Chronic sinusitis. Introduction.
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Chronic Disease↗
Biomedical subjects
B Bertrand
Publications and source records attributed to B Bertrand.
Anatomical variations and sinusitis.
Paranasal sinus anatomy and variations have gained interest with the introduction of functional endoscopic sinus surgery and the concept of the ostiomeatal complex. Anatomical variations can be divided in structural abnormalities, (increased) pneumatization and supplementary openings. Most anatomical variations are equally found in control and sinusitis patients. The anatomical variations which are most commonly associated with sinus pathology are septal deviations, true conchae bullosae and supplementary maxillary ostia but the latter one only when recycling is present. The knowledge of anatomical variations is most important in the surgical management and specifically in the prevention of complications.
Adolescent↗
Allergy and sinusitis.
Nasal allergy is statistically related to inflammatory chronic sinusitis as a risk factor. But one question still remains unanswered: are the reactions and modifications observed in the sinuses after natural exposure to a nasal allergen or after nasal allergen challenge linked to an IgE mediated mechanism? Similarities in symptoms, eosinophils and mediators of inflammation in the mucosa have been found between allergic rhinitis and sinusitis. The same applies for the deposition of Major Basic Protein (MBP) and treatment results, especially when topical steroids are found. An original prospective study was held among 106 patients (24 patients allergic to perennial allergens, 82 non allergic patients) suffering from bilateral chronic inflammatory (no polyposis) ethmoidal sinusitis. The allergic group was submitted to a 3 months antiallergic treatment (Cetirizine 10 mg once a day, Beclomethasone dipropionate 50 micrograms three times a day) before being referred for bilateral endonasal ethmoidectomy under endoscopic control. Scores for rhinorrhea, nasal obstruction and global comfort (global assessment) were compared before and after ethmoidectomy. Both groups were significantly improved by surgery. Comparing both groups, no significant difference was found before and after surgery regarding the three above mentioned parameters. This suggests that 1) symptoms are common to both perennial nasal allergy and chronic ethmoidal sinusitis, 2) medical treatment failure in allergy must require a CT scan of the sinuses to assess a possible accompanying chronic sinusitis, 3) chronic ethmoidal sinusitis is probably the leading factor responsible for nasal symptoms such as rhinorrhea and nasal obstruction when associated with perennial allergy.
Allergens↗
Diagnostic techniques in chronic sinusitis: endoscopy, sinusomanometry.
The first endoscope was conceived as early as 1806. Since then successive technical advances led endoscopy of the nose and paranasal sinuses to a routine procedure. From the rediscovery of the rigid telescopes by Hopkins in the fifties, progress has stemmed essentially from the quality of the more powerful cold lights and the improvement in the light output of the fiber optics. Exam procedures of the nose and sinuses are conducted under general as well as local anesthesia, and are commonly combined with concomitant diagnostic procedures: measure of the mucociliary clearance with indicators, biopsies, smear sampling for bacterial and fungal examinations, and sinusomanometry which can help to estimate the patency of the maxillary ostium and of the nasofrontal duct. Sinus endoscopy has been widely used to correlate efficiency of other diagnostic techniques such as plain X-rays, CT scanners, A and B mode ultrasonography. A similar work should be done for MRI. Endoscopic exploration is the key to the management of chronic pathology as it brings precise information on the quality of the naso-sinus mucosa, the presence of secretions and, combined with sinusomanometry, the functional state of the ostia or ducts.
Anesthesia, General↗
Medical and surgical management of chronic sinusitis.
The treatment of chronic sinusitis has four objectives: to control infection, to reduce tissue edema, to facilitate the drainage of sinus secretions and to maintain ostial permeability. Medical treatment includes antibiotics, decongestants, mucolytics, steroids and analgesics. Surgical treatment may be conservative, functional or radical. At present, "FESS" is the "Golden Standard". It is focused on the middle ostiomeatal complex and the ethmoid cells. The extent of the operation is adapted according to each case. In spite of standardization of the operative procedure, this type of surgery is risky. Most of the reported complications are minor. Major complications require an immediate aggressive medico-surgical treatment to minimize the sequelae. Precise and complete pre-operative evaluation, good preparation of the patient, meticulous and adapted surgical technique and experience acquired through a regular practice of this type of surgery play a major role to lower the risks of complications.
Administration, Topical↗
Sinusitis in the immunocompromised host.
In the immunocompromised host, uncommon pathogens have been documented as causing sinusitis. Resistance to standard antibiotics for sinusitis in the immunocompromised individual must prompt nasal culture and biopsy for early diagnosis. Immunocompromised host include neutropenic patients, Human Immuno-Deficiency (HIV) infected patients and non-HIV-suppressed patients. Unusual bacterial organisms (Pseudomonas Aeruginosa), mycobacteria, fungi (Aspergillosis) and viral infection (Cytomegalovirus) have all been found to cause sinusitis in immunocompromised patients. Early detection of these infections with appropriate anti-infective agents associated with radical or functional endoscopic surgery seems to be the optimal treatment. Recovery of immunity remains the major prognostic factor.
AIDS-Related Opportunistic Infections↗
Sinusitis of dental origin.
Acute or chronic sinusitis may be odontogenic. Bacteria involved in odontogenic sinusitis are specific organisms associated with the teeth (Streptococcus sanguis, Streptococcus salivarius, Streptococcus mutans, anaerobic germs). They are often secondary to an intrasinus foreign body following periodontitis. The treatment is both naso-sinusal and dental. Cysts of the maxilla can also invade the sinus. In particular, radiculo-dental cysts (periapical) must be surgically excised, in some cases associated with a middle meatotomy. Finally, one should look for oro-antral fistulae. The surgical technique for its closure should take into account the reversibility of the sinus lesions.
Acute Disease↗
Mycotic sinusitis.
In recent years, Extramucosal Fungal Sinusitis (EFS) in immunocompetent hosts have aroused increasing interest from both clinicians and pathologists. Histopathologically, they are characterized by the presence of fungal hyphae in the lumen of the sinus with no tissue invasion. They include two different entities: the mycetoma and the atopical fungal sinusitis (AFS). The mycetoma is the most frequent and best recognized form of EFS. The clinical picture is that of a unilateral symptomatic chronic sinusitis, often painful, unresponsive to appropriate medical treatment. CT scanning is very evocative in most cases. Definitive diagnosis requires histological and bacteriological examinations of the sinus contents. Surgery is the treatment of choice. Additional antifungal therapy is not indicated unless there is fungal tissue invasion. AFS is a distinct form of EFS. It typically occurs in an atopic patient with a long story of either chronic sinusitis or recalcitrant nasal polyposis recurring after adequate medical treatment or previous sinus surgery. Histopathologically, the pathognomonic pattern shows an "allergic mucin" and scanty fragmented fungal hyphae. Culture is the only way to identify the causative agent. Management should include wide radical sinus surgery combined with long-term nasal steroids. In spite of proper medico-surgical management, the prognosis remains variable and recurrences frequently arise.
Administration, Intranasal↗
Ciliary dyskinesia in the nose and paranasal sinuses.
Primary ciliary dyskinesia is a rare autosomal recessive disorder of which 50% with situs inversus Kartagener's syndrome. Secondary ciliary dyskinesia is a frequent observation, mostly in association with or after respiratory tract infections. Diagnosis and differential diagnosis are mostly based on the typical clinical picture, the absence of mucociliary clearance and ciliary activity and the electron microscopical demonstration of ultrastructural abnormalities. However, these investigations are not always conclusive. Functional and ultrastructural ciliary evaluation after ciliogenesis in tissue culture is essential and crucial.
Cilia↗
[Primary cardiac sarcoma treated by orthoptic cardiac transplantation. Apropos of a case].
The authors report a new case of cardiac sarcoma treated by cardiac transplantation. This treatment has been proposed for these malignant tumours of poor prognosis when simple excision is impossible, with variable results. This patient is in good general condition 20 months after transplantation. Transplantation is a therapeutic procedure which should be considered in malignant tumours limited to the heart.
Adult↗
Once daily mometasone furoate aqueous nasal spray is as effective as twice daily beclomethasone dipropionate for treating perennial allergic rhinitis patients.
BACKGROUND: Perennial allergic rhinitis is chronic and persistent, may lead to a constellation of secondary complaints including sinusitis, mouth-breathing, and some symptoms resembling a permanent cold, and often requires constant medical intervention. Well-tolerated nasal corticosteroids, alone or in combination with antihistamines, have been found to be very effective in treating this condition. OBJECTIVE: To compare the effectiveness and tolerability of mometasone furoate aqueous suspension, a new once daily nasal spray, to placebo vehicle and to beclomethasone dipropionate, administered twice daily, in patients with perennial allergic rhinitis. METHODS: This was a randomized, double-blind, placebo-controlled, double-dummy, parallel group study, in 427 patients age 12 years and older at 24 centers in Canada and Europe. Patients allergic to at least one perennial allergen, confirmed by medical history, skin testing, and adequate symptomatology were eligible to receive one of the following regimens for 3 months: mometasone furoate, 200 micrograms only daily; beclomethasone dipropionate, 200 micrograms twice daily (400 micrograms total dose); or placebo vehicle control. The primary efficacy variable was the change from baseline in total AM plus PM diary nasal symptom score over the first 15 days of treatment. RESULTS: Three hundred eighty-seven patients were valid for efficacy. For the primary efficacy variable, mometasone furoate was significantly (P < or = .01) more effective than placebo and was indistinguishable from beclomethasone dipropionate. Similar trends were seen among individual symptoms, physician symptom evaluations, and therapeutic response. There was no evidence of tachyphylaxis. All treatments were well tolerated. CONCLUSIONS: Mometasone furoate nasal spray adequately controls symptoms of perennial allergic rhinitis, offers the advantage of once daily treatment, and is well tolerated.
Administration, Intranasal↗
Triosite implants and fibrin glue in the treatment of atrophic rhinitis: technique and results.
Nine patients with primary or secondary atrophic rhinitis were treated by narrowing of the nasal fossae using a new surgical technique (derived from the Eryes procedure) in which a Triosite and fibrin glue mixture is implanted via the labial vestibule route. The results were good or excellent in seven patients. No rejections occurred. Osseocoalescence, as evaluated by computed axial tomography at 6 months, was good. Inspiratory intrasnasal pain in patients with postsurgical atrophic rhinitis improved following the operation. The surgical technique, which is quick and easy to perform, avoids the discomfort of nostril closure or the implantation of grafts from other parts of the body. Complicated flap procedures are also avoided.
Adult↗
[Left ventricular diastolic function: value of its study with mitral and pulmonary venous Doppler phonocardiography and apexography].
The study of mitral flow and pulmonary venous flow by Doppler provides a non-invasive method of assessing diastolic function. But there are difficulties in differentiating normal pattern from "pseudo-normal" (Appleton Type II) (E/A Mitral > 1). Phonocardiography enables the recording of early (B3) and late (B4) diastolic gallops. The apexogramme enables calculation of the a/H and D/H ratios (amplitude of the "D" wave resulting from rapid early diastolic filling to the total amplitude of the apexogramme). These two techniques record pulsatile phenomena ("pulse waves") arising from variations in intra-left ventricular pressure. They may complete the interpretation of Doppler recordings of velocities of blood flow ("flow waves"). To evaluate the value of each technique, the authors studied left ventricular diastolic function by Doppler phonocardiography and apexography in 60 subjects (38 patients of which 30 with ischaemic heart disease, and 22 healthy subjects). The results showed that increase in velocity and deceleration slope of the Doppler mitral E wave was associated with the presence of a B3 and correlated (r = 0.60; p = 0.0001) with the D/H ratio of the apexogramme. On the other hand, the absence of correlation between the mitral A wave velocity and a B4 associated with an increased a/H ratio enables the differentiation of normal Doppler mitral flow (absence of B4, Doppler a/H ratio < 12%) from pseudo-normal appearances (B4, a/H ratio > 12%). Therefore, the evaluation of diastolic function by Doppler mitral and pulmonary venous flow analysis may be usefully completed by phonocardiography and apexography.
Adult↗
Cetirizine and pseudoephedrine retard alone and in combination in the treatment of perennial allergic rhinitis: a double-blind multicentre study.
We compared the efficacy and safety of 5 mg cetirizine (CTZ), 120 mg pseudoephedrine retard (PER) and their combination (COM), given twice daily for three weeks, for the treatment of perennial allergic rhinitis. Two hundred and ten evaluable patients (97 males and 113 females) were included in the study and randomly allocated to one of three treatment groups, each of 70 patients. Nasal obstruction, sneezing, rhinorrhoea, nasal and ocular pruritus were scored each day throughout the study by patients using a symptom scale ranging from 0 (no symptom) to 3 (severe). The mean proportion of days without symptoms was higher in the COM group (11.8%) than in the CTZ (6.8%) and PER (5.1%) groups, but the differences were not statistically significant. The mean percentage of days when symptoms were absent or at most mild was significantly higher in the COM group (64.8%) than in either CTZ (45.5%; p = 0.003) or PER groups (40.6%; p = 0.0001). In addition, evaluation of symptoms by investigators and their global evaluation at the end of treatment showed statistically significant differences in favour of COM compared, to both CTZ and PER. The most frequent adverse events were somnolence in the CTZ and COM groups (8.6% and 12.9%, respectively) while insomnia was most frequent in the PER group. No clinically significant abnormalities were found in haematological or biochemical tests. These results indicate that the combined treatment was more effective than and as well tolerated as treatment with each individual agent.
Adult↗
Choanal polyp of sphenoidal origin. Report of two cases.
Clinical presentation and Imaging of two cases of choanal polyp extruding from the sphenoid sinus are presented. The clinical, radiological and pathological features of the choanal polyp are reviewed. The major role of radical endoscopic sinus surgery consisting of a complete removal of the polyp and of its insertion into the paranasal sinus cavity is emphasized.
Adolescent↗
[Primitive extracranial meningioma: a case report of intratemporal and naso-sinusal localization].
The authors report on the rare extracranial locations regarding a case of infratemporal fossa and paranasal sinus meningioma. These tumours formulate pathogenic questions, the hypothesis of which are exposed. Diagnosis gets difficult because of the atypical location of these meningiomas. Computerized tomography scan is the examination of choice for assessing the extension of these lesions. The only treatment is surgical.
Brain Neoplasms↗
[Syncopal neuralgia of the glossopharyngeal nerve caused by tumoral invasiveness. Therapeutic management. Apropos of 2 cases].
Cases of glossopharyngeal neuralgia are relatively rare, and are occasionally secondary to an upper cervical carcinomatous invasion. The combination with syncopal episodes suggests the creation of a reflex pathway between the glossopharyngeal nerve and the vagus nerve by connections between the bulbar nuclei. The fact that the syncopal episode is systematically preceded by a neuralgic crisis enables its differentiation from other active vasomotor phenomena. Treatment is based essentially on pain-killers and occasionally, in the event of escape, by a neurosurgical resection of the root of the glossopharyngeal nerve and of the upper part of the vagus nerve. In the light of two recent cases, the authors recall the therapeutic management and the physiopathological mechanism of this particular form of neuralgia.
Analgesics, Opioid↗
Lethal disseminated Fusarium infection with sinus involvement in the immunocompromised host: case report and review of the literature.
A case of disseminated invasive fusarial infection (DFI) with sinus involvement in a patient with acute myeloblastic leukaemia is reported. Amphotericin B with rifampin were administrated and wide radical sinus surgery was performed. Nevertheless, the patient died six weeks later. The four principal forms of fusarial infections in humans are discussed: toxicosis, allergic fungal sinusitis, locally invasive infection, and disseminated invasive infection. Prognosis of DFI in the immunocompromised host is usually poor, and treatment is difficult. Profound and prolonged neutropaenia appears to be the major predisposing factor. The literature on infections caused by Fusarium species in immunocompromised hosts is reviewed, especially those where the sinuses were involved.
Amphotericin B↗