Efficacy of targeted medical therapy in chronic rhinosinusitis, and predictors of failure.

BACKGROUND: No standardized medical therapy for chronic rhinosinusitis (CRS) is universally accepted. Success of medical therapy is reportedly 50% to 88%, but studies differ in inclusion criteria, medications, duration of therapy, and defining "success." The objectives of this study were to determine efficacy of a standardized targeted medical therapy (TMT) regimen in CRS and to analyze factors associated with failure of therapy. METHODS: Retrospective analysis of prospectively collected data was performed. CRS was diagnosed based on CRS Taskforce guidelines. TMT was defined as a minimum 4-week treatment with oral antibiotics, oral steroids, topical nasal steroids, topical nasal decongestant rotation, and saline nasal douching. "Failure" was defined as relapse/persistence of signs/symptoms or need for surgery. One hundred forty-five patients that received TMT, with a minimum 2-month follow-up, were identified. The results of therapy were reviewed to determine efficacy and analyze factors associated with failure. RESULTS: Seventy-four patients (51.03%) were successfully treated. Failures included 26 patients (17.8%) with only partial improvement and 45 (31.03%) who underwent surgery. Only history of facial pressure/pain (p = 0.049), presence of mucosal inflammation (p = 0.013), and higher endoscopic severity grade (p = 0.011) were associated with failure of TMT. CONCLUSIONS: TMT was unequivocally successful in 51% of patients. Failures included 31% who underwent surgery and 18% with partial benefit. Surgery was avoided in 69%. Facial pressure/pain, mucosal inflammation, and higher endoscopic severity grade were associated with failure of medical therapy.

Nasal amphotericin irrigation in chronic rhinosinusitis.

PURPOSE OF REVIEW: To review the literature on the use of amphotericin irrigation for the treatment of chronic rhinosinusitis. RECENT FINDINGS: Although the etiology of acute rhinosinusitis is usually bacterial in nature, the exact etiology of chronic rhinosinusitis is unclear. Recent literature reports pointed to fungal colonization as a likely pathogenesis. It was hypothesized that a nonallergic eosinophilic immunoglobulin response to these fungi by the host was the cause of the symptoms, not a fungal invasion into the mucosa. The paper reviews the most recent articles investigating the use of amphotericin irrigation, as well as sprays and oral medications, of the nasal and sinus mucosa in patients with chronic rhinosinusitis. SUMMARY: The use of amphotericin for patients with chronic rhinosinusitis is not substantiated by the majority of publications. Although some studies found improvement on radiographic images, the symptoms of the disorder were not improved even with fungal eradication. Further studies need to be carried out to determine if changes in dosage, treatment time or route of administration could improve results.

Chronic rhinosinusitis and psoriasis: do mutually exclusive systemic Th1 and Th2 disease patterns exist?

CONCLUSION: Our results support the theory that chronic rhinosinusitis (CRS) is a systemic Th alteration, the relevance of which is discussed in detail. OBJECTIVE: CRS imposes a heavy burden on society; however, a reliable CRS therapy has not been found. Developing a better understanding of this pathology will help us in our search for more effective therapies. One question, which is rarely examined, is the possibility of CRS existing as a systemic immune alteration in Th response. Thus, the goal of this study was to examine the occurrence of CRS, a Th2 pathology, with Th1 pathologies such as psoriasis. PATIENTS AND METHODS: This study was performed via a retrospective electronic query of our medical center in regards to patients coded with the respective diagnosis. RESULTS: Analysis of the data showed that occurrence of CRS rarely coincided with the occurrence of psoriasis and other such Th1 pathologies.

Contemporary management of tumors of the salivary glands.

Management of tumors of the salivary glands requires a detailed understanding of the anatomy and pathologic processes affecting these glands. Salivary glands give rise to benign and malignant neoplasms and are affected by a variety of systemic diseases. CT remains the most common primary imaging study; magnetic resonance imaging and ultrasound have also been explored. Fine-needle aspiration as part of the diagnostic evaluation remains controversial due to varying sensitivities and specificities. Surgical extirpation is the primary modality for management of tumors of the salivary glands. Parotid surgery carries a potentially high morbidity with possible unsightly scarring and facial nerve damage. Nontraditional surgical approaches and instrumentation, as well as facial nerve monitoring, can decrease the morbidity of a parotidectomy. In specific instances, malignant salivary gland tumors warrant cervical lymphadenectomy. Adjuvant therapy is primarily accomplished with radiation. Chemotherapy continues to play a palliative role in salivary gland malignancies; however, newer trials are investigating the therapeutic role of chemotherapy.

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.

Mandible fracture patterns: a suburban trauma center experience.

PURPOSE: Mandible fractures are among the most frequently seen injuries in the trauma center setting. Recent shifts in the mechanism and age distribution of patients sustaining these injuries are well documented. This study attempts to define current, predictable patterns of fracture based on patient characteristics and mechanism of injury. MATERIAL AND METHODS: The charts of 134 patients with 225 mandible fractures treated over a 7-year period by the Otolaryngology-Head and Neck Surgery, Plastic and Reconstructive Surgery and Oral-Maxillofacial Surgery services, our institution, were retrospectively reviewed. Patients were categorized based on age, mechanism of fracture, and anatomic location of fracture. Multivariate analysis of data was performed to determine significant relationships among groups. RESULTS: Violent crimes such as assault and gunshot wounds accounted for the majority of fractures (50%) in this study, with motor vehicle accidents less likely (29%). Overall, parasymphyseal fractures were most frequent (35%), whereas angle and body fractures were also common (15% and 21%, respectively). There was a statistically significant association of motor vehicle accidents with parasymphyseal fractures (45%), and gunshot wounds with body fractures (36%), whereas assault victims had a higher than predicted frequency of angle fractures (27%) and fewer parasymphyseal fractures (19%). Patients aged 17 to 30 were more likely to suffer from gunshot wounds, whereas older adults (age 31-50) were more likely to be assault victims. Patients over age 50 suffered fractures from falls at a higher than expected rate. Although children and young adults seemed to suffer more parasymphyseal fractures and older adults body fractures, these correlations failed to show statistical significance. Parasymphyseal fractures were most frequently associated with fractures at other sites within the mandible, ipsilateral body fractures being the most common. CONCLUSIONS: Updated data on the association of patient age and mechanism of injury with fracture pattern can guide treating physicians in anticipating and diagnosing traumatic mandible fractures.