A pilot prospective prevalence study of chronic rhinosinusitis associated with inflammatory bowel disease.

Background: Inflammatory bowel disease (IBD) is characterized by chronic inflammation of the gastrointestinal tract. Extra-intestinal manifestations such as pulmonary diseases have been reported. Chronic rhinosinusitis (CRS), an inflammatory condition of the sinonasal mucosa, has been associated with several lung diseases. Given the relationship between lung and intestinal pathologies, and lung and sinus pathologies, we aimed to determine the prevalence of IBD among CRS patients. Methods: Pilot prevalence study. Ninety-two CRS patients were screened for IBD symptoms from October 2018 to January 2020. Patient-reported disease symptoms and overall quality of life were evaluated using the Sino-Nasal Outcome Test 22 (SNOT-22), Short Inflammatory Bowel Disease Questionnaire (SIBDQ), and EuroQol 5 Dimension 5 Level (EQ-5D-5L) questionnaires. The Modified Lund-Kennedy (MLK) endoscopic and Lund-Mackay (LM) grading systems were used to confirm CRS diagnoses. Individuals who reported subjective symptoms of IBD were referred to a gastroenterologist clinic for further diagnostics. Results: Twenty of the 92 (20.2%, 95% CI: 12.6%-29.8%) CRS patients reported symptoms of IBD and four individuals (4.26%, 95% CI: 1.17%-10.50%) were subsequently diagnosed with IBD. Compared to patients without IBD symptoms (n = 72), those with symptoms (n = 20) reported significantly worse SNOT-22 (P = 0.002), SIBDQ (P < 0.05), and EQ-5D-3L (P = 0.0063) scores. However, these patients did not exhibit significantly different MLK (P = 0.81) or LM (P = 0.04) scores. Conclusion: The prevalence of IBD may be elevated among individuals with CRS relative to the general Canadian population. This pilot study suggests that CRS with IBD is associated with lower quality of life. Further cross-sectional studies with larger sample sizes are required.

A Clinical Decision Analysis for Use of Antibiotic Prophylaxis for Nonabsorbable Nasal Packing.

OBJECTIVE: Nonabsorbable nasal packing is often placed for the treatment of epistaxis or after sinonasal or skull base surgery. Antibiotics are often prescribed to prevent toxic shock syndrome (TSS), a rare, potentially fatal occurrence. However, the risk of TSS must be balanced against the major risk of antibiotic use, specifically Clostridium difficile colitis (CDC). The purpose of this study is to evaluate in terms of cost-effectiveness whether antibiotics should be prescribed when nasal packing is placed. STUDY DESIGN: A clinical decision analysis was performed using a Markov model to evaluate whether antibiotics should be given. SETTING: Patients with nonabsorbable nasal packing placed. METHODS: Utility scores, probabilities, and costs were obtained from the literature. We assess the cost-effectiveness of antibiotic use when the risk of community-acquired CDC is balanced against the risk of TSS from nasal packing. Sensitivity analysis was performed for assumptions used in the model. RESULTS: The incremental cost-effectiveness ratio for antibiotic use was 334,493 US dollars (USD)/quality-adjusted life year (QALY). Probabilistic sensitivity analysis showed that not prescribing antibiotics was cost-effective in 98.0% of iterations at a willingness to pay of 50,000 USD/QALY. Sensitivity analysis showed that when the risk of CDC from antibiotics was greater than 910/100,000 or when the incidence of TSS after nasal packing was less than 49/100,000 cases, the decision to withhold antibiotics was cost-effective. CONCLUSIONS: Routine antibiotic prophylaxis in the setting of nasal packing is not cost-effective and should be reconsidered. Even if antibiotics are assumed to prevent TSS, the risk of complications from antibiotic use is of greater consequence. LEVEL OF EVIDENCE: 3a.

Experiencia de 10 años en pacientes operados por rinosinusitis fúngica invasiva aguda / 10-year experience in patients operated for acute invasive fungal rinosinusitis

INTRODUCCIÓN: La rinosinusitis fúngica invasiva aguda (RSFIA) es una enfermedad poco frecuente, de alta mortalidad. Se presenta principalmente en pacientes inmunocomprometidos con múltiples comorbilidades, lo que dificulta su manejo. El objetivo de este trabajo es describir una cohorte de pacientes operados por RSFIA, sus características clínicas y mortalidad, los agentes etiológicos y el rendimiento de los métodos de diagnóstico. MATERIAL Y MÉTODO: Estudio prospectivo no concurrente de pacientes operados por RSFIA entre el 2005 y 2015 en nuestro centro. RESULTADOS: Se incluyeron 32 pacientes, 62,5% (20/32) hombres, con una edad promedio de 39,4 años (16-65 años). La mortalidad global fue del 71,9%, correspondiendo un 46,9% a mortalidad en agudo y un 25% a tardía. Las neoplasias hematológicas fueron la enfermedad de base más frecuente, correspondiendo al 84,4% (27/32) de los casos, seguida de la diabetes mellitus en un 9,4% (3/32). El 62,5% (20/32) de los pacientes presentó neutropenia al diagnóstico, y un 80% (16/20) de ellos, neutropenia febril. El síntoma más frecuente fue la fiebre en un 65,6% (21/32), luego dolor facial o cefalea en un 53,1% (17/32). Se identificó Aspergillus en el 37,5% (12/32), seguido por Rhizopus en el 31,3% (10/32). No se encontró asociación entre las variables estudiadas y un mayor riesgo de mortalidad. CONCLUSIONES: La RSFIA es una enfermedad agresiva con una alta mortalidad, siendo fundamental el diagnóstico oportuno. Es necesario optimizar los criterios de sospecha para un diagnóstico precoz que permita mejorar el pronóstico

INTRODUCTION: Acute invasive fungal rhinosinusitis (AIFRS) is rare but has high mortality. It is more frequent in immunocompromised patients with multiple comorbidities, which make their management more difficult. The aim of this study is to describe a cohort of patients operated due to AIFRS, their clinical characteristics, mortality, aetiological agent and efficacy of diagnostic tests. MATERIAL AND METHOD: Non-concurrent prospective study of patients with AIFRS who were operated between 2005 and 2015 in our centre. RESULTS: Thirty-two patients were included, 62.5% (20/32) men, with an average age of 39.4 years (16-65 years). Overall mortality was 71.9%; acute mortality 46.9% and late mortality 25%. Haematological malignancies were the most common underlying disease, present in 84.4% (27/32) of cases, followed by diabetes mellitus in 9.4% (3/32). On diagnosis, 62.5% (20/32) of patients were neutropenic, 80% (16/20) of them with febrile neutropenia. Fever was the most frequent symptom, present in 65.6% (21/32) of patients, followed by facial pain or headache in 53.1% (17/32). Aspergillus was identified in 37.5% (12/32) of cases and Rhizopus in 31.3% (10/32). There was no association between the analysed variables and increased risk of mortality. CONCLUSIONS: AIFRS is an aggressive disease with a high mortality rate, therefore a timely diagnosis is fundamental. It is necessary to optimise suspicion criteria for an early diagnosis in order to improve the prognosis

10-year experience in patients operated for acute invasive fungal rhinosinusitis. / Experiencia de 10 años en pacientes operados por rinosinusitis fúngica invasiva aguda.

INTRODUCTION: Acute invasive fungal rhinosinusitis (AIFRS) is rare but has high mortality. It is more frequent in immunocompromised patients with multiple comorbidities, which make their management more difficult. The aim of this study is to describe a cohort of patients operated due to AIFRS, their clinical characteristics, mortality, aetiological agent and efficacy of diagnostic tests. MATERIAL AND METHOD: Non-concurrent prospective study of patients with AIFRS who were operated between 2005 and 2015 in our centre. RESULTS: Thirty-two patients were included, 62.5% (20/32) men, with an average age of 39.4 years (16-65 years). Overall mortality was 71.9%; acute mortality 46.9% and late mortality 25%. Haematological malignancies were the most common underlying disease, present in 84.4% (27/32) of cases, followed by diabetes mellitus in 9.4% (3/32). On diagnosis, 62.5% (20/32) of patients were neutropenic, 80% (16/20) of them with febrile neutropenia. Fever was the most frequent symptom, present in 65.6% (21/32) of patients, followed by facial pain or headache in 53.1% (17/32). Aspergillus was identified in 37.5% (12/32) of cases and Rhizopus in 31.3% (10/32). There was no association between the analysed variables and increased risk of mortality. CONCLUSIONS: AIFRS is an aggressive disease with a high mortality rate, therefore a timely diagnosis is fundamental. It is necessary to optimise suspicion criteria for an early diagnosis in order to improve the prognosis.

The effect of topical epinephrine 1:1000 with and without infiltration of 1% lidocaine with epinephrine 1:100,000 on endoscopic surgical field visualization: a double-blind randomized controlled study.

BACKGROUND: The objective of this study is to determine whether the infiltration of 1% lidocaine with 1:100,000 epinephrine in addition to topical application of 1:1000 epinephrine significantly improves surgical field grading scale score over topical 1:1000 epinephrine alone. METHODS: A prospective, double-blind, randomized, controlled study was performed of 40 patients undergoing bilateral endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS). Patients were enrolled and randomly assigned to receive infiltration with 1% lidocaine with 1:100,000 epinephrine on 1 side of the nasal cavity vs plain saline on the other side in preparation for ESS. Both groups received topical application of 1:1000 epinephrine. Surgical videos were recorded and Wormald surgical field grading scale was assigned by 2 blinded reviewers. The number of extra 1:1000 epinephrine pledgets used during the surgery, estimated blood loss, and surgical duration were also recorded. RESULTS: There were no statistically significant differences in Wormald surgical field grading scale, number of extra pledgets used, or estimated blood loss between the nasal cavity side infiltrated with 1% lidocaine with 1:100,000 epinephrine in comparison to infiltration with saline. The side infiltrated with 1% lidocaine with 1:100,000 epinephrine had a reduced operative time compared to the side infiltrated with saline (p = 0.002). There were no differences in postoperative bleeding from questionnaire completed by patient at the first postoperative visit. CONCLUSION: Addition of infiltration of 1% lidocaine with epinephrine 1:100,000 to topical application of epinephrine 1:1000 for preparation of ESS does not significantly improve surgical field of view compared to topical epinephrine alone.

Microcurrent technology for rapid relief of sinus pain: a randomized, placebo-controlled, double-blinded clinical trial.

BACKGROUND: Transcutaneous electrical nerve stimulation has proven to be effective in alleviating chronic pain from facial myalgias. We evaluated the efficacy of a novel handheld microcurrent-emitting device in short-term, office-based treatment of patients with sinus pain. This device, which is U.S. Food and Drug Administration (FDA)-cleared, detects and treats regions corresponding to nerve fibers. METHODS: Randomized, double-blinded, placebo-controlled trial. Seventy-one participants with facial pain attributed to self-reported nasal/sinus disease were recruited from a tertiary rhinologic practice and the surrounding community and randomly assigned to either office-based use of an active (n = 38) or placebo (n = 33) microcurrent emitter. The study device was repetitively applied by each patient to the bilateral periorbital areas for 5 minutes. A visual analogue scale (VAS) for pain severity was administered before, and 10 minutes after, treatment. RESULTS: Active microcurrent-treated patients had a reduction in mean pain score from 5.63 pretreatment to 3.97 posttreatment (mean difference, 1.66; 95% confidence interval [CI], 1.20 to 2.12). Patients using the sham device also reported sinus pain reductions (mean difference, 0.91; 95% CI, 0.61 to 1.21). However, the active device demonstrated a significantly greater reduction in pain compared to sham (0.75-point difference, p = 0.007). Notably, 23.7% of patients using the active device had a reduction of 3 or more points by VAS compared to 0% of sham device patients (p = 0.003). One minor occurrence of transient facial skin erythema was noted. CONCLUSION: This trial suggests that treatment of rhinologic facial pain using this noninvasive microcurrent device is safe and effective in providing rapid relief of nasal/sinus pain. Additional studies with longer term follow-up are warranted.

Comparison of outcomes following culture-directed vs non-culture-directed antibiotics in treatment of acute exacerbations of chronic rhinosinusitis.

BACKGROUND: Acute exacerbations in patients with chronic rhinosinusitis (CRS) are often treated with courses of systemic antibiotics. Poor correlation between microbiologic culture results and the sinus microbiome in CRS has caused increased debate as to the relevance of culture-directed antibiotics. There is currently sparse data comparing outcomes of culture-directed antibiotics vs non-culture-directed antibiotics for treatment of CRS. METHODS: This work reports a retrospective review. A total of 946 CRS patients treated with antibiotics were examined; 122 CRS patients with acute exacerbations were treated with culture-directed (n = 61) vs empiric (n = 61) antibiotics. Lund-Kennedy (LK) and 22-item Sino-Nasal Outcome Test (SNOT-22) scores were compared pretreatment and posttreatment, with short-term (<1 month) and long-term (1-6 months) follow-up. Patient demographics, comorbidities, and prior surgical history were collected. RESULTS: Both groups had similar pretreatment SNOT-22 scores (p = 0.25) while the culture group had higher baseline LK endoscopy scores (p < 0.01). All data were adjusted for pertinent comorbidities, surgical history, co-therapeutics, and baseline scores. There was no difference in improvement in culture-directed and empirically treated groups in the short-term (p = 0.77) and long-term (p = 0.58) for minimal clinically important difference (MCID) of SNOT-22 and no difference in the short-term for LK scores (p = 0.11), but there was significantly more improvement in long-term LK scores in the culture-directed group (p = 0.01). CONCLUSION: Culture-directed therapy improves long-term endoscopy scores but does not yield an advantage in improving short-term endoscopy scores, nor in improving short-term and long-term quality of life scores in CRS patients. A prospective study is necessary to examine the relevance of routine microbiologic cultures in CRS patients.

Frequency of Acute Otitis Media in Children Under 24 Months of Age Before and After the Introduction of the 10-valent Pneumococcal Conjugate Vaccine Into the National Immunization Program in Chile.

BACKGROUND: Streptococcus pneumoniae is the leading cause of acute otitis media (AOM). Ten-valent pneumococcal conjugated vaccine (PCV-10) was introduced to the Chilean National Immunization Program (NIP) in 2011. The aim of this study was to estimate the frequency of AOM in children <24 months of age attending the emergency department (ED) of Hospital Sótero del Río (HSR) 4 years before and 4 years after the introduction of PCV-10 in the Chilean NIP. METHODS: Register-based nested case-control study. Cases (n = 1907) were all children <24 months of age with a clinical diagnosis discharge of AOM at the ED of HSR, and controls (n = 244,334) were all other children <24 months of age attended at the same ED in the same time period, with any other discharge diagnosis. The data were obtained through HSR Statistical Service. RESULTS: In the study period, there was a mean of 30,695 children <24 months managed each year at the ED of HSR. The percentage with AOM in the prevaccine period was 0.94% and in the postvaccine period was 0.62%, respectively (P = 0.026). Exposure to the PCV-10 was associated with a decreased risk to develop AOM in children <24 months, with an odds ratio of 0.659 (95% confidence interval: 0.60-0.72). CONCLUSIONS: Our study showed a significant decrease in the percentage and risk of AOM in children <24 months of age who visited the ED of HSR after implementation of PCV-10 in the NIP in Chile.

Profile of inflammatory mediators in tonsils of patients with periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome.

The purpose of this study was to analyze the levels of white blood cells and profile of proinflammatory Th1, Th2, Th17, and T regulatory tissue cytokines in the tonsils of periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) patients to contribute to the pathophysiological understanding of the PFAPA syndrome. A cohort of PFAPA patients who had tonsillectomy during 2010 and 2011 was included and compared to control patients who had tonsillectomy for tonsillar hypertrophy. White blood cell counts were measured during flares in PFAPA patients and before tonsillectomy in the control group. Cytokine gene expression was analyzed in removed tonsils by real-time PCR. Nine PFAPA patients with a median age of 5.3 years (1.7-8 years) and 17 hypertrophic tonsils of patients with a median age of 4.8 years (2.3-8.4 years) participated in this study. Tonsillectomy was performed during afebrile period between PFAPA flares. Three of the nine patients had recurrent episodes of aphthous stomatitis without fever after tonsillectomy. Leukocyte and neutrophil counts were higher in PFAPA patients compared to controls (p < 0.05). Eosinophil counts were lower in PFAPA patients during flares (p = 0.006). IL-1ß, TNF-α, TGF-ß, IL-17, and IFN-γ levels were similar in the tonsils of patients and controls. IL-4 gene expression in the tonsils was lower in PFAPA patients compared to those of the controls (p = 0.04). Proinflammatory, effector, and regulatory cytokine gene expression in tonsil tissue of PFAPA children removed in a noninflammatory asymptomatic interval and in control patients were similar. However, IL-4 cytokine gene expression in the tonsils and peripheral blood eosinophils were lower in the PFAPA patients suggesting a potential pathogenesis pathway based on an inhibition of Th2 responses.

Operative technique with rapid recovery for ingrown nails with granulation tissue formation in childhood.

BACKGROUND: Ingrown toenail is a common disease that causes pain and discomfort. There are conservative and surgical treatments, but many have the drawbacks of recurrence and long recovery time. OBJECTIVE: To analyze for the first time the results of a technique called nail splinting using a flexible tube secured using a suture (FTSS) performed on a series of patients with ingrown toenails. METHODS AND MATERIALS: A retrospective descriptive study of 71 pediatric patients operated on using the FTSS technique between 2001 and 2009 was performed. The data were collected using medical record review or telephone survey. The main outcomes were high percentage of success and shorter recovery time than with partial matrix excision. RESULTS: Sixty-two patients (87.3%) were cured using a single procedure, with an average follow-up of 13.1 months. Recurrence occurred in nine patients (12.6%); three required the classic technique with resection of the matrix and nail bed plastic surgery, and in 6, FTSS was repeated with good results. CONCLUSION: Flexible tube secured using a suture has a lower recurrence rate than matricectomy. Additional advantages are the speed with which complaints can be monitored and quick return to school because recovery may be as short as 48 hours.

The European lactase persistence genotype determines the lactase persistence state and correlates with gastrointestinal symptoms in the Hispanic and Amerindian Chilean population: a case-control and population-based study.

BACKGROUND: The lactase persistent (LP) or lactase non-persistent (LNP) state in European adults is genetically determined by a single nucleotide polymorphism (SNP) located 13.9 kb upstream of the lactase (LCT) gene, known as LCT C>T(-13910) (rs4988235). The LNP condition leads to an inability to digest the milk sugar lactose leading to gastrointestinal symptoms and can affect nutrient and calcium intake in certain populations. OBJECTIVES: The authors studied a group of 51 Chilean patients to assess whether this SNP influences the LP/LNP state in this population, and determined the prevalence of LCT C>T(-13910) genotypes in a representative sample of 216 Hispanics and 43 Amerindians with correlation to digestive symptoms. DESIGN: Case-control study done in Chilean patients with clinical suspicion of LNP that were assessed using clinical survey, hydrogen breath test (HBT) and SNP genotyping. The population sample of Hispanics and Amerindians was assessed by clinical survey and SNP genotyping. RESULTS: Of the 51 patients with clinical suspicion of LNP, 29 were HBT-positive. The CC genotype (LNP) was present in 89.7% of the patients with positive HBT and in only 4.7% of those with negative HBT. The prevalence of the CC genotype was 56.9% in the Hispanic population and 88.3% in Amerindians, and was associated with a higher self-reported clinical intolerance to ingestion of dairy products. CONCLUSION: The LP/LNP state is determined by the LCT C>T(-13910) variant in Chileans. This variant predicts digestive symptoms associated with the ingestion of lactose and is a good tool for the diagnosis of primary adult hypolactasia. The LCT T(-13910) allele is rare in the Amerindian population and is suggestive of European ancestry in this contemporary population.