Peter-John Wormald

Oral steroids and doxycycline: Two different approaches to treat nasal polyps

BACKGROUND There is little scientific evidence to support the current practice of using oral glucocorticosteroids and antibiotics to treat patients with chronic rhinosinusitis and nasal polyps. OBJECTIVE We evaluated the effects of oral glucocorticoids and doxycycline on symptoms and objective clinical and biological parameters in patients with chronic rhinosinusitis and nasal polyps. METHODS In a double-blind, placebo-controlled, multicenter trial, we randomly assigned 47 participants with bilateral nasal polyps to receive either methylprednisolone in decreasing doses (32-8 mg once daily), doxycycline (200 mg on the first day, followed by 100 mg once daily), or placebo for 20 days. Participants were followed for 12 weeks. Patients were assessed for nasal peak inspiratory flow and symptoms and by nasal endoscopy. Markers of inflammation such as eosinophilic cationic protein (ECP), IL-5, myeloperoxidase, matrix metalloproteinase 9, and IgE were measured in nasal secretions. Concentrations of eosinophils, ECP, and soluble IL-5 receptor alpha were measured in peripheral blood samples. RESULTS Methylprednisolone and doxycycline each significantly decreased nasal polyp size compared with placebo. The effect of methylprednisolone was maximal at week 3 and lasted until week 8, whereas the effect of doxycycline was moderate but present for 12 weeks. Methylprednisolone significantly reduced levels of ECP, IL-5, and IgE in nasal secretions, whereas doxycycline significantly reduced levels of myeloperoxidase, ECP, and matrix metalloproteinase 9 in nasal secretions. CONCLUSION This is the first double-blind, placebo-controlled study to show a significant effect of oral methylprednisolone and doxycycline on size of nasal polyps, nasal symptoms, and mucosal and systemic markers of inflammation.

Confocal Scanning Laser Microscopy Evidence of Biofilms in Patients With Chronic Rhinosinusitis

Objectives: The recent detection of bacterial biofilms on the sinus mucosa of patients with chronic rhinosinusitis (CRS) has implicated biofilms in the pathogenesis of this condition. Electron microscopy has been the main modality used to document the presence of biofilms on sinus tissue, however, it has inherent problems associated with tissue preparation and sampling. Recently, Confocal Scanning Laser Micrsocopy (CSLM) has emerged as a noninvasive, nondestructive technique for the analysis of biofilms. This study used CSLM as the means of investigating biofilm presence in CRS patients.

The effect of bacterial biofilms on post-sinus surgical outcomes

Background Although the existence of biofilms on the sinus mucosa of patients with chronic rhinosinusitis (CRS) is now well established, the role that these structures play remains unclear. It is thought that biofilms may contribute to the recalcitrant and persistent nature that characterizes CRS, but little research exists documenting the effect that they have on postoperative mucosal outcomes. This article presents a retrospective analysis of sinus surgical patients and correlates the presence of biofilms with mucosal outcomes. This study was performed to evaluate the role that bacterial biofilms have on post-sinus surgical outcomes. Methods A retrospective analysis of prospectively collected data was performed on 40 patients undergoing endoscopic sinus surgery (ESS) for CRS. Preoperative demographic, clinical, and radiologic data were recorded from each patient and, intraoperatively, sinus culture specimens and mucosal samples were obtained for microbiological and microscopic examination. Biofilm determination was performed using confocal scanning laser microscopy. Postoperatively, patients were followed up for a minimum of 8 months with endoscopic evaluation of their sinonasal mucosa. The presence of ongoing symptoms was recorded also. Results Bacterial biofilms were found in 20 (50%) of the 40 CRS patients. Patients with biofilms had significantly worse preoperative radiological scores and, postoperatively, had statistically worse postoperative symptoms and mucosal outcomes. The only other factor that was statistically related to an unfavorable outcome was the presence of fungus at the time of surgery. In this study the presence of polyps, eosinophilic mucin, or pus was not related to poor outcomes. Conclusion This retrospective study showed that bacterial biofilms and fungus were correlated with the persistence of postoperative symptoms and mucosal inflammation after sinus surgery for CRS. This provides evidence that biofilms indeed may play an active role in perpetuating inflammation in CRS patients and may explain the recurrent and resistant nature of this disease. Therapies targeted at removing biofilms may be important in the management of recalcitrant CRS.

Endoscopic removal of sinonasal inverted papilloma including endoscopic medial maxillectomy

Objectives/Hypothesis Surgical excision is regarded as the treatment of choice for sinonasal inverted papilloma. Resection can be performed endoscopically or through an external approach. Debate exists about which approach to use. The study presents different endoscopic techniques for various tumor locations and reviews the results.

Powered endoscopic dacryocystorhinostomy

Objectives To describe powered endoscopic dacryocystorhinostomy (DCR) with full sac exposure and primary mucosal anastomosis and report perioperative and follow‐up results achieved with this procedure.

The microbiome of chronic rhinosinusitis: culture, molecular diagnostics and biofilm detection

BackgroundBacteria and fungi are believed to influence mucosal inflammation in chronic rhinosinusitis (CRS). However their presence and relationship to disease is debated. This study used multiple detection methods to compare microbial diversity and microbial abundance in healthy and diseased sinonasal mucosa. The utility of contemporary detection methods is also examined.MethodsSinonasal mucosa was analyzed from 38 CRS and 6 controls. Bacterial and fungal analysis was performed using conventional culture, molecular diagnostics (polymerase chain reaction coupled with electrospray ionization time-of-flight mass spectrometry) and fluorescence in situ hybridization.ResultsMicrobes were detected in all samples, including controls, and were often polymicrobial. 33 different bacterial species were detected in CRS, 5 in control patients, with frequent recovery of anaerobes. Staphylococcus aureus and Propionibacterium acnes were the most common organisms in CRS and controls, respectively. Using a model organism, FISH had a sensitivity of 78%, and a specificity of 93%. Many species were detected in both CRS and controls however, microbial abundance was associated with disease manifestation.ConclusionsThis study highlights some cornerstones of microbial variations in healthy and diseased paranasal sinuses. Whilst the healthy sinus is clearly not sterile, it appears prevalence and abundance of organisms is critical in determining disease. Evidence from high-sensitivity techniques, limits the role of fungi in CRS to a small group of patients. Comparison with molecular analysis suggests that the detection threshold of FISH and culture is related to organism abundance and, furthermore, culture tends to select for rapidly growing organisms.

Correlation between preoperative symptom scores, quality-of-life questionnaires, and staging with computed tomography in patients with chronic rhinosinusitis.

Background This study evaluates the correlation between preoperative symptoms, quality-of-life questionnaires (chronic sinusitis survey and 20-Item Sinonasal Outcome Test [SNOT-20]), and staging on computer tomography (CT). It consisted of a prospective cohort study of all consecutive patients undergoing surgery for medically nonresponsive chronic sinusitis, which took place at a tertiary care center. Methods Two hundred twenty-one patients completed the Chronic Sinusitis Survey (CSS) questionnaire and the SNOT-20. A visual analog scale (VAS) symptom score was completed also. The average age of the patients was 44.5 years and the male/female ratio was 1.3:1. The symptom scores of all three questionnaires were compared with the Lund-MacKay CT scan score of the sinuses. Results The median Lund-MacKay CT score was 12 (mean ± SD, 12.7 ± 5.7). There was no significant correlation between the SNOT-20 questionnaire and the Lund-MacKay CT score (p = 0.026; p = 0.764) and between the CSS and the Lund-MacKay CT score (p = —0.158; p = 0.058). Furthermore, there was no significant correlation between a single VAS symptom score relating to overall sinonasal symptom severity and the Lund-MacKay CT scan score (p = 0.135; p = 0.121). However, a weak but statistically significant correlation was found between the VAS score based on the sum of five sinonasal symptoms and the Lund-MacKay CT scan score (p = 0.197; p = 0.020). Conclusion The score, based on the sum of five sinonasal VAS symptoms, correlates to the disease severity as measured by the Lund-MacKay CT scan score. The SNOT-20 questionnaire and the CSS symptom score do not correlate to the Lund-MacKay CT scan score, although a correlation was found between the CSS score and the Lund-MacKay CT score in various subgroups of our patient population.

Characterization of bacterial and fungal biofilms in chronic rhinosinusitis.

Background Conclusive evidence exists that biofilms are present on the mucosa of chronic rhinosinusitis (CRS) patients. Less is known about the species constituting these biofilms. This study developed a fluorescence in situ hybridization (FISH) protocol for characterization of bacterial and fungal biofilms in CRS. Methods Fifty CRS patients and 10 controls were recruited. Bacteria FISH probes for Staphylococcus aureus, Haemophilus influenzae, and Pseudomonas aeruginosa and a universal probe for fungi were applied to sinus mucosal specimens and then analyzed using confocal scanning laser microscopy. Results Thirty-six of 50 CRS patients had biofilms present in contrast to 0/10 controls, suggesting a role for biofilms in the pathogenesis of this disease. S. aureus was the most common biofilm-forming organism. Eleven of 50 CRS patients had characteristic fungal biofilms present. Conclusion This is the largest study of biofilms in CRS. It has validated mucosal tissue cryopreservation for delayed biofilm analysis. Fungal biofilms have been identified and the importance of S. aureus biofilms in the polymicrobial etiology of CRS is highlighted.

Salvage frontal sinus surgery: the endoscopic modified Lothrop procedure.

Objectives/Hypothesis Until recent years, the osteoplastic flap with frontal sinus obliteration has been the gold standard for recalcitrant frontal sinusitis. The present series evaluated the role of the endoscopic modified Lothrop procedure, which has recently been advocated as an alternative.

Different biofilms, different disease? A clinical outcomes study.

A potential role for biofilms in Chronic Rhinosinusitis (CRS) has been proposed, and the adverse impact they have on disease severity and postoperative outcomes has also been well described. Recent advances have allowed the species within the biofilms of CRS patients to be clearly characterized. This study investigates whether different biofilm species have different disease outcomes.