Extended endoscopic approaches to the maxillary sinus.

OBJECTIVES: Treatment of inflammatory and neoplastic disease in the maxillary sinus, pterygopalatine and infratemporal fossae requires appropriate surgical exposure. As modern rhinology evolves, so do the techniques available. This paper reviews extended endoscopic approaches to the maxillary sinus and the evidence supporting each technique. METHODS: A literature search of the Ovid Medline and PubMed databases was performed using appropriate key words relating to endoscopic approaches to the maxillary sinus. RESULTS: Mega-antrostomy and medial maxillectomy have a role in the surgical treatment of refractory inflammatory disease and sinonasal neoplasms. The pre-lacrimal fossa approach provides excellent access but can be limited because of anatomical variations. Both the transseptal and endoscopic Denker's approaches were reviewed; these appear to be associated with morbidity, without any significant increase in exposure over the afore-described approaches. CONCLUSION: A range of extended endoscopic approaches to the maxillary sinus exist, each with its own anatomical limitations and potential complications.

Small-colony variants and phenotype switching of intracellular Staphylococcus aureus in chronic rhinosinusitis.

BACKGROUND: Chronic rhinosinusitis (CRS) has been linked to the gram-positive bacteria Staphylococcus aureus (S. aureus) in its biofilm or intracellular forms. Recent evidence suggests that S. aureus also exists in a small-colony variant (SCV) form as a mechanism of altering its virulence capabilities. The aim of this study was to investigate the presence of SCVs in sinonasal mucosa of CRS patients and whether the phenomenon of phenotype switching can be applied to intracellular epithelial infections. METHODS: Sinonasal specimens were examined for the presence of intramucosal S. aureus and characterized to the strain level. An airway epithelial cell culture infection model was utilized to investigate whether bacteria were capable of alterations in virulence phenotype. RESULTS: Intramucosal organisms harvested from sinonasal biopsies demonstrate phenotypic growth patterns and lack of coagulase activity consistent with SCVs. Intracellular infection of airway epithelial cell cultures with S. aureus led to decreased secretion of enterotoxins and phenotypic growth alterations consistent with SCVs. CONCLUSIONS: Regulation of S. aureus virulence factors is a dynamic process, and exposure to the intracellular environment appears to provide the necessary conditions to enable these alterations in an attempt for the bacterium to survive and persist within host tissues. Further work is required to ascertain whether SCVs in CRS hold a clinically relevant pathogenic role in recalcitrant disease.

Is nasal steroid spray bottle contamination a potential issue in chronic rhinosinusitis?

BACKGROUND: Intranasal steroids are the first line of treatment for chronic rhinosinusitis. Although contamination of adjunctive devices (e.g. irrigation bottles) has been much investigated, little is known about nasal contamination of the metered-dose spray bottles used to deliver intranasal steroids, and the potential influence on disease chronicity. METHODS: Twenty-five prospectively recruited patients with stable chronic rhinosinusitis underwent microbiological analysis of their nasal vestibule and middle meatus and also of their steroid bottle tip and contents. Additionally, bottle tips were inoculated in vitro with Staphylococcus aureus and various sterilisation techniques tested. RESULTS: For 18 of the 25 (72 per cent) patients, both nasal and bottle tip swabs grew either Staphylococcus aureus or coagulase-negative staphylococci. Staphylococcus aureus was cultured from 7 of the 25 (28 per cent) patients, and 5 of these 7 had concomitant bacterial growth from both nose and steroid bottle. Thus, the cross-contamination rate was 71 per cent for Staphylococcus aureus infected patients and 20 per cent overall. Sterilisation was effective with boiling water, ethanol wipes and microwaving, but not with cold water or dishwashing liquid. CONCLUSION: Nasal steroid spray bottle tips can become contaminated with sinonasal cavity bacteria. Simple sterilisation methods can eliminate this contamination. Patient education on this matter should be emphasised.

Inflammasome gene expression alterations in Staphylococcus aureus biofilm-associated chronic rhinosinusitis.

BACKGROUND: The role of inflammasomes in chronic inflammation has been the subject of intense research in recent years. Chronic rhinosinusitis (CRS), a persistent inflammatory disease, continues to be investigated hoping that a clearer pathophysiologic description will guide discovery of future treatment modalities. This study investigates the role of inflammasome complexes in CRS patients with Staphylococcus aureus biofilm infection, a key culprit associated with disease severity and recalcitrance. METHODOLOGY: Sinonasal tissue samples were collected from CRS patients with (P+) and without (P-) polyps and controls. S. aureus biofilm status was obtained using fluorescence in situ hybridization and classified as biofilm positive (B+) or negative (B-). RNA was analysed using a Human Inflammasome PCR array, profiling the expression of 84 genes involved in inflammasome function. RESULTS: Sixteen samples were obtained: 5 B+P+, 5 B-P- and 6 controls. Comparing B+P+ vs. controls showed the greatest number of differentially expressed genes. In particular, Absent in Melanoma 2 (AIM2) was consistently and significantly up-regulated in the B+P+ vs. B-P- and controls. In contrast, when comparing the B-P- vs. controls, no genes showed significant changes. CONCLUSION: Our results indicate the involvement of inflammasome complexes and their signalling pathways in CRS patients with polyps and S. aureus biofilms. In particular, AIM2, activated by intracellular double-stranded DNA, is up-regulated in this group, implying that S. aureus may play a role in intracellular triggering of the inflammasome response. Studies with further patient stratification and assessing corresponding protein expression are needed to further characterize the role of inflammasomes in CRS.

The "M" shaped microflap for treatment of complex Reinke's Space Oedema of the vocal cords.

Reinke's Space Oedema is characterized by a subepithelial collection of fluid and pseudo-myxomatous tissue within the lamina propria superficialis of the vocal cord. We have observed, in a number of cases, the phenomenon of bilobular and/or centrally located Reinke's Space Oedema. Bilobular oedema occurs when the sub-epithelial oedema is organised as a double bulge of the vocal cord in the superoinferior plane due to adhesions or sulcus at the free edge of the vocal cord. Herewith, a simple, yet easily reproducible, modified technique is presented of an "M" shaped microflap for the treatment of bilobular and also centrally located Reinke's Space Oedema of the vocal cords, using Carbon Dioxide laser and/or cold micro instruments allowing maintenance of an appropriate amount of lamina propria superficialis and easy coverage of the potentially exposed part of the ligament. Our technique involves removal of the upper bulge of the affected vocal cord with Carbon Dioxide laser or cold instruments, followed by an "M" shaped remodelling of the microflap so that the mucosa can be effectively draped over the lamina propria superficialis and vocal ligament.