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PubMed2000

Prognosis and prediction of response to surgery in allergic patients with chronic sinusitis.

BACKGROUND: Chronic rhinosinusitis (CRS) occurs frequently in patients with atopy, but little is known of the prognosis after surgery and of factors that may predict a poor outcome. OBJECTIVE: Our purpose was to assess the long-term prognosis in atopic patients with CRS who undergo surgery and whether certain immune markers could predict a worse prognosis in this setting. METHODS: Fifteen patients with diffuse involvement of the sinuses on computed tomographic (CT) scan but without nasal polyposis underwent ethmoidectomy with middle meatotomy for CRS when it was clinically indicated. All patients had a biopsy of the inferior turbinate and of the most inflamed areas of the maxillary and ethmoid sinuses at the time of surgery. Follow-up was performed by video endoscopy and by assessment of 2 chronic sinusitis questionnaires at 0, 6, and 24 months postoperatively. The number of lymphocyte subsets (CD3, CD4, CD8), mast cells and eosinophils, and cells expressing IL-4 and IL-5 messenger RNA (mRNA) in all 3 biopsy sites at the time of surgery were compared with the clinical response after surgery. RESULTS: Seven patients had persistent improvement after surgery, with a decrease in pain, rhinorrhea, or nasal obstruction and a decrease in the need for medication. Eight patients were unchanged or worsened after surgery with disabling rhinorrhea and repeated sinusitis. We found no difference in the number of inflammatory cells, lymphocyte subsets, or IL-4 mRNA-positive cells in the sinus mucosa between responders and nonresponders. However, an increased number of cells expressing IL-5 mRNA was found in the ethmoid sinus at the time of surgery in patients who did not respond to the surgical intervention (P =.007). CONCLUSION: More than 50% of patients with perennial rhinitis and CRS do not improve after surgery, a response that may be predicted by more cells expressing IL-5 mRNA in the ethmoid sinuses. The increased number of cells expressing IL-5 mRNA may have the potential to be used as a marker for prediction of the response to surgery. The worsening of symptoms in some patients with CRS after sinus surgery could be a result of the disturbance of the anatomy of the sinuses and exposure to the environmental allergens.

Adolescent↗
PubMed1996

Chronic sinusitis.

Symptoms of chronic sinusitis include facial pain, rhinorrhea and malaise. Infection, allergies and vasomotor rhinitis/ sinusitis are the usual causes. Physical examination, laboratory results and routine radiologic findings are often minimal. Computed tomographic scanning, however, may show pathology that is not apparent on standard radiographs. Nonpharmacologic treatments should be considered first. Increased exercise and nasal steam inhalation may help. Dietary restrictions or a change in environment are occasionally quite beneficial. Intranasal corticosteroids and brief courses of local decongestants are frequently appropriate. Systemic therapy, including decongestants, anti-inflammatory agents, antibiotics and, occasionally, antihistamines, offers treatment directed at the causes of chronic sinusitis. When aggressive medical treatment is unsuccessful, nasal surgery, particularly endoscopic surgery, directed at abnormalities of the ostiomeatal unit, may offer significant benefit for selected patients.

Chronic Disease↗
PubMed2001

Immunopathologic study of chronic sinusitis: a proposal for atopic and non-atopic IgE-activated mast cell allergic inflammation.

Paranasal sinus mucosa was examined in this study for mast cell membrane-bound IgE. The study material was from 54 patients identified in hospital records as having one of the following diagnoses: chronic sinusitis, chronic sinusitis with asthma, or chronic sinusitis with associated nasal polyps. Formalin-fixed tissue samples taken during endoscopic sinus surgery were routinely processed and examined with hematoxylin and eosin stains. Additional sectioned tissue was analyzed by fluorescence microscopy for mast cells after the use of anti-IgE and anti-tryptase antisera; 45% of the cases of chronic sinusitis, 50% of the cases of chronic sinusitis with polyposis, and 69% of the cases of chronic sinusitis with asthma exhibited 10 or more IgE-positive mast cells in the sinus mucosa. Significant numbers of individuals with chronic sinusitis have coexistent allergic disorders. Some individuals in this study who were not allergic by hospital record review also manifested IgE-positive mast cells in the sinus mucosa; a basis for this finding is proposed.

Adolescent↗
PubMed1999

Clinical practice guidelines for the management of chronic sinusitis in children.

Chronic sinusitis in children is a common and vexing disease for clinicians and the public. There are insufficient data in the literature to develop an evidence-based clinical guideline. Experience in managing pediatric chronic sinusitis has been gained through a multidisciplinary clinic at our institution during the past 3 years. A panel of experts was formed, and with the guidance of a guideline methodologist, the development of a rigorous outcome-based guideline was undertaken. Symptom-improvement and recurrence estimates for a variety of medical and surgical treatments were assessed. Wide probability estimates were made by the panelists in most cases. Although we refrained from making specific recommendations, we developed a ranked series of practical treatment options taking into account side effects and costs.

Anti-Bacterial Agents↗
PubMed2002

[Revision endoscopic sinus surgery for chronic sinusitis and polyps].

OBJECTIVE: To investigate common reasons for revision endoscopic sinus surgery (RESS) and evaluate the effect of RESS. METHODS: Before the revision surgery 114 patients were examined by CT scans and nasal endoscopy, after surgery all the patients were followed up for more than 2 years. RESULTS: There were 16 cases of recurrence of polyps, 98 cases of recurrence of sinusitis. Among 114 cases there were 18 cases of anterior ethmoid sinus disease, 2 frontal recess stenosis, 31 anterior ethmoid sinuse disease with maxillary ostium obstruction, 6 middle turbinate adhesion, 18 posterior ethmoid sinus disease, 36 posterior ethmoid sinus disease with sphenoid sinus disease, 3 isolated sphenoid sinusitis. There were 15 cases with septal deviation. 99 cases were successful and 15 unsatisfied. CONCLUSION: Sinus disease that was not completely resected during the original surgical procedure due to the surgeon's less experience was the most common reason for the RESS, another reason was recurrent polyposis. The results were very rewarding except nasal polyposis.

Adolescent↗
PubMed1994

Functional endoscopic sinus surgery in patients with chronic sinusitis and asthma.

Twenty asthma patients who underwent functional endoscopic sinus surgery for chronic sinusitis were studied. Medical records and questionnaire data for these 20 patients were studied regarding the impact of sinus disease and functional endoscopic sinus surgery on their asthma. We found that 95% reported that their asthma was worsened by their sinus disease (95% confidence interval, 0.74 to 0.99+), and 85% reported that functional endoscopic sinus surgery improved their asthma (0.60 to 0.97). Of the 13 patients who used both inhalers and systemic medication, 53.8% were able to eliminate some of their medication (0.21 to 0.79). Furthermore, 61.5% of these patients had a concomitant reduction in their inhaler use (0.28 to 0.85). All patients (six) who used only inhalers experienced a reduction in their inhaler use (0.54 to 1.00), and two patients were able to eliminate their inhalers completely. One of two patients who were steroid dependent was able to discontinue steroids after surgery. Of patients who used steroids intermittently (13), 53.8% were able to eliminate the use of steroids after surgery (0.21 to 0.79). Patients who required preoperative hospital admissions (4) and emergency room or urgent physician office visits (18) had a 75.0% and 81.3% (p < 0.001) reduction in visits, respectively, after surgery. Because 43% of the cost of asthma is the result of hospitalizations and emergency department/urgent physician office visits, a significant impact on health care costs can be realized with functional endoscopic sinus surgery in this patient population.

Adolescent↗
PubMed1994

Results of endoscopic sinus surgery in pediatric patients with chronic sinusitis and asthma.

OBJECTIVE: To determine the efficacy of endoscopic sinus surgery in pediatric patients with chronic sinusitis and asthma. SETTING: Patients were selected from the tertiary care practice of a pediatric pulmonologist (R.S.) and immunologist (R.L.W.); all underwent sinus surgery at Children's Medical Center at Dallas (Tex). PATIENTS: Fourteen pediatric patients aged 3.5 to 13 years with severe asthma requiring at least intermittent systemic steroid therapy. All patients had a history of sinusitis aggravating asthma and all had computed tomographic evidence of chronic sinus disease. INTERVENTION: All patients underwent endoscopic sinus surgery consisting of bilateral total ethmoidectomies and middle meatus antrostomies at a minimum. MAIN OUTCOME MEASURES: The period 12 months prior to surgery was compared with 12 months postoperatively with regard to total hospitalization days for asthma treatment, number of school days missed, pulmonary function test results, and systemic glucocorticoid medication requirements. Symptom scores for asthma and sinusitis were assessed via parental questionnaire both preoperatively and postoperatively. RESULTS: No significant difference was found for pulmonary function test results. Eleven of 14 patients demonstrated a significant reduction in hospitalization and school days missed. Twelve of 14 patients experienced a reduction in glucocorticoid requirements. Eleven of 14 and 13 of 14 patients experienced a significant improvement in asthma and sinusitis symptom scores. CONCLUSION: Endoscopic sinus surgery was effective in reducing sinusitis and improving the overall management of asthma in a majority of study patients.

Absenteeism↗
PubMed2004

[Gastroesophageal reflux disease and chronic sinusitis].

BACKGROUND: It is increasingly suggested that there may be a connection between gastrooesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR) and chronic sinusitis. We therefore wished to establish whether the literature contains sufficient evidence to support this assumption. MATERIAL AND METHODS: We performed a search in Medline (PubMed) and EMBASE with the key words "GERD, GER, reflux, sinusitis, chronic sinusitis". The literature obtained was assessed with regard to the reported results and their evidence levels. The level of evidence was classified according to the usual levels I - IV, only levels Ia or Ib being considered sufficient evidence for a knowledge gain confirmed by therapeutic trials. RESULTS: A total of 77 references were found in Medline and 142 in EMBASE. A large number of these were narrative review articles addressing the connection between GERD or sinusitis and asthma or GERD or sinusitis and chronic cough. Only 12 papers and one case report dealt more or less directly with the question of a connection between chronic sinusitis and reflux. None of the studies could be classed as evidence level I (randomised controlled trials), ten were classed as level III studies, one as level IIb and one as level IV. DISCUSSION AND CONCLUSIONS: The existing studies do not allow us to pinpoint LPR (and even less so GERD) as a clear-cut factor in the aetiopathogenesis of chronic sinusitis. However, despite all their deficiencies and limitations the studies nevertheless do show that reflux into the pharynx and nasopharynx is possible. This reflux (= LPR) can lead to chronic inflammation which can be successfully treated with antireflux therapy with proton pump inhibitors. Quantification of the association is not currently possible. An above-average proportion of the patients with chronic rhinosinusitis appear to have GERD/LPR. However the prevalence of GERD in the population is generally high. It has not yet been established with sufficient certainty whether the LPR must be regarded as a causative factor, whether it exacerbates or chronifies the disease or whether it is merely an epi-phenomenon which does not require specific treatment. To answer this important question we need prospective randomised controlled studies which will provide evidence of sufficient quality. These should be conducted with the help of standardised documentation.

Adolescent↗
PubMed1995

Concha bullosa: frequency and appearances on CT and correlations with sinus disease in 308 patients with chronic sinusitis.

The purposes of this study were to determine the prevalence of concha bullosa in patients with chronic sinusitis, to assess the origin of the pneumatisation (from the anterior or posterior ethmoid cells), and to evaluate the significance of the concha bullosa in the genesis of inflammatory sinus disease. We reviewed the CT studies of 308 patients with chronic sinusitis, assigning four grades of pneumatisation: absent, small, medium and large. Unilateral or bilateral concha bullosa was found in 164 patients (53%). In 79% of cases it was pneumatised via the posterior ethmoidal cells and in 21% via the anterior. A small concha bullosa was associated with abnormalities of the maxillary sinus, ethmoidal cells and ostiomeatal unit respectively in 49%, 28% and 34% of cases, whereas with a large concha bullosa the association was 55%, 36% and 41% respectively on the ipsilateral side and 55%, 32% and 41% on the contralateral side. The usually accepted hypothesis that the concha bullosa may contribute to the pathogenesis of inflammatory sinus disease seems doubtful.

Adult↗
PubMed1981

Chronic sinusitis.

Patients with chronic sinusitis often have a paucity of symptoms. However, patients may have exacerbations of acute sinusitis superimposed on the chronic disease, which may cause sinus pain, fever, and malaise. More often, though, patients seek evaluation for nasal stuffiness, hyposmia or cacosmia, and purulent nasal and postnasal secretions. Antibiotics seldom eradicate the disease; sinus drainage is the immediate goal of treatment. In maxillary sinusitis, construction of a nasoantral window is the best form of definitive treatment.

Aged↗
PubMed1995

Triadic nose drops in the treatment of chronic sinusitis.

Thirty patients with chronic sinusitis have been treated with triadic nose drops consisting of ephedrine, dexamethason and lincomycin. Twenty three cases were cured, five cases improved and there was no effect in two cases. This study suggests that triadic nose drops are beneficial in chronic sinusitis. The pathogenesis and treatment of chronic sinusitis is discussed.

Administration, Intranasal↗
PubMed1998

Expression of IgE heavy chain transcripts in the sinus mucosa of atopic and nonatopic patients with chronic sinusitis.

We have recently shown the increased mRNA expression of interleukin (IL)-4 and IL-13 in sinus biopsies from allergic subjects with chronic sinusitis (ACS), whereas only IL-13 mRNA was elevated in biopsies obtained from nonallergic subjects with chronic sinusitis (NCS). In the lymph nodes and spleen, these cytokines may promote IgE production through transcriptional activation of the germline IgE heavy chain promoter, an event which precedes immunoglobulin isotype switching to IgE in B cells. We hypothesized that local expression of IL-4 and/or IL-13 might act by inducing germline IgE heavy chain transcript expression locally in the sinus mucosa of chronic sinusitis patients. Mucosal sinus biopsies were obtained from 13 patients with ACS, 12 subjects with NCS, and 11 normal control individuals. The numbers of B cells in the sinus mucosa were studied by immunocytochemistry with anti-CD20 monoclonal antibodies. In situ hybridization was performed using antisense radiolabeled riboprobes complementary to the IgE epsilon -heavy chain germline (Iepsilon) and heavy chain constant region (Cepsilon) gene transcripts. Riboprobes specific for the IgG gamma-heavy chain constant region (Cgamma) were used as an isotype control. Immunocytochemical analysis indicated augmented numbers of CD20-positive B cells in the biopsies obtained from ACS patients compared with NCS subjects (P < 0.05) and normal control subjects (P < 0.01). Statistically significant increases were observed in the numbers of cells expressing Iepsilon and Cepsilon transcripts in the sinus mucosa of ACS patients compared with those with NCS (P < 0. 001) and normal controls (P < 0.001), while Cgamma RNA expression did not differ significantly between the groups. In three randomly selected ACS biopsies, 92-100% of cells expressing Cepsilon transcripts and 100% of Iepsilon RNA-positive cells coexpressed CD20 immunoreactivity. Cells expressing Cepsilon transcripts were also significantly increased in NCS compared with normal controls (P < 0. 05). The results of this study suggest that local IgE class switching occurs in the pathogenesis of ACS and that ACS and NCS are both associated with increased expression of Cepsilon transcripts.

Adult↗
PubMed1999

Urokinase-type plasminogen activator and plasminogen activator inhibitor antigen in tissue extracts of paranasal sinus mucous membranes affected by chronic sinusitis and antrochoanal polyps.

We examined the effect of pH on the extraction of urokinase-type plasminogen activator (u-PA) and plasminogen activator inhibitor-1 (PAI-1) from paranasal sinus mucous membrane associated with chronic sinusitis and antrochoanal polyps. The specific activity of u-PA extracted with buffer at pH 7.4 was stronger than that extracted with buffer at pH 4.2. The antigen level of u-PA extracted with the acidic buffer was significantly higher than that extracted with the neutral buffer. In contrast, the difference in antigen levels of PAI-1 extracted with the acidic buffer and neutral buffer was not significant. Based on these results, we inferred that the u-PA-PAI-1 complex was extracted by the acidic buffer and the activity of u-PA was therefore decreased.

Antigens↗
PubMed2002

Anatomic variations of the paranasal sinus area in pediatric patients with chronic sinusitis.

Endoscopic endonasal surgery has been performed in children. Therefore, we need to know the precise anatomy and anatomic variations of the lateral nasal wall. This is important in order to achieve better surgical results and avoid complications. We also need to know the relationship between the anatomic variations and sinonasal disease. For the purpose of this study we assessed the anatomic variations of the lateral nasal wall and the association of these variations with chronic sinusitis in children. Forty-seven children with chronic sinus disease were included in the study. There were 25 female and 22 male patients with ages ranging from 2 to 16 years (mean 10.5+/-3.8 years). On coronal and axial computed tomographic (CT) scans, the anatomic variations of the lateral nasal wall and sinusitis were assessed. A pneumatized middle concha (MC) was the most common anatomic variation, followed by pneumatization of the superior concha (SC), Haller cell and agger nasi cell. Secondary MC, large ethmoidal bulla, maxillary sinus hypoplasia, Onodi cell, and uncinate process pneumatization were relatively rare. Maxillary sinusitis was the most common sinus infection, followed by ethmoidal, sphenoidal and frontal sinusitis in that order. There was no significant relationship between the sinusitis and anatomic variations except for some minor associations. In conclusion, anatomic variations in the lateral nasal wall are common in children. Local, systemic or environmental factors appear to be more important in pediatric sinusitis than the anatomic variations. Due to the absence of a definitive relationship between the anatomic variations and sinus disease, aggressive surgical interventions should be avoided while performing endonasal endoscopic surgery in the children.

Adolescent↗
PubMed1990

An update on chronic sinusitis.

The management of chronic sinus disease has been revolutionized by the application of computed tomographic (CT) imaging and rigid endoscopes in diagnostic evaluation and surgical treatment. These diagnostic advances have led to a better understanding of sinus pathophysiology and the development of more rational surgical treatment. Obstruction of mucociliary drainage in the anterior ethmoid sinus-middle meatus region (ostiomeatal complex) is now understood to be the cause of chronic symptomatic sinus disease. Involvement of the maxillary or frontal sinus is usually secondary to disease in the ostiomeatal complex. Three cases are presented to illustrate the use of CT scanning and nasal endoscopy in the evaluation of chronic sinusitis. Precise identification and correction of ostiomeatal complex obstruction with endoscopic surgical techniques has proven efficacious and is associated with minimal patient morbidity. Endoscopic sinus surgery is emerging as the treatment of choice for medically unresponsive chronic sinus disease.

Adult↗