Rinosinusitis por pseudallescheria boydii: caso clínico / Rhinosinusitis caused by pseudallescheria boydii: a clinical case

Se presenta un caso clínico de rinosinusitis etmoidomaxilar micótica por Pseudallescheria boydii, con presentación de bola fúngica maxilar en una paciente inmunocompetente de 42 años de edad. El diagnóstico de infección por hongo fue efectuado por histopatología, y la identificación del agente, por estudio microbiológico. Fue tratada quirúrgicamente sin recibir tratamiento antifúngico sistémico. Evolucionó satisfactoriamente y con exámenes endoscópicos que mostraron un seno maxilar libre de enfermedad hasta el último control dos meses después del tratamiento quirúrgico. Se comentan aspectos clínicos, diagnósticos y terapéuticos de la pseudallescheriosis rinosinusal

[Treatment of acute ethmoiditis according to a protocol based on clinical stage]. / Behandeling van acute etmoïditis volgens een protocol gebaseerd op het klinische stadium.

OBJECTIVE: To describe the results of application of a systematic treatment protocol, meant to reduce the risk of serious complications, when treating acute ethmoiditis. DESIGN: Prospective study. SETTING: Academic hospital of the 'Vrije Universiteit (VU)', Amsterdam, The Netherlands. METHOD: From January 1988 to March 1994, 25 children with acute ethmoiditis were admitted to the VU hospital. Eight of them had Chandler stage I, 8 stage II, 3 stage III, 3 stage IV and 3 stage V. The treatment protocol was stepwise, based on the Chandler stages and focused on intensive antibiotic treatment in combination with surgical drainage of the ethmoid complex and (or) the orbit. RESULTS: All children with ethmoiditis stages I-III were cured without rest symptoms. One patient with ethmoiditis stage IV and a pre-existent lymphatic leukaemia died of pulmonary complications of a massive fungal infection, 8 months after treatment. One patient with ethmoiditis stage V finally had permanent psychomotor retardation. CONCLUSION: The used treatment protocol offered the possibility to treat patients with acute ethmoiditis stepwise, depending on stage, with satisfying results. Especially the treatment result in patients with ethmoiditis stage V was good.

Staging of chronic hyperplastic rhinosinusitis: treatment strategies.

In 1990 we reported an initial prospective study of 100 patients using a four-stage system for classification of chronic rhinosinusitis. Between January 1988 and July 1992, we used this system in staging an additional 1814 patients, on whom 2980 intranasal sphenoethmoidectomies were performed. In this staging system a protocol trial of medication was given for 2 weeks, followed by axial and coronal computed tomography. Medication consisted of a second-generation cephalosporin antibiotic, usually cefuroxime; a 4-day burst of intraoral steroids, usually prednisone; and an antihistamine decongestant if not contraindicated. The stages of chronic hyperplastic rhinosinusitis included the stages described in the 1990 report (i.e., stage I, single-focus disease; stage II, discontiguous disease throughout the ethmoid labyrinth; stage III, diffuse disease responsive to medication; and stage IV, diffuse disease unresponsive to or poorly responsive to medication). The results of this study have shown that the computed tomography staging system based on computed tomography extent of disease after medical therapy is a simple, easily remembered, and very effective modality for the classification of chronic sinusitis. This system provides a rationale for discussing and planning surgery with patients and physicians and is a convenient reference for the reporting of end results. More importantly, a linear relationship between disease stage and outcomes is demonstrated. This statistically highly significant feature of the staging system provides a firm basis for the production of outcomes after various treatment strategies, particularly ethmoidectomy and the treatment of sinusitis.

Prognostic factors, outcomes and staging in ethmoid sinus surgery.

Although the literature is replete with papers discussing the results of surgery for chronic inflammatory sinus disease, critical comparison of results is difficult due to limited knowledge of the prognostic factors and the variable criteria reported for success. Detailed prospective and retrospective data collection was therefore undertaken to evaluate the results of surgical intervention in 120 patients who underwent endoscopic sinus surgery. Results were evaluated both by symptom questionnaire and by endoscopic follow-up examination. Over 240 data fields were collected on each patient, including information regarding presenting symptoms, endoscopic and computed tomography (CT) findings and surgical procedures performed. In order to reduce potential bias, the results of the follow-up questionnaires were compared to questionnaires from other patients unable to return for follow-up endoscopy. Mean follow-up time was 18 months. Potential prognostic variables were evaluated statistically. A strong correlation was identified between the extent of disease and the surgical outcome. Other identified potential factors appeared to have little or no significance. Therefore, a staging system for inflammatory sinus disease based on the extent of disease is suggested.