Long-term low-dose antibiotics in recalcitrant chronic rhinosinusitis: a retrospective analysis.

INTRODUCTION: In recalcitrant Chronic RhinoSinusitis (CRS) treatment with intranasal corticosteroids, short-term antibiotics and even sinus surgery is frequently insufficient. Long-term low-dose administration of antibiotics has been suggested as a treatment option in these patients. We analysed the outpatient clinic population treated with different long-term low-dose antibiotics at the AMC Amsterdam. PATIENTS AND METHODS: Eligible patients, who were treated with trimethoprim-sulfamethoxazole or macrolides, were retrospectively identified from our outpatient clinic in 2009. The two main outcome measures were sinonasal complaints and nasal endoscopic findings. A 5-point grading scale was used to score the results compared with the pre-treatment situation. This was measured at several time-points during, and after the antibiotic course, and at the end of the follow-up term. RESULTS: Seventy-six patients were included, 53 per cent had asthma and all of them had undergone sinus surgery. Seventy-eight per cent showed improvement of the symptoms, and 84 per cent demonstrated improvement of the sinonasal mucosa at the end of the course. No significant difference was found between the trimethoprim-sulfamethoxazole and macrolide group. DISCUSSION: Long-term low-dose treatment with antibiotics seems to improve CRS symptoms and the appearance of the sinonasal mucosa on nasal endoscopy. However, at this stage, strong conclusions are immature because no placebo-group has been included. Despite increasing use of long-term low-dose treatment of recalcitrant CRS in referral centres, hard clinical evidence is lacking. More research is urgently required.

Lack of efficacy of long-term, low-dose azithromycin in chronic rhinosinusitis: a randomized controlled trial.

BACKGROUND: In persistent chronic rhinosinusitis (CRS), conventional treatment is often insufficient. Long-term, low-dose administration of macrolides has been suggested as a treatment option. The MACS (Macrolides in chronic rhinosinusitis) study is a randomized placebo-controlled trial evaluating the efficacy of azithromycin (AZM) in CRS. METHODS: We describe a group of patients with recalcitrant CRS with and without nasal polyps unresponsive to optimal medical and (in 92% also) surgical treatment. Patients were treated with AZM or placebo. AZM was given for 3 days at 500 mg during the first week, followed by 500 mg per week for the next 11 weeks. Patients were monitored until 3 months post-therapy. The assessments included Sino-Nasal Outcome Test-22 (SNOT-22), a Patient Response Rating Scale, Visual Analogue Scale (VAS), Short Form-36 (SF-36), rigid nasal endoscopy, peak nasal inspiratory flow (PNIF), Sniffin' Sticks smell tests and endoscopically guided middle meatus cultures. RESULTS: Sixty patients with a median age of 49 years were included. Fifty per cent had asthma and 58% had undergone revision sinus surgery. In the SNOT-22, Patient Response Rating Scale, VAS scores and SF-36, no significant difference between the AZM and the placebo groups was demonstrated. Nasal endoscopic findings, PNIF results, smell tests and microbiology showed no relevant significant differences between the groups either. CONCLUSION: At the investigated dose of AZM over 3 months, no significant benefit was found over placebo. Possible reasons could be disease severity in the investigated group, under-dosage of AZM and under-powering of the study. Therefore, more research is urgently required.

Osteitic bone in recalcitrant chronic rhinosinusitis.

INTRODUCTION: There is increasing interest in the underlying bone of the paranasal sinuses as an important player in recalcitrant Chronic Rhinosinusitis. Close inspection of CT scans often reveals areas of increased bone density and irregular thickening of the sinus walls. This osteitic bone could at least partly explain, why inflammation of the mucosa persists. METHODS: We searched PubMed for all relevant studies, using the following text words: chronic rhinosinusitis, sinusitis, bone, osteitis, osteomyelitis, histology, and treatment. Cited references of retrieved articles were also examined. RESULTS: Background, available data, potential diagnostic options, treatment implications, and suggestions for future research are discussed. CONCLUSION: Osteitis is associated with CRS, however its role in the pathogenic process is not well defined. More research is needed.

Long terms results of Draf type III (modified endoscopic Lothrop) frontal sinus drainage procedure in 122 patients: a single centre experience.

OBJECTIVES: To assess the effectiveness and factors associated with restenosis after Draf type III (Endoscopic Modified Lothrop) frontal sinus drainage procedure. DESIGN: Retrospective analysis of prospectively collected data. PATIENTS: A hundred and twenty two consecutive patients undergoing Draf III procedure for recalcitrant chronic frontal rhinosinusitis (CRS) (71%), frontal sinus mucocoele (15%), benign frontal sinus tumours (9%) and cystic fibrosis with severe CRS (5%) were followed up for an average of 33 months. OUTCOME MEASURES: Symptom burden (Visual Analogue Scale and Rhinosinusitis Outcome Measure), patency of neo-ostium and revision surgery. RESULTS: At the end of follow up, ninety percent of patients had a patent neo-ostium, while 88% were either clinically better or completely asymptomatic. Thirty-nine patients required endoscopic revision surgery and 9 eventually underwent frontal sinus obliteration. Sixty percent of revision operations were performed during the first two years. RSOM showed a significant improvement in both general and nasal symptoms while on a VAS, headache improved significantly. The only factor weakly associated with re-stenosis was the presence of allergy. There were no major complications during any of the procedures. CONCLUSION: Draf III Procedure is safe and effective for patients who have failed conventional frontal sinus procedures and a valid alternative to frontal sinus obliteration. Although the revision rate may appear to be quite significant, it can often be performed as an outpatient procedure and needs to be balanced against the reduced morbidity and the ease of follow-up.

Fever is not a symptom of chronic rhinosinusitis.

INTRODUCTION: In the chronic rhinosinusitis (CRS) definition of the RhinoSinusitis Task Force (RSTF) of the American Academy of Otolaryngology-Head and Neck Surgery, fever is one of the minor symptoms. In the EP3OS definition, fever is not mentioned as a contributing factor. The main aim of this study was to evaluate the role of fever in CRS. PATIENTS AND METHODS: Patients with CRS, scheduled for surgery were compared with a control group consisting of patients without CRS, suffering from esthetic complaints or obstruction of the nose. Temperature prior to surgery was measured and analyzed. RESULTS: In both groups, hundred patients were included. In the CRS group the mean temperature was 36.94 degrees C, with a maximum of 37.8 degrees C. The control group revealed a mean temperature of 36.87 degrees C. Analysis demonstrated no significant difference between the mean temperatures of the CRS patients and the controls (p = 0.306). Additional analysis, correcting for possible confounders, did not reveal significant differences between both groups either. DISCUSSION: There have been several attempts to define CRS in the past, but an all including definition or classification system for this disorder does not currently exist. Fever is a factor under discussion. We found no significant difference between the preoperative body temperature in CRS patients and controls. These results suggest that fever is not a relevant symptom in CRS.

Nebulized bacitracin/colimycin: a treatment option in recalcitrant chronic rhinosinusitis with Staphylococcus aureus? A double-blind, randomized, placebo-controlled, cross-over pilot study.

INTRODUCTION: Despite optimal medical therapy and endoscopic sinus surgery there still remains a group of unfortunate patients suffering from exacerbations of recalcitrant chronic sinusitis. We have performed a pilot study in order to determine whether nebulized topical antibiotic therapy improves sinusitis symptoms more than saline-based placebo in patients with recalcitrant chronic rhinosinusitis. PATIENTS AND METHODS: A randomized, placebo-controlled, double-blind, cross-over pilot study was conducted in 14 patients with recalcitrant CRS. Nasal irrigation with bacitracin/colimycin or placebo using the RhinoFlow nebulizer twice daily was administered in combination with oral levofloxacin. Severity of a diversity of symptoms was measured using the VAS score, a Disease-Specific Symptom Score and the SF-36 questionnaire. Nasal endoscopic findings were also assessed. RESULTS: For most VAS items and Disease-Specific Symptom Scores, a reduction in severity of symptoms was noted in both the bacitracin/colimycin and the placebo group. No significant difference was found between the 2 arms (bacitracin/colimycin vs. placebo). Most SF-36 items improved, compared with the situation before treatment in both groups. However no significant difference was found between the verum and placebo arm. Endoscopic findings did not reveal significant differences when comparing the 2 treatments. CONCLUSION AND DISCUSSION: The outcome of this study suggests a beneficial effect of nebulizing the nose with saline. This study again shows that adding antibiotics to local saline is not effective. Although the placebo-controlled studies looking at the effect of local antibiotics are all small they all point to the same direction: no effect. Definite conclusions however need a large randomized, multicenter study.

Optimal site for throat culture: tonsillar surface versus posterior pharyngeal wall.

To determine the optimal site of throat culture for the detection of potential pathogens by comparing culture results from the tonsillar surface and the posterior pharyngeal wall in children selected for adenotonsillectomy and in children without upper respiratory disease. Cotton culture swabs were taken from the tonsillar surface and the posterior pharyngeal wall of 50 children selected for adenotonsillectomy for symptoms of recurrent tonsillitis and/or adenotonsillar hypertrophy and of 50 children without upper respiratory disease. Potential respiratory pathogens were identified. In the overall group (n = 100), positive culture results were found in 67 posterior pharyngeal wall samples and 47 tonsillar surface samples (P = 0.001). Haemophilus influenzae was the most frequently isolated micro-organism both in the posterior pharyngeal wall and the tonsillar surface samples; 55 and 35%, respectively (P = 0.001). Group A beta-haemolytic streptococci were found in the samples of the posterior pharyngeal wall and the tonsillar surface in 17 and 13%, respectively (P = 0.2). When dealing with patients with sore throat, sampling both tonsillar surfaces is enough for the detection of group A beta-haemolytic streptococci. When detection of other bacteria is also important, such as for research purposes, the posterior pharyngeal wall should be sampled as well.