Ciliary dyskinesia in severe chronic rhinosinuitis patients and using a modified fess approach for management

ABSTRACT

Defective ciliary ultrastructure and impaired mucociliary clearance play an important role in the development of severe or refractory chronic respiratory tract disease which is still a challenging problem. The aim of this study was to define the role of ciliary dyskinesia in severe chronic rhinosinusitis. Also, the validity of a modified functional endoscopic sinus surgery [FESS] for treating such patients is evaluated in this study. Fifteen patients [8 males and 7 females with a mean age = 17.2 years] with severe chronic rhinosinusitis [i.e., refractory to medical treatment] with suspected ciliary dyskinesia [i.e., with prolonged saccharin test more than 45 minutes] were included in this study. All patients had a preoperative computerized tomographic [CT] sean documentation of their severe multiple sinus disease. They were treated with a modified FESS under general anaesthesia during which nasal biopsies from the middle turbinate were taken for evaluation by transmission electron microscopy [TEM] to detect ultrastuctural abnormalities. Also, two nasal biopsies from normal volunteers were taken as controls. The patients were followed up postoperatively for a period of 9 to 18 months [average 12 months] both clinically [by nasal endoscope] and radiologically [by coronal CT scan] with special emphasis on patency of middle meatal antrostomy [MMA]. Transmission electron microscopic [TEM] study of nasal epithelium of control subjects revealed normal ciliated pseudostratified columnar epithelium. While in the study group, ciliated cells were detected in 11 [73%] biopsies with 4[27%] cases having no cilia. However, foci of normal ciliated epithelium were found in only 7 [47%] biopsies and often in epithelial invaginations. Six patients [40%] in the study group had shown rimary Ciliary dyskinesia [PCD]. Nine [60%] of study group patients showed Secondary Ciliary dyskinesia [SCD] with variable ultratructural defects affecting minor population of cilia in the specimen [5 secimens or 33%], or with squamous metaplsia or denuded surface with complete loss of cilia [4 specimens or 27%]. All biopsies showed variable loss of differentiated epithelial cells ranging from denuded epithelim to basal cell hyperplasia often associated with squamous metaplasia secondary to chronic sinonasal disease. This study demonstrated that patients with severe or refractory chronic rhinosinusitis exhibit a prominent loss of differentiated epithelial cells, as well as ciliary defects, most of which are likely to be secondary to the chronic disease process. The modified FESS used in this study was highly effective in treating patients with severe or refractory chronic rhinosinusitis with ciliary dyskinesias [either primary or secondary] with patent MMA and relief of their severe manifestations as it improves the gravitational drainage and aireation of the paranasal sinuses besides respecting the mucociliaray clearance concepts