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Although biofilms have been implicated in the pathogenesis of chronic rhinosinusitis (CRS), there is little evidence that their presence or absence has any effect on the outcomes of endoscopic sinus surgery (ESS). The aim of this study was to investigate the effect of biofilms on postsurgical outcomes after ESS. A prospective, blinded study of 51 consecutive patients undergoing ESS for CRS was conducted. Preoperatively, patients assessed their symptoms using internationally accepted standardized symptom scoring systems and quality-of-life (QOL) measures, i.e., the 10-point Visual Analog Scale (VAS), Sino-Nasal-Outcome-Test 20, and global severity of CRS. Their sinonasal mucosa was graded using the Lund-Kennedy scale and the extent of radiological disease on computed tomography scans was scored using the Lund-McKay scale. Random sinonasal tissue samples were assessed for biofilm presence using confocal laser microscopy. At each postoperative visit, patients reassessed their sinus symptoms and completed QOL measures. Postsurgical state of their sinonasal mucosa was graded endoscopically. Bacterial biofilms were found in 36 of 51 (71%) CRS patients. Patients with biofilms presented with significantly worse preoperative radiology and nasendoscopy scores (p = 0.003 and 0.01, respectively). After a median follow-up period of 16 months postsurgery, biofilm-positive patients had statistically worse sinus symptoms (VAS, p = 0.002) and worse nasendoscopy scores (p = 0.026). They also required extra postoperative visits and multiple antibiotic treatments deviating from the standard postoperative care required by biofilm-negative patients. This study has shown that patients with biofilms have more severe disease preoperatively and persistence of postoperative symptoms, ongoing mucosal inflammation, and infections. This study strengthens the evidence for the role that biofilms may play in recalcitrant CRS.

Systematic reviews support nasal saline irrigation for chronic or recurrent sinus symptoms, but trials have been small and few in primary care settings. Steam inhalation has also been proposed, but supporting evidence is lacking. We investigated whether brief pragmatic interventions to encourage use of nasal irrigation or steam inhalation would be effective in relieving sinus symptoms. We conducted a pragmatic randomized controlled trial involving adults (age 18-65 yr) from 72 primary care practices in the United Kingdom who had a history of chronic or recurrent sinusitis and reported a \"moderate to severe\" impact of sinus symptoms on their quality of life. Participants were recruited between Feb. 11, 2009, and June 30, 2014, and randomly assigned to 1 of 4 advice strategies: usual care, daily nasal saline irrigation supported by a demonstration video, daily steam inhalation, or combined treatment with both interventions. The primary outcome measure was the Rhinosinusitis Disability Index (RSDI). Patients were followed up at 3 and 6 months. We imputed missing data using multiple imputation methods. Of the 961 patients who consented, 871 returned baseline questionnaires (210 usual care, 219 nasal irrigation, 232 steam inhalation and 210 combined treatment). A total of 671 (77.0%) of the 871 participants reported RSDI scores at 3 months. Patients' RSDI scores improved more with nasal irrigation than without nasal irrigation by 3 months (crude change -7.42 v. -5.23; estimated adjusted mean difference between groups -2.51, 95% confidence interval -4.65 to -0.37). By 6 months, significantly more patients maintained a 10-point clinically important improvement in the RSDI score with nasal irrigation (44.1% v. 36.6%); fewer used over-the-counter medications (59.4% v. 68.0%) or intended to consult a doctor in future episodes. Steam inhalation reduced headache but had no significant effect on other outcomes. The proportion of participants who had adverse effects was the same in both intervention groups. Advice to use steam inhalation for chronic or recurrent sinus symptoms in primary care was not effective. A similar strategy to use nasal irrigation was less effective than prior evidence suggested, but it provided some symptomatic benefit. ISRCTN, no. 88204146.

Background Chronic rhinosinusitis (CRS) in European country ranges in elderly patients from 4.5 to 12% of population and has a significant effect on quality of life. In these patients, rhinosinusitis is linked to immune functions changes with age and to mucosal paraphysiological alterations such as crusting formations with atrophic epithelium, variations of nasal airflow and modifications of the mucociliary clearance. Failure of medical treatments leads to surgery in patients with persistent symptoms and radiographic signs of CRS. The choice of appropriate post-surgical topic treatments is important for healing time and for preventing mucosal complications such as synechiae, crusting formation and atrophy with secondary bacterial and fungal infections. Aims Defining the effects of topic alpha-tocopherol acetate administration on nasal mucosa healing after endoscopic sinus surgery in CRS of elderly patients. Methods In this study were included 32 patients, mean age 68.6, who underwent FESS because affected by CRS not responsive to medical treatments. After surgical treatment, we distinguish two groups basing on local nasal therapy. Results We investigated, in the postoperative time, the role of alpha-tocopherol acetate compared to gomenol oil. Follow-up was performed at 7–15 days and 1–3 months after surgery. We evaluated mucosal restoration using Rhinoscopy Sum Score and quality of life using Nasal Six Items Symptom Questionnaire. We observed a faster healing time and less recurrence of complications in patients who underwent topic treatment with alpha-tocopherol acetate. Discussion In our research, we observed that alpha-tocopherol acetate has no contraindications and side effects. Conclusions Our study showed the effectiveness of alpha-tocopherol acetate topic treatment in elderly patients affected by CRS after FESS, in improving and speeding up the process of restoring the sinonasal mucosa, compared to another topic medication.

Although both nasal steroids and macrolide antibiotics have been recommended for the treatment of chronic rhinosinusitis without nasal polyps (CRSsNPs), whether there is any difference in their clinical efficacy remains unexplored. In addition, few studies have investigated their clinical efficacy in a Chinese population living in China, who present distinct inflammatory patterns compared with white patients in western countries. This study compares the efficacy of mometasone furoate and clarithromycin treatment in CRSsNP in Chinese adults in a preliminary prospective, open-label, randomized trial. Forty-three CRSsNP patients were randomized to receive mometasone furoate nasal spray at 200 μg (n = 21) or clarithromycin tablet at 250 mg (n = 22) once daily for 12 weeks. Patients were assessed before the treatment and after 4, 8, and 12 weeks after treatment. Subjective symptoms were scored on a visual analog scale. Endoscopy physical findings were scored according to Lanza-Kennedy scoring system. Moreover, smoking and atopic status and coexistence of allergic rhinitis (AR) and asthma were recorded. Before the treatment, no significant difference in symptoms and nasal endoscopic physical findings were found between mometasone furoate and clarithromycin group. As early as 4 weeks after dosing, a significant reduction of total symptom scores, nasal obstruction, headache, rhinorrhea and overall burden scores, and mucosal swelling and nasal discharge scores were observed in both groups. No significant difference in symptom or endoscopic scores was observed between these two groups at any posttreatment observation time point. The coexistence of AR was correlated with lower scores of mucosal edema and nasal secretion in the mometasone furoate group after 12-week treatment. Mometasone furoate and clarithromycin show a comparable clinical effect for CRSsNPs in Chinese adults. Mometasone furoate is more effective in improving edema and secretion for CRSsNP patients with concomitant AR.

Trimethoprim/sulfamethoxazole has been suggested as a treatment option for chronic rhinosinusitis with purulence. This study aimed to assess the functional and endoscopic outcomes after a three-month course of low-dose trimethoprim/sulfamethoxazole. A prospective study was performed, comprising patients referred to a tertiary care medical centre with a diagnosis of chronic rhinosinusitis with purulence. Trimethoprim/sulfamethoxazole was prescribed at 960 mg/day for three months. Sinonasal complaints and endoscopic findings were documented, and bacteriological data were compared. Fifteen patients were included. Staphylococcus aureus was the most common bacterium cultured (86 per cent). Improvement in nasal function, as measured by the 22-item Sino-Nasal Outcome Test, was highly significant at three months (p < 0.0005). This improvement slightly decreased but remained significant at 6, 9 and 12 months. No side effects were noted. Endoscopic scores revealed similar and concordant improvements. Long-term low-dose trimethoprim/sulfamethoxazole therapy seems to be a safe option for selected patients. Additional randomised multicentre studies remain necessary.

The study was designed to assess the usefulness of postoperative antibiotics in patients undergoing endoscopic sinus surgery (ESS). The effects of antibiotics in the postoperative period of ESS patients were evaluated in a prospective, randomized, double-blind, placebo-controlled study. Fifty patients were treated with amoxicillin/clavulanate for 2 weeks after ESS, while the other half received placebo. Preoperatively, the symptom, endoscopic, and CT scores were recorded. In the postoperative period, symptom and endoscopic scores were recorded on the 5th, 12th, 21st, and 30th days. In estimating the length of the blood crust formation episode, a Kaplan-Meier plot was used. Seventy-five patients completed the study: forty in the antibiotic-treated group and thirty-five in the placebo group. On the 5th day, nasal obstruction and drainage were significantly better in the antibiotic-treated group. In addition, a statistically significant difference in the endoscopic scores was noted between the treatment and placebo groups on days 5 and 12. The use of an antibiotic (amoxicillin/clavulanate) in the postoperative period is able to improve the outcome in the early blood crust healing phase: nasal obstruction and drainage are reduced and the endoscopic score objectively showed a faster recovery.

Many surgeons use absorbable packing materials after endoscopic sinus surgery (ESS). Despite their popularity, some of these agents have been shown to contribute to synechiae formation. Microporous polysaccharide hemospheres (MPH) is a plant-based hemostatic powder that does not interfere with regenerating sinus mucosa in the animal model. The goal of this study was to examine the impact of MPH on healing and synechiae formation after ESS in human subjects. A prospective, randomized, controlled, double-blind study was performed. Forty consenting adult patients with chronic sinusitis requiring symmetric ESS were randomized to receive MPH unilaterally at the conclusion of surgery. The opposite side was untreated. Standard postoperative care was performed bilaterally. Outcomes measured included blinded observer ratings for synechiae formation, edema, and infection. Each side was examined endoscopically and scored at postoperative days 7, 14, and 30. Twenty men and 20 women with an average age of 48.2 years were included. There were no complications and all patients were discharged home the same day. There was no significant difference in synechiae formation at any point postoperatively. The rate of synechiae formation was determined to be 10% (4/40) on the MPH-treated side versus 7.5% (3/40) on the untreated side (p = 0.7639). In addition, there were no significant differences observed in edema (p = 0.7480) or infection (p = 0.5533). The use of MPH after sinus surgery does not increase synechiae formation and does not appear to deleteriously affect the healing of postoperative sinus cavities.

Chronic rhinosinusitis (CRS) occurs in >10% of the adult population in Europe and the USA and can be differentiated into CRS without nasal polyps and CRS with nasal polyps (CRSwNP). Both phenotypes are characterized by a high disease burden and an overlapping spectrum of symptoms, with facial pain and loss of smell being the most differentiating. Great progress has been made in the understanding of CRS pathophysiology: from the epithelium and epithelial–mesenchymal transition to innate and adaptive immunity pathways and, finally, on the role of eosinophils and Staphylococcus aureus in the persistence of disease. Although clinical manifestations and diagnostic tools (including nasal endoscopy and imaging) have undergone major changes over the past few years, management (including pharmacotherapy, surgery and biologics) has experienced enormous progress based on the growing knowledge of key mediators in severe CRSwNP. The introduction of endotyping has led to a differentiation of ‘tailored’ surgical approaches, focusing on the mucosal concept in those with severe CRSwNP and on the identification of patients eligible for extended surgery and possibly biologics in the future. This Primer on chronic rhinosinusitis summarizes the epidemiology, physiology, diagnosis and management of this disorder and discusses the quality of life of patients with this condition.

A number of herbal preparations have been reported being used as adjunctive treatment of patients with chronic rhinosinusitis (CRS) after functional endoscopic sinus surgery (FESS). This study was designed to examine the efficacy of Chinese herbal medicine (CHM) in the postoperative care of post-FESS patients. Patients with CRS who underwent FESS were prospectively enrolled in the study. Before surgery, they were evaluated by various methods, including the Chinese version of the Rhinosinusitis Outcome Measure (CRSOM-31), nasal endoscopy, acoustic rhinometry, and computed tomography (CT). After surgery, they were randomized to take CHM (Tsang-Erh-San extract granules and Houttuynia extract powder) for 8 weeks, amoxicillin for 4 weeks, or placebo. They were revaluated by CRSOM-31, nasal endoscopy, and acoustic rhinometry at 8 weeks and by CT at 12 weeks after surgery. Ninety-seven patients (33 in the CHM group, 34 in the amoxicillin group, and 30 in the placebo group) completed the study. In the CHM group, CRSOM-31 and endoscopic scores significantly decreased, and the second minimal cross-sectional area of the nasal cavity measured by acoustic rhinometry significantly increased after treatment. In the amoxicillin and placebo groups, CRSOM-31, endoscopic, and CT scores significantly decreased after treatment. However, there were no significant differences in subjective and objective treatment outcomes among three groups of patients. Our results showed there was no significant benefit of using CHMs (Tsang-Erh-San extract granules and Houttuynia extract powder) or oral amoxicillin in post-FESS care of CRS patients. Additional investigation is necessary for post-FESS care.

Nasal congestion is one of the most common complaints dealt with in otorhinolaryngology. Side effects of decongestants are frequently seen in patients with chronic nasal congestion. This leads to an increasing demand of alternative treatments such as acupuncture. Future studies on acupuncture should aim at objectifying effects by both physical measuring and double blinding. Therefore, we were interested in whether these effects can potentially be measured as increase in nasal airflow (NAF) in ventus (\"wind\") disease of traditional Chinese medicine (TCM). Twenty-four patients with a history of nasal congestion due to hypertrophic inferior turbinates or chronic sinusitis without polyposis were additionally diagnosed according to the Heidelberg model of TCM. They were asked to score the severity of their nasal congestion on a visual analog scale (VAS). The acupuncturist was blinded according to the Heidelberg blinding assay. NAF was measured by using active anterior rhinomanometry (ARM). Specific verum acupoints according to the Chinese medical diagnosis were tested against nonspecific control acupoints. VAS and NAF were scored and measured before and 15 and 30 minutes after acupuncture. Control acupuncture showed a significant improvement in VAS and a deterioration of NAF. Verum acupuncture showed highly significant improvements in VAS and NAF. In addition, verum acupuncture improved NAF and VAS significantly over time. Our control and verum acupoints fulfill the condition of a control and verum treatment, respectively. Measuring NAF by RRM and scoring VAS are possible and reflect acupuncture effects in vivo.