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.

SCUAD and chronic rhinosinusitis. Reinforcing hypothesis driven research in difficult cases

BACKGROUND

Our objective is to present recent research findings on recalcitrant chronic rhinosinusitis (CRS) in relation to "Severe Chronic Upper Airway Disease" (SCUAD).

METHODOLOGY

Literature review using Medline and Em base databases (search terms 'chronic rhinosinusitis'; "chronic sinusitis" or"Severe Chronic Upper Airway Disease") limited to articles published in the English language.

RESULTS

Complex pathophysiological mechanisms characterize various forms of chronic rhinitis and rhinosinusitis (CRS), where inflammation persists in spite of adequate medical treatment. In these cases, a multifactorial etiology often underlies the development of sino-nasal inflammation. The interaction between chronic upper and lower airway inflammation via neurogenic and systemic pathways may complicate the therapy of these patients, and lead to insufficient symptom control.

CONCLUSION

The recently introduced definition of"Severe Chronic Upper Airway Disease" (SCUAD) increases awareness of those patients with persistent inflammation and symptoms despite guideline-driven pharmacologic treatment. The concept of SCUAD may prove helpful in directing research towards clarifying the definition, diagnosis and pathophysiology of rhinitis and rhinosinusitis,their limits and overlap. In this review, a hypothesis on SCUAD immunopathology is also presented.

The Relationship of Paranasal Sinus Opacification to Hospital-Acquired Pneumonia in the Neurologic Intensive Care Unit Patient

BACKGROUND

The association between intensive care unit (ICU) sinusitis and the development of lower airway infections remains unclear. The objective of this study was to determine the correlation between the development of radiographic sinus opacification and pneumonia in the neurologic ICU setting.

METHODS

A retrospective review of head computed tomography or magnetic resonance imaging of 612 patients admitted to the neurocritical care unit at a tertiary care center from April 2013 through April 2014 was performed. Paranasal sinus opacification was measured using Lund-Mackay scores (LMS). A diagnosis of pneumonia was determined by the ICU team from radiographic, laboratory, and pulmonary data. Exclusion criteria included a history of endonasal surgery, sinonasal malignancy, facial fractures, ICU admission less than 3 days, or inadequate imaging.

RESULTS

Worsening sinus opacification occurred in 42.6% of patients and pneumonia in 18.5% of patients during ICU admission. Of the patients who developed pneumonia, 71.7% also developed worsening sinus opacification (P < .001). In 80.2% of cases, the sinus opacification developed prior to the diagnosis of pneumonia. The mean highest LMS for patients who developed pneumonia was 4.24 compared to 1.99 in patients who did not develop pneumonia (P < .001). Sinus air-fluid levels or complete sinus opacification occurred in a larger proportion of patients who developed pneumonia (46.9% vs 19.4%, P < .001). Mortality rates for patients with no pneumonia or sinusitis, pneumonia only, sinusitis only, and sinusitis with pneumonia were 7.6%, 15.6%, 18.3%, and 25.9%, respectively (P < .001).

CONCLUSIONS

This study finds a strong relationship between worsening sinus opacification in the neurologic ICU patient to the development of hospital-acquired pneumonia and increased mortality.

Sinus opacification in the intensive care unit patient

OBJECTIVES/HYPOTHESIS

The significance of sinus opacification in intensive care unit (ICU) patients remains uncertain. Our objectives were to determine the baseline incidence and risk factors associated with the development of radiographic sinus abnormalities in the ICU population.

METHODS

A retrospective study of head computed tomography scan or magnetic resonance imaging from April 2013 through April 2014 of 612 neurologic ICU patients at the University of Pittsburgh Medical Center Presbyterian Hospital, Pittsburgh, Pennsylvania, was performed. Images were scored by the Lund-Mackay system (LMS). Exclusion criteria included prior sinus or skull base surgery, history of sinonasal malignancy, facial fractures, ICU admission less than 3 days, or inadequate imaging.

RESULTS

At the time of admission, 40.7% of patients had a LMS greater than zero (mean 2.2). Worsening sinus opacification occurred in 42.6% of patients (mean highest LMS 4.6) during ICU admission. There was a peak between days 8 and 10, during which 65% of scans exhibited worsening opacification compared to baseline. On multivariate analysis, risk factors associated with increased sinus opacification (higher LMS) included the presence of an endotracheal tube (odds ration [OR] 3.28, P < .001) or nasogastric tube (OR 3.34, P < .001) and increased length of stay (OR 2.50, P < .001). Age greater than 60 was found to be protective for the development of worsening sinus opacification (OR 0.57, P = .007).

CONCLUSION

Using serial imaging and comparison control groups, this study finds that there is a high baseline incidence of sinus opacification in the ICU population. Prolonged length of stay, younger age, and presence of nasogastric or endotracheal tubes all corresponded to worsening LMS.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:2433-2438, 2016.

Endoscopically Directed Middle Meatal Cultures Versus Maxillary Sinus Taps in Acute Bacterial Maxillary Rhinosinusitis: A Meta-Analysis

OBJECTIVES: The aim of this study was to verify the correlation of endoscopically directed middle meatal (EDMM) cultures with maxillary sinus tap and culture (MST) in acute bacterial rhinosinusitis (ABRS).

STUDY DESIGN AND METHODS: Meta-analysis of the previous literature, unpublished data, and a prospective trial supported by the Sinus & Allergy Health Partnership. EDMM and MST cultures were obtained and their results compared. Inclusion for both the unpublished and prospective trial as well as prior published literature in the meta-analysis required the studies to compare EDMM versus MST in the acute setting of bacterial rhinosinusitis with both symptomatic and radiologic evidence of ABRS.

RESULTS: Three articles and 1 national presentation were identified for inclusion. Additional data from unpublished studies and the prospective trial were combined. The pooled data consisted of 126 patients with 131 culture pairs. For known pathogenic bacteria for ABRS and in comparison to MST, EDMM had a sensitivity of 80.9%, a specificity of 90.5%, a positive predictive value of 82.6%, a negative predictive value of 89.4%, and an overall accuracy of 87.0% (95% confidence interval, 81.3%-92.8%); 70.5% (12/17) of false positive culture pairs were of known pathogens for ABRS that would not be expected to be contaminants.

CONCLUSIONS AND SIGNIFICANCE: This meta-analysis shows that EDMM is a highly sensitive and accurate culture method for acute ABRS and may be more sensitive than MST given the presence of pathogenic bacteria not found on antral lavage. EDMM is a viable, and possibly preferred, culture method for determining antimicrobial efficacy and bacterial resistance patterns.

EBM rating: A-1a

Effect of Subcutaneous Dupilumab on Nasal Polyp Burden in Patients With Chronic Sinusitis and Nasal Polyposis: A Randomized Clinical Trial

IMPORTANCE

Dupilumab has demonstrated efficacy in patients with asthma and atopic dermatitis, which are both type 2 helper T-cell-mediated diseases.

OBJECTIVE

To assess inhibition of interleukins 4 and 13 with dupilumab in patients with chronic sinusitis and nasal polyposis.

DESIGN, SETTING, AND PARTICIPANTS

A randomized, double-blind, placebo-controlled parallel-group study conducted at 13 sites in the United States and Europe between August 2013 and August 2014 in 60 adults with chronic sinusitis and nasal polyposis refractory to intranasal corticosteroids with 16 weeks of follow-up.

INTERVENTIONS

Subcutaneous dupilumab (a 600 mg loading dose followed by 300 mg weekly; n = 30) or placebo (n = 30) plus mometasone furoate nasal spray for 16 weeks.

MAIN OUTCOMES AND MEASURES

Change in endoscopic nasal polyp score (range, 0-8; higher scores indicate worse status) at 16 weeks (primary end point). Secondary end points included Lund-Mackay computed tomography (CT) score (range, 0-24; higher scores indicate worse status), 22-item SinoNasal Outcome Test score (range, 0-110; higher scores indicating worse quality of life; minimal clinically important difference ≥8.90), sense of smell assessed using the University of Pennsylvania Smell Identification Test (UPSIT) score (range, 0-40; higher scores indicate better status), symptoms, and safety.

RESULTS

Among the 60 patients who were randomized (mean [SD] age, 48.4 years [9.4 years]; 34 men [56.7%]; 35 with comorbid asthma), 51 completed the study. The least squares (LS) mean change in nasal polyp score was -0.3 (95% CI, -1.0 to 0.4) with placebo and -1.9 (95% CI, -2.5 to -1.2) with dupilumab (LS mean difference, -1.6 [95% CI, -2.4 to -0.7]; P < .001). The LS mean difference between the 2 groups for the Lund-Mackay CT total score was -8.8 (95% CI, -11.1 to -6.6; P < .001). Significant improvements with dupilumab were also observed for the 22-item SinoNasal Outcome Test (LS mean difference between groups, -18.1 [95% CI, -25.6 to -10.6]; P < .001) and sense of smell assessed by UPSIT (LS mean difference, 14.8 [95% CI, 10.9 to 18.7]; P < .001). The most common adverse events were nasopharyngitis (33% in the placebo group vs 47% in the dupilumab group), injection site reactions (7% vs 40%, respectively), and headache (17% vs 20%).

CONCLUSIONS AND RELEVANCE

Among adults with symptomatic chronic sinusitis and nasal polyposis refractory to intranasal corticosteroids, the addition of subcutaneous dupilumab to mometasone furoate nasal spray compared with mometasone alone reduced endoscopic nasal polyp burden after 16 weeks. Further studies are needed to assess longer treatment duration, larger samples, and direct comparison with other medications.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01920893.

Clear anterior rhinorrhea in the population

BACKGROUND

Clear anterior rhinorrhea is commonly observed in older adults and is widely known as "senile rhinorrhea." Although appreciated in the literature, no studies support that clear rhinorrhea increases with age. Our goal was to determine the prevalence of clear rhinorrhea in adults and the variation between young and old. Additionally, we sought to determine if clear rhinorrhea was bothersome enough for patients to seek treatment.

METHODS

A questionnaire was randomly distributed to 158 adults, 76 young adults on the University of Pittsburgh Undergraduate campus, and 82 older adults at Longwood Retirement Community in 2011.

RESULTS

Older subjects reported more drip and an increase in rhinorrhea over time regardless of gender (p < 0.05). Participants wanting to seek treatment reported drip occurred more often, that they used more tissues, and were more bothered by drip compared to those not wanting treatment (p < 0.05).

CONCLUSION

Clear, anterior rhinorrhea affects older adults regardless of gender significantly more often and more severely than young adults (p < 0.05). The more frequent and bothersome the nasal drip, the more likely individuals would elect treatment.

Impact of quality improvement measures on the delivery of allergy immunotherapy: a 2-year follow-up

BACKGROUND

Anaphylaxis is the most serious potential complication from allergy treatment with subcutaneous immunotherapy (SCIT). Quality measures were developed with the goal to decrease the incidence of complications resulting from SCIT and improve the safety of care provided.

METHODS

The incidence and characteristics of anaphylaxis episodes resulting from SCIT was measured between 2008 and 2012 prior to implementation of quality measures including vial verification, vial testing, and standardized training across 6 allergy delivery sites. Errors and anaphylaxis rates were then tracked prospectively over a 2-year period after implementation of these process measures.

RESULTS

From 2008 to 2012 there were 9 episodes of anaphylaxis or 0.02% of injections/year. Eight patients had sufficient information from which to derive meaningful data. Patient identification error led to anaphylaxis in 2 patients, dosing error in 2, and compounding error in 1 patient. In 2 patients, anaphylaxis occurred with advancement during pollen season, and in 1 patient no clear reason could be identified although she had asthma as a risk factor. After implementation of quality improvement measures the anaphylaxis rate fell to 0 of 8948 injections for years 2013 and 2014.

CONCLUSION

Errors in the mixing and administration of allergy serum comprised the majority of identifiable factors that led to anaphylaxis. Implementation of quality measures, including vial verification and vial testing, can improve safety and decrease anaphylaxis rates in the delivery of allergy immunotherapy.

Measurement of Nasal Polyp Patient Symptomatology over Time Using the Sinonasogram: Initial Validation

Objectives:

Chronic rhinosinusitis with nasal polyps is a common disorder that requires multiple methods to monitor disease burden. There is no validated questionnaire to monitor nasal polyp patient symptoms over time. We describe a novel 10-item questionnaire (Sinonasogram) which is currently used in clinical practice to evaluate current and 4-week symptoms that are common to patients with chronic rhinosinusitis.

Methods:

Twenty-five consecutive patients with nasal polyps seen in a university setting were included in this retrospective review. Patients were included if they had multiple visits to clinic and filled out the Sinonasogram questionnaire at each visit. Nasal polyp score was graded on a (0-5) scale. Statistical analysis was performed to determine correlation between changes in current, 4-week, and total Sinonasogram score and changes in nasal polyp score and to determine internal consistency.

Results:

Twenty-five patients were included for analysis with a total of 81 clinic visits. Changes in total and current Sinonasogram scores were significantly correlated with changes in nasal polyp scores ( P = .004, P = .002). Individual symptom scores best predicting nasal polyp size were nasal obstruction, hyposmia, and anterior rhinorrhea ( P < .001, P < .001, P < .001). Cronbach’s alpha test for internal consistency was 0.8244 for current Sinonasogram score and 0.8878 for 4-week Sinonasogram score.

Conclusions:

The Sinonasogram is a valid tool for monitoring nasal polyp symptoms and can predict changes in nasal polyp size. Symptoms that were found to be most associated with nasal polyps were nasal obstruction, hyposmia, and anterior rhinorrhea.

Ask the Experts: An Endoscopic Potpourri

Program Description:

Rhinologic diagnostic and treatment problems commonly create dilemmas in practice. This miniseminar provides for interactive discussion of the management options and the decision rationale involved in difficult sinus diagnostic and treatment situations. A case presentation format is used with case presentations from each of the panelists emphasizing questions with regard to differential diagnosis, evaluation, imaging, and treatment. Cases are representative of those encountered by either a general otolaryngologist or a subspecialty rhinologist but have critical decision points for discussion. The session focuses on the decision-making process, frontal sinus disease, revision surgery, and fungal sinusitis, as well as common tumors.

Educational Objectives:

(1) Review the surgical decision-making process in chronic sinus disease. (2) Implement different imaging modalities and improved quality of interpretation for both computed tomography and magnetic resonance images. (3) Improve the management of difficult-to-treat chronic rhinosinusitis.

Clinical and pathologic characteristics of intranasal abuse of combined opioid-acetaminophen medications

BACKGROUND

The nonmedical abuse of prescription opioids via intranasal administration is a growing problem. The objective of this study is to investigate of the typical presentation of intranasal opioid-acetaminophen abuse and outline optimal therapy.

METHODS

This study was a retrospective chart review. Patients with intranasal pathology from inhalation of combined opioid-acetaminophen medications (COAMs) from 3 academic otolaryngology practices in western Pennsylvania from January 2012 to October 2012 were included in the review.

RESULTS

Seven adults ranging in age from 23 to 46 years were identified with nasal complaints from the intranasal inhalation of COAMs. All patients presented with nasal pain and were found to have fibrinous necrotic nasal mucosa involving the posterior nasal cavity and nasopharynx. Of the 7 patients, 6 (85.7%) presented with a septal perforation. Pathology and culture revealed fungus in 85.7% of the patients; however, no invasive fungal disease was noted in any of the specimens. Patients did not improve with either systemic or topical antifungal therapy. Polarizable material characteristic of talc used as a tablet binder was present in the histopathology of 4 of 7 (57.1%) patients. Patients who abstained from intranasal drug use along with serial debridement demonstrated the greatest improvement.

CONCLUSION

Intranasal COAM abuse causes nasal pain, tissue necrosis with potential septal and palatal perforation, and noninvasive fungal colonization. Antifungal therapy was of no benefit in the current series of patients. Current therapy should focus on recognition of the etiology of patients' pathology and encourage abstinence from intranasal use of these drugs along with serial debridements.

Medical management of allergic fungal rhinosinusitis following endoscopic sinus surgery: an evidence-based review and recommendations

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.

Identifying asthma triggers

Asthma has many triggers including rhinosinusitis; allergy; irritants; medications (aspirin in aspirin-exacerbated respiratory disease); and obesity. Paradoxic vocal fold dysfunction mimics asthma and may be present along with asthma. This article reviews each of these triggers, outlining methods of recognizing the trigger and then its management. In many patients more than one trigger may be present. Full appreciation of the complexity of these relationships and targeted therapy to the trigger is needed to best care for the patient with asthma.

Defining quality metrics and improving safety and outcome in allergy care

BACKGROUND

The delivery of allergy immunotherapy in the otolaryngology office is variable and lacks standardization. Quality metrics encompasses the measurement of factors associated with good patient-centered care. These factors have yet to be defined in the delivery of allergy immunotherapy. We developed and applied quality metrics to 6 allergy practices affiliated with an academic otolaryngic allergy center.

METHODS

This work was conducted at a tertiary academic center providing care to over 1500 patients. We evaluated methods and variability between 6 sites. Tracking of errors and anaphylaxis was initiated across all sites. A nationwide survey of academic and private allergists was used to collect data on current practice and use of quality metrics.

RESULTS

The most common types of errors recorded were patient identification errors (n = 4), followed by vial mixing errors (n = 3), and dosing errors (n = 2). There were 7 episodes of anaphylaxis of which 2 were secondary to dosing errors for a rate of 0.01% or 1 in every 10,000 injection visits/year. Site visits showed that 86% of key safety measures were followed. Analysis of nationwide survey responses revealed that quality metrics are still not well defined by either medical or otolaryngic allergy practices. Academic practices were statistically more likely to use quality metrics (p = 0.021) and perform systems reviews and audits in comparison to private practices (p = 0.005).

CONCLUSION

Quality metrics in allergy delivery can help improve safety and quality care. These metrics need to be further defined by otolaryngic allergists in the changing health care environment.

Ask the Experts: An Endoscopic Potpourri

Program Description:

Rhinologic diagnostic and treatment problems commonly create dilemmas in practice. This miniseminar provides for interactive discussion of the management options and the decision rationale involved in difficult sinus diagnostic and treatment situations. A case presentation format is used with case presentations from each of the panelists, emphasizing questions with regard to differential diagnosis, evaluation, imagining, and treatment. Cases are representative of those encountered by either a general otolaryngologist or a subspecialty rhinologist, but have critical decision points for discussion. The session focuses on the decision making process, frontal sinus disease, revision surgery, and fungal sinusitis, as well as common tumors.

Educational Objectives:

1) Review the surgical decision making process in chronic sinus disease. 2) Implement different imaging modalities and improved quality of interpretation for both CT and MRI images. 3) Improve the management of difficult to treat chronic rhinosinusitis.

In-Office Safety: Are You Putting Your Patient at Risk?

Program Description:

This one-hour miniseminar will focus on three important office procedures: Compounded pharmaceuticals: Many office-based pharmaceuticals are used by otolaryngologists daily. Otolaryngologists need to know what common drug preparations are compounded for use in the office. This 15-minute segment will provide tips to physicians to ensure their pharmaceuticals are safe. Allergy vial preparation and injections: A 15-minute presentation will explore current allergy practices and emphasize current safety concerns. Sterilization and safe use of equipment: Best evidence and recommendations for safe equipment reuse and sterilization techniques for office based procedures will be reviewed during this 15-minute segment.

Educational Objectives:

1) Recognize the dangers associated with the use of compounded pharmaceuticals in the office and safe practices for use of these substances. 2) Implement recommendations for enhancing safe allergy practice, including vial preparation, advancement, and office injections. 3) Apply safe sterilization and device reuse and hygienic practice for the office and steps to implement safe office practice.

Subcutaneous immunotherapy for allergic rhinitis: an evidence based review of the recent literature with recommendations

BACKGROUND

Allergic rhinitis is a common allergic disease with increasing prevalence in Western Societies. Medical therapy is first line treatment, and is aimed at reducing symptoms of immunoglobulin E (IgE)-mediated inflammation of the nasal passages. In patients with disease refractory to medical therapy, subcutaneous immunotherapy is an option. The aim of this study is to update a recent Cochrane review with available level 1 evidence for seasonal and perennial allergic rhinitis.

METHODS

A systematic review of the literature was performed from 2006 to 2011 and compared with data from a 2007 Cochrane review on immunotherapy for seasonal allergic rhinitis. We included all studies of level 1 evidence. All forms of single extract immunotherapy were considered. Studies with primary asthma related end-points were excluded. Primary end-points were instruments of clinical efficacy (ie, symptom-medication scores) and adverse events.

RESULTS

We retrieved 12 level 1 studies for review. In total, 1512 patients were randomized into treatment groups, alternative study groups (alternative duration of therapy or sublingual immunotherapy [SLIT]), or placebo. Efficacy was evaluated based on reported symptom and/or medication score, validated quality of life instruments, immunological assays, challenge testing, and adverse events.

CONCLUSION

Subcutaneous immunotherapy improves symptom and/or medication scores and validated quality of life measures. In addition, associated changes in surrogate markers of immunologic protection are observed. Subcutaneous immunotherapy is safe when administered to carefully selected patients and in settings capable of responding to systemic reactions. Subcutaneous immunotherapy is recommended for patients with seasonal or perennial allergic rhinitis not responsive to conservative medical therapy, and whose symptoms significantly affect quality of life.

Categorizing nasal polyps by severity and controller therapy

OBJECTIVE

To analyze a new categorization of chronic rhinosinusitis with nasal polyposis (CRSwNP) according to severity and controller therapy, modified from the 2007 stepwise treatment for asthma.

DESIGN

Prospective categorization of 50 new or established patients over a 3-month period.

SETTING

Tertiary center of Hôtel-Dieu de France Hospital, Beirut, Lebanon.

PATIENTS

Fifty consecutive adult patients with nasal polyposis referred by primary care physicians for sinonasal complaints or by pulmonologists for worsening lower airway control including asthma.

INTERVENTIONS

All patients were categorized according to CRSwNP severity scale and treated with stepwise therapy based on the study schematic.

MAIN OUTCOME MEASURES

The Modified Sinonasal Questionnaire and the visual analog scale were used to assess patients' response to the treatment regimen and to modify the severity scale and the step treatment accordingly.

RESULTS

Ten new medication-naïve patients with CRSwNP were categorized by severity, which directed the subsequent treatment plan. All patients showed improvement in severity with the stepwise treatment plan. Thirty-seven of 40 patients with established CRSwNP seen in follow-up were easily categorized by degree of control, and subsequent treatment directed by therapy guidelines resulted in improvement.

CONCLUSIONS

Initial categorization of medication-naïve patients with CRSwNP and patients with established CRSwNP facilitated delivery of successful directed stepwise therapy that resulted in improvement of classification of severity in most patients. This proposed classification may provide a useful template for future studies comparing patients with CRSwNP.

Evidence for primary laryngeal inhalant allergy: a randomized, double-blinded crossover study

BACKGROUND

Despite anecdotal reports, no controlled studies to date link allergen exposure with a change in vocal function or dysphonia. The aim of this study was to determine whether allergen exposure in susceptible individuals impairs vocal function.

METHODS

The study was a prospective, double-blind, placebo-controlled study in which subjects serve as their own controls. The participants were 5 inhalant allergic adults with suspected dysphonia from allergies, without evidence of reactive lower airways based on methacholine challenge. All subjects were exposed to 2 experimental conditions in which they were challenged with (1) orally inhaled diluent placebo on 1 day, and (2) orally inhaled allergen on another day. Conditions were randomly ordered across subjects and separated by at least 48 hours. Phonatory threshold pressure (PTP) at the 80th percentile pitch was measured prior to diluent and allergen challenge, and 15 and 60 minutes postchallenge to assess potential change in vocal function after challenge testing.

RESULTS

A repeated measures ANOVA revealed a significant main effect for treatment (allergen vs placebo, p = 0.013) with greater PTP required post-allergen challenge compared to placebo and an effect size of 0.821.

CONCLUSION

A primary causal relationship between allergen exposure and impaired vocal function, as assessed by PTP, was observed in adults with documented allergy independent of asthma or nasal exposure. The current design establishes a safe model for laryngeal inhalant allergen challenge.

Use of nasopharyngeal culture to determine appropriateness of antibiotic therapy in acute bacterial rhinosinusitis

BACKGROUND

Rhinosinusitis is one of the top 5 diagnoses for which an antibiotic is prescribed, often without a clear bacterial etiology. This study evaluated whether nasopharyngeal culture and gram stain could serve as a surrogate for endoscopically obtained middle meatal cultures in directing appropriate therapy for acute bacterial rhinosinusitis (ABRS). This study also investigated the utility of a rapid sinus test screen in differentiating bacterial from nonbacterial rhinosinusitis.

METHODS

Thirty-one adult patients met inclusion criteria for ABRS. Samples were obtained from both the middle meatus and nasopharynx for Gram stain and culture. Nasal mucous samples were tested with a rapid sinus test strip measuring pH, levels of protein, nitrites, and leukocyte esterase.

RESULTS

Sixty-one percent (61%) of nasopharyngeal and 48% of middle meatal samples grew pathogenic bacteria. The concordance rate was 84% between the 2 sites (p = 0.0006). The following pathogenic organisms were detected: Moraxella catarrhalis, Streptococcus pneumoniae, Haemophilus influenzae, Pseudomonas aeruginosa, and Staphylococcus aureus. For nasopharyngeal samples, reliance on Gram stain alone exhibited a sensitivity of 31% and specificity of 100% and, similarly, for middle meatus samples, 47% and 93%, respectively. The rapid sinus test revealed a sensitivity of 83% and specificity of 7%.

CONCLUSION

Nasopharyngeal and middle meatal cultures exhibited high concordance for pathogenic bacteria. Gram stain exhibited moderate sensitivity and excellent specificity. Nasopharyngeal cultures could provide a viable method, especially in a primary care setting, for determining the appropriateness of antibiotic therapy. The rapid sinus test's lack of specificity precluded its utility in the differentiation between bacterial and nonbacterial rhinosinusitis.

Clinical Consensus Statement

Objective

To develop a consensus statement on the appropriate use of computed tomography (CT) for paranasal sinus disease.

Subjects and Methods

A modified Delphi method was used to refine expert opinion and reach consensus by the panel.

Results

After 3 full Delphi rounds, 33 items reached consensus and 16 statements were dropped because of not reaching consensus or redundancy. The statements that reached consensus were grouped into 4 categories: pediatric sinusitis, medical management, surgical planning, and complication of sinusitis or sinonasal tumor. The panel unanimously agreed with 13 of the 33 statements. In addition, at least 75% of the panel strongly agreed with 14 of 33 statements across all of the categories.

Conclusions

For children, careful consideration should be taken when performing CT imaging but is needed in the setting of treatment failures and complications, either of the pathological process itself or as a result of iatrogenic (surgical) complications. For adults, imaging is necessary in surgical planning, for treatment of medical and surgical complications, and in all aspects of the complete management of patients with sinonasal and skull base pathology.

Bilateral sinonasal polyposis in a patient with unilateral choanal atresia

Sinonasal polyposis is a disorder of hyperplastic mucosal inflammation that subsequently leads to the development of smooth, pale, non-neoplastic masses. The theories on its pathogenesis are diverse and remain debated within the medical community. A distinct, widely accepted, and unifying theory is absent, and probably unrealistic given the varying possible causes. The case reported here, which demonstrates nasal polyp formation within an atretic nasal cavity, suggests that nasal airflow or aerodynamics may have little to no effect on its etiology. It also seems to provide evidence that at least in some individuals nasal polyps appear to be due to an inflammatory disorder independent of inhalant allergen challenge.

Otolaryngologists' perceptions of odontogenic maxillary sinusitis

OBJECTIVES/HYPOTHESIS

Odontogenic maxillary sinusitis (OMS) is a common cause of chronic rhinosinusitis (CRS); however, the condition is infrequently mentioned in recent rhinosinusitis guidelines and often overlooked as a cause of sinusitis by otolaryngologists, dentists, and radiologists. The goal of this survey is to assess otolaryngologists' perceptions of the incidence, diagnosis, and treatment of OMS.

STUDY DESIGN

Physician survey.

METHODS

Ninety-three board certified otolaryngologists in the United States completed a 17-question survey on etiologies of CRS, which also included questions on alternative diagnoses and radiologic findings to reduce respondent bias toward the survey's focus on odontogenic sinusitis. Results were compared between self-reported general otolaryngologists and rhinologists.

RESULTS

Both groups recognized an odontogenic source as a common cause of maxillary sinusitis and reported treating an average of 2.9 patients per year with OMS who were initially misdiagnosed. Most otolaryngologists surveyed perceived radiologists to never or rarely report on dental pathology in their sinus computed tomography (CT) interpretation.

CONCLUSIONS

Both general otolaryngologists and rhinologists recognize odontogenic sinusitis is common, although often initially misdiagnosed. With increasing awareness of OMS, we believe that otolaryngologists and radiologists will review sinus CT scans for the presence of periapical abscesses and dental pathology. The otolaryngologist should suspect an odontogenic etiology of purulent maxillary CRS in patients failing to improve with antibiotics, regardless of a negative dental workup.

Concurrent septoplasty during endoscopic sinus surgery for chronic rhinosinusitis: does it confound outcomes assessment?

OBJECTIVES/HYPOTHESIS

To determine if chronic rhinosinusitis (CRS)-specific health-related quality-of-life (HRQoL) outcomes are affected by concurrent septoplasty performed during endoscopic sinus surgery (ESS) for medically refractory CRS.

STUDY DESIGN

Prospective, multicenter cohort study.

METHODS

A total of 221 patients with medically refractory CRS without nasal polyposis who elected primary ESS were included in this study. Patients were dichotomized into two cohorts: concurrent septoplasty (n = 108) or no septoplasty (n = 113) during ESS. The main outcomes of interest included two CRS-specific HRQoL instruments: the Rhinosinusitis Disability Index (RSDI) and the Chronic Sinusitis Survey (CSS). Symptom presentation was assessed using eight sinonasal visual analog scale (VAS) symptom scores.

RESULTS

There were no differences in CRS-specific HRQoL improvements on all RSDI and CSS measures following ESS between cohorts with or without septoplasty (all P > .05). In patients with medically refractory CRS, the presence of septal deviation did not result in a different CRS-specific symptom presentation compared to patients without septal deviation (all baseline VAS symptom score comparisons P > .295).

CONCLUSIONS

To optimize nasal patency and improve surgical access, septoplasty is commonly performed during ESS. Based on the results of this study, concurrent septoplasty does not appear to affect CRS-specific HRQoL or symptom outcomes and does not function as a confounding factor in HRQoL improvement.

Prospective observational study of chronic rhinosinusitis: environmental triggers and antibiotic implications

BACKGROUND

A prolonged course of antibiotic therapy is often initiated for chronic rhinosinusitis (CRS) based on symptomatology. We examined differences in clinical manifestations and underlying conditions in patients with symptoms typical for CRS. CT scan abnormality of the sinuses was the gold standard for diagnosis of CRS.

METHODS

We performed a prospective observational study of 125 adults with classic symptoms of CRS undergoing nasal endoscopy and sinus CT.

RESULTS

The patients were classified into 2 groups: (1) those with radiographic evidence of sinusitis by CT (Sx + CT) (75) and (2) those with normal CT scans of the sinus (Sx - CT) (50). Decreased smell was significantly more common in Sx + CT than in Sx - CT patients, (P = .003). Paradoxically, headache, facial pain, and sleep disturbance occurred significantly more frequently in patients with Sx - CT than in patients with Sx + CT (P < .05). The absence of mucopurulence on endoscopy proved to be highly specific for Sx - CT patients (100%). On the other hand, sensitivity was low; only 24% of Sx + CT patients demonstrated mucopurulence by endoscopy. Improvement in response to antibiotics was similar between both CRS categories.

CONCLUSIONS

Most symptoms considered to be typical for CRS proved to be nonspecific. Interestingly, symptoms that were more severe were significantly more likely to occur in younger patients who were Sx - CT. The efficacy of antibiotic therapy was uncertain. We suggest that objective evidence of mucopurulence assessed by endoscopy or CT should be obtained if antibiotics are to be given for prolonged duration. We recommend a moratorium for the widespread practice of a prolonged course of empiric antibiotics in patients with presumed CRS.

Rhinology/Allergy

Program Description: The miniseminar provides an open forum for interactive discussion of management options and the decision rationale involved in sinus and skull base cases of varying complexity. A case presentation format is utilized with case presentations from each of the panelists. Questions regarding differential diagnosis, evaluation, imaging, and treatment are posed to the audience in multiple choice format. The responses provided by the audience response system are then discussed and expanded upon by the panelists in an interactive discussion. In general, cases are selected that might be encountered by either a general otolaryngologist or a subspecialty rhinologist, but which have important decision and management dilemmas. Each panelist has been chosen because of their depth of knowledge in the field and because of the clarity of their presentations. Particular emphasis is placed on the decision making process and on frontal sinus disease, revision surgery, and fungal sinusitis, as well as the management of more common tumors. The rationale behind each recommendation will be carefully elucidated. Discussion from the floor is encouraged and the use of a touch pad audience response system creates audience participation as an integral aspect of the case discussions.

Educational Objectives: 1) Improve knowledge of the surgical decision making process in chronic sinus disease. 2) Learn different imaging modalities and improve quality of interpretation for both CT and MRI images. 3) Improve understanding of the management of difficult to treat chronic rhinosinusitis.

Clinical Consensus Statement: Appropriate Use of Computed Tomography for Paranasal Sinus Disease

Program Description: The miniseminar will consist of a lively panel discussion on the newly developed AAO-HNS clinical consensus statement (CS) on the appropriate use of computed tomography (CT) for paranasal sinus disease. There is increasing scrutiny by government, health policy makers, and third-party payers, regarding issues of radiation safety and appropriate utilization with CT imaging. Unlike clinical practice guidelines that could encompass other disciplines, CSs produced by the AAO-HNS are focused on the specialty of otolaryngology-head and neck surgery. Because clinical evidence is lacking, the terms “evidence-based,” and “guideline” should not be used in the context of CSs. Nonetheless, the development panel has conducted a systematic review to ensure that the best available evidence is identified to support decisions, even if this evidence is limited to case series or previously published consensus documents.

Educational Objectives: 1) Learn about the systematic review that was conducted to identify the best available evidence to support decisions on the appropriate use computed tomography (CT) for paranasal sinus disease. 2) Understand when it is most appropriate to use CT for paranasal sinus disease.

Unrecognized odontogenic maxillary sinusitis: a cause of endoscopic sinus surgery failure

BACKGROUND

Endoscopic sinus surgery (ESS) is reported to improve symptoms in approximately 85% of patients. Reasons for failure include misdiagnosis, technical inadequacies, underlying severe hyperplastic disease, biofilm, and immunodeficiency. Only one previous case of unrecognized odontogenic maxillary sinusitis has been cited in the literature as a reason for failure to improve with sinus surgery. This study was designed to characterize clinical and radiographic findings in patients who fail to improve with ESS because of an unrecognized dental etiology.

METHODS

Five patients, with odontogenic maxillary sinusitis with prior unsuccessful ESS, were prospectively enrolled. Demographics and clinical aspects including duration of illness, prior sinus surgeries and therapies, and radiographic data were assessed.

RESULTS

Five adults underwent an average of 2.8 sinus surgeries with persistence of disease and symptoms until their dental infection was treated. Duration of symptoms ranged from 3 to 15 years. In four of five patients, the periapical abscess was not noted on the original CT report but could be seen in retrospect. Three of five patients had been seen by their dentists and told they had no dental pathology. All five patients underwent dental extractions and one patient underwent an additional ESS after dental extraction. These procedures led to a resolution of sinusitis symptoms in all five patients.

CONCLUSION

Unrecognized periapical abscess is a cause of ESS failure and the radiological report frequently will fail to note the periapical infection. Dentists are unable to recognize periapical abscesses reliably with dental x-rays and exam. In patients with maxillary sinus disease, the teeth should be specifically examined as part of the radiological workup.

Exostoses of the paranasal sinuses

While bony exostoses of the external auditory canal have long been recognized as a complication of cold-water swimming, bony exostoses of the paranasal sinuses have not been previously reported. We present an unusual case of multiple exostoses of the paranasal sinuses, which began coincident with nasal irrigation with cold gentamicin solution. The patient had had prior endoscopic sinus surgery. Topical antibiotic gentamicin irrigation lessened recurrence of bacterial sinus episodes. He admitted to using the irrigation directly from the refrigerator daily for two years. A biopsy was consistent with exostosis. Patients should be counseled to avoid irrigating their paranasal sinuses with cold irrigants. Laryngoscope, 2010.

Rhinitis medicamentosa as a cause of increased intraoperative bleeding

Rhinitis medicamentosa occurs with repeated and prolonged use of topical decongestants. The resultant reduced ability to respond to decongestants mediated via enlarged capillary endothelial gaps can lead to profuse bleeding during turbinate surgery. We recommend that patients with rhinitis medicamentosa be weaned off topical decongestants prior to elective turbinate surgery to minimize this complication. The management of rhinitis medicamentosa and a case of intraoperative hemorrhage are presented.

When surgery, antibiotics, and steroids fail to resolve chronic rhinosinusitis

This article examines the modalities in the treatment of chronic rhinosinusitis (CRS). A correct diagnosis is the first requirement in the successful management of CRS. CRS-directed therapy might fail if the actual cause of symptoms is nonsinogenic. Nasal endoscopy and sinus computed tomography are the primary modalities used in the diagnosis of sinusitis. Allergy and gastroesophageal reflux, may not directly cause sinusitis, but they frequently mimic the symptoms of sinusitis. Therapy can include avoidance of allergens and desensitization in the former and antireflux therapy in the latter. Underlying systemic causes of refractory sinusitis include immunodeficiency and systemic granulomatous and eosinophilic syndromes. Correct diagnosis is essential to directed therapy. Patients with aspirin exacerbated respiratory disease may benefit from aspirin desensitization. Optimization of mucociliary clearance can be augmented with nasal lavage and mucolytics. Additional nonsteroidal antiinflammatory modalities include use of the leukotriene modulators, montelukast and zileuton. Patients with elevated IgE may benefit from omalizumab (anti-IgE); however, cost constraints restrict use to those patients who have severe asthma. This article also includes management strategies beyond the usual antibiotics, steroids, and sinus surgery. Once immunodeficiency and confounding local mimics of sinusitis are addressed, additional interventions should be tried separately initially to assess the individual patient's response to therapy.

Diagnosis and management of chronic rhinosinusitis in adults

Chronic rhinosinusitis (CRS) is characterized by mucosal inflammation affecting both the nasal cavity and paranasal sinuses; its causes are potentially numerous, disparate, and frequently overlapping. The more common conditions that are associated with CRS are perennial allergic and nonallergic rhinitis, nasal polyps, and anatomical mechanical obstruction (septum/turbinate issues). Other less common etiologies include inflammation (eg, from superantigens), fungal sinusitis or bacterial sinusitis with or without associated biofilm formation, gastroesophageal reflux, smoke and other environmental exposures, immune deficiencies, genetics, and aspirin-exacerbated respiratory disease. A diagnosis of CRS is strongly suggested by a history of symptoms (eg, congestion and/or fullness; nasal obstruction, blockage, discharge, and/or purulence; discolored postnasal discharge; hyposmia/anosmia; facial pain and/or pressure) and their duration for > 3 months. A definitive diagnosis requires physical evidence of mucosal swelling or discharge appreciated during physical examination coupled with CT imaging if inflammation does not involve the middle meatus or ethmoid bulla. Multivariant causation makes the diagnosis of CRS and selection of treatment complex. Furthermore, various types of health care providers including ear, nose, and throat (ENT) specialists, allergists, primary care physicians, and pulmonologists treat CRS, and each is likely to have a different approach. A structured approach to the diagnosis and management of CRS can help streamline and standardize care no matter where patients present for evaluation and treatment. A 2008 Working Group on CRS in Adults, supported by the American Academy of Otolaryngic Allergy (AAOA), developed a series of algorithms for the differential diagnosis and treatment of CRS in adults, based on the evolving understanding of CRS as an inflammatory disease. The algorithms presented in this paper address an approach for all CRS patients as well as approaches for those with nasal polyps, edema observed on nasal endoscopy, purulence observed on nasal endoscopy, an abnormal history and physical examination, and an abnormal history and normal physical examination.

Fungal rhinosinusitis: a categorization and definitional schema addressing current controversies

BACKGROUND

Fungal (rhino-) sinusitis encompasses a wide spectrum of immune and pathological responses, including invasive, chronic, granulomatous, and allergic disease. However, consensus on terminology, pathogenesis, and optimal management is lacking. The International Society for Human and Animal Mycology convened a working group to attempt consensus on terminology and disease classification.

DISCUSSION

Key conclusions reached were: rhinosinusitis is preferred to sinusitis; acute invasive fungal rhinosinusitis is preferred to fulminant, or necrotizing and should refer to disease of <4 weeks duration in immunocompromised patients; both chronic invasive rhinosinusitis and granulomatous rhinosinusitis were useful terms encompassing locally invasive disease over at least 3 months duration, with differing pathology and clinical settings; fungal ball of the sinus is preferred to either mycetoma or aspergilloma of the sinuses; localized fungal colonization of nasal or paranasal mucosa should be introduced to refer to localized infection visualized endoscopically; eosinophilic mucin is preferred to allergic mucin; and allergic fungal rhinosinusitis (AFRS), eosinophilic fungal rhinosinusitis, and eosinophilic mucin rhinosinusitis (EMRS) are imprecise and require better definition. In particular, to implicate fungi (as in AFRS and EMRS), hyphae must be visualized in eosinophilic mucin, but this is often not processed or examined carefully enough by histologists, reducing the universality of the disease classification. A schema for subclassifying these entities, including aspirin-exacerbated rhinosinusitis, is proposed allowing an overlap in histopathological features, and with granulomatous, chronic invasive, and other forms of rhinosinusitis. Recommendations for future research avenues were also identified.

Double-Blind, Placebo-Controlled Trial of Reformulated Azelastine Nasal Spray in Patients with Seasonal Allergic Rhinitis

Background

Azelastine nasal spray is a topical antihistamine with a distinctive taste that may be objectionable to some patients. The primary objectives of this clinical trial were (1) to determine if a reformulated azelastine nasal spray (Astepro) with sucralose as a taste-masking agent provides comparable efficacy to the original formulation (Astelin) and (2) to evaluate dose–response relationships between groups.

Methods

Eight hundred thirty-five patients with seasonal allergic rhinitis were randomized to six treatment groups: (1) original azelastine nasal spray, 1 spray/nostril b.i.d.; (2) reformulated azelastine, 1 spray/nostril b.i.d.; (3) placebo, 1 spray/nostril b.i.d.; (4) original azelastine nasal spray, 2 sprays/nostril b.i.d., (5) reformulated, 2 sprays/nostril b.i.d.; and (6) placebo, 2 sprays/nostril b.i.d. The primary efficacy variable was the change from baseline to day 14 in total nasal symptom score (TNSS) consisting of runny nose, sneezing, itchy nose, and nasal congestion.

Results

Original azelastine nasal spray and the reformulated spray produced comparable improvements in the TNSS at both dosages. There was a dose-related difference in TNSS comparing the 1- and 2-spray dosages. The percentage changes from baseline in the TNSS in the 2-sprays/nostril dosage groups were 27.9% (p < 0.001) with the reformulated nasal spray, 23.5% (p < 0.01) with the original formulation, and 15.4% with placebo. The incidence of bitter taste was 7% with the reformulated spray and 8% with the original at the 2-sprays/nostril dosage.

Conclusion

The results of this study showed efficacy both with original azelastine nasal spray and with the reformulated nasal spray and a clear dose–response difference between the 1- and 2-spray dosages.