Rhinosinusitis

The internist's literature on chronic rhinosinusitis: An evaluation of the amount and quality of published information

July 31, 2010     Alexander C. Chester, MD, FACP
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Abstract

Most patients with chronic rhinosinusitis (CRS) are treated by internists, yet the information available to internists about CRS is rarely assessed. The author undertook a study to evaluate the amount and quality of information about CRS that is available to internists. Four information sources were analyzed: (1) five journals routinely read by internists, published over a 10-year period and searched on PubMed for the “exploded” terms chronic and sinusitis; (2) seven representative general and outpatient medicine texts, searched on MD Consult and STAT!Ref; (3) the 14th edition of the Medical Knowledge Self-Assessment Program (MKSAP 14), a review of internal medicine; and (4) four commonly used Internet databases. The five journals contained a total of 37,250 cited articles of various types over the study period; CRS was mentioned in only 19 of them. The standard medical texts offered little information about CRS, and MKSAP 14 did not mention CRS at all in the text, although it included some information in the questions and answers. Finally, among the online sources, UpToDate, a proprietary Internet database, offered an excellent discourse on CRS; in contrast, the Physicians' Information and Education Resource, maintained by the American College of Physicians, contained no information about CRS in its 436 subject modules. The author concludes that, with few exceptions, the literature routinely available to internists offers little information about CRS.

One-year results: Transantral balloon dilation of the ethmoid infundibulum

February 1, 2010     James Stankiewicz, MD, FACS, Theodore Truitt, MD, and James Atkins Jr., MD
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Abstract

A prospective, multicenter research study is under way to demonstrate long-term improvement in chronic rhinosinusitis symptoms after transantral balloon dilation of the ethmoid infundibulum. Trial results from an interim analysis of symptomatic status using the Sino-Nasal Outcome Test 20 survey demonstrate significant and sustained improvement through post-procedure 1-year follow-up. Additionally, these data provide evidence that the symptomatic improvements following balloon expansion within the ostiomeatal unit to treat medically refractory inflammation of the maxillary sinuses, either alone or with concomitant anterior ethmoid disease, are similar.

Nasal foreign body as the cause of a subperiosteal orbital abscess in a child

February 1, 2010     Benjamin D. Webb, MD, Kevin D. Pereira, MD, MS (ORL), and Samer Fakhri, MD, FACS, FRCS
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Abstract

We present what to the best of our knowledge is the first reported case of an orbital abscess as a result of acute rhinosinusitis caused by obstruction of the middle meatus secondary to the impaction of a nasal foreign body in a child. The patient, a 5-year-old Hispanic boy, had presented with left periorbital edema, eye pain, rhinorrhea, headache, and a fever. The presence of a nasal foreign body had been suggested by a finding of a low-density signal in the left anterior nasal cavity and middle meatus on computed tomography. Endoscopic drainage of the abscess through the involved sinuses revealed that the foreign body was a wad of cotton. The cotton was removed, and the patient recovered uneventfully.

Impaired mucociliary clearance in allergic rhinitis patients is related to a predisposition to rhinosinusitis

March 31, 2009     Ioannis Vlastos, MD, Ioannis Athanasopoulos, MD, PhD, Nicholas S. Mastronikolis, MD, PhD, Theodora Panogeorgou, MD, Vassilios Margaritis, MD, Stefanos Naxakis, MD, PhD, and Panos D. Goumas, MD
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Abstract

Although mucociliary clearance has been shown to be impaired in patients with allergic rhinitis and chronic rhinosinusitis, its exact role in relation to a predisposition to rhinosinusitis is unknown. To investigate this possible association, we conducted a prospective study of 125 patients with allergic rhinitis. Of this group, 23 patients were classified as being sinusitis-prone based on their history of antibiotic consumption for the treatment of rhinosinusitis; the remaining 102 patients were deemed to be not sinusitis-prone. The saccharine test was used to evaluate mucociliary clearance in all patients. Several variables-age, sex, smoking habits, rhinitis severity, and medication history-were examined. We found that the sinusitis-prone patients had a significantly greater mucociliary clearance time than did those who were not prone (median: 15 and 12 min, respectively; p = 0.02). No other statistically significant differences were seen between the 2 groups with respect to any other variables that might have affected mucociliary clearance. We conclude that impaired mucociliary clearance in allergic rhinitis patients is associated with a predisposition to rhinosinusitis.

Superior turbinate pneumatization in patients with chronic rhinosinusitis: Prevalence on paranasal sinus CT

September 25, 2008     Seth J. Kanowitz, MD, Annette O. Nusbaum, MD, Joseph B. Jacobs, MD, and Richard A. Lebowitz, MD
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Abstract

With the availability of high-resolution computed tomography (CT), a great deal of attention has been paid to the anatomy of the paranasal sinuses. But while investigators have focused on the osteomeatal complex and its relation to chronic rhinosinusitis, there has been little discussion of the superior turbinate. Although a few anatomic studies have tried to quantify pneumatization of the superior turbinate, the prevalence of this finding on radiography is not well addressed in the literature. We prospectively studied 100 consecutively presenting patients who underwent coronal CT of the paranasal sinuses (200 sides) for the evaluation of symptoms of chronic rhinosinusitis at an academic tertiary referral center to determine the prevalence of pneumatization of the superior turbinate. We found evidence of pneumatization in 44 of the 200 sides, for a prevalence of 22%. In all, pneumatized superior turbinates were found in 27 patients (27%)—bilaterally in 17 (17%) and unilaterally in 10 (10%).

Correlation of the ethmoid infundibulum to the medial orbital wall in maxillary sinus hypoplasia: “Infundibular lateralization,” a diagnostic CT finding

December 1, 2007     Arif Ali, DLO, MS, Mary Kurien, DLO, MS, and K.G. Selvaraj, PhD
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Abstract

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.

Assessment of quality of life among patients with sinonasal disease as determined by an Internet survey based on the Rhinosinusitis Disability Index

July 31, 2007     William C. Kinney MD, MHA; Michael S. Benninger, MD
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Abstract
We conducted a survey to measure patient quality of life with the Rhinosinusitis Disability Index adapted for the Internet. Our target population was patients who were seeking information on sinonasal disease on the World Wide Web. Usable responses were obtained from 896 patients with self-diagnosed sinonasal disease. According to the survey responses, patients with chronic rhinosinusitis were significantly more bothered by their condition than were patients with allergic rhinitis. Also, women were significantly more impaired by recurrent acute sinusitis and chronic rhinosinusitis than were men. Our findings are consistent with the results of previous surveys conducted by means other than the Internet. This project represents the first quality-of-life survey of an unsolicited group of individuals with sinonasal disease. We believe that use of the Internet will allow researchers to obtain larger patient populations than is now typical with traditional means of survey dissemination.

The prevalence of Samter's triad in patients undergoing functional endoscopic sinus surgery

June 30, 2007     Ji-Eon Kim, MD; Stilianos E. Kountakis, MD, PhD
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Abstract
We conducted a retrospective study to determine the prevalence of Samter's triad (nasal polyps, asthma, and aspirin sensitivity) in 208 consecutively presenting patients who had undergone functional endoscopic sinus surgery (FESS) for chronic rhinosinusitis from September 2001 through August 2003. Overall, Samter's triad was found in 10 patients (4.8%); subgroup analyses showed that the prevalence of Samter's triad was 5.9% in adults, 9.4% in patients with nasal polyps alone, 16.9% in patients with asthma alone, and 25.6% among patients with both polyps and asthma. On average, patients with Samter's triad had undergone approximately 10 times as many previous FESS procedures as had the patients without Samter's triad (mean: 5.2 vs. 0.53; p < 0.001). In addition to Samter's triad, four other factors were independently and significantly associated with a higher number of previous FESS procedures: nasal polyps alone, asthma alone, both polyps and asthma, and cystic fibrosis alone. Finally, at 6 months following their most recent surgery, patients with Samter's triad had significantly higher rates of symptom recurrence (nasal obstruction, facial pain, postnasal drip, and anosmia) and a recurrence of nasal polyps.

The prevalence and effect of asthma on adults with chronic rhinosinusitis

June 30, 2007     Melanie W. Seybt, MD; Kevin C. McMains, MD; Stilianos E. Kountakis, MD, PhD
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Abstract
We conducted a retrospective review of 145 consecutively presenting adults treated for chronic rhinosinusitis (CRS) in a tertiary care institution. Our goals were to determine (1) the prevalence of asthma in these patients, (2) the prevalence of specific CRS symptoms in both asthmatic and nonasthmatic patients, and (3) the frequency of surgical treatment for CRS in patients with and without asthma. We found that asthma was present in 23.4% of CRS patients, a much higher rate than the 5% prevalence of asthma in the general adult population. Patients with asthma had a significantly higher prevalence of nasal polyps (47 vs. 22%; p = 0.004), olfactory dysfunction (26 vs. 6%; p = 0.001), and nasal congestion (85 vs. 60%; p = 0.027) than did those without asthma. Patients without asthma had a significantly higher prevalence of headache (72 vs. 53%; p = 0.037) and rhinorrhea (58 vs. 38%; p = 0.047). The prevalence of postnasal drip and environmental allergies in the two groups was similar. Although the difference between the proportions of patients with and without asthma who required primary sinus surgery was not statistically significant (76 vs. 64%; p = 0.175), patients with asthma did require significantly more revision sinus procedures overall (mean: 2.9 vs. 1.5; p = 0.003).

Associations between fatigue and medication use in chronic rhinosinusitis

July 31, 2006     Neil Bhattacharyya, MD, FACS; Lynn J. Kepnes, RNP
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Abstract
We conducted a prospective study of 586 adults to determine if associations exist between fatigue symptom scores and three classes of medications prescribed for the treatment of chronic rhinosinusitis (CRS): prescription nonsedating antihistamines, topical nasal steroids, and antibiotics. Patients were assessed with the assistance of the Rhinosinusitis Symptom Inventory and Likert-scale fatigue symptom scores. On multivariate analysis and correcting for disease severity, we found that significantly higher fatigue symptom scores were associated with the use of nonsedating antihistamines (mean Likert score: 2.75 vs. 2.27 for patients not taking a nonsedating antihistamine; p = 0.029). Higher fatigue scores were also associated with a greater number of antibiotic courses and more total weeks of antibiotic use (p < 0.001 in both cases). No association was seen between fatigue scores and the use of topical nasal steroids (mean Likert score: 2.65 vs. 2.24; p = 0.658). We recommend that long-term use of a nonsedating antihistamine be scrutinized in CRS patients who report symptoms of fatigue.

Pharmacokinetically enhanced amoxicillin/clavulanate (2,000/125 mg) in acute bacterial rhinosinusitis caused by Streptococcus pneumoniae, including penicillin-resistant strains

July 31, 2006     Jack B. Anon, MD; Berrylin Ferguson, MD; Monique Twynholm, MSc; Brian Wynne, MD; Elchonon Berkowitz, PhD; Michael D. Poole, MD, PhD
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Abstract
We evaluated the efficacy of a new pharmacokinetically enhanced formulation of amoxicillin/clavulanate (2,000/125 mg) twice daily for the treatment of acute bacterial rhinosinusitis (ABRS) caused by Streptococcus pneumoniae, particularly penicillin-resistant S pneumoniae (PRSP; penicillin minimum inhibitory concentrations [MICs]: ≥2 µg/ml. A total of 2,482 patients received study medication (safety population). Of these, 2,324 were clinically evaluable (efficacy population), and 1,156 of them had at least one pathogen isolated at screening (bacteriology population). S pneumoniae was isolated from 371 patients in the bacteriology population, including 37 with PRSP. Follow-up in the bacteriology population on days 17 through 28 revealed that amoxicillin/clavulanate therapy was successful in 345 of 371 patients with S pneumoniae infection (93.0%) and in 36 of 37 patients with PRSP infection (97.3%), including 7 of 8 patients (87.5%) whose amoxicillin/clavulanic acid MICs were 4/2 µg/ml or higher. Pharmacokinetically enhanced amoxicillin/clavulanate was generally well tolerated, as only 2.2% of patients withdrew because of adverse events. This agent represents a valuable new therapeutic option for the empiric treatment of ABRS, particularly in areas where antimicrobial-resistant pathogens (including β-lactamase'positive organisms) are prevalent, and for the treatment of patients who are at increased risk of infection with PRSP.

 
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