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Background: Biofilms have been shown to be resistant to conventional antibiotic treatment. This study uses a sheep biofilm model developed by our department to investigate several novel topical anti-biofilm treatments., Methods: Staphylococcal biofilms were grown in 54 sheep frontal sinuses over 8 days: Each sinus was randomized to (1) no intervention, (2) single mupirocin flush, (3) regular 12-hourly mupirocin flushes for 5 days, (4) Citric Acid Zwitterionic Surfactant (CAZS) via hydrodebrider, (5) gallium nitrate, (6) CAZS with gallium nitrate, (7) CAZS with mupirocin, and (8) saline regular flushes. Sheep were sacrificed and the sinus mucosa harvested 1 or 8 days after treatment to assess treatment and any biofilm regrowth. Confocal scanning laser microscopy was used to confirm the presence or absence of biofilms, and the extent of biofilm reduction was quantitated using fluorescent in situ hybridization and colony forming unit counts., Results: In the control sheep biofilm coverage averaged 31.7%. Saline and mupirocin b.d. washes for 5 days had 23% and 0.84% coverage, respectively, when harvested on day 8. A single mupirocin and gallium wash had 7.7% and 16.2% on day 1 and 5.88% and 16.0% on day 8. CAZS with hydrodebrider had 6.66% on day 1 but 21.95% on day 8 whereas CAZS with hydodebrider and gallium had 13.3% on day 8., Conclusion: This study shows that regular treatment with mupirocin produced the most marked reduction in biofilm surface area coverage (0.84% and 1.25%) with sustained effects over the 8-day follow-up period.

Background: Nasal douching is common practice in treatment of chronic sinusitis and after endoscopic sinus surgery. Current nasal delivery techniques show inconsistent sinus penetration. The aim of this study was to compare sinonasal penetration of nasal douching to an optimized nasal nebulizer in an operated cadaver model., Methods: Fourteen preserved cadavers were used receiving complete sphenoethmoidectomies with a Draf III, wide maxillary antrostomy, or medial maxillectomy. Seven control cadavers received nasal douching with one standardized squeeze bilaterally of a 200-mL nasal irrigation bottle and seven intervention cadavers were nebulized with 3 minutes of the PARI sinus device bilaterally. Douching solutions were stained with methylene blue. Independent observers documented sinonasal anatomy, staining intensity, and percentage area covered by dye using standardized grading protocols., Results: Combined data showed a significant increase in intensity of stain (2.06 versus 0.26, p < 0.001), percentage of stain (49.96% versus 4.19%, p < 0.001), and circumference stained (76.59% versus 12.7%, p < 0.001) with the plastic nasal irrigation squeeze bottle versus PARI device. Analysis of individual sinuses consistently showed significant increases in indices of nasal douching relative to nebulization. The PARI sinus nebulizer was noted to reach the ethmoids regularly (92% incidence), whereas the other sinuses were not reached as regularly with incidences noted at frontal (43%), maxillary (46%), and sphenoid (54%). This compares to 96% of all sinuses being stained by the squeeze bottle., Conclusion: In all measured indices, the nasal douching method with the squeeze bottle was superior to the PARI sinus nebulizer in highly dissected sinonasal cadaver models.

Background: Nasal packing usually is placed after endoscopic sinus surgery (ESS) to control hemorrhage, but also may be used to prevent adhesions from forming and promote faster healing of damaged mucosa., Methods: A literature review was performed to identify all forms of scientifically evaluated absorbable packing for ESS. Only English studies identifiable within the PubMed database were included. Studies were categorized by level of evidence and evaluated for methodological errors., Results: Thirty-eight studies met the inclusion criteria. There was a diverse range of article evidence and quality., Conclusion: The most effective hemostatic agent currently available is FloSeal; however, this product causes an increase in adhesion formation. For the purpose of preventing adhesions, resorbable packs appear to have no benefit over either nonresorbables or no packing. If the middle turbinate is unstable at the conclusion of surgery, suturing it to the septum may reduce adhesions. Although mitomycin C, hyaluronic acid, and retinoic acid all have shown potential in these roles, to date, none have shown to be useful in the post-ESS chronic sinusitis human patient.

Background: Significant bleeding with blood clot formation in the postoperative period may predispose to the formation of postoperative adhesions. A topical hemostatic agent would potentially improve postoperative comfort and lessen adhesion formation. This pilot study was performed to evaluate the effects of a novel topical hemostatic agent AMICAR (epsilon-aminocaproic acid; Xanodyne Pharmacal, Inc., Florence, KY) on postoperative bleeding after endoscopic sinus surgery (ESS)., Methods: In a prospective randomized controlled pilot study full thickness mucosal injuries were created on the lateral nasal wall, ethmoturbinal and the maxillary ostium on both sides of 10 sheep. Eosinophilic chronic sinusitis was confirmed both by endoscopy and by biopsy before full thickness injuries. The topical hemostatic agent (AMICAR) was sprayed onto a randomly selected side with or without mucoadhesive methyl cellulose (5 sheep in each group). The control side received a spray of saline of equal volume. The degree of bleeding in the surgical field was graded using a visual analog scale until total hemostasis was achieved. The grades at 2-minute intervals as well as the time to achieve total hemostasis were recorded., Results: Eosinophilia of the epithelium did not correlate with the severity of bleeding (p<0.05). There was a statistically significant reduction in the grade of bleeding in the lateral nasal wall both superior and inferior to the middle turbinate attachment when AMICAR alone was used compared with normal saline (p=0.004 and p=0.003, respectively) but when AMICAR was used in combination with methyl cellulose this significance was lost (p=0.076 and p=0.502)., Conclusion: AMICAR may be considered for use either during or after sinus surgery to reduce bleeding.

Background: Although the existence of biofilms on the sinus mucosa of patients with chronic rhinosinusitis (CRS) is now well established, the role that these structures play remains unclear. It is thought that biofilms may contribute to the recalcitrant and persistent nature that characterizes CRS, but little research exists documenting the effect that they have on postoperative mucosal outcomes. This article presents a retrospective analysis of sinus surgical patients and correlates the presence of biofilms with mucosal outcomes. This study was performed to evaluate the role that bacterial biofilms have on post-sinus surgical outcomes., Methods: A retrospective analysis of prospectively collected data was performed on 40 patients undergoing endoscopic sinus surgery (ESS) for CRS. Preoperative demographic, clinical, and radiologic data were recorded from each patient and, intraoperatively, sinus culture specimens and mucosal samples were obtained for microbiological and microscopic examination. Biofilm determination was performed using confocal scanning laser microscopy. Postoperatively, patients were followed up for a minimum of 8 months with endoscopic evaluation of their sinonasal mucosa. The presence of ongoing symptoms was recorded also., Results: Bacterial biofilms were found in 20 (50%) of the 40 CRS patients. Patients with biofilms had significantly worse preoperative radiological scores and, postoperatively, had statistically worse postoperative symptoms and mucosal outcomes. The only other factor that was statistically related to an unfavorable outcome was the presence of fungus at the time of surgery. In this study the presence of polyps, eosinophilic mucin, or pus was not related to poor outcomes., Conclusion: This retrospective study showed that bacterial biofilms and fungus were correlated with the persistence of postoperative symptoms and mucosal inflammation after sinus surgery for CRS. This provides evidence that biofilms indeed may play an active role in perpetuating inflammation in CRS patients and may explain the recurrent and resistant nature of this disease. Therapies targeted at removing biofilms may be important in the management of recalcitrant CRS.

Background: Chronic rhinosinusitis (CRS) is a common inflammatory disorder of the paranasal sinuses. An abnormal host response to common bacterial or fungal pathogens is thought to be an important factor in the disease process. Host sinonasal epithelium plays an important role in initially recognizing the presence of microbes and responding by increasing production of antimicrobial peptides and cytokines, with recruitment of phagocytes and lymphocytes of the adaptive immune system, to eliminate the infection. Recently, the innate immune system and its complex interplay with the adaptive immune system are increasingly being recognized as important in the pathogenesis of chronic inflammatory diseases such as asthma and CRS., Methods: Review of recent findings on innate immunity in the pathogenesis of CRS., Results: New areas of research into potentially novel therapies for CRS are highlighted in this review, with emphasis on toll-like receptors, antimicrobial peptides (cathelicidins and defensins), and surfactant proteins., Conclusion: This review provides an overview of innate immunity in the sinonasal tract and discusses potential use of innate immune peptides as treatments against fungi, biofilms, and superantigens in CRS.

Background: The sheep is an established model for endoscopic surgical procedures, as well as for postsurgical healing. Standardization of the presence and the degree of eosinophilia within this model still has not been done. This study was undertaken to show the eosinophilic response secondary to Oestrus ovis parasitic infestation within the nasal cavity to standardize the sheep model of chronic rhinosinusitis (CRS) and to set diagnostic criteria for CRS in sheep., Methods: Nasal mucosal secretions were obtained from sheep naturally infested with O. ovis and showed signs of CRS and from sheep treated with ivermectin to prevent the infestation. Full thickness mucosal biopsy specimens from the lateral nasal wall were obtained also from these sheep. After histological fixing and staining, the degree of eosinophilia in the mucous secretion smears and in the epithelial layer of the lateral nasal wall was quantified using a light microscope., Results: The average number of eosinophils in the mucous secretions and in the nasal wall epithelium was significantly higher in the sheep that showed signs of rhinosinusitis and had visible O. ovis larvae compared with control sheep (p = 0.003 and p = 0.05, respectively)., Conclusion: Based on the average numbers of eosinophils observed the diagnostic criterion for CRS in sheep is two eosinophils per high-power field averaged over three fields of secreted mucous smears or an average of at least one eosinophil per high-power field of nasal wall epithelial biopsy specimens.

Background: Eosinophilic mucus chronic rhinosinusitis (EMCRS) patients are a subgroup of CRS with a poorer prognosis due to frequent recurrences of disease. The cathelicidin antimicrobial peptide (CAMP) is an important innate defense peptide but its role in CRS is not well characterized. The purpose of this study was to investigate CAMP mRNA and protein expression from EMCRS, CRS, and normal control patients., Methods: Biopsy specimens of nasal mucosa and nasal polyps were taken from 59 CRS patients and 9 controls. CAMP mRNA and protein levels were analyzed by real-time quantitative reverse-transcriptase polymerase chain reaction, immunoassay, Western blot, and immunohistochemistry., Results: The expression of CAMP mRNA was significantly increased in EMCRS patients compared with CRS patients (p = 0.0004). By immunohistochemistry, expression of CAMP was localized to nasal epithelial, submucosal glands, and inflammatory subepithelial cells. Western blotting confirmed the presence of CAMP in EMCRS, CRS, and control patients. However, we did not detect statistically significant differences in the protein levels in tissue homogenates between EMCRS, CRS, and control patients., Conclusion: This study shows expression of CAMP in nasal mucosa supporting its role in innate defenses against inhaled pathogens. Although CAMP mRNA was up-regulated in EMCRS patients, there were no statistically significant differences in protein levels in the nasal mucosa of EMCRS compared with CRS patients and controls.

Background: The aim of this study was to describe our two-surgeon fully endoscopic approach to pituitary surgery and to report results in terms of tumor remission, improvement in vision, and complications. A retrospective chart review was performed., Methods: Our prospectively recorded surgical database was searched for all endoscopic transsphenoidal procedures between January 2001 and December 2005. Those patients who had surgery had their medical charts reviewed and presenting symptoms and signs, lesion characteristics, endocrine investigations, operative details, complications, and treatment outcomes recorded., Results: Thirty-two patients were included in the study. Twenty-three patients had macroadenomas, five patients had microadenomas, and four patients had other pathologies. Most patients with macroadenomas had significant supra- or parasellar extension. Of the 14 patients who had visual loss at presentation, 13 had postoperative improvement. Two patients had postoperative cerebrospinal fluid leaks, which were successfully treated endoscopically. Eight patients required some form of hormone replacement after surgery. After a mean follow-up of 31 months, the overall remission rate for patients with macroadenomas was 82% and for patients with microadenomas was 100%., Conclusion: The fully endoscopic transsphenoidal approach provides excellent visualization for tumor resection and results in acceptable remission rates.

Background: Fungus is thought to play an important role in some subgroups of chronic rhinosinusitis (CRS) patients with eosinophilic mucus (EMCRS). The cathelicidin LL-37 is an important innate defense peptide with antimicrobial activity but its responses in CRS and EMCRS patients have not been established. We investigated the innate immune responses of LL-37 in nasal tissue from CRS and EMCRS patients to fungal allergen challenge., Methods: The levels of LL-37 produced by nasal tissue and secreted in response to fungal allergen challenge were determined by a nasal tissue explant in vitro model. LL-37 mRNA and protein levels were quantified by real-time reverse-transcriptase-polymerase chain reaction and immunoassay methods., Results: LL-37 mRNA expression in CRS, but not EMCRS patients, is significantly upregulated by Aspergillus (mean fourfold increase) and Alternaria (mean sixfold increase) extracts in a dose-response manner (p < 0.001). LL-37 peptide levels in the nasal tissue from CRS patients are increased in response to Alternaria (p < 0.05). In contrast, with EMCRS patients, the expression of LL-37 peptide in nasal tissue is increased with Aspergillus (p < 0.001) but is reduced with Alternaria. We also observed a trend where levels of secreted LL-37 were decreased with higher doses of Alternaria and Aspergillus extracts., Conclusion: LL-37 is significantly up-regulated at the mRNA and protein level in CRS patients in response to fungal allergens. However, EMCRS patients do not show increased LL-37 at either the mRNA or the protein level in response to Alternaria.

Background: Bacterial biofllms have been shown in chronic diseases such as cystic fibrosis, cholesteatoma, and otitis media with effusion. Recently, their detection on the mucosal tissue of sinusitis patients has implicated them in the pathogenesis of this condition. We present an animal model using sheep experimentally infected with Staphylococcus aureus to study the possible association between biofilm and sinusitis., Methods: Twenty-four sheep underwent bilateral endoscopic sinus surgery to identify their frontal ostia. The frontal sinuses were treated in one of the following ways according to preoperative randomization: (1) ostium left patent, (2) ostium left patent and bacteria instilled, (3) ostium occluded, or (4) ostium occluded and bacteria instilled. The frontal mucosa was harvested at day 7 and examined for biofilm presence using confocal scanning laser microscopy (CSLM) as well as scanning electron microscopy (SEM) and transmission electron microscopy (TEM)., Results: All three modalities showed different rates of biofilm detection. Three-dimensional structures that could be interpreted as biofilms were documented in 86% (n = 36) of the sinuses analyzed using SEM. These structures were seen in all four study groups. The detection rate using the other two modalities was much lower with CSLM, showing biofilms in 48% (n = 20) and TEM in only 29% (n = 12) of the sinuses analyzed. Unlike SEM, these two modalities only detected bacterial biofilms in sinuses randomized to bacterial instillation., Conclusion: The demonstration of bacterial biofilms in this animal model of sinusitis further supports the hypotheses that biofilms may play a role in the pathogenesis of this condition. There is an obvious discrepancy in the sensitivity and specificity of biofilm detection using the three modalities mentioned. CSLM appears to be the most objective technique. The inherent flaws, sampling error, and subjectivity involved in SEM and TEM make these less reliable in documenting biofilm existence.

Background: Canine fossa puncture (CFP) is a technique that improves access to the maxillary sinus and may be required to ensure complete disease removal from this sinus. Traditional approaches through the canine fossa often have resulted in injury to branches of the infraorbital nerve. The aim of this study was to determine the frequency, severity, and duration of complications using recently described. landmarks for determining the optimal site for anatomically directed CFP (aCFP) and a new endoscopic retractor and drill guide that enable endoscopically guided canine fossa trephination (eCFT). These complication rates have been compared with those that we have described previously using a standard technique of CFP., Methods: A total of 63 patients were included with 36 bilateral procedures giving a total number of 99 procedures performed. Of these, 32 procedures were performed using anatomic landmarks (aCFP) and 67 were performed with additional endoscopic guidance (eCFT). Patients were assessed at a mean time of 12.6 months (range, 3-26 months) after surgery by telephonic survey and their complications were assessed and graded for severity on a 0- to 10-point scale., Results: The combined frequency of adverse events after aCFP and eCFT were 45% compared with the previously reported 76% with the traditional technique (p = 0.001). The number of patients complaining of persisting adverse effects was reduced from 29% after CFP to 5% after aCFP and eCFT (p < 0.001). The 67 eCFT technique had a significantly lower frequency of adverse events (40%) than the aCFP technique (53%; p < 0.05)., Conclusion: The recently described landmarks to site the CFP result in statistically fewer complications. This complication rate is further reduced if CFT is performed under direct endoscopic vision.

Background: The aim of this study was to determine whether atopy influences either clinical and radiological severity or surgical revision rates in patients with chronic rhinosinusitis (CRS)., Methods: Patients who had been scheduled for endoscopic sinus surgery were classified as having CRS or nasal polyposis. Their atopic status was determined by ImmunoCAP testing. Disease severity was assessed clinically by the Lund symptom and Sino-Nasal Outcome Test 20 (SNOT-20) quality-of-life scores and radiologically by the Lund-Mackay CT score., Results: One hundred ninety-three consecutive patients with rhinosinusitis were included in the study. The prevalence of atopy in this group was found to be 30%. No association was found between atopic status and Lund symptom scores. Analysis of the SNOT-20 scores indicated that atopic patients had higher sneezing scores (p < 0.03), reduced productivity (p < 0.01), and reduced concentration (p < 0.01). The mean CT score was significantly higher in the atopic patients than in nonatopic patients overall (14.2+/-1.6 versus 12.2+/-1.3; p = 0.05), although within each of the clinical subgroups no statistically significant relationship was observed between a patients' atopic status and their CT scores. The rate of revision surgery was not significantly different between atopic and nonatopic patients., Conclusion: These results suggest that atopic status has minimal impact on the severity of CRS.

Background: The aim of this study was to determine the expression of cell cycle regulation genes in patients with inverted papilloma (IP) and compare this with expression in patients with nasal polyps (NPs)., Methods: Tissue from 18 patients with IP and 5 patients with NPs were stained by immunohistochemistry techniques for p53 and p27. Measurement of the gene expression was performed by three assessors, who we blinded with respect to the specimens., Results: The mean score for p53 expression (3.33) was significantly higher in the IP group than the NP group (1.46). The mean difference between IP and NPs was 1.80 (CI, 1.15-2.46; p = 0.003). Additionally, we showed in a number of individuals variation in the p53 expression within the same specimen. There was no difference in the mean scores for p27, with the mean difference 0.79 (CI, 0.30-1.89; p = 0.147)., Conclusion: Our study established a significantly increased expression of p53 in IP when compared with NPs. Additionally, there appear to be two different cell populations identified within the same specimens, which exhibited variation in their p53 expression.

Background: Insulin-like growth factors (IGFs) I and II, being potent promoters of cellular growth and differentiation, were investigated for their effectiveness in improving the rate of scratch closure in human respiratory epithelium in vitro., Methods: Human epithelial cell lines from the nasal, bronchial, and tracheal regions were analyzed for their response to IGF-I and IGF-II, in a confluent monolayer scratch assay. IGF-binding proteins (IGFBPs) produced by certain cells are able to reduce the effectiveness of the IGFs. Consequently, the analogues LongR3 IGF-I, Des1-3 IGF-I and Arg3 IGF-I were investigated also because of their lower affinity for the IGFBPs, while still retaining unaffected affinity for the IGF-I receptor., Results: All growth factors that were analyzed significantly improved the rate of scratch closure in bronchial and tracheal epithelial cells (p < or = 0.05). In comparison, scratch closure was markedly slower in nasal epithelial cells and IGF-I was the most effective growth factor at effecting scratch closure in these cells. The IGF-I analogues did not significantly improve scratch closure compared with IGF-I, despite the presence of IGFBP-3 in nasal, bronchial, and tracheal epithelial cells., Conclusion: Addition of IGF-I to wounded nasal epithelial cells increases the rate of scratch closure and therefore may have potential for improving the healing of the nasal mucosa.

Background: Vidian neurectomy has in the past been advocated for the treatment of vasomotor rhinitis. With the recent better understanding of nasal and sinus anatomy, the surgical technique and outcomes of this procedure have been reassessed in this preliminary report., Methods: A total of nine patients with symptoms of vasomotor rhinitis underwent 14 endoscopic vidian neurectomies between 1998 and 2001. All patients had negative screening for allergies on their serum or on skin-prick tests. The surgical technique for endoscopic vidian neurectomy is presented. The outcomes for the patients were retrospectively assessed with patients asked to score their pre- and postoperative symptoms rating these symptoms on a scale of 1-10 after a mean follow-up of 25 months (range, 21-36 months)., Results: On this retrospective analysis there was a significant improvement in the symptoms of rhinorrhea (p = 0.018) and nasal obstruction (p = 0.011). There was no significant difference between the pre- to postoperative symptoms for postnasal drip or sneezing. The most common minor adverse effect was dry eyes (35.7%) and nasal crusting (28.6%)., Conclusion: Endoscopic vidian neurectomy improves the symptoms of nasal obstruction and rhinorrhea in patients with vasomotor rhinitis.

Background: Noninvasive fungal sinusitis is a heterogenous group of conditions including allergic fungal sinusitis (AFS) and nonallergic eosinophilic fungal sinusitis (NEFS). Th2-mediated cascades have been postulated to be the major inflammatory response in patients with AFS although other mechanisms also may be involved. The detailed mucosal Th2 cytological status of NEFS still has not been studied in great depth., Methods: Using a meticulous patient selection algorithm over a 2-year period, infundibular mucosal tissue from patients with AFS, NEFS, chronic rhinosinusitis (CRS), and normal controls was studied (n = 59). Immunohistochemistry for mast cells, eosinophils, and immunoglobulin E (IgE) cells was performed and cell counts per unit area were measured., Results: Mast cell, eosinophil, and IgE+ cell numbers were significantly raised in patients with AFS, NEFS, and CRS when compared with controls. There was no significant difference between cell numbers in patients with AFS and NEFS., Conclusion: Patients with AFS exhibit a classic Th2 inflammatory response in nasal mucosal tissue with NEFS and CRS patients showing evidence of a similar Th2 cascade, including the presence of IgE+ cells.

Background: The aim of this study was to determine whether there was any benefit or detrimental consequences of placing a hyaluronic acid pack (Merogel) into the middle meatus after endoscopic sinus surgery (ESS)., Methods: A randomized controlled blinded study was performed in 42 patients with chronic sinusitis undergoing ESS. The patients were randomized to receive Merogel on one side and no packing on the other side. Patients were assessed at 2, 4, and 6-8 weeks after surgery and the presence of synechia, edema, and infection was noted with the observer blinded to the side that had received the Merogel., Results: At 2 weeks the side packed with Merogel had 35% synechiae, 83% edema, and 30% mucopurulent discharge and on the control side the figures were similar with 22.5% synechiae, 83% edema, and 28% mucopurulent discharge. In both groups these figures improved over the observation period but percentages in the groups remained similar. At no time point was the difference between the packed and unpacked sides statistically significant for any of the measures when assessed with Fisher's exact test., Conclusion: Merogel nasal packing has no significant beneficial or detrimental effect in terms of synechia, edema, or infection when placed in the middle meatus after ESS.

Background: There is a lack of knowledge about the healing of the nasal respiratory mucosa after endoscopic sinus surgery (ESS). Nasal packs often are placed after ESS in an attempt to improve hemostasis and reduce adhesion formation. Most nasal packs need to be removed in the postoperative period. This is uncomfortable for the patient and the affect of these packs on the healing process is unknown., Methods: We have standardized the sheep as a suitable animal model to examine the healing of the nasal epithelium after ESS. The nasal mucosa of sheep was wounded under endoscopic guidance and either packed with expandable polyvinyl acetate-based pack (Merocel), which was removed at the 5th postoperative day, or left unpacked to serve as control. Serial biopsies of the wounded area were taken every 28 days, up to 112 days postwounding, for examination using light and scanning electron microscopy., Results: There was no significant difference in the rate of reepithelialization between the packed and control sides of the sheep (p > 0.05). There was no significant difference in the total amount of surface cilia coverage between the packed and control sides at any time points (p > 0.05). There was no significant difference in the maturity of the cilia between the packed and control sides at any time points (p > 0.05)., Conclusion: The use of Merocel packing postoperatively neither impairs nor promotes wound healing in the postoperative period.

Background: A hyaluronic acid-based nasal pack has been shown previously to have a beneficial effect on mucosal healing in a healthy sheep model. However, endoscopic sinus surgery (ESS) usually is performed in the presence of infection and inflammation. The aim of this study was to examine the efficacy of hyaluronic acid-based nasal packing on mucosal healing in a sheep model of chronic sinusitis., Methods: A standardized sheep model of chronic sinusitis was used. Full-thickness mucosal injuries were performed under endoscopic guidance with a microdebrider. Adjacent wounds were created between the lateral nasal wall and the ethmoid turbinate. Then, the injuries were either packed with a dissolvable hyaluronic acid-based pack or left unpacked to serve as a control. Serial biopsies of the healing mucosa were performed at days 28, 56, 84, and 112 postsurgery, and the presence or absence of adhesions between the ethmoid turbinate and lateral nasal wall was noted. The biopsy specimens were assessed for reepithelialization and epithelial height using light microscopy, and for reciliation using scanning electron microscopy., Results: There was no significant difference in reepithelialization or relative epithelial height between the packed sides and the control sides at any time point. There was a statistically significant difference in reciliation between the two groups at day 112 but this was not deemed clinically significant. The packing had no significant effect on adhesion formation., Conclusion: In the sheep model of chronic sinusitis, a dissolvable hyaluronic acid-based pack did not have any significant effect on mucosal healing or adhesions formation after ESS, as assessed by examining reepithelialization, epithelial height, reciliation, and the presence of adhesions.

Background: Endoscopic sinus surgery (ESS) is the accepted surgical treatment for chronic refractory rhinosinusitis. Prolonged healing and adhesion formation remain common problems. This study investigates the use of a hyaluronic acid-based pack impregnated with insulin-like growth factor (IGF) 1 to facilitate more rapid and effective healing after ESS in a healthy sheep model and a sheep model of chronic sinusitis., Methods: This study used 12 healthy sheep and 9 sheep with chronic sinusitis. In each sheep one side (computer randomized) was used as a control. Under endoscopic guidance, mucosal injuries and adhesions were created on both sides and were either packed with a hyaluronic acid pack impregnated with IGF-1 or left unpacked as a control. Serial biopsies were performed for 4 months., Results: In the healthy sheep there was a statistically significant (p < 0.05) improvement in reepithelialization in IGF-1 packed wounds at day 28 (89% for IGF-1 versus 44% for controls). In both healthy sheep and sheep with sinusitis there was no significant difference in mucosal reepithelialization at any of the other measured time points. In the sinusitis group, there was a significant decrease in ciliary regeneration at day 56 in the Merogel/IGF-1 group compared with the control group: 59.20% versus 77.68% (p < 0.01) and at day 112, 69.70% versus 87.26% (p < 0.01)., Conclusion: Hyaluronic acid impregnated with IGF-1 improved reepithelialization in the healthy sheep but not in the sheep with chronic rhinosinusitis. These packs had a detrimental effect on mucosal ciliary regeneration in the sheep with chronic rhinosinusitis.

Background: The aim of this study was to determine the effect of pterygopalatine fossa infiltration with lidocaine and adrenalin on bleeding in the surgical field during endoscopic sinus surgery., Methods: A prospective blind randomized controlled trial was performed. Fifty-five patients were randomized to receive a unilateral transoral infiltration of the pterygopalatine fossa with 2 mL of 2% lidocaine and 1:80,000 adrenalin. The operating surgeon was blinded as to which side had been infiltrated at the start of surgery. The surgical field was graded on a previously validated surgical field grading scale every 15 minutes with the side being operated on alternated every 30 minutes. The pulse, mean arterial blood pressure, and end-tidal CO2 concentration were monitored with each surgical field observation., Results: At each individual time point from 30 minutes to 3.5 hours there was a significant difference in surgical grade between injected and noninjected sides in favor of the injected side (p = 0.01). The difference between surgical grades averaged across all time points was slight but significant. The injected side had an overall mean of 2.59 (SE, 0.22) compared with 2.99 (SE, 0.23) for the noninjected side. Heart rate also was found to correlate independently to surgical grade., Conclusion: Injection of the pterygopalatine fossa resulted in an improved surgical field during endoscopic sinus surgery.

Background: Patients with extensive disease affecting the maxillary sinus may require a canine fossa approach for complete removal of disease. This study was designed to determine the complications associated with this procedure., Methods: We performed a retrospective study of 21 patients who had undergone a canine fossa puncture at an academic hospital complex in Adelaide, Australia., Results: A total of 37 canine fossa punctures were made in 21 patients. Twenty-eight of the 37 (75.7%) sides in which a canine fossa puncture was performed experienced a complication. The most common complaint was of cheek swelling in 14 (38%) followed by facial pain in 12 (32%), facial numbness in 11 (30%), cheek pain in 10 (27%), dental numbness in 10 (27%), gingival complications in 9 (24%), and facial tingling in 6 (16%) of sides. Most complications (75.5%) resolved within the 1st month after surgery. Six patients (28.6%) had persistent complications with facial tingling in 3 patients (50%) followed by facial numbness and tingling in 1 patient (11%), facial numbness alone in 1 patient (8.3%), and facial pain in 1 patient (7.1%)., Conclusion: Canine fossa antrostomy is a technique that provides additional access to the maxillary sinus. Surgeons need to be aware that, although minor, a significant number of patients will experience both transient and long-term complications.

Background: This study was designed to assess the relative efficiency of three different culture media for isolating fungi in patients suspected of having noninvasive fungal sinusitis., Methods: A prospective study was performed of 209 operative samples of sinus "fungal-like" mucin from 134 patients on 171 occasions and processed for microscopy and fungal culture in Sabouraud's dextrose agar, potato dextrose agar, and broth media., Results: Ninety-three (69%) of 134 patients had evidence of fungal infection. Two-thirds of patients had negative microscopy samples yet 56% of these went on to positive cultures. Forty-five percent cultured Aspergillus genus. Discrepancy between the fungi cultured in different media and on different occasions was common. With a single culture medium up to 19% of patients and 15% of samples would have been falsely labeled fungal negative., Conclusion: Increasing the number and type of fungal culture media used increases the number and range of fungal isolates from mucin in patients with the features of fungal sinusitis. Negative specimen microscopy is unreliable. All specimens should be cultured in multiple media and on multiple occasions when fungal sinusitis is suspected.

Background: Cells pneumatizing through the frontal ostium may vary in the degree of frontal sinus penetration. This series describes the use of the axillary flap technique and the endoscopic modified Lothrop procedure (EMLP) for the removal of cells that pneumatize to a varying degree through the frontal ostium into the frontal sinus., Methods: Out of a total of 204 patients undergoing endoscopic sinus surgery, 31 patients had a cell on one side and 7 patients had bilateral obstructive cells resulting in 38 sides undergoing an axillary flap approach for the removal of the obstructing cell. In 13 patients, the obstructing cell was deemed inaccessible by conventional technique and these patients underwent an EMLP for removal of the obstructing cell., Results: All patients who underwent both the axillary flap approach and the EMLP had a patent frontal ostium confirmed endoscopically at the last follow-up visit. However, 8 of the 38 sides (21%) that underwent the axillary flap procedure had residual minor symptoms with four patients (30%) who underwent an EMLP having a recurrence of minor symptoms, Conclusion: The axillary flap and the EMLP can be used to remove successfully ethmoidal cells that have pneumatized through the frontal ostium.

Background: The aim of this study was to document the prevalence of noninvasive fungal sinusitis in patients with chronic sinusitis and thick viscous secretions in South Australia., Methods: We studied of 349 patients with chronic rhinosinusitis undergoing endoscopic sinus surgery in a specialized rhinology practice. Patients with nasal polyposis and thick fungal-like sinus mucin had operative samples sent for microscopy and fungal culture. Evidence of atopy was taken as positive radioallergosorbent or skin-prick tests to fungi., Results: One hundred and thirty-four (38%) patients were noted to have thick, viscid sinus mucin, raising suspicion of fungal disease. Ninety-three patients had positive fungal cultures or microscopy (26.6%). It was possible to classify 95.5% of the patients into subgroups of noninvasive fungal sinusitis or nonfungal sinusitis: 8.6% of patients with allergic fungal sinusitis, 1.7% of patients with allergic fungal sinusitis-like sinusitis, 15.2% of patients with chronic fungal sinusitis, one patient with a fungal ball, and the remaining 69% of patients with nonfungal chronic sinusitis., Conclusion: This is the first prospective study to evaluate the prevalence of these increasingly widely recognized conditions. It highlights the need for otolaryngologists to be alert to these not uncommon diagnoses in order for early, appropriate medical and surgical management to be instituted.

Background: Nitric oxide (NO) is produced in significant quantities in the nasal sinuses and is thought to have a beneficial effect on the mucociliary transport of the sinuses and nose and to have significant antibacterial properties that contribute to the health of the sinuses. Recently, the concept of "mini-functional endoscopic sinus surgery" has been introduced where the uncinate is removed without enlargement of the maxillary ostium. Although no scientific evidence has been published, enlargement of the ostium is thought to possibly disrupt the mucociliary pathway and decrease the concentration of NO in the nose and sinuses. The aim of this study was to establish the effect of enlargement of the maxillary ostium on sinus and nasal NO., Methods: Twenty-nine patients who were post-endoscopic sinus surgery were included with 52 who were maxillary sinus ostia cannulated. There were 22 large maxillary sinus ostia and 30 small ostia. Smoking, allergy status, and topical steroid use were recorded. NO levels were measured in the nose and maxillary sinus after decongestion with patients mouth breathing and breath holding., Results: This study shows that enlargement of the maxillary sinus ostium above its normal size (20 mm2) produces a significant decrease in both the maxillary sinus and the nasal cavity NO levels. In addition, the size of the ostium showed a significant correlation to the sinus NO level. Use of topical nasal steroid sprays and topical decongestants were shown to effect NO levels in the sinuses and nasal cavity. The lowered levels of NO were found irrespective of the technique of measurement of the NO., Conclusions: The effect of this lowered NO level on the susceptibility of the maxillary sinuses to recurrent infection is yet to be determined.

Introduction: There is a paucity of knowledge about the healing of the nasal respiratory mucosa after endoscopic sinus surgery (ESS). Nasal packs often are placed after ESS in an attempt to reduce adhesions but the effect of these packs on the healing of the nasal mucosa is not known., Methods: A standardized normal animal model (the sheep) was used to examine the healing of the nasal epithelium after ESS. A full-thickness wound was created in the nasal mucosa and either packed with a dissolvable hyaluronic acid-based pack or left unpacked to serve as control. The wounded areas were biopsied at 28, 56, 84, and 112 days postinjury and epithelialization, and cilial regeneration was assessed by light microscopy and scanning electron microscopy., Results: The wounds with the dissolvable hyaluronic acid-based packs showed no differences in reepithelialization up to 84 days postwounding. However, a significant increase in reepithelialization was observed on day 84 in packed wounds compared with unpacked controls, indicating an increased rate of healing at that time point. In addition, there was a significant increase in the epithelial height in the packed wounds on day 28, indicating that packing was affecting the epithelial maturity of the mucosa. No significant difference was observed in cilial regeneration between the packed and control wounds., Conclusions: Application of the hyaluronic acid-based nasal packs to wounds after ESS may improve reepithelialization of the nasal mucosa but appears to have minimal effect on reciliation at the time points studied in normal-healing wounds.

Aims: The use of multiplanar reconstructed computed tomography (CT) images of frontal recess and sinuses was assessed with regard to depiction and understanding of anatomy and effect on surgical approach., Materials and Methods: Three otorhinolaryngologists and one radiologist read CT scans of 43 patients referred for routine paranasal sinus scans. Spiral (helical) CT scans were obtained and coronal and parasagittal reconstructions were imaged. Three hundred forty-two readings were analyzed. The scans were assessed in the coronal plane and then in the parasagittal plane. The images were assessed for (i) Bent and Kuhn classification of frontal ethmoidal sinus air cells, (ii) size of frontal sinus ostium (assessed as unsure, normal, small, or large), (iii) use of parasagittal scans regarding additional understanding of the anatomy with particular reference as to how the agger nasi cell and frontal ethmoidal cells were arranged in a three-dimensional space, and (iv) if the parasagittal scan and subsequent three-dimensional picture created altered the surgical approach. The first two criteria were assessed in the coronal plane and then in the parasagittal plane., Results: There was no statistically significant difference between the Bent and Kuhn classification of frontoethmoidal cells on coronal and reconstructed parasagittal images (t-test; p > 0.05). The parasagittal scans were significantly better than the coronal scans for identifying and assessing the size of the frontal sinus ostium (p < 0.001; chi-square test). Assuming an intraobserver change rate (repeat error) of 10% on CT scan observations, an exact binomial test was performed on S-PLUS, which showed that there was a significant (p < 0.001) proportion of observers who changed their rating after looking at the parasagittal scan. There also was significant improvement in observers' abilities to identify and classify the size of the frontal ostium as reflected by the number of observers who changed from being unsure on the coronal scans to sure on the parasagittal scans. Observers felt that the parasagittal scans improved their three-dimensional understanding of the anatomy of the frontal recess by 58% on a 10-point Lickert scale. In 55% of these observations, the surgical plan was altered by a mean of 70.2% on a 10-point Lickert scale based on additional information obtained by viewing the parasagittal scans., Conclusions: The three-dimensional understanding of the frontal recess is improved greatly by using both coronal and parasagittal reconstructed images as compared with coronal images alone. This had important implications on the planning of the surgery in the frontal recess.