Clinical Approach to Dental Root Canal Filler-Induced Maxillary Sinus Fungal Mass Using Transnasal Endoscopy.

Accidentally extruded root canal filler within the sinuses may induce maxillary sinusitis with fungal mass. The authors describe 2 cases of gutta-percha-induced fungal masses in the left maxillary sinus of 2 women. The lesions were evaluated preoperatively using both computed tomography and magnetic resonance imaging, providing comprehensive insights into the condition. In one patient, the lesion was located such that it could be resected through the middle meatal antrostomy alone. However, the second patient presented with an anteroinferiorly situated lesion that necessitated not only a transnasal approach but also an endoscopic modified medial maxillectomy. Both patients recovered uneventfully after surgery. This case series is the first published report of 2 cases of gutta-percha-induced maxillary sinus fungal masses, with their imaging findings, successfully treated through different routes through transnasal endoscopic surgery. These reports highlight the need for a collaborative approach between dental practitioners and otolaryngologists. In addition to the patient's wishes, surgical interventions must consider the unique characteristics of each case and the potential for collaboration across different medical specialties.

Association between habitual snoring and vigilant attention in elementary school children.

OBJECTIVES: Vigilant attention (VA) is a fundamental neurocognitive function. However, the association between habitual snoring (HS) and VA in community-based children remains unclear. Therefore, this study aimed to elucidate the association. METHODS: The study included 2014 children from grades 1-6 across six elementary schools. Snoring frequency was evaluated using a questionnaire administered to parents. VA was assessed using a brief 3-min psychomotor vigilance test (PVT-B). Generalized linear models and multivariate logistic regression analysis were utilized to examine the association between snoring frequency and PVT-B performance. Impaired PVT-B performance was defined as the worst quartile of PVT-B metrics. RESULTS: The PVT-B performance significantly improved with advancing school grade level (p trend < 0.0001). A significant negative correlation was observed between snoring frequency and PVT-B performance. Particularly, in grade 1, HS was associated with a higher risk of impaired PVT-B performance, including response speed (mean reciprocal reaction time) (adjusted odds ratio [aOR] 2.56, 95% confidence interval [CI]: 1.20-5.50), more slowest 10% RT (aOR 3.28, 95% CI: 1.51-6.88), and more lapse500 (number of lapse of reaction time ≥ 500 ms) (aOR 3.18, 95% CI: 1.45-6.80) compared to children without snoring. CONCLUSIONS: Our findings show that VA rapidly improves throughout elementary school. Additionally, younger children with HS are at risk of VA deficits, emphasizing the importance of early intervention for HS.

Intravascular papillary endothelial hyperplasia of the maxillary sinus extending into the contralateral nasal cavity.

INTRODUCTION: Intravascular papillary endothelial hyperplasia (IPEH) predominantly occurs in the subcutaneous and dermal regions and rarely originates from the sinonasal mucosa. CASE PRESENTATION: We report on the case of a 58-year-old male patient who presented with progressive bilateral nasal obstruction, left-sided epiphora, and intermittent epistaxis. Computed tomography revealed a soft tissue opacity in the left maxillary sinus with intersinusoidal nasal wall demineralization, extending into the surrounding ethmoid cells and the right nasal cavity through a contralateral deviation of the nasal septum. Contrast-enhanced T1-weighted magnetic resonance imaging further confirmed these findings. The IPEH originating from the maxillary sinus extended into the contralateral nasal cavity, and it was successfully removed using an endoscopic endonasal approach, avoiding overly aggressive treatment. CONCLUSION: This case report highlights the diagnostic challenges of IPEH in the sinonasal region and the importance of considering IPEH as a differential diagnosis in patients presenting with nasal obstruction, epiphora, and intermittent epistaxis.

A Patient With Lobular Capillary Hemangioma Originating From the Inferior Turbinate Following Cauterization With Silver Nitrate.

Lobular capillary hemangiomas (LCH), which usually originate in the skin and mucous membranes of the oral cavity, are uncommon from the posterior portion of the inferior turbinate. Although the exact cause of LCH in the nasal cavity has not been elucidated, trauma, caused by factors such as intranasal packing and habitual nose-picking, has been reported as one of the causes. In addition, 2 cases of LCH caused by submucosal resection with powered instrumentation to the inferior turbinate have been reported, suggesting that various types of traumas to the nasal mucosa can cause LCH. The authors report the first case of LCH formation in the posterior portion of the inferior turbinate after cauterization with silver nitrate.

Case report: Saccadic ping-pong gaze in progressive supranuclear palsy with predominant postural instability.

We report a 63-year-old female patient with progressive supranuclear palsy (PSP). She presented predominant postural instability and "saccadic ping-pong gaze" (SPPG). She had unprovoked falls recurrently within a year from the onset of gait disturbance. She tended to fall backward with eye closure but had no freezing of gait on examination. She showed no signs of nuchal dystonia, limb tremor, rigidity, spasticity, or ataxia. The dopaminergic response was negative. On the initial examination, her vertical eye movements were normal, but frequent macro square wave jerks and SPPG were observed. SPPG consisted of short-cycle, horizontal conjugate irregular pendular oscillations of the eye position from the midpoint with superimposed small saccades. SPPG was observed usually in the dark, not in the daylight, and with eye closure by using electrooculogram and infrared charge-coupled device imaging. One and a half years after the first examination, she was diagnosed as probable PSP with vertical supranuclear gaze palsy. SPPG was first described in patients who are unconscious by Johkura in 1998 as a "saccadic" variant of "ping-pong gaze (PPG)." PPG, short-cycle periodic alternating gaze, has been described in comatose patients since 1967. On the other hand, abnormal eye movement, which looks the same as SPPG in coma, has been described in conscious patients with PSP or spinocerebellar degeneration (SCD) in Japanese literature since 1975. However, it has been called "transient alternating saccades (TAS)." Nowadays, we believe it is more appropriate to call this abnormal eye movement "SPPG" instead of TAS. Here, we propose that PSP, a neuro-degenerative disease, should be added as one of the etiologies of SPPG. We discuss the differences between PPG/SPPG in coma and SPPG in PSP and the possible pathophysiological mechanism of SPPG in relation to cerebellar oculomotor dysfunctions.

Impact of antiallergy agents on CPAP therapy and sleep quality with spring pollinosis in Japanese.

PURPOSE: Allergic rhinitis (AR) is associated with obstructive sleep apnea (OSA) and nasal obstruction causes decreased adherence to continuous positive airway pressure (CPAP). The purpose is to evaluate the effects of antiallergic agents on CPAP adherence and sleep quality. METHODS: A longitudinal study was made of patients who use CPAP for OSA and treated with antiallergy agents for spring pollinosis. We compared the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), nasal symptoms scores (NSS), and data from CPAP before and after treatment. Then, we classified the subjects into two groups based on the baseline PSQI score: one group without a decreased sleep quality (PSQI < 6) and the other group with decreased sleep quality (PSQI ≥ 6). RESULTS: Of 28 subjects enrolled, 13 had good sleep quality and 15 had poor sleep quality. PSQI showed significant improvements after medication (p = 0.046). ESS showed no significant differences after AR medication (p = 0.565). Significant improvement was observed after the prescription of antiallergy agents in all items of NSS (sneezing, p < 0.05; rhinorrhea, p < 0.01; nasal obstruction, p < 0.01; QOL, p < 0.01). The percentage of days with CPAP use more than 4 h increased significantly after the administration of rhinitis medication (p = 0.022). In the intragroup comparisons of PSQI ≥ 6 group, PSQI decreased significantly (p < 0.05). For the NSS in intragroup comparisons of PSQI ≥ 6 group, all parameters showed significant improvement (sneezing, p = 0.016; rhinorrhea, p = 0.005; nasal obstruction, p < 0.005; QOL, p < 0.005). CONCLUSION: The use of antiallergy agents can improve CPAP adherence and sleep quality in patients with OSA on CPAP.

Creutzfeldt-Jakob disease with dizziness initially presenting to the otolaryngology department.

Creutzfeldt-Jakob disease is a fatal transmissible prion disease of the central nervous system. Dizziness as an initial manifestation of Creutzfeldt-Jakob disease is rare. However, patients with Creutzfeldt-Jakob disease and dizziness may initially visit the otolaryngology department, but this is uncommon. We report the case of a 56-year-old woman with Creutzfeldt-Jakob disease who initially presented with dizziness as an emergency patient to the otolaryngology department. Primary position upbeat nystagmus was identified using a charge-coupled device camera with infrared illumination. Electronystagmography revealed impaired smooth pursuit and diminished optokinetic nystagmus. Based on these findings, we immediately suspected an intracranial cause of dizziness and reached a presumptive diagnosis of sporadic Creutzfeldt-Jakob disease, thus preventing severe transmission. This case emphasizes that Creutzfeldt-Jakob disease should be included as a differential diagnosis for patients with dizziness and abnormal eye movements, such as primary position upbeat nystagmus, which might be caused by intracranial disease.

Impact of radiotherapy for head and neck cancer on obstructive sleep apnea: a prospective study.

BACKGROUND: In recent years, a relatively high prevalence of obstructive sleep apnea (OSA) in patients following radiotherapy (RT) for head and neck cancer (HNC) has been reported; however, little is known regarding the impact of RT on sleep disorders and the underlying mechanisms. This aim of this study was to elucidate the pathogenesis of OSA by comparing the clinical and sleep test parameters and magnetic resonance imaging (MRI) findings before and after HNC treatment with radiation. METHODS: This prospective study included patients scheduled for RT with or without chemotherapy or bioradiotherapy for HNC. Patients diagnosed with HNC between May 2017 and August 2020 were consecutively recruited. The results of the sleep tests were analyzed both before and after treatment. The clinical characteristics of the patients and cephalometric and MRI parameters were also measured. RESULTS: First, a total of 32 patients (64.8±11.8 years old; BMI, 22.7±3.6 kg/m2) underwent pre-treatment sleep tests. The prevalence of OSA [apnea hypopnea index (AHI) ≥5] in these patients was 81.3% (26 patients) before treatment, and the mean AHI was 20.8±19.0 events/hr. Next, 21 patients performed a sleep test both before and after treatment. Regarding subjective symptoms, there were no significant differences in the Epworth Sleepiness Scale (ESS) (P=0.142) or Pittsburgh Sleep Quality Index (PSQI) (P=0.935) after treatment; however, the BMI and neck circumference significantly decreased after treatment (P<0.0001 and P=0.0001, respectively). The incidence of OSA in these patients was 81.0% (17 patients) before treatment and 85.7% (19 patients) after treatment (P=1.0). Overall, the AHI was not significantly different, changing only from 14.5 to 14.9 after treatment (P=0.147). The MRI parameters showed that the retroglossal pharyngeal area increased significantly after treatment (P=0.007). CONCLUSIONS: This study found that the prevalence of OSA before and after RT for HNC was higher than that in the normal population, despite a significant decrease in BMI and increase in the retroglossal pharyngeal area after treatment. We suggest that physicians who manage patients with HNC should consider the occurrence of OSA before and after treatment.

Severe obstructive sleep apnea after concurrent chemoradiotherapy for laryngeal and hypopharyngeal cancer managed by CPAP.

Concurrent chemoradiotherapy (CCRT) is one of the most promising treatments for advanced head and neck cancer (HNC). On the other hand, CCRT may induce severe edema in laryngo-pharyngeal structures in association with radiation. This is a report of a 66-year-old man with severe obstructive sleep apnea (OSA) associated with edema in laryngo-hypopharynx after CCRT for advanced laryngeal and hypopharyngeal cancer. Tracheostomy was avoided and OSA was controlled by continuous positive airway pressure (CPAP). Subjective symptoms of sleepiness were improved. Though laryngeal edema appeared during the course of CCRT in this case, OSA was not evaluated until snoring had been pointed out and he complained of sleepiness. CCRT for laryngeal and hypopharyngeal cancer have a risk of occurrence of OSA due to irreversible mucous edema in the upper airway. Patients for whom CCRT is planned should be informed about the occurrence of OSA before the treatment because symptoms associated with OSA can negatively impact not only the daytime quality of life but also increase the risk of cardiovascular events. The OSA treatment for post CCRT would be expected to have a positive impact on not only cardiovascular and metabolic systems but also on the cancer treatment survival rate.

Clinical, polysomnographic, and cephalometric features of obstructive sleep apnea with AHI over 100.

PURPOSE: Obstructive sleep apnea (OSA) is induced by a sleep-related collapse of the upper airway in association with multiple factors. The severity of OSA is determined by the apnea-hypopnea index (AHI). Although obesity and sex differences are common factors in OSA, the level of the AHI varies to the same degree according to the age and sex and degree of obesity. However, only a few studies have evaluated AHI over 100/h, those reports did not describe why they set the AHI cutoff at 100/h. The purpose of this study was to elucidate the pathogenesis of "very" severe OSA, defined as having an AHI > 100/h. METHODS: AHI > 100/h was set as very severe OSA (VS-OSA) in this study. As controls, moderate to severe OSA patients, matched with VS-OSA for age, sex, and body mass index (BMI), were enrolled. The findings of polysomnography and cephalography between VS-OSA and controls were compared. RESULTS: Eleven patients in the VS-OSA group (mean AHI 110.2/h) and 22 patients in the control group (mean AHI 41.6/h) were compared (mean age 50.2 vs 50.6, male:female 5:6 vs 10:12, mean BMI 35.4 kg/m2 vs 34.5 kg/m2). There were no significant differences in the clinical characteristics. In the polysomnographic parameters, the VS-OSA group showed apnea predominance, the mean percutaneous oxygen saturation (SO2) was significantly lower in all sleep stages, and the minimum SO2 was significantly lower (49.0% vs 77.5%, p = 0.002). A similar apnea duration and rather shorter hypopnea duration were shown. The time of apnea-to-arousal was significantly earlier (- 0.1 s vs 0.9 s, p = 0.003). Lung-to-finger circulation time showed no differences. The cephalometric findings showed no significant differences. CONCLUSIONS: VS-OSA patients were more likely to have apnea predominance, desaturation when sleeping despite a similar apnea duration, and rather shorter hypopnea duration, and arousals were evoked significantly earlier.

Age-stratified sex differences in polysomnographic findings and pharyngeal morphology among children with obstructive sleep apnea.

BACKGROUND: Childhood obstructive sleep apnea (OSA) has important implications for growth, learning, behavior, cognition and cardiovascular health as well as snoring and OSA in adulthood. In this study, we elucidated the sex differences in polysomnographic (PSG) findings and pharyngeal radiographic data in pediatric OSA patients. METHODS: Sixty three children (age between 3 and 15 years old) with OSA [defined as apnea-hypopnea index (AHI) ≥1/h by polysomnography] were enrolled. Lateral neck radiographs were obtained from the patients. All subjects were separated by age: pre-adolescent group (3-8 years old) and adolescent group (9-15 years old). RESULTS: Overall, 45 patients in the pre-adolescent group (33 boys and 12 girls) and 18 patients in the adolescent group (10 boys and 8 girls) were enrolled, and sex differences were compared in each group. We found sex differences in craniofacial features and severity of OSA in the adolescent group, in which girls with OSA had more upper airway space, in addition to lower AHI, lower 3% oxygen desaturation index (ODI), higher minimum SO2 and better sleep efficiency than the boys. CONCLUSIONS: The present study found revealed sex differences in pediatric OSA patients in the adolescent group. Girls in the adolescent group had more upper airway space in addition to lower AHI, lower 3% ODI, higher minimum SO2 and better sleep efficiency than boys.

Dominant negative connexin26 mutation R75W causing severe hearing loss influences normal programmed cell death in postnatal organ of Corti.

BACKGROUND: The greater epithelial ridge (GER) is a developmental structure in the maturation of the organ of Corti. Situated near the inner hair cells of neonatal mice, the GER undergoes a wave of apoptosis after postnatal day 8 (P8). We evaluated the GER from P8 to P12 in transgenic mice that carry the R75W + mutation, a dominant-negative mutation of human gap junction protein, beta 2, 26 kDa (GJB2) (also known as connexin 26 or CX26). Cx26 facilitate intercellular communication within the mammalian auditory organ. RESULTS: In both non-transgenic (non-Tg) and R75W + mice, some GER cells exhibited apoptotic characteristics at P8. In the GER of non-Tg mice, both the total number of cells and the number of apoptotic cells decreased from P8 to P12. In contrast, apoptotic cells were still clearly evident in the GER of R75W + mice at P12. In R75W + mice, therefore, apoptosis in the GER persisted until a later stage of cochlear development. In addition, the GER of R75W + mice exhibited morphological signs of retention, which may have resulted from diminished levels of apoptosis and/or promotion of cell proliferation during embryogenesis and early postnatal stages of development. CONCLUSIONS: Here we demonstrate that Cx26 dysfunction is associated with delayed apoptosis of GER cells and GER retention. This is the first demonstration that Cx26 may regulate cell proliferation and apoptosis during development of the cochlea.

Craniofacial anatomical risk factors in men with obstructive sleep apnea and heart failure: a pilot study.

PURPOSE: Obstructive sleep apnea (OSA) is complicated with heart failure (HF); however, the reason for this is not well understood. Craniofacial anatomic risk factors may contribute to OSA pathogenesis in HF patients. However, there are no data about cephalometric findings among OSA patients with HF. METHODS: Consecutive patients with HF and OSA (defined as total apnea-hypopnea index (AHI) ≥15/h) were enrolled. As controls, OSA patients without HF but matching the test group in age, BMI, and obstructive AHI were also enrolled. RESULTS: Overall, 17 OSA patients with HF and 34 OSA patients without HF were compared. There are no significant differences in the characteristics or polysomnographic parameters between 2 groups. In the cephalometric findings, compared with patients without HF, patients with HF showed a significantly greater angle between the line SN to point "A" (SNA) and a longer inferior airway space and greater airway area. However, the tongue area of patients with HF was more than those without HF. CONCLUSIONS: The craniofacial structures of OSA patients with HF were different from those without HF. OSA patients with HF had an upper airway anatomy that is more likely to collapse when sleeping while recumbent, despite having a larger airway space.

A common copy-number breakpoint of ERBB2 amplification in breast cancer colocalizes with a complex block of segmental duplications.

INTRODUCTION: Segmental duplications (low-copy repeats) are the recently duplicated genomic segments in the human genome that display nearly identical (> 90%) sequences and account for about 5% of euchromatic regions. In germline, duplicated segments mediate nonallelic homologous recombination and thus cause both non-disease-causing copy-number variants and genomic disorders. To what extent duplicated segments play a role in somatic DNA rearrangements in cancer remains elusive. Duplicated segments often cluster and form genomic blocks enriched with both direct and inverted repeats (complex genomic regions). Such complex regions could be fragile and play a mechanistic role in the amplification of the ERBB2 gene in breast tumors, because repeated sequences are known to initiate gene amplification in model systems. METHODS: We conducted polymerase chain reaction (PCR)-based assays for primary breast tumors and analyzed publically available array-comparative genomic hybridization data to map a common copy-number breakpoint in ERBB2-amplified primary breast tumors. We further used molecular, bioinformatics, and population-genetics approaches to define duplication contents, structural variants, and haplotypes within the common breakpoint. RESULTS: We found a large (> 300-kb) block of duplicated segments that was colocalized with a common-copy number breakpoint for ERBB2 amplification. The breakpoint that potentially initiated ERBB2 amplification localized in a region 1.5 megabases (Mb) on the telomeric side of ERBB2. The region is very complex, with extensive duplications of KRTAP genes, structural variants, and, as a result, a paucity of single-nucleotide polymorphism (SNP) markers. Duplicated segments are varied in size and degree of sequence homology, indicating that duplications have occurred recurrently during genome evolution. CONCLUSIONS: Amplification of the ERBB2 gene in breast tumors is potentially initiated by a complex region that has unusual genomic features and thus requires rigorous, labor-intensive investigation. The haplotypes we provide could be useful to identify the potential association between the complex region and ERBB2 amplification.

Gene transfer targeting mouse vestibule using adenovirus and adeno-associated virus vectors.

HYPOTHESIS: The present study assessed how to inject a gene into the mouse vestibule and which is the optimum gene to the mouse vestibule adenovirus (AdV) vector or adeno-associated virus (AAV) vector. BACKGROUND: Loss of vestibular hair cell is seen in various balance disorder diseases. There have been some reports concerning gene delivery to the mouse vestibule in recent years. To effectively induce transgene expression at the vestibule, we assessed the efficiency of inoculating the mouse inner ear using various methods. METHODS: We employed an AdV- and AAV-carrying green fluorescent protein using a semicircular canal approach (via a canalostomy) and round window approach. RESULTS: AAV injection via canalostomy induced gene expression at the hair cells, supporting cells, and fibrocytes at the vestibular organs without auditory or balance dysfunction, suggesting it was the most suitable transfection method. This method is thus considered to be a promising strategy to prevent balance dysfunction. CONCLUSION: AAV injection via canalostomy to the vestibule is the noninvasive and highly efficient transfection method, and this study may have the potential to repair balance disorders in human in the future.

Novel use of a Weerda laryngoscope for transoral excision of a cervical ganglioneuroma: a case report.

INTRODUCTION: A ganglioneuroma is a benign neoplasm arising from neural crest cells of the sympathetic nerve fibers and is most commonly seen in the posterior mediastinum or retroperitoneum. Although very uncommon, ganglioneuromas must be included in the differential diagnosis of neck masses. In young adult women, neck incisions made for excision of these benign tumors should be avoided whenever possible. CASE PRESENTATION: We herein describe the case of a 19-year-old Japanese woman with a ganglioneuroma. The tumor was found in the parapharyngeal space, an unusual location. A fine-needle aspiration biopsy was performed but was considered inadequate to make a definitive diagnosis, so the asymptomatic lesion was surgically excised using a Weerda laryngoscope. The lesion measured 4 × 3 cm in size and was encapsulated. A pathological analysis showed the presence of two distinct cell types, ganglion cells and Schwann cells, embedded in a loose myxoid stroma. The final diagnosis was a ganglioneuroma. CONCLUSION: A complete excision was made possible by using a transoral approach with a novel use of the Weerda laryngoscope. Although its applicability to specific cases depends on the location, size and nature of the tumor, we believe that the Weerda laryngoscope will continue to be useful for performing transoral surgery for cervical tumors.

Bacteriologic evaluation of sinus aspirates taken by balloon catheter devices in chronic rhinosinusitis: preliminary study.

PURPOSE: Chronic rhinosinusitis (CRS) is known to be a polymicrobial infection involving both aerobes and Gram-positive and Gram-negative anaerobes. Accurate bacterial evaluation by adequate culture methods can justify subsequent antimicrobial strategies. METHODS: Two specimens were obtained from each of 10 patients undergoing catheter-based Balloon Sinuplasty™, one from the middle meatus (endoscopic approach) and the other from the sinus (catheter-based approach). RESULTS: The bacterial culture from the middle meatus was positive in 9 of 10 patients, including 6 different aerobes without anaerobes. The bacterial culture of aspirates from the sinuses were positive in 8 out of 10 patients, with 4 different aerobic bacteria and 4 different anaerobic bacteria. Anaerobes were isolated in 0% of middle meatus samples, which was significantly lower than the 62.5% (5/8) detected in the sinus samples. CONCLUSIONS: Bacterial culture of sinus aspirates using a catheter-based technique improves the recovery of bacterial pathogens from CRS patients.

An immunohistochemical study of sinonasal hemangiopericytoma.

We present herein the imaging and pathological features of a 28-year-old male with a sinonasal hemangiopericytoma-like tumor occupying the left nasal meatus. At the initial visit, a nasal polyp was suspected, but, as the patient was bleeding readily, an angiomatoid lesion was also regarded as a possible diagnosis. Based on a thorough histopathological analysis, a sinonasal hemangiopericytoma-like tumor was diagnosed. Hematoxylin and eosin staining also showed a mild degree of nuclear pleomorphism and a slight increase in mitotic activity, and immunohistochemical studies using anti-CD34, MIB-1, and Vimentin antibodies were useful for distinguishing the hemangiopericytoma-like tumor from true hemangiopericytoma and a solitary fibrous tumor.

Bacteriology of recurrent exacerbation of postoperative course in chronic rhinosinusitis in relation to asthma.

OBJECTIVES: Co-mobidity of asthma is known to result in a poor prognosis of post-endoscopic sinus surgery (post-ESS). Bacterial infection may play a key role in recurrent pathophysiology of sinusitis in post-ESS. METHODS: Forty-two patients with CRS associated with asthma undergoing ESS were enrolled. Bacterial culture was performed from the sinus cavity at the time of acute infectious episodes. Recurrence of sinonasal disease was analyzed in terms of steroid responsiveness and peak expiratory flow (PEF). RESULTS: Totally 75 aspirates were obtained during post-ESS; 2 repeat aspirates from 10 patients, 3 from 5 patients, and 4 from 2 patients. Only 6 specimens (8.0%) obtained from 5 patients (11.9%) showed no growth whereas 83 isolates were recovered from 69 specimens. Sixteen patients had at least one episode of a significant decline of PEF. All except one patient complained of symptoms and signs of upper respiratory infections prior to a depression of PEF. Positive culture was obtained in 10 out of 11 patients examined at the time of acute exacerbation of CRS. CONCLUSION: Bacterial infection may play a critical role of recurrent polyps and refractory symptoms during post-ESS follow-up. Moreover, worsening of sinusitis accompanies asthma exacerbation.