Diagnosis and management of chronic rhinosinusitis in adults.

Chronic rhinosinusitis (CRS) is characterized by mucosal inflammation affecting both the nasal cavity and paranasal sinuses; its causes are potentially numerous, disparate, and frequently overlapping. The more common conditions that are associated with CRS are perennial allergic and nonallergic rhinitis, nasal polyps, and anatomical mechanical obstruction (septum/turbinate issues). Other less common etiologies include inflammation (eg, from superantigens), fungal sinusitis or bacterial sinusitis with or without associated biofilm formation, gastroesophageal reflux, smoke and other environmental exposures, immune deficiencies, genetics, and aspirin-exacerbated respiratory disease. A diagnosis of CRS is strongly suggested by a history of symptoms (eg, congestion and/or fullness; nasal obstruction, blockage, discharge, and/or purulence; discolored postnasal discharge; hyposmia/anosmia; facial pain and/or pressure) and their duration for > 3 months. A definitive diagnosis requires physical evidence of mucosal swelling or discharge appreciated during physical examination coupled with CT imaging if inflammation does not involve the middle meatus or ethmoid bulla. Multivariant causation makes the diagnosis of CRS and selection of treatment complex. Furthermore, various types of health care providers including ear, nose, and throat (ENT) specialists, allergists, primary care physicians, and pulmonologists treat CRS, and each is likely to have a different approach. A structured approach to the diagnosis and management of CRS can help streamline and standardize care no matter where patients present for evaluation and treatment. A 2008 Working Group on CRS in Adults, supported by the American Academy of Otolaryngic Allergy (AAOA), developed a series of algorithms for the differential diagnosis and treatment of CRS in adults, based on the evolving understanding of CRS as an inflammatory disease. The algorithms presented in this paper address an approach for all CRS patients as well as approaches for those with nasal polyps, edema observed on nasal endoscopy, purulence observed on nasal endoscopy, an abnormal history and physical examination, and an abnormal history and normal physical examination.

Analysis of possible cross-contamination with the Venturi system atomizer.

BACKGROUND: The physics behind the Venturi atomizers suggest a possibility of bacterial colonization and the potential for patient cross-contamination. A protocol for use of the atomizer and clinically appropriate demonstration of cross contamination has not been established. METHODS: Three sterilized atomizers filled with a solution of 2% Pontocaine and 1% ephedrine (two test and one control) were used during a 5-day study period. Clinic staff was instructed to (1) use a nozzle tip, (2) use a nasal speculum, (3) avoid contact between the atomizer and the patient, and (4) apply a continuous, <1-second spray to the nasal cavity. Samples were obtained from each of the atomizers three times per day and plated on chocolate agar plates. The number and type of bacterial colony were registered. RESULTS: No respiratory pathogens grew from any of the 45 plated samples. Nine of 30 experimental atomizer samples produced 12 bacterial colonies. Of the 12 bacterial colonies obtained, 6 colonies of coagulase-negative Staphylococcus, 5 colonies of Corynebacterium sp., and 1 colony of Bacillus sp. were identified. One of 15 plated control atomizer samples produced two colonies of coagulase-negative Staphylococcus. An average of 1.3 colonies per positive test plate and an average of 2.0 colonies per positive control plate were identified. There was no evidence of an increasing number of colonies per plate or persistence of any particular bacteria identified over time to suggest contamination or colonization of the system reservoir. CONCLUSION: There is no risk of cross-contamination of patients with the use of the Venturi system atomizer as outlined in this study. Culture results from this study were consistent with random culture contamination during the plating and/or culturing period. There was no evidence to support the idea of bacterial colonization of the atomizers. Continued use of the Venturi system atomizer is an acceptable practice.

Application of image-guidance to surgery of the orbit.

CAS can be useful in orbital surgery. It can help to identify various structures, although it is certainly not necessary, nor is it a replacement for knowledge of the orbit's anatomy and its relationship to surrounding structures.

The low skull base-is it important?

PURPOSE OF REVIEW: Little is published regarding variations of skull-base anatomy and their relevance to the performance of endoscopic sinus surgery. Several catastrophic complications have occurred in patients with low-lying skull-base variation. This review's purpose is to make the reader aware of skull-base variation, their recognition, and a surgical plan for sinus surgery in these patients. RECENT FINDINGS: Only a few papers are available for review discussing variations of the low-skull base. Recent findings in reviewing multiple CT scan indicate several variations of the skull. It has also been noted that there are variations of thickening in the skull (ie, lateral ethmoid, thicker bone, more medial, thinner bone). Several case reports have surfaced reflecting how a low-lying skull-base can play a role in brain-related complications. These figures are reviewed. SUMMARY: A knowledge of orbital and skull-base variations preoperatively can help plan the surgical procedure and avoid major complication. The preoperative CT scan is the key to preoperative knowledge. The use of special techniques to aid in localization of a low-lying skull-base including image computer guidance is recommended.

Long-term outcomes of endoscopic repair of cerebrospinal fluid leaks and meningoencephaloceles.

BACKGROUND: The management and surgical approach to cerebrospinal fluid (CSF) leaks and meningoencephaloceles have undergone transformation throughout the last 10 years. It is our interest to examine the long-term surgical outcome and reoccurrence rates of CSF leaks or meningoencephaloceles in patients having endoscopic surgical repair. METHODS: We performed a retrospective evaluation of 50 patients that underwent endoscopic surgical repair of a CSF leak, meningoencephalocele, or both, between September 1985 and October 2003. RESULTS: Cumulatively, reoccurrence rates were 15% (7/47) among the CSF leak patients with an average time frame for reoccurrence ranging from 1 to 25 months (average, 7 months). Patients with meningoencephaloceles had an overall reoccurrence rate of 8% (1/13). In addition, a Medline search on CSF leaks and meningoencephaloceles provided the names of 32 authors that have studied outcomes of endoscopic surgical repair. Of the 151 patients still followed in the 5- to 10-year postoperative group, there were 37 recurrences of CSF leaks and 5 reoccurrences of the meningoencephaloceles with a total recurrence rate of 27% (37 + 5/151). Of the 19 patients still followed in the >10-year postoperative group, there were three reoccurrences of CSF leaks and no reoccurrences of meningoencephaloceles, giving a reoccurrence rate of 16% (3 + 0/19). CONCLUSION: Based on our cumulative results, a reoccurrence of a CSF leak or meningoencephalocele after endoscopic repair will occur within the first 2 years postoperatively. Once patients pass these postoperative time frames they are relatively free of reoccurrence from this very effective surgical management. Endoscopic repair results are better than craniotomy with much less morbidity.

The low skull base: an invitation to disaster.

BACKGROUND: Knowledge of anatomy including variations observed with endoscopy or computerized tomography scan is vital to the performance of safe endoscopic sinus surgery. The lower-than-normal skull base/cribriform plate is an anatomic variation, which if not noted preoperatively, can lead to entrance into the brain causing major injury. METHODS: Four case studies of chronic rhinosinusitis are reviewed in which either the whole anterior skull base or the cribriform plate is lower than usual and major complications occurred. RESULTS: All four cases had unilateral or bilateral entrance into the skull base/cribriform plate of the brain in the biopsy specimen, postoperative cerebrospinal fluid leak, and/or brain hemorrhage. One patient died from the injury, three patients had marked neurological sequelae. The low skull base and its meaning for the surgeon is discussed at length. CONCLUSION: The preoperative anatomy as determined by endoscopy and computerized tomography scanning has to be identified. Variations or abnormalities should be noted and taken into consideration for preoperative and operative planning. Failure to note skull base or cribriform anatomy variations may lead to brain entrance, injury, and death.

Cost analysis in the diagnosis of chronic rhinosinusitis.

BACKGROUND: The present treatment regimen for a diagnosis of chronic rhinosinusitis involves a prolonged course of antibiotic therapy along with other adjunctive therapy. The decision to start treatment is made after diagnosis of chronic rhinosinusitis, which is based on subjective symptoms. The working hypothesis of this study is that the diagnosis based on subjective symptoms is inaccurate, leading to inappropriate antibiotic therapy and unnecessary health care expense. METHODS: One hundred patients were evaluated prospectively to determine which patients qualified for this study. Seventy-eight patients satisfied current criteria for a diagnosis of rhinosinusitis. RESULTS: Fifty-three percent (41 patients) of the 78 patients did not have a diagnosis of chronic sinusitis based on same-day computed tomography (CT) scanning. A charge analysis comparing treatment after diagnosis with medical therapy alone and CT scan for failures versus CT scanning with medical treatment for positive scans was performed. Although the most economical method of treatment was initiating medical therapy, it was also the least sensitive and specific in that 52% of patients didn't require the treatment. Endoscopy and/or CT screening with medical therapy were much better at appropriate diagnosis and targeted therapy but charge analysis indicated a much higher cost. CONCLUSION: Presently, the current subjective diagnostic paradigm for chronic rhinosinusitis is most cost-effective but least accurate. Objective evaluations (endoscopy and CT scanning) to aid in diagnosis are more accurate but more costly. Where cost constraints are important, careful considerations of alternatives are important.

A diagnostic dilemma for chronic rhinosinusitis: definition accuracy and validity.

BACKGROUND: The current definition of chronic rhinosinusitis is a symptom-based definition with minimal reliance on objective information. Based on this definition, patients are diagnosed and treatedl with medical therapy. A computed tomography (CT) scan is obtained only if the patient is not improved after medical therapy. No study is available evaluating in an evidence-based manner the accuracy of the current definition and its impact on diagnosis and treatment. METHODS: This study represents 78 patients evaluated in a prospective fashion who met the subjective criteria for the definition of chronic rhinosinusitis. All patients underwent a complete history with a questionnaire evaluating symptom severity, a physical exam including anterior rhinoscopy and endoscopy, and a CT scan obtained on the day of their initial visit. Objective CT scan findings were compared with the subjective findings and related to the ultimate diagnosis of chronic sinusitis. RESULTS: Only 37/78 (47%) had a positive (+) CT scan, indicating demonstrable sinusitis. There also was no real diffrence in symptom severity between patients with positive (+) and negative (-) CT scanning. CONCLUSION: The current symptom-based definition of chronic sinusitis poorly predicts whether a patient truly has chronic sinusitis and needs reevaluation.

Nasal endoscopy and the definition and diagnosis of chronic rhinosinusitis.

OBJECTIVES: Although endoscopy has been shown by a few authors to be a valuable tool for the diagnosis of chronic rhinosinusitis, its true role in the evaluation of the patient with chronic rhinosinusitis has not been elucidated. The current definition of chronic rhinosinusitis is a symptom-based definition, and objective testing such as endoscopy or computed tomography (CT) is not included. However, the current treatment paradigm for chronic rhinosinusitis is dependent on the definition for diagnosis. Patients are treated with 4 weeks of antibiotics and decongestant/antihistamines/steroids based on the definition. This study aims to evaluate in a prospective fashion the place of endoscopy in the diagnosis of chronic rhinosinusitis. STUDY DESIGN: A group of 78 patients meeting the definition of chronic rhinosinusitis were subjected to same-day endoscopy and CT scanning. RESULTS: Seventeen (22%) of 78 patients had positive endoscopic and CT results. There were 20 (26%) of 78 patients with negative endoscopic and positive CT results. Six (8%) patients had positive endoscopic and negative CT results, and 35 (45%) had negative endoscopic and negative CT results. Overall, 37 (47%) patients had positive CT results, and 41 (53%) patients had negative CT results. Endoscopy showing the presence of purulence, nasal polyps, or watery congested mucosa correlated well with CT results. Negative endoscopy correlated with CT results in 65% of patients. CONCLUSION: The use of endoscopy to corroborate the diagnosis in nonpolypoid or nonpurulent rhinosinusitis in previously unoperated patients is questioned. Patients who meet the subjective definition of chronic rhinosinusitis should have a high degree of sensitivity and specificity with endoscopy or CT. The fact this is not the case questions the accuracy of the definition and the treatment paradigm. SIGNIFICANCE: According to this study, positive endoscopic results correlated well with CT, and negative endoscopic results correlated in 71% of patients with negative CT results.

Aspirin-sensitive versus non-aspirin-sensitive nasal polyp patients: analysis of leukotrienes/Fas and Fas-ligand expression.

OBJECTIVE: The goal of the present study was to identify levels of leukotrienes released by leukocytes and nasal polyps from aspirin-sensitive patients (ASPs) and non-aspirin-sensitive patients (NASPs) after exposure to various concentrations of aspirin. Eosinophil expressions of apoptosis regulators were also compared. STUDY DESIGN AND SETTING: Leukotriene release from nasal polyps and leukocytes of ASPs and NASPs was measured after exposure to differing concentrations of aspirin. Eosinophils were analyzed for Fas and Fas ligand receptors using flow cytometry. RESULTS: NASPs showed increased leukotriene release from nasal polyps on increased aspirin exposure. Polyps from ASPs did not show any change. ASPs showed greater leukotriene release from blood on increasing aspirin exposure compared with NASPs. Flow cytometric analysis showed eosinophils in the peripheral blood of ASPs have decreased Fas expression compared with those of NASPs. CONCLUSIONS: This study showed differences in leukotriene release and eosinophil apoptosis between ASPs and NASPs. SIGNIFICANCE: These findings suggest a role of leukotrienes and eosinophils in aspirin sensitivity mechanisms in blood.