Acute Exacerbations Of Chronic Rhinosinusitis Research Articles

Indications for Referral for Pediatric Rhinosinusitis

Rhinosinusitis in children is defined as inflammation of the nose and paranasal sinuses (Fokkens et al. Rhinology. 2012;50:1–12). Pediatric chronic rhinosinusitis (CRS) is relatively uncommon compared to acute rhinosinusitis (ARS) and is characterized by sinus symptoms lasting over 12 weeks despite medical therapy. Pathogenesis of this disease is multifactorial and generally involves an initial insult (usually a viral sinusitis) followed by bacterial seeding and mucosal inflammation. The diagnosis of chronic rhinosinusitis in the pediatric population can be challenging as symptoms can be very similar to common conditions such as allergic rhinitis or adenoiditis. In many cases, objective findings such as inflammation seen on nasal endoscopy or sinus CT scans are necessary to confirm the diagnosis of CRS. The mainstay of treatment of pediatric CRS is medical therapy with surgical therapy reserved for the minority of patients. Standard medical therapy usually includes a combination of nasal corticosteroid sprays, nasal irrigation, and decongestants. Antibiotics are usually reserved for bacterial acute exacerbations of CRS and usually target the most common offending pathogens (Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis). Referral to an otolaryngologist is recommended for children who fail medical therapy, have orbital complications of sinusitis, or require surgery. There are currently many alternate medical treatment options available to physicians; however, data supporting their efficacy is lacking in many cases. Recent studies show that even minimally invasive surgical procedures, such as adenoidectomy and/or balloon sinuplasty can lead to significant symptom improvement. Further, traditional endoscopic sinus surgery offers a safe, highly effective treatment option when necessary.

Immunological profiling in chronic rhinosinusitis with nasal polyps reveals distinct VEGF and GM-CSF signatures during symptomatic exacerbations.

The mechanisms and immune pathways associated with chronic rhinosinusitis (CRS) are not fully understood. Immunological changes during acute exacerbation of CRS may provide valuable clues to the pathogenesis and perpetuation of the disease. To characterize local and systemic immune responses associated with acute worsening of sinonasal symptoms during exacerbation in CRS with nasal polyps (CRSwNP) compared to controls. This was a non-interventional prospective study of individuals with CRSwNP and normal controls. Subjects underwent a baseline visit with collection of nasal secretions, nasal washes, and serum specimens. Within 3days of acute worsening of sinonasal symptoms, subjects underwent a study visit, followed by a post-visit 2weeks later. The sinonasal outcome test-22 (SNOT-22) scores and immunological parameters in the specimens were analysed using a novel, unsupervised learning method and by conventional univariate analysis. Both CRSwNP patients and control subjects showed a significant increase in SNOT-22 scores during acute exacerbation. Increased nasal levels of IL-6, IL-5, and eosinophil major basic protein were observed in CRSwNP patients. A network analysis of serum specimens revealed changes in a set of immunological parameters, which are distinctly associated with CRSwNP but not with controls. In particular, systemic increases in VEGF and GM-CSF levels were notable and were validated by a conventional analysis. CRSwNP patients demonstrate distinct immunological changes locally and systemically during acute exacerbation. Growth factors VEGF and GM-CSF may be involved in the immunopathogenesis of subjects with CRS and nasal polyps experiencing exacerbation.

What rhinologists and allergists should know about the medico-legal implications of antibiotic use: a review of the literature.

Antibiotics are commonly used in the management of both acute rhinosinusitis and acute exacerbations of chronic rhinosinusitis. With their common use, they have become the leading medication for litigation. It is crucial for the provider to be familiar with potential complications and the medico-legal ramifications of their use. The objectives of this review were to outline the existing data of the medico-legal implications of prescribing oral antibiotics. An OVID search of the following terms was performed: antibiotics or antibacterial agents AND medico-legal, malpractice, jurisprudence, or informed consent. This search was then narrowed to English language articles and the titles and abstracts were searched for relevance. An OVID search identified 272 articles. This search was then narrowed, resulting in 13 articles that were relevant and included in the current review. Five articles involved database reviews of litigation associated with medications. Antibiotics were the most common medication associated with litigation. Allergic reaction was the single most common reason for litigation. Lawsuits associated with medications are disproportionately costly and antibiotics are the most common type of medication to result in litigation. Although the use of electronic medical records (EMRs) may decrease the frequency of these lawsuits, it is up to the physician to be familiar with the agents prescribed, their risks, and be vigilant regarding possible reactions.

A randomised, double blind, placebo-controlled, multi-centric parallel arm trial to assess the effects of homoeopathic medicines on chronic rhinosinusitis

Background: Chronic rhinosinusitis (CRS) is one of the most common illnesses interfering with patient's quality of life and work. Observational studies conducted by the Council indicate positive outcome. This protocol has been developed to ascertain the usefulness of homoeopathic intervention in comparison with control group in a randomised control setting. Objectives: Primary objective is to evaluate the changes in TSS (Total Symptoms Score) and SNOT-22 (Sino-nasal Outcome Test-22) within the two groups of the study (Homoeopathy + Placebo). Secondary objective is to evaluate changes in SNOT-22 at end of the trial, changes in Lund and Mackay staging of CT scan, rhinoscopy grading, absolute eosinophil count, global assessment by investigator and patient, and number of acute exacerbations of CRS (for frequency, duration and intensity) as per TSS scale compared to placebo. Methods/Design: This is a randomised double blind, placebo-controlled, multi-centric parallel arm trial of 6 months (three months treatment and three months observation period) with 14 days run-in period. The primary outcome is a composite of the changes in the TSS and SNOT-22 over 3 months from baseline with area under the curve and changes over 3 months in the Sinus Nasal Outcome Test 22 (SNOT-22) from baseline. Prescription shall be made as per the homoeopathic principles. Efficacy data will be analysed in the intention-to-treat population. Discussion: This trial will help to evaluate the efficacy of homoeopathic individualised treatment using LM-potencies versus placebo in patients suffering from CRS as per the homoeopathic dictum.

National burden of antibiotic use for adult rhinosinusitis

National burden of antibiotic use for adult rhinosinusitis

Acute Exacerbation of Chronic Rhinosinusitis (AECRS) with Orbital Complications in an Atrophic Rhinitis Patient: A Mere Co-incidence?

Recurrent Acute Exacerbations of Chronic Rhinosinusitis (AECRS) in a setting of atrophic rhinitis are perplexing clinical situations. While either may act as the primary factor, repeated inflammation in a vessel-poor atrophied tissue is unusual. Progressive mucosal degeneration, vascularity and the effect of bacterial colonization are the factors suggested to play an important role for the pathobiogenesis of the co-existence of the two diseases. Through presentation of a case, a brief attempt has been made here to explore the temporal relationship between rhinosinusitis and atrophic rhinitis; in the process, other noteworthy features of the patient have also been highlighted.

Topical Antimicrobials in the Management of Chronic Rhinosinusitis: A Systematic Review

Chronic rhinosinusitis (CRS) is a common disease that can significantly impact health. The mainstay of medical treatment is topical steroids and oral antibiotics, but little is known about the efficacy of topical antibiotics. The purpose of this study was to identify evidence for the use of topical antibiotics in the treatment of CRS and exacerbations of CRS. Systematic review of literature with a search of the MEDLINE, EMBASE, and CINAHL databases; Cochrane Central Register of Controlled Trials (Third Quarter 2007); and Cochrane Database of Systemic Reviews (3rd Quarter 2007) databases were performed. The dates of search were from December 1, 1949 to September 30, 2007. Fourteen studies that fulfilled the inclusion criteria were identified: seven were controlled trials and of these, five were double blinded and randomized. Only one of the randomized studies showed a positive outcome. Overall, there was low-level corroborative evidence for the use of antibacterials. No definite conclusions could be made regarding the use of antifungals. Currently, there is evidence for the use of nasal irrigation or nebulization rather than delivery by nasal spray. For the antibacterial studies, the highest level of evidence currently exists for studies that have used postsurgical patients and culture-directed therapy. Both stable and acute exacerbations of CRS appear to benefit from topical antimicrobials. Topical antibiotics appear effective in the management of CRS. Given the combination of low-level evidence (level III, with inherent potential confounders of natural progression of disease and placebo effect) and the level IIb evidence being limited to the cystic fibrosis group of patients, topical antibiotics should not be first-line management but may be attempted in patients refractory to the traditional topical steroids and oral antibiotics. Larger and better-designed randomized double-blind placebo-controlled trials are required to more fully evaluate this emerging modality of treatment.

Frequency and Pattern of Immunodeficiency in Patients with Recurrent Acute Rhinosinusitis or Acute Exacerbations of Chronic Rhinosinusitis

Frequency and Pattern of Immunodeficiency in Patients with Recurrent Acute Rhinosinusitis or Acute Exacerbations of Chronic Rhinosinusitis

Concurrent Endoscopic Sinus Surgery and Rhinoplasty

Concerns over increased surgical risk and associated complications have been reported regarding concurrent endoscopic sinus surgery (ESS) and rhinoplasty procedures. The aim of this study was to evaluate the overall safety of these concurrent procedures in our experience. A chart review was performed on 48 consecutive patients undergoing concurrent ESS and rhinoplasty between January 1998 and January 2005 with a mean follow-up of 12 months. The extent of surgical procedures, revisions required, and postoperative complications were documented. Thirty-one (65%) women and 17 (35%) men ranging in age from 16 to 56 years with a mean age of 37 years were included in this study. Forty-five patients (93.7%) underwent a primary rhinoplasty procedure, whereas the other three (6.3%) underwent a revision rhinoplasty. Four patients required minor rhinoplasty revision procedures for a rhinoplasty revision rate of 4/48 or 8.3%. Complications noted in three separate cases included partial nasal obstruction, pain near osteotomy site, and localized infection for a complication rate of 3/48 or 6.3%. In this study, rhinoplasty revisions did not appear to be related to the fact that ESS was performed at the same time as rhinoplasty. In addition, the only complication possibly attributed to a combined approach was a postoperative infection that developed in an insulin-dependent diabetic patient who underwent a rhinoplasty for functional reasons. Consequently, we recommend screening patients with poor wound healing factors in addition to those with acute exacerbations of chronic rhinosinusitis or severe chronic rhinosinusitis before performing concurrent ESS and rhinoplasty. In our experience, complications noted during concurrent ESS and rhinoplasty were minor, indicating the overall safe nature of this combined procedure when performed in appropriate patients.

The Impact of Endoscopic Cultures on Care in Rhinosinusitis

The objectives of this retrospective, observational study were primarily to analyze endoscopically guided culture results (EGCRs) from an office setting in patients with subclassifications of chronic rhinosinusitis (CRS) and to determine the frequency EGCR-altered patient management; and secondarily to determine whether purulent secretions are more likely to be positive for a bacterial pathogen. Consecutive symptomatic patients with nasal secretions not currently on antibiotics were cultured endoscopically. Patients were classified as chronic rhinosinusitis (CRS; n = 41) or acute exacerbation of chronic rhinosinusitis (AECRS; n = 27). Initial therapy was individualized and 32 of 68 (47%) had an antibiotic initiated before availability of the EGCR. Patients were reassessed 2 to 4 days later, and therapy was continued or altered based on clinical course and EGCR. EGCRs were positive in 41 of 68 (60.2%) of all patients. Incidence of positive cultures was not statistically different between CRS (21 of 41 [51%]) and AECRS (20 of 27 [74%]) patients. Initial therapy was changed in 45 of 68 (66%) patients. In 35 of 68 (51.4%), the change was directed by EGCR; in 11 of 77 (14.2%), the change was unsubstantiated by EGCR, and in no cases was an antibiotic initiated inappropriate to EGCR. The frequency of pathogens in the subgroups of CRS and AECRS, respectively, were Staphylococcus aureus (9 of 41 [22%]; 9 of 27 [33%]), acute pathogens (6 of 41 [14.6%], 7 of 27 [25.9%]), and Pseudomonas aeruginosa (5 of 41 [12%], 5 of 27 [18.5%]) and were not statistically different between subgroups. Purulent cultures were not significantly more likely to be Gram stain-positive than nonpurulent cultures (12 of 34 [35%] compared with 6 of 34 [17.6%], respectively; P = .1). Purulent cultures were more likely to be culture-positive (25 of 34 [73.5%]) compared with nonpurulent secretions (17 of 34 [50%]; P < .05). AECRS was significantly more likely to be purulent (21 of 27 cases) compared with CRS (13 of 41 cases, P < .001). EGCR directed a change in therapy in 35 of 68 (51.4%) patients with CRS. The pathogens isolated from CRS and AECRS were similar and predominately S. aureus, acute pathogens, and P. aeruginosa. Purulent secretions are more frequently bacteriologically positive than nonpurulent secretions and more common in AECRS than CRS.

Endoscopically Guided Aerobic Cultures in Postsurgical Patients with Chronic Rhinosinusitis

There is considerable amount of debate in the literature regarding the microbial flora of normal, acutely infected, and chronically infected paranasal sinuses. Few studies have specifically looked at the microbial flora of healthy and infected sinus cavities after functional endoscopic sinus surgery. One hundred thirty-four cultures were studied. All cultures were obtained using a standard technique. The nasal cavities were decongested and anesthetized, and nasal endoscopy was performed. When purulent secretions were identified, specimens of purulent secretions were obtained for incubation. Sensitivities were tested according to microorganisms identified. Empiric therapy generally consisted of afluoroquinolone, amoxicillin/clavulanate, or a later-generation cephalosporin, and adjustment in individual instances when appropriate. Twelve cultures showed no growth, 86 grew a single microorganism, and 35 grew two or more microorganisms for a total of 151 microorganisms identified. The most common microorganisms were Staphylococcus aureus, coagulase-negative staphylococci, and Pseudomonas aeruginosa. Other organisms that were cultured <5% of the time included Streptococcus pneumoniae, Haemophilus influenza, Moraxella catarrhalis, Serratia liquefaciens, Stenotrophomonas (Xanthomonas) maltophilia, alcaligenes, Fusobacterium, Escherichia coli, diphtheroids, Acinetobacter species, Klebsiella species, skin flora, and mixed Gram-negative and Gram-positives. Endoscopically guided aerobic cultures in postsurgical patients with acute exacerbations of chronic rhinosinusitis most commonly grew S. aureus, coagulase-negative staphylococci, and pseudomonal species. These cultures altered antibiotic treatment management decisions in a significant number of cases regardless of patients' clinical characteristics or history of previous culture.

New medical management techniques for acute exacerbations of chronic rhinosinusitis.

In the past 2 years, intranasal nebulized medications have emerged as a widely prescribed treatment for medical management of chronic rhinosinusitis. This represents an innovative and advanced approach to treating acute exacerbations of chronic rhinosinusitis topically. The use of specially formulated medication compounds delivered by unique nebulization equipment is reviewed in the treatment of patients with chronic sinus disease. Scientific data including related upper and lower respiratory literature is included, as well as the important aspects of factors affecting nebulized medication delivery to the sinuses. The benefits, effectiveness, risks, and adverse effects of intranasal nebulized medications are also addressed. A treatment algorithm identifying appropriate use of nebulized medications in the treatment plan for chronic sinusitis patients is then presented in diagrammatic format.

Nebulized Antibiotics for the Treatment of Acute Exacerbations of Chronic Rhinosinusitis

We studied the effectiveness of aerosol delivery of antibiotics to the sinuses via a nebulizer in 41 patients who had chronic, recurrent sinusitis that had persisted despite endoscopic sinus surgery and that had not responded to multiple courses of oral antibiotics. We compared pre- and post-treatment symptom scores in five categories: nasal obstruction, facial pain, pressure, mucopurulent rhinorrhea, and malaise. Following 3 to 6 weeks of treatment, 34 patients (82.9%) experienced either an excellent or good response to treatment. Side effects were infrequent, mild, and transient. We conclude that nebulized antibiotics should be considered for all patients with chronic sinusitis who have undergone functional endoscopic sinus surgery and who have failed to respond to oral antibiotics or who do not tolerate them.