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Gitomer SA, Poore TS, Anand GS, Cañadas KT. Differing rates of fungi in sinonasal cultures from pediatric sinusitis patients. Int J Pediatr Otorhinolaryngol 2022; 156:111125. [PMID: 35398790 DOI: 10.1016/j.ijporl.2022.111125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 02/03/2022] [Accepted: 03/26/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Pediatric chronic rhinosinusitis (PCRS) is a unique clinical entity and the underlying source of inflammation is unknown. Certain subgroups, such as children with nasal polyps and cystic fibrosis (CF) sinusitis are often recalcitrant to standard medical PCRS treatments that target bacterial inflammation. Fungal infection and allergy to fungal proteins drive inflammation in other airway diseases, resulting in chronic inflammation of both the upper and lower airways. However, there is limited understanding of the role of fungi in the pathophysiology of PCRS. The objective of this study is to define the frequency of fungal infection in pediatric CRS patients, hypothesizing that certain subgroups may have more frequent positive fungal sinus cultures than other subgroups of pediatric sinusitis. METHODS Retrospective study of patients undergoing sinus surgery at a tertiary care pediatric hospital to determine the period prevalence of positive fungal cultures in subgroups of patients. RESULTS 400 children from 2012 to 2019 were included. 265 patients had surgical culture results available. Of the 52 patients with CF 11 (21%) had positive fungal sinus cultures. Similarly, 28% of the 25 patients with non-CF nasal polyps had positive cultures. Only 8.2% of 110 CRS without polyps patients had positive cultures, significantly fewer than other subgroups (X2 (1, N = 240) = 17.22, p < 0.01). CONCLUSION Children with CF and children with nasal polyps had more frequent positive fungal cultures than children without nasal polyps having sinus surgery. This confirms that pediatric CF and pediatric CRS with polyps represent unique populations to study the impact of fungal infection in CRS. Further research is required to determine if these fungi represent colonization or contribute to the inflammatory environment of the airways.
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Affiliation(s)
- Sarah A Gitomer
- Pediatric Otolaryngology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA; Pediatric Otolaryngology, The University of Colorado, Anschutz Medical Campus, Children's Children's Hospital Colorado, Aurora, CO, USA.
| | - T Spencer Poore
- Department of Pediatrics, Division of Pediatric Pulmonology and Sleep Medicine, The University of Colorado, Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA
| | - Grace S Anand
- Pediatric Otolaryngology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Karina T Cañadas
- Pediatric Otolaryngology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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Computer-Assisted Analysis of Oral Antifungal Therapy in Chronic Rhinosinusitis with Airway Mycosis: a Retrospective Cohort Analysis. Antimicrob Agents Chemother 2021; 65:e0169721. [PMID: 34491802 DOI: 10.1128/aac.01697-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Environmental fungi are etiologically related to chronic rhinosinusitis (CRS) with airway mycosis, but their infectious role remains uncertain, in part because of potentially inadequate methods of disease quantitation. Our objective was to determine objective radiographic and symptomatic outcomes of oral antifungal therapy in adult patients with CRS and airway mycosis by using computer-assisted analysis. We conducted a retrospective study of 65 patients with CRS and culture-proven airway mycosis in a single-center referral-based academic practice, comparing paired sinus computed tomography (CT) scans and symptom scores prior to and during chronic oral antifungal therapy using computer-assisted analysis of sino-mucosal area (CAASMA). A comparator group received standard therapy without antifungals. Administration of antifungals was associated with significantly reduced sinus mucosal thickening as assessed by CAASMA (-6.85% absolute reduction; 95% confidence interval [CI], -11.8283 to -1.8717; P < 0.005), but not by Lund-Mackay score. In contrast, standard care alone was linked by CAASMA to enhanced mucosal thickening (4.14% absolute increase; 95% CI, -1.8066 to 10.0866; P < 0.005). Thirty of the 41 antifungal-treated patients (73%) showed decreased sinus mucosal burdens, while only 21 patients (43%) receiving standard therapy showed improved imaging (odds ratio [OR], 11.65; 95% CI, 3.2 to 42.2; P < 0.05). Nineteen patients (50%) noted improved symptoms at the time of a follow-up CT scan, while only 8 patients (20%) on standard therapy improved (OR, 6.21; 95% CI, 1.7 to 22.7; P < 0.05). These retrospective findings indicate that oral antifungals can reduce mucosal thickening and improve symptoms in CRS with airway mycosis. Randomized clinical trials are warranted to verify these findings.
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Medikeri G, Javer A. Optimal Management of Allergic Fungal Rhinosinusitis. J Asthma Allergy 2020; 13:323-332. [PMID: 32982320 PMCID: PMC7494399 DOI: 10.2147/jaa.s217658] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 08/13/2020] [Indexed: 01/02/2023] Open
Abstract
Introduction Allergic fungal rhinosinusitis (AFRS) is a chronic disorder with significant morbidity and a high recurrence rate needing long-term follow-up. Even after its first description many decades ago, there is still considerable uncertainty about the management of this condition. Description In this chapter, we breakdown the topic “Optimal management of allergic fungal rhinosinusitis” into sub-headings in order to discuss the latest research and available literature under each topic in great detail. Every attempt has been made to incorporate the highest level of evidence that was available at the time of writing. Summary Pre-operative diagnosis and further management prior to surgery is important. Steroids help in reducing inflammation and help improve the surgical field. Surgery remains the mainstay in the management of this condition along with long-term medical management. Oral steroids are reserved for acute flare-ups in the background of associated lung concerns. Oral and topical antifungal agents have no role in the control of the disease. Biological agents are being prescribed predominantly by respiratory physician colleagues, mainly for the control of the chest-related issues rather than for sinus disease. Immunotherapy as an adjunct with surgery is promising. Conclusion AFRS is a disease with many variables and a wide range of symptomatic presentation. It takes a keen clinician to identify the disease and subsequently manage the condition. Treatment involves long-term follow-up with early detection of recurrence or flare-ups. Any of the mentioned modalities of management may be employed to effectively control the condition, and treatment protocols will have to be tailor-made to suit each individual patient. Various medications and drugs such as Manuka honey, antimicrobial photodynamic therapy, hydrogen peroxide and betadine rinses appear to be promising. More robust studies need to be undertaken to ascertain their routine use in clinical practice.
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Affiliation(s)
| | - Amin Javer
- Rhinology & Skull Base Surgery, St. Paul's Sinus Center, Vancouver, BC, Canada
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Abstract
BACKGROUND Allergic fungal rhinosinusitis (AFRS) is a common condition in which sinusitis develops as an IgE-mediated response to common sinonasal fungal organisms. If that response leads to blockage of sinus ostia, bone expansion and erosion by expansive cysts containing dense inspissated debris may occur with the potential for critical neurovascular compression including damage to the anterior visual pathway. METHODS Review of clinical and imaging features of 2 patients who sustained catastrophic clinical outcomes. RESULTS The first patient had pansinusitis with massive mucocele-like cysts expanding the sphenoid sinus and cranial base and causing compression of the anterior visual pathway that led to persistent severe vision loss despite extensive sinus surgery. The second patient developed sphenoethmoidal expansion with a marked inflammatory response and presumed conversion to invasive fungal sinusitis that caused anterior visual pathway vision loss, bilateral ocular motor palsies from extension into the cavernous sinuses, and death from a large middle cerebral artery stroke. CONCLUSIONS Although AFRS is most often benign and treatable, it may rarely produce catastrophic outcomes, especially if the sphenoid sinus is involved. Irreversible vision loss may occur from compression, and ocular motor palsies and death from conversion to invasive fungal disease. Close ophthalmologic and imaging monitoring is necessary in patients with expanded sinuses, and prophylactic sinus surgery may be indicated in certain cases.
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Abstract
BACKGROUND Nasal polyposis is a benign hyperplastic growth of nasal mucosa. There is a paucity of evidence on the prevalence and incidence of nasal polyposis. Although nasal polyps can be asymptomatic, they can cause a spectrum of nasal problems including nasal obstruction, rhinorrhoea, nasal congestion, anosmia resulting in ageusia. Nasal polyps are mostly associated with chronic rhinosinusitis, The current management of chronic rhinosinusitis with nasal polyps is controversial and is not curative. METHODS A Medline search was conducted, using the keywords 'rhinosinusitis', 'sinusitis', 'classification' and ''aetiology. FINDINGS The current treatment of nasal polyposis in chronic rhinosinusitis with nasal polyps is still challenging. Emerging research through endotypes profiling aims to better understand the complexities of this heterogeneous disease to personalise treatment and provide a cure. Randomised controlled trials aim to provide robust evidence for current management options.
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Affiliation(s)
- NH Ta
- Norfolk and Norwich University Hospital, Norwich Medical School, University of East Anglia, Norwich, UK
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Sivasubramaniam R, Harvey RJ. How to Assess, Control, and Manage Uncontrolled CRS/Nasal Polyp Patients. Curr Allergy Asthma Rep 2018; 17:58. [PMID: 28770480 DOI: 10.1007/s11882-017-0728-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW Chronic rhinosinusitis (CRS) is a multidimensional inflammatory disorder of the nose and paranasal sinuses. We reviewed the recent literature to identify improved methods to assess, control, and manage these difficult to control patients. RECENT FINDINGS The role of endotyping in CRS has offered a better understanding of the underlying pathophysiology and allows for more targeted treatment. The understanding of systemic disorders and their role in CRS and the importance of topical treatment reaching the sinuses has also allowed for better control of these patients. We have provided some of the commonly identified causes for uncontrolled CRS and a sensible approach to assessing these patients. We have also focused on common areas of pitfalls in the surgery and choice of patients and the role for ongoing systemic treatment. The future of managing this difficult condition includes endotyping using inflammatory markers and individualizing the treatment to the patient by using specific monoclonal antibodies.
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Affiliation(s)
| | - Richard J Harvey
- Rhinology and Skull Base, Macquarie University, Sydney, Australia. .,Sydney ENT Clinic, 67 Burton Street, Darlinghurst, NSW, 2010, Australia.
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Snidvongs K, Thanaviratananich S. Update on Intranasal Medications in Rhinosinusitis. Curr Allergy Asthma Rep 2017; 17:47. [PMID: 28602009 DOI: 10.1007/s11882-017-0720-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This review describes beneficial effects and adverse events of various intranasal medications in treating rhinosinusitis. Application of intranasal steroids has been described in treating all subtypes of adult rhinosinusitis, but reports are limited in pediatrics and mostly in acute pediatric subgroups resulted in benefits While saline irrigation is effective for patients with chronic rhinosinusitis without polyps and in pediatric acute rhinosinusitis, there is no evidence yet for saline drips and sprays. Application of intranasal antifungals and nasal irrigation with surfactant brings more harm than benefits. There is no evidence supporting the use of intranasal antibiotics. We also review influence of devices, methods, and patient head position on nasal and paranasal sinus drug delivery.
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Affiliation(s)
- Kornkiat Snidvongs
- Department of Otolaryngology, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand.
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Jiang RS, Twu CW, Liang KL. Efficacy of nasal irrigation with 200 μg/mL amphotericin B after functional endoscopic sinus surgery: a randomized, placebo-controlled, double-blind study. Int Forum Allergy Rhinol 2017; 8:41-48. [PMID: 29083530 DOI: 10.1002/alr.22033] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 10/01/2017] [Accepted: 10/03/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Previous studies have shown controversial results of topical amphotericin B (AMB) nasal irrigation for chronic rhinosinusitis (CRS). The purpose of this study was to evaluate the efficacy of 200 μg/mL AMB nasal irrigation as an adjuvant therapy after functional endoscopic sinus surgery (FESS). METHODS Patients with CRS who had received FESS for treatment were recruited and assigned to 1 of 2 groups at random at 1 month postsurgery. In the AMB group patients received nasal irrigation with 200 μg/mL of AMB for 2 months on a daily basis. In the control group normal saline irrigation was given instead. Before FESS and before and after nasal irrigation, patients' sinonasal symptoms were assessed through a questionnaire that was a Taiwanese version of the 22-item Sino-Nasal Outcome Test (TWSNOT-22). In addition, patients received endoscopic examination, acoustic rhinometry, smell test, saccharine transit test, and bacterial cultures obtained from their middle meati. RESULTS A total of 73 patients completed the study between December 2014 and January 2017. Among them, 37 received nasal irrigation with AMB solution, and 36 with saline. In the AMB group, scores of TWSNOT-22 dropped significantly after irrigation compared with before (p = 0.005). In the control group, TWSNOT-22 scores did not changed after irrigation (p = 0.451). However, there were no significant differences in TWSNOT-22, endoscopic score, smell test, saccharine transit test, and bacterial culture rate after irrigation between 2 groups. CONCLUSION Our study showed that in post-FESS care, nasal irrigation with 200 μg/mL of AMB did not provide additional benefit compared with saline irrigation.
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Affiliation(s)
- Rong-San Jiang
- Department of Otolaryngology, Taichung Veterans General Hospital, Taichung, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Department of Nursing, HungKuang University, Taichung, Taiwan
| | - Chih-Wen Twu
- Department of Otolaryngology, Taichung Veterans General Hospital, Taichung, Taiwan.,Faculty of Medicine, National Yang-Ming Medical University, Taipei, Taiwan
| | - Kai-Li Liang
- Department of Otolaryngology, Taichung Veterans General Hospital, Taichung, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Faculty of Medicine, National Yang-Ming Medical University, Taipei, Taiwan
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Chronic Rhinosinusitis and the Evolving Understanding of Microbial Ecology in Chronic Inflammatory Mucosal Disease. Clin Microbiol Rev 2017; 30:321-348. [PMID: 27903594 DOI: 10.1128/cmr.00060-16] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Chronic rhinosinusitis (CRS) encompasses a heterogeneous group of debilitating chronic inflammatory sinonasal diseases. Despite considerable research, the etiology of CRS remains poorly understood, and debate on potential roles of microbial communities is unresolved. Modern culture-independent (molecular) techniques have vastly improved our understanding of the microbiology of the human body. Recent studies that better capture the full complexity of the microbial communities associated with CRS reintroduce the possible importance of the microbiota either as a direct driver of disease or as being potentially involved in its exacerbation. This review presents a comprehensive discussion of the current understanding of bacterial, fungal, and viral associations with CRS, with a specific focus on the transition to the new perspective offered in recent years by modern technology in microbiological research. Clinical implications of this new perspective, including the role of antimicrobials, are discussed in depth. While principally framed within the context of CRS, this discussion also provides an analogue for reframing our understanding of many similarly complex and poorly understood chronic inflammatory diseases for which roles of microbes have been suggested but specific mechanisms of disease remain unclear. Finally, further technological advancements on the horizon, and current pressing questions for CRS microbiological research, are considered.
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Luk LJ, DelGaudio JM. Topical Drug Therapies for Chronic Rhinosinusitis. Otolaryngol Clin North Am 2017; 50:533-543. [DOI: 10.1016/j.otc.2017.01.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Barshak MB, Durand ML. The role of infection and antibiotics in chronic rhinosinusitis. Laryngoscope Investig Otolaryngol 2017; 2:36-42. [PMID: 28894821 PMCID: PMC5510277 DOI: 10.1002/lio2.61] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2016] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE To review the current understanding of the role of infection and antibiotics in chronic rhinosinusitis. REVIEW METHODS PubMed literature search. RESULTS Chronic rhinosinusitis (CRS) in adults is an inflammatory condition and the role of infection is unclear. Biofilms are present in both CRS and normal patients so their role in CRS is unknown. Sinus cultures in CRS demonstrate a mixture of aerobic and anaerobic bacteria but may be hard to interpret due to contaminating nasal flora. Staphylococcus aureus is common in CRS patients but also present in 20-30% of nasal cultures in the normal population; eradicating this organism did not lead to symptom improvement versus placebo in a randomized controlled trial (RCT). In CRS patients who develop an episode of acute rhinosinusitis (ARS), bacteria typical of ARS can generally be cultured and require short-course treatment. For CRS, topical antibacterial or antifungal agents have shown no benefit over placebo in RCTs, although RCTs of topical antibacterial agents have been small. Oral macrolides and doxycycline, antibiotics with anti-inflammatory properties, are the only systemic antibiotics that have been evaluated in RCTs. One RCT found 3 weeks of doxycycline beneficial in patients with polyps but follow up was short (<3 months); RCTs of prolonged macrolide therapy have produced mixed results, and most show no benefit after cessation of therapy. Long-term antibiotic therapy may produce side effects and select increasingly resistant flora. The American Academy of Otolaryngology-Head and Neck Surgery guidelines recommend against treatment of CRS with antifungal agents but do not comment on the role of antibacterial treatment. CONCLUSION The role of infection in CRS is unknown, and the only well-defined role for antibiotics is for treatment of ARS episodes or their infectious complications. LEVEL OF EVIDENCE N/A.
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Affiliation(s)
- Miriam Baron Barshak
- Massachusetts General Hospital and Massachusetts Eye and Ear InfirmaryBostonMassachusetts
| | - Marlene L. Durand
- Massachusetts General Hospital and Massachusetts Eye and Ear InfirmaryBostonMassachusetts
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Abstract
The sinonasal tract is frequently affected by nonneoplastic inflammatory diseases. Inflammatory lesions of the sinonasal tract can be divided into 3 main categories: chronic rhinosinusitis, which encompasses a heterogeneous group of entities, all of which result in mucosal inflammation with or without polyps-eosinophils; infectious diseases; and autoimmune diseases and vasculitides, which can result in midline necrosis and facial deformities. This article reviews the common inflammatory lesions of the sinonasal tract with emphasis on infectious diseases, vasculitis, iatrogenic, and diseases of unknown cause. Many of these lesions can result in midline destruction and result in facial deformity.
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Affiliation(s)
- Kathleen T Montone
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, 3400 Spruce Street, 6 Founders, Philadelphia, PA 19104, USA.
| | - Virginia A LiVolsi
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, 3400 Spruce Street, 6 Founders, Philadelphia, PA 19104, USA
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deShazo RD, Stringer S, Skipworth LB. Possible allergic fungal sinusitis. Ann Allergy Asthma Immunol 2016; 116:290-4. [PMID: 27055989 DOI: 10.1016/j.anai.2015.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 07/31/2015] [Accepted: 08/05/2015] [Indexed: 10/22/2022]
Affiliation(s)
- Richard D deShazo
- Department of Medicine, School of Medicine, University of Mississippi Medical Center, Jackson, Mississippi; Department of Pediatrics, School of Medicine, University of Mississippi Medical Center, Jackson, Mississippi.
| | - Scott Stringer
- Department of Otolaryngology and Communicative Sciences, School of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Leigh Baldwin Skipworth
- Department of Medicine, School of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
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Abstract
INTRODUCTION Chronic rhinosinusitis (CRS) is a broad clinical syndrome linked by mucosal inflammation. Primary treatment modalities are corticosteroids and antibiotics with surgery an option for failures, but the level of supporting evidence is generally low. The primary reason is that CRS is a symptom complex and not a specific disease. Areas covered: The primary treatment modalities for CRS are corticosteroids, antibiotics and surgery. Corticosteroids, which have very broad anti-inflammatory properties, also have the strongest evidence for efficacy. Antibiotics are likely effective in a subpopulation of patients but the various phenotypes and endotypes that make up CRS have thus far been poorly defined. Early surgery as well as biologics may also be more efficacious and cost effective in some phenotypes as well. Expert commentary: A better understanding of the inflammatory pathways that drive CRS will permit investigators to separate patient groups. This will allow for clinical trials that target specific subpopulations and more personalized therapy for CRS patients in the future.
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Affiliation(s)
- Nsangou Ghogomu
- a Feinberg School of Medicine, Department of Otolaryngology, Head and Neck Surgery , Northwestern University , Chicago , IL , USA
| | - Robert Kern
- a Feinberg School of Medicine, Department of Otolaryngology, Head and Neck Surgery , Northwestern University , Chicago , IL , USA
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Hashemian F, Hashemian F, Molaali N, Rouini M, Roohi E, Torabian S. Clinical effects of topical antifungal therapy in chronic rhinosinusitis: a randomized, double-blind, placebo-controlled trial of intranasal fluconazole. EXCLI JOURNAL 2016; 15:95-102. [PMID: 27065776 PMCID: PMC4822190 DOI: 10.17179/excli2015-678] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 01/26/2016] [Indexed: 02/03/2023]
Abstract
Several studies have been in favor of fungi as a possible pathogenesis of chronic rhinosinusitis (CRS); however, to date, there is no scientific consensus about the use of antifungal agents in disease management. The aim of the present study was to investigate the efficacy of intranasal fluconazole in improving disease symptoms and objective outcomes of patients with CRS. A randomized, double-blind, placebo-controlled study was conducted on 54 patients who were diagnosed with CRS and had not been responsive to routine medical treatments. They were randomly assigned to receive either fluconazole nasal drop 0.2 % or placebo in addition to the standard regimen for a duration of 8 weeks. Patients' outcomes were evaluated according to Sino-Nasal Outcome Test 20 (SNOT-20), endoscopic scores, and Computed Tomography (CT) scores. No statistically significant difference was found in SNOT-20 (p = 0.201), endoscopic (p = 0.283), and CT scores (p = 0.212) of the patients at baseline and after 8-week course of treatment between drug and placebo group. Similar to many studies, the use of topical antifungal treatment for patients with CRS was not shown to be significantly effective. However, further studies are needed to obtain high levels of consistent evidence in order to arrive at a decision whether antifungal therapy is effective in management of CRS or not.
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Affiliation(s)
- Farshad Hashemian
- Department of Clinical Pharmacy, Faculty of Pharmacy, Islamic Azad University, Pharmaceutical Sciences Branch, Tehran, Iran
| | - Farnaz Hashemian
- Department of Otolaryngology, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Najmeh Molaali
- Department of Clinical Pharmacy, Faculty of Pharmacy, Islamic Azad University, Pharmaceutical Sciences Branch, Tehran, Iran
| | - Mohammadreza Rouini
- Department of Pharmaceutics, Tehran University of Medical Sciences, Tehran, Iran
| | - Elnaz Roohi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Islamic Azad University, Pharmaceutical Sciences Branch, Tehran, Iran
| | - Saadat Torabian
- Department of Community Medicine, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
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Li N, Peters AT. Chronic rhinosinusitis management beyond intranasal steroids and saline solution irrigations. Allergy Asthma Proc 2015; 36:339-43. [PMID: 26314815 DOI: 10.2500/aap.2015.36.3866] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Chronic rhinosinusitis (CRS) is a heterogeneous disease with clinical manifestations that are influenced by the presence or absence of nasal polyposis. Understanding of the current and future treatment modalities for CRS is essential in preventing exacerbation and morbidity associated with this chronic condition. OBJECTIVE The aim of this article is to review the evidence behind current medical therapies and potential new treatments for CRS. METHODS Scientific literature regarding intranasal and systemic antibiotics, intranasal systemic corticosteroids, and monoclonal antibodies as interventions for CRS with and without nasal polyps was reviewed. RESULTS The literature supports the use of topical or systemic glucocorticoids in patients with nasal polyps, and there appears to be a role for systemic antibiotics in the treatment of acute exacerbations of CRS with nasal polyps. The response to corticosteroids or antibiotics in the treatment of exacerbations of CRS without nasal polyps is variable. Due to the lack of appropriately designed trials, there is weak evidence for the adjunctive use of immunotherapy at this time. Monoclonal antibodies that target Immunoglobulin E and T helper cell 2 cytokines have been clinically effective in symptom reduction for some patients with CRS with nasal polyps although further studies are needed. CONCLUSION Current therapies used in the treatment of CRS are discussed.
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Affiliation(s)
- Newton Li
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Anselmo-Lima WT, Sakano E, Tamashiro E, Nunes AAA, Fernandes AM, Pereira EA, Ortiz É, Pinna FDR, Romano FR, Padua FGDM, Mello Junior JF, Teles Junior J, Dolci JEL, Balsalobre Filho LL, Kosugi EM, Sampaio MH, Nakanishi M, Santos MCJD, Andrade NAD, Mion ODG, Piltcher OB, Fujita RR, Roithmann R, Voegels RL, Guimarães RES, Meirelles RC, Paula Santos R, Nakajima V, Valera FCP, Pignatari SSN. Rhinosinusitis: evidence and experience: October 18 and 19, 2013 - São Paulo. Braz J Otorhinolaryngol 2015; 81:S1-S49. [PMID: 25697512 PMCID: PMC10157818 DOI: 10.1016/j.bjorl.2015.01.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Wilma T Anselmo-Lima
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (USP), São Paulo, SP, Brazil
| | - Eulália Sakano
- Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil
| | - Edwin Tamashiro
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (USP), São Paulo, SP, Brazil
| | | | | | | | - Érica Ortiz
- Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil
| | - Fábio de Rezende Pinna
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, SP, Brazil
| | - Fabrizio Ricci Romano
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, SP, Brazil
| | | | | | - João Teles Junior
- Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brazil
| | | | | | | | | | | | | | | | - Olavo de Godoy Mion
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, SP, Brazil
| | | | | | - Renato Roithmann
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Richard Louis Voegels
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, SP, Brazil
| | | | - Roberto Campos Meirelles
- Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brazil
| | | | - Victor Nakajima
- Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (UNESP), São Paulo, SP, Brazil
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Lee JT, Chiu AG. Topical anti-infective sinonasal irrigations: update and literature review. Am J Rhinol Allergy 2015; 28:29-38. [PMID: 24717876 DOI: 10.2500/ajra.2014.28.3988] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Sinonasal anti-infective irrigations have emerged as a promising therapeutic modality in the comprehensive management of chronic rhinosinusitis (CRS), particularly in the context of recalcitrant disease. The purpose of this article was to delineate the current spectrum of topical anti-infective therapies available and evaluate their role in the treatment of CRS. METHODS A systematic literature review was performed on all studies investigating the use of topical antimicrobial solutions in the medical therapy of CRS. Anti-infective irrigations were stratified into topical antibacterial, antifungal, and additive preparations according to their composition and respective microbicidal properties. RESULTS The use of topical antibiotic irrigations has been supported by low-level studies in the treatment of refractory CRS, with optimal results achieved in patients who have undergone prior functional endoscopic sinus surgery and received culture-directed therapy. Multiple evidence-based reviews have not established any clinical benefit with the administration of topical antifungals, and their use is not currently recommended in the management of routine CRS. Topical additives including surfactants may be beneficial as adjunctive treatment for recalcitrant CRS, but additional research is needed to investigate their efficacy in comparison with other agents and establish safety profiles. CONCLUSION Topical anti-infective solutions are not recommended as first-line therapy for routine CRS but may be considered as a potential option for patients with refractory CRS who have failed traditional medical and surgical intervention. Additional research is necessary to determine which patient populations would derive the most benefit from each respective irrigation regimen and identify potential toxicities associated with prolonged use.
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Affiliation(s)
- Jivianne T Lee
- Orange County Sinus Institute, Southern California Permanente Medical Group, Irvine, California, USA
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Abstract
PURPOSE OF REVIEW Biofilms have been observed on the sinus mucosa of patients with chronic rhinosinusitis and are associated with poor clinical outcomes after surgery. This article summarizes the recent studies which describe the efficacy of treating biofilms in chronic rhinosinusitis. RECENT FINDINGS Biofilms are polymicrobial communities comprised of bacteria that tend to be more antibiotic-resistant than when in planktonic forms. Antibiotic therapy against biofilms is usually associated with relapse following cessation of treatment and may also have an adverse effect on normal commensal microflora. Surfactants can improve clinical symptoms, but their use has been limited by side effects. Other treatment modalities that physically remove or disrupt biofilms, such as ultrasound, have shown some efficacy in small trials. The impact of surgery on biofilms has not been extensively investigated. SUMMARY The nature of biofilms makes their removal difficult. No currently available treatment directed against them has demonstrated lasting efficacy.
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Wang T, Su J, Feng Y. The effectiveness topical amphotericin B in the management of chronic rhinosinusitis: a meta-analysis. Eur Arch Otorhinolaryngol 2014; 272:1923-9. [PMID: 25217082 DOI: 10.1007/s00405-014-3269-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 08/29/2014] [Indexed: 12/28/2022]
Abstract
Chronic rhinosinusitis (CRS) is believed to be the result of an exaggerated reaction to fungi in the nasal mucosa, and topical amphotericin B (AMB) is a commonly used treatment. The purpose of this study was to perform a meta-analysis of high-quality comparative studies to examine the efficacy of topical AMB for the treatment of CRS. A search was conducted of Medline, Cochrane, EMBASE, and ISI Web of Knowledge until December 31, 2013 using combinations of the search terms chronic rhinosinusitis, human, treatment, antibiotics, nasal irrigation, nebulized, nasal lavage, sinonasal rinses, and antimicrobials. Inclusion criteria were (1) comparative studies, (2) a diagnosis of CRS or chronic sinusitis, and (3) the intervention was a topical antifungal. The primary outcome measure was quality of life (QOL), and the secondary was nasal endoscopy score. Of 235 article initially identified, five randomized controlled trials were included in the meta-analysis. Analysis of four studies with complete QOL data found no difference between treatment and placebo groups [standard difference in means 0.78, 95 % confidence interval (CI) -0.25 to 1.81, P = 0.138]. Analysis of four studies with complete nasal endoscopy score data found no difference between the treatment and placebo groups (standard difference in means 0.34, 95 % CI -0.08 to 0.76, P = 0.117). AMB is not more effective than placebo in improving QOL or nasal endoscopy scores in patients with CRS.
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Affiliation(s)
- Tianqi Wang
- Department of Otorhinolaryngology, Head and Neck Surgery Capital Medical University Xuanwu Hospital, No. 45 Changchunjie Street, Xicheng District, Beijing, 100053, China,
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Montone KT. The molecular genetics of inflammatory, autoimmune, and infectious diseases of the sinonasal tract: a review. Arch Pathol Lab Med 2014; 138:745-53. [PMID: 24878014 DOI: 10.5858/arpa.2013-0038-ra] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT The sinonasal tract is frequently affected by a variety of nonneoplastic inflammatory disease processes that are often multifactorial in their etiology but commonly have a molecular genetic component. OBJECTIVE To review the molecular genetics of a variety of nonneoplastic inflammatory diseases of the sinonasal tract. DATA SOURCES Inflammatory lesions of the sinonasal tract can be divided into 3 main categories: (1) chronic rhinosinusitis, (2) infectious diseases, and (3) autoimmune diseases/vasculitides. The molecular diagnosis and pathways of a variety of these inflammatory lesions are currently being elucidated and will shed light on disease pathogenesis and treatment. CONCLUSIONS The sinonasal tract is frequently affected by inflammatory lesions that arise through complex interactions of environmental, infectious, and genetic factors. Because these lesions are all inflammatory in nature, the molecular pathology surrounding them is most commonly due to upregulation and down-regulation of genes that affect inflammatory responses and immune regulation.
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Affiliation(s)
- Kathleen T Montone
- From the Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Gan EC, Thamboo A, Rudmik L, Hwang PH, Ferguson BJ, Javer AR. Medical management of allergic fungal rhinosinusitis following endoscopic sinus surgery: an evidence-based review and recommendations. Int Forum Allergy Rhinol 2014; 4:702-15. [PMID: 25044729 DOI: 10.1002/alr.21352] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Revised: 04/13/2014] [Accepted: 05/12/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Allergic fungal rhinosinusitis (AFRS) is a subset of polypoid chronic rhinosinusitis that is characterized by the presence of eosinophilic mucin with fungal hyphae within the sinuses and a Type I hypersensitivity to fungi. The treatment of AFRS usually involves surgery in combination with medical therapies to keep the disease in a dormant state. However, what constitutes an optimal medical regimen is still controversial. Hence, the purpose of this article is to provide an evidence-based approach for the medical management of AFRS. METHODS A systemic review of the literature on the medical management of AFRS was performed using Medline, EMBASE, and Cochrane Review Databases up to March 15, 2013. The inclusion criteria were as follows: patients >18 years old; AFRS as defined by Bent and Kuhn; post-sinus surgery; studies with a clearly defined end point to evaluate the effectiveness of medical therapy in postoperative AFRS patients. RESULTS This review identified and assessed 6 medical modalities for AFRS in the literature: oral steroids; topical steroids; oral antifungals; topical antifungals; immunotherapy; and leukotriene modulators. CONCLUSION Based on available evidence in the literature, postoperative systemic and standard topical nasal steroids are recommended in the medical management of AFRS. Nonstandard topical nasal steroids, oral antifungals, and immunotherapy are options in cases of refractory AFRS. No recommendations can be provided for topical antifungals and leukotriene modulators due to insufficient clinical research reported in the literature.
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Affiliation(s)
- Eng Cern Gan
- St Paul's Sinus Centre, Division of Otolaryngology-Head and Neck Surgery, University of British Columbia, Vancouver, BC, Canada
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Abstract
Chronic rhinosinusitis (CRS) is the second most common chronic medical condition in the United States. It represents a group of disorders characterized by inflammation of the nasal mucosa and paranasal sinuses of at least 12 weeks duration. CRS with or without nasal polyps is defined as inflammation of the nose characterized by two or more symptoms, one of which should be either nasal blockage, obstruction, congestion, or nasal discharge (anterior/posterior nasal drip); with or without facial pain/pressure; and/or with or without reduction or loss of smell. Symptomatology should be supported by obvious disease evident in either nasal endoscopy or computed tomography imaging. Although CRS is not likely to be cured by either medical or surgical therapy, it can generally be controlled. Best medical evidence supports maintenance therapy with intranasal corticosteroids and saline irrigation. For exacerbations, short to intermediate courses of antibiotics (up to 4-weeks) with or without oral corticosteroids are recommended. For patients with difficult-to-treat CRS, functional endoscopic sinus surgery provides an adjunctive therapeutic option.
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Affiliation(s)
- Russell A Settipane
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
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Ragab A, Samaka RM. Immunohistochemical dissimilarity between allergic fungal and nonfungal chronic rhinosinusitis. Am J Rhinol Allergy 2013; 27:168-76. [PMID: 23710950 DOI: 10.2500/ajra.2013.27.3882] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUNDS Diagnosis of allergic fungal rhinosinusitis (AFRS) is complicated because of the presence of fungi on mucosal surfaces of sinonasal passages. The objectives of this study were to define, using immunohistochemistry, lymphocyte populations associated with noninvasive fungal-related chronic rhinosinusitis (CRS; AFRS and FBs [FB]) relative to CRS with nasal polyposis (CRSwNP) and CRS without nasal polyposis (CRSsNP) as a means of diagnosing different forms of CRS. METHODS Sinus CT scans, nasal endoscopy scores, and the presence of eosinophilic fungal mucin or FBs were used to prospectively define patient groups with CRS who had failed medical treatment and were undergoing endoscopic sinus surgery. Four patient groups were identified: AFRS, FB, CRSwNP, and CRSsNP. Tissue specimens were studied and graded for histopathological changes. Immunophenotyping of mucosal lymphocytes was performed using anti-CD3, -CD20, -CD4, -CD8, -CD56, and -perforin antibodies. RESULTS Nasal polyposis scores were similar between AFRS and CRSwNP. Radiological changes associated with AFRS can also be present in CRSwNP, e.g., heterogenicity in 9/30 (30%), expansion in 25/30 (83%), and bony attenuation of the ethmoid trabeculae in 19/30 (63%). Different grades of basement membrane thickness, edema, and fibrosis were observed. In both types of noninvasive fungal rhinosinusitis, CD3+ T lymphocytes were most commonly identified. In cases of AFRS, most T cells were CD8+ (p < 0.001). In FB cases, CD4+ lymphocytes were dominant (p < 0.001). In nonfungal CRS cases, CD20+ lymphocytes (B lymphocytes) predominated (p < 0.001). CONCLUSION Although CT scans and histological examination can assist the diagnosis of rhinosinusitis, tissue immunophenotyping can be used in defining different types of fungal and nonfungal CRS cases.
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Affiliation(s)
- Ahmed Ragab
- Department of Otorhinolaryngology, Menoufia University Hospital, Shebin El-Kom, Egypt.
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Montone KT. Role of fungi in the pathophysiology of chronic rhinosinusitis: an update. Curr Allergy Asthma Rep 2013; 13:224-8. [PMID: 23247763 DOI: 10.1007/s11882-012-0332-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The pathogenesis of chronic rhinosinusitis (CRS) is multi-factorial with an infectious process likely at least partly involved. While bacteria have been proposed to play a critical role in CRS, fungi have also been implicated by some investigators, although the pathogenesis of fungi in CRS represents a significant controversy among rhinologists. Fungal-associated factors believed to be involved in CRS include the ability of fungi to induce significant inflammatory reactions by different means through inducing localized cytokine production in the sinonasal tract. Despite these observations, randomized, controlled studies on CRS patients using antifungal therapy have not resulted in significant improvement in CRS patients. The role of fungi in the pathogenesis of CRS remains controversial.
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Affiliation(s)
- Kathleen T Montone
- Division of Surgical Pathology, Department of Pathology and Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, 6 Founders, Philadelphia, PA 19104, USA.
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27
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Abstract
Chronic rhinosinusitis (CRS) is a common disorder characterized by mucosal inflammation of the nose and paranasal sinuses with sinonasal symptoms persisting for greater than 12 weeks. The etiology of CRS is incompletely understood. Current understanding supports inflammation, rather than infection, as the dominant etiologic factor. CRS significantly impacts patients' quality of life and health care expenditure. There is no standard management of CRS. Treatment strategies differ based on divergent etiologies of the various CRS subclasses. Both systemic and topical agents are used. These interventions differ in CRS with nasal polyposis (CRSwNP), CRS without nasal polyposis (CRSsNP) and specific situations such as allergic fungal rhinosinusitis or aspirin-exacerbated respiratory disease. Antibiotics are the most commonly prescribed medication for CRS, but their role in management is not strongly supported by high-level studies. This paper provides a succinct review of the evidence supporting or refuting common therapeutic agents in the management of CRS. Novel and emerging strategies will also be discussed.
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Affiliation(s)
- Rachel B Cain
- Department of Otorhinolaryngology, Mayo Clinic, Phoenix, AZ, USA
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