Erin D. Wright

Canadian clinical practice guidelines for acute and chronic rhinosinusitis

This document provides healthcare practitioners with information regarding the management of acute rhinosinusitis (ARS) and chronic rhinosinusitis (CRS) to enable them to better meet the needs of this patient population. These guidelines describe controversies in the management of acute bacterial rhinosinusitis (ABRS) and include recommendations that take into account changes in the bacteriologic landscape. Recent guidelines in ABRS have been released by American and European groups as recently as 2007, but these are either limited in their coverage of the subject of CRS, do not follow an evidence-based strategy, or omit relevant stakeholders in guidelines development, and do not address the particulars of the Canadian healthcare environment.Advances in understanding the pathophysiology of CRS, along with the development of appropriate therapeutic strategies, have improved outcomes for patients with CRS. CRS now affects large numbers of patients globally and primary care practitioners are confronted by this disease on a daily basis. Although initially considered a chronic bacterial infection, CRS is now recognized as having multiple distinct components (eg, infection, inflammation), which have led to changes in therapeutic approaches (eg, increased use of corticosteroids). The role of bacteria in the persistence of chronic infections, and the roles of surgical and medical management are evolving. Although evidence is limited, guidance for managing patients with CRS would help practitioners less experienced in this area offer rational care. It is no longer reasonable to manage CRS as a prolonged version of ARS, but rather, specific therapeutic strategies adapted to pathogenesis must be developed and diffused.Guidelines must take into account all available evidence and incorporate these in an unbiased fashion into management recommendations based on the quality of evidence, therapeutic benefit, and risks incurred. This document is focused on readability rather than completeness, yet covers relevant information, offers summaries of areas where considerable evidence exists, and provides recommendations with an assessment of strength of the evidence base and degree of endorsement by the multidisciplinary expert group preparing the document.These guidelines have been copublished in both Allergy, Asthma & Clinical Immunology and the Journal of Otolaryngology-Head and Neck Surgery.

Impact of Perioperative Systemic Steroids on Surgical Outcomes in Patients With Chronic Rhinosinusitis With Polyposis: Evaluation With the Novel Perioperative Sinus Endoscopy (POSE) Scoring System

Objectives/Hypothesis: The objective of this randomized, double‐blind, placebo‐controlled study was to assess the effect of perioperative systemic steroids on subjective and objective surgical outcomes for patients undergoing endoscopic sinus surgery (ESS) for chronic rhinosinusitis with polyposis (CRSwP). The secondary objective was to begin validation of the newly developed Perioperative Sinus Endoscopy (POSE) scoring system.

Revision Rates after Endoscopic Sinus Surgery: A Recurrence Analysis

Objectives: Chronic rhinosinusitis with nasal polyposis is often refractory to medical and surgical management, especially in patients with asthma and aspirin intolerance. We used a contemporary database to investigate recurrence and revision surgery rates following endoscopic sinus surgery. Methods: We performed a cohort study using a survival analysis technique. Records were reviewed of 549 patients with nasal polyposis who underwent endoscopic sinus surgery over a 10-year period. The main outcome measure was disease-free and surgery-free survival following endoscopic sinus surgery, investigated with Kaplan-Meier analyses. Results: Patients with Samters triad were significantly more likely to have a recurrence and undergo a second surgery following recurrence (risk-odds ratio, 2.7; 95% confidence interval, 1.5 to 3.2; p < 0.01) than were patients without asthma or with only asthma from the triad. The presence of initial frontal sinus disease also increased the likelihood of revision surgery (risk-odds ratio, 1.6; 95% confidence interval, 1.2 to 1.8; p < 0.05). Conclusions: This is the first study to use survival analysis to document revision surgery rates following endoscopic sinus surgery. Revision surgery occurs at a high rate, especially in patients with asthma, Samters triad, or frontal sinus disease. Patients should routinely be informed during clinical consultations about the likelihood of recurrence. Early intervention for frontal sinus disease may be considered.

Triamcinolone-impregnated nasal dressing following endoscopic sinus surgery: a randomized, double-blind, placebo-controlled study.

To evaluate the impact of steroid‐impregnated absorbable nasal dressing on wound healing and surgical outcomes after endoscopic sinus surgery (ESS).

Increased expression of major basic protein (MBP) and interleukin-5(IL-5) in middle ear biopsy specimens from atopic patients with persistent otitis media with effusion.

BACKGROUND: Molecular biologic evidence to support an etiologic role for allergy in the pathogenesis of persistent otitis media with effusion (OME) is lacking. OBJECTIVE: The goal of this article was to document expression of allergy-associated Th-2-type cytokines and inflammatory cells in the middle ear mucosa of children with persistent OME. METHODS: With immunocytochemistry (CDS, major basic protein) and in situ hybridization (interleukin-5 mRNA), middle ear biopsy specimens from 7 children with persistent OME were stained. Nonatopic stapedectomy patients with no history of otitis media served as controls (n = 7). RESULTS: There was a statistically significant (P < 0.05) difference in expression of CDS, major basic protein, and interleukin-5 between experimental and control subjects. All 8 OME patients proved to be atopic by ELISA testing. CONCLUSIONS: Type I allergy involving a Th-2-type cytokine and cellular profile may be a contributing factor in the persistence of OME in atopic children. SIGNIFICANCE: The middle ear may serve as a target organ for allergic inflammation, suggesting that appropriate allergy management may be a useful adjunct to the management of OME.

Oral corticosteroids in the management of adult chronic rhinosinusitis with and without nasal polyps: an evidence-based review with recommendations.

Oral steroids are commonly used in the management of chronic rhinosinusitis (CRS) with and without nasal polyps (CRSwNP and CRSsNP, respectively). Past reports have included evaluation of the evidence for the use of oral steroids in CRS subtypes. However, a review with evidence‐based recommendations for all CRS subtypes has never been performed. The purpose of this article is to provide a comprehensive, evidence‐based approach for the utilization of oral steroids in the management of CRS.

International Consensus Statement on Allergy and Rhinology: Rhinosinusitis

Isam Alobid, MD, PhD1, Nithin D. Adappa, MD2, Henry P. Barham, MD3, Thiago Bezerra, MD4, Nadieska Caballero, MD5, Eugene G. Chang, MD6, Gaurav Chawdhary, MD7, Philip Chen, MD8, John P. Dahl, MD, PhD9, Anthony Del Signore, MD10, Carrie Flanagan, MD11, Daniel N. Frank, PhD12, Kai Fruth, MD, PhD13, Anne Getz, MD14, Samuel Greig, MD15, Elisa A. Illing, MD16, David W. Jang, MD17, Yong Gi Jung, MD18, Sammy Khalili, MD, MSc19, Cristobal Langdon, MD20, Kent Lam, MD21, Stella Lee, MD22, Seth Lieberman, MD23, Patricia Loftus, MD24, Luis Macias‐Valle, MD25, R. Peter Manes, MD26, Jill Mazza, MD27, Leandra Mfuna, MD28, David Morrissey, MD29, Sue Jean Mun, MD30, Jonathan B. Overdevest, MD, PhD31, Jayant M. Pinto, MD32, Jain Ravi, MD33, Douglas Reh, MD34, Peta L. Sacks, MD35, Michael H. Saste, MD36, John Schneider, MD, MA37, Ahmad R. Sedaghat, MD, PhD38, Zachary M. Soler, MD39, Neville Teo, MD40, Kota Wada, MD41, Kevin Welch, MD42, Troy D. Woodard, MD43, Alan Workman44, Yi Chen Zhao, MD45, David Zopf, MD46

The silent sinus syndrome is a form of chronic maxillary atelectasis: a systematic review of all reported cases.

Background The terms chronic maxillary atelectasis (CMA) and silent sinus syndrome (SSS) have been used to describe spontaneous enophthalmos in association with a contracted ipsilateral maxillary sinus. Despite the use of differing taxonomy, it appears that these two terms describe the same clinical entity. Nevertheless, many reports still discuss CMA and SSS in isolation or as distinct conditions. Methods A systematic review of all reported cases of CMA and SSS was performed (1964-2006). Case reports were excluded if they involved facial trauma, diagnosis of mucocele, or previous surgery. Eligible cases were reviewed and entered into a database. Data were evaluated based on literature of publication, reported diagnosis, demographics, ophthalmologic examination, results of imaging, and operative findings. Only complete data sets were included in an additional analysis whereby the diagnostic criteria for CMA and SSS were applied and the data sets were compared. Results Of the 105 cases reviewed, 55 contained complete data sets. Twenty-seven of these cases met the diagnostic criteria for SSS, and 48 could be diagnosed as CMA, with 23 meeting the criteria for both conditions. Comparing the cases across diagnoses, the only difference observed was that of the presence of sinus-related symptoms, which by definition distinguishes CMA III from SSS. Conclusion The entity termed SSS fits within the staging classification of CMA. We propose abandoning the term SSS and recommend universal adoption of the CMA staging system, which uses nomenclature that more accurately portrays the pathophysiology and natural history of this condition.

Monocyte chemotactic proteins in allergen-induced inflammation in the nasal mucosa: Effect of topical corticosteroids

BACKGROUND Human allergen-induced rhinitis is associated with the recruitment and activation of inflammatory cells, particularly eosinophils and CD4(+) T cells, in the nasal mucosa. Chemokines are inflammatory mediators capable of attracting specific inflammatory cell populations. Monocyte chemotactic proteins (MCPs), a subfamily of CC chemokines, have been shown to induce chemotactic activity particularly in eosinophils, T cells, and monocytes under in vitro assay conditions. OBJECTIVE To assess the contribution of MCPs in the recruitment of inflammatory cells in vivo, we investigated the allergen-induced late response in subjects with allergic rhinitis. METHODS Patients were randomized to receive a 6-week treatment with either topical corticosteroid (n = 6) or a matched placebo (n = 6). Nasal inferior turbinate biopsy specimens were obtained from all subjects before and during allergen-induced late responses. By using immunocytochemistry, tissue sections were examined for the presence of MCP-1, MCP-3, and MCP-4 and for the phenotype of infiltrating cells within the nasal mucosa. In addition, double sequential immunocytochemistry was used to confirm the phenotype of MCP-immunoreactive positive cells. Furthermore, the effect of topical corticosteroids on the expression of MCPs and on the cellular infiltrate was also examined. RESULTS MCP-1, MCP-3, and MCP-4 were expressed in all the baseline samples, with prominent staining observed within the nasal epithelium. Biopsy specimens taken after challenge exhibited significant upregulation in the expression of MCP-3 and MCP-4 (P <.001). On the other hand, this increase in response to allergen was reduced in patients pretreated with topical corticosteroids. Colocalization experiments revealed that the majority of MCP+ cells in the subepithelium were macrophages, followed by T cells and eosinophils. CONCLUSION Our results demonstrate that allergen-induced rhinitis is associated with an increased expression of MCP-3 and MCP-4, which may be closely related to the influx of inflammatory cells and may thus contribute to the pathogenesis of allergic rhinitis.

Acute Bacterial Sinusitis in Adults: Management in the Primary Care Setting

Sinus disease is inherently associated with viral upper respiratory tract infections and occurs in 90% of individuals with the common cold. Acute bacterial sinusitis occurs in 0.5 to 2% of these individuals. Although the diagnosis of acute bacterial sinusitis is usually based on physical findings, no one sign or symptom is either sensitive or specific for sinusitis. The predictive power can be significantly improved when all signs and symptoms are combined into a clinical impression. Imaging studies have not been shown to be cost effective in the initial assessment and treatment of patients in the primary care setting. Simple plain films may be indicated to resolve the diagnosis in patients with an equivocal history or to follow patients admitted to hospital with severe sinus disease. The initial management of acute sinusitis should be directed toward the relief of symptoms with a 7-day course of decongestants and mucoevacuents. For patients who fail to improve with symptomatic treatment, a 10-day course of amoxicillin is recommended. Second line antibiotics should be initiated if improvement is not seen within 72 to 96 hours.