The Medical Management of Rhinosinusitis

Dental management of Kartagener syndrome: A case report

BACKGROUND

Kartagener syndrome (KS) is recognized as an inherited, autosomal recessive disorder characterized by a combination of chronic sinusitis, bronchiectasis, and situs inversus. It affects one in 12,500-50,000 live births worldwide.

AIM

This paper aims to discuss the dental management of patients diagnosed with KS.

CASE REPORT

A 31-year-old male with KS manifests by impaired cilia motility which increases the risk of a frequent lung infection. The dental examination revealed that the patient required comprehensive oral hygiene care which included patient education and nonsurgical periodontal therapy under local anesthesia.

CONCLUSIONS

Dental care providers should ask affected patients with KS about their signs and symptoms of cardiac and pulmonary disease and seek consultation with their attending physician regarding these health concerns before the initiation of general anesthesia and perhaps conscious sedation administration. Patients with KS with emerging cardiac and/or respiratory impairment should be referred promptly for medical assessment.

Efficacy of Targeted Middle Meatal Antibiotics and Endoscopic Sinus Surgery

Background

Postoperative infection remains a significant comorbidity of endoscopic sinus surgery (ESS) delayed healing, synechia formation, etc. The objective of this study was to compare the incidence of postoperative infection after ESS in patients receiving conventional postoperative oral antibiotic prophylaxis versus a synthetic bioabsorbable antibiotic–soaked nasal sponge used in the middle meatus (MM) in lieu of oral antibiotics.

Methods

A prospective randomized multicenter trial included 321 chronic rhinosinusitis patients undergoing minimally invasive ESS who received either 1 week of oral antibiotics and a saline-soaked bioabsorbable MM sponge (control group) or no oral antibiotics and the placement of a bacitracin-soaked bioabsorbable sponge in the MM (study group). Evaluations performed at baseline, 3-weeks, and 3-months postoperatively included the 20-item Sino-Nasal Outcome Test and nasal endoscopic examination.

Results

The 3-week postoperative infection rate was not significantly different between the study (n = 165) and control groups (n = 156): 5.4% versus 3.8%; p > 0.05. In addition, there was no significant difference between the two patient groups on evaluation of MM granulations, synechia, middle turbinate lateralization, or sponge retention.

Conclusion

Antibiotic-soaked synthetic bioabsorbable MM sponges show equivalent efficacy in controlling post ESS infections compared with conventional postoperative oral antibiotics. Topical antibiotic delivery to the MM via bioabsorbable sponges may reduce the need for postoperative systemic antibiotics and provide a cost-effective alternative that eliminates the issues of antibiotic side effects, drug–drug interactions, and medication compliance in the postoperative setting.

The Economic Burden and Symptom Manifestations of Chronic Rhinosinusitis

Background

The aim of this study was to delineate patient symptoms and economic burdens of chronic rhinosinusitis (CRS).

Methods

Adult patients with CRS were assessed prospectively with a survey instrument. Symptom scores for major and minor symptoms of CRS, medication use, physician visits for CRS, and work days missed were determined. Cost analyses were conducted.

Results

Three hundred twenty-two patients were studied prospectively (mean age, 42.3 years). Nasal obstruction and facial congestion were the most common and severe major symptoms, and headache and fatigue were the most common and severe minor symptoms. Patients received an average of 2.7 antibiotic courses and used nasal steroids and prescription antihistamines 18.3 and 16.3 weeks, respectively, in a 12-month period. Mean medical resource costs were $921 per patient-year. CRS caused an average of 4.8 days of missed work per 12-month period. The overall yearly economic cost of CRS was $1539 per patient.

Conclusion

Nasal and facial symptoms prevail over systemic and oropharyngeal symptoms in CRS. Significant medical resource expenditures and global economic costs accompany CRS.

Therapeutic Choices in the Treatment of Acute Community-Acquired Bacterial Rhinosinusitis

Background

Acute bacterial rhinosinusitis (ABRS) is a common medical problem affecting a large percentage of the population. The disease will most often follow a viral upper respiratory tract infection.

Methods

Appropriately diagnosed, ABRS is best treated with antibiotics, but other medications may play a role in some circumstances. Increasing antibiotic resistance to the common bacteria causing ABRS has occurred in the past 20 years, driven largely by inappropriate or unnecessary antibiotic use.

Results

There are many antibiotics available that may be used for the treatment of ABRS. The selection of the best antibiotic option is determined by evaluating a number of factors, with the potential antibiotic resistance being an important consideration.

Conclusion

This article reviews current recommendations for the antibiotic treatment of ABRS.

Microbiology of Sinus Puncture versus Middle Meatal Aspiration in Acute Bacterial Maxillary Sinusitis

Background

Maxillary sinus puncture is considered the gold standard for diagnosing acute bacterial maxillary sinusitis (ABMS) and for identifying bacterial pathogens in antimicrobial trials of ABMS. However, sinus puncture and aspiration is an invasive, time-consuming procedure that is limited by discomfort to the patient and possible complications. Therefore, the diagnostic usefulness in clinical practice and patient enrollment in studies of ABMS is hindered and alternatives for maxillary sinus puncture are being investigated.

Methods

We designed a prospective clinical and microbiological outpatient study. Cultures obtained by endoscopically guided middle meatal aspiration were compared with those from sinus puncture and aspiration in 24 patients with ABMS.

Results

Considering puncture and aspiration as the gold standard, endoscopy cultures provided a sensitivity of 80%, specificity of 100%, positive predictive value of 100%, negative predictive value of 78.6%, and correlation of 88.5%.

Conclusions

In our study, endoscopic sampling compared favorably with sinus puncture and aspiration.

Nasal Mycology of Chronic Rhinosinusitis

Background

Ponikau used a novel collection and culturing method to recover fungi from nasal secretion in patients with chronic rhinosinusitis. The same method had been used previously in Europe with a similar result. However, the use of Ponikau's method has not been reported in Asia.

Methods

Fifty-one patients with chronic rhinosinusitis who were scheduled for functional endoscopic sinus surgery were enrolled in this study. One day before functional endoscopic sinus surgery, swab specimens were obtained from middle meatuses and were sent to the microbiology laboratory for routine bacterial and fungal cultures. Then, the same nasal cavity was lavaged with 20 mL of sterile water. The exhaled fluid was collected and processed using the Ponikau method. Skin testing with Candida extract was done also in all patients. The results obtained by different culture methods were compared.

Results

Bacteria grew from 45 of 51 swab specimens. The culture rate was 88.2%. Fungi were cultured from 6 of 51 swab specimens (11.8%) and from 25 of 51 lavage specimens (49%). The fungal culture rates were significantly different between swab and lavage specimens (p < 0.001). Candida was the most common cultured fungi in the lavaged specimens.

Conclusions

The study showed that Ponikau's method resulted in a higher fungal culture rate than that obtained with the swab method, but the culture rate was lower than the bacterial culture rate. Additional study is needed to investigate the role of fungi in the pathogenesis of chronic rhinosinusitis.

Endoscopically Directed Middle Meatal Cultures Versus Maxillary Sinus Taps in Acute Bacterial Maxillary Rhinosinusitis: A Meta-Analysis

OBJECTIVES: The aim of this study was to verify the correlation of endoscopically directed middle meatal (EDMM) cultures with maxillary sinus tap and culture (MST) in acute bacterial rhinosinusitis (ABRS).

STUDY DESIGN AND METHODS: Meta-analysis of the previous literature, unpublished data, and a prospective trial supported by the Sinus & Allergy Health Partnership. EDMM and MST cultures were obtained and their results compared. Inclusion for both the unpublished and prospective trial as well as prior published literature in the meta-analysis required the studies to compare EDMM versus MST in the acute setting of bacterial rhinosinusitis with both symptomatic and radiologic evidence of ABRS.

RESULTS: Three articles and 1 national presentation were identified for inclusion. Additional data from unpublished studies and the prospective trial were combined. The pooled data consisted of 126 patients with 131 culture pairs. For known pathogenic bacteria for ABRS and in comparison to MST, EDMM had a sensitivity of 80.9%, a specificity of 90.5%, a positive predictive value of 82.6%, a negative predictive value of 89.4%, and an overall accuracy of 87.0% (95% confidence interval, 81.3%-92.8%); 70.5% (12/17) of false positive culture pairs were of known pathogens for ABRS that would not be expected to be contaminants.

CONCLUSIONS AND SIGNIFICANCE: This meta-analysis shows that EDMM is a highly sensitive and accurate culture method for acute ABRS and may be more sensitive than MST given the presence of pathogenic bacteria not found on antral lavage. EDMM is a viable, and possibly preferred, culture method for determining antimicrobial efficacy and bacterial resistance patterns.

EBM rating: A-1a

Effects of Fluticasone Furoate on Clinical and Immunological Outcomes (IL-17) for Patients With Nasal Polyposis Naive to Steroid Treatment

Objectives:

We investigated the effect of topical steroids on clinical outcomes and related immune response of chronic rhinosinusitis with nasal polyp (CRSwNP) patients and in eradicating some polyps. We want to explore a new potential mechanism linked to Th-17 cells.

Methods:

Prospective, double-blind, placebo-controlled studies with 24 allergic and nonallergic patients were randomized to either placebo or fluticasone furoate for 12 weeks. Assessment of clinical response, endoscopic score with biopsies of the inferior turbinate, and polyps before and after treatment were performed. Biopsies were stained for T-cells, eosinophils, neutrophils, and IL-17A/F.

Results:

Steroid treatment improved the mean symptoms scores from 7.12 to 4.02 ( P < .01) and the polyp score from 5.13 to 3.31 ( P < .05), but the comparison with placebo was not statistically significant in nonallergics due to insufficient study power. Steroid treatment decreased eosinophil counts on allergics but not neutrophils or T-cells. The IL-17A/F expression was higher in nonallergics with high neutrophil counts and was inclined by steroids. Compared to baselines, IL-17 cells were significantly less in allergic individuals and were not observed in allergics and with high neutrophil counts.

Conclusion:

Topical steroids were more effective on certain nasal polyp phenotypes. Identification of polyp phenotype might be essential to ensure a better therapeutic response to intranasal corticosteroids.

Effects of intranasal steroid spray in bacterial culture of chronic rhinosinusitis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Does olfactory function improve after endoscopic sinus surgery?

OBJECTIVE

To examine the impact of endoscopic sinus surgery (ESS) on olfactory impairment in patients with chronic rhinosinusitis (CRS) over intermediate and long-term follow-up. We hypothesized that patients with mild olfactory dysfunction (hyposmia) would benefit from ESS, whereas patients with severe olfactory dysfunction (anosmia) would not.

STUDY DESIGN

Prospective, multi-institutional cohort study.

SUBJECTS AND METHODS

A total of 111 patients presenting for ESS for treatment of CRS were examined preoperatively, and at 6 and 12 months postoperatively. Demographic, comorbidity, and Smell Identification Test (SIT) data were collected at each time point. Univariate and multivariate analyses were performed.

RESULTS

The prevalence of gender-adjusted olfactory dysfunction prior to surgery was 67.5 percent. Surprisingly, hyposmic patients did not significantly improve after surgery. In contrast, patients with anosmia significantly improved after ESS (baseline, 6-month SIT scores: 9.7 +/- 2.0, 21.3 +/- 11.2; P = 0.001). Improvement was sustained at 12-month follow-up (21.7 +/- 10.7; P = 0.001). Multivariate linear regression analysis showed that baseline olfactory category and nasal polyposis were significantly associated with improvement in postoperative olfactory function (P = 0.035, P = 0.002).

CONCLUSION

Contrary to our hypotheses, patients with severe olfactory dysfunction significantly improved after ESS and sustained improvement over time, whereas patients with mild olfactory dysfunction did not.

Clinical practice guideline on adult sinusitis

This executive summary will alert clinicians to key evidence-based statements in a multidisciplinary, clinical practice guideline on adult sinusitis developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation. Included in the guideline are 17 boldfaced action statements: 3 on viral rhinosinusitis, 7 on acute bacterial rhinosinusitis, and 7 on chronic rhinosinusitis and recurrent acute rhinosinusitis. Evidence profiles that accompany each statement are summarized to show why it was made and how it can be implemented. Guideline statements regarding acute rhinosinusitis focus on diagnosing presumed bacterial illness and using antibiotics appropriately. Guideline statements regarding chronic rhinosinusitis or recurrent acute rhinosinusitis focus on appropriate use of diagnostic tests. Surgical therapy is not discussed.

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

OBJECTIVE

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

STUDY DESIGN AND SETTING

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

RESULTS

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

CONCLUSION

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

SIGNIFICANCE

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

An assessment of sinus quality of life and pulmonary function in children with cystic fibrosis

BACKGROUND

Treatment of patents with cystic fibrosis (CF) is primarily directed at the lungs. However, there is a growing feeling that the status of the sinuses may have a profound influence on the status of the lungs in these patients. A number of investigators have demonstrated a relationship among coexisting rhinitis, sinusitis, other upper airway conditions, and lung disease. Several studies have shown that treatment and resolution of sinusitis results in an improvement in a number of pulmonary conditions. We hypothesize that pulmonary function test scores will be lower in patients with CF with more severe sinusitis.

METHODS

Consecutive CF patients were asked to complete a sinus-specific quality-of-life instrument, the 16-item Sino-Nasal Outcome Test (SNOT-16), and these scores, were compared to FEV, scores.

RESULTS

Univariate analysis revealed a significant correlation between SNOT-16 and FEV1 in patients under the age of 12. There was a trend toward significance in the older children and evaluation of the raw data shows that children with the highest FEV, had the lowest SNOT-16.

CONCLUSION

This study indicates that the severity of sinus disease correlates with the severity of pulmonary disease in CF patients under the age of 12. We plan to use the SNOT-16 to assess sinus interventions on pulmonary status.

Symptom and disease severity differences between nasal septal deviation and chronic rhinosinusitis

OBJECTIVE

To determine whether patients with chronic rhinosinusitis (CRS) exhibit more severe sinonasal symptom scores as compared with patients with nasal septal deviation (NSD) alone.

METHODS

Two patient cohorts were prospectively identified: patients undergoing surgery for NSD alone and those undergoing endoscopic sinus surgery for CRS without NSD. Patients in the NSD group were required to have normal paranasal sinus CT scans, whereas patients in the CRS group were required to have radiographic evidence of CRS. All patients completed the Rhinosinusitis Symptom Inventory (RSI). Statistical comparisons were conducted between cohorts with respect to RSI symptom domains and medical resource utilization.

RESULTS

A total of 42 patients were identified in the NSD group (mean age, 40.8 years) and 155 patients were identified in the CRS group (mean age, 44.9). Patients with CRS demonstrated higher severity scores for the nasal symptom domains (60.3 [CRS] versus 53.9 [NSD], P = 0.037). Oropharyngeal symptoms and total symptoms were also worse for the CRS group versus the NSD group (29.8 versus 23.1, P = 0.014 and 43.0 versus 37.0, P = 0.030). Facial and systemic symptom scores did not differ between groups. Patients with CRS demonstrated significantly higher utilization rates for topical nasal steroids (21.2 versus 12.2 weeks, P = 0.006) and oral antibiotics (7.9 weeks versus 2.1 weeks, P < 0.001), but not for oral antihistamines (P = 0.420).

CONCLUSIONS

Although patients with CRS manifest higher sinonasal symptom scores than patients with NSD alone, differentiating these 2 diagnoses on the basis of symptoms alone is difficult. These data suggest that as a disease process, CRS confers a significant disease burden with more significant negative symptom impact.

Maxillary sinus puncture and culture in the diagnosis of acute rhinosinusitis: the case for pursuing alternative culture methods

OBJECTIVE

Traditional assessments of the microbial flora associated with acute bacterial rhinosinusitis have relied on maxillary sinus punctures (taps) and culture. These taps are now considered the gold standard for obtaining cultures and are used as the method of identifying bacterial pathogens in antimicrobial trials. Maxillary sinus taps are limited by discomfort to the patients and technical concerns. Because of these factors, the standard of performing taps has limited antibiotic trials and microbial surveillance. Alternatives to maxillary sinus taps have been explored.

STUDY DESIGN

We conducted a retrospective, systematic review of the literature from 1950 to 2000 of articles comparing culture techniques in the nose and paranasal sinuses for acute bacterial rhinosinusitis.

RESULTS

Nasal cultures have poor correlation to maxillary sinus cultures, whereas there is 60% to 85% concordance between endoscopically guided middle meatal cultures and maxillary sinus cultures. These studies, however, are all limited by small sample sizes and therefore are inadequate to make any concrete recommendations regarding the relative role of endoscopically guided middle meatal cultures as a formal method of pathogen identification in acute bacterial rhinosinusitis.

CONCLUSION

A formal prospective study with sufficient sample size to assess the concordance between the microbial flora of the maxillary sinus punctures and middle meatal cultures in acute rhinosinusitis is recommended.

Determination of the "incidental" Lund score for the staging of chronic rhinosinusitis

OBJECTIVE

Determine normative values for the Lund score for computed tomographic (CT) scans of the paranasal sinuses.

METHODS

Patients undergoing CT of the paranasal sinus region for nonsinusitis causes were evaluated and staged according to the Lund-MacKay system. Complete and near complete Lund scores were computed from these scans and the frequencies of incidental paranasal abnormalities were tabulated.

RESULTS

A total of 199 patients who underwent CT scans of the internal auditory canals, pituitary, or orbits demonstrated adequate visualization of the paranasal sinuses. In 91 patients, the imaging was sufficient to compute a complete Lund score with a mean of 4.26 (95% CI, 3.43 to 5.10). In 130 patients, all sinuses were adequately imaged except for the ostiomeatal complex. For this near complete group, the mean prorated Lund score was 4.26 (95% CI, 3.55 to 4.97). Both of these scores differed significantly from an expected score of zero (P < 0.001).

CONCLUSIONS

The Lund score in the general population is not 0. A Lund score ranging from 0 to 5 may be considered within an incidentally "normal" range, and should be factored into clinical decision-making.

Treatment of chronic rhinosinusitis refractory to other treatments with topical antibiotic therapy delivered by means of a large-particle nebulizer: results of a controlled trial

OBJECTIVE

To study the efficacy of nebulized topical saline-tobramycin solution in patients with chronic rhinosinusitis refractory to medical and surgical therapy.

STUDY DESIGN AND SETTING

Twenty patients in whom endoscopic sinus surgery failed to relieve symptoms entered a randomized, double-blind trial of tobramycin-saline solution or saline-only solution administered thrice daily to the nasal passages by means of a large-particle nebulizer apparatus for 4 weeks, followed by a 4-week observation period. Outcome measures of symptoms, quality of life, and endoscopic aspect of sinus mucosa were assessed.

RESULTS

Both treatments were well tolerated and produced equivalent improvement in symptoms, quality of life, and mucosal aspect. Treatment with the tobramycin-saline solution gave more rapid improvement of pain, but led to the development of nasal congestion.

CONCLUSION

Therapy with a 4-week course of large-particle nebulized aerosol therapy improves symptomatology and objective parameters of rhinosinusitis in patients refractory to surgical and medical therapies. Addition of tobramycin appears of minimal benefit. The mechanism of this effect is unexplained.

SIGNIFICANCE

Large-particle nebulized aerosol therapy may offer a safe and effective management alternative for patients with refractory rhinosinusitis.

Chronic rhinosinusitis: allergy and sinus computed tomography relationships

The management of chronic or recurrent rhinosinusitis problems is multifaceted and should include consideration of contributory and potentially correctable medical and anatomic factors. To date, the relationship between allergy and rhinosinusitis has not been clearly defined. The purpose of this study is to improve understanding of the relative roles of perennial and seasonal allergens in the cause of chronic rhinosinusitis. A retrospective review of 200 consecutive patients was carried out on patients who had chronic rhinosinusitis refractory to medical therapy and who subsequently underwent functional endoscopic sinus surgery. All of these patients had allergy testing for common perennial and seasonal inhalant allergens before surgery. Each patient had sinus CT imaging before undergoing the surgery. The CT scans of each patient were staged according to a validated, standardized grading system by investigators blinded to allergic profile. Allergy testing indicated that 84% of all patients tested positive for allergies. Moreover, 60% of all patients had significant allergic sensitivity; 52% of all patients had multiple allergen sensitivities. Furthermore, there was a predominance of perennial allergens, especially house dust mite over seasonal allergens. The vast majority of our patients undergoing functional endoscopic sinus surgery had concomitant allergy. This study highlights the potential contribution of perennial allergies to the development of rhinosinusitis. Given this direction, future studies may reveal that in the care of patients with perennial allergic rhinitis, early intervention with identification of the offending allergen(s), and subsequent treatment through avoidance, pharmacotherapy, and/or immunotherapy may help in the prevention of recurrent and chronic rhinosinusitis.