The keys to functional endoscopic sinus surgery are an understanding of the underlying mechanisms of paranasal sinus disease and the ability to diagnose the causes accurately. Previously unrecognized causes of recurrent acute sinusitis and of chronic sinus symptomatology can now be identified by careful diagnostic evaluation. Systematic nasal endoscopy and high-resolution computed tomographic imaging provide complementary diagnostic information that can allow for the recognition of problems not identifiable by other means. The ability to diagnose these problems and to correct them with functional endoscopic surgery heralds new possibilities in the field.

We sought to correlate the clinical, radiographic, and bacteriologic findings in maxillary sinusitis in 30 children who had both upper-respiratory-tract symptoms and abnormal maxillary radiographs. Cough, nasal discharge, and fetid breath were the most common signs, but fever was present inconsistently. Facial pain or swelling and headache were prominent symptoms in older children. Bacterial colony counts of greater than or equal to 10(4) colony-forming units per milliliter were found in 34 of 47 sinus aspirates obtained from 23 children. The most common species recovered were Streptococcus pneumoniae, Haemophilus influenzae, and Branhamella catarrhalis. No anaerobic bacteria were isolated. Viruses were isolated from only two sinus aspirates. There was a poor correlation between the predominant species of bacteria recovered from either the nasopharyngeal or throat culture and the bacteria isolated from the sinus aspirate. This study demonstrates that children with both upper-respiratory-tract symptoms and abnormal sinus radiographs are likely to harbor bacteria in their sinuses, suggesting that such children have bacterial sinusitis.

The incidence of infectious maxillary sinusitis (IMS) and its clinical relevance was prospectively studied in 162 consecutive critically ill patients who were mechanically ventilated for a period longer than 7 d. All had a paranasal computed tomographic (CT) scan within 48 h of admission and were divided into three groups according to the radiologic aspect of their maxillary sinuses: Group 1 = normal maxillary sinuses (n = 40), Group 2 = maxillary mucosal thickening (n = 26), Group 3 = radiologic maxillary sinusitis (RMS) defined as the presence of an air fluid level and/or opacification of maxillary sinuses (n = 96). Group 1 patients were randomized between nasal and oral endotracheal intubation with a gastric intubation performed via the same route and had a second paranasal CT scan 7 d later. Endotracheal and gastric tubes were left in their original position in Group 2 patients and a second paranasal CT scan was performed 7 d later. All patients of Group 3 underwent a transnasal puncture for bacteriologic analysis of maxillary sinus content. Forty-five spontaneously breathing patients served as a control group. In all patients with RMS, the occurrence of bronchopneumonia (BPN) was prospectively assessed for 7 d following the initial CT scan. Upon inclusion, only 25% of the patients had normal maxillary sinuses whereas all patients in the control group had normal paranasal CT scans. After 7 d, 46% of Group 2 patients had evidence of RMS. Risk factors for RMS were nasal placement and duration of endotracheal and gastric intubation.(ABSTRACT TRUNCATED AT 250 WORDS)

This study compared the relative effectiveness of two antimicrobial preparations, amoxicillin and amoxicillin-clavulanate potassium (Augmentin), in the treatment of acute maxillary sinusitis in children 2 to 16 years of age. Of 171 children with persistent (ten to 30 days' duration) nasal discharge or daytime cough or both, 136 (80%) had abnormal maxillary sinus radiographs. These children were stratified by age and severity of symptoms and randomly assigned to receive either amoxicillin, amoxicillin-clavulanate potassium, or placebo. After the exclusion of 28 children with throat cultures positive for group A Streptococcus and 15 who did not complete their medication, the remaining 93 children were evaluated: 30 received amoxicillin, 28 received amoxicillin-clavulanate potassium, and 35 received placebo. Clinical assessment was performed at three and ten days. On each occasion, children treated with an antibiotic were more likely to be cured than children receiving placebo (P less than .01 at three days, P less than .05 at ten days). The overall cure rate was 67% for amoxicillin, 64% for amoxicillin-clavulanate potassium, and 43% for placebo.

This article outlines the treatment planning, surgical technique, and experiences with patients requiring maxillary sinus floor elevation for simultaneous autogenous bone grafting and placement of hydroxylapatite-coated dental implants. The results of six cases followed for up to 4 years are described.

Image-guided surgery has recently been described in the literature as a useful technology for improved functional endoscopic sinus surgery localization. Image-guided surgery yields accurate knowledge of the surgical field boundaries, allowing safer and more thorough sinus surgery. We have previously reviewed our initial experience with The InstaTrak System. This article presents a multicenter clinical study (n=55) that assesses the system's capability for localizing structures in critical surgical sites. The purpose of this paper is to present quantitative data on accuracy and performance. We describe several new advances including an automated registration technique that eliminates the redundant computed tomography scan, compensation for head movement, and the ability to use interchangeable instruments.

Maxillary sinus aspiration and quantitative culture of the aspirate were performed in 50 patients, ranging in age from 1 to 16 years, with clinical and radiographic evidence of acute sinusitis. Of 79 sinuses aspirated, at least one was found to be infected in 35 (70%) children. Streptococcus pneumoniae, Branhamella catarrhalis, and Haemophilus influenzae were the most common organisms recovered. All H. influenzae were nontypeable. Twenty percent of the H. influenzae and 27% of the B. catarrhalis organisms were beta-lactamase positive and amoxicillin resistant. The subjects received either amoxicillin or cefaclor at a dose of 40 mg/kg/day in three doses for 10 days. The clinical cure rate with amoxicillin was 81%, compared to 78% with cefaclor. Radiographic improvement was similar in both treatment groups. Antibiotic therapy failed in four patients; three had been given amoxicillin, and one cefaclor. In three of these, a beta-lactamase-positive antibiotic-resistant bacterial species was recovered from the maxillary sinus aspirate; the fourth aspirate was sterile.

Digital volume tomography (DVT, NewTom, NewTom AG, Marburg, Germany) is a novel technique for maxillofacial imaging at a lower radiation dose and lower cost than CT. We describe four clinical cases to illustrate its potential advantages.

Ostial obstruction is a major factor in the pathogenesis of sinusitis. Detailed diagnostic evaluation in patients with maxillary sinusitis demonstrates the prominence of disease in the ethmoidal infundibulum and in adjacent ethmoid cells. Surgical procedures performed to improve maxillary sinusitis by inferior meatal antrostomy leave residual disease in the ostiomeatal area and may result in persistent mucociliary obstruction. Historically, the possibility of closure following ostial manipulation and the importance of dependent drainage of the maxillary sinus have been cited as arguments against the middle meatal approach. In this study of middle meatal antrostomies the patency rate was 98% between 4 and 32 months. The postoperative endoscopic findings and symptomatic improvement suggest that mucociliary clearance occurs through the surgically widened ostium. We conclude that endoscopic middle meatal antrostomy does not lead to ostial stenosis.

The role of nasal allergy in chronic maxillary sinusitis without an air-fluid level was studied in 37 patients. Seventy-three nasal provocation tests with various inhalant allergens were performed in 37 patients by means of rhinomanometry, and maxillary sinus radiographs were performed before and repeatedly after the allergen challenge. Forty-one positive nasal responses (NRs) occurred in 29 patients; 13 were immediate only, 18 were late only, and 10 NRs were dual responses. Of these responses, 32 demonstrated radiographic changes, primarily an increase in mucosal edema and/or opacification. These responses were accompanied by increased pressure in the maxillary sinuses, acute headache, and sometimes otalgia. Eight patients did not develop any NRs; however, increased thickening of the mucosal membrane of the maxillary sinuses, accompanied by subjective symptoms, was recorded in three of these nonresponders. These results demonstrate the role of nasal allergy in some patients with chronic maxillary sinusitis, which may affect the diagnostic and therapeutic approaches to this disorder.