Rhinosinusitis

Effects of nasal saline lavage on pediatric sinusitis symptoms and disease-specific quality of life: A case series of 10 patients

February 2, 2015     Sandra Y. Lin, MD; Katherine M. Baugher, DO; David J. Brown, MD; Stacey L. Ishman, MD
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Abstract

We conducted a prospective study to assess (1) the effects of daily nasal irrigation in children with chronic sinonasal symptoms and (2) the impact that treatment had on disease-specific quality of life as assessed by a validated instrument, the five-item Sinus and Nasal Quality of Life Survey (SN-5), and by an overall nasal quality-of-life (NQL) score based on a 10-point faces scale. Our patient population was made up of 10 children-7 girls and 3 boys, aged 3 to 9 years (mean: 6.1)-who had presented with symptoms of chronic rhinosinusitis for more than 3 months and who had not responded to previous medical management. Patients were administered nasal saline lavage daily for 1 month. These patients and/or their caregivers completed an SN-5 questionnaire upon entry into the study and at the completion of treatment. At study's end, a comparison of pre- and post-treatment scores with paired Student t tests showed that the mean total SN-5 score improved significantly over baseline, falling 45% from 21.4 to 11.7 (p = 0.0002). Moreover, significant overall improvement was seen in each of the five subcategories of the SN-5 survey (p = 0.0009 to 0.038). The NQL scores also improved significantly from 4.7 to 7.7 (p = 0.0034). Compliance with nasal lavage was generally good among the 10 patients, as 8 of them used at least 75% of the recommended quantity of saline at least once a day. During a follow-up period that ranged from 2 to 23 months (mean: 10.4), only 1 patient required an adenoidectomy for symptom control. The results of this pilot study suggest that nasal saline lavage may significantly alleviate chronic sinonasal symptoms and improve disease-specific quality of life in children with symptoms of chronic rhinosinusitis.

An uncommon cause of allergic fungal sinusitis: Rhizopus oryzae

January 19, 2015     Marie Devars du Mayne, MD; Maxime Gratacap, MD; David Malinvaud, MD, PhD; Frederic Grenouillet, PhD; Pierre Bonfils, MD, PhD
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Abstract

We report what we believe is the first case of allergic fungal rhinosinusitis (AFRS) caused by the fungus Rhizopus oryzae. Our patient was a 32-year-old woman who presented with unilateral nasal polyps and chronic nasal dysfunction. Computed tomography of the sinuses detected left-sided pansinusitis and bone erosion. T2-weighted magnetic resonance imaging demonstrated a signal void that suggested the presence of a fungal infection. The patient underwent unilateral ethmoidectomy. Histologic examination of the diseased tissue identified allergic mucin with 70% eosinophils and no fungal hyphae. Mycologic culture detected R oryzae. After a short period of improvement, the patient experienced a recurrence, which was confirmed by radiology. A second surgery was performed, and the same fungal hyphae were found in the mucus and on culture, which led us to suspect AFRS. Since no IgE test for R oryzae was available, we developed a specific immunologic assay that confirmed the presence of specific IgG, which identified a high degree of immunologic reaction against our homemade R oryzae antigens. With a long course of systemic antifungal treatment, the patient's symptoms resolved and no recurrence was noted at 5 years of follow-up.

Chronic rhinosinusitis in patients requiring surgical repair of a midface fracture

September 17, 2014     Joshua C. Yelverton, MD; Peter Jackson, MD; Robert S. Schmidt, MD
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Abstract

Midface fractures commonly occur following trauma to the face and may cause changes in the normal sinus outflow system. To the best of our knowledge, no study has examined the incidence of rhinosinusitis following midface fractures. We report the incidence of chronic rhinosinusitis in patients who underwent surgical repair of a midface fracture. Our evaluation tool was the 20-item Sino-Nasal Outcome Test quality-of-life survey (SNOT-20). We mailed a demographic survey and the SNOT-20 questionnaire to 486 eligible patients who had undergone surgical repair of either a midface (n = 234) or mandible (n = 252) fracture; we had intended to use the latter cohort as a control group. Of the 234 midface patients, 34 (14.5%) returned a usable survey, but only 7 of the 252 mandibular patients (2.8%) did so, which was not a sufficient number for analysis; therefore we used normative data obtained from another study for comparison purposes. The mean SNOT-20 score in our cohort was 24.15, which was similar to the 28.7 mean score in the control cohort of patients with rhinosinusitis. The highest mean scores for the individual components of the SNOT-20 were for “Wake up at night,” “Lack of a good night's sleep,” “Wake up tired,” and “Frustrated/restless/irritable.” The components that the most patients found bothersome were “Facial pain/pressure,” “Need to blow nose,” “Runny nose,” and “Lack of a good night's sleep.” We conclude that patients who experience a midface fracture have a much higher risk of developing chronic rhinosinusitis that negatively affects their long-term quality of life. These patients should be monitored with long-term follow-up and treated appropriately.

Balloon sinus dilation in the office setting

August 27, 2014     Joseph P. Mirante, MD, FACS; Michael A. Munier, MD, FACS; Dewey A. Christmas Jr., MD; Eiji Yanagisawa, MD, FACS
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The ability to complete operative procedures in the office setting avoids the time and cost of working in a hospital or outpatient surgical center operating room.

Rhinotopic therapy for refractory chronic rhinosinusitis: A study of 20 cases

May 7, 2014     Alan H. Shikani, MD, FACS; Karim A. Chahine, MD; Mohannad A. Alqudah, MD
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Abstract

The management of refractory chronic rhinosinusitis (CRS) after endoscopic sinus surgery is complex and challenging. We conducted a prospective clinical pilot study to evaluate the effectiveness of a rhinotopic protocol for the treatment of refractory CRS. Our study population was made up of 20 patients-8 men and 12 women, aged 31 to 76 years (mean: 50.1)-who were treated in our tertiary care rhinology fellowship training program. The rhinotopic protocol consisted of twice-daily saline rinses, each of which was followed by the administration of a nebulized corticosteroid and then a nebulized antibiotic. This regimen was administered for 6 weeks. Thereafter, patients underwent a once-weekly endoscopic sinus debridement followed by topical intrasinus installation of a corticosteroid and antibiotic. The duration of follow-up was 24 weeks, and thus the total study duration was 30 weeks. Treatment outcomes were based on Lund-Kennedy symptom scores and Lund-Kennedy endoscopic appearance scores. We found a 56% improvement in the mean symptom score after 3 weeks of therapy and 77% after 6 weeks. Subsequent follow-up revealed 90% improvement 4 weeks following the completion of therapy and 95% at 8 weeks post-therapy. Thereafter, we saw a small decrease in improvement: 73% at 16 weeks of follow-up and 65% at 24 weeks. Analysis of endoscopic appearance scores revealed a 55% improvement at 3 weeks of therapy and 84% at 6 weeks. The same general pattern emerged during follow-up, with 94% improvement 4 weeks after the cessation of therapy, 96% at 8 weeks, 76% at 16 weeks, and 75% at 24 weeks. Sinus cultures performed 4 weeks after the cessation of therapy found no growth in 13 patients (65%), normal respiratory flora in 5 patients (25%), a persistent pathogen in 1 patient (5%), and the emergence of a new pathogen in another (5%). Analysis of symptom scores and endoscopic appearance scores revealed that the rhinotopic protocol resulted in statistically significant improvement (p < 0.001) throughout the treatment period and follow-up period, although the improvement gradually declined over time. We therefore conclude that a rhinotopic protocol can be an effective treatment for refractory CRS.

Extensive pneumatization of the ethmoid sinus in a case of velocardiofacial syndrome

December 20, 2013     Dewey A. Christmas, MD; Joseph P. Mirante, MD, FACS; Eiji Yanagisawa, MD, FACS

Endoscopic view of the sphenoid sinus seen through the posterior ethmoid sinus

October 23, 2013     Joseph P. Mirante, MD, FACS; Dewey A. Christmas, MD; Eiji Yanagisawa, MD, FACS
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Care must be taken when entering the sphenoid sinus, to dissect inferiorly and medially to avoid injury to the vital structures of the lateral wall of the sphenoid sinus.

How closely related are allergic rhinitis, asthma, and chronic sinusitis?

September 18, 2013     Mahmoud Ghaderi, DO, FAOCO
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Various triggers may have different presentations and thus create a clinically known diverse group of diseases that we have classically grouped as chronic rhinosinusitis.

Endoscopic view of the drainage pathway of a pneumatized uncinate process

August 21, 2013     Dewey A. Christmas, MD; Joseph P. Mirante, MD, FACS; and Eiji Yanagisawa, MD, FACS
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Pneumatized structures of the nose and sinuses have a mucosal lining whose mucociliary clearance will be associated with a drainage pathway into the nose.

Bipolar microdebrider may reduce intraoperative blood loss and operating time during nasal polyp surgery

August 10, 2012     Nishant Kumar, MD; Raj Sindwani, MD, FACS
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Abstract

Bleeding during endoscopic sinus surgery (ESS) can interrupt the flow of the procedure and increase the risk of complications. Advances in microdebrider design now allow for bleeding to be controlled by bipolar energy during the suctioning and shaving of polyps. We conducted a retrospective study to examine the effects of this technology on blood loss and operating times during ESS for chronic rhinosinusitis with nasal polyps (CRS+P). Our patient population was made up of 80 patients who had undergone ESS for CRS+P by the same surgeon from January 2007 through May 2008. All surgeries were performed with either the PK diego bipolar microdebrider (Gyrus ACMI, ENT Division; Bartlett, Tenn.) or a standard microdebrider. There were 40 patients in each group. The PK group was made up of 23 males and 17 females, aged 14 to 66 years (mean: 43.1), and the control group included 21 males and 19 females, aged 17 to 71 years (mean: 43.1); there were no statistically significant differences between the two groups in terms of sex and age. In addition to demographic data, the charts were reviewed for comorbidities and operative variables; the latter included blood loss, operating room (OR) time, and complications. The preoperative treatment and anesthesia protocols were similar for all patients, and all patients demonstrated a similar disease burden on imaging (mean Harvard CT stage: 3.12 for the PK group and 3.15 for the controls; p > 0.05). We found that during ESS, the PK group experienced significantly less intraoperative blood loss than did the controls (means: 86.0 and 123.0 ml, respectively; p = 0.015). In addition, the PK device was associated with significantly shorter OR times (means: 88.9 and 101.4 min, respectively; p = 0.026). There were no complications in either group. We conclude that using a microdebrider with bipolar capabilities during ESS may offer the advantages of less blood loss and shorter operating times in patients with nasal polyps.

Allergic fungal rhinosinusitis in children

July 5, 2012     Ross Shockley, MD; Soham Roy, MD
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Allergic fungal rhinosinusitis most often occurs in adolescents or young adults who exhibit nasal obstruction, congestion, purulent or clear rhinorrhea, anosmia, and headache--classic manifestations of chronic sinusitis.

The role of antifungal therapy in the prevention of recurrent allergic fungal rhinosinusitis after functional endoscopic sinus surgery: A randomized, controlled study

August 15, 2011     Yaser Khalil, MD, Adel Tharwat, MD, Asmaa Gaber Abdou, MD, Enas Essa, MD, Abdel Hamid Elsawy, MD, Osama Elnakib, MD, and Nada Farag Elnaidany, PhD
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Abstract

Allergic fungal rhinosinusitis (AFRS) is the most common form of fungal sinus disease. Its recurrence rate is high despite numerous strategies to prevent it. We conducted a study to assess the effect of systemic and topical antifungal agents-both separately and in combination-in preventing recurrence of AFRS following functional endoscopic sinus surgery (FESS). Our initial study population was made up of 50 adults who were diagnosed with AFRS by clinical, radiologic, histopathologic, and laboratory workup and who subsequently underwent FESS. Postoperatively, these patients were randomized into 5 different treatment groups matched for sex, age, and socioeconomic status. Four of the groups received a different antifungal regimen in addition to convenient medical treatment (CMT), while a fifth group served as a control. The antifungal regimens included oral itraconazole (group A), fluconazole nasal spray (group B), combined oral itraconazole and nasal fluconazole (group C), and irrigation with a fluconazole solution through the nasal fossa (group D); the group of 10 controls (group E) received CMT only. A total of 41 patients were available for follow-up (9 mo maximum). Recurrence rates in the 5 groups were 66.7, 10.0, 14.3, 28.6, and 75.0%, respectively. Based on our findings, we conclude that treatment with topical fluconazole as either a nasal spray or an irrigation solution can significantly reduce the rate of recurrence of AFRS after FESS.

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