Controversies in the treatment of chronic rhinosinusitis

Cone Beam Computed Tomography in the Assessment of the Effectiveness of Physical Therapy with the Use of the Electromagnetic Field Combined with Light Radiation Emitted by LEDs in the Treatment of Inflammation of the Paranasal Sinuses-A Case Study

Modern high-resolution volumetric tomography, commonly known as cone beam computed tomography (CBCT), is one of the most innovative imaging techniques which can provide views of anatomical structures not attainable by conventional techniques. Magnetic field LED therapy is a physical therapy method, combining the effects of the Extremely Low Frequency-Electromagnetic Field (ELF-EMF) and high-power light radiation emitted by Light Emitting Diodes (LEDs). The method has been widely applied in the treatment and rehabilitation of complications of many medical conditions, including in dentistry. The aim of this study was to use CBCT to assess the effectiveness of the simultaneous use of electromagnetic field and LED light in the physical therapy of paranasal sinusitis. Treatments employing the electromagnetic field combined with LED light were administered to a 39-year-old female outpatient of the physiotherapy ward for rehabilitation therapy of paranasal sinusitis. Normal sinus pneumatization was restored almost completely. Reduction in the swelling of the sinus mucosa was so significant that even the pneumatization of the ethmoid bulla was restored. Physical therapy with the simultaneous use of ELF-EMF and LED light was found to be effective in the rehabilitation of the patient with paranasal sinusitis. Positive effects of the treatment were confirmed by CBCT findings.

Local drug delivery systems for inflammatory diseases: Status quo, challenges, and opportunities

Inflammation that is not resolved in due course becomes a chronic disease. The treatment of chronic inflammatory diseases involves a long-term use of anti-inflammatory drugs such as corticosteroids and nonsteroidal anti-inflammatory drugs, often accompanied by dose-dependent side effects. Local drug delivery systems have been widely explored to reduce their off-target side effects and the medication frequency, with several products making to the market or in development over the years. However, numerous challenges remain, and drug delivery technology is underutilized in some applications. This review showcases local drug delivery systems in different inflammatory diseases, including the targets well-known to drug delivery scientists (e.g., joints, eyes, and teeth) and other applications with untapped opportunities (e.g., sinus, bladder, and colon). In each section, we start with a brief description of the disease and commonly used therapy, introduce local drug delivery systems currently on the market or in the development stage, focusing on polymeric systems, and discuss the remaining challenges and opportunities in future product development.

Design and characterization of plasticized bacterial cellulose/waterborne polyurethane composite with antibacterial function for nasal stenting

A nasal stent capable of preventing adhesions and inflammation is of great value in treating nasal diseases. In order to solve the problems of tissue adhesion and inflammation response, we prepared plasticized bacterial cellulose (BCG) and waterborne polyurethane (WPU) composite with antibacterial function used as a novel nasal stent. The gelation behavior of BCG could contribute to protecting the paranasal sinus mucosa; meanwhile, the WPU with improved mechanical property was aimed at supporting the narrow nasal cavity. The thickness, size and the supporting force of the nasal stent could be adjusted according to the specific conditions of the nasal. Thermogravimetric analysis, contact angle and water absorption test were applied to investigate the thermal, hydrophilic and water absorption properties of the composite materials. The composite materials loaded with poly(hexamethylene biguanide) hydrochloride maintained well antibacterial activity over 12 days. Animal experiments further revealed that the mucosal epithelium mucosae damage of BCG-WPU composite was minor compared with that of WPU. This new type of drug-loaded nasal stent can effectively address the postoperative adhesions and infections while ensuring the health of nasal mucosal, and thus has an immense clinical application prospects in treating nasal diseases.

Evaluation of the Role of Nasal Endoscopy and Computed Tomography Individually in the Diagnosis of Chronic Rhinosinusitis

The aims of this study were to assess the individual roles of nasal endoscopy (NE) and computed tomography (CT) in the diagnosis of chronic rhinosinusitis, to evaluate their sensitivity and specificity and determine the superiority of one over the other, if any. The study was conducted over 19 months on patients above 18 years of age attending the ENT OPD at Jaipur Golden Hospital, Rohini, Delhi with persistence of symptoms of chronic rhinosinusitis (CRS) for ≥12 weeks. NE was done in each patient followed by NCCT-PNS (4 mm cuts) evaluated with the Lund Mackay system and score ≥4 was suggestive of disease. On NE, mucopurulent discharge and edema in the middle meatus and ethmoid region were all seen in equal distribution amongst the patients. Polyps in the middle meatus were identified in the least number of patients. On observation for anatomical variants, paradoxical middle turbinate was seen in most patients and prominent agger nasi region in the least patients. On CT the order of involvement of the paranasal sinuses from most to least was-anterior ethmoids, maxillary sinus, posterior ethmoids, sphenoid and frontal sinuses. Ostiomeatal complex was involved in approximately one-third of the patients who had been diagnosed with CRS with CT. Frequency of disease on DNE and CT had a sensitivity of 72.2% and specificity of 63.6% with a p value of 0.024, and positive and negative predictive values of 61.9 and 73.7% respectively. It was concluded at the end of the study that there was a significant correlation between DNE and CT in the diagnosis of CRS.

Position statement of the Brazilian Academy of Rhinology on the use of antihistamines, antileukotrienes, and oral corticosteroids in the treatment of inflammatory sinonasal diseases

Introduction

Inflammatory conditions of the nose and paranasal sinuses are very prevalent in the general population, resulting in marked loss of quality of life in affected patients, as well as significant work, leisure, and social activity losses. These patients require specific and specialized treatment. A wide range of oral medications are available.

Objective

The present document is aimed to clarify, for professionals treating patients with inflammatory sinonasal diseases, both specialists and general practitioners, specific oral therapies in noninfectious nasal inflammatory conditions.

Methods

The methodology used to create this article included the search for the key words: oral corticosteroids, antihistamines, antileukotrienes, rhinitis, rhinosinusitis in the MEDLINE and EMBASE databases in the last 5 years. Since no relevant article was found for the text on the subject of interest in the last 5 years, the search was extended for another 5 years, and so on, according to the authors’ needs.

Results

Relevant literature was found regarding the use of antihistamines, antileukotrienes and oral corticosteroids in these conditions. The Brazilian Academy of Rhinology emphasizes, after extensive discussion by the collegiate, key points in the treatment with these drugs.

Conclusion

There is support in the literature for the use of these drugs; however, final considerations about the role of each of them have been made.

Effects of functional endoscopic sinus surgery on the treatment of bronchiectasis combined with chronic rhino-sinusitis

CONCLUSION

Idiopathic bronchiectasis is closely associated with chronic rhino-sinusitis. It can effectively control bronchiectasic symptoms to treat chronic rhino-sinusitis by FESS in the cases with bronchiectasis and chronic rhino-sinusitis.

OBJECTIVE

To explore the effect of functional endoscopic sinus surgery (FESS) on the treatment of bronchiectasis combined with chronic rhino-sinusitis.

METHODS

In this study, a total of 161 cases with bronchiectasis and chronic rhino-sinusitis were divided into medication group and operation group according to the therapeutic method for chronic rhino-sinusitis selected by them. For the treatment of chronic rhino-sinusitis, the cases in the operation group received FESS, but in the medication group cases took drugs alone. The score of clinical symptoms for bronchiectasis, forced expiratory volume in one second (FEV1), SNOT-22 score, and Lund-Mackay score were evaluated for all cases before and after treatment, respectively, and then the value changes in the score of clinical symptoms, FEV1, SNOT-22 score, and Lund-Mackay score between both time points were calculated. The frequency of acute exacerbation for bronchiectasis was also recorded within the 6-month follow-up.

RESULTS

In this study, 58.9% of cases with bronchiectasis had chronic rhino-sinusitis. Follow-up lasted 6 months. Compared with pre-therapy, post-therapy score of clinical symptoms, SNOT-22 score, and Lund-Mackay score were all significantly decreased (all p < 0.05), but post-therapy FEV1 failed to significantly improve (p > 0.05) in both groups. During the 6-month follow-up, the frequency of acute exacerbation was significantly less in the operation group than in the medication group (p < 0.01). Post-treatment score of clinical symptoms (p < 0.01), SNOT-22 score (p < 0.05), and Lund-Mackay score (p < 0.05) also were all significantly less in the operation group than in the medication group. However, there was no significant difference in post-therapy FEV1 between the two groups (p > 0.05).

Drug-eluting nasal implants: formulation, characterization, clinical applications and challenges

Chronic inflammation and infection of the nasal sinuses, also referred to as Chronic Rhinosinusitis (CRS), severely affects patients’ quality of life. Adhesions, ostial stenosis, infection and inflammation relapses complicate chronic sinusitis treatment strategies. Drug-eluting stents, packings or implants have been suggested as reasonable alternatives for addressing these concerns. This article reviewed potential drug candidates for nasal implants, formulation methods/optimization and characterization methods. Clinical applications and important considerations were also addressed. Clinically-approved implants (Propel™ implant, the Relieva stratus™ MicroFlow spacer, and the Sinu-Foam™ spacer) for CRS treatment was an important focus. The advantages and limitations, as well as future considerations, challenges and the need for additional research in the field of nasal drug implant development, were discussed.

Clinical profile of recurrent community-acquired pneumonia in children

BACKGROUND

The aim of this case-control study was to analyse the clinical characteristics of children with recurrent community-acquired pneumonia (rCAP) affecting different lung areas (DLAs) and compare them with those of children who have never experienced CAP in order to contribute to identifying the best approach to such patients.

METHODS

The study involved 146 children with ≥2 episodes of radiographically confirmed CAP in DLA in a single year (or ≥3 episodes in any time frame) with radiographic clearing of densities between occurrences, and 145 age- and gender-matched controls enrolled in Milan, Italy, between January 2009 and December 2012. The demographic and clinical characteristics of the cases and controls were compared, and a comparison was also made between the cases with rCAP (i.e. ≤3 episodes) and those with highly recurrent CAP (hrCAP: i.e. >3 episodes).

RESULTS

Gestational age at birth (p = 0.003), birth weight (p = 0.006), respiratory distress at birth (p < 0.001), and age when starting day care attendance (p < 0.001) were significantly different between the cases and controls, and recurrent infectious wheezing (p < 0.001), chronic rhinosinusitis with post-nasal drip (p < 0.001), recurrent upper respiratory tract infections (p < 0.001), atopy/allergy (p < 0.001) and asthma (p < 0.001) were significantly more frequent. Significant risk factors for hrCAP were gastroesophageal reflux disease (GERD; p = 0.04), a history of atopy and/or allergy (p = 0.005), and a diagnosis of asthma (p = 0.0001) or middle lobe syndrome (p = 0.001). Multivariate logistic regression analysis, adjusted for age and gender, showed that all of the risk factors other than GERD and wheezing were associated with hrCAP.

CONCLUSIONS

The diagnostic approach to children with rCAP in DLAs is relatively easy in the developed world, where the severe chronic underlying diseases favouring rCAP are usually identified early, and patients with chronic underlying disease are diagnosed before the occurrence of rCAP in DLAs. When rCAP in DLAs does occur, an evaluation of the patients' history and clinical findings make it possible to limit diagnostic investigations.

Oral plus nasal corticosteroids improve smell, nasal congestion, and inflammation in sino-nasal polyposis

OBJECTIVES/HYPOTHESIS

To assess the effect of oral plus intranasal corticosteroids on subjective outcomes (smell and nasal congestion) and objective outcomes (tissue eosinophilia and nitric oxide) in severe nasal polyposis (NP).

STUDY DESIGN

After a 4-week steroid washout period (w0), severe NP were randomized into a treatment group (n = 67) that receive oral prednisone for 2 weeks (w2) plus intranasal budesonide for 12 weeks (w12), and a control group (n = 22) that received no steroid treatment.

METHODS

Barcelona Smell Test 24 (BAST-24), nasal congestion, tissue eosinophilia, and nasal nitric oxide (nNO) were assessed.

RESULTS

Before treatment, patients showed a significant impairment of smell detection (30.7 ± 39.5%), identification (7.1 ± 16.1%), and forced choice (13.8 ± 23.3%) in BAST-24 compared to healthy population. At w2, the treatment group showed a significant improvement in detection, identification, and forced choice. Positive effect was also seen after 12 weeks of intranasal corticosteroids. A significant reduction of nasal congestion (1.17 ± 1.0 vs. 2.73 ± 0.5) and polyp tissue eosinophilia (10.9 ± 4.2 vs. 41.2 ± 12.2) with an increase of nNO (650 ± 317 vs. 420 ± 221 ppb) were observed at w2 compared to w0 and to the control group. These effects were also seen at w12.

CONCLUSIONS

Combined oral and intranasal corticosteroids improve smell and nasal congestion and decrease nasal inflammation, as measured by reduced tissue eosinophilia and increased detection of nNO. Severity of smell loss correlates with degree of nasal congestion but not with inflammation, as measured by tissue eosinophilia or nasally exhaled nNO. Our findings suggest that improvement in smell may be related to improved conduction of odorants to the olfactory neuroepithelium.

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.

Aspirin sensitivity and chronic rhinosinusitis with polyps: a fatal combination

Aspirin-exacerbated respiratory disease (AERD) refers to aspirin sensitivity, chronic rhinosinusitis (CRS), nasal polyposis, asthma, eosinophil inflammation in the upper and lower airways, urticaria, angioedema, and anaphylaxis following the ingestion of NSAIDs. Epidemiologic and pathophysiological links between these diseases are established. The precise pathogenesis remains less defined, even though there is some progress in the understanding of several molecular mechanisms. Nevertheless, these combinations of diseases in patients classified by AERD constitute a fatal combination and may be difficult to treat with standard medical and surgical interventions. This paper reviews in brief the epidemiology, clinical features, diagnosis, molecular pathogenesis, and specific therapies of patients classified by AERD and postulates future attempts to gain new insights into this disease.