American Journal of Rhinology and Allergy

Conclusive evidence exists that biofilms are present on the mucosa of chronic rhinosinusitis (CRS) patients. Less is known about the species constituting these biofilms. This study developed a fluorescence in situ hybridization (FISH) protocol for characterization of bacterial and fungal biofilms in CRS.

Fifty CRS patients and 10 controls were recruited. Bacteria FISH probes for Staphylococcus aureus, Haemophilus influenzae, and Pseudomonas aeruginosa and a universal probe for fungi were applied to sinus mucosal specimens and then analyzed using confocal scanning laser microscopy.

Thirty-six of 50 CRS patients had biofilms present in contrast to 0/10 controls, suggesting a role for biofilms in the pathogenesis of this disease. S. aureus was the most common biofilm-forming organism. Eleven of 50 CRS patients had characteristic fungal biofilms present.

This is the largest study of biofilms in CRS. It has validated mucosal tissue cryopreservation for delayed biofilm analysis. Fungal biofilms have been identified and the importance of S. aureus biofilms in the polymicrobial etiology of CRS is highlighted.

Although biofilms have been implicated in the pathogenesis of chronic rhinosinusitis (CRS), there is little evidence that their presence or absence has any effect on the outcomes of endoscopic sinus surgery (ESS). The aim of this study was to investigate the effect of biofilms on postsurgical outcomes after ESS.

A prospective, blinded study of 51 consecutive patients undergoing ESS for CRS was conducted. Preoperatively, patients assessed their symptoms using internationally accepted standardized symptom scoring systems and quality-of-life (QOL) measures, i.e., the 10-point Visual Analog Scale (VAS), Sino-Nasal-Outcome-Test 20, and global severity of CRS. Their sinonasal mucosa was graded using the Lund-Kennedy scale and the extent of radiological disease on computed tomography scans was scored using the Lund-McKay scale. Random sinonasal tissue samples were assessed for biofilm presence using confocal laser microscopy. At each postoperative visit, patients reassessed their sinus symptoms and completed QOL measures. Postsurgical state of their sinonasal mucosa was graded endoscopically.

Bacterial biofilms were found in 36 of 51 (71%) CRS patients. Patients with biofilms presented with significantly worse preoperative radiology and nasendoscopy scores (p = 0.003 and 0.01, respectively). After a median follow-up period of 16 months postsurgery, biofilm-positive patients had statistically worse sinus symptoms (VAS, p = 0.002) and worse nasendoscopy scores (p = 0.026). They also required extra postoperative visits and multiple antibiotic treatments deviating from the standard postoperative care required by biofilm-negative patients.

This study has shown that patients with biofilms have more severe disease preoperatively and persistence of postoperative symptoms, ongoing mucosal inflammation, and infections. This study strengthens the evidence for the role that biofilms may play in recalcitrant CRS.

Nasal surgery is commonly involved in surgical treatment for obstructive sleep apnea (OSA). The aim of this study was to investigate the outcomes of nasal surgery for OSA using evidence-based methodology.

The MedLine database (1999∼2009) was searched for original articles published in peer-reviewed journals concerning nasal surgery for snoring/sleep apnea. Data extracted from these articles were reviewed and analyzed using meta-analysis technology.

Thirteen articles were critically appraised. Two studies provided control groups and 11 articles (84.6%) consisted of prospective noncontrolled clinical trials (level II in evidence strength). The weighted mean apnea/hypopnea index measured by polysomnography in nine studies decreased from 35.2 ± 22.6 to 33.5 ± 23.8 event/hour after nasal surgery (overall, p = 0.69). The pooled success rate of nasal surgery in treating OSA was 16.7%. Epworth Sleepiness Scale scores in eight studies decreased from 10.6 ± 3.9 to 7.1 ± 3.7 (overall, p <0.001). Nasal surgery for snoring assessed by individual questionnaires and visual analog scale reported significant improvement (p < 0.05).

The critical literature appraisal and meta-analyses show that nasal surgery can effectively reduce daytime sleepiness and snoring. However, the efficacy of nasal surgery in treating OSA is limited.

Little is known regarding the epidemiology of chronic rhinosinusitis (CRS) in racial and ethnic minorities in the United States. This study was designed to comprehensively evaluate the current prevalence of CRS across various treatment settings to identify possible disparities in health care access and use between racial and ethnic populations.

The National Health Interview Survey (NHIS), National Ambulatory Medical Care Survey (NAMCS), and National Hospital Ambulatory Medical Care Survey (NHAMCS) database registries were extracted to identify the national prevalence of CRS in race/ethnic populations and resource use in ambulatory care settings. Systematic literature review identified studies reporting treatment outcomes in minority patients electing endoscopic sinus surgery (ESS). Data were supplemented using a multi-institutional cohort of patients undergoing surgical treatment.

National survey data suggest CRS is a significant health condition for all major race/ethnic groups in the United States, accounting for a sizable portion of office, emergency, and outpatient visits. Differences in insurance status, work absenteeism, and resource use were found between race/ethnic groups. Despite its prevalence, few published studies include information regarding minority patients with CRS. Most (90%) cohort studies did not provide details of race/ethnicity for ESS outcomes. Prospective cohort analysis indicated that minority surgical patients accounted for only 18%, when compared with national census estimates (35%).

CRS is an important health condition for all major race/ethnic groups in the United States. Significant differences may exist across racial and ethnic categories with regard to CRS health status and health care use. Given current demographic shifts in the United States, specific attention should be given to understanding CRS within the context of racial and ethnic populations. Public clinical trial registration ( www.clinicaltrials.gov ) I.D. No. NCT00799097.

This article reviews our treatment results of sinonasal inverted papilloma (SNIP) over the past 18 years. A retrospective observational study was performed.

Fifty-six patients with SNIP seen between 1990 and 2008 with follow-up of >2 years were retrospectively analyzed.

Forty patients (71%) had primary endoscopic resection and 16 patients (29%) had endoscopic-assisted external approaches. Ten patients (18%) had small nasoethmoid residual disease resectable under local anesthesia in the outpatient department. Eight patients (14%) had recurrences requiring revision under general anesthesia, most of which were maxillary and frontal disease requiring additional external approaches. Comparing patients with and without a history of previous surgery (36% versus 64% of all patients), the former had a higher chance of requiring external approaches during the primary resection (45% versus 29%), a higher recurrence rate (45% versus 25%), and a higher chance of external approaches for revision (44% versus 22%). All the first recurrences were at the original tumor site. Eighty-nine percent of the first recurrences were diagnosed within the first 2 years postoperation.

Thirty-two percent of our patients had recurrence after their primary resection. Recurrences in the nasoethmoid area are usually small and resectable endoscopically under local anesthesia in the outpatient department whereas those inside the maxillary and frontal sinuses are likely to require additional external approaches under general anesthesia. A minimum of 2 years of follow-up is recommended for the preliminary report on the treatment results of this condition. Lifelong follow-up is recommended for possible late recurrences and metachronous multifocal disease.

Human exposure to fungal elements is inevitable, with normal respiration routinely depositing fungal hyphae within the nose and paranasal sinuses. Fungal species can cause sinonasal disease, with clinical outcomes ranging from mild symptoms to intracranial invasion and death. There has been much debate regarding the precise role fungal species play in sinonasal disease and optimal treatment strategies.

A literature review of fungal diseases of the nose and sinuses was conducted.

Presentation, diagnosis, and current management strategies of each recognized form of fungal rhinosinusitis was reviewed.

Each form of fungal rhinosinusitis has a characteristic presentation and clinical course, with the immune status of the host playing a critical pathophysiological role. Accurate diagnosis and targeted treatment strategies are necessary to achieve optimal outcomes.

Endoscopic dacryocystorhinostomy (DCR) is an effective surgical procedure to treat saccal and postsaccal stenosis or nasolacrimal duct obstruction. The use of silicone tube after endoscopic DCR is still controversial. A prospective randomized study was conducted to compare the success rate between the use of silicone stent and no use of silicone stent in endoscopic DCR.

A prospective randomized study was conducted at Aseer Central Hospital and Abha Private Hospital, Abha, Kingdom of Saudi Arabia, on all patients undergoing endoscopic DCR between July 1, 2006 and 30 June 30, 2010. Patients were allocated randomly for endoscopic DCR with or without stent. The data collection included age, sex, diagnosis, method, and duration of surgery. Patients were followed up postoperatively at 1 week, 1 month, and then every 3 months for 1 year.

During the period of the study a total of 173 cases of postsaccal stenosis underwent endoscopic DCR (67 male and 106 female subjects). The mean age was 51.8 years (range, 18–72 years). A stent was used in 92 patients (53.2%) and not used in 81 patients (46.8%). With silicone tubing the success rate was 96%, and without silicone tubing it was 91%, an overall success rate of 94%. The odds ratio of failure without a silicone tube was 3.25 but confidence interval was from 0.84 to 12.60 and the difference between these two groups was statistically not significant (p = 0.117).

In this study, there was no statistically significant advantage of using endoscopic DCR with stent over the endoscopic DCR without stent.

Patients with chronic rhinosinusitis (CRS) often remain symptomatic after technically proficient functional endoscopic sinus surgery. Current hypothesis indicates biofilms may contribute to the persistence of infection. However, few studies showed biofilms in postoperative patients. This study was designed to identify bacterial biofilms on postoperative mucosa, as well as to investigate the healing of sinus mucosa after surgery.

After intraoperative mucosa was obtained for assessment of biofilms, 27 patients were followed up for 6 months. Postoperative medications and symptoms were recorded. As indicated by endoscopic evaluation, biopsy specimens of postoperative edema, scar, or adhesion were obtained. Samples were prepared for scanning electron microscopy (SEM) and hematoxylin and eosin (H&E) staining.

Fifteen postoperative samples were taken from the 20 patients with intraoperative biofilms. Under SEM, postoperative biofilms were identified in 4/6 scar samples and 5/9 edema samples. There was no significant difference in biofilm presence between samples of scar and edema. Microcolonies were also identified on postoperative scar under H&E staining. The presence of intraoperative and postoperative biofilms was correlated with the severity of preoperative Lund-MacKay computed tomography score and postoperative Lund-Kennedy endoscopic score. Compared with intraoperative samples, postoperative samples from the same nine patients significantly recovered from ciliary damage, metaplasia, and basement membrane thickness. Postoperative cultures were positive in samples with and without postoperative biofilms.

Biofilms persist after treatment, and may cause the unfavorable outcomes of surgery for CRS. The mucosa with biofilms can recover after surgery. Apparent bacterial plaque can be identified by H&E staining.

To compare the causes of failure between external and endoscopic dacryocystorhinostomy (DCR) techniques for the treatment of lacrimal obstruction.

A retrospective cohort study.

The study population consisted of 53 consecutive patients who underwent revision endoscopic DCR from 2002 to 2013 for lacrimal duct obstruction. Identified causes of previous DCR failure were compared between patients whose initial surgery was performed through an external versus an endoscopic approach.

Reasons for surgical failure after external (n = 21) versus endoscopic (n = 32) DCR included cicatricial closure of the internal lacrimal ostium (52.4 versus 53.1%; p = 0.96), inadequate removal of bone overlying the lacrimal sac (23.8 versus 9.4%; p = 0.15), sump syndrome (9.5 versus 9.4%; p = 0.99), and intranasal adhesions (65 versus 37.5%; p = 0.05). Adhesions that involved the middle turbinate were a particularly impactful cause of failure when the DCR was performed through an external versus the endoscopic approach (57.1 versus 28.1%; p = 0.04). Septoplasty was more likely to be needed at the time of revision surgery if the initial procedure was performed externally (71.1 versus 15.6%; p = 0.02). Surgical success rates for revision DCR were comparable between the groups (75.0% external versus 73.3% endoscopic; p = 0.90), with a mean follow-up of 12.7 months.

DCR failure associated with intranasal adhesions was more likely to occur when the surgery was performed through an external rather than an endoscopic approach. Endoscopic instrumentation allowed for identification and correction of intranasal pathology at the time of DCR, includingan enlarged middle turbinate or a deviated septum, which may improve surgical outcome.

The nasal mucosa is characterized by a multirow high prismatic ciliated epithelium representing the first barrier of the immune defense system against microbial and other environmental pathogenic influences. A number of nonspecific defense mechanisms, including the presence of lactoferrin, peroxidases, proteases, interferons, and lysozymes in nasal secretions, act to counter inflammatory processes. The surfactant proteins (SPs) known from the lungs are important components of the innate immune system. They also influence the rheology of fluids and reduce the surface tension of gas–fluid interphases. The objective of this study was to investigate the protein expression of all four SPs. A specific aim was detection and characterization of SP-C, which had previously not been confirmed in human nasal mucosa.

The expression of mRNA for SP-A, -B, -C and -D was investigated using reverse transcriptase polymerase chain reaction on samples of both healthy nasal mucosa and nasal mucosa altered by inflammatory processes (allergic rhinitis and chronic rhinosinusitis). The distribution of all four proteins was determined with monoclonal antibodies using Western blot analysis as well as immunohistochemical methods.

The results show that all four SPs, including SP-C not detected before this, are nasal mucosa components. A shift was also observed in the expression behavior of the SP-A, -B, and -D in nasal mucosa with inflammatory changes.

Based on these results, SPs appear to have an important function in immunologic and rheological process of the nasal mucosa and support the prospective therapeutic use of liposomal nasal sprays.