Safe treatment of ethmoid sinusitis utilizing minimally invasive ethmoid punch sinusotomy in chronic rhinosinusitis without polyposis patients.

OBJECTIVES/HYPOTHESIS: Current rhinologic practice is devoid of minimally invasive procedures dedicated to the treatment of ethmoid sinusitis to improve ventilation and topical drug delivery. We have recently described a handheld spiral punch to create minimally invasive ethmoid punch sinusotomy (EPS) sites into the ethmoid bulla and basal lamella, which significantly increased irrigant access to the ethmoid sinuses in cadaver models. Here, we conducted a clinical feasibility study to determine the initial safety evaluation of EPS in chronic rhinosinusitis without polyposis (CRSsNP) patients with active ethmoid disease. STUDY DESIGN: Single-arm, institutional review board-approved observational study. METHODS: This study was performed in CRSsNP patients who failed medical management; were candidates for standard, traditional functional endoscopic sinus surgery; and were offered the option of EPS. EPS characteristics (patency, remucosalization) and complications (closure, mucus recirculation) were collected. Alterations in radiographic disease and symptoms after EPS were determined by Lund Mackay (LM) scoring and 22-item Sinonasal Outcome Test (SNOT-22) scoring, which was collected up to 6 months post-procedure. RESULTS: Thirty-two of 40 possible ethmoid compartments (17 of 20 anterior, 15 of 20 posterior) underwent EPS. Twenty-nine of 32 EPS sites remained patent (n = 29, 90.6%), with a minority displaying evidence of restenosis (n = 9, 28.1%) or closure (n = 3, 9.3%). All patent EPS sites had complete remucosalization (n = 29, 100%) with no evidence of mucus recirculation (n = 0, 0%) or other complications secondary to healing or device use. Ethmoid sinus cavities with a pre-EPS LM score of 1 or 2 universally improved to an LM score of 0 following EPS (n = 30 of 30, 100%). SNOT-22 scores significantly improved, with a mean reduction of 33.1 (49.6 ± 7.5 pre-EPS vs 16.5 ± 7.7 post-EPS, p < .0001). CONCLUSIONS: This feasibility study demonstrates that EPS appears to be a safe, minimally invasive procedure to treat ethmoid sinusitis in CRSsNP patients unresponsive to medical therapy that establishes ethmoid ventilation, and likely improves effective sinus irrigation. Conducting a clinical trial would be appropriate in assessing a potential role for EPS in the management of this condition. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:1268-1275, 2017.

Impact of chronic rhinosinusitis on work productivity through one-year follow-up after balloon dilation of the ethmoid infundibulum.

BACKGROUND: Although multiple clinical trials have demonstrated that balloon dilation of sinus ostia in patients diagnosed with chronic rhinosinusitis (CRS) results in sustained symptomatic improvement, less data are available to measure the effects of sinusitis on worker productivity. The objective of our research was to analyze work and activity impairment before and after transantral, endoscopically-guided balloon dilation of the maxillary sinus ostia and ethmoid infundibulum. METHODS: Subjects diagnosed with CRS and computed tomography (CT) evidence of disease in the maxillary sinuses alone, or maxillary and anterior ethmoid sinuses, completed the Work Productivity and Activity Impairment (WPAI) questionnaire and the Work Limitation Questionnaire (WLQ) before treatment and at 3, 6, and 12 months postprocedure. RESULTS: A total of 56 subjects were enrolled and 53 completed the 1-year follow-up. The lost productivity composite score computed from the WLQ improved by 73% (9.0 to 2.4; p < 0.0001) at 1-year follow-up whereas lost productivity at work as measured by the WPAI improved by approximately 76% (38.3 to 9.2; p < 0.0001) 12 months after treatment. CONCLUSION: These results indicate that sinus-related health problems impose a substantial burden on work productivity and physical/mental activity levels. Treatment of CRS by dilating the maxillary sinus ostium and ethmoid infundibulum can significantly improve quality of life (QOL) and work productivity.

Up-regulation of heparanase in the ethmoid sinus mucosa of patients with chronic sinusitis.

BACKGROUND: Heparanase (HPA) is known to be involved in tissue remodeling of various organs with inflammatory diseases. The aim of this study was to investigate the level of expression and the pattern of distribution of HPA in normal human sinus mucosa, inflammatory sinus mucosa, and nasal polyps to evaluate the possible effect of HPA on the tissue remodeling of chronic inflammatory sinus mucosa and nasal polyps. METHODS: Normal sinus mucosa was obtained from the ethmoid sinus during endoscopic reduction in 25 patients with blowout fractures. Inflammatory sinus mucosa and nasal polyps were obtained from 25 patients undergoing endoscopic sinus surgery for chronic sinusitis with nasal polyps. The levels of expression and the pattern of distribution of HPA were evaluated in normal human sinus mucosa, inflammatory sinus mucosa, and nasal polyps, using reverse transcriptase-polymerase chain reaction, immunohistochemical analysis, and Western blot analysis. RESULTS: HPA mRNA and protein were detected in inflammatory sinus mucosa and nasal polyps but not in normal sinus mucosa. HPA was mainly localized in the vascular endothelium, epithelium, submucosal glands, and inflammatory cells of inflammatory sinus mucosa. In nasal polyps, inflammatory cells and vascular endothelium showed immunopositivity in the entire portion, whereas glands and epithelial cells did not show positivity. CONCLUSION: Our results indicate that HPA is not constitutively expressed in normal sinus mucosa and is upregulated in chronic inflammatory sinus mucosa and nasal polyps, suggesting that HPA may play an important role in the tissue remodeling in chronic sinusitis.

Symptomatic SUNCT syndrome associated with ipsilateral paranasal sinusitis.

Sinusitis has rarely been associated with short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) syndrome. We describe a case of symptomatic SUNCT syndrome caused by sinusitis, which showed typical features of SUNCT syndrome. The patient's symptoms completely resolved without recurrence after endoscopic sinus surgery followed by antibiotic treatment. We suggest that ipsilateral paranasal sinusitis accompanied by the spreading of inflammation through a dehiscence in the lamina papyracea could lead to the development of SUNCT syndrome.

Comparison of radical (nasalisation) and functional ethmoidectomy in patients with severe sinonasal polyposis. A retrospective study.

OBJECTIVE: To compare the 5-year outcomes of two endoscopic surgical approaches for diffuse and severe nasal polyposis. STUDY DESIGN: A natural experimental situation gave us the opportunity to compare the results 5 years after radical ethmoidectomy (nasalisation) (n= 39), and functional ethmoidectomy (n= 37). The two surgical procedures were performed by two different surgeons on 76 consecutive patients. There was no random assignment for this retrospective study. METHODS: Five years after surgery, the criteria for comparison were 1) functional results based on a questionnaire using visual analogue scales in patients free of revision surgery; 2) endoscopic and CT-scan assessments of anatomical results. The CT-scans were blinded and randomized, and opacities were measured using a computerized model; 3) the recurrence rate of nasal polyps. RESULTS: Five years after surgery, the overall nasal functional benefit was scored 8.41 +/- 0.40 (mean +/- SEM) after nasalisation, and 5.69 +/- 0.83 after ethmoidectomy P= 0.002) in patients free of revision surgery. The endoscopic appearance of the mucosa was methodically scored according to a pre-defined scale. Results were significantly better in the nasalisation group (6.03 +/- 0.7 versus 3.27 +/- 1.0, P= 0.02). A good correlation was found between the endoscopic and CT-scan scores (r= -0.78, P= 0.0001 for nasalisation, and r= -0.65, P= 0.001 for ethmoidectomy). The total recurrence rate was 22.7% in the nasalisation group, and 58.3% in the ethmoidectomy group (chi2= 10.41, P< 0.01). CONCLUSION: Our study suggests that in the treatment of nasal polyposis complete ethmoidectomy leads to better long term results than incomplete ethmoidectomy.

Relationship between pediatric sinusitis and middle turbinate pneumatization--ethmoidal sinus pyocele thought to be caused by middle turbinate pneumatization.

OBJECTIVE: To investigate whether the presence of pediatric middle turbinate pneumatization causes narrowing of the ostiomeatal complex (OMC) and is associated with the development of paranasal sinusitis. METHODS: CT scans of 190 nasal sides of 95 children (1-15 years old) were analyzed for the presence of middle turbinate pneumatization and mucosal thickness in the paranasal sinus. RESULTS: Middle turbinate pneumatization was detected in nine (4.6%) of the nasal cavities. Only one of these sides was in a patient younger than 10 years of age, while the other eight sides were in patients at least 13 years old. In six of those nine sides with pneumatization, paranasal sinusitis was also found. However, the images showed that in five sides the middle turbinate pneumatization itself did not obstruct the OMC. In addition, the mean +/- standard deviation (S.D.) of the total score for the paranasal sinus opacification on the side which had the middle turbinate pneumatization was 5.67 +/- 2.95. The corresponding value for the 76 sides without pneumatization was 5.29 +/- 2.53, and the difference between these mean total scores was not statistically significant. However, in one side, the OMC was obstructed or narrowed due to the middle turbinate pneumatization, and an ethmoidal sinus pyocele formed on this side. CONCLUSION: A causal relationship was not found between middle turbinate pneumatization and the mechanism of development of paranasal sinusitis in children. However, in the event that the OMU becomes obstructed at some time, frequent cycles of improvement and aggravation of pediatric paranasal sinusitis may occur and lead to the development of a serious condition.

Estudo da ultra-estrutura da face medial da bolha etmoidal em pacientes com rinossinusite crônica / Ultrastructural study of medial face of ethmoidal bulla in patients with chronic rhinosinusitis

As alterações ultra-estruturais da mucosa dos seios paranasais representam um papel importante na fisiopatologia da rinossinusite crônica. Com o objetivo de conhecer estas alterações, foi estudada a ultra-estrutura da mucosa da bolha etmoidal, As pesquisas foram feitas em 21 pacientes, submetidos à análise histopatológica e da ultra-estrutura, com microscópio eletrônico de varredura. Observou-se epitélio respiratório, cilíndrico ciliado e pseudo estratificado. Foi freqüente o achado de regiões com espaçamentos evidentes entre as células epiteliais. A rinossinusite crônica provavelmente provoca a decomposição da camada celular por falta de coesão entre seus elementos e metaplasia do epitélio de revestimentob / The ultrastructural changes in paranasal sinus mucosa play an important role in the pathophysiology of chronic rhinosinusitis. To improve knowledge about these alterations, the ultrastructure of medial wall of ethmoidal bulla was studied. Portions of the ethmoid bulla wall of twenty-one patients were submitted to histopathological examination with scanning electron microscope. Although the metaplasia was difficult to detect in the light microscopy, its presence was confirmed by electronic microscopy. Basal cells hyperplasia was observed in the majority of the cases. Seromucous glands and hyperplasic acinus were found in all cases. Chronic rhinosinusitis probably leads to a decomposition of cellular layer, due to a loss of cohesion between its elements and the covering squamous metaplasia...

Amaurosis unilateral irreversible secundaria a esfenoetmoiditis / Unilateral irreversible visual loos due to sphenoethmoiditis

La celulitis orbitaria secundaria a sinusitits paranasal se caracteriza por proptosis, alteraciones en la movilidad ocular, edema palpebral, quemosisi y/o hiperemia conjuntival previos a disminución o pérdida de la función visual. En caso de sinusitis posterior o esfenoetmoidal, la pérdida temprana y rápidamente progresiva de la función visual puede anteceder o acompañar a signología orbitaria inflamatoria leve, pudiendo ser dicha pérdida resultado de la combinación de edema intracanalicular o alteraciones vasculares del nervio óptico. Se describe el caso de una paciente pediátrica con diagnóstico de esfenoetmoiditis y pérdida unilateral permanente de la función visual a pesar del tratamiento médico y quirúrgico

A comparison of the efficacy, tolerability and safety of azithromycin and co-amoxiclav in the treatment of sinusitis in adults.

The efficacy, tolerability and safety of azithromycin and co-amoxiclav in the treatment of non-severe acute maxillary/ethmoidal sinusitis were compared in a randomized, open clinical trial in 254 adult patients. The predominant pathogens were Streptococcus pneumoniae and Haemophilus influenzae (83 patients). Azithromycin was administered orally to 165 patients at a single daily dose of 500 mg for 3 days, and co-amoxiclav (4:1) to 89 patients, at a dose of 500 mg three times daily for 10 days. The overall clinical response rates were 87.5% for azithromycin and 83.7% for co-amoxiclav at follow-up (day 21-28). Microbiological responses to both drugs were good, with only five patients in each group having a persistent infection after treatment. Both drugs were well tolerated and produced similar incidences of adverse events, which were mostly gastrointestinal. Azithromycin was as effective, and as well tolerated as co-amoxiclav, and its shorter simpler dosing regime may offer advantages in compliance and cost.

Histology and histomorphometry of ethmoid bone in chronic rhinosinusitis.

Mucosal changes have been well described in chronic sinusitis, yet little is known about the underlying bone, despite clinical and experimental evidence suggesting that bone may be involved in chronic sinusitis. Techniques of undecalcified bone analysis were used for detailed histologic examination of ethmoid bone in chronic sinusitis compared with controls. Bone synthesis, resorption, and inflammatory cell presence were specifically assessed. Additionally, histomorphometry techniques were used to determine ethmoid bone physiology in individuals undergoing surgery for chronic sinusitis. Overall, individuals undergoing surgery for chronic sinusitis were found to have evidence of marked acceleration in bone physiology with histologic changes including new bone formation, fibrosis, and presence of inflammatory cells. These findings are compared with osteomyelitis in long bone and the jaw. The suggestion that underlying bone may serve as a catalyst for chronic sinusitis is supported and implications for therapy are discussed.

Anosmia and chronic sinus disease.

Chronic sinus disease associated with progressive mucosal disease is often a cause for anosmia. Despite aggressive allergic, medical, and surgical intervention, long-term relief of anosmia has been difficult to document. Fifty patients sought treatment for subjective anosmia and symptoms of progressive sinusitis and underwent endoscopic sinus surgery. After surgery 52% maintained significant improvement in smell by subjective measures that correlated with objective olfactory University of Pennsylvania Small Identification test ("UPSIT") results. Of the remaining patients, some had intermittent improvement, but most remained hyposmic or anosmic despite clinically well-healed ethmoid surgical beds. Of the preoperative and postoperative historical, clinical, and radiological data analyzed, severity of the presenting sinus disease (defined as stage II In the Kennedy staging criteria or disease extending beyond the ethmoids on preoperative computed tomography scan) and persistent mucosal disease in the surgical bed are associated with persistent anosmia (p = 0.005).

Results of endoscopic sinus surgery in pediatric patients with chronic sinusitis and asthma.

OBJECTIVE: To determine the efficacy of endoscopic sinus surgery in pediatric patients with chronic sinusitis and asthma. SETTING: Patients were selected from the tertiary care practice of a pediatric pulmonologist (R.S.) and immunologist (R.L.W.); all underwent sinus surgery at Children's Medical Center at Dallas (Tex). PATIENTS: Fourteen pediatric patients aged 3.5 to 13 years with severe asthma requiring at least intermittent systemic steroid therapy. All patients had a history of sinusitis aggravating asthma and all had computed tomographic evidence of chronic sinus disease. INTERVENTION: All patients underwent endoscopic sinus surgery consisting of bilateral total ethmoidectomies and middle meatus antrostomies at a minimum. MAIN OUTCOME MEASURES: The period 12 months prior to surgery was compared with 12 months postoperatively with regard to total hospitalization days for asthma treatment, number of school days missed, pulmonary function test results, and systemic glucocorticoid medication requirements. Symptom scores for asthma and sinusitis were assessed via parental questionnaire both preoperatively and postoperatively. RESULTS: No significant difference was found for pulmonary function test results. Eleven of 14 patients demonstrated a significant reduction in hospitalization and school days missed. Twelve of 14 patients experienced a reduction in glucocorticoid requirements. Eleven of 14 and 13 of 14 patients experienced a significant improvement in asthma and sinusitis symptom scores. CONCLUSION: Endoscopic sinus surgery was effective in reducing sinusitis and improving the overall management of asthma in a majority of study patients.

[Symptomatic malformations of the first branchial arch]. / Malformación del primer arco branquial sintomática.

Congenital malformations of the branchial arches are not infrequent. Among them first branchial cleft anomalies are common and they are to remain asymptomatic. The case reported is one of symptomatic fistula auris, which at the beginning led us to the initial diagnosis of an orbital cellulitis, secondary to ethmoidal sinusitis. We have made a review of the literature dealing with these anomalies and we expose in the paper an update perusal of the clinical features and the management of this rare complication.

Ciliary beating frequency in chronic sinusitis.

Ciliary beating frequency, one component of mucociliary function, was measured outside of the sinus in vitro with a photoelectric method in 150 patients with chronic sinusitis and in 26 control subjects. In the mucosal samples of 35 patients (23%), no ciliary activity was seen. Ciliary beating frequency in maxillary sinus mucosa of the rest of the 115 patients (77%) was, as an average, 16.6 +/- 3.0 Hz (range, 10.9 to 23.3 Hz) and it was 15.9 +/- 2.6 Hz (range, 13.2 to 22.8 Hz) for the control patients. No differences in ciliary beating frequency were found according to quality of sinus secretion, prevalent respiratory allergy, or mucosal thickness. However, in sinuses with purulent secretion, ciliary beating frequency was slightly better (P < .05) than in "empty" sinuses. The study suggests that in many cases of chronic sinusitis, the sinus mucosa still has a capacity to recure.

[The functional status of the thyroid gland and adrenal cortex in newborn babies and infants with acute ethmoiditis]. / Funktsional'noe sostoianie shchitovidnoi zhelezy i kory nadpochechnikov u novorozh-dennykh i grudnlykh detei s ostrymi étmoiditami.

Using the RIA method, thyroxine (T4), triiodothyroxine (T3), and cortisol (C) were measured in 10 patients with acute ethmoiditis, aged from 13 days to 6 months. At the peak of the disease, i. e. when infection toxicosis was very manifest, T3 was significantly lower and T4 tended to decrease. During the convalescence period T3 increased distinctly and T4 continued to decline. It can be concluded that the thyroid function was inhibited during the toxic period; however, this inhibition was transient and required no intervention. Nevertheless, in the case of complications, especially sepsis, transient hypothyrosis may develop which requires substitution therapy. Variations in cortisol serum concentrations were insignificant.

Functional endoscopic sinus surgery: morbidity and early results.

Functional endoscopic sinus surgery is a new alternative to conventional sinus surgery as a means of managing recalcitrant sinus disease. This approach to sinus pathology focuses on the importance of the functional ostiomeatal complex and anterior ethmoid sinuses in the pathogenesis of sinus disease. In an effort to assess the morbidity and initial results of this procedure, 85 cases were reviewed. A total of 82% of the patients had bilateral maxillary and ethmoid sinusitis, and 45% had pansinusitis, frequently associated with allergic rhinitis (56%) and nasal polyps (58%). A total of 82% of the patients were operated on as outpatients under local anesthesia. There were no major complications associated with the surgery and minor complications were rare. Disease control was achieved in 88% of patients with short-term follow-up.