The prognostic variables affecting the frontal sinusotomy patency outcome and how to manage: A prospective study

OBJECTIVES

The study aimed to assess the factors affecting the frontal sinus patency after endoscopic frontal sinusotomy.

DESIGN

A prospective cohort study.

SETTING

Tertiary centre hospital.

MAIN OUTCOME MEASURES

Fifty patients with refractory chronic frontal sinusitis (83 operated frontal sinuses) had frontal sinusotomy and followed up for six months. Multiple operative factors were included the type of the procedure, intraoperative sinus findings, degree of mucosal preservation and middle turbinate stability. Other factors were also assessed, including smoking, the presence of allergic rhinitis, asthma, gastroesophageal reflux and other associated medical comorbidities.

RESULTS

The sinus patency success rate was 75.9%. There was a significant difference regarding the intraoperative anteroposterior sinus ostium diameter (5.36 ± 1.45 mm vs 8.88 ± 2.38 mm, P-value: .001* in the failed group and the success group, respectively). There was a significant association between the patency outcome and the presence of associated medical comorbidities (P-value: .001*), the presence of allergic rhinitis (P-value: .001*), the degree of sinus mucosal preservation (P-value: .012*) and the degree of middle turbinate stability (P-value: .001*). The multivariate analysis showed that the intraoperative anteroposterior diameter of the sinus ostium, middle turbinate stability and presence of allergic rhinitis were significant predictors (P-value: .012*, .042* and .013*, respectively).

CONCLUSION

Sinuses with anteroposterior ostium diameters less than 5.36 mm are more susceptible to restenosis. The flail middle turbinate increases the risk of postoperative middle meatus synechia and frontal sinus patency failure. The presence of allergic rhinitis has a negative impact on the patency outcome.

Spatial Distribution of (R)-salbutamol in Rat Brain Following Nasal and Intravenous Administration Using DESI-MS

Recent studies have shown that β2-Adrenoreceptor is a regulator of the a-synuclein gene driving risk of Parkinson’s disease. The β2-AR agonist (R)-salbutamol, eutomer of rac-salbutamol, may hold therapeutic potential for Parkinson’s disease (PD) following nasal administration. In this study, we use desorption electrospray ionization mass spectrometry (DESI-MS) to analyze spatial distribution of (R)-salbutamol in rat brain following nasal and intravenous administration. Here, we report that (R)-salbutamol efficiently deliver to the brain and had more drug dosage exposure in rat’s brain through nasal route administration than that of intravenous route administration. In conclusion, administering (R)-salbutamol through nasal route of administration may hold advantages in improving spatial distribution and increased exposure of drug in brain.

Impact of Draf III, Draf IIb, and Draf IIa frontal sinus surgery on nasal irrigation distribution

BACKGROUND

Delivery of topical pharmacotherapy to the paranasal sinuses remains integral to the management of chronic rhinosinusitis. The frontal sinus remains a difficult access site for irrigations, often limited by its position relative to the nostril and ethmoid sinus. In view of the previous demonstration of improved frontal sinus irrigation with Draf III vs Draf IIa, in this work we sought to evaluate topical access of Draf IIb relative to Draf IIa and Draf III modification of the frontal sinus outflow tract.

METHODS

Unfixed human cadaver heads were dissected using Draf IIa, Draf IIb, and Draf III frontal sinusotomies. Draf IIa, Draf IIb, and Draf III frontal sinusotomies were performed in progressive sequence on each cadaver head. Nasal irrigation fluid access to the frontal sinus was tested after each successive frontal sinus intervention. Irrigations were performed using Frankfort horizontal and vertex positioning. Blinded reviewers were then asked to evaluate nasal irrigation access based on an ordinal scale.

RESULTS

Eight cadaveric specimens (age, 78 ± 12.3 years; 62.5% female) were assessed. The greatest distribution scores were recorded by Draf III, then IIb, and then IIa (90.7% vs 81.3% vs 50.1%; p < 0.001). Similarly, the rate of lavage was greatest with Draf III (50% vs 12.5% vs 12.5%). Vertex positioning and increasing volume trended toward improved distribution but did not reach statistical significance.

CONCLUSION

Adequate delivery of topical therapy to the paranasal sinuses by nasal irrigation remains critical in the postoperative state. Although increasing the dimensions of the frontal recess improves nasal irrigation delivery, the Draf III procedure provides the optimal delivery of pharmacotherapy in those with frontal sinus disease.

Responses of Well-differentiated Human Sinonasal Epithelial Cells to Allergen Exposure and Environmental Pollution in Chronic Rhinosinusitis

Background

Evidence suggests that intrinsic cell dysfunction leads to dysregulated immune responses to environmental triggers in chronic rhinosinusitis (CRS). Although epidemiological and in vivo studies support this theory, in vitro studies are lacking.

Methods

Epithelial cells from human sinonasal mucosa were cultured using an air–liquid interface culture model producing a well-differentiated phenotype. Specimens were characterized as chronic rhinosinusitis with (CRSwNP) or without (CRSsNP) nasal polyps and healthy control mucosa. Culture wells were exposed to house dust mite (HDM), diesel exhaust particles (DPM), or a combination (HDM + DPM) over 24 hours and responses in the 3 groups compared. Ciliary beat frequency (CBF) and transepithelial electrical resistance (TEER) were measured to assess mucociliary and barrier function, respectively. Interleukin-6 (IL-6) and 33 (IL-33) were measured after 24 hours. Results following challenge testing are expressed as fold change from baseline.

Results

Baseline CBF was lower in CRSsNP compared with control (5.27 ± 0.51 Hz vs 5.88 ± 1.22 Hz, P = .003). HDM significantly reduced CBF and TEER in the CRSwNP group compared with its vehicle (CBF: 0.55 ± 0.25 vs 1.03 ± 0.22, P < .001; TEER: 0.54 [0.13] Ω cm2 vs 0.93 [0.5] Ω cm2, P = .001). In CRSwNP and CRSsNP, HDM induced an increase in IL-6 compared with its vehicle (CRSwNP: 81.11 [67.19] pg/mL vs 3.15 [44.64] pg/mL, P = .016; CRSsNP: 321.46 [182.04] pg/mL vs 21.54 [53.93] pg/mL, P = .004). Results are expressed as median (interquartile range) and in IL-33 in CRswNP (84.04 [69.96] pg/mL vs 16.62 [20.19] pg/mL, P = .025). Exposure to DPM did not affect CBF, TEER, and cytokine release in all groups.

Conclusion

CRSwNP and CRSsNP cells exhibit altered responses particularly to HDM even after they have been removed from their host and cultured in vitro, suggesting an intrinsic cell dysfunction of the upper airway epithelium.

Impact of intraoperative hydrodebrider treatment on postoperative sinonasal inflammation

BACKGROUND

The impact of intraoperative hydrodebrider sinus irrigation (HSI) during endoscopic sinus surgery (ESS) on postoperative inflammation, endoscopy, and patient-reported outcomes has not been studied.

METHODS

A clinical trial of 12 patients with symmetric chronic rhinosinusitis were prospectively randomized to HSI on one side after undergoing bilateral ESS. The contralateral side was not treated with any irrigation and served as an internal control. Preoperative computed tomography, endoscopic, 22-item Sino-Nasal Outcome Test (SNOT-22), and symptom visual analog scale (VAS) scores for each side were obtained. At 1 and 3 months postsurgery, endoscopy, SNOT-22, and sinus VAS were recorded. Sinonasal mucus levels of interleukin (IL)-6, IL-10, IL-17a, and tumor necrosis factor (TNF) alpha were measured at the time of surgery, 1 and 3 months, postoperatively, from each side.

RESULTS

VAS scores improved on both sides (p < 0.05) and SNOT-22 improved at all postoperative time points (p < 0.05). Endoscopic scores of HSI-treated sides did not improve compared with baseline. HSI had no additional significant impact on postoperative VAS at any time point. HSI significantly decreased IL-17a levels when compared with the control side at 1 month (p = 0.034) and 3 months (p = 0.031). No significant change was seen in TNF-alpha, IL-6, or IL-10 on either side at any time point.

CONCLUSION

Intraoperative HSI at the time of ESS failed to establish any improvement in postoperative endoscopy or most local cytokine levels after ESS.

Fungicidal activity of lysozyme is inhibited in vitro by commercial sinus irrigation solutions

BACKGROUND

Lysozyme is an innate immune peptide with bactericidal and fungicidal activity (FA). Despite increased expression of lysozyme protein in chronic rhinosinusitis (CRS) sinus mucosa, CRS patients experience repeated bacterial and/or fungal infections. Commercial sinus irrigation solutions are often used to provide symptomatic relief. However, one of the mechanisms of action of lysozyme involves ionic interactions with the microbial cell wall, which may be inhibited by ionic solutions such as commercial sinus irrigation solutions.

OBJECTIVE

Determine if the FA of lysozyme is reduced in the presence of solutions with increasing ionic strength and inhibited in the presence of commercial sinus irrigation solutions.

METHODS

Using an in vitro colony-forming unit (CFU) assay, the FA of lysozyme (5 μM) was tested against a fungi commonly isolated from CRS patients, Aspergillus fumigatus, in solutions of increasing ionic strength or commercial sinus irrigation solutions. FA was presented as percent of control.

RESULTS

FA of lysozyme against A. fumigatus was 95% in a 21-mM ionic strength solution. However, with increasing ionic strength, FA decreased and was abolished in a 46-mM ionic strength solution. Commercial sinus irrigation solutions abolished the FA of lysozyme against A. fumigatus.

CONCLUSION

The in vitro FA of lysozyme is dependent on the ionic strength of the solution. The use of sinus irrigation solutions should be further evaluated with regard to maintaining functional activity of cationic antimicrobial peptides involved in sinonasal innate immunity.

Nasal nitric oxide and sinonasal disease: a systematic review of published evidence

OBJECTIVE

To critically and systematically review the data available on the sinonasal application of nasal nitric oxide measurement, particularly its use as a diagnostic, prognostic, or treatment effect indicator.

DATA SOURCES

EMBASE 1980 to February 10, 2010; Medline 1950 to February 10, 2010; Cochrane Collaboration database; NHS Evidence Health Information Resources database. Review Methods. The databases were searched using a search strategy designed to include manuscripts relevant both to nitric oxide measurement and sinus or nasal problems. A title search was carried out on these manuscripts to select those relevant to clinical or basic science aspects of nitric oxide measurement. A subsequent abstract search selected those manuscripts concerning the application of nitric oxide measurement to sinonasal problems. The manuscripts selected were subject to a full-text review to extract data sets of nasal nitric oxide readings for different patient groups.

RESULTS

Initially, 1088 manuscripts were selected. A title search found 335 manuscripts of basic scientific or clinical interest. An abstract search found 35 manuscripts directly relating to nitric oxide measurement in sinonasal disease. Full-text analysis produced 20 studies with extractable data on nasal nitric oxide levels in clearly defined patient groups. Studies did not show sufficient homogeneity to enable substantial meta-analysis of aggregated data.

CONCLUSION

Current evidence shows that nasal nitric oxide is not a clinically useful measure for sinonasal disease. Although there is some evidence that sinus surgery is associated with lowered nasal nitric oxide levels, there is no evidence that this is associated with deterioration in sinus health.