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Background Despite recent evidence suggesting that Staphylococcus aureus exists within the sinonasal epithelium of chronic rhinosinusitis (CRS) patients, certain questions remain. The intracellular environment may provide a protective niche for pathogenic bacteria to evade host immunity and yet provide a reservoir for reinfection. To date, no studies have examined the impact of this bacterial phenotype; therefore, this study was designed to evaluate the role of intracellular S. aureus on postsurgical outcomes. Methods This study included 51 patients undergoing endoscopic sinus surgery (ESS) for medically-recalcitrant CRS. Sinonasal mucosa harvested at the time of surgery was dually stained with fluorescent molecular probes and imaged using confocal scanning laser microscopy for biofilm and intracellular status. Patients were followed in their early and late postoperative course for evidence of ongoing disease and signs of clinical relapse. Results Intracellular S. aureus was identified in 20 of 51 (39%) patients, and all were associated with surface biofilm. Biofilm alone was found in 16 of 51 (31%) patients and 15 of 51 (29%) patients had no evidence of S. aureus. Intracellular positive patients had a significantly higher risk of late clinical and microbiological relapse (p = 0.014). In this study, biofilm status without coexisting intracellular bacteria did not appear to impact on outcomes. Conclusion Clinical and microbiological relapse of disease following ESS is significantly associated with intracellular S. aureus. Evidence suggests that this disease association is independent to surface biofilm status. Intracellular bacteria should be taken into consideration when designing novel treatment strategies to lessen the chance of reinfection.

Background Staphylococcus aureus (S. aureus) biofilm has been associated with severe and recalcitrant cases of chronic rhinosinusitis (CRS). However, its role in the pathophysiology of this condition is not completely understood. This study aims to develop a sinonasal tissue explant model to analyze the interaction of S. aureus biofilm with the mucosa in vitro. Methods Sinonasal tissue samples from 5 control patients undergoing pituitary surgery were cultured with and without S. aureus biofilm in vitro. Confocal scanning laser microscopy (CSLM) using the Live/Dead BacLight stain and histology were performed on the tissue explants after 24 hours of biofilm challenge. Measurements of IL-6, at both the messenger RNA (mRNA) level (using quantitative reverse-transcriptase polymerase chain reaction [qRT-PCR]) and the protein level (using enzyme-linked immunosorbent assay [ELISA]), were undertaken to evaluate biofilm-mucosa interaction. Results Viability of the explants after 24 hours was confirmed by CSLM and histology. Although light microscopy failed to identify S. aureus biofilms, its presence was confirmed in the biofilm-challenged samples by CSLM. IL-6 mRNA transcript levels were 4.9-fold upregulated in biofilm-treated tissue compared to controls (p = 0.0485). A similar trend was observed at the protein level (p = 0.0313). Conclusion The sinonasal tissue explant is a viable and functional model capable of analyzing direct biofilm-mucosal interactions and can advance our understanding of the role played by S. aureus biofilm in sinus inflammation. Our model suggests that S. aureus biofilms in the initial phase of growth are not inert bystanders but elicit an immune response in the sinonasal mucosa.

Purpose of review Evidence suggests that some structural changes caused by mucosal remodeling may be primarily irreversible, which theoretically challenges the current management model of chronic rhinosinusitis (CRS). The relationship between inflammation and remodeling in the mucosa remains complex, yet better understanding of involved pathways holds potential clinical implications. This article reviews the controversies as well as current applications from the literature. Recent findings First, the relationship between inflammation and remodeling is a complex one involving multiple pathways, with evidence suggesting that remodeling is not a simple fibrotic end-stage process secondary to long-standing inflammation. Second, anti-inflammatory approaches alone are probably not successful in reversing changes such as collagen deposition, indicating that early treatment might be crucial for preventing disease progression. Third, a dysfunctional sinus remains a pure clinical/surgical phenomenon with lack of histological characterization. Fourth, maximal/extensive surgical techniques are advocated for patients with severe disease or dysfunctional sinuses. Summary Reversibility of remodeling holds implications for the management of CRS. Although clinical applications (both medical and surgical) exist, further research is required for solidifying current evidence as well as exploring new avenues for therapy.

Background Stenosis of sinus ostia following endoscopic sinus surgery (ESS) is the most common reason for revision surgery. Chitosan-dextran (CD) gel has been shown to be an effective hemostatic agent; however, its effects on ostial stenosis are unknown. This study aims to quantify the effect of CD gel on circumferential scarring following ESS. Methods A prospective, blinded, randomized, controlled trial was conducted in 26 patients undergoing ESS. Measurements of neo-ostia were taken using a standard-sized measuring probe. CD gel was applied unilaterally, while contralateral sides received no gel. Ostial diameters were measured by a blinded observer at 2, 8, and 12 weeks postoperation. Sinus ostial areas calculated as a proportion of the original were compared for each ostium at each time point. Results Intraoperative ostial areas were comparable for CD gel and control sides (38 mm2 vs 39 mm2, 131 mm2 vs 120 mm2, and 203 mm2 vs 193 mm2, in frontal, sphenoid, and maxillary ostia, respectively; p > 0.05). CD gel significantly improved sinus ostial patency. The largest difference was seen when ostial areas at 12 weeks were compared with their corresponding baseline areas (66% vs 31% frontal, p 0.05) at 12 weeks. Conclusion CD gel produced significantly less stenosis of all neo-ostia following ESS and may reduce the necessity for revision surgery in patients with chronic rhinosinusitis.

Background Fungal biofilms have been discovered in chronic rhinosinusitis (CRS) patients, but factors contributing to their establishment are obscure. A recent animal study showed bacterial co-inoculation was required. We examine the role of 4 bacterial species and a cilia toxin on fungal biofilm formation in a sheep sinusitis model. The importance of epithelial integrity on fungal biofilm formation is also examined. Methods Forty-eight frontal sinuses were inoculated with Aspergillus fumigatus alone, with 1 of 4 bacteria, or a cilia toxin. Bacterial and fungal biofilm was determined using confocal scanning laser microscopy. Inflammation and cilia integrity were assessed using light microscopy and transmission electron microscopy, respectively. Results No fungal biofilm formed when inoculated alone. Florid fungal biofilm developed in more than 75% of sinuses associated with bacterial biofilm of all species, except Haemophilus influenzae, which failed to establish bacterial biofilm. Fungal biofilm also established in association with cilia toxin. Significant cilial damage was incited by all bacterial biofilms and cilia toxin, and was associated with fungal proliferation. Fungal biofilm formation did not significantly increase mucosal inflammation or epithelial damage over that caused by the bacteria or cilia toxin alone. Conclusion Bacterial biofilms cause sinonasal mucosal inflammation and epithelial injury, which provides conditions appropriate for fungal biofilm proliferation. The role of cilia in sinonasal mucosal defense against fungal organisms has been demonstrated. Without such an insult, fungal biofilms fail to proliferate in occluded sinuses. Improving cilial recovery postoperatively and treating bacterial biofilms may be key factors in reducing recalcitrance in allergic fungal rhinosinusitis patients.

Our understanding of chronic rhinosinusitis (CRS) show biofilm and osteitis play a role in the disease's pathogenesis and refractory. Studies point to its role in pathogenesis and poor prognosis. Outside the research laboratory, biofilm detection remains difficult and specific treatment remains elusive. It is believed that osteitis is a nidus of inflammation and occurs more commonly in patients with refractory CRS. However, osteitis may be exacerbated by surgery and a marker of refractory disease, not a causative agent. Surgery remains the mainstay treatment for biofilm and osteitis with mechanical disruption and removal of disease load providing the most effective treatment.

Objectives: Nasal irrigation is standard in the management of chronic rhinosinusitis both before and after surgical intervention. Numerous irrigation devices are commercially available. The aim of this study was to compare the efficacy of a handheld pulse irrigation device against the gold standard manual squeeze bottle after endoscopic sinus surgery (ESS). Methods: Five cadaveric specimens were prepared with video visualization ports into each sinus. Endoscopic sinus surgery was performed on each cadaver from minimal to maximal dissection. Sinuses were irrigated with fluorescein solution using both devices following each dissection. The irrigations were video recorded. A blinded independent observer scored each irrigation according to a defined scale. Results: Comparison of the 2 devices using an intraclass correlation coefficient (ICC = 0.39) showed the 2 systems differed. Observation of individual sinuses showed the squeeze bottle consistently provided greater irrigation in the maxillary ( P < .006), frontal ( P < .0001), and sphenoid ( P < .0001) sinuses. Pulse irrigation improved only in the maxillary sinus following ESS. Conclusion: The squeeze bottle consistently demonstrated superior irrigation in both native and operated conditions. Interestingly, saline penetration was not significantly improved after opening of the frontal and sphenoid sinuses. This is likely due to decreased backpressure in the nasal passage after opening the sinus cavities.

Adhesion formation and ostial stenosis are common causes of surgical failure after endoscopic sinus surgery (ESS). Postoperative topical steroid application has been shown to improve wound healing. Chitosan-dextran gel (CD gel) is an effective hemostatic nasal dressing. This study aims to determine the effect of the addition of budesonide to CD gel on postoperative ostial stenosis and adhesion formation following ESS.This prospective, blinded, randomized controlled trial was conducted between October 2012 and April 2015. Thirty-six patients over 18 years undergoing ESS were randomized to receive either: no treatment, CD gel, CD gel with 1 mg/ 2 mL budesonide, or topical steroid cream to their left or right sinuses (different treatment each side). Each sinus ostium and endoscopic features of wound healing was measured intraoperation, and 2 weeks, 3 months, and 12 months postoperation.Data was analyzed using the analysis of variance (ANOVA) and post hoc Tukey honestly significant difference (HSD) tests. There was a significant reduction in stenosis within all 3 sinuses ostia sites when CD + budesonide was compared to control, with the greatest effect seen at 12 months: The mean ± standard deviation (SD) percentage of baseline areas at 12 months were 76% ± 6.2% vs 37% ± 23.5%, 76% ± 6.3% vs 52% ± 4.9%, and 83% ± 6.5% vs 58% ± 5.0% (all p0.05), for CD + budesonide compared to control in the frontal, sphenoid, and maxillary sinuses, respectively. The incidence of adhesions was 4% in the CD + budesonide group compared to 15% in the control group.This study has shown that CD gel, when combined with topical budesonide solution, improves long-term sinus ostial patency and prevents ostial stenosis post-ESS.

The frontal sinus is considered the most challenging sinus to address surgically. There are no current classifications of the degree of surgical complexity of different frontal sinus configurations. The aim of this study is to develop a classification system of the degree of complexity of frontal recess surgery based on preoperative computed tomography (CT) scans.Authors were asked to submit a classification system. These were circulated to all authors. Selection of the final 3 classifications was based on a majority consensus. These classifications were compared further for time-taken, ease-of-use, and interrater agreement. These were assessed by the authors on 10 CT scans representing a range of anticipated surgical difficulty.Out of 3 compared classifications, classification A was the quickest to score (1.44 minutes vs 1.57 minutes and 2.25 minutes), subjectively easiest (3.23 vs 4.07 and 5 on a visual analogue scale [VAS]), and had a moderate interrater agreement (0.52 vs 0.42 and 0.79). In addition, the grading of complexity was as good whether measurements were taken on the CT scans or whether size of the frontal ostium was visually estimated.We propose a fast, easy classification to anticipate the complexity of surgery in the frontal sinus and recess, for patients undergoing primary surgery.

The unconventional toll-like receptor (TLR) CD180 is implicated in chronic inflammatory diseases; however, its role in chronic rhinosinusitis (CRS) has yet to be investigated. Here we study the expression of CD180, its homologue TLR4 and myeloid differentiation factor 1 (MD1) on mucosal and systemic immune cell populations in relation to serum immunoglobulin G (IgG) levels.A total of 70 patients were recruited to the study. Mucosal and peripheral blood samples were prospectively collected from CRS patients and non-CRS controls without evidence of sinus disease. The expression of TLR4, MD1, and CD180 was investigated using qualitative real-time polymerase chain reaction (qRT-PCR), immunohistochemistry, and flow cytometry. Serum IgG levels were determined using enzyme-linked immunosorbent assay (ELISA).CRS with nasal polyps (CRSwNP) patients had significantly increased messenger RNA (mRNA) expression of CD180 and MD1 compared to controls (5.54-fold and 2.1-fold, respectively, p0.01). B cells lacking CD180 were lower in CRSwNP tissue compared to CRS without nasal polyps (CRSsNP) and controls (21.07 ± 6.41 vs 41.61 ± 7.82 vs 40.06 ± 8.06; p0.01) but higher in blood (39.18 ± 8.3 vs 17.95 ± 7.82 and 12.49 ± 4.92; p ≤ 0.05).Changes in mucosal and peripheral CD180-expressing B cells were identified in CRSwNP patients compared to CRSsNP and controls. This suggests a role for these cells in the dysregulated immune response in these patients.

Carotid artery injury during endonasal surgery is a feared and potentially catastrophic complication. Simulation training provides the opportunity for a realistic experience with management of major vascular injuries. The sheep model of carotid artery injury reproduces the challenges of dealing with vascular emergencies during endoscopic sinus and skull base surgery, which include working in narrow nasal confines, high-flow/high-pressure vascular injury, and the immediately challenging surgical field. Simulated vascular emergencies allow for research and development; training using various surgical techniques to control the field, including hemostatic products or direct vascular closure techniques; and consequently improved patient care and outcomes.

There is increasing evidence to suggest that the sinus microbiome plays a role in the pathogenesis of chronic rhinosinusitis (CRS). However, the concentration of these microorganisms within the sinuses is still unknown. We show that flow cytometry can be used to enumerate bacteria and virus-like particles (VLPs) in sinus flush samples of CRS patients. This was achieved through trialling 5 sample preparation techniques for flow cytometry. We found high concentrations of bacteria and VLPs in these samples. Untreated samples produced the highest average bacterial and VLP counts with 3.3 ± 0.74 x 10(7) bacteria ml(-1) and 2.4 ± 1.23 x 10(9) VLP ml(-1) of sinus flush (n = 9). These counts were significantly higher than most of the treated samples (p < 0.05). Results showed 10(3) and 10(4) times inter-patient variation for bacteria and VLP concentrations. This wide variation suggests that diagnosis and treatment need to be personalised and that utilising flow cytometry is useful and efficient for this. This study is the first to enumerate bacterial and VLP populations in the maxillary sinus of CRS patients. The relevance of enumeration is that with increasing antimicrobial resistance, antibiotics are becoming less effective at treating bacterial infections of the sinuses, so alternative therapies are needed. Phage therapy has been proposed as one such alternative, but for dosing, the abundance of bacteria is required. Knowledge of whether phages are normally present in the sinuses will assist in gauging the safety of applying phage therapy to sinuses. Our finding, that large numbers of VLP are frequently present in sinuses, indicates that phage therapy may represent a minimally disruptive intervention towards the nasal microbiome. We propose that flow cytometry can be used as a tool to assess microbial biomass dynamics in sinuses and other anatomical locations where infection can cause disease.

Objectives: To investigate the efficacy of chitosan-dextran hydrogel (CDH) in preventing postoperative adhesions between the tympanic membrane (TM) and intratympanic structures, and to evaluate its ototoxicity in an animal study. Methods: In the first step, ototoxicity was evaluated with 7 male albino guinea pigs (GPs) via auditory brainstem responses (ABR) before and 4 weeks after unilateral intratympanic injection of CDH and saline solution contralaterally. In the second step, 12 GPs underwent bilateral ear surgery. The middle ear (ME) mucosa was abraded, and the cavity was filled with CDH on one side and packed with Gelfoam on the contralateral side. A control group of 6 GPs underwent the same procedure except that no material was applied in the ME. The animals were euthanized at the end of the 7th week, and otomicroscopic findings were noted and the temporal bones harvested for the histologic examination. The findings were scored and compared. Results: There was no statistically significant difference between the pre- and postoperative ABR thresholds. In the otomicroscopic findings, the most prominent difference between the two groups was the presence of retraction of the TM in the Gelfoam group. The histopathologic findings revealed a higher degree of inflammation in the Gelfoam group compared with the CDH group. Conclusion: This study demonstrated that CDH has no ototoxic effects in GPs. Its use as an ME packing material revealed significantly less TM retraction and inflammatory reaction compared with Gelfoam.

Cytokine mediated changes in paracellular permeability contribute to a multitude of pathological conditions including chronic rhinosinusitis (CRS). The purpose of this study was to investigate the effect of interferons and of Th1, Th2, and Th17 cytokines on respiratory epithelium barrier function. Cytokines and interferons were applied to the basolateral side of air-liquid interface (ALI) cultures of primary human nasal epithelial cells (HNECs) from CRS with nasal polyp patients. Transepithelial electrical resistance (TEER) and permeability of FITC-conjugated dextrans were measured over time. Additionally, the expression of the tight junction protein Zona Occludens-1 (ZO-1) was examined via immunofluorescence. Data was analysed using ANOVA, followed by Tukey HSD post hoc test. Our results showed that application of interferons and of Th1 or Th2 cytokines did not affect the mucosal barrier function. In contrast, the Th17 cytokines IL-17, IL-22, and IL-26 showed a significant disruption of the epithelial barrier, evidenced by a loss of TEER, increased paracellular permeability of FITC-dextrans, and discontinuous ZO-1 immunolocalisation. These results indicate that Th17 cytokines may contribute to the development of CRSwNP by promoting a leaky mucosal barrier.

Background The purpose of this level 4, retrospective cohort study was to detail the outcomes of primary, revision, and endoscopic modified Lothrop procedure (EMLP) (Draf III) frontal sinus surgery and evaluate whether risk factors would help determine which patients would benefit from which procedures. Methods The study used a retrospective chart review. Endoscopic assessment of frontal ostium patency and patient reported symptoms were prospectively collected on patients who underwent frontal sinusotomy between January 2003 and December 2009. High-risk cohorts were studied to assess their response to standard endoscopic sinus surgery (ESS) compared with EMLP. Results A total of 339 patients who met the inclusion and exclusion criteria underwent either primary or revision endoscopic frontal sinus surgery. The average ± standard deviation (SD) length of follow-up was 20.8 ± 18.7 (95% confidence interval [CI], 18.0–22.9) months. Postsurgical recurrence of disease with persistence of symptoms requiring an EMLP occurred in 9 patients in the primary group and 38 in the revision group. The highest risk groups for failure of standard frontal sinusotomy were patients with nasal polyps, asthma, Lund-Mackay score >16, and frontal ostium size

Background The role that bacterial biofilms might play in recalcitrant forms of chronic rhinosinusitis (CRS) is increasingly being recognized. However, the detection of bacteria existing in this form, using standard culture, is limited by their unique metabolically inactive properties. All current biofilm diagnostic modalities require invasive mucosal biopsies, which limit their use to the operating theatre. Methods Twenty CRS patients and 5 controls were enrolled in a prospective study to assess the feasibility of noninvasively diagnosing S. aureus biofilms by detecting the biofilm matrix polysaccharide poly-N-acetylglucosamine (PNAG). An immunofluorescence protocol was developed for PNAG detection and compared with both standard microbiological cultures and fluorescence in situ hybridization (FISH). Results Thirteen of 20 CRS patients had evidence of S. aureus biofilm formation using FISH. Of these, 12 had detectable PNAG. Interestingly none of the S. aureus FISH-negative patients were PNAG-positive despite the presence of coagulase-negative Staphylococci biofilms, some of which may exhibit PNAG in their pathogenic forms. The development of a noninvasive S. aureus biofilm diagnostic test provides a reliable means to identify a high-risk group of CRS patients who harbor S. aureus biofilms. The ability to be used outside of the perioperative period to assess surgical efficacy, guide management, and evaluate new treatment modalities provides a significant advance in this field of research and clinical practice. Conclusion This study has confirmed the feasibility of noninvasive detection of S. aureus biofilms with a simple test that produces results comparable to the more invasive methods that are currently relied upon.

Background The complex interplay between host, environment, and microbe in the etiopathogenesis of chronic rhinosinusitis (CRS) remains unclear. This study focuses on the host-microbe interaction, specifically the regulation of nitric oxide (NO) and reactive oxygen species (ROS) against the pathogenic organism Staphylococcus aureus (S. aureus). NO and ROS play crucial roles in innate immunity and in the first-line defense against microbial invasion. Methods Sinonasal tissue samples were harvested from CRS and control patients during surgery. CRS patients were classified S. aureus biofilm-positive (B+) or biofilm-negative (B−) using fluorescence in situ hybridization and clinically as polyp-positive (P+) or polyp-negative (P−). Samples were assessed using an NO polymerase chain reaction (PCR) array containing 84 genes involved in NO and ROS regulation, and gene expression of all subgroups were compared to each other. Results Twenty-three samples were analyzed with 31 genes significantly changed, the greatest seen in the B+P+ CRS patients. Four genes consistently displayed differential expression between the groups including the cytoprotective oxidation resistance 1 (OXR1) and peroxiredoxin 6 (PRDX6), neutrophil cytosolic factor 2 (NCF2), and the prion protein (PRNP) genes. Conclusion Alteration in gene expression points to impaired innate immune responses differing among CRS subgroups based on S. aureus biofilm and polyp status. The consistent alteration of 4 genes among distinct groups demonstrates that S. aureus biofilms and polyps are associated with specific changes in gene expression. Further studies are required to validate these findings in a wider cohort of patients and correlate this to protein expression and disease manifestation.

Patients with aggressive nasal polyp recurrence form an important subgroup of patients with refractory sinus disease. The objectives of this study were to establish patterns of polyp recurrence and evaluate the effect of frontal sinus surgery (Draf 2a vs. Draf 3) on polyp recurrence.Retrospective cohort study reviewing 338 consecutive operations.Polyp recurrence was defined according to the Lund-Kennedy mucosal edema score. Survival analysis methods were used for statistics.After complete sphenoethmoidectomies, Draf 2a frontal sinusotomies, and middle meatal antrostomies persistent polyp recurrence occurred in 19.8% of patients after 6 months and increased to 22.7% of patients after 12 months. Polyps first recurred in the area of the frontal sinus/ostium (55%) followed by the ethmoids (38%). Asthma and aspirin sensitivity were the most important variables affecting recurrence (hazard ratios, 1.71, 1.79, respectively; P.05) The Draf 3 procedure was a significant factor in reducing recurrence, especially in asthma and aspirin intolerant patients. The overall revision rate was 18% (follow-up duration12 months, median = 29 months), with a 37% revision rate in the FESS group versus 7% in the Draf 3 group (P.001). Survival analysis showed that the Draf 3 significantly reduced the risk of revision (hazard ratio = 0.258, P = .0026).Nasal polyposis is characterized by a high rate of recurrence. The presence of asthma or aspirin intolerance leads to more aggressive recurrence, and in these patients the Draf 3 drillout procedure becomes a good option for improved long-term outcomes and reducing the need for revision surgery.

Immunofluorescence is a fundamental tool used to analyse tissue and cell samples with a wide variety of available antibodies targeting specific proteins or molecules. Staphylococcal surface protein A is used both in clinical, research and industrial settings for its ability to bind mammalian immunoglobulin G. Spurious binding between protein A and IgG antibodies can lead to false-positive fluorescence and misleading results. Here we demonstrate this occurring in formalin-fixed patient samples that harbour Staphylococcus aureus infection, and characterise methods to overcome this issue. Specifically the use of F(ab′) fragment antibodies or blocking with human IgG is shown to prevent antibody–protein A interaction in formalin-fixed S. aureus smears, biopsies obtained from infected patients, and experimentally infected tissue samples.

Objectives/Hypothesis: Chronic rhinosinusitis (CRS) recalcitrant to surgery is a frustrating clinical entity. Recently, mupirocin sinonasal rinses have been suggested as an efficacious treatment alternative in these patients where Staphylococuccus aureus infection is demonstrated. To our knowledge, how best to treat this S aureus reservoir has not been previously evaluated in a double-blinded, randomized, placebo-controlled trial. Study Design: Prospective, double-blinded, placebo-controlled study. Methods: Twenty-five S aureus-positive CRS patients with persistent sinonasal infection despite endoscopic sinus surgery received either a 1-month, twice-daily treatment course of mupirocin sinonasal rinses (MUP) or saline rinses (CON). The primary outcome was S aureus-culture negativity at the conclusion of treatment; secondary rhinological outcomes included subjective and objective measures of rhinosinusitis. Results: Twenty-two patients satisfactorily completed the treatment period. Of CON patients, 0/13 (0.0%) returned an S aureus-negative sinonasal culture at 1month, compared to 8/9 (88.9%) of MUP patients (P < .01). Improvements in rhinological outcomes observed in MUP patients following treatment were not subsequently evident when these patients were followed up at a delayed assessment 2 to 6 months after completing treatment. Conclusions: Mupirocin sinonasal rinses are an effective short-term anti-S aureus treatment in surgically recalcitrant CRS as assessed by microbiological and selected rhinological outcomes, although the latter improvements may not be durable with time.

The European Position Paper on Rhinosinusitis and Nasal Polyps 2012 is the update of similar evidence based position papers published in 2005 and 2007. The document contains chapters on definitions and classification, we now also proposed definitions for difficult to treat rhinosinusitis, control of disease and better definitions for rhinosinusitis in children. More emphasis is placed on the diagnosis and treatment of acute rhinosinusitis. Throughout the document the terms chronic rhinosinusitis without nasal polyps (CRSsNP) and chronic rhinosinusitis with nasal polyps (CRSwNP) are used to further point out differences in pathophysiology and treatment of these two entities. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. Last but not least all available evidence for management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is analyzed and presented and management schemes based on the evidence are proposed. This executive summary for otorhinolaryngologists focuses on the most important changes and issues for otorhinolaryngologists. The full document can be downloaded for free on the website of this journal: http://www.rhinologyjournal.com.

Background: Canine fossa trephine (CFT) is an adjunctive technique to sinus surgery in patients with recalcitrant maxillary sinusitis. CFT allows for disease clearance in areas of the maxillary sinus that are hard to reach with standard endoscopic techniques. The objective of this study was to compare the surgical outcome of CFT to standard middle meatal antrostomy (MMA) in matched patients with the severely diseased maxillary sinus. Study design: Prospective clinical study Methods: Patients undergoing sinus surgery were enrolled in either the CFT or MMA group. All patients had nasal polyps, Lund Mackay score of 2 in the maxillary sinus, and nasal endoscopy showing the maxillary sinus full of polyps. The patients were followed and the maxillary sinus was graded endoscopically at 3, 6 and 12 months after the surgery. Length of surgery, disease recurrence and need for revision surgery was documented. Results: Forty-two CFTs and MMA were performed in each group. At 6 and 12 months the CFT group demonstrated statistically significant improvement in nasal endoscopy scores. Six patients recurred by the one year mark in the MMA group, 4 of which underwent revision surgery. In the CFT group 2 patients recurred, one who underwent a unilateral revision CFT. Furthermore the CFT did not prolong the surgical time and was often faster than performing a MMA. Conclusion: CFT allows for clearance of all gross disease in the maxillary sinus and appears to improve postoperative outcome at 6 and 12 months and decrease the need for revision surgery.

Chronic rhinosinusitis (CRS) is a very common condition that remains poorly understood from a pathogenic standpoint. Recent interest has been sparked by a potential role for biofilms in this process, with a significant body of evidence implicating them in inciting sinonasal inflammation. Biofilms are clearly present on the sinus mucosa of CRS patients, and their presence there is associated with severe disease characteristics and surgical recalcitrance. We are beginning to understand the importance of the species within these biofilms, but there may be other as-yet-unidentified factors at play in influencing disease outcomes. Recent exciting research has emerged documenting the immune response to the presence of biofilms-research that will ultimately solidify the nature and extent of the contribution of biofilms in CRS pathogenesis. Future research should focus on evidence-based antibiofilm treatments with reference to efficacy and timing of treatment.

Through recent advances in research, our understanding of chronic rhinosinusitis (CRS) has evolved to consider it as an inflammatory condition of the mucosa brought about by multiple factors. However, surgical management is still ruled by the classical concepts of functional endoscopic sinus surgery (FESS), which emphasizes the importance of ostial obstruction and sinus ventilation. These concepts fail to provide sufficient explanation for the presence of a subset of patients with refractory CRS who fail to respond to conventional FESS. Recent outcome studies have shown that high-grade mucosal inflammation often results in a poor outcome and that this patient group may show improved results with more radical surgery. This review examines the "inflammatory load hypothesis" as a possible explanation. We hypothesize that the grade of the inflammation is the most important predictor of long-term outcomes. Surgery, therefore, has a significant role not only in reestablishing ventilation, but also with removing the inflammatory load in the affected sinuses. We suspect that in these severely diseased patients, a more radical removal of local proinflammatory factors during surgery may improve patient outcomes.

Background: Persistent infection following endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) is a frustrating entity for the patient and rhinologist alike. Mupirocin nasal washes have been proposed as an efficacious treatment in such patients. Two small studies have reported excellent short-term posttreatment outcomes; however, the long-term microbiological outcomes following treatment are not known; likewise, the rate of mupirocin-resistance following treatment has not been explored. Methods: This was a retrospective chart review of 61 patients with Staphylococcus aureus (S. aureus)-positive surgically-recalcitrant CRS having undergone 0.05% mupirocin nasal rinse treatment, twice daily for 4 weeks. Specific outcomes reported included posttreatment culture results, time to first posttreatment S. aureus culture, and mupirocin-sensitivity following treatment. Results: Of 57 patients meeting minimal posttreatment follow-up criteria, 42 (73.7%) progressed to microbiological failure by subsequently cultured S. aureus. Mean time to first positive culture was 144 days. Of the 42 patients who progressed to microbiological relapse, full antibiotic sensitivity data was available for 41; of these, only 1 was found to subsequently harbor a mupirocin-resistant strain of S. aureus, thus yielding a posttreatment resistance rate of 2.4%. Conclusion: Treatment with mupirocin nasal washes in S. aureus–positive, surgically recalcitrant CRS has a high microbiological failure rate, with 73.7% of patients subsequently re-culturing S. aureus. Our current treatment regime of 0.05% nasal washes twice daily for 4 weeks is associated with a posttreatment resistance rate that is consistent with other studies of topical mupirocin use, suggesting that mupirocin washes are no more likely to induce resistance than nasal vestibule decolonization in the high-risk medical or surgical patient. © 2011 ARS-AAOA, LLC.

Background There is increasing evidence to support the use of anesthetics to affect operative fields during endoscopic sinus surgery and thus the speed, thoroughness, and safety of the surgery itself. Previous research has suggested preoperative beta-blockers improve surgical fields (SFs); our study is novel in showing the impact of a beta-blocker infusion on SFs during sinus surgery. Methods A prospective, randomized, double-blind, placebo-controlled trial was conducted in 40 patients. Patients undergoing endoscopic sinus surgery for chronic rhinosinusitis received a constant infusion of i.v. esmolol or saline in addition to a standard inhaled anesthetic protocol. At regular 15-minutes intervals, the quality of SF, heart rate (HR), systolic blood pressure (SBP), and diastolic blood pressure (DBP) were assessed. Total blood loss was also recorded. Results Average vital sign parameters (HR/SBP/DBP) were significantly lower in the esmolol group (69.1/90.2/55.1 versus 77.2/99.5/63.5; p < 0.01). The esmolol infusion improved SFs relative to control (2.3 versus 2.6; p = 0.045). Esmolol infusion resulted in good SFs (grades 1 and 2) more often than poor fields (grades 3 and 4); on the contrary, the control group showed more poor than good SFs (chi-square; p = 0.04). A correlation between increasing HR and worsening SFs was identified (r = 0.259; p = 0.002). The control group had significantly higher average blood loss (1.3 versus 0.8 mL/min; p = 0.037). Conclusion Esmolol-induced relative hypotension and bradycardia during endoscopic sinus surgery achieves significantly improved SFs relative to saline control.

Carotid artery injury during endonasal surgery is the most feared and catastrophic complication. Internal carotid artery injury is more frequent during skull base surgery, and risk factors include acromegaly, previous revision surgery, and prior radiotherapy and bromocriptine therapy. Nasal packing is frequently used to gain hemostasis, often resulting in vascular occlusion. Recent research recommends the crushed muscle patch treatment as an effect hemostat that maintains vascular patency. Endovascular techniques are recommended for vascular control and complication management. Coil or balloon embolization is preferred in patients with adequate collateral cerebral blood flow, and stent-graft placement or bypass surgery is indicated in those who do not.

Background Biofilms in chronic rhinosinusitis (CRS) patients are associated with recalcitrant disease patterns. Citric acid/zwitterionic surfactant (CAZS) has been shown to have significant efficacy at in vitro biofilm eradication. Unique hydrodebrider systems have been shown to have effective antibiofilm efficacy. The aim of this study was to evaluate the efficacy of the CAZS/hydrodebrider treatment on Staphylococcus aureus biofilms in the sheep model of CRS. Methods Forty-two sheep frontal sinuses were inoculated with S. aureus, followed by 7 days of biofilm growth. Sinuses were randomized to one of nine treatment groups: control, hydrodebrider with saline or CAZS (killed on day 0 or day 7 posttreatment), CAZS, or saline flush (killed on day 0 or day 7 posttreatment). Confocal scanning laser microscopy (CSLM) was used to confirm extent of biofilm reduction. Samples of each sinus were taken, assessing cilia morphology using electron microscopy. Results A mean of 37.22 ± 9.65% of control (no treatment) CSLM images taken showed biofilms. Both CAZS flush and CAZS/hydrodebrider treatments showed initial improvements in biofilms but biofilm regrowth followed treatment, 14.74 ± 9.58% to 18.91 ± 12.14% and 15.60 ± 13.92% to 24.70 ± 3.66%, respectively (p > 0.05). Saline/hydrodebrider treatments showed a nonsignificant improvement in biofilm treatment, which was maintained, 18.34 ± 11.85% to 12.04 ± 10.28% (p > 0.05). Cilial morphology grade was significantly worse in the CAZS treatment groups (p < 0.05). Conclusion CAZS solution (with and without a hydrodebrider system) can significantly adversely affect cilia morphology. The hydrodebrider system, when combined with saline, may be a useful treatment adjunct for mucosal biofilms.

Background Outcomes for revision endoscopic sinus surgery (RESS) are rarely reported in relation to technique. Our goal was to document the outcome of full-house functional endoscopic sinus surgery (FESS) (FHF) (complete sphenoethmoidectomy with Draf IIA frontal sinusotomy) for treatment of this recalcitrant group. Methods Twenty-one patients with chronic sinusitis having had at least 1 previous sinus surgery (mean, 2.14) underwent FHF, followed by postoperative nasal douching and oral antibiotics for 12 weeks. After a minimum 6 months of follow-up, patients were asked to complete a 5-item Patient Response Score (PRS) (graded on a 6-point scale from 1 = completely improved to 6 = much worse). Objective measures collected included computed tomography (CT) Lund MacKay score (L-M score, LMS), and endoscopic findings: mucosal swelling (MS) and mucopus (MP) (graded on a 4-point scale from 0 = none to 3 = severe). Results Patients were divided into 3 subgroups based on months of follow up from surgery: 6-12, 12-18, and 18-24. There was no statistical difference in any outcome based on length of follow up. Mean symptom outcome was reported as much improved (PRS = 1.9 ± 0.1). Both mucosal swelling and mucopus improved dramatically (2.48 vs 0.29, p < 0.001; 2.52 vs 0.29, p < 0.001, respectively). LMS also improved dramatically (11.52 vs 2.1, p < 0.001). Presence of nasal polyps did not affect any subjective or objective outcome. Conclusion Marked improvements in symptoms and mucosal findings were consistently obtained with FHF between 6 and 24 months postoperatively. © 2011 ARS-AAOA, LLC.

To cite this article: Foreman A., Holtappels G., Psaltis A.J., Jervis-Bardy J., Field J., Wormald P.-J., Bachert C. Adaptive immune responses in Staphylococcus aureus biofilm–associated chronic rhinosinusitis. Allergy 2011; 66: 1449–1456. Abstract Background: The etiopathogenesis of chronic rhinosinusitis (CRS) is currently an area of intense debate. Recently, biofilms have been proposed as a potential environmental trigger in this disease. In particular, Staphylococcus aureus biofilms appear to be a predictor of severe disease recalcitrant to current treatment paradigms. However, direct causal links between biofilms and host immune activation are currently lacking. This study aimed to document both the adaptive immune responses that characterize S. aureus biofilm–associated CRS and the relative contributions of staphylococcal superantigens and S. aureus biofilms in the inflammatory make-up of this disease. Methods: A total of 53 disease subjects and 15 controls were recruited. Sinonasal mucosa was collected for the determination of S. aureus and Haemophilus influenzae biofilms and presence of total and superantigen-specific IgE and for the measurement of cytokines that characterize the T-helper pathways. Results: Staphylococcus aureus biofilms and superantigens are significantly associated in CRS patients, suggesting the biofilm may be a nidus for superantigen-eluting bacteria. The presence of S. aureus biofilms is associated with eosinophilic inflammation, across the spectrum of CRS, on the back of a T-helper2 skewing of the host’s adaptive immune response (elevated Eosinophilic Cationic Protein and IL-5). This can be distinguished from the superantigenic effect resulting in the induction of IgE. Conclusion: This study provides novel evidence of a link between S. aureus biofilms and skewing of the T-cell response toward the T-helper2 pathway that is independent of superantigen activities. Further research is required to confirm the cause–effect relationship of this association.

BackgroundBacterial biofilms have been implicated in chronic rhinosinusitis (CRS). However, direct evidence in support of fungal biofilms in sinus disease is lacking in the literature. This study was designed to develop and characterize an in vitro Aspergillus fumigatus biofilm model on primary human sinonasal epithelial cell culture.MethodsSinonasal biopsy specimens harvested during endoscopic sinus surgery of six CRS patients and three pituitary tumor (control) patients were cultured in Dulbecco's modified Eagle media (DMEM; Invitrogen)/Hams F12 airway media to encourage epithelial cell proliferation. Epithelial cells separated by immunomagnetic beads were seeded in tissue culture-treated Y-shaped microslides. At confluence the primary cultures were inoculated with A. fumigatus spores. Fungus was allowed to germinate and form biofilms under two in vitro conditions: (1) static (no flow through of media) and (2) continuous flow coculture (continuous flow movement of media). At regular intervals cocultures were stained with FUN-1, concanavalin A–alexa fluor 488, and examined by confocal scanning laser microscopy. Comstat software was used to assess biomass and thickness.ResultsA. fumigatus formed three-dimensional biofilm structures with parallel-packed, cross-linked hyphae and channels/passages. Metabolically active hyphae showed orange–red fluorescing intravacuolar structures. Extracellular matrix (ECM) between/around the hyphae fluoresced intense green. A. fumigatus biofilms development occurred in five stages: (1) conidial attachment to epithelial cells, (2) hyphal proliferation, (3) ECM production, (4) hyphal parallel packing and cross-linking, and (5) channel/pores formation. Mature biofilms showed basal conidial, middle hyphal, and superficial ECM layers. Biofilms formed underflow conditions displayed more robust and faster growth kinetics when compared with that under static conditions, with a thick, stocky, wrinkly/undulating hyphal growth and extensive ECM production. The differences in biomass and average thickness of the cocultures under static and flow conditions were statistically significant after similar periods of incubation (p = 0.0002; p < 0.0001, respectively.ConclusionTo our knowledge, this is the first article of an in vitro model characterizing A. fumigatus biofilm formation using primary human sinonasal epithelium under different growth conditions.

Objectives/Hypothesis: Chronic rhinosinusitis (CRS) patients with biofilms have persistent postoperative symptoms, ongoing mucosal inflammation, and recurrent infections. Recent evidence suggests that biofilms of differing species confer varying disease profiles in CRS patients. We aimed to prospectively investigate the effects of Staphylococcus aureus, Pseudomonas aeruginosa, Haemophilus influenzae, and fungal biofilms on outcomes following endoscopic sinus surgery (ESS). Study Design: Prospective blinded study. Methods: In this prospective blinded study, 39 patients undergoing ESS for CRS assessed their symptoms preoperatively using internationally accepted standardized symptom scoring systems and quality-of-life measures (10-point visual analog scale, Sino-Nasal Outcome Test-20, global severity of CRS). Their sinonasal mucosa was graded (Lund–Kennedy scale) and extent of radiologic disease on computed tomography scans scored (Lund-McKay scale). Random sinonasal tissue samples were assessed for different bacterial species forming biofilms by using fluorescent in-situ hybridization and confocal laser microscopy. For 12 months after surgery, CRS symptoms, quality of life, and objective evidence of persisting disease were assessed by using the preoperative tools. Results: Different bacterial species combinations were found in 30 of 39 patients; 60% of these 30 biofilms were polymicrobial biofilms and 70% had S aureus biofilms. Preoperative nasendoscopy and radiologic disease severity were significantly worse in patients with multiple biofilms (P = .02 and P = .01, respectively), and they had worse postsurgery mucosal outcomes on endoscopy (P = .01) requiring significantly more postoperative visits (P = .04). Those with S aureus biofilms progressed poorly with their symptom scores and quality-of-life outcomes, with significant differences in nasendoscopy scores (P = .007). Conclusions: S. aureus biofilms play a dominant role in negatively affecting outcomes of ESS with persisting postoperative symptoms, ongoing mucosal inflammation, and infections.

OBJECTIVES/HYPOTHESIS: The Modified Endoscopic Lothrop procedure (MELP) or Draf 3 is a complex procedure, performed for chronic frontal sinusitis that is refractory to standard functional endoscopic sinus surgery. The procedure involves drilling of the frontal T (formed by the septum and middle turbinate`s attachment to the skull base) onto the olfactory fossa often with exposure of the first olfactory neuron and may affect olfactory function. This study was performed to assess patients` subjective sense of smell following this procedure. STUDY DESIGN: Prospective study of retrospective data. METHODS: Sixty-eight patients, who underwent modified endoscopic Lothrop by the senior author (PJW) between 2003 and 2008, completed a post-operative questionnaire asking about their perception of olfactory function. All patients had their pre-operative subjective sense of smell documented prior to undergoing surgery. Patient records were reviewed for pertinent medical information such as the presence of asthma, aspirin sensitivity and nasal polyps. RESULTS: This study found that the majority of patients reported improvement in their sense of smell post-operatively, while only a small number reported a negative impact on their smell. Thirty-nine patients reported an improvement in their post-operative smell grade. Twenty patients reported no change in their smell grade, while the remaining 9 patients stated that their sense of smell worsened after surgery. No statistically significant correlation was found between patient outcome and the presence of asthma, nasal polyps, or Samter`s triad. CONCLUSIONS: The Modified endoscopic Lothrop procedure/Draf 3 had a positive effect on subjective sense of smell post-operatively in this cohort of patients.

Background The role of fungi in the spectrum of chronic rhinosinusitis (CRS) is poorly understood. Fungal biofilms have recently been discovered in CRS patients. We have developed an animal model for the investigation of sinonasal fungal biofilms. The role of type I hypersensitivity and pathogenic bacteria is presented. Methods Thirty sheep were sensitized with fungal antigens—Aspergillus fumigatus and Alternaria alternata, or control. Endoscopic surgery was performed to expose both frontal sinus ostia—1 was occluded. Fungi with or without Staphylococcus aureus were inoculated into the sinus. Skin-prick tests assessed for fungal allergy. Fungal and S. aureus biofilms, histology, and culture rates were assessed. Results Forty-five percent of experimental sheep were sensitized to fungal antigen. Only 1 sinus inoculated with fungus developed minimal fungal biofilm. Eighty percent developed fungal biofilm when S. aureus was co-inoculated. The presence of hypersensitivity to fungus was not related to fungal biofilm development. Conclusion Significant fungal biofilm only occurred when S. aureus was the co-inoculum. Hypersensitivity was not requisite. The relationship of S. aureus to fungal biofilms is of great clinical interest. Fungi may be opportunistic pathogens that simply require inflamed mucosa with weakened innate defenses; alternatively, a cross-kingdom synergy could be contributing to fungal proliferation. © 2011 ARS-AAOA, LLC.

Background: Despite increasing evidence of a role for Staphylococcus aureus (S. aureus) biofilms in chronic rhinosinusitis (CRS), the origin of this organism in the postsurgical sinonasal cavity had been unclear. Recently, we suggested that the increased culture rate of S. aureus following endoscopic sinus surgery (ESS) may be related to biofilm activity. This study, therefore, was designed to evaluate the origin of early postoperative sinonasal S. aureus and assess the early postoperative outcomes in patients culture-positive for this organism. Methods: Twenty-nine patients undergoing ESS for medically-recalcitrant CRS were prospectively enrolled. A comprehensive intraoperative S. aureus screening protocol was followed for all patients (including swabs for culture and tissue for fluorescence in situ hybridization [FISH] S. aureus biofilm analysis); early postoperative management included endoscopically-guided swabs for culture in all patients. Results: Twenty of 29 (69.0%) patients cultured S. aureus postoperatively, of which 17 of 20 (85.0%) were screen-positive at surgery. Seven of 11 (63.6%) intraoperatively biofilm-positive but culture-negative patients progressed to culture S. aureus post-ESS. S. aureus culture was associated with selected poorer early post-ESS outcomes. Conclusion: S. aureus persists in the sinonasal cavity despite ESS. The postoperative culture of sinonasal S. aureus in patients previously biofilm-positive but culture-negative may reflect the dynamic ability of S. aureus to adapt to the surgically-altered microenvironment with subsequent biofilm dispersal and release of planktonic clones. © 2011 ARS-AAOA, LLC.

Chronic rhinosinusitis is a common disease whose underlying aetiopathogenesis has not been completely understood. Amongst a range of other potential environmental triggers in this disease, a role has recently been proposed for bacterial biofilms. Adopting the biofilm paradigm to explain the initiation and maintenance of this disease may help to clarify previous inconsistencies in this disease that have resulted in the role of bacteria being questioned. Of particular interest is the association of bacterial biofilms with recalcitrant disease states. Over the last five years, research has progressed rapidly since biofilms were first identified on the surface of diseased sinonasal mucosa. Their presence there has now been associated with more severe disease that is often recalcitrant to current management paradigms. Technological advances are allowing accurate characterization of the bacterial and fungal species within these biofilms, which would appear to be an important step in improving our understanding of how these bacterial communities might interact with the host to cause disease. This is an unanswered, yet highly important, question in this field of research that will undoubtedly be an area of investigation in the near future. As the body of evidence suggesting biofilms may be involved in this disease grows, research interest has switched to the development of antibiofilm therapies. Given the unique properties of bacteria existing in this form, biofilm eradication strategies will need to incorporate novel medical therapies into established surgical practices as we attempt to improve the outcomes of our most difficult patients.

Objectives/Hypothesis: Low pH, hydrogen peroxide generation, and the hyperosmolarity mechanisms of antimicrobial action are ubiquitous for all honeys. In addition, manuka honey has been shown to contain high concentrations of methylglyoxal (MGO), contributing the relatively superior antimicrobial activity of manuka honey compared to non-MGO honeys. In high concentrations, manuka honey is effective in killing Staphylococcusaureus biofilms in vitro. Lower concentrations of honey, however, are desirable for clinical use as a topical rinse in chronic rhinosinusitis in order to maximize the tolerability and practicality of the delivery technique. This study, therefore, was designed to evaluate the contribution of MGO to the biofilm-cidal activity of manuka honey, and furthermore determine whether the antibiofilm activity of low-dose honey can be augmented by the addition of exogenous MGO. Study Design: In vitro microbiology experiment. Methods: Five S.aureus strains (four clinical isolates and one reference strain) were incubated to form biofilms using a previously established in vitro dynamic peg model. First, the biofilm-cidal activities of 1) manuka honey (790 mg/kg MGO), 2) non-MGO honey supplemented with 790 mg/kg MGO, and 3) MGO-only solutions were assessed. Second, the experiment was repeated using honey solutions supplemented with sufficient MGO to achieve concentrations exceeding those seen in commercially available manuka honey preparations. Results: All honey solutions containing a MGO concentration of 0.53 mg/mL or greater demonstrated biofilm-cidal activity; equivalent activity was achieved with ≥1.05 mg/mL MGO solution. Conclusions: MGO is only partially responsible for the antibiofilm activity of manuka honey. Infusion of MGO-negative honey with MGO, however, achieves similar cidality to the equivalent MGO-rich manuka honey.

Background Saline nasal irrigation is a mainstay in the medical management of chronic rhinosinusitis (CRS) with proven efficacy. However, bacterial contamination of irrigation bottles has recently been reported and this may contribute to recurrent infections. Sterilization is effective but could a change in bottle design obviate the need for regular sterilization? Methods A total of 20 stable CRS patients were given a NasalCare® (Techworld Corporation, Inc., Downington, PA) irrigation bottle to use regularly for 1 week. This bottle incorporates a 1-way valve to prevent irrigant regurgitation. Swabs were taken from their sinonasal cavity and 3 sites on the bottle—nozzle, valve, and inner surface. Results This study cultured a range of organisms from all sites of the bottle, including common CRS pathogens such as S. aureus, P. aeruginosa, and E. coli. Whereas the bottle's inner surface had the lowest bacterial recovery rate, the frequent culture of organisms at this site suggests a 1-way valve cannot completely prevent irrigant reflux. The high rate of organism detection at the nozzle and valve of the bottle is concerning, as bacteria at these sites may be transported to the nose during nasal douching. Conclusion Saline irrigation will continue to be an essential component of CRS management. However, despite employing a 1-way liquid valve in this study, nasal irrigation bottles can still become contaminated with bacteria. Thus, patient education, irrespective of bottle design, will be essential in preventing bacterial contamination of nasal irrigation devices. The results of our survey suggest this message is not getting across to our patients. © 2011 ARS-AAOA, LLC.

Background This study compares the anatomic and functional outcomes of primary powered endoscopic dacryocystorhinostomy (DCR) in surgeons of differing levels of experience. Methods A retrospective interventional study was performed of all consecutive powered endoscopic DCRs performed at a tertiary institution over a period of 10 years from 2002 to 2012. All patients completed a minimum of 3 months follow-up after stent removal. Patient records were reviewed for demographic data, clinical and surgical profiles, adjunctive procedures, complications, and success rates at last follow-up. The level of surgeon's experience performing the DCR was also documented. Anatomic success was defined as patent ostium on irrigation and functional success as free flow of dye into ostium on functional endoscopic dye test and resolution of epiphora. Results Among the 160 DCRs performed by the consultant, all except four underwent intubation; 54.4% (68/125) of these patients required adjunctive procedures. There were no major complications in this group and at a long-term mean follow-up of 14.2 months, the anatomic and functional success rates were 98.1 and 95.6%, respectively. Among the 100 DCRs performed by the fellows, all underwent intubation and 40.8% (29/71) of the patients required adjunctive procedures. The complications include three cases of ostium granulomas and two patients each with postoperative bleeding, stent prolapse, and turbinoseptal synechiae. At the mean follow-up of 10.9 months, the final anatomic success was achieved in 95% of the cases and functional success in 89% of the cases. Conclusion Powered endoscopic dacryocystorhinostomy is an effective procedure and offers excellent results in the hands of experienced surgeons. A good transfer of knowledge and skills along with supervision when required ensures a good surgical success rate, even when the training fellows operate.

Background The use of nasal irrigation in the management of postoperative endoscopic sinus surgery (ESS) patients is commonplace; however, the potential contamination of these bottles is concerning. The Sinugator® cordless pulsating nasal wash (NeilMed Pharmaceuticals, Inc., Santa Rosa, CA) is a battery-operated, positive pressure, pulsatile pump with a unidirectional flow. The principal aim of this study was to determine the incidence of cross-contamination using the pulsating nasal irrigation device and compare it with the traditional squeeze bottle. Methods Eleven post-ESS patients were given a NeilMed Sinugator nasal wash to use 3 times per day. A sterile nasal swab was obtained at the initial and second postoperative visits. A swab of the plastic irrigation reservoir was collected at the second visit. Results The overall contamination rate of bottles was found to be 45%. During the study several different organisms were cultured in the nose and bottles. The most commonly isolated organisms were coliforms and Staphylococcus aureus. We did not observe concomitant organisms in the nasal cultures and bottles in any subject. Conclusion Despite using a motorized irrigation device, patients and their bottles grew positive cultures. However, no cross-contamination between the patients and bottles was identified, which can be attributed to a design that minimizes backwash.

Background: Effective treatment for recalcitrant rhinosinusitis requires unobstructed surgical marsupialization of sinus cavities and use of delivery systems that will topically penetrate the sinuses. Aims: To determine the extent of sinus penetration achieved with nasal irrigation by varying the ostial size and head position. Methods: Ten thawed fresh-frozen cadaver heads were dissected in a staged manner. After each stage of dissection, sinus squeeze-bottle irrigations were performed in three head positions, and endoscopes placed via external ports into the sinus cavities viewed the sinus ostia. An ordinal scale was developed to grade ostial penetration of irrigations. Three reviewers independently graded the outcomes. Results: Irrigant entry into sinuses increased with ostial size (P < .001) and the greatest differential of improvement in sinus penetration is obtained at an ostial size of 4.7 mm. Stages 2 and 3 (larger sinus ostia) of maxillary and sphenoid dissections have statistically greater irrigant penetration relative to earlier stages. Frontal sinus irrigation is worse in vertex to ceiling head position. There does not appear to be any significant advantage to head position with maxillary and sphenoid sinuses. Conclusions: This study shows that the larger the sinus ostium, the better the penetration of irrigant into the sinus, with an ostium of at least 4.7 mm allowing maximal penetration in the maxillary and sphenoid sinuses. The same benefit was not noted in the frontal sinus. Head position was only relevant to the frontal sinus where less penetration was seen with the head neutral (vertex to ceiling) position when compared to forward angled positions. Laryngoscope, 2010

Objectives: Since the advent of endonasal skull base surgery, internal carotid artery (ICA) injury has been considered the most dramatic and challenging intraoperative complication. A large vascular injury creates an immediately challenging surgical scenario with rapid blood loss that may result in exsanguination of the patient. Recently we have developed an animal model of the endoscopic, endonasal vascular injury. We describe important surgical steps required in managing the surgical field during a catastrophic vascular event. Methods: A total of 42 endoscopic carotid artery injuries and 25 endoscopic venous injuries were performed. Throughout the injuries, the “two-surgeon” technique was used to achieve surgical field control. Videoendoscopy was performed throughout the implementation of these surgical techniques. Results: Techniques found useful in controlling the surgical field included the two-surgeon technique, careful selection of the most appropriate nostril for endoscope positioning, large bore suction placement, suction guidance of the vascular stream through the contralateral nostril, and avoidance of suction obstruction. Only once the surgical field could be controlled can the injury site be addressed. Conclusions: Controlling the endoscopic endonasal surgical field during vascular injuries relies on the cooperation of the surgical team and a step-based approach including careful endoscopic maneuvering within the nasal corridor, and appropriate suction selection and positioning with respect to the endoscope. Laryngoscope, 2011

Objective: To evaluate the effectiveness of the modified endoscopic Lothrop (MEL) procedure for the management of failed osteoplastic flap (OPF) with obliteration of the frontal sinuses. Setting: Adelaide University Academic Hospital Complex. Study Type: Prospective case study of 16 patients presenting with symptoms after OPF with obliteration of the frontal sinuses. Materials and Methods: Sixteen patients presented with symptoms of frontal sinus pain after having previously undergone OPF and fat obliteration of the frontal sinuses. All patients underwent computed tomography scanning; 13 underwent magnetic resonance imaging scanning, and 6 underwent a bone scan with technetium to exclude frontal osteitis. All patients underwent exploration of the frontal sinuses by way of the MEL procedure. Results: Fifteen patients were found to have a frontal sinus mucocele, whereas one patient had no mucocele with only new bone and fibrous tissue found at the MEL procedure. Twelve of the 16 patients with mucoceles had resolution of their frontal headaches, with 15 having a patent and healthy communication between the mucocele and the nasal cavity. The one patient without a mucocele continues to have frontal pain. One patient underwent a successful MEL procedure but had persistent symptoms until a supraorbital ethmoid mucocele was removed at a revision procedure. Two other patients continued to have frontal headaches and pain despite a healthy ostium into the frontal sinus mucocele. Conclusions: MEL is a viable alternative to revision OPF for symptomatic patients who are shown to have a mucocele of the frontal sinuses.

Endoscopic sinus surgery is an excellent treatment option in the management of medically refractory chronic rhinosinusitis. Continual refinements in endoscopic technique are simultaneously allowing an expanded range of applications and a lower rate of complications for this kind of surgery. However, the potential for serious complications is ever present. The sinus surgeon must always be aware of this, and actively seek to identify high-risk situations preoperatively. The technical points presented in this article should be followed to minimize the risk of complications.

Objectives/Hypothesis: A potential role for biofilms in Chronic Rhinosinusitis (CRS) has been proposed, and the adverse impact they have on disease severity and postoperative outcomes has also been well described. Recent advances have allowed the species within the biofilms of CRS patients to be clearly characterized. This study investigates whether different biofilm species have different disease outcomes. Study Design: Retrospective review. Methods: Twenty-four patients with medically recalcitrant CRS undergoing Endoscopic Sinus Surgery (ESS), in whom we had previously characterized their biofilms using fluorescence in situ hybridization (FISH), were reviewed a median of 11 months after their surgery. They were evaluated for preoperative disease markers and evidence of on-going disease in the postoperative period. Results: Thirty-seven biofilms were identified in the 24 patients. Almost half had polymicrobial biofilms. The presence of polymicrobial, rather than single-species biofilms adversely affected preoperative disease severity but did not alter postsurgical outcome. Patients with single organism Haemophilus influenzae biofilms presented with mild disease symptomatically and radiologically and achieved normal mucosa a short time after their surgery. Conversely, patients with Staphlococcus aureus in their biofilm makeup had more severe disease and a more complicated postoperative course. The effect of Pseudomonas aeruginosa and fungal biofilms is less clear. Conclusions: Different biofilm species are associated with different disease phenotypes. H. influenzae biofilms are typically found in patients with mild disease, whereas S. aureus is associated with a more severe, surgically recalcitrant pattern. Laryngoscope, 2010

Background This study was performed to explore whether or not a neural reflex linking the esophagus and the nasal airway exists, as a pathogenic mechanism accounting for the association between gastroesophageal reflux (GER) disease and chronic rhinosinusitis (CRS). A prospective trial of healthy human volunteers was performed. Methods Ten healthy volunteers without GER or sinonasal disease were investigated using an acid infusion challenge test. Normal saline and hydrochloric acid were infused into the lower esophagus through an esophageal manometry catheter. Nasal responses in symptom score, nasal inspiratory peak flow, and mucus production were analyzed after the esophageal challenge. Results A tendency for an increase in nasal mucus production was observed after esophageal stimulation with both normal saline and HCl. This returned to baseline level 45 minutes after the acid infusion. A similar trend was also observed with the measurements of nasal symptom scores and, to a lesser extent, nasal inspiratory peak flow. Conclusion These results support the possibility that a neural reflex exists between the esophagus and the paranasal sinuses via the vagus nerve. If indeed present, the reflex-mediated rhinitis derived from this neuropathic inflammation may contribute to the development of CRS in patients with GER. Further study is required to define the relationship between GER and CRS.

Complete removal of polyps and thick mucus from the severely diseased maxillary sinus is key in allowing the resolution of symptoms. The canine fossa trephination (CFT) procedure is a highly effective means of clearing diseased material from all areas of the maxillary sinus and is especially useful in patients with Sampter's triad and fungal sinusitis. However, many surgeons have failed to adopt this technique for fear of its potential complications. Numerous technical refinements have been developed in recent years, significantly reducing the rate of adverse outcomes following the CFT. This article describes the steps involved in performing the CFT, with an emphasis on the avoidance of complications.