Chronic Hyperplastic Rhinosinusitis Research Articles

DISEASE PHENOTYPE-DRIVEN ALTERATIONS IN CELLULAR AND HUMORAL IMMUNITY DURING CHRONIC RHINOSINUSITIS

Abstract Human nasal cavity and paranasal sinuses play a crucial role in the physiological processes in vivo that accounts for the constant attention of doctors of many specialties to the state and pathological changes in the respiratory compartments noted above. Rhinosinusites hold one of the leading places in the pattern of inflammatory pathology of the paranasal sinuses, regardless of patient age, the climatic zone of residence and living style level. Chronic vs. acute rhinosinusitis is less widespread but considered to be the most common chronic disease. This pathology develops on average in 5% population, and CRS incidence increased more than by 2-fold over the last 10 years. In the pattern of subjects admitted to otorhinolaryngological hospitals, CRS comprises 25-30% that progressively elevates by mean 1-2% every year. The aim of the study was to evaluate disease phenotype-driven alterations in cellular and humoral immunity in patients with chronic rhinosinusitis. 91 patients with chronic rhinosinusitis were selected. For the study of cellular immunity, a flow cytometry was used with Cytomics FC500 (Beckman coulter, USA) and monoclonal antibodies: CD3+, CD4+, CD8+, CD16+, CD19+ (Beckman Coulter). To measure the levels of blood serum immunoglobulins of various classes (A, M, E, G), an enzyme-linked immunosorbent analysis (ELISA) was used. Statistical data processing was carried out using Statistica for Windows 8.0 application programs (StatSoftink., USA, 2008). The study revealed changes in the cellular and humoral links of immunity in chronic rhinosinusitis coupled to distinct disease phenotypes: with chronic allergic rhinosinusitis - 5; in chronic polypose rhinosinusitis - 4; in chronic infectious rhinosinusitis - 3; In chronic hyperplastic rhinosinusitis - 4. With allergic chronic rhinosinusitis, it was linked to higher absolute B-lymphocyte count, hypergammaglobulinemia E and a decrease in 3 indices of relative synthesis were revealed. Polypose chronic rhinosinusitis was associated with elevated in absolute B-lymphocyte level, hypergammaglobulinemia E and decrease in 2 indices of relative synthesis, whereas infectious chronic rhinosinusitis was accompanied by increased B-lymphocyte level and decrease in 2 indices of relative synthesis. Hyperplastic chronic rhinosinusitis patients had higher in absolute T- and B-lymphocyte count and a decreased absolute cytotoxic T-lymphocyte level along with 2 indices of relative synthesis.

Experimental substantiation of diagnostic criteria of chronic hyperplastic rhinosinusitis

The authors in the process of experiment developed a model of generation of local chronic inflammatory processes in the nasal cavity. It has been established that the chronic hyperplastic inflammation of the nasal cavity mucous membrane simulated in the experiment, manifests itself in the changes of behavioral responses, the reduced body weight gain, high deep body temperature, development of tolerance for repeated local injection of infectious-allergic irritants, which confirms the clinical data on the interrelation between the local and systemic immune response in chronic hyperplastic rhinosinusitis and determines the search for diagnostic characteristics of the disease.

The presence of fungal-specific IgE in serum and sinonasal tissue among patients with sinonasal polyposis

Nasal polyposis (NP) is a common inflammatory disorder with different proposed etiologies. There is some evidence that the local production of specific IgE against fungal allergens may contribute to the pathogenesis of this condition. The aim of this study was to compare local and systemic production of fungal-specific IgE among patients with NP. In a prospective cross-sectional study, 141 patients with sinonasal polyposis who were surgical candidates were enrolled. Total IgE and fungal-specific IgE antibodies in serum and tissue homogenates were measured by the ELISA and ImmunoCAP method, respectively. Twelve cases (9.45 %) met the allergic fungal rhinosinusitis (AFRS) criteria while the remaining 129 patients showed histopathological features of chronic hyperplastic rhinosinusitis. Considering a cutoff point of 0.4 KUI/L for specific IgE as a positive reaction against fungal elements, seven and 62 cases showed positive results in serum and homogenate tissue, respectively. All serum positive reactions were seen among patients with AFRS. In conclusion, IgE antibody could be locally produced in the nasal polyp tissue while not detectable in the serum.

288 IL1B but not IL8 Polymorphisms Are Increased in Aspirin Exacerbated Respiratory Disease Patients Versus Aspirin Tolerant Asthmatics

BackgroundAspirin exacerbated respiratory disease (AERD) is a syndrome characterized by chronic hyperplastic rhinosinusitis, nasal polyposis, asthma and aspirin sensitivity. The mechanisms by which produce these manifestations of intolerance are not fully defined, the current research involve alterations in the metabolism of arachidonic acid, cyclooxygenase 1 (COX-1) inhibition and its deviation from substrate to the lipoxygenase (LO) pathway, inducing increased synthesis of leukotrienes (LT). Biological plausibility of this fact has led to the search for polymorphisms in genes responsible for LT synthesis however others factors such as genetics polymorphisms in pro-inflammatory cytokines like, IL1B and IL8 could be associated.Methods78 patients with AERD, 135 aspirin-tolerant asthma (ATA) and 134 healthy control subjects participated. All participants who underwent a simple spirometry, methacholine challenge and nasal challenge with Lysine-aspirin (L-ASA), both tests performed according to international guidelines. Peripheral blood was drawn by venipuncture, genomic DNA was obtained using the commercial BDtract DNA isolation kit. We selected 2 polymorphisms in 2 genes related to chronic inflammation rs16944 in IL1B, and rs4073 in IL8, Allelic discrimination of SNPs was performed by Real Time PCR (PCR-RT) on a 7300 Real Time PCR Systems. Statistical analysis was performed between groups of cases (AERD and ATA) versus control group with Epi-info v.6.04 by χ2 test to identify the difference between the allele and genotype frequencies of each polymorphism made, considering a significant P value <0.05, in addition to the calculation of odds ratios and confidence intervals of 95%.ResultsWe find no association between IL1B (rs16944) to GG and GA genotypes in ATA patients versus control group neither AERD versus control group. Interestingly, the AA genotype showed increased frequency in the AERD patients versus the ATA patients (FG = 0.19 versus 0.07), this association remained significant (P = 0.018, OR 2.98, CI, 1.17-7.82).ConclusionsThis is the first observation that IL1B polymorphisms are involved in AERD, suggest that patients carrying out the IL1B-511 polymorphism (rs16944 AA genotype) may show enhanced susceptibility to develop AERD.

The IL1B-511 Polymorphism (rs16944 AA Genotype) Is Increased in Aspirin-Exacerbated Respiratory Disease in Mexican Population

Aspirin exacerbated respiratory disease (AERD) is characterized by chronic hyperplastic rhinosinusitis, nasal polyposis, asthma, and aspirin sensitivity. The mechanisms which produce these manifestations of intolerance are not fully defined, current research focuses on cyclooxygenase 1 (COX-1) inhibition, metabolism of arachidonic acid, and the COX pathway to the lipoxygenase (LO) route, inducing increased synthesis of leukotrienes (LT). The biological plausibility of this model has led to the search for polymorphisms in genes responsible for proinflammatory cytokines synthesis, such as IL1B and IL8. We performed a genetic association study between IL8-251 (rs4073) and IL1B-511 (rs16944) polymorphisms in AERD, aspirin-tolerant asthma (ATA), and healthy control subjects. Using allelic discrimination by real-time PCR, we found statistically nonsignificant associations between AERD, ATA, and healthy control subjects for the GG and GA genotypes of IL1B (rs16944). Interestingly, the AA genotype showed an increased frequency in the AERD patients versus the ATA group (GF = 0.19 versus 0.07, p = 0.018, OR 2.98, and 95% CI 1.17–7.82). This is the first observation that IL1B polymorphisms are involved in AERD. Thus, future studies must investigate whether interleukin-1β is released in the airways of AERD patients and whether it relates to genetic polymorphisms in the IL1B gene.

The Role of Allergy and Smoking in Chronic Rhinosinusitis and Polyposis

The article considers the interrelatedness of allergic rhinitis and chronic rhinosinusitis (CRS). The negative impact of perennial allergy and tobacco use on polyposis in sinus surgery patients is explored. A retrospective chart review, performed by the first author over a 6-year period, of patients who underwent functional endoscopic sinus surgery for CRS. The subjects' allergy status and smoking history are scrutinized by summary statistics and a multiple linear logistic model for predicting the presence of polyps. High prevalence of perennial allergic rhinitis (PAR) is seen in the subject population (56.4%). Both PAR and tobacco use are associated with nasal polyposis (P = .0073 and P = .0114, respectively). The close association of PAR and CRS suggests a possible causal link. Management of allergic rhinitis and tobacco cessation may provide greater control of chronic hyperplastic rhinosinusitis.

Inflammatory Pathway Gene Expression in Chronic Rhinosinusitis

The main objective in this preliminary experiment was to compare gene expression in the sinus mucosa of patients with chronic hyperplastic rhinosinusitis (CRS) against normal subjects, using gene microarray technology. The specific aim was to examine alterations in inflammatory mediator expression in patients with CRS. We performed a prospective experimental study. Total RNA samples were obtained from the sinus mucosa biopsies of 14 patients with chronic hyperplastic sinusitis and 4 normal controls, using the Affymetrix recommended protocol. The data for 22,000 genes on the GeneChip U133A were generated from 18 hybridizations. Affymetrix GeneChip 5.0 was used as the image acquisition software for the U133A chips. Data normalization, log transformation, statistical analysis, and pattern study were performed with GeneSpring software. Comparison between patients with CRS and normal controls were performed using the Welch t-test, with log transformed data. There were a total of 1283 genes scored as differentially expressed between groups. The value of p, the probability of a false positive, was set to <0.05. Hierarchical clustering was applied to study coexpression patterns of the 1283 significant genes. The inflammatory pathway was overlaid with the differential expressed gene list. Four genes involved in the inflammatory pathway, interleukin (IL)-6, IL-12A, IL-13, and tumor necrosis factor (TNF) alpha (2) were consistently overexpressed in patients with hyperplastic CRS. There is overexpression of four major genes of the inflammatory pathway (IL-6, IL-12A, IL-13, and TNF-alpha (2)) in patients with CRS compared with the normal population. Defining gene expression profiles may help elucidate new key factors in the pathogenesis of CRS and perhaps aid in the development of new therapeutic modalities.

Immunolocalization of Surfactant Protein A and D in Sinonasal Mucosa

Surfactant-associated proteins (SP) A and D are in the family of collectin proteins that play an integral part in the innate defense system. SP-A and SP-D expression and function are altered in a variety of inflammatory and infectious diseases of the lungs, such as asthma, allergies, and cystic fibrosis. Our prior studies are the first to identify the presence of these proteins in the human sinonasal cavity. The objective of this study was to immunolocalize SP-A and SP-D in human sinonasal tissue. Sinonasal mucosal biopsies were performed in patients with various forms of chronic hyperplastic rhinosinusitis with nasal polyposis and nondiseased mucosa from patients undergoing transsphenoidal hypophysectomy. (n = 10) Immunolocalization of surfactant proteins was performed with antibodies to SP-A and SP-D using immunoperoxidase staining technique. Isotype-negative controls were performed on all specimens. Analyses of mucosal biopsy specimens from human sinonasal tissue reveals staining within respiratory and intermediate (metaplastic)-type surface epithelium. In addition, staining was intense in the submucosal ductal epithelium of the seromucinous glands. These properties appear to be consistent regardless of disease state and location within the sinuses. This is the first study to immunolocalize SP-A and SP-D in sinonasal human mucosa. These are secreted proteins that are intricately involved in innate immunity in the lungs. Their secretion in the upper airway indicates that future studies may allow manipulation of these proteins and development of novel treatments for sinonasal pathology.

The Association of Total IgE and Specific IgE Anti-Staphylococcal Enterotoxin with Chronic Hyperplastic Rhinosinusitis

The Association of Total IgE and Specific IgE Anti-Staphylococcal Enterotoxin with Chronic Hyperplastic Rhinosinusitis

Molecular and Cellular Staging for the Severity of Chronic Rhinosinusitis

To correlate objective and subjective clinical parameters with molecular, cellular, and histologic markers and to acknowledge the importance of these basic science parameters in a severity classification system for chronic rhinosinusitis (CRS). Retrospective analysis of prospectively collected data of consecutive patients undergoing endoscopic sinus surgery for CRS in an academic institution. The preoperative computed tomography (CT) scans of all patients with CRS scheduled for surgery were graded according to Lund and Mackay. The patients completed a Sino-Nasal Outcome Test (SNOT)-20 questionnaire and had a preoperative nasal endoscopy performed, which was graded by assigning an endoscopy score according to Lanza and Kennedy. Subjects had a medical questionnaire regarding presence of aspirin sensitivity, allergic rhinitis, asthma, and medication usage. Subjects also underwent pulmonary function testing and had skin tests for allergies. At the time of surgery, blood was drawn to determine the level of peripheral eosinophilia and the degree of polymorphisms of the leukotriene C4 synthase gene. Sinus mucosal and polyp tissue was examined pathologically for the number of eosinophils per high-powered filed (HPF) and was stained for EG2 to determine the portion of activated eosinophils. Leukotriene C4 levels (pg/g of tissue) were determined using a sensitive competitive enzyme immunoassay. Endoscopy and SNOT-20 scores were reevaluated 1 year after surgery. Data were analyzed for disease-severity correlation to recommend a severity classification system for CRS that incorporates the contribution of clinical, molecular, cellular, and histologic parameters. The presence of polyps resulted in higher preoperative CT scores and higher preoperative and postoperative symptom scores. Average preoperative CT scores were significantly higher in asthmatics and allergy patients and correlated with endoscopy scores. Patients with more than five eosinophils/HPF of sinus tissue had higher frequency of polyps and asthma and higher CT and endoscopy scores than patients without sinus tissue eosinophilia (less than or equal to 5 cells/HPF sinus tissue). The subgroup of patients with eosinophilic nasal polyps (eosinophilic hyperplastic rhinosinusitis) had more severe disease by CT and endoscopy than the subgroup of patients with nasal polyps (hyperplastic rhinosinusitis) but without eosinophilia. Similarly, patients without polyps but with tissue eosinophilia had more severe disease than patients without polyps and without eosinophilia. Leukotriene C4 levels were elevated in all patient groups. Symptom scores did not correlate with any of the parameters. We suggest the following severity classification system for CRS: 1) eosinophilic chronic hyperplastic rhinosinusitis (ECHRS): patients with polyps and sinus tissue eosinophilia; 2) noneosinophilic chronic hyperplastic rhinosinusitis (NECHRS): patients with polyps but without sinus tissue eosinophilia; 3) eosinophilic chronic rhinosinusitis (ECRS): patients without polyps but with sinus tissue eosinophilia; 4) noneosinophilic chronic rhinosinusitis (NECRS): patients without polyps and without sinus tissue eosinophilia.

Churg-Strauss Syndrome Development during Asthma Therapy with Leukotriene Receptor Antagonists: Just a Coincidental Association?

A report on our clinical experience based on 3 male patients who developed Churg-Strauss syndrome (CSS) after standard oral montelukast use. All patients affected by moderate asthma and chronic hyperplastic rhinosinusitis were treated with inhaled corticosteroids and ß2 agonists. Systemic corticosteroid treatment consisted in oral daily prednisone in case 1, in short courses of oral betamethasone in case 2, and in remote and isolated administrations of oral betamethasone and intramuscular methylprednisolone in case 3. Because of the improvement of the asthma symptoms after montelukast use, patient 1 decided to take half the dose of prednisone for 10 days and patient 2 decided to discontinue systemic and inhaled corticosteroids for 45 days. Overt CSS was heralded by vasculitic skin lesions and developed in each patient with severe organ damage, consisting in renal, myocardial and gastrointestinal involvement. Remission was obtained by standard CSS therapy after montelukast withdrawal. According to the unmasking hypothesis, antileukotriene treatment, by enabling the reduction in systemic corticosteroid therapy in case 1 and its discontinuation in case 2, might have only permitted the precipitation of the vasculitis. However antileukotriene-associated CSS reportedly occurred in systemic corticosteroid-naïve patients and relapsed in one patient after antileukotriene treatment. These observations lend support to the concept that the precipitation of the vasculitic phase may be associated with leukotriene modifier deleterious effects. In conclusion there is not enough evidence to prove that antileukotriene treatment plays a direct causative role in the pathogenesis of CSS. Further clinical and experimental research is required to clarify the antileukotriene associated CSS controversy.

Gene expression of thymic stromal lymphopoietin in nasal mucosa and nasal polyps

Problem: Thymic stromal lymphopoietin (TSLP) produced by epithelial cells is capable of initiating via dendritic cells (CD11c+) a Th2 immune response. The aim of this study was to evaluate the expression of TSLP and Interleukin 5 (IL-5) in nasal mucosa and to discuss their role for chronic hyperplastic rhinosinusitis with nasal polyps (CHS/NP). Methods: Twelve subjects with CHS/NP and 12 subjects undergoing routine surgery for septal deviation without sinusitis (controls) were included in this study. Homogenized mucosal specimens were analyzed by relative quantitative real-time-PCR for the expression of TSLP and IL-5. Allergy screening tests revealed that 5 subjects of CHS/NP were sensitized to aeroallergens. None of the controls had positive allergy screening tests. Results: The tissue expression of TSLP was significantly higher in CHS/NP compared to the control group (ANOVA, P = 0.004). Bonferroni‘s post hoc analyses (CHS/NP with allegy vs CHS/NP without allergy vs controls) revealed significant higher expression levels in both CHS/NP subgroups with and without allergic sensitization than in controls. Interestingly, the factor “sensitization” had no significant effect on the TSLP expression within the CHS/NP group. Whereas IL-5 was expressed in all nasal polyps, it was only detectable in 58% of control nasal mucosa. Furthermore, IL-5 expression in CHS/NP was significantly higher compared to controls (ANOVA, P = 0.002). Correlational analyses revealed that there was a significant relation between TSLP and IL-5 expression (r 24 = 0.65, P = 0.001). Conclusion: In this study we first demonstrated TSLP gene expression in nasal mucosa. TSLP was significantly higher expressed in nasal polyps than in healthy mucosa, supporting the hypothesis that this mediator may play an important role for the inflammation in CHS/NP. Interestingly, TSLP seems to be involved in regulation of IL-5 expression. Significance: In contrast to other cytokines TSLP could be produced by resident nasal epithelial cells, inducing a Th2 immune response at the beginning of the sinus disease. Support: None reported.

Naturally Draining Ostium of an Agger Nasi Cell: A Case Report

We describe the case of a 61-year-old woman who underwent functional endoscopic sinus surgery for chronic hyperplastic rhinosinusitis. During surgery, we were able to visualize the natural ostium of her left agger nasi cell. To our knowledge, such a finding has not been previously documented in the literature.

Lymphocyte subpopulations and cytokines in nasal polyps: is there a local immune system in the nasal polyp?

Purpose The pathogenesis of chronic hyperplastic rhinosinusitis with massive nasal polyposis is still not entirely known. The present study evaluates the lymphocyte subpopulations and their production of cytokines using a technique for detection of intracytoplasmic cytokines by flow cytometry. This information may allow us to determine whether the source of these lymphocytes is from peripheral blood, the common mucosal immune system, or both. Methods Detection of intracytoplasmic cytokines by flow cytometry was performed using a fluoresceinated monoclonal antibody directed against CD4+ and CD8+ lymphocytes and a rhodamine-labeled intracytoplasmic monoclonal antibody directed against four cytokines. In this way, the percentage of lymphocytes synthesizing TH1 and TH2 cytokines were identified in nasal polyp lymphocytes and the corresponding peripheral blood lymphocytes of 13 patients. Results Lymphocytes producing interferon-gamma and IL-2, as well as IL-4 and IL-5, were found in the nasal polyps, suggesting that the nasal polyp possesses both TH1 and TH2 cytokine expression. There are also significant differences between the percentage of lymphocytes producing these cytokines between nasal polyps and peripheral blood, suggesting that nasal polyp lymphocytes derive from at least another source than only peripheral blood lymphocytes. Statistical analysis of four groups of patients demonstrated that no statistically significant difference in the lymphocyte subpopulations in atopic versus non-atopic patients, nor aspirin-intolerant versus aspirin-tolerant patients. In general, CD8 cells always produce more interferon-gamma than IL-2 in both peripheral blood and nasal polyps. In contrast with this data, CD4 cells produce more IL-2 in the peripheral blood than in nasal polyps. Conclusions Data support the concept that nasal polyp lymphocyte subpopulations may be derived from both the local mucosal immune system as well as from random migration of peripheral blood lymphocytes secondary to adhesion molecules and chemokines, which are known to be present in nasal polyps.

Clinical features of asthmatic patients with increased urinary leukotriene E4 excretion (hyperleukotrienuria): Involvement of chronic hyperplastic rhinosinusitis with nasal polyposis

Background The urinary leukotriene E4 (U-LTE4) concentration is significantly increased in patients with aspirin-intolerant asthma (AIA). However, the relationship between the clinicopathogenetic factors of asthma and the U-LTE4 concentration remains undetermined. Objective We sought to examine the clinical features of asthmatic patients with increased excretion levels of U-LTE4 (hyperleukotrienuria). Methods We measured the U-LTE4 concentrations in 137 asthmatic patients (including 64 patients with AIA) who were in clinically stable condition. A U-LTE4 concentration of 150 pg/mg creatinine or greater (mean U-LTE4 + 3 SDs of normal healthy control subjects) was indicative of hyperleukotrienuria. Results The basal concentration of U-LTE4 was significantly higher in the patients with AIA than in those with aspirin-tolerant asthma (ATA; median, 227.2 vs 90.3 pg/mg creatinine; P < .01). Compared with normal leukotrienuria in the patients with AIA, hyperleukotrienuria in the patients with AIA was associated with older age and decrease in pulmonary function. On the other hand, compared with normal leukotrienuria in the patients with ATA, hyperleukotrienuria in the patients with ATA was associated with severe asthma and chronic hyperplastic rhinosinusitis with nasal polyposis (CHRS/NP), which are well-known symptoms of the aspirin triad, as well as hypereosinophilia and anosmia. The patients with ATA with CHRS/NP excreted U-LTE4 at significantly high concentrations. There were significant decreases in the U-LTE4 concentrations before and after the sinus surgery in both the AIA and ATA groups ( P < .05). Conclusion Cysteinyl leukotrienes are not strictly associated with aspirin intolerance itself but rather with clinical features, such as CHRS/NP, that are similar to those seen in AIA. CHRS/NP might be involved in cysteinyl leukotriene overproduction in asthmatic patients.

Investigations on allergic fungal genesis of chronic rhinosinusitis

The incidence of allergic fungal sinusitis (AFS) is estimated differently. The importance of hyphal findings in nasal mucus for initiation of chronic hyperplastic sinusitis is not proven. 124 patients with clinical signs and CT-scan findings of a chronic-hyperplastic rhinosinusitis were treated by functional endoscopic sinus surgery. During the operation a thick mucus was found in each patient. The mucus was isolated and investigated by histopathological analysis with special Grocott-stain and a culture for fungal growth was initiated. Furthermore the diagnostic for allergic reactions against fungus was done by prick- and RAST-tests. 21 patients had positive histopathological findings of fungus. In 10 cases fungal hyphae were found embedded in typical eosinophilic mucus. A positive allergic reaction against fungus was seen in 7 of these 10 patients. The culture results showed different pictures according to the isolated species, in 3 cases of the 10 AFS cases the culture was negative. The other 11 cases of 21 positive histological findings of fungus were cases of a fungus ball. The other 103 patients were without any sign for fungus in the HE- or Grocott-stain. A high incidence of AFS is not evident in group of chronic hyperplastic rhinosinusitis. The presence of eosinophilic "allergic" mucus is not the evidence for AFS. The inflammatory cascade leading to the clinical picture is a multifactorial event. The role of detectable fungus hyphae have to be estimated by further investigations.

Functional endoscopic sinus surgery- a newer surgical concept in the management of chronic sinusitis

Two hundred and ten patients suffering from chronic hyperplastic rhinosinusitis refractory to medical treatment were subjected to Functional Endoscopic Sinus Surgery using the classical Messerklinger technique ( MT FESS). Of these, 147 (70%) had complete relief of symptoms, 39 (18.5%) had partial relief of symptoms and 15(7.17%) had no/poor relief of symptoms in the follow-up period varying from 6-33 months (Mean 18.3 months). Sine (4.2%) patients were lost to follow-up. The merits and demerits of Functional Endoscopic Sinus Surgery are discussed.

Staging of chronic hyperplastic rhinosinusitis: treatment strategies.

In 1990 we reported an initial prospective study of 100 patients using a four-stage system for classification of chronic rhinosinusitis. Between January 1988 and July 1992, we used this system in staging an additional 1814 patients, on whom 2980 intranasal sphenoethmoidectomies were performed. In this staging system a protocol trial of medication was given for 2 weeks, followed by axial and coronal computed tomography. Medication consisted of a second-generation cephalosporin antibiotic, usually cefuroxime; a 4-day burst of intraoral steroids, usually prednisone; and an antihistamine decongestant if not contraindicated. The stages of chronic hyperplastic rhinosinusitis included the stages described in the 1990 report (i.e., stage I, single-focus disease; stage II, discontiguous disease throughout the ethmoid labyrinth; stage III, diffuse disease responsive to medication; and stage IV, diffuse disease unresponsive to or poorly responsive to medication). The results of this study have shown that the computed tomography staging system based on computed tomography extent of disease after medical therapy is a simple, easily remembered, and very effective modality for the classification of chronic sinusitis. This system provides a rationale for discussing and planning surgery with patients and physicians and is a convenient reference for the reporting of end results. More importantly, a linear relationship between disease stage and outcomes is demonstrated. This statistically highly significant feature of the staging system provides a firm basis for the production of outcomes after various treatment strategies, particularly ethmoidectomy and the treatment of sinusitis.

Staging of chronic hyperplastic rhinosinusitis: Treatment strategies

In 1990 we reported an initial prospective study of 100 patients using a four-stage system for classification of chronic rhinosinusitis. Between January 1988 and July 1992, we used this system in staging an additional 1814 patients, on whom 2980 intranasal sphenoethmoidectomies were performed. In this staging system a protocol trial of medication was given for 2 weeks, followed by axial and coronal computed tomography. Medication consisted of a second-generation cephalosporin antibiotic, usually cefuroxime; a 4-day burst of intraoral steroids, usually prednisone; and an antihistamine decongestant if not contraindicated. The stages of chronic hyperplastic rhinosinusitis included the stages described in the 1990 report (i.e., stage I, single-focus disease; stage II, discontiguous disease throughout the ethmoid labyrinth; stage III, diffuse disease responsive to medication; and stage IV, diffuse disease unresponsive to or poorly responsive to medication). The results of this study have shown that the computed tomography staging system based on computed tomography extent of disease after medical therapy is a simple, easily remembered, and very effective modality for the classification of chronic sinusitis. This system provides a rationale for discussing and planning surgery with patients and physicians and is a convenient reference for the reporting of end results. More importantly, a linear relationship between disease stage and outcomes is demonstrated. This statistically highly significant feature of the staging system provides a firm basis for the production of outcomes after various treatment strategies, particularly ethmoidectomy and the treatment of sinusitis. (OTOLARYNGOL HEAD NECK SURG 1995;112:210-4.)

Intranasal sphenoethmoidectomy: an evolution of technique.

Intranasal sphenoethmoidectomy was originally used primarily for the provision of adequate drainage of acute and subacute bacterial sinusitis. However, the spectrum of inflammatory sinus disease has changed dramatically since the popularization of broad-spectrum antibiotics, and chronic hyperplastic rhinosinusitis has replaced acute sinusitis as the primary indication for ethmoidectomy. In such cases total or almost total disease removal is crucial to providing long-term drainage and ventilation. We describe several modifications of the Yankauer sphenoethmoidectomy technique that enable the sinus surgeon to provide clearance of disease and excellent drainage for all sinuses by complete marsupialization of the sphenoid, ethmoid, and maxillary sinuses. These modifications include (1) complete rather than partial removal of the middle turbinate, (2) extended middle meatal antrostomy with palatine bone resection to the pterygoid process with delineation of the inferior and medial orbital wall, and (3) introduction of operative endoscopes as adjunctive tools in areas inaccessible to conventional visualization. The current technique and results in nearly 2000 procedures are described.