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Abstract
The goal of the present work was to investigate possible risk factors for the poor response of some cases of
chronic sinusitis to endoscopic sinus surgery in spite of the precision of the surgical technique. Eleven
adult patients who were scheduled for revision endoscopic sinus surgery underwent a complete allergy
workup. At the time of surgery, a tiny biopsy was taken from the maxillary sinus mucosa close to the
middle turbinate. The specimens were processed for histochemical and transmission electron microscopic
examination.
Six patients (55 per cent) proved to be allergic. Their sinus mucosa showed eosinophilic inltration (6.1
cells/mm 2), and mast cell degranulation. This proves that allergens can reach the sinus mucosa and have a
direct impact on it. Another three patients (27 per cent) were non-allergic but exhibited mucosal
eosinophilia (5.0 cells/mm2), and two of them showed mast cell degranulation. These patients were
diagnosed as having nonallergic rhinosinusitis with eosinophilia (NARSE). The nasal mucosa of the
remaining two patients did not reveal any characteristic pathological ndings, and no pathologic diagnosis
could be established for them. None of the patients showed electron microscopic evidence of purulent
inammatory changes, and the bacterial cultures recovered normal respiratory ora in nine patients (82
per cent).
The present research spotlights the importance of allergy and nonallergic eosinophilic inltration of the
mucosa as possible risk factors that may degrade the results of endoscopic sinus procedures and discusses
some pertinent pathological and clinical aspects.
Key words: Paranasal Sinuses; Sinusitis; Surgical Procedures, Operative; Treatment Failure
Introduction
Some stubborn cases of chronic sinusitis respond
poorly to different treatment modalities including
well-performed endoscopic sinus procedures. The
aetiology of chronic sinusitis is multifactorial and
ranges from anatomical abnormalities, to atopy,
ciliary dysfunction, immune deciencies, as well as
1
several other factors. Some of these factors may be
subtle or hidden and may be the underlying cause
behind the refractoriness of some patients.
The goal of the present study is to investigate
some of the possible causes of the poor response of
some patients with chronic sinusitis to endoscopic
sinus procedures in spite of the surgical technique.
From the Departments of Otolaryngology and Medical Laboratories, Saqr Hospital (United Arab Emirates), and Alexandria
Medical School (Alexandria, Egypt).
Accepted for publication: 29 August 2001.
112
some risk factors for refractory chronic sinusitis: an immunohistochemical and electron microscopic study
113
TABLE I
patients data
Patient no.
1
2
3
4
5
6
7
8
9
10
11
C1
C2
Positive
allergens (No.)
Serum IgE
(SIU)
0
9
0
4
0
7
0
6
5
0
9
0
0
6.1
51
4.4
44
6.8
48
2.9
50
51
7.5
62
2.8
3.6
Atopy
MBP
Cells/mm2
2
1
2
1
2
1
2
1
1
2
1
2
2
0
6
5
5
4
6
0
8
4
6
8
0
0
Eosinophils
Degranulated
mast cells
2
1
1
1
1
1
1
1
1
2
2
1
1
1
1
1
1
1
2
1
2
114
(a)
(b)
(c)
(d)
Fig. 1
(A) A high power histological section demonstrating positive staining for MBP (arrow) in the maxillary sinus mucosa of a patient
with chronic rhinosinusitis. (3 200). (B) A high power histological section demonstrating negative staining for MBP in a control
patient. (3 200). (C) A transmission electron micrograph showing an eosinophil with the characteristic bilobed nucleus (N), and the
specific granules (*). Some granules show the electro-lucent crystalloids in the center. (3 22 000). (D) A transmission electron
micrograph showing a degranulated mast cell. Many granules (arrow) are seen well outside the cell membrane. (3 18 000).
Discussion
The study sought to nd a pathological explanation
for the poor response of some cases of chronic
sinusitis to properly performed endoscopic procedures. The study showed two possible culprits:
allergy and NARSE. There was no pathological or
bacteriological evidence of purulent inammation.
There is circumstantial evidence supporting
allergy as a risk factor for sinusitis.1,69 However,
how allergic disease can lead to sinusitis is still
1,9
unclear. In subjects with local predisposing factors,
such as anatomical defects, it is conceivable that the
associated nasal mucosal inammation could induce
obstruction of the sinus ostia. In subjects without
obvious predisposing factors, different mechanisms
should exist.
In the effector phase of allergic reactions, several
chemical mediators, such as histamine and leukotrienes, are released from mast cells. These
mediators stimulate target tissues resulting in mucosal swelling and exessive discharge. The mast cells
also release chemo-attractants that attract other
inammatory cells, notably esoinophils, into the
local tissues. The eosinophils release other media-
some risk factors for refractory chronic sinusitis: an immunohistochemical and electron microscopic study
115
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Address for correspondence:
Samy Elway, M.D.,
PO Box 3114,
Ras Al-Khaima,
United Arab Emirates.
Fax: 1 971(7) 2222760
E-mail: elwany@emirates.net.ae
Dr S. Elwany takes responsibility for the integrity of the
content of the paper.
Competing interests: None declared