Management of complicated pediatric rhinosinusitis in the COVID-19 era

With the ongoing development of the COVID-19 pandemic, research continues to emerge regarding the pathophysiology, characteristics, and treatment considerations for patients with COVID-19. No reports have highlighted the specific challenges posed in the management of pediatric patients with COVID-19 who present with complicated rhinosinusitis. In this report, we discuss our preoperative, intraoperative, and postoperative multidisciplinary treatment strategy for these cases and provide two examples of complicated rhinosinusitis cases in COVID-19 patients, treated with two different approaches. Pearls, insights, and a brief review of the literature are discussed.

Impact of Respiratory Virus Infections in Exacerbation of Acute and Chronic Rhinosinusitis

Rhinosinusitis (RS) is a symptomatic disease classification of many causes and is a major economic burden worldwide. It is widely accepted that RS is further classified into acute (ARS) and chronic (CRS) rhinosinusitis based on the duration of the symptoms, and that viral infection plays a large role in initiating or potentiating the disease. In this review, we examine the role of respiratory virus infection in the exacerbation of ARS and CRS. We explore the epidemiology of viral exacerbation of ARS and CRS and highlight key viruses that may cause exacerbation. We also review the current understanding of viral infections in the upper airway to further explain the putative underlying mechanisms of inflammatory events in ARS and CRS exacerbation. Advances in accurate diagnosis of the etiologic respiratory viruses of ARS and CRS symptoms which can lead to better disease management are also surveyed. In addition to the current treatments which provide symptomatic relief, we also explore the potential of harnessing existing antiviral strategies to prevent ARS and CRS exacerbation, especially with improved viral diagnostic tools to guide accurate prescription of antivirals against causative respiratory viruses.

Herbal drug BNO 1016 is safe and effective in the treatment of acute viral rhinosinusitis

CONCLUSION

Daily intake of 480 mg of BNO 1016 for 15 days is an effective treatment in acute viral rhinosinusitis.

OBJECTIVES

The pooled efficacy data of two similar randomized placebo-controlled clinical trials were analyzed. Safety was evaluated on the basis of the individual trials.

METHODS

The efficacy analysis was based on 589 patients. Treatment was performed orally with either 3 × 160 mg BNO 1016 (n = 294) or 3 × placebo (n = 295) for 15 days. In both trials patients underwent five visits to the investigational sites. Symptoms were evaluated according to the EPOS 2012 guideline. Ultrasonography was used to confirm the diagnosis at onset of treatment and the remission of symptoms at the last visit. Efficacy was evaluated by the investigator as the mean major symptom score (MSS) at the end of treatment (visit 5, day 14). Patients reported symptoms and social/emotional consequences of rhinosinusitis using a quality of life questionnaire (SNOT-20 GAV).

RESULTS

MSS improved during the treatment period by a mean of 10.02 ± 1.61 score points to 2.47 ± 2.55 for BNO 1016 and of 9.87 ± 1.52 to 3.63 ± 3.63 for placebo. Differences between treatment groups at end of therapy (1.16 ± 3.14 score points; p < 0.0001) and patient-assessed quality of life (p = 0.0015) were statistically significant in favor of BNO 1016.

[The role of respiratory viruses in etiology of rhinosinisitis in the children]

The objective of the present study was to elucidate the role of respiratory viruses in etiology of acute rhinosinusitis (ARS) in the children and adolescents. We analysed the results of a microbiologial study of 50 aspirates from the paranasl sinuses. It was shown that acute rhinosinusitis had bacterial and viral-bacterial etiology in 8% and 24% of the cases respectively. In 42% of the cases the pathogen could not be identified by any of the methods used in the study.

Human rhinoviruses

Human rhinoviruses (HRVs), first discovered in the 1950s, are responsible for more than one-half of cold-like illnesses and cost billions of dollars annually in medical visits and missed days of work. Advances in molecular methods have enhanced our understanding of the genomic structure of HRV and have led to the characterization of three genetically distinct HRV groups, designated groups A, B, and C, within the genus Enterovirus and the family Picornaviridae. HRVs are traditionally associated with upper respiratory tract infection, otitis media, and sinusitis. In recent years, the increasing implementation of PCR assays for respiratory virus detection in clinical laboratories has facilitated the recognition of HRV as a lower respiratory tract pathogen, particularly in patients with asthma, infants, elderly patients, and immunocompromised hosts. Cultured isolates of HRV remain important for studies of viral characteristics and disease pathogenesis. Indeed, whether the clinical manifestations of HRV are related directly to viral pathogenicity or secondary to the host immune response is the subject of ongoing research. There are currently no approved antiviral therapies for HRVs, and treatment remains primarily supportive. This review provides a comprehensive, up-to-date assessment of the basic virology, pathogenesis, clinical epidemiology, and laboratory features of and treatment and prevention strategies for HRVs.

[The etiologic diagnostics of rhinosinusitis using clinical laboratory methods]

The examination was applied to 81 children aged 5-15 years, including 64 children with diagnosis of rhinosinusitis. The control group consisted of 17 healthy children. The set of laboratory clinical diagnostic techniques was applied to detect the causes of pathology. It is established that children with rhinosinusitis suffered from concurrent bacterial and virus infections. The morphologic presentation of mucous membrane of nasal cavity reflects the etiologic factor and the stage of inflammatory process. The detection of concentration of IL-4, IL-6 and IL-8 of blood serum gives a possibility to diagnose children with combined mechanisms of development of rhinosinusitis.

Observational study on the performance of the Narhinel method (nasal aspirator and physiological saline solution) versus physiological saline solution in the prevention of recurrences of viral rhinitis and associated complications of the upper respiratory tract infections (URTI), with a special focus on acute rhinosinusitis and acute otitis of the middle ear

AIM

The aim of this study was to assess the validity of Narhinel method in the prevention of recurrences of viral rhinitis and of any associated sequelae, in particular acute otitis of the middle ear (AOM) and acute rhinosinusitis (AR).

METHODS

This was a prospective observational study, in children aged from two months to two years, observed for five months during the cold season and carried out by family pediatricians (FIMP association) in Friuli Venezia Giulia, Italy. The study enrolled 435 patients. The observed population consisted of two groups: the first one of 238 children treated with Narhinel method and the second one of 197 patients treated only with the physiological saline solution. In compliance with the guidelines of an observational trial, the children were prescribed the therapeutic treatments used as a routine. The patients were recruited for the trial after the responsible parent had signed the informed consent form. The study protocol had been approved by the Ethics Committee of the area of Pordenone. In order to be recruited, patients had to comply with the following criteria: symptoms suggestive of the common cold; age > or =2 months < or =2 years; male and female. Patients presenting one or more of the following characteristics were not included: systemic diseases; congenital nasal obstruction (choanal atresia); infections of the upper and lower respiratory tracts other than common cold; systemic and/or topical use of antibiotics and/or corticosteroids at the moment of recruitment. During the five months of the observation period, all the therapies that the investigators had decided it was necessary to administer had been included and recorded in the CRF. Patients evaluations were carried out for five months. The clinical assessment was performed at baseline (B), in the first week (Fw) and monthly and described as M1 to 5; several clinical parameters were analyzed (anterior and posterior rhinorrhoea, oral respiration, noisy nasal respiration, and nasally transmitted thoracic sounds) and measured by the pediatrician at all examinations from B to M5. Other parameters were derived from the parents' daily observations, recorded in a diary and made note of the quality of sleep, diet and respiration, and the use of any drug during any relapse of acute rhinitis (common cold episode). Recurrence of AOM and AR was assessed by the pediatrician at M1-2-3-4-5. Safety of use was determined using the Italian Health Ministry incident/near incident report sheets for Medical Device and based on diaries where the parents took note of any events which occurred during the observation period. Parental satisfaction and compliance were assessed through a questionnaire given to the parents at the end of the last visit (M5).

RESULTS

In the Narhinel group, the mean age was inferior (statistically significant): 8.9 compared to 11.4 months in the physiological saline solution group. The frequency of recurrences from viral rhinitis was very similar in the two groups and a decrease (statistical significant) was observed from M3 through M5 in both groups. Rhinorrhea, oral breathing, and other upper respiratory symptoms, improved in the two groups even if in the Narhinel one the improvement was more prominent during the first two months of observation. There was no difference in the frequency of AR between the groups: at M4 and M5, there was a statistically significant decrease in the frequency of episodes. The frequency of AOM varied in the two groups considering a comparison intra-groups: at M5 the decrease of episodes was statistically significant in the Narhinel group. In Narhinel group, AR and acute AOM seem to be more markedly controlled (frequency) especially for AOM. The frequency of adverse events (AEs) did not vary in the two groups: in the Narhinel one there was a difference (not statistically significant and not clinically relevant) in the number of patients with AEs, especially crying and nasal bleeding. One serious AE was reported in the physiological saline solution group. A 14-month-old child developed laryngospasm which recovered completely after hospital treatment with adrenaline. This event was not related to treatment with saline solution and causality was assessed as "unlikely" by the investigator. In the Narhinel group, one serious event of moderate convulsion febrile in a male patient (age of 0.9) was reported. The causality relationship was assessed by the investigator as improbable. Parents' satisfaction was higher (statistically significant) in the Narhinel group compared to the physiological saline solution alone group.

CONCLUSION

In acute rhinites (common cold) both medical devices are effective nevertheless Narhinel method is valid and shows better results in AOM and AR. Moreover Narhinel method was also more appreciated by parents than physiological saline solution. According to authors' experience, the Narhinel method is safe and its performance is valid in the prevention of AOM and AR in children.

[The role of infection in the development of polypous rhinosinusitis in patients with bronchial asthma]

At present, many authors accept the many-factor theory of development of polypous rhinosinusitis associated with bronchial asthma according to which this condition should be regarded as an inflammatory syndrome in subjects predisposed to a specific tissue reaction. Inflammation induced by an infection is accompanied by the release of protease-inhibiting enzymes that turn inflammation into a chronic process thereby contributing to tissue disintegration, remodeling of mucous membranes, and development of polyps.

Respiratory syncytial virus rhinosinusitis in intensive care unit patients

This study reported a case of rhinosinusitis for Respiratory Syncytial Virus in Intensive Care Unit patient. The settings were Intensive Care Unit at Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil. One female HIV-infected patient with respiratory failure and circulatory shock due to splenic and renal abscesses, who developed rhinosinusitis caused by RSV and bacteria. Respiratory viruses can play a pathogenic role in airways infection allowing secondary bacterial overgrowth.

[Acute rhinosinusitis in children]

Rhinosinusitis in children is mainly caused by virus. After medical examination and according to the evolution, two clinical situations are defined: sub acute and persisting rhinosinusitis or acute and severe rhinosinusitis. Due to the development of sinus cavities, location of rhinosinusitis varies with age, ethmoïditis being the first location in young child. Imaging is recommended in cases of severe symptomatology or extra maxillary locations or for complications. Antibiotherapy is recommended in severe cases or complications. The choice of drugs is supported by the bacterial epidemiology of these infections and the level of resistance in France of the different microorganisms involved. In other cases, management includes symptomatic treatment and obvious informations on the different modalities of evolution.

Detection of rhinovirus in turbinate epithelial cells of chronic sinusitis

BACKGROUND

In contrast to the well-established association of rhinovirus (RV) with acute sinusitis, little is known about the role of RV infections in the pathogenesis of chronic sinusitis. Therefore, we assayed the nasal cavity mucosae of chronic sinusitis patients lacking signs of acute viral infection for the presence of RV.

METHODS

Nasal lavage fluids and turbinate epithelial cells from 39 sinusitis patients and 27 control subjects were tested. Turbinate epithelial cells were collected using a Rhino-probe mucosal curette. Picornavirus was assayed by an initial reverse-transcription polymerase chain reaction (PCR), and picornavirus-positive samples were assayed by nested reverse-transcription PCR to detect RV.

RESULTS

All lavage fluids from both groups, as well as control epithelial cells, were negative for picornavirus. In contrast, 8 of 39 (21%) epithelial cell samples from sinusitis patients were positive for picornavirus. RV-specific nested-PCR revealed that all eight of these samples were positive for RV.

CONCLUSION

The detection of RV in the turbinate epithelial cells of chronic sinusitis patients suggests that RV may be important in the pathogenesis of chronic sinusitis.

Sinusitis: viral, bacterial, or fungal and what is the role of Staph?

Recently, it has been recognized that inflammation is the major cause of chronic rhinosinusitis (CRS) rather than bacterial infection. Fungi have emerged as a possible pathogenic agent that drives CRS. One clear-cut group of fungal sinusitis can be divided into invasive and noninvasive. The condition that the allergist is most likely to see is allergic fungal sinusitis. Generally, it appears in atopic, immunocompetent, adolescents and young adults and is marked by the presence of nasal polyps and allergic mucin, which includes eosinophils, Charcot-Leyden crystals, and fungal hyphae. Computer tomographic imaging shows sinus opacification with hyperdense areas. Treatment has been successful with definitive nasosinus surgery and long-term oral prednisone. There is some evidence that fungi also may account for a large percentage of the remaining CRS patients. In this instance, the immune response to common airborne fungi appears to be IgG mediated rather than IgE mediated. Promising therapeutic results have been seen with intranasal antifungal agents but larger multicenter double-blinded placebo-controlled studies are needed. Another unanswered question includes the possible role of staphylococcus-derived enterotoxins in the pathogenesis of CRS.

Persistent inflammation and hyperresponsiveness following viral rhinosinusitis

OBJECTIVES

To develop a murine model of viral rhinosinusitis.

STUDY DESIGN

Randomized, controlled, animal model.

METHODS

Mice were intranasally inoculated with Sendai virus (SeV) or ultraviolet (UV)-inactivated virus. On days 3 and 10 postinfection, nasal lavage fluid was obtained for viral culture. On days 4, 10, and 38 postinfection, sinus mucosa was harvested and analyzed by flow cytometry for CD3-, CD4-, CD8-, CD25-, CD11b-, CCR3-, and GR1-positive cells. Nasal hyperresponsiveness to histamine challenge was measured on days 8 and 36 postinoculation.

RESULTS

On day 3, viral cultures were positive from all SeV-inoculated mice but from none of the UV-inactivated mice (P<or=.0039). There was no growth of virus from either group on day 10. On day 4, flow cytometry on SeV-infected sinus cells showed a significant increase in macrophages (P<or=.03) and neutrophils (P<or=.02) compared with controls. This inflammation resolved by day 10. On day 38, mice inoculated with SeV had significantly more CD8+ (P<or=.044) and CD4+CD25+ (P<or=.017) cells than did controls. On day 8, there was a significant increase in both sneezing (P<or=.002) and nasal rubbing (P<or=.002) in the SeV-infected group to histamine challenge compared with controls. This difference continued to day 36.

CONCLUSIONS

Inoculation with SeV results in an acute infection that resolves spontaneously within 10 days. Infected mice develop a significant increase in T-suppressor and T-regulatory cells after resolution of the acute infection, which persists for at least 38 days. The persistence of these T cells is associated with hyperresponsiveness to histamine. This mouse model has some parallels to chronic rhinosinusitis after a viral infection in humans and should allow us to clarify the pathophysiology of this disease.

Beginning Antibiotics for Acute Rhinosinusitis and Choosing the Right Treatment

Acute bacterial sinusitis (ABS) is an extremely common problem in both children and adults. There are three clinical presentations of acute sinusitis: (1) onset with persistent symptoms (nasal symptoms or cough or both for > 10 but < 30 d without evidence of improvement); (2) onset with severe symptoms (high fever and purulent nasal discharge for 3-4 consecutive days); and (3) onset with worsening symptoms (respiratory symptoms, with or without fever, which worsen after several days of improvement). Images to confirm the presence of acute sinusitis are necessary in older children (> 6 years) and adults to enhance the certainty of diagnosis. The predominant bacterial species that are implicated in acute sinusitis are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis in children. In the last decade, there has been an increasing prevalence of penicillin-resistant S. pneumoniae, and beta-lactamase-producing H. influenzae and M. catarrhalis. Although there has been some controversy in the literature regarding the effectiveness of antibiotics in the treatment of ABS, most studies in which the diagnosis of acute bacterial sinusitis is confirmed with images and appropriate anti-biotics are prescribed show superior outcomes in recipients of antibiotics. Therapy may be initiated with high-dose amoxicillin or amoxicillin-clavulanate. In penicillin-allergic patients or those who are unresponsive to amoxicillin, amoxicillin-clavulanate is appropriate. Alternatives include cefuroxime, cefpodoxime, or cefdinir. In cases of serious drug allergy, clarithromycin or azithromycin may be prescribed. The optimal duration of therapy is unknown. Some recommend treatment until the patient becomes free of symptoms and then for an additional 7 d.

Assessment of infectious organisms associated with chronic rhinosinusitis in cats

OBJECTIVE

To determine detection rates for feline herpesvirus type 1 (FHV-1), Mycoplasma spp, fungi, and bacteria in flush samples and biopsy specimens from the nasal cavities of cats with and without chronic rhinosinusitis (CRS).

DESIGN

Prospective study.

ANIMALS

10 CRS-affected cats and 7 cats without signs of respiratory tract disease.

PROCEDURES

Nasal flush samples and biopsy specimens were collected from all cats for bacterial (aerobic and anaerobic), fungal, and mycoplasmal cultures; additional biopsy specimens were collected for virus isolation and polymerase chain reaction (PCR) assay (to detect FHV-1 DNA).

RESULTS

Aerobic bacteria were detected in flush samples from 5 of 7 control cats; culture of flush samples from CRS-affected cats yielded aerobic bacteria (9/10 cats), anaerobic bacteria (3/10), and Mycoplasma spp (2/10). No fungal organisms were isolated from any cat. Potential pathogens were isolated significantly more often from CRS-affected cats than from control cats. Bacterial culture of biopsy specimens yielded aerobic bacteria (2/7 control cats and 4/10 CRS-affected cats) and anaerobic bacteria (2/10 CRS-affected cats). Although FHV-1 was not detected in nasal biopsy specimens from control or CRS-affected cats, FHV-1 DNA was detected via PCR assay in specimens from 4 of 7 control cats and 3 of 10 CRS-affected cats.

CONCLUSIONS AND CLINICAL RELEVANCE

Compared with findings in control cats, anaerobic bacteria, Mycoplasma spp, and a variety of potentially pathogenic organisms were detected more commonly in samples from cats with CRS. In both groups, FHV-1 was detected via PCR assay as a nonviable organism or in noncultivable amounts.

Nasal airflow, mucociliary clearance, and sinus functioning during viral colds: effects of allergic rhinitis and susceptibility to recurrent sinusitis

BACKGROUND

The aim was to compare nasal airflow and mucociliary clearance (MCC) and their association with paranasal sinus functioning during acute natural colds and convalescence in allergic and sinusitis-susceptible patients and healthy controls.

METHODS

Nine allergic subjects, 16 sinusitis-susceptible subjects, and 20 healthy controls were examined during days 2-4 of acute colds and 3 weeks later by taking viral specimens, recording symptoms, performing rhinomanometry and dyed saccharin tests, and evaluating sinus functioning with computed tomography (CT).

RESULTS

Viral etiology of the cold was identified in 31 (69%) subjects. Nasal airflow was decreased and MCC time prolonged during the cold compared to convalescence. A higher proportion of the allergic subjects, but not of the sinusitis-susceptible subjects, compared to the control subjects tended to have abnormal nasal airflow and MCC values. Abnormal nasal airflow and MCC values associated significantly with higher ipsilateral paranasal sinus CT scores.

CONCLUSION

Abnormal nasal airflow and MCC rates seem to be associated with impaired functioning of paranasal sinuses during viral colds and tend to be more common in allergic subjects.

Otolaryngologic manifestations of human immunodeficiency virus infection

The otolaryngologist is uniquely positioned to detect and pursue manifestations of HIV in the head and neck. The presentation of problems subsequent to HIV infection is quite varied, but close investigation will often reveal treatable problems.

Nasopharyngeal reservoir of bacterial otitis media and sinusitis pathogens in adults during wellness and viral respiratory illness

BACKGROUND

The carriage rate of pathogenic bacteria in the nasopharynx (NP) was determined using three separate techniques for obtaining samples.

METHODS

The NP of 99 healthy adults was sampled with (1) nasal swab, (2) oral swab, and (3) nasal aspiration; 49 adults with common cold were sampled with an oral swab and nasal aspiration. Three selective agars were used to detect Streptococcus pneumoniae, Hemophilus influenzae, and Moraxella catarrhalis.

RESULTS

Seventy-three percent of healthy adults and 74% of cold sufferers had at least one pathogen detected in the NP. Detection rates were 65% (oral NP swab), 38% (catheter aspiration), and 28% (nasal swab; p < 0.001). Carriage rates for S. pneumoniae, M. catarrhalis, and H. influenzae were 45, 33, and 30%, respectively. Both a nasal and an oral sample were required for optimal detection.

CONCLUSION

Bacterial pathogens were present in the NP of three-quarters of adults during wellness and during colds.

Viral respiratory infections due to rhinoviruses: current knowledge, new developments

Viral respiratory infections (VRIs) are among the most common reasons for which primary care providers are consulted. VRIs due to rhinoviruses-the most commonly implicated etiologic agent-constitute a syndrome characterized by signs and symptoms of a cold. Rhinoviruses have been implicated in respiratory tract illnesses such as sinusitis and otitis media, as well as lower respiratory complications in high-risk populations. Most patients treat VRI with over-the-counter remedies that have been demonstrated to produce marginal clinical benefits. The development of novel antiviral agents has intensified interest in VRIs. Pleconaril, a capsid-function inhibitor currently under FDA review, has been shown in clinical trials to reduce the duration and severity of rhinovirus VRIs. By targeting the cause of illness, antiviral agents represent an opportunity to reduce the substantial clinical burden of VRI. Furthermore, effective therapies can potentially reduce inappropriate antibiotic use for viral infections.

Respiratory consequences of rhinovirus infection

Rhinoviruses, a genus of the family Picornaviridae, are the cause of more than 50% of respiratory tract infections. Complications of rhinovirus infections, which include otitis media, sinusitis, exacerbations of asthma, and other pulmonary diseases, can be significant in certain populations. Reverse transcriptase-polymerase chain reaction has allowed the identification of rhinoviruses and led to a greater appreciation of the role of this pathogen in upper and lower respiratory tract disease. Furthermore, antiviral agents with broad activity against rhinoviruses have recently been developed, have undergone clinical trials, but have not been approved for clinical use. By altering the clinical course of picornavirus infections, it may be possible to minimize their potential adverse consequences.

Histologic and immunologic observations of viral-induced rhinosinusitis in the mouse

Viral upper respiratory infection is one of the most common diagnoses made in primary care offices. Although symptoms resolve within 1 week for many patients, a percentage develops rhinosinusitis, and many of these patients are treated with antibiotics. We have developed a model of viral rhinosinusitis using intranasal inoculation of reovirus into mice that were then killed on postinoculation days 2, 4, 7, 10, 14, or 21 and heads were embedded in paraffin for histological and immunohistochemical analyses. Reovirus-like immunoreactivity was noted in the septa and paranasal sinus mucosa in mice as early as day 2, with peak intensity seen on day 4, and scant staining seen on day 7. Complete absence of viral staining was seen by day 10, which corresponded with increased intracellular adhesion molecule 1 immunostaining in the nose. By day 10, a large mucosal influx of B cells was observed, with a moderate influx of macrophages and smaller influx of T cells. By day 14, there was a peak in the number of B cells with a corresponding, but less pronounced peak in T cells, while macrophages began to decline at this point. By day 21, the panel of immune markers returned to near normal levels. The results of this study suggest that the immune system continues to produce a response as long as 2 weeks after clearance of viral antigens. One proposed mechanism for this phenomenon is that local factors such as cytokines are released continually after infection, even in the absence of persistent viruses or bacteria.

Respiratory illness caused by picornavirus infection: a review of clinical outcomes

BACKGROUND

Respiratory infections result from invasion of the respiratory tract, mainly by viruses, and are the leading cause of acute morbidity in individuals of all ages worldwide. During peak season, picornaviruses cause 82% of all episodes of acute nasopharyngitis (the common cold), the most frequent manifestation of acute respiratory infection, and produce more restriction of activity and physician consultations annually than any other viral or bacterial source of respiratory illness.

OBJECTIVE

This article reviews the clinical impact and outcomes of picornavirus-induced respiratory infections in specific populations at risk for complications. It also discusses the potential economic impact of the morbidity associated with picornavirus-induced respiratory infection.

METHODS

Relevant literature was identified through searches of MEDLINE, OVID, International Pharmaceutical Abstracts, and Lexis-Nexis. The search terms used were picornavirus, rhinovirus, enterovirus, viral respiratory infection, upper respiratory infection, disease burden, economic, cost, complications, asthma, COPD, immunocompromised, elderly otitis media, and sinusitis. Additional publications were identified from the reference lists of the retrieved articles.

CONCLUSIONS

Based on the clinical literature, picornavirus infections are associated with severe morbidity as well as considerable economic and societal costs. Future research should focus on identifying patterns of illness and the costs associated with management of these infections. New treatments should be assessed not only in terms of their ability to produce the desired clinical outcome, but also in terms of their ability to reduce the burden of disease, decrease health care costs, and improve productivity.

Herpesvirus type 1-8 in sinus aspirates from HIV-infected patients and immunocompetent individuals

Sinusitis is frequently occurring in HIV-infected patients, but in a substantial number of cases the etiology is unknown. The purpose of this study was by PCR 1) to determine the prevalence of the eight human herpesviruses in sinus aspirates from 24 HIV-positive/AIDS patients with sinusitis 2) to relate the presence of herpesvirus DNA to clinical and immunological parameters and 3) to compare the prevalence of herpesvirus DNA in sinus aspirates from HIV-infected patients with the prevalence observed in 50 immunocompetent patients with sinusitis. DNA from HSV-1, EBV, CMV and HHV-8 was detected in 8 (33%) of the sinus aspirates from HIV-infected patients. In the immunocompetent patients, one of the herpesviruses, HHV-6, was found in one sinus aspirate. These data indicate that herpesviruses are frequently found in sinus aspirates from HIV-infected patients with sinusitis, whereas they do not seem to be related to clinical signs of sinusitis in immunocompetent individuals. The cause of these discrepancies may be due to uncontrolled reactivation of herpesviruses, which is known to occur in immunocompromised individuals. It remains to be established whether the herpesviruses play a pathogenic role in the development of sinusitis in HIV-infected patients.

Analysis of human papillomavirus in schneiderian papillomas as compared to chronic sinusitis and normal nasal mucosa

Schneiderian papillomas (SPs) are tumours arising from the surface epithelium (schneiderian epithelium) of the nasal cavity and paranasal sinuses. Evidence points toward a viral etiology, specifically human papillomavirus (HPV). Although substantial data indicate HPV as a likely etiology, little is known about the role of HPV in benign nasal pathologies or in normal nasal mucosa. The objective of this study was to characterize the relationship between HPV and SP, chronic sinusitis (CS), and normal nasal mucosa. A case-control study was undertaken, matching patients with SP to patients with CS. Patients with normal nasal mucosa served as a control group. All patients had their tissues analyzed for the presence of various HPV subtypes using line blot assay. A total of 168 patients were identified (74 SP, 74 CS, 20 control). Of these, 70 (41.7%) had detectable deoxyribonucleic acid and 9 of 70 (12.9%) had detectable HPV of subtypes 6, 11, and 16. None had detectable HPV type 18. Significant differences were detected in the presence of HPV in the CS, SP, and control groups, as well as in the presence of low- versus high-risk subtypes among investigation and control groups. Significant differences exist in HPV infectivity among SP, benign nasal pathologies such as CS, and normal nasal mucosa. Human papillomavirus plays an important role, at least in part, in the development of SP, with types 6, 11, and 16 being more pivotal than other types. Line blot assay is a useful technique in identifying HPV in SP.

Complications of allergic rhinitis

Upper and lower respiratory diseases, including asthma, sinusitis, and otitis media with effusion, frequently complicate allergic rhinitis. The close association of nasal allergies with these conditions has been supported by extensive epidemiologic evidence. Similar models have been proposed to explain the pathophysiologic links between allergic rhinitis and both sinusitis and otitis media with effusion. In these models, inflammation caused by nasal allergy and/or viral infection leads to obstruction, fluid accumulation, bacterial infection, and acute disease. If these diseases are unsuccessfully treated, a chronic state of inflammation, obstruction, and infection develops that can cause mucosal damage and, ultimately, chronic disease. A number of studies have investigated the roles and interactions of viruses and allergens in the development of otitis media with effusion. Diagnosing and prophylactically treating nasal allergies in patients with this condition may help prevent recurrent episodes and improve the response to therapy.

Rhinosinusitis and atopy in patients infected with HIV

HYPOTHESIS

Rhinosinusitis is common during HIV infection; its prevalence is uncertain and could probably be related to clinical features, immunoallergological status, and diagnostic criteria

METHODS

Seventy-four patients hospitalized with HIV infection were prospectively evaluated for the presence of rhinosinusitis based on clinical findings, nasal endoscopy, or paranasal sinus computed tomography (CT). Immune status, nasal smear, features of atopy (based on the prick test), and its contribution to sinusal inflammatory pathology were also evaluated.

RESULTS

Most patients were severely immunosuppressed: CD4+ 155+/-201 cells/mL and 12+/-11% (mean +/- SD). Thirty-five percent of the patients presented at least two criteria of rhinosinusitis (clinical findings, nasal endoscopy, and CT: 35%; clinical findings and CT: 50%; nasal endoscopy and CT: 15%). CT scan showed multiple sinus involvement, opacification over 25% of the total volume of the maxillary sinus in 50% of patients, and opacification of the sphenoidal sinus in 40% of cases. Atopy was present in 18% of patients, a figure which reflects the expected prevalence in our geographic area. Two independent predictors were associated with a higher probability of rhinosinusitis: bilateral absence of maxillary infundibular patency (odds ratio, 7.5; 95% CI = 2.03-27.9) and low total count (odds ratio, 0.99; 95% CI = 0.99-1.00) or percentage of CD4+ (odds ratio, 0.93; 95% CI = 0.88-1.00).

CONCLUSIONS

There is a high prevalence of rhinosinusitis in HIV-infected individuals. This finding is related to a decreased cellular immunity, but it does not appear to be related to IgE-related immediate hypersensitivity. Nasal endoscopy should be the first-step diagnostic test. However, when clinical suspicion exists and endoscopy fails to explain symptoms, CT scan is a valuable adjunct to establish this diagnosis.

Rhinoviruses: important respiratory pathogens

The most frequent viruses associated with respiratory infections are human rhinoviruses (HRVs). Although the majority of HRV infections are mild and self-limited, HRV is an important cause of respiratory disease across all age groups. Recent studies using reverse transcriptase polymerase chain reaction to detect HRV genomes have established the importance of HRVs in predisposing to or causing otitis media, sinusitis and exacerbations of asthma, as well as other lower respiratory tract disorders. Among elderly people, infants and immunocompromised hosts HRV infections are often associated with lower respiratory tract morbidity and rarely mortality. How often active viral replication occurs in the middle ear, sinuses or the lower respiratory tract remains to be determined. However, the high incidence of HRV infections and their frequent association with upper and lower respiratory tract complications highlight the need for more effective means of prevention and treatment.

Microbiology of acute and chronic sinusitis in children and adults

The microbiology of infections of the paranasal sinuses can be anticipated according to the patient's age, clinical presentation, and immunocompetence. In acute sinus disease, viral upper respiratory infections frequently precede bacterial superinfection by Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Staphylococci and respiratory anaerobes are common in chronic sinus infection, which may also be caused by exacerbations of infection with the bacterial species that cause acute disease. Enterobacteriaceae may be found in patients with nosocomial sinusitis who are predisposed to the development of sinusitis by prolonged nasogastric and nasotracheal intubation. Immunosuppressed patients have episodes of sinusitis caused by the usual agents associated with acute sinusitis in immunocompetent patients, and they may also become infected with a broad array of unusual agents, including mycobacterial species, fungi, and protozoa.

Chronic sinusitis in children

In children, sinusitis is a common, generally uncomplicated, and self limiting disease which drops with age. The diagnosis is difficult because of relatively non specific signs and symptoms that overlap with viral upper respiratory infection and allergy. Plain paranasal sinus radiographs are not adequate, in determining the extent of involvement in recurrent or chronic sinusitis and so CT scan has become the standard. Viral illness appears to be the most common predisposing factor. Immune defects (mainly IG2 and IGA) may exist in a significant percentage of children. The role of allergy seems less important. With advances in the genetic field of cystic fibrosis, genetic factors are advocated in chronic or recurrent sinusitis. The most common bacterial pathogens in pediatric sinusitis patients are SP (Streptococcus Pneumoniae), HI (Hemophilus Influenza) and MC (Moraxella Catarrhalis). Other less frequent bacterial species include group A streptococcus, group C streptococcus, streptococcus viridans, peptostreptococcus, moraxella species and Eikenella corrodens. Respiratory anaerobes are not common. Antibiotics resistant to the action of the beta-lactamase are the cornerstone in medical treatment. In recurrent acute sinusitis prophylactic antimicrobials may be helpful. The indication for surgery remains controversial. To date, we have no prospective studies comparing surgical to medical therapy in order to guide us in deciding surgical indication. It is therefore recommended to follow a conservative track and to limit surgical procedures in children with suppurative complications, nasal obstruction from polyposis or refractory sinusitis aggravating chronic pulmonary disease such as asthma.

Sinusitis in the immunocompromised host

In the immunocompromised host, uncommon pathogens have been documented as causing sinusitis. Resistance to standard antibiotics for sinusitis in the immunocompromised individual must prompt nasal culture and biopsy for early diagnosis. Immunocompromised host include neutropenic patients, Human Immuno-Deficiency (HIV) infected patients and non-HIV-suppressed patients. Unusual bacterial organisms (Pseudomonas Aeruginosa), mycobacteria, fungi (Aspergillosis) and viral infection (Cytomegalovirus) have all been found to cause sinusitis in immunocompromised patients. Early detection of these infections with appropriate anti-infective agents associated with radical or functional endoscopic surgery seems to be the optimal treatment. Recovery of immunity remains the major prognostic factor.

Microbiology of chronic sinusitis

Much controversy still exists about the role of viruses, bacteria and fungi in sinusitis. Until recently, it was not really known that the sinuses take part in the infectious process of a common cold (viral rhinitis). Indeed, CT scans show that in the vast majority of otherwise healthy volunteers with a common cold, and without a previous history of recurrent or chronic sinusitis, the sinuses are involved too. A viral rhinitis alone, however, does not seem to be able to elicit a "clinical" acute sinusitis. Bacteria determine the clinical picture and outcome of sinusitis. There is not much controversy about the role of bacteria in acute sinusitis, S. pneumoniae, H. influenzae and M. catarrhalis being the most frequently involved bacteria. Much more conflicting reports are published about the normal flora of the sinuses, the role of anaerobes and the microbiology of chronic sinusitis. In this chapter the defense and pathophysiologic mechanisms of viral, bacterial and fungal infection of the nasal and sinusal mucosa are described. It is postulated that, although bacteria are very important in acute sinusitis, their role in chronic sinusitis is minimal, the bacteria being opportunistic colonisers.

Detection of rhinovirus in sinus brushings of patients with acute community-acquired sinusitis by reverse transcription-PCR

Of 20 adults with acute community-acquired sinusitis (ACAS), rhinovirus was detected in specimens from 10 (50%) patients, including maxillary aspirates from 8 (40%) patients and nasal swabs from 9 (45%) patients, by reverse transcription-PCR (RT-PCR). Human coronavirus was detected by RT-PCR in nasal swabs from 3 of 20 patients but in no sinus secretions. These findings suggest that rhinovirus is an important cause of ACAS and that viral invasion of the sinus cavity itself may be a common event during the disease.

Adenovirus and respiratory syncytial virus in chronic sinusitis using polymerase chain reaction

The aim of this study is to investigate the role of adenovirus and respiratory syncytial virus (RSV) in chronic sinusitis using the polymerase chain reaction (PCR) to assay for the viruses. PCR has proved to be more sensitive and specific than viral cultures and immunoassays in the detection of viruses. Adenovirus and RSV are among the most common viruses to cause upper respiratory tract infections. Sinus mucosa biopsies from 20 patients undergoing endoscopic sinus surgery were sterilely collected. Four specimens (20%) tested positive for RSV by PCR and none tested positive for adenovirus. Only one specimen tested positive for RSV and one for adenovirus by viral culture and immunofluorescence. Bacterial cultures tested positive in 40% of the 20 specimens. PCR can be used to detect RSV in patients with chronic sinusitis and PCR is more sensitive than viral culture and immunofluorescence techniques on sinus polyps and mucosa.

Cytomegalovirus sinusitis. A new manifestation of AIDS

Cytomegalovirus is a common pathogen in patients infected with the human immunodeficiency virus. In this article, cytomegalovirus sinusitis is described and documented for the first time, to our knowledge. Cytomegalovirus was cultured from the sinuses of four patients who were positive for the human immunodeficiency virus and who had antibiotic-resistant infections. In one patient who underwent surgery, cytomegalovirus inclusions were documented consistent with invasive infection. Optimal treatment has yet to be determined, but in this case surgery did provide temporary relief of sinus symptoms.

Human herpesvirus 6: infection and disease following autologous and allogeneic bone marrow transplantation

Human herpesvirus 6 activity (HHV-6) was studied in 15 allogeneic and 11 autologous marrow transplantation patients. After transplantation, HHV-6 was isolated from the peripheral blood mononuclear cells of 12 of 26 patients (6 allogeneic and 6 autologous). All isolates were variant B. Eleven of 26 and 12 of 19 patients showed salivary shedding of HHV-6 DNA before and after transplantation, respectively. The antibody titer increased in 7 of 26 patients. Thus, 23 of 26 patients showed evidence of active HHV-6 infection either by virus isolation, salivary shedding, or increases in antibody titers. The fraction of saliva specimens positive in 19 patients was negatively associated with their antibody titers (P= .005). The proportion of cultures positive increased after transplantation (P = .007). Sinusitis was associated with HHV-6 isolation in autologous recipients (P= .002). In allogeneic patients, active human cytomegalovirus infection was associated with HHV-6 isolation (P = .04). No association was observed between HHV-6 infection and GVHD, pneumonia, delay in engraftment, or marrow suppression. Of the 120 clinical events analyzed in 26 patients, HHV-6 was defined as a probable cause of 16 events in 9 patients based on the propinquity of HHV-6 activity and the clinical event plus the absence of other identified causes of the event.

Effects of viral and bacterial infection on nasal and sinus mucosa

There is still controversy over the role of viruses and bacteria in rhinologic infections, especially in sinusitis. Until recently it was not fully known whether the sinuses do in fact take part in the infectious process of a common cold (viral rhinitis). CT scans show that in the vast majority of otherwise healthy volunteers with a common cold, and without a previous history of recurrent or chronic sinusitis, the sinuses are involved; there was, however, in these individuals no typical symptomatology of acute sinusitis. A viral rhinitis alone does not seem to be able to elicit a "clinical" acute otitis. Bacteria determine the clinical picture and outcome of sinusitis. There is not much controversy about the role of bacteria in acute sinusitis, S. pneumoniae, H. influenzae, and M. catarrhalis being the most frequently involved. Much more conflicting reports are published about the normal flora of the sinuses, the role of anaerobes and the microbiology of chronic sinusitis. In this paper the mechanisms of viral and bacterial infection of the nasal and sinusal mucosa are described and the results of microbiological studies in sinusitis reported by other authors and our own group are discussed. It is postulated that, although bacteria are very important in acute sinusitis, their role in chronic sinusitis is minimal, the bacteria being opportunistic colonisers.

Cytomegalovirus as precipitating factor of acute bacterial sinusitis in an immunocompetent patient. A case report

The authors report the first case of cytomegalovirus (CMV) isolated from the maxillary sinus of an immunocompetent patient with acute bacterial sinusitis. CMV has not been previously reported in the maxillary sinus of immunocompetent patients. The authors' hypothesis is that CMV can act as a precipitating factor for acute bacterial sinusitis.