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Background T2R bitter taste receptors play a crucial role in sinonasal innate immunity by upregulating mucociliary clearance and nitric oxide (NO) production in response to bitter gram-negative quorum-sensing molecules in the airway surface liquid. Previous studies showed that phytochemical flavonoid metabolites, known as anthocyanidins, taste bitter and have antibacterial effects. Our objectives were to examine the effects of anthocyanidins on NO production by human sinonasal epithelial cells and ciliary beat frequency, and their impact on common sinonasal pathogens Pseudomonas aeruginosa and Staphylococcus aureus.Methods Ciliary beat frequency and NO production were measured by using digital imaging of differentiated air-liquid interface cultures prepared from primary human cells isolated from residual surgical material. Plate-based assays were used to determine the effects of anthocyanidins on bacterial swimming and swarming motility. Biofilm formation and planktonic growth were also assessed.Results Anthocyanidin compounds triggered epithelial cells to produce NO but not through T2R receptors. However, anthocyanidins did not impact ciliary beat frequency. Furthermore, they did not reduce biofilm formation or planktonic growth of P. aeruginosa. In S. aureus, they did not reduce planktonic growth, and only one compound had minimal antibiofilm effects. The anthocyanidin delphinidin and anthocyanin keracyanin were found to promote bacterial swimming, whereas anthocyanidin cyanidin and flavonoid myricetin did not. No compounds that were tested inhibited bacterial swarming.Conclusion Results of this study indicated that, although anthocyanidins may elicited an innate immune NO response from human cells, they do not cause an increase in ciliary beating and they may also cause a pathogenicity-enhancing effect in P. aeruginosa. Additional studies are necessary to understand how this would affect the use of anthocyanidins as therapeutics. This study emphasized the usefulness of in vitro screening of candidate compounds against multiple parameters of both epithelial and bacterial physiologies to prioritize candidates for in vivo therapeutic testing.

Background One of the challenges in the current expansion of endoscopic sinonasal surgery is the ability to adequately reconstruct the skull base. Laser tissue welding (LTW) uses laser energy coupled to a biological solder to produce tissue bonds with burst thresholds exceeding human intracranial pressure. This technology could be used to reduce the rate of postoperative cerebrospinal fluid (CSF) leak. We performed this study to determine whether LTW can create durable tissue bonds in sinonasal mucosa that support normal wound healing and produce minimal collateral thermal injury.Methods Bilateral maxillary sinus mucosal incisions were made in 20 New Zealand white rabbits and one side was repaired using LTW. Burst pressure thresholds were measured on postoperative days 0, 5, and 15 and were compared with control using a two- way ANOVA and a post hoc Tukey test. Welds were examined histologically for thermal injury, inflammation, and fibroplasia and graded on a 4-point scale by three blinded observers.Results The burst pressures of the LTW group were significantly higher than control on postoperative day 0 (120.85 mm Hg, N = 4, SD = 47.84 versus 7.85 mm Hg, N = 4, SD = 0.78), and day 5 (132.56 mm Hg, N = 8, SD = 24.02 versus 41.7 mm Hg, N = 8, SD = 7.2; p < 0.05). By postoperative day 15 there was no significant difference between LTW (169.64 mm Hg, N = 8, SD = 18.49) and control (160.84 mm Hg, N = 8, SD = 14.16) burst thresholds. There was no evidence of thermal injury to the surrounding tissue in any group as well as no difference between experimental group and control with respect to inflammation or fibroplasia.Conclusion This is the first in vivo study showing that LTW is capable of producing tissue bonds exceeding human intracranial pressure with negligible thermal injury in sinonasal tissue. Welding can be performed endoscopically using a fiberoptic cable and may be useful in CSF leak and skull base repair.

Background Recently, biofilms have been implicated in the pathogenesis of recalcitrant chronic rhinosinusitis (CRS). We sought to determine the prevalence of biofilm-forming cultures obtained from patients with CRS and clinical factors that may contribute to biofilm formation.Methods Endoscopically guided sinonasal cultures were obtained in duplicate from CRS patients with evidence of mucopurulence. Bacterial swabs were sent for microbiological characterization and were simultaneously evaluated for biofilm-forming capacity by a modified Calgary Biofilm Detection Assay. Biofilm formation was based on concomitant values of biofilm-forming Pseudomonas aeruginosa O1 (PAO1) (positive control) and non-biofilm-forming mutants sad-31 (type IV pili) and sad-36 (flagella K; negative control). Samples, with growth greater than the sad-31 mutant, were designated as biofilm formers.Results Sinonasal cultures were obtained from 157 consecutive patients (83 female patients) over a 4-month period. Forty-five samples (28.6%) showed biofilm formation. Among patients with a prior history of functional endoscopic sinus surgery (FESS), 30.7% (n = 42) showed biofilm growth. For patients naive to surgical intervention (n = 20), only 15% showed biofilm formation. A positive, statistically significant correlation existed between biofilm formation and number of prior FESS procedures. Polymicrobial cultures, Pseudomonas aeruginosa, and/or Staphylococcus aureus comprised 71% of samples. Chi-squared analysis showed an association with prior infections, but not with any pharmacologic therapy or comorbidies.Conclusion We show a high percentage of CRS patients (28.6%) whose sinonasal mucopurulence has biofilm-forming capacity. Postsurgical patients had a high prevalence of biofilm-forming bacteria, a possible reflection of the severe nature of their disease. Additional studies are warranted.

Background Chronic rhinosinusitis (CRS) that is refractory to medical or surgical intervention may involve a particularly resistant form of infection known as a bacterial biofilm. Bacterial biofilms are three-dimensional aggregates of bacteria that often are recalcitrant to antibiotics secondary to physical barrier characteristics. To date, all studies investigating biofilms in CRS have been descriptive in either human or animal tissue. To better understand the interactions of bacterial biofilms with respiratory epithelium, we describe an in vitro model of biofilm sinusitis by establishing mature biofilms on airway epithelial air-liquid interface cultures.Methods Airway epithelial cell cultures were grown on collagen-coated semipermeable support membranes as an air-liquid interface on tissue culture inserts. Confluent air-liquid interface cultures were inoculated with the biofilm-forming PAO-1 strain of Pseudomonas aeruginosa and compared with cultures inoculated with two mutant strains (sad-31 and sad-36) unable to form biofilms. Inoculated tissue transwells were incubated for 20 hours, allowing for biofilm growth. The semipermeable membranes were then harvested and imaged with confocal laser scanning microscopy and scanning electron microscopy.Results Microscopic analysis revealed the formation of biofilm-forming towers in the PAO-1 inoculated wells. The bacterial biofilms were supported by a viable airway epithelial cell surface monolayer.Conclusion This study shows a reliable method for analysis of in vitro interactions of bacterial biofilms and airway epithelium. The experimental manipulation of this air-liquid interface model will help explore novel treatment approaches for bacterial biofilm-associated CRS.

Background Image-guided functional endoscopic sinus surgery (IG- FESS) using preoperatively acquired CT images for navigation has been proven to facilitate complicated endoscopic sinus procedures and decrease the need for revision procedures. However, this system does not render the intraoperative anatomic changes that occur throughout the procedure. The purpose of this study is to show the technical feasibility and the potential impact of intraoperative CT scanning in conjunction with real-time update of computer-assisted navigation during ESS.Methods Intraoperative CT scanning was performed in selected patients undergoing FESS. A scan was taken before the conclusion of surgery performed by skilled endoscopic sinus surgeons. The scans were evaluated for residual disease or cellular partitions. Where indicated, intraoperative scan was then loaded into the image guidance system and intraoperative scans were then used for additional IGS. The scan findings were documented.Results Intraoperatively acquired CT scans were obtained successfully in <40 seconds and able to be loaded into the image guidance system within minutes. All surgeries were preformed without complication. New information obtained from the intraoperative CT scan led to alteration in the surgical plan in 30% of patients.Conclusion Intraoperative CT scanning can be preformed with currently available technology and has the potential to improve the extent of surgery in patients with complicated anatomy and extensive disease.

Background Symptoms of postnasal drainage and thickened mucus are commonly seen in patients with chronic rhinosinusitis (CRS) recalcitrant to sinus surgery and conventional medical therapies. Chemical surfactants can act as a mucolytic by reducing water surface tension and have the potential to serve as an antimicrobial agent. Baby shampoo is an inexpensive, commercially available solution containing multiple chemical surfactants. This is an in vitro study of its antimicrobial effects on Pseudomonas biofilms with translation to a clinical study for use as an adjuvant nasal wash in patients with CRS who remain symptomatic despite adequate sinus surgery and conventional medical therapies.Methods In vitro testing was performed to determine the optimal concentration of baby shampoo that disrupted preformed bacterial biofilms and inhibited biofilm formation. This concentration was then used in a prospective study of symptomatic post–functional endoscopic sinus surgery (FESS) patients who irrigated twice a day for 4 weeks. Validated outcome forms and objective smell testing was performed before and after therapy.Results One percent baby shampoo in normal saline was the optimal concentration for inhibition of Pseudomonas biofilm formation. Baby shampoo had no effect on the eradication of preformed Pseudomonas biofilms. Eighteen patients with CRS with an average of 2.8 surgeries were studied after irrigating with 1% baby shampoo solution. Two patients discontinued use because of minor nasal and skin irritations; 46.6% of patients experienced an overall improvement in their subjective symptoms, and 60% of patients noted improvement in specific symptoms of thickened mucus and postnasal drainage.Conclusion Baby shampoo nasal irrigation has promise as an inexpensive, tolerable adjuvant to conventional medical therapies for symptomatic patients after FESS. Its greatest benefit may be in improving symptoms of thickened nasal discharge and postnasal drainage.

Background The endoscopic resection of sinonasal inverted papillomas (IPs) has been well described. However, the majority of published reports in the literature are small case series with limited clinical follow-up. The aim of this retrospective study was to review the experience with the endoscopic and endoscopic-assisted resection of IPs at a major academic tertiary care facility and assess long-term outcomes.Methods A retrospective review of endoscopic and endoscopic-assisted resections of IP was performed. Charts were reviewed for standard demographic data, operative technique, adjuvant approaches, complications, and postoperative follow-up times.Results One hundred fourteen patients (average age, 56 years) underwent endoscopic or endoscopic-assisted resection for IPs with a mean disease-free follow-up of 40 months (7–135 months). Seventeen patients developed disease after endoscopic or endoscopic-assisted resection for a recurrence rate of 15%. Average time to recurrence was 23 months. Combined approaches were used when indicated in 34% (39/114) of patients, including adjuvant osteoplastic flap, midface degloving, trephine, or Caldwell-Luc approaches. Four patients (4%) had cerebrospinal fluid leaks that were successfully repaired endoscopically.Conclusion In this large series of endoscopically resected IPs with extensive clinical follow-up, recurrences occurred an average of 23 months after the procedure. This emphasizes the importance of long-term endoscopic follow-up to detect recurrences in all patients. Endoscopic or endoscopic-assisted resection of IPs is a valid technique in this series with recurrence rates comparable with open approaches.

Background Air–liquid interface cultures using murine tracheal respiratory epithelium have revolutionized the in vitro study of airway diseases. However, these cultures often are impractical because of the small number of respiratory epithelial cells that can be isolated from the mouse trachea. The ability to study ciliary physiology in vitro is of utmost importance in the research of chronic rhinosinusitis (CRS). Our hypothesis is that the murine nasal septum is a better source of ciliated respiratory epithelium to develop respiratory epithelial air–liquid interface models.Methods Nasal septa and tracheas were harvested from 10 BALB/c mice. The nasal septa were harvested by using a simple and straightforward novel technique. Scanning electron microscopy was performed on all specimens. Cell counts of ciliated respiratory epithelial cells were performed at one standard magnification (1535×). Comparative analysis of proximal and distal trachea, midanterior and midposterior nasal septal epithelium, was performed.Results Independent cell counts revealed highly significant differences in the proportion of cell populations (p < 0.00001). Ciliated cell counts for the trachea (106.9 ± 28) were an average of 38.7% of the total cell population. Nasal septal ciliated epithelial cells (277.5 ± 16) comprised 90.1% of the total cell population.Conclusion To increase the yield of respiratory epithelial cells harvested from mice, we have found that the nasal septum is a far superior source when compared with the trachea. The greater surface area and increased concentration of ciliated epithelial cells has the potential to provide an eightfold increase in epithelial cells for the development of air–liquid interface cultures.

Background Although multiple etiologies contribute to the development of chronic rhinosinusitis (CRS), a common pathophysiological sequelae is ineffective sinonasal mucociliary clearance, leading to stasis of sinonasal secretions, with subsequent infection and/or persistent inflammation. Proper therapeutic intervention typically restores mucociliary activity, suggesting that the pathophysiological process(es) responsible for CRS-associated mucostasis may be reversible. We previously demonstrated a blunted response of CRS sinonasal cilia after purinergic stimulation. This study investigated whether the blunted ciliary response is unique to purinergic stimulation and addressed whether the blunted effect is primarily caused by local CRS-associated mediators or inherent genetic defects in ciliary function.Methods A dual temperature-controlled perfusion chamber, differential interference contrast microscopy, and high-speed digital video were used to analyze both basal as well as cholinergic, adrenergic, and purinergic stimulation of cilia in human sinonasal mucosal explants. Additionally, enzymically dissociated sinonasal ciliated cells were maintained ex vivo in submersion, on glass coverslips, and assessed daily for purinergic ciliary beat frequency stimulation.Results Cholinergic and adrenergic stimulation generally were blunted in mucosal explants obtained from CRS patients. Ex vivo maintenance of samples demonstrated that the majority of CRS samples developed a stimulatory phenotype within 36 hours of culturing.Conclusion CRS is a common debilitating disease principally affecting sinonasal epithelial function with a resultant diminution of mucociliary transport. Presently, little is known about how this disease process affects the sinonasal epithelial ciliated cells. Our data suggest that ciliary response to environmental insults is blunted in a reversible manner in CRS patients.

Background Epidermoid tumors of the craniofacial skeleton are uncommon, with the exception of acquired cholesteatoma of the temporal bone. These lesions may be primary embryologic in origin or, less frequently, may be iatrogenic or posttraumatic.Methods We report three cases of unusually encountered epidermoids, all of which were managed by endoscopic marsupialization via paranasal sinus approaches. We also review the pathophysiology and clinical presentation of these rare entities.Results The first patient is a 60-year-old man with a congenital epidermoid of the petrous apex removed via an endoscopic transsphenoid approach assisted by image-guided surgical navigation with CT/MRA merge. The second case is a 48-year-old woman with a history of trauma found to have a mass in the pterygopalatine space. An endoscopic transmaxillary approach was used to ligate the internal maxillary artery and marsupialize the cyst into the maxillary sinus. The third patient is a 22-year-old woman with a supraorbital ethmoid epidermoid tumor discovered intraoperatively during surgery for a presumed mucocele. This patient also had a known history of trauma. The cyst was marsupialized into the adjacent frontal sinus. Image-guided surgical navigation using CT was performed in the latter two cases. All patients are free of recurrence with follow-up ranging from 14 to 26 months.Conclusion With advancements in endoscopic techniques, including the use of image guidance, many of these relatively uncommon lesions can be managed by minimally invasive approaches via the paranasal sinuses.

Background Although multiple etiologies contribute to the development of rhinosinusitis, a common pathophysiological sequelae is ineffective sinonasal mucociliary clearance, resulting in stasis of sinonasal secretions, with subsequent infection, and persistent inflammation. The respiratory cilia beat continually at a basal rate, while during times of stress, such as exercise or infection, ciliary beat frequency (CBF) increases, accelerating mucus clearance. Previous investigations have led to conflicting results with some authors reporting decreased CBF while others have found normal values of CBF in patients with chronic rhinosinusitis (CRS). Additionally, these studies have only analyzed basal CBF. The goal of this study was to compare the basal as well as the stimulated sinonasal CBF in patients with CRS versus controls.Methods A dual temperature controlled perfusion chamber, differential interference contrast microscopy, and high-speed digital video were used to analyze both basal and adenosine triphosphate (100 μM)–stimulated CBF in human sinonasal mucosal explants.Results Although no difference in basal CBF was detected between control and CRS patients, a marked difference in stimulated CBF was noted. Exogenously applied adenosine triphosphate resulted in a 50–70% increase of CBF in control tissue with a minimally observed CBF increase in explants from CRS patients.Conclusion Dynamic regulation of respiratory ciliary activity is critical for the respiratory epithelium to adapt to varying environmental situations. Thus, diminished or absent adaptation could predispose the sinonasal cavity to accumulation of inhaled infectious and noxious particulate matter resulting in infection/inflammation. Our findings suggest that CRS patients have decreased sinonasal ciliary adaptation to environmental stimuli.

Background The pathogenesis of chronic rhinosinusitis (CRS) has been found to be multifactorial, with environmental, general host, and local anatomic factors all contributing to its development. Recent studies have indicated that local osteitis of the underlying bone also may play a critical role in the elaboration of CRS by inducing persistent inflammatory changes in the surrounding mucosa. The purpose of this study was to determine the clinical incidence rate of osteitis in patients with CRS undergoing functional endoscopic sinus surgery.Methods From January to July 2003, a prospective study was performed on 121 patients undergoing functional endoscopic sinus surgery for CRS. Age, number of previous surgeries, radiographic bony characteristics, and pathological findings were all documented. The presence of concurrent osteitis was assessed using both radiographic (neoosteogenesis) and pathological (bony remodeling) criteria.Results The mean age of the patients was 44.3 years. Fifty-eight percent of the cases were revision surgeries, with each patient having an average of 2.2 operative procedures in the past. Computed tomography (CT) showed neoosteogenesis in 36% of patients, and 53% showed pathological evidence of osteitis on histological analysis of surgical specimens.Conclusion Concurrent osteitis can be found in 36–53% of patients with CRS, using both radiographic and pathological criteria, respectively. Although a causal relationship between osteitis and CRS can not be inferred from this data, these clinical findings correlate well with previous evidence of bone involvement in CRS found in animal models, further reaffirming the association between underlying osteitis and the pathogenesis of CRS.

Background Mucociliary clearance, a primary host defense mechanism, depends on mucus production and its clearance by the coordinated beating of cilia lining the airways. Numerous investigations have analyzed ciliary activity in brushings from the inferior turbinate. To date, only one study has investigated whether there exists variation in ciliary beat frequency (CBF) within the sinonasal cavity. We analyzed CBF from the inferior turbinate, uncinate process, and sphenoethmoid recess in nonsinusitis patients to determine regional variability of ciliary activity within the sinonasal cavity.Methods Explants of sinonasal epithelium were analyzed at 37°C. Beating cilia were visualized with differential interference contrast microscopy. Images were captured using a high-speed digital camera with a sampling rate of 250 frames per second. A one-dimensional tracking algorithm analyzed individual pixel grayscale values within each frame of the video. The differences in grayscale were plotted as a time-dependent waveform, and frequency was calculated as the inverse of the peak-to-peak distance. A minimum of three areas of beating cilia were analyzed per regional sample. Statistical analysis was performed with repeated-measures analysis of variance.Results Complete sampling of all three sites was accomplished in 10 patients. No difference in CBF within the sinonasal cavity was identified (p < 0.05). The mean CBF for all sites in all patients was 12.6 ± 2.9 Hz, in agreement with published values.Conclusion This study shows no regional differences in CBF within the sinonasal cavity, supporting previous work and validating analysis of inferior turbinate cilia.

Background Mucociliary clearance is a critical upper airway host defense mechanism. Ciliated epithelium in the mammalian airway continually beat at a baseline frequency. Importantly, during times of stress such as exercise or infection, the cilia beat faster to increase clearance. Nasal epithelial ciliary beat frequency (CBF) has been analyzed previously in ex vivo specimens using a variety of methods including photodiode detectors and conventional video recording. Recent studies performed using lower airway ciliated mucosa have shown poor correlation between CBF quantified by photodiode/conventional video and those using high-speed digital video capture at temperatures close to physiological temperatures. Thus, to more rigorously interrogate sinonasal CBF at physiological conditions, we have incorporated a high-speed digital video camera to our CBF analysis system. This is the first report of sinonasal epithelial CBF analysis performed using high-speed video digital analysis.Methods Ex vivo samples of sinonasal epithelium were placed in lactated Ringer's in a temperature-controlled microscope stage chamber. An edge of tissue containing beating cilia was observed at a magnification of 630 X using differential interference contrast microscopy. The images were captured using a high-speed digital camera with a sampling rate of 250 frames per second. CBF was determined using computerized data analysis.Results The mean nasal CBF was calculated from a minimum of five regions for each sample. Temperature curves were generated from tissue obtained from chronically infected subjects.Conclusion Analysis of high-speed digital video capture of sinonasal CBF observed under differential interference contrast microscopy is a powerful method to investigate environmental as well as host influences on mucociliary clearance within the upper airways.

Background The development of chronic rhinosinusitis, a mucocele, or persistent headaches is a common indication for the removal of a frontal sinus osteoma. The best surgical approach to ensure complete and safe removal of the lesion is less clearcut. The advent of specialized frontal sinus instruments, angled endoscopes, and surgical navigational systems has made removal of frontal sinus osteomas possible through an endoscopic approach. The aim of this study is to review our recent experience with the surgical management of frontal sinus osteomas, and the anatomic features that make specific lesions more or less amenable to endoscopic resection.Methods A retrospective review of all frontal sinus osteomas surgically resected from the years 1999 to 2003 was used. This period was selected to reflect the invention and popularization of surgical navigation systems and specialty instruments designed specifically for the frontal sinus. CT scans, operative reports and postoperative course were reviewed.Results Nine patients were identified. A grading system was devised to reflect the three variables involved in the limitations for endoscopic removal. These are the location of the base of attachment, relative size to the frontal recess, and location in relation to a virtual sagittal plane through the lamina papyracea. Three osteomas were removed through an endoscopic approach. Four were removed by a combined osteoplastic flap and endoscopic dissection of the frontal recess. Two were removed through an osteoplastic flap with obliteration of the sinus.Conclusion The ability to remove a frontal sinus osteoma endoscopically can be determined preoperatively, taking into account the location and size of the lesion. There is still a role for external procedures in the surgical management of these lesions, and such procedures may be combined with endoscopic techniques for optimal results.

Background Bacterial biofilms have been documented on middle ear mucosa, tonsils, and cholesteatoma. In addition, we have described previously bacterial biofilms on frontal recess stents placed during surgery for chronic sinusitis. We hypothesize that bacterial biofilms are present on the mucosa of animals with sinuses experimentally infected with Pseudomonas aeruginosa.Methods We instilled Pseudomonas aeruginosa at log phase growth into the right maxillary sinus in 22 New Zealand white rabbits and harvested specimens 1–20 days later. We then examined the tissues with scanning electron microscopy (SEM) and light microscopy. Mucosa from the middle turbinate on the contralateral side was used as a control.Results We identified evidence of bacterial biofilms on the mucosa of all 22 animals under SEM. Twenty-one of 22 animals had sinus cultures positive for Pseudomonas. Bacterial biofilms were identified by evidence of glycocalyx, water channels, and three-dimensional structure. These images were similar to other images of known biofilms.Conclusion This is evidence of the presence of bacterial biofilms in an animal model of sinusitis. This model may serve as a means to study the efficacy and safety of pharmacologic and surgical treatments on the disruption and elimination of bacterial biofilms. Additional study into the role of bacterial biofilms in perpetuating chronic sinusitis is warranted.

Background Bacterial biofilms have been documented on middle ear mucosa, tonsils, and cholesteatoma. We hypothesize that bacterial biofilms are present in mucosa of patients with chronic sinusitis. We believe that frontal sinus stents may serve as a reservoir for biofilms.Experiment We studied silicone frontal sinus stents removed from six patients 1 to 4 weeks after FESS with scanning electron microscopy (SEM).Results We identified evidence of bacterial biofilms on the frontal recess stents in six of six patients under SEM. Five of these patients had sinus cultures positive for Staphylococcus aureus. Bacterial biofilms were identified by evidence of glycocalyx, water channels, and three-dimensional structure. These images were similar to other images of known biofilms.Conclusions This is evidence of the possible presence of bacterial biofilms on frontal sinus stents in patients with chronic sinusitis. Further study into the role of bacterial biofilms in perpetuating chronic sinusitis is warranted.

Background Frontal sinus obliteration (FSO) traditionally has represented the final stage in the algorithm for difficult to manage frontal sinus disease. In addition, FSO has been used in selected cases of frontal sinus trauma. However, this procedure has been associated with failure in 5–10% of cases. Advances in surgical instrumentation and image-guided surgical navigation have permitted endoscopic management of these failures.Methods Eleven patients presenting with failure of a previously performed FSO were managed endoscopically with the assistance of image-guided surgical navigation.Results Initial frontal sinus pathology included chronic inflammatory disease in six patients and frontal sinus trauma in two patients. Two patients underwent obliteration after neurosurgical frontal craniotomy and one patient underwent obliteration after curettage of a frontal sinus ossifying fibroma. Frontal sinuses were obliterated with fat in eight cases, bone chips in two cases, and bone cement in one case. The mean time interval to FSO failure was 11.1 years (range, 4 months–35 years). The etiology of failure included mucocele in eight patients, chronic frontal sinusitis in two patients, and Pott's puffy tumor in one patient. All 11 patients were managed endoscopically, of which 3 patients underwent a trans-septal frontal sinusotomy. Two patients required revision endoscopic surgery, but all were patent at last follow-up (mean, 14.8 months).Conclusion Endoscopic management of failed FSO may be performed safely. These approaches are viable alternatives to open revision procedures in the management of failed FSO. (American Journal of Rhinology 18, 279–284, 2004)

An association between chronic sinusitis and asthma has been noted for many years, although the precise nature of the relationship is poorly understood. Earlier studies, using traditional surgical techniques, have demonstrated subjective improvement in asthmatic complaints. Reports demonstrating improvement following endoscopic sinus surgery for chronic sinusitis are rare. To report our experience with endoscopic sinus surgery and asthmatics, we reviewed the charts of 75 consecutive patients with asthma and chronic sinusitis who underwent endoscopic sinus surgery between 1994 and 1996. Study criteria included the following: chronic sinusitis, one year preoperative and one year postoperative follow-up from endoscopic sinus surgery, and asthma requiring inhaled steroids and oral prednisone for control. Many patients required prednisone bursts for control of asthma. Number of days and total dose of oral prednisone were used as objective measures of asthma control. Number of weeks of antibiotics was used as a relative measure of sinusitis. Fourteen of the 15 patients meeting study criteria decreased their postoperative prednisone requirement by total number of days (preoperative 84 versus postoperative 63 days [p < 0.0001]). Postoperatively, patients required an average of 1300 mg less oral prednisone (p < 0.033). Antibiotic use also decreased, with an average use of antibiotic nine weeks preoperatively versus seven weeks postoperatively (p < 0.045). This study provides corroborative objective evidence that, at least in the short term, endoscopic sinus surgery is efficacious in the management of patients with chronic sinusitis and asthma.