Treating acute sinusitis

Copyright © 2000 Australian Prescriber Reproduced with permission from Australian Prescriber The document attached has been archived with permission from the publisher/copyright holderInfections in the nose involve the sinuses because the lining of the nose and the paranasal sinuses is continuous. The major sinuses drain through a common tract – the ostiomeatal complex, which is located under the middle turbinate. Acute sinusitis usually follows a cold and presents with nasal obstruction, facial pain, dental pain, purulent rhinorrhoea, sinus tenderness and in some cases fever and malaise. The diagnosis is made on the history, the patient’s lack of response to topical decongestants and on finding pus in the nose with associated sinus tenderness. Treatment consists of combining topical or systemic decongestants with saline irrigations and an antibiotic, usually amoxycillin. Referral to a specialist should be considered if patients fail to respond to second line antibiotic therapy and for those who get recurrent episodes of sinusitis.Peter John Wormal

Quinsy tonsillectomy or interval tonsillectomy - a prospective randomised trial

Fifty-one patients with peritonsillar abscesses were randomised to undergo either quinsy tonsillectomy (aT) or interval tonsillectomy (IT), and the two groups were compared. The QT group lost fewer (10,3 v. 17,9) working days and less blood during the operation (158,6 ml v. 205,7 ml); haemostasis was easier and the operation was technically simpler in this group. There was no significant difference in length of hospital stay and neither group had intra- or postoperative complications. Only 64% of the IT group returned for tonsillectomy. In this study QT had distinct advantages over drainage and IT in the management of peritonsillar abscesses

Myringoplasty - effects on hearing and contributing factors

Indications for myringoplasty are chronic otorrhoea and hearing impairment. Some authors have described poor postoperative hearing results and sensorineural hearing loss associated with the surgery, and question the indication for myringoplasty on an ear with normal hearing « 25 dB). This study of 211 Consecutive myringoplasties performed over 1 year details the 'take rate,' hearing gains and losses, and factors found to influence the above. The take rate of 78% is comparable with figures in the literature. The most significant factors influencing this are the grade of the surgeon and the size of the perforation. The average pre-operative air-bone gap was closed from 23,7 dB to 13,9 dB with a 4,5% incidence of postoperative sensorineural hearing loss. Postoperatively 77,9% of patients had an air-bone gap of less than 20 dB. We conclude that myringoplasty is a beneficial procedure, closing the tympanic membrane and improving the hearing

Traceroute sampling makes random graphs appear to have power law degree distributions

The topology of the Internet has typically been measured by sampling traceroutes, which are roughly shortest paths from sources to destinations. The resulting measurements have been used to infer that the Internet's degree distribution is scale-free; however, many of these measurements have relied on sampling traceroutes from a small number of sources. It was recently argued that sampling in this way can introduce a fundamental bias in the degree distribution, for instance, causing random (Erdos-Renyi) graphs to appear to have power law degree distributions. We explain this phenomenon analytically using differential equations to model the growth of a breadth-first tree in a random graph G(n,p=c/n) of average degree c, and show that sampling from a single source gives an apparent power law degree distribution P(k) ~ 1/k for k < c

Endoscopic orbital decompression for Graves' ophthalmopathy

Graves’ disease may occasionally result in significant proptosis that is either cosmetically unacceptable or causes visual loss. This has traditionally been managed surgically by external decompression of the orbital bony skeleton. Trans-nasal endoscopic orbital decompression is emerging as a new minimally-invasive technique, that avoids the need for cutaneous or gingival incisions. Decompression of the medial orbital wall can be performed up to the anterior wall of the sphenoid sinus. This can be combined with resection of the medial and posterior portion of the orbital floor (preserving the infra-orbital nerve). This technique produces decompression which is comparable to external techniques. We present a series of 10 endoscopic orbital decompressions with an average improvement of 4.4 mm in orbital proptosis. There was an improvement in visual acuity in all patients with visual impairment. Endoscopic orbital decompression is recommended as an alternative to traditional decompression techniques.Desmond T. H. Wee, A. Simon Carney, Mark Thorpe and Peter J. Wormal

Effect of packing on nasal mucosa of sheep

The effects of packing with ribbon gauze and neuropatties on the nasal mucosa was assessed using sheep as an animal model. Fourteen sheep either underwent ribbon gauze or neuropattie nasal packing. Trauma to nasal mucosa caused by ribbon gauze and neuropatties was compared to mucosa on the lateral aspect of the middle turbinate which was not in contact with any packing. This tissue was used as a control. Ribbon gauze packing resulted in significant loss of 68 per cent of the ciliated surface of the mucosa when compared with the control group with a 15 per cent loss of ciliated surface (p < 0.005). Neuropattie packing also resulted in significant loss of 50 per cent of the ciliated surface of the mucosa when compared with the control group (p < 0.005). There was no significant difference in loss of ciliated mucosa in the specimens packed with ribbon gauze or neuropatties (p = 0.25). Nasal packing results in a significant mucosal injury with loss of cilia. This may influence the mucociliary clearance of the nose in the post-operative healing phase. Pre-operative nasal packing should be used circumspectly and if possible avoided.Chi-kee Leslie Shaw, Robert B. Dymock, Allison Cowin and Peter-John Wormal

Efficacy of endoscopic sinus surgery for paranasal sinus mucocele including modified endoscopic Lothrop procedure for frontal sinus mucocele

This study evaluated the efficacy of the modified endoscopic Lothrop procedure (MELP) for complicated frontal mucoceles and endoscopic marsupialization for other paranasal sinus mucoceles. It was a retrospective, consecutive case review of sinus mucoceles treated endoscopically by a single surgeon over a four-year period (1998-2002). There were 41 mucoceles in 28 patients, including 24 frontal, eight frontoethmoidal, three ethmoidal, five maxillary and one frontal mucocele. Twenty-one patients underwent the modified Lothrop procedure for frontal mucoceles, and seven underwent simple drainage and marsupialization for frontoethmoidal, ethmoidal and maxillary mucoceles. At median follow-up of 16 months, all patients had a patent mucocele opening. Patients treated by drainage and marsupialization did not have any complications or mucocele recurrence. All patients treated by the modified endoscopic Lothrop procedure had improvement in symptoms and signs. Four patients had minor complications including epistaxis and adhesions and five required further surgery. The average hospital in-patient stay was 2 ± 1.4 days. Endoscopic techniques, including MELP are effective in the short term for the management of complex and simple paranasal sinus mucoceles. MELP has a useful place in the management of mucoceles with a significant bony partition from an adjacent sinus or nasal cavity. It is also indicated when the mucocele is associated with loss of lateral support in the sinus with risk of medial-wall collapse of the orbital contents obstructing drainage.Jwu Jin Khong, Raman Malhotra, Dinesh Selva and Peter John Wormal

Allergy and sinus disease

The document attached has been archived with permission from the editor of the Medical Journal of Australia (08 January 2008). An external link to the publisher’s copy is includedWilliam B Smith and Peter-John Wormal

Th17 Cytokines Disrupt the Airway Mucosal Barrier in Chronic Rhinosinusitis

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