To compare the microbiology results of the study with ones in the literature, those studies were sel ected which used modern aerobic and anaerobic techniques. Bacter ial etiology, pathophysiology and management of chronic rhinosinusitis have been most controversial. As sta ted, literature is sparse and difficult to interpret 14 . Results from our study indicate that the frequencies of organism isolation were different from those in the other studies with respect to pathogen found in microbiol ogical analysis ( Table III ). In particular, we found a predominance of S. aureus and members of the family Enterobacteriaceae compared with the predominance found in other studies of chronic sinus disease. Our study shows that aerobes were the lead ing cause of chronic rhinosinusitis. Staphylococcus aureus is a highly virulent bacteria and can cause various infections. In most of studies investigating the microbiology of chronic s inustis, Staphylococcus aureus was present in 15% to 40% of sinuses, had been reported as most frequent isolate. In our study Staphylococcus aureus is present in 60% of results. In our study, second most common was MRSA (16%), which may not have been reported in most of the past literatures 15 . Other organisms isolated were Streptococci, Pseudomonas, and Enterobacter which were similar to other recent studies. Bacterial pathogens in chronic rhinosinusitis are distinct from those found in acute rhinosinusitis, as is evident from our data. Streptococcus pneumoniae and Haemophilus influenzae are the predominant pathogens in acute sinusitis. However both organisms were not found in our study. This difference can impact the choice of ant ibiotics. We did not found any anaerobes in our study, in contra st to other studies. It is possible that technical factors or i mproper processing could have decreased the number of fasti dious anaerobic organisms in our study. We detected funga l pathogens in 6 patients. Candida spp. was found in 4 of them The study has several important limitations that re quire discussion. The small sample size and patient popul ation at a regional referral center may not be representative of community at large. We attempted to follow a consistent and r eproducible technique for harvesting specimens during FESS. In 4 of 60 patients, no pathogenic organism was reported. In this cross sectional we examined the microbiolog y of chronic sinusitis. We found S. aureus to be the most frequent classical pathogenic bacteria isolated, followed by MRSA. Results also indicated that, in this select group of 60 patients, anaerobes do not play a prominent role in causing t he disease. But the results do not imply that anaerobes cannot b e involved in other patients with chronic sinus disease. Our s tudy supports the hypothesis that bacterial etiology is predomina ntly, but not the only cause of chronic sinusitis. Fungal and all egic etiology was also found in few patients in the study. The pa thogenesis of chronic sinusitis is likely multifactorial with all ergy, mucosal inflammation, the hosts? local immune system, viral infection, and fungus-based eosinophilic inflammation playing a role 13 .
Murray J P & Jackson M S, Complications after tr eatment of chronic maxillary sinus disease with Caldwell-Luc p rocedure, Laryngoscope, 93 (1983) 282. 2. Hamaguchi Y, Ohi M, Sakakura Y & Miyoshi Y, Sign ificance of lysosomal proteases; cathepsins B and H in maxil lary mucosa and nasal polyp with non-atopic chronic infl ammation, Rhinology, 24 (1986) 187. 3. Melen I, Lindahl L & Andreasson L, Short and lon g-term treatment results in chronic maxillary sinusitis, Acta Otolaryngol (Stockholm) 102 (1986) 282. 4. Bjorkwall T, Bacteriological examinations in max illary sinusitis, Acta Otolaryngol (Stockholm) 83 (1950) 9. 5. Brook I, Aerobic and anaerobic bacterial flora o f normal maxillary sinuses, Laryngoscope 91 (1981) 372. 6. Su W Y, Liu C, Hung S Y & Tsai W F, Bacteriologi cal study in chronic maxillary sinusitis, Laryngoscope , 93 (1983) 931. 7. Almadori G, Bastianini L, Bistoni F, Maurizi M, Ottaviani F, Paludetti G & Scuteri F, Microbial flora of nose an d paranasal sinuses in chronic maxillary sinusitis, Rhinology , 24 (1986) 257. 8. Paju S, Bernstein J M, Haase E M & Scannapies F A, Molecular analysis of bacterial flora associated wi th chronically inflamed maxillary sinuses, J Med Microbiol , 52 (2003) 591. 9. Aral M, Keles E & Kaygusuz I, The microbiology o f ethmoid and maxillary sinuses in patients with chronic sinu sitis, Am J Otolaryngol, 24 (2003) 163. 10. Niederfuhr A, Kirsche H & Riechelmann H, The ba cteriology of chronic rhinosinusitis with or without nasal pol yps, Arch Otolaryngol Head and Neck Surgery, (2009) 135. 11. Krouse J H, Computed tomography stage, allergy testing, and quality of life in patients with sinusitis, Otolaryngol Head and Neck Surgery , 123 (2000) 389. 12. Bhattacharyya N, A comparison of symptom scores and radiographic staging systems in chronic rhinosinusi tis, American Journal of Rhinology 19 (2005) 175. 13. Busaba N Y, Siegel N S & Salman S D, Microbiolo gy of chronic ethmoid sinusitis, Am J Otolaryngol, 25 (2004) 379. 14. Kingdom T T & Swain R E, The microbiology and antimicrobial resistance patterns in chronic rhinos inusitis, Am J Otolaryngol, (2004) 323. 15. Doyle P W & Woodham J D, Evaluation of microbio logy of chronic sinusitis, J Clin Microbiol (1991) 2396.
3 This study was performed in Kasturba Medical College and Allied Hospital, Manglore during the per iod of two months (July?August? 2010) which include 60 patient s, diagnosed as chronic rhinosinusitis (30 women and 3 0 men, mean age: 41? 9.97). 2.1 Patient selection Patients presenting with a history of chronic sinus itis of more than 6 weeks duration, which was supported by X-ray and/or CT scan findings and confirmed by office endoscopies to be consistent with chronic sinusitis, were included in the study. Specifically, the diagnosis had to include the foll owing: (i) symptoms of nasal obstruction or purulent nasal dis charge, discomfort or fullness over the sinuses, episodes o f recurrent acute sinusitis, and/or disturbances in olfaction; (ii) radiological evidence of thickening and/or opacification of the chronic sinus, and (iii) signs of inflamed nasal mucosa; pu rulent exudate in the middle meatus, nasal cavity, or naso pharynx; and/or polyposis, (iv) with allergic rhinitis. It s hould be noted that these criteria do not differentiate infectious from allergic chronic sinus disease. 2.2 Collection of specimens Endoscopic examination of the nasal cavity and the sinuses was done on all the patients. Surgery was performed und er local anesthesia. A nasal swab specimen was then taken fr om the area of the middle meatus, which was not disinfecte d, and this culture was considered representative of the backgr ound nasal flora. The endoscopes were sterilized in a glutaral dehyde solution for 10 min and washed prior to use. In ord er to decrease the risk of contamination, swab specimens were taken from within the sinus air cells upon entering the s inus. Swab specimens for microbiological analysis were inserte d immediately and aseptically into a modified anaerob ic transport medium, transported immediately to the laboratory. 2.3 Microbiological analysis Swab samples are inoculated into the culture media within 1 to 4 hrs of collection. Swab specimens were mixed with little amount of culture broth in order to provide aeratio n to the tissue. They were immediately inoculated, onto agar media (including MacConkey agar and chocolate agar) incuba ted at 35?C for checking growth of aerobic microorganisms p resent in the sample. The plates will be evaluated daily for atleast two days 13 . The swab was inoculated via thioglycollate broth in anaerobic plate medium (Schaedler agar) and incubat ed anaerobically at 35 o C. Anaerobic plates were placed into an anaerobic atmosphere immediately after plating and were examined at 48 h. The swab sample was further teste d for fungal analysis by culturing the swab on to Saboura ud Chloroamphenicol agar. Statistical analysis of data: Data were recorded and analyzed using SPSS version 11.5. and study was evaluated us ing Chi- Sqaure test.
Chronic paranasal sinusitis is generally a mild disease. It?s a common disorder that causes major p hysical, emotional, and economical effects, and is associate d with poor quality of life. Chronic sinusitis is infection of t he sinuses lasting for more than 3 months. However, it is impo rtant to realize that it afflicts a significant percentage o f the population and causes considerable long term morbidity. The et iology of chronic sinusitis isn?t well known, while bacterial infection is believed to be a major causative factor in the deve lopment of disease. Despite the tremendous advances in medicin e over the last few decades, there have been relatively few im provements in the diagnosis and treatment of the disease. Many patients with the chronic sinus disease are subjected to mul tiple courses of antibiotics and surgeries, with little or no imp rovement in their condition. Long-term results of medical and s urgical therapies have resulted in cure rates that vary bet ween 29 and 80% 1-3 . Knowledge of the normal microbial flora can help in assessment of the significance of organisms isolate d from the sinuses of patients. No studies have examined the n ormal flora of the chronic sinuses. Bjorkwal l4 in this study found normal healthy maxillary antra to be sterile in 54 cases; however, other studies have shown conflicting results 4-7 . It is difficult to extrapolate these results to the chronic sinuses. The diagnostic criteria for acute maxillary sinusit is are well-established, but the definition of chronic maxillary sinusitis is controversial with respect to the impo rtance of bacteria in the initiation and progression of the d isease. Aspirates from community-acquired acute rhinosinusi tis usually harbour bacterial species such as Streptococcus pneumoniae , Haemophilus influenzae and Moraxella catarrhalis . In contrast, microbiological cultures from chronically inflamed sinuses that fail to respond t o antibiotic therapy are often found to be sterile or harbour a limited number of bacterial species, such as coagulase-nega tive Staphylococci , Prevotella spp. or Fusobacterium nucleatum . Chronic sinusitis has thus been considered to be a c hronic inflammatory condition rather than a microbial infe ction. The role of bacteria in the chronicity of inflammation is unknown 8 . Ventilatory obstruction of the sinus ostium plays t he key role in its pathogenesis. Acute infection destroys the norm al ciliated epithelium impairing drainage from the sinus. Pooli ng and stagnation of secretions in the sinuses invites inf ections. Factors such as virulence of organism causing sinus itis, condition of sinus mucosa, decrease in mucociliary clearance, and immunity of host are effective in the pathogene sis of sinusitis 9 . Persistence of infection causes mucosal changes, such as loss of cilia, edema and polyp formation, t hus continuing the vicious cycle 10 . The diagnosis of this disease is commonly confirmed by computed tomography (CT) scanning of the paranasa l sinuses. However, the severity of patients? symptom s does not always correlate well with CT stage of the disease 11,12 . Hence, all symptoms of sinusitis cannot be solely attribut ed to the objective findings obtained by radiological examina tions. The use of endoscopes expanded our knowledge about sinu s infections by enabling the detailed examination of the intranasal cavity. Taking collections to determine the microbiology of each sinus with a lower probability of contamination has been possible by endoscopy 10 . Lack of progress, paucity of knowledge on microbiology and histopathology of the chronic sinu s disease available to us, was the impetus of our study to ev aluate the microbiology of chronic sinusitis in patients under going FESS. We undertook this study to examine the microbiology of sinuses of patients with chronic sinusitis
During the period of study, 60 patients with chroni c sinusitis were included in the study. Microbiological data an d clinical data were available for all 60 patients. 3.1 Clinical findings The clinical diagnosis of chronic sinusitis was con firmed for all 60 patients. Extensive data for all the patients we re available for clinical evaluation. The average age of the pat ients was 41 years (range, 10 to 70 years). The male to female r atio was 1:1. The average duration of symptoms was 1.5 years (ran ged from less than 1 year to 15 years). History of allergy w as present in 22(36.7%) of 60 patients. Out of these 22 patients, 16(73%) were on antihistaminic treatment. DNS was present i n 52(87%) of 60 patients. In 8(15.3%) of these 52 patients sp ur was present. Turbinate hypertrophy was present in 20(33 .3%) patients. Paranasal sinus tenderness was present in 20(33.3%) patients, frontal sinus most commonly involved3.2 CT Scan and Intra-op findings In 20 (33.3%) of 60 patients, concha bullosa was pr esent. 4 (2.4%) patients had pansinusitis. In 24 (40%) of 60 patients, polypoidal mucosa was found. Mucopurulent discharge in sinuses was present in 10 (16.7%) out 60 patients. 3.3 Microbiology results Data were available for microbiological analysis fo r 60 swab specimens from the patients. 56 (93.3%) out of 60 p atients results were positive for pathogenic organisms. Out of 60 patients, 50 samples were positive for aerobic orga nisms, none were positive for anaerobes, fungal growth was repo rted in 6 samples and in 4 samples no growth was found ( Table I ). Out of 50 samples positive for aerobic organisms, Staphylococcus aureus was present in 30 (60%), MRSA was positive in 8 (16%), followed by Streptococcus 6 (12%). Other organisms found were Enterobacter 2 (4%), Actinomycetes 2 (4%), Acinetobacter 2 (4%), Pseudomonas 2 (4%), Klebsiella 2 (4%) ( Figure I ). More than one organisms were found in a patient. 6 out of 56 patients were positive for fun gal organisms. Aspergillus niger 2 (35.7%), Candida albicans 2 (35.7%), Candida kruzei 2 (35.7%) ( Table II ).