The Bacteriology of Middle Meatus and Ethmoid Sinuses in Chronic Rhinosinusitis: Epidemiological Analysis and Surgical Impact.

OBJECTIVES: The aim of this study was to explore the difference between sinus bacteriology in chronic rhinosinusitis patients with and without nasal polyposis. We also analyzed the possible differences in culture results from swabs taken from the middle meatus versus the ethmoid sinus. METHODS: Retrospective chart review of adult chronic rhinosinusitis patient data from the year 2006 to 2020. Nasal swabs were taken under endoscopic guidance either intraoperatively from either the ethmoid sinus or middle meatus, or in the outpatient clinic from the middle meatus. The results were categorized based on the most common microorganisms affecting the nose and sinuses. RESULTS: We found that, the presence of nasal polyps seemed to have no effect on sinus bacteriology as whole. There was also no significant difference between the bacteriology of chronic rhinosinusitis patients who did not need surgery and those who did. Finally, we found that middle meatal cultures, taken endoscopically, give similar bacteriology results to that of ethmoid sinus cultures (taken intraoperatively). CONCLUSION: Middle meatal culture results accurately represent true sinus flora, and therefore can be used to aid in appropriate culture guided antibiotic therapy for patients visiting the outpatient clinic.

Intraoperative bacterial analysis in nasal polyposis: Clinical and functional impact.

BACKGROUND: The impact of Staphylococcus aureus on onset of nasal polyposis has been the focus of numerous studies, but there have been few studies of other germs found in the ethmoid of operated patients or of their impact on post-operative results. MATERIAL AND METHODS: All patients undergoing endoscopic radical ethmoidectomy for nasal polyposis in the teaching hospital of Nantes (France) between 2006 and 2016 had intraoperative ethmoid cavity bacterial sampling. Phenotypic characteristics, pre- and post-operative symptoms and endoscopic findings were analyzed. Mann-Whitney tests and Kruskal-Wallis correlation analysis were used to assess clinical/bacteriological correlations. OBJECTIVES: The main objective was to describe bacterial colonization of patients undergoing surgery for nasal polyposis, and to assess correlations with phenotypic features, functional results and postoperative clinical course. RESULTS: One hundred and seven patients were included. A total of 26% were not infected, 55% mono-infected and 19% multi-infected. In 27.3%, staphylococci were isolated; in 30.5%, isolates were gram-negative bacilli. There were no significant correlations between presence or type of pathogen and symptom profile. CONCLUSION: This study confirmed the high rate of pathogenic bacteria in nasal cavities in case of polyposis, with high frequencies of S. aureus but also of gram-negative bacilli, raising the question of their involvement in the inflammatory reactions underlying the nasal polyposis.

[Staphylococcus aureus biofilm influences the expression of lysozyme, SLPI and gp340 in a human sinonasal explant model].

OBJECTIVE: To investigate the influences of staphylococcus aureus in planktonic and biofilm forms on the expression of lysozyme, SLPI and gp340 in the human sinonasal explant model. METHOD: Mucosa samples from ethmoid sinus were collected from ten patients of cerebrospinal fluid leak and were cultured with and without S. aureus biofilms and planktonic cells. After the infection, the explant model was confirmed by CLSM, and the secretion of lysozyme, SLPI and gp340 was detected by enzyme-linked immunosorbent assay (ELISA) at 8, 16, and 24 h after S. aureus challenge. Expressions of lysozyme, SLPI and gp340 in mRNA and protein levels after 24 h S. aureus challenge were detected using RT-PCR, immunohistochemistry and Western bolt assay respectively. RESULT: The secretion of lysozyme, SLPI and gp340 in the explant model was observed with a trend to increase in a time-dependent manner. At 8 and 16 h after S. aureus challenge, the secretion of lysozyme, SLPI and gp340 in biofilms group was significantly higher than these in planktonic cells group and control group (P<0. 05). S. aureus biofilms enhanced the mRNA expressions of lysozyme, SLPI and gp340 significantly compared with planktonic cells and controls, and the mRNA expressions in the explant model challenged by planktonic cells were significantly higher than controls (P < 0.05). Although the Western bolt assay showed no differences between the lysozyme expression in the planktonic cells group and control group (P > 0.05), the biofilms enhanced the expressions of lysozyme, SLPI and gp340 significantly compared with planktonic cells and controls (P < 0.05). CONCLUSION: S. aureus biofilm induced the expressions of lysozyme, SLPI and gp340 to a higher level than planktonic cells, indicating that S. aureus biofilm was an influencing factor on the innate immune system.

Paediatric nasal polyps in cystic fibrosis.

Patients with cystic fibrosis (CF) are at increased risk of nasal polyps. We present the case of a 17-month-old Caucasian patient with CF who presented with hypertelorism causing cycloplegic astigmatism, right-sided mucoid discharge, snoring and noisy breathing. Imaging suggested bilateral mucoceles in the ethmoid sinuses. Intraoperatively, bilateral soft tissue masses were noted, and both posterior choanae were patent. Polypectomy and bilateral mega-antrostomies were performed. Histological examination revealed inflammatory nasal polyposis typical of CF. The role of early functional endoscopic sinus surgery (FESS) in children with CF nasal polyposis remains questionable as the recurrence rate is higher, and no improvement in pulmonary function has been shown. Our case, however, clearly demonstrates the beneficial upper airway symptom relief and normalisation of facial appearance following FESS in a child with this condition.

Bacterial biofilms in chronic rhinosinusitis; distribution and prevalence.

CONCLUSION: Biofilms were more prevalent in patients with CRSwNP compared to both CRSsNP and controls, and also on the ethmoid bulla compared to the middle turbinate, supporting a biofilm-related pathogenesis of CRSwNP. OBJECTIVE: To investigate the prevalence of biofilms in patients with chronic rhinosinusitis with nasal polyps (CRSwNP) compared to patients with chronic rhinosinusitis without nasal polyps (CRSsNP) and controls. To examine the prevalence of biofilms in different anatomical localizations. STUDY DESIGN: Cross-sectional. METHODS: This study comprised 27 patients with CRSsNP, 34 patients with CRSwNP, and 25 controls. Biopsies from the middle turbinate, the uncinate process, and the ethmoid bulla were harvested pre-operatively, snap frozen in isopentane, cooled, and stored at -80°C. Prepared with Invitrogens' Baclight LiveDead kit and investigated with confocal scanning laser microscopy. RESULTS: Biofilms were studied in 33/34 (97%) CRSwNP, 22/27 (82%) CRSsNP, and 14/25 (56%) controls. The difference in point prevalence between patients with CRSwNP vs CRSsNP (p = 0.042, χ(2) = 4.12), CRSwNP vs Controls (p < 0.001, χ(2) = 15.0), and CRSsNP vs controls (p = 0.047, χ(2) = 3.96) were all significant. Biofilms were found in 43/54 (80%) ethmoid bulla, 39/55 (71%) uncinate process, and 31/50 (62%) middle turbinate. The difference between the ethmoid bulla and the middle turbinate locations (p = 0.047, χ(2) = 3.93) was significant.

Investigation of bacterial repopulation after sinus surgery and perioperative antibiotics.

BACKGROUND: Endoscopic sinus surgery (ESS) enjoys high success rates, but repopulation with pathogenic bacteria is 1 of the hallmarks of poorer outcomes. There are many hypothesized sources of repopulating bacteria; however, this process remains largely unexplored. This study examined changes in the sinus microbiome after ESS and medical therapies to identify potential sources for postsurgical microbial repopulation. METHODS: Samples from the anterior nares, ethmoid sinus, and nasopharynx were taken at the time of surgery from 13 subjects undergoing ESS for chronic rhinosinusitis (CRS). Patients were treated postoperatively with 2 weeks of oral antibiotics and saline rinses. The ethmoid sinus was sampled at 2 and 6 weeks postoperatively; microbiota were characterized using quantitative polymerase chain reaction (qPCR) and 16S ribosomal RNA (rRNA) gene sequencing. The Morisita-Horn beta-diversity index (M-H) was used to compare similarity between samples. RESULTS: The bacterial burden of the ethmoid was higher 2 weeks postoperatively than 6 weeks postoperatively (p = 0.01). The 6-week samples most closely represented the anterior nares and ethmoid at surgery (M-H = 0.58 and 0.59, respectively), and were least similar to the nasopharynx (M-H = 0.28). Principal coordinates analysis (PCoA) plots illustrate that the ethmoid microbiota temporarily shifted after surgery and antibiotics but returned toward baseline in many subjects. CONCLUSION: Bacterial communities colonizing the ethmoid 6 weeks postoperatively were most similar to anterior nasal cavity and pretreatment sinus microbial profiles, indicating a high degree of resilience in the sinonasal microbiome of most subjects. Interestingly, surgery and postoperative antibiotic therapy does not appear to reduce bacterial burden, but rather, shifts the microbial consortia.

Fungal ball within Onodi cell mucocele causing visual loss.

The Onodi cell is a pneumatized posterior ethmoid cell located laterally and superiorly to the sphenoid sinus and closely related to the optic nerve. A mucocele is a benign, expansile, cystlike lesion of the paranasal sinuses that is filled with mucoid secretion. Therefore, optic neuropathy caused by an infected mucocele in an Onodi cell is uncommon. Furthermore, fungal infection superimposed on an Onodi cell mucocele is extremely rare and has not been reported previously. Here, we describe the first case of fungal ball within Onodi cell mucocele causing visual loss, which was completely removed via transnasal endoscopic approach.

Enhanced expressions of lysozyme, SLPI and glycoprotein 340 in biofilm-associated chronic rhinosinusitis.

Lysozyme, secretory leukocyte proteinase inhibitor (SLPI) and glycoprotein 340 (gp340) are important effectors of the innate immune system in sinonasal mucosa. Bacterial biofilms (BBF) are highly organized bacterial communities resistant to host defense systems. The aim of this study was to investigate the expression of lysozyme, SLPI and gp340 in sinus mucosa from chronic rhinosinusitis (CRS) patients with different BBF status. In this prospective cohort study, 63 CRS patients undergoing endoscopic sinus surgery and 20 controls were enrolled and their mucosal samples from ethmoid sinus were obtained. Biofilms were examined by confocal scanning laser microscopy (CSLM), and the expressions of lysozyme, SLPI and gp340 in mRNA and protein levels were detected using reverse transcription polymerase chain reaction (RT-PCR), immunohistochemistry and Western blot assay, respectively. As a result, 35/63 (55.6%) of the patients were BBF positive in the CRS group and none in controls. Both mRNA and protein levels of lysozyme, SLPI and gp340 in patients with CRS were significantly higher than those in controls. When sub-classified according to BBF status, the CRS patients with BBF revealed the significantly enhanced mRNA and protein levels of lysozyme, SLPI and gp340. In conclusion, our study demonstrates that lysozyme, SLPI and gp340 are constitutively expressed in sinus mucosa and their up-regulated expressions on both the mRNA and protein levels are associated with BBF in CRS patients. These findings may offer an insight into the interaction between BBF and the innate immune system.

Rhinoscleroma in an immigrant from Egypt: a case report.

Rhinoscleroma is a chronic indolent granulomatous infection of the nose and the upper respiratory tract caused by Klebsiella rhinoscleromatis; this condition is endemic to many regions of the world including North Africa. We present a case of rhinoscleroma in a 51-year-old Egyptian immigrant with 1-month history of epistaxis. We would postulate that with increased travel from areas where rhinoscleroma is endemic to other non-endemic areas, diagnosis of this condition will become more common.

Relationship between bacterial biofilm and clinical features of patients with chronic rhinosinusitis.

The purpose of this study was to investigate the incidence of bacterial biofilm (BBF) in patients with chronic rhinosinusitis (CRS) using confocal scanning laser microscopy (CSLM), and to assess the relationship between BBF and clinical features of CRS. This was a prospective observational study of the sinus mucosa of 27 CRS patients and 10 controls undergoing endoscopic sinus surgery (ESS). Clinical information was recorded preoperatively and sinus mucosal specimens were collected intraoperatively. We determined the existence of BBF with BacLight/CSLM detection, and proposed a BBF scoring system based on its morphologic features. Clinical parameters, including symptom score, endoscopy score, CT score and symptom duration, were compared between CRS patients with and without BBF, and among CRS patients with different BBF score. BBF was found in 16/27 (59.26%) CRS patients and none in 10 controls. SNOT-20 symptom score and individual symptoms including need to blow nose, cough and postnasal discharge were significantly more severe in CRS patients with BBF than those without. BBF score was better correlated than BBF existence with SNOT-20 score (r = 0.811, P < 0.001 vs. r = 0.604, P = 0.001), and correlated with both endoscopy score (r = 0.490, P = 0.009) and symptom duration (r = 0.487, P = 0.010), neither was correlated with BBF (P = 0.824; P = 0.263). BBF score is likely to guide anti-BBF therapy in CRS patients.

[Bacteriology of ethmoidal sinus in chronic rhinosinusitis with and without nasal polyps].

OBJECTIVE: To compare the bacteriologic features of anterior ethmoidal biopsy specimens between chronic rhinosinusitis without nasal polyps (CRSNP-), chronic rhinosinusitis with nasal polyps(CRSNP+) and control patients. METHOD: The biopsy specimens obtained during the nasal endoscopic surgery were cultured for aerobic and anaerobic bacteria. RESULT: One hundred and nineteen biopsy specimens were processed for homogenization and semiquantitatively bacterial culture of aerobe and anaerobe. Bacterial culture were positive in 104 specimens (total culture-positive rate was 87.4%). The positive rate of aerobe or facultative anaerobe culture were 86.5%, 85.7%, 90.0% in CRSNP- group, CRSNP+ group and control group, respectively. There were no significant differences between 3 groups (P > 0.05). Mixed growth of aerobe and anaerobe bacteria were mainly detected in the biopsy specimens and the positive rate were 78.4%, 81.0% and 85.0% in CRSNP- group, CRSNP+ group and control group. There were no significant differences in 3 groups (P > 0.05). The most common aerobe bacteria found in 3 groups were coagulase-negative staphylococci and corynebacterium species and there were no significant differences between 3 groups (P > 0.05). The positive rate of anaerobic bacteria culture were 78.4%,76.2% and 77.5% in 3 groups. There were no significant differences between the groups (P > 0.05). Propionibacterium and peptostreptococcus species were the most common anaerobes, and there were no significant differences between 3 groups (P > 0.05). CONCLUSION: There are no significant differences in the bacteriologic features of ethmoidal biopsy specimens between CRSNP+, CRSNP- and control patients. Therefore, bacterial infection may not play a key role in the pathogenesis of nasal polyps in CRS patients.

A biofilm exists on healthy mucosa of the paranasal sinuses: a prospectively performed, blinded, scanning electron microscope study.

OBJECTIVES: Based on our hypothesis that biofilm is nothing else but normal, otherwise abundantly colonised mucosal mucous blanket, the aim of this study was to check out whether bacterial biofilm exists exclusively at the diseased mucosal surfaces or at healthy mucosa of paranasal sinuses as well. DESIGN: Prospective and blinded. SETTING: Tertiary academic hospital. PARTICIPANTS: The patients suffering from the diseases not related to the chronic inflammation of the paranasal sinuses. Mucosal tissue samples from healthy sphenoid sinuses were taken from 48 patients who underwent pituitary gland surgery and from ethmoidal sinuses mucosa of the 17 patients who underwent endonasal endoscopic orbital decompression because of Graves' disease. MAIN OUTCOME MEASURES: The samples were submitted blindly along with similar samples from patients with chronic rhinosinusitis to two scanning electron microscope experts. In all samples the looked for the main signs of biofilm presence of: the 'towers', rod-shaped bacteria and water channels. RESULTS: Signs of biofilm presence were found in 45 out of 48 pituitary gland surgery patients (94%) and in all of 17 EEOD patients (100%). CONCLUSIONS: Our study showed the presence of the biofilm at the surface of the healthy mucosa of the paranasal sinuses. This suggests that perhaps so called bacterial biofilm is nothing else but regular respiratory mucosal blanket, a part of the mucociliary system itself, containing a great number of bacteria.

Primary sinonasal tuberculosis in a Nigerian woman presenting with epistaxis and proptosis: a case report.

Tuberculosis is the second leading cause of death worldwide after human immunodeficiency virus/AIDS and is especially prevalent in developing countries. We report a case of primary sinonasal tuberculosis without pulmonary involvement, which is rare, in a 27-year old female Nigerian fish farmer. She had a 3-year history of right-eye proptosis, bilateral nasal masses, and epistaxis. Cranial computed tomography suggested an extensive sinonaso-orbital neoplastic lesion. We performed a right external frontoethmoidectomy. Histologically, the excised nasal polyps revealed tuberculosis. Six months of antituberculosis therapy provided satisfactory improvement. Sinonasal tuberculosis, despite its rarity, should be added to the differential diagnosis of nasal and paranasal sinus disorders, and histologic evaluation remains the hallmark of diagnosis. Therapy with a short-duration, multidrug combination, rather than the longer-duration treatment regimen hitherto used, could be quite valuable, especially in the setting of a developing country with poor patient compliance.

Recurrent unilateral periorbital cellulitis in a pediatric patient--an anatomic abnormality.

A 2-year-old male, otherwise healthy, suffered a total of 7 episodes of recurrent right-sided periorbital celluitis (POC) which began at 11 months of age. Five of the 7 episodes of right eye swelling/erythema required hospital admission for intravenous antibiotics. Imaging studies demonstrated a well-defined dehiscence in the lamina papyracea. Endoscopic sinus surgery was performed and an abnormal uncinate process was visualized, fused to the lateral nasal wall and ethmoid bulla. Post-operatively, the patient had no further infections. Nasal endoscopy and high-resolution imaging in pediatric patients with recurrent POC could identify those who would benefit from early surgical intervention.

Ethmoid sinus mycology of chronic rhinosinusitis.

This goal of this study was to demonstrate whether fungi were present in the ethmoid sinus in patients with chronic rhinosinusitis. Before surgery, swab specimens were collected from the middle meatus for conventional fungal cultures, and lavaged fluid was collected from the nasal cavity for fungal cultures by Ponikau's method. During surgery, tissue specimens were taken from the inferior turbinate and the anterior ethmoid sinus for conventional fungal cultures and detection of fungal DNA by polymerase chain reaction. The ethmoid sinus mucosa with coating mucus was also collected for fungal cultures by Ponikau's method. Among 53 specimens, three middle meatal specimens and 27 lavaged specimens (50.9%) grew fungi. Inferior turbinal mucosa did not grow fungi, but three ethmoid sinus specimens grew fungi by the conventional fungal culture method and by Ponikau's method. Alternaria DNA was detected in 42 inferior turbinal specimens (79.3%) and in 39 ethmoid sinus specimens (73.6%). Our study showed that although fungi were rarely cultured from the ethmoid sinus Alternaria DNA was detected in most of the ethmoid sinus mucosa.

Paranasal sinus fungus ball: diagnosis and management.

Paranasal sinus fungus ball is an extramucosal mycosis, usually occurring in immunocompetent people as a monolateral lesion. To review the literature data and to report the Policlinico S. Matteo, University of Pavia experience, 81 patients presenting paranasal fungus ball have been treated (January 1994 to May 2005). Twenty-seven men and 54 women (19-91 years old; mean 49.4 years) were considered. Seventy-three patients had a single sinus affected, but eight presented multiple localisations. Maxillary was the most involved sinus followed by sphenoidal and ethmoidal. Moulds have been isolated in 28/81 cases. Histology showed fungal colonisation but not invasion in all cases. Tomography showed bone erosion in 33.3% of patients. All have been treated only by functional endoscopic sinus surgery. Seventy-seven of 81 patients have been cured. Four of 81 patients needed another surgical treatment. Follow up was between 6 and 132 months (average: 63 months). Fungus ball is a sinusal pathology caused by mycetes like Aspergillus spp. Histology confirms the fungal aethiology excluding tissue invasion. Mycological culture consented to identify the pathogenic mould in 34.5% of cases. Actually functional endoscopic sinus surgery is the gold standard for treatment of this pathology, and antifungal therapy is unnecessary.

Rhinocerebral mucormycosis with perineural spread.

We describe the histopathologic findings of perineural invasion in orbital mucormycosis in a man with diabetes in ketoacidosis. Linear enhancement on MRI beginning at the orbital apex was correlated with fungal tracking of the trigeminal and lacrimal nerves. Mucormycosis can spread considerable distances from its primary focus of infection along peripheral nerves, a phenomenon that can be identified clinically with contrast-enhanced MRI.

Antibiotic sensitivities of Streptococcus pneumoniae, viridans streptococci, and group A hemolytic streptococci isolated from the maxillary and ethmoid sinuses.

OBJECTIVES: To investigate antibiotic sensitivities of Streptococcus pneumoniae, viridans streptococci, and group A hemolytic streptococci isolated from the culture materials obtained from the sinuses of patients undergoing functional endoscopic sinus surgery due to chronic sinusitis. PATIENTS AND METHODS: We recruited 93 patients (63 males, 30 females; mean age 36+/-17.5; range 19 to 68 years) who underwent functional endoscopic sinus surgery due to chronic sinusitis. Before surgical intervention, in order to eliminate a possible contamination from the skin and neighboring structures, nasal mucosa was cleansed with povidone-iodine solution. Nasal smear samples were obtained from all the patients before and after applying povidone-iodine solution. Streptococcus pneumoniae, viridans streptococci and group A hemolytic streptococci that were isolated from the cultures were tested for antibiotic sensitivity. RESULTS: The number of anaerobic bacteria isolated from 58 patients (62.3%) before applying povidone-iodine was 72, following the application of povidone-iodine a total of 16 microorganisms were identified from 12 patients (12.9%). Microorganisms were isolated from 95.6% (89/93) of the samples obtained from the maxillary sinuses and 91.3% (85/93) of the samples obtained from the ethmoid sinuses. The most commonly identified microorganisms from both sinuses were coagulase negative staphylococcus followed by viridans streptococci, coagulase positive staphylococcus, Streptococcus pneumoniae and group A hemolytic streptococci. For viridans streptococcal strains that were isolated, 33.3% were resistant to tetracycline, 23.8% to chloramphenicol, and 19.04% to penicillin. Hemolytic streptococci strains were sensitive to penicillin, ofloxacin, ceftriaxone, and cefepime in all the groups; however, they had 50% resistance to erythromycin and chloramphenicol and 100% resistance to tetracycline. The resistance pattern of the isolated Streptococcus pneumoniae strains were as follows: 25% to penicillin, 66.6% to trimethoprim/sulfamethoxazole, 41.6% to erythromycin, 58.3% to tetracycline, 33.3% to chloramphenicol and 16.6% to rifampin. All of the isolated strains were sensitive to vancomycin. CONCLUSION: We suggest that identification of strains that are resistant to penicillin and other antibiotics is an important tool for choosing empirical treatment for Streptococcus pneumoniae, viridans streptococci, and group A hemolytic streptococci in clinical practice. Viridans streptococci which are frequently isolated from chronic sinusitis patients should be kept in mind.