DISORDERS OF THE NOSE AND SINUSES
From the University of Miami Miller School of Medicine’s 32nd Annual Chandler Clinical Concepts of
Otolaryngology
| CHRONIC INFLAMMATORY RHINOSINUSITIS: THE ROLE OF FUNGUS —Bradley F. Marple, MD, Associate Professor
and Vice Chairman, University of Texas Southwestern Medical Center, Department of Otolaryngology—Head and
Neck Surgery, Dallas
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| General: biomass of fungus greater than biomass of mammals; eukaryotic; ubiquitous (more prolific in areas with high humidity);
important role in ecosystem (decomposition of organic matter); 50,000 species of fungi; 3 classes play role in sinonasal
disease (Zygomycetes [invasive disease], Aspergillus [invasive and inflammatory disease], Dematiaceous
[allergic fungal rhinosinusitis; AFRS])
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| Role of fungus in sinonasal disease: fungal allergy; invasive fungal rhinosinusitis (granulomatous in immunocompetent
people); noninvasive fungus as cause of inflammation; eosinophilic fungal rhinosinusitis (EFRS); saprophytic growth of
fungus
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| Fungal allergy: IgE-mediated type I hypersensitivity reaction, type III hypersensitivity reaction and T-cell mediated type
IV hypersensitivity reaction; typical allergic reaction to fungus (antigen); controversy in way allergy treated because of
lack of standardization of antigens for testing and treatment
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| Allergic fungal rhinosinusitis: patients relatively young (mean age 22 yr); atopic (60%㫞%; specific fungal IgE sensitivity
>90%); no linkage to aspirin sensitivity; patients immunocompetent; radiographic characteristics—bony deformation;
mucocele-type expansion; heterogeneity of material in fungal mucocele (reflecting chelation of heavy metals);
20% to 25% of patients show areas of bony dehiscence (bone not eroded; calcium in bone becomes demineralized); noninvasive
in majority of patients; hallmark of disease—fungal mucin; characteristic gross appearance; histology shows
eosinophils and fungal hyphae without invasion of adjacent mucosa; diagnostic criteria—Bent and Kuhn criteria most
specific and standard; include type I hypersensitivity, polyposis, typical computed tomography (CT) findings, and eosinophilic
mucin containing fungi with no tissue invasion; Cody reported 2 criteria necessary for diagnosis as histologic
identification (hyphae and eosinophils in mucin) and allergy to fungus; consortium defined AFRS as presence of eosinophilic
mucin (identified grossly), histology that demonstrates noninvasive fungi, and fungus-specific IgE; summary—
fungus ubiquitous; eosinophils frequently associated with many forms of chronic rhinosinusitis (CRS); AFRS appears to
differ from other forms of CRS (eosinophilic inflammatory mediators greatest in AFRS, as compared to other forms of
CRS); IgE associated with disease process
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| Eosinophilic fungal rhinosinusitis: Mayo Clinic research; Ponikau and Cody— majority of patients from clinic had
fungi in nose when sampled, as did control group of normal patients; 93% of patients going to surgery for CRS had eosinophils
and at least one fungal hyphae; allergy testing showed no difference in incidence of allergy between CRS group
and other groups; suggested that AFRS (based on definition) did not exist and recommended all CRS be called EFRS;
Shin and Kita—drew peripheral blood from patients with CRS and from controls, extracted mononuclear cells, and exposed
them to Alternaria; showed that in patients with CRS, Alternaria stimulates T cell production of interleukin (IL)-
5, IL-13, and interferon (IF)-γ (statistically significant from control group); hypothesized that fungi etiologic agents of
CRS in susceptible patients; developed treatment plans to treat fungus (amphotericin B irrigation); 2002 study—
uncontrolled; irrigation of CRS patients’ noses; endoscopic staging showed improvement in mucosa; some data corroborated
by other researchers; Weshta (2004)—74 patients with CRS randomized to amphotericin B spray or saline control;
CT scores showed no difference between groups; patients in amphotericin B group reported feeling significantly worse
than control group; conclusion that amphotericin B has no effect; controversy about method of delivery (spray may not
disstribute medication as well as irrigation); Mayo Clinic study—double-blind placebo-controlled; 24 patients with
CRS randomized to amphotericin B irrigation or saline; no statistically significant improvement in any outcome measures,
but trend toward improvement in those on amphotericin B irrigation (based on radiographic resolution); no change
in inflammatory mediators, eosinophils, or amount of Alternaria in nose; currently no consensus on effectiveness of amphotericin
B
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| Controversies: fungus as sole cause of CRS—fungus present in every case of disease; fungus can be isolated from diseased
host and grown in culture; however, fungus present in healthy individuals also, so fungi probably not only cause of
disease; whether existence of EFRS negates that of AFRS—histopathologic findings (presence of mucin) important to
definition, but so are clinical findings; phenotypic clinical expression combined with measured fungal IgE shows statistically
significant difference; Mayo Clinic patients with low incidence of allergy have no clinical expression that suggests
AFRS; IgE levels (skin testing or total IgE levels) significantly elevated in patients who have clinical manifestations of disease
process; presence of fungi with eosinophils does not rule out another disease process; argument that definition of EFRS
overly broad (based on microscopic diagnosis that may be present in many people and no different from homogenized group
of patients diagnosed with CRS); too sensitive as diagnostic category; on other hand, definition of AFRS narrow (requires
very specific clinical findings); allergic mucin identified grossly rather than histologically; could be dealing with range of
diseases or different diseases determined by overlapping inflammatory processes; possibly not looking with right tools; in
mid 1990s, idea that CRS not single disease, but exists as syndrome; number of etiologic starting points could lead to clinical
manifestation of disease; CRS task force (2003)—expert panel reviewed all literature and recommended changing diagnosis
(continuous signs or symptoms of inflammatory disease in nose for >12 wk) and considering inflammatory causes of disease;
added requirement of specific length of symptoms and identifiable signs (documentable) that indicate inflammation by
anterior rhinoscopy, endoscopy, or imaging; key that disease process inflammatory, not necessarily infectious; clinical
classification of CRS—person presents with CRS (cause not really known); long course of antibiotics typical therapy;
possible etiologic starting points (allergy, fungi, bacteria) that could give rise to relatively uniform inflammatory process; inflammatory
process (mixed TH 1/TH 2 inflammatory process); common cytokines (IL-5, IL-4, IL-8, and IF-ã); potential future
treatment—identify true etiologic starting points; allergy immunotherapy for allergies; antifungal therapy for fungi;
treat bacteria in some cases; superantigen; biofilm; corticosteroid therapy tends to improve symptoms in some patients
(more than with antibiotics); anti-IL-5; soluble IL-4 receptors; anti-IgE; immunotherapy; antileukotrienes; macrolides; CRS
definition (international panel)—inflammatory entity, not necessarily caused by allergic rhinitis, but allergic rhinitis can act
as cofactor and affect severity of disease; anatomic abnormalities, humoral immune defects, and abnormal mucociliary function
can play role in attenuating disease process; bacterial infection can attenuate, but may not be cause in all cases; separate
CRS into 2 groups (with and without nasal polyps); histologically separate groups (those with eosinophilic features and
those with other inflammatory features); categorize concept of fungi as causative agent in CRS by eosinophilic fungal inflammation
under noninvasive fungal disease; separate into IgE-dependent and IgE-independent; test separately to see if
possible to merge into one disease process
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| Conclusion: data compelling that fungus holds potential role in pathogenesis of some cases of CRS; current data insufficient
to support claim fungus sole cause for CRS; think of fungus as cofactor or contributor to disease
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| THE ROLE OF SURGERY IN CRS: HOW MUCH IS ENOUGH? —Roy Casiano, MD, Professor and Vice Chairman,
Department of Otolaryngology, and Director, General Otolaryngology Division, University of Miami Miller School of
Medicine, Miami
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| Patients’ expectations: address in realistic fashion; discuss in terms of resolution or improvement of symptoms (eg, with
turbinate surgery, nasal obstruction, headache, and frequency of recurrent purulent infection improve); discuss improbability
that surgery will clear other allergy-type symptoms; discuss probability of reduction in medication use (asthma
medications, antibiotics, and oral corticosteroids)
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| Expected outcomes: recurrent infections—can expect reduction in frequency and severity, but not total elimination;
multiple surgeries possibly necessary; outcome contingent on adequate drainage and sustained ventilation of all affected
sinuses (persistence of mucin and fibrosis in one sinus may cause continuation of symptoms); if mucociliary dysfunction
or local or systemic immunologic dysfunction present, symptoms may continue; recurrent infections despite adequate
medical therapy and surgery vary by type of disease, not necessarily by stage of disease; more surgical skill required for
minimal disease than for advanced disease; patients with odontogenic infections, limited unilateral allergic fungal sinusitis
(AFS), or mycetoma do well with surgery, whereas those with bilateral diffuse disease may not do as well; nasal
obstruction—septoplasty; trimming turbinates (not removal; inferior turbinates in particular); removal of polyps with
microdebrider; opening up cavity not only allows patients to breathe better, but facilitates administration of medication
into nasal airway; headaches—patients may not complain once headache becomes chronic; coexisting disease may
cause headaches (eg, migraine-variant headaches; tension headaches; rebound headaches; allergies; vasculitic disorders);
persistent obstructed cells in ethmoid, mucocele, persistent crusting, and medications may also cause headache; other
possible modifiers of outcome—common vasculitic or inflammatory disorders beyond control of surgery and alter physician’s
ability to deal with inflammatory disorder of airway; environmental factors (eg, tobacco, cocaine, other recreational
drugs)
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| Indications for surgery: absolute—extensive problem due to blockage (eg, mucocele); allergic fungal sinusitis; cerebrospinal
fluid rhinorrhea; most procedures done with endoscope if have access to nose; combination of endoscopy with
external procedure if approach from 2 directions necessary; Pott’s Puffy tumor treated with endoscopic drainage and antibiotics;
relative—adults with CRS who do not improve with medical therapy (treat medically for while and evaluate
compliance); recurrent acute sinusitis (surgery may make worse; follow for while before operating); CRS considered
syndrome with multiple etiologies
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| Recalcitrant sinusitis: localized persistent disease—1 or 2 sinuses only; due to mucociliary transport problem, inadequate
ventilation of cell or reobstructed cell; generalized disease—systemic problem (eg, allergies; environmental sensitivities);
diffuse mucociliary dysfunction caused by chronic infection or multiple surgeries
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| Surgical techniques to address persistent disease: in isolated disease of maxillary, sphenoid, or frontal sinuses have
more leeway as to surgical intervention; extended sinusotomy—for maxillary disease, combined middle and inferior
meatal antrostomy facilitates access into sinus during clinic; suction more readily done than through middle meatus alone
and allows irrigation into sinus; frontal disease addressed with Lothrop procedure (Draf III; lesser extension into frontal
sinus [Draf II]); in sphenoid disease, common cavity indicated (removing intersinus septum and rostrum) and stripping
mucous membranes; mucosal exenteration; endoscopic Lothrop procedure—remove portion of perpendicular plate of
septum; remove intersinus septum to create common cavity
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| SEPTOPLASTY —Bradley Marple, MD
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| Terminology: septoplasty defined as surgical reconstruction of nasal septum; submucous resection defined as resection of
osseous and cartilaginous nasal septum, leaving dorsal and caudal struts; current procedural terminology (CPT) code
30520 for septoplasty (no separate code for endoscopic procedure)
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| Indications: nasal airway obstruction; epistaxis not amenable to other treatments; nasal contact headaches (controversial
topic); sinus ostium obstruction; surgical access to sinuses
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| Technique: incision—advantage of endoscopic septoplasty (as opposed to Killian or hemitransfixion incision), is ability
to carry incision where needed (eg, if dealing with deviation of bony septum, can bypass cartilaginous septum, and make
incision at osseocartilaginous junction); generous incision important (need to raise mucoperiosteal flap); make mucoperiosteal
incision on side of convexity (as transition made through cartilage or bone to contralateral side, angle acute if
incision on side of concavity, and perforation likely when elevating mucoperiosteal flap); mucoperiosteal elevation—
in submucoperiosteal plane; suction instrument needed (accumulation of blood in plane between cartilage, bone, mucoperiosteum,
and mucoperichondrium; suction Cottle elevator [preferred] or 9 F Frazier tip suction catheter; transition
(cartilaginous or bony incision)—offset from mucosal incision; use same instruments as in open septoplasty (Cottle,
D-knife, or #15 Bard-Parker blade); removal of cartilage and bone—piecemeal or segmental fashion, depending on location
in nose; closure—single mattress suture
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| Splinting options: packing; splints; Stucker stitch (horizontal mattress stitch to coapt mucoperiosteal layers); rationale to
prevent hematoma, maintain symmetry, and prevent synechiae; alternative to splint—quadrangular cartilage bypassed,
midline position achieved from osteocartilaginous junction posteriorly; middle turbinate used as splint of posterior septum
with through-and-through stitch; benefit that splint avoided and have excellent access to middle meatus
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| Endoscopic septoplasty: advantages—improved visualization; easy to incorporate into endoscopic sinus surgery; excellent
for isolated deflections and ideal for posterior deflections; instruction of trainees; disadvantages—not recommended
for extreme anterior deviations or if extensive septoplasty required; logistics—timing of septoplasty when part
of other procedure; other structures contributing to deflection, eg, concha bullosa
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Educational Objectives
| The goal of this program is to provide the listener with information on the pathogenesis of chronic rhinosinusitis (CRS), the
role of surgery in CRS, and septoplasty. After hearing and assimilating this program, the clinician will be better able to:
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 | 1. Discuss the role of fungus in the etiology of CRS.
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| 2. Discuss controversies surrounding the distinction between allergic fungal rhinosinusitis (AFRS) and eosinophilic
fungal rhinosinusitis (EFRS).
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| 3. Discuss role of surgery in CRS.
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| 4. Describe an endoscopic septoplasty technique.
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| 5. Discuss advantages and disadvantages of endoscopic septoplasty
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Discussed on This Program
Amphotericin B [several trade names]
Suggested Reading
Chiu AG, Kennedy DW: Surgical management of chronic rhinosinusitis and nasal polyposis: a review of the evidence.
Curr Allergy Asthma Rep 4:486, 2004; Cohen NA, Kennedy DW: Endoscopic sinus surgery: where we are-and where
we’re going. Curr Opin Otolaryngol Head Neck Surg 13:32, 2005; Dolan RW: Endoscopic septoplasty. Facial Plast
Surg 20:217, 2004; Durr DG, et al: Sinonasal endoscopy reporting format: emphasis on chronic rhinosinusitis. Curr Opin
Otolaryngol Head Neck Surg 12:237, 2004; Gubisch W: Extracorporeal septoplasty for the markedly deviated septum.
Arch Facial Plast Surg 7:218, 2005; Iro H, et al: Endoscopic sinus surgery: its subjective medium-term outcome in
chronic rhinosinusitis. Rhinology 42:200, 2004; Kuhn FA: Role of endoscopy in the management of chronic rhinosinusitis.
Ann Otol Rhinol Laryngo Suppl 193:15, 2004; Lee BJ, et al: Overcorrected septum as a complication of septoplasty.
Am J Rhinol 18:393, 2004; Luong A, Marple BF: Allergic fungal rhinosinusitis. Curr Allergy Asthma Rep 4:465, 2004;
Pant H, et al: Fungal-specific humoral response in eosinophilic mucus chronic rhinosinusitis. Laryngoscope 115:601,
2005; Raynor EM: Powered endoscopic septoplasty for septal deviation and isolated spurs. Arch Facial Plast Surg
7:410, 2005; Sasama J, et al: New paradigm for the roles of fungi and eosinophils in chronic rhinosinusitis. Curr Opin
Otolaryngol Head Neck Surg 13:2, 2005; Schubert MS: Allergic fungal sinusitis. Otolaryngol Clin North Am 37:301,
2004; Schubert MS: Allergic fungal sinusitis: pathogenesis and management strategies. Drugs 64:363, 2004; Staevska
M, Baraniuk JN: Persistent nonallergic rhinosinusitis. Curr Allergy Asthma Rep 5:233, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reports
nothing to disclose.
Drs. Marple and Casiano were recorded at the University of Miami Miller School of Medicine’s 32nd Annual Chandler
Clinical Concepts of Otolaryngology, held June 2-5, 2005, in Duck Key, Florida. The Audio-Digest Foundation
thanks the speakers and the sponsors for their cooperation in the production of this program.
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