A rare case of Escherichia coli and Rhizopus sinusitis complicated with pneumocephalus, E. coli psoas abscess and sepsis

Sinusitis is a common ailment a clinician comes across in their day-to-day practice. Simple as it may sound, it may become a very debilitating condition depending on the comorbidities of the patient and the organism involved. Rhizopus and Escherichia coli are less common organisms to affect the sinuses, but they are more common in immunocompromised patients such as patients with uncontrolled diabetes. Rhizopus can be a very debilitating infection as it erodes into the bone and blood vessels resulting in tissue necrosis. However, coinfection of both of these organisms is a very rare occurrence. Psoas abscess is also a less common infection in the immunocompetent patients but it is more common among the immunocompromised patients. It is extremely rare for both of these organisms to cause sinusitis in one patient, and for E. coli to simultaneously infect two different sites in the same patient. We report a case where a diabetic patient who had E. coli and Rhizopus coinfected sinusitis with simultaneous E. coli psoas abscess was successfully managed. The Rhizopus was treated with liposomal amphotericin B for 16 weeks while E. coli was treated with IV Meropenum. Furthermore, pneumocephalus is a condition that usually occurs following head trauma but the patient we are reporting developed pneumocephalus following Rhizopus sinusitis, which was treated with high-flow oxygen.

The incidence of anaerobic bacteria in adult patients with chronic sinusitis: A prospective, single-centre microbiological study

INTRODUCTION

Chronic sinusitis caused by anaerobes is a particular concern clinically, because many of the complications are associated with infections caused by these organisms. The aim of this study was to evaluate the incidence of anaerobic bacteria in chronic sinusitis in adults as a part of a prospective microbiological study.

MATERIALS AND METHODS

Over a one-year period, aspirations of maxillary sinus secretions and/or ethmoid cavities were derived in n = 79 adult patients with chronic sinusitis by endoscopy in a tertiary-care teaching hospital in Hungary. The qualitative and quantitative compositions of the total cultivable aerobic and anaerobic bacterial and fungal flora cultured on the samples were compared. Correct anaerobic species level identifications were carried out according to standard methods.

RESULTS

Bacteria were recovered for all of the 79 aspirates and the numbers of the significant cultured isolates (with colony forming units ≥103) were between 1 and 10. A total of 206 isolates, 106 anaerobic and 100 aerobic or facultative-anaerobic strains were isolated. The most common aerobic bacteria were Streptococcus pneumoniae (n = 40), Haemophilus influenzae (n = 29), Moraxella catarrhalis (n = 6), Staphylococcus aureus (n = 7) and Streptococcus pyogenes (n = 6). The anaerobic bacteria included black-pigmented Prevotella spp. and Porphyromonas spp. (n = 27), Actinomyces spp. (n = 13), Gram-positive anaerobic cocci (n = 16), Fusobacterium spp. (n = 19) and Cutibacterium acnes (n = 8).

CONCLUSIONS

This study illustrates the microbial dynamics in which anaerobic and aerobic bacteria prevail and highlights the importance of obtaining cultures from patients with chronic sinusitis for guidance in selection of proper antimicrobial therapy.

Intraoperative bacterial analysis in nasal polyposis: Clinical and functional impact

BACKGROUND

The impact of Staphylococcus aureus on onset of nasal polyposis has been the focus of numerous studies, but there have been few studies of other germs found in the ethmoid of operated patients or of their impact on post-operative results.

MATERIAL AND METHODS

All patients undergoing endoscopic radical ethmoidectomy for nasal polyposis in the teaching hospital of Nantes (France) between 2006 and 2016 had intraoperative ethmoid cavity bacterial sampling. Phenotypic characteristics, pre- and post-operative symptoms and endoscopic findings were analyzed. Mann-Whitney tests and Kruskal-Wallis correlation analysis were used to assess clinical/bacteriological correlations.

OBJECTIVES

The main objective was to describe bacterial colonization of patients undergoing surgery for nasal polyposis, and to assess correlations with phenotypic features, functional results and postoperative clinical course.

RESULTS

One hundred and seven patients were included. A total of 26% were not infected, 55% mono-infected and 19% multi-infected. In 27.3%, staphylococci were isolated; in 30.5%, isolates were gram-negative bacilli. There were no significant correlations between presence or type of pathogen and symptom profile.

CONCLUSION

This study confirmed the high rate of pathogenic bacteria in nasal cavities in case of polyposis, with high frequencies of S. aureus but also of gram-negative bacilli, raising the question of their involvement in the inflammatory reactions underlying the nasal polyposis.

Microbiology of the Maxillary Sinus in Adults with Chronic Sinus Disease

Antimicrobial therapy is a part of the care of patients with chronic sinus disease (CSD), but the etiologic role of microorganisms in this condition is unclear. Twenty patients with CSD undergoing functional endoscopic sinus surgery who had been off antibiotics for at least 1 week before surgery had a maxillary sinus aspirate for quantitative culture for aerobic bacteria and fungi and a semiquantitative culture from the antrostomy of the same maxillary sinus during endoscopic surgery. Six (30%) of the patients had infection of the maxillary sinus diagnosed by the presence of ≥ 103 cfu/mL of organisms in the sinus aspirate (Haemophilus influenzae in two patients and one patient each with Moraxella catarrhalis, α-streptococcus, mixed oropharyngeal flora, or Alternaria sp.). All antrostomy specimens obtained by nasal endoscopy during surgery were positive, but the antrostomy cultures did not correlate with the sinus aspirate cultures from the same sinus. Staphylococcus aureus and/or Gram negative rods in eight antrostomy cultures did not predict the presence of these pathogens in any of the maxillary sinus aspirates. Conversely, the bacteria detected with the quantitative aspirate culture in five of the six infected sinuses were not found in the antrostomy specimen; only the fungal sinus infection correlated with the antrostomy culture. Infection of the maxillary sinuses occurred in patients with both limited and severe disease by CT imaging. About one third of patients with CSD necessitating surgery had microbial infection of the maxillary sinus, but antrostomy cultures obtained via endoscopy did not predict the organisms infecting the sinus.

Endoscopically Guided Aerobic Cultures in Postsurgical Patients with Chronic Rhinosinusitis

Background

There is considerable amount of debate in the literature regarding the microbial flora of normal, acutely infected, and chronically infected paranasal sinuses. Few studies have specifically looked at the microbial flora of healthy and infected sinus cavities after functional endoscopic sinus surgery.

Methods

One hundred thirty-four cultures were studied. All cultures were obtained using a standard technique. The nasal cavities were decongested and anesthetized, and nasal endoscopy was performed. When purulent secretions were identified, specimens of purulent secretions were obtained for incubation. Sensitivities were tested according to microorganisms identified. Empiric therapy generally consisted of a fluoroquinolone, amoxicillin/clavulanate, or a later-generation cephalosporin, and adjustment in individual instances when appropriate.

Results

Twelve cultures showed no growth, 86 grew a single microorganism, and 35 grew two or more microorganisms for a total of 151 microorganisms identified. The most common microorganisms were Staphylococcus aureus, coagulase-negative staphylococci, and Pseudomonas aeruginosa. Other organisms that were cultured <5% of the time included Streptococcus pneumoniae, Haemophilus influenza, Moraxella catarrhalis, Serratia liquefaciens, Stenotrophomonas (Xanthomonas) maltophilia, alcaligenes, Fusobacterium, Escherichia coli, diphtheroids, Acinetobacter species, Klebsiella species, skin flora, and mixed Gram-negative and Gram-positives.

Conclusion

Endoscopically guided aerobic cultures in postsurgical patients with acute exacerbations of chronic rhinosinusitis most commonly grew S. aureus, coagulase-negative staphylococci, and pseudomonal species. These cultures altered antibiotic treatment management decisions in a significant number of cases regardless of patients’ clinical characteristics or history of previous culture.

Microbiology of Middle Meatus in Chronic Rhinosinusitis

Background

Nasal endoscopy allows the collection of middle meatus secretion samples and is an alternative method for determining microorganisms in rhinosinusitis. This study assessed endoscopically collected middle meatus secretions in patients with chronic rhinosinusitis (CRS) and compared those findings with ipsilateral maxillary sinus aspirates and microbiological data of healthy individuals.

Methods

Middle meatus samples were collected from 114 CRS patients for aerobic, anaerobic, and fungal cultures; maxillary sinus secretions were collected from 13 of these patients. Twenty-three healthy volunteers served as controls.

Results

Aerobes were isolated in 86% of CRS patients, anaerobes were isolated in 8% of CRS patients, and fungi were isolated in 11% of CRS patients; the most frequent microorganisms were Staphylococcus aureus (36%), coagulase-negative Staphylococcus (20%), and Streptococcus pneumoniae (17%). Middle meatus and maxillary sinus cultures presented the same pathogens in 80% of cases. In healthy individuals, coagulase-negative Staphylococcus (56%), S. aureus (39%), and S. pneumoniae (9%) were the most frequent isolates.

Conclusion

The culture of endoscopically collected middle meatus secretions is effective in identifying microorganisms in CRS patients.

[Epithelial dysfunction associated with pyo-inflammatory diseases of the ENT organs]

The modern concept of epithelial-endothelial dysfunction and epithelial-endothelial distress-syndrome associated with pyo-inflammatory ENT diseases is presented. It has provided a basis for the analysis of the initial stages of etiopathogenesis of acute and chronic inflammation in the ENT system including the mucous and associated lymphoid tissues as well as the Pirogov-Waldeyer limphopharyngeal ring making up the first protective barrier. The leading role of dysbiosis of synanthropic microflora and endotoxins of the Gram-negative bacteria in the mechanisms of regional responsiveness of the organism to the infection and chronic endotoxic aggression is demonstrated. The regional and synthetic mechanisms underlying the interaction between the external and internal media of the organism are subjected to the analysis with special reference to those operating in epithelium. The possible variants of the outcome of these processes are considered including both the recovery and the development of chronic inflammation. It has been proved that the exhaustion of the internal reserves for the stabilization of the epithelium-associated lymphoid tissue system including the Pirogov-Waldeyer limphopharyngeal ring leads to the formation of epithelial dysfunction as the initial stage of epithelial-endothelial dysfunction and epithelial-endothelial distress-syndrome. It is concluded that the modern concept of epithelial-endothelial dysfunction and epithelial-endothelial distress-syndrome is a fundamental interdisciplinary phenomenon.

Endoscopically guided sinonasal cultures: A direct comparison with maxillary sinus aspirate cultures

Sinusitis is a common medical problem that can at times be challenging to treat. Although most cases respond to empiric therapy, success is not achieved universally. If empiric therapy fails, it is important to identify the causative bacterial pathogen. Antral puncture is the traditional diagnostic method to recover and identify pathogens in sinusitis; however, it remains a painful, invasive test with potential complications. In contrast, rigid sinonasal endoscopy permits recovery of mucopus emanating from the sinus ostia with little pain and few possible complications. Endoscopy also affords important visual information that can confirm or refute a historical/clinical diagnosis of sinusitis. Although previous studies have shown poor correlation between nasal cavity swab cultures and maxillary sinus aspiration cultures, few investigations have compared endoscopically guided middle meatal cultures with cultures obtained from maxillary sinus aspiration. Thirteen patients with maxillary sinusitis in one or both sinuses underwent endoscopically guided culture of the middle meatus and maxillary sinus puncture with aspiration and culture (16 total study samples). Results from the microbiologic analysis were compared. Endoscopically guided middle meatal cultures accurately identified the predominant bacterial pathogen and correlated with the cultures from maxillary sinus aspiration in more than 90% of infections. These preliminary results suggest that endoscopically guided sinonasal cultures hold promise as a viable alternative to maxillary sinus aspiration. Endoscopically guided cultures appear to be an effective, noninvasive diagnostic tool for otolaryngologists managing sinusitis.

Bacteriology of the Middle Meatus in Chronic Rhinosinusitis with and without Polyposis

There are only limited data in the literature, and none specifically from the Middle East, on the pathogenic bacteria in chronic rhinosinusitis (CRS) as opposed to healthy nasal cavities and their association with disease severity. The present study was conducted in the department of head and neck surgery of a tertiary medical center. Middle meatal swabs were taken preoperatively from patients with CRS with nasal polyposis (CRSwNP) (n = 60), CRS without nasal polyposis (CRSsNP) (n = 50), and control patients with septal deviation (n = 26) or no nasal abnormalities (n = 27). Culture findings were compared among the groups and correlated with CRS severity. Positive pathogenic culture rates were 78% in the CRSwNP group and 64% in the CRSsNP group. Twenty pathogenic bacterial species were identified; the most common was Staphylococcus aureus (27%). The most common Gram-negative isolate was Citrobacter spp. (17%). Gram-negative species were significantly more prevalent in the CRSwNP group than the others. Mean Lund-Mackay scores were 12.8 in the CRSwNP group and 6.9 in the CRSsNP group, and were unrelated to the culture findings. Positive culture rates were significantly higher in the septal deviation (54%) than the nasal healthy group (26%), although both values were significantly lower than in the CRS groups. In conclusion, patients with CRS have higher rates of bacterial isolates than patients without CRS. CRSwNP is associated with more Gram-negative bacteria than CRSsNP, regardless of disease severity. The relatively high positive culture rate in patients with septal deviation merits investigation.

Etiology, diagnosis and management of chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a common health care problem, yet many aspects of this diagnosis remain poorly understood. Its etiology is often debated and remains a significant area of research. The diagnosis of CRS is based on subjective symptoms, duration of symptoms and objective evidence of inflammation. Each of these criteria must be met to make a diagnosis of CRS. Management of CRS often involves a combination of systemic and topical therapies with surgery reserved for patients who fail medical therapy. This review provides a comprehensive view of the etiology, diagnosis and management of CRS.

Correlation between culture-identified bacteria in the middle nasal meatus and CT score in patients with chronic rhinosinusitis

The aim of this study was to compare bacteriological findings in the middle nasal meatus in patients with chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP) and without nasal polyps (CRSsNP) and healthy controls, and to investigate the correlation between the prevalence of culture-identified bacteria and the severity of sinus disease. Bacterial culture was performed using a swab from the middle nasal meatus under endoscopic control in 72 patients with CRSwNP, 25 patients with CRSsNP and 59 healthy controls. Computed tomography (CT) scans were graded for severity using the Lund-Mackay scoring system. Patients with more severe forms of CRS with and without nasal polyps had significantly higher rates of pathogenic bacteria in the middle nasal meatus compared with patients with lower CT scores of the paranasal sinuses. There were no significant differences in bacterial species among CRSwNP, CRSsNP and control patients. These results demonstrate, for the first time, that colonization by pathogenic bacteria in patients with CRSwNP and CRSsNP is associated with a more severe form of the disease, as assessed by a pre-operative CT scan of the paranasal sinuses. The results suggest a role for bacterial infection in the pathogenesis of CRS. However, bacteria do not appear to play a role in the development of nasal polyposis in patients with CRS.

Bacteriology and antibiotic resistance in chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a prevalent health care problem that may be commonly encountered in patients desiring aesthetic or reconstructive rhinoplasty. The purpose of this article is to review the common bacterial pathogens associated with CRS, as well as patterns of bacterial resistance in this patient subset. Close understanding of microbial pathogens involved in CRS and their associated resistance patterns will guide facial plastic surgeons in optimally managing this important potential comorbidity, and in turn positively influence the outcome of rhinoplasty.

Anaerobic bacteria in upper respiratory tract and head and neck infections: microbiology and treatment

Anaerobes are the predominant components of oropharyngeal mucous membranes bacterial flora, and are therefore a common cause of bacterial infections of endogenous origin of upper respiratory tract and head and neck. This review summarizes the aerobic and anaerobic microbiology and antimicrobials therapy of these infections. These include acute and chronic otitis media, mastoiditis and sinusitis, pharyngo-tonsillitis, peritonsillar, retropharyngeal and parapharyngeal abscesses, suppurative thyroiditis, cervical lymphadenitis, parotitis, siliadenitis, and deep neck infections including Lemierre Syndrome. The recovery from these infections depends on prompt and proper medical and when indicated also surgical management.

Bacteriologic evaluation of sinus aspirates taken by balloon catheter devices in chronic rhinosinusitis: preliminary study

PURPOSE

Chronic rhinosinusitis (CRS) is known to be a polymicrobial infection involving both aerobes and Gram-positive and Gram-negative anaerobes. Accurate bacterial evaluation by adequate culture methods can justify subsequent antimicrobial strategies.

METHODS

Two specimens were obtained from each of 10 patients undergoing catheter-based Balloon Sinuplasty™, one from the middle meatus (endoscopic approach) and the other from the sinus (catheter-based approach).

RESULTS

The bacterial culture from the middle meatus was positive in 9 of 10 patients, including 6 different aerobes without anaerobes. The bacterial culture of aspirates from the sinuses were positive in 8 out of 10 patients, with 4 different aerobic bacteria and 4 different anaerobic bacteria. Anaerobes were isolated in 0% of middle meatus samples, which was significantly lower than the 62.5% (5/8) detected in the sinus samples.

CONCLUSIONS

Bacterial culture of sinus aspirates using a catheter-based technique improves the recovery of bacterial pathogens from CRS patients.

The role of Stenotrophomonas maltophilia in refractory chronic rhinosinusitis

BACKGROUND

Stenotrophomonas maltophilia is a multidrug-resistant Gram-negative bacillus that has been implicated in serious nosocomial infections. This microbe has also been isolated from sinus cultures in refractory chronic rhinosinusitis (CRS). The goal of this study was to elucidate the implications of S. maltophilia-positive cultures in the setting of CRS. The objectives of the study were (1) to define clinical and microbiological characteristics and (2) to assess management strategy and overall outcomes of S. maltophilia-positive sinus cultures in CRS patients.

METHODS

A retrospective review was performed of 101 patients over a 5-year period.

RESULTS

The mean age was 56.9 years with a female/male ratio of 1.1:1. Previous sinus surgery had been performed in 90.1% of patients. Greater than 97% of patients had been given antibiotics in the previous 6 months. The most common presenting symptom was discolored nasal drainage (76.2%) with endoscopic evidence of pus or crusting in 83.2% of cases. Monotherapy with trimethoprim sulfamethoxazole (TMX) or fluoroquinolones was used in 41 and 26%, respectively. This intervention resulted in overall symptom and endoscopic improvement in 70% of cases.

CONCLUSION

The presence of S. maltophilia isolates on culture are associated with clinically relevant symptoms and endoscopic findings in patients with refractory CRS. Despite its multidrug-resistant nature, monotherapy with TMX or fluoroquinolones appears to be effective in providing patients with bacterial infection with symptom relief in a majority of cases.

Bacteriology of the middle meatus aspirate in patients with cystic fibrosis

The combination of factors, such as abnormal viscosity of the paranasal sinus secretions, decreased sinus drainage, and impaired mucociliary clearance may account for the establishment of a suitable and opportune environment for the colonization of bacteria in the paranasal sinuses of patients with cystic fibrosis.

Aim

The goal of the present study was to assess the bacteriology of the middle meatus aspirate in patients diagnosed whit cystic fibrosis.

Material and Methods

Through a cross-sectional prospective study, a sample consisting of 23 patients evaluated for 2 years, was assessed. Firstly, we established the relationship between the middle meatus culture and the maxillary sinus x-ray. In second, we studied the relationship between the middle meatus aspirate bacteriology and the sputum bacteriology.

Results

In total, 42 aspirates of the middle meatus were carried out. In 17 (73.91%) of the 23 patients, the aspirates were negative; and in 6 (26.08%) they were positive. Out of the 42 aspirates, 31 (78.8%) were negative, and 11 (26.2%) were positive. The presence of Pseudomonas aeruginosa was observed in 18.18% of the positive cultures, and Staphylococcus aureus was observed in 27.28%.

Conclusion

The great majority of the middle meatus aspirates of the patients with cystic fibrosis were negative.

Microbiologia do meato médio na rinossinusite crônica

Este foi um estudo prospectivo que visou identificar a microbiologia do meato médio em pacientes com rinossinusite crônica (RSC) e compará-la com a de indivíduos sadios. MATERIAL E MÉTODOS: Foram incluídos 134 pacientes RSC e 50 voluntários sadios, que constituíram o grupo controle. As amostras foram coletadas endoscopicamente e submetidas a exames pelo método de Gram com contagem leucocitária e culturas para aeróbios, anaeróbios e fungos. RESULTADOS: Nos pacientes com RSC foram cultivados 220 microorganismos, dentre os quais os mais freqüentes foram o Staphylococcus aureus, presente em 31% das amostras, e o Staphylococcus coagulase-negativo (SCN) em 23%. Gram-negativos ou facultativos foram isolados em 37% das amostras, anaeróbios em 12%, e fungos em 14%. Ao exame bacterioscópico evidenciou-se alguns ou numerosos leucócitos em 74% das amostras com culturas positivas. Nos indivíduos sadios o SCN foi isolado em 40% das amostras e o Staphylococcus aureus em 18%. Em 12% dos indivíduos a cultura para fungos foi positiva, e o exame direto negativo. Todas as culturas anaeróbias foram estéreis. Quanto à contagem leucocitária todos apresentaram nenhum ou raros leucócitos. CONCLUSÃO: Os grupos apresentaram resultados semelhantes quanto à microbiologia, entretanto, diferiram em relação à contagem leucocitária, o que auxilia na diferenciação um microorganismo infectante de um colonizante.

Bacteriologia do aspirado do meato médio em pacientes com fibrose cística

A combinação de fatores como viscosidade das secreções dos seios paranasais, diminuição da drenagem sinusal e comprometimento do transporte mucociliar podem ser responsáveis pela criação de um ambiente propício e adequado para a colonização de bactérias nos seios paranasais de pacientes com fibrose cística. OBJETIVO: Analisar a bacteriologia do aspirado do meato médio de pacientes portadores de fibrose cística. MATERIAL E MÉTODO: Através de um estudo prospectivo de delineamento transversal, avaliou-se uma amostra composta de 23 pacientes, avaliados durante 2 anos. Realizaram-se relações entre a cultura do meato médio e a avaliação radiológica do seio maxilar e a avaliação clínica. Secundariamente, estudou-se a relação da bacteriologia do aspirado do meato médio e a do escarro. RESULTADOS: No total foram realizadas 42 aspirações do meato médio. Em 17 (73,91%) dos 23 pacientes, as culturas foram negativas e, em 6 (26,08%), positivas. Das 42 aspirações, 31 (73,8%) foram negativas e 11 (26,2%), positivas. A presença de Pseudomonas aeruginosa foi observada em 18,18% das culturas positivas e o Staphylococcus aerus em 27,28%. CONCLUSÃO: A maioria das culturas do aspirado do meato médio de pacientes com fibrose cística foi negativa.

Microbiology of middle meatus in chronic rhinosinusitis

This was a prospective study which assessed endoscopically collected middle meatus secretions in patients with chronic rhinosinusitis (CRS) and compared those findings with microbiological data of healthy individuals.

METHODS

Middle meatus samples were collected from 134 CRS patients. In the laboratory, samples were Gram stained for microscopic examination with white blood cels (WBCs) count and also send for aerobic, anaerobic and fungal cultures. Fifty volunteers served as control.

RESULTS

In CRS patients a total of 220 microorganisms were isolated. The most frequent microorganisms were Staphylococcus aureus (31%), coagulase-negative Staphylococcus (CNS) (23%). Gram-negative or facultative microorganisms were isolated in 37% of the samples, anaerobes in 12% and fungi in 14%. Seventy four percent of the samples with positive cultures presented many or few WBC. In the control group, 76% of cultures were positive for aerobes and 12% for fungi. No anaerobes were isolated. There were rare or no WBC in the fifty samples. The most frequent microorganisms were CNS (40%), Staphylococcus aureus (18%).

CONCLUSION

The microbiology of the middle meatus is similar in CRS patients and healthy individuals. Despite this, there was an important difference between the WBC count in these two groups, which helps to distinguish an infective from a saprophitic microorganism.

Microbiology of the Maxillary and Ethmoid Sinuses in Patients with Chronic Rhinosinusitis Submitted to Functional Endoscopic Sinus Surgery

Chronic rhinosinusitis microbiology studies show the presence of aerobe and anaerobe microorganisms, fungus and virus and their incidence vary according to each study. These studies guide us on choosing the most adequate antimicrobial agent to eliminate the infectious process, thus, helping in restoring rhinosinusal mucosa. Study design: Clinical prospective. Aim: This work aimed at studying the microbiology of the maxillary and/or ethmoid sinuses of patients with chronic rhinosinusitis and with indication of functional endoscopic sinus surgery. Materials and methods: During surgery, we collected secretion and/or fragments of maxillary and/or ethmoid sinus mucosa from 41 patients to perform Gram stain, fungus direct research, aerobe and anaerobe microorganism culture and fungus culture. Results: We identified the presence of aerobe microorganisms in 21 patients (51.2%), anaerobe microorganisms in 16 (39%) and fungus in 1 (2.4%). In the studied population, only 12 patients (29.2%) presented microorganisms considered pathogenic when analyzed together with the semi-quantitative leukocyte count. Staphylococcus coagulase-negative and Staphylococcus aureus were the most frequent microorganisms found, in 5 (12.18%) and in 4 (9.75%) patients respectively. Conclusion: This study reveals that Staphylococcus coagulase-negative and Staphylococcus aureus were the most frequent microorganisms isolated from patients with chronic rhinosinusitis.

The role of bacteria in chronic rhinosinusitis

Sinusitis generally develops as a complication of viral or allergic inflammation of the upper respiratory tract. The bacterial pathogens in acute sinusitis are S. pneumoniae, H. influenzae, and M. catarrhalis, while anaerobic bacteria and S. aureus predominant in CRS.

Chronic sinusitis in children and adults: role of bacteria and antimicrobial management

The nasopharynx serves as the reservoir for anaerobic bacteria as well as pathogenic bacteria that can cause respiratory infections including sinusitis. Some of these organisms possess the ability to interfere with the growth of potential pathogens and may play a role in preventing infections. Anaerobic bacteria emerge as pathogens as the infection becomes chronic. This may result from the selective pressure of antimicrobial agents that enable resistant anaerobic organisms to survive, and from the development of conditions appropriate for anaerobic growth, which include the reduction in oxygen tension and an increase in acidity within the sinus. Anaerobes were identified in chronic sinusitis in adults and children whenever techniques for their cultivation were employed. The predominant isolates were pigmented Prevotella, Fusobacterium, and Peptostreptococcus spp. The choice of antimicrobial agent in chronic sinusitis should provide coverage for the usual pathogens in acute sinusitis as well as beta-lactamase-producing aerobic and anaerobic organisms.

The role of anaerobic bacteria in sinusitis

The normal oropharyngeal flora contained aerobic and anaerobic bacteria that can cause respiratory infections including sinusitis. Some of these bacteria can interfere with the growth of potential pathogens and may play a role in preventing infections. Anaerobic bacteria emerge as pathogens as the infection becomes chronic. This may be the result of the selective pressure of antimicrobial agents that enable resistant anaerobic organisms to survive, and from the development over time of conditions appropriate for anaerobic growth, which include the reduction in oxygen tension and an increase in acidity within the sinus cavity. Anaerobes were isolated in acute maxillary sinusitis of odontogenic origin and in over half of the patients with chronic sinusitis whenever proper techniques for their cultivation were employed. These organisms were also recovered in acute sinusitis that was associated with dental infections. The predominant isolates were pigmented Prevotella and Porphyromonas, Fusobacterium and Peptostreptococcus spp.

Prevalence of pus in radiologically diseased sinuses in patients undergoing surgery for chronic rhinosinusitis

OBJECTIVE

To establish the prevalence of pus in radiologically diseased sinuses in patients undergoing sinus surgery and to correlate this with the bacterial load in the sinuses.

STUDY DESIGN AND SETTING

A prospective study performed on adult patients with the diagnosis of chronic sinusitis undergoing endoscopic sinus surgery at an Adelaide group of academic hospitals. In 45 consecutive and unselected patients, a radiologically diseased sinus was surgically opened, and a specially designed suction aspirator was placed into the sinus under endoscopic control. These aspirates were Gram stained and cultured to quantify the polymorphonuclear neutrophil count, bacterial flora, and bacterial colony count. The CT scans of all patients were graded by using the Lund-Mackay scoring system.

RESULTS

A variety of bacteria, most commonly staphylococci, were cultured from a radiologically diseased sinus in 88% of patients. There was no correlation between the bacterial colony count and presence of pus, and only 11% of patients had microscopic evidence of inflammation in sinus aspirates. There was no correlation between the Lund-Mackay CT score and the presence of pus in the sinus.

CONCLUSIONS

The majority of patients undergoing surgery for chronic sinusitis did not have a purulent exudate, and there was no correlation with the bacterial load. The usefulness of antibiotics in the treatment of chronic rhinosinusitis, in the absence of macroscopic pus, is questionable.

The microbiology and antimicrobial resistance patterns in chronic rhinosinusitis

OBJECTIVES

The purpose of this study was to review the microbiology of chronic rhinosinusitis (CRS) in patients undergoing endoscopic sinus surgery (ESS) and comment on antimicrobial resistance trends.

METHODS

A retrospective review of 101 patients undergoing ESS during the period of 1997 to 2001 was performed. Patients were divided into groups based on their surgical history. Fifty-five patients without prior ESS history were placed in the primary group; 46 patients who had undergone prior ESS were placed in the revision group. Intraoperative microbiology culture data were reviewed and antimicrobial resistance data analyzed.

RESULTS

Data on 101 patients were analyzed. There were 182 total cultures sent, yielding 257 isolates. The most common isolates were coagulase-negative Staphylococcus (SCN) (45% of cultures), gram-negative rods (25% of cultures), and Staphylococcus aureus (24% of cultures). Pseudomonas aeruginosa was isolated in 9% of cultures. When comparing the 2 patient groups, we did not find consistent trends in the differences in the prevalence of these isolates. Antimicrobial resistance for SCN (P = .01) and S aureus (P < .001) was greater in the revision surgery. Overall, 62% of patients were found to have at least 1 isolate with decreased antibiotic sensitivity.

CONCLUSION

The most prevalent microorganisms in patients with CRS are SCN, S aureus, and gram-negative rods. Perhaps more importantly, the antimicrobial sensitivities of these microorganisms appear to be a growing problem. These findings suggest increased antimicrobial resistance in patients undergoing revision ESS when compared with patients undergoing surgery for the first time.

Bacterial Infection After Endoscopic Sinus Surgery: A Controlled Prospective Study

OBJECTIVES/HYPOTHESIS

The objective was to determine whether infections occurring after endoscopic sinus surgery represent overgrowth of sinonasal flora versus de novo bacterial infection.

STUDY DESIGN

Prospective controlled cohort study.

METHODS

A cohort of adult patients was prospectively followed after endoscopic sinus surgery. Baseline postoperative control cultures of the ethmoid sinus were obtained. Patients with acute infectious exacerbations of chronic rhinosinusitis had endoscopic culture, and these results were compared with baseline culture data.

RESULTS

One hundred thirteen patients were followed for a mean period of 14.5 months after endoscopic sinus surgery. Baseline postoperative culture data revealed that the ethmoid labyrinth was sterile in 23% of cases, carried oral flora in 18% of cases, and was colonized in 60% of cases. Gram-positive cocci, particularly staphylococcal species, were the most common colonizing organisms (41% of cases). Twenty acute exacerbations were cultured in 17 patients during the follow-up period. All infectious cultures recovered bacteria; one culture recovered only oral flora. Gram-positive cocci predominated (56% of isolates) with Staphylococcus aureus being the most common isolate (28%). Of the 36 isolates, only 9 isolates (25%) corresponded to bacteria identified at the time of baseline culture.

CONCLUSION

Although the postoperative sinonasal cavity may be colonized by bacteria after endoscopic sinus surgery, infections arising postoperatively most commonly represent de novo infections by bacteria other than colonizing bacteria. Empirical therapy based on baseline data may be misleading; acute exacerbations of chronic rhinosinusitis after endoscopic sinus surgery should be cultured to guide optimal antibiotic therapy.

The role of infection in chronic rhinosinusitis

Chronic rhinosinusitis is a common condition, yet little is understood about its pathogenesis. Chronic infection traditionally has been considered a significant factor in the etiology and manifestations of chronic rhinosinusitis. Bacteria can be recovered in most cases of chronic rhinosinusitis, most commonly consisting of Staphylococcus species, anaerobes, and in some cases, gram-negative bacteria. Increasing trends toward bacterial resistance have been identified in chronic rhinosinusitis. Recently, a potential role for fungal infection has emerged. A knowledge of the microbiology of chronic rhinosinusitis will help guide treatment, but more research is required to understand further the exact role of infection in the pathophysiology of chronic rhinosinusitis.

Maxillary sinus puncture and culture in the diagnosis of acute rhinosinusitis: the case for pursuing alternative culture methods

OBJECTIVE

Traditional assessments of the microbial flora associated with acute bacterial rhinosinusitis have relied on maxillary sinus punctures (taps) and culture. These taps are now considered the gold standard for obtaining cultures and are used as the method of identifying bacterial pathogens in antimicrobial trials. Maxillary sinus taps are limited by discomfort to the patients and technical concerns. Because of these factors, the standard of performing taps has limited antibiotic trials and microbial surveillance. Alternatives to maxillary sinus taps have been explored.

STUDY DESIGN

We conducted a retrospective, systematic review of the literature from 1950 to 2000 of articles comparing culture techniques in the nose and paranasal sinuses for acute bacterial rhinosinusitis.

RESULTS

Nasal cultures have poor correlation to maxillary sinus cultures, whereas there is 60% to 85% concordance between endoscopically guided middle meatal cultures and maxillary sinus cultures. These studies, however, are all limited by small sample sizes and therefore are inadequate to make any concrete recommendations regarding the relative role of endoscopically guided middle meatal cultures as a formal method of pathogen identification in acute bacterial rhinosinusitis.

CONCLUSION

A formal prospective study with sufficient sample size to assess the concordance between the microbial flora of the maxillary sinus punctures and middle meatal cultures in acute rhinosinusitis is recommended.

Contemporary trends in microbiology and antibiotic resistance in otolaryngology

OBJECTIVE

to determine current microbiologic yields and characterize antibiotic resistance patterns for organisms cultured from head and neck infections.

METHODS

results of out-patient cultures submitted from an academic otolaryngology practice over the period 1994-1998 were reviewed. A database was constructed, and culture results were analyzed for sites of infection, organism recovery rate, infecting microbiological agent, antibiotic resistance patterns, and 5-year trends. chi(2) analysis was used to determine associations between site of infection, infecting agent and antibiotic resistance over the years of the study.

RESULTS

a total of 986 aerobic cultures were reviewed. The most common sites cultured were the nose/paranasal sinuses (469), throat (377), and ear (23). In 465 (47.2%) cultures, normal flora or no growth occurred. Of the throat culture subset, 69.7% were negative, whereas 69.1% of sinonasal cultures recovered organisms. Gram positive cocci were the most commonly recovered organism type (30.9%), followed by Gram negative rods (GNR, 17.2%). These rates remained relatively constant over the years of the study. GNR were found in 39.1 and 25.2% of ear and sinus cultures, respectively. Antibiotic sensitivities were conducted on 257 specimens (49.3% of positive cultures). The average number of antibiotic resistances per bacteria remained stable at approximately 1.59 over the years (P=0.086, analysis of variance (ANOVA)). Antibiotic resistance rates increased for clindamycin, cefazolin, and erythromycin over the years of the study (P<0.05, chi(2)). Ciprofloxacin, gentamicin and trimethoprim-sulfamethoxazole resistance rates did not increase over the years of the study. Vancomycin resistance did not occur.

CONCLUSIONS

as a significant proportion of head and neck cultures will be negative, their utility should be re-examined. GNR infections are more common in the head and neck than earlier thought. There is a trend towards increasing antibiotic resistance in head and neck infections, urging careful and appropriate use of antibiotics.

Correlation between microbiology and previous sinus surgery in patients with chronic maxillary sinusitis

Aspirates of 108 chronically inflamed maxillary sinuses were processed for aerobic and anaerobic bacteria. There were 295 bacterial isolates: 109 aerobic and facultative, and 186 anaerobic. The predominant aerobic isolates were Staphylococcus aureus (17 isolates), alpha-hemolytic streptococci (14), Pseudomonas aeruginosa (12), Moraxella catarrhalis (10), and Haemophilus spp (8). The predominant anaerobes were Peptostreptococcus spp (61), Prevotella spp (45), Fusobacterium spp (15), and Propionibacterium acnes (14). Analysis of the medical histories revealed a correlation only between the microbial results and previous sinus surgery. Pseudomonas aeruginosa and gram-negative aerobic bacilli (GNAB) were more often isolated in patients who had surgery (9 of 33 patients had P aeruginosa and 17 had GNAB) than in patients who did not have surgery (3 of 75 had P aeruginosa and 7 had GNAB; p < .001). Anaerobes were isolated more often in patients who did not have surgery (69 of 75 patients) than in those who had previous surgery (21 of 33 patients; p < .001). These findings illustrate the unique microbiological features of chronic maxillary sinusitis that persist after sinus surgery.

Interleukin-1 beta, interleukin-5, interleukin-6, interleukin-8, and tumor necrosis factor-alpha in chronic sinusitis: response to systemic corticosteroids

Recently, the role of various cytokines in the pathogenesis of chronic rhinosinusitis has come under investigation. Various studies have reported increased levels of interleukin-3, interleukin-4, interleukin-5, interleukin-13, and granulocyte macrophage-colony stimulating factor in the sinonasal mucosa of patients with chronic rhinosinusitis. The present study investigated the levels of pro-inflammatory cytokines, including interleukin-1 beta (IL-1 beta), interleukin-5 (IL-5), interleukin-6 (IL-6) interleukin-8 (IL-8), and tumor necrosis factor-alpha (TNF-alpha), in the sinonasal mucosa of patients with chronic rhinosinusitis, and evaluated the response of these cytokines to oral corticosteroids. Chronic rhinosinusitis subjects (n = 15) and control subjects (n = 9) underwent nasal endoscopy and biopsy of the sinonasal mucosa. Chronic rhinosinusitis subjects were subsequently treated with a 10-day tapering dose of prednisone followed by a second sinonasal endoscopic exam and biopsy. Mucosal biopsy specimens were immunostained for IL-1 beta, IL-5, IL-6, IL-8, and TNF-a. In chronic rhinosinusitis subjects, mucosal levels of IL-1 beta, IL-6, IL-8, and TNF-alpha were significantly elevated when compared with control subjects, and levels of IL-5 demonstrated a strong trend toward elevation. In posttreatment chronic rhinosinusitis subjects, levels of IL-6 were significantly decreased when compared with pretreatment levels, and TNF-alpha levels demonstrated a significant trend toward reduction. These findings support the hypothesis that the inflammatory response in chronic rhinosinusitis is associated with elevated levels of pro-inflammatory cytokines, and suggest that oral corticosteroids may exert a beneficial effect by significantly reducing the levels of IL-6 and TNF-alpha.

The effect of corticosteroids in the treatment of experimental sinusitis

Emerging evidence indicates that medically recalcitrant sinusitis may be associated with a prolonged and excessive state of inflammation rather than a simple bacterial infection. Corticosteroids have been anecdotally reported to be helpful in treating patients with sinusitis; however, there are no scientific studies documenting the safety and efficacy of corticosteroid therapy in sinusitis. To resolve the controversy over whether corticosteroids promote or inhibit the resolution of sinusitis, we present a prospective study of 80 rabbits with surgically introduced pseudomonal sinusitis that were then treated in one of four arms: control, ceftazidime, methylprednisolone, and ceftazidime with methylprednisolone. Sinus cavities were then evaluated after 5, 14, 21, and 28 days of treatment both by histologic inflammation grading and bacterial quantification. Results showed a significant decrease in bacterial loads in both the antibiotic and antibiotic with steroid arms over control animals, although no difference was seen between the two. Histologic grading showed a similar trend, although statistical significance was not obtained. Overall, this study demonstrated no clear advantage of steroids in the treatment of sinus infections using this model. At the same point, no significant reduction in the effectiveness of antibiotic therapy was seen with concurrent steroid use. A number of limitations of the animal model are noted and the need for human studies in this area is discussed.

Endoscopically guided sinonasal cultures: a direct comparison with maxillary sinus aspirate cultures

Sinusitis is a common medical problem that can at times be challenging to treat. Although most cases respond to empiric therapy, success is not achieved universally. If empiric therapy fails, it is important to identify the causative bacterial pathogen. Antral puncture is the traditional diagnostic method to recover and identify pathogens in sinusitis; however, it remains a painful, invasive test with potential complications. In contrast, rigid sinonasal endoscopy permits recovery of mucopus emanating from the sinus ostia with little pain and few possible complications. Endoscopy also affords important visual information that can confirm or refute a historical/clinical diagnosis of sinusitis. Although previous studies have shown poor correlation between nasal cavity swab cultures and maxillary sinus aspiration cultures, few investigations have compared endoscopically guided middle meatal cultures with cultures obtained from maxillary sinus aspiration. Thirteen patients with maxillary sinusitis in one or both sinuses underwent endoscopically guided culture of the middle meatus and maxillary sinus puncture with aspiration and culture (16 total study samples). Results from the microbiologic analysis were compared. Endoscopically guided middle meatal cultures accurately identified the predominant bacterial pathogen and correlated with the cultures from maxillary sinus aspiration in more than 90% of infections. These preliminary results suggest that endoscopically guided sinonasal cultures hold promise as a viable alternative to maxillary sinus aspiration. Endoscopically guided cultures appear to be an effective, noninvasive diagnostic tool for otolaryngologists managing sinusitis.

Endoscopically guided sinus cultures in normal subjects

The study of healthy sinus flora has been pursued with Caldwell-Luc, antral puncture, and anterior rhinoscopy. Increasingly, nasal endoscopy has been used to obtain cultures, yet the significance of findings using this technique remains uncertain. Our ability to interpret the growing number of these cultures will be greatly enhanced by determining the results of this technique in patients without sinusitis. The goal of this study is to identify the bacterial flora of the sinuses in 25 healthy volunteers. Gram stain, aerobic, and anaerobic cultures were performed on swabs taken from the middle meatus and sphenoethmoid recesses. Eighteen cultures were sterile for aerobic organisms. Of the remaining 32 cultures, 41 isolates were retrieved. Predominant aerobes were S. aureus, Staphylococcus coagulase-negative, and diphtheroids; P. acnes was the predominant anaerobe.

Antimicrobial resistance in bacterial chronic sinusitis

Recent reports describe the emergence of antimicrobial resistant bacteria in acute sinusitis and an increased incidence of enteric gram negative bacilli in chronic sinusitis. The objective of this cross sectional study is to identify the emergent resistance patterns in bacterial chronic sinusitis. Specifically, this article seeks to characterize the bacteriology of outpatient chronic sinusitis, then to compare the antimicrobial susceptibilities of the bacterial isolates with standard culture data from a tertiary care center. Between March and August, 1994, 113 new outpatients presented with chronic sinusitis at a major teaching institution. Of these patients 34 underwent endoscopically guided aerobic culture of the paranasal sinuses and nasal cavities. Of the 48 total cultures, there were 43 positive cultures yielding 72 isolates. Thirty-eight cultures had two or fewer isolates; four cultures had three plus isolates, and one culture grew out normal flora. The most frequently isolated organisms were coagulase negative Staphylococcus (SCN), 20 (28%); Pseudomonas aeruginosa, 12 (17%); and Staphylococcus aureus, 9 (13%). Within the limited sample size for each isolate, Staphylococcus coagulase negative, Pseudomonas, and Pneumococcus demonstrated higher antimicrobial resistance compared to the medical center's corresponding nonurinary isolates. Additionally, three of six patients with Pseudomonal aeruginosa (50%) had a quinolone resistant strain. These preliminary data suggest that both an increased incidence of antimicrobial resistance and of enteric gram negative bacilli may exist in these outpatient, tertiary care center patients with chronic bacterial sinusitis.

Endoscopically guided cultures in chronic sinusitis

In chronic sinusitis, culture-directed antibiotics are often recommended as a cornerstone of treatment. The significance of Gram-negative rods (GNRs), coagulase-negative Staphylococci (SCN), and Staphylococcus aureus has been controversial. In an effort to determine host factors which correlate with culture results, 507 endoscopically-guided cultures are reviewed from 265 patients. A history of asthma, allergic rhinitis, prior sinus surgery, and the concurrent use of antibiotics, steroids, and irrigations were some of the host factors compared by X2. The results were compared to a control group of 50 cultures from healthy volunteers. SCN, S. aureus, P. aeruginosa, and Streptococcus were the most common isolates. GNRs were present in 27% of cultures and were more common in patients who had prior sinus surgery or were using irrigations. P. aeruginosa was more common in patients taking systemic steroids. SCN occurred with the same incidence in patients and control subjects but was more prevalent in cultures obtained intraoperatively and in patients taking systemic steroids. No identifiable host factor was associated with S. aureus. S. aureus occurred at similar rates in patients and control subjects but grew heavily in patients and exhibited only light growth in controls. Topical nasal steroids appear to have no statistically significant effect on bacterial cultures. Findings from this study further our understanding of chronic sinusitis and may help guide practitioners in the treatment of this disease.

Role of middle meatus aspiration culture in the diagnosis of chronic sinusitis

Although empiric antibiotic therapy is often used for sinusitis, the emergence of antibiotic resistance has increased the failure rate of this approach. Culture-directed therapy usually increases treatment success, but traditional antral puncture is often accompanied by poor patient and physician acceptance. Endoscopically directed middle meatal aspiration culture is increasingly used in this setting, but studies have not convincingly demonstrated the validity of this technique. Both endoscopic middle meatal and direct antral cultures were performed during endoscopic sinus surgery. Cytologic examination was performed to confirm the presence of inflammatory cells. When culture results were compared in 21 specimen pairs, exact correlation was found in 18 (85.7%). Based on this study, endoscopically directed middle meatus aspiration culture appears to be a valuable alternative to antral puncture for guiding organism-specific antibiotic therapy in sinusitis.

The Medical Management of Rhinosinusitis

The management of rhinosinusitis depends on a number of variables related to the duration and severity of symptoms in the individual patient. Furthermore acute rhinosinusitis is managed differently than chronic rhinosinusitis. Because a variety of conservative and pharmacologic interventions are available, the physician can find it difficult to develop a cohesive and logical approach to treatment. An understanding of the pathophysiology, microbiology, and natural history of rhinosinusitis is necessary to formulate the best treatment plan for the individual patient.

Gram negative sinusitis: a bacteriologic and histologic study in rabbits

Recent investigations of chronic sinusitis that is "recalcitrant" to traditional medical and surgical therapy indicate that gram negative bacteria are frequently involved, most commonly Pseudomonas aeruginosa. Analysis of infection-induced histopathologic changes in the underlying sinus mucosa may provide important insight into the recalcitrant nature of these infections. Therefore, the aim of this investigation is to experimentally induce sinus infection in the rabbit with Pseudomonas aeruginosa, a bacterium commonly associated with "recalcitrant sinusitis," and evaluate the histopathologic findings. A unilateral maxillary sinusitis was induced in 33 New Zealand white rabbits. Histologic analysis at 4, 14, 21, and 28 days revealed a moderate inflammation that persisted throughout the study period. Initial changes included edema, loss of submucosal glands, and ulceration. Fibroplasia and bone remodeling were evident throughout the study. Epithelial plaque formation occurred early in the infection, whereas goblet cell formation was a later change. Experimental sinusitis induced by Pseudomonas aeruginosa causes an intense transmucosal injury. The histopathologic injury and response to Pseudomonas aeruginosa appears to be more intense than that noted on previous investigations of experimental sinusitis using other bacteria. The significant histopathologic changes noted could explain the recalcitrant nature of gram negative sinusitis observed clinically in patients.

Management of sinusitis in the asthmatic patient

OBJECTIVE

To describe pathophysiologic links between sinusitis and asthma; to identify means of diagnosing sinusitis in the asthmatic; to discuss the management of asthmatic patients with sinusitis, both medical and surgical; to examine the outcome of managing the asthmatic patient with sinusitis.

DATA SOURCES

Prospective and retrospective data from the author's experience was evaluated. Medline database was searched from January 1, 1984, using the keywords "asthma" and "sinusitis" without restriction to species or language; 48 articles identified. Relevant articles referenced in retrieved sources, current texts in otorhinolaryngology and sinus disease were also utilized.

STUDY SELECTION

From data source abstracts, pertinent articles (33) and book chapters meeting the objectives of our paper were intensively reviewed.

RESULTS

Clinical and experimental studies indicate that sinonasal inflammation can result in worsening of lower airway disease, while the exact nature of this relationship remains debated. Regardless of mechanism, identification of the asthmatic patient with chronic sinusitis using the techniques of nasal endoscopy and CT scanning can lead to treatment of sinusitis with overall sinus and asthmatic disease improvement. Proper management is first medical, while surgical approaches are reserved for persistent cases. Traditional, more radical, surgical approaches have shown good results overall, while newer techniques of functional endoscopic sinus surgery which respect anatomy and mucosal function are less studied but expected to result in similar or better long-term outcome.

CONCLUSIONS

Sinusitis and asthma coexist and impact on one another at many different levels. Proper identification of the asthmatic patient with chronic sinusitis can be readily discerned by an accurate and thorough history and physical examination including nasal endoscopy and CT scanning. Proper medical and surgical management of sinusitis in the asthmatic patient can result in both improved sinonasal and asthmatic symptoms with fewer physician visits and decreased need for medication.