The microbiology of chronic rhinosinusitis with and without nasal polyps.

OBJECTIVE: To compare the microbiological features in middle meatus samples from chronic rhinosinusitis (CRS) patients with nasal polyps (CRSwNP) and those without nasal polyps (CRSsNP), and control subjects. METHODS: A total of 136 CRSwNP patients, 66 CRSsNP patients, and 49 control subjects who underwent endoscopic surgery in Beijing TongRen Hospital were enrolled between January 2014 and January 2016. Swab samples were obtained from the middle meatus during surgery and processed for the presence of aerobic and non-aerobic bacteria and fungi. Information on the allergic rhinitis, asthma, the percentage of eosinophils in peripheral blood, and the history of smoking and surgery was collected. RESULTS: The overall isolation rate for bacteria was 81.3% for the three groups, with the lowest in the CRSsNP group (77.3%) and the highest in the CRSwNP group (88.4%). There were no significant differences in isolation rates among the three groups (P = 0.349). The three most common bacterial species were: Coagulase-negative Staphylococcus (24.3%), Corynebacterium (19.9%), and Staphylococcus epidermidis (19.1%) in the CRSwNP group; S. epidermidis (21.2%), Corynebacterium (21.2%), Coagulase-negative staphylococcus (18.2%), and Staphylococcus aureus (13.6%) in the CRSsNP group; S. epidermidis (30.6%), Coagulase-negative Staphylococcus (28.6%), and S. aureus (14.3%) in the control group. For the bacterial species with high isolation rates, no significant difference in the microbial cultures was observed among the three groups; whereas in the CRSwNP group, a relatively high proportion of Citrobacter (5.9%, a bacterium with low isolation rate) was observed compared with the CRSsNP and control groups (all 0.0%). Furthermore, when samples were categorized into subgroups according to the percentage of eosinophils, some bacterial species showed different rates in the CRSwNP group (e.g., S. aureus, 3.3% in the subgroup with normal percentage of eosinophils, 17.2% in the subgroup with increased percentage of eosinophils, P = 0.011). CONCLUSIONS: There were no significant differences in the microbiological features (except Citrobacter) in middle meatus samples from CRSwNP patients, CRSsNP patients, and control subjects. S. aureus may promote eosinophilic inflammatory response, while S. epidermidis may promote non-eosinophilic inflammatory response.

The intranasal endoscopic removal of schwannoma of the pterygopalatine and infratemporal fossae via the prelacrimal recess approach.

OBJECTIVE: This study was undertaken to analyze the results of a novel surgical method-the endoscopic prelacrimal recess approach (PLRA)-in patients with tumors involving the pterygopalatine fossa (PPF) and infratemporal fossa (ITF). The surgical technique and indications for this approach are also discussed. METHODS: The authors analyzed data from 7 cases involving patients who underwent resection of PPF and ITF tumors by means of the endoscopic PLRA from 2004 to 2013. Preoperative and postoperative imaging studies were available in all cases and were reviewed. The surgical specimens were all confirmed to be schwannomas. RESULTS: All tumors were completely resected via endoscopic PLRA. There were no recurrences noted over a 28-month follow-up period. In 4 cases, the patients experienced postoperative facial numbness during the first two weeks after surgery, which gradually lessened thereafter. One patient continued to have mild facial numbness at most recent follow-up. The numbness had fully resolved in the other 3 cases. CONCLUSIONS: The intranasal endoscopic removal of schwannoma from PPF and ITF via PLRA can spare the whole lateral nasal wall, resulting in a reduction in morbidity. This is a novel minimally invasive surgical method for PPF and ITF tumors.

[The role of peripheral blood eosinophil percentage in classification of chronic rhinosinusitis with nasal polyps].

OBJECTIVE: Trying to find a useful marker to subclassify chronic rhinosinusitis (CRS), ratio of eosinophil in peripheral blood was investigated. METHODS: Histologic characteristics of surgical samples were analyzed in 119 CRS with nasal polyps (CRSwNP) patients, who were classified into eosinophil CRSwNP (ECRSwNP) group and non-ECRSwNP group. Peripheral blood eosinophil percentage, olfactory function, skin prick test, serum total IgE and sinus CT scan in two groups were all examined and analyzed. To evaluate the discriminatory power of eosinophil to diagnose ECRSwNP, the Receiver Operating Characteristic(ROC)curve was analysed. RESULTS: There were significant differences in Ratio of EOS, serum total IgE, and olfactory function scores, between ECRSwNP group and non-ECRSwNP group(mean value were 7.31%: 3.90%, 60.9 IU/L: 28.9 IU/L, 5.8: 0.4 respectively, U value were 620.01, 1020.53 and 1092.52, respectively, all P < 0.05). However, there was no difference in skin prick test between two groups. In CT scan exam, there were no differences in Lund-Mackay scores in frontal sinus, anterior ethmoid sinus, posterior ethmoid sinus, sphenoid sinus and ostiomeatal complex area, but maxillary sinus, between ECRSwNP group and non-ECRSwNP group (U value were 27.5, 23.5, 22.5, 31.5, 28.5, respectively, all P > 0.05, and U value of maxillary sinus was 12.01, P < 0.05 ). Peripheral blood eosinophil percentage and serum total IgE were related with pathology of nasal polyps (r value were 0.55, 0.24, and P value were 0.001, 0.01, respectively), especially blood eosinophilia can be a predictor of ECRSwNP. The area under curve was 0.818 and cutoff value was 5.65%. CONCLUSIONS: ECRSwNP is different from non-ECRSwNP in many clinical features. Peripheral blood eosinophil percentage is consistent with histologic features of ECRS, which is a useful marker as 5.65% in classification of CRS.

Analysis of transforming growth factor ß signaling in chronic rhinosinusitis.

BACKGROUND: It has been reported that there is a significant difference in the local tissue concentration of transforming growth factor (TGF)-ß1 between chronic rhinosinusitis without nasal polyps (CRSsNP) and chronic rhinosinusitis without nasal polyps (CRSwNP) patients. TGF-ß has been reported to play an important role in regulating epithelial cell repair in lower airway remodeling and may be a critical factor involved in the remodeling process of chronic rhinosinusitis (CRS). METHODS: Ethmoidal mucosal samples collected from CRS and healthy control patients were analyzed for TGF-ß1, TGF-ß receptor I, TGF-ß receptor II, Smad3, phospho-Smad3, Smad7, and Smad anchor for receptor activation by Western blotting analysis. The proliferation of sinonasal epithelial cells at baseline and after TGF-ß1 and/or EGF stimulation was evaluated by the MTT assay. RESULTS: In CRSsNP, TGF-ß1, TGF-ß receptor I, TGF-ß receptor II, and Smad3 protein levels were significantly higher than controls. In CRSwNP, TGF-ß1, Smad3, and pSmad3 protein levels were significantly lower than controls. Smad7 protein was significantly higher in CRS than controls. In vitro experiments demonstrated that the baseline proliferation levels of sinonasal epithelial cells were lower in CRS than controls. CONCLUSIONS: CRSwNP is characterized by a lower level of TGF-signaling compared with the control. In CRSsNP, although the upstream signaling of TGF-ß was enhanced, the high Smad7 protein expression may restrain the downstream signaling components (e.g., pSmad3) and the TGF-ß antiproliferative effect on sinonasal epithelium. The difference in the local tissue concentration of TGF-ß1 between CRSsNP and CRSwNP patients did not result in significant differences in epithelial proliferation.

[Removal of Schwannoma in the pterygopalatine and infratemporal fossa via endoscopic prelacrimal recess approach].

OBJECTIVE: To sum up and analyze the results of surgical removal of Schwannoma in the pterygopalatine and infratemporal fossa (PPF and ITF) through postero-lateral wall via prelacrimal recess approach (PLRA). The surgical technique and indications were presented and discussed. METHODS: Six patients aged from 29-59 year-old with Schwannoma in the PPF and ITF, who received the tumor resection via PLRA under endoscope, were enrolled in this paper. Three were female and 3 were male. All of them received preoperative CT and MRI. The PPF and ITF were approached via prelacrimal recess endoscopically under general anesthesia. Schwannoma was histopathologically confirmed after surgery. The postoperative periodical CT and MRI follow up was conducted. RESULTS: The tumors were removed completely in these 6 patients. No recurrence was found during 19.3 months follow up on the average. Three patients had obvious numbness in the V2 innervation area 1 or 2 weeks after operation and disappeared afterwards. Only 1 patient had mild altercation numbness at the end of follow up. CONCLUSIONS: Schwannoma involved PPF and ITF can be removed endoscopically via PLRA. The lateral wall of nasal cavity might be kept intact. It is a novel minimally transnasal invasive approach to PPF and ITF with less damage and complications.

[CT and MRI diagnosis of lesions in unilateral maxillary sinus].

OBJECTIVE: To study the CT and MRI findings of lesions in unilateral maxillary sinus, and to compare the effect of CT and MRI in the differential diagnosis of lesions in unilateral maxillary sinus. METHODS: Retrospective analysis of CT and contract-enhanced MRI imaging data from 34 patients with lesions in unilateral maxillary sinus which were diagnosed by endoscopic sinus surgery and postoperative pathology. The CT and contract-enhanced MRI's value in the differential diagnosis in lesions in unilateral maxillary sinus was analysed. RESULTS: All 34 patients had unilateral maxillary sinus lesions. On CT: soft tissue density shadow in the unilateral maxillary sinus was found in all 34 cases. Five cases showed spot high density with thickening bone in the maxillary sinus wall. Eleven cases showed expansion of the opening of maxillary sinuses. Two cases showed broken lateral wall of nasal cavity . One case showed soft tissue density shadow in the maxillary sinus with curve edge with high density shadow which had a tooth shadow in it. Other 14 cases showed only soft density shadow in the maxillary sinuses. On MRI: all 34 cases revealed lower signals on T1WI compared to gray matter. Little loss signal were found in the inner of the maxillary sinus fungal balls on T1WI. Enhanced MR imaging showed no enhanced in nasal sinusitis, sinus cysts and polyp of posterior naris. In homogenous enhancing and "the cerebral convolution sign" were found in the hemorrhagic and necrotic nasal polyp, the nasal inverted papilloma and the malignant tumor cases. Higher signals were seen in the nasal sinusitis, fungal balls and the polyp of posterior naris cases on T2WI. In homogenous signal with different levels were found in the hemorrhagic and necrotic nasal polyp, the nasal inverted papilloma and the malignant tumor cases on T2WI. CONCLUSIONS: CT and MRI examination are important in the diagnosis of the unilateral maxillary sinus lesions. Both CT and MRI had more differential diagnostic value in the unilateral maxillary sinus lesions than only CT used.

[Clinical application of Draf IIb frontal sinusotomy and it's modified procedures].

OBJECTIVE: To summarize the follow-up outcomes of Draf IIb frontal sinusotomy and it's modified procedures, and to discuss the surgical indications and prognostic factors. METHODS: Thirty-two patients treated between 2004 and 2010 were enrolled in this study. There were 15 patients for recurrent frontal inverted papilloma (IP), 6 for mucocele, 4 for recurrent frontal sinusitis, 3 for osteoma, 2 for meningoencephalocele with cerebrospinal fluid rhinorrhea, 1 for meningoencephalocele alone and 1 for acute frontal sinusitis. All patients underwent preoperative paranasal sinus computed tomography (CT) scans. Patients with tumor accepted magnetic resonance imaging (MRI). The patients with meningoencephalocele and cerebrospinal fluid rhinorrhea received magnetic resonance cisternography (MRC). The Draf IIb frontal sinusotomy and it's modified Draf IIb-1-3 procedures were applied endoscopically under general anesthesia mainly by high speed bur and power system. The postoperative CT scan was obtained as a base line for follow-up 1 week after the operation. Postoperative follow-up was performed under endoscope. RESULTS: Among 19 cases of Draf IIb, 12 were recurrent IP of frontal sinus, 4 were mucocele, 2 were recurrent frontal sinusitis and 1 were osteoma. Five cases received Draf IIb-1, 2 for each recurrent IP of frontal sinus and recurrent frontal sinusitis and 1 for osteoma. Six cases received Draf IIb-2, 3 for meningoencephalocele, 1 for each IP, acute frontal sinusitis and osteoma. Two cases received Draf IIb-3 were mucocele. The follow-up ranged from 8 to 73 months. Twenty-two cases of the frontal nepostium were widely opened, 7 were stenosis and 3 were closed. Revision surgery was seen in 2 cases with IP. All of them had no complications. CONCLUSIONS: The Draf IIb frontal sinusotomy and it's modified procedures are suitable for complex frontal sinus disease, which can be selected according to pathological and anatomical features, and have a good prospect for clinical application.

Pharyngeal aerodynamic characteristics of obstructive sleep apnea/hypopnea syndrome patients.

BACKGROUND: The role of nasal obstruction in the pathogenesis of obstructive sleep apnea/hypopnea syndrome (OSAHS) has been debated for decades. In this prospective study, we compared the pharyngeal aerodynamic characteristics of OSAHS patients and normal people, and investigated the contribution of total nasal airway resistance to the pathophysiology of OSAHS. METHODS: Computational fluid dynamics (CFD) was used to extract the average pressure and average airflow velocity in three transverse cross-sectional planes of the pharynx for statistical analysis, and the correlation between nasal resistance and the average pressure in the pharyngeal cavity was investigated. RESULTS: The negative pressure within the pharyngeal cavity was significantly higher in OSAHS patients than in normal subjects, and total nasal airway resistance correlated well with the average pressure in three consecutive transverse cross-sections of the pharyngeal cavity. CONCLUSIONS: Greater negative pressure within the pharyngeal cavity contributed to the increased collapsibility of the pharynx in OSAHS patients, and the strong correlation between nasal resistance and pharyngeal pressure suggests that the nose plays a role in the pathogenesis of OSAHS.

[A histopathological study: chronic rhinosinusitis in adolescents versus adults].

OBJECTIVE: To conduct a histopathology study of adolescents with chronic rhinosinusitis (CRS) to compare the sinus mucosa with adult CRS and to explore their different pathological characteristics and lesion patterns. METHODS: Twenty cases of adolescents (median age: 14 years; range: 11-16 years) and 16 cases of adult CRS (median age: 36 years; range: 21-56 years) were performed functional endoscopy operation despite conventional medical therapy, histopathology of uncinate process mucosa were analyzed for inflammatory cell and morphologic studies. Archival tissue from adolescents and adults with CRS were stained with HE, AB-PAS (alcian blue-periodic acid-schiff) as well as Van Gieson. Statistical analysis t-test was performed using SPSS. RESULTS: Adolescents CRS sinus mucosa, as compared with adult CRS control, had a higher density of submucosal lymphocytes (t = 2.09, P = 0.04), higher density of submucosal plasma cell (t = 2.46, P = 0.02), lower density of submucosal eosinophils (t = -3.72, P = 0.01), thinner basement membranes and more intact epithelium (t = -2.50, P = 0.02 and t = 5.63, P = 0.00 respectively) and fewer submucosal mucous glands (t = -2.13, P = 0.04). There were significant differences between two groups. CONCLUSION: Lymphocytes were the predominant inflammatory cell type in the sinus mucosa of adolescents with CRS. But it has less eosinophilic inflammation, more plasma cell infiltration, basement membrane thickening, and mucus gland hyperplasia in characteristic adult CRS. Differences between adolescents and adult CRS suggest differing pathogenic mechanisms or progression in the inflammatory response with a protracted disease.

Value of nasal mucosa congestion index in choosing treatment strategies for chronic rhinosinusitis.

CONCLUSION: The mucosa compliance in lesions is determined by the congestion index, enabling us to determine whether the patient is sensitive to pharmacotherapy and to choose surgical management rationally. OBJECTIVE: To explore the correlation between the nasal mucosa congestion index and tissue remodeling in chronic rhinosinusitis (CRS) and to provide objective evidence for clinical choice of therapeutic methods. PATIENTS AND METHODS: Forty-four patients with CRS who underwent nasal endoscopic surgery were enrolled in the study. The congestion indexes of the nasal mucosa were measured using an acoustic rhinometer and specimens were taken from the uncinate process mucosa to evaluate vascular density and degree of fibrosis. The correlations were statistically analyzed. RESULTS: There was an inverse correlation between the congestion index and degree of fibrosis (r=- 0.522, p=0.00) and a direct correlation between the congestion index and vascular density (r=0.838, p=0.00) in nasal mucosa. There was a significant correlation between the congestion index and the combination of degree of fibrosis and vascular density with a determination coefficient (R(2)) of 0.778.

[Comparison study between clinical diagnosis and experimental diagnosis of fungal sinusitis].

OBJECTIVE: To compare the differences between clinical diagnosis and laboratory diagnosis of fungal sinusitis. METHODS: One hundred cases of fungal sinusitis were reviewed in this study. The clinical characters including symptoms, physical signs, images and intraoperative signs were the main aspects of clinical diagnosis. The results of clinical diagnosis, pathology, direct observation of the nasal and sinus samples with microscope and the fungal culture were compared. RESULTS: The numbers of fungal ball, allergic fungal sinusitis, acute fulminant invasive fungal sinusitis, and chronic invasive fungal sinusitis were 82, 10, 6, and 2 respectively. The positive rates of clinical diagnosis, pathology, direct observation with microscope and the fungal culture were 95%, 61%, 78%, and 74% respectively. There was significant difference among the positive rates of above methods (P < 0. 01). CONCLUSION: Clinical diagnosis can be used as the preliminary method for fungal sinusitis diagnosis. The demonstrative diagnosis needs to combine all above methods. The culture was the main method for confirm the types of pathogenic fungus.

[Endoscopic management of the inverted papilloma involving frontal sinus and its drainage pathway].

OBJECTIVE: The endoscopic management of inverted papilloma has gained increasing popularity over the last 15 years. However, the appropriate management of lesions involving the frontal sinus and its drainage pathway still has to be determined. METHODS: We performed a retrospective review of the results of the patients with inverted papilloma in the Otolaryngology Head and Neck Surgery department, Beijing Tongren Hospital from 2004 to 2007 to identify the patients with lesions involving frontal sinus and its drainage pathway. By its appearance on nasal endoscopic examination and CT scanning, the tumors were defined using Krouse staging system. Sinus endoscopy was used to screen for disease after endoscopic resection. And their clinical outcomes were analyzed. RESULTS: A total of nine patients (8 males and one female) with inverted papilloma who had frontal sinus and its drainage pathway involvement were identified. All tumors were defined as T3 lesions. Preoperative and postoperative pathologic examinations revealed inverted papilloma as the diagnosis. Four cases with lateral wall of frontal recess attachment underwent endoscopic Draf II A frontal sinusotomy. Three cases with either lateral and posterior walls of frontal recess and frontal infundibulum attachment or medial and posterior walls of frontal recess and frontal infundibulum attachment underwent Draf II B procedure. Two cases with either posterior wall of frontal recess and frontal infundibulum attachment or medial, lateral and posterior walls of frontal recess and frontal infundibulum attachment underwent Draf III procedure. All patients remain disease free with an average follow-up of 13 months. CONCLUSIONS: Extensive inverted papilloma (Krouse T3 lesions) can be treated successfully with an endoscopic approach.

[Evidence of bacterial biofilms in chronic rhinosinusitis].

OBJECTIVE: To observe the presence of bacterial biofilms in mucosal specimens in patients operated for chronic rhinosinusitis. METHODS: A total of 12 subjects undergoing endoscopic sinus surgery were included. The control group was 6 patients with obstructive sleep apnea-hypopnea syndrome. Six patients with chronic rhinosinusitis were enrolled in the study group. Mucosa of uncinate process, ethmoid bulla or maxillary sinus was obtained during endoscopic sinus surgery. All the samples were prepared using standard methods for scanning electron microscopy. Patients' information such as age, gender, symptoms, sinus CT, endoscopic examination, skin prick test were recorded in detail. RESULTS: Standard-preparation scanning electron microscopy displayed denuded epithelium and disarrayed cilia in chronic rhinosinusitis patient's mucosa. In the study group, bacterial biofilms of different morphology were seen in five samples; One sample showed filamentous structure like fungi. Using strict scanning electron microscopy morphologic criteria, 83.3% samples in the study group were found to have micrographic evidence of biofilms. No bacterial biofilms were detected in the control group. CONCLUSIONS: In the patients undergoing surgery for chronic rhinosinusitis, different degree of mucosal injury could be found. Bacteria biofilms of different life stages were demonstrated to be present. No bacterial biofilms were detected in the control group.

[CT evolution of nasal steroid management of chronic rhinosinusitis].

OBJECTIVE: To evaluate the efficacy of topical steroid treatment of nonpolypoid chronic sinusitis. METHODS: Two cohorts of adult and children with nonpolypoid chronic sinusitis were investigated. The first cohort consisted of 11 pediatric patients [mean age, (11.8 +/- 3.2) years] with a mean Lund score of 10.3 +/- 5.7 (x +/- s). The second cohort consisted of 13 adult patients [mean age, (36.7 +/- 11.0) years] with a mean Lund score of 12.2 +/- 5.7. The mean duration of the nasal budesonide (Rhinocort) treatment was (7.5 +/- 3.2) weeks for adult patients (256 microg/d) and (7.0 +/- 3.4) weeks for pediatric patients (128 microg/d). Each Lund score and the patient's assessment of nasal symptoms were evaluated after treatment. RESULTS: The average Lund score was significantly decreased to 6.5 -/+ 7.5 (t = 3.82, P < 0.01) in adult patients and to 2.6 +/- 3.7 (t = 5.08, P < 0.01) in pediatric patients after treatment. Thirty-eight percent of the adult patients and 73% of the pediatric patients were cured on CT images. The patient's self-assessment of efficacy was positively correlated with pretreatment Lund score in adult patients (r = 0.676, P < 0.05), but not so in pediatric patients. CONCLUSIONS: These findings demonstrate that most of patients with nonpolypoid chronic sinus did well with topical steroid treatment. Therefore, surgery was required in few patients.

[Spiral computed tomography analysis of fronto-ethmoidal cells in normal subjects].

OBJECTIVE: The purpose of this study was to determine the prevalence of frontoethmoidal cells in normal Chinese subjects. METHODS: Two hundred and two Chinese subjects without symptoms of frontal sinus disease were undergone spiral computed tomography (CT). The multiplanar reconstruction images were evaluated using a standard triplanar reconstruction protocol on a computer workstation. RESULTS: There were 121 males and 81 females. The mean age was (39.4 +/- 13.5) years. Of all the frontal cells identified in 159 sides (39.4%) of frontal recesses, the prevalence of type I, type II, type III and type cells were 24.3% (98 sides), 6.9% (28 sides), 8.2% (33 sides) and 0% (0 side) respectively. Suprabulbar cell, supraorbital ethmoid cells, and frontal bulbar cell were identified in 148 sides (36.6%) Jian-hu, 22 sides (5.4%), and 36 sides (8.9%) respectively. While the interfrontal septal cells was found in 25 patients (12.4%). The prevalence of agger nasi cell was 94. 1% (380 sides). Two hundred and forty-four uncinate processes (60.4%) had one superior attachment for each uncinate process; the other 160 uncinate processes (39.6%) had two superior attachments for each uncinate process. The single superior attachment of the uncinate process into the surrounding structures was identified to have the following distribution: 53.0% (n=214) to the lamina papyracea, 5.2% (n=21) to the middle turbinate, 2.2% (n=9) to the skull base. Most of the uncinate process' two superior attachments were either into the lamina papyracea and the skull base (27.5%, n=111) or into the lamina papyracea and the middle turbinate (8.7%, n=35). The other 14 uncinate processes (3.5%) superiorly attached to the skull base and the middle turbinate. The prevalence of recessus terminalis was 89.1% (n=360). CONCLUSION: The result demonstrated the normal frontal recess pneumatization patterns in normal Chinese.

The validity of an Internet-based Self-assessment Program for Depression.

The Internet-based Self-assessment Program for Depression (ISPD) has been found to have good test-retest reliability for major depressive disorder (MDD). The purpose of this study was to further examine the validity of the ISPD for MDD. We found sensitivity and specificity of MDD by ISPD to be 81.8% and 72.7% respectively. Internet may play an important role for patients to self-assess their possibility of getting MDD.