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PubMed1981

[Atrial stimulation and intranodal migration of sinus pacemaker in man (author's transl)].

In order to demonstrate, in man, sinus node pacemaker shift following atrial stimulation, we compared, in 26 patients, the curve of sinus node function obtained with Strauss' method with that resulting by the scanning with premature atrial stimulation of the first returning cycle following either a single premature atrial induced beat (140 ms shorter than the basic cycle) (group A), or a train of 8 consecutive atrial beats induced with a rate slightly faster (10 beats/m) than the control sinus rhythm (group B). Assuming that no changes in sinus pacemaker automaticity or in sinoatrial conduction occur owing to atrial stimulation, curves with the same shape should be observed if the site of the dominant pacemaker remains unchanged: whereas, different lengths of the compensatory phase (zone I) should be expected if an intranodal pacemaker shift occurs. For evaluating the length of the compensatory zone (zone I), we calculate, on the curve of the sinus node function, the mean value of the relation points included in the first third of the reset zone (zone II). According to our results, the length of the compensatory phase (zone I) evaluated on the curve resulting by the scanning of the first returning cycle following either a single premature atrial induced beat (group A), or eight consecutive atrial beats (group B) was shorter than that observed with the original Strauss' method (10% and 18% respectively). However, only in the group B, this difference was statistically significant. In addition, a significant inverse relationship between the shortening of the compensatory zone and the sinoatrial conduction index was also observed. Considering that our results have been corrected in such way as to repeal eventual changes in sinus pacemaker automaticity or sinoatrial conduction following atrial stimulation, the shortening of the compensatory zone, we have observed in our patients, strongly suggests an intranodal sinus pacemaker shift. If we assume that this result could represent an indirect evidence of this phenomenon, some clinical implications may follow: 1) another limitation, in addition to others known (intraatrial conduction delay, sinus arrhythmia, changes in sinus node automaticity, difference between retrograde and antegrade conduction time) could decrease the accuracy of atrial stimulation techniques in the estimation of the sinoatrial conduction time; 2) sinus pacemaker shift following atrial stimulation, may induce an understimulation of the true sinoatrial conduction time; however, according to our results, the error is generally small, so that it does no preclude the usefulness of atrial stimulation techniques in the evaluation of sinoatrial conduction; 3) the more evident and significant shortenings of the compensatory phase occurred with atrial pacing technique: this finding could explain why shorter sinoatrial conduction times are generally observed with Narula's method in comparison with Strauss' method.

Adult↗
PubMed1983

[Lengthening of the direct sinoatrial conduction time: a criterion of sinus node dysfunction].

In order to determine the significance of prolongation of the direct sinoatrial conduction time (DSACT), an attempt was made to record the sinus node potential in 110 patients which was successful in 84 cases. The DSACT was normal in 45 cases (Group A) and prolonged (over 130 ms) in 39 cases (Group B). The symptomatology, standard ECG and the results of investigation of sinus node function by atrial stimulation of the two groups were compared. The DSACT was prolonged in all 13 patients with paroxysmal sinoatrial block or the sick sinus syndrome, in 71% of 15 patients with permanent sinus bradycardia, in 88% of 22 patients with a corrected sinus node recovery time of over 525 ms, in 82% of 38 patients with a sinoatrial conduction time estimated by the extrastimulus method of over 130 ms or an abnormal zone II, in 80% of 39 patients with sinoatrial conduction times estimated by Narula's method of over 130 ms; therefore, 87% of the 35 patients with probable sinus node dysfunction had long DSACT. On the other hand only 2 out of 35 patients (6%) with apparently normal sinus node function had prolonged DSACT. These results indicate that prolongation of the DSACT is a sensitive and specific criterion of sinus node dysfunction. In cases of sinus node dysfunction dizziness and/or syncope without any known cause were common complaints in patients in Group B but absent in patients in Group A. A prolonged DSACT could be of prognostic significance in sinus node dysfunction.

Aged↗
PubMed1982

The direct negative chronotropic action of prazosin on the canine sinus node.

The direct and indirect chronotropic effects of prazosin were studied in 22 anesthetized dogs using the technique of selective perfusion of the sinus node. Concentrations of 1, 10, 50 and 100 micrograms/ml of prazosin produced cumulative, dose-related reductions in mean sinus rat of 4 +/- 2; 10 +/- 6; 15 +/- 9 and 27 +/- 15 beats/min, respectively (P less than .0001). Intranodal prazosin did not significantly alter the positive chronotropic sinus node response to norepinephrine (0.05 and 0.1 micrograms/ml) administered via the same route. Sinus rate increases during stimulus frequency response curves after right stellate stimulation were not influenced by prior administration of prazosin. Sinus bradycardia elicited by submaximal vagal stimulation also was not affected by intranodal prazosin.l In six reserpinized dogs, methoxamine (10 and 25 micrograms/ml) injected into the sinus node artery caused a sinus rate increase of 10 4/- 2 and 14 +/- 3 beats/min (P less than .001). Intranodal prazosin (50 micrograms/ml) prevented this effect. Taken together, these results indicate that prazosin exerts a direct negative chronotropic action on the canine sinus node and that this effect is at least in part mediated through interference with alpha-1 receptors located in or near the sinus node. Prazosin has little or no effect on the presynaptic alpha-2 receptors nor does it interfere with the cholinergic mechanism in the sinus node.

Animals↗
PubMed1982

Electric sign of the activity of the sinus node in the dog heart.

The possibility of local recording of the electrical activity of the sinus node was investigated on 22 dogs. Using a small unipolar electrode positioned at the proximity of the sinus node and applying a 2-4-fold electric amplification, an early, slow and low-amplitude wave could be recorded 20-40 ms before the P wave. This early wave gradually decreased when the electrode was moved away from the sinus node and finally fused into the local P wave. Temporary arrest of sinus node activity by injection of adenosine into the sinus node artery, electrical stimulation of the vagal nerve by infiltration with phenol of the sinus node region made the local P wave to disappear. Similarly, no early action before the P wave could be seen if the sinus node was driven electrically. The early wave recorded in the proximity of the sinus node represents the depolarization of the sinus node, and it is suitable to study the pacemaker activity of the sinus node together with sinoauricular conduction.

Action Potentials↗
PubMed1981

Bedside evaluation of postoperative sinus node function in children.

Sinus node dysfunction in children frequently results from the surgical correction of congenital heart defects. We evaluated postoperative sinus node function at the bedside in 25 children by utilizing atrial epicardial electrodes which were placed near the sinus node at the time of operation. Sinoatrial conduction times (SACTs) and corrected sinus node recovery times (CSNRTs) were determined within 3 days of operation in each patient. Group 1 consisted of 20 patients (aged 1 month to 13 years) with normal postoperative sinus node function. Mean (+/- SD) SACTs and CSNRTs were 122 +/- 33 msec (range 61 to 187 msec) and 165 +/- 54 msec (range 52 to 253 msec), respectively. Preoperative evaluation of sinus node function during cardiac catheterization showed that preoperative and postoperative SACTs and CSNRTs were not significantly different (p greater than 0.05) in any of nine patients. Group 2 was composed of five children (aged 1 to 14 years) with postoperative sinus node dysfunction. Three had abnormal SACTs of 230 msec or greater and two children had first-degree sinus node entrance block. Two patients had prolonged CSNRTs. Electrocardiographic (ECG) monitoring revealed evidence of sinus node dysfunction in four of the five patients in Group 2. This report describes a simple and safe means of evaluating postoperative sinus node function at the bedside. The data are comparable to those obtained using more conventional methods during cardiac catheterization.

Adolescent↗
PubMed1997

The relationship between the sinus node and the right atrial appendage.

BACKGROUND: The developmental anatomy of the right atrium, particularly the union between its sinus venarum (sinus) and atrial portions, has not been completely settled. Invagination of the embryonic sinus into the atrium brings about electrical and structural union between these primitive chambers but results in the formation of the terminal crest, a seemingly bulky and intrusive band of muscle separating sinus from atrium. However, it is unlikely that a structure that can be found in all mammalian species is merely a functionless remnant. Structural differences between the smooth sinus and the deeply trabeculated right atrial appendage emphasize the two-part shape of the right atrium, but it is hypothesized that the sinus and atrium form a single, well-knit chamber shaped for the supply of nutrient blood to atrial conducting tissues rather than for downstream bloodflow. METHODS AND RESULTS: The morphology of the right atrium was studied grossly and microscopically in 54 adult hearts. The distribution of Thebesian sinusoids arising from the right atrial appendage was identified by ink perfusion and clearing of several additional adult and fetal hearts. The sinus node was found to be precisely co-extensive with the undercut portion of the terminal crest and with pectinate muscles lining the pyramidal portion of the right atrial appendage. Sinusoids and interpectinate spaces related to the undercut portion of the terminal crest are limited to the area of the sinus node. CONCLUSION: These findings support the hypothesis that the right atrial appendage, pectinate muscles and terminal crest evolved to supply nutrient blood to conducting myocardium of the sinus portion of the right atrium, and that this chamber, like the right ventricle, is structured as a single and completely finished unit. Interpectinate spaces and Thebesian sinusoids offer clues to the location of conducting pathways, including the sinus node.

Adolescent↗
PubMed1996

[Unroofed coronary sinus syndrome].

Unroofed coronary sinus syndrome or coronary sinus septal defect is a rare congenital cardiac anomaly. We performed corrective operations in 9 patients with such condition. Of them, seven patients had the completely unroofed coronary sinus and persistent left superior vena cava (PLSVC) directly draining into the left atrium (LA). One patient had PLSVC and the partially unroofed terminal portion of the coronary sinus (CS), or sinus ostium open into LA. Another patient had total anomalous pulmonary vein connection and the partially unroofed mid-portion of CS without PLSVC. The operative methods of the unroofed coronary sinus included: ligating PLSVC and repairing ostium primum or secundum atrial septal defects in 4 cases; creating an intra-atrial tunnel from PLSVC to the right atrium (RA) and repairing the atrial septal defect in 2 cases; reconstructing the intra-atrial septal with a patch as a baffle to guide PLSVC or sinus ostium respectively towards RA in 2 cases; enlarging the defect on the coronary sinus roof and repairing the atrial septal defect of the coronary sinus type in one case. No patient died in this group. Because unroofed coronary sinus syndrome has atypical clinical manifestation and usually complicates varied congenital anomalies, its preoperative diagnosis is very difficult in some times and may draw the reliable support from echocardiography and catheterization. The operative program and method must depend not only upon its type but also upon PLSVC presence of absence, and communication between PLSVC and RSVC.

Adolescent↗
PubMed1977

Carcinomas of the paranasal sinuses: a study of sixty-six cases.

The therapy records of 66 patients with carcinomas of the paranasal sinuses were reviewed; primary carcinomas occurred in the maxillary sinus in 50 patients, the ethmoid sinus in 11 patients, the sphenoid sinus in 4 patients and the frontal sinus in 1 patient. The tumors of the maxillary sinus were staged retrospectively according to the American Joint Committee staging system recommended in 1976; 1 of 2 patients with T1, 5 of 11 patients with T2, 10 of 34 patients with T3 and 1 of 3 patients with T4 lesions showed no evidence of disease (NED) at 3 years. Combined high dose irradiation (6,000 rads in 6 weeks) followed by radical surgery in 4 to 6 weeks was well tolerated; this approach is recommended for the treatment of T1, T2, and selected T3-4 maxillary sinus lesions. Only 2 of 11 patients with ethmoid sinus lesions survived at 3 years.

Adult↗
PubMed2006

Ontogeny and homology of the paranasal sinuses in Platyrrhini (Mammalia: Primates).

The identity and taxonomic distribution of paranasal sinuses among living platyrrhines has remained a contentious issue (e.g., Cave [1967] Am J Phys Anthropol 26:277-288 vs. Hershkovitz [1977] Chicago: University of Chicago Press) largely because the ontogenetic data required for their detection and identification (e.g., Cave [1967]; Maier [2000] Cambridge, UK: Cambridge University Press, 99-132.) were not attainable without sacrificing valuable juvenile and subadult specimens. Non-invasive computed tomography (CT) scanning of ontogenetic series of skulls for 10 platyrrhine genera demonstrates the presence of maxillary and ethmoid sinuses, as well as homologs of the human sphenoid and frontal sinuses. Differences in the latter two sinuses between platyrrhines and hominoids highlight the need for early developmental data in establishing sinus homology. In particular, the identification of homologous recesses in the cartilaginous nasal capsule, from which sinuses later develop, emerges as the critical step. This developmental approach also reveals that the anterior and posterior ethmoid sinuses are each sets of serial homologs, a point which reconciles previous difficulties in establishing sinus homologies across mammalian orders (e.g., Paulli [1900] Gegenbaurs Morphol Jahrb 28:147-178, 179-251, 483-564).

Age Factors↗
PubMedDate not supplied

Bacteriology of chronic sinusitis in relation to middle meatal secretion.

BACKGROUND: The bacteriology of chronic sinusitis has been studied widely, but some factors may affect the results, such as sample sources and sampling techniques. However, whether the presence of secretion in the middle meatus affects the culture result has been studied rarely. METHODS: When patients with chronic sinusitis underwent functional endoscopic sinus surgery, swab specimens were taken from the ipsilateral middle meatuses and ethmoid sinuses under endoscopic guidance. While taking specimens from the middle meatuses, we observed the presence of secretions in the middle meatuses. The severity of chronic sinusitis was evaluated by preoperative computed tomography, which was scored by the Lund-Mackay system. The scores of the frontal, anterior ethmoid, maxillary sinus, and ostiomeatal complex were cumulated. RESULTS: Between March 2001 and February 2004, 210 pairs of specimens were collected. The secretion was present in 82 middle meatuses and was absent in the other 128 middle meatuses. The culture rates of middle meatus and ethmoid sinus specimens were 70.7 and 51.2%, respectively, for patients with secretions in the middle meatuses and 53.1 and 44.5%, respectively, for patients without secretions in the middle meatuses. The culture rate was significantly different for middle meatus specimens (p = 0.011) and the mean cumulated computed tomography score also was significantly higher in patients with secretions in the middle meatuses than in patients without secretions in the middle meatuses (p < 0.001). CONCLUSION: The results of this study suggest that the presence of secretion in the middle meatus indicates more severe disease in the anterior group of paranasal sinuses.

Adolescent↗
PubMed2003

The role of Chlamydia pneumoniae infection in children with chronic sinusitis.

BACKGROUND: Chlamydia pneumoniae infection is a frequent cause of lower respiratory disease in both adults and children. However, its role in upper respiratory disease, including sinusitis, is less clear. OBJECTIVE: To determine the role of infection with C. pneumoniae in chronic sinusitis in children. DESIGN: Prospective collection of specimens. SETTING: Tertiary care academic medical center. PARTICIPANTS: Children with clinical and radiologic evidence of chronic sinusitis unresponsive to medical management undergoing adenoidectomy, maxillary sinus lavage, or endoscopic sinus surgery for treatment. Intervention Nasopharyngeal and middle meatal swabs and portions of surgical specimens were obtained and cultured for C. pneumoniae. RESULTS: Specimens were obtained from 20 children (14 boys and 6 girls) aged 3 through 16 years. Thirteen bilateral endoscopic ethmoidectomies with maxillary antrostomies, 10 adenoidectomies, and 3 bilateral maxillary sinus lavages were performed. Chlamydia pneumoniae was isolated from the nasopharyngeal swab and adenoid tissue of 1 child (aged 6 years); however, his middle meatal swabs and maxillary sinus aspirates were negative. After 10 days of treatment with clarithromycin, repeat nasopharyngeal cultures were negative for C. pneumoniae. CONCLUSIONS: With the use of sensitive culture methods, C. pneumoniae was not isolated from sinus specimens of children enrolled in this study. This preliminary study suggests that C. pneumoniae does not play a significant role in chronic sinusitis in children.

Adolescent↗
PubMed1986

Pneumatisation of the maxillary sinus in normal and symptomatic children.

The pattern of pneumatisation and normal width of the maxillary sinus in 191 Nigerian infants and children whose age range was 6 months to 14 years was determined. Fifty-four percent of children with no respiratory tract or sinus infection had an opaque maxillary sinus. A figure of 44.5% was obtained amongst children with suspected bronchopneumonia. Only 41.5% of suspected cases of sinusitis, acute and chronic middle ear disease had opaque sinuses. The highest rate of sinus opacity was seen in children under 2 years who were asymptomatic. The mean maximal width of the normally aerated sinus was 8.74 mm for children under 2 years, 16.5 mm for 3-6 years, 21.5 mm for 7-11 years and 25 mm for children 12 years and above. We conclude that maxillary sinus opacity in our experience is an unreliable index for the diagnosis of sinusitis in children.

Adolescent↗
PubMedDate not supplied

Anti-inflammatory activity of clarithromycin in adults with chronically inflamed sinus mucosa.

In a phase IV, open-label study, 25 patients with clinically stable chronic sinusitis and persistent maxillary sinus inflammation were treated for 14 days with clarithromycin 500 mg twice daily. Biopsy specimens of the maxillary sinus mucosa were obtained pretreatment and evaluated for macrophages (CD68), eosinophils (MBP), elastase, interleukin-6 (IL-6), IL-8, tumor necrosis factor-alpha (TNF-alpha), and activity of eosinophils (EG2), as well as edema score. Clinical signs and symptoms were assessed pretreatment, at the end of treatment, and 1 and 2 weeks later. Statistically significant reductions (P < or = .05) from pretreatment were observed for all markers of sinus mucosal inflammation, including CD68, EG2, elastase, IL-6, IL-8, TNF-alpha, and edema score, with a trend to decreased total eosinophil count. Improvement was observed for all clinical signs and symptoms of chronic sinusitis--sinus pain, sinus headache, nasal congestion, nasal discharge, and mucopurulent discharge--up to 14 days after the end of treatment. Cultures to evaluate persistent infection with Chlamydia pneumoniae showed negative results. Significant reductions in various markers of sinus mucosal inflammation support the role of clarithromycin in modulating immunologic responses. Improvement of clinical signs and symptoms in patients with chronic inflammatory sinusitis not meeting criteria for known or presumed bacterial infection was also noted up to 2 weeks after completion of a 14-day course of clarithromycin.

Adult↗
PubMed2005

Maxillary sinus atelectasis in a wild born gibbon (Hylobates moloch).

In a mixed sex sample of ten adult gibbon (Hylobates moloch) skulls, one cranium of a male with maxillary sinus atelectasis of the left side was identified. While external inspection revealed a slight drop of the left orbital floor, serial coronal computer tomography (CT) scans show characteristic changes of the left maxillary sinus and its surrounding structures. In addition to the sunken orbital floor, radiological features of the specimen include an inward bowing of the medial sinus wall, sinus opacification, and a reduction in maxillary sinus size to a slit-like cavity, which suggest a diagnosis of silent sinus syndrome. This report is the first, to our knowledge, of maxillary sinus atelectasis in a non-human primate. This finding is valuable for the understanding of the pathogenesis and etiology of maxillary sinus atelectasis. At the same time, however, paleoanthropologists and primatologists may refer to this information when dealing with the interpretation of maxillary sinus pneumatization of partially broken archaeological and fossil skulls.

Animals↗
PubMed1981

Comparison between transillumination and the roentgenogram in diagnosing paranasal sinus disease.

The reliability of transillumination versus roentgenogram to diagnose maxillary and frontal paranasal sinus disease was assessed in 52 subjects with rhinitis and/or asthma. Two different otolaryngologists transilluminated the sinuses while the roentgenograms were evaluated by a radiologist and a third otolaryngologist. Patients filled in questionnaires of symptoms. There was excellent agreement (p < 0.001) between otolaryngologists regarding transillumination of the frontal sinuses but not the maxillary sinuses. Similarly, transillumination of the frontal sinuses correlated well with the roentgenograms. This was not true for transillumination of the maxillary sinuses. Although pain in the upper teeth related well to the presence of frontal disease, sinus headache was a frequent complaint but not useful as a predictor of sinus disease. Even though transillumination of the frontal paranasal sinus has some predictive value, the technique of transillumination has limited usefulness as a diagnostic tool and is not an adequate substitute for roentgenogram.

Adolescent↗
PubMed1994

Screening for sinus disease in patients with asthma: a computed tomography-controlled comparison of A-mode ultrasonography and standard radiography.

BACKGROUND: Paranasal sinus disease and bronchial asthma are frequently associated. Patients with asthma often have chronic inflammatory changes of the paranasal mucosa rather than acute bacterial sinusitis. Our aim was to compare the rankings of A-mode ultrasonography and standard radiography as routine screening procedures in the diagnostic workup of these patients. METHODS: We compared the evaluation of the maxillary sinuses by A-mode ultrasonography and standard radiographs. Computed tomography served as a gold standard in 19 patients with asthma who had no history of sinus surgery. RESULTS: Computed tomography showed at least some minimal mucosal thickening in any of the paranasal sinuses in 74% and of the maxillary sinuses in 61% of the patients. Compared with the results of computed tomography, plain-view radiography gave a specificity of 86.7% for the maxillary sinuses. Although all cases of severe mucosal thickening were detected, sensitivity for minimal mucosal hyperplasia was low, at 52.2%. In contrast, A-mode ultrasonography demonstrated a sensitivity of 70% but a specificity of only 22%. CONCLUSIONS: Even symptom-free patients with asthma show a high prevalence of at least limited mucosal thickening in the paranasal sinuses. Acute sinusitis is not a common finding. A-mode ultrasonography does not allow sufficient evaluation of this mucosal hyperplasia and is therefore not suitable for initial screening in these patients. It may prove helpful as a follow-up in selected patients with known anatomic characteristics, however, especially when antral fluid is involved. For routine screening in patients with asthma, a conventional Waters' view radiograph should be used in conjunction with direct visualization of the ostial-meatal area by fiberoptic or rigid rhinoscopy. This combination provides information about the degree of mucosal hyperplasia as well as mucosal inflammation and secretion.

Adult↗
PubMed1999

Malondialdehyde levels and superoxide dismutase activity in experimental maxillary sinusitis.

OBJECTIVE: Acute maxillary sinusitis is one of the most common diseases in human. Reactive oxygen metabolites (ROMs) produced also physiologically in the body, are normally neutralised by antioxidative enzymes such as superoxide dismutase (SOD). Infection is one of the causes of increased ROMs production. The most important mechanism of tissue damage produced by ROMs is the peroxidation of lipids found in cell membranes and it may be estimated by malondialdehyde (MDA) levels. The purpose of this study, is to investigate tissue damage caused by ROMs in maxillary sinusitis in 24 rabbits. METHODS: Experimental sinusitis was induced by blocking the right nose and inoculating Staphylococcus aureus into the right maxillary sinuses. Left maxillary sinuses were the control group. Animals were divided into three groups and killed at 3, 5 and 7 days. Mucosas of each maxillary sinus were examined histopathologically and MDA levels were determined. Blood samples were obtained preoperatively (control blood) and on killing days (experimental blood). Serum MDA levels and erythrocyte SOD activities were determined. RESULTS: All the infected sinuses displayed signs of the inflammation. MDA levels and SOD activities in the experimental blood samples were significantly higher than those of the control group (P < 0.05). Mucosal MDA levels in the experimental group were significantly higher than the controls (P < 0.01). CONCLUSIONS: In maxillary sinusitis caused by S. aureus an increased ROMs production was observed and it may contribute to tissue damage of sinusitis.

Acute Disease↗
PubMed2003

Sinus computed tomography scan and markers of inflammation in vocal cord dysfunction and asthma.

BACKGROUND: The inappropriate closure of the vocal cords is characteristic of vocal cord dysfunction (VCD). These patients present with wheezing and frequently receive a misdiagnosis of asthma. OBJECTIVE: To demonstrate the ability of computed tomography (CT) scored for the presence and extent of sinus disease and markers of inflammation to distinguish patients with VCD from patients with asthma. METHODS: Comparisons of 13 patients with VCD were made to 77 patients presenting to the emergency room with acute asthma, 31 non-acute asthmatic patients, and 65 nonasthmatic controls. Evaluation consisted of exhaled nitric oxide gas (eNO), circulating eosinophils, and total serum immunoglobulin (Ig)E, as well as the sinus CT scan. RESULTS: Extensive sinus CT changes were present in 23 of 74 acute asthmatic patients, 5 of 29 non-acute asthmatic patients, and 2 of 59 nonasthmatic controls. In addition, absolute eosinophil counts, eNO, and total IgE were significantly elevated among the asthmatic patients. Sinus symptoms reported by questionnaire did not predict sinus CT findings. Among the patients with VCD, none had extensive sinus disease. They also had normal eNO, low IgE, and normal eosinophil count. Five of the patients presenting to the emergency room who were identified as acute asthmatic were identified with VCD by laryngoscopy and were all characterized by the absence of significant inflammation on their sinus CT scan, low IgE, and normal eosinophil count. CONCLUSIONS: Among patients presenting with intermittent or reversible airway obstruction, patients with VCD can be distinguished from asthma by minimum or absence of inflammation in their sinuses as shown by CT scan. Clinical symptom scores are not predictive of presence or extent of sinus disease in most cases.

Adolescent↗