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Gowrav MP, Siree KG, Amulya TM, Bharathi MB, Ghazwani M, Alamri A, Alalkami AY, Kumar TMP, Ahmed MM, Rahamathulla M. Novel Rhinological Application of Polylactic Acid-An In Vitro Study. Polymers (Basel) 2023; 15:polym15112521. [PMID: 37299320 DOI: 10.3390/polym15112521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/18/2023] [Accepted: 05/19/2023] [Indexed: 06/12/2023] Open
Abstract
A novel approach to the treatment of sinusitis is the use of nasal stents. The stent is loaded with a corticosteroid, which prevents complications in the wound-healing process. The design is such that it will prevent the sinus from closing again. The stent is 3D printed using a fused deposition modeling printer, which enhances the customization. The polymer utilized for the purpose of 3D printing is polylactic acid (PLA). The compatibility between the drugs and polymers is confirmed by FT-IR and DSC. The drug is loaded onto the polymer by soaking the stent in the drug's solvent, known as the solvent casting method. Using this method, approximately 68% of drug loading is found to be achieved onto the PLA filaments, and a total of 72.8% of drug loading is obtained in terms of the 3D-printed stent. Drug loading is confirmed by the morphological characteristics of the stent by SEM, where the loaded drug is clearly visible as white specks on the surface of the stent. Drug release characterization is conducted by dissolution studies, which also confirm drug loading. The dissolution studies show that the release of drugs from the stent is constant and not erratic. Biodegradation studies were conducted after increasing the rate of degradation of PLA by soaking it in PBS for a predetermined duration of time. The mechanical properties of the stent, such as stress factor and maximum displacement, are discussed. The stent has a hairpin-like mechanism for opening inside the nasal cavity.
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Affiliation(s)
- M P Gowrav
- Department of Pharmaceutics, JSS College of Pharmacy, JSS Academy of Higher Education and Research, Mysuru 570015, Karnataka, India
| | - K G Siree
- Department of Pharmaceutics, JSS College of Pharmacy, JSS Academy of Higher Education and Research, Mysuru 570015, Karnataka, India
| | - T M Amulya
- Department of ENT, JSS Medical College and Hospital, JSS Academy of Higher Education & Research, Mysuru 570004, Karnataka, India
| | - M B Bharathi
- Department of ENT, JSS Medical College and Hospital, JSS Academy of Higher Education & Research, Mysuru 570004, Karnataka, India
| | - Mohammed Ghazwani
- Department of Pharmaceutics, College of Pharmacy, King Khalid University, Abha 61421, Saudi Arabia
| | - Ali Alamri
- Department of Pharmaceutics, College of Pharmacy, King Khalid University, Abha 61421, Saudi Arabia
| | - Abdulatef Y Alalkami
- Department of Pharmacy, Mental Health Hospital, Ministry of Health, Abha 61421, Saudi Arabia
| | - T M Pramod Kumar
- Department of Pharmaceutics, JSS College of Pharmacy, JSS Academy of Higher Education and Research, Mysuru 570015, Karnataka, India
| | - Mohammed Muqtader Ahmed
- Department of Pharmaceutics, College of Pharmacy, Prince Sattam Bin Abdul Aziz University, Al Kharj 11942, Saudi Arabia
| | - Mohamed Rahamathulla
- Department of Pharmaceutics, College of Pharmacy, King Khalid University, Abha 61421, Saudi Arabia
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Krishniya P, Rajpurohit P, Sharma VK, Aseri Y, Verma PC. A Prospective Correlation Study Between Computerized Tomography of Paranasal Sinuses and Nasal Endoscopy Findings in Patients of Chronic Rhinosinusitis Undergoing Functional Endoscopic Sinus Surgery. Indian J Otolaryngol Head Neck Surg 2022; 74:4706-4712. [PMID: 36742912 PMCID: PMC9895699 DOI: 10.1007/s12070-021-03030-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 12/07/2021] [Indexed: 02/07/2023] Open
Abstract
In order to diagnose chronic rhinosinusitis (CRS), diagnostic nasal endoscopy (DNE) and computed tomography (CT) scan both are important investigations. But both have their pros and cons, some findings are seen better in DNE and others in CT. Our study aims to correlate DNE and CT findings. 50 patients with CRS were included in this observational prospective study done at tertiary care hospital. Preoperative each patient underwent DNE and got CT scan followed by scoring using Lund Kennedy and Lund Mackay grading respectively. Functional Endoscopic Sinus Surgery (FESS) was performed and intraoperative findings were correlated with CT scan for each of them. The sensitivity of endoscopy was 93.18% and the specificity was 83.33%. Positive predictive value of DNE was 97.62% and negative predictive value was 62.50%. Most of the endoscopy positive patients of CRS were CT positive. Also, the sensitivity of CT PNS was highest for all groups of sinus disease while specificity was high for posterior group of sinuses (81.82%) and frontal sinus (89.19%). Both DNE and CT scan should be used for planning the management of CRS. DNE tells better about middle meatal secretions, condition of mucosa, polyps. But in situations where due to anatomical variation DNE is difficult, CT scan helps us. CT identifies the extent of disease, the anatomical variants and vital relations of PNS. Overdiagnosis through CT is checked by DNE.
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Affiliation(s)
- Pratibha Krishniya
- Department of Otorhinolaryngology and Head and Neck Surgery, Jawahar Lal Nehru Medical College, Ajmer, India
| | - Pragya Rajpurohit
- Department of Otorhinolaryngology and Head and Neck Surgery, Jawahar Lal Nehru Medical College, Ajmer, India
| | - Vikrant Kumar Sharma
- Department of Otorhinolaryngology and Head and Neck Surgery, Jawahar Lal Nehru Medical College, Ajmer, India
| | - Yogesh Aseri
- Department of Otorhinolaryngology and Head and Neck Surgery, Jawahar Lal Nehru Medical College, Ajmer, India
| | - P. C. Verma
- Department of Otorhinolaryngology and Head and Neck Surgery, Jawahar Lal Nehru Medical College, Ajmer, India
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Murali S, Arunachalam R, Saravanam PK, Thattarakkal VR. Assessment of Olfaction Following Endoscopic Sinus Surgery. Indian J Otolaryngol Head Neck Surg 2022; 74:1353-1360. [PMID: 36452713 PMCID: PMC9702161 DOI: 10.1007/s12070-021-02500-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 03/02/2021] [Indexed: 10/21/2022] Open
Abstract
To assess the olfactory outcomes following Endoscopic Sinus Surgery (ESS) in patients diagnosed with Chronic Rhinosinusitis (CRS) and Sinonasal polyposis (SNP). To assess and compare the pre-operative and post-operative olfactory scores of patients undergoing ESS/ ESS + polypectomy/ESS + Septoplasty by subjective and objective methods. This is a prospective, cohort study which included a total of 60 patients. Subjective assessment was done using a Questionnaire. Preoperative olfactory assessment was performed with Sniffing Sticks. Olfactory assessment was done at 1st,3rd, 6th and 12th week following surgery. The preoperative and postoperative scores were statistically analysed and compared. In patients who underwent ESS, there was a significant reduction in olfactory scores in the immediate few weeks after surgery which improved over time by the end of 3 months. In patients who underwent ESS with polypectomy, there was a significant improvement in olfactory scores from the third week following surgery which was sustained over 3rd month follow-up. In patients who underwent ESS with Septoplasy, there was a significant decrease in olfactory scores during the initial few weeks with a marginal improvement during 3 months follow-up. At the end of 12 weeks post ESS, no patient was found to be anosmic. Patients with pre-existing hyposmia did not show statistically significant change post surgery.However patients with anosmia showed statistically significant improvement in olfactory function, but did not become normosmic at 12th post-operative week. Majority of normosmics did not have alteration in their olfactory perception at 12th post-operative week.
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Affiliation(s)
- Shivagamasundari Murali
- Department of ENT, Head and Neck Surgery, Sri Ramachandra Institute of Higher Education and Research, Porur, Chennai, Tamil Nadu 600116 India
| | - Ravikumar Arunachalam
- Department of ENT, Head and Neck Surgery, SRM Medical College Hospital and Research Center, Chengalpet, Chennai, Tamil Nadu 603203 India
| | - Prasanna Kumar Saravanam
- Department of ENT, Head and Neck Surgery, Sri Ramachandra Institute of Higher Education and Research, Porur, Chennai, Tamil Nadu 600116 India
| | - Vinay Raj Thattarakkal
- Department of ENT, Head and Neck Surgery, Sri Ramachandra Institute of Higher Education and Research, Porur, Chennai, Tamil Nadu 600116 India
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Orlandi RR, Kingdom TT, Smith TL, Bleier B, DeConde A, Luong AU, Poetker DM, Soler Z, Welch KC, Wise SK, Adappa N, Alt JA, Anselmo-Lima WT, Bachert C, Baroody FM, Batra PS, Bernal-Sprekelsen M, Beswick D, Bhattacharyya N, Chandra RK, Chang EH, Chiu A, Chowdhury N, Citardi MJ, Cohen NA, Conley DB, DelGaudio J, Desrosiers M, Douglas R, Eloy JA, Fokkens WJ, Gray ST, Gudis DA, Hamilos DL, Han JK, Harvey R, Hellings P, Holbrook EH, Hopkins C, Hwang P, Javer AR, Jiang RS, Kennedy D, Kern R, Laidlaw T, Lal D, Lane A, Lee HM, Lee JT, Levy JM, Lin SY, Lund V, McMains KC, Metson R, Mullol J, Naclerio R, Oakley G, Otori N, Palmer JN, Parikh SR, Passali D, Patel Z, Peters A, Philpott C, Psaltis AJ, Ramakrishnan VR, Ramanathan M, Roh HJ, Rudmik L, Sacks R, Schlosser RJ, Sedaghat AR, Senior BA, Sindwani R, Smith K, Snidvongs K, Stewart M, Suh JD, Tan BK, Turner JH, van Drunen CM, Voegels R, Wang DY, Woodworth BA, Wormald PJ, Wright ED, Yan C, Zhang L, Zhou B. International consensus statement on allergy and rhinology: rhinosinusitis 2021. Int Forum Allergy Rhinol 2021; 11:213-739. [PMID: 33236525 DOI: 10.1002/alr.22741] [Citation(s) in RCA: 384] [Impact Index Per Article: 128.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/09/2020] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
| | | | | | | | | | - Amber U Luong
- University of Texas Medical School at Houston, Houston, TX
| | | | - Zachary Soler
- Medical University of South Carolina, Charleston, SC
| | - Kevin C Welch
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | | | | | | | - Claus Bachert
- Ghent University, Ghent, Belgium.,Karolinska Institute, Stockholm, Sweden.,Sun Yatsen University, Gangzhou, China
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - David A Gudis
- Columbia University Irving Medical Center, New York, NY
| | - Daniel L Hamilos
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Richard Harvey
- University of New South Wales and Macquarie University, Sydney, New South Wales, Australia
| | | | | | | | | | - Amin R Javer
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | | | | | | | | | | | | | - Valerie Lund
- Royal National Throat Nose and Ear Hospital, UCLH, London, UK
| | - Kevin C McMains
- Uniformed Services University of Health Sciences, San Antonio, TX
| | | | - Joaquim Mullol
- IDIBAPS Hospital Clinic, University of Barcelona, Barcelona, Spain
| | | | | | | | | | | | | | | | | | | | - Alkis J Psaltis
- University of Adelaide, Adelaide, South Australia, Australia
| | | | | | | | - Luke Rudmik
- University of Calgary, Calgary, Alberta, Canada
| | - Raymond Sacks
- University of New South Wales, Sydney, New South Wales, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | - De Yun Wang
- National University of Singapore, Singapore, Singapore
| | | | | | | | - Carol Yan
- University of California San Diego, La Jolla, CA
| | - Luo Zhang
- Capital Medical University, Beijing, China
| | - Bing Zhou
- Capital Medical University, Beijing, China
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Koch M, Sertel-Nakajima J, Messlinger K. Responses of spinal trigeminal neurons to noxious stimulation of paranasal cavities - a rat model of rhinosinusitis headache. Cephalalgia 2020; 41:535-545. [PMID: 33203222 DOI: 10.1177/0333102420970467] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The pathophysiology of headaches associated with rhinosinusitis is poorly known. Since the generation of headaches is thought to be linked to the activation of intracranial afferents, we used an animal model to characterise spinal trigeminal neurons with nociceptive input from the dura mater and paranasal sinuses. METHODS In isoflurane anaesthetised rats, extracellular recordings were made from neurons in the spinal trigeminal nucleus with afferent input from the exposed frontal dura mater. Dural and facial receptive fields were mapped and the paranasal cavities below the thinned nasal bone were stimulated by sequential application of synthetic interstitial fluid, 40 mM potassium chloride, 100 µM bradykinin, 1% ethanol (vehicle) and 100 µm capsaicin. RESULTS Twenty-five neurons with input from the frontal dura mater and responses to chemical stimulation of the paranasal cavities were identified. Some of these neurons had additional receptive fields in the parietal dura, most of them in the face. The administration of synthetic interstitial fluid, potassium chloride and ethanol was not followed by significant changes in activity, but bradykinin provoked a cluster of action potentials in 20 and capsaicin in 23 neurons. CONCLUSION Specific spinal trigeminal neurons with afferent input from the cranial dura mater respond to stimulation of paranasal cavities with noxious agents like bradykinin and capsaicin. This pattern of activation may be due to convergent input of trigeminal afferents that innervate dura mater and nasal cavities and project to spinal trigeminal neurons, which could explain the genesis of headaches due to disorders of paranasal sinuses.
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Affiliation(s)
- Michael Koch
- Institute of Physiology and Pathophysiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Julika Sertel-Nakajima
- Institute of Physiology and Pathophysiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Karl Messlinger
- Institute of Physiology and Pathophysiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
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Zisi D, Challa A, Makis A. The association between vitamin D status and infectious diseases of the respiratory system in infancy and childhood. Hormones (Athens) 2019; 18:353-363. [PMID: 31768940 PMCID: PMC7092025 DOI: 10.1007/s42000-019-00155-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 10/29/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE Respiratory tract infections (RTIs) are a major cause of illness worldwide and the most common cause of hospitalization for pneumonia and bronchiolitis. These two diseases are the leading causes of morbidity and mortality among children under 5 years of age. Vitamin D is believed to have immunomodulatory effects on the innate and adaptive immune systems by modulating the expression of antimicrobial peptides, like cathelicidin, in response to both viral and bacterial stimuli. The aim of this review is to summarize the more recently published data with regard to potential associations of 25-hydroxyvitamin D [25(OH)D] with infectious respiratory tract diseases of childhood and the possible health benefits from vitamin D supplementation. METHODS The literature search was conducted by using the PubMed, Scopus, and Google Scholar databases, with the following keywords: vitamin D, respiratory tract infection, tuberculosis, influenza, infancy, and childhood. RESULTS Several studies have identified links between inadequate 25(OH)D concentrations and the development of upper or lower respiratory tract infections in infants and young children. Some of them also suggest that intervention with vitamin D supplements could decrease both child morbidity and mortality from such causes. CONCLUSIONS Most studies agree in that decreased vitamin D concentrations are prevalent among most infants and children with RTIs. Also, normal to high-serum 25(OH)D appears to have some beneficial influence on the incidence and severity of some, but not all, types of these infections. However, studies with vitamin D supplementation revealed conflicting results as to whether supplementation may be of benefit, and at what doses.
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Affiliation(s)
- Dimitra Zisi
- Child Health Department, Faculty of Medicine, University of Ioannina, P.O. Box 1187, 451 10, Ioannina, Greece
| | - Anna Challa
- Child Health Department, Faculty of Medicine, University of Ioannina, P.O. Box 1187, 451 10, Ioannina, Greece
| | - Alexandros Makis
- Child Health Department, Faculty of Medicine, University of Ioannina, P.O. Box 1187, 451 10, Ioannina, Greece.
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Lopatin AS, Ivanchenko OA, Soshnikov SS, Mullol J. Cyclamen europaeum improves the effect of oral antibiotics on exacerbations and recurrences of chronic rhinosinusitis: a real-life observational study (CHRONOS). ACTA ACUST UNITED AC 2019; 38:115-123. [PMID: 29967550 DOI: 10.14639/0392-100x-1342] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 01/15/2017] [Indexed: 11/23/2022]
Abstract
SUMMARY Chronic rhinosinusitis (CRS) is an inflammatory disease of the nose and paranasal sinuses affecting 11% of the European population. Cyclamen europaeum plant extract (CE) has demonstrated efficacy in treating acute rhinosinusitis, but its role in CRS exacerbations remains unknown. In this real-life, prospective, epidemiological, observational study, a total of 317 patients with exacerbations of CRS without nasal polyps (CRSsNP) of moderate severity were treated using three different options: oral antibiotics, CE extract nasal spray, or the combination of oral antibiotic with CE extract. The main outcomes were the effect of treatment on sinonasal symptoms and endoscopic appearance after 6 weeks of therapy, and the number of recurrences of CRS exacerbations after 6 months of follow-up. On the top of oral antibiotics, CE extract significantly improved sinonasal symptoms and endoscopic findings and caused a 4-fold reduction of CRS recurrences. When administered in monotherapy, CE extract was at least as effective as antibiotic in monotherapy on relief of both symptoms and reduction of CRS recurrences. In patients with CRS exacerbation of moderate severity, CE extract nasal spray in monotherapy or added to standard antibiotic treatment significantly reduces sinonasal symptoms and CRS recurrences compared to antibiotics in monotherapy.
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Affiliation(s)
- A S Lopatin
- Policlinic N. 1, Medical Department, Business Administration of the President of the Russian Federation, Moscow, Russia
| | - O A Ivanchenko
- Consultative and Diagnostic Policlinic N. 121, Moscow Healthcare Department, Moscow, Russia
| | - S S Soshnikov
- Department of Mathematical Modelling in Medicine, Central Research Institute for Public Health, Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - J Mullol
- Rhinology Unit and Smell Clinic, ENT Department, Hospital Clínic & Clinical and Experimental Respiratory Immunoallergy, IDIBAPS& CIBERES. Barcelona, Catalonia, Spain
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Broza YY, Braverman I, Haick H. Breath volatolomics for diagnosing chronic rhinosinusitis. Int J Nanomedicine 2018; 13:4661-4670. [PMID: 30147315 PMCID: PMC6097827 DOI: 10.2147/ijn.s171488] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Purpose Chronic rhinosinusitis (CRS) is one of the most common chronic diseases treated by primary care physicians. It is increasingly recognized that CRS and nasal polyposis (NP) comprise several disease processes with diverse causes. Hence, subgroups of sinusitis need to be differentiated so that patients can be screened appropriately and personalized medical treatment provided. Patients and methods To address this need, we use a cross-reactive nanoarray based on either molecularly modified gold nanoparticles or molecularly modified single-walled carbon nanotubes, combined with pattern recognition for analyzing breath samples. Breath samples were collected from three groups of volunteers (total 71) at the Hillel Yaffe Medical Center: CRS, NP, and control. Results Nanoarray results discriminated between patients with sinusitis and the control group with 87% sensitivity, 83% specificity, and 85% accuracy. The system also discriminated well between the subpopulations: 1) CRS vs control (76% sensitivity, 90% specificity); 2) CRS vs NP (82% sensitivity, 71% specificity); and 3) NP vs control (71% sensitivity, 90% specificity). Conclusion This preliminary study shows that a nanoarray-based breath test for screening population for sinusitis-related conditions is feasible.
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Affiliation(s)
- Yoav Y Broza
- The Department of Chemical Engineering and Russell Berrie Nanotechnology Institute, Technion - Israel Institute of Technology, Haifa, Israel,
| | - Itzhak Braverman
- The Otolaryngology - Head & Neck Surgery Unit, The Hillel Yaffe Medical Center, The Technion Faculty of Medicine, Hadera, Israel
| | - Hossam Haick
- The Department of Chemical Engineering and Russell Berrie Nanotechnology Institute, Technion - Israel Institute of Technology, Haifa, Israel,
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Kaszuba SM, Stewart MG. Medical Management and Diagnosis of Chronic Rhinosinusitis: A Survey of Treatment Patterns by United States Otolaryngologists. ACTA ACUST UNITED AC 2018. [DOI: 10.1177/194589240602000214] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background This study was performed to identify current patterns of diagnostic criteria and medical treatment for chronic rhinosinusitis (CRS) by otolaryngologists in the United States. Methods A 15-item survey was mailed to a random sample of 200 members of the American Academy of Otolaryngology–Head and Neck Surgery; statistical analysis was performed. Results The overall response rate was 40.0%. Of respondents, 73% defined CRS as lasting >12 weeks. Seventy-three percent also believed radiological imaging was necessary for definitive diagnosis, but only 30% believed nasal endoscopy was necessary. Regarding treatment, respondents reported use of oral antibiotics (94%) and nasal corticosteroids (94%) as part of maximum medical management; oral decongestants, oral mucoevacuants, and allergy testing were used only by about one-half of the respondents, and less frequently topical decongestants (38%), oral corticosteroids (36%), and oral antihistamines (27%) were used. Oral corticosteroids were more likely to be used by specialists that self-classified as rhinologists than by other otolaryngologists (p = 0.005), but rhinologists were less likely to use radiological imaging (p = 0.04) as a diagnostic criterion. Pediatric otolaryngologists used allergy testing in medical management more frequently than other otolaryngologists (p < 0.001). Overall, the basis for choice of maximal medical management was personal clinical experience (74%), rather than clinical research results or expert recommendations. Conclusion We had a fairly small sample of returned surveys; therefore, our findings may not be generalizable to the entire population of U.S. otolaryngologists. Nevertheless, in our survey, U.S. otolaryngologists agree on the use of oral antibiotics and nasal corticosteroids as part of maximal medical management for CRS but do not agree on other adjuvant therapies or on the use of endoscopy as a diagnostic criterion.
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Affiliation(s)
- Scott M. Kaszuba
- Bobby R. Alford Department of Otorhinolaryngology and Communicative Sciences, Baylor College of Medicine, Houston, Texas
| | - Michael G. Stewart
- Bobby R. Alford Department of Otorhinolaryngology and Communicative Sciences, Baylor College of Medicine, Houston, Texas
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Conley DB, Tripathi A, Ditto AM, Reid K, Grammer LC, Kern RC. Chronic Sinusitis with Nasal Polyps: Staphylococcal Exotoxin Immunoglobulin E and Cellular Inflammation. ACTA ACUST UNITED AC 2018. [DOI: 10.1177/194589240401800503] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background The etiology of chronic sinusitis with nasal polyposis (CS/NP) remains enigmatic. Frequently, Staphylococcus aureus is present in the nose of CS/NP patients, although the significance is unclear. Recent reports have suggested the hypothesis that these bacteria may secrete exotoxins triggering the inflammatory mucosal changes seen in CS/NP. This mechanism of immunopathology has been established in other diseases associated with Staphylococcus colonization and exotoxin secretion such as atopic dermatitis. In atopic dermatitis, the exotoxins incite a local superantigen response in which clonal T-cell activation and massive cytokine release occur in the affected skin. Second, these exotoxins can act as traditional allergens, stimulating a typical immunoglobulin E (IgE) response in the serum, which has been correlated with disease severity. This study is designed to begin the assessment of the hypothesis that a similar mechanism takes place in CS/NP. Methods Serum was drawn from patients with CS/NP undergoing endoscopic sinus surgery as well as 13 atopic and nonatopic control subjects without sinusitis. IgE levels to S. aureus exotoxins A (SEA), SE exotoxins B (SEB), and toxic shock syndrome toxin 1 were measured using enzyme-linked immunosorbent assay. Tissue eosinophilia and the presence of lymphocytes on hemotoxylin and eosin-stained sections of polyps were scored by a blinded pathologist and correlated to presence of toxin IgE in the serum. Results Staphylococcal exotoxin (SE)-specific IgE was found in the serum of 5/10 (50%) of the patients with CS/NP. In contrast, 0/13 control patients had IgE to the exotoxins (p = 0.031). Polyp eosinophil, lymphocyte, and mononuclear cell counts were compared in IgE exotoxin-positive and -negative subjects. A trend toward increased eosinophil counts in patients with SE IgE (SE IgE+) was present, but not statistically significant. Conclusion These results indicate that a high percentage of CS/NP patients show a systemic IgE response to S. aureus exotoxins in comparison with controls without CS/NP. Although these results are consistent with the actions of Staphylococcus toxins in other diseases, additional work is necessary to establish a local superantigen response in the nasal mucosa of CS/NP patients. (American Journal of Rhinology 18, 273–278, 2004)
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Affiliation(s)
- David B. Conley
- Department of Otolaryngology—Head and Neck Surgery Chicago, Illinois
| | - Anju Tripathi
- Division of Allergy and Immunology, Department of Medicine Chicago, Illinois
| | - Anne M. Ditto
- Division of Allergy and Immunology, Department of Medicine Chicago, Illinois
| | - Kathryn Reid
- Center for Sleep and Circadian Biology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Leslie C. Grammer
- Division of Allergy and Immunology, Department of Medicine Chicago, Illinois
| | - Robert C. Kern
- Department of Otolaryngology—Head and Neck Surgery Chicago, Illinois
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11
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Stankiewicz JA, Chow JM. A Diagnostic Dilemma for Chronic Rhinosinusitis: Definition Accuracy and Validity. ACTA ACUST UNITED AC 2018. [DOI: 10.1177/194589240201600404] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The current definition of chronic rhinosinusitis is a symptom-based definition with minimal reliance on objective information. Based on this definition, patients are diagnosed and treated with medical therapy. A computed tomography (CT) scan is obtained only if the patient is not improved after medical therapy. No study is available evaluating in an evidence-based manner the accuracy of the current definition and its impact on diagnosis and treatment. Methods This study represents 78 patients evaluated in a prospective fashion who met the subjective criteria for the definition of chronic rhinosinusitis. All patients underwent a complete history with a questionnaire evaluating symptom severity, a physical exam including anterior rhinoscopy and endoscopy, and a CT scan obtained on the day of their initial visit. Objective CT scan findings were compared with the subjective findings and related to the ultimate diagnosis of chronic sinusitis. Results Only 37/78 (47%) had a positive (1) CT scan, indicating demonstrable sinusitis. There also was no real difference in symptom severity between patients with positive (1) and negative (2) CT scanning. Conclusion The current symptom-based definition of chronic sinusitis poorly predicts whether a patient truly has chronic sinusitis and needs reevaluation.
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Affiliation(s)
- James A. Stankiewicz
- Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Maywood, Illinois
| | - James M. Chow
- Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Maywood, Illinois
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Ghasemi A, Allafasghari A, Mofidi M. A new ultrasound sign in the diagnosis of pediatric maxillary sinusitis. Med J Islam Repub Iran 2018; 32:16. [PMID: 30159267 PMCID: PMC6108240 DOI: 10.14196/mjiri.32.16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Indexed: 11/18/2022] Open
Abstract
Background: Computed tomography scans (CT scan) and X-rays are used to diagnose paediatric maxillary sinusitis. This study aimed at exploring the diagnostic value of the conventional and colour Doppler ultrasounds and their specific findings in cases of paediatric sinusitis. Methods: A total of 60 children diagnosed with sinusitis were included in this study. The conventional and colour Doppler ultrasounds of the sinus were performed on each of them. The symptoms that suggested increased blood flow to the sinuses were interpreted as positive findings on the colour Doppler ultrasound and were named "Ghasemi signs" for the purpose of this study. Such symptoms included unilateral artery bumps on the front artery, reduction of arterial resistive index (RI) to less than 0.5, and diameter of 2 mm or above for maxillary arteries. Sensitivity, specificity, and positive and negative predictive values, and accuracy of the conventional and colour Doppler ultrasounds were also calculated. Results: Compared to CT scan, the conventional ultrasound showed sensitivity and specificity of 73.4% and 100%, respectively. Sensitivity and specificity for the colour Doppler ultrasound were 89.36% and 100%, respectively. The maxillary artery diameter in normal and affected maxillary sinuses were, respectively, 2.4 mm (2.1-2.6, 95% CI) and 1.7 mm (1.6-1.9, 95% CI), with p<0.001. The RI of the affected sinuses were 0.47 (0.45-0.49, 95% CI), and those of the normal sinuses were 0.58 (0.54-0.61, 95% CI), with p<0.001. Conclusion: The findings of this study revealed that the conventional ultrasound agrees with the CT scans in the diagnosis of paediatric maxillary sinusitis. This diagnostic modality becomes even more valuable when the colour Doppler is used, particularly when considering the specific symptoms (Ghasemi signs) suggested by this study.
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Affiliation(s)
- Ahmad Ghasemi
- Department of Radiology, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, Iran
| | - Atabak Allafasghari
- Department of Radiology, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mani Mofidi
- Emergency Medicine Department, Rasoul Akram Hospital, Emergency Management Research Center, Iran University of Medical Sciences, Tehran. Iran
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Post-adenoidectomy quality of life in children with refractory chronic rhinosinusitis. The Journal of Laryngology & Otology 2017; 131:773-778. [DOI: 10.1017/s002221511700113x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjective:This study aimed to evaluate post-adenoidectomy quality of life in children with refractory chronic rhinosinusitis.Methods:A prospective interventional study of children aged 4–12 years with chronic refractory rhinosinusitis was conducted. A total of 60 children completed follow up. Nasal endoscopy and non-contrast computed tomography of the paranasal sinuses were performed, and both symptoms and their effects on patient quality of life pre- and post-adenoidectomy were evaluated.Results:The most frequent symptoms were nasal obstruction, cough, fever and fatigue, which were experienced by 100 per cent, 90 per cent, 85 per cent and 81.7 per cent of children, respectively. Nasal endoscopy showed oedema and discharge were present in all children. A statistically significant post-operative improvement in sinus and nasal quality of life was seen in 53 children (88.3 per cent).Conclusion:Adenoidectomy is a simple, first-line surgical procedure for managing paediatric chronic rhinosinusitis refractory to maximal medical therapy and leads to an improved quality of life.
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Rudmik L, Xu Y, Kukec E, Liu M, Dean S, Quan H. A validated case definition for chronic rhinosinusitis in administrative data: a Canadian perspective. Int Forum Allergy Rhinol 2016; 6:1167-1172. [DOI: 10.1002/alr.21801] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 03/18/2016] [Accepted: 04/12/2016] [Indexed: 01/28/2023]
Affiliation(s)
- Luke Rudmik
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery; University of Calgary; Calgary Alberta Canada
- Department of Community Health Sciences; University of Calgary; Calgary Alberta Canada
| | - Yuan Xu
- Department of Community Health Sciences; University of Calgary; Calgary Alberta Canada
| | - Edward Kukec
- Data Integration, Measurement and Reporting (DIMR); Alberta Health Services; Calgary Alberta Canada
| | - Mingfu Liu
- Data Integration, Measurement and Reporting (DIMR); Alberta Health Services; Calgary Alberta Canada
| | - Stafford Dean
- Data Integration, Measurement and Reporting (DIMR); Alberta Health Services; Calgary Alberta Canada
| | - Hude Quan
- Department of Community Health Sciences; University of Calgary; Calgary Alberta Canada
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Yasan H, Doğru H, Baykal B, Döner F, Tüz M. What is the Relationship Between Chronic Sinus Disease and Isolated Nasal Septal Deviation? Otolaryngol Head Neck Surg 2016; 133:190-3. [PMID: 16087012 DOI: 10.1016/j.otohns.2005.04.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2004] [Accepted: 04/22/2005] [Indexed: 01/11/2023]
Abstract
Objective The aim of this retrospective study is to examine the role of isolated nasal septal deviation (NSD) in the pathogenesis of chronic rhinosinusitis (CRS). Study Design and Setting The interaction between isolated NSD and chronic sinus disease were retrospectively evaluated in 1452 patients. Out of 1452 patients, 152 patients were included in the study. Patients with anatomical variants other than NSD were excluded from the study. Patients with NSD were enrolled in the study group and patients without NSD were enrolled in the control group. Results There was no statistically significant difference between NSD group and non-NSD group with respect to the CRS. Conclusions The mild to moderate degree of NSD was not a risk factor for chronic sinus disease. Only gross deviation of the nasal septum itself is a risk factor for the development of CRS. Significance Excluding the subjects with ostiomeatal anatomic variations has differentiated this study from the previously reported researches (isolated NSD).
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Affiliation(s)
- Hasan Yasan
- Ear, Nose and Throat-Head and Neck Surgery Department, Suleyman Demirel University, School of Medicine, Isparta, Turkey.
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Orlandi RR, Kingdom TT, Hwang PH, Smith TL, Alt JA, Baroody FM, Batra PS, Bernal-Sprekelsen M, Bhattacharyya N, Chandra RK, Chiu A, Citardi MJ, Cohen NA, DelGaudio J, Desrosiers M, Dhong HJ, Douglas R, Ferguson B, Fokkens WJ, Georgalas C, Goldberg A, Gosepath J, Hamilos DL, Han JK, Harvey R, Hellings P, Hopkins C, Jankowski R, Javer AR, Kern R, Kountakis S, Kowalski ML, Lane A, Lanza DC, Lebowitz R, Lee HM, Lin SY, Lund V, Luong A, Mann W, Marple BF, McMains KC, Metson R, Naclerio R, Nayak JV, Otori N, Palmer JN, Parikh SR, Passali D, Peters A, Piccirillo J, Poetker DM, Psaltis AJ, Ramadan HH, Ramakrishnan VR, Riechelmann H, Roh HJ, Rudmik L, Sacks R, Schlosser RJ, Senior BA, Sindwani R, Stankiewicz JA, Stewart M, Tan BK, Toskala E, Voegels R, Wang DY, Weitzel EK, Wise S, Woodworth BA, Wormald PJ, Wright ED, Zhou B, Kennedy DW. International Consensus Statement on Allergy and Rhinology: Rhinosinusitis. Int Forum Allergy Rhinol 2016; 6 Suppl 1:S22-209. [DOI: 10.1002/alr.21695] [Citation(s) in RCA: 333] [Impact Index Per Article: 41.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 11/13/2015] [Accepted: 11/16/2015] [Indexed: 02/06/2023]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Valerie Lund
- Royal National Throat Nose and Ear Hospital; London UK
| | - Amber Luong
- University of Texas Medical School at Houston
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Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, Brook I, Kumar KA, Kramper M, Orlandi RR, Palmer JN, Patel ZM, Peters A, Walsh SA, Corrigan MD. Clinical practice guideline (update): Adult Sinusitis Executive Summary. Otolaryngol Head Neck Surg 2015; 152:598-609. [PMID: 25833927 DOI: 10.1177/0194599815574247] [Citation(s) in RCA: 147] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The American Academy of Otolaryngology-Head and Neck Surgery Foundation has published a supplement to this issue featuring the updated "Clinical Practice Guideline: Adult Sinusitis" as a supplement to Otolaryngology-Head and Neck Surgery. To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 14 developed recommendations address diagnostic accuracy for adult rhinosinusitis, the appropriate use of ancillary tests to confirm diagnosis and guide management (including radiography, nasal endoscopy, computed tomography, and testing for allergy and immune function), and the judicious use of systemic and topical therapy. Emphasis was also placed on identifying multiple chronic conditions that would modify management of rhinosinusitis, including asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia. An updated guideline is needed as a result of new clinical trials, new systematic reviews, and the lack of consumer participation in the initial guideline development group.
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Affiliation(s)
- Richard M Rosenfeld
- Department of Otolaryngology, SUNY Downstate Medical Center, Brooklyn, New York, USA
| | - Jay F Piccirillo
- Department of Otolaryngology-Head and Neck Surgery, Washington University in St Louis, School of Medicine, St Louis, Missouri, USA
| | | | - Itzhak Brook
- Department of Pediatrics, Georgetown University, Washington, DC, USA
| | - Kaparaboyna Ashok Kumar
- Department of Family Medicine, University of Texas Health Sciences Center at San Antonio, San Antonio, Texas, USA
| | - Maggie Kramper
- Department of Otolaryngology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Richard R Orlandi
- Division of Otolaryngology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - James N Palmer
- Department Otolaryngology, University of Pennsylvania Hospital, Philadelphia, Pennsylvania, USA
| | - Zara M Patel
- Department of Otolaryngology Head & Neck Surgery, Emory University, Atlanta, Georgia, USA
| | - Anju Peters
- Department of Internal Medicine, Northwestern University Allergy Division, Chicago, Illinois, USA
| | - Sandra A Walsh
- Consumers United for Evidence-Based Healthcare, Davis, California, USA
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Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, Brook I, Ashok Kumar K, Kramper M, Orlandi RR, Palmer JN, Patel ZM, Peters A, Walsh SA, Corrigan MD. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg 2015; 152:S1-S39. [PMID: 25832968 DOI: 10.1177/0194599815572097] [Citation(s) in RCA: 492] [Impact Index Per Article: 54.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE This update of a 2007 guideline from the American Academy of Otolaryngology--Head and Neck Surgery Foundation provides evidence-based recommendations to manage adult rhinosinusitis, defined as symptomatic inflammation of the paranasal sinuses and nasal cavity. Changes from the prior guideline include a consumer added to the update group, evidence from 42 new systematic reviews, enhanced information on patient education and counseling, a new algorithm to clarify action statement relationships, expanded opportunities for watchful waiting (without antibiotic therapy) as initial therapy of acute bacterial rhinosinusitis (ABRS), and 3 new recommendations for managing chronic rhinosinusitis (CRS). PURPOSE The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing adult rhinosinusitis and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to improve diagnostic accuracy for adult rhinosinusitis, promote appropriate use of ancillary tests to confirm diagnosis and guide management, and promote judicious use of systemic and topical therapy, which includes radiography, nasal endoscopy, computed tomography, and testing for allergy and immune function. Emphasis was also placed on identifying multiple chronic conditions that would modify management of rhinosinusitis, including asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia. ACTION STATEMENTS The update group made strong recommendations that clinicians (1) should distinguish presumed ABRS from acute rhinosinusitis (ARS) caused by viral upper respiratory infections and noninfectious conditions and (2) should confirm a clinical diagnosis of CRS with objective documentation of sinonasal inflammation, which may be accomplished using anterior rhinoscopy, nasal endoscopy, or computed tomography. The update group made recommendations that clinicians (1) should either offer watchful waiting (without antibiotics) or prescribe initial antibiotic therapy for adults with uncomplicated ABRS; (2) should prescribe amoxicillin with or without clavulanate as first-line therapy for 5 to 10 days (if a decision is made to treat ABRS with an antibiotic); (3) should reassess the patient to confirm ABRS, exclude other causes of illness, and detect complications if the patient worsens or fails to improve with the initial management option by 7 days after diagnosis or worsens during the initial management; (4) should distinguish CRS and recurrent ARS from isolated episodes of ABRS and other causes of sinonasal symptoms; (5) should assess the patient with CRS or recurrent ARS for multiple chronic conditions that would modify management, such as asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia; (6) should confirm the presence or absence of nasal polyps in a patient with CRS; and (7) should recommend saline nasal irrigation, topical intranasal corticosteroids, or both for symptom relief of CRS. The update group stated as options that clinicians may (1) recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of viral rhinosinusitis; (2) recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation) for symptomatic relief of ABRS; and (3) obtain testing for allergy and immune function in evaluating a patient with CRS or recurrent ARS. The update group made recommendations that clinicians (1) should not obtain radiographic imaging for patients who meet diagnostic criteria for ARS, unless a complication or alternative diagnosis is suspected, and (2) should not prescribe topical or systemic antifungal therapy for patients with CRS.
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Affiliation(s)
- Richard M Rosenfeld
- Department of Otolaryngology, SUNY Downstate Medical Center, Brooklyn, New York, USA
| | - Jay F Piccirillo
- Department of Otolaryngology-Head and Neck Surgery, Washington University in St Louis, School of Medicine, St Louis, Missouri, USA
| | | | - Itzhak Brook
- Department of Pediatrics, Georgetown University, Washington, DC, USA
| | - Kaparaboyna Ashok Kumar
- Department of Family Medicine, University of Texas Health Sciences Center at San Antonio, San Antonio, Texas, USA
| | - Maggie Kramper
- Department of Otolaryngology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Richard R Orlandi
- Division of Otolaryngology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - James N Palmer
- Department Otolaryngology, University of Pennsylvania Hospital, Philadelphia, Pennsylvania, USA
| | - Zara M Patel
- Department of Otolaryngology Head & Neck Surgery, Emory University, Atlanta, Georgia, USA
| | - Anju Peters
- Department of Internal Medicine, Northwestern University Allergy Division, Chicago, Illinois, USA
| | - Sandra A Walsh
- Consumers United for Evidence-Based Healthcare, Davis, California, USA
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Lopatin AS, Ivanchenko OA, Soshnikov SS. Comparative study of the efficiency of different treatment regimens for chronic rhinosinusitis. ACTA ACUST UNITED AC 2015. [DOI: 10.17116/rosrino201523247-56] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Tengroth L, Arebro J, Kumlien Georén S, Winqvist O, Cardell LO. Deprived TLR9 expression in apparently healthy nasal mucosa might trigger polyp-growth in chronic rhinosinusitis patients. PLoS One 2014; 9:e105618. [PMID: 25133733 PMCID: PMC4136868 DOI: 10.1371/journal.pone.0105618] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 07/25/2014] [Indexed: 11/17/2022] Open
Abstract
Background The origin of nasal polyps in chronic rhinosinusitis is unknown, but the role of viral infections in polyp growth is clinically well established. Toll-like receptors (TLRs) have recently emerged as key players in our local airway defense against microbes. Among these, TLR9 has gained special interest in viral diseases. Many studies on chronic rhinosinusitis with nasal polyps (CRSwNP) compare polyp tissue with nasal mucosa from polyp-free individuals. Knowledge about changes in the turbinate tissue bordering the polyp tissue is limited. Objectives To analyse the role of TLR9 mediated microbial defense in tissue bordering the polyp. Methods Nasal polyps and turbinate tissue from 11 patients with CRSwNP and turbinate tissue from 11 healthy controls in total were used. Five biopsies from either group were analysed immediately with flow cytometry regarding receptor expression and 6 biopsies were used for in vitro stimulation with a TLR9 agonist, CpG. Cytokine release was analysed using Luminex. Eight patients with CRSwNP in total were intranasally challenged with CpG/placebo 24 hours before surgery and the biopsies were collected and analysed as above. Results TLR9 expression was detected on turbinate epithelial cells from healthy controls and polyp epithelial cells from patients, whereas TLR9 was absent in turbinate epithelial cells from patients. CpG stimulation increased the percentage cells expressing TLR9 and decreased percentage cells expressing VEGFR2 in turbinate tissue from patients. After CpG stimulation the elevated levels of IL-6, G-CSF and MIP-1β in the turbinate tissue from patients were reduced towards the levels demonstrated in healthy controls. Conclusion Defects in the TLR9 mediated microbial defense in the mucosa adjacent to the anatomic origin of the polyp might explain virus induced polyp growth. CpG stimulation decreased VEGFR2, suggesting a role for CpG in polyp formation. The focus on turbinate tissue in patients with CRSwNP opens new perspectives in CRSwNP-research.
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Affiliation(s)
- Lotta Tengroth
- Division of Ear, Nose and Throat Diseases, Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Julia Arebro
- Division of Ear, Nose and Throat Diseases, Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Susanna Kumlien Georén
- Division of Ear, Nose and Throat Diseases, Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Ola Winqvist
- Department of Medicine, Unit of Translational Immunology, Karolinska Institute, Stockholm, Sweden
| | - Lars-Olaf Cardell
- Division of Ear, Nose and Throat Diseases, Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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Histopathologic Relationship Between Ethmoid Sinus and Ipsilateral Middle Turbinate in Non-Polypose Chronic Sinusitis by FESS. Indian J Otolaryngol Head Neck Surg 2014; 65:324-8. [PMID: 24427670 DOI: 10.1007/s12070-012-0483-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Accepted: 01/16/2012] [Indexed: 10/14/2022] Open
Abstract
Chronic rhinosinusitis (CRS) is a common disease with significant effects on the quality of life. Infection was previously a common cause of rhino sinusitis, while nowadays its main cause is inflammation. Non-polyposis CRS patients who were resistant to medical treatment and underwent endoscopic sinus surgery in Ghaem and Imam Reza hospitals were studied from December 2008 to November 2009. There were 11 males and four females ranging in age from 14 to 57 years with the average age of 32.2. First, samples were taken from the ethmoid sinus and the ipsilateral middle turbinate. Then, histopathologic research on grade of inflammation, mucosal thickness, inflammatory cell count, metaplasia type, and hypersecretion was performed. Fifteen patients were studied. There were positive statistical correlations between inflammation grade, eosinophil counts and plasma cell counts in ethmoid and turbinate; but such a correlation was not found in lymphocyte and neutrophil in two sites. The prominent inflammatory cell in both areas was the same for 11 patients; whereas in other four cases, it was insignificantly different. Positive statistical correlation between the inflammation grades in two sites shows the coexistence of rhinitis and sinusitis; therefore, this proves the correct combination usage of rhinosinusitis. Prominent cells of the samples which were obtained from two places were similar for most patients, so this similarity is a sign of inflammatory process presence in both places. The prominent cells were mostly lymphocytes.There were more lymphocytes than eosinophils in non-allergic patients.
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Erwin EA, Faust RA, Platts-Mills TAE, Borish L. Epidemiological analysis of chronic rhinitis in pediatric patients. Am J Rhinol Allergy 2012; 25:327-32. [PMID: 22186247 DOI: 10.2500/ajra.2011.25.3640] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Nonallergic rhinitis is a poorly understood entity, especially among pediatric patients. OBJECTIVE The objective of this study was to identify clinical features that may distinguish phenotypes of allergic and nonallergic patients and to evaluate the usefulness of current diagnostic modalities. METHODS We reviewed medical records for 151 pediatric patients with perennial rhinitis, evaluated in a multidisciplinary allergy and otolaryngology clinic. Results obtained by standard history, validated sinus and Nasal Quality of Life Survey (SN-5), epicutaneous allergy testing, acoustic rhinometry, and sinus CT were compared. RESULTS Nasal congestion was the most frequent primary presenting complaint (62%). Among subjects having a positive allergy test, associated eye symptoms were more frequent (p = 0.01) and responses to the SN-5 allergic domain were higher (p = 0.02). Sinus CT scores were similar among allergic and nonallergic subjects (median 7 and 8, respectively) and did not correlate with symptom scores (p = 0.6). Among nonallergic subjects, quality of life ratings weakly correlated with sinus CT scores (r = 0.4; p = 0.05). By rhinometry, absolute mean cross-sectional area was similar among allergic (0.32 cm(2)) and nonallergic (0.36 cm(2)) subjects and did not correlate with symptom scores (p = 0.8 for allergic and p = 0.6 for nonallergic subjects). Distinct groups of nonallergic patients including those with prominent conjunctival pruritus (n = 24), frequent cold symptoms (n = 3), and chronic sinus disease (n = 2) were observed. CONCLUSION It is difficult to distinguish allergic and nonallergic rhinitis in patients with perennial disease, but associated eye symptoms and questionnaire responses are predictive of allergy. Acoustic rhinometry and sinus CT suggest that physical obstruction and sinus disease are not related to nasal symptoms including, surprisingly, the sensation of congestion.
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Affiliation(s)
- Elizabeth A Erwin
- Center for Innovation in Pediatric Practice, Nationwide Children's Hospital, Columbus, Ohio 43205, USA.
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Wu CC, Lee TJ, Chang PH, Tsai CN, Lee YS, Fu CH, Huang CC. Similar cellular proliferation activities in nasal polyps and adjacent inferior turbinate. Am J Otolaryngol 2012; 33:14-9. [PMID: 21377232 DOI: 10.1016/j.amjoto.2010.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2010] [Revised: 12/01/2010] [Accepted: 12/12/2010] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Nasal polyps (NP) are regulated by proinflammatory transcription factors such as activator protein-1 (AP-1), which comprises members of the proto-oncogene Jun and Fos protein families. The binding of AP-1 proteins to the 12-O-tetradecanoylphorbol-13-acetate (TPA)-response element can activate target genes and regulate many critical cellular processes. The proliferating cell nuclear antigen (PCNA) gene contains AP-1 sites, and its expression is regulated by AP-1 activity. In this study, NP and inferior turbinate (IT) were evaluated, compared with normal mucosa, to see if diffuse inflammation and active cellular proliferation exist. MATERIALS AND METHODS A diseased group of 20 subjects and control group of 20 subjects were enrolled in this study. NP and IT were evaluated with expression of phospho-c-Jun, c-Fos, PCNA, major basic protein by immunohistochemistry, and eosinophil numbers by cell counts. RESULT The expression of phospho-c-Jun, c-Fos, PCNA, major basic protein, and eosinophil numbers showed no significant difference in IT and NP of the same patients, but all were significantly higher in IT and NP compared with normal mucosa (P < .05). CONCLUSION Our result demonstrated strong evidence that diffuse mucosal inflammation and active cellular proliferation do exist in rhinosinusitis with nasal polyposis. As the degree of the disease severity increases, the difference of eosinophilic infiltration and cellular proliferation activity between NP and its adjacent mucosa decreases. An integrated anti-inflammatory treatment may be more important than surgical intervention.
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Abstract
Rhinosinusitis is a very common disease worldwide and specifically in the US population. It is a common disease in children but may be underdiagnosed. Several reasons may account to the disease being missed in children. The symptoms in children are limited and can be very similar to the common cold or allergic symptoms. Cough and nasal discharge may be the only symptoms present in children. A high index of suspicion is necessary to make the diagnosis of rhinosinusitis in these children. The majority of those children are treated medically. Only a few number will require surgical intervention when medical treatment fails. Complications of rhinosinusitis, even though rare, can carry a high morbidity and mortality rate.
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Histopathologic characteristics of inferior turbinate vs ethmoidal polypin chronic rhinosinusitis. Ann Diagn Pathol 2011; 15:233-6. [PMID: 21396869 DOI: 10.1016/j.anndiagpath.2010.10.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2010] [Revised: 10/12/2010] [Accepted: 10/25/2010] [Indexed: 11/22/2022]
Abstract
It seems apparently that the 2 separate anatomical areas (nasal cavity and paranasal sinus mucosa) are indeed one single unit with an identical behavior during inflammatory process. Similar histopathologic evidence in long-term condition could emphasize on the concept of rhinosinusitis in patients with inflammatory paranasal sinus disease. Prospective study was performed on 50 consecutive patients with polyposis in 2 different groups, one with and the other without asthma. Inferior turbine and polyp with ethmoid sinus origin were selected to compare the histopathologic findings of the surgical specimens from the 2 sites (affected sinus vs apparently unaffected nose). The general degree of inflammation, epithelial thickening, and inflammatory cell count were measured. The degree of inferior turbinate inflammation correlated with that of the ipsilateral polyp of ethmoid sinus in both groups. In addition, the total inflammatory cell count was comparable. There was no statistically significant difference in total polymorphonuclear, lymphocyte, and eosinophil count between the 2 sites in each group (P > .05). The ethmoid sinus inflammation in polypoid chronic sinusitis is accompanied by a proportionate inferior turbinate inflammation, not only in the patients with asthma but also in those with isolated sinonasal polyposis.
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Abstract
Background The objective of this study was to determine the disease burden of sinusitis relative to other medical conditions. Methods The adult sample of the National Health Interview Survey for calendar years 1997 to 2006 was analyzed, extracting 1-year prevalence data for the disease conditions sinusitis, hay fever, peptic ulcer, acute asthma, and chronic bronchitis. Disease burden data for emergency room visits, general and specialist visits, health care spending, and workdays lost were also extracted. The influence of each disease condition on disease burden variables was statistically determined. Comparisons among outcomes variables were conducted across disease conditions to determine their relative economic and health care impacts. Results Adult patients were studied (313,982; mean age, 45.2 years). The 1-year disease prevalences were: sinusitis (15.2%), hay fever (8.9%), ulcer (2.4%), acute asthma (3.8%), and chronic bronchitis (4.8%). Patients with sinusitis were significantly more likely to: visit the emergency room (22.7% versus 17.4%, p < 0.001), spend greater than $500/year on health care (55.8% versus 45.0%, p < 0.001), and see a medical specialist (33.6% versus 22.3%, p < 0.001), than those without sinusitis. Patients with sinusitis missed an average of 5.67 workdays per 12 months versus 3.74 workdays for those without (p < 0.001). The number of workdays lost with sinusitis was similar to that of acute asthma (5.79 workdays, p > 0.05), and health care spending with sinusitis was significantly greater than that of ulcer disease, acute asthma, and hay fever (p < 0.004). Conclusions Sinusitis imparts a significant disease burden both within and outside of the health care system that is comparable with or exceeds that of other conditions commonly thought to be more serious.
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Affiliation(s)
- Neil Bhattacharyya
- Division of Otolaryngology, Brigham and Women's Hospital, Boston, Massachusetts; and Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts
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Pearlman AN, Conley DB. Review of current guidelines related to the diagnosis and treatment of rhinosinusitis. Curr Opin Otolaryngol Head Neck Surg 2008; 16:226-30. [PMID: 18475076 DOI: 10.1097/moo.0b013e3282fdcc9a] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Rhinosinusitis is one of the most common medical complaints, affecting nearly 31 million US citizens annually. Multiple medical professionals including emergency medicine, internal medicine, allergy, and otolaryngology treat rhinosinusitis, resulting in high-practice variability. This review will discuss recommendations of the 2007 American Academy of Otolaryngology - Head and Neck Surgery's multispecialty panel on evidence based clinical practice guidelines for diagnosis and treatment of rhinosinusitis. RECENT FINDINGS The task force for recommendations defines rhinosinusitis as follows: acute bacterial, viral, chronic, or recurrent acute rhinosinusitis. For acute rhinosinusitis three symptoms are required: purulent nasal discharge with nasal obstruction and/or facial pain-pressure-fullness lasting between 10 days and 4 weeks. For viral rhinosinusitis, imaging is not recommended and treatment is symptomatic. For acute bacterial rhinosinusitis in an otherwise healthy patient, symptomatic relief is recommended including pain control. Amoxicillin is the first-line antibiotic of choice if needed. Radiographic imaging should be considered if an infectious complication is suspected. Chronic rhinosinusitis is likely when symptoms persist for greater than 12 weeks, with computed tomography being the gold standard for diagnostic testing. Nasal endoscopy and allergy/immune testing are also considered. SUMMARY Accurate diagnosis of rhinosinusitis with recommended treatments should standardize management. However, these recommendations are guidelines and the clinician's judgment is highly important.
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Affiliation(s)
- Aaron N Pearlman
- Feinberg School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Northwestern University, Chicago, IL 60611, USA
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Rosenfeld RM. Clinical practice guideline on adult sinusitis. Otolaryngol Head Neck Surg 2007; 137:365-77. [PMID: 17765760 DOI: 10.1016/j.otohns.2007.07.021] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2007] [Accepted: 07/11/2007] [Indexed: 11/16/2022]
Abstract
This executive summary will alert clinicians to key evidence-based statements in a multidisciplinary, clinical practice guideline on adult sinusitis developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation. Included in the guideline are 17 boldfaced action statements: 3 on viral rhinosinusitis, 7 on acute bacterial rhinosinusitis, and 7 on chronic rhinosinusitis and recurrent acute rhinosinusitis. Evidence profiles that accompany each statement are summarized to show why it was made and how it can be implemented. Guideline statements regarding acute rhinosinusitis focus on diagnosing presumed bacterial illness and using antibiotics appropriately. Guideline statements regarding chronic rhinosinusitis or recurrent acute rhinosinusitis focus on appropriate use of diagnostic tests. Surgical therapy is not discussed.
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Affiliation(s)
- Richard M Rosenfeld
- Department of Otolaryngology, SUNY Downstate Medical Center, Long Island College Hospital, Brooklyn, NY, USA.
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Rosenfeld RM, Andes D, Bhattacharyya N, Cheung D, Eisenberg S, Ganiats TG, Gelzer A, Hamilos D, Haydon RC, Hudgins PA, Jones S, Krouse HJ, Lee LH, Mahoney MC, Marple BF, Mitchell CJP, Nathan R, Shiffman RN, Smith TL, Witsell DL. Clinical practice guideline: adult sinusitis. Otolaryngol Head Neck Surg 2007; 137:S1-31. [PMID: 17761281 DOI: 10.1016/j.otohns.2007.06.726] [Citation(s) in RCA: 626] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2007] [Revised: 06/20/2007] [Accepted: 06/20/2007] [Indexed: 12/23/2022]
Abstract
OBJECTIVE This guideline provides evidence-based recommendations on managing sinusitis, defined as symptomatic inflammation of the paranasal sinuses. Sinusitis affects 1 in 7 adults in the United States, resulting in about 31 million individuals diagnosed each year. Since sinusitis almost always involves the nasal cavity, the term rhinosinusitis is preferred. The guideline target patient is aged 18 years or older with uncomplicated rhinosinusitis, evaluated in any setting in which an adult with rhinosinusitis would be identified, monitored, or managed. This guideline is intended for all clinicians who are likely to diagnose and manage adults with sinusitis. PURPOSE The primary purpose of this guideline is to improve diagnostic accuracy for adult rhinosinusitis, reduce inappropriate antibiotic use, reduce inappropriate use of radiographic imaging, and promote appropriate use of ancillary tests that include nasal endoscopy, computed tomography, and testing for allergy and immune function. In creating this guideline the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of allergy, emergency medicine, family medicine, health insurance, immunology, infectious disease, internal medicine, medical informatics, nursing, otolaryngology-head and neck surgery, pulmonology, and radiology. RESULTS The panel made strong recommendations that 1) clinicians should distinguish presumed acute bacterial rhinosinusitis (ABRS) from acute rhinosinusitis caused by viral upper respiratory infections and noninfectious conditions, and a clinician should diagnose ABRS when (a) symptoms or signs of acute rhinosinusitis are present 10 days or more beyond the onset of upper respiratory symptoms, or (b) symptoms or signs of acute rhinosinusitis worsen within 10 days after an initial improvement (double worsening), and 2) the management of ABRS should include an assessment of pain, with analgesic treatment based on the severity of pain. The panel made a recommendation against radiographic imaging for patients who meet diagnostic criteria for acute rhinosinusitis, unless a complication or alternative diagnosis is suspected. The panel made recommendations that 1) if a decision is made to treat ABRS with an antibiotic agent, the clinician should prescribe amoxicillin as first-line therapy for most adults, 2) if the patient worsens or fails to improve with the initial management option by 7 days, the clinician should reassess the patient to confirm ABRS, exclude other causes of illness, and detect complications, 3) clinicians should distinguish chronic rhinosinusitis (CRS) and recurrent acute rhinosinusitis from isolated episodes of ABRS and other causes of sinonasal symptoms, 4) clinicians should assess the patient with CRS or recurrent acute rhinosinusitis for factors that modify management, such as allergic rhinitis, cystic fibrosis, immunocompromised state, ciliary dyskinesia, and anatomic variation, 5) the clinician should corroborate a diagnosis and/or investigate for underlying causes of CRS and recurrent acute rhinosinusitis, 6) the clinician should obtain computed tomography of the paranasal sinuses in diagnosing or evaluating a patient with CRS or recurrent acute rhinosinusitis, and 7) clinicians should educate/counsel patients with CRS or recurrent acute rhinosinusitis regarding control measures. The panel offered as options that 1) clinicians may prescribe symptomatic relief in managing viral rhinosinusitis, 2) clinicians may prescribe symptomatic relief in managing ABRS, 3) observation without use of antibiotics is an option for selected adults with uncomplicated ABRS who have mild illness (mild pain and temperature <38.3 degrees C or 101 degrees F) and assurance of follow-up, 4) the clinician may obtain nasal endoscopy in diagnosing or evaluating a patient with CRS or recurrent acute rhinosinusitis, and 5) the clinician may obtain testing for allergy and immune function in evaluating a patient with CRS or recurrent acute rhinosinusitis. DISCLAIMER This clinical practice guideline is not intended as a sole source of guidance for managing adults with rhinosinusitis. Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. It is not intended to replace clinical judgment or establish a protocol for all individuals with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem.
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Affiliation(s)
- Richard M Rosenfeld
- Department of Otolaryngology, SUNY Downstate Medical Center and Long Island College Hospital, Brooklyn, NY 11201-5514, USA.
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Bhattacharyya N. Cytological characterization of persistent paranasal sinus secretions after endoscopic sinus surgery. ACTA ACUST UNITED AC 2007; 21:1-4. [PMID: 17283552 DOI: 10.2500/ajr.2007.21.2982] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The aim of this study was to characterize the cellular composition of persisting sinus secretions after endoscopic sinus surgery (ESS). METHODS Consecutive adult patients with persisting abnormal sinus secretions post-ESS were prospectively evaluated. Sinus secretions were aspirated and submitted for cytological analysis. Semiquantitative cell counts were obtained for epithelial cells (graded as present or absent), eosinophils (graded on a 4-point Likert severity scale), and neutrophils (3-point Likert scale). Prior operative histopathology from ESS and Lund CT scores were reviewed. Statistical analyses were conducted to determine the relationships between preoperative Lund score, operative histopathology, and subsequent cellular infiltrate in sinus secretions. RESULTS Forty-three patients (mean age, 49 years) were enrolled. Epithelial cells were present in 13 (30.2%) of these individuals. Cytological eosinophilia was rated as absent in 14 (32.6%) cases, mild in 5 (11.6%) cases, moderate in 18 (41.9%) cases, and severe in 6 (14.0%) cases. Neutrophil presence was absent in 24 (55.8%) cases, present/mild in 15 (34.9%) cases, and severe in 4 (9.3%) cases. No significant correlation could be found between the presence of each of these three cell types, the presence or absence of polyps, or preoperative Lund score (all p > 0.05). Sloughed epithelial cell presence was inversely but significantly correlated with original sinus histopathological inflammation (Spearman's rho, -0.348; p = 0.04); eosinophilic cytology tended to increase with prior operative histopathology inflammatory grade but neutrophils did not. CONCLUSION The cytological profile of persisting secretions after ESS is dominated by eosinophils and to a lesser degree neutrophils. The presence of sloughed epithelial cells may signify ongoing mucosal damage from persisting sinonasal inflammation.
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Affiliation(s)
- Neil Bhattacharyya
- Division of Otolaryngology, Brigham and Women's Hospital, Boston Department of Otology and Laryngology, Harvard Medical School, Boston, MA 02115, USA.
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Smart BA. The impact of allergic and nonallergic rhinitis on pediatric sinusitis. Curr Allergy Asthma Rep 2006; 6:221-7. [PMID: 16579872 DOI: 10.1007/s11882-006-0038-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
There is a great deal of published evidence that there is a relationship between both allergic and nonallergic rhinitis and sinusitis in both pediatric and adult patients. The relationship between rhinitis and sinusitis may involve inflammation in one compartment leading to secondary inflammation in the other compartment, such as in the case of rhinitis leading to obstruction of the osteomeatal complex. The relationship may also involve individual manifestations of a shared process, such as allergic disease. A better understanding of the relationship between rhinitis and sinusitis may significantly influence the treatment of these common and important conditions.
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Affiliation(s)
- Brian A Smart
- Asthma and Allergy Center, DuPage Medical Group, 454 Pennsylvania Avenue, Glen Ellyn, IL 60137, USA.
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Abstract
OBJECTIVES/HYPOTHESIS The objectives of this prospective, double-blind diagnostic cohort study were to explore the relationship between patients' reported symptoms of chronic rhinosinusitis (CRS) and radiographic findings in CRS to define clinically based diagnostic criteria for CRS and to determine a classification scheme that would allow for the accurate diagnosis of patients with CRS. METHODS A prospective series of adult patients undergoing evaluation for potential chronic rhinosinusitis was studied. Patients' symptoms were tabulated with the Rhinosinusitis Symptom Inventory (RSI), which records symptoms associated with CRS on a Likert scale (5 = maximally severe). Medication and resource utilization were also tabulated. Scores for nasal, facial, oropharyngeal, systemic, and total symptom domains were computed (100 = maximum severity). Concurrent paranasal sinus computed tomography was obtained for each patient and scored according to the Lund-McKay system with reviewer blinding. Patients were classified as normal or representing true CRS according to previously published diagnostic radiographic criteria under two analyses. In analysis 1, Lund scores < or = 1 were considered nondiseased and scores > or = 2 were considered as representing true CRS. In analysis 2, Lund scores < or = 3 represented normal and scores > or = 4 represented true CRS. For each analysis, univariate statistics were computed to determine differences among patients' reported symptoms with and without true CRS. Subsequently, classification analysis using classification regression trees was conducted to determine heuristics among clinically based criteria for the diagnosis of CRS. RESULTS Seven hundred three adult patients were enrolled (mean age, 43.1 years). The most commonly reported symptoms in order of decreasing severity and presence were nasal obstruction, nasal congestion, discharge, fatigue, headache, facial pressure, and dysosmia, all with mean severity scores > or = 2.0. Patients were previously treated for approximately 3 months each with topical nasal steroids, oral antihistamines, and oral antibiotics. Patients missed substantial workdays (mean, 3.8/year) and incurred significant physician visits (mean, 3.5/year) as a result of CRS. The nasal symptom domain exhibited the greatest severity (51.8) followed closely by the facial symptom domain (47.3). According to the analysis 1, 144 (20.5%) patients were classified as normal and 559 (79.5%) as true CRS. Only the presence of polyps (P < .001) and dysosmia (P = .008) distinguished between normal and diseased patients; there were no significant differences between groups for the other symptoms and RSI domains. Classification analysis revealed that the presence of polyps, absence of dental pain, and low congestion/obstruction scores in the presence of dental pain predicted true CRS. Finally, a history of extended antibiotic courses before presentation also predicted true CRS. In the second analysis, 243 (34.6%) were normal versus 460 (65.4%) with true CRS. Only polyp presence and dysosmia exhibited statistically significant differences between normal and diseased patients (P < .001). The mean RSI nasal domain was higher for true patients with CRS (P = .01). Classification analysis identified polyp presence and dysosmia score >2 effectively predicted CRS. Fatigue < or = 2, discharge < or = 4, and obstruction < or = 3 further predicted for CRS. Symptoms despite a > or = 5.5-week trial of nasal steroids also predicted CRS. Other major and minor symptoms, RSI domains, and resource factors failed to influence diagnostic classification. CONCLUSIONS The diagnosis of CRS based on symptom criteria is difficult because most symptoms (other than dysosmia) do not distinguish between radiographically normal and diseased patients. A classification scheme for CRS based on the presence or absence of polyps is valid. It is possible to classify patients with true CRS based on symptoms, but this requires complicated heuristics. Corroborating radiographic evidence should be required to establish the diagnosis of CRS before long periods of therapy or surgical intervention.
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Affiliation(s)
- Neil Bhattacharyya
- Division of Otolaryngology, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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Busaba NY, Shin HJ, Faquin WC. Correlation between middle turbinate and ipsilateral ethmoid histopathology in chronic rhinosinusitis. Otolaryngol Head Neck Surg 2006; 134:250-4. [PMID: 16455373 DOI: 10.1016/j.otohns.2005.10.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2005] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Study the concept of "rhinosinusitis" in patients with inflammatory paranasal sinus disease (IPSD). STUDY DESIGN AND SETTING Prospective case control series in a tertiary care facility. Twenty-two consecutive patients with IPSD without polyposis were enrolled. A partial middle turbinectomy and ethmoidectomy were performed and the histopathologic findings of the surgical specimens from the 2 sites was studied. The general degree of inflammation, epithelial thickening, and inflammatory cell count were measured. RESULTS The degree of middle turbinate inflammation correlated with that of the ipsilateral ethmoid sinus (Spearman's rho coefficient = 0.450; P < 0.05). Epithelial thickness was more prominent in the ethmoid sinus. The total inflammatory cell count was comparable. There was a statistically significant correlation among total inflammatory cell count, plasma cell count, and eosinophil count between the 2 sites. CONCLUSION The ethmoid sinus inflammation in IPSD is accompanied by a commensurate ipsilateral middle turbinate inflammation. SIGNIFICANCE The data support the use of the term "rhinosinusitis."
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Affiliation(s)
- Nicolas Y Busaba
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.
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Ponikau JU, Sherris DA, Kephart GM, Adolphson C, Kita H. The role of ubiquitous airborne fungi in chronic rhinosinusitis. Curr Allergy Asthma Rep 2006; 5:472-6. [PMID: 16216172 DOI: 10.1007/s11882-005-0028-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Chronic rhinosinusitis (CRS) is a confusing disease for both allergists and otorhinolaryngologists, partially due to its poorly understood pathophysiology and partially due to its limited treatment options. Several recent reports now provide evidence for a better understanding of the etiology and the relationship of CRS to airborne fungi, especially to Alternaria. First, the development of novel methods enables detection of certain fungi in mucus from the nasal and paranasal sinus cavities. Second, a non-immunoglobulin E-mediated immunologic mechanism for reactivity of CRS patients to certain common fungi has been described. Third, these fungi are surrounded by eosinophils in vivo, suggesting that they are targeted by eosinophils. Fourth, the preliminary results of studies using antifungal agents to treat patients with CRS are promising. Overall, these recent discoveries provide a logical mechanism for the pathophysiology of CRS, and they also suggest promising avenues for treatment of CRS with antifungal agents.
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Affiliation(s)
- Jens U Ponikau
- Department of Otorhinolaryngology, University at Buffalo, The State University of New York, 3C41 Millard Fillmore Hospital, 3 Gates Circle, Buffalo, NY 14209, USA.
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Sasama J, Sherris DA, Shin SH, Kephart GM, Kern EB, Ponikau JU. New paradigm for the roles of fungi and eosinophils in chronic rhinosinusitis. Curr Opin Otolaryngol Head Neck Surg 2005; 13:2-8. [PMID: 15654207 DOI: 10.1097/00020840-200502000-00003] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Chronic rhinosinusitis represents a challenge with its poorly understood pathophysiology and limited treatment options. Potential roles of fungi and eosinophils in the etiology and pathophysiology of chronic rhinosinusitis are summarized. RECENT FINDINGS Previously, the fungal role in chronic rhinosinusitis was limited to the rare subgroup, allergic fungal rhinosinusitis. Critical examination of earlier diagnostic criteria for allergic fungal rhinosinusitis reveals limitations. By using updated diagnostic standards and novel sensitive techniques to detect fungi, a higher number of patients can now be diagnosed with fungal rhinosinusitis. A novel non-IgE-mediated immunologic mechanism in chronic rhinosinusitis patients links the predominant eosinophilic inflammation to certain fungi. Overall, these new findings have implications for surgical and medical approaches, including anti-inflammatory and antifungal medications. SUMMARY Several classification schemes and diagnostic criteria describe chronic rhinosinusitis and make comparisons difficult. Preselection of patient groups within the chronic rhinosinusitis population and the lack of sensitive diagnostic techniques have prevented a full understanding of the syndrome complex of chronic rhinosinusitis. New results suggest a broader role for fungi in the pathophysiology of chronic rhinosinusitis, linking the eosinophilic inflammation to the presence of certain molds in the nasal and paranasal cavities. Although fungi are commonly found in nearly everyone, only chronic rhinosinusitis patients respond to them with an eosinophilic inflammation. These findings support a shift in the etiologic understanding of chronic rhinosinusitis away from a bacteriologic infectious pathogenesis to a fungal-driven inflammatory pathophysiology. Herein, the authors review earlier studies and describe an updated view on an old paradigm.
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Affiliation(s)
- Jan Sasama
- Department of Otorhinolaryngology, Mayo Clinic Rochester, Rochester, Minnesota 55905, USA.
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Abstract
The nasal cavity, paranasal sinuses, and lungs are considered separate organs of the respiratory tract. However, a growing body of evidence links the upper and lower airways. For example, the coexistence and impact of allergic and nonallergic rhinitis on asthma is now documented. In addition, inflammation of the nose (rhinitis) commonly is associated with inflammation of sinuses (sinusitis), as reflected in the term rhinosinusitis. In this paper, we review the impact of rhinosinusitis on asthma as it relates to the links between allergic and nonallergic rhinitis and asthma; viral upper respiratory tract infections and asthma; allergic and nonallergic infectious/inflammatory rhinosinusitis and allergic and nonallergic hyperplastic rhinosinusitis and asthma; and the aspirin-exacerbated respiratory disease syndrome and asthma.
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Affiliation(s)
- Roger W Fox
- Division of Allergy and Immunology, USF College of Medicine, James A. Haley Veterans Medical Center, 13000 Bruce B. Downs Boulevard,111D, Tampa, FL 33612, USA.
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Bhattacharyya N, Fried MP. The accuracy of computed tomography in the diagnosis of chronic rhinosinusitis. Laryngoscope 2003; 113:125-9. [PMID: 12514395 DOI: 10.1097/00005537-200301000-00023] [Citation(s) in RCA: 120] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the sensitivity, specificity, and diagnostic accuracy of paranasal sinus computed tomography (CT) in the diagnosis of chronic rhinosinusitis (CRS). STUDY DESIGN Prospective dual cohort study. METHODS One hundred seventy-one consecutive patients undergoing endoscopic sinus surgery for CRS were evaluated with CT and staged according to the Lund system. Histopathological findings from sinus specimens were reviewed and graded. A second contemporaneous control group of 130 patients undergoing CT of the sinus regions for other reasons but without a diagnosis of CRS was also staged. Sensitivity, specificity, and the receiver-operator characteristic were determined for the sinus CT in the diagnosis of CRS. Positive and negative predictive values were also computed. RESULTS In the disease-positive group of patients with CRS, the mean Lund score was 9.8 (95% confidence interval, 9.0-10.6). The mean inflammatory grade on histopathological study was 2.3 (range, 0-4). For the control group (without disease), the mean Lund score was 4.3 (95% confidence interval, 3.5-5.0). The AUC for the receiver-operator characteristic was 0.802 (P <.001). Selecting a Lund score cut-off value of greater than 2 as abnormal, the sinus CT exhibited sensitivity and specificity of 94% and 41%, respectively. Increasing the cut-off value to 4 changed the sensitivity and specificity to 85% and 59%, respectively. CONCLUSIONS The paranasal sinus CT scan exhibits good sensitivity and above-average specificity for the diagnosis of CRS. When added to the history and physical findings, CT may add to the diagnostic accuracy of CRS.
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Affiliation(s)
- Neil Bhattacharyya
- Division of Otolaryngology, Brigham and Women's Hospital, Boston, MA 02467, USA.
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