Osteitis and paranasal sinus inflammation: what we know and what we do not

Tissue Interleukin-33: A Novel Potential Regulator of Innate Immunity and Biomarker of Disease Severity in Chronic Rhinosinusitis with Nasal Polyps

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a disease of real interest for researchers due to its heterogenicity and complex pathophysiological mechanisms. Identification of the factors that ensure success after treatment represents one of the main challenges in CRSwNP research. No consensus in this direction has been reached so far. Biomarkers for poor outcomes have been noted, but nonetheless, their prognostic value has not been extensively investigated, and needs to be sought. We aimed to evaluate the correlation between potential prognostic predictors for recalcitrant disease in patients with CRSwNP.

METHODS

The study group consisted of CRSwNP patients who underwent surgical treatment and nasal polyp (NP) tissue sampling. The preoperative workup included Lund-Mackay assessment, nasal endoscopy, eosinophil blood count, asthma, and environmental allergy questionnaire. Postoperatively, in subjects with poor outcomes, imagistic osteitis severity was evaluated, and IL-33 expression was measured.

RESULTS

IL-33 expression in NP was positively and significantly correlated with postoperative osteitis on CT scans (p = 0.01). Furthermore, high osteitis CT scores were related to high blood eosinophilia (p = 0.01). A positive strong correlation was found between postoperative osteitis and the Lund-Mackay preoperative score (p = 0.01), as well as the nasal endoscopy score (p = 0.01).

CONCLUSIONS

Our research analyzed the levels of polyp IL-33, relative to blood eosinophilia, overall disease severity score, and osteitis severity, in patients with CRSwNP. These variables are prognostic predictors for poor outcomes and recalcitrant disease. Considering the importance of bone involvement in CRSwNP, this research aims to provide a better insight into the correlations of osteitis with clinical and biological factors.

Clinical and immunologic implication of neo-osteogenesis in chronic rhinosinusitis

INTRODUCTION

Chronic rhinosinusitis (CRS) is a multifactorial disease characterized by long-term inflammation of the nasal and sinus passages. Neo-osteogenesis which is a major finding of recalcitrant CRS is clinically related to the disease severity and surgical outcomes of CRS.

AREAS COVERED

The immunological and molecular mechanisms underlying neo-osteogenesis of CRS remain unclear, and many recent studies have suggested the importance of inflammatory mediators secreted by immune cells. This paper provides a broader understanding of neo-osteogenesis in CRS by reviewing recent updates and evidence of the association between CRS pathophysiology and neo-osteogenesis.

EXPERT OPINION

Crosstalk between the bone and mucosa eventually results in refractory CRS. In addition, both eosinophilic and non-eosinophilic CRS cytokines can play a role in neo-osteogenesis and trigger an enhanced CRS-associated immune response. The significance of predicting neo-osteogenesis in advance or during postoperative care could be essential for effectively managing refractory CRS and enhancing the prognosis of CRS patients.

The Impact of Osteitis on Quality of Life in Patients with Chronic Rhinosinusitis

Introduction: Chronic rhinosinusitis (CRS) is a significant health problem worldwide with an estimated prevalence of 5-12% in the general population. Osteitis refers to inflammation of bone characterized by bone remodeling, neo-osteogenesis and thickening of adjacent mucosa. These changes are evidenced by specific radiological appearance on Computerized Tomography (CT) which may be localized or diffuse dependent on extent of disease. Osteitis act as a marker of severity in chronic rhinosinusitis and can significantly affect the patient's Quality of Life (QOL) proportional to its severity. Aim: To analyze the impact of osteitis on quality of life in patients with chronic rhinosinusitis as evidenced by pre-operative Sinonasal Outcome Test-22(SNOT-22) scores. Materials & Methods: 31 patients diagnosed to have chronic rhinosinusitis with co-existing osteitis were enrolled in this study based on computerized tomography scan Paranasal Sinuses (PNS) findings and graded as per the calculated Global Osteitis Scoring Scale. Accordingly, patients were categorised into those without significant osteitis, with mild, moderate and severe osteitis. Baseline quality of life in these patients was assessed using the Sinonasal Outcome Test-22 (SNOT-22) and its association with the severity of osteitis analysed. Results: There is a very strong correlation between severity of osteitis and quality of life in the study population based on the Sinonasal Outcome Test-22 scores (p = 0.000). The mean Global Osteitis score was 21.65 with standard deviation 5.66. Maximum score obtained was 38 and minimum score 14. Conclusion: • Osteitis has a significant impact on quality of life in patients with chronic rhinosinusitis. • Severity of osteitis has a direct relation to quality of life in chronic rhinosinusitis.

Alleviation of Surgery-Induced Osteitis in Sinonasal Cavity by Dexamethasone-Loaded Poly(lactic-co-glycolic acid) (PLGA) Microparticles with Strong Calcium-Binding Affinity

For the treatment of sinus surgery-induced osteitis in chronic rhinosinusitis (CRS), oral or intranasal administration of corticoids is generally used, although it has critical limitations and unavoidable side effects. To overcome these limitations, we designed dexamethasone (Dex)-loaded poly(lactic-co-glycolic acid) (PLGA) microparticles with bone-specific binding affinity, which could release the encapsulated Dex in a sustained manner on the exposed bone after the surgical wound in the nasal cavity. In a previous report, we prepared poly(butyl methacrylate-co-methacryloyloxyethyl phosphate) (PBMP) with both calcium-binding phosphomonoester groups and PLGA-binding butyl groups to introduce strong calcium-binding property to PLGA particles. In this study, after successful encapsulation of Dex in the PBMP-coated PLGA particles, we applied the Dex-PLGA/PBMP to the treatment of post-operative osteitis in the sinonasal cavity. The Dex-PLGA/PBMP showed more than 5-times higher binding affinity to the hydroxyapatite (HA) surface compared to the non-coated PLGA particles, without altering the morphology and encapsulation efficiency. After establishing the neo-osteogenesis mouse model by mechanical injury of the nasal mucosa, the activity of intranasally administered Dex-PLGA/PBMP was examined to inhibit the formation of undesirable new woven bone during the wound healing process. In addition, significantly lower osteocalcin activity was observed in the group treated with Dex-PLGA/PBMP, indicating decreased activation of osteoblasts. Overall, these results demonstrate that the PLGA/PBMP microparticle strategy has great potential for the treatment of CRS-related osteitis by localized corticoid delivery on the exposed bones with minimal side effects.

Radical versus Functional Endoscopic Sinus Surgery for Osteitis in Chronic Rhinosinusitis

INTRODUCTION

Osteitis in chronic rhinosinusitis (CRS) is a predictive factor of disease severity and an important potential reason for disease recalcitrance. Other than medical treatment, transnasal endoscopic surgery could be another choice to deal with osteitis in CRS.

OBJECTIVE

In this study, 2 different surgical outcomes and influence in patients with osteitis in CRS were discussed.

METHODS

A retrospective analysis of 51 cases was carried out. Osteitis in CRS was confirmed by sinus computed tomography (CT). According to surgical management, patients were divided into the radical endoscopic sinus surgery (RESS) group (n = 24) and functional endoscopic sinus surgery (FESS) group (n = 27). Baseline measures and postoperative outcomes were evaluated by symptom visual analog scale (VAS), peripheral blood eosinophil percentage, serum total IgE, skin prick test, endoscopy Lund-Kennedy score, CT scan Lund-Mackay score, and global osteitis scoring scale (GOSS) in 2 groups.

RESULTS AND CONCLUSIONS

There was no significant difference between the 2 groups in age, gender, and complicated with allergic rhinitis and asthma. The preoperative symptom VAS score and endoscopy Lund-Kennedy score were higher in the RESS group than in the FESS group, and the Lund-Mackay score and GOSS score were similar in the 2 groups. One year after surgery, symptom VAS scores, endoscopy Lund-Kennedy score, and Lund-Mackay score were significantly lower in the 2 groups. The endoscopy Lund-Kennedy score and Lund-Mackay score were lower in the RESS group than in the FESS group 1 year after surgery. RESS was more effective in reducing inflammatory load of sinuses in patients with osteitis in CRS.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

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.

Osteitis in Chronic Rhinosinusitis

PURPOSE OF REVIEW

Osteitis is recognized as a common factor in recalcitrant chronic rhinosinusitis (CRS). There is evidence for the association of osteitis with revision surgeries and CRS severity, in terms of higher Lund-Mackay scores. This is a narrative review on the osteitis in CRS patients.

RECENT FINDINGS

Evidence to date is inconclusive with regard to the etiology and pathogenesis of this bony thickening. Histopathology of osteitis in primary CRS is likely a process of neo-osteogenesis and bone remodeling. For better understanding, various associating factors have been studied including an inflammatory pattern of rhinosinusitis. Recent studies have associated osteitis with nasal polyps and tissue eosinophilia with the increase in periostin expression and P-glycoprotein mucosal expression. There is no association of osteitis to symptoms or quality of life. Osteitis is an outcome of neo-osteogenesis rather than inflammatory processes in CRS patients without a prior history of surgery. While CT has become a staple in osteitis assessment, the standards for grading osteitic severity remain in an experimental stage. There is no association between the presence or severity of osteitis at the time of surgery and clinical outcomes at 1 year after surgery. This review provides a comprehensive overview of the pathogenesis, epidemiology, and correlation with clinical and biological factors of osteitis in CRS patients.

Establishment and verification of a mouse model of nasal wound healing

OBJECTIVES

Poor wound healing as reflected by the development of synechia and osteitis after endoscopic sinus surgery may trigger disease recurrence. Animal models provide insights into the pathogenesis of poor wound healing and may aid in the development of new therapeutics. Here, we established a mouse model of nasal wound healing and confirmed its utility.

STUDY DESIGN

Animal study.

METHODS

Unilateral intranasal wounds were induced using a small interdental brush in 6-week-old C57BL/6 mice. Forty-five mice were divided into three groups (each n = 15): one control and two experimental groups (intranasal vs. intraperitoneal dexamethasone). Mice were sacrificed on days 2, 14, and 28 after injury (each n = 5). Serial changes in nasal wound histopathology were described, and intergroup differences were analyzed.

RESULTS

On day 2, mucosal detachment, hemorrhage, and exudate were observed. On day 14, synechiae featuring neo-osteogenesis (bone lacunae, osteoblasts, and multinucleated osteoclasts) between the septum and the maxilloturbinate were prominent, followed by wound maturation on day 28: fewer lacunae and smaller osteoblasts. Macrophages were evident only on day 2, and lymphocytes were predominant on day 28. The amount of exudate on day 2 and the synechial area on day 28 were significantly reduced in mice that received dexamethasone systemically compared with control mice, with similar trends in those treated intranasally.

CONCLUSION

Our mouse model of nasal wound healing was characterized by the development of bony synechia and neo-osteogenesis, not soft-tissue synechia. The model may be useful in the assessment of novel therapeutics to prevent those wounds.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:E266-E271, 2019.

Frontal sinus revision rate after nasal polyposis surgery including frontal recess clearance and middle turbinectomy: A long-term analysis

OBJECTIVE

To determine the frontal sinus revision rate after nasal polyposis (NP) surgery including frontal recess clearance (FRC) and middle turbinectomy (MT), to search for predictive factors and to analyse surgical management.

METHODS

Longitudinal analysis of 153 patients who consecutively underwent bilateral sphenoethmoidectomy with FRC and MT for NP with a minimum follow-up of 7 years. Decision of revision surgery was made in case of medically refractory chronic frontal sinusitis or frontal mucocele. Univariate and multivariate analysis incorporating clinical and radiological variables were performed.

RESULTS

The frontal sinus revision rate was 6.5% (10/153). The mean time between the initial procedure and revision surgery was 3 years, 10 months. Osteitis around the frontal sinus outflow tract (FSOT) was associated with a higher risk of frontal sinus revision surgery (p=0.01). Asthma and aspirin intolerance did not increase the risk, as well as frontal sinus ostium diameter or residual frontoethmoid cells. Among revised patients, 60% required multiple procedures and 70% required frontal sinus ostium enlargement.

CONCLUSIONS

Our long-term study reports that NP surgery including FRC and MT is associated with a low frontal sinus revision rate (6.5%). Patients developing osteitis around the FSOT have a higher risk of frontal sinus revision surgery. As mucosal damage can lead to osteitis, FSOT mucosa should be preserved during initial NP surgery. However, as multiple procedures are common among NP patients requiring frontal sinus revision, frontal sinus ostium enlargement should be considered during first revision in the hope of reducing the need of further revisions.

Biofilm and Osteitis in Refractory Chronic Rhinosinusitis

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.

Microarray analysis of the genes associated with osteitis in chronic rhinosinusitis

OBJECTIVES/HYPOTHESIS

Although numerous studies have examined epithelial remodeling in chronic rhinosinusitis (CRS), bone remodeling (osteitis) has only recently gained attention as a potential significant contributor to the pathophysiology of recalcitrant CRS. The purpose of this study was to compare gene expression profiles between osteitic bone and the adjacent diseased mucosa in patients with CRS to determine which genes affect mucosal and bony remodeling.

STUDY DESIGN

Prospective experimental analysis.

METHODS

Samples were obtained from sites of osteitic bone and overlying mucosa in CRS patients demonstrating osteitis on computed tomography and compared to healthy controls. The entire transcripted gene expression profile was determined by microarray following RNA isolation and compared between tissue samples. The expression differences were verified by reverse transcriptase-polymerase chain reaction and immunohistochemical staining.

RESULTS

Growth differentiation factor 5 and exostosin glycosyltransferase 1 were significantly upregulated and positively correlated with mucosal eosinophilic inflammation in osteitic bone. Fibroblast growth factor was significantly increased in osteitic bone. Additionally, colony stimulating factor was positively correlated with the degree of osteitis.

CONCLUSIONS

These findings will add a new perspective to our current understanding of the recalcitrant CRS.

LEVEL OF EVIDENCE

NA Laryngoscope, 127:E85-E90, 2017.

Comprehensive review on endonasal endoscopic sinus surgery

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.

Clinical and biological markers of difficult-to-treat severe chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a chronic inflammatory disease of the upper airways of which two major phenotypes exist, CRS without nasal polyps (CRSsNP) and CRS with nasal polyps (CRSwNP). Some patients with CRS have suboptimal response to current guideline treatments. These patients remain severe and uncontrolled by treatment and have a poor quality of life. It is highly important to identify both clinical and biological markers, so-called biomarkers, in this subset of patients. The presence of nasal polyps and comorbidity with asthma and with aspirin-exacerbated respiratory disease (AERD) are the most common clinical traits that have been associated to difficult-to-treat severe CRS. In addition to clinical traits, numerous biological markers, with known etiopathogenic roles in CRS, have been associated to difficult-to-treat or recalcitrant CRS. This review summarizes the existing knowledge of the clinical and biological markers associated to difficult-to-treat or uncontrolled severe CRS.

Differing roles for TGF-β/Smad signaling in osteitis in chronic rhinosinusitis with and without nasal polyps

BACKGROUND

Chronic rhinosinusitis (CRS) without nasal polyps (CRSsNP) and with nasal polyps (CRSwNP) is reported to involve different inflammatory processes in sinonasal mucosa and bone tissue, and these processes remain uncharacterized.

OBJECTIVE

We aimed to investigate the molecular mechanisms of osteitis in Chinese patients with CRS to better understand the pathogenesis of CRS.

METHODS

The study included 10 controls, 16 patients with CRSsNP, and 23 patients with CRSwNP. Ethmoid bone tissue samples were evaluated by histologic examination. Quantitative real-time reverse transcription polymerase chain reaction was used to assess expression of transforming growth factor (TGF) β1, TGF-β receptor I and II, Smad2, and Smad3. Immunohistochemical examination of osteoblast expression of TGF-β1, TGF-β receptor I and II, phosphorylated (p) Smad2, and p-Smad3 in ethmoid bone tissue was also performed.

RESULTS

The histopathologic evaluation of ethmoid sinus bone tissue showed that eosinophils had infiltrated the periosteum and induced TGF-β1 expression, periosteal thickening, increased osteoblast activity, and neo-osteogenesis. Messenger RNA levels of TGF-β1, TGF-β receptor I, and Smad3 in CRSwNP ethmoid bone tissues were significantly higher than those in ethmoid bone tissues of patients with CRSsNP and the controls. Immunohistochemical staining showed that TGF-β1, TGF-β receptor I, p-Smad2, and p-Smad3 protein expression was upregulated in patients with CRSwNP, consistent with the corresponding messenger RNA levels.

CONCLUSION

Different signaling pathways are involved in osteitis in CRS and are activated by the TGF-β/Smad signaling pathway in CRSwNP versus the TGF-β/Smad-independent signaling pathway in CRSsNP. Eosinophil infiltration of the periosteum, along with TGF-β1 expression, in CRSwNP indicates that eosinophils may play an important role in the bone remodeling process in CRSwNP.

Osteitis is associated with P-glycoprotein overexpression in patients with chronic sinusitis without nasal polyps

BACKGROUND

P-glycoprotein (P-gp) is a membrane-bound efflux pump that is up-regulated in eosinophilic chronic rhinosinusitis and participates in epithelial cytokine secretion. Osteitis is associated with eosinophilic inflammation and may represent a method to predict patients with P-gp overexpression. The purpose of this article was to determine whether P-gp overexpression and increased osteitis scores are associated in patients with chronic rhinosinusitis (CRS).

METHODS

An Institutional Review Board-approved study was performed using sinus tissue in 38 patients with CRS. P-gp expression was calculated using quantitative fluorescent immunohistochemistry to generate an epithelial-to-background staining ratio. Patients were stratified into low and high P-gp expression groups. Osteitis was scored radiologically using the Kennedy Osteitis Score (KOS) and Global Osteitis Score (GOS). Serum eosinophilia was assessed. KOS and GOS were compared using a Pearson's correlation coefficient. Osteitis scores and serum eosinophil concentrations between P-gp expression groups were compared using a nonparametric Mann-Whitney U test (two tailed).

RESULTS

Among the 38 patients, 7(18.42%) had high P-gp expression (mean ± SD, 4.86 ± 1.33) whereas 31(81.57%) had low expression ratios (1.93 ± 0.45). No patients in the high P-gp expression group had undergone prior surgery. Median serum eosinophil values were significantly greater in the high versus low P-gp expression group (6.98 ± 2.17 versus 2.36 ± 1.38, p < 0.001). GOS and KOS values were significantly greater in the high versus low P-gp expression group (15.86 ± 4.91 versus 6.29 ± 1.25 and 4.55 ± 4.33 verus 2.23 ± 1.71; p < 0.001). KOS and GOS values were significantly correlated (r = 0.835; p < 0.001).

CONCLUSION

Increased osteitis burden as measured by either the KOS or the GOS is associated with increased P-gp membranous expression in CRS. Radiographic quantification of osteitis may therefore be used to identify patients with P-gp overexpression thereby providing a novel potential therapeutic target.

Clinical predictors of neo-osteogenesis in patients with chronic rhinosinusitis

BACKGROUND

Neo-osteogenesis of the paranasal sinuses is a radiologic finding of unclear clinical significance. Although current evidence suggests that these bony changes represent an inflammatory response rather than an infectious osteitis, bacteria associated with the sinonasal mucosa may induce inflammatory mediators as a mechanism of neo-osteogenesis. The objectives of this study were (1) to determine whether there is an association between bacteria isolated on sinus culture and neo-osteogenesis, and (2) to identify other predictive factors for neo-osteogenesis.

METHODS

Ninety patients undergoing sinus surgery for medically refractory CRS were recruited. Radiologic evidence of neo-osteogenesis was assessed by the Global Osteitis Scoring Scale (GOSS) and mucosal disease severity was assessed by the Lund-Mackay score (LMS). Bacterial culture was obtained endoscopically at the preoperative office visit or during surgery. Multiple and logistic regression models were used to evaluate the association between the types of bacterial species isolated, number of previous surgeries, and severity of neo-osteogenesis.

RESULTS

Thirty of the 90 (33.3%) patients had radiologic evidence of neo-osteogenesis. Pseudomonas aeruginosa was significantly associated with neo-osteogenesis (odds ratio [OR], 3.97; 95% confidence interval [CI], 1.12 to 13.56), whereas Staphylococcus aureus was not. The number of previous surgeries, especially 2 or more previous surgeries, was associated with the extent of neo-osteogenesis (OR, 3.48; 95% CI, 1.14 to 10.51). The LMS was also significantly associated with the extent of neo-osteogenesis.

CONCLUSION

The presence of P. aeruginosa in the sinuses is an independent predictor of neo-osteogenesis, whereas S. aureus is not. The number of previous surgeries and the LMS are also independently associated with the severity of neo-osteogenesis.

Chronic rhinosinusitis osteoblasts differ in cellular properties from normal bone

BACKGROUND

Osteitis, characterized by bony thickening and remodeling, is often considered a hallmark of recalcitrant rhinosinusitis. However, there is limited literature examining the bone in chronic rhinosinusitis (CRS) pathology. In this study we cultured osteoblasts from bone harvested during sinus surgery as well as from nondiseased controls to compare their cellular properties.

METHODS

Sinus bone was collected during sinus and skull-base surgery and placed in proliferation media. Outgrowth of cells occurred at 2 weeks and the cells were confirmed to be osteoblasts by alkaline phosphatase staining. Cellular adhesion was determined by replating and counting adhered cells at 4 hours. Proliferation of cells plated for 24 hours was assayed by measuring [(3) H]-thymidine incorporation. Calcium content was measured by changing cells to differentiation media and measuring the calcium content on days 7, 14, and 21.

RESULTS

Alkaline phosphatase assay showed more than 90% of osteoblasts staining in all samples. Osteoblasts from patients with CRS had significant decreases in adhesion (p < 0.01) compared to osteoblasts from skull-base patients. There was a significant (p < 0.05) increase in calcium content in rhinosinusitis samples compared with the nondiseased sinus bone samples.

CONCLUSION

To date, this is the first known study that shows a direct comparison of osteoblast properties between patients with and without CRS. Our results indicate that there are fundamental phenotypic differences in adhesion and mineralization between osteoblasts in patients with CRS compared to controls.

Relationship between biofilms and clinical features in patients with sinus fungal ball

The presence of bacterial biofilms (BBF) and fungal biofilms (FBF) is associated with greater disease severity in chronic rhinosinusitis. However, researches on biofilms in fungal rhinosinusitis are rare. This study investigated the relationship between biofilms and clinical features in patients with sinus fungal ball (SFB). Sixty-four SFB patients undergoing endoscopic sinus surgery and 21 controls were enrolled in this study. Mucosal samples from nasal sinuses were collected for biofilm detection under confocal scanning laser microscopy (CSLM). The general clinical data, Lund-Mackay computed tomography (CT) score, Lund-Kennedy endoscopy score, Global Osteitis Scoring Scale (GOSS) score, Sinonasal Outcome Test (SNOT)-22 score and visual analog scale (VAS) score were recorded. Associations between these parameters and biofilms were assessed. Under CSLM, the positive rates of BBF and FBF were 45.3 % (29/64) and 21.9 % (14/64), respectively in the SFB group but none in controls. When sub-classified according to biofilm status, the BBF-positive subgroup had significantly higher Lund-Mackay score and GOSS score than the BBF-negative one, but there were no differences in demographic characteristics, health-related quality-of-life and endoscopic inflammatory severity. BBF and FBF coexisted on the sinus mucosa of the patients with SFB. BBF was associated with more severe disease, but the distribution of FBF did not affect the severity of SFB.

Facial structure alterations and abnormalities of the paranasal sinuses on multidetector computed tomography scans of patients with treated mucosal leishmaniasis

BACKGROUND/OBJECTIVES

Mucosal leishmaniasis (ML) is a progressive disease that affects cartilage and bone structures of the nose and other upper respiratory tract structures. Complications associated with ML have been described, but there is a lack of studies that evaluate the structural changes of the nose and paranasal sinuses in ML using radiological methods. In this study, we aimed to assess the opacification of the paranasal sinuses in patients with treated ML and any anatomical changes in the face associated with ML using multidetector computed tomography scans (MDCT) of the sinuses. We compared the findings with a control group.

METHODOLOGY/PRINCIPAL FINDINGS

We evaluated 54 patients with treated ML who underwent CT scans of the sinuses and compared them with a control group of 40 patients who underwent orbital CT scans. The degree of sinus disease was assessed according to the Lund-Mackay criteria. Forty of the 54 patients with a history of ML (74.1%) had a tomographic score compatible with chronic sinusitis (Lund-Mackay ≥4). CT scans in the leishmaniasis and control groups demonstrated significant differences in terms of facial structure alterations. Patients from the ML group showed more severe levels of partial opacification and pansinus mucosal thickening (42.6%) and a greater severity of total opacification. Patients from the ML group with a Lund-Mackay score ≥4 presented longer durations of disease before treatment and more severe presentations of the disease at diagnosis.

CONCLUSION/SIGNIFICANCE

CT scans of the sinuses of patients with ML presented several structural alterations, revealing a prominent destructive feature of the disease. The higher prevalence in this study of chronic rhinosinusitis observed in CT scans of patients with treated ML than in those of the control group suggests that ML can be considered a risk factor for chronic rhinosinusitis in this population (p<0.05).

Evidence-based surgery for chronic rhinosinusitis with and without nasal polyps

Meta-analysis of both large outcome studies as well as cohort studies support the safety and efficacy of Endoscopic Sinus Surgery for Chronic Rhinosinusitis. The efficacy of endoscopic sinus surgery is demonstrated in the improvement of both disease-specific and generic QOL as well as objective measures. However, this must be interpreted together with a well-recognized long-term 15-20 % revision rate, seen more often in patients with ASA trias and cystic fibrosis as well as osteitis and previous surgery. The effect of surgery is higher in managing nasal obstruction (effect size 1.7) and less so hyposmia (effect size 0.8). Allergy has an additive role on the symptomatology of CRS; however, its role if any on the outcome of ESS for CRS is unclear. The concurrent presence of aspiring sensitivity and asthma is associated with increased disease burden and more revision surgeries. Improved phenotyping of CRS may lead in the future to better tailoring of surgical treatments.

Correlation between bacterial biofilms and osteitis in patients with chronic rhinosinusitis

OBJECTIVES/HYPOTHESIS

Bacterial biofilms (BBF) and osteitis are potential contributors to the local inflammatory load in chronic rhinosinusitis (CRS). This study investigated the relationship between BBF and osteitis status in CRS patients.

STUDY DESIGN

Prospective cohort study.

METHODS

Eighty-four CRS patients undergoing endoscopic sinus surgery and 22 control patients were enrolled in this study. Mucosal and bony samples from ethmoid sinus were obtained for confocal scanning laser microscopy and microscopic examination. Biofilm volume (BV), biofilm score (BS), histopathologic bony grade, Global Osteitis Scoring Scale (GOSS) score, and Hounsfield unit (HU) value on computed tomography were recorded. Associations between these parameters describing BBF and osteitis were assessed.

RESULTS

The histopathologic bony grade 2 (0-3) versus 0 (0-3) (P < 0.001), GOSS score 4.5 (0-31) versus 0 (0-26) (P = 0.014) and HU value 431.5 (310-509) versus 354 (288-499) (P < 0.001) in patients with BBF were greater than those without BBF. The bony grade (r = 0.683, P < 0.001 and r = 0.664, P < 0.001), GOSS score (r = 0.314, P = 0.004 and r = 0.312, P = 0.004), and HU value (r = 0.539, P < 0.001 and r = 0.520, P < 0.001) were significantly increased with higher BV and BS.

CONCLUSION

A total of 84.8% of the bone underlying mucosa with BBF had some form of osteitis in ethmoid sinus, and approximately 46.4% of CRS patients were from a subgroup with both BBF and osteitis. The volume of BBF correlated well with severity of osteitis in CRS patients.