Endoscopic sinus surgery in patients infected with HIV.

OBJECTIVES: To be able to plan appropriate surgical treatment for patients with HIV infection who have sinusitis refractory to medical therapy. DESIGN: We retrospectively reviewed the charts of 186 patients with HIV who required surgical treatment for sinusitis between 1987 and 1998. One hundred six charts provided the necessary information and an adequate follow-up to be included in the study. Collected data included preoperative and postoperative symptoms, radiographic staging, CD4 count at the time of surgery when available, and type and extent of surgery. RESULTS: Surgical treatment evolved over the 12 years from limited surgery to standard endoscopic sinus surgery (ESS). Eighteen patients had invasive fungal disease or complications of sinusitis requiring radical surgery. Thirty-six patients were treated with minimal procedures to address involved sinuses only. These patients were treated between 1987 and 1991. Recurrent disease or further complications occurred in 80.6% of the patients in this group. Since 1992, 52 patients were treated with standard ESS following the same indications for HIV- patients. This group had an improvement of symptoms in 75% of the cases, a rate comparable to the success rate in HIV- patients. CONCLUSIONS: HIV+ patients undergoing standard ESS enjoy a satisfactory success rate. HIV+ patients with surgical indication for endoscopic sinus surgery should be treated as non-HIV+ patients. Apparently, low CD4 count (< 100) does not serve as a contraindication for definitive surgery.

Frontal sinus surgery: endoscopic technique and preliminary results.

Endoscopic frontal sinus surgery, once the last frontier in the evolution of endoscopic sinus surgery, is considered difficult, risky to the patient, and likely to result in a high failure rate. We clarify the surgical anatomy for frontal sinus surgery that, based on a review of our data, provides safe and predictable access to the frontal sinus. We studied 200 consecutive patients with respect to indications, endoscopic and radiographic findings, results, and complications. The study will describe the technique in detail, including the following points: 1) computed tomography identification of the superior attachment of the uncinate process; 2) complete removal of the uncinate process, including its superior attachments, by using the microdebrider; 3) removal of the agger nasi cell, if present; and 4) verification of an open frontal sinus by a transillumination or image-guided system. Postoperative assessment of patients' symptoms and the confirmation of a patent frontal sinus by office endoscopy and transillumination indicated a 90% patency for short-term follow-up (average 12.2 months). There were no major complications. Postoperative complications included frontal recess stenosis, polypoid mucosa occluding the frontal recess, and middle turbinate lateralization. All of these situations may lead to recurrence of infection and symptoms. In-depth understanding of anatomic variations of the uncinate process and precise surgical removal of its superior attachments provide surgical access to the frontal sinus that is based on the natural ostia and is, therefore, more likely to remain patent.

Epidemiology of Haemophilus influenzae type B disease among Navajo Indians.

During a 7-year period ending June 30, 1980, the annual incidence of all Haemophilus influenzae type b disease among Navajo children less than 5 years old was 214 per 100,000, and that of H. influenzae meningitis was 152 per 100,000. Eighty-one percent of H. influenzae meningitis occurred in children 12 months of age or younger, and 64 percent clustered in children ages 4 through 8 months. Meningitis accounted for 70 percent of all invasive disease. No epiglottitis was observed. The epidemiology is similar to that in Yupik Eskimos, who have an even higher rate of H. influenzae type b disease than Navajos but are a much smaller population. Mortality from H. influenzae meningitis was low (4 percent) among Navajo children, but neurological sequelae were observed in at least 16 percent of the survivors. This high rate of sequelae may be due in part to clustering of cases in infancy. Among normal Navajo neonates, 79 percent had maternal capsular type b antibody titers greater than or equal to 0.15 micrograms per deciliter (microgram per dl), and the whole group had a geometric mean titer of 0.51 micrograms per dl. By age 4 months, when meningitis cases became frequent, only 14 percent of Navajo infants had antibody titers greater than or equal to 0.15 micrograms per dl. Twelve of 67 asymptomatic infants (18 percent), each monitored every 2 months, had H. influenzae type b or a cross-reacting organism isolated from the pharynx on at least one occasion before they were 9 months old. Active immunization would be theoretically indicated in this population with high H.influenzae type b exposure and disease, but a vaccine would have to confer substantial immunity in very young infants.