Tonsils are major sites of persistence of SARS-CoV-2 in children.

In the present study, we show that SARS-CoV-2 can infect palatine tonsils, adenoids, and secretions in children without symptoms of COVID-19, with no history of recent upper airway infection. We studied 48 children undergoing tonsillectomy due to snoring/OSA or recurrent tonsillitis between October 2020 and September 2021. Nasal cytobrushes, nasal washes, and tonsillar tissue fragments obtained at surgery were tested by RT-qPCR, immunohistochemistry (IHC), flow cytometry, and neutralization assay. We detected the presence of SARS-CoV-2 in at least one specimen tested in 27% of patients. IHC revealed the presence of the viral nucleoprotein in epithelial surface and in lymphoid cells in both extrafollicular and follicular regions, in adenoids and palatine tonsils. Also, IHC for the SARS-CoV-2 non-structural protein NSP-16 indicated the presence of viral replication in 53.8% of the SARS-CoV-2-infected tissues. Flow cytometry showed that CD20+ B lymphocytes were the most infected phenotypes, followed by CD4+ lymphocytes and CD123 dendritic cells, CD8+ T lymphocytes, and CD14+ macrophages. Additionally, IF indicated that infected tonsillar tissues had increased expression of ACE2 and TMPRSS2. NGS sequencing demonstrated the presence of different SARS-CoV-2 variants in tonsils from different tissues. SARS-CoV-2 antigen detection was not restricted to tonsils but was also detected in nasal cells from the olfactory region. Palatine tonsils and adenoids are sites of prolonged RNA presence by SARS-CoV-2 in children, even without COVID-19 symptoms. IMPORTANCE This study shows that SRS-CoV-2 of different lineages can infect tonsils and adenoids in one quarter of children undergoing tonsillectomy. These findings bring advancement to the area of SARS-CoV-2 pathogenesis, by showing that tonsils may be sites of prolonged infection, even without evidence of recent COVID-19 symptoms. SARS-CoV-2 infection of B and T lymphocytes, macrophages, and dendritic cells may interfere with the mounting of immune responses in these secondary lymphoid organs. Moreover, the shedding of SARS-CoV-2 RNA in respiratory secretions from silently infected children raises concern about possible diagnostic confusion in the presence of symptoms of acute respiratory infections caused by other etiologies.

Chronic rhinosinusitis with nasal polyps does not harbor KRAS, BRAF, and EGFR mutations.

BACKGROUND: Chronic rhinosinusitis is a chronic inflammation of the nasal mucosa and nasal polyps are present in ~25%-30% of cases (chronic rhinosinusitis with nasal polyps [CRSwNP]). CRSwNP is associated with significant morbidity and decreased quality of life, making it clinically important. Inflammation leads to DNA damage and DNA mutations occur in some inflammatory diseases. Notably, mutations in KRAS, BRAF, and EGFR have been reported in different human benign and malignant neoplastic lesions. In addition, KRAS mutations have also been reported in non-neoplastic tissues under chronic inflammatory conditions. Importantly, KRAS mutations have been reported in oncocytic sinonasal papillomas and sinonasal squamous cell carcinoma associated with oncocytic sinonasal papilloma and EGFR mutations have been reported in sinonasal adenocarcinoma, inverted sinonasal papilloma, and sinonasal squamous cell carcinoma associated with inverted sinonasal papilloma. The molecular pathogenesis of nasal polyps remains unclear. Therefore, the present study aimed to investigate the presence of KRAS, BRAF, and EGFR pathogenic mutations in CRSwNP. METHODS: Fourteen chronic rhinosinusitis-associated nasal polyp samples were direct sequenced, targeting KRAS exons 2, 3, and 4 (encompassing important hotspot mutations, including codons 12, 13, 61 and 146), BRAF exons 11 and 15, and EGFR exons 19 and 20. RESULTS: No pathogenic mutations were detected in the sequenced regions of KRAS, BRAF, and EGFR genes. CONCLUSION: This finding suggests that mutations in these genes are not a frequent event in CRSwNP, and, if they occur, they might represent marginal events at best.

Progressive chronic calvarial osteomyelitis in rhino-orbital mucormycosis associated with COVID-19.

We describe two cases of extensive indolent calvarial osteomyelitis after rhino-orbital-mucormycosis in diabetic patients previously diagnosed with COVID-19. Both patients presented with acute rhino-orbital symptoms about one month after being diagnosed with COVID-19. Treatment with intravenous liposomal Amphotericin B and prompt radical surgical debridement was instituted, but calvarial osteomyelitis ensued and persisted chronically despite maintenance of antifungal therapy and partial debridement of necrotic calvarial bone. The patients were discharged to continue antifungal therapy on a day-hospital regime. After more than 8 months of treatment, they remain with radiological signs of osteomyelitis but with no symptoms or intracranial extension of the infection. Calvarial indolent osteomyelitis secondary to mucormycosis is extremely rare, and little is known regarding its treatment. We believe it can be controlled with medical treatment and partial bony debridement although more studies are necessary to better define therapy.

Efficacy of House Dust Mite Sublingual Immunotherapy in Patients with Atopic Dermatitis: A Randomized, Double-Blind, Placebo-Controlled Trial.

BACKGROUND: Sensitization to house dust mites (HDMs) is frequent in patients with atopic dermatitis. OBJECTIVE: To investigate the efficacy of sublingual immunotherapy (SLIT) with Dermatophagoides pteronyssinus extract in patients with atopic dermatitis sensitized to HDM. METHODS: In this randomized, double-blind, placebo-controlled trial, we enrolled 91 patients 3 years or older, with SCORing Atopic Dermatitis (SCORAD) score greater than or equal to 15 and positive skin test result and/or IgE to D pteronyssinus. Patients were stratified according to age (<12 and ≥12 years) to receive HDM SLIT or placebo for 18 months. Primary outcome was a greater than or equal to 15-point decrease in SCORAD score. Secondary outcomes were decreases in SCORAD and objective SCORAD, Eczema Area and Severity Index, visual analog scale for symptoms, and pruritus scale scores; Investigator's Global Assessment 0/1; and decrease greater than or equal to 4 points in Dermatology Life Quality Index. Background therapy was maintained. RESULTS: A total of 66 patients completed the study (35 HDM SLIT, 31 placebo). After 18 months, 74.2% and 58% of patients in the HDM SLIT group and the placebo group, respectively, showed greater than or equal to 15-point decrease in SCORAD score (relative risk, 1.28; 95% CI, 0.89-1.83). Significant SCORAD score decreases from baseline of 55.6% and 34.5% in HDM SLIT and placebo groups (mean difference, 20.4; 95% CI, 3.89-37.3), significant objective SCORAD score decreases of 56.8% and 34.9% in HDM SLIT and placebo groups (mean difference, 21.3; 95% CI, 0.66-41.81), and more patients with Investigator's Global Assessment 0/1 in the HDM SLIT group as compared with the placebo group (14 of 35 vs 5 of 31; relative risk, 2.63; 95% CI, 1.09-6.39) were observed at 18 months. CONCLUSIONS: Our results suggest that HDM SLIT may be effective in HDM-sensitized patients as an add-on treatment for atopic dermatitis.

Translation and cross-cultural adaptation of the pediatric sleep questionnaire (PSQ*) into Brazilian Portuguese.

INTRODUCTION: Obstructive sleep apnea is a frequent entity in childhood that can lead to important consequences for the health and children's quality of live. Polysomnography is the gold-standard exam to diagnose obstructive sleep apnea, but it is expensive, complex, and poorly affordable in Brazil. The pediatric sleep questionnaire has shown to be a valuable screening test for obstructive sleep apnea. It is a simple questionnaire with good sensitivity and specificity compared to polysomnography in the countries where it has been validated. OBJECTIVE: Translation and cross-cultural adaptation of the pediatric sleep questionnaire (PSQ), into Brazilian Portuguese. METHODS: The translation of the PSQ into Brazilian Portuguese was carried out in accordance with good practices. The validated and adapted questionnaire was applied to parents/caregivers of 60 children (40 of them with obstructive sleep apnea and 20 controls) aged 2-18 years. Retest was applied to 30 children with obstructive sleep apnea. The following tests were performed: internal consistency, test-retest, validation of questionnaire (the latter by ROC curve). RESULTS: Brazilian PSQ has shown high internal consistency by Cronbach's alpha (0.86 for the total test, 0.83 for subscale "snoring", 0.64 for "sleepiness" and 0.65 for "behavior"). Test-retest presented a correlation of 0.89 for subscale "snoring", 0.93 for "sleepiness" and 0.86 for "behavior". Accuracy by ROC curve was 0.99. Nine was considered the optimal value to discriminate patients with obstructive sleep apnea from controls, with a sensitivity of 0.92 and specificity of 1.0. CONCLUSION: The translation and cross-cultural adaptation of the PSQ into Brazilian Portuguese proved to be successful. In places with difficult access to polysomnography, PSQ can be a useful tool in screening and follow-up of children with obstructive sleep apnea.

Translation and cross-cultural adaptation of the pediatric sleep questionnaire (PSQ*) into Brazilian Portuguese / Tradução e adaptação transcultural do pediatric sleep questionnaire (PSQ*) para o português do Brasil

Abstract Introduction Obstructive sleep apnea is a frequent entity in childhood that can lead to important consequences for the health and children's quality of live. Polysomnography is the gold-standard exam to diagnose obstructive sleep apnea, but it is expensive, complex, and poorly affordable in Brazil. The pediatric sleep questionnaire has shown to be a valuable screening test for obstructive sleep apnea. It is a simple questionnaire with good sensitivity and specificity compared to polysomnography in the countries where it has been validated. Objective Translation and cross-cultural adaptation of the pediatric sleep questionnaire (PSQ), into Brazilian Portuguese. Methods The translation of the PSQ into Brazilian Portuguese was carried out in accordance with good practices. The validated and adapted questionnaire was applied to parents/caregivers of 60 children (40 of them with obstructive sleep apnea and 20 controls) aged 2-18 years. Retest was applied to 30 children with obstructive sleep apnea. The following tests were performed: internal consistency, test-retest, validation of questionnaire (the latter by ROC curve). Results Brazilian PSQ has shown high internal consistency by Cronbach's alpha (0.86 for the total test, 0.83 for subscale "snoring", 0.64 for "sleepiness" and 0.65 for "behavior"). Test-retest presented a correlation of 0.89 for subscale "snoring", 0.93 for "sleepiness" and 0.86 for "behavior". Accuracy by ROC curve was 0.99. Nine was considered the optimal value to discriminate patients with obstructive sleep apnea from controls, with a sensitivity of 0.92 and specificity of 1.0. Conclusion The translation and cross-cultural adaptation of the PSQ into Brazilian Portuguese proved to be successful. In places with difficult access to polysomnography, PSQ can be a useful tool in screening and follow-up of children with obstructive sleep apnea.

Resumo Introdução A apneia obstrutiva do sono é uma doença comum na infância que pode trazer consequências importantes para a saúde e qualidade de vida das crianças. O exame padrão‐ouro para o diagnóstico (polissonografia) é um exame caro, complexo e disponível em poucos centros. O pediatric sleep questionnaire, PSQ, tem demonstrado ser um bom teste de triagem para apneia obstrutiva do sono, por ser um questionário simples e com boa sensibilidade e especificidade quando comparado à polissonografia nos países em que foi validado. Objetivo Tradução e adaptação transcultural do PSQ para o português do Brasil. Método Foi feita a tradução do PSQ para o português do Brasil, de acordo com as boas práticas. O questionário validado e adaptado foi aplicado aos pais/responsáveis de 60 crianças com 2-18 anos, 40 com apneia obstrutiva do sono e 20 controles. O reteste foi feito em 30 crianças com apneia obstrutiva do sono. Foram avaliados: consistência interna, teste‐reteste, validação do conteúdo e acurácia do questionário, pela curva ROC (do inglês receiver operating characteristic curve). Resultados O PSQ‐Brasil apresentou alta consistência interna, pelo coeficiente Alfa de Cronbach (0,86 para o teste total; 0,83 para o subdomínio "ronco"; 0,64 para "sonolência" e 0,65 para "comportamento". O teste‐reteste teve concordância de 0,89 para o subdomínio "ronco"; 0,93 para sonolência" e 0,86 para "comportamento". A acurácia medida pela curva ROC foi de 0,99. O valor de 9,0 foi considerado ideal para diferenciar os pacientes com apneia obstrutiva do sono e controles, com sensibilidade de 0,92 e especificidade de 1,0. Conclusão A tradução e adaptação transcultural do PSQ para o português do Brasil mostrou‐se bem‐sucedida. Em locais com dificuldade de acesso à polissonografia, o PSQ pode ser uma ferramenta útil na suspeição diagnóstica e seguimento das crianças com apneia obstrutiva do sono.

Biodegradable Electrospun Nanofibers: A New Approach For Rhinosinusitis Treatment.

Biodegradable polymeric nanofibers containing mometasone furoate can be a new approach to drug delivery to treat chronic rhinosinusitis, providing controlled steroid delivery to the sinonasal mucosa. This study aimed to develop biodegradable polymeric nanofibers and explore the safety of these fibers in an in vivo rabbit model. The nanofibers' development has been optimized using the Response Surface Methodology (RSM) obtained with Design of Experiments (DoE) with the best conditions related to the polymer concentration and proportion of solvents used in the electrospinning process. The nanofibers were prepared, operating as a determinant factor, the nanofiber formation and its diameter evaluated by Scanning Electron Microscopy (SEM). The ideal system obtained was assessed by SEM, thermogravimetric analysis (TGA), X-ray diffraction (XRD), differential scanning calorimetry (DSC), assay, and drug delivery by UHLPC validated method. The results showed that the drug is dispersed in the polymeric matrix, is stable, and showed sustained release kinetics in a bio-relevant nasal environment (Higuchi model kinetics). In vivo tests, the level of inflammation at the animals' mucosa which received the nanofiber with the mometasone furoate was lower than those that received the nanofibers without the drug (α = 0.05). Histopathology analysis showed that the polymeric nanofibers containing mometasone are safe when topically applied on the sinonasal mucosa, opening a new horizon in chronic rhinosinusitis treatment.

Biofilm and Planktonic Antibiotic Resistance in Patients With Acute Exacerbation of Chronic Rhinosinusitis.

INTRODUCTION: The recalcitrant nature of patients with acute exacerbation of chronic rhinosinusitis (AECRS) potentially involves persisting colonization of the sinonasal mucosa by bacterial biofilms. Biofilms are known to be highly resistant to antibiotics, which may trigger or maintain chronic inflammation in the sinonasal mucosa. However, little is known about the relationship between the minimum inhibitory concentration (MIC) and antibiofilm concentrations of bacteria obtained from AECRS patients. MATERIAL AND METHODS: Thirty bacterial strains from 25 patients with AECRS were identified and underwent MIC determination (VITEK® 2). The planktonic isolates were submitted to an in vitro formation of biofilms (Modified Calgary Biofilm Device) and determination of minimum biofilm inhibitory concentration (MBIC) and minimum biofilm eradication concentration (MBEC) for amoxicillin, amoxicillin/clavulanic acid, clarithromycin, and levofloxacin. MIC of the planktonic forms was compared with MBIC and MBEC levels, according to the breakpoints established by the Clinical Laboratory Standards Institute guidelines. RESULTS: The main bacteria retrieved was S. aureus (60%), followed by other Gram-positive and Gram-negative bacteria in lower frequencies. 76.7% of strains formed biofilm in vitro (n=23/30). The planktonic isolates presented high rates of resistance for amoxicillin (82.6%) and clarithromycin (39.1%), and lower rates for amoxicillin/clavulanic acid (17.4%). The biofilm-forming bacteria counterparts presented higher levels of MBIC and MBEC compared to the MIC levels for amoxicillin, amoxicillin/clavulanic acid, and clarithromycin. Levofloxacin was highly effective against both planktonic and biofilm forms. Planktonic resistant forms were associated with levels of antibiofilm concentrations (MBIC and MBEC). CONCLUSIONS: Biofilm-forming bacteria from AECRS patients are prevalent, and biofilm forms are highly resistant to antibiotics compared to their planktonic counterparts. Antibiotic resistance observed in planktonic forms is a good indicator of biofilm resistance, although near 20% of susceptible planktonic bacteria can produce antibiotic tolerant biofilms.

Asthma Is the Dominant Factor for Recurrence in Chronic Rhinosinusitis.

BACKGROUND: Factors associated with recurrence of chronic rhinosinusitis (CRS) are still poorly recognized. OBJECTIVE: To evaluate which risk factors could influence the risk of recurrence among patients undergoing endoscopic sinus surgery in long-term follow-up. METHODS: Patients with CRS who underwent endoscopic sinus surgery were followed for an average period of 12 years in a nonconcurrent cohort. After surgery, patients were considered to an additional endoscopic sinus surgery if appropriate medical therapy failed during this period. The presence of nasal polyps, asthma, nonsteroidal anti-inflammatory drug-exacerbated respiratory disease, smoking habits, peripheral blood eosinophilia, and atopy were assessed. The recurrence-free interval between groups (with or without these risk factors) was analyzed by Kaplan-Meyer curves, and the indication for a revisional surgery was considered to be the unfavorable event. RESULTS: A total of 201 patients were enrolled in this study. Patients with chronic rhinosinusitis with nasal polyps (CRSwNP) were more likely than patients with chronic rhinosinusitis without nasal polyps (CRSsNP) to need revisional surgery (adjusted hazard ratio, 2.02). Asthma was the only factor that was significantly related to recurrence both in patients with CRSsNP (hazard ratio, 5.54) and in patients with CRSwNP (hazard ratio, 3.27). Although eosinophilia itself was not related to a higher chance of recurrence, its presence influenced the outcome of CRSwNP compared with CRSsNP and the impact of asthma among patients with CRSwNP. CONCLUSIONS: Prognosis in patients with CRSwNP was inferior to that in patients with CRSsNP. Asthma was the only factor that increased the chance of recurrence in patients with either CRSsNP or CRSwNP.

Human adenovirus replication and persistence in hypertrophic adenoids and palatine tonsils in children.

The role of human adenovirus (HAdV) infection in different acute diseases, such as febrile exudative tonsillitis, conjunctivitis, and pharyngoconjunctival fever is well established. However, the relationships, if any, of HAdV persistence and reactivation in the development of the chronic adenotonsillar disease is not fully understood. The present paper reports a 3-year cross-sectional hospital-based study aimed at detecting and quantifying HAdV DNA and mRNA of the HAdV hexon gene in adenoid and palatine tonsil tissues and nasopharyngeal secretions (NPS) from patients with adenotonsillar hypertrophy or recurrent adenotonsillitis. HAdV C, B, and E were detectable in nearly 50% of the patients, with no association with the severity of airway obstruction, nor with the presence of recurrent tonsillitis, sleep apnea or otitis media with effusion (OME). Despite the higher rates of respiratory viral coinfections in patients with HAdV, the presence of other viruses, including DNA and RNA viruses, had no association with HAdV replication or shedding in secretions. Higher HAdV loads in adenoids showed a significant positive correlation with the presence of sleep apnea and the absence of OME. Although this study indicates that a significant proportion (~85%) of individuals with chronic adenotonsillar diseases have persistent nonproductive HAdV infection, including those by HAdV C, B, and E, epithelial and subepithelial cells in tonsils seem to be critical for HAdV C production and shedding in NPS in some patients, since viral antigen was detected in these regions by immunohistochemistry in four patients, all of which were also positive for HAdV mRNA detection.

Anatomical terminology of the internal nose and paranasal sinuses: cross-cultural adaptation to Portuguese / Anatomical terminology of the internal nose and paranasal sinuses: cross-cultural adaptation to Portuguese

Abstract Introduction: Functional endonasal endoscopic surgery is a frequent surgical procedure among otorhinolaryngologists. In 2014, the European Society of Rhinology published the "European Position Paper on the Anatomical Terminology of the Internal Nose and Paranasal Sinuses", aiming to unify the terms in the English language. We do not yet have a unified terminology in the Portuguese language. Objective: Transcultural adaptation of the anatomical terms of the nose and paranasal cavities of the "European Anatomical Terminology of the Internal Nose and Paranasal Sinuses" to Portuguese. Methods: A group of rhinologists from diverse parts of Brazil, all experienced in endoscopic endonasal surgery, was invited to participate in the creation of this position paper on the anatomical terms of the nose and paranasal sinuses in the Portuguese language according to the methodology adapted from that previously described by Rudmik and Smith. Results: The results of this document were generated based on the agreement of the majority of the participants according to the most popular suggestions among the rhinologists. A cross-cultural adaptation of the sinonasal anatomical terminology was consolidated. We suggest the terms "inferior turbinate", "nasal septum", "(bone/cartilaginous) part of the nasal septum", "(middle/inferior) nasal meatus", "frontal sinus drainage pathway", "frontal recess" and "uncinate process" be standardized. Conclusion: We have consolidated a Portuguese version of the European Anatomical Terminology of the Internal Nose and Paranasal Sinuses, which will help in the publication of technical announcements, scientific publications and the teaching of the internal anatomical terms of the nose and paranasal sinuses in Brazil.

Resumo: Introdução: A cirurgia endoscópica funcional endonasal é um procedimento cirúrgico frequente entre os otorrinolaringologistas. Em 2014, a Sociedade Europeia de Rinologia publicou o "Documento Europeu para Posicionamento sobre a Terminologia Anatômica Interna do Nariz e das Cavidades Paranasais" com o objetivo de unificar os termos na língua inglesa. Ainda não dispomos de uma terminologia unificada na língua portuguesa. Objetivo: Adaptação transcultural dos termos anatômicos do nariz e das cavidades paranasais para o português da "European Anatomical Terminology of the Internal Nose and Paranasal Sinuses". Método: Um grupo de rinologistas de todo o Brasil, com experiência em cirurgia endoscópica endonasal, foi convidado a participar da elaboração desse posicionamento sobre os termos anatômicos do nariz e das cavidades paranasais para o português conforme metodologia adaptada da previamente descrita por Rudmik e Smith. Resultados: Os resultados desse documento foram gerados a partir da concordância da maioria dos participantes conforme as sugestões mais populares entre os rinologistas. Uma adaptação transcultural da terminologia anatômica nasossinusal foi consolidada. Sugerimos que se busque uniformizar termos como "concha inferior", "septo nasal", "porção (óssea/cartilaginosa) do septo nasal", "meato (médio/ inferior) nasal", "via da drenagem do seio frontal", "recesso frontal" e "processo uncinado". Conclusão: Consolidamos uma versão adaptada em português da "European Anatomical Terminology of the Internal Nose and Paranasal Sinuses" que auxiliará a publicação de comunicados técnicos, publicações científicas e o ensino dos termos anatômicos internos do nariz e das cavidades paranasais no Brasil.

Anatomical terminology of the internal nose and paranasal sinuses: cross-cultural adaptation to Portuguese.

INTRODUCTION: Functional endonasal endoscopic surgery is a frequent surgical procedure among otorhinolaryngologists. In 2014, the European Society of Rhinology published the "European Position Paper on the Anatomical Terminology of the Internal Nose and Paranasal Sinuses", aiming to unify the terms in the English language. We do not yet have a unified terminology in the Portuguese language. OBJECTIVE: Transcultural adaptation of the anatomical terms of the nose and paranasal cavities of the "European Anatomical Terminology of the Internal Nose and Paranasal Sinuses" to Portuguese. METHODS: A group of rhinologists from diverse parts of Brazil, all experienced in endoscopic endonasal surgery, was invited to participate in the creation of this position paper on the anatomical terms of the nose and paranasal sinuses in the Portuguese language according to the methodology adapted from that previously described by Rudmik and Smith. RESULTS: The results of this document were generated based on the agreement of the majority of the participants according to the most popular suggestions among the rhinologists. A cross-cultural adaptation of the sinonasal anatomical terminology was consolidated. We suggest the terms "inferior turbinate", "nasal septum", "(bone/cartilaginous) part of the nasal septum", "(middle/inferior) nasal meatus", "frontal sinus drainage pathway", "frontal recess" and "uncinate process" be standardized. CONCLUSION: We have consolidated a Portuguese version of the European Anatomical Terminology of the Internal Nose and Paranasal Sinuses, which will help in the publication of technical announcements, scientific publications and the teaching of the internal anatomical terms of the nose and paranasal sinuses in Brazil.

How to avoid the inappropriate use of antibiotics in upper respiratory tract infections? A position statement from an expert panel / Como evitar o uso inadequado de antibióticos nas infecções de vias aéreas superiores? Posição de um painel de especialistas

Abstract Introduction: Bacterial resistance burden has increased in the past years, mainly due to inappropriate antibiotic use. Recently it has become an urgent public health concern due to its impact on the prolongation of hospitalization, an increase of total cost of treatment and mortality associated with infectious disease. Almost half of the antimicrobial prescriptions in outpatient care visits are prescribed for acute upper respiratory infections, especially rhinosinusitis, otitis media, and pharyngotonsillitis. In this context, otorhinolaryngologists play an important role in orienting patients and non-specialists in the utilization of antibiotics rationally and properly in these infections. Objectives: To review the most recent recommendations and guidelines for the use of antibiotics in acute otitis media, acute rhinosinusitis, and pharyngotonsillitis, adapted to our national reality. Methods: A literature review on PubMed database including the medical management in acute otitis media, acute rhinosinusitis, and pharyngotonsillitis, followed by a discussion with a panel of specialists. Results: Antibiotics must be judiciously prescribed in uncomplicated acute upper respiratory tract infections. The severity of clinical presentation and the potential risks for evolution to suppurative and non-suppurative complications must be taken into 'consideration'. Conclusions: Periodic revisions on guidelines and recommendations for treatment of the main acute infections are necessary to orient rationale and appropriate use of antibiotics. Continuous medical education and changes in physicians' and patients' behavior are required to modify the paradigm that all upper respiratory infection needs antibiotic therapy, minimizing the consequences of its inadequate and inappropriate use.

Resumo Introdução: A resistência bacteriana a antibióticos nos processos infecciosos é um fato crescente nos últimos anos, especialmente devido ao seu uso inapropriado. Ao longo dos anos vem se tornando um grave problema de saúde pública devido ao prolongamento do tempo de internação, elevação dos custos de tratamento e aumento da mortalidade relacionada às doenças infecciosas. Quase a metade das prescrições de antibióticos em unidades de pronto atendimento é destinada ao tratamento de alguma infecção de vias aéreas superiores, especialmente rinossinusites, otite média aguda supurada e faringotonsilites agudas, sendo que uma significativa parcela dessas prescrições é inapropriada. Nesse contexto, os otorrinolaringologistas têm um papel fundamental na orientação de pacientes e colegas não especialistas, para o uso adequado e racional de antibióticos frente a essas situações clínicas. Objetivos: Realizar uma revisão das atuais recomendações de utilização de antibióticos nas otites médias, rinossinusites e faringotonsilites agudas adaptadas à realidade nacional. Método: Revisão na base PubMed das principais recomendações internacionais de tratamentos das infecções de vias aéreas superiores, seguido de discussão com um painel de especialistas. Resultados: Os antibióticos devem ser utilizados de maneira criteriosa nas infecções agudas de vias aéreas superiores não complicadas, a depender da gravidade da apresentação clínica e dos potenciais riscos associados de complicações supurativas e não supurativas. Conclusões: Constantes revisões a respeito do tratamento das principais infecções agudas são necessárias para que sejam tomadas medidas coletivas no uso racional e apropriado de antibióticos. Somente com orientação e transformações no comportamento de médicos e pacientes é que haverá mudanças do paradigma de que toda infecção de vias aéreas superiores deva ser tratada com antibióticos, minimizando por consequência os efeitos de seu uso inadequado.

How to avoid the inappropriate use of antibiotics in upper respiratory tract infections? A position statement from an expert panel.

INTRODUCTION: Bacterial resistance burden has increased in the past years, mainly due to inappropriate antibiotic use. Recently it has become an urgent public health concern due to its impact on the prolongation of hospitalization, an increase of total cost of treatment and mortality associated with infectious disease. Almost half of the antimicrobial prescriptions in outpatient care visits are prescribed for acute upper respiratory infections, especially rhinosinusitis, otitis media, and pharyngotonsillitis. In this context, otorhinolaryngologists play an important role in orienting patients and non-specialists in the utilization of antibiotics rationally and properly in these infections. OBJECTIVES: To review the most recent recommendations and guidelines for the use of antibiotics in acute otitis media, acute rhinosinusitis, and pharyngotonsillitis, adapted to our national reality. METHODS: A literature review on PubMed database including the medical management in acute otitis media, acute rhinosinusitis, and pharyngotonsillitis, followed by a discussion with a panel of specialists. RESULTS: Antibiotics must be judiciously prescribed in uncomplicated acute upper respiratory tract infections. The severity of clinical presentation and the potential risks for evolution to suppurative and non-suppurative complications must be taken into 'consideration'. CONCLUSIONS: Periodic revisions on guidelines and recommendations for treatment of the main acute infections are necessary to orient rationale and appropriate use of antibiotics. Continuous medical education and changes in physicians' and patients' behavior are required to modify the paradigm that all upper respiratory infection needs antibiotic therapy, minimizing the consequences of its inadequate and inappropriate use.

Polymorphisms in chronic rhinosinusitis with nasal polyps - a systematic review / Polimorfismos na rinossinusite crônica com pólipos nasais - uma revisão sistemática

Abstract Introduction: Chronic rhinosinusitis with nasal polyps is a multifactorial disease with a complex pathophysiology involving multiple genetic and environmental factors. Objective: The purpose of this work review is to focus on the importance of genetic studies in chronic rhinosinusitis with nasal polyps besides the several barriers that exists for its understanding. Methods: A systematic review on studies of association between single nucleotide polymorphisms and chronic rhinosinusitis with nasal polyps based on a PubMed/Medline and Periódicos CAPES search of all articles published between January 2005 and January 2015 was made. The search was guided on studies containing the terms polymorphisms, rhinosinusitis, and polyps. Results: Two studies found an association of MMP-9 and MMP-2 polymorphisms and chronic rhinosinusitis with nasal polyps, but not in patients with recurrent nasal polyps. Other studies found an association of nasal polyps with MMP-9 polymorphisms, but not with MMP-2 ones. There is evidence of an association of LTC4S, NOS2A, PTGDR, MET, COX-2, OSF-2, and LF polymorphisms and the risk of developing nasal polyps, especially when combined with chronic allergic rhinitis and asthma. Conclusion: Genetic studies on chronic rhinosinusitis with nasal polyps are promising and may offer insights into its pathophysiology, which is likely affected by multiple genetic factors.

Resumo Introdução: A rinossinusite crônica com pólipos nasais é uma doença multifatorial com uma fisiopatologia complexa envolvendo múltiplos fatores genéticos e ambientais. Objetivo: O objetivo deste trabalho é enfatizar a importância dos estudos genéticos na rinossinusite crônica com pólipos nasais, além das diversas barreiras existentes para sua compreensão. Método: Realizou-se uma revisão sistemática de estudos de associação entre polimorfismos de nucleotídeo único e rinossinusite crônica com pólipos nasais com base em uma busca feita nos bancos de dados PubMed/Medline e Periódicos CAPES de todos os artigos publicados entre janeiro de 2005 e janeiro de 2015. A busca foi direcionada à estudos contendo os termos polimorfismos, rinossinusite e pólipos. Resultados: Dois estudos encontraram uma associação entre os polimorfismos MMP-9 e MMP-2 e rinossinusite crônica com pólipos nasais, mas não em pacientes com pólipos nasais recorrentes. Outros estudos encontraram uma associação de pólipos nasais com polimorfismos MMP-9, mas não com MMP-2. Existem evidências de uma associação dos polimorfismos LTC4S, NOS2A, PTGDR, MET, COX-2, OSF-2 e LF e o risco de desenvolver pólipos nasais, especialmente quando combinados com rinite alérgica crônica e asma. Conclusão: Estudos genéticos sobre rinossinusite crônica com pólipos nasais são promissores e podem oferecer conhecimento sobre sua fisiopatologia, que é provavelmente afetada por múltiplos fatores genéticos.

First Clinical Consensus and National Recommendations on Tracheostomized Children of the Brazilian Academy of Pediatric Otorhinolaryngology (ABOPe) and Brazilian Society of Pediatrics (SBP) / Primeiro Consenso Clínico e Recomendações Nacionais em Crianças Traqueostomizadas da Academia Brasileira de Otorrinolaringologia Pediátrica (ABOPe) e Sociedade Brasileira de Pediatria (SBP)

Abstract Introduction: Tracheostomy is a procedure that can be performed in any age group, including children under 1 year of age. Unfortunately health professionals in Brazil have great difficulty dealing with this condition due to the lack of standard care orientation. Objective: This clinical consensus by Academia Brasileira de Otorrinolaringologia Pediátrica (ABOPe) and Sociedade Brasileira de Pediatria (SBP) aims to generate national recommendations on the care concerning tracheostomized children. Methods: A group of experts experienced in pediatric tracheostomy (otorhinolaryngologists, intensive care pediatricians, endoscopists, and pediatric pulmonologists) were selected, taking into account the different regions of Brazil and following inclusion and exclusion criteria. Results: The results generated from this document were based on the agreement of the majority of participants regarding the indications, type of cannula, surgical techniques, care, and general guidelines and decannulation. Conclusion: These guidelines can be used as directives for a wide range of health professionals across the country that deal with tracheostomized children.

Resumo Introdução: A traqueostomia é um procedimento que pode ser feito em qualquer faixa etária, inclusive em crianças abaixo de um ano. Infelizmente no Brasil existe uma enorme dificuldade dos profissionais de saúde em lidar com esta condição e uma falta de padronização dos cuidados. Objetivo: Este consenso clínico realizado pela Academia Brasileira de Otorrinolaringologia Pediátrica (ABOPe) e Sociedade Brasileira de Pediatria (SBP) tem como objetivo gerar recomendações nacionais sobre os cuidados e condutas diante das crianças traqueostomizadas. Método: Foram selecionados um grupo de especialistas com experiência em traqueostomia na infância (otorrinolaringologistas, pediatras intensivistas, endoscopistas, pneumopediatras) que tivessem comprovada atuação prática no assunto, e que também contemplassem as diversas regiões do Brasil, de acordo com os critérios de inclusão e exclusão. Resultados: Os resultados gerados neste documento foram obtidos a partir da concordância da maioria dos participantes em relação as indicações, tipo de cânula, técnicas cirúrgicas, cuidados e orientações gerais e decanulação. Conclusão: Estas diretrizes poderão servir como norteadoras para os mais diversos profissionais de saúde em todo país que lidam com as dificuldades das crianças traqueostomizadas.