Cases Of Chronic Rhinosinusitis Research Articles

Involvement of B2 receptor in bradykinin-induced proliferation and proinflammatory effects in human nasal mucosa-derived fibroblasts isolated from chronic rhinosinusitis patients.

Chronic rhinosinusitis (CRS) is a chronic inflammatory disease of the sinonasal mucosa either accompanied by polyp formation (CRSwNP) or without polyps (CRSsNP). CRSsNP accounts for the majority of CRS cases and is characterized by fibrosis and neutrophilic inflammation. However, the pathogenesis of CRS, especially CRSsNP, remains unclear. Immunohistochemistry of CRSsNP specimens in the present study showed that the submucosa, perivascular areas, and the mucous glands were abundant in fibroblasts. Therefore, we investigated the effects bradykinin (BK), an autacoid known to participate in inflammation, on human CRSsNP nasal mucosa-derived fibroblasts (NMDFs). BK increased CXCL1 and -8 secretion and mRNA expression with EC50 ranging from 0.15~0.35 μM. Moreover, BK enhanced cell proliferation and upregulated the expressions of proinflammatory molecules, including cell adhesion molecules (CAMs) and cyclooxygenase (COX)-1 and -2. These functionally caused an increase in monocyte adhesion to fibroblast monolayer. Using pharmacological intervention and BKR siRNA knockdown, we demonstrated that the BK-induced CXCL chemokine release, cell proliferation and COX and CAM expressions were mainly through the B2 receptor (B2R). Accordingly, the B2R was preferentially expressed in the NMDFs than B1R. The B2R was highly expressed in the CRSsNP than the control specimens, while the B1R and kininogen (KNG)/BK expression slightly increased in the CRSsNP mucosa. Collectively, we report here for the first time that fibroblasts, KNG/BK, and BKRs are overexpressed in CRSsNP mucosa and BK upregulates chemokine expression, proliferation, and proinflammatory molecule expression in NMDFs via B2R activation, which lead to a functional increase in monocyte-fibroblast interaction. Our findings reveal a critical role of fibroblast, KNG/BK, and BKRs in the development of CRSsNP.

Epidemiology of chronic fungal rhinosinusitis in rural India.

A descriptive epidemiological study of fungal rhinosinusitis (FRS) was conducted in rural north India in the form of house-to-house survey of villages of two districts each of Punjab and Haryana provinces using a clinical case definition of chronic rhinosinusitis (CRS). The suspected cases were investigated further in the laboratory to confirm FRS. Air and environment were sampled in different seasons to find Aspergillus spore count. The prevalence of chronic FRS cases was at 0.11% of the population and Aspergillus flavus was the predominant (97.6%) agent of all types of chronic FRS. The chronic FRS patients were classified as allergic FRS 41 (56.1%), chronic granulomatous FRS 13 (17.8%), eosinophilic FRS 11 (15.0%), fungal ball 7 (9.5%) and chronic invasive FRS 1 (1.3%). Aspergillus spores were present in large numbers (~20%) in air with significantly higher counts of A. flavus during winter months in the wheat-thrashing areas of Punjab as compared to Haryana (P = 0.0079). The present study identified high prevalence (27.5% of CRS cases) of chronic FRS cases in rural north India and its possible association with wheat harvesting seasons.

Surgical management of rhinosinusitis in endoscopic-endonasal skull-base surgery.

Endoscopic-endonasal skull base surgery (ESBS) provides an important approach to select pathologies. There remains a paucity of data, however, regarding morbidity in patients undergoing ESBS with comorbid acute rhinosinusitis (ARS), a fungal ball (FB), or chronic rhinosinusitis (CRS). A retrospective database review between January 2008 and January 2013 identified 35 patients with concurrent skull-base pathology and refractory ARS, FB, CRS, and CRS with nasal polyposis (CRSP) who underwent endoscopic sinus surgery (ESS) and ESBS. Two of 35 (5.7%) had an FB, 3 of 35 (8.6%) had ARS, 19 of 35 (54.2%) had CRSP, and 11 of 35 (31.4%) had CRS. Five of 35 (14.3%) were staged procedures whereas 30 of 35 (85.7%) underwent concurrent ESS and ESBS. Four patients (80%) who were staged carried diagnoses of an FB and ARS. Two patients in the concurrent group required revision ESS for recurrent polyposis. There were no cases of intraorbital or intracranial infectious complications. Management of the paranasal sinuses is paramount to maintain healthy sinonasal function in patients undergoing ESBS. In our experience, most cases of CRS and CRSP can be surgically managed at the time of ESBS without increased risk of intracranial infection. Patients with ARS at the time of surgery or an FB should be staged to avoid postoperative ESBS morbidity.

A cross-sectional evaluation of the correlation between disease severity and quality of life in chronic rhinosinusitis patients in Nigeria.

Quality of Life (QoL) studies are increasingly being used as the primary outcome measure in chronic rhinosinusitis (CRS) globally. However, little is known about QoL and the interplay of identifiable factors on QoL in CRS in sub-Saharan Africa. This study investigated the correlation between disease severity and QoL in chronic rhinosinusitis patients. A total of 147 adults with subjective severity rating of CRS were studied. Participants were assessed using designed questionnaire, Individual Rhinosinusitis Symptom Severity Score Assessment (IRSSSA) and Rhinosinusitis Disability Index (RSDI) questionnaires to elicit socio-demographic/clinical profile, CRS symptom severity and QoL, respectively. The mean age of the participants was 36.86 ± 11.91 years. The mean severity score of all 147 CRS cases was 3.8 ± 1.13. The majority of participants (N = 80; 54.4 %) had moderate disease. The RSDI mean scores for the participants for overall HRQoL were 40.6 ± 19.8. (Median = 40; Range = 77), for physical domain 15.2 ± 7.7, functional domain 12.1 ± 6.4 and emotional domain 13.2 ± 8.2. The trend of association between the disease severity scores and the overall HRQoL on Pearson linear correlation indicates a positive linear association of worsening overall HRQoL with increasing disease severity (R = 0.83; P < 0.0001). The severity of CRS impacted negatively on the HRQoL. All domains were significantly affected by the disease severity particularly the physical domain. Patients adjudged severity of their disease and its' impact on their quality of life should be considered in the determination of the line of their management which could include psychosocial intervention.

Sinonasal Outcomes Test‐22 as a Tool to Identify Chronic Rhinosinusitis among Adults with Cystic Fibrosis

Objectives: (1) Investigate the ability of a sinus-specific health-related quality of life questionnaire (HRQoL) to distinguish clinically significant chronic rhinosinusitis (CRS) among adults with cystic fibrosis (CF). (2) Determine an appropriate cutoff score on the Sinonasal Outcomes Test-22 (SNOT-22) with sufficient test sensitivity and specificity, to assist caregivers in identifying adults with CF who may warrant specialist referral and treatment. Methods: Participants were enrolled at an adult-specific CF clinic in a tertiary academic hospital in Vancouver, Canada. Subjects completed the SNOT-22 followed by endoscopic assessment by otolaryngologists. The Canadian Clinical Practice Guidelines for Chronic Rhinosinusitis were used to confirm diagnosis of CRS. Results: To date, 52 of 80 individuals with a confirmed diagnosis of CF have participated in this study. Thirty-nine (75.0%) individuals were identified with CRS, 12 (30.8%) of whom presented with nasal polyposis. Aggregate SNOT-22 scores were significantly higher among individuals with CRS compared to non-CRS counterparts (39.4 ± 20.0 vs 22.7 ± 8.7, P = .007, 95% confidence interval [CI] for mean difference: 4.7, 28.7). A SNOT-22 score &gt;26 was found to have a test sensitivity of 74.4% and specificity of 66.7% for diagnosis of CRS (AUC = 0.77, P &lt; .01). Using SNOT-22 scores related to rhinological symptoms increased the likelihood ratio of a positive test when compared to aggregate scores (8.3 vs 2.2, respectively). Conclusions: The SNOT-22 significantly discriminates between CF adults with and CF adults without CRS. Using rhinological symptom scores increases the likelihood of detecting true CRS cases. The use of this questionnaire may assist specialists in identifying individuals who have clinically significant CRS, warranting specialist referral and treatment.

A Study of Adherence to the AAO-HNS “Clinical Practice Guideline: Adult Sinusitis”

A retrospective study was conducted to determine if physicians in otolaryngology practice adhered to the clinical practice guideline for adult sinusitis that had been issued by the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) 3 years earlier. We analyzed data obtained from the charts of 90 adults who had presented to an otolaryngology outpatient department with a diagnosis of chronic rhinosinusitis (CRS), acute bacterial rhinosinusitis (ABRS), or acute viral rhinosinusitis (AVRS); there were 76 cases of CRS, 11 cases of ABRS, and 3 cases of AVRS. Our goal was to ascertain how closely the treating physician had adhered to the AAO-HNS recommendations with respect to diagnosis, treatment, and prevention of these diseases. The study group was made up of 10 otolaryngologists. We evaluated 7 clinical practice metrics for CRS, 7 metrics for ABRS, and 3 for AVRS. We found that individual physician adherence rates for cases of CRS ranged from 0 to 100%; average scores for the 7 metrics ranged from 4 to 88%. For cases of ABRS, adherence scores ranged from 0 to 100%; average scores for the 7 metrics ranged from 0 to 41%. For AVRS, the rate of adherence for all 3 metrics was 0%. This study revealed wide variations in adherence to the AAO-HNS guideline, but overall adherence was generally poor. Adherence appeared to be worse for the acute types of rhinosinusitis than for chronic rhinosinusitis. In view of these findings, a worksheet was developed that clinicians could use to improve compliance with the guidelines.

Burkholderia cepacia complex isolation in non-polypoid chronic rhinosinusitis

PurposeBurkholderia cepacia complex (Bcc) infections of the head and neck have been infrequently reported in immunocompetent patients, while their association with cystic fibrosis is quite well known. One of the main problems associated with Bcc is their intrinsic resistance to most clinically-available antimicrobials. Bcc has already been isolated in sinonasal polyposis, while here we report for the first time on its isolation in patients with chronic rhinosinusitis (CRS) but no nasal polyposis. Materials and methodsThirty-four consecutive surgically-treated CRS patients without cystic fibrosis were recruited. ResultsBcc was isolated in 4 cases of CRS without polyposis, and in another case in sinonasal polyposis. All tested Bcc strains isolated in non-polypotic CRS were resistant to ciprofloxacin, amikacin, ertapenem, amoxicillin/clavulanate, cefotaxime, and gentamicin. ConclusionsThe novel finding of Bcc species in CRS without polyposis as well suggests that the mechanism by which these bacteria adhere to the epithelium of the upper respiratory tract may be important in the host’s colonization.

Genetic Variation in Genes Encoding Airway Epithelial Potassium Channels Is Associated with Chronic Rhinosinusitis in a Pediatric Population

BackgroundApical potassium channels regulate ion transport in airway epithelial cells and influence air surface liquid (ASL) hydration and mucociliary clearance (MCC). We sought to identify whether genetic variation within genes encoding airway potassium channels is associated with chronic rhinosinusitis (CRS).MethodsSingle nucleotide polymorphism (SNP) genotypes for selected potassium channels were derived from data generated on the Illumnia HumanHap550 BeadChip or Illumina Human610-Quad BeadChip for 828 unrelated individuals diagnosed with CRS and 5,083 unrelated healthy controls from the Children's Hospital of Philadelphia (CHOP). Statistical analysis was performed with set-based tests using PLINK, and corrected for multiple testing.ResultsSet-based case control analysis revealed the gene KCNMA1 was associated with CRS in our Caucasian subset of the cohort (598 CRS cases and 3,489 controls; p = 0.022, based on 10,000 permutations). In addition there was borderline evidence that the gene KCNQ5 (p = 0.0704) was associated with the trait in our African American subset of the cohort (230 CRS cases and 1,594 controls). In addition to the top significant SNPs rs2917454 and rs6907229, imputation analysis uncovered additional genetic variants in KCNMA1 and in KCNQ5 that were associated with CRS.ConclusionsWe have implicated two airway epithelial potassium channels as novel susceptibility loci in contributing to the pathogenesis of CRS.

Accuracy of Phenotyping Chronic Rhinosinusitis in the Electronic Health Record

Chronic rhinosinusitis (CRS) is prevalent, morbid, and poorly understood. Extraction of electronic health record (EHR) data of patients with CRS may facilitate research on CRS. However, the accuracy of using structured billing codes for EHR-driven phenotyping of CRS is unknown. We sought to accurately identify CRS cases and controls using EHR data and to determine the accuracy of structured billing codes for identifying patients with CRS. We developed and validated distinct algorithms to identify patients with CRS and controls using International Classification of Diseases, Ninth Revision (ICD-9) and Current Procedural Terminology codes. We used blinded clinician chart review as the reference standard to evaluate algorithm and billing code accuracy. Our initial control algorithm achieved a control positive predictive value (PPV) of 100% (i.e., negative predictive value of 100% for CRS). Our initial algorithm for CRS cases relied exclusively on billing codes and had a low case PPV (54%). Notably, ICD-9 code 471.x was associated with a case PPV of 85%, whereas the case PPV of ICD-9 code 473.x was only 34%. After multiple algorithm iterations, we increased the case PPV of our final algorithm to 91% by adding several requirements, e.g., that ICD-9 codes occur with 1 or more evaluations by a CRS specialist to enhance availability of objective clinical data for accurately phenotyping CRS. These algorithms are an important first step to identify patients with CRS, and may facilitate EHR-based research on CRS pathogenesis, morbidity, and management. Exclusive use of coded data for phenotyping CRS has limited accuracy, especially because CRS symptomatology overlaps with that of other illnesses. Incorporating natural language processing (e.g., to evaluate results of nasal endoscopy or sinus computed tomography) into future work may increase algorithm accuracy and identify patients whose disease status may not be ascertained by only using billing codes.

One airway: Biomarkers of protection from upper and lower airway injury after World Trade Center exposure

Firefighters exposed to World Trade Center (WTC) dust have developed chronic rhinosinusitis (CRS) and abnormal forced expiratory volume in 1s(FEV1). Overlapping but distinct immune responses may be responsible for the clinical manifestations of upper and lower airway injury. We investigated whether a panel of inflammatory cytokines, either associated or not associated with WTC-LI, can predict future chronic rhinosinusitis disease and its severity. Serum obtained within six months of 9/11/2001 from 179 WTC exposed firefighters presenting for subspecialty evaluation prior to 3/2008 was assayed for 39 cytokines. The main outcomes were medically managed CRS (N=62) and more severe CRS cases requiring sinus surgery (N=14). We tested biomarker-CRS severity association using ordinal logistic regression analysis. Increasing serum IL-6, IL-8, GRO and neutrophil concentration reduced the risk of CRS progression. Conversely, increasing TNF-α increased the risk of progression. In a multivariable model adjusted for exposure intensity, increasing IL-6, TNF-α and neutrophil concentration remained significant predictors of progression. Elevated IL-6 levels and neutrophil counts also reduced the risk of abnormal FEV1 but in contrast to CRS, increased TNF-α did not increase the risk of abnormal FEV1. Our study demonstrates both independent and overlapping biomarker associations with upper and lower respiratory injury, and suggests that the innate immune response may play a protective role against CRS and abnormal lung function in those with WTC exposure.

Surgical Treatment of Nasal Polyposis: A Comparison between Cutting Forceps and Microdebrider

Nasal polyposis (NP) is defined as a specific form of chronic rhinosinusitis (CRS), characterized by bilateral and multifocal polyps. Functional endoscopic sinus surgery represents the gold standard therapy when medical treatment fails. The availability of different tools raises the question of which one provides significant advances in technique and surgical outcome. This study considered the outcome of the surgical treatment of NP in relation to several comorbidities and the surgical device used: the microdebrider versus the Blakesley traditional forceps. Other studies compared the two instruments but did not evaluate the clinical relevance of history of comorbidities such as asthma, allergy, and eosinophilia. A prospective randomized single-blind study was designed to analyze 311 cases of bilateral CRS with NP. Each patient served as his/her own control, meaning that one side was operated on using the Blakesley forceps and the opposite side using the microdebrider. The follow-up period was 13.3 ± 1.2 months. The Blakesley forceps caused a significantly lower NP recurrence rate than the microdebrider (p < 0.001), which was more effective in preventing synechia formation (p < 0.05). Only asthma was significantly associated with a higher recurrence rate, without being influenced by the instrument used (p < 0.001). The manual instrument allowed for a significantly lower recurrence incidence but yielded a higher rate of synechia formation compared with the microdebrider. Only asthma was significantly associated with a poorer clinical outcome, and gender, age, allergy, and eosinophilia did not affect the surgical prognosis.

The occurrence of molds in patients with chronic sinusitis

Chronic rhinosinusitis (CRS) is a common inflammatory condition of nasal and paranasal sinus mucosa. Although pathogenic bacteria were postulated as main etiological factor responsible for most cases of CRS, the involvement of molds was recently proved in some cases. The aim of the study was to conduct mycological analysis of material obtained from patients operated on due to chronic sinusitis. The study included 107 patients, 45 women and 62 men. During the surgery, a fragment of mucosa from the region of the ethmoid bulla was obtained as microbiological characteristics of this material closely resemble those of sinus mucosa. In addition, maxillary sinus lavage was obtained. The control group comprised patients without chronic sinusitis. The dithiothreitol solution method was used for the lavage examination. The tissue material (mucosal fragment from the region of the ethmoid bulla) was incubated in 2% liquid Sabouraud medium for 24 h. The material was inoculated onto culture media. The presence of molds was detected in 67% of examined samples. Overall, 41 species belonging to 12 genera were isolated. The most frequently detected genera included Penicillium spp. (46%) and Aspergillus spp. (16%). In addition, Cladosporium spp. (11%), Fusarium spp. (7%), Acremonium spp. (4%), Eurotium spp. (4%), Alternaria spp. (2%), Chaetomium spp. (1%), Geotrichum spp. (1%), Verticillium spp. (1%), Rhizopus spp. (1%), and some unidentified colonies (5%) were isolated. Penicillium crustosum, Penicillium citrinum, Aspergillus niger, Cladosporium cladosporioides, and Fusarium verticillioides were the most prevalent species.

National burden of antibiotic use for adult rhinosinusitis

National burden of antibiotic use for adult rhinosinusitis

Incidence and associated premorbid diagnoses of patients with chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a prevalent condition with underexplored risk factors. We sought to determine CRS incidence and evaluate associations with a range of premorbid medical conditions for chronic rhinosinusitis without nasal polyps (CRSsNP) and chronic rhinosinusitis with nasal polyps (CRSwNP) using real-world clinical practice data. Electronic health records data from 446,480 Geisinger Clinic primary care patients were used for a retrospective longitudinal cohort study for data from 2001-2010. By using logistic regression, newly diagnosed CRS cases between 2007 and 2009 were compared with frequency-matched control subjects on premorbid factors in the immediate (0-6 months), intermediate (7-24 months), and entire observed timeframes before diagnosis. The average incidence of CRS was 83 ± 13 CRSwNP cases per 100,000 person-years and 1048 ± 78 CRSsNP cases per 100,000 person-years. Between 2007 and 2009, 595 patients with incident CRSwNP and 7523 patients with incident CRSsNP were identified and compared with 8118 control subjects. Compared with control subjects and patients with CRSsNP, patients with CRSwNP were older and more likely to be male. Before diagnosis, patients with CRS had a higher prevalence of acute rhinosinusitis, allergic rhinitis, chronic rhinitis, asthma, gastroesophageal reflux disease, adenotonsillitis, sleep apnea, anxiety, and headaches (all P < .001). Patients with CRSsNP had a higher premorbid prevalence of infections of the upper and lower airway, skin/soft tissue, and urinary tract (all P < .001). In the immediate and intermediate timeframes analyzed, patients with CRS had more outpatient encounters and antibiotic prescriptions (P < .001), but guideline-recommended diagnostic testing was performed in a minority of cases. Patients who are given a diagnosis of CRS have a higher premorbid prevalence of anxiety, headaches, gastroesophageal reflux disease, sleep apnea, and infections of the respiratory system and some nonrespiratory sites, which results in higher antibiotic, corticosteroid, and health care use. The use of guideline-recommended diagnostic testing for confirmation of CRS remains poor.

Some Polymorphisms in Epstein-Barr Virus–induced Gene 3 Modify the Risk for Chronic Rhinosinusitis

Forkhead box protein 3 (FOXP3), a transcription factor required for development and function of regulatory T cell, and Epstein-Barr virus-induced gene 3 (EBI3), a downstream target of FOXP3, may be important in the development of chronic rhinosinusitis (CRS) with or without sinonasal polyposis (CRSwNP and CRSsNP, respectively). Our objective was therefore to examine the presence of any associations between specific single nucleotide polymorphisms (SNPs) in/around the FOXP3 and EBI3 genes and risk for CRS in Chinese subjects. A population-based case-control association analysis was performed. DNA extracted from peripheral blood leukocytes from 667 subjects with CRS (360 CRSwNP and 306 CRSsNP) and 330 healthy controls was assessed for SNPs selected and complemented with tagging SNPs. A total of seven SNPs (4 in FOXP3 and 3 in EBI3 genes) were genotyped and genetic association tests were performed. In the single-locus analyses of CRS risk, the allele frequencies of rs428253 (p = 0.0191) in EBI3 gene and rs2232365 (p = 0.0307) and rs3761548 (p = 0.0221) in FOXP3 gene were significantly different between the CRS cases and the controls. Furthermore, genotype association analysis showed a significant protective effect only between EBI3_rs428253 (CG/CC; p = 0.029) and CRS after adjustment. Similarly, stratified analysis of CRS risk on category showed rs428253 of the EBI3 gene to play a protective role among both CRSwNP (CG/CC; p = 0.002) and CRSsNP (GG/CC; p = 0.023) subjects. Haplotype analysis of the FOXP3 gene region further indicated that CRS risk was higher in individuals carrying the haplotype GG in rs2294018-rs2232365 block, compared with wild-type AG haplotype, and AG in rs3761548-4824747 block, compared with wild-type CG haplotype. The findings of this study suggest that SNPs in FOXP3 and EBI3 genes modify the risk for development of CRS.

Associations between obesity and inflammatory sinonasal disorders

Determine whether adult obesity is associated with chronic rhinosinusitis (CRS) and/or allergic rhinitis (AR). Cross-sectional analysis of medical panel survey. The Medical Expenditure Panel Survey, a large-scale household-based survey of health care utilization in the United States (2008 and 2010) was examined, identifying adult cases of CRS and AR. The presence or absence of obesity (body mass index ≥ 30 kg/m(2) ) was determined. Adjusting for age, sex, race, geographic region, insurance coverage, and Charlson Comorbidity Index, odds ratios for the presence of CRS and/or AR in the presence of obesity were determined. The relations between body mass index as a linear variable and the presence of CRS and AR were determined. A total of 17.6 ± 0.6 million adults reported AR (7.7% ± 0.3%) and 13.0 ± 0.5 million reported CRS (5.7% ± 0.2%; weighted estimates). Additionally, 64.9 ± 1.4 million adults (29.0% ± 0.4%) were classified as obese based on body mass index. The adjusted odds ratio for AR when obesity was present was 1.22 (P < .001, 95% confidence interval = 1.12-1.33). The adjusted odds ratio for CRS when obesity was present was 1.31 (P < .001, 95% confidence interval = 1.18-1.45). Increasing body mass index as a continuous variable was significantly associated with the presence of both AR (odds ratio = 1.023, P < .001) and CRS (odds ratio = 1.022, P < .001). The current data demonstrate an increased prevalence of adult obesity associated with both AR and CRS.

Topical therapies in the management of chronic rhinosinusitis: an evidence‐based review with recommendations

Topical therapies have become an integral component in the management plan for chronic rhinosinusitis (CRS). Several topical therapy strategies have been evaluated, but a formal comprehensive evaluation of the evidence has never been performed. The purpose of this article is to provide an evidence-based approach for the utilization of topical therapies in the management of CRS. A systematic review of the literature was performed and the guidelines for development of an evidence-based review with recommendations were followed. Study inclusion criteria were: adult population >18 years old; chronic rhinosinusitis (CRS) based on published diagnostic criteria; and clearly defined primary clinical end-point. We focused on reporting higher-quality studies (level 2b or higher), but reported on lower-level studies if the topic contained insufficient evidence. We excluded drug-eluting spacer and stent therapy from this review. This review identified and evaluated the literature on 5 topical therapy strategies for CRS: saline irrigation, topical steroid, topical antibiotic, topical antifungal, and topical alternatives (surfactant, manuka honey, and xylitol irrigations). Based on the available evidence, sinonasal saline irrigation and standard topical nasal steroid therapy are recommended in the topical treatment of CRS. Nonstandard (off-label) topical sinonasal steroid therapies can be an option for managing CRS. The evidence recommends against the use of topical antifungal therapy and topical antibiotic therapy delivered using nebulized and spray techniques in routine cases of CRS. There is insufficient clinical research to provide recommendations for alternative therapies or topical antibiotic therapy delivered using other delivery methods (eg, irrigations).

Methicillin‐resistant Staphylococcus aureus sinusitis in nonhospitalized patients: A systematic review of prevalence and treatment outcomes

Methicillin-resistant Staphylococcus aureus (MRSA) has been isolated from patients with acute rhinosinusitis (ARS) and chronic rhinosinusitis (CRS), although the exact prevalence is unknown. Similarly, the optimal treatment regimen for MRSA sinusitis has not been determined. The aim of this study was to summarize the existing data on prevalence and treatment outcomes for MRSA sinusitis in nonhospitalized patients. A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. MEDLINE, Embase, and Cochrane databases were queried for English-language studies published between 1942 and 2012. Studies were excluded that did not provide quantitative data on the prevalence or treatment of ARS or CRS with MRSA-positive cultures. An itemized assessment of the risk of bias was conducted for each included study. Of 409 studies identified during systematic review, 12 studies met the criteria for analysis. The level of evidence and freedom from bias of these studies were generally low. The prevalence of MRSA among all culture isolates ranged from 0% to 15.9% for ARS and 1.8% to 20.7% for CRS. Six studies reported quantitative treatment outcomes using variable measures, in which resolution of infection ranged from 58.3% to 100%. The treatment regimens were heterogeneous and included single- and multiple-agent therapy with oral, topical, and parental antibiotics. MRSA-positive cultures are found in a small but significant number of cases of ARS and CRS. Treatment of MRSA sinusitis may be effective, although treatment regimens and outcome measures are variable. Prospective studies utilizing standardized parameters are warranted.

Functional Limitations and Workdays Lost Associated with Chronic Rhinosinusitis and Allergic Rhinitis

Chronic rhinosinusitis (CRS) and allergic rhinitis are associated with functional limitations, but these impacts are not known on a population basis. Our objective was to epidemiologically determine functional limitations and workdays lost that are associated with CRS and allergic rhinitis in adults. The Medical Expenditure Panel Survey for calendar year 2007 was examined to identify cases of CRS and allergic rhinitis. Functional limitation variables for activity limitation, work limitation, social limitation, and cognitive limitation determined by the survey also were extracted. Using multivariate models adjusting for age, gender, race, ethnicity, education level, insurance status, geographic region, as well as the Charlson comorbidity index, incremental differences in workdays lost and these functional limitations were determined for patients with and without CRS and allergic rhinitis. Among 225.1 million adults, the prevalences of CRS and allergic rhinitis were 4.9 ± 0.2% and 7.9 ± 0.3%, respectively. Patients with CRS demonstrated an incremental 1.04 ± 0.3 workdays lost per year along with significant increased adjusted odds ratios for activity limitation (odds ratio, 1.54), work limitation (1.50), and social limitation (1.49, all p < .005) but not cognitive limitation (1.05, p = .213). Patients with allergic rhinitis demonstrated an incremental 0.60 ± 0.45 workdays lost along with significant increased adjusted odds ratios for activity limitation (1.42), work limitation (1.43), social limitation (1.47), and cognitive limitation (1.32, all p < .019). Both CRS and allergic rhinitis impart significantly increased odds ratios for activity, work, and social limitations. Allergic rhinitis also carries with it statistically significant odds of functional cognitive limitation. The total aggregate workdays missed in the United States may be estimated at 11.5 million workdays and 10.7 million workdays for CRS and allergic rhinitis, respectively.

Role of fungi in pathogenesis of chronic rhinosinusitis

Fungi have been suggested to play an important role in the pathogenesis of chronic rhinosinusitis (CRS). This review describes the recent knowledge concerning the role of fungi in the pathogenesis of CRS and allergic fungal rhinosinusitis (AFRS) and the clinical implications for treatment. Recent studies show that, although there are several potential deficits in the innate and potentially also in the acquired immunity of CRS patients that might reduce or change their ability to react to fungi, there are not many arguments to suggest a causative role for fungi in CRS with or without nasal polyps. However, due to the intrinsic or induced change in immunity of CRS patients, fungi might have a disease-modifying role. The fact that AFRS is more prevalent in warm and humid areas may point to fungi as a factor in this disease. Almost a decade after the launching of the hypothesis by Ponikau, the absence of convincing immunological data or evidence for clinical improvement of CRS upon therapy with antifungal agents now means that the hypothesis that fungi play a role in a majority of the cases of CRS has to be rejected and antifungal treatment should not be used.