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The role of antibiotics in treating chronic rhinosinusitis.

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Chronic rhinosinusitis (CRS) is an inflammatory disease of the paranasal sinuses that occurs in 1% to 5% of the U.S. It may significantly decrease quality of life. CRS is defined as an inflammatory condition of the paranasal sinuses that persists for 12 weeks or longer, despite medical management. Treatment is directed at enhancing mucociliary clearance, improving sinus drainage/outflow, eradicating local infection (with antibiotics) and inflammation (with steroids), and improving access for topical medications. The microbiology of rhinosinusitis e volves through several stages . The early phase (acute) is generally caused by a virus that may be followed by an aerobic bacterial infection in 2% to 10% of patients. Aerobic ( Staphylococcus aureus ) and anaerobic (Prevotella and Fusobacteria) members of the oral flora emerge as predominant sinus cavity isolates. Antimicrobials are one component of comprehensive medical and surgical management for this disorder. Antimicrobialtherapy of chr
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Chronic sinusitis is associated with higher risk of some head and neck cancers

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Chronic rhino-sinusitis (CRS) may be involved in causing of certain head and neck cancers (HNCs), because of immunodeficiency or inflammation. Several studies explored this issue. Tsou et al. who studied the Taiwan Longitudinal Health Insurance Database found a 3.55-fold increased risk of developing nasopharyngeal cancer (NPC) compared with individuals without rhinosinusitis associations between and CRS throughout a 3-year period.  Riley et al. conducted a systematic review found a 2.7- fold increased risk of developing NPC in patients with CRS compared with patients without sinusitis.   Beachler and Engels of the National Institutes of Health, Bethesda, Maryland evaluated the associations of chronic sinusitis with subsequent HNC, including NPC, human papillomavirus-related oropharyngeal cancer (HPV-OPC), and nasal cavity and paranasal sinus cancer (NCPSC), in an elderly US individuals. They evaluated 483 546 Medicare beneficiaries treated from 2004 through 2011. CRS was associated
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Bacteriology of normal non-Inflamed sinuses and its significance

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Attempts to recover organisms from non-inflamed tonsils were carried out for over seven decades. Some studies failed to find any microorganisms and others recovered them only in a portion of the cases. Only three studies identified bacteria in all sinus sample.  Brook evaluated the microbiology of maxillary sinuses of 12 adults and found an average of 4 isolates/sinus  of aerobic and anaerobic bacteria. The predominant anaerobes were Prevotella   Fusobacterium ,and Peptostreptococcus spp., and Propionibactreium acnes . The most common aerobic bacteria were beta-hemolytic Streptococcoci, Staphylococcus aureus , Streptococcus pneumoniae , and Haemophillus parainfluenzae . Ramakrishnanet al. collected middle meatus specimens from 28 individuals with no sinusitis. Bacterial colonization was assessed in these specimens using quantitative PCR and 16S rRNA pyrosequencing. All subjects were positive for bacterial colonization of the middle meatus. S. aureus, S. epidermidis and P. acnes were
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Clinical Practice Guidelines for Adult Sinusitis by the American Academy of Otolaryngology—Head and Neck Surgery Foundation

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The American Academy of Otolaryngology—Head and Neck Surgery Foundation has p ublished an updated “Clinical Practice Guideline: Adult Sinusitis” as a supplement to Otolaryngology–Head and Neck Surgery. The guideline recommendations address diagnostic accuracy for adult rhinosinusitis, the appropriate use of ancillary tests to confirm diagnosis and guide management (including radiography, nasal endoscopy, computed tomography, and testing for allergy and immune function), and the judicious use of systemic and topical therapy. Emphasis was also placed on identifying multiple chronic conditions that would modify management of rhinosinusitis, including asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia. The treatment recommendations include: Symptoms of viral sinusitis can be treated symptomatically by relieving pain, and administration of nasal steroid sprays, and/or nasal saline rinse (irrigation). Acute bacterial sinus can be watchful waited without antibiotics
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Chronic sinusitis may be linked to an hyperactive immune system

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A recent study in JAMA Otolaryngology--Head& Neck Surgery , in October 2013, suggested that chronic rhinosinusitis (CRS) may be caused by an overactive immune response to normal microbes, and not necessarily to bacterial infection. Investigators from Saint Louis University School of  Medicine in Missouri lead by Dr. Rajeev Aurora found that patients and healthy controls tended to have qualitatively similar microorganisms in their sinus cavity. While control patients sinus lavage samples triggered interleukin (IL)-5 production in peripheral blood leukocytes from patients, this did not occur with leukocytes from controls. The investigators obtained sinus cavity samples from thirty patients with CRS and 12 controls. They used deep sequencing to characterize the patients'  microbiomes and search for pathogens that may potentially trigger an immune response. They also identified the immune cells and cytokines in the specimens. Almost all the recovered fungal and bacterial species we
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Patient’s outcome in acute invasive fungal sinusitis

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Acute invasive fungal sinusitis (AIFS) is an aggressive and often fatal infection. Despite improvements in medical and surgical therapy, survival remains limited and the factors that contribute to patient outcomes remain poorly understood. Turner et al from the Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee performeda  systematically reviews of  the literature to characterize prognostic factors associated with survival after AIFS.. The authors reviewed 52 studies comprising a total of 807 patients, and analyzed the prognostic factors as they related to the treatment, presentation, and outcomes. Univariate and multivariate logistic regression was used to identify prognostic factors. The most common presenting symptoms of patients with AIFS were facial swelling (64.5%), fever (62.9%), and nasal congestion (52.2%). Most patients were treated with a combination of intravenous antifungal medication and surgery. The overall
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US FDA issues guidelines for developing drugs for acute bacterial sinusitis

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The US Food and Drug Administration (FDA) has issued guidelines for the pharmaceutical  industry for developing antimicrobials for the treatment of acute bacterial sinusitis (ABS). The FDA stated that any new drug being studied for ABS should have documenting in-vitro antibacterial activity against the most commonly pathogens associated with ABS. These include  Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Even though animal models of ABS has been developed, particularly for S. pneumoniae infection, they cannot substitute for clinical trials in patients that must be conducted to evaluate drug safety and efficacy. The FDA recommend that two adequate and well-controlled human trials establishing safety and efficacy be conducted for that indication.  However, a single trial for an ABS indication may be appropriate if there is data from other clinical trials demonstrating effectiveness in other respiratory tract diseases s
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