Sinus Cultures Research Articles

Contemporary Update on the Microbiology of Paranasal Sinusitis

Background: Sinusitis, whether acute or chronic, is likely due at least in part to disruptions in the microbiota of the paranasal sinuses. Sinus cultures are often employed to guide medical treatment. Objective: To quantify the contemporary microbiology of the paranasal sinuses and better understand the utility of paranasal sinus cultures. Methods: We identified patients from 2018 to 2019 with sinus cultures taken by an otolaryngologist in the outpatient setting in our healthcare system with a concurrent diagnosis of acute or chronic rhinosinusitis. These cultures were analyzed based on their culture type and result. The most commonly isolated bacteria were further analyzed by species; Staphylococcus resistance patterns were analyzed as well. Results: A total of 2302 culture samples were collected: 2012 (87%) bacterial, 287 (13%) fungal, and 3 (0.1%) mycobacterial cultures. The results of more than half (1142, 57%) of these bacterial cultures were positive for a named genus, while those of 592 (29%) were positive for normal sinus flora and 16 (0.8%) for normal oral flora, and those of 183 (9%) showed no growth. The results of another 79 (4%) bacterial cultures were positive for unnamed bacteria, which were not further classified (e.g., Gram-negative rods). Of the positive bacterial cultures with named genera, the most common genera identified was Staphylococcus (383, 34%). Of these, the most common species of Staphylococcus was S. aureus (311, 81%), 42 of which (14%) showed methicillin resistance (MRSA). Of the fungal cultures, 265 (92%) resulted in no growth, and all three mycobacterial cultures showed no growth. Conclusions: In contrast to fungal cultures, the majority (57%) of sinus bacterial cultures showed positive results, with the identification of a named genus, highlighting the potential utility of this assay in guiding medical therapy.

Biofilm-producing Bacteria and Quality of Life after Endoscopic Sinus Surgery in Patients with Chronic Rhinosinusitis with Nasal Polyposis.

Chronic rhinosinusitis (CRS) is one of the most common health disorders in humans and has a major impact on health-related quality of life (HRQoL). Of the many factors contributing to the etiology of CRS, less is known about the correlation between CRS and bacterial biofilms and their impact on HRQoL. The aim of this prospective study was to investigate the relationship between biofilm-producing bacteria and patients' objective findings and HRQoL. Forty-eight patients with CRSwNP were enrolled in a 12-month prospective study. The Lund-Mackay (LM) CT and endoscopic Lund-Kennedy (LK) scores were obtained before endoscopic sinus surgery (ESS), and patients completed the HRQoL instruments: the 22-item Sinonasal Outcome Test (SNOT-22), the 36-item Short Questionnaire (SF-36), and the visual analog scale (VAS). A sinus culture was obtained at ESS, bacteria were isolated, and in vitro quantification of the biofilm was performed. The LK score and HRQoL were determined postoperatively at months 1, 3, 6, and 12. The most common bacterial isolates in patients with CRSwNP were Staphylococcus aureus (28%), coagulase-negative staphylococci (52%), and Pseudomonas aeruginosa (8%). Preoperatively, the highest LM and LK scores were found in patients with strong biofilm producers. Postoperative LK scores were significantly reduced in all patients. Postoperative VAS scores were significantly reduced from month 1 to month 12 postoperatively. Patients with strong biofilm producers had significantly worse nasal blockage, secretion, headache, facial pressure and pain, and loss of smell preoperatively, compared to patients with low biofilm producers. The most significant reduction in preoperative scores SNOT-22 and SF-36 (excluding physical functioning) was seen in patients with S. aureus and P. aeruginosa. Patients with strong biofilm producers had higher LK and LM scores preoperatively, and greater improvement in LK and HRQoL scores postoperatively. Microbiologic surveillance of all CRS patients is recommended.

SAT058 Diabetes Complicated By DKA, Mucormycosis And Covid-19

Abstract Disclosure: A. Gordon: None. Background: Mucormycosis is an invasive opportunistic fungal infection, that although rare, has an estimated all-cause mortality of 54%. Even with aggressive treatment, significant tissue necrosis and bone destruction can occur. Risk factors include diabetes, acidosis (as in diabetic ketoacidosis), excess iron, transplant, malignancy, kidney and liver disease, immunosuppressant and corticosteroid use - and in more recent times, the Covid-19 infection. We present a case of invasive rhino-orbital cerebral mucormycosis in the setting of DKA, uncontrolled diabetes and Covid-19. Case: A 60-year-old female with history of uncontrolled type 2 diabetes (HbA1c 14.3%) presented after being found unresponsive. Her exam was significant for encephalopathy, complete left eye ophthalmoplegia and right-sided hemiparesis. She was hemodynamically stable without fever. Initial labs showed significant hyperglycemia with an elevated anion gap and beta-hydroxybutyrate indicative of diabetic ketoacidosis (DKA). She had a lumbar puncture which showed leukocytosis with neutrophilia (146 WBC, 39% neutrophils), elevated glucose and normal protein; CSF culture was negative for growth. She also tested positive for Covid-19 although CXR was unremarkable and she did not require treatment. Initial CT/CTA head/neck showed complete occlusion of the left cervical internal carotid artery with associated acute/subacute infarcts in the left frontal, parietal, temporal and occipital lobes. CT sinuses showed severe frontal, maxillary and ethmoid sinus mucosal wall thickening with left premaxillary soft tissue swelling and leftward nasal septum deviation. Finally, orbital imaging showed left cavernous sinus thrombosis, left superior ophthalmic vein thrombosis, and necrosis vs devascularization of the extraocular muscles. She was initially treated with fluids, an insulin infusion and broad-spectrum antibiotics and was evaluated by neurology, ophthalmology, infectious disease and otolaryngology. She underwent surgical debridement with left maxillary antrostomy, left total ethmoidectomies and septoplasty. Sinus cultures were positive for MSSA (methicillin sensitive staph aureus) and tissue pathology showed angioinvasive fungal disease compatible with Mucor/Rhizomucor species. Antimicrobial coverage was changed to intravenous Nafcillin and Amphotericin B, and she underwent further surgical debridement twice more. Repeat brain imaging to evaluate for disease progression is pending. Discussion: Early detection and aggressive treatment of Mucormycosis with surgical debridement and Amphotericin B can improve patient outcomes, however the mortality rate is still significant. Therefore, tight glycemic control in high risk groups is imperative, particularly in those with uncontrolled diabetes complicated by DKA and Covid-19 infection (with or without steroid treatment). Presentation: Saturday, June 17, 2023

C2 (Clinical Case) Complicated Sinusitis in an Adolescent Swimmer in the COVID-19 Pandemic: An Unexpected Microbial Player

Abstract Introduction/Background There are increasing reports of complicated sinusitis following post-pandemic viral surges. Streptococcus anginosus and Staphylococcus aureus (SA) are common causes. However, unusual pathogens may need to be considered in the face of inadequate therapeutic response. Case Description A previously healthy 13-year-old boy presented with fever, facial pain, and headache two weeks following presumed COVID-19 infection based on exposure history and symptoms. While recovering, he had been swimming daily and recalled inhaling pool water. On examination he was febrile with a tender mid-forehead swelling and left periorbital swelling without features of orbital cellulitis. There was no meningism or focal neurological deficits. Investigations revealed leukocytosis (19.1 x109/L), elevated CRP (156.8 mg/L) and sterile blood cultures. Head imaging confirmed sinusitis complicated by Pott’s puffy tumor, a small subdural empyema and sinus venous thrombosis. Ceftriaxone, metronidazole, and vancomycin were initiated with de-escalation of the latter to cloxacillin after sinus cultures grew methicillin-sensitive SA. Despite broadening to meropenem and vancomycin, he progressed to develop cerebritis. Legionella species identified from intracranial sampling using 16s RNA, allowed targeted therapy with levofloxacin and successful resolution after six weeks of therapy. Discussion The development of this patient’s Pott’s puffy tumor and intracranial complications seemed consistent with post-viral sinusitis in terms of onset and growth of SA. However, his inadequate response to broad-spectrum therapy and sterile cultures from intracranial sampling prompted request for 16sRNA testing. Subsequent disclosure of freshwater swimming exposure with aspiration event raised concerns for water-borne pathogens such as Legionella. The aspiration event occurring in presence of persisting congestion, resulted in Legionella species seeding already inflamed sinuses and further tracking intracranially. Without special cultures required to recover Legionella, this pathogen was initially missed, resulting in disease progression and delayed targeted therapy. Fluroquinolones or macrolides are required for treatment of this pathogen. Conclusion Given that post-viral sinusitis may be anticipated during viral surges, practitioners should consider the role of waterborne pathogens in hosts with significant swimming exposure who worsen on usual therapy. Microbiology and infectious diseases involvement is encouraged to optimize detection and management of waterborne infection. Practitioners are reminded that in the face of therapeutic failure, it is critical to revisit the history for unusual exposures, determine immunocompetence, and explore potential bug-drug mismatch.

Sinus culture differences in patients with radiographic evidence of odontogenic disease

PurposeOdontogenic sinusitis is a well-known entity with a different pathogenesis than chronic rhinosinusitis. Nonspecific symptoms can make diagnosis difficult. This study aims to compare culture results between patients with and without computed tomography findings indicative of possible odontogenic disease. Materials and methodsThis was a retrospective cohort study in which patients undergoing endoscopic sinus surgery for chronic sinusitis over a three-year period at a single institution were reviewed. CT imaging was reviewed for evidence of dental disease, specifically periapical lucency, dehiscence of the floor of the maxillary sinus, oroantral fistula, or foreign body. Culture results were then assessed and compared between groups with CT evidence of a possible odontogenic source to those without. ResultsOverall, 231 patients were evaluated. 92 patients (39.8 %) were found to have evidence of a likely odontogenic source on CT. Cultures were available for 118 of 231 patients (51.1 %). Patients with CT signs of odontogenic disease were significantly more likely to grow Proteus mirabilis (p = 0.018) and Klebsiella pneumoniae (p = 0.037) on culture. Patients without CT signs of odontogenic sources were significantly more likely to grow Pseudomonas aeruginosa (p = 0.009). Of note, patients with CT findings concerning for an odontogenic source were also more likely to grow fungi other than Aspergillus and Mucor species on culture (p = 0.004). ConclusionPatients with CT findings concerning for an odontogenic source of sinus disease showed differences in culture results that could be important in differentiating pathogenesis of sinus disease.

Otorhinologic Disorders in 22q11.2 Deletion Syndrome.

Investigate incidence and natural history of otologic and sinonasal disease associated with 22q11.2 deletion syndrome. Case series. Tertiary care children's hospital. Charts from consecutive children born 2000 to 2018 with a diagnosis of 22q11.2 deletion, DiGeorge, or velocardiofacial syndrome based on the International Classification of Diseases (ICD)-9 and ICD-10 codes were reviewed. Otologic and rhinologic diagnoses and surgeries and immune and microbiologic laboratory findings were collected from the medical record. After the exclusion of patients with no 22q11.2 deletion (n = 101), otologic care at an outside hospital (n = 59), and loss to follow-up prior to 3 years of age (n = 22), 128 were included. Males comprised 80 (62.5%) patients, 115 (89.8%) were white, and the median age at genetic confirmation of 22q11.2 deletion was 119 days (range 0 days to 14.6years). Recurrent acute otitis media (RAOM), chronic otitis media with effusion, chronic rhinosinusitis, and recurrent acute sinusitis were diagnosed in 54 (42.2%), 37 (28.9%), 10 (7.8%), and 8 (6.3%), respectively. Tympanostomy tubes were placed in 49 (38.3%). Adenoidectomy and sinus surgery were performed in 38 (29.7%) and 4 (3.1%), respectively. Neither immunoglobulin nor cluster of differentiation deficiency increased the odds of RAOM diagnosis, tympanostomy tube placement, or chronic/recurrent sinusitis. Methicillin-resistant Staphylococcus aureus was the most common organism in sinus cultures (4/13, 30.8%). Streptococcus pneumonia dominated otorrhea cultures (11/21, 52.4%). Approximately half of children with 22q11.2 deletion may experience otologic disease that often requires surgical management. Future studies will utilize a larger cohort to examine the role of immunodeficiency in otologic and rhinologic disease in this population.

Microbiology of Maxillary Sinus Infections: Systematic Review on the Relationship of Infectious Sinus Pathology with Oral Pathology

The main objective of this systematic review was to evaluate the microbiology of maxillary sinus infections and to determine whether an odontogenic origin of the infection can be established. The PIE question posed was the following: In patients with sinus and dental symptomatology who come for ENT or dental assessment and who undergo a microbiological study of the maxillary sinus and are found to have infectious sinus pathology, is the infectious sinus pathology related to an odontogenic origin? The literature review was carried out in PubMed, Web of Science, and the Cochrane Library. A total of 2769 articles were identified in the three databases used. Inclusion and exclusion criteria were applied, and after eliminating duplicates, 55 full-text publications were identified as suitable for inclusion. After reading this series of publications, four articles were excluded due to lack of data in the article. Finally, 51 studies were included in the qualitative analysis. In this study, the microorganisms were classified into three groups: group 1 (microorganisms of the oral microbiome related in the literature to oral pathology, namely caries and periodontal disease), group 2 (microorganisms found in the oral microbiome but not related to oral disease), and group 3 (microorganisms not identified in the microbiome). This review included 51 articles and a total of 6415 patients who underwent surgery in 7051 sinuses. Most sinus infections were caused by group 2 (63.51%) or group 1 (24.21%) bacteria. Within group 1, the most frequent bacteriological agents in sinus infections were Peptostreptococcus spp. (35.22%) and St. Viridans spp. (39.89%). In group 2, the most frequent bacteriological agents in sinus infections were H. influenzae (29%) and Streptococcus spp. (23.63%). In group 3, the most frequent cause of sinusitis of dental origin was dental caries, followed by foreign bodies (implants) and sinus elevation. Different studies have shown that certain species of bacteria isolated from maxillary sinus cultures are more frequently associated with rhinosinusitis of odontogenic origin. The results of this systemic review show that, among the bacterial species most frequently found, anaerobic species predominate over aerobic species, especially Peptostreptococcus and Staphylococcus aureus, which are part of the oral microbiome, suggesting an odontogenic origin of maxillary sinus infection. Therefore, bacterial cultures of maxillary sinus aspirate can be of great use to clinicians in the differential diagnosis of odontogenic sinusitis.

Associations of Microbial Diversity with Age and Other Clinical Variables among Pediatric Chronic Rhinosinusitis (CRS) Patients.

Chronic rhinosinusitis (CRS) is a heterogenous disease that causes persistent paranasal sinus inflammation in children. Microorganisms are thought to contribute to the etiology and progression of CRS. Culture-independent microbiome analysis offers deeper insights into sinonasal microbial diversity and microbe-disease associations than culture-based methods. To date, CRS-related microbiome studies have mostly focused on the adult population, and only one study has characterized the pediatric CRS microbiome. In this study, we analyzed the bacterial diversity of adenoid tissue, adenoid swab, maxillary sinus, and sinus wash samples from 45 pediatric CRS patients recruited from the Johns Hopkins All Children's Hospital (JHACH) in St. Petersburg, FL, USA. The alpha diversity in these samples was associated with baseline nasal steroid use, leukotriene receptor antagonist (LTRA) use, and total serum immunoglobulin (Ig) E (IgE) level. Streptococcus, Moraxella, and Haemophilus spp. were most frequently identified from sinus cultures and the sequenced 16S rRNA gene content. Comparative analyses combining our samples with the samples from the previous microbiome study revealed differentially abundant genera between patients with pediatric CRS and healthy controls, including Cutibacterium and Moraxella. Additionally, the abundances of Streptobacillus and Staphylococcus were consistently correlated with age in both adenoid- and sinus-derived samples. Our study uncovers new associations of alpha diversity with clinical parameters, as well as associations of specific genera with disease status and age, that can be further investigated.

Inflammatory endotype of odontogenic sinusitis.

Odontogenic sinusitis (ODS) is distinct from non-odontogenic rhinosinusitis with regard to clinical features as well as diagnostic and therapeutic approaches. While numerous studies have explored immune profiles of chronic rhinosinusitis, very few studies have explored the inflammatory endotype of ODS. Odontogenic sinusitis was diagnosed by confirming infectious sinusitis adjacent to infectious maxillary odontogenic pathology. Maxillary sinus cultures and mucosal biopsies were obtained during endoscopic endonasal surgery in ODS and control patients. Controls were patients undergoing endoscopic skull base surgery with no sinus disease. Specimens were snap frozen in liquid nitrogen and stored at -80°C. Analysis was performed using a multiplex assay to measure Th-1 (TNFα, IFNγ, IL-2,12,18), Th-2 (IL-4,5,9,13), Th-17 (IL-17A,17F,22), and innate (CCL5,CXCL9,CXCL10, IL-6,8,10,12,23,27) immune pathways. Groups were compared via independent sample t-tests; if assumptions were violated, nonparametric Wilcoxon ranked sum tests were performed. Specimens from 22 ODS patients were compared to nine controls. ODS mucosal tissue was sampled in the setting of the following dental pathologies: post-dental extraction (n=15), untreated apical periodontitis (n=2), apical periodontitis after root canal therapy (n=2), and maxillary sinus bone grafting with or without dental implantation (n=3). The following cytokines were significantly elevated in ODS compared to controls: IFNγ, TNFα, IL-6, 8, 10, 27, and CXCL9. IL-17 levels were similar in both ODS and controls. Therefore, ODS demonstrated heightened innate and Th1 immune activity. ODS demonstrated both innate immune and Th1 inflammatory endotypes. Further studies are needed to explore ODS immunopathobiology and its potential impact on ODS management.

Diagnostic Value of Middle Meatal Cultures versus Maxillary Sinus Culture in Acute and Chronic Sinusitis: A Systematic Review and Meta-Analysis.

Background: To assess the diagnostic utility of middle meatal culture (MMC) in patients with acute and chronic sinusitis; Methods: Six databases were thoroughly reviewed up to March 2022. Sensitivity, specificity, and negative and positive predictive values were extracted. Methodological quality was evaluated using the QUADAS-2 instrument; Results: Fifteen reports were analyzed. MMC results exhibited a significant correlation (r = 0.7590, 95% confidence interval [CI] [0.6855; 0.8172], p < 0.0001) with those of maxillary sinus puncture. The diagnostic odds ratio (DOR) of MMC (reference = maxillary sinus culture) was 8.5475 [3.9238; 18.6199]. The area under the summary receiver operating characteristic curve was 0.761. The sensitivity and specificity of MMC were 0.7759 [0.6744; 0.8526] and 0.7514 [0.6110; 0.8534], respectively. We performed subgroup analysis based on age (children vs. adults), duration of disease (acute vs. chronic), and specimen collection method (biopsy, swabs, suction tips). The DORs, specificities, and negative and positive predictive values varied significantly. Diagnostic accuracy was highest for children and individuals with chronic disease, and when samples were collected via suction.; Conclusions: MMC provided fair diagnostic accuracy in patients with acute or chronic sinusitis. Although some institutional differences were evident, the middle meatal and maxillary sinus culture results were similar.

Differing rates of fungi in sinonasal cultures from pediatric sinusitis patients

ObjectivesPediatric chronic rhinosinusitis (PCRS) is a unique clinical entity and the underlying source of inflammation is unknown. Certain subgroups, such as children with nasal polyps and cystic fibrosis (CF) sinusitis are often recalcitrant to standard medical PCRS treatments that target bacterial inflammation. Fungal infection and allergy to fungal proteins drive inflammation in other airway diseases, resulting in chronic inflammation of both the upper and lower airways. However, there is limited understanding of the role of fungi in the pathophysiology of PCRS. The objective of this study is to define the frequency of fungal infection in pediatric CRS patients, hypothesizing that certain subgroups may have more frequent positive fungal sinus cultures than other subgroups of pediatric sinusitis. MethodsRetrospective study of patients undergoing sinus surgery at a tertiary care pediatric hospital to determine the period prevalence of positive fungal cultures in subgroups of patients. Results400 children from 2012 to 2019 were included. 265 patients had surgical culture results available. Of the 52 patients with CF 11 (21%) had positive fungal sinus cultures. Similarly, 28% of the 25 patients with non-CF nasal polyps had positive cultures. Only 8.2% of 110 CRS without polyps patients had positive cultures, significantly fewer than other subgroups (X2 (1, N = 240) = 17.22, p < 0.01). ConclusionChildren with CF and children with nasal polyps had more frequent positive fungal cultures than children without nasal polyps having sinus surgery. This confirms that pediatric CF and pediatric CRS with polyps represent unique populations to study the impact of fungal infection in CRS. Further research is required to determine if these fungi represent colonization or contribute to the inflammatory environment of the airways.

Odontogenic sinusitis: A state‐of‐the‐art review

Odontogenic sinusitis (ODS) is more common than historically reported, and is underrepresented in the sinusitis literature. ODS is distinct from rhinosinusitis in that it is infectious sinusitis from an infectious dental source or a complication from dental procedures, and most commonly presents unilaterally. ODS clinical features, microbiology, and diagnostic and treatment paradigms are also distinct from rhinosinusitis. ODS evaluation and management should generally be conducted by both otolaryngologists and dental providers, and clinicians must be able to suspect and confirm the condition. ODS suspicion is driven by certain clinical features like unilateral maxillary sinus opacification on computed tomography, overt maxillary dental pathology on computed tomography, unilateral middle meatal purulence on nasal endoscopy, foul smell, and odontogenic bacteria in sinus cultures. Otolaryngologists should confirm the sinusitis through nasal endoscopy by assessing for middle meatal purulence, edema, or polyps. Dental providers should confirm dental pathology through appropriate examinations and imaging. Once ODS is confirmed, a multidisciplinary shared decision‐making process should ensue to discuss risks and benefits of the timing and different types of dental and sinus surgical interventions. Oral antibiotics are generally ineffective at resolving ODS, especially when there is treatable dental pathology. When both the dental pathology and sinusitis are addressed, resolution can be expected in 90%–100% of cases. For treatable dental pathology, while primary dental treatment may resolve the sinusitis, a significant percentage of patients still require endoscopic sinus surgery. For patients with significant sinusitis symptom burdens, primary endoscopic sinus surgery is an option to resolve symptoms faster, followed by appropriate dental management. More well‐designed studies are necessary across all areas of ODS.

Pantoea dispersa rhinosinusitis: clinical aspects of a rare sinonasal pathogen.

There is no report in the literature targeting the role of Pantoea dispersa in rhinosinusitis and P. dispersa has not been identified as a commensal bacterium in the sinonasal cavity. We aimed to investigate the role of P. dispersa in rhinosinusitis. We retrospectively reviewed the data of patients diagnosed with rhinosinusitis at a medical center in Taiwan. A total of 274 rhinosinusitis patients underwent sinus culture between July 2017 and July 2019. All 23 patients with acute P. dispersa rhinosinusitis experienced purulent rhinorrhea; three (13%) had nasal obstruction, but none had olfactory dysfunction, facial pressure/pain and nasal polyp. The patients with P. dispersa received a significantly shorter duration of antibiotic treatment (19.9 ± 2.6 vs. 28.9 ± 2.5days, P = 0.015) and had lower surgery rate (0% vs. 16.7%, P = 0.043) than other patients. Patients with olfactory dysfunction were more likely to receive surgical treatment (P = 0.018). Acute rhinosinusitis caused by P. dispersa resulted in less surgical interventions and shorter treatment durations. Olfactory dysfunction may imply longer course and possibility for surgical intervention in chronic rhinosinusitis. The present study revealed that P. dispersa had the potential to colonize in human sinonasal cavities and cause rhinosinusitis.

The Bacteriology of Middle Meatus and Ethmoid Sinuses in Chronic Rhinosinusitis: Epidemiological Analysis and Surgical Impact.

The aim of this study was to explore the difference between sinus bacteriology in chronic rhinosinusitis patients with and without nasal polyposis. We also analyzed the possible differences in culture results from swabs taken from the middle meatus versus the ethmoid sinus. Retrospective chart review of adult chronic rhinosinusitis patient data from the year 2006 to 2020. Nasal swabs were taken under endoscopic guidance either intraoperatively from either the ethmoid sinus or middle meatus, or in the outpatient clinic from the middle meatus. The results were categorized based on the most common microorganisms affecting the nose and sinuses. We found that, the presence of nasal polyps seemed to have no effect on sinus bacteriology as whole. There was also no significant difference between the bacteriology of chronic rhinosinusitis patients who did not need surgery and those who did. Finally, we found that middle meatal cultures, taken endoscopically, give similar bacteriology results to that of ethmoid sinus cultures (taken intraoperatively). Middle meatal culture results accurately represent true sinus flora, and therefore can be used to aid in appropriate culture guided antibiotic therapy for patients visiting the outpatient clinic.

Endoscopic Sinus Surgery for Cystic Fibrosis: Variables Influencing Sinonasal and Pulmonary Outcomes.

Endoscopic sinus surgery is a well-established treatment for chronic rhinosinusitis in patients with cystic fibrosis, though its benefits seem to be limited to improving sinonasal symptoms rather than affecting lung function. This study aims to identify clinical and demographic factors that may influence sinonasal and pulmonary outcomes after surgery. This is a six-year retrospective analysis of adult cystic fibrosis patients who underwent endoscopic sinus surgery at a tertiary care center. 22-Item Sino-Nasal Outcomes Test scores and mean forced expiratory volume data at baseline and three to six months after surgery were analyzed using t-test and stepwise regression with the following covariates: age, gender, lung transplant, revision surgery, and pseudomonas on sinus culture. 119 surgeries were performed on 88 patients, with 69% on patients with transplant. The overall mean (Standard Deviation) improvement in 22-Item Sino-Nasal Outcomes Test score was 9.42 (18.15) for the entire cohort (P < .001). Pseudomonas on culture was associated with less improvement in sinonasal scores (P = .002). There was no significant change in forced expiratory volume after surgery (P = .94). Revision surgery (P = .004) and older age (P = .007) were associated with less favorable change of pulmonary function on stepwise regression (P = .002). There was no correlation between change in sinonasal scores and pulmonary function. Although surgery was associated with a clinically and statistically significant improvement in sinonasal scores in cystic fibrosis patients, patients with pseudomonas may experience less benefit. Revision surgery and older age may be associated with less favorable pulmonary outcomes. Awareness of such variables may help when deciding which cystic fibrosis patients should undergo surgery.

Isavuconazonium Sulfate Use in Multi-Modal Management of Invasive Mucormycosis in Four Pediatric Allogeneic Hematopoietic Cell Transplant Patients.

Prolonged neutropenia increases the risk for lethal invasive fungal infections (IFIs) such as those caused by Rhizopus species. Isavuconazonium sulfate is a new triazole that lacks pediatric dosing recommendations. Clinical courses of 4 pediatric patients with IFIs in the peri-allogeneic hematopoietic cell transplantation (alloHCT) period between 2015 and 2017 were reviewed. The reviews included previously unreported pharmacokinetic and safety data, and the IFIs included Rhizopus. Isavuconazonium sulfate was initiated with a loading dose followed by daily dosing, adjusted to a goal trough concentration of >3 mg/L based on adult literature. This target was achieved at a median of 7 days, demonstrating varying rates of metabolism. Renal insufficiency, electrolyte disturbances, and transaminitis were noted, although attribution was confounded by other alloHCT complications. One patient survived infection-free to hospital discharge and 1 of 3 deceased patients had evidence of an unresolved IFI (case 2). Case 2 was subtherapeutic for 39% of the duration of treatment, compared with others at an average of 29%, suggesting this target trough to be clinically relevant because case 2 demonstrated positive sinus and nasal cultures for Rhizopus on autopsy. We recommend initiation of isavuconazonium 10 mg/kg with a maximum dose of 372 mg. A loading dose of 10 mg/kg is used every 8 hours for 6 doses followed by 10 mg/kg dosing every 24 hours. Monitoring must continue beyond steady state. If early monitoring is not possible, we recommend a first drug level at week 3. If dose increases are required, a partial reload has been more successful instead of increasing daily doses. Further larger studies are needed to demonstrate optimum dosing in pediatric patients.

Longitudinal analysis of sinus microbiota post endoscopic surgery in patients with cystic fibrosis and chronic rhinosinusitis: a pilot study

BackgroundCystic fibrosis is a debilitating, autosomal recessive disease which results in chronic upper and lower airway infection and inflammation. In this study, four adult patients presenting with cystic fibrosis and chronic rhinosinusitis were recruited. Culture and molecular techniques were employed to evaluate changes in microbial profiles, host gene expression and antimicrobial resistance (AMR) in the upper respiratory tract over time.MethodsSwab samples from the sinonasal cavity were collected at the time of surgery and at follow-up clinics at regular time intervals for up to 18 months. Nucleic acids were extracted, and DNA amplicon sequencing was applied to describe bacterial and fungal composition. In parallel, RNA was used to evaluate the expression of 17 AMR genes and two inflammatory markers (interleukins 6 and 8) using custom qPCR array cards. Molecular results were compared with routine sinus and sputum culture reports within each patient.ResultsBacterial amplicon sequencing and swab culture reports from the sinonasal cavity were mostly congruent and relatively stable for each patient across time. The predominant species detected in patients P02 and P04 were Pseudomonas aeruginosa, Staphylococcus aureus in patient P03, and a mixture of Enterobacter and S. aureus in patient P01. Fungal profiles were variable and less subject specific than bacterial communities. Increased expressions of interleukins 6 and 8 were observed in all patients throughout the sampling period compared with other measured genes. The most prevalent AMR gene detected was ampC. However, the prevalence of AMR gene expression was low in all patient samples across varying time-points.ConclusionsWe observed a surprising degree of stability of sinonasal microbial composition, and inflammatory and AMR gene expression across all patients post sinus surgery.

Intranasal Application of Lactococcus lactis W136 Is Safe in Chronic Rhinosinusitis Patients With Previous Sinus Surgery.

Objective: Modulation of the dysbiotic gut microbiome with “healthy” bacteria via a stool transplant or supplementation is increasingly practiced, however this approach has not been explored in the nasal passages. We wished to verify whether Lactococcus lactis W136 (L. lactis W136) bacteria could be safely applied via irrigation to the nasal and sinus passages in individuals with chronic rhinosinusitis (CRS) with previous undergone endoscopic sinus surgery, and whether this was accompanied by bacterial community flora modification.Study Design: Prospective open-label pilot trial of safety and feasibility.Setting: Academic tertiary hospital center.Subjects and Methods: Twenty-four patients with CRS refractory to previous medical and surgical therapy received a 14-day course of BID sinus irrigations containing 1.2 × 109 CFU live L. lactis W136. Patients were monitored for safety using questionnaire, sinus endoscopy, otoscopy, UPSIT-40 smell testing, and endoscopically-obtained conventional sinus culture and a swab for 16S microbiome profiling.Results: All 24 patients receiving at least one treatment successfully completed treatment. L. lactis W136 probiotic treatment was safe, with no major adverse events or new infections. Treatment was associated with improvement in sinus symptoms, QOL, and mucosal scores, which remained improved during the subsequent 14-day observation period. Microbiome changes associated with treatment were limited to an increase of the pathobiont Dolosigranulum pigrum, a bacteria identified as potentially beneficial in the upper airways. Subgroup analysis suggested differences in microbiomes and responses for CRSsNP and CRSwNP phenotypes, but these did not attain significance.Conclusion: Intranasal irrigation of live L. lactis W136 bacteria to patients with refractory chronic rhinosinusitis was safe, and was associated with effects on symptoms, mucosal aspect and microbiome composition. Intranasal bacteria may thus find a role as a treatment strategy for CRS.Clinical Trials Registration: www.ClinicalTrials.gov. identifier: NCT04048174.

Comparison of bacterial maxillary sinus cultures between odontogenic sinusitis and chronic rhinosinusitis.

Bacterial odontogenic sinusitis (ODS) is distinct from other forms of rhinosinusitis. Diagnosing ODS can be challenging because of nonspecific clinical presentations and underrepresentation in the literature. The purpose of this study was to compare maxillary sinus bacterial cultures between patients with ODS and chronic rhinosinusitis (CRS), to determine whether certain bacteria are associated with ODS. This was a retrospective case-control study of 276 consecutive patients from August 2015 to August 2019 who underwent endoscopic sinus surgery (ESS) for bacterial ODS, CRS without nasal polyps (CRSsNP), or CRS with nasal polyps (CRSwNP). When present, pus was sterilely cultured from maxillary sinuses after maxillary antrostomy, and aerobic and anaerobic cultures were immediately sent for processing. Demographics and culture results were compared between ODS and CRS patients, and then separately between ODS and CRSsNP, and ODS and CRSwNP. ODS culture results were also compared between different dental pathologies (endodontic vs oroantral fistula). The following bacteria were significantly more likely in ODS compared to CRS: mixed anaerobes, Fusobacterium spp., Eikenella corrodens, Streptococcus intermedius, Streptococcus anginosus, and Streptococcus constellatus. Staphylococcus aureus and Pseudomonas aeruginosa were inversely related to ODS. There were no significant differences in cultures between the different dental pathologies. Certain bacteria were more likely to be associated with ODS compared to CRS when purulence was cultured from the maxillary sinus. Physicians should evaluate for an odontogenic source of sinusitis when these ODS-associated bacteria are identified in maxillary sinus cultures.

Simultaneous Orbital and Intracranial Abscesses in 17 Cases.

To describe the demographics, clinical presentation, treatment, and outcomes of a rare cohort with simultaneous orbital and intracranial abscesses. A historical cohort study of 17 patients with simultaneous orbital and intracranial abscesses between 2010 and 2018 was performed. The demographics, location of abscesses, treatment, and outcomes of these patients were analyzed. The mean age was 26.9 years (range 5-83 years). Fourteen patients (82%) were male. In this cohort, the most common orbital abscess location was the superior orbit, involved in 14 patients (82%). The most common site of intracranial abscess was the frontal lobe, involved in 16 patients (94%). Concurrent sinus disease was present in 16 patients (94%). Surgical evacuation was the standard of treatment, with 94% of patients undergoing at least one surgical procedure. Streptococcus species were the most common, isolated from 6 sinus cultures (43%), 3 orbitotomy cultures (21%), and 4 craniectomy cultures (36%). Staphylococcus species were also common. Most patients (94%) had stable or improved mental status and visual function at the conclusion of their treatment. Simultaneous orbital and intracranial abscesses are rare. Local invasion from the orbit into the intracranial space may occur from direct spread, thus superior orbital abscesses pose the greatest risk for intracranial spread. Additional factors such as infection with Streptococcus and Staphylococcus species as well as male sex appear to be risk factors for intracranial spread. For those who develop intracranial abscesses, young age and absence of seizures or altered mental status at presentation may be associated with favorable outcomes.