The effect of bacterial biofilms on post-sinus surgical outcomes

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

Quality-of-life outcomes after sinus surgery in allergic fungal rhinosinusitis versus nonfungal chronic rhinosinusitis

Background:  Given the differences in pathophysiology between Allergic Fungal Rhinosinusitis (AFRS) and other CRS (chronic rhinosinusitis) subgroups, it remains unclear on whether these patients respond differently to a combination of surgical and medical treatment.  Objective: The aim of this study was to evaluate differences in quality of life (QoL) outcomes for a cohort of patients undergoing endoscopic sinus surgery (ESS) for CRS.  Methods:  This retrospective review included CRS patients who underwent ESS between 2010 and 2013. QoL was measured using the 22-item Sino-Nasal Outcome Test (SNOT-22). Variables collected included baseline demographics, SNOT-22 scores before ESS and 1, 3, 6, 9, and 12-months post-ESS. Groups tested were CRS with nasal polyposis (CRSwNPs), CRS without nasal polyposis (CRSsNPs), and patients with AFRS. A linear mixed effects regression model was utilized to calculate the adjusted mean QoL differences.  Results: Among the 250 patients included, 61.6% had CRSwNPs (n=154), 28.8% had CRSsNPs (n=72) and 9.6% had allergic fungal rhinosinusitis (n=24). Significant differences were seen in SNOT-22 scores between pre and post-operative visits and between the aetiological subgroups (p<0.001). Multivariate analysis revealed significantly greater improvement in QoL for patients with allergic fungal rhinosinusitis in comparison to those with CRSsNPs at 9-months [change in SNOT-22 = 22.6, 95% CI 1.2 – 44.1, p<0.03] and 12-months follow-up [change in SNOT-22 = 20.2, 95% CI 0.5 – 39.9, p<0.04].  Conclusions: Patients with allergic fungal rhinosinusitis experience a more prolonged QoL benefit from surgical and targeted medical intervention compared to those with CRSsNPs. This may reflect the severity of inflammation that they present with compared to other CRS subtypes

Effect of using multiple culture media for the diagnosis of noninvasive fungal sinusitis

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