CT characterization of developmental variations of the paranasal sinuses in cystic fibrosis

Pediatric Paranasal Sinuses- Development, Growth, Pathology & Functional Endoscopic Sinus Surgery

The paranasal sinuses (maxillary, frontal, ethmoid, and sphenoid sinuses) are complex anatomical structures. The development and growth of these have been investigated utilizing a number of different methods ranging from cadaveric analysis to modern cross sectional imaging with 3D modeling. An understanding of normal pediatric paranasal sinus embryology and development enables us to better determine when pathology may be affecting the normal developmental process. Cystic fibrosis, chronic sinusitis, deviated nasal septum and cleft lip and palate are some of the conditions which have been shown to effect paranasal sinus development to varying degrees. Functional endoscopic sinus surgery (FESS) is becoming increasingly common and an understanding of sinus anatomy together with when periods of rapid growth occur during childhood is important clinically. Although concerns have been raised regarding the impact of FESS on facial growth, there is limited evidence of this in regards to either changes in anthropomorphic measurements or clinical assessments of symmetry post operatively.

Increased Inflammatory Markers Detected in Nasal Lavage Correlate with Paranasal Sinus Abnormalities at MRI in Adolescent Patients with Cystic Fibrosis

Chronic rhinosinusitis (CRS) is a characteristic feature of cystic fibrosis (CF) multiorgan disease and develops early in the life of patients with CF. The study aimed to correlate the inflammatory markers and the presence of structural abnormalities detected by MRI in the paranasal sinuses of patients with CF. Methods: Nasal lavage and MRI of the paranasal sinuses was performed in a cohort of 30 CF patients (median age 14 y; range 7–20 y). Morphological abnormalities characteristic of CF were evaluated with a dedicated CRS MRI scoring system and correlated with different inflammation parameters measured in nasal lavage. Inflammation of the paranasal sinuses was positively associated with structural abnormalities in MRI. The concentration of the pro-inflammatory markers neutrophil elastase (NE) and the neutrophil elastase/alpha1-antitrypsin (NE/A1AT) complex correlated significantly with CRS-MRI sum score (p < 0.05, r = 0.416 and p < 0.05, r = 0.366, respectively). S. aureus infection was associated with the increased pro-inflammatory cytokine activity of IL-6 and IL-8, and increased levels of NE/A1AT complex in our patients (p < 0.05, respectively). CRS-MRI sum score and individual sinus MRI scores were positively associated with inflammatory activity as a sign of CRS pathology present in CF.

Assessment of variations in sphenoid sinus pneumatization in Indian population: A multidetector computed tomography study

Background and Purpose:

The purpose of our study was to assess the prevalence of variations in the extent of sphenoid pneumatization in the Indian population and compare with existing literature.

Materials and Methods:

This retrospective study included 500 patients who underwent CT of the paranasal sinuses. The multiplanar reformations of paranasal sinus were assessed for the type of pneumatization of the sphenoid sinus and type of clival, lateral recess, lesser wing, and anterior recess extensions.

Results:

The conchal, presellar, incomplete sellar, and complete sellar types comprised 0%, 1.2%, 22.2%, and 76.6% of patients. The extensions of pneumatization subtypes in the study population were clival in 76.6% subjects; lateral recess, lesser wing, and anterior recess in 59.7%, 20.4%, and 20.4% of sinuses, respectively. The pure forms were seen in 25.4% and combined forms in 61% of sinuses. The presellar type (1.2%) was less common and sellar type (98.8%) being common in our population compared to the Caucasian and East Asian population. The sphenoid sinuses were extensively pneumatized in our population compared to the Chinese and Caucasian population, the prevalence being 76.6%, 68%, and 44.5% for clival; 59.7%, 46%, and 28.3% for lateral recess; 20.4%, 32%, and 12% for lesser wing extension, respectively. The pure forms were relatively less common and combined forms being more common compared to the Chinese and Caucasian population in our study.

Conclusion:

The extent of pneumatization of the sphenoid sinus has clinical and surgical implications in sellar and central skull base lesions, and variability in different populations confirms that ethnicity influences the differences in prevalence.

Evaluation of the Association between Paranasal Sinus Osteomas and Anatomic Variations Using Computed Tomography

Objective:

The pathogenesis of paranasal sinus osteoma (PSO) has not been fully elucidated. It is thought that both embryological and developmental factors play a role in the etiology. The aim of the present study was to investigate the association of frequency and localization of PSOs detected on computed tomography (CT) examination with osteoma presence.

Methods:

In this retrospective study conducted in December 2017 through March 2020 in Gaziosmanpaşa University Faculty of Medicine, images of a total of 18,867 patients who underwent paranasal sinus, maxillofacial CT and brain CT angiography were reviewed for the presence of PSOs. Sizes of PSOs and accompanying mucosal pathologies were identified. Associations between PSOs and paranasal sinus variations were evaluated statistically compared to the control group (200 patients without PSO).

Results:

A total of 176 patients (0.92%) were found to have PSO. Average age of the patients with PSO was 59.9 years (range: 18–93). PSOs were unilateral in 152 patients while 24 patients had multiple osteomas. Female/male ratio was 1.1/1. PSOs were most commonly located in the frontal sinuses. Frequencies of vertical concha bullosa, secondary middle turbinate, twisted uncinate, supraorbital ethmoid cell, intersinus septal cell, ethmoidomaxillary cell, Haller’s cell, frontal sinus hypoplasia and sphenoid sinus hypoplasia were significantly higher in the patient group compared to the control group.

Conclusion:

Higher or lower incidence rates of some anatomic variations in the patients with PSO could be explained by the possible effects of genetic and/or environmental factor. Additional studies are needed to evaluate these possible associations.

The Risks of Complications During Endoscopic Sinus Surgery in Cystic Fibrosis Patients: An Anatomical and Endoscopic Study

OBJECTIVE/HYPOTHESIS

An increasing proportion of adult cystic fibrosis (CF) patients is being referred to endoscopic sinus surgery (ESS) in order to relieve the symptoms of chronic rhinosinusitis (CRS). Given that CFTR mutations profoundly alter sinonasal development, we want to explore the relationship between their peculiar surgical anatomy and the risk of postoperative complications.

STUDY DESIGN

Retrospective case-control study.

METHODS

Paranasal sinuses CT scans of 103 CF adult patients with CRS were compared to those belonging to a cohort of 100 non-CF adult patients to explore their anatomical differences. Secondly, CF and non-CF patients who received primary/revision ESS were analyzed in order to assess their preoperative CT scan in terms of surgically relevant variants, and according to the CLOSE checklist. Surgical outcomes were statistically compared in order to explore the differences between groups.

RESULTS

CF group presented more frequently with smaller and less pneumatized paranasal sinuses and a higher Lund-Mckay score compared with controls. No anatomical differences emerged in terms of genotype stratification. Non-CF CRS patients undergoing ESS showed a significantly deeper olfactory fossa and a more frequent supraorbital pneumatization compared to CF patients (P < .001 and P = .031, respectively). Whereas this latter group underwent more often aggressive surgical procedures (P = .001), no difference in terms of postoperative adverse events was found (P = .620).

CONCLUSIONS

Despite receiving more often aggressive ESS procedures, adult CF patients do not show an increased risk of postoperative complication and this may be linked to a different proportion of anatomical and surgically-relevant variants.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E2481-E2489, 2021.

The impact of ivacaftor on sinonasal pathology in S1251N-mediated cystic fibrosis patients

IMPORTANCE

Sinonasal symptoms in patients suffering from cystic fibrosis can negatively influence the quality of life and sinuses can be a niche for pathogens causing infection and inflammation leading to a decrease of lung function. Ivacaftor, a potentiator of the Cystic Fibrosis Transmembrane Conductance Regulator protein, has shown improvement in pulmonary function in cystic fibrosis patients with different forms of class III gating mutations. However, the effects of ivacaftor on sinonasal pathology have hardly been studied.

OBJECTIVE

To determine the impact of ivacaftor therapy on sinonasal pathology in patients with cystic fibrosis with an S1251N mutation.

DESIGN

Prospective observational mono-center cohort study, between June 2015 and December 2016.

SETTING

A tertiary referral center in Utrecht, The Netherlands.

PARTICIPANTS

Eight patients with cystic fibrosis with an S1251N mutation, treated with the potentiator ivacaftor were investigated.

EXPOSURES

Ivacaftor (Kalydeco, VX-770) therapy. Computed tomography imaging of paranasal sinuses. Nasal nitric oxide concentration measurements and nasal endoscopy.

MAIN OUTCOMES AND MEASURES

Primary outcome is opacification of paranasal sinuses examined with computed tomography scan analysis and scaled by the modified Lund-Mackay score before and one year after treatment. Secondary outcomes are nasal nitric oxide concentration levels, sinonasal symptoms and nasal endoscopic findings before and approximately two months and in some cases one year after treatment.

RESULTS

Computed tomography scan analysis showed a significant decrease in opacification of the majority of paranasal sinuses comparing the opacification score per paranasal sinus before and after one year of treatment with ivacaftor. Median nasal nitric oxide levels significantly improved from 220.00 (IQR:136.00-341.18) to 462.84 (IQR:233.17-636.25) (p = 0.017) parts per billion. Likewise, the majority of sinonasal symptoms and nasal endoscopic pathology decreased or resolved at two months after the use of ivacaftor.

CONCLUSION AND RELEVANCE

Ivacaftor appears to improve sinonasal outcome parameters and thereby sinonasal health in patients with cystic fibrosis with an S1251N mutation.

Sinus Development and Pneumatization in a Primary Ciliary Dyskinesia Cohort

Background

Primary ciliary dyskinesia (PCD) is a genetically diverse disease which causes impaired mucociliary clearance, and results in pulmonary, otologic, and rhinologic disease in affected patients. Genetic mutations in multiple genes impair the ability of patients to clear mucous from the lungs, middle ear, and sinonasal cavity and lead to chronic pulmonary and sinonasal symptoms.

Methods

We identified 17 PCD patients who had available CT scans. Volumes for bilateral maxillary, sphenoid, and frontal sinuses were calculated. A control population of patients who had preoperative CT scans for endoscopic endonasal resection of skull base pathology without sinonasal cavity involvement was also identified.

Results

The mean age of PCD was 33 and ranged from 13 to 54 years. Patients were age- and gender-matched to a control group that underwent resection of anterior skull-base tumors and had a mean age of 35 that ranged between 17–53 years old. The volumes for all thee sinus cavities were significantly smaller (p < 0.007) compared to the control population. The average Lund-Mackay score was 10.6 in the PCD cohort (range 6–16) in comparison to an average of 0.7 in the control cohort (range 0–2).

Conclusions

Overall sinus volumes were smaller in patients with PCD compared to our control population. Future studies will be aimed at understanding defects in sinus development as a function of specific genetic mutations in PCD patients. Ultimately, a better understanding of the underlying pathophysiology of PCD will allow us to identify the optimal treatment practices for this unique patient group.

Chronic rhinosinusitis in patients with cystic fibrosis-Current management and new treatments

OBJECTIVES

The purpose of this article is to provide a state-of-the-art review of the literature and summarize the latest publications on medical and surgical treatment of cystic fibrosis (CF) chronic rhinosinusitis (CRS), with an emphasis on describing recent advancements in cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapies.

METHODS

A comprehensive literature review was conducted utilizing the PubMed database with search phrases detailed within the body of the article. Abstracts were reviewed to include publications detailing medical, surgical, and CFTR modulating therapies for CF CRS. Findings from studies not previously reviewed and publications regarding CFTR modulators were emphasized.

RESULTS

No clear guidelines for treatment of CF CRS are available. Nasal saline rinses, topical steroids, topical antibiotics, and topical dornase alfa are reported medical therapies. Ivacaftor has some sinonasal symptomatic benefit. A new triple therapy CFTR modulator, elexacaftor/tezacaftor/ivacaftor, is capable of treating 90% of patients with CF and has shown the greatest FEV1 improvement of any CFTR modulator yet. There is no clear consensus on surgical indications or technique, though aggressive surgery in recalcitrant disease has shown some symptomatic benefit. Endoscopic sinus surgery after lung transplantation may benefit some patients in whom the sinuses serve as a reservoir for recurrent pulmonary infections by decreasing rates of bronchiolitis obliterans syndrome and improving 5 year survival.

CONCLUSION

As lifespan increases for patients with CF, further investigation into medical therapy, CFTR modulator sinonasal outcomes, and surgical technique and outcomes for CF CRS is needed.

LEVEL OF EVIDENCE

5.

Surgical Management of Chronic Rhinosinusitis in Cystic Fibrosis

Cystic fibrosis patients frequently develop chronic rhinosinusitis as a result of their propensity to form inspissated mucus and impairment of mucociliary clearance. They exhibit variable symptom burden even in the setting of positive radiographic and endoscopic findings. Current evidence suggests a positive effect of managing sinonasal disease on pulmonary health. Topical antimicrobial and mucolytic therapies are frequently required to manage the disease with surgery reserved for refractory cases. Endoscopic sinus surgery has been demonstrated to be safe and efficacious in controlling symptoms of chronic rhinosinusitis in patients with comorbid cystic fibrosis. However, the impact of surgery on pulmonary health remains an active area of investigation. In addition, a growing body of research has suggested a more extended surgical approach creating large sinonasal cavities with gravity-dependent drainage pathways, followed by adjuvant medical therapies, as an ideal strategy to optimally control disease and prevent pulmonary exacerbations. In this manuscript, we provide an up-to-date review of current evidence in the surgical management of chronic rhinosinusitis in cystic fibrosis patients.

Localization of orbit in patients with maxillary sinus hypoplasia: a radiological study

PURPOSE

We aimed to investigate the medial and inferior localization of orbit in patients with maxillary sinus hypoplasia using paranasal computerized tomography.

METHODS

We included 76 patients who had a hypoplastic maxillary sinus at least on one side, and 76 patients with normal maxillary sinuses (control group). To assess the localization of orbit, we measured the distances from middle meatal antrostomy point to medial border of orbital medial wall and to the lower border of orbital floor in all patients. We performed statistical comparisons between the groups.

RESULTS

Of 76 patients, 26 (34.2%) had unilateral and 50 (65.8%) had bilateral maxillary hypoplasia. Of 126 maxillary sinuses, 70 (55.6%) was type 1, 42 (33.3%) was type 2 and 14 (11.1%) was type 3 hypoplastic. The mean distance from antrostomy point to lamina papyracea was 4.36 ± 2.62 mm in the hypoplasia group, and 1.08 ± 1.7 mm in the control group. The mean distance from antrostomy point to orbital floor was 1.53 ± 1.73 mm in the hypoplasia group, and 1.87 ± 1.96 mm in the control group. Lamina papyracea showed a significant medial localization in the maxillary hypoplasia group as compared to the control group (p < 0.001).

CONCLUSION

The orbit has a medial localization in patients with maxillary sinus hypoplasia resulting in a higher complication risk during endoscopic sinus surgery.

Coexistence of frontal sinus hypoplasia with maxillary sinus hypoplasia: a radiological study

The goal of this study was to determine whether frontal sinus hypoplasia coexists with maxillary sinus hypoplasia. Analyzing paranasal CT scans retrospectively, we included 86 patients who had a hypoplastic maxillary sinus at least on one side and 80 patients with bilateral normal maxillary sinuses (control group). We classified hypoplastic maxillary sinuses using the classification system previously defined by Bolger et al. (Otolaryngol Head Neck Surg 103(5):759-765, 1990). We classified the frontal sinuses as aplastic, hypoplastic, medium-sized, and hyperplastic; as previously defined by Guerram et al. (Am J Phys Anthropol 154(4):621-627, 2014). We compared the presence of frontal sinus hypoplasia using Chi-square test between the groups. The mean age of the maxillary sinus group was 43.2 (range 18-84) years. Of 86 patients, 33 (38.4%) had unilateral and 53 (61.6%) had bilateral maxillary sinus hypoplasia. Of 139 maxillary sinuses totally included, 73 (52.5%) were type 1, 51 (36.7%) were type 2 and 15 (10.8%) were type 3 hypoplastic maxillary sinuses. Of 332 frontal sinuses totally included, 25 (7.5%) were aplastic, 32 (9.6%) were hypoplastic, 172 (51.9%) were medium-sized, and 103 (31%) were hyperplastic. Of 86 patients with a hypoplastic maxillary sinus at least on one side, 29 (33.7%) had a hypoplastic and/or aplastic frontal sinus, while 10 (12.5%) had a hypoplastic and/or aplastic frontal sinus at least on one side in control group. Incidence of frontal sinus hypoplasia and/or aplasia was significantly higher in patients with maxillary sinus hypoplasia compared to the patients with bilaterally normal maxillary sinuses (χ² = 10.384, P = 0.001). Maxillary sinus hypoplasia has a significantly higher coexistence with frontal sinus hypoplasia. This study may have an implication for anatomical studies about the development of the paranasal sinuses and paranasal sinus surgery as well as further morphological studies.

Characterization of primary rat nasal epithelial cultures in CFTR knockout rats as a model for CF sinus disease

OBJECTIVE

The objectives of the current experiments were to develop and characterize primary rat nasal epithelial cultures and evaluate their usefulness as a model of cystic fibrosis (CF) sinonasal transepithelial transport and CF transmembrane conductance regulator (CFTR) function.

STUDY DESIGN

Laboratory in vitro and animal studies.

METHODS

CFTR^+/+ and CFTR^-/- rat nasal septal epithelia (RNSE) were cultured on semipermeable supports at an air-liquid interface to confluence and full differentiation. Monolayers were mounted in Ussing chambers for pharmacologic manipulation of ion transport and compared to similar filters containing murine (MNSE) and human (HSNE) epithelia. Histology and scanning electron microscopy (SEM) were completed. Real-time polymerase chain reaction of CFTR^+/+ RNSE, MNSE, and HSNE was performed to evaluate relative CFTR gene expression.

RESULTS

Forskolin-stimulated anion transport (ΔIsc in μA/cm² ) was significantly greater in epithelia derived from CFTR^+/+ when compared to CFTR^-/- animals (100.9 ± 3.7 vs. 10.5 ± 0.9; P < 0.0001). Amiloride-sensitive I_SC was equivalent (-42.3 ± 2.8 vs. -46.1 ± 2.3; P = 0.524). No inhibition of CFTR-mediated chloride (Cl^- ) secretion was exhibited in CFTR^-/- epithelia with the addition of the specific CFTR inhibitor, CFTR_Inh -172. However, calcium-activated Cl^- secretion (UTP) was significantly increased in CFTR^-/- RNSE (CFTR^-/- -106.8 ± 1.6 vs. CFTR^+/+ -32.2 ± 3.1; P < 0.0001). All responses were larger in RNSE when compared to CFTR^+/+ and CFTR^-/- (or F508del/F508del) murine and human cells (P < 0.0001). Scanning electron microscopy demonstrated 80% to 90% ciliation in all RNSE cultures. There was no evidence of infection in CFTR^-/- rats at 4 months. CFTR expression was similar among species.

CONCLUSION

The successful development of the CFTR^-/- rat enables improved evaluation of CF sinus disease based on characteristic abnormalities of ion transport.

LEVEL OF EVIDENCE

NA. Laryngoscope, 127:E384-E391, 2017.

Sinus hypoplasia in the cystic fibrosis rat resolves in the absence of chronic infection

BACKGROUND

Sinus hypoplasia is a hallmark characteristic in cystic fibrosis (CF). Chronic rhinosinusitis (CRS) is nearly universal from a young age, impaired sinus development could be secondary to loss of the cystic fibrosis transmembrane conductance regulator (CFTR) or consequences of chronic infection during maturation. The objective of this study was to assess sinus development relative to overall growth in a novel CF animal model.

METHODS

Sinus development was evaluated in CFTR^-/- and CFTR^+/+ rats at 3 stages of development: newborn; 3 weeks; and 16 weeks. Microcomputed tomography (microCT) scanning, cultures, and histology were performed. Three-dimensional sinus and skull volumes were quantified.

RESULTS

At birth, sinus volumes were decreased in CFTR^-/- rats compared with wild-type rats (mean ± SEM: 11.3 ± 0.85 mm³ vs 14.5 ± 0.73 mm³ ; p < 0.05), despite similar weights (8.4 ± 0.46 gm vs 8.3 ± 0.51 gm; p = 0.86). CF rat weights declined by 16 weeks (378.4 ± 10.6 gm vs 447.4 ± 15.9 gm; p < 0.05), sinus volume increased similar to wild-type rats (201.1 ± 3.77 gm vs 203.4 ± 7.13 gm; p = 0.8). The ratio of sinus volume to body weight indicates hypoplasia present at birth (1.37 ± 0.12 vs 1.78 ± 0.11; p < 0.05) and showed an increase compared with CFTR^+/+ animals by 16 weeks (0.53 ± 0.02 vs 0.46 ± 0.02; p < 0.05). Rats did not develop histologic evidence of chronic infection.

CONCLUSION

CF rat sinuses are smaller at birth, but develop volumes similar to wild-type rats with maturation. This suggests that loss of CFTR may confer sinus hypoplasia at birth, but normal development ensues without chronic sinus infection.

Medical and Surgical Advancements in the Management of Cystic Fibrosis Chronic Rhinosinusitis

PURPOSE OF REVIEW

The purpose of this review is to provide otolaryngologists with the most up-to-date advancements in both the medical and surgical management of CF-related sinus disease.

RECENT FINDINGS

Recent studies have supported more aggressive CRS management, often with a combination of both medical and surgical therapies. Comprehensive treatment strategies have been shown to reduce hospital admissions secondary to pulmonary exacerbations in addition to improving CRS symptoms. Still, current management strategies are lacking in both high-level evidence and standardized guidelines.

SUMMARY

The unified airway model describes the bi-directional relationship between the upper and lower airways as a single functional unit and suggests that CRS may play a pivotal role in both the development and progression of lower airway disease. Current strategies for CF CRS focus primarily on amelioration of symptoms with antibiotics, nasal saline and/or topical medicated irrigations, and surgery. However, there are no definitive management guidelines and there remains a persistent need for additional studies. Nevertheless, otolaryngologists have a significant role in the overall management of CF, which requires a multi-disciplinary approach and a combination of both surgical and medical interventions for optimal outcomes of airway disease. Here we present a review of currently available literature and summarize medical and surgical therapies best suited for the management of CF-related sinus disease.

Incidental findings in MRI of the paranasal sinuses in adults: a population-based study (HUNT MRI)

BACKGROUND

Diagnostic imaging of the head is used with increasing frequency, and often includes the paranasal sinuses, where incidental opacifications are found. To determine the clinical relevance of such findings can be challenging, and for the patient such incidental findings can give rise to concern if they are over-reported. Studies of incidental findings in the paranasal sinuses have been conducted mostly in patients referred for diagnostic imaging, hence the prevalence in the general population is not known. The purpose of this study was to determine the prevalence and size of incidental opacification in the paranasal sinuses in a non-selected adult population using magnetic resonance imaging (MRI) without medical indication, and to relate the results to sex and season.

METHODS

Randomly and independent of medical history, 982 participants (518 women) with a mean age of 58.5 years (range, 50-66) underwent MRI of the head as part of a large public health survey in Norway. The MRIs included 3D T1 weighted volume data and 2D axial T2 weighted image (WI). Opacifications, indicating mucosal thickenings, polyps, retention cysts, or fluid, were recorded if measuring more than 1 mm.

RESULTS

Opacifications were found in 66% of the participants. Mucosal thickenings were found in 49%, commonly in the maxillary sinuses (29%) where 25% had opacifications that were less than 4 mm in size. Other opacifications occurred in the anterior ethmoid (23%), posterior ethmoid (21%), frontal sinus (9%), and sphenoid (8%). Polyps and retention cysts were also found mainly in the maxillary sinuses in 32%. Fluid was observed in 6% of the MRIs. Mucosal thickening was observed more frequently in men than in women (P <0.05). No seasonal variation was found.

CONCLUSIONS

In this large non-selected sample, incidental opacification in the paranasal sinuses was seen in two out of three participants, and mucosal thickening was seen in one out of two. Fluid was rare. Knowledge of incidental opacification is important because it can affect clinical practice.

Chronic osteitic rhinosinusitis as a manifestation of cystic fibrosis: A case report

A 28-year-old male patient with a history of cystic fibrosis (CF) was referred to the University of Connecticut School of Dental Medicine for an evaluation of a cystic lesion in the right maxilla using cone-beam computed tomography (CBCT). CF is an autosomal recessive disease characterized by an abnormal production of viscous mucus, affecting the mucociliary clearance. The CBCT scan revealed a large cystic lesion in the right maxilla extending from the right maxillary second molar to the midline in the region of the right central incisor with a significant buccal expansion. Further evaluation revealed complete opacification of the paranasal sinuses with medial bulging of the lateral maxillary sinus walls. The maxillary and sphenoid sinuses also appeared hypoplastic. The peculiar finding seen in this case was the presence of marked sclerosis and an increase in the thickness of the adjacent bony framework. This report aimed to describe the common sinonasal findings associated with CF and its underlying pathophysiology.

Sinonasal inhalation of tobramycin vibrating aerosol in cystic fibrosis patients with upper airway Pseudomonas aeruginosa colonization: results of a randomized, double-blind, placebo-controlled pilot study

Rationale

In cystic fibrosis (CF), the paranasal sinuses are sites of first and persistent colonization by pathogens such as Pseudomonas aeruginosa. Pathogens subsequently descend to the lower airways, with P. aeruginosa remaining the primary cause of premature death in patients with the inherited disease. Unlike conventional aerosols, vibrating aerosols applied with the PARI Sinus™ nebulizer deposit drugs into the paranasal sinuses. This trial assessed the effects of vibrating sinonasal inhalation of the antibiotic tobramycin in CF patients positive for P. aeruginosa in nasal lavage.

Objectives

To evaluate the effects of sinonasal inhalation of tobramycin on P. aeruginosa quantification in nasal lavage; and on patient quality of life, measured with the Sino-Nasal Outcome Test (SNOT-20), and otologic and renal safety and tolerability.

Methods

Patients were randomized to inhalation of tobramycin (80 mg/2 mL) or placebo (2 mL isotonic saline) once daily (4 minutes/nostril) with the PARI Sinus™ nebulizer over 28 days, with all patients eligible for a subsequent course of open-label inhalation of tobramycin for 28 days. Nasal lavage was obtained before starting and 2 days after the end of each treatment period by rinsing each nostril with 10 mL of isotonic saline.

Results

Nine patients participated, six initially receiving tobramycin and three placebo. Sinonasal inhalation was well tolerated, with serum tobramycin <0.5 mg/L and stable creatinine. P. aeruginosa quantity decreased in four of six (67%) patients given tobramycin, compared with zero of three given placebo (non-significant). SNOT-20 scores were significantly lower in the tobramycin than in the placebo group (P=0.033).

Conclusion

Sinonasal inhalation of vibrating antibiotic aerosols appears promising for reducing pathogen colonization of paranasal sinuses and for control of symptoms in patients with CF.

Cystic fibrosis chronic rhinosinusitis: a comprehensive review

BACKGROUND

Advances in the care of patients with cystic fibrosis (CF) have improved pulmonary outcomes and survival. In addition, rapid developments regarding the underlying genetic and molecular basis of the disease have led to numerous novel targets for treatment. However, clinical and basic scientific research focusing on therapeutic strategies for CF-associated chronic rhinosinusitis (CRS) lags behind the evidence-based approaches currently used for pulmonary disease.

METHODS

This review evaluates the available literature and provides an update concerning the pathophysiology, current treatment approaches, and future pharmaceutical tactics in the management of CRS in patients with CF.

RESULTS

Optimal medical and surgical strategies for CF CRS are lacking because of a dearth of well-performed clinical trials. Medical and surgical interventions are supported primarily by level 2 or 3 evidence and are aimed at improving clearance of mucus, infection, and inflammation. A number of novel therapeutics that target the basic defect in the cystic fibrosis transmembrane conductance regulator channel are currently under investigation. Ivacaftor, a corrector of the G551D mutation, was recently approved by the Food and Drug Administration. However, sinonasal outcomes using this and other novel drugs are pending.

CONCLUSION

CRS is a lifelong disease in CF patients that can lead to substantial morbidity and decreased quality of life. A multidisciplinary approach will be necessary to develop consistent and evidence-based treatment paradigms.

Pathogenesis and management of nasal polyposis in cystic fibrosis

Beginning in preschool age, during their lives, up to 50% of cystic fibrosis (CF) patients experience obstructing nasal polyposis (NP), which is rare in non-CF children. Pathogenetic factors of NP in general and especially in CF are still obscure. However, defective epithelial ion transport from mucosal glands plays a central role in CF, and viscous secretions impair mucociliary clearance, promoting chronic pathogen colonization and neutrophil-dominated chronic inflammation. Presently, CF-NP is not curable but can be clinically stabilized, though the large variety of proposed treatment modalities indicates a lack of standardization and of evidence of treatment efficacy. When conservative measures are exhausted, surgical intervention combining individually adapted endoscopic sinus surgery and supportive conservative treatment is performed. Topical steroids, approved as the gold standard for non-CF NP, may be beneficial, but they are discussed to be less effective in neutrophilic inflammation, and CF-specific antimicrobial and mucolytic therapy, as is true of all treatment modalities, urgently requires evaluation by controlled clinical trials within interdisciplinary networks.

Sinus hypoplasia precedes sinus infection in a porcine model of cystic fibrosis

OBJECTIVES/HYPOTHESIS

Chronic sinusitis is nearly universal in humans with cystic fibrosis (CF) and is accompanied by sinus hypoplasia (small sinuses). However, whether impaired sinus development is a primary feature of loss of the cystic fibrosis transmembrane conductance regulator (CFTR) or a secondary consequence of chronic infection remains unknown. Our objective was to study the early pathogenesis of sinus disease in CF.

STUDY DESIGN

Animal/basic science research.

METHODS

Sinus development was studied in a porcine CF model.

RESULTS

Porcine sinus epithelia expressed CFTR and exhibited transepithelial anion transport. Disruption of the CFTR gene eliminated both. Sinuses of newborn CF pigs were not infected and showed no evidence of inflammation, yet were hypoplastic at birth. Older CF pigs spontaneously developed sinus disease similar to that seen in humans with CF.

CONCLUSIONS

These results define a role for CFTR in sinus development and suggest the potential of the CF pig as a genetic model of CF-sinus disease in which to test therapeutic strategies to minimize sinus-related CF morbidity.

Aplasia and agenesis of the frontal sinus in Turkish individuals: a retrospective study using dental volumetric tomography

Agenesis of the paranasal sinuses is an uncommon clinical condition that appears mainly in the frontal (12%) and maxillary (5-6%) sinuses; in some populations, it appears at a higher proportion. This study investigated the prevalence of agenesis of the frontal sinuses using dental volumetric tomography (DVT) in Turkish individuals. The frontal sinuses of 410 patients were examined by DVT scans in the coronal planes for evidence of the absence of the frontal sinuses. A bilateral and unilateral absence of the frontal sinuses was seen in 0.73% and 1.22% of cases, respectively. In one case, both agenesis and aplasia of the frontal sinus was seen (0.24%). The low percentage of frontal sinus agenesis must be considered during pre-surgical planning related to the sinuses. DVT may be used as a diagnostic tool for the examination of frontal sinus aplasia.

Radiological imaging of inflammatory lesions in the nasal cavity and paranasal sinuses

Paranasal sinus development and pneumatisation variants are described, and rhinosinusitis and different patterns of inflammatory sinonasal diseases are reviewed. Other inflammatory sinonasal diseases, e.g., fungal sinusitis, mucocele, pyocele and sinonasal manifestations in systemic diseases, are briefly described. Computed tomography (CT) is the primary modality in diagnosing and mapping suspected inflammatory sinonasal disease. Magnetic resonance (MR) imaging is complementary to CT if fungal sinusitis, pyocele or malignancy are suspected.

Proposal of a CT scoring system of the paranasal sinuses in diagnosing cystic fibrosis

The purpose of this study was to develop a paranasal sinus CT scoring system that could be used as a diagnostic tool to discriminate cystic fibrosis (CF) patients from control patients examined for sinonasal disease. The model should include as few and easily applicable criteria as possible, supported by statistical analyses and clinical judgement. We used data from 116 CF and 136 control patients. The CF patients were grouped according to the number of confirmed CF mutations: genetically verified (CF-2), or based on sweat testing and clinical findings alone (CF-1, CF-0). Nine paranasal sinus CT criteria, including development, pneumatisation variants and inflammatory patterns, were evaluated. The final model included three criteria: (a) frontal and (b) sphenoid sinus development, and (c) absence of three pneumatisation variants. This model discriminated CF-2 from controls with overlap of summed scores in only 8 of 206 patients. When this model was applied in the CF-1 and CF-0 groups, two populations seemed to exist. A larger group with summed scores overlapping that of the CF-2 group and a smaller group with summed scores overlapping that of the control group. We conclude that this CT scoring system may support, as well as exclude, a CF diagnosis in cases of diagnostic uncertainty.