Maxillary sinus floor elevation using Beta-Tricalcium-Phosphate (beta-TCP) or natural bone: same inflammatory response

Sinus elevation is a common procedure to increase bone volume in the atrophic maxilla to allow placement of dental implants. Autogenous bone is the gold standard but is limited in quantity and causes morbidity at the donor site. β-TCP is a synthetic biomaterial commonly used in that purpose. It appears to induce a poor inflammatory response. This study aimed to evaluate the degree of edema of the sinus mucosa after sinus lift surgery according to the type of biomaterial. Forty sinuses (20 patients) were included retrospectively and divided into 2 groups according to the biomaterial that was used: synthetic biomaterial (BTCP group), natural bone (BONE group). A control group (CTRL group) was constituted by the non-grafted maxillary sinuses. Twelve measurements per sinus were realized on pre- and post-operative computed tomography and averaged to provide the sinus membrane thickness value (SM.Th). SM.Th was thicker post-operatively in the BTCP and BONE groups in comparison with the CTRL group and in comparison with pre-operative measurements. No difference was found post operatively between the BTCP and BONE groups. We found that a synthetic biomaterial (β-TCP) induced the same degree of edema, and thus of inflammation, as natural bone. It constitutes therefore an interesting alternative to autogenous bone for maxillary sinus lifts.

Multiple Mott Cells in Periapical Lesion of the Oral Cavity

An entity of bizarre plasma cells has been observed, containing spherical inclusions of immunoglobulins within the cytoplasm. These cells are termed as Mott cells and are believed to occur commonly in cases of chronic inflammation. Until now, they were reported to occur in systemic diseases, various hematolymphoid malignancies and in some syndromes; but their occurrence in chronic periapical infections of the oral cavity, given the paucity of available literature, raises questions about their obscure nature. In the present case report, a 24-year male presented with a draining sinus and periapical lesion involving the maxillary right incisors. After clinical and radiographic examination, an excisional biopsy sample of the periapical lesion was obtained. Histopathological examination revealed multiple bizarre Mott cells in the connective tissue stroma. The significance, nature or fate of these Mott cells is still unknown. Frequently overlooked or a chance occurrence, the presence of these multiple Mott cells in chronic inflammatory lesions of the oral cavity could be of some significance and demand increased awareness and further research.

Experimental Model of Fungal Sinusitis: A Pilot Study in Rabbits

We have established an experimental model of fungal sinusitis in rabbits to analyze the chronology and the pathogenesis of the development of noninvasive fungal sinusitis due to Aspergillus fumigatus. Thirty-four Pasteurella-free New Zealand white rabbits divided into three groups were included in this study. In the first group (10 rabbits), A fumigatus was inoculated into the maxillary sinus. In the second group (10 rabbits), A fumigatus was inoculated into the maxillary sinus in the presence of a wound in the mucosa. In the third group (14 rabbits), A fumigatus was inoculated into the maxillary sinus in the presence of a blocked ostium. On days 15 and 30, endoscopic, histopathologic, bacterial, and mycological examinations of both maxillary cavities and mucous membrane were performed. The rabbits were painlessly sacrificed 30 days after inoculation; mucosal and bone biopsies of the maxillary sinus cavities were performed for histopathologic studies. We found that noninvasive fungal sinusitis had been induced in 2 rabbits of the second group and 8 rabbits of the third group. We conclude that introduction of fungi into a sinus with a blocked ostium induces fungal sinusitis. The present model of experimental fungal sinusitis seems to be reproducible and suitable for further studies of the development of fungal sinusitis.

[Changes in the mucous membrane of the patients with chronic maxillary sinusitis caused by foreign bodies]

The objective of the present work was to study the morphofunctional changes in maxillary sinus mucosa of the patients with odontogenic maxillary sinusitis (OMS) associated with the presence of a foreign body depending on its duration. A total of 105 hospitalized patients were examined and operated. Biopsy samples taken from mucosa and contents of the maxillary sinuses during surgery were investigated. The histological study included the standard sample processing followed by paraffin embedding of the material and staining of the micropreparations with hematoxylin and eosin. It was shown that foreign bodies present in the maxillary sinuses cause marked structural reorganization of the mucous membrane usually with the predominance of hypertrophic and polypous changes.

[Frequency of detection of anaerobic microorganisms in the maxillary sinuses of patients with different forms of chronic maxillary sinusitis]

The aim of the investigation was to determine the frequency of detection of anaerobic microorganisms in the maxillary sinuses of patients with different forms of chronic maxillary sinusitis. 36 patients were examined. Fence clinical material was carried out from the walls of the maxillary sinus with transport tubes Ames during "Operation maxillary sinusotomy." In order to create anaerobic conditions, we used a set of equipment and supplies (manufacturer bio Mérieux, France) of a company bio Merieux in Ukraine--"Company Diaveritas." It was found that the presence of anaerobic infection is not typical for chronic sinusitis of the odontogenic origin. A wider range of pathogens (60%), observed in chronic odontogenic sinusitis with the presence of a foreign body in the lumen of the sinus. In the mixed associations set aside 50% of anaerobic flora.

Rare sarcoma presented as sinusitis

Myxofibrosarcoma (MFS) also known as myxoid variant of malignant fibrous histocytoma is one of the most common soft tissue sarcomas of the extremities in adult and elderly patients with rare occurrences in head and neck region. Low-grade MFS is unusual among low-grade sarcomas because it often recurs relentlessly and multiplies despite wide local resection with gross negative margins. We report a case of extreme rarity and a tumour of aggressive nature in the maxillary sinus, which presented with non-specific sinonasal symptoms and we present a review of the radiological and histopathological characteristics of this rare tumour and recent evidence of management.

[Observation on ultrastructure of maxillary sinus mucosa in experimental acute sinusitis]

OBJECTIVE

To observe ultrastructure of maxillary sinus mucosa of experimental acute sinusitis in rabbits.

METHOD

Twenty-five rabbits were randomly divided into experimental group (20 rabbits) and blank control group (5 rabbits). We established a rhinogenic model of experimental acute sinusitis in experimental group. Five rabbits chosen randomly in experimental group were sacrificed and dissected after 1, 2, 3, and 4 weeks, and the tissue (0.3 cm x 0.3 cm) of sinus mucosa were prepared for visualization by transmission electron microscope (TEM). Animals in blank control group were sacrificed after 1 week.

RESULT

Under the transmission electron microscope, in the blank control group, cilia of maxillary sinus mucosa lined up in order without ciliary loss, no stretched endoplasmic reticulum or turgescent mitochondria was observed. However, in the experimental group, inordinate array and loss of cilia was observed, a few compound cilia and cytoplasmic protrusion were also found. Both endoplasmic reticulum and mitochondria were swelling, and the lymphocytes were infiltrating with fibroblast proliferation in the submucosa. There was statistically significant difference between the experimental group and the blank control group (P < 0.05). In the experimental group, the number of compound cilia increased from 1 to 4 weeks, and the amount of compound cilia of the mucosa at 3 and 4 weeks was significantly higher than that at 1 week (P < 0.05). Swelling of mitochondria and endoplasmic reticulum was severe at 2 weeks and abated gradually with time, the results at 2 weeks were different from those of experimental group at 4 weeks (P < 0.05).

CONCLUSION

The obstruction of nasal sinuses and the bacterial infection might lead to ultrastructural changes of maxillary sinus mucosa, and these ultrastructural changes were believed to the important processes of pathological changes in acute sinusitis.

[Cellular and tissue reactions of the mucous membrane of the maxillary sinus in the patients presenting with odontogenic aspergillous maxillary sinusitis]

The results of this morphological study of the mucous membrane of the maxillary sinuses in the patients presenting with the non-invasive fungal form of odontogenic sinusitis revealed the signs of granulematous inflammation. Epithelium underwent metaplasia into the single-row cubic or prismatic layer. The invasive form of fungal odontogenic sinusitis was characterized by allergic inflammation with intensive infiltration of maxillary sinus mucosa by antigen-representing and effector cells.

[Influence of biological features of pathogens on maxillary sinus mucous chronic inflammation]

The morphological and microbiological research of maxillary sinus mucosa from 124 patients with the clinic diagnosis of chronic purulent maxillary sinusitis has been carried out. We've found out the correlation between morphological transformation of sinus mucosa and biological properties of leading microorganism.

[Specific features of the development of chronic inflammation in the maxillary sinus]

The present morphological study was based on the analysis of materials obtained during the surgical treatment of 64 patients aged from 15 to 68 years presenting with long-term chronic purulent maxillary sinusitis. All the patients had been inadequately treated with antibacterial preparations during the pre-hospitalization period. It was shown that the patients developed well-apparent pathomorphological changes in maxillary sinus mucosa that promoted chronization of the inflammatory process.

[Structure of maxillary sinus mucous membrane under normal conditions and in odontogenic perforative sinusitis]

Methods of light, electron microscopy and immunohistochemistry were used to study the samples of maxillary sinus (MS) mucous membrane (MM) under normal conditions and in odontogenic sinusitis. To study the normal structure, the samples were obtained at autopsy from 26 human corpses 12-24 hours after death. Electron microscopic and immunohistochemical study was performed on biopsies of grossly morphologically unchanged MS MM, obtained during the operations for retention cysts in 6 patients. MS MM in perforative sinusitis was studied using the biopsies obtained from 43 patients. The material is broken into 4 groups depending on perforative sinusitis duration. Under normal conditions, MS MM is lined with a pseudostratified columnar ciliated epithelium. Degenerative changes of ciliated epithelial cells were already detected at short time intervals after MS perforations and become apparent due to reduction of specific volume of mitochondria and, rough endoplasmic reticulum, and increase of nuclear-cytoplasmic ratio. In the globlet cells, the reduction of nuclear-cytoplasmic ratio was associated with the disturbance of the secretory product release. At time intervals exceeding 3 months, epithelium underwent metaplasia into simple cuboidal and stratified squamous keratinized, while in MS MM lamina propria, cellular infiltration was increased. CD4+ cell content in sinus MM gradually increased, while at late periods after perforation occurrence it decreased. Low CD4+ cell count within the epithelium and the absence of muromidase on the surface of MS MM was detected. With the increase of the time interval since MS perforation, the number of CD8+ and CD20+ cells in MS MM was found to increase.

[Morphofunctional changes of maxillary sinus mucosa in odontogenic fungal sinusitis]

Complex morphological research of maxillary sinus mucosa in odontogenic fungal sinusitis has revealed signs of granulomatous inflammation. In epithelium occurred metaplasia of simple cubic or columnar layer. Epithelium fiber-synthetic and plastic functions showed significant down-regulation.

Silent sinus syndrome causing cyclovertical diplopia masquerading as superior oblique paresis in the fellow eye

Silent sinus syndrome is an insidious maxillary sinus inflammatory disease causing a lowering, thinning, or even absorption of the orbital floor. Patients usually present with progressive enophthalmos and hypoglobus. We report a 41-year-old man with silent sinus syndrome who presented with cyclovertical diplopia masquerading as superior oblique muscle paresis in the fellow eye. Inferior oblique myectomy in the fellow eye resulted in excellent alignment.

Near-infrared imaging of the sinuses: preliminary evaluation of a new technology for diagnosing maxillary sinusitis

Diagnosing sinusitis remains a challenge for primary care physicians. There is a need for a simple, office-based technique to aid in the diagnosis of sinusitis without the cost and radiation risk of conventional radiologic imaging. We designed a low-cost near-infrared (NIR) device to transilluminate the maxillary sinuses. The use of NIR light allows for greater interrogation of deep-tissue structures as compared to visible light. NIR imaging of 21 patients was performed and compared with computed tomography (CT) scans. Individual maxillary sinuses were scored on a scale from 0 to 2 based on their degree of aeration present on CT and similarly based on the NIR signal penetration into the maxilla on NIR images. Our results showed that air-filled and fluid/tissue-filled spaces can be reasonably distinguished by their differing NIR signal penetration patterns, with average NIR imaging scores for fluid-filled maxillary sinuses (0.93+/-0.78, n=29) significantly lower than those for normal maxillary sinuses (1.62+/-0.57, n=13) (p=0.003). NIR imaging of the sinuses is a simple, safe, and cost-effective modality that can potentially aid in the diagnosis of sinusitis. Long-term, significant device refinement and large clinical trials will be needed to determine the diagnostic accuracy of this technique.

Silent sinus syndrome with spontaneous orbital floor reconstruction

PROBLEM

Silent sinus syndrome is rare and its pathophysiology is unclear. We report a case of silent sinus syndrome characterized by progressive enophtalmos with chronic maxillary atelectasis and asymptomatic chronic maxillary sinusitis.

METHODOLOGY

The patient had no history of sinusitis, facial trauma, or sinus surgery. Computed tomography revealed opacification of the right maxillary sinus and inferior bowing of the osteopenic orbital floor. Silent sinus syndrome was diagnosed and functional endoscopic maxillary antrostomy without orbital floor reconstruction was performed.

RESULTS

At one-year follow-up, computed tomography showed optimal ventilation of the maxillary sinus, restoration of the orbital floor, and withdrawal of the orbital content to its normal position.

CONCLUSION

Endoscopic maxillary antrostomy without orbital floor reconstruction is effective and associated with limited risks for complications; however, the results are observed in the long term.

[The analysis of the bacterial and fungal flora in maxillary sinuses in patients operated due to FESS method]

INTRODUCTION

The aim of this work was to analyse the bacterial and fungal flora in maxillary sinuses in patients operated due to the FESS method.

MATERIAL AND METHODS

Studies were conducted on 110 patients, including 47 women aged 17-78 and 63 men aged 17-66, who underwent endoscopic surgical procedures due to chronic polypoid maxillary sinusitis between 2006 and 2007. 214 cultures were prepared altogether. During the endoscopic operation on paranasal sinuses, a cannula was introduced along the natural entrance and material for the culture and antibiogram was removed by suction.

RESULTS

In the studied material of 214 cultures, 72 (33.6%) cultures obtained positive results, including 2 cases with bacterial and fungal floras present simultaneously (Aspergillus fumigatus and Aspergillus niger) in 38 operated patients. In 25 (34.5%) cultures we noted the presence of Staphylococcus epidermidis, which was sensitive to the following antibiotics: Cotrimoxazole, Rifampicin, Vankomycin, Teicoplanin and Levofloxacin. Staphylococcus epidermidis was isolated in 22 (31.0%) cultures, showing 100% sensitivity to similar antibiotics like the previous one. Another bacteria (Escherichia coli) was cultured in 10 cultures (13.8%), in 70% of the cases every second bacteria was Staphylococcus epidermidis with 100% sensitivity mainly to cephalosporins and aminoglycosides. In 3 cultures (4.17%) we found Klebsiella pneumoniae, with 100% sensitivity to cephalosporins and aminoglycosides and 100% resistance to penicillins. In three cases Pseudomonas fluorescens and Proteus mirabilis (4.17% each) were cultured with their sensitivity and resistance similar to those of Klebsiella pneumoniae. Two cases (2.8% each) in the cultures were noted: Citrobacter freundii, Streptococcus oralis and Hafnia alvei, which were 100% sensitive to some cephalosporins and aminoglycosides whereas their resistance to penicillins and Cefuroxime was as high as 100%.

CONCLUSION

In the operated patients suffering from chronic polypoid maxillary sinuses we found 33.6% of positive results in the bacterial flora. This indicates that the changes were accompanied by an acute inflammatory condition, thus surgical procedures had to be followed by a guided antibiotic. The cultured bacteria demonstrated sensitivity to some cephalosporins and aminoglycosides and resistance to penicillins, which proves the abuse of penicillins in the treatment of acute inflammatory states of upper airways.

Development of maxillary accessory ostium following sinusitis in rabbits

OBJECTIVES/HYPOTHESIS

Maxillary accessory ostium is one of the anatomical variations that may play a role in the development of chronic maxillary sinusitis. Although some authors claim that accessory ostia develop following acute maxillary sinusitis, it is not clear whether they are congenital or acquired.

STUDY DESIGN

Animal experimental study.

METHODS

Ten New Zealand type rabbits were used in the study. In phase 1, lateral nasal walls of five New Zealand type rabbits were examined for the presence of natural and accessory ostia of the maxillary sinus and any area resembling fontanelles in humans. In phase 2, experimental sinusitis was induced in the right sides of the other five rabbits. Following sacrifice, lateral nasal walls were examined for the development of accessory ostia.

RESULTS

Six of the ten sides of phase 1 animals contained a membranous part in the medial wall of the maxillary sinus resembling the fontanelles in humans (60%). None of them had an accessory maxillary ostium. Accessory ostia developed in two of the five sides with sinusitis (40%).

CONCLUSIONS

We have shown for the first time that accessory maxillary ostia develop following experimental sinusitis in rabbits. Further studies in humans are indicated.

[Clinical application of a modified trocar for the treatment of maxillary sinus pathology]

A new instrument has been developed to facilitate access into a maxillary sinus for the purpose of diagnostic endoscopy and adequate surgical sanation. The cannula of this trocar has a proximal coniform portion and a distal cylindrical part with a lateral aperture and a fixing tip. Such design ensures perfect sanation of the maxillary sinus. The instrument has three stylets one of which (non-traumatic) makes possible the approach to the canine fossa and two others (having concave edges and shaping knife-like blades) to the maxillary sinus. These two stylets are used to gently cut the anterior wall of the sinus and obtain osteo-periosteal fragments in the form of three lobes. Maxillary microsinusotomy being completed, the lobes become spontaneously apposed which leads to rapid healing and formation of a soft scar along the section line as well as to complete restoration of the anterior wall of the maxillary sinus. Cannulas of two different diameters are available that enable the instrument to be used for the treatment of adults and children.

Correlation of the ethmoid infundibulum to the medial orbital wall in maxillary sinus hypoplasia: "infundibular lateralization" a diagnostic CT finding

In patients with chronic rhinosinusitis, the presence of maxillary sinus hypoplasia (MSH) may be obscured by extensive mucosal disease or nasal polyposis. Recognition of MSH and its effect on adjacent anatomic structures is of utmost clinical significance in endoscopic sinus surgery. Failure to recognize the impact that MSH has on the position of the ethmoid infundibulum relative to the medial orbital wall could lead to inadvertent damage to the wall during surgery. We conducted a prospective study of 75 patients with clinically and endoscopically proven chronic rhinosinusitis to evaluate the prevalence of MSH. We found that MSH was present in 12 patients (16.0%); 7 of the 75 patients (9.3%) had bilateral disease, and 5 (6.7%) had unilateral disease. We then correlated the relationship of the ethmoid infundibulum to the medial orbital wall as determined by computed tomography in patients with and without MSH. We found that in most cases of MSH, the ethmoid infundibulum was displaced lateral to the medial wall of the orbit; the correlation between MSH status and displacement was statistically significant (p < 0.05). We propose the term "infundibular lateralization" to describe this consistent radiologic finding in MSH.

Ethmomaxillary sinus

Ethmomaxillary sinus is a variation of the posterior ethmoid cells. It is formed by the extension of the posterior ethmoid cells into the maxillary sinus and drains into superior nasal meatus. It is incidentally seen on paranasal sinus computerized tomography (CT) scans. Its prevalence has been reported as 0.7 and 2% in two studies. In this study, paranasal CT scans of 466 patients were investigated for the presence of ethmomaxillary sinus. The patients had paranasal CT with the preliminary diagnoses of septal deviation, chronic inflammatory paranasal sinus disease and nasal turbinate disorders. The ethmomaxillary sinus was present in nine of those patients (1.93%). It was septated in one of them. The CTs were further investigated for other anatomical variations and co-existent mucosal disease of the paranasal sinuses.

Bone changes after maxillary sinus surgery: an experimental scanning electron microscopy study

AIMS

The purpose of this study was to explore the pathogenic role of bone in sinus surgery, and to determine whether mucosal disease after sinus surgery may be induced by underlying disease within the bone.

MATERIAL AND METHODS

Twenty-five rabbits were divided into five groups. In group one, wide surgical removal of the maxillary sinus mucosa and creation of a nasoantral window were undertaken. In group two, only nasoantral window creation was undertaken. In group three, the mucosa of the anterior maxillary sinus was removed. In group four, a strip of mucosa around the ostium was removed. Group five was used as a control.

RESULTS

After three months, in the groups which had undergone wide surgical removal, the medial sinus walls were observed to be retracted and the inner curtain of the bone disturbed, with alteration of the haversian canal system and osteoclastic bone resorption.

CONCLUSIONS

After radical sinus surgery, electron microscopic changes were observed in the bony walls, similar to those changes seen in osteomyelitis.

An animal model for the study of topical medications in sinusitis

BACKGROUND

Rhinosinusitis after functional endoscopic sinus surgery often is recalcitrant to conventional medical management. Topical therapies have been popularized as a method to deliver powerful medications to diseased mucosa while limiting systemic toxicity. The aim of this study was to develop an animal model that will provide objective data in studying the efficacy of topical medications and establish a platform for translation to human clinical trials.

METHODS

The maxillary sinus ostium of white rabbits was obstructed with a pledget through an antrostomy created in the anterior face of the maxilla. The sinus was inoculated with Pseudomonas aeruginosa (PAO1) and 7 days later the antrostomy was reopened, the ostial obstruction was removed, and a single lumen catheter was placed. Normal saline was irrigated through the catheter for 7 days in one group of rabbits while a control group received no irrigation. At the end of 7 days, the rabbits were euthanized, analyzed under light microscopy, and bacterial counts of the nasal lavage were determined.

RESULTS

Sinusitis was confirmed in all rabbits 7 days after inoculation. Purulence, mucosal, and underlying bony inflammation persisted in both the control and the saline irrigation groups at study end. Nasal lavage bacterial counts were persistently elevated throughout the study period, indicative of bacterial viability.

CONCLUSION

An animal model has been created for the study of topical medications in sinusitis. A novel catheter delivery system within an unoccluded maxillary sinus is described that will aid in efficacy studies of topical medications in the management of recalcitrant rhinosinusitis.

Computed tomographic assessment of chronic rhinosinusitis with asthma

BACKGROUND

The purpose of this study was to investigate differences in the extent of disease in patients with chronic rhinosinusitis (CRS) both with and without asthma.

METHODS

Medical records and computed tomographic (CT) scans of 48 consecutive asthmatic patients and 523 nonasthmatic patients with CRS between April 1995 and December 2001 were reviewed, retrospectively. Each sinus in the ostiomeatal complex CT scans was assigned a score of 0-2 according to the extent of disease using the Lund-Mackay scoring system, and the ratios of the score of each sinus to the total score were analyzed for the difference between the asthmatic and nonasthmatic groups. A Mann-Whitney test was used for statistical evaluation, with p < 0.05 accepted as statistically significant.

RESULTS

The ratios of ethmoid sinus score to total score were higher in asthmatic patients than in nonasthmatic patients (p < 0.001), and the ratios of the score of maxillary sinus to total score were lower in asthmatic patients than in nonasthmatic patients (p < 0.001).

CONCLUSION

Our study shows that the ethmoid sinus is the preferred site of CRS in patients with coexisting asthma.

Use of an in vitro assay for determination of biofilm-forming capacity of bacteria in chronic rhinosinusitis

BACKGROUND

Bacterial biofilms are increasingly implicated in the pathogenesis of chronic disease and have been established in several chronic ear, nose, and throat conditions, including chronic sinusitis (CRS). However, this relies on specialized imaging methods not widely available. We wished to assess the capacity of an easily performed, inexpensive in vitro test to assess biofilm production by bacteria recovered from individuals with CRS with or without nasal polyposis.

METHODS

Bacterial isolates were recovered from patients consulting an academic tertiary rhinology practice. Biofilm formation was determined with an in vitro staining method using crystal violet. Ten isolates of Pseudomonas aeruginosa, Staphylococcus aureus, and 11 of coagulase-negative staphylococcus from patients with CRS having previously undergone endoscopic sinus surgery for >1 year were assessed. Samples were cultured 24 hours at 37 degrees C on 96-well plates in tryptic soy broth 0.5% glucose medium. After staining with crystal violet, optical density at 570 nm was measured to quantify biofilm production. Biofilm-forming capacity was compared with positive and negative controls for each species obtained from commercial sources.

RESULTS

Positive controls all grew biofilms, with a tendency of lesser biofilm formation at higher dilutions. Twenty-two of 31 clinical samples produced a biofilm greater or equal to the positive control. Biofilm was recovered consistently for all three species studied.

CONCLUSION

This in vitro assessment method is capable of detecting biofilm-forming capacity in bacteria recovered from individuals with CRS. This simple assay may be a useful complement to existing techniques for clinical research.

A bioarcheological study of maxillary sinusitis

Maxillary sinusitis was studied as an indicator of poor air quality. Seven skeletal samples were examined from North America, England, and Nubia, and selected to represent different geographic locations, environments, and subsistence economies. Frequency rates varied from 17.2 to 51.5% of individuals affected with one or both sinuses preserved. Hardin Village had the highest frequency (51.5%), followed by the Aleuts (42.9%), "Illinois" (38.6%), Indian Knoll (38.5%), Kulubnarti (21.8%), Christchurch, Spitalfields (18.0%), and "South Dakota" (17.2%). Male frequencies ranged from 16.7 to 36.7%, but the female frequency ranged more widely from 18.0 to 76.5%. At most sites female rates exceeded male. The effect of urban and rural environment on sinusitis occurrence, and also subsistence economy, biological sex, and social status were explored, and comparative sites also considered; urban agricultural sites had a mean frequency of 48.5%, rural agricultural sites had a mean frequency of 45.0%, and hunter-gatherer sites had a mean frequency of 40.0%. In the urban sites male and female frequencies were near equal, but in the rural agricultural and hunter-gatherer sites female frequencies exceeded male frequencies. Dental disease was not found to have much impact on sinusitis frequency. The importance of the link between poor air quality and respiratory health is highlighted in clinical studies in both developed and developing countries, but also in bioarcheological studies.

A comparison between functional and radical sinus surgery in an experimental model of maxillary sinusitis

PURPOSE OF THE STUDY

To compare functional and radical surgery in a maxillary sinusitis' treatment during in vivo experiments in rabbits.

METHODS

An experimental chronic maxillary sinusitis was induced in 21 New Zealand white rabbits by inducing mucosal trauma combined with an injection of Streptococcus pneumoniae, and a maxillary sinus ostium occlusion during 28 days. Functional surgery (FS) by reopening the natural ostium and radical surgery (RS) by reopening the natural ostium were performed in association with removal of the sinus mucosa. They were macroscopically and histologically evaluated 15 days, 1 month and 2 months after the surgery.

RESULTS

FS had diminished chronic inflammatory criteria (lymphoid and plasma cells) faster that RS ([15 days (p = 0.016)]; [1 month (p = 0.03)]; [2 months (p = 0.03)]). Mucosa fibrosis was more important after RS ([15 days (p = 0.016)]; [1 month (p = 0.03)]; [2 months (p = 0.016)]).

CONCLUSION

FS accelerates healing with less fibrosis that RS in pathological mucosa altered by a chronic inflammation.

Development and characterization of an animal model of dental sinusitis

CONCLUSION

The results of this study confirm that the present rabbit model of dental maxillary sinusitis (dMxS) is reproducible and simulates human dental sinusitis with respect to initiation, progression and inflammation. It is applicable to further studies of sinusitis of odontogenic origin.

OBJECTIVES

To induce acute dMxS in rabbits by using their own oral microflora to create a periapical infection and to follow morphological, radiographic, bacteriological and histological changes to the sinus mucosa.

MATERIAL AND METHODS

The experimental animals comprised 26 New Zealand White rabbits. Maxillary premolar root canals were identified bilaterally and the continuously growing germs of the roots were severed by diathermy. The animals were randomized into 2 groups: in Group 1 (n=20) the teeth were left open for the entire study period; in Group 2 (n=6) the root canals were sealed 1 week after the initial intervention. The animals in Group 1 were sacrificed at intervals ranging from 2 h to 9 months after intervention. All animals in Group 2 were sacrificed 6 months after intervention. After macroscopic and radiographic examination, post-mortem inspection of the paranasal sinus cavity and maxillary complex and microbiological sampling, the entire nasal sinus complex with the hard palate in situ was resected and processed for serial coronal sectioning.

RESULTS

In Group 1, after 3 months, the radiographic changes ranged from widening of the periodontal space to bone reaction. At sacrifice, changes in the sinus mucosa ranged from signs of mucosal inflammation to purulent dMxS. Microbial growth, predominantly Gram-negative aerobes, increased over time. In Group 2, the findings were generally more pronounced. Anaerobic microorganisms were predominant. In both groups the findings were consistent with dMxS.

Normalization of maxillary sinus mucosa after functional endoscopic sinus surgery in pediatric chronic sinusitis

OBJECTIVES

To observe the recovery of maxillary sinus mucosa after endoscopic sinus surgery in children with chronic maxillary sinusitis. Functional endoscopic sinus surgery (FESS) was used to perform a middle meatal antrostomy, leaving the antral mucosa intact for later observation.

METHODS

Between January 1998 and December 2003, 43 children with chronic sinusitis were enrolled in the study. Pre-operative patient profiles, including a history of symptoms, signs and allergies, were collected. Phidiatap test was used to check allergy. Saccharine transit time tests were performed for each side of the nasal cavity. Under endoscopic observation, the antral mucosa was macroscopically divided into edematous and polypoid types.

RESULTS

Sixty-four (76.2%) of the 84 antrums had edematous type mucosa in which 73.4% (48/64) of cases were found to have returned to normal within 8 weeks. The polypoid antral mucosa exhibited a slower recovery with 80% (16/20) returning to normal within 4 months. The preoperative saccharine transit time significantly correlated with recovery of the antral mucosa (p < 0.05), but allergy did not (p > 0.05).

CONCLUSION

The antral mucosa in children with chronic maxillary sinusitis was predominantly of the edematous type. Most recovered within 2 months of having FESS. The prolonged saccharine transit time and polypoid type antral mucosa were associated with delayed mucosal recovery, warranting follow-up of more than 4 months.

Demonstration of biofilm in human bacterial chronic rhinosinusitis

BACKGROUND

Bacterial biofilms may explain why some patients with bacterial chronic rhinosinusitis (CRS) improve while on antibiotics but relapse after completion of the antibiotic. In the human host, biofilms exist as a community of bacteria surrounded by a glycocalyx that is adherent to a foreign body or a mucosal surface with impaired host defense. Biofilms generate planktonic, nonadherent bacterial forms that may metastasize infection and generate systemic illness. These planktonic bacteria are susceptible to antibiotics, unlike the adherent biofilm.

METHODS

We reviewed four cases of CRS using transmission electron microscopy (TEM) to assay for typical colony architecture of biofilms. Bacterial communities surrounded by a glycocalyx of inert cellular membrane materials consistent with a biofilm were shown in two patients.

RESULTS

In the two patients without biofilm, a nonbacterial etiology was discovered (allergic fungal sinusitis) in one and in the other there was scant anaerobic growth on culture and the Gram stain was negative. Culture of the material from the biofilm grew Pseudomonas aeruginosa in both patients. Pseudomonas from the biofilm showed a glycocalyx, not present in Pseudomonas cultured for 72 hours on culture media. Both patients' symptoms with bacterial biofilms were refractory to culture-directed antibiotics, topical steroids, and nasal lavages. Surgery resulted in cure or significant improvement.

CONCLUSION

Biofilms are refractory to antibiotics and often only cured by mechanical debridement. We believe this is the first TEM documentation of bacterial biofilms in CRS in humans.

Bacterial location in chronic sinusitis

BACKGROUND

In chronic nonallergic sinusitis, it is often assumed that bacteria invade the sinus mucosa where the inflammatory condition begins and is maintained. However, the bacterial presence in a normal or moderately damaged epithelial layer has never been proved in biopsy studies.

METHODS

In this study, mucosal samples from six consecutive patients with chronic sinusitis were examined. Transmission electron microscopy was used and the presence of bacterial invasion and formation of phagosomes containing bacteria as a marker of host response were studied.

RESULTS

Phagocytosis of bacteria was observed in the sinus mucosa in samples from only one patient. In the other five patients, no signs of phagocytosis were seen.

CONCLUSION

Based on these results, we concluded that in chronic sinusitis, bacterial invasion in sinus mucosa is not an obligatory phenomenon.

Bacteriology of chronic maxillary sinusitis associated with nasal polyposis

Aspirates from 48 chronically inflamed maxillary sinuses from patients who had nasal polyposis were processed for aerobic and anaerobic bacteria. Bacterial growth was present in 46 (96%) specimens. Aerobic or facultative bacteria were present in 6 (13%) specimens, anaerobic bacteria alone in 18 (39%), and mixed aerobic and anaerobic bacteria in 22 (48%). There were 110 bacterial isolates (2.4 per specimen). Thirty-nine of the isolates were aerobic or facultative organisms (0.85 per specimen). The predominant aerobic or facultative organisms were: Staphylococcus aureus, microaerophilic streptococci, Haemophilus influenzae and Moraxella catarrhalis. Seventy-one anaerobes were isolated (1.5 per specimen), Peptostreptococcus spp., Prevotella spp., Porphyromonas asaccharolytica and Fusobacterium spp. being predominant. These findings illustrate for the first time the presence of polymicrobial aerobic-anaerobic flora in patients with chronic maxillary sinusitis who had nasal polyposis.

Rhinocerebral mucormycosis: pathways of spread

Rhinocerebral mucormycosis is an invasive, opportunistic fungal infection usually seen in immunocompromised patients, and particularly in the setting of diabetes or immune deficiency. It is assumed that the port of entry is colonization of the nasal mucosa, allowing the fungus to spread via the paranasal sinuses into the orbit. Involvement of the brain and cavernous sinus occurs by way of the orbital apex; therefore, spheno-ethmoidectomy with or without maxillectomy seems to be the definitive method to eradicate this infection. We conducted a prospective study of ten patients with rhinocerebral mucormycosis from February 2000 to April 2004. Rhinocerebral mucormycosis was clinically diagnosed in 11 patients, 10 of whom were included in our study upon histopathological confirmation. Diabetes was the most common underlying disorder seen in nine out of ten patients. In this study, the patients were assessed for predisposing factors, presenting signs and symptoms, sites of extension, the number and sites of surgical debridement, as well as the outcome. Ocular, sinonasal and facial soft tissue involvement was common. Involvement of the pterygopalatine fossa at the time of debridement was evident in all patients. No invasion through the lamina papiracea or the walls of the maxillary sinus was identified. At the time of this communication, six out of ten patients were alive. For the four who died, the causes were hypokalemia, cardiac arrythmia and refractory pneumonia. Pterygopalatine fossa is considered to be the main reservoir for rhinocerebral mucormycosis, and extension into the orbit and facial soft tissues usually follows this route. After proliferation in the nasal cavity, the mucor reaches the pterygo-palatine fossa, inferior orbital fissure and finally the retroglobal space of the orbit, resulting in ocular signs. The facial soft tissues, palate and infratemporal fossa can be infected through connecting pathways from the pterygo-palatine fossa; therefore, debridement of the pterygopalatine fossa seems to be the definitive method of managing this infection.

[Influence of the nasogastric tube in the pathology of the maxillary sinus]

INTRODUCTION

Nasoesophageal tube (NT) is very often used by the ear, nose and throat specialists in head and neck oncological surgery. It is well known the irritative effect that it has on the nasosinusal mucosa. The aim of this study is to analyze the relationship between the use of the NT and the pathology of the maxillary sinuses.

MATERIAL AND METHOD

The study was carried out in 25 patients treated in our department who had been fed by NT, after surgery. A plain sinus X-ray was performed in the pre-operatory period and a control radiograph in the post-operatory period, and the results have been analyzed.

RESULTS AND CONCLUSIONS

No sinusitis had been observed whatever length of time the NT remained in situ.

Maxillary sinus pathology in 119 patients--a histopathologic study

INTRODUCTION

Information on histopathological changes within sinus mucosa is lacking, both in the general population, and in subjects with specific facial morphology and chronic respiratory obstruction.

AIMS AND OBJECTIVES

To provide baseline data of the frequency and nature of pathological changes in the maxillary sinus in a specified group of patients.

METHODS

119 patients undergoing elective maxillary osteotomies were selected. These included patients with (70) and without (49) vertical maxillary excess (VME), and mouth and nasal breathers. The frequency and nature of the histopathological changes within the maxillary antral lining were recorded.

RESULTS

Patients ranged from 13 to 47 years, with a M:F ratio of 1:2.4. The findings included congestion (95%), submucosal oedema (90%), retention cysts (26%), true polyps (4.6%) and inflammation. There was eosinophilia (68%), basement membrane thickening (28%), goblet cell hyperplasia (95%) and dystrophic calcification (59%).

CONCLUSIONS

A significant degree of sinus pathology was found in this specified group of patients. This was probably due to their living in a polluted urban environment. In the presence of such widespread pathological changes and the virtual impossibility of obtaining "normal" control tissue, investigators may find it impossible to correlate maxillary sinus pathology with either facial form or breathing pattern.

Endothelial L-selectin ligands in sinus mucosa during chronic maxillary rhinosinusitis

RATIONALE

Chronic rhinosinusitis is characterized by persistent inflammation of the nasal and paranasal mucosa with numerous emigrated leukocytes. L-selectin on leukocytes and its endothelial glycosylated ligands initiate organ-specific leukocyte infiltration into inflamed tissues.

OBJECTIVES

The purpose of this study was to evaluate the endothelial expression of functionally active endothelial L-selectin ligands, sulfated sialyl Lewis x, in maxillary sinus mucosa from patients with chronic rhinosinusitis and from normal control subjects.

METHODS

Maxillary sinus mucosa specimens (116) were obtained surgically and immunohistochemically stained with monoclonal antibodies detecting sialyl Lewis x or sulfated extended core 1 lactosamines. The severity of the inflammation was determined by intraoperative endoscopic findings, computed tomography scans, and histopathologic assessment of the specimens.

MEASUREMENTS AND MAIN RESULTS

The percentage of vessels expressing endothelial sulfated sialyl Lewis x epitopes increased during chronic rhinosinusitis compared with uninflamed control tissue, especially in patients with additional allergic rhinitis, and decreased in specimens from aspirin-intolerant patients with preoperative oral corticosteroid treatment. In addition, the expression level of endothelial sulfated sialyl Lewis x epitopes and the number of mucosal eosinophils correlated with the severity of the inflammation, and decreased in specimens taken 9 months postoperatively compared with intraoperative samples, especially in patients with intranasal corticosteroid treatment.

CONCLUSIONS

Our results suggest that functionally active L-selectin ligands might guide leukocyte traffic into maxillary sinus mucosa preferentially in patients with severe findings of chronic maxillary rhinosinusitis, thus leading to aggravation of the inflammation.

[Mucosal pathologic and ultrastructure changes of experimental maxillary sinusitis in rabbits]

OBJECTIVE

To investigate mucosal pathologic and ultrastructure changes relate to experimental maxillary sinusitis process in rabbits. The demarcation of acute and chronic maxillary sinusitis will be determined according to pathologic effects.

METHOD

Thirty New Zealand white rabbits have been induced sinusitis will be divided into different groups according to the time of process. The pathologic changes are observed by microscope, scanning electric microscope and transmission electric microscope.

RESULT

Within 3 weeks to induce infection the inflammation mainly show in acute style while after 3 weeks the main manifestation are chronic changes. In epithelium layer cilia shedding increased, the number of goblet cell added, squamous epithelium metaplasia and epithelia necrosis were observed during inflammatory process. In lamina propria glands metaplasia and decreased, the fibrosis is densed.

CONCLUSION

The pathologic changes of maxillary mucosa are related to process. The borderline of acute and chronic experimental maxillary sinusitis is 3 weeks.

Periorbital swelling: the important distinction between allergy and infection

Orbital cellulitis and abscess formation are rare complications of sinusitis, however acute orbital inflammation is secondary to sinusitis in about 70% of cases. Delay in diagnosis must not occur to avoid serious complications such as blindness and life threatening intracranial sepsis. A case is reported in which despite late referral, emergency surgical intervention was sight saving.

Unusual recurrence in ureters and maxillary sinus of Langerhans cell histiocytosis involving mastoid bone

We present a case of Langerhans cell histiocytosis (LCH) diagnosed in the mastoid bone. The tumor recurred in the ureter and maxillary sinus mucosa two years later. The diagnosis of LCH was based on morphology and immunohistochemistry. Involvement of the ureter and the maxillary sinus in LCH is extremely rare. To the best of our knowledge, this is the first case of LCH affecting the mastoid bone in a 16-year-old boy and recurring later in the ureter and maxillary sinus mucosa.

Evidence of bacterial biofilms in a rabbit model of sinusitis

BACKGROUND

Bacterial biofilms have been documented on middle ear mucosa, tonsils, and cholesteatoma. In addition, we have described previously bacterial biofilms on frontal recess stents placed during surgery for chronic sinusitis. We hypothesize that bacterial biofilms are present on the mucosa of animals with sinuses experimentally infected with Pseudomonas aeruginosa.

METHODS

We instilled Pseudomonas aeruginosa at log phase growth into the right maxillary sinus in 22 New Zealand white rabbits and harvested specimens 1-20 days later. We then examined the tissues with scanning electron microscopy (SEM) and light microscopy. Mucosa from the middle turbinate on the contralateral side was used as a control.

RESULTS

We identified evidence of bacterial biofilms on the mucosa of all 22 animals under SEM. Twenty-one of 22 animals had sinus cultures positive for Pseudomonas. Bacterial biofilms were identified by evidence of glycocalyx, water channels, and three-dimensional structure. These images were similar to other images of known biofilms.

CONCLUSION

This is evidence of the presence of bacterial biofilms in an animal model of sinusitis. This model may serve as a means to study the efficacy and safety of pharmacologic and surgical treatments on the disruption and elimination of bacterial biofilms. Additional study into the role of bacterial biofilms in perpetuating chronic sinusitis is warranted.

A case of Wegener?s granulomatosis with pulmonary bleeding successfully treated with double filtration plasmapheresis (DFPP)

We report a case of a 41-year-old Japanese man who presented with rapidly progressive glomerulonephritis, chronic sinusitis, and positive cytoplasmic-antineutrophil cytoplasmic antibody (c-ANCA). Renal biopsy showed crescentic glomerulonephritis, and he was diagnosed as having Wegener's granulomatosis. During the clinical course, he suffered from pulmonary bleeding, and combination therapy of steroid, immunosuppressant, and double filtration plasmapheresis (DFPP) was started. He rapidly entered remission after assistance through DFPP, suggesting the potential efficacy of DFPP for Wegener's granulomatosis, especially with pulmonary bleeding.

[Infection transfer between the maxillary sinus and endocranium]

BACKGROUND

Rhinogenous brain abscesses usually originate from a frontal sinusitis, rarely from the ethmoidal system or the maxillary sinus. However, there are different pathways that can lead to the transfer of a maxillary infection to the endocranial compartment.

PATIENT

A patient with frontal brain abscesses originating from a maxillary sinus infection is presented and diagnostic steps, therapy as well as pathophysiology are discussed.

PATHOPHYSIOLOGY

The venous plexus of the maxillary sinus drains through the posterior wall of the antrum of Highmore into the deep facial vein that leads into the pterygoid plexus and then through the rete foraminis ovalis into the cavernous sinus. In addition, numerous small veins perforate the osseous roof of the maxillary sinus and enter the orbit joining the superior or inferior ophthalmic vein. They are also connected to the cavernous sinus or the pterygoid plexus. A number of veins perforate the anterior wall of the maxillary sinus communicating with the angular vein that drains into the superior ophthalmic vein and into the cavernous sinus. From the cavernous sinus, the blood arrives at the deep middle cerebral vein that usually communicates through the white substance towards the brain's superficial venous system.

CONCLUSION

The presence of these maxillo-cerebral venous anastomoses explains the spread of infection from the maxillary sinus to the white substance of the brain without any direct association with the base of the skull.

[Efficacy of cefotiam hexetil in acute maxillary sinusitis, with a short five day vs ten day treatment]

OBJECTIVE

The aim of this multicentric, randomized, double blind study with direct individual benefit, was to compare two therapeutic regimens of cefotiam hexetil administration, 5 days vs 10 days, in acute maxillary sinusitis.

METHOD

The study was conducted in ambulatory patients treated by general practitioners according to AFSAPS (French agency for sanitary safety) guidelines for treatment of acute maxillary sinusitis. Five hundred and fifty three GPs included 1042 patients presenting with acute maxillary sinusitis in the study from December 2000 to July 2001. Patients were randomly treated with cefotiam hexetil 200 mg bid over a 5 day period followed by 5 days of placebo, or with cefotiam hexetil 200 mg bid over a 10 day period.

RESULTS

No significant difference was noted in each treatment group. Radiography performed in 72.2% of included patients confirmed the diagnosis in 78.8% of the cases. No significant difference occurred in the number and percentage of cured patients. In the ITT analysis (1018 patients) the clinical cure rates were respectively 85.5% and 85.3% in the 5 day and in the 10 day treatment groups, In the PP analysis (800 patients) the clinical cure rates were respectively 88.6% in each group. The low incidence of adverse effects (3.36%) was confirmed in both groups.

CONCLUSION

A 5 day course of cefotiam hexetil 200 mg bid is as effective as a 10 day course in the treatment of acute maxillary sinusitis in adults.

Virtual endoscopy in odontogenic sinus disease. Study technique and main pathological findings

The use of CT scans in dental pathology is an established technique. The potential applications of Dentascan are further enhanced by the use of virtual navigation software, resulting in endoscopy-like imaging of the maxillary sinus, thus optimising both the diagnostic and therapeutic approach to sinus pathology of dental origin. The aim of this paper is to illustrate the technical-methodological aspects of maxillary sinus virtual endoscopy with Dentascan software and to document the most important and frequent diseases.

Isolated chronic maxillary sinusitis of non-dental origin does not correlate per se with ipsilateral intranasal structural abnormalities

A case series of 35 patients with isolated chronic maxillary sinusitis of inflammatory non-dental origin was retrospectively reviewed to determine the correlation of ipsilateral intranasal structural abnormalities. The records were examined for computed tomographic, nasal endoscopic, and intraoperative findings. The incidence of ipsilateral and contralateral intranasal structural abnormalities at the ostiomeatal complex region, including conchae bullosae, Haller cells, paradoxical middle turbinates, and septal deviations, was determined. Nineteen of 35 patients (54%) had ipsilateral abnormalities and 16 (46%) did not. Of the 19 patients with ipsilateral abnormalities, 4 had Haller cells, 4 had conchae bullosae, 2 had paradoxical middle turbinates, and 12 had septal deviations. (Two patients had multiple ipsilateral factors.) Of the 16 patients with contralateral abnormalities, 4 had Haller cells, 3 had conchae bullosae, 2 had paradoxical middle turbinates, and 9 had septal deviations. Ten patients had only contralateral abnormalities, and 6 had no identifiable anatomic abnormality. The difference between the incidences of ipsilateral and contralateral abnormalities in this series of 35 patients with isolated chronic maxillary sinusitis was not statistically significant when the factors were analyzed as a group or by individual factor (range in odds ratios for the various factors, 1 to 1.54; range in p values for the various factors, .25 to 1). Thus, the data show that ipsilateral structural abnormalities at the ostiomeatal complex region, including conchae bullosae, Haller cells, paradoxical middle turbinates, and septal deviations, did not correlate per se with isolated chronic maxillary sinusitis that was not attributable to dental disease.

Effect of WEB 2170 BS, platelet activating factor receptor inhibitor, in the rabbit model of sinusitis

Platelet activating factor (PAF), a potent inflammatory mediator, is a biologically active phospholipid. Recent studies have shown that PAF may play an important role in the pathogenesis of inflammation. WEB 2170 BS has been shown to be a PAF antagonist both in vitro and in vivo. Nitric oxide (NO) is present in the mammalian nasal airways and originates primarily from the paranasal sinuses. Measurement of NO is thought to be a surrogate marker of upper airway inflammation. In this study, the antiinflammatory effects of WEB 2170 BS were investigated in a rabbit model of sinusitis. To induce experimental sinusitis, we applied killed Staphylococcus aureus percutaneously to the maxillary sinus of rabbits without occlusion of the natural ostium. Either WEB 2170 BS solution or placebo was administered intraperitoneally 2 hours before sinus inoculation, and this procedure was repeated twice daily for 4 days. The outcome of the treatment was determined by the measurement of NO metabolite levels and NO synthase activity in the samples of sinus mucosa and by histopathologic evaluation of sinus mucosa. The pathological grading was determined by the number of inflammatory cells found in the sinus mucosa. The levels of NO metabolites and NO synthase activity were found to be significantly lower in the WEB 2170 BS-treated group than in the control group. Histopathologic analysis of the sinus mucosa indicated decreased inflammation in the treated group as compared to the controls. These results demonstrate that WEB 2170 BS may produce significant anti-inflammatory effects in this model of sinusitis.