Recurrent Sinusitis Research Articles

Five Years of Experience in a Single Center: Retrospective Analysis of Adult Patients with Common Variable Immunodeficiency

Objective: Common Variable Immune Deficiency (CVID) is a heterogeneous immune disorder characterized by impaired and/or inadequate B cell differentiation with hypogammaglobulinemia. It is characterized by frequent and recurrent respiratory infections, autoimmune disorders, chronic lung diseases, granulomatous diseases, and increased risk for lymphoid malignancies. Materials and Methods: The medical records of 47 patients (22 females, 25 males) who had been followed up at our clinic and had sufficient data in their files were retrospectively reviewed. Patients were diagnosed with CVID according to the ESID (European Society for Immunodeficiency) criteria. Results: The median age of the patients was 32 (19-65) years. The most frequent clinical presentation of the patients was with recurrent upper respiratory infections (46%), pneumonia (29.8%), otitis media (23.4%) and chronic sinusitis (17%). During the follow-up period, 17 patients (36.8%) developed autoimmune complications, 14 (29.8%) of whom had autoimmune cytopenia. A total of 26 patients (55.3%) had bronchiectasis confirmed with computed tomography of the thorax. Lymphopenia was detected in 13 patients (27.7%). The median immunoglobulin level at the time of diagnosis was IgG 2.77 (0.33-6.90) g/L, IgM 0.31 (0.06-5.99) g/L, and IgA 0.25 (0.01- 5.02) g/L. Conclusion: CVID is very heterogeneous in terms of both clinical and laboratory features. Moreover, it is more common than expected, particularly in adulthood. The centers dealing with CVID should share their experiences in order to increase awareness among physicians.

A possible role for B cells in COVID-19? Lesson from patients with agammaglobulinemia

Summary COVID-19 had a mild clinical course in patients with Agammaglobulinemia lacking B lymphocytes, whereas it developed aggressively in Common Variable Immune Deficiency. Our data offer mechanisms for possible therapeutic targets.

Fat obliteration of the front sinus in recurrent frontal sinusitis: a clinical case

Aim. To describe a case of fat obliteration using platelet-rich plasma in a patient with recurrent chronic frontal sinusitis.Materials and methods. A clinical case of a 60-year-old patient who had repeatedly performed extranasal frontotomy for recurrent chronic frontal sinusitis with a short-term effect is described. Due to the ineffectiveness of conservative and traditional surgical treatment, taking into account the characteristics of the clinical picture and the presence of a cosmetic defect in the area of projection of the right frontal sinus, as well as CT results (postoperative bone defect of the right half of the frontal bone), a right-side extranasal frontotomy was performed. The operation involved sinus obliteration with adipose tissue obtained from areas of the thigh anterior surface by lipoaspiration under low pressures with the addition of platelet-rich plasma (PRP) prepared by a single centrifugation of whole venous blood. An assessment of the patient’s condition and fat transplant was carried out on the basis of objective examination after 4 and 6 months and 1.5 year after the surgery and the results of control computed tomography (CT).Results. No complaints regarding nasal breathing from the frontal sinus were registered during control examinations. A good cosmetic result and the absence of pain during palpation in the right frontal sinus were observed. According to CT results, the density of the contents of the frontal sinus corresponded to that of adipose tissue; the volume of material did not changed.Conclusion. Frontal sinus obliteration with adipose tissue and PRP addition is a promising method for treating patients with recurrent chronic frontal sinusitis and repeatedly performed extranasal frontotomy. This method has several advantages over other methods.

Recurrent ethmoid mucocele with cellulitis in a patient with Pfeiffer syndrome

Pfeiffer syndrome is one of six craniosynostosis syndromes and presents with craniosynostosis (the premature fusion of one or more calvarial sutures) and skeletal abnormalities. The aetiology of Pfeiffer syndrome is thought to be caused by mutations in the fibroblast growth factor genes FGFR1 and FGFR2. The anatomical complexity of craniosynostosis syndromes means that the long-term management of patients requires a multidisciplinary team approach. Patients with craniosynostosis syndromes are predisposed to sinus infections, including sinusitis, due to structural abnormalities and iatrogenic alterations in sinus anatomy following reconstruction. In this case report, we report a 14-year-old boy with Pfeiffer syndrome who presented with periorbital cellulitis secondary to recurrent ethmoid sinusitis. To the best of our knowledge, this is the first case of ethmoid sinusitis in a patient with Pfeiffer syndrome reported in the literature.

P228 Risk of sinusitis in patients with rheumatoid arthritis: association with different treatment strategies

Abstract Background There is an established increase risk of infection in rheumatoid arthritis (RA). Most published data examine serious events, which affect 3-5% of patients annually. Approximately half of the patients experience non-serious infection, which does not require parental antibiotics or hospitalisation. Sinusitis events affecting patients on biologics (particularly TNF inhibition) have been observed but not well described, with a prevalence of 2-17%. Sinusitis is associated with treatment discontinuation and surgical interventions. We aim to describe the rates of sinusitis with different RA treatment strategies and provide estimates of risk difference. Methods The population was adults with RA, enrolled in the British Society for Rheumatology Biologics Register for Rheumatoid Arthritis registry (BSRBR-RA) during the first 3 years of study on biologic treatment. The predictor was treatment strategy at the time of event (csDMARD only, TNF inhibitors, IL-6 inhibitors and anti-CD20). The primary outcome was sinusitis according to MeddraPT codes reported by patients (via patient diary) or clinician (on an adverse event form). A multi-failure Cox survival model was used to compare risk across treatment groups. A multivariate model adjusted for confounders (age, gender, entry year in BSRBR-RA, disease duration, baseline disease activity by DAS-28, HAQ, comorbidities, smoking status and steroid use. Results 23,584 patients were included, contributing to a total of 64,035 patient-years of follow up. There were 797 infective events in 580 patients. This corresponded to a rate of 0.95 per year (95% CI 0.87 to 0.1.02). The sinusitis rate was numerically highest with anti-CD20 (Rituximab) and lowest with csDMARDs (Table 1). In the adjusted Cox proportional hazard model, all 3 biologics strategies had a significantly higher rate of sinusitis compared to csDMARD cohort; (TNFi 2.76 (95%CI 1.85 to 4.12); IL-6R 2.51 (1.00 to 6.29); anti-CD20 3.14 (1.46 to 6.72). Conclusion Sinusitis is more common in patients prescribed biologics compared to the csDMARD. The highest rate was seen with rituximab. This would fit biologically, as the primary immunodeficiency phenotype of recurrent sinusitis aligns with antibody defects e.g. common variable immunodeficiency. However, it is interesting to observe that sinusitis is more common across the treatment classes. Disclosures K. Halai None. K. Bechman None. S. Norton None. A.P. Cope None. K.L. Hyrich Honoraria; AbbVie paid to the institution and grant income from Pfizer and Bristol-Myers Squibb for activities outside of this work. J.B. Galloway Honoraria; or speaking or attending conferences from AbbVie, Bristol-Myers Squibb, Celgene, Janssen, Pfizer and Union Chimique Belge.

Indications and Outcomes for Patients With Limited Symptoms Undergoing Endoscopic Sinus Surgery.

Previous research have suggested that chronic rhinosinusitis (CRS) patients with lower symptomatic scores, demonstrated by a 22-item Sinonasal Outcome Test (SNOT-22) score <20, may not achieve meaningful quality of life improvement following endoscopic sinus surgery (ESS). However, indications for ESS are continuing to be defined and many low SNOT-22 scoring patients still undergo elective surgery for CRS and other benign sinonasal pathologies. The outcomes for these patients have not been previously studied. We sought to evaluate surgical indications and outcomes for those patients with limited symptoms undergoing ESS. We screened 2829 ESS procedures from 2010-2018 to identify patients with a preoperative SNOT-22 score <20. We reviewed disease characteristics, preoperative Lund-Mackay (LM) scores, and pre- and postoperative SNOT-22 scores in patients with at least 3 months' follow-up. Of all surgical ESS patients screened, 114 had low preoperative SNOT-22 scores (4.0%). Indications for these surgeries included CRS (50.0%), odontogenic sinus disease (11.4%), mucocele (10.5%), recurrent acute sinusitis (7.0%), fungal ball (5.3%), and silent sinus syndrome (4.4%). Specifically, among CRS patients, 45.6% had pulmonary comorbidities and/or systemic immunodeficiencies. Moreover, 100% of CRS patients with nasal polyps and 73.1% of CRS without polyps had LM scores >5. Patients with preoperative SNOT-22 scores between 15 and 19 achieved an average 6.5 point reduction (P < .001) postoperatively, whereas those with scores between 10 and 14 had a 5.4 point reduction (P < .001), and preoperative scores <9 resulted in no significant decrease in postoperative symptom scores (P = .98). Overall, there was a 3.3 point SNOT-22 reduction among all patients at 3 months postoperatively (P < .001). Patients with limited sinonasal symptoms may benefit from surgical treatment despite asymptomatic clinical presentations. A case-by-case analysis of comorbidities or unique clinical features should inform surgical decision-making for patients with lower SNOT-22 scores.

SUN-424 TREATMENT OF BRONCHIECTASIS WITH MACROLIDE IN ANCA-ASSOCIATED VASCULITIS ACHIEVED REMISSION: A CASE REPORT

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is the most common cause of pulmonary vasculitis which most frequently manifests with diffuse alveolar haemorrhage (DAH). Proteinase 3-ANCA is most common in granulomatosis with polyangiitis (75%), whereas myeloperoxidase-ANCA occurs more frequently in patients with renal-limited vasculitis (70%). A 69-year-old female presented with two months history of lethargy and weight loss. Her medical history was significant for chronic airway disease and recurrent sinusitis. She takes regular inhaled corticosteroid and salbutamol as required. Pre-hospital investigations revealed areas of patchy pulmonary consolidation. She was treated with oral antibiotics for chest infection. On admission, she had significant renal impairment (creatinine 595umol/L, eGFR 6ml/min/1.73m2). Part of acute kidney injury investigations, a strongly positive PR3/c-ANCA with a titre of 1:2560 was reported. Induction therapy with methyl-prednisone and cyclophosphamide was commenced. Renal biopsy confirmed crescentic glomerulonephritis. On day 9 of admission, she developed haemoptysis with radiological features consistent with diffuse alveolar haemorrhage. She underwent plasma exchanges. The admission was also complicated by cardiopulmonary arrest, gastrointestinal haemorrhage and CMV colitis with prolonged recovery. During twelve-weeks of hospital admission she received four doses of rituximab. She then maintained on azathioprine and prednisone. She was readmitted with hyperkalaemia, worsening renal function with rising inflammatory markers. Trimethroprim-sulphamethoxasole prophylaxis was ceased with resultant improvement in renal function. Urinalysis did not suggest renal relapse. These episodes were treated temporarily increasing prednisone to restore remission. Positron emission tomography (PET) scan was organised to assess the disease activity, which showed inflammatory foci in both lungs. Infective screen remained negative. She then was started on macrolide (azithromycin) for bronchiectasis. Since then, inflammatory markers returned to normal and she remained well with stable renal function. View Large Image Figure ViewerDownload Hi-res image Download (PPT) This case demonstrated the necessity of multiple immunomodulatory therapies for severe AAV. Treatment of relapses remains challenging especially for frequent relapses which required intensification of immunosuppressive regimen.

A case of nasal mass, skin ulcers and inflammatory joint pain: granulomatosis with polyangiitis versus lymphoma

We report a case of a 62-year-old woman presenting with a 6-month history of inflammatory joint pain in hands, knees and feet, a 3-month history of recurrent sinusitis and ‘facial cellulitis’, and a 2-month history of lower limb skin lesions. On examination, a soft tissue mass was eroding

Rhinolith in case of chronic recurrent sinusitis: case report

Rhinolith is a rare mineralized mass located in the nose. A rhinolith can be asymptomatic for many years and can be detected by chance during a routine examination. Unilateral nasal congestion and nasal discharge are the most common symptoms. Rhinolite cases are often followed as chronic sinusitis or allergic rhinitis. The diagnosis is made by rigid endoscopic examination and paranasal sinus tomography. Treatment is surgical removal of the mass. We present this case as a case of rhinolite followed by chronic sinusitis for many years in the light of literature.

Trans-implant treatment of chronic recurrent maxillary sinusitis via dynamic implants with an internal port: Experience with 31 cases

This study was performed to test a protocol for trans-implant treatment of chronic recurrent maxillary sinusitis (CRS), via implants with an internal removable sealing screw. The appropriate indications for treatment, optimal number of treatment sessions, and general schedule of treatment and follow-up were assessed. This was a retrospective study of 31 patients with CRS who were managed with trans-implant lavage. Of these patients, 28 (referred for a sinus elevation procedure) underwent a simultaneous implantation procedure and treatment of the sinusitis. Three patients received treatment for sinusitis via an already existing implant. The suggested sinusitis treatment protocol includes the drainage of pus through the punctured sinus floor and three sessions of antral irrigation/lavage, four cone beam computed tomography scans, and four transnasal endoscopic observations. The suggested combined protocol includes the simultaneous evaluation of the implant status and the sinusitis treatment results on days 30 and 60 after surgery. Of the 31 patients, 28 (90%) had complete relief of most of their symptoms (nasal obstruction/discharge, anosmia/hyposmia) up to day 30 postoperative. Follow-up nasal endoscopy demonstrated no evidence of active sinus disease. Twenty-seven implants were well-osseointegrated and were still in use for prosthetic purposes. In one case, the implantation failed because of poor bone quality. For the remaining 30 cases, both clinical and radiological results showed stability of the implants and no CRS recurrence during the whole follow-up period. The dental implant with an internal central port and an integral sealing screw may be used for drainage, irrigation, observation, and further treatment of the maxillary sinus in cases of CRS.

TNF-Alpha Inhibitors and Rhinosinusitis-A Systematic Review and Meta-Analysis.

Background Tumor necrosis factor alpha (TNFα) plays key role in immunologic process. Patients receiving anti-TNFα therapy may likely be more predisposed to infections including sinus disorders. Objectives Our aims were to review literature and evaluate data regarding TNFα antagonist therapy and its association with reference to various sinus disorders in the form of a systematic review and meta-analysis. Methods Different keyword combinations were used in the screening of the literature including leading scientific databases (PubMed, Embase, and Web of Science). Papers reporting sinus disorders as supposed adverse events of the treatment were included into the meta-analysis. Results A thorough review of literature searches extracted 1154 records and 8 articles were found through other sources. Seventeen papers fulfilled our criteria for inclusion into the meta-analysis. Among 16 174 observed patients, 3018 suffered from a sinus infection. An event rate (ER) of 0.058 was calculated for all the cases. Analysis with regard to the confirmed diseases showed an 0.038 ER. Calculations were performed in accordance to the diagnostic categories used for sinus disorder. Six groups were found including the following: “Bacterial Sinusitis” (ER: 0.046), “Chronic Rhinosinusitis” (ER: 0.027), “Sinusitis Requiring Prescription Medication” (ER: 0.295), “Recurrent Sinusitis” (ER: 0.070), “Sinusitis” (ER: 0.076), “Acute Rhinosinusitis” (ER: 0.002) and, lastly, “Maxillary Sinusitis” (ER: 0.028). Conclusions Our results exhibited a similar prevalence to the healthy population; therefore, infective sinus disorders cannot directly be considered as complications of TNFα antagonist therapy.

Severe haemoptysis in a 5 year old child with Kartagener’s syndrome: case report

Kartagener`s syndrome, a rare autosomal recessive disorder is a type of Primary Ciliary Dyskinesia (PCD) associated situs inversus, bronchiectasis, sinusitis and male infertility. We present a case of a 5-year-old girl who came with features of bilateral glue ear, recurrent sinusitis, recurrent hemoptysis and dextrocardia. She was diagnosed to have Kartagener`s syndrome and was evaluated for recurrent hemoptysis.

Detection and phylogeny of Staphylococcus aureus sequence type 398 in Taiwan

BackgroundMethicillin-resistant Staphylococcus aureus (MRSA) ST398 is a livestock associated-bacterium that is most prevalent in Europe. Human-adapted MRSA ST398 was recently reported from China, but there is no data available yet for Taiwan.MethodsTo identify S. aureus ST398 isolates, we examined 6413 S. aureus isolates (5632 MRSA and 781 susceptible strains) that were collected in Taiwan between 1995 and 2017. If isolates could not be typed by pulsed-field gel electrophoresis upon Sma I digestion, we performed further characterization and complete genome sequencing.ResultsWe identified 18 ST398 S. aureus isolates from 16 subjects (0.28%), including 6 sensitive and 12 resistant strains. Of these, 14 were colonizing isolates, 3 were clinical (infecting) isolates and one isolate was from a pork specimen. All 3 infecting isolates were MSSA strains identified in 2015 from two children with recurrent otitis media or sinusitis. The other 3 MSSA isolates were identified from workers handling pork (2) or pork meat (1) in 2015. The first 5 MRSA colonizing isolates were identified from residents in two nursing homes in 2012. Six MRSA isolates were identified from residents and foreign employees at a nursing home in 2016 and one MRSA from a foreign worker in 2017. Phylogenetic analysis of genome sequences indicated that all 12 local ST398 MRSA strains cluster together, human-adapted and phylogenetically related to a human MRSA strain identified in China in 2002. Two local MSSA isolates could be linked to isolates from livestock. The toxin profiles were similar for the MRSA and MSSA isolates.ConclusionsOur results demonstrate that S. aureus ST398 was present in Taiwan in 2012 and potentially earlier. Although some isolates could be linked to livestock, most ST398 S. aureus isolates identified in Taiwan, particularly MRSA, represent human-adapted strains. Local transmission of human-adapted MRSA ST398 strains has occurred in nursing homes in Taiwan, possibly after import from China. Further surveillance is needed.

Спондилогенные гаймороэтмоидиты у детей

A comparative study of 71 patients aged 3 to 10 years was carried out, the average age was 4.73±1.99 years, including 29 males (40.8%) and 42 females (59.1%). Patients were divided into 2 groups. The first group, “spondylogenic acute sinusitis”, was 40 people; the second – “spondylogenic recurrent sinusitis” – 31 patients. In the course of the study, clinical, radiological, electrophysiological (electromyographic) data were compared and the tactics of managing and treatment of the children with a diagnosis of acute spondylogenic sinusitis who received a birth injury of the cervical spine were formed. The treatment regimen consisted of a comparative analysis of the traditional standard of treatment (prescribing decongestants, nasal cavity toilet, antibacterial drops in the nose, secretolytics, if it necessary antibiotics) of spondylogenic acute and recurrent sinusitis with an integrated method that includes the basics of traditional treatment with the addition of local effects on the affected cervical vertebral-motor segments (acupressure, light traction over the cervical spine, post-isometric relaxation of the neck muscles). The persistent positive effect we obtained from the complex treatment of “spondylogenic sinusitis in children” prompts a special study of the relationship of congestive inflammatory phenomena in the nasal cavity and paranasal sinuses with birth trauma of the cervical spine of neuropathologists, obstetrician-gynecologists together with otorhinolaryngologists.

Low Baseline Pneumococcal Antibody Titers Predict Specific Antibody Deficiency, Increased Upper Respiratory Infections, and Allergy Sensitization.

BackgroundInadequate titers of pneumococcal antibody (PA) are commonly present among patients with recurrent respiratory infections.ObjectiveWe sought to determine the effect of the degree of inadequacy in baseline PA titers on the subsequent polysaccharide vaccine response, the incidence of sinusitis, and allergic conditions.MethodsA total of 313 patients aged 6 to 70 years with symptoms of recurrent respiratory infections were classified by baseline-pPA (percentage of protective [≥1.3 µg/mL] PA serotypes/total tested serotypes) and postvaccination pPA (post-pPA): Group A (adequate baseline-pPA), Group B (inadequate baseline-pPA, adequate post-pPA, responders), and Group C (inadequate baseline-pPA, inadequate postpPA, nonresponders, specific antibody deficiency [SAD]). Immunity against Streptococcus pneumoniae was defined as adequate when the pPA was ≥70%. Each group and combined groups, Group AB (inadequate baseline-pPA), and Group BC (adequate post-pPA) were analyzed for demographics, history of sinusitis, recurrent sinusitis in the following year, allergic conditions, and association with inadequate individual serotype titers.ResultsOver 80% of patients with respiratory symptoms had inadequate baseline-pPA. Baseline-pPA and SAD prevalence are inversely related (odds ratio = 2.02, 95% CI: 1.15–3.57, P = .01). Inadequate serotype 3 antibody titer is highly associated with SAD (odds ratio = 2.02, 96% CI: 1.61–5.45, P < .01). The groups with inadequate pPA (Group B and C, or BC) had significantly higher percentage of patients with chronic rhinosinusitis (P < .001), allergic sensitization, and allergic rhinitis (P < .05). Group A contained higher percentage of patients with recurrent upper airway infections (P < .001).ConclusionLow baseline-pPA and low antibody titers to serotype 3 are highly associated with SAD, increased incidence of respiratory infections including CRS and allergic conditions.

Lung abscess caused by Streptococcus intermedius in an immunocompetent patient

Lung abscesses are most commonly polymicrobial, being caused by both anaerobic and aerobic bacteria, usually from the oral flora. A particular pathogen present in the oral flora, Streptococcus intermedius, has been known to cause aggressive pyogenic infections such as abscesses, most often on the soft tissues, liver and brain. Though less common, these infections can also occur in the lungs of immunocompetent individuals without preceding risk factors. In such cases, a presentation with productive cough and fever can be misdiagnosed as tracheobronchitis or pneumonia. We present the case of an immunocompetent patient without significant underlying risk factors, who was initially misdiagnosed as recurrent sinusitis, that was found to have a lung abscess due to S. intermedius infection.

Post Autologous Bone Marrow Transplant Associated With a Resultant Mixed Polyclonal/Monoclonal Hyper-IgG3.

There have been few studies illustrating the post immunological phenotype of patients receiving autologous bone marrow transplant (ABMT) for the treatment of diffuse large B-cell lymphoma. High-dose chemotherapy and autologous bone marrow transplantation have been shown to be the only potential curative treatment modalities for B-cell lymphoma. Autologous bone marrow transplantation, although widely utilized in patients with non-Hodgkin lymphoma recurrence, does have an association with immunologic side effects, although serologic changes where rarely reported unless accompanied by recurrent infections. We report the first case of a 62-year-old female patient who experienced recurrent infections, namely, sinusitis and pneumonia, after receiving an ABMT with subsequent hyper-IgG3 phenotype

Occupational Rhinitis: Classification, Diagnosis, and Therapeutics.

Occupational rhinitis (OR), an inflammatory disease of the nose, refers to any nasal symptoms reported to be work-related. The purpose of this review is to provide a current overview of the classification, diagnosis, and treatment of OR. Occupational rhinitis (OR) can further beclassified into allergic or non-allergic depending on the causative agent(s) and pathogenesis. Presenting symptoms are similar to non-OR including nasal congestion, anterior and posterior rhinorrhea, sneezing, and nasal itching. Despite its high prevalence in a spectrum of workplaces, OR is under reported as it is often considered a nuisance rather than a potential precursor to occupational asthma (OA). The diagnosis of OR is obfuscated as it is difficult to determine if this condition was caused by environmental determinants in or outside the workplace. Furthermore, workers may have a pre-existing history of allergic or non-allergic rhinitis leading theclinician and worker to overlook inciting agents in the workplace. In this case, a diagnosis ofOR is still possible depending on the exposures but must be differentiated from work-exacerbated rhinitis. Further complicating the diagnosis of OR is the lack of evidence-based research focused on this condition as it is often trivialized due to the perception that it has an insignificant impact on the worker's health. The reality is that OR can have a significant impact on the worker's quality of life and is associated with a number of comorbidities including occupationalasthma, recurrent sinusitis, headaches, eustachian tube dysfunction, and sleep disorders similar to non-occupational rhinitis. However, one significant difference between these disorders is that workers diagnosed with OR are eligible for worker's compensation. Treatment of OR involves avoidance of the inciting agent(s) and medications similar to those used to treat non-OR conditions. This review summarizes recent progresses on the etiology, risk factors, diagnosis, and therapy of OR. In addition, suggested areas of further research with potential targets for modifications in the workplace environment as well as therapeutic interventions will be discussed.

Nasal polyps and rhinosinusitis.

Rhinosinusitis is defined as inflammation of one or more of the paranasal sinuses and affects approximately 12% of the population. Acute rhinosinusitis is defined as symptoms that last < 12 weeks, and chronic rhinosinusitis (CRS) is defined as symptoms that last > 12 weeks. CRS is divided into three groups: CRS with nasal polyps (CRSwNP), CRS without nasal polyps (CRSsNP), and allergic fungal rhinosinusitis. Nasal polyps are inflammatory outgrowths of paranasal sinus mucosa caused by chronic mucosal inflammation and are present in 20% of patients with CRS. Nasal polyps typically present with nasal congestion, nasal obstruction, and anosmia or hyposmia, and occur more frequently in patients with persistent asthma, aspirin-exacerbated respiratory disease (AERD), CRS, and cystic fibrosis. The sinus cavities are lined with pseudostratified ciliated columnar epithelial cells interspersed with mucous goblet cells. Cilia continuously sweep the mucous toward the ostial openings and are important in maintaining the proper environment of the sinus cavities. The frontal, maxillary, and anterior ethmoid sinuses drain into the ostiomeatal unit of the middle meatus. The posterior ethmoid sinuses and superior sphenoid sinuses drain into the sphenoethmoid recess of the superior meatus. Most acute sinus infections are caused by viruses, and, therefore, it is not surprising that the majority of patients improve within 2 weeks without antibiotic treatment. A bacterial infection should be considered if symptoms worsen or fail to improve within 7-10 days. Combining an intranasal corticosteroid with an antibiotic reduces symptoms more effectively than antibiotics alone. Topical nasal steroids are the treatment of choice for nasal polyps. They significantly decrease polyp size, nasal congestion, and rhinorrhea, and increase nasal airflow. Short courses of oral steroids may be needed to reduce polyp size, followed by maintenance therapy with topical steroids. Surgery is reserved for patients in which polyps cause severe obstruction or recurrent sinusitis and for patients for whom medical therapy has failed. Aspirin desensitization may decrease the requirement for polypectomies and sinus surgery in patients with AERD.

A combined staged novel approach for reconstruction of persisting Oro-antral fistulae defects utilizing tripled layer closure and open sinus lifting

This study aimed to assess the clinical outcome of a designated approach purpose to reconstruct large oro-antral fistulae combining tripled layer soft tissue closure along with later sinus lifting and bone grafting. The study constituted of three non-smokers male patients, which were subjected to failed previous surgical closures of large oro-antral fistulae, with a subsequent maxillary sinus infection and morbid vascular bed. After definite eradication of the persisting infection, the large communications were planned to be restored by three soft tissue flaps, the first of which based on utilizing the dense epithelial fistulous sinus tract, which was crafted, instead of being eliminated and adapted to the underlying bony defect to represent a shield that sealed the defect, obliterated the dead space, withstood the postoperative fluid overload and supported the overlying pedicled fat pad and the buccal advancement flap, which represented the second and third layers of closure. Three months later, open sinus lifting and bone grafting of the defects were carried out. Although two patients complained significant postoperative pain, limitation of mouth opening and swelling, all the reconstructed defects healed uneventfully, none of them revealed postoperative infection, wound dehiscence or relapse throughout the investigation period, and the patients neither exhibited any sign of recurrent maxillary sinusitis nor graft failure, furthermore, C.B.C.T. six months postoperatively, demonstrated that the reconstructed defects are well organized to receive proper sized dental implants. The authors recommend implementing this study over a broadened sample size, as this study was restrained by the small number of participants.