Ultra-short antibiotic prophylaxis guided by preoperative microbiological nasal swabs in endoscopic endonasal skull base surgery

PURPOSE

Endoscopic endonasal skull base surgery (EESBS) is a clean-contaminated procedure. Guidelines regarding the antibiotic prophylaxis in EESBS have not been developed yet, and today, there are no universally accepted protocols. In this article, we investigated the efficacy of our new ultra-short antibiotic prophylaxis protocol for EESBS guided by the cultural results of preoperative microbiological nasal swabs.

METHODS

We defined as "nasal swab-related antibiotic protocol" the administration of a first-generation cephalosporin (cefazolin 2 g) in patients whose nasal swabs revealed the presence of normal nasal flora or methicillin-sensitive Staphylococcus aureus (MSSA), and the administration of vancomycin 1 g intravenously in patients whose nasal swabs revealed the presence of methicillin-resistant Staphylococcus aureus (MRSA) or with reported cephalosporin/penicillin allergy. This case-control study included 120 patients who underwent EESBS. The case group included 60 cases who received the "nasal swab-related antibiotic protocol," while the control group included 60 cases who received the "standard hospital antibiotic protocol" used in neurosurgery (cefazolin 2 g plus metronidazole 500 mg at induction, and 2 g of cefazolin repeated after 180 min).

RESULTS

The preoperative microbiological nasal swabs showed normal nasal flora in 42 patients (70%), MSSA in 17 patients (28.3%), and MRSA in 1 patient (1.6%). During the study period, no cases of meningitis or sinusitis occurred in the case group ("nasal swab-related antibiotic protocol"), while two infections (3.3%, 1 sinusitis and 1 meningitis) were reported in the control group ("standard hospital antibiotic protocol"). Mean length of hospitalization was 6.5 days for the case group and 8.5 days in the control group. "Standard hospital antibiotic protocol" is less expensive (range, 2.88-5.42 euros) compared with our new "nasal swab-related antibiotic protocol" (range, 10.02-32.56 euros), but in line with other antibiotic prophylaxis protocols reported in literature.

DISCUSSION

The low complication rates of our case series (0%) is comparable to complication rates reported in literature (1.6% for meningitis and 8% for sinusitis). Compared with other perioperative antibiotic regimens reported in literature, the "nasal swab-related antibiotic protocol" is cheap and at least equally effective. We discuss the rationale on which we based the choice of chemoprophylaxis, the timing, and the length of our regimen.

CONCLUSIONS

Our study confirmed the safety and efficacy of our easily applicable and low-cost antibiotic prophylaxis protocol.

Dipeptidyl peptidase-4 inhibitor treatment could decrease chronic rhinosinusitis in diabetic patients

AIM

To evaluate the relationship between dipeptidyl peptidase-4 inhibitor (DPP4i) treatment and chronic rhinosinusitis (CRS) in diabetic patients.

METHODS

We used the Longitudinal Health Insurance Database for this population-based and population-matched cohort design study. Chi-square and Wilcoxon rank-sum tests were used to evaluate the association between categorical and continuous variables, respectively. The Kaplan-Meier method with the log-rank test was used to estimate the risk of CRS and DPP4i users.

RESULTS

A total of 6198 diabetic patients were included in this cohort study. DPP4i users had a lower risk of developing CRS. The risk of CRS was significantly lower in women, patients with a Diabetes Complications Severity Index score higher than 4, patients with comorbidities, and patients with higher cumulative defined daily dose in the DPP4i group.

CONCLUSION

The results of our study demonstrate that the use of DPP4i treatment could decrease CRS risk in diabetic patients in Taiwan.

Revisiting the Clinical Scoring System for the Prognosis of Chronic Rhinosinusitis with Nasal Polyps

PURPOSE

To evaluate the Japanese Epidemiological Survey of Refractory Eosinophilic Chronic Rhinosinusitis (JESREC) classification, a clinical scoring system, for predicting disease control status in chronic rhinosinusitis with nasal polyps (CRSwNP) and to investigate prognostic factors.

MATERIALS AND METHODS

In total, 134 CRSwNP patients who underwent functional endoscopic sinus surgery after maximal medical treatment were enrolled. These patients were categorized into four groups according to JESREC classification: 1) non-eosinophilic CRSwNP (non-ECRSwNP), 2) mild eosinophilic CRSwNP (ECRSwNP), 3) moderate ECRSwNP, and 4) severe ECRSwNP. Disease control status among the patients was evaluated at 1 year after surgery, and the patients were divided into two groups (disease-controlled and disease-uncontrolled groups) for the investigation of prognostic factors.

RESULTS

There was no significant difference in disease control status between non-ECRSwNP and ECRSwNP groups (p=0.970). Age, Lund-Mackay CT scores, global osteitis scores, tissue neutrophil count, and tissue eosinophil count were associated with disease control status. In subgroup analysis of the non-ECRSwNP group, only high tissue neutrophil count was related with disease control status, whereas for the ECRSwNP group, young age, high Lund-Mackay CT scores, high global osteitis scores, and high tissue and blood eosinophil counts were associated with disease control status.

CONCLUSION

No difference in disease control status was identified between non-ECRSwNP and ECRSwNP cases. Tissue neutrophilia, however, appeared to be associated with disease control status in non-ECRSwNP cases, whereas tissue and blood eosinophilia was associated with ECRSwNP cases.

Chronic Rhinosinusitis

Chronic rhinosinusitis is an inflammatory disease of the paranasal sinuses that occurs in 1% to 5% of the U.S.

POPULATION

It may significantly decrease quality of life. Chronic rhinosinusitis is defined by the presence of at least two out of four cardinal symptoms (i.e., facial pain/pressure, hyposmia/anosmia, nasal drainage, and nasal obstruction) for at least 12 consecutive weeks, in addition to objective evidence. Objective evidence of chronic rhinosinusitis may be obtained on physical examination (anterior rhinoscopy, endoscopy) or radiography, preferably from sinus computed tomography. Treatment is directed at enhancing mucociliary clearance, improving sinus drainage/outflow, eradicating local infection and inflammation, and improving access for topical medications. First-line treatment is nasal saline irrigation and intranasal corticosteroid sprays. There may be a role for antibiotics in patients with evidence of an active, superimposed acute sinus infection. If medical management fails, endoscopic sinus surgery may be effective. Patients not responding to first-line medical therapy should be referred to an otolaryngologist, and selected patients with a history suggestive of other comorbidities (e.g., vasculitides, granulomatous diseases, cystic fibrosis, immunodeficiency) may also benefit from referral to an allergist or pulmonologist.

Ventilator-Associated Pneumonia: A Review

Ventilator-associated pneumonia is the most frequent intensive care unit (ICU)-related infection in patients requiring mechanical ventilation. In contrast to other ICU-related infections, which have a low mortality rate, the mortality rate for ventilator-associated pneumonia ranges from 20% to 50%. These clinically significant infections prolong duration of mechanical ventilation and ICU length of stay, underscoring the financial burden these infections impose on the health care system. The causes of ventilator-associated pneumonia are varied and differ across different patient populations and different types of ICUs. This varied presentation underscores the need for the intensivist treating the patient with ventilator-associated pneumonia to have a clear knowledge of the ambient microbiologic flora in their ICU. Prevention of this disease process is of paramount importance and requires a multifaceted approach. Once a diagnosis of ventilator-associated pneumonia is suspected, early broad-spectrum antibiotic administration decreases morbidity and mortality and should be based on knowledge of the sensitivities of common infecting organisms in the ICU. De-escalation of therapy, once final culture results are available, is necessary to minimize development of resistant pathogens. Duration of therapy should be based on the patient’s clinical response, and every effort should be made to minimize duration of therapy, thus further minimizing the risk of resistance.

Prophylactic antibiotic therapy for fractures of the maxillary sinus

We conducted a study to examine the incidence of acute sinusitis following maxillary sinus fractures, as well as the impact of antibiotics in the postinjury period. Fifty patients who presented to our institution with a fracture of the maxillary sinus were prospectively randomized to receive either a nasal saline spray and a 3-day course of antibiotics (either amoxicillin/clavulanate or levofloxacin) or nasal saline alone; there were 25 patients in each group. After a minimum of 3 days, all patients were assessed for acute sinusitis. Follow-up data were available on 17 patients (a total of 21 fractured sinuses) in the antibiotic group (68%) and 14 patients (17 fractured sinuses) in the control group (56%). The groups were balanced in terms of demographics, location of fractures, mechanism of fracture, and time to follow-up. After 3 days, 95.23% of the fractured sinuses in the antibiotic group and 88.23% of the fractured sinuses in the control group exhibited signs or symptoms consistent with or suggestive of acute sinusitis. Very few sinuses in either group showed no evidence of sinusitis: only 1 in the antibiotic group (4.76%) and 2 in the control group (11.76%); this difference was not significant (p = 0.5768). We conclude that while the clinical rate of acute sinusitis after maxillary sinus fractures is high, a 3-day course of antibiotics is not effective in preventing its symptoms in the postinjury period.

A live-attenuated pneumococcal vaccine elicits CD4+ T-cell dependent class switching and provides serotype independent protection against acute otitis media

Acute otitis media (AOM) caused by Streptococcus pneumoniae remains one of the most common infectious diseases worldwide despite widespread vaccination. A major limitation of the currently licensed pneumococcal vaccines is the lack of efficacy against mucosal disease manifestations such as AOM, acute bacterial sinusitis and pneumonia. We sought to generate a novel class of live vaccines that (1) retain all major antigenic virulence proteins yet are fully attenuated and (2) protect against otitis media. A live vaccine candidate based on deletion of the signal recognition pathway component ftsY induced potent, serotype-independent protection against otitis media, sinusitis, pneumonia and invasive pneumococcal disease. Protection was maintained in animals coinfected with influenza virus, but was lost if mice were depleted of CD4(+) T cells at the time of vaccination. The live vaccine induced a strong serum IgG2a and IgG2b response that correlated with CD4(+) T-cell mediated class switching. Deletion of genes required for microbial adaptation to the host environment is a novel live attenuated vaccine strategy yielding the first experimental vaccine effective against pneumococcal otitis media.

Wegener granulomatosis as an uncommon cause of panhypopituitarism in childhood

Wegener granulomatosis (WG) is a cytoplasmic antineutrophil cytoplasmic antibody (c-ANCA)-associated, multi-system, necrotizing granulomatous vasculitis. Inflammation of the nasal or oral mucosa, and lung and kidney involvements are typical in the course of the disease. In rare cases, pituitary involvement may occur and cause panhypopituitarism. Pituitary involvement is very rare, and only two pediatric case reports have been published to date out of a total of 24 cases. This is a case report of an adolescent patient who presented with panhypopituitarism symptoms and was later diagnosed with WG. A 16-year-old female patient complained of fever, headache, purulent nasal discharge and severe muscle and joint pain. Additionally, she had polyuria and polydipsia. Investigations revealed a pituitary mass and panhypopituitarism. Positivity of c-ANCA and renal biopsy result compatible with WG confirmed the diagnosis.

[The potential of prophylaxis and optimization of the treatment of rhinosinusitis in the children presenting with stenosing laryngotracheitis]

The objective of the present work was to estimate the clinical, prophylactic, and microbiological effectiveness of fusafungine applied for the treatment of acute rhinosinusitis (ARS) in the children that develops as a consequence of acute stenosing laryngotracheitis. The study included 61 children presenting with ARS and concomitant acute stenosing laryngotracheitis (ASLT) that were treated with fusafungine (Bioparox). Both tolerance and safety of this preparation were evaluated. Fusaferine was prescribed after reduction of pharyngeal stenosis. The children were divided into two groups. Group 1 was comprised of the patients with the respiratory symptoms and rhinosinusitis (n = 36), group 2 consisted of the children with the respiratory symptoms in the absence of rhinosinusitis (n = 25). Subgroups of the children treated with fusafungine and without it were distinguished to estimate the clinical, prophylactic, and microbiological effectiveness of fusafungide. Within the first days after hospitalization, 59% of the children with diagnosis ASLT developed bilateral rhinosinusitis, in all probability of viral etiology. Fusafungine produced the clinically apparent effect in the patients with ASLT regardless of the presence of ARS. Specifically, this preparation decreased the degree of hypertrophy of pharyngeal tonsils three times faster than standard therapy; moreover, it reduced the requirement for systemic antibiotics by 1.9 times. The treatment with fusaferine prevented the development of acute bilateral rhinosinusitis in the children with ASLT and promoted compete decontamination of the nasopharynx from M. catarrhalis, Str. pneumonia, Str. pyogenes, H. influenza, Cor. s the nasopharynx pecies, E. faecalis, and C. albicans. The frequency of adverse reactions of organoleptic character was estimated at 16.6%.

[Prevention and cure sinusitis complicated by endoscopic transnasal approach in surgical treatment of pituitary adenoma]

OBJECTIVE

To recognize the causes, methods of prevention and cure of sinusitis complicated by endoscopic transnasal approach in surgical treatment of pituitary adenomas.

METHOD

The data of 187 patients who underwent surgical treatments of pituitary adenomas through endoscopic transnasal approach were collected, and the surgical complications were analyzed.

RESULT

Endoscopic transnasal transsphenoidal approach were used successfully in 187 cases, twelve cases (6.4%) were suffered from sinusitis complication after surgery. The most frequent sinusitis complication was sphenoiditis, 9 cases (4.8%) were suffered, 2 cases (1.1%) were suffered from ethmoidal sinusitis, 1 case (0.5%) was suffered from maxillary sinusitis. Ten cases were treated with correspond medication in clinic. Two cases were ineffective with expectant treatment, and cured by second endoscopic sinusitis operation at last.

CONCLUSION

Endoscopic transnasal transsphenoidal approach offered a simple and rapid access to the sella, and also, it is a safe, valuable and efficient procedure for removing pituitary adenomas. It was obviously that timely accurate diagnosis for the sinusitis complication and comprehensive perioperative management may lead to less incidence of postoperative sinusitis complication in surgical treatment of pituitary adenomas through endoscopic transnasal approach, increase the achievement rate and improve survival quality obviously.

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.

[Rhinitis, sinusitis and allergy]

The allergic and infectious diseases of the nasal mucous represent two of the most frequent and chronic upper airways diseases in children and young adults. They are a public health problem of great magnitude due to the high prevalence that causes a great welfare pressure in terms of ambulatory consultations, significant deterioration of the quality of life so much for the patient who suffers them, like for the relatives and affect the community for the high socioeconomic costs that these generate. It is indispensable to know the physiopathology to be able to realize in time a suitable diagnosis and with it to offer a treatment adapted to diminish it recurrence.

[Revision endoscopic sinus surgery and combined therapy for recurrent sinusitis]

OBJECTIVE

To investigate the efficacy of revision endoscopic sinus surgery and combined therapy on recurrent sinusitis and polyps.

METHOD

Revision endoscopic sinus surgery was performed in 72 patients, of which endoscopic nasal lateral wall dissection was used in 3 cases, the endoscopic frontal sinus surgery (Draf I-II) was used in 16 cases, and all patients received combined therapy including peri-operation conservative management and nasal endoscopy examination during the follow-up period.

RESULT

All patients were followed up for more than one year. Of 72 patients, 52 patients were successfully cured, 10 patients showed improvement, but there was no change in other 13 patients. The total efficacy rate was 91.67% (66/72). No serious complication occurred.

CONCLUSION

The treatment efficacy can be greatly improved by enough preoperative preparation, fine operation, combined pre-operation conservative therapy and postoperative follow-up.

Intra- and postoperative application of Mitomycin C in the middle meatus reduces adhesions and antrostomy stenosis after FESS

AIM

Obstruction of the osteomeatal complex is the commonest anatomic finding in revision endoscopic sinus surgery. This study assesses the efficacy of topical mitomycin C in the middle meatus, intra- and postoperatively in the prevention of adhesion formation and restenosis of the maxillary sinus antrostomy.

MATERIALS AND METHODS

At the end of endoscopic surgery for chronic rhinosinusitis and four weeks postoperatively 30 patients received a pledget soaked with 1 ml of mitomycin C (0.5 mg/ml) in the middle meatus for 5 minutes while a pledget soaked in saline was placed in the contralateral side. Patients were assessed at least 6 months postoperatively by a blinded observer for the presence of synechiae and antrostomy stenosis. Medical records were reviewed for episodes of recurrent sinusitis.

RESULTS

Adhesions were observed in 8 patients. All adhesions rated as moderate to severe (4 patients) were observed in the control side (p = 0.043). Restenosis was observed in 2 sides treated with mitomycin C and in 9 control sides (p = 0.032). Recurrent symptoms of sinusitis occurred in three patients on the saline side.

CONCLUSION

Mitomycin C is safe and effective in the prevention of severe adhesions and antrostomy stenosis when applied twice, during surgery and the early postoperative period.

Chronic rhinonsinusitis and nasal polyposis: the etiopathogenesis revealed?

Nasal polyps represent a severe eosinophilic inflammation of the upper airways which is characterized by poor impact of therapeutic intervention and frequent recurrences. Based on distinct cytokine, mediator and cell profiles, chronic sinonasal disease in Caucasians can be differentiated into several subgroups such as chronic rhinosinusitis without nasal polyps, chronic rhinosinusitis with nasal polyps, and nasal polyps in cystic fibrosis patients,. In Caucasians, nasal polyps showed a Th2 polarisation with high IL-5 concentrations, while chronic rhinosinusitis without polyps was characterized by a Thl polarisation with high levels of IFN-gamma. In the Caucasian nasal polyps we found that significantly more nasal polyp patients are colonized with S. aureus and that colonization increased in patients with concomitant asthma and aspirin sensitivity. Although there was no major difference in the presence of enterotoxin genes in S. aureus strains derived from nasal polyp or control patients, we found an increased immune response to S. aureus enterotoxins in nasal polyps, which resulted in a more pronounced eosinophilic inflammation and higher total IgE production in those polyps affected. We suggest that S. aureus superantigens amplify the inflammation in about 50% of nasal polyps, resulting in a strong Th2 polarisation, eosinophil activation, and an overproduction of IgG4 and IgE. These findings imply new therapeutic approaches apart from the currently used topical and systemic steroid therapy for nasal polyposis. In three double blind placebo controlled studies it was shown that firstly, oral corticosteroids only led to a short term reduction of polyp size. Secondly that a low dose of doxycycline treatment for 20 days had a sustained clinically relevant effect on polyp size for more than 3 months and thirdly we also showed a significant effect on polyp size by selective antagonizing IL-5 with a monoclonal antibody.

Role of neutrophils in preventing and resolving acute fungal sinusitis

Acute fungal sinusitis (AFS) is a devastating disease of the paranasal sinuses afflicting immunocompromised individuals. Knowledge about this disease is limited to clinical observations because there are no animal models in which to study the pathogenesis of the infection. Our goal was to develop a murine model of AFS and examine the role of neutrophils in host defense within the nasal cavity. Female C57BL/6 mice were depleted of neutrophils using anti-Gr-1 monoclonal antibody from day -1 to day 5 postinfection to initiate a transient neutropenia within the mice. At day 0, Aspergillus fumigatus conidia were administered intranasally. The untreated Aspergillus-exposed group had significant neutrophil recruitment by day 3, but by day 7 the leukocyte numbers had returned to unexposed levels. There was not a significant influx of mononuclear cells at either time point. In contrast, beginning at day 3 postinfection and continuing through day 7, anti-Gr-1-treated mice had increased cellular recruitment consisting of banded neutrophils at day 3 and mature neutrophils at day 7. Hyphal masses developed only in the anti-Gr-1-treated mice (25 to 36%) but only during the period of treatment. When the treatment was discontinued, hyphal masses could no longer be detected in the nasal cavities of these mice. In contrast, cyclophosphamide treatment did not induce neutropenia, and the nasal cavity remained free of hyphal masses. These studies demonstrate the feasibility of using this model to study AFS and implicate neutrophils in protection of the sinuses against acute Aspergillus infection and in clearance of established hyphal masses.

Current issues in the management of acute bacterial sinusitis in children

OBJECTIVE

To review and summarize recent challenges in the microbiology and treatment of acute bacterial sinusitis (ABS), one of the most common infectious diseases in the pediatric community.

METHODS

A review of recent medical literature from 1990 to 2006 was acquired using the National Library of Medicine's PUBMED database.

RESULTS

Multiple mechanisms of penicillin resistance have been identified: porin channel blockage, beta-lactamase production, and changes in penicillin-binding proteins (PBPs). Other factors affecting treatment efficacy include the role of normal nasopharyngeal flora, such as alpha-streptococci. The more widely documented shift in the causative pathogens of acute otitis media (AOM) following the release of the heptavalent pneumococcal conjugate vaccine (PCV7) has also been documented in two studies of ABS in children.

CONCLUSIONS

Treatment of ABS in children is complicated by a number of emerging changes in pathogen resistance patterns. These include beta-lactamase-negative ampicillin resistance (BLNAR) and multi-drug resistance, bacterial interference, and geographic data. These phenomena are likely to impact the treatment of URIs. Appropriate diagnosis and differentiation from viral sinusitis is essential prior to initiating therapy. Clinician education about these emerging issues remains an important strategy in diagnosing and treating ABS in children. This includes an understanding of known patient adherence to antibiotic therapy, such as taste, tolerability, dosing schedule, therapy duration, and patient preference. Clinicians should review judicious ABS treatment approaches that employ agents with documented efficacy against implicated pathogens.

Rhinosinusitis: prevention strategies

Risk factors of recurrent sinusitis involve upper respiratory infections, bacterial load of the adenoids, day care attendance and exposure to tobacco smoke as well as sinonasal abnormalities, including septal deviation, choanal atresia, polyps and hypoplasia of sinuses. Furthermore, several systemic disorders can facilitate the development of chronic sinusitis, such as allergic rhinitis, gastro-esophageal reflux disease (GER), cystic fibrosis, primary ciliary dyskinesia, and immunodeficiency diseases. A clinical practice guideline for the management of sinusitis is available only for the acute disease, but does not include for the management of the chronic form (i.e. chronic/recurrent sinusitis) and even less for the prevention strategies. As several studies indicate that the majority of children respond to sequential medical followed by surgical interventions, when needed, the best prevention of recurrence or chronicity is to properly treat acute sinusitis; in addition, children should be removed from larger and crowded day care whenever possible and should not be exposed to cigarette smoke. If allergic rhinitis co-exists, it can be managed with nasal steroids sprays and anti-histamines, although the long-term results are controversial. In case of chronic sinusitis, the strategy of prevention is to assess and to cure the associated conditions.

[Diseases of the upper respiratory tract]

A great number of agents found in inhaled air, whether in the environment or in the workplace, can cause symptoms and diseases of the upper respiratory tract. Unfortunately, establishing the cause-and-effect relationship between exposure to one of the various types of agents that can provoke such diseases and the diseases themselves is not routine practice among the health professionals involved. A comprehensive list of these agents and their relationships with the effects and onset of such illnesses is available in the literature. Chief among these ills are rhinosinusitis, dysphonia and ulceration/perforation of the nasal septum, as well as tumors in the nasal cavity or paranasal sinuses, all of which can be work related. Although widely available, diagnostic procedures for the investigation of occupational etiology are not yet routinely employed. In general, early identification of, and discontinuation of the contact with, the causal agent can resolve the problem, thereby averting the development of the chronic form of the disease. As with other types of occupational respiratory diseases, prevention and control programs are indispensable in the fight against these illnesses.

Biofilms in ear, nose, and throat infections: how important are they?

BACKGROUND

Biofilms present a new challenging concept in sustaining chronic, common antibiotic-resistant ear, nose, and throat (ENT) infections. They are communities of sessile bacteria embedded in a matrix of extracellular polymeric substances of their own synthesis that adhere to a foreign body or a mucosal surface with impaired host defense. The aim of this paper is to review the literature on ENT diseases that can be attributed to biofilm formation and to discuss options for future treatment.

MATERIALS AND METHODS

Literature review from Medline and database sources. Electronic links and related books were also included.

STUDY SELECTION

Controlled clinical trials, animal models, ex vivo models, laboratory studies, retrospective studies, and systematic reviews.

DATA SYNTHESIS

Biofilm formation is a dynamic five-step process guided by interbacterial communicating systems. Bacteria in biofilms express different genes and have markedly different phenotypes from their planktonic counterparts. Detachment of cells, production of endotoxin, increased resistance to the host immune system, and provision of a niche for the generation of resistant organisms are biofilm processes that could initiate the infection process. Effective prevention and management strategies include interruption of quorum sensing, inhibition of related genes, disruption of the protective extrapolymer matrix, macrolides (clarithromycin and erythromycin), and mechanical debridement of the biofilm-bearing tissues. With regard to medical indwelling devices, surface treatment of fluoroplastic grommets and redesign of cochlear implants could minimize initial microbial colonization.

CONCLUSION

As the role of biofilms in human infection becomes better defined, ENT surgeons should be prepared to deal with their unique and tenacious nature.

Aspirin challenge and desensitization for aspirin-exacerbated respiratory disease: a practice paper

Aspirin desensitization is indicated for patients who have aspirin-exacerbated respiratory disease and whose asthma and/or rhinosinusitis is suboptimally controlled with inhaled corticosteroids and leukotriene-modifying drugs. In this practice paper, the general requirements for aspirin desensitization are presented, the locations where desensitizations can be safely performed are outlined, prechallenge patient preparation is discussed, an oral aspirin challenge protocol is presented, treatment of adverse reactions is reviewed, and maintenance of aspirin desensitization is discussed.

[Using antibiotics in case of influenza]

Acute respiratory bacterial infection is the most common complication of influenza and a leading cause for excess rate of outpatient visits, hospitalization, and death (pneumonia). Influenza promotes bacterial infection as stated by epidemiologic evidence of temporal association between outbreaks or peaks of both influenza and bacterial pneumonia. The bacteria involved are Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus. However, Gram-negative rods, Klebsiella pneumoniae, Pseudomonas aeruginosa, anaerobes and methicillin resistant S. aureus may be involved in institutionalized elderly patients. Various studies confirm that antibiotics are over-prescribed in patients with influenza or influenza like illness, even in the absence of bacterial infection signs, and in patients without comorbidity. No data has proven the benefice of antibiotic prescription in influenza-infected patients without bacterial infection. Neuraminidase inhibitors may be of interest for the management of influenza infected patients, because they can decrease the risk of bacterial complications and the use of antibiotics.

Indikationen und Nutzen der Pneumokokken-Konjugat-Vakzine

Streptococcus pneumoniae is a leading cause of bacterial pneumonia, meningitis, sinusitis, and acute otitis media in children and adults worldwide. Especially in the age group of < 2 years the incidence of invasive pneumococcal is high. The vulnerability of children to S. pneumoniae can also be demonstrated by the high rate of sequelae (> 20 % in Germany) and the high mortality (7.5 %) in pneumococcal meningitis. A 7-valent pneumococcal conjugate vaccine that was shown to be highly efficacious in preventing invasive pneumococcal disease in infants in the USA was licensed in Europe in 2001. It is expected that broad usage of the vaccine would reduce the incidence of invasive pneumococcal disease and the levels of pneumococcal resistance significantly.

[Risk factors and preventive steps for nasosinusitis after radiotherapy of nasopharyngeal carcinoma]

OBJECTIVE

To study the risk factors and preventive steps of nasosinusitis after radiotherapy of nasopharyngeal carcinoma (NPC).

METHOD

Two hundreds and thirtyone NPC patients were retrospectively analysed.

RESULT

Among 231 NPC patients, 98 patients (42.4%) had nasosinusitis before radiotherapy, 165 patients (66.7%) suffered from nasosinusitis after radiotherapy. The rate of nasosinusitis in NPC patients with high T stage and nasalcavity anatomical aberrance was higher than in others (P = 0.014, CR = 1. 973; P = 0. 034, OR = 2.156), and the rate of nasosinusitis in NPC patients with nasopharynx therapy was low (P = 0.008, OR = 0.675), most patients with nasosinusitis before radiotherapy had not any improve after radiotherapy,and effected the effect of radiotherapy.

CONCLUSION

To reduce nasosinusitis after radiotherapy and improve patients quality of life, we suggest that nasopharyngeal cavity therapy should be carried out during and after irradiation for NPC patients, especially for those patients with high T stage and nasalcavity anatomical aberrance, and for those who had nasosinusitis before radiotherapy.

Acute community-acquired bacterial sinusitis: continuing challenges and current management

Acute sinusitis is one of the most common infections seen in general clinical practice. The most common cause of acute sinusitis is viral; however, many patients receive a prescription for an antibiotic. Such injudicious prescribing habits have a major impact on health care costs, contribute to the increasing prevalence of drug-resistant strains of common respiratory pathogens, and reflect many of the challenges in differentiating viral and bacterial disease. Sinus puncture and culture of the aspirate, the diagnostic reference standard in the research setting, are not appropriate for routine clinical practice. However, certain clinical signs and symptoms that do not improve or that worsen after 7-10 days are currently accepted criteria for diagnosis of bacterial sinusitis. Accurate diagnosis can select patients who would benefit most from antimicrobial use. Antimicrobial agents should be selected on the basis of local resistance patterns, and their spectrum of activity should cover the common bacterial pathogens, including resistant strains.

Fluticasone propionate aqueous nasal spray does not influence the recurrence rate of chronic rhinosinusitis and nasal polyps 1 year after functional endoscopic sinus surgery

BACKGROUND

Local corticosteroids are widely used in the treatment of nasal polyps and chronic rhinosinusitis both before and after nasal surgery. Their efficacy after functional endoscopic sinus surgery (FESS) has not been fully established by placebo-controlled trials.

OBJECTIVE

This double-blind placebo-controlled randomized study was performed in order to investigate whether fluticasone propionate aqueous nasal spray (FPANS) reduces the recurrence rate of nasal polyps and chronic rhinosinusitis during the first year after FESS.

PATIENTS AND METHODS

The trial looked at 162 patients aged 18 years and older requiring FESS for chronic rhinosinusitis or nasal polyps. After FESS combined with peri-operative systemic corticosteroids, patients were randomized and given FPANS 400 microg b.i.d., FPANS 800 microg b.i.d. or placebo b.i.d. for the duration of 1 year. Patients were withdrawn from the trial (but still included in the study for statistical purposes) if there were recurrent or persistent diseases, defined as progressive regrowth of nasal polyps, recurrent signs and symptoms of chronic sinusitis combined with abnormalities on computed tomography scan and persistent complaints for at least 2 months after FESS.

RESULTS

A significant reduction of symptoms was seen after FESS. After 1 year, 46 patients had been withdrawn from the trial because of recurrent diseases and 32 patients because of persistent symptoms. No differences in the number of patients withdrawn because of recurrent or persistent diseases were found between the patients treated with FPANS and patients treated with placebo. We were also unable to find a positive effect of FPANS compared with placebo in several subgroups such as patients with nasal polyps, high score at FESS or no previous sinus surgery.

CONCLUSION

This placebo-controlled study does not show that treatment with FPANS up to 1 year after FESS had a positive effect compared with placebo.

Effects of mould remediation on school teachers' health

The follow-up study of the health of teachers (n = 56) of three mould damage schools were done with self-administered symptom questionnaire before and 1 year after the remediation of school buildings. Technical and microbiological investigations were done parallel at the same time. In the beginning of the study symptoms of allergic rhinitis, sinusitis, conjunctivitis and fatigue were high compared to normal population and 1 year after the intervention a decrease in fatigue (OR = 0.4) and headache (OR = 0.2) was observed. An association between female gender and sinusitis was found before the remediation (OR = 8.1). Age over 40 years was a risk factor for voice problems and more than 10 working years at the same school were associated with increased risk for conjunctivitis (OR = 8.5) and headache (OR = 5.4). Other exposure situations such as mould problems at home and mould exposure during leisure time also have an effect on teachers' health. Significant reduction was found in symptoms of fatigue and headache after the cessation of exposure, while respiratory symptoms need much longer time to relieve after the remediation. Age, female gender, atopy, long-term exposure time and other exposure situations might be the risk factors for prolonged symptoms among mould exposed teachers.

Daily interruption of sedative infusions and complications of critical illness in mechanically ventilated patients

OBJECTIVE

In critically ill patients receiving mechanical ventilation, daily interruption of sedative infusions decreases duration of mechanical ventilation and intensive care unit length of stay. Whether this sedation strategy reduces the incidence of complications commonly associated with critical illness is not known.

DESIGN

Blinded, retrospective chart review.

SETTING

University-based hospital in Chicago, IL.

PATIENTS

One hundred twenty-eight patients receiving mechanical ventilation and continuous infusions of sedative drugs in a medical intensive care unit.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We performed a blinded, retrospective evaluation of the database from our previous trial of 128 patients randomized to daily interruption of sedative infusions vs. sedation as directed by the medical intensive care unit team without this strategy. Seven distinct complications associated with mechanical ventilation and critical illness were identified: a) ventilator-associated pneumonia; b) upper gastrointestinal hemorrhage; c) bacteremia; d) barotrauma; e) venous thromboembolic disease; and f) cholestasis or g) sinusitis requiring surgical intervention. The incidence of complications was evaluated for each patient's hospital course. One hundred twenty-six of 128 charts were available for review. Patients undergoing daily interruption of sedative infusions experienced 13 complications (2.8%) vs. 26 (6.2%) in those subjected to conventional sedation techniques (p =.04).

CONCLUSIONS

Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation reduces intensive care unit length of stay and, in turn, decreases the incidence of complications of critical illness associated with prolonged intubation and mechanical ventilation.

Chronic sinusitis: defective T-cells responding to superantigens, treated by reduction of fungi in the nose and air

In this study, the author used endoscopic sinus photography to study the effects of reduction of fungi in the nose, and in environmental air, on the sinus mucosa of 639 patients diagnosed with chronic rhinosinusitis. Sinus mucosal photographs were taken before and after reduction of fungal load in the nose and air, to determine if there was an optimum environmental air fungal load associated with sinus mucosal recovery to normal appearance. Systemic symptoms associated with fungal exposure, which resolved when fungus was removed from the patient and the environmental air and reappeared with recurrent environmental fungal exposure, are also discussed and are termed systemic fungal symptoms. Interventions consisted of nasal fungal load reduction with normal saline nasal irrigations and antimicrobial nasal sprays, and environmental air fungal load reduction with high-efficiency particulate air (HEPA) filtration in combination with ionizers or evaporation of a solution of botanical extract. Main outcome measures were obtained with environmental air 1-hr gravity-plate fungal colony counts, laser air particle counts, and endoscopic sinus photography. Blood levels of immunoglobulins IgG and IgE for 7 common molds were also determined. After intervention, 94% of patients who used antimicrobial nasal sprays and who reduced their environmental fungal air count to 0-4 colonies per 1-hr agar gravity-plate exposure (n = 365) exhibited normal sinus mucosa by endoscopic exam. Environmental air fungal counts that exceeded 4 colonies resulted in sinus mucosal abnormalities ranging from edema, to pus and/or nasal polyps at higher counts. Neutralization of allergy, and/or surgery, were used as appropriate following implementation of environmental measures. On the basis of these observations, as well as detailed clinical experience and a review of the current literature, the author hypothesizes that the pathogenesis of chronic rhinosinusitis, allergic fungal sinusitis, and systemic fungal symptoms is a genetic defect at the variable beta chain helper T-cell receptor (TCR Vbeta) site which requires the presence of an antigen (fungus). Chronic sinusitis patients who have recurring exposure to environmental air that contains fungal concentrations in excess of 4 colonies per 1-hr agar plate exposure appear to have an increased risk of persistent chronic sinusitis and/or systemic symptoms, regardless of the medical treatment provided.

Rhinosinusitis

History, physical examination, and allergy testing may distinguish the syndromes of rhinitis, classified as allergic, infectious, perennial, nonallergic, and miscellaneous. All may be associated with sinusitis, probably on the basis of obstruction of the osteomeatal complex. Although topical nasal steroids are useful in the treatment of all forms of rhinitis, diagnosis of the offending type in a given patient is necessary for optimal management.

Comparison of the efficacy of IGIV-C, 10% (caprylate/chromatography) and IGIV-SD, 10% as replacement therapy in primary immune deficiency. A randomized double-blind trial

A novel method of large-scale chromatography has been developed to improve recovery and purity of immunoglobulin G (IgG) from pooled plasma. The current study compares safety, toxicity and efficacy of two intravenous immunoglobulin products: a novel formulation, IGIV caprylate/chromatography (IGIV-C; Gamunex, 10%) and a licensed solvent/detergent-treated product, Gamimune N, 10% (IGIV-SD). The study, a randomized, double-blind, parallel group, therapeutic equivalence trial, was conducted at 25 treatment centers in Canada and the United States. Patients (n=172) having confirmed chronic primary immunodeficiency (PID), aged 1-75 years, and receiving IGIV therapy were enrolled. For 9 months, patients were treated with IGIV-C or IGIV-SD in accordance with the patient's individualized treatment regimen utilized before study entry. The primary endpoint was the proportion of patients with >or=1 validated acute sinopulmonary infection during the treatment period. Secondary endpoints included the proportion of patients with all infections, time to first infection, annual infection rates, lung function parameters, infusion-related safety and viral safety. The annual validated infection rate in the IGIV-C group was 0.18 compared to 0.43 in the IGIV-SD group (p=0.023). Nine patients receiving IGIV-C experienced validated infections, compared to 17 patients in IGIV-SD group (p=0.06). Acute sinusitis (validated plus clinically defined) was less frequent in the IGIV-C group (p=0.012). Presence of bronchiectasis did not affect efficacy. Adverse reactions were similar in frequency and severity in both groups. No evidence of viral transmission was observed. IGIV-C appears to be superior to IGIV-SD in preventing validated sinopulmonary infections, especially acute sinusitis, in patients with PID.

Treatment of recurrent chronic hyperplastic sinusitis with nasal polyposis

OBJECTIVE

To demonstrate the long-term efficacy of intranasal furosemide, an inhibitor of the sodium chloride cotransporter channel at the basolateral surface of the respiratory epithelial cell, vs no therapeutic intervention vs intranasal mometasone furoate, a corticosteroid, in preventing relapses of chronic hyperplastic sinusitis with nasal polyposis.

DESIGN

Randomized prospective controlled study. Patients were examined every 6 months during follow-up (range, 1-9 years).

PATIENTS

One hundred seventy patients with bilateral obstructive or minimally obstructive chronic hyperplastic sinusitis with nasal polyposis.

INTERVENTION

All patients were surgically treated in the ENT Department, University of Siena Medical School. One month after surgery, group 1 patients (n = 97) started treatment with intranasal furosemide, group 2 (n = 40) received no therapeutic treatment, and group 3 (n = 33) were treated with mometasone.

MAIN OUTCOME MEASURES

Clinical and instrumental evaluation of postoperative outcomes.

RESULTS

Seventeen (17.5%) of 97 patients in group 1, 12 (30.0%) of 40 patients in group 2, and 8 (24.2%) of 33 patients in group 3 experienced nasal polyposis relapses. We noted a prevalence of early-stage relapse in patients treated with furosemide or mometasone, whereas patients who did not receive any treatment experienced more severe grades of chronic hyperplastic sinusitis with nasal polyposis (P<.005).

CONCLUSION

Use of intranasal furosemide represents a valid therapeutic treatment in the prevention of chronic hyperplastic sinusitis with nasal polyposis.

Medical management in functional endoscopic sinus surgery failures

Functional endoscopic sinus surgery has a high rate of success, ranging from 75 to 95% improvement in symptoms for patients who have medically refractory chronic rhinosinusitis. However, symptom improvement does not necessarily correlate with disease resolution, and even asymptomatic patients may require long-term medical management and endoscopic surveillance if late recurrence is to be avoided. The 5 to 25% percent of patients who continue to have symptoms create a challenge for the rhinologist. Correct diagnosis is the hallmark of successful treatment of this recidivistic population, carried out through history, nasal endoscopy, and radiologic (computed tomography) studies. Particularly in patients with a primary complaint of headache or facial pain, the initial preoperative diagnosis should also be revisited, particularly before further surgical intervention is considered. Once a proper diagnosis is made, management is multifaceted, including topical and systemic medications, and mechanical improvements in the sinus drainage pathways, either through treatments in the office or revision surgery. Therefore, we strongly recommend that chronic rhinosinusitis be viewed as a medical disease in which surgery plays a therapeutic role. Frequently, persistent inflammation slowly settles down over time with appropriate medical management.

[Reduction of acute recurrence in patients with chronic recurrent hypertrophic sinusitis by treatment with a bacterial immunostimulant (Enterococcus faecalis Bacteriae of human origin]

A double-blind, placebo-controlled multicenter study in 157 patients with chronic recurrent sinusitis investigated the occurrence of acute relapses during treatment of patients with a bacterial immunostimulant (3 x 30 drops/day), comprised of cells and autolysate of human Enterococcus faecalis bacteria (Symbioflor 1, n = 78) in comparison to placebo (n = 79). The study included a treatment period of 6 months and a follow-up period of 8 months. Under verum the occurrence of relapses (50 incidents) was about half (56%) the number observed under placebo (90 incidents). In the Kaplan-Meier test the verum preparation emerged as significantly superior (p = 0.045, log rank test) compared to placebo. This superiority of verum was found during the treatment period with 17 vs. 33 relapses (p = 0.019) as well as during the follow-up observation with 33 vs. 57 relapses (p = 0.013). The time interval to the first relapse was clearly longer under verum (513 days) than under placebo (311 days). The relative risk for a relapse under the test preparation compared to placebo was 49.0% during the treatment and 55.8% during the follow-up period. Severity of the acute relapses was comparable in both groups. However, antibiotic therapy was only required in 2 patients treated with verum compared to 6 patients in the placebo group. Both preparations were well tolerated and serious side effects did not occur in either group. No changes in laboratory tests--hematology and clinical chemistry--were observed. Potential immunomodifying effects of the test preparation in view of the significant reduction in relapses were discussed.

Modulation of murine allergic rhinosinusitis by CpG oligodeoxynucleotides

BACKGROUND

Allergic rhinosinusitis is characterized by eosinophilic inflammation of the upper airway, which is induced by TH-2 cytokines. CpG oligodeoxynucleotides (ODN) are known to induce TH-1 and to suppress TH-2 cytokines in a variety of settings, including murine models of asthma.

OBJECTIVE

To examine the effect of CpG ODN in a murine model of upper airway allergic inflammation and to correlate with reduction of its manifestations of sneezing and nasal scratching.

METHODS

BALB/c mice were sensitized using Ovalbumin (Ova) intraperitoneally and challenged with aerosolized Ova. CpG ODN were administered at the time of Ova sensitization. Outcomes measured included nasal symptoms, submucosal eosinophilia in the areas lined by respiratory or olfactory epithelium, and bone marrow eosinophilia. To delineate the mechanism of CpG ODN-induced suppression of eosinophilic inflammation, in vitro experiments were carried out to examine the effect of stimulation with Ova on splenocytes obtained from mice that were treated with CpG or control ODN (or no ODN) in vivo. Supernatant was collected after 72 hours of incubation and cytokines were measured by enzyme linked immunosorbent assay.

RESULTS

CpG ODN administered at the time of Ova sensitization effectively abrogated nasal symptoms and eosinophilic upper airway inflammation compared with mice treated with control ODN or with no ODN. Cytokine data revealed that Ova sensitization suppressed IFN-gamma and induced IL-4 and IL-5 compared with non-sensitized mice. CpG ODN treatment reversed these effects.

CONCLUSION

CpG ODN prevents the development of TH-2-mediated eosinophilic inflammation and symptoms in a murine model of allergic rhinosinusitis.