Refractory Sinusitis Research Articles

Powered Instrumentation in Dissection of the Frontal Recess

The use of powered instrumentation in functional endoscopic sinus surgery has become very popular due to its safety and thoroughness. An area which has been more problematic in the use of this technique has been the frontal recess, due to its anatomic location and associated risk of serious complications. We have done a number of powered dissections of the frontal recess as a surgical treatment of refractory frontal sinusitis, and find that it is extremely safe and effective. The ability of the powered devices to preserve normal mucosa allows an adequate surgical approach while significantly decreasing the postoperative risk of frontal recess stenosis and reocclusion. We feel that powered dissection of the frontal recess offers a significant advantage over standard techniques in this anatomic location.

Pilot study of outcomes in pediatric rhinosinusitis.

To determine outcomes achieved by treating refractory pediatric rhinosinusitis with a stepped protocol of additional antibiotics, adenoidectomy, and functional endoscopic sinus surgery (FESS). Prospective cohort with follow-up at 2 to 3 months and at 10 to 12 months. Hospital-based pediatric otolaryngology practice with community satellite offices. Consecutive 10-month sample of 41 children aged 2 to 13 years who met the following criteria: (1) roentgenographically documented sinusitis, (2) at least one 3-week course of a beta-lactamase stable antibiotic, (3) 3 months or more of clinical symptoms or three or more annual recurrences, (4) no obstructive adenoid hyperplasia, and (5) no cystic fibrosis. Fifteen children (37%) received additional antibiotics alone. Nonresponders underwent adenoidectomy (n = 10) when adenoids were present or FESS (n = 16) when adenoids were scant or if adenoidectomy did not provide relief (n = 2). Unblinded, oral survey of symptomatic response, caregiver expectations, and quality-of-life issues. Responses from the 12 survey questions were combined to produce a sinusitis response score. Caregiver expectations were met in 88% of children 1 year after treatment but were more often exceeded in patients undergoing FESS (50%) compared with those receiving antibiotics with or without adenoidectomy (13%). Functional endoscopic sinus surgery improved all major symptoms in 100% of children compared with 67% of those receiving antibiotics alone and 75% of those receiving antibiotics and undergoing adenoidectomy. In contrast, complete symptom resolution occurred in only 27% of patients, with no significant differences among groups. The median sinusitis response score of 84% was not associated with treatment level but was negatively associated with male gender. A stepped treatment approach to refractory sinusitis can improve quality of life for children and caregivers. Additional antibiotic therapy and adenoidectomy should be considered before FESS, even if the adenoids are nonobstructing.

Immunologic defects in patients with chronic recurrent sinusitis: Diagnosis and management

Twenty patients with chronic refractory sinusitis or rhinitis were identified to have immune defects on the basis of total immunoglobulin level, immunoglobulin G subclass, and vaccine response. Eight patients were immunoglobulin A deficient, five had low immunoglobulin levels with vaccine hyporesponse, and four had low immunoglobulin levels with normal vaccine responses. Three subjects showed isolated immunoglobulin G1 deficiency. Demographic variables such as age, sex, infection pattern, and any other related disorders were studied retrospectively, which may have contributed to the diagnosis. An immunologic screen was essential for the diagnosis of immunodeficiency in these patients. Treatment options included prophylactic antibiotics, management of associated allergies, functional endoscopic sinus surgery, and replacement therapy with immunoglobulin in selected patients. (OTOLARYNGOL HEAD NECK SURG 1995;112:242-7.)

Chronic Sinusitis as a Manifestation of Primary Immunodeficiency in Adults

Twenty-three adult patients evaluated at a university medical center for severe refractory sinusitis were found to have a primary immunodeficiency on the basis of total immunoglobulin, IgG subclass, and vaccine response determinations. The most common finding was IgG3 deficiency with antibody hyporesponsiveness to pneumococcal vaccine. Treatment options included prophylactic antibiotics and aggressive management of associated allergies with intravenous immunoglobulin reserved for severely affected patients who failed more conservative therapy.

Allergic Rhizomucor sinusitis

Summary Dr. Marc F. Goldstein : In conclusion, AFS is a benign noninvasive disease of the paranasal sinuses that can be caused by a variety of fungal organisms. This report highlights the first case of AFS caused by Rhizomucor . Recognition of AFS as a distinct clinicopathologic entity separate from other causes of clinical and radiographic sinusitis, especially invasive fungal sinusitis and neoplasm, is important. The clinical diagnosis of AFS needs to be considered in the differential diagnosis of chronic refractory sinusitis if surgical specimens are to be properly analyzed both histologically and microbiologically. Proper diagnosis is important to ensure optimal therapy, including surgical debridement and oral corticosterois. In addition, accurate diagnosis avoids the unnecessary use of antifungal drugs or radical surgical procedures or both.

The role of the immunologist in sinus disease

The clinical immunologist is playing an increasingly important role in the evaluation and management of sinus disease. Although most patients with sinus disease are not immunodeficient, a significant proportion of patients with chronic sinusitis unresponsive to medical and/or surgical therapy may have an immunodeficiency. Most immunodeficient patients for whom sinusitis is a major clinical problem tend to be those with humoral immunodeficiency diseases. The role of immunoglobulin replacement therapy is well established for patients with global immunoglobulin and antibody deficiencies (e.g., X-linked agammaglobulinemia and common variable immunodeficiency) and may be helpful in controlling refractory sinusitis in patients with more selective immunoglobulin deficiencies (e.g., IgG subclass deficiency and selective antibody deficiencies), but efficacy in these conditions remains to be established by controlled studies. Many immunodeficient patients have a history of repeated sinus surgery before the recognition of their immune defect. Even in immunodeficient patients treated with antibiotics and immunoglobulin replacement therapy, functional endoscopic sinus surgery is successful in only half of the patients.

Response to Pneumococcal Vaccine

I was disturbed to read in "Immunologic Defects in Patients with Refractory Sinusitis" by Shapiro et al that I was quoted as saying "a normal response to pneumococcal immunization was defined as a rise to more than 200 ng/mL for antigens 3, 7, 9, and 14." In both those references as well as many other publications from my laboratory, I indicate that by radioimmunoassay, the only technique which my laboratory uses, 200 to 300 ng of antibody N/mL is a normal preimmunization level.

In Reply: Response to Pneumococcal Vaccine

We regret any confusion concerning the definition of an adequate response to pneumococcal vaccine as defined in the article "Immunologic Defects in Patients with Refractory Sinusitis." The citation of Dr Schiffman's work in this area was intended to credit his research on the value of assessing pneumococcal responsiveness as an indication of immunologic integrity. Because we studied a sample of children and wished to focus on the lowest concentration of antibody that could be considered protective, we chose the value of 200 mg/L, citing the work of Lawrence, who looked at the percentage of children attaining this level after immunization, and noting that 97% and 98% for antigens 3 and 7, respectively, did so.

Immunologic Defects in Patients With Refractory Sinusitis

Sixty-one patients with chronic sinusitis who were referred for an allergy evaluation were evaluated for immunologic competence including assessment of quantitative serum immunoglobulin levels, IgG subclass levels, and response to pneumococcal and Haemophilus influenzae vaccines. In addition to chronic sinus disease, recurrent otitis media and asthma exacerbation were common problems in this group. Five patients had an elevated age-adjusted IgE level and 22 patients had positive prick tests to one or more environmental inhalants; these findings suggest an allergic component in this subgroup. Twelve additional patients had highly reactive intradermal tests to common environmental allergens, which also may be clinically significant for underlying atopy. Eleven patients had low immunoglobulin levels, 6 had low immunoglobulin levels and vaccine hyporesponsiveness, and 17 had poor vaccine response only. Thus, 34 of 61 patients with refractory sinusitis had abnormal results on immune studies, with depressed IgG3 levels and poor response to pneumococcal antigen 7 being most common. In addition to allergy, immunologic incompetence may be an important etiologic factor in patients with chronic, refractory sinusitis.

Microscopic antrostomies in children: a review of the literature in chronic sinusitis and a plan of medical and surgical treatment.

Potential complications, morbidity, treatment failures and "nasal cripples" make one cautious about advising radical sinus surgery. Though antibiotics have greatly reduced the need for radical surgery, some patients do not respond to conservative treatment. Reviewed is pertinent literature concerning treatment of chronic, refractory sinusitis in children, particularly intranasal antrostomy. Medical treatment for chronic sinusitis precedes surgical intervention. Allergic history, nasal cytology and radiographic examination are essential. Since principles of adequate surgical drainage and ventilation have long been established, controlled antrostomy procedure is done with the aid of the operating microscope, creating a nasal mucosal flap. A new instrument is presented---a self-retaining stabilized retractor speculum which allows adequate visualization with the microscope while protecting the mucosal flap and freeing both hands for the procedure.