Brazilian guideline for the use of immunobiologicals in chronic rhinosinusitis with nasal polyps ‒ 2024 update

INTRODUCTION

Biologics targeting type 2 inflammation have revolutionized the way we treat patients with Chronic Rhinosinusitis with Nasal Polyps (CRSwNP). Particularly in severe and difficult-to-control cases, these drugs have provided a new reality for these patients, allowing for the effective and safe treatment of extensive diseases that were not completely managed with the typical strategy of surgery and topical medications.

OBJECTIVES

The experience achieved with the approval of these medications by ANVISA for use in CRSwNP and the knowledge obtained regarding outcomes, adverse effects, and the ideal patient profile prompted the update of the previously published guideline, with a detailed review of the most recent scientific literature, the personal experiences of experts, and the adaptation to the reality of the Brazilian healthcare system, both public and private.

RESULTS

We proposed a new eligibility criterion for biologics in patients with CRSwNP based on four pillars of indication: the impact of the disease on the patient's life, whether in the presence of specific symptoms or in overall quality of life; the extent of sinonasal disease; the presence of type 2 comorbidities, considering other associated diseases that may also benefit from anti-T2 biologics, and the presence of biomarkers to define type 2 inflammation, especially those associated with worse disease prognoses.

CONCLUSIONS

This innovative and pioneering method has two major advantages. First, it ensures a comprehensive evaluation of patients; second, it is flexible, as advancements in our understanding of the disease and changes in cost-effectiveness can be addressed by simply adjusting the required score for indication, without the need to modify the entire evaluation scheme.

Smell loss associated with SARS-CoV-2 is not clinically different from other viruses: a multicenter cohort study

BACKGROUND

Although the COVID-19 pandemic has increased the prevalence of cases with olfactory loss, other respiratory viruses can also cause this condition. We aimed to compare the prevalence of acute SARS-CoV-2 infection and other respiratory viruses in patients with sudden smell loss, and to assess the impact of SARS-CoV-2 viral load and co-infection on olfactory symptoms.

METHODS

Patients with sudden smell loss were recruited in a multicenter prospective cohort study in 15 hospitals in Brazil. Clinical questionnaire, Connecticut Chemosensory Clinical Research Center (CCCRC) olfactory test and nasopharyngeal swab to perform a PCR-based respiratory viral panel were collected at first visit (day 0) and 30 and 60 days after recruitment.

RESULTS

188 of 213 patients presented positive test result for SARS-CoV-2, among which 65 were co-infected with other respiratory viruses (e.g., rhinovirus, enterovirus, and parainfluenza). 25 had negative test results for SARS-CoV-2. Patients in both SARSCoV-2 and non-SARS-CoV-2 groups had objective anosmia (less than 2 points according to the psychophysical olfactory CCCRC) at day 0, with no significant difference between them. Both groups had significant smell scores improvement after 30 and 60 days, with no difference between them. Co-infection with other respiratory viruses, and SARS-CoV-2 viral load did not impact olfactory scores.

CONCLUSION

Patients with sudden smell loss associated with SARS-CoV-2 and other respiratory viruses had similar presentation, with most participants initiating with anosmia, and total or near total recovery after 60 days. SARS-CoV-2 viral load and co-infections with other respiratory viruses were not associated with poorer olfactory outcomes.

International Frontal Sinus Anatomy Classification (IFAC): evaluation of frontoethmoidal cells prevalence in a Brazilian population

OBJECTIVES

The aim of this study was to evaluate the prevalence of the frontal cell variants according to International Frontal Sinus Anatomy Classification (IFAC), in the population of a Brazilian tertiary hospital, and analyze the reliability of the classification between observers.

METHODS

A cross-sectional study in the Hospital de Clínicas of the State University of Campinas, Brazil. One hundred and three Computed Tomography's (CTs) were evaluated by radiologists and otorhinolaryngologist to estimate the prevalence of frontoethmoidal cells according to the IFAC. Intraclass Correlation Coefficient (ICC) among examinators was used to evaluate reliability of this findings.

RESULTS

103 CT scans, totaling 206 sides, were evaluated independently. The agger nasi cell was the most prevalent, present in 95.63% of cases, 37.86% of the exams contained supra agger cells, frontal supra agger cell showed prevalence 37.37%; suprabular cell was present in 77.18% of the sides. As for the frontal suprabular cell, the prevalence was 30.09%, the supraorbital ethmoid cell was present in 32.03%, and frontal septal cell had a 33.49% prevalence. The ICC among the evaluators was classified as "good reliability" or "excellent reliability" for all cells.

CONCLUSION

This study describes the frontal cell prevalence among a population in tertiary Brazilian hospital, using the IFAC. This classification had a high ICC.

LEVEL OF EVIDENCE

Level 2: Individual cross-sectional study with consistently applied reference standard and blinding.

Achieving the best method to classify Eosinophilic Chronic Rhinosinusitis: a systematic review

BACKGROUND

Chronic Rhinosinusitis is currently classified into eosinophilic and non-eosinophilic, according to the histologic quantification of the number of eosinophils in nasal mucosa biopsy. There is a lack of unanimous histopathologic criteria and methodology for this classification and no consensus regarding a cut-off point for Eosinophils per High power field.

METHODOLOGY

A systematic electronic search was performed on BVS, PUBMED, PUBMED PMC, SCOPUS, WEB OF SCIENCE, EMBASE, COCHRANE and PROQUEST databases looking for studies that reported a cut point for classification of Eosinophilic Chronic Rhinosinusitis (eCRS), and data concerning methodology of classification was extracted.

RESULTS

We identified 142 studies that reported 29 different cut-off values for classification of eCRS, and different methods of histologic analysis. Out of these studies 13 reported their own methodology to establish the cut-off point, and used different reference standards as polyp recurrence, asthma and allergy, immunocytochemistry, quality of life index, standard deviation of the control population and cluster analysis.

CONCLUSIONS

Further studies are needed to determine a precise cut-off point, especially international multicentered cluster analysis. Moreover, methodologic standardization of biopsy and analysis is needed to certify comparable results. Multiple biopsy sites, densest cellular infiltration area examination and oral steroids restriction at least four weeks before sampling are advisable.

Guideline for the use of immunobiologicals in chronic rhinosinusitis with nasal polyps (CRSwNP) in Brazil

•

The use of immunobiologicals is an option for the management of patients with chronic rinosinusitis with nasal polyps (CRSwNP) refractory to conventional treatment.

•

The guideline lists the main drugs currently available in Brazil, their indications, and recommendations for use.

Introduction

Severe uncontrolled chronic rhinosinusitis with nasal polyps has a negative impact on an individual’s quality of life. Therefore, new biologics have emerged for use in specific phenotypes of chronic rhinosinusitis, changing the paradigms of its treatment.

Objective

To review the current status of biologic treatment indications in chronic rhinosinusitis.

Methods

The Brazilian Academy of Rhinology brought together different specialists to suggest a course of action, considering its particularities and aspects related to the national reality.

Results

Of particular interest for decision making will be the identification of subgroups of patients refractory to pre-existing treatment options and the construction of a strategy that improves their quality of life, with the best cost-benefit ratio.

Conclusion

The use of biologics is a valid option for treatment in more severe cases. This strategy must be better understood and improved in the future, with more studies and greater clinical experience.

Topical tretinoin in chronic rhinosinusitis with nasal polyps: a randomized clinical trial

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) is usually treated with corticosteroids, given their anti-inflammatory effects. Unlike the nasal administration, the oral and ocular use of tretinoin, an immunoregulatory drug, is well established. Therefore, tretinoin was thought to act on nasal polyps, and possible adverse and/or therapeutic effects were investigated.

METHODS

A first-in-human open-label trial was conducted enrolling patients with CRSwNP randomized into: a control group (CTR, n = 15), treated with budesonide for 24 weeks; and an intervention group (TRT, n = 15), who received budesonide and 0.1% tretinoin in the last 12 weeks. Primary endpoint included histopathological analysis and tissue immunoassay (Multiplex) for tumor necrosis factor α (TNF-α), interleukin (IL)-1β, IL-4, IL-5, IL-13, and matrix metalloproteinase 9 (MMP-9) at 12 and 24 weeks. Secondary endpoints were: adverse events report, endoscopy (modified Lund-Kennedy scoring system [LKS]), quality of life (22-item Sino-Nasal Outcome Test [SNOT-22]), and olfactory test (Connecticut Chemosensory Clinical Research Center) at baseline, at 12 weeks, and at 24 weeks, in addition to serum biochemistry and tomographic findings (Lund-Mackay computed tomography [CT] staging system [LMS]) at baseline and 24 weeks.

RESULTS

TRT showed less microscopic edema (2/13 [15.4%] vs 8/13 [61.5%]; p = 0.044) as well as no increase in cytokines levels. All adverse events were categorized as "grade 1" (asymptomatic; mild). The most interesting part of this study was the improvement in smell between baseline (T0) and week 24 (T2) in TRT only (p = 0.041).

CONCLUSION

Transnasal tretinoin associated with budesonide was safe and well tolerated, and it should be investigated as a treatment option for some CRSwNP endotypes. ©2021 ARSAAOA, LLC.

Anatomical terminology of the internal nose and paranasal sinuses: cross-cultural adaptation to Portuguese

INTRODUCTION

Functional endonasal endoscopic surgery is a frequent surgical procedure among otorhinolaryngologists. In 2014, the European Society of Rhinology published the "European Position Paper on the Anatomical Terminology of the Internal Nose and Paranasal Sinuses", aiming to unify the terms in the English language. We do not yet have a unified terminology in the Portuguese language.

OBJECTIVE

Transcultural adaptation of the anatomical terms of the nose and paranasal cavities of the "European Anatomical Terminology of the Internal Nose and Paranasal Sinuses" to Portuguese.

METHODS

A group of rhinologists from diverse parts of Brazil, all experienced in endoscopic endonasal surgery, was invited to participate in the creation of this position paper on the anatomical terms of the nose and paranasal sinuses in the Portuguese language according to the methodology adapted from that previously described by Rudmik and Smith.

RESULTS

The results of this document were generated based on the agreement of the majority of the participants according to the most popular suggestions among the rhinologists. A cross-cultural adaptation of the sinonasal anatomical terminology was consolidated. We suggest the terms "inferior turbinate", "nasal septum", "(bone/cartilaginous) part of the nasal septum", "(middle/inferior) nasal meatus", "frontal sinus drainage pathway", "frontal recess" and "uncinate process" be standardized.

CONCLUSION

We have consolidated a Portuguese version of the European Anatomical Terminology of the Internal Nose and Paranasal Sinuses, which will help in the publication of technical announcements, scientific publications and the teaching of the internal anatomical terms of the nose and paranasal sinuses in Brazil.

How to avoid the inappropriate use of antibiotics in upper respiratory tract infections? A position statement from an expert panel

INTRODUCTION

Bacterial resistance burden has increased in the past years, mainly due to inappropriate antibiotic use. Recently it has become an urgent public health concern due to its impact on the prolongation of hospitalization, an increase of total cost of treatment and mortality associated with infectious disease. Almost half of the antimicrobial prescriptions in outpatient care visits are prescribed for acute upper respiratory infections, especially rhinosinusitis, otitis media, and pharyngotonsillitis. In this context, otorhinolaryngologists play an important role in orienting patients and non-specialists in the utilization of antibiotics rationally and properly in these infections.

OBJECTIVES

To review the most recent recommendations and guidelines for the use of antibiotics in acute otitis media, acute rhinosinusitis, and pharyngotonsillitis, adapted to our national reality.

METHODS

A literature review on PubMed database including the medical management in acute otitis media, acute rhinosinusitis, and pharyngotonsillitis, followed by a discussion with a panel of specialists.

RESULTS

Antibiotics must be judiciously prescribed in uncomplicated acute upper respiratory tract infections. The severity of clinical presentation and the potential risks for evolution to suppurative and non-suppurative complications must be taken into 'consideration'.

CONCLUSIONS

Periodic revisions on guidelines and recommendations for treatment of the main acute infections are necessary to orient rationale and appropriate use of antibiotics. Continuous medical education and changes in physicians' and patients' behavior are required to modify the paradigm that all upper respiratory infection needs antibiotic therapy, minimizing the consequences of its inadequate and inappropriate use.

IV Brazilian Consensus on Rhinitis - an update on allergic rhinitis

INTRODUCTION

The guidelines on allergic rhinitis aim to update knowledge about the disease and care for affected patients. The initiative called "Allergic Rhinitis and its Impact on Asthma", initially published in 2001 and updated in 2008 and 2010, has been very successful in disseminating information and evidence, as well as providing a classification of severity and proposing a systemized treatment protocol. In order to include the participation of other medical professionals in the treatment of allergic rhinitis, it is important to develop algorithms that accurately indicate what should and can be done regionally.

OBJECTIVE

To update the III Brazilian Consensus on Rhinitis - 2012, with the creation of an algorithm for allergic rhinitis management.

METHODS

We invited 24 experts nominated by the Brazilian Association of Allergy and Immunology, Brazilian Association of Otorhinolaryngology and Head and Neck Surgery and Brazilian Society of Pediatrics to update the 2012 document.

RESULTS

The update of the last Brazilian Consensus on Rhinitis incorporated and adapted the relevant information published in all "Allergic Rhinitis and its Impact on Asthma" Initiative documents to the Brazilian scenario, bringing new concepts such as local allergic rhinitis, new drugs and treatment evaluation methods.

CONCLUSION

A flowchart for allergic rhinitis treatment has been proposed.

Slowly progressive invasive rhino-orbito-cerebral aspergillosis: case report and literature review

This is a report of a patient with aspergillosis infection, which was thought to be a tumoral lesion during its investigation. This is not a common disease in Western countries, and this report should increase our awareness for differential diagnosis of nasal masses. Early diagnosis is desired in order to increase the survival rates.

Newborn nasal obstruction due to congenital nasal pyriform aperture stenosis

Introduction:

Nasal obstruction is an important condition that can lead to severe respiratory distress in newborns. There are several differential diagnoses, and one of them is congenital nasal pyriform aperture stenosis (CNPAS). CNPAS is a rare case of respiratory distress caused by excessive growth of the nasal process of the maxilla and leads to narrowing of the anterior third of the nasal cavity. Diagnosis, associated anomalies, and treatment strategies are reviewed by the following presentation of two cases.

Case Presentation:

We report two cases of infants diagnosed with CNPAS. The patients in the first case had no concomitant comorbidities, and the outcome was successful after surgical correction of stenosis. The patient in the second case had an associated holoprosencephaly, and although surgical correction and nasal cavity patency, the patient remains dependent on tracheostomy due to dysphagia and neurologic impairment.

Discussion:

Airway obstruction affects 1 in 5000 children, and CNPAS is a diagnosis frequently forgotten and even unknown to neonatal and pediatric intensivists. Newborns are obligate nasal breathers, and, nasal obstruction, therefore, can lead to severe respiratory distress. CNPAS is not only rare but, many times, is not easily recognized. It is important to bear in mind the diagnostic criteria when evaluating infants with nasal obstruction. Conservative treatment should be prioritized, but surgical treatment is required in severe cases with failure to thrive and persistent respiratory distress. Respiratory distress and dysphagia may persist to some degree despite correction of the stenotic pyriform aperture due to associated narrowing of the entire nasal cavity and association with other anomalies.

Final Comments:

CNPAS is a rare condition and may be lethal in newborns. Differential diagnosis of nasal obstruction must be remembered to recognize this anomaly, and the otolaryngologist must be familiarized with this condition and its diagnosis. Precise surgical treatment in severe cases have high rates of success in children without other comorbidities.

Rhinosinusitis in hematopoietic stem cell-transplanted patients: influence of nasosinus mucosal abnormalities?

Introduction

Rhinosinusitis is characterized by inflammation extending from the mucosa of the nasal cavity into the paranasal sinuses. There are some aggravating features, such as immunosuppression, that can cause the nasal mucosal inflammation to linger for a long period, resulting in chronic or recurrent episodes. Such immunosuppression is the major feature of patients undergoing a hematopoietic stem cell transplant (HSCT); rhinosinusitis prevalence is higher in this group compared to immunocompetent patients. Nasal epithelial abnormalities have been described in, and may have some influence over, recurrent sinus infections among those patients. However, it is not clear whether rhinosinusitis can trigger mucosal abnormalities or whether a preexisting vulnerability for sinusitis recurrence is more likely. The objective of the study was to verify the influence of rhinosinusitis on nasal epithelial damage in patients undergoing hematopoietic stem cell transplantation.

Method

A total of 30 allogeneic HSCT patients were divided into two groups: 24 patients with chronic or recurrent rhinosinusitis and 6 patients without rhinosinusitis. These patients underwent a biopsy of the uncinate process that was analyzed by transmission electron microscopy and optical microscopy.

Results

The nasal mucosa analysis by optical microscopy showed no significant abnormalities. The ciliary orientation was obviously normal in the transplanted patients without rhinosinusitis. There was a trend toward a difference in the amount of cilia (decreased) and the primary modification of the ultrastructure of transplanted patients with rhinosinusitis.

Conclusion

HSCT patients, with and without rhinosinusitis, showed no significant histological abnormalities, except for ciliary disorientation and a possible decrease in ciliary and ultrastructural abnormalities in HSCT patients with rhinosinusitis.

Sinonasal disorders in hematopoietic stem cell transplantation

Introduction

hematopoietic stem cell transplantation (HSCT) is associated with more respiratory infections due to immunosuppression.

Objective

this study aimed to verify the frequency of rhinosinusitis after HSCT, and the association between rhinosinusitis and chronic graft vs. host disease (GVHD) and type of transplantation, clinical treatment, surgical treatment, and survival.

Methods

this was a retrospective study in a tertiary university hospital. A total of 95 patients with hematological diseases undergoing HSCT between 1996 and 2011 were selected.

Results

chronic myeloid leukemia was the most prevalent disease. The type of transplant most often performed was the allogenic type (85.26%). The frequency of rhinosinusitis was 36%, with no difference between the autologous and the allogenic types. Chronic GVHD occurred in 30% of patients. Patients with GVHD had a higher frequency and recurrence of rhinosinusitis, in addition to more frequent need for endoscopic sinusectomy and decreased overall survival.

Conclusion

there was a higher frequency of rhinosinusitis in HSCT and GVHD. The type of transplant does not appear to predispose to the occurrence of rhinosinusitis. GVHD seems to be an aggravating factor and requires a more stringent treatment.

Endoscopic endonasal transsphenoidal resection of pituitary adenomas: preliminary evaluation of consecutive cases✩✩Please cite this article as: Chone CT, Sampaio MH, Sakano E, Paschoal JR, Garnes HM, Queiroz L, et al. Endoscopic endonasal transsphenoidal resection of pituitary adenomas: preliminary evaluation of consecutive cases. Braz J Otorhinolaryngol. 2014;80:146–51.,✩✩✩✩Study conducted at Department of Otolaryngology Head and Neck, Department of Neurosurgery, Centro Medico de Campinas Hospital, Department of Endocrinology, Department of Surgical Pathology, Universidade Estadual de Campinas, Campinas, SP, Brazil

Introduçáo

A cirurgia endoscópica endonasal ganhou aceitação crescente por otorrinolaringologistas e neurocirurgiões. Em muitos centros, esta tecnica é agora rotineiramente utilizada para as mesmas indicações que a técnica microcirúrgica convencional.

Objetivo

Descrever resultados cirúrgicos relativos à remissão hormonal, ressecção do tumor e complicações de série consecutiva de pacientes com adenoma da hipófise submetidos à ressecção endoscópica.

Método

Estudo de série de pacientes consecutivos com adenomas da hipófise, submetidos à cirurgia endoscópica endonasal, avaliados quanto à taxa de tumor residual, remissão funcional, sintomas, complicações e o tamanho do tumor.

Resultados

De 47 pacientes consecutivos, 17 eram portadores de adenomas funcionantes, sete produtores de GH, cinco com doença de Cushing e cinco prolactinomas. Dos adenomas funcionantes, 12 foram macroadenomas, cinco microadenomas, e 30 macroadenomas não funcionantes. Dos adenomas funcionantes, 87% melhoraram. Em relação ao déficit visual, 85% melhoraram ao longo do tempo. A maioria dos pacientes que apresentou queixas de cefaléia melhorou (76%). Complicações cirúrgicas ocorreram em 10% dos pacientes, com duas lesões da carótida, duas fístulas liquóricas e uma fatalidade em um paciente com um histórico complicado.

Conclusão

A cirurgia hipofisária endoscópica endonasal é uma técnica viável, rendendo bons resultados cirúrgicos e funcionais e baixa morbidade.

© 2014 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Publicado por Elsevier Editora Ltda. Todos os direitos reservados.

Valor prognóstico da tomografia computadorizada de seios paranasais no transplante de células-tronco hematopoiéticas

Abstract

Hematopoietic Stem Cell Transplant (HSCT) causes immunosuppression and predisposition to sinusitis. CT scans are complementary exams used in the diagnosis of sinusitis; however, its use in every patient is questionable.

Aim

to check the usefulness of ordering a CT scan prior to HSCT and to study the relationship between anatomical variations and sinusitis.

Method

prospective study in which we performed paranasal CT scans before and after HSCT, using the Lund and Mackay score.

Results

77.5% and 61% of CT scans showed no evidence of sinus disease before and after HSCT. CT staging was not associated with sinusitis after HSCT. Anatomical variations were related to radiographic disease severity, but not to development of sinusitis after HSCT. There was no relation between pre-CT staging and sinusitis after BMT.

Conclusion

CT scans are not useful for all patients before HSCT. Anatomical variation is not a predictive feature to sinusitis but it can determine its severity.

Chronic GVHD: predictive factor for rhinosinusitis in bone marrow transplantation

Introduction

Bone marrow transplantation (BMT) is a treatment option for hematological diseases and immunodeficiency. It is frequently used today. BMT predisposes patients to upper airway infections and its complications, such as rhinosinusitis (RS). Chemotherapy, radiotherapy, viral infections, antibiotic therapy, graft versus host disease (GVHD) are rhinosinusitis predisposing conditions.

Aim

to investigate RS frequence in this population and its relationship to GVHD; to try and establish the best treatment for RS in these patients.

Method

ENT evaluation of two groups. One group with 35 patients (gI) and another with 24 patients (gII), before and after BMT. They were treated with antibiotics, maxillary sinus punction or endoscopic sinusectomy.

Results

none of them had RS before BMT. 42.8% from gI had RS and 34% had GVHD; in the gII, 58% had RS and 25% had GVHD. 49% from both groups had RS and 30.5% had GVHD. There was significantly more RS in chronic GVHD patients. Surgery was used to treat RS in chronic GVHD patients who underwent BMT.

Conclusion

RS frequence was 49%; GVHD is a predisposing condition to RS; sinusectomy may be necessary to control RS in GVHD patients.

Moxifloxacin vs amoxicillin/clavulanate in the treatment of acute sinusitis

PURPOSE

The aim of this study was to compare the efficacy and safety of moxifloxacin with that of amoxicillin/clavulanate for the treatment of acute bacterial sinusitis in adults.

MATERIALS AND METHODS

Five hundred seventy-five patients from Latin American countries were randomized to receive oral moxifloxacin 400 mg once daily for 7 days, or oral amoxicillin/clavulanate 500/125 mg 3 times daily for 10 days, in a prospective, open study.

RESULTS

At the test-of-cure visit (7-14 days after the end of therapy), the clinical success rate in the moxifloxacin group was 93.4% similar to that in the amoxicillin/clavulanate group (92.7%). Documented bacteriological eradication plus presumed eradication rates in the moxifloxacin (96.5%) and the amoxicillin/clavulanate (96.7%) groups were also similar. Drug-related adverse events were recorded in 32.2% of patients in the moxifloxacin group and 29.7% in the amoxicillin/clavulanate group. Patient discontinuation in the trial due to adverse events occurred for 10 patients in the moxifloxacin group and 6 in the amoxicillin/clavulanate group.

CONCLUSIONS

Overall, in terms of clinical and bacteriological response, moxifloxacin was equivalent to amoxicillin/clavulanate for the treatment of acute bacterial sinusitis in adults.

Endoscopic study of the intranasal ostium in external dacryocystorhinostomy postoperative. Influence of saline solution and 5-fluorouracil

PURPOSE

To study, through endoscopy, the postoperative structural changes of the intranasal ostium following external dacryocystorhinostomy and to evaluate the influence of saline solution and 5-fluorouracil.

METHODS

Fifty patients were distributed into the following groups: Group SS-dacryocystorhinostomy and an injection of saline solution during surgery (13 patients); Group 5--FU1-dacryocystorhinostomy and an injection of 5 fluorouracil during surgery (17 patients); Group C--dacryocystorhinostomy only (11 patients); Group 5--FU3-dacryocystorhinostomy and 3 injections, 1 during surgery and 1 on the third and fifth postsurgical days (9 patients).

RESULTS

Pair-wise group comparisons using the nonparametric Mann-Whitney test revealed that there was a significant reduction of the ostium area only in Group 5-FU1 vs. Group SS on the 60th postoperative day (P <.01); however, a comparative study among the 4 groups using the Kruskal-Wallis test showed no significant changes in the ostium area on the 60th postoperative day. The ostium area within groups at the 30th vs 60th postoperative day was significantly reduced for Group C (P < .05; Mann-Whitney test); no significant changes were found for the other groups.

DISCUSSION

These results suggest that the use of 5-fluorouracil in external dacryocystorhinostomy does not significantly influence the final size of the surgical fistula as determined 2 months postsurgery.

Nasal and paranasal sinus endoscopy, computed tomography and microbiology of upper airways and the correlations with genotype and severity of cystic fibrosis

OBJECTIVE

Many studies have assessed clinical and functional aspects of lower airway affections in cystic fibrosis. Conversely, few studies have been performed to assess the clinical and functional affections of upper airways. The objective of the present study was to correlate the variables obtained by nasal and paranasal sinuses endoscopy, paranasal sinus laboratory and computed tomography (CT) scan findings, and to check the association with severity and genotype of cystic fibrosis patients.

METHODS

Clinical and laboratory study of 50 patients with cystic fibrosis at a university center. All patients were submitted to CT scan, nasal and paranasal endoscopy and bacterioscopy of maxillary sinus, trachea and oropharynx secretion. Severity of cystic fibrosis was assessed by Shwachman score and the most frequent genetic mutations were identified.

RESULTS

The prevalence of polyposis in the studied population was 36% and it was greater among homozygote for DeltaF 508. Shwachman score was correlated with age (p=0.003). The genotype was correlated with presence of nasal polyposis (p=0.006). There was no association between affections in CT scan and severity of cystic fibrosis (CF). Patients presented high prevalence of early colonization of Pseudomonas aeruginosa.

CONCLUSIONS

Sinus disease in CF patients presents several clinical, endoscopic and tomographic affections. Although most of them are not correlated with severity and disease genotype, severity of CF is correlated with age and presence of polyposis is genotype-dependent.

DECH crônica: fator preditivo para rinossinusite no transplante de medula óssea

INTRODUÇÃO: transplante de medula óssea (TMO) é uma opção de tratamento para doenças hematológicas, tumorais e imunodeficiências e tem sido realizado com maior freqüência. O TMO predispõe a infecções de VAS e complicações, dentre estas as rinossinusites (RS). Quimioterapia, radioterapia, infecções virais, antibioticoterapia e doença do enxerto versus hospedeiro (DECH) são fatores predisponentes para RS. OBJETIVO: Verificar freqüência das RS no TMO e relação com DECH. Tentar estabelecer qual melhor tratamento para as RS no TMO. MÉTODO: Avaliação otorrinolaringológica de 2 grupos com 35 (gI) e 24 (gII) pacientes, antes e depois do TMO; e tratados individualmente com antibióticos e/ou punção de seios maxilares e/ou sinusectomia endoscópica. RESULTADOS: Nenhum apresentou RS antes do TMO; 42,8% dos TMO do gI tiveram RS e 34%, DECH; enquanto 58% do gII tiveram RS e 25%, DECH. No total, 49% tiveram RS e 30,5% com DECH. Houve significativa maior freqüência de RS em DECH crônica. A cirurgia foi indicada para tratamento de RS no TMO com DECH crônica. CONCLUSÃO: A freqüência de RS no TMO foi de 49%; DECH crônica é um fator predisponente para RS; a sinusectomia pode ser necessária nos pacientes com DECHc e RS.

An open multicenter study of the use of gatifloxacin for the treatment of non-complicated acute bacterial rhinosinusitis in adults

The bacteriological and clinical efficacy and the safety of gatifloxacin for the treatment of non-complicated acute rhinosinusitis was evaluated in 49 adult patients in an open-label multicenter study in Brazil. Patients under age 18, or with associated systemic diseases, were excluded. Diagnosis was based on symptoms, otorhinolaryngological examination, and X-rays of the sinus. At the first visit, all patients were treated with a single daily dose of 400 mg gatifloxacin for 10 days. Middle nasal meatus secretion was collected and sent for culture before and after treatment. Patients were all reevaluated at days 3 to 5; days + 1 to + 5 and 18 to 25 days + 7 to + 14 . Ninety three percent of the patients were considered clinically cured at the end of the treatment. The most frequent bacteria isolated were Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis, and at the end of the treatment, presumed bacteriological eradication was observed in almost all patients. Adverse effects were observed in 19 of the cases, mostly mild and self limiting, including diarrhea, abdominal pain, nausea and vomiting. Treatment had to be interrupted in two cases. Gatifloxacin was found to be efficacious and safe for the treatment of acute rhinosinusitis in adults.

The EBV action in tonsils and adenoids

The bacteria involved in tonsil disease have been well studied, but we cannot say the same for the viruses. The method to detect virus make this approach difficult to study. Epstein–Barr Virus (EBV) infection usually occurs in early childhood and can persist in palatine and pharyngeal tonsil lymphocytes. EBV has been closely associated with the undifferentiated form of nasopharyngeal carcinoma (NPC) in its effect. Nevertheless, the presence of EBV in non-neoplastic lymphoid tissue of the nasopharynx and tonsil has rarely been investigated. Our objective was to study the frequency of EBV in tonsils and adenoids and to define the correlation between EBV and adenoid hyperplasia.

In this study, we looked for EBV in adenoid and tonsil tissue of 165 patients (2 and 15 years old ) by in situ hybridization (ISH) for EBER 1/2 RNA. Resection of the adenoids was done for relief of upper respiratory tract obstruction, and the tonsils were resected because of recurrent tonsillitis and/or hyperplasia with upper airway obstruction. We divided the adenoid samples in two groups: one group 12–24 months old (average 18 months old) and the second group, 25 months to 15 years old. Tonsils were obtained from 85 patients, 3–13 years old (mean age 5.6 years) who underwent surgery due to recurrent tonsillitis or hyperplasia.

EBV was demonstrated in lymphoid cells of 11 (34.3%) out of 32 adenoids for the first group and 36 (72%) out of 48 children of the second group. EBV was found in the respiratory epithelial cells of adenoid in one case.

Children under 24 months of age can be infected by EBV, and this virus might be responsible for obstructive hyperplasia. Tonsils are less affected by EBV than the adenoids, suggesting that the EBV is more attracted to the adenoid tissue than the tonsillar tissue.

Eosinophilic angiocentric fibrosis of the nasal cavity

Eosinophilic angiocentric fibrosis (EAF) is a rare condition of unknown etiology that causes stenosis of the upper respiratory tract. We report one case in which immunohistochemical studies were performed that involved the mucosa of the lateral nasal wall and septum of a 54-year-old woman. The lesion showed areas with vascular proliferation, small-vessel vasculitis, and dense inflammatory infiltrate consisting of T lymphocytes, macrophages, polyclonal plasma cells, and numerous eosinophils and neutrophils. Other areas were hypocellular and fibrotic, and in those, the collagen bundles showed perivascular onion-skin whorling. The clinical and histologic similarities between our case and those previously described, in addition to the immunohistochemical findings, support the hypothesis that eosinophilic angiocentric fibrosis is a chronic inflammatory condition with a peculiar and striking stromal response.

Comparative bacteriology of the surface of normal and pathological palatine tonsils in children

There are only few studies on the normal bacteriology of tonsils. The purpose of this study was to acquire knowledge about the normal microflora: patients without recurrent tonsillitis (RT) and without tonsil hypertrophy (TH) and to compare these results with the pathological microflora: patients who have recurrent tonsillitis and/or tonsillar hypertrophy. We did 132 cultures of tonsil surface obtained from normal children and 96 cultures from pathological surfaces during the summer and in the winter. Comparing normal and pathological groups, we found Neisseria spp and Enterobacteria spp more frequently in the normal group. There are differences in the surface microflora of tonsils from normal persons and from individuals with tonsillitis.

Histopathological comparison between tonsil and adenoid responses to allergy

In a previous study of adenoid tissue from allergic and non-allergic patients, we concluded that in allergic children edema of the "chorium" was present in 80.4% and that treatment with antihistamine drugs may reduce this edema. The purpose of the present study was to compare the histopathology of the palatine tonsil and adenoid from allergic patients. Tissue samples were obtained from 153 patients (56 tonsils and 97 adenoids from allergic children). We analysed the intensity of the edema and its cellular components in the chorium of palatine tonsils and adenoids. The frequently seen edema in the adenoids was significantly different from that in the tonsils. The squamous epithelium of the tonsils was thicker and bad stronger intercellular junctions than the columnar epithelium of the adenoids. This fact probably makes difficult the contact of the antigen with the chorium.

[Nasal rhinosporidiosis in children]

Rhinosporidiosis is a rare fungal disease resulting from infection by Rhinosporidium seeberi. There seems to be a relationship between the disease and agriculture, suggesting that Rhinosporidium lives in soil, and many authors agree that water is a necessary medium of transmission. The sites of infection are the nose (most common), eye, nasopharynx, penile urethra and external ear. Nasal cases generally present obstruction, epistaxis, watery or mucopurulent discharge, presence of tumoral pedunculated polypoid mass, generally with septal implantation. Histological examination presents characteristic sporangia in large numbers and in the submucosa a granulomatous host response. The treatment is by surgical excision (recurrence occurs in 10% of cases), and medical treatment used diaminodiphenylsulfone or Amphotericin B to avoid recurrent cases. We present a case of Rhinosporidiosis in a 10 years-old child, female, with 3 months history of nasal obstruction, epistaxis and presence of nasal mass in left nasal cavity that was submitted to surgical excision.

[Antral choanal polyp--cause of nasal obstruction in children: report of 12 cases]

Nasal obstruction is a common pediatric clinical complaint that involves a great number of pathologies (allergic rhinopathy,adenoid hypertrophy, septal deformities, infectious sinusitis, tumours, choanal atresia, nasal foreign bodies, etc.). Not only the history, and a through physical examination but also, the subsidiary exams are of great value in the etiologic diagnostic. Antro-choanal polyp (Killian's polyp) must be remembered in the differential diagnosis of nasal obstruction, when a sinus roentgenogram with unilateral maxillary opacification is seen. Clinically, the lesion often protrudes into the nasopharynx and in some cases it may even be seen extending into the oropharynx. The surgical procedure usually employed is a unilateral Caldwell-Luc antrostomy, with oropharyngeal remotion. We present 12 pediatric patients with antral-choanal polyps,and discuss history, radiology, nasal/nasopharyngeal endoscopic evaluation, considerations about the origin and surgical treatment of choice.

Button battery as a foreign body in the nasal cavities. Special aspects

Alkaline batteries as foreign bodies in the nasal cavities are dangerous because they can cause liquefaction necrosis with subsequent severe local tissue destruction. Batteries found in the nasal cavities should be removed immediately to prevent sequelae such as septal perforations or nasal meatus stenosis. Due to the common use of these batteries (e.g. watches, electronic toys and games, calculators) physicians and the general public should be more aware of this type of foreign body and the peculiarities in their management. We present five cases of button battery foreign bodies in the nasal cavities and review 12 cases described in the literature and discuss the special aspects of these foreign bodies.