Oral levofloxacin-induced optic neuritis progressing in loss of vision.

This case report highlights a rare adverse drug reaction caused by levofloxacin, resulting in optic neuritis progressing into unilateral loss of vision. A 49-year-old male patient was diagnosed to suffer from left maxillary and ethmoid sinusitis and was only prescribed oral levofloxacin 500 mg tablets once daily for 5 days. Within a few minutes after taking the first dose of the drug, the patient experienced respiratory distress, dizziness, confusion with pain, and loss of color vision, followed by almost complete loss of vision in the right eye. The left eye was normal. After ophthalmologic examinations and investigations, he was diagnosed to suffer from optic neuritis, probably (according to Naranjo adverse drug reaction probability scale) induced by levofloxacin.

Safety of ethmoid sinus drug-eluting catheter insertion.

OBJECTIVES: We sought to evaluate an instrument that allows a drug-eluting catheter to be inserted into the ethmoid sinuses and to demonstrate its safety and reproducibility in a cadaver model. METHODS: A drug-eluting catheter was placed into 12 cadaveric anterior and posterior ethmoid sinuses by use of a trocar-based insertion device. The device's position was analyzed with computed tomographic scans, and postprocedural dissection was performed. RESULTS: The drug-eluting catheter system was successfully inserted in all ethmoid sinuses without injury to the medial orbital wall, skull base, or sphenoid face. The final position of the distal tip of the catheter averaged 8.1 mm (root mean square [RMS], 3.3 mm) from the skull base, 5.6 mm (RMS, 3.5 mm) from the sphenoid face, and 5.0 mm (RMS, 3.5 mm) from the lamina papyracea; the proximal tip was at the face of the ethmoid bulla and 17.1 mm (RMS, 3.5 mm) below the skull base. CONCLUSIONS: A trocar-based instrument can relatively safely and reproducibly introduce a drug-eluting catheter into the ethmoid sinuses without injuring the skull base, lamina papyracea, or sphenoid face. This device may allow safe topical drug delivery into the ethmoid sinuses and serve as a vehicle to treat chronic ethmoid sinusitis with direct and sustained topical therapy.

Woakes' syndrome.

Woakes' syndrome is a rare entity defined as recurrent sinonasal polyposis with a consequent nasal pyramid deformity. Only a few cases are reported in the literature. The goal of this study is to present the features of Woakes' syndrome through a clinical case. A 42-year-old man presented with a history of ASA triad. He started self-medication for 5 years. He returned to the otorhinolaryngology department for the aggravation and persistence of symptoms. CT scans showed the deformity and thinning of the nasal bones. A functional endoscopic sinus surgery and correction of nasal pyramid deformity were performed. At 6 months' follow-up, good functional and aesthetic outcomes were observed. Woakes' syndrome was described more than 130 years ago. Treatment includes endoscopic sinonasal surgery and local treatment. Adequate management and good adherence to the therapeutic protocol could be factors to prevent this syndrome.

Burkholderia cepacia complex infection in a case of sinonasal polyposis recurrence without cystic fibrosis.

Burkholderia cepacia complex (BCC) has been rarely isolated in infections of the ear, nose and throat region in immunocompetent patients without cystic fibrosis. There is only one previous study in literature that reported BCC isolation in immunocompetent patients with sinonasal polyposis. We describe herein a rare case of multiresistant sinonasal infection by BCC in an immunocompetent patient with recurrent sinonasal polyposis. BCC seems to be a potentially emerging bacterial pathogen of sinonasal structures in patients with polyposis, also after FESS.

Ethmoidal pneumocele following drainage of an ethmoidal mucocele.

Ethmoidal pneumocele is a rare condition with little known about its etiology. We report a 5-year-old boy who had recurrent right orbital cellulitis, non-axial proptosis, and inferolateral globe displacement. Initial radiological investigations demonstrated an ethmoidal mucocele. There was complete resolution of inflammatory signs with endoscopic drainage of the mucocele; however, repeat CT revealed a residual pneumocele with continued proptosis and lateral displacement of the globe. This case illustrates the potential for chronic sinusitis and iatrogenic drainage of an ethmoidal mucocele to progress to a pneumocele.

Orbital cellulitis after faden operation on the medial rectus.

BACKGROUND: Orbital cellulitis after strabismus surgery is uncommon, may cause blindness and may lead to death. Very few cases have been described in detail due to the low incidence of this complication. METHODS: We report the first case of orbital cellulitis following Faden operation on the medial rectus muscle. We believe that the infection was due to asymptomatic ethmoid sinusitis. Our case is compared with other cases previously reported. RESULTS: A two-year-old boy was surgically treated for residual esotropia after two botulinum toxin A injections. Two days after surgery, signs of orbital cellulitis developed in his right orbit. CT-scan disclosed right ethmoid sinusitis that spread to the orbit after surgery. After intravenous antibiotic treatment, the infection resolved with full restoration of visual acuity and ocular motility. CONCLUSION: Despite adequate measures to prevent infection, orbital cellulitis may complicate strabismus surgery. Patients must be instructed to recognize early symptoms of this severe infection and call the surgeon immediately. Diagnosis may be confirmed by CT-scanning of the orbits. Prompt treatment with intravenous antibiotics usually leads to full recovery.

[Fever of unknown origin--pyelonephritis? Pneumonia? Mastoiditis? Ethmoiditis?]. / Goraczka o nieustalonej przyczynie --pyelonephritis? Pneumonia? Mastoiditis? Ethmoiditis?

Fever of unknown origin is alarming phenomenon in childhood. Diagnostic procedures should be focused on severe bacterial infection: pyelonephritis, pneumonia and other respiratory tract infections such as mastoiditis and sinusitis in particular ethmoiditis. The principles of treatment and diagnostics were discussed depending on age and general status of the child.

[Successful treatment of invasive sinus aspergillosis with micafungin and itraconazole].

BACKGROUND: We report a case of invasive sinus aspergillosis that extended to the orbital cavity and cavernous sinus and was improved by treatment with micafungin and itraconazole. CASE REPORT: A 83-year-old woman was referred to our hospital because of headache and impaired of eye movement on the right side. Physical examination revealed impaired function of cranial nerves, II, II, IV, and VI on the right side. MRI showed evidence of inflammation of the right sphenoid sinus and ethmoidal sinus and an enhancing mass in the right cavernous sinus and orbit. Because a culture of a specimen from the right sphenoid sinus extracted during endoscopic sinus surgery, yielede Aspergillus fumigatus, a diagnosed of invasive sinus aspergillosis complicated by cavernous sinus symdrome and orbital apex symdrome was made. It was difficult to completely remove the mass in the sinuses surgically and drug therapy with micafungin was started and then itraconazole was added. The clinical manifestations and the impaired function of cranial nerves II, III, IV, and VI improved, and MRI showed regression of the mass in the sinuses temporary in response to drug therapy. CONCLUSION: Invasive sinus aspergillosis often progresses rapidly in the absence of surgery. Our case is valuable, because invasive sinus aspergillosis was improved by drug therapy alone, and combined treatment with micafungin and itraconazole was effective.

[Acute ethmoiditis in children, a series of 125 cases]. / Ethmoïdites aiguës extériorisées de l'enfant: à propos d'une série de 125 cas.

UNLABELLED: Acute ethmoiditis are bacterial infections of ethmoid sinuses, which may spread to the orbital or the endocranial spaces. It is essential to fit the antibiotherapy to the bacteria responsible for these infections. POPULATION AND METHODS: The charts of children hospitalized from 1995 to 2003 for an acute ethmoiditis were reviewed, particularly the results of bacterial exams and the antibiotics delivered. RESULTS: Over this 9-year period, 125 children (mean age 4.5 years) were hospitalized for acute ethmoiditis. Eighty were checked for blood cultures, which were sterile in 73 cases, and in the other cases, grew Staphylococcus, S. Pneumoniae or Streptococcus pyogenes. Seric soluble antigens were absent in the 5 cases where they were looked for. Ten children had a puncture of a subperiostal abscess: it was sterile in 5 cases, Staphylococcus was found in 4 cases, S. pneumoniae in the last case. Most children received an association of cefotaxim and fosfomycine for a mean duration of 5.6 days. Thirteen per cent of the children received 3 or 4 antibiotics. DISCUSSION: It is always difficult to found the bacteria responsible for an acute ethmoiditis. In our serie as in others, the most frequent bacteria were Staphylococcus, S. pneumoniae and S. pyogenes. CONCLUSION: In view of the bacteria responsible for these infections and their antibiotic resistance, we suggest the association of cefotaxim and fosfomycin for the first line of treatment of acute ethmoiditis.

[Postseptal orbital cellulitis and sinusitis. Descriptive study of 8 cases and literature review]. / Celulitis orbitaria retroseptal y sinusitis. Presentación de 8 casos y revisión de la literatura.

This is a retrospective study of 8 patients with postseptal orbital cellulitis (stages II-V of Chandler) caused by sinusitis during 1999-2003. The variables analyzed in this study included age, sex, delay in diagnosis, aetiology, imaging studies, microbiology specimens collected and treatment. Delays in diagnosis were frecuent. CT was the best radiologic study. Polymicrobial infections were the rule, including anaerobes. 4 patients of 8 needed surgical drainage. A general guideline for the management of periorbital and orbital cellulitis according to the clinical staging of the process is presented.

Suppurative complications of frontal sinusitis in children.

A retrospective review of children diagnosed and treated for suppurative complications of paranasal sinusitis was undertaken to describe clinical presentation, microbiology, and treatment. This review includes children with subgaleal abscess and osteomyelitis of the frontal bone, subdural empyema, frontal lobe abscess, meningitis, and encephalitis. Staphylococcus aureus and group C beta-hemolytic Streptococcus were isolated agents. All children were treated with intravenous antibiotics with drainage of both the sinus and extracranial and intracranial suppurations. Results of treatment in the series support the opinion that combined aggressive surgical and antibiotic treatment is a preferred method in complicated sinusitis in children.

Nocardia asteroides sinusitis in a pediatric patient: Case report with 20 year follow-up and review of the literature.

Nocardia Asteroides infection in a non-immunocompromised pediatric patient is extremely rare. We present a case of ethmoid sinusitis and orbital subperiosteal abscess caused by N. asteroides with a 20 year follow up and a review of the literature. N. asteroides was grown from intraoperative cultures for mycobacteria following surgical incision and drainage of the abscess. Postoperatively, the patient received a seven month course of trimethoprim-sulfamethozaxole and had no subsequent sequelae. Nocardia infections are common in immunocompromised patients. We present what we believe to be the first case of pediatric Nocardia sinusitis with 20-year follow up.

Improved outcome of zygomycosis in patients with hematological diseases?

Zygomycosis is an opportunistic fungal infection that is increasingly reported in hematological patients. We describe 2 cases of successfully treated rhino-cerebral zygomycosis and give an overview of 120 patients from the literature with underlying hematological or oncological disorders. These data document the improved survival in sinus (15/17 patients surviving) and cutaneous (6/9 patients surviving) disease. Hematological patients with pulmonary (9/30 patients surviving) or disseminated (4/38 patients surviving) zygomycosis still have a poor prognosis. The clinical course of sinus-orbital involvement (4/11 patients surviving) follows sinus-cerebral (2/3 patients surviving) or cerebral (3/6 patients surviving) disease. Besides deoxycholate amphotericin B (AmB) (24/62 patients surviving), patients seem to benefit from liposomal amphotericin B (L-AmB) (10/16 patients surviving) or sequential AmB/L-AmB treatment (6/8 patients surviving). Alternative treatment options lead only in a few patients to success.

Computed tomography imaging of the maxillary and ethmoid sinuses in children with short-duration purulent rhinorrhea.

INTRODUCTION: Adults with a common cold often have paranasal sinus effusions detected by computed tomographic (CT) scans. There are no comparable data for children. The purpose of this study was to document the sinus CT findings in children with short-duration purulent rhinorrhea. DESIGN: Thirty children, 3 to 12 years of age (median age, 7 years), with purulent rhinorrhea for a mean duration of 5 days (and always less than 9 days) were enrolled in the study. The children were otherwise well. Institutional Review Board (IRB)-approval was obtained before enrollment of the first patient. Informed written consent was obtained from each child's parent. CT imaging of the maxillary and ethmoid sinuses was obtained on the day of the initial visit (occasionally, the following day). Follow-up CT scans were obtained from cooperative children/parents, 3 to 4 weeks later. RESULTS: Opacification or an air/fluid level in the maxillary sinuses was seen in 27 (90%) of 30 study children at study entry. Ethmoid sinuses were not opacified without opacification of a maxillary sinus. Three weeks later, 24 of 27 study children, who had positive CT scans on study entry, improved clinically. Of 17 follow-up CT scans, 10 (58%) normalized, 4 had improvement of bilateral disease, and 3 improved with unilateral disease. None appeared worse than baseline. CONCLUSIONS: Pansinus opacification (ethmoid and maxillary sinuses), on CT scans in children with short-duration purulent nasal drainage was seen in 70% of children. An additional 20% had isolated maxillary sinus effusions (10% had no effusion). Three-week follow-up CT scans on 17 children were normal in 60% and improved (partial clearance) in 40%. In this patient population, the decision to treat with antibiotics should be made on clinical grounds alone.

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.

Successfully treated candida sinusitis in an AIDS patient.

An AIDS patient with a subdural empyema as a complication of candida sinusitis is presented. Clinical features resembled those of invasive aspergillosis or phycomycosis. Microbiological diagnosis was established by blood cultures, sinus cultures, and histopathological examination. An aggressive surgical approach first to the sinuses and then to the subdural space, together with fluconazole produced a satisfactory result.

Effect of intranasal treatment with capsaicin on the recurrence of polyps after polypectomy and ethmoidectomy.

The aim of this study was to evaluate the influence of five intranasal applications of capsaicin, performed after endoscopic polypectomy associated with partial middle turbinectomy and anterior ethmoidectomy, on the recurrence of nasal polyps and the intensity of nasal obstruction and rhinorrhea. Fifty-one patients (19 females, 32 males, mean age 43 years) suffering from nasal polyposis for more than 1 year were included in this double blind, randomized, placebo-controlled study. During post-surgical controls, local anaesthesia and vasoconstriction of the middle meatus area were performed in all patients with a cotton pellet soaked with lidocain and adrenaline. In 29 patients, the same type of cotton pellet soaked with capsaicin (3 x 10(-6) mol. dissolved in 70% ethanol) was left into the middle meatus of both nostrils for 20 min. As a control group, 22 patients, matched for age and sex, were treated with the capsaicin vehicle alone (70% ethanol). All patients studied received the intranasal treatment once a week for 5 weeks. Subjective evaluations of nasal airway resistance (NAR) and rhinorrhea were recorded by means of a visual analogue scale. Clinical staging of the nasal polyposis (graded from stage 0 = absence of polyp to stage 3 = polyps occupying the entire nasal cavity) was evaluated by the same ENT specialist (ZW) using a 0 degrees endoscope. All parameters were recorded for each patient 1 week before surgery, then once a month for 9 months. Patients treated by endoscopic surgery followed by intranasal capsaicin application, reported a marked reduction in their NAR compared with the pretreatment evaluation (p<0.001). In contrast, patients treated with the vehicle alone did not have any significant improvement of their subjective NAR. Subjective rhinorrhea was not modified by either treatment. Patients treated with capsaicin showed a significant smaller staging of their nasal polyposis compared with the control group (p<0.001). These observations suggest that endoscopic surgery followed by intranasal capsaicin application reduces polyps and nasal obstruction recurrence and could be an alternative treatment to expensive corticosteroids in developing countries.

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

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

The place of endonasal endoscopy in the treatment of orbital cellulitis.

Orbital cellulitis secondary to acute sinusitis is uncommon, dangerous, and can lead to blindness and death. The ethmoid is the predominantly involved sinus. Management policy consists of early drainage of the affected sinus combined with systemic antibiotic therapy. If no improvement is achieved within the first 48 h, exploration of the fronto-ethmoidal region is mandatory. Endonasal endoscopic surgery facilitates early drainage of the affected sinus, eradication of the disease from the fronto-ethmoidal region, and drainage of the subperiosteal abscess. Sixteen cases of orbital cellulitis were treated successfully by endonasal endoscopic surgery with no complications.