Update on the management of chronic rhinosinusitis

Clinical Efficacy of Topical Nasal Pomegranate Fruit Extract for Chronic Rhinitis and Chronic Rhinosinusitis

Objective: To evaluate the clinical efficacy of topical nasal Pomegranate Fruit Extract (PFE) for Chronic Rhinitis (CR), Chronic Rhinosinusitis with Nasal Polyposis (CRSwNP), and Chronic Rhinosinusitis without Nasal Polyposis (CRSsNP). Methods: Prospective, double-blinded, randomized study including 111 consecutive patients, between April 2012 and January 2017, afflicted by CRSwNP, CRSsNP, and CR. Patients from each group were randomly assigned to either PFE treatment or placebo twice daily for 30 days. Therapeutic efficacy was assessed by Ear Nose and Throat, blood and tomographic examinations, and the SNOT-20 questionnaire. Results: CR patients treated with PFE suffered significantly less from thick nasal discharge, difficulty falling asleep, reduced productivity, reduced concentration, and sadness (P = .004, P = .02, P = .03, P = .007 and P = .02, respectively). Conclusions: Topical nasal PFE was found to have some benefits for CR patients, however, not for CRS with or without Nasal Polyposis.

An algorithmic approach to sinonasal evaluation preceding bone marrow transplantation

<b>Introduction:</b> The authors conducted this study to review the available resources and prepare an algorithmic approach to pre-transplantation sinonasal evaluation.</br></br> <b>Materials and methods:</b> The sources of data were PubMed, Cochrane databases, and Google Scholar. We searched the available database for English-language studies using the keywords rhinosinusitis, transplantation, post -transplant sinusitis. Studies of all designs were included.</br></br> <b>Results:</b> Thirty-five relevant studies were retrieved from a total of 182 articles. The review of references guided us to 5more publications.</br></br> <b>Discussion:</b> We have proposed an algorithmic approach to sinonasal evaluation before transplantation which can provide a brief but comprehensive assessment of the patients. The evaluation begins with a thorough history and physical examination, including nasal endoscopy with careful attention to objective evidence of inflammation. CT scan should not be considered in all of the cases.</br></br> <b>Conclusion:</b> We have suggested an algorithm to provide a comprehensive and cost-effective way for the evaluation of sinonasal diseases before planned immunosuppression in order to assist in reducing post-transplantation morbidity and mortality.

Frequency and causes of self-medication in patients with chronic rhinosinusitis, North of Iran, 2018-2019

PURPOSE

Chronic rhinosinusitis (CRS) is a frequent respiratory disease. As self-medication is a common issue in the world, this study aimed to estimate its frequency in patients with CRS.

METHODS

144 CRS patients referred to a university hospital, were evaluated for self-medication, included type, duration, frequency, and its causes, their SNOT-22 questionnaire and Lund-MacKay scores. The data were analyzed using SPSS v.21 and the level of significance was considered as P ≥ 0.05.

RESULTS

30.6% of the cases used self-medication (65.9% used chemical drugs and 63.6% used herbal drugs), not associated with their age, gender, educational or economic level. The most common chemical drugs were antibiotics, analgesics and decongestants (75.9%, 55.2% and 10.3%, respectively) and the most common non-pharmaceutical agents included steam inhalation and herbal infusions (71.4%). The efficacy of self-medication was rated as "none" to "little" in 54.64% of cases. The mean SNOT-22 score was 59.54 ± 10.93 and 73.27 ± 8.12 in cases without and with self-medication (P = 0.034), and the mean Lund-MacKay score was 11.8 ± 5.3 and 17.2 ± 4.3 in cases without and with self-medication, respectively (P = 0.002). The top reasons for self-medication were "considering the disease unimportant" and believing chemical drugs being "harmful", "expensive", or "non-effective". Most patients who used self-medication did "not" advise it to others (80%).

CONCLUSION

The high rate of self-medication in CRS patients calls for greater attention to this issue in these patients. It seems that self-medication is significantly associated with more severe grades of disease and lower QOL in CRS cases.

Antibiotic Treatment for Chronic Rhinosinusitis: Prescription Patterns and Associations With Patient Outcome and the Sinus Microbiota

Background

Chronic rhinosinusitis (CRS) is a common and debilitating inflammatory condition of the sinuses, afflicting 5% of the general population. Although antibiotics are frequently prescribed for the medical management of CRS, there is surprisingly little evidence to support their efficacy. In this study, we aimed to establish associations between medication usage, the sinus microbiota and patients’ clinical outcomes.

Methods

Antibiotic prescription patterns for the year before sample collection of 156 CRS patients, 45 disease control patients (mostly requiring septoplasty and inferior turbinate reduction) and 35 healthy control subjects were examined and analyzed together with previously published bacterial 16S rRNA gene amplicon data from our group.

Results

The highest antibiotic usage was observed among the two CRS patient categories. Despite heavy antibiotic usage, CRS patients’ clinical outcomes as indicated by patient questionnaires and radiologic scores were similar to those patients that did not receive any antibiotics. The sinus microbiota was dominated by members of the bacterial genera Corynebacterium and Staphylococcus in all three cohorts. Bacterial community dispersion as measured by principal coordinate analysis was significantly higher in CRS patients compared to healthy control subjects, but not disease control patients. Pairwise comparisons within cohorts revealed differences in the relative 16S rRNA gene sequence abundances of the genera Staphylococcus and Lawsonella between antibiotic users and non-users. However, overall antibiotic effects were minimal and unpredictable.

Conclusion

The unpredictable effects of antibiotic treatment on the sinus microbiota found in this study, together with the lack of differences in patients’ symptom scores between cohorts, do not support preoperative antibiotic treatment for CRS patients.

Invasive pseudomembranous upper airway and tracheal Aspergillosis refractory to systemic antifungal therapy and serial surgical debridement in an Immunocompetent patient

BACKGROUND

The development of respiratory infections secondary to Aspergillus spp. spores found ubiquitously in the ambient environment is uncommon in immunocompetent patients. Previous reports of invasive upper airway aspergillosis in immunocompetent patients have generally demonstrated the efficacy of treatment regimens utilizing antifungal agents in combination with periodic endoscopic debridement, with symptoms typically resolving within months of initiating therapy.

CASE PRESENTATION

A 43-year-old previously healthy female presented with worsening respiratory symptoms after failing to respond to long-term antibiotic treatment of bacterial sinusitis. Biopsy of her nasopharynx and trachea revealed extensive fungal infiltration and Aspergillus fumigatus was isolated on tissue culture. Several months of oral voriconazole monotherapy failed to resolve her symptoms and she underwent mechanical debridement for symptom control. Following transient improvement, her symptoms subsequently returned and failed to fully resolve in spite of increased voriconazole dosing and multiple additional tissue debridements over the course of many years.

CONCLUSIONS

Invasive upper airway aspergillosis is exceedingly uncommon in immunocompetent patients. In the rare instances that such infections do occur, combinatorial voriconazole and endoscopic debridement is typically an efficacious treatment approach. However, some patients may continue to experience refractory symptoms. In such cases, continued aggressive treatment may potentially slow disease progression even if complete disease resolution cannot be achieved.

Intraoral Dual Wavelength Laser Diode Therapy for Chronic Maxillary Sinusitis

Background

Chronic sinusitis is one of the most common chronic diseases involving different age groups. The different etiological factors and difficult diagnostic procedures contribute to misdiagnosis and chronicity of sinusitis. There is no standard treatment for sinusitis. Long term use of corticosteroids and antibiotics may lead to numerous adverse side effects. Laser therapy has been suggested as a non-invasive treatment for sinusitis. It has anti-inflammatory and antibacterial effects. When considering maxillary sinusitis, discharge tends to collect in the sinus base due to its anatomy and altered physiology. To improve penetration of laser into the maxillary sinus, intraoral laser at the vestibule depth of the maxilla may be more effective.

Material and Subject

Thirty-four patients with chronic maxillary sinusitis were assigned into two groups. All were assessed before and after treatment. Group A received laser radiation plus standard medical treatment and group B received medical treatment only. The treatment plan was performed in 12 sessions using a Diode laser with a wavelength of 810 nm and 980nm. The SNOT-22 questionnaire and Computed Tomography were used to evaluate patients. A p-value < 0.05 was considered statistically significant.

Results

Both groups showed a significant improvement in symptoms following treatment (p < .001), however, the laser therapy group demonstrated greater improvements for all variables in response to treatment as compared to the traditional treatment group (p < .001).

Conclusions

Using high intensity intra-oral laser therapy with medical treatment is more effective than using medical treatment only for treatment of chronic maxillary sinusitis.

Contribution of Epithelial Cell Dysfunction to the Pathogenesis of Chronic Rhinosinusitis with Nasal Polyps

Background

In the past, the airway epithelium was thought to be primarily an inert physical barrier. We now know that the upper airway epithelium plays a critical role in both innate and adaptive immunity, and that epithelial dysfunction is strongly associated with inflammatory airway disease. The pathogenesis of chronic rhinosinusitis is poorly understood, but growing evidence supports a key role for the airway epithelium in the pathophysiology of the disease.

Objective

The purpose of this study is to explore our current understanding of how dysfunction in human sinonasal epithelial cells (HSNECs) contributes to the pathogenesis of chronic rhinosinusitis with nasal polyps (CRSwNP) and to examine how current and developing therapies affect epithelial cell functions.

Methods

A literature review of papers published in English pertaining to epithelial cell dysfunction in patients with CRSwNP was performed using the PubMed database. The search utilized combinations of the following key words: sinusitis, polyps, epithelium, pathophysiology, barrier function, dendritic cells, eosinophils, T cells, complement, mucociliary clearance, vitamin D, cytokines, chemokines, taste receptors, steroids, saline, and therapy.

Results

HSNEC mucociliary clearance, barrier function, secretion of cytokines, influence on dendritic cells, influence on T-cells, regulation of eosinophils, vitamin D metabolism, complement production, and taste receptor function are altered in patients with CRSwNP and contribute to the pathogenesis of the disease. Current therapies utilized to manage CRSwNP counteract the effects of HSNEC dysfunction and relieve key symptoms of the disease.

Conclusion

HSNECs are key players in both innate and adaptive immunity, and altered epithelial functions are closely intertwined with the pathogenesis of CRSwNP. Our review supports further investigation of altered HSNEC function in patients with CRSwNP and supports development of novel epithelial-targeted therapies for its management.

Antibiotic Sensitivity Pattern of Bacterial Isolates in Patients with Chronic Rhinosinusitis in Kaduna, Nigeria

Introduction  A common practice in the management of patients with chronic rhinosinusitis (CRS), the empirical use of antibiotics may contribute to treatment failure and to the development of antimicrobial resistance.

Objective  To determine the antibiotic sensitivity pattern of aerobic and anaerobic bacteria associated with CRS.

Methods  This was a prospective cross-sectional study in which endoscopically guided middle meatal swabs (IBM Spss, version 16.0, Chicago, IL, USA) were aseptically taken from patients diagnosed with CRS after obtaining informed consent and ethical clearance. The samples were sent to the laboratory for qualitative and semiquantitative analysis via gram stain, aerobic, anaerobic cultures and antibacterial sensitivity tests. The collected data was analyzed using SPSS for Windows, version 16 (SPSS Inc, Chicago, IL, USA). Simple statistical parameters and paired sample t -test were used, as appropriate.

Results  There were 74 (56.92%) bacterial growths, out of which 55 (74.32%) were aerobic and 19 (25.68%) were anaerobic isolates, from a total of 130 patients. About 13 (17.5%–18%) of these bacterial growths yielded a mixed growth of aerobic and anaerobic isolates. The most common bacterial isolates were 26 (35.14%) Staphylococcus aureus , Haemophilus influenzae 9 (12.16%), Streptococcus viridians 8 (10.81%), and Streptococcus pneumoniae 5 (6.76%). Augmentin, ciprofloxacin, and Peflacine were found to be most effective, followed by levofloxacin, Rocephin, erythromycin and Zinat in that order.

Conclusion  Augmentin, ciprofloxacin and Peflacine have a sensitivity of 100%, while most of the organisms show resistance to Ampiclox, amoxicillin, and Septrin.

Antibiofilm effects of amoxicillin-clavulanic acid and levofloxacin in patients with chronic rhinosinusitis with nasal polyposis

PURPOSE

Microbial biofilms have been implicated in the pathogenesis of chronic rhinosinusitis with nasal polyposis (CRSwNP). The aim of our study was to evaluate in vitro effects of amoxicillin-clavulanic acid and levofloxacin on biofilm formation by bacterial species isolated from sinus tissue in patients with CRSwNP.

METHODS

The sinus mucosal specimens were harvested from the upper parts and roof of ethmoid cavity of 48 patients with CRSwNP. Each sample was washed thoroughly in three separate beakers of sterile saline to remove any planktonic bacteria and further subjected to microbiology analysis. The biofilm-forming capacity of isolated strains was detected by microtiter-plate method and the effects of subinhibitory (1/2× to 1/16× MIC) and suprainhibitory concentrations (4, 8, 16, 32, and 64 µg/ml) of amoxicillin-clavulanic acid and levofloxacin on biofilm production were investigated.

RESULTS

Bacterial strains were isolated in 42 (87.5%) patients: one microorganism in 80.9% and two microorganisms in 19.1% of patients. The most prevalent bacteria in CRSwNP biofilms were Staphylococcus epidermidis (34%) and S. aureus (28%) followed by S. haemolyticus (12%), Pseudomonas aeruginosa (8%), Moraxella catarrhalis (6%), Streptococcus pneumoniae (6%), and other staphylococci (6%). Subinhibitory concentrations of amoxicillin-clavulanic acid and levofloxacin significantly reduced biofilm formation (p < 0.01 and p < 0.05, respectively), with better efficacy of amoxicillin-clavulanic acid (1/2-1/8× MIC) on staphylococci and levofloxacin (1/2- 1/4× MIC) on M. catarrhalis and P. aeruginosa biofilm formation. Suprainhibitory concentrations of both tested antibiotics (4-64 µg/ml) significantly eradicated mature biofilms of staphylococci (p < 0.01). The effect of levofloxacin on eradication of staphylococcal biofilms was more noticeable, compared to the effect of amoxicillin-clavulanic acid (p < 0.01). Suprainhibitory concentrations of both tested antibiotics had no effect on eradication of previously formed M. catarrhalis and P. aeruginosa biofilms (p > 0.05).

CONCLUSIONS

The amoxicillin-clavulanic acid and levofloxacin are shown to be potent antibiofilm agents in patients with CRSwNP. The effects of tested compounds depend on bacterial species and the volume of formed biofilm.

Chronic Rhinosinusitis and the Evolving Understanding of Microbial Ecology in Chronic Inflammatory Mucosal Disease

Chronic rhinosinusitis (CRS) encompasses a heterogeneous group of debilitating chronic inflammatory sinonasal diseases. Despite considerable research, the etiology of CRS remains poorly understood, and debate on potential roles of microbial communities is unresolved. Modern culture-independent (molecular) techniques have vastly improved our understanding of the microbiology of the human body. Recent studies that better capture the full complexity of the microbial communities associated with CRS reintroduce the possible importance of the microbiota either as a direct driver of disease or as being potentially involved in its exacerbation. This review presents a comprehensive discussion of the current understanding of bacterial, fungal, and viral associations with CRS, with a specific focus on the transition to the new perspective offered in recent years by modern technology in microbiological research. Clinical implications of this new perspective, including the role of antimicrobials, are discussed in depth. While principally framed within the context of CRS, this discussion also provides an analogue for reframing our understanding of many similarly complex and poorly understood chronic inflammatory diseases for which roles of microbes have been suggested but specific mechanisms of disease remain unclear. Finally, further technological advancements on the horizon, and current pressing questions for CRS microbiological research, are considered.

Intranasal Delivery of Topically-Acting Levofloxacin to Rats: a Proof-of-Concept Pharmacokinetic Study

PURPOSE

To evaluate the potential of levofloxacin intranasal administration as a promising alternative approach to treat local infections such as chronic rhinosinusitis, by delivering drug concentrations directly to the site of infection.

METHODS

Drug concentrations were measured in plasma, olfactory bulb and nasal mucosa of anterior (ANM) and posterior regions after intranasal (0.24 mg/kg) and intravenous (10 mg/kg) administration to rats, and pharmacokinetic parameters were compared between routes. For intranasal administration a thermoreversible in-situ gel was used.

RESULTS

Plasma and olfactory bulb exposure to levofloxacin was minimal following intranasal dose, preventing systemic and central nervous system adverse effects. Levofloxacin concentration-time profile in ANM revealed higher concentrations during the first 60 min of the study following intranasal administration than the corresponding ones obtained after intravenous administration. A rapid and continuous decay of levofloxacin concentration in this nasal region was observed after intranasal delivery, resulting in much lower values at the last sampling time-points.

CONCLUSION

The higher dose-normalized concentrations and pharmacokinetic exposure parameters of levofloxacin in ANM after intranasal administration, demonstrates that intranasal delivery of the formulated gel is, by itself, advantageous for delivering levofloxacin to biophase and thus an attractive approach in management of chronic rhinosinusitis.

The role of infection and antibiotics in chronic rhinosinusitis

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.

Allergic Aspergillus Rhinosinusitis

Allergic fungal rhinosinusitis (AFRS) is a unique variety of chronic polypoid rhinosinusitis usually in atopic individuals, characterized by presence of eosinophilic mucin and fungal hyphae in paranasal sinuses without invasion into surrounding mucosa. It has emerged as an important disease involving a large population across the world with geographic variation in incidence and epidemiology. The disease is surrounded by controversies regarding its definition and etiopathogenesis. A working group on "Fungal Sinusitis" under the International Society for Human and Animal Mycology (ISHAM) addressed some of those issues, but many questions remain unanswered. The descriptions of "eosinophilic fungal rhinosinusitis" (EFRS), "eosinophilic mucin rhinosinusitis" (EMRS) and mucosal invasion by hyphae in few patients have increased the problem to delineate the disease. Various hypotheses exist for etiopathogenesis of AFRS with considerable overlap, though recent extensive studies have made certain in depth understanding. The diagnosis of AFRS is a multi-disciplinary approach including the imaging, histopathology, mycology and immunological investigations. Though there is no uniform management protocol for AFRS, surgical clearing of the sinuses with steroid therapy are commonly practiced. The role of antifungal agents, leukotriene antagonists and immunomodulators is still questionable. The present review covers the controversies, recent advances in pathogenesis, diagnosis, and management of AFRS.

Prevention of sinonasal inflammation by a synthetic glycosaminoglycan

BACKGROUND

Glycosaminoglycans (GAGs) are polysaccharides that are distributed on respiratory epithelial cells, endothelial cells, and submucosal glands. Uniquely positioned, certain GAGs exhibit anti-inflammatory properties in respiratory diseases and serve important roles in repairing mucosal surfaces and modulating mucociliary clearance. We hypothesized that topical administration of a synthetic GAG (GM-0111) would prevent sinonasal inflammation in a mouse model of rhinosinusitis (RS).

METHODS

To test our hypothesis, C57BL/6 mice were intranasally administered fluorescent GM-0111, and sinonasal tissues were examined for coating and penetration ability. To test therapeutic feasibility, mice (n = 6) were given GM-0111 or hyaluronic acid (HA; 800 μg dose) prior to inducing RS with inflammatory molecule LL-37 (115 μg dose). After 24 hours, sinonasal tissues were harvested for histological and biochemical analysis of inflammatory markers (inflammatory cell infiltration, lamina propria [LP] thickening, and neutrophil enzyme myeloperoxidase [MPO]) and cell death.

RESULTS

GM-0111 was observed within sinonasal tissues 1 hour and 24 hours after intranasal administration, indicating rapid and effective coating and penetration. GM-0111 prevented sinonasal tissues from developing inflammatory changes, with significant reductions in mast cell infiltration (p < 0.05), LP thickening (p < 0.001), and MPO levels (p < 0.01) when compared to tissues treated with LL-37 and those pretreated with HA. GM-0111 reduced cell death within sinonasal tissues in contrast to LL-37-treated tissues.

CONCLUSION

We report a new synthetic GAG (GM-0111) that uniformly coats and penetrates into the sinonasal mucosa to prevent sinonasal inflammation and cell death in a mouse model of RS.

A new Strategy to Improve Drug Delivery to the Maxillary Sinuses: The Frequency Sweep Acoustic Airflow

PURPOSE

Enhancement of intranasal sinus deposition involves nebulization of a drug superimposed by an acoustic airflow. We investigated the impact of fixed frequency versus frequency sweep acoustic airflow on the improvement of aerosolized drug penetration into maxillary sinuses.

METHODS

Fixed frequency and frequency sweep acoustic airflow were generated using a nebulizing system of variable frequency. The effect of sweep cycle and intensity variation was studied on the intranasal sinus deposition. We used a nasal replica created from CT scans using 3D printing. Sodium fluoride and gentamicin were chosen as markers.

RESULTS

Studies performed using fixed frequency acoustic airflow showed that each of maxillary sinuses of the nasal replica required specific frequency for the optimal aerosol deposition. Intranasal sinus drug deposition experiments under the effect of the frequency sweep acoustic airflow showed an optimal aerosol deposition into both maxillary sinus of the nasal replica. Studies on the effect of the duration of the sweep cycle showed that the shorter the cycle the better the deposition.

CONCLUSIONS

We demonstrate the benefit of frequency sweep acoustic airflow on drug deposition into maxillary sinuses. However further in vivo studies have to be conducted since delivery rates cannot be obviously determined from a nasal replica.

Intra-oral low level laser therapy in chronic maxillary sinusitis: A new and effective recommended technique

Background

Chronic sinusitis is one of the most common chronic diseases involving different age groups. Because the nature and etiology of chronic sinusitis are not completely known, there is not any standard treatment for this disease. It has been suggested that low-level laser can be used in treating chronic sinusitis but there are limited studies about its usage. In this research, intra-oral radiation of low-level laser has been described and implemented for the first time. Suggested hypotheses about the efficacy of this type of radiation (intra-oral) in treating chronic maxillary sinusitis includes this fact that the depth of maxilla’s vestibule is also the floor of maxillary sinus and sinus discharges collect in this area because of gravity effect. Therefore, with considering suitable radiation angle, this area gets the most benefits of laser’s anti-inflammatory effects.

Material and Methods

In this study, 20 patients with chronic maxillary sinusitis were included. They were assessed before and after treatment. Treatment plan was performed in 8 sessions every other days using low-level diode laser with 810 nm. Snot-22 questionnaire and rhinomanometry were used for evaluating patients. Changes of signs and symptoms were recorded in questionnaire every session and 6 months after treatment. Friedman and Wilcoxon tests were used for data analyses. In this study, P value < 0.05 was considered statistically significant.

Results

All variables and all symptoms of patients were improved using intra-oral low-level laser and this improvement was statistically significant (P value<0.05). There was also significant decrease in nasal airway resistance and significant increase in air flow (P value<0.05). Six month after treatment completion, there was no significant difference between the results of completion and the results of 8th treatment session (P value< 0.05).

Conclusions

Using intra-oral low-level laser is a suitable way to treat patients with chronic maxillary sinusitis.

Key words:Chronic sinusitis, maxillary sinusitis, low-level laser.

Mechanisms of Glucocorticoid Action in Chronic Rhinosinusitis

The innate immune system and its complex interplay with the adaptive immune system are increasingly being recognized as important factors in the pathogenesis of chronic rhinosinusitis (CRS). Adaptive immune components, including resident and inflammatory cells, and their associated mediators, have been the subject of most research in CRS. For this reason, theories of CRS pathogenesis have involved the concept that inflammation, rather than infection, is the dominant etiologic factor in CRS. Therefore, glucocorticoids are increasingly used to treat CRS. This review will outline our current knowledge of action mode of glucocorticoids in CRS.

Is sinus disease the cause of my headaches? An update on sinus disease and headache

The interplay between head pain caused by sinus disease and primary headaches is complex. Classification of secondary headaches, attributed to disorders of the nose or paranasal sinuses has been recently updated. New treatments including office- based procedures are emerging for patients with chronic sinusitis. This paper briefly reviews sinus disease and headache.