Rinosinusitis crónica en niños: revisión de la evaluación y manejo actual / Chronic rhinosinusitis in children: review of the evaluation and current management

La rinosinusitis crónica (RSC) en niños corresponde a la inflamación de la mucosa de la cavidad nasal y senos paranasales, presentando síntomas como obstrucción nasal, descarga nasal, presión o dolor facial y tos, presentes por más de 12 semanas. Conlleva una gran carga de morbilidad para quienes la padecen, y un alto costo económico. Su diagnóstico constituye un desafío debido a la sobreposición de síntomas con infecciones respiratorias altas y otras condiciones no infecciosas. En los últimos años se han dilucidado nuevos factores contribuyentes como los biofilms , disfunción del microbioma, y el creciente papel de mecanismos inflamatorios no infecciosos. El estudio imagenológico de elección es la tomografía computarizada, preferentemente en casos de duda diagnóstica, falta de respuesta a tratamiento o sospecha de complicaciones. El tratamiento de primera línea es el manejo médico, basado en irrigación nasal, posible uso de antibióticos prolongados y corticoides nasales. Para casos refractarios se plantean intervenciones quirúrgicas, siendo la adenoidectomía la primera elección, principalmente en niños menores; otras intervenciones incluyen la cirugía endoscópica de cavidades paranasales. Nuevas terapias biológicas están siendo estudiadas basadas en los mecanismos inflamatorios no infecciosos de la RSC y su relación con comorbilidades como el asma.

Chronic rhinosinusitis (CRS) in children is the inflammation of the nasal and sinus mucosa, presenting symptoms such as obstruction, nasal discharge, pressure or facial pain and cough, which extends for more than 12 weeks. It represents a great burden for those affected, with high economic cost. Its diagnosis constitutes a challenge due to the overlap of symptoms with other upper respiratory infections and other non-infectious conditions. In recent years, new contributing factors have been elucidated, such as biofilms, microbiome dysfunction, and the growing role of noninfectious inflammatory mechanisms. Diagnosis depends on the recognition of characteristic symptoms and their duration. The imaging study of choice is computed tomography, especially in cases of diagnostic doubt, lack of response to treatment or suspicion of complications. First-line treatment of is based on nasal irrigation, possible use of prolonged antibiotics and nasal corticosteroids. For refractory cases, surgical intervention is proposed, with adenoidectomy being the first choice, mainly in younger children; other interventions include endoscopic sinus surgery. New biological therapies are being studied based on noninfectious inflammatory mechanisms of CRS and its comorbidities such as asthma.

Manejo multidisciplinario de rinosinusitis bacteriana aguda posterior a elevación de seno maxilar: reporte de caso rehabilitado a tres años de seguimiento / Multidisciplinary management of acute bacterial rhinosinusitis after maxillary sinus lift: three years follow-up: case report

La cirugía de elevación de seno maxilar se considera como la técnica de aumento óseo más predecible. Sin embargo, no está exenta de complicaciones las cuales deben ser manejadas adecuadamente. Se presenta un caso clínico rehabilitado, con un seguimiento de 3 años, en el cual se realizó un manejo multidisciplinario y resolutivo de complicaciones asociadas a la técnica quirúrgica de elevación de membrana sinusal vía ventana lateral. Frente a una infección postoperatoria, como la presentada en el caso, hay que considerar iniciar un tratamiento antibiótico en el momento adecuado para impedir el agravamiento del cuadro clínico o un cambio de esquema en caso de resistencia antimicrobiana.

Maxillary sinus lift surgery is considered the most predictable bone augmentation technique. However, this procedure is not without complications, which must be handled properly. We present a rehabilitated clinical case, with a 3-year follow-up, in which a multidisciplinary and resolutive management of complications associated with the surgical technique of sinus lift procedure, using lateral window approach, was performed. In case of postoperative infection, such as the one presented in this report, it is necessary to consider starting an antibiotic treatment at the adequate moment to prevent the aggravation of the illness or change the pharmacological treatment in case of antimicrobial resistance.

Sinusitis en Pediatría / Sinutisis in Pediatrics

Resumen Sinusitis, definida como enfermedad inflamatoria de la mucosa de los senos paranasales, es una enfermedad con alta prevalencia e incidencia en la población general, especialmente en Pediatría.1 Los padecimientos alérgicos e infecciosos de la mucosa nasal representan dos de las enfermedades más frecuentes de las vías aéreas superioras crónicas en niños y adultos jóvenes. Es un problema de salud pública de gran magnitud debido a su alta prevalencia, lo que ocasiona gran presión asistencial en términos de consultas ambulatorias, deterioro significativo de la calidad de vida para el paciente y sus familiares además, implica un fuerte impacto en la comunidad por los altos costos socioeconómicos que generan.2 Su etiología multifactorial y la creciente resistencia bacteriana a antibióticos, especialmente a penicilinas naturales o sintéticas sugiere reconsiderar los fundamentos anatómicos y funcionales con la finalidad de establecer conductas razonables de diagnóstico, terapéutica médica y quirúrgica que permitan un diagnóstico y tratamiento apropiado para disminuir su recurrencia.1,2

Abstract Sinusitis, defined as an inflammatory disease of the paranasal sinuses, is a disease with high prevalence and incidence in the general population, especially among children. The allergic and infectious diseases of the nasal mucosa represent two of the most frequent diseases of the chronic upper airways in children and young adults. It is a public health problem of great magnitude due to its high prevalence, which causes great assistance pressure in terms of outpatient consultations, significant deterioration of the quality of life for the patient and their families, and it also implies a strong impact on the community due to the high socio-economic costs. Its multifactorial etiology and the increasing bacterial resistance to antibiotics, especially natural or synthetic penicillins, suggest reconsidering the anatomical and functional foundations in order to establish reasonable diagnostic, medical and surgical therapeutic behaviors that allow a diagnosis and appropriate treatment to decrease its recurrence.

Rinosinusitis crónica: una revisión de su etiopatogenia / Chronic rhinosinusitis: a review of its etiopathogenesis

RESUMEN La rinosinusitis crónica (RSC) se define como una inflamación sintomática de las cavidades nasales y paranasales. Es una enfermedad altamente prevalente, que conlleva una gran carga económica asociada y cuyo tratamiento médico actual consigue un alivio sintomático en aproximadamente 50% de los pacientes. Tradicionalmente se ha clasificado de acuerdo a la presencia o ausencia de pólipos nasales, sin embargo, no se conoce con total claridad los mecanismos que llevan a la diferenciación de ambos fenotipos. Se estima que existirían tanto factores exógenos como endógenos involucrados que configurarían un origen multifactorial de la enfermedad. La RSC es motivo de intensa investigación científica actual dado su impacto y prevalencia, de manera de determinar con mejor precisión los objetivos de un eventual tratamiento de mayor efectividad. Es por ello que presentamos una revisión actualizada en relación a los mecanismos fisiopatológicos subyacentes en RSC.

ABSTRACT Chronic rhinosinusitis (CRS) is defined as a symptomatic inflammation of the nasal and paranasal cavities. It is a highly prevalent disease carrying a large associated economic burden, and its current medical treatment achieves symptomatic relief in approximately 50% of patients. Traditionally, it has been classified according to the presence or absence of nasal polyps. However, the mechanisms that lead to the differentiation of both phenotypes are not fully understood. It has been estimated that there are both exogenous and endogenous factors involved that would configure a multifactorial origin of the disease. Given its impact and prevalence, CRS is currently a subject of intense scientific research, in order to accurately determine the targets for a more effective treatment. For this reason, we present an updated review in relation to the underlying pathophysiological mechanisms in CRS.

Sinusitis in patients undergoing allogeneic bone marrow transplantation – a review / Sinusite em pacientes submetidos a transplante alogênico de medula óssea – uma revisão

Abstract Introduction Sinusitis is a common morbidity in general population, however little is known about its occurrence in severely immunocompromised patients undergoing allogeneic hematopoietic stem cell transplantation. Objective The aim of the study was to analyze the literature concerning sinusitis in patients undergoing allogeneic bone marrow transplantation. Methods An electronic database search was performed with the objective of identifying all original trials examining sinusitis in allogeneic hematopoietic stem cell transplant recipients. The search was limited to English-language publications. Results Twenty five studies, published between 1985 and 2015 were identified, none of them being a randomized clinical trial. They reported on 31–955 patients, discussing different issues i.e. value of pretransplant sinonasal evaluation and its impact on post-transplant morbidity and mortality, treatment, risk factors analysis. Conclusion Results from analyzed studies yielded inconsistent results. Nevertheless, some recommendations for good practice could be made. First, it seems advisable to screen all patients undergoing allogeneic hematopoietic stem cell transplantation with Computed Tomography (CT) prior to procedure. Second, patients with symptoms of sinusitis should be treated before hematopoietic stem cell transplantation (HSCT), preferably with conservative medical approach. Third, patients who have undergone hematopoietic stem cell transplantation should be monitored closely for sinusitis, especially in the early period after transplantation.

Resumo Introdução A sinusite é uma doença comum na população em geral, porém pouco se sabe sobre a sua ocorrência em pacientes gravemente imunocomprometidos submetidos a transplante alogênico de células-tronco hematopoiéticas. Objetivo O objetivo do estudo foi analisar a literatura sobre sinusite em pacientes submetidos a transplante alogênico de medula óssea. Método Uma busca na base de dados eletrônica foi realizada com o objetivo de identificar todos os artigos originais que investigaram sinusite em receptores de transplante alogênico de células-tronco hematopoiéticas. A busca foi limitada a publicações em língua inglesa. Resultados Foram identificados 25 estudos, publicados entre 1985 e 2015, sendo que nenhum deles era um ensaio clínico randomizado. Eles incluíram 31-955 pacientes, discutindo diferentes questões, ou seja, valor da avaliação sinonasal pré-transplante e seu impacto na morbidade e mortalidade pós-transplante, tratamento, análise de fatores de risco. Conclusão Os resultados dos estudos analisados produziram resultados inconsistentes. No entanto, algumas recomendações para boas práticas poderiam ser feitas. Em primeiro lugar, parece aconselhável avaliar todos os pacientes submetidos a transplante alogênico de hematopoiéticas com tomografia computadorizada (TC) antes do procedimento. Em segundo lugar, os pacientes com sintomas de sinusite devem ser tratados antes de um Transplante de Células-Tronco Hematopoiéticas (TCTH), de preferência com abordagem clínica conservadora. Em terceiro lugar, os pacientes que se submeteram a TCTH devem ser cuidadosamente monitorizados para sinusite, especialmente no período inicial após o transplante.

Manejo de la rinosinusitis crónica en pacientes con fibrosis quística / Management of chronic rhinosinusitis in patients with cystic fibrosis

La rinosinusitis crónica es una patología que se presenta en pacientes con fibrosis quística y se asocia a la expresión de numerosos genes que determinan una alteración en la secreción de cloro del canal CFTR e hiperplasia de las glándulas submucosas del epitelio sinusal. En este artículo se efectúa una revisión acerca de las indicaciones y distintas alternativas de cirugía endoscópica nasal para la rinosinusitis crónica en pacientes con fibrosis quística. Se realizó una búsqueda de artículos en PubMed, la biblioteca de Cochrane y en SciELO con fecha de publicación hasta el año 2014, en los que se trata específicamente la rinosinusitis crónica asociada a fibrosis quística.

Chronic sinusitis is a condition that occurs in patients with cystic fibrosis and is associated with the expression of numerous genes that determine an alteration in the secretion of chloride channel CFTR and hyperplasia of submucosal glands sinus epithelium. This article reviews about the indications and alternatives of endoscopic nasal surgery for chronic rhinosinusitis in patients with cystic fibrosis. Searches were performed in PubMed, Cochrane Library, and SciELO with a publication date until 2014, specifically chronic rhinosinusitis associated with cystic fibrosis.

Oftalmoparesia dolorosa episódica asociada a rinosinusitis aguda recurrente: un caso de síndrome de Tolosa Hunt / Painful episodic ophtalmoparesis associated to acute recurrent rhinosinusitis: a case of Tolosa Hunt Syndrome

El síndrome de Tolosa Hunt es un cuadro inflamatorio del seno cavernoso, idiopático y caracterizado por uno o más episodios de dolor orbital unilateral asociado o seguido de paresia oculomotora (afección del III, IV y VI nervio craneal) y en ocasiones con compromiso de la rama maxilar del nervio trigémino. Nosotros presentamos un hombre de 27 años con episodios de oftalmoparesia dolorosa derecha concomitantes a cuadros de rinosinusitis agudas. Su estudio fue negativo y en una de sus recurrencias se encontró en la RM de alta resolución de senos cavernosos, compromiso inflamatorio con captación de gadolinio de los nervios III, IV, V2 y VI derechos. Dado los hallazgos, se planteó el diagnóstico de STH exacerbado por la rinosinusitis e inició tratamiento corticoidal prolongado.

Tolosa Hunt Syndrome is the idiopathic inflammation of cavernous sinus, characterized by one or more episodes of unilateral orbital pain followed by ophtalmoparesis (III, IV o VI nerve palsy) and sometimes the affection of maxillary branch of the trigeminal nerve. We describe the case of a 27 years old man with episodes of painful right ophtalmoparesis associated with acute rhinosinusitis. On high resolution MRI there was inflammation of the III, IV, V2 and VI right nerves with gadolinium enhancement. We propose the THS diagnosis exacerbated by rhinosinusitis and started on chronic steroid therapy.

Sinonasal disorders in hematopoietic stem cell transplantation / Afecções nasossinusais em pacientes transplantados de células-tronco hematopoiéticas,

INTRODUCTION: hematopoietic stem cell transplantation (HSCT) is associated with more respiratory infections due to immunosuppression. OBJECTIVE: this study aimed to verify the frequency of rhinosinusitis after HSCT, and the association between rhinosinusitis and chronic graft vs. host disease (GVHD) and type of transplantation, clinical treatment, surgical treatment, and survival. METHODS: this was a retrospective study in a tertiary university hospital. A total of 95 patients with hematological diseases undergoing HSCT between 1996 and 2011 were selected. RESULTS: chronic myeloid leukemia was the most prevalent disease. The type of transplant most often performed was the allogenic type (85.26%). The frequency of rhinosinusitis was 36%, with no difference between the autologous and the allogenic types. Chronic GVHD occurred in 30% of patients. Patients with GVHD had a higher frequency and recurrence of rhinosinusitis, in addition to more frequent need for endoscopic sinusectomy and decreased overall survival. CONCLUSION: there was a higher frequency of rhinosinusitis in HSCT and GVHD. The type of transplant does not appear to predispose to the occurrence of rhinosinusitis. GVHD seems to be an aggravating factor and requires a more stringent treatment. .

INTRODUÇÃO: O transplante de células troncas hematopoiéticas (TCTH) associa-se a mais infecções respiratórias devido a imunossupressão. OBJETIVO: Este trabalho tem o objetivo de verificar a frequência das rinossinusites pós-TCTH, a associação entre a rinossinusite e a doença do enxerto contra hospedeiro (DECH) crônico e o tipo de transplante e o tratamento clinico e o tratamento cirúrgico e a sobrevida. MÉTODO: Estudo retrospectivo em hospital universitário terciário. Foram selecionados 95 pacientes com doença hematológica submetidos a TCTH entre 1996 a 2011. RESULTADOS: A leucemia mieloide crônica foi a doença mais prevalente. O tipo de transplante mais realizado foi o alogênico (85,26%). A frequência de rinossinusite foi de 36%, sem diferença entre os tipos de transplante autólogo e alogênico. A DECH crônica ocorreu em 30% dos pacientes. Os pacientes com DECH tiveram maior frequência e recorrência de rinossinusite, além de mais necessidade de sinusectomia endoscópica e de diminuição da sobrevida global. CONCLUSÃO: Houve maior frequência de rinossinusite no TCTH e DECH. O tipo de transplante não parece predispor a ocorrência da rinossinusite. A DECH parece ser um fator agravante e necessita de tratamento mais rigoroso. .

An experimental model of chronic rhinosinusitis in rabbits without bacterial inoculation

PURPOSE: Evaluate and compare two different experimental techniques of maxillary sinus ostium occlusion using N-butyl cyanoacrylate in developing chronic histological findings without the inoculation of pathogenic bacteria among rabbits. METHODS: In a randomized study, sixteen New Zealand rabbits were assigned for occlusion of the right maxillary sinus through a transmaxillary approach or through the roof of the nasal cavity. The contralateral sinus served as a control. After 12 weeks, the animals were sacrificed for blinded histopathological analysis of the maxillary sinus mucosa. RESULTS: Histopathological changes consistent with CRS were found in eight (100%) of the maxillary sinuses approached transmaxillary and three of those through the roof of the nasal cavity (37.5%), p 0.008 and 0.250, respectively, comparing with the control side. Chronic mucosal changes were significantly better induced using the transmaxillary approach (p 0.026). CONCLUSION: It is possible to induce a model of chronic sinusitis among rabbits with transmaxillary sinus occlusion without bacterial inoculation. This model can be replicated for future cellular studies. .

Update in the management of allergic fungal sinusitis

Over the last 3 decades, allergic fungal sinusitis [AFS] has been defined as a clinically and pathologically distinct form of chronic rhinosinusitis. The etiology, pathogenesis, and natural history of the disease has not been fully understood, and the appropriate treatment for AFS is also controversial. The management of AFS includes a combination of functional endoscopic sinus surgery and medical treatment in the form of pre- and post-operative systemic steroids, local steroids, and allergic immunotherapy. Close follow-up and coordination between the surgeon and physician is needed for optimum outcome. Despite aggressive medical and surgical treatment, high recurrence rates have been reported. In this review, we study the current literature and data regarding various surgical and non-surgical treatment options for AFS

As alterações nasofibroscópicas e tomográficas de seios paranasais são preditoras de gravidade em pacientes com fibrose cística / Nasal endoscopic and CT scan alterations of the paranasal sinuses as predictors of severity in patients with cystic fibrosis

A fibrose cística (FC) resulta de mutação no gene regulador da condutância transmembrana, responsável pelo controle dos processos secretores. As vias aéreas superiores (VAS) geralmente são comprometidas na forma de pansinusite crônica. OBJETIVO: Avaliar as alterações das VAS nos pacientes com FC e determinar a correlação entre os achados tomográficos e endoscópicos nasossinusais e a gravidade da doença. MÉTODO: Estudo transversal, prospectivo com 20 pacientes maiores de 5 anos com diagnóstico de FC avaliando escore de Shwachman-Kulczycki (S-K), tomografia de seios paranasais (TC) (escore de Lund-Mackay) e videonasofibroscopia (escore de Meltzer). RESULTADOS: Alterações tomográficas foram observadas em 94% dos casos. Alterações endoscópicas nas VAS foram encontradas em dez pacientes. Pólipo nasal ocorreu em três pacientes (15%). Observou-se correlação entre a intensidade das alterações da TC e o escore S-K (p = 0,0097) e entre os achados endoscópicos e o escore S-K (p = 0,0318). Observou-se relação positiva entre a presença de colonização crônica e os achados endoscópicos (p = 0,0325), o que não foi observado com os achados tomográficos (p = 0,2941). CONCLUSÃO: Há correlação inversa entre o escore clínico de S-K e os achados de TC e nasofibroscopia. Portanto, os pacientes clinicamente mais graves de acordo com o escore de S-K apresentam maior comprometimento de VAS.

Cystic Fibrosis (CF) results from mutation in the transmembrane conductance regulator gene, responsible for controlling secretory processes. The upper airways (UA) are usually involved in the form of chronic pansinusitis. OBJECTIVE: To evaluate UA changes in patients with CF and to establish the correlations between sinonasal CT and endoscopic endonasal findings and disease severity. METHOD: Cross-sectional and prospective study with 20 patients older than 5 years with CF, assessing the Shwachman-Kulczycki (S-K) score, paranasal sinus tomography (CT) (Lund-Mackay score) and nasal endoscopy (Meltzer score). RESULTS: CT scan alterations were observed in 94% of cases. Endoscopic alterations findings in the upper airways were found in 10 patients. Nasal polyps were found in 3 patients (15%). There was a correlation between the intensity of changes on the CT and S-K score (p = 0.0097), and between endoscopic findings and S-K score (p = 0.0318). There was a positive correlation between the presence of chronic colonization and endoscopic findings (p = 0.0325), which was not observed on the CT (p = 0.2941). CONCLUSION: There is an inverse correlation between the S-K clinical score and nasal endoscopy and CT findings. Therefore, patients who are clinically more severe according to the S-K score have greater UA involvement.

Sinus floor elevation procedure with immediate implant placement using artificial bone substitutes: a prospective clinical study

This study was designed to evaluate the clinical status of implants placed immediately in lifted maxillary sinus using Resorbable Tissue Replacement [R.T.R.] cone bone substitutes. Twenty implants were placed in twenty patients in the period between Jan. 2006 and Sept. 2010. Lateral approach, open window method for sinus lift with placement of Resorbable Tissue Replacement Cone bone substitutes were carried out. A 4-6 mm of the bone level was required in the alveolar ridge for primary stability, with sufficient interarch space for the prosthesis. All implants were placed in upper molar region simultaneously with sinus lift procedure in conjunction with Tissue Replacement Cone bone substitutes. The implant survival was defined when the prosthesis had been delivered and followed for two years without infection, pain, and mobility after loading. Twenty patients, 13 males and 7 females, with an average age of 41 years old were participated in this study. A total of twenty implants were followed up for two years. Eighteen patients with eighteen implants [90.0%] showed no signs of sinusitis or other complications and the periimplant health judged to be good with a periimplant sulcus depth of 2-3mm. Two implants [10%] showed mobility before loading. A good survival rate was observed in implants placed immediately in lifted maxillary sinus using Resorbable Tissue Replacement [R.T.R.] cone bone substitutes

Rinossinusites / Rhinosinusitis

A rinossinusite é uma doença frequente na prática diária de clínicos gerais, pediatras, alergologistas, pneumologistas e otorrinolaringologistas. Embora tenha baixa mortalidade e alta morbidade, há situações específicas que precisam ser reconhecidas, em que as complicações podem colocar a vida do paciente em risco. Por ser abordada por diversas especialidades e ter formas variadas de apresentações, é importante definir uma classificação comum a fim de estabelecer diagnósticos mais precisos, racionalizar a solicitação de exames complementares e instituir tratamentos adequados. Dessa forma, haverá uma redução nos custos do tratamento, nas complicações e nas formas crônicas da doença, garantindo uma melhor qualidade de vida para o paciente.

Amalgam tattoo: a cause of sinusitis?

Little attention has been paid to the toxicity of silver amalgam fillings, which have been used over the centuries in Dentistry. Amalgam particles may accidentally and/or traumatically be embedded into the submucosal tissue during placement of a restoration and perpetuate in such area. This article presents a case of amalgam tattoo and investigates whether it is related to the patient's repeated episodes of sinusitis. The patient was a 46-year-old woman with a 2 mm diameter radiopaque lesion in the right oral mucosa detected on a panoramic radiograph and presented as a black macula clinically. A complete surgical resection was carried out. The histopathological examination revealed deposits of dark-brownish pigments lining the submucosal tissue with adjacent lymphocytic inflammatory infiltrate and multinucleated giant cells phagocyting pigments. There was a negative staining for both iron and melanin. One year after lesion removal, the patient reported that the sinusitis crises had ceased after repeated episodes for years. It may be speculated that the inflammatory process related to amalgam tattoo seems to lead to a local immune response that causes sinusitis because it enhances the human leukocyte antigen DR (HLA-DR) tissue expression.

Efeitos do cigarro sobre o epitélio respiratório e sua participação na rinossinusite crônica: [revisão] / Effects of cigarette smoking on the respiratory epithelium and its role in the pathogenesis of chronic rhinosinusitis: [review]

O crescente consumo de cigarro tem despertado preocupações com o desenvolvimento e agravamento de doenças, em especial às relacionadas ao trato respiratório. Objetivo: Neste artigo revisamos as evidências que apontam os efeitos da fumaça de cigarro sobre o epitélio respiratório bem como o seu papel na fisiopatogenia na rinossinusite crônica. Conclusão: Embora existam dados que fortaleçam um vínculo entre o hábito de fumar e a RSC, em seu conjunto, os estudos demonstram que deve haver grande dependência da susceptibilidade individual na resposta à fumaça de cigarro para o desenvolvimento ou manutenção da RSC. Uma adequada orientação a esses pacientes para interrupção do consumo de cigarro, assim como o reforço de campanhas de combate ao tabagismo, são de extrema importância para o controle dessa doença de grande impacto sócio-econômico.

The increasing consumption of cigarettes has aroused concerns about the development and worsening of diseases, particularly those related to the respiratory tract. AIM: In this paper we review the evidence suggesting the effects of cigarette smoking on the respiratory epithelium and its role in the pathogenesis in chronic rhinosinusitis. Conclusions: Although there is evidence supporting a link between smoking and CRS, studies suggest that there might be individual susceptibility to cigarette smoking causing the development and/or maintenance of CRS. Proper patient educations to quit smoking as well as reinforcement of antismoking campaigns are extremely important to control this disease of major socio-economic impact.

Aspergilosis sinusal no invasiva por Aspergillus parasiticus en niño inmunocomprometido / Non invasive sinusal aspergillosis by Aspergillus parasiticus in an immunecompromised child

El presente trabajo tiene la finalidad de exponer un caso clínico de un niño inmunosuprimido con antecedentes de hospitalización previa, a los 6 años de edad con múltiples síntomas y signos (poliadenopatías, desnutrición, sepsis en cavidad bucal y foco pulmonar, además de pancitopenia). Permaneció en terapia intermedia durante 38 días, cumpliendo varios esquemas antibióticos sin buena respuesta a los mismos. Fue derivado al Hospital Ricardo Gutiérrez (Buenos Aires) desconociéndose la terapéutica seguida en esa oportunidad. Cinco años después (2007) es ingresado nuevamente a nuestro hospital por cuadro de epistaxis cefaléa, compromiso del estado general y neutropenia febril, por lo que se inicia tratamiento antibiótico, además de estudio con mielograma confirmándose el diagnóstico de leucemia linfocítica aguda. Cinco días después de su ingreso expulsa espontáneamente, desde las fosas nasales material granulomatoso el cual fue enviado a estudio micológico (examen directo y cultivo), detectándose alta presencia de Aspergillus parasiticus en ambos exámenes, lo cual fue ratificado por histopatología como una aspergilosis sinusal no invasiva. El paciente fue remitido a la Sala de Inmunodeprimidos donde recibió tratamiento intravenoso con 350 mg/día de anfotericina B-complejo lipídico y terapia específica para LLA. Presentó una evolución tórpida y al 12º día el paciente falleció por su mal estado general y progresión terminal de su enfermedad de base.

This present paper is meant to reveal the clinical case of an immunesuppressed boy having been previously in a hospital, when he was 6, showing multiple symptoms and signs (polyadenopaties, malnutrition, buccal sepsis and pulmonary focus, in addition to pancitopia). He stayed under intermediate therapy for 38 day being submitted to varied antibiotic schemes, though yielding no satisfactory responses to them. Later on he was derived to the Hospital Ricardo Gutiérrez (Buenos Aires), yet therapeutics used at that place being unknown. Five years later (2007), he is admitted again in our hospital because of cephalea epistaxis, a compromised health condition and fevered neutropenia, so he is given an antibiotic treatment in addition to a mielographic studyyet it is confirmed the diagnosis of an acute lymphocytic leukemia. Five days after his admittance, he discharges granulomatous matter from his nasal cavities which was sent for a mycological study. Direct exam and culture, detecting high presence of Aspergillus parasiticus on both exams which was ratified by histopathology as a non invasive sinusal aspergillosis. The patient was sent to the Immunedepressed Ward where he received intravenous treatment with 350mg/day anfotericina Blipidic complex and a specific therapy for LLA. He had a torpid evolution and on the 12nd day the patient died as a result of his very bad health condition as well as the terminal progression of his base disease.

Microbiologia do meato médio em indivíduos sadios / Microbiology of middle meatus in healthy individuals

Introdução: A microbiologia nasossinusal de indivíduos sadios é pouco documentada. Seu conhecimento permite a determinação dos agentes colonizantes nasossinusais e a monitoração dos padrões de resistência bacteriana. Objetivos: Determinar a microbiologia do meato médio em indivíduos sadios e compará-la com a de pacientes com rinossinusite crônica. Método: Foram incluídos 61 indivíduos sadios. As amostras foram coletadas sob visão endoscópica e submetidas a exame de Gram com contagem leucocitária e cultura para aeróbios, anaeróbios e fungos. 114 pacientes com rinossinusite crônica constituíram o grupo controle. Resultados: Nos indivíduos sadios foram isolados 58 microorganismos, sendo os mais prevalentes Staphylococcus coagulase-negativos, Staphylococcus e Corynebacterium. Fungos foram cultivados em 10%.Todas as amostras apresentaram leucócitos raros ou ausentes. Identificou-se resistência à penicilina em 75% dos Staphylococcus aureus e 69% dos Staphylococcus coagulase-negativos. Quanto à oxacilina, 100% dos Staphylococcus aureus e 92% dos Staphylococcus coagulase-negativos foram sensíveis. No grupo controle foram cultivados 158 microorganismos. Os mais freqüentes foram Staphylococcus aureus e coagulase-negativos. Os Gram-negativos representaram 26% dos aeróbios. Entre as amostras com cultura positiva, 73% apresentavam alguns ou numerosos leucócitos. Conclusão: Ausência ou raridade de leucócitos, Staphylococcus coagulase-negativos e Corynebacterium foram mais freqüentes em sadios, e Streptococcus pneumoniae, anaeróbios, Staphylococcus coagulase-negativos oxacilino-resistentes e Gram-negativos mais freqüentes no grupo controle.

Introduction: The nasosinusal microbiology of healthy individuals is not much documented. Its knowledge allows to determine the nasosinusal colonizing agents and to monitor the patterns of bacterial resistance. Objective: To evaluate the microbiology of the middle meatus in healthy individuals and to compare it with that of patients with chronic rhinosinusitis. Method: 61 healthy individuals were included. The samples were collected under endoscopic view and Gram stained with leucocytes count and aerobic, anaerobic and fungus cultures. 114 patients with chronic rhinosinusitis formed the control group. Results: In healthy individuals 58 microorganisms were isolated. The most frequent ones were coagulase-negative Staphylococcus, Staphylococcus and Corynebacterium. Fungi were cultivated in 10%. There were rare or no white blood cells in all samples. There was penicillin resistance in 75% of the Staphylococcus aureus and 69% of the coagulase-negative Staphylococcus. As for oxacillin, 100% of Staphylococcus aureus and 92% of coagulase-negative Staphylococcus were sensitive. In the control group 158 microorganisms were cultivated. The most common ones were Staphylococcus aureus and coagulase-negative Staphylococcus. Gram-negatives represented 26% of the aerobics. 73% of the samples with positive cultures presented a few or many white blood cells. Conclusion: Rare or no white blood cell, coagulase-negative Staphylococcus and Corynebacterium were more frequent in healthy individuals and Streptococcus pneumoniae, anaerobics and oxacillin resistant coagulase-negative Staphylococcus and Gram-negative were more frequent in the control group.