Impact of rhinosinusitis in health care delivery: the Quebec experience

[The evolution of methods of active irrigation of paranasal sinuses in rhinosinusitis. Part 1]

Inflammation of the paranasal sinuses significantly reduces the quality of life of people and causes marked economic damage to society. The striking clinical picture of sinusitis has always forced doctors to study the disease, as evidenced by the first records of the anatomy and diseases of the paranasal sinuses by doctors in ancient Egypt more than 3.000 years BC. Sinusitis has been treated in different ways in different historical periods. Effective medication treatment appeared relatively recently and began to steadily replace the older instrumental methods, to which many people had a preconceived notion of invasiveness. However, many studies are showing the positive effect of active drainage methods and, moreover, there is data showing that the discomfort during such procedures is slightly higher than during dental treatment under local anesthesia. This article presents a review of the available scientific literature on the use of different treatments for bacterial rhinosinusitis at different historical stages, ranging from the first publications on puncture techniques to balloon dilatation and the modern approach to conservative treatment.

Association of Chronic Rhinosinusitis With Depression and Anxiety in a Nationwide Insurance Population

Importance

Chronic rhinosinusitis (CRS) is associated with a decreased quality of life, affecting physical and emotional aspects of daily function, the latter of which could manifest as depression and anxiety.

Objective

To evaluate the risk of depression and anxiety in CRS, depending on the CRS phenotype (CRS without nasal polyps [CRSsNP] and CRS with nasal polyps [CRSwNP]).

Design, Setting, and Participants

This retrospective nationwide cohort study used population-based insurance data (consisting of data from approximately 1 million patients). The study population included 16 224 patients with CRS and 32 448 individuals without CRS, with propensity score matching between groups according to sociodemographic factors and enrollment year. Data were collected from January 1, 2002, through December 31, 2013, and analyzed from July 1 through November 15, 2018.

Main Outcomes and Measures

Survival analysis, the log-rank test, and Cox proportional hazards regression models were used to calculate the incidence, survival rate, and hazard ratio (HR) of depression and anxiety for each group.

Results

Among the 48 672 individuals included in the study population (58.8% female), the overall incidence of depression during the 11-year follow-up was 1.51-fold higher in the CRS group than in the non-CRS group (24.2 vs 16.0 per 1000 person-years; adjusted HR, 1.54; 95% CI, 1.48-1.61). The incidence of anxiety was also higher in the CRS group than in the comparison group (42.2 vs 27.8 per 1000 person-years; adjusted HR, 1.57; 95% CI, 1.52-1.62). Moreover, the adjusted HRs of developing depression (CRSsNP, 1.61 [95% CI, 1.54-1.69]; CRSwNP, 1.41 [95% CI, 1.32-1.50]) and anxiety (CRSsNP, 1.63 [95% CI, 1.57-1.69]; CRSwNP, 1.45 [95% CI, 1.38-1.52]) were greater in patients with CRSsNP than in those with CRSwNP.

Conclusions and Relevance

This observational study suggests that CRS is associated with an increased incidence of depression and anxiety. Specifically, findings from this study found that patients without nasal polyps showed a higher risk of developing depression and anxiety than those with nasal polyps.

Comparison of the therapeutic effect of the Persian Medicine Protocol with the common treatment of chronic rhinosinusitis: a randomized clinical trial

Background

Chronic rhinosinusitis is one of the most common diseases affecting the quality of life of patients. Patients suffer from high costs in the diagnosis and treatment of the disease. Frequent recurrence and failure of therapeutic protocols are among the most important issues in the management of this disease. In view of this, the use of traditional and complementary therapies to promote the treatment of this disease has been increasingly taken into account.

Objective

Comparison of the effectiveness of the Persian Medicine Protocol with the conventional therapy in the treatment of chronic rhinosinusitis.

Methods

A randomized clinical trial was conducted at Imam Reza Hospital in Mashhad, Iran from July 2016 to March 2017. For patients with chronic rhinosinusitis symptoms, endoscopy of the sinuses was performed by an ENT specialist and in the case of negative endoscopy, paranasal sinus CT scan was requested. A total of 42 patients with chronic rhinosinusitis were randomly assigned to two groups. The first group (classical) received systemic and intranasal cortisone, and the second group (traditional) received a therapeutic Persian medicine protocol including intranasal lavender oil, and Liquorice Marjoram Tea (L. M. tea) for six weeks. The symptoms of the patients were evaluated using the SNOT-22 questionnaire at the beginning of the study and at the sixth week. If no improvement occurs, treatment continued for 12 weeks. Data were analyzed by SPSS version 16, using ANOVA, independent-samples and paired-samples t-test, Wilcoxon signed-rank test, and simple linear regression.

Results

In 20 patients in the traditional group, the decrease in SNOT score was observed as 56% after 6 weeks treatment (p=0.001), which is similar to the effect of the first group (classical). Although there was no statically significant difference between the two groups, in clinical terms, the difference in mean systemic symptoms such as confusion with 1.05 (p=0.5) and fatigue with 1.63 (p=0.01) had more improvement in the traditional group, and the difference in mean local symptoms such as nasal congestion with 2.37 (p=0.78) and runny nose with 1.95 (p=0.14) had a more decrease in the classical group.

Conclusion

The results of this trial indicate the effectiveness of the Persian Medicine Protocol (including Lavender oil and L.M tea) in the treatment of chronic rhinosinusitis, especially on improving systemic symptoms. Nevertheless more clinical studies are necessary to support the acquired results.

Trial registration

This trial was registered at the Iranian Center for Clinical Trials (ID: IRCT2015112425217N1).

Funding

This research is part of a PhD thesis and is funded by the Vice-Chancellor for Research at Mashhad University of Medical Sciences, Grant No. 931673.

Long-Term Quality of Life Measures after Functional Endoscopic Sinus Surgery

Background

Chronic rhinosinusitis (CRS) is a common disease that has a significant impact on quality of life (QOL). The aim of this study was to evaluate the longer-term effects of combined medical and surgical therapy for CRS on overall health status and QOL.

Methods

We used a prospective study that utilized the Short-Form 36 Survey at baseline presentation and at a mean time of 3 years post-functional endoscopic sinus surgery to assess the general health status of patients who presented for their initial visit from 1996 to 1998. Of the 200 randomly selected patients, 150 respondents completed follow-up surveys (a 75% response rate).

Results

Eighty-nine (59.3%) women and 61 (40.7%) men were included in the study. Baseline QOL scores indicated significant differences between patients with CRS and published norms in 6/8 subscale parameters (role physical, bodily pain, general health, social function, vitality, and mental health). Significant improvement in all six categories was maintained at the end of the study period (p < 0.05) with QOL scores within limits of published norms for the general population.

Conclusion

Our data indicate that functional endoscopic sinus surgery, combined with appropriate postoperative care, is effective at maintaining a significant improvement in the overall general health status of patients for at least 3 years after surgical intervention and that the overall scores return to a range of normative values for the general population.

Is there a relationship between sinusitis and psychological disorders?

Chronic rhinosinusitis refers to inflammation of the nasal and sinuses mucosa and the main criteria for diagnosis of this disease related to the nasal cavity or the facial area. According to several reports based on the relationship of this disease with mental disorders, psychological issues are missing in the criteria of chronic rhinosinusitis diagnosis. In this study the etiology and clinical symptoms of the disease were studied by searching scientific databases and authentic Iranian Medicine books such as Avicenna's book The Canon of Medicine (Al-Qanun fi't-Tibb) that now taught in medicine schools of the Traditional East Asian; the results of this study showed that rhinosinusitis accompaniment with psychological symptoms are listed in abundance not only in old books but also in scientific literature before 1928 but after the discovery of antibiotics and extreme attention in the context of physiopathological assignment of diseases to pathogens, this relationship has been weakened. Given the positive results of recent studies on rhinosinusitis accompaniment with psychological disorders it is suggested that more studies are needed to explore the relationship between chronic rhinosinusitis and psychological diseases and, if necessary, to be included in the diagnostic criteria as a diagnostic standard.

A population-based study investigating chronic rhinosinusitis and the incidence of asthma

OBJECTIVES/HYPOTHESIS

Chronic rhinosinusitis (CRS) is an inflammatory disease of the paranasal sinuses, associated with reduced health-related quality of life and increased utilization of healthcare services. Chronic upper and lower respiratory diseases often coexist, although the extent to which CRS is associated with developing asthma remains unclear. To investigate the effect of CRS on receiving a subsequent diagnosis of asthma, we used data from a previously conducted national, longitudinal survey.

METHODS

Respondents from the Canadian National Population Health Survey from 1998/1999 to 2010/2011 were used. Data were analyzed from 11,555 (66.9%) subjects, ≥ 19 years of age and reporting no asthma at baseline. Respondents were reviewed for 12 years to determine the cumulative incidence of asthma. Logistic regression was used to estimate the effect of CRS on the development of asthma, adjusting for age, gender, body mass index, cigarette smoking, and food- or nonfood-related allergies.

RESULTS

During the 12-year study period, 6.0% (95% confidence interval [CI] [95% CI]: 5.4%-6.7%) of respondents developed asthma. Baseline CRS (odds ratio [OR]: 2.7, 95% CI: 1.9-3.9), female gender (OR: 1.4, 95% CI: 1.1-1.8), and allergies (OR: 2.6, 95% CI: 2.1 - 3.3) were significantly associated with developing asthma. After adjustment, respondents with CRS were significantly more likely to develop asthma than non-CRS counterparts (OR: 2.0, 95% CI: 1.4-2.9).

CONCLUSION

Results indicate that one in 13 individuals with CRS will be subsequently diagnosed with asthma. Given the economic burden and use of healthcare services associated with asthma, providers managing CRS may consider increased awareness and subsequent treatment for asthma.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:1296-1302, 2016.

Biodegradable nasal stents (MgF2 -coated Mg-2 wt %Nd alloy)-A long-term in vivo study

Despite innovative surgical techniques and use of current frontal sinus stents from different materials, the problem of treatment failure with consecutive reoperation remains present. The aim of our study is to investigate biocompatibility, degradation kinetics, and functionality of a newly developed fluoride-coated magnesium-based nasal stent. A minipig anatomy of frontal sinus adapted design and an external surgical approach were developed and established. The functionality of the stents was evaluated endoscopically. The stent-tissue blocks were analysed after 90 and 180 days using microcomputed tomography (µ-CT), histology, scanning electron microscopy (SEM), and energy-dispersive X-ray spectroscopy (EDS). Functional evaluation revealed an unobstructed stent lumen in all cases. Histological analysis showed moderate mucosal hyperplasia with a mild, nonspecific inflammatory response, and nonosteoconductive effect. Rejection reactions or necrosis did not occur. The volumetric analysis of the stents showed 51% volume loss after 180 days. The EDS analysis did not detect any neodymium (Nd) in the mucosa or bone. The Mg-2 wt % Nd stents are a promising option when treating the narrow passages following paranasal sinus surgery. In particular, its good biocompatibility and good functionality facilitate the re-epithelization of these constricted passages. © 2015 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 105B: 350-365, 2017.

[The functional disturbances in the vegetative nervous system associated with nasal and paranasal sinuses pathology]

The authors undertook the analysis of the literature data on the functional state of the vegetative nervous system (VNS) in the patients presenting with otorhinolaryngological pathology. These data suggest the participation of VNS in the origin and development of many ENT diseases. Moreover, they demonstrate the absence of commonly accepted approaches to the study of VNS and the assessment of clinical manifestations of vegetative dysfunction syndrome. The necessity of the further investigationsinto this problem is emphasized taking into consideration various types of vegetative constitution in the patients suffering from diseases of the upper respiratory tract.

The significance of response shift in sinus surgery outcomes

BACKGROUND

Functional endoscopic sinus surgery (FESS) aims to improve quality-of-life (QOL). Perception of QOL can change according to one's current medical or emotional state. This is known as response shift. It can be measured by the "then-test," which asks patients to report pretreatment symptoms after receiving treatment. Patients often do not understand their disease burden until their symptoms are improved. This study aims to assess the significance of response shift in FESS outcomes.

METHODS

This was a prospective cohort study that included chronic rhinosinusitis patients from 2010 to 2012 who completed a preoperative 20-item Sino-Nasal Outcome Test (SNOT-20). Two SNOT-20 forms were mailed approximately 6 months after surgery. Patients completed 1 SNOT-20 according to their preoperative symptoms in light of their current state of health ("then-test") and the other based on postoperative symptoms. The preoperative and postoperative SNOT-20 difference represented the treatment effect and the preoperative SNOT-20 and then-test difference represented the response shift.

RESULTS

Thirty-two completed responses were obtained. Using a 0 to 5 scale, mean treatment effect was -0.96 (p < 0.01), which signifies a QOL improvement. Mean response shift was +0.42 (p = 0.01). This positive value signifies that patients felt they were worse off preoperatively, likely due to a positive change in health status. The actual treatment effect is the sum of the measured treatment effect and response shift, which was -1.38.

CONCLUSION

Response shift exists and can be quantified. The actual treatment effect was more profound when response shift was included. Therefore, future studies should account for this often unmeasured, potential change in QOL.

Outcomes and cost benefits of functional endoscopic sinus surgery in severely asthmatic patients with chronic rhinosinusitis

OBJECTIVES

To evaluate the outcomes (using validated outcome tools) and cost benefits of functional endoscopic sinus surgery in a population of severely asthmatic patients with chronic rhinosinusitis.

METHODS

A prospective cohort study was conducted. The study comprised consecutive patients diagnosed with asthma and chronic rhinosinusitis for whom medical treatment had failed and who were scheduled for functional endoscopic sinus surgery. General health and disease-specific outcome questionnaires were completed pre- and post-operatively. Costs associated with both functional endoscopic sinus surgery and out-patient visits to a comprehensive asthma clinic were calculated.

RESULTS

A total of 47 patients completed the surveys. The average improvement in Chronic Sinusitis Survey scores following functional endoscopic sinus surgery was 17 per cent. The average reduction in out-patient asthma clinic visits was 50 per cent, which translates to an average cost saving of $1035 Canadian dollars per patient per year.

CONCLUSION

Functional endoscopic sinus surgery is a cost-effective treatment modality for asthmatic patients with chronic rhinosinusitis. This information is important for: the distribution and planning of resources, prioritising health programmes, and establishing practice guidelines.

Determinants of outcomes of sinus surgery: a multi-institutional prospective cohort study

OBJECTIVES

1) To measure the proportion of patients with chronic rhinosinusitis (CRS) who experience clinically significant improvement after endoscopic sinus surgery (ESS) in a prospective, multi-institutional fashion. 2) To identify preoperative characteristics that predict clinically significant improvement in quality of life (QOL) after ESS.

STUDY DESIGN

Prospective, multi-institutional cohort study.

SETTING

Academic tertiary care centers.

SUBJECTS AND METHODS

A total of 302 patients with CRS from three centers were enrolled between July 2004 and December 2008 and followed for an average of 17.4 months postoperatively. Preoperative patient characteristics, CT scan, endoscopy score, and pre- and postoperative quality of life (QOL) data were collected. Univariate and multivariate analyses were performed.

RESULTS

Patients improved an average of 15.8 percent (18.9 points) on the Rhinosinusitis Disability Index and 21.2 percent (21.2 points) on the Chronic Sinusitis Survey (both P < 0.001). Patients significantly improved on all eight Medical Outcomes Study Short Form-36 (SF-36) subscales (all P < 0.001). Among patients with poor baseline QOL, 71.7 percent of patients experienced clinically significant improvement on the RSDI and 76.1 percent on the CSS. Patients undergoing primary surgery were 2.1 times more likely to improve on the RSDI (95% confidence interval [CI], 1.2, 3.4; P = 0.006) and 1.8 times more likely to improve on the CSS (95% CI, 1.1, 3.1; P = 0.020) compared with patients undergoing revision surgery.

CONCLUSION

In this prospective, multi-institutional study, most patients experienced clinically significant improvement across multiple QOL outcomes after ESS. Specific patient characteristics provided prognostic value with regard to outcomes.

Regional variations in chronic rhinosinusitis, 2003-2006

OBJECTIVES

1. Characterize patient visits for chronic rhinosinusitis on the basis of age, gender, race, diagnostic services, and medication use. 2. Evaluate regional differences in patient visits for chronic rhinosinusitis.

STUDY DESIGN

Analysis of cross-sectional survey data from two national databases of ambulatory medical encounters.

SETTING

Not applicable.

SUBJECTS AND METHODS

Four years (2003-2006) of data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey were analyzed. Visits involving chronic rhinosinusitis were identified by using reported diagnostic codes from the International Classification of Diseases, Ninth Revision. They were weighted to provide national estimates of care. Data were analyzed with the Pearson chi(2) test using the SPSS 16.2 Complex Samples Module, taking into account the complex survey design and multiple time periods.

RESULTS

A total of 4617 patient visits for chronic rhinosinusitis were identified, accounting for 1.95 percent of all visits. With the application of weights to this sample, these visits represent 91.2 million national visits. A significantly higher proportion of visits in the South involved African Americans (Pearson chi(2) = 69.5, F = 6.7, df = 2.8, 2118, P < 0.01). Significantly fewer diagnostic services were provided or ordered in the Northeast (Pearson chi(2) = 64.8, F = 4.0, df = 4.3, 3247, P < 0.01). Providers in the Northeast were also significantly less likely to order or renew more than three medications at the visit (Pearson chi(2) = 54.0, F = 3.1, df = 2.6, 1930, P < 0.05). No regional differences were seen for age, gender, or setting type.

CONCLUSION

Significant regional variations exist for chronic rhinosinusitis in patient demographics, diagnosis, and management. Continuing research is needed to refine physician awareness, evaluation, and treatment of this disorder.

Important research questions in allergy and related diseases: 3-chronic rhinosinusitis and nasal polyposis - a GALEN study

Chronic rhinosinusitis is one of the most common health care challenges, with significant direct medical costs and severe impact on lower airway disease and general health outcomes. The diagnosis of chronic rhinosinusitis (CRS) currently is based on clinical signs, nasal endoscopy and CT scanning, and therapeutic recommendations are focussing on 2 classes of drugs, corticosteroids and antibiotics. A better understanding of the pathogenesis and the factors amplifying mucosal inflammation therefore seems to be crucial for the development of new diagnostic and therapeutic tools. In an effort to extend knowledge in this area, the WP 2.7.2 of the GA(2)LEN network of excellence currently collects data and samples of 1000 CRS patients and 250 control subjects. The main objective of this project is to characterize patients with upper airway disease on the basis of clinical parameters, infectious agents, inflammatory mechanisms and remodeling processes. This collaborative research will result in better knowledge on patient phenotypes, pathomechanisms, and subtypes in chronic rhinosinusitis. This review summarizes the state of the art on chronic rhinosinusitis and nasal polyposis in different aspects of the disease. It defines potential gaps in the current research, and points to future research perspectives and targets.

The health and resource utilization of Canadians with chronic rhinosinusitis

OBJECTIVES

To determine the impact of chronic rhinosinusitis (CRS) on the physical and mental health and health-resource utilization of Canadians.

STUDY DESIGN

Cross-sectional.

METHODS

Data from the detailed health portion of cycle 3 (1998-1999) of the National Population Health Survey (NPHS), which involved 17,000 Canadians, were used to evaluate Canadians with self-reported CRS.

RESULTS

NPHS data confirmed lower mental and physical health, with CRS sufferers being almost three times more likely to report their health as poor (4.6% vs. 1.7%). Health Utility Index data identified a significant decline in the mental health of patients with CRS, which was associated with more depression (8.4% vs. 4.1%), more antidepressant use (9.1% vs. 4.6%), and more visits to mental-health professionals (11.8% vs. 7.0%).

CONCLUSIONS

CRS significantly affects both physical and mental health. The mental impact of CRS remains largely unrecognized and should be of greater focus during patient care and in further research.

Systematic review of change in bodily pain after sinus surgery

OBJECTIVES

To determine whether bodily pain is increased in patients with chronic rhinosinusitis (CRS) and if bodily pain improves following endoscopic sinus surgery (ESS).

METHODS

All studies reporting results of more than 10 adult patients analyzing the response of bodily pain to ESS were retrieved by searching MEDLINE, EMBASE, Web of Science, Cochrane databases, and additional web-based sources (from January 1, 1980, to May 1, 2008); by examining bibliographies of retrieved articles; and by contacting investigators in the field.

RESULTS

Of 279 ESS symptom outcome studies, only studies measuring results using the 36-Item Short Form Health Survey (SF-36) quality-of-life survey instrument measured bodily pain. Eleven observational ESS studies (1019 patients) reported mean preoperative SF-36 bodily pain scores at 0.89 SD below general population norms (24% more severe bodily pain than general population norms) and significantly below norms for a population 25 years older. Using a repeated-measures design, nine of 11 studies noted significant improvement in SF-36 bodily pain domain scores following ESS, with a moderate-sized combined effect of 0.55 (95% confidence interval, 0.45-0.64; I(2) = 44%) using the fixed-effects model. This pooled effect corresponded to a mean improvement of 11.8 U on the SF-36 bodily pain domain scale.

CONCLUSIONS

Bodily pain is increased in patients with CRS awaiting ESS, exceeding the normative bodily pain scores of a general normative population 25 years older. Using within-subject comparisons, a clinically and statistically significant improvement in bodily pain is noted after ESS, an improvement similar to that previously described for fatigue.

[9-years results of the functional endoscopic sinus surgery in ENT department in Poznań--from microscope to four hands technique]

Surgical procedure is used in chronic rhinosinusitis and aims at restoring proper drainage and ventilation. For this reason the surgery of this region is referred to as functional and in English literature is termed as FESS. It supplanted classical method of Caldwell-Luc or Denker. In the study nine years experience in the Department of Otolaryngology, Head and Surgery University of Poznań in the treatment of chronic sinusitis has been presented. 1463 patients treated with FEES were analyzed. Moreover, the method of selecting patients for the surgery, the diagram showing surgeries performed step by step as well as a list of various surgeries and intraoperative complications were presented. This work is the first part of the study. In the other part the results of the treatment based on the questionnaires sent to patients will be presented.

Important research questions in allergy and related diseases: nonallergic rhinitis: a GA2LEN paper

Nonallergic rhinitis (NAR) can be defined as a chronic nasal inflammation which is not caused by systemic IgE-dependent mechanisms. It is common and probably affects far more than 200 million people worldwide. Both children and adults are affected. However, its exact prevalence is unknown and its phenotypes need to be evaluated using appropriate methods to better understand its pathophysiology, diagnosis and management. It is important to differentiate between infectious rhinitis, allergic/NAR and chronic rhinosinusitis, as management differs for each of these cases. Characterization of the phenotype, mechanisms and management of NAR represents one of the major unmet needs in allergic and nonallergic diseases. Studies on children and adults are required in order to appreciate the prevalence, phenotype, severity and co-morbidities of NAR. These studies should compare allergic and NAR and consider different age group populations including elderly subjects. Mechanistic studies should be carried out to better understand the disease(s) and risk factors and to guide towards an improved diagnosis and therapy. These studies need to take the heterogeneity of NAR into account. It is likely that neuronal mechanisms, T cells, innate immunity and possibly auto-immune responses all play a role in NAR and may also contribute to the symptoms of allergic rhinitis.

Fluoroquinolones compared with beta-lactam antibiotics for the treatment of acute bacterial sinusitis: a meta-analysis of randomized controlled trials

BACKGROUND

The presumed superiority of newer fluoroquinolones for the treatment of acute bacterial sinusitis is based on laboratory data but has not yet been established on clinical grounds.

METHODS

We performed a meta-analysis of randomized controlled trials comparing the effectiveness and safety of fluoroquinolones and beta-lactams in acute bacterial sinusitis.

RESULTS

We identified 8 randomized controlled trials investigating the newer "respiratory" fluoroquinolones moxifloxacin, levofloxacin and gatifloxacin. In the primary effectiveness analysis involving 2133 intention-to-treat patients from 5 randomized controlled trials, the extent of clinical cure and improvement did not differ between fluoroquinolones and beta-lactams (odds ratio [OR] 1.09, 95% confidence interval [CI] 0.85-1.39) at the test-of-cure assessment, which varied from 10 to 31 days after the start of treatment. Fluoroquinolones were associated with an increased chance of clinical success among the clinically evaluable patients in all of the randomized controlled trials (OR 1.29, 95% CI 1.03-1.63) and in 4 blinded randomized controlled trials (OR 1.45, 95% CI 1.05-2.00). There was no statistically significant difference between fluoroquinolones and amoxicillin-clavulanate (OR 1.24, 95% CI 0.93-1.65). Eradication or presumed eradication of the pathogens isolated before treatment was more likely with fluoroquinolone treatment than with beta-lactam treatment (OR 2.11, 95% CI 1.09-4.08). In the primary safety analysis, adverse events did not differ between treatments (OR 1.17, 95% CI 0.86-1.59). However, more adverse events occurred with fluoroquinolone use than with beta-lactam use in 2 blinded randomized controlled trials. The associations described here were generally consistent when we included 3 additional studies involving other fluoroquinolones (ciprofloxacin and sparfloxacin) in the analysis.

INTERPRETATION

In the treatment of acute bacterial sinusitis, newer fluoroquinolones conferred no benefit over beta-lactam antibiotics. The use of fluoroquinolones as first-line therapy cannot be endorsed.

Patients undergoing sinus surgery: constructing a demographic profile

OBJECTIVES

The objective of this study is to construct an accurate and representative demographic profile of patients undergoing sinus surgery for chronic rhinosinusitis (CRS). This will enable future studies to enroll representative samples so that results can be more easily compared across studies and generalized to the U.S. population.

METHODS

The investigators interrogated the databases of the National Survey of Ambulatory Surgery to gather demographic data. Whenever the NSAS provided incomplete characterization, deficiencies were corrected using state-level data provided by the Health care Cost and Utilization Project. The constructed profile was compared with available profiles of patients with CRS and demographic data provided by the U.S. Census Bureau.

RESULTS

The demographic profile of patients undergoing sinus surgery is 52.7% female with a mean age of 38.5 years. A total of 93.5% of surgery is performed on an outpatient basis with 78.8% of patients having private insurance sources. No significant difference in occurrence of surgery was found between months of the year or between regions of the country. The constructed race profile is 85.7% white, 5% black, 1.2% Asian/Pacific Islander, 0.2% Native American, and 7.8% other.

CONCLUSIONS

A novel integration of national and state databases can be used to create a demographic profile of patients undergoing surgery for CRS. The creation of this profile enables further study of representative populations of patients with CRS and enables thoughtful analysis of the existing literature. The difficulty in creating the profile highlights the need for complete and accurate healthcare information collection by national and state agencies.

The efficacy of cefdinir in acute bacterial rhinosinusitis

Acute bacterial rhinosinusitis is a common infection resulting in substantial morbidity. Cefdinir, an oral cephalosporin, has extended-spectrum, bactericidal activity against common acute bacterial rhinosinusitis pathogens, including Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. Cefdinir shows rapid oral absorption and good respiratory tissue penetration, and may be administered once daily. In randomised clinical trials, cefdinir showed efficacy similar to that of other recommended regimens in the treatment of acute bacterial rhinosinusitis, namely amoxicillin/clavulanate and levofloxacin. Cefdinir is well tolerated and has shown a low propensity to suppress the normal commensal flora. Cefdinir oral suspension is rated highly by children in terms of its taste and smell. As the only once-daily beta-lactam currently recommended by acute bacterial rhinosinusitis guidelines (for first-line use in patients with mild acute bacterial rhinosinusitis and no recent antibacterial use), cefdinir offers a convenient and attractive treatment option.

[Quality of life. An important parameter in respiratory tract diseases]

Sinusitis is one of the most frequent diseases in humans. Despite severe complications sinusitis may be considered a non-serious disease compared to other illnesses. Therefore, sinusitis is sometimes erroneously regarded as a banal disorder. It is mostly unknown that patients suffering from sinusitis may have a marked impairment of their quality of life (QOL). The term health-related QOL comprises physical and psychological well-being as well as aspects of daily life and social life from the patient's perspective. Validated measures (questionnaires) are able to quantify the impairment of QOL as well as the influence of therapy on QOL. Especially in the treatment of sinusitis, QOL becomes a relevant additional parameter due to the fact that clinical and subjective, patient-based criteria do not correlate sufficiently. This article provides an overview of available QOL questionnaires on sinusitis, highlights results of QOL studies in sinusitis, and elucidates the relevance of QOL in clinical trials as well as in the relation between the physician and the patient.

Development and validation of a new health-related quality of life instrument for patients with sinusitis

BACKGROUND AND OBJECTIVE

There are few validated measures of sinusitis-specific health-related quality of life (HRQL). This study used patient focus and pretesting groups followed by a prospective cohort study to develop and validate a HRQL instrument for patients with sinusitis.

METHODS

Instrument development involved a systematic literature review, use of expert input, and patient focus and pretesting groups. Patients were recruited from the practices of primary care providers and otolaryngologists. The derived survey instrument then underwent prospective testing in patients with acute sinusitis, chronic sinusitis, allergic rhinitis, and asymptomatic controls. Reduced item scales of the original instrument were developed for symptom frequency and bothersomeness. The psychometric properties of the survey instrument were evaluated for reliability, construct validity, responsiveness, and interpretability.

RESULTS

In the prospective study, 47 patients with acute sinusitis and 50 patients with chronic sinusitis were compared to 18 patients with allergic rhinitis and 60 patients without nasal symptoms. Forty-three (91.5%) patients with acute sinusitis completed the questionnaire at baseline and at 1-month follow-up. Internal consistency was high for the symptom impact scale for acute and chronic sinusitis patients. The symptom frequency and especially bothersomeness scales had lower internal consistency particularly for acute sinusitis patients. Reproducibility among surgical patients retested prior to their procedure was good for each scale. A high degree of disciminant validity was demonstrated when comparing sinusitis patients to other groups, and a high degree of convergent validity was seen when the new measures were compared to other HRQL measures at baseline. Among patients with acute sinusitis, the responsiveness and interpretability of the symptom frequency, bothersomeness and impact scales were excellent.

CONCLUSIONS

This study developed and validated a new sinusitis-specific HRQL instrument. The instrument included symptom frequency, bothersomeness and impact scales. It was shown to be valid in patients with acute and chronic sinusitis, and highly responsive and interpretable in acute sinusitis patients managed in the primary care setting.

Acute bacterial rhinosinusitis: clinical impact of resistance and susceptibility

Sinusitis is a common disorder associated with notable direct and indirect economic costs. Acute bacterial rhinosinusitis (ABRS) is a relatively poorly defined clinical syndrome characterized by a high spontaneous resolution rate, wide variations in presenting symptoms, and an incomplete understanding of the pathogenesis and clinical course of the disease. Streptococcus pneumoniae and Haemophilus influenzae are the most common causative pathogens in adult ABRS. A relative lack of bacteriological eradication data compared with other respiratory illnesses, uncertainty on the part of many clinicians as to when to treat, and increasing rates of antimicrobial resistance hamper logical treatment strategies. Because it is impossible to know which cases of ABRS will spontaneously resolve and which will not, antimicrobials are recommended. In general, antimicrobial treatment for ABRS should cover both S. pneumoniae and H. influenzae while considering the risk of infection with resistant organisms. Treatment guidelines for ABRS were developed by the Sinus and Allergy Health Partnership in 2000 and were updated in 2004. This article discusses a Sinusitis Therapeutic Outcome Model, a data-driven model used in the development of the treatment guidelines, with respect to different scenarios involving ABRS to illustrate the implications of antimicrobial selection on therapeutic outcome.

Effects of low-toxicity particulate matter on human nasal function

Chronic nasal and paranasal sinus problems affect approximately 15% of the population in industrialized countries. Recent studies suggest that particulate matter might contribute to this condition. The effects of acute exposure to low-toxicity particulate matter on human nasal airflow, mucociliary transport, and nasal discomfort should be assessed. Thirty-two healthy volunteers were exposed to 0 (control), 500, 1000, and 5000 micrograms/m3 calcium carbonate dust for 3 hours and nasal saccharin transport time (STT), rhinomanometry, and visual analog scales (VAS) on nasal discomfort were obtained. A dose dependent decrease of STT (P = 0.02) and nasal patency (P = 0.04), and increased sensation of nasal obstruction (P = 0.002) and dryness (P = 0.03) was observed. The results indicate that acute exposure to low-toxicity particulate matter in concentrations frequently encountered in western agglomeration areas may affect nasal functions and cause nasal symptoms.