of the diversity of included studies. Sensitivity analysis of particular tested groups and single proportion tests were also performed. The main outcome measure was residual staphylococcal infection, as confirmed by culture or PCR. Results Two RCTs, two prospective studies and two retrospective studies were included. A random effects model meta-analysis of the pooled data identified a relative risk of residual infection of 0.13 (95% CI: 0.06–0.26, p<0.05) with low heterogeneity (I2 = 0%). The proportion of residual staphylococcal infections after 1 month was 0.08 (95% CI: 0.04–0.16). However, this proportion increased to 0.53 at 6 months (95% CI: 0.27–0.78). Conclusions The short-term use of mupirocin has a strongly reductive effect on staphylococcal infection in chronic rhinosinusitis. Although there is currently a lack of clear evidence, future studies with well-designed inclusion criteria and randomized controlled trials are needed to examine mupirocin’s long-term effect on chronic rhinosinusitis.
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Affiliation(s)
- Jong Seung Kim
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Chonbuk National University, Jeonju, Republic of Korea
- Research Institute of Clinical Medicine of Chonbuk National University–Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Republic of Korea
| | - Sam Hyun Kwon
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Chonbuk National University, Jeonju, Republic of Korea
- Research Institute of Clinical Medicine of Chonbuk National University–Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Republic of Korea
- * E-mail:
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Fastenberg JH, Hsueh WD, Mustafa A, Akbar NA, Abuzeid WM. Biofilms in chronic rhinosinusitis: Pathophysiology and therapeutic strategies. World J Otorhinolaryngol Head Neck Surg 2016; 2:219-229. [PMID: 29204570 PMCID: PMC5698538 DOI: 10.1016/j.wjorl.2016.03.002] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 03/26/2016] [Accepted: 03/31/2016] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND There is increasing evidence that biofilms are critical to the pathophysiology of chronic infections including chronic rhinosinusitis (CRS). Until relatively recently, our understanding of biofilms was limited. Recent advances in methods for biofilm identification and molecular biology have offered new insights into the role of biofilms in CRS. With these insights, investigators have begun to investigate novel therapeutic strategies that may disrupt or eradicate biofilms in CRS. OBJECTIVE This review seeks to explore the evidence implicating biofilms in CRS, discuss potential anti-biofilm therapeutic strategies, and suggest future directions for research. RESULTS The existing evidence strongly supports the role of biofilms in the pathogenesis of CRS. Several anti-biofilm therapies have been investigated for use in CRS and these are at variable stages of development. Generally, these strategies: 1) neutralize biofilm microbes; 2) disperse existing biofilms; or 3) disrupt quorum sensing. Several of the most promising anti-biofilm therapeutic strategies are reviewed. CONCLUSIONS A better understanding of biofilm function and their contribution to the CRS disease process will be pivotal to the development of novel treatments that may augment and, potentially, redefine the CRS treatment paradigm. There is tremendous potential for future research.
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Affiliation(s)
- Judd H. Fastenberg
- Department of Otorhinolaryngology – Head & Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, 3400 Bainbridge Ave, Bronx, NY, 10467, USA
| | | | | | | | - Waleed M. Abuzeid
- Department of Otorhinolaryngology – Head & Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, 3400 Bainbridge Ave, Bronx, NY, 10467, USA
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Jain R, Hoggard M, Biswas K, Zoing M, Jiang Y, Douglas R. Changes in the bacterial microbiome of patients with chronic rhinosinusitis after endoscopic sinus surgery. Int Forum Allergy Rhinol 2016; 7:7-15. [PMID: 27641913 DOI: 10.1002/alr.21849] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Revised: 07/12/2016] [Accepted: 08/04/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Endoscopic sinus surgery (ESS) improves symptoms for many chronic rhinosinusitis (CRS) patients by enlarging the size of sinus ostia, improving mucociliary clearance, and facilitating access for topical therapies. However, the effect of surgery on the sinonasal microbiota remains poorly understood. This study examined changes in bacterial communities in CRS patients before and after surgery. METHODS Swab samples were taken from the middle meatus of 23 patients undergoing ESS. Follow-up swabs were taken in clinic (mean 120 days postsurgery). Symptom scores and antibiotic use were recorded. Bacterial communities were characterized using 16s ribosomal RNA (rRNA) gene-targeted amplicon sequencing and bacterial abundance was measured using quantitative polymerase chain reaction (PCR). Coexisting asthma, aspirin sensitivity, antibiotic use, and presence of polyps were controlled for. RESULTS Unpredictable shifts in bacterial community composition were seen postoperatively. ESS was associated with increased bacterial richness. Many taxa had changes in average relative abundance and prevalence. Staphylococcus was the only dominant taxa to increase significantly in relative abundance (p = 0.002). Changes in bacterial communities were driven more by intersubject variability (p = 0.007) than other study factors. Finegoldia, a minority taxon, was associated with a reduction in abundance following ESS, increases in patients with higher symptoms scores, and reductions in patients with reduced total bacterial burden. CONCLUSION This study documented changes in bacterial composition and abundance in the middle meatus following ESS. The complexity of these changes reflects the variability between patients. Modern molecular techniques highlight the currently limited knowledge of the impact of therapies on the microbiology of CRS.
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Affiliation(s)
- Ravi Jain
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Michael Hoggard
- School of Biological Sciences, The University of Auckland, Auckland, New Zealand
| | - Kristi Biswas
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Melissa Zoing
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Yannan Jiang
- Department of Statistics, The University of Auckland, Auckland, New Zealand
| | - Richard Douglas
- Department of Surgery, The University of Auckland, Auckland, New Zealand
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Varshney R, Lee JT. Current trends in topical therapies for chronic rhinosinusitis: update and literature review. Expert Opin Drug Deliv 2016; 14:257-271. [PMID: 27500891 DOI: 10.1080/17425247.2016.1214563] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Chronic rhinosinusitis (CRS) affects millions of patients worldwide. The disease is multifactorial with influences including anatomic factors, immunological disturbances, and altered sinonasal microbiome. Although oral medications are effective in controlling some symptoms, they are associated with side effects and long-term use is not ideal. Thus, topical therapies have emerged as an alternative delivery method for localized, high-concentration medication with less side effects. Areas covered: This is a review of the various topical therapies available or under investigation for the management of CRS. Common medications such as saline, steroids, and antimicrobials will be discussed. Furthermore, additives including manuka honey, xylitol, surfactant, N-chlorotaurine, Dead Sea salt, and sodium hyaluronate will be addressed. Innovations in topical therapies, such as drug-eluting biomaterials and photodynamic therapy, will also be reviewed. Expert opinion: Although topical therapies provide a high dose of active substance at the site of disease, their efficacy in CRS is not clear. Topical saline and intranasal steroids appear to consistently demonstrate therapeutic benefits. However, other topical medications require further investigation to determine long-term clinical efficacy and safety. A better understanding of their effects on the sinonasal mucociliary system is needed before they become the standard of care in CRS.
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Affiliation(s)
- Rickul Varshney
- a Orange County Sinus Institute , Southern California Permanente Medical Group , Irvine , CA , USA
| | - Jivianne T Lee
- a Orange County Sinus Institute , Southern California Permanente Medical Group , Irvine , CA , USA.,b Department of Head & Neck Surgery , David Geffen School of Medicine at UCLA , Los Angeles , CA , USA
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Bachert C, Hamilos DL. Are Antibiotics Useful for Chronic Rhinosinusitis? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 4:629-38. [DOI: 10.1016/j.jaip.2015.12.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 11/24/2015] [Accepted: 12/02/2015] [Indexed: 10/22/2022]
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Tajudeen BA, Schwartz JS, Palmer JN. Understanding Biofilms in Chronic Sinusitis. Curr Allergy Asthma Rep 2016; 16:10. [PMID: 26758863 DOI: 10.1007/s11882-015-0591-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Chronic sinusitis is a burdensome disease that has substantial individual and societal impact. Although great advances in medical and surgical therapies have been made, some patients continue to have recalcitrant infections. Microbial biofilms have been implicated as a cause of recalcitrant chronic sinusitis, and recent studies have tried to better understand the pathogenesis of chronic sinusitis as it relates to microbial biofilms. Here, we provide an overview of biofilms in chronic sinusitis with emphasis on pathogenesis, treatment, and future directions. In addition, recent evidence is presented, elucidating the role of bitter taste receptors as a possible key factor leading to biofilm formation.
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Affiliation(s)
- Bobby A Tajudeen
- Department of Otorhinolarygology-Head and Neck Surgery, The University of Pennsylvania, 3400 Spruce Street, 5th Floor Silverstein Bldg., Philadelphia, PA, 19104, USA.
| | - Joseph S Schwartz
- Department of Otorhinolarygology-Head and Neck Surgery, The University of Pennsylvania, 3400 Spruce Street, 5th Floor Silverstein Bldg., Philadelphia, PA, 19104, USA.
| | - James N Palmer
- Department of Otorhinolarygology-Head and Neck Surgery, The University of Pennsylvania, 3400 Spruce Street, 5th Floor Silverstein Bldg., Philadelphia, PA, 19104, USA.
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Head K, Chong LY, Piromchai P, Hopkins C, Philpott C, Schilder AGM, Burton MJ. Systemic and topical antibiotics for chronic rhinosinusitis. Cochrane Database Syst Rev 2016; 4:CD011994. [PMID: 27113482 PMCID: PMC8763400 DOI: 10.1002/14651858.cd011994.pub2] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND This review is one of six looking at the primary medical management options for patients with chronic rhinosinusitis.Chronic rhinosinusitis is common and is characterised by inflammation of the lining of the nose and paranasal sinuses leading to nasal blockage, nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Systemic and topical antibiotics are used with the aim of eliminating infection in the short term (and some to reduce inflammation in the long term), in order to normalise nasal mucus and improve symptoms. OBJECTIVES To assess the effects of systemic and topical antibiotics in people with chronic rhinosinusitis. SEARCH METHODS The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; CENTRAL (2015, Issue 8); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 29 September 2015. SELECTION CRITERIA Randomised controlled trials (RCTs) with a follow-up period of at least three months comparing systemic or topical antibiotic treatment to (a) placebo or (b) no treatment or (c) other pharmacological interventions. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease-specific health-related quality of life (HRQL), patient-reported disease severity and the commonest adverse event - gastrointestinal disturbance. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score and the adverse events of suspected allergic reaction (rash or skin irritation) and anaphylaxis or other very serious reactions. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics. MAIN RESULTS We included five RCTs (293 participants), all of which compared systemic antibiotics with placebo or another pharmacological intervention.The varying study characteristics made comparison difficult. Four studies recruited only adults and one only children. Three used macrolide, one tetracycline and one a cephalosporin-type antibiotic. Three recruited only patients with chronic rhinosinusitis without nasal polyps, one recruited patients with chronic rhinosinusitis with nasal polyps and one had a mixed population. Three followed up patients for 10 to 12 weeks after treatment had finished. Systemic antibiotics versus placebo Three studies compared antibiotics with placebo (176 participants).One study (64 participants, without polyps) reported disease-specific HRQL using the SNOT-20 (0 to 5, 0 = best quality of life). At the end of treatment (three months) the SNOT-20 score was lower in the group receiving macrolide antibiotics than the placebo group (mean difference (MD) -0.54 points, 95% confidence interval (CI) -0.98 to -0.10), corresponding to a moderate effect size favouring antibiotics (moderate quality evidence). Three months after treatment, it is uncertain if there was a difference between groups.One study (33 participants, with polyps) provided information on gastrointestinal disturbances and suspected allergic reaction (rash or skin irritation) after a short course of tetracycline antibiotic compared with placebo. We are very uncertain if antibiotics were associated with an increase in gastrointestinal disturbances (risk ratio (RR) 1.36, 95% CI 0.22 to 8.50) or skin irritation (RR 6.67, 95% CI 0.34 to 128.86) (very low quality evidence). Systemic antibiotics plus saline irrigation and intranasal corticosteroids versus placebo plus saline irrigation and intranasal corticosteroids One study (60 participants, some with and some without polyps) compared a three-month course of macrolide antibiotic with placebo; all participants also used saline irrigation and 70% used intranasal corticosteroids. Disease-specific HRQL was reported using SNOT-22 (0 to 110, 0 = best quality of life). Data were difficult to interpret (highly skewed and baseline imbalances) and it is unclear if there was an important difference at any time point (low quality evidence). To assess patient-reported disease severity participants rated the effect of treatment on a five-point scale (-2 for "desperately worse" to 2 for "cured") at the end of treatment (three months). For improvement in symptoms there was no difference between the antibiotics and placebo groups; the RR was 1.50 (95% CI 0.81 to 2.79; very low quality evidence), although there were also slightly more people who felt worse after treatment in the antibiotics group. There was no demonstrable difference in the rate of gastrointestinal disturbances between the groups (RR 1.07, 95% CI 0.16 to 7.10). General HRQL was measured using the SF-36. The authors stated that there was no difference between groups at the end of treatment (12 weeks) or two weeks later. Systemic antibiotics versus intranasal corticosteroids One study (43 participants, without polyps) compared a three-month course of macrolide antibiotic with intranasal corticosteroids. Patient-reported disease severity was assessed using a composite symptom score (0 to 40; 0 = no symptoms). It is very uncertain if there was a difference as patient-reported disease severity was similar between groups (MD -0.32, 95% CI -2.11 to 1.47; low quality evidence). Systemic antibiotics versus oral corticosteroids One study (28 participants, with polyps) compared a short course of tetracycline antibiotic (unclear duration, ˜20 days) with a 20-day course of oral corticosteroids. We were unable to extract data on any of the primary efficacy outcomes. It is uncertain if there was a difference ingastrointestinal disturbances (RR 1.00, 95% CI 0.16 to 6.14) or skin irritation (RR 2.00, 95% CI 0.20 to 19.62) as the results for these outcomes were similar between groups (very low quality evidence). AUTHORS' CONCLUSIONS We found very little evidence that systemic antibiotics are effective in patients with chronic rhinosinusitis. We did find moderate quality evidence of a modest improvement in disease-specific quality of life in adults with chronic rhinosinusitis without polyps receiving three months of a macrolide antibiotic. The size of improvement was moderate (0.5 points on a five-point scale) and only seen at the end of the three-month treatment; by three months later no difference was found.Despite a general understanding that antibiotics can be associated with adverse effects, including gastrointestinal disturbances, the results in this review were very uncertain because the studies were small and few events were reported.No RCTs of topical antibiotics met the inclusion criteria.More research in this area, particularly evaluating longer-term outcomes and adverse effects, is required.
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Affiliation(s)
- Karen Head
- UK Cochrane CentreSummertown Pavilion18 ‐ 24 Middle WayOxfordUK
| | - Lee Yee Chong
- UK Cochrane CentreSummertown Pavilion18 ‐ 24 Middle WayOxfordUK
| | - Patorn Piromchai
- Faculty of Medicine, Khon Kaen UniversityDepartment of OtorhinolaryngologyKhon KaenThailand
| | - Claire Hopkins
- Guy's HospitalENT DepartmentGerat Maze PondLondonUKSE1 9RT
| | - Carl Philpott
- Norwich Medical School, University of East AngliaDepartment of MedicineNorwichUKNR4 7TJ
| | - Anne GM Schilder
- Faculty of Brain Sciences, University College LondonevidENT, Ear Institute330 Grays Inn RoadLondonUKWC1X 8DA
| | - Martin J Burton
- UK Cochrane CentreSummertown Pavilion18 ‐ 24 Middle WayOxfordUK
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Orlandi RR, Kingdom TT, Hwang PH, Smith TL, Alt JA, Baroody FM, Batra PS, Bernal-Sprekelsen M, Bhattacharyya N, Chandra RK, Chiu A, Citardi MJ, Cohen NA, DelGaudio J, Desrosiers M, Dhong HJ, Douglas R, Ferguson B, Fokkens WJ, Georgalas C, Goldberg A, Gosepath J, Hamilos DL, Han JK, Harvey R, Hellings P, Hopkins C, Jankowski R, Javer AR, Kern R, Kountakis S, Kowalski ML, Lane A, Lanza DC, Lebowitz R, Lee HM, Lin SY, Lund V, Luong A, Mann W, Marple BF, McMains KC, Metson R, Naclerio R, Nayak JV, Otori N, Palmer JN, Parikh SR, Passali D, Peters A, Piccirillo J, Poetker DM, Psaltis AJ, Ramadan HH, Ramakrishnan VR, Riechelmann H, Roh HJ, Rudmik L, Sacks R, Schlosser RJ, Senior BA, Sindwani R, Stankiewicz JA, Stewart M, Tan BK, Toskala E, Voegels R, Wang DY, Weitzel EK, Wise S, Woodworth BA, Wormald PJ, Wright ED, Zhou B, Kennedy DW. International Consensus Statement on Allergy and Rhinology: Rhinosinusitis. Int Forum Allergy Rhinol 2016; 6 Suppl 1:S22-209. [DOI: 10.1002/alr.21695] [Citation(s) in RCA: 333] [Impact Index Per Article: 41.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 11/13/2015] [Accepted: 11/16/2015] [Indexed: 02/06/2023]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Valerie Lund
- Royal National Throat Nose and Ear Hospital; London UK
| | - Amber Luong
- University of Texas Medical School at Houston
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Weber RK, Hosemann W. Comprehensive review on endonasal endoscopic sinus surgery. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2015; 14:Doc08. [PMID: 26770282 PMCID: PMC4702057 DOI: 10.3205/cto000123] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.
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Affiliation(s)
- Rainer K. Weber
- Division of Paranasal Sinus and Skull Base Surgery, Traumatology, Department of Otorhinolaryngology, Municipal Hospital of Karlsruhe, Germany
- I-Sinus International Sinus Institute, Karlsruhe, Germany
| | - Werner Hosemann
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Greifswald, Germany
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