New bone formation in unilateral rhinosinusitis

Osteitis in Diseases With Unilateral Opacification of Paranasal Sinuses

OBJECTIVES

Chronic rhinosinusitis (CRS) is a common disease with mucosal inflammation, and may sometimes be accompanied by bone thickening. The disease is usually bilateral; when it is unilateral, there may be a specific disease. This study aimed to investigate the association between unilateral sinus opacification and osteitis.

METHODS

In total, 104 patients with computed tomography revealing unilateral sinus opacification were included in this study. Patients were retrospectively evaluated using the Global Osteitis Scoring Scale (GOSS) score, Lund-Mackey (LM) score, polyp score, and blood tests.

RESULTS

In total, 47, 11, 9, 17, and 20 patients had CRS, paranasal sinus cyst, inverted papilloma, mycetoma, and odontogenic sinusitis, respectively. The GOSS score in patients with mycetoma was higher than that in patients with CRS. However, no significant differences in the GOSS scores between patients with mycetoma, inverted papilloma, and odontogenic sinusitis existed. 10 of the 104 patients had osteitis with extensive bone thickening and a GOSS score of 4 or higher. Patients with CRS and mycetoma tended to have a higher GOSS score for the maxillary sinus than for the other sinuses. There was a significant positive correlation between the GOSS score and LM score in patients with diseases other than paranasal sinus cyst.

CONCLUSIONS

Mycetoma is more likely to cause osteitis than CRS, and a unique mechanism of osteitis exacerbation is predicted. As there is a positive correlation between bone thickening and sinus inflammation, a close association between osteitis and mucosal inflammation is inferred in diseases involving unilateral sinus opacification.

Preliminary study on AI-assisted diagnosis of bone remodeling in chronic maxillary sinusitis

OBJECTIVE

To construct the deep learning convolution neural network (CNN) model and machine learning support vector machine (SVM) model of bone remodeling of chronic maxillary sinusitis (CMS) based on CT image data to improve the accuracy of image diagnosis.

METHODS

Maxillary sinus CT data of 1000 samples in 500 patients from January 2018 to December 2021 in our hospital was collected. The first part is the establishment and testing of chronic maxillary sinusitis detection model by 461 images. The second part is the establishment and testing of the detection model of chronic maxillary sinusitis with bone remodeling by 802 images. The sensitivity, specificity and accuracy and area under the curve (AUC) value of the test set were recorded, respectively.

RESULTS

Preliminary application results of CT based AI in the diagnosis of chronic maxillary sinusitis and bone remodeling. The sensitivity, specificity and accuracy of the test set of 93 samples of CMS, were 0.9796, 0.8636 and 0.9247, respectively. Simultaneously, the value of AUC was 0.94. And the sensitivity, specificity and accuracy of the test set of 161 samples of CMS with bone remodeling were 0.7353, 0.9685 and 0.9193, respectively. Simultaneously, the value of AUC was 0.89.

CONCLUSION

It is feasible to use artificial intelligence research methods such as deep learning and machine learning to automatically identify CMS and bone remodeling in MSCT images of paranasal sinuses, which is helpful to standardize imaging diagnosis and meet the needs of clinical application.

Correlation of Kennedy Osteitis Score with the Tissue and Peripheral Eosinophil Counts in Patients of Eosinophilic Chronic Rhinosinusitis

Background

The presence of osteoid bone in chronic rhinosinusitis especially the eosinophilic subtype is commonly associated with recalcitrant illness. In practice, the radiological features of osteitis sinus alterations are frequently described, but the clinical and histopathologic implications are not well understood.

Objective

This study was done to correlate the radiological and the clinico-histopathological aspects in patients of eosinophilic chronic rhinosinusitis.

Methods

A cross-sectional study was done on sixty patients of chronic rhinosinusitis with nasal polyposis (CRSwNP) patients especially the eosinophilic subtype undergoing sinus surgery. Radiologically, osteitis was graded using standards that had already been published in the literature. Analysis was done on the relationships between CT documented osteitis, histopathological, and peripheral eosinophilic counts in patients of eosinophilic chronic rhinosinusitis.

Results

The patients with higher tissue eosinophilia and higher peripheral eosinophils had higher osteitis score. Pearson's correlation coefficient between Tissue Eosinophils and KOS was highly significant with p-value <0.001 (0.891). R2 value for KOS versus Tissue Eosinophils was 79.44%,implying that 79.44% variations were explained by Tissue Eosinophils in KOS. And R2 value for KOS versus Peripheral Eosinophils was 74.26%, implying that 74.26% variations were explained by Peripheral Eosinophils in KOS. Thereby, showing a positive relationship between the variables that were studied.

Conclusion

Kennedy Osteitis Score, histopathological and peripheral eosinophilia can be used as a marker to predict the disease severity in eosinophilic chronic rhinosinusitis.

Computed Tomography Evaluation of Unilateral Chronic Maxillary Sinusitis With Osteitis

BACKGROUND

Computed tomography (CT) is the preferred noninvasive method for the evaluation of osteitis in chronic sinusitis. Some scholars believe that the bone changes associated with chronic sinusitis always show high attenuation (high density) and are positively correlated with the severity of the disease. However, sinus bone remodeling is a complex process that may cause high or low attenuation. There have been few reports on the spread of osteitis. Therefore, additional research on sinus CT is necessary.

OBJECTIVE

To observe bony changes in chronic maxillary sinusitis (CMS) by CT and reveal the mechanism.

METHODS

A retrospective study was conducted in 45 patients with unilateral CMS with bony changes in the sinus walls. The patients' clinical data and CT results were analyzed and compared between the affected and normal sides. We propose the location, involvement, attenuation, and thickness method to evaluate CMS with osteitis.

RESULTS

Of the 45 patients, 40 (88.9%), 2, 12, and 7 had posterior external, medial, anterior, and superior lesions, respectively. The nasal region, sphenoid bone, palatine bone, and zygomatic arch were involved in 3, 12, 8, and 18 (40%) patients, respectively. Computed tomography indicated high attenuation in 30 (75.0%) and low attenuation in 10 (25.0%) patients; 6 (15.0%) showed new bone marrow cavities. The bone thickness was significantly different between the affected and normal sides in 40 patients (P < .001), including members of both the high- and low-attenuation groups (high-attenuation group: P < .001; low-attenuation group: P < .01). However, there was no significant difference in the thickness of the affected side between the high- and low-attenuation groups (P > .05).

CONCLUSIONS

Chronic rhinosinusitis with bony changes may occur in the maxillary sinus walls and spread to adjacent bones. Both increased and decreased attenuation may occur in these circumstances. Analyzing the CT features of bone changes in unilateral CMS can improve the accuracy of disease diagnosis.

Osteitis in Chronic Rhinosinusitis

PURPOSE OF REVIEW

Osteitis is recognized as a common factor in recalcitrant chronic rhinosinusitis (CRS). There is evidence for the association of osteitis with revision surgeries and CRS severity, in terms of higher Lund-Mackay scores. This is a narrative review on the osteitis in CRS patients.

RECENT FINDINGS

Evidence to date is inconclusive with regard to the etiology and pathogenesis of this bony thickening. Histopathology of osteitis in primary CRS is likely a process of neo-osteogenesis and bone remodeling. For better understanding, various associating factors have been studied including an inflammatory pattern of rhinosinusitis. Recent studies have associated osteitis with nasal polyps and tissue eosinophilia with the increase in periostin expression and P-glycoprotein mucosal expression. There is no association of osteitis to symptoms or quality of life. Osteitis is an outcome of neo-osteogenesis rather than inflammatory processes in CRS patients without a prior history of surgery. While CT has become a staple in osteitis assessment, the standards for grading osteitic severity remain in an experimental stage. There is no association between the presence or severity of osteitis at the time of surgery and clinical outcomes at 1 year after surgery. This review provides a comprehensive overview of the pathogenesis, epidemiology, and correlation with clinical and biological factors of osteitis in CRS patients.

Development of CT-based methods for longitudinal analyses of paranasal sinus osteitis in granulomatosis with polyangiitis

Background

Even though progressive rhinosinusitis with osteitis is a major clinical problem in granulomatosis with polyangiitis (GPA), there are no studies on how GPA-related osteitis develops over time, and no quantitative methods for longitudinal assessment.

Here, we aimed to identify simple and robust CT-based methods for capture and quantification of time-dependent changes in GPA-related paranasal sinus osteitis and compare performance of the methods under study in a largely unselected GPA cohort.

Methods

GPA patients (n = 121) with ≥3 paranasal CT scans obtained ≥12 months apart and control patients not having GPA or rhinosinusitis (n = 15) were analysed by: (i) Global osteitis scoring scale (GOSS), originally developed for chronic rhinosinusitis; (ii) Paranasal sinus volume by manual segmentation; (iii) Mean maxillary and sphenoid diameter normalised to landmark distances (i.e. diameter ratio measurement, DRM).

Results

Time-dependent changes in GPA-related osteitis were equally well measured by the simple DRM and the labour-intensive volume method while GOSS missed ongoing changes in cases with extensive osteitis. GOSS at last CT combined with DRM identified three distinct patient groups: (i) The no osteitis group, who had no osteitis and no change in DRM from baseline CT to last CT (45/121 GPA patients and 15/15 disease controls); (ii) Stable osteitis group, with presence of osteitis, but no change in DRM across time (31 GPA); (iii) Progressive osteitis, defined by declining DRM (45 GPA).

Conclusions

We suggest DRM and GOSS as complementary methods for capturing, classifying and quantifying time-dependent changes in GPA-related osteitis.

Electronic supplementary material

The online version of this article (10.1186/s12880-019-0315-7) contains supplementary material, which is available to authorized users.

Bony Changes in a Unilateral Maxillary Sinus Fungal Ball

Objectives:

In the paranasal sinus fungal ball (SFB), changes that occur in the underlying bone have not been well described. Recently, bacterial coinfection has been reported in patients with paranasal SFB. We evaluated whether bone changes occur in patients with unilateral maxillary SFB, and also how bacteria in an SFB affect the bony wall of the sinus.

Methods:

A retrospective study of patients with a unilateral maxillary SFB undergoing endoscopic sinus surgery was conducted from July 2009 to December 2015. Preoperative computed tomography images of the patients were reviewed. Wall thickness (WT) and wall density (WD) of the diseased sinus were measured and compared to the normal sinus. Specimens of the sinus aspirates were obtained during surgery for aerobic and anaerobic cultures.

Results:

Forty-three patients were included (mean, 55.7 ± 12.8 years). Thirty-one cultures (72.1%) were positive for bacteria. Thickening was evident in the anterior, lateral, and posterior walls of the diseased sinus. The average WT was 1.69 ± 0.45 mm on the diseased sinus and 1.14 ± 0.31 mm on the normal sinus (P < 0.001). In the diseased sinus, the difference in the average WT between the culture-positive and culture-negative groups was not significant (P = 0.44). The average WD on the diseased sinus was higher than that on the normal sinus (P < 0.001).

Conclusions:

Osteitic change occurred in most patients with a unilateral maxillary SFB. The presence of bacteria in sinus secretions does not greatly affect the development of osteitic changes in unilateral maxillary SFB.

Osteitis in chronic rhinosinusitis: a review of the literature

BACKGROUND

The role of osteitis, or inflammation involving bone, is 1 potential reason for disease recalcitrance in chronic rhinosinusitis (CRS) and is not extensively studied. This review article will discuss osteitis in CRS, including pathophysiology, diagnostic methods, clinical significance, and treatment modalities.

METHODS

A systematic review of the literature was performed using PubMed search terms osteitis, osteomyelitis, bone involvement, hyperostosis, neo-osteogenesis, osteoneogenesis, remodeling, single positron emission computed tomography (SPECT), and nuclear scintigraphy, with each term cross-referenced with chronic rhinosinusitis. This search was then narrowed to English language articles, which were reviewed for relevance. Cited references of relevant articles were also examined.

RESULTS

The PubMed search identified 231 articles, which after reviewing for inclusion criteria resulted in 26 articles that were included in the current review. Pathophysiology, including current understanding of molecular mechanisms contributing to osteitis, is discussed. Histology, computed tomography (CT), and SPECT have been used to establish a diagnosis. Radiographic staging systems exist but are not standardized. Osteitis has been treated both with intravenous antibiotics and surgery. Five articles involved assessment of outcomes in patients with osteitis.

CONCLUSION

Osteitis involves inflammatory changes in the underlying bone that may lead to recalcitrant CRS. Osteitis is associated with worsened measures of disease severity such as CT, endoscopy, and olfactory scores, and affects the degree of improvement in quality-of-life measures after both medical and surgical treatment. Future studies directed at characterizing the underlying molecular mechanisms including earlier and precise identification may improve our ability to treat this significant aspect of CRS.

Comparison of clinical data, CT, and bone histopathology in unilateral chronic maxillary sinusitis

OBJECTIVES

To evaluate bone changes demonstrated by computed tomography (CT) as a predictor of the severity of chronic rhinosinusitis.

STUDY DESIGN

Cross-sectional study.

SETTINGS

Tertiary referral university medical center.

SUBJECTS AND METHODS

Thirty-eight patients diagnosed with unilateral chronic maxillary sinusitis underwent endoscopic sinus surgery from 2003 to 2009. Preoperative CTs of all patients were reviewed by a single radiologist blinded to the pathologic diagnosis. Bone density was evaluated and expressed in Hounsfield units (HU). Sinus wall thickness (WT) was also measured and compared with the contralateral side. All the histopathologic specimens were reviewed. A database was constructed containing demographic data, clinical symptoms, CT measurements, and histopathologic findings.

RESULTS

Average age was 44.07 years, with 22 women (57.9%) and 16 men (42.1%). The average wall density (WD) was 828.7 HU, and no correlation was found between the density of the diseased maxillary sinus bony walls and the severity of the histopathologic inflammatory process of the soft tissue (P = .474). The average wall thickness of the diseased sinuses was 2.6 mm, and a correlation was found between inflammation severity and wall thickness (P = .018). Wall thickening was found in 97.3% of the cases and an increase in density in 78.9% without correlation between WD and WT.

CONCLUSION

Wall thickness but not WD obtained from CT scans may be a simple index for evaluation of unilateral chronic rhinosinusitis and its severity. Further studies confirming these results and comparing them with clinical correlates are indicated.

The impact of osteitis on disease severity measures and quality of life outcomes in chronic rhinosinusitis

BACKGROUND

The significance of osteitis in the management of recalcitrant chronic rhinosinusitis (CRS) has yet to be clearly understood and clinical outcomes data for these patients is lacking. Osteitis has been characterized by inflammatory infiltrate, osteoneogenesis, and bony sclerosis with remodeling. In this study we sought to determine if osteitis negatively impacts quality-of-life (QOL) or clinical outcomes following endoscopic sinus surgery (ESS).

METHODS

A total of 190 adult patients with CRS were prospectively enrolled.Osteitis was characterized by quantifiable bony thickening on sinus computed tomography (CT). Baseline measures and postoperative outcomes were evaluated using endoscopy exam, olfactory testing, and 2 validated disease-specific QOL surveys: the Chronic Sinusitis Survey (CSS) and Rhinosinusitis Disability Index (RSDI). Bivariate and multivariate analyses were performed to evaluate differences between patients with and without osteitis.

RESULTS

Patients with osteitis (n = 79) had higher prevalence of nasal polyposis and prior ESS (both p < 0.001) and significantly worse baseline CT, endoscopy, and olfactory scores (all p < 0.001) than patients without osteitis. There was no difference in baseline QOL scores between patients with and without osteitis. Following ESS, there were significant improvements in all QOL measures in both groups; however, patients without osteitis were more likely to exhibit clinically meaningful improvement on physical RSDI subscale scores, independent of other clinical factors (79.0% vs 62.3%; odds ratio [OR]: 3.85, p = 0.011).

CONCLUSION

Osteitis is associated with worse baseline measures of disease severity and inflammation. Our data suggest that whereas patients with osteitis improve after ESS, the presence of osteitis is associated with a reduced chance of improvement in some outcome measures.

[Silent sinus syndrome associated with intrasinusal ossification]

BACKGROUND

The silent sinus syndrome (SSS) is a rare cause of diplopia and facial asymmetry. It is commonly attributed to a sinus atelectasis secondary to ostiomeatal obstruction. Surgical dissection of the maxillary sinus mucosal lining is known to cause auto-obliteration by bone formation.

CLINICAL CASE

A 45 year-old female patient was referred for vertical diplopia with enophthalmia, and a slight depression of the left cheekbone. Antrostomy was performed for chronic obstructive maxillary sinusitis six months before. CT scan revealed a major collapse of superior, anterior, and posterior left maxillary sinus with expansion of the orbital volume. The de novo maxillary sinus ossification evolved over two years of follow-up. It was normal lamellar bone. The left orbital floor was rebuilt. Diplopia progressively resolved.

DISCUSSION

The association of SSS and intraluminal osteogenesis has never been reported. The first might be due to a peroperative dissection of the maxillary sinus mucosal lining. SSS was due to meatal obstruction secondary to inadequate antrostomy.

Impact of chronic rhinosinusitis and endoscopic sinus surgery on bone remodeling of the paranasal sinuses

BACKGROUND

Osteitis or bone remodeling is one of the distinct radiological findings in chronic rhinosinusitis (CRS). Bone remodeling of the paranasal sinuses can be affected by many factors including age, sex, chronic inflammation, and surgery. The aim of this study was to investigate radiological evidence of mucosal and bone remodeling and to assess the impact of recurrent rhinosinusitis after surgery on remodeling in patients with CRS.

METHODS

Controls (n = 25) and patients with CRS undergoing primary (n = 25) and revision (n = 15) endoscopic sinus surgery (ESS) were included in this study. Bone remodeling of the ethmoid sinus was checked by the presence of new bone formation (NBF) and measurement of bone density (HU). Bone remodeling of the maxillary sinus was measured by the vertical and horizontal lengths at maximal cross-sectioned CT images.

RESULTS

Lund-Mackay scores were significantly increased in the revision ESS group (p = 0.009) and NBF(+) group (p = 0.014). NBF was significantly increased in the revision ESS group compared with the primary ESS group (odds ratio = 0.127; CI, 0.029-0.562; p = 0.006). There was a significant difference in ethmoid bone density among controls, primary, and revision ESS (p = 0.0001). The maximal sizes of the maxillary sinus were significantly decreased in CRS groups when compared with controls (p < 0.05).

CONCLUSION

In the revision ESS group, soft tissue and bone remodeling may be greater than in the primary ESS group.