Introduction: Chronic rhinosinusitis (CRS) is an upper airway inflammatory disorder lasting more than 12 weeks. It is a significant health burden affecting 5 to 12 % of general population and is one of most common cause for loss of workforce in society. Bacterial pathogens, both aerobes and anaerobes are implicated to most of the cases of CRS including altered natural flora, mucociliary dysfunction, inflammation and oedema of sinus mucosa leading to various symptoms of CRS. Symptomatological association of microbiota is needed so as to target the treatment and prevent undue use of antibiotics. 

Aim & Objective: To identify type of predominant bacterial flora in maxillary sinusitis and to associate the symptomatology of chronic maxillary rhinosinusitis with causative bacteria. 

Methodology: A prospective observational study was conducted in Department of ENT in association with Department of Microbiology BRD Medical College Gorakhpur Between January 1st 2019 to December 31st 2019. All patients between 15 years to 70 years of age irrespective of gender with symptoms of chronic maxillary sinusitis more than 12 weeks were included in the study.

Result & Observation: The most common etiological agent associated with CRS in this study was observed as Staphylococcus aureus followed by Pseudomonas aeruginosa. Headache followed by nasal blockage were the most common symptoms exhibit by patients with CRS.  

Conclusion: Chronic maxillary sinusitis is a multifactorial entity. Knowledge of microbiota and their association with specific symptoms paves a path to targeted antimicrobial treatment. This causal association is useful in predicting the course the treatment but a study with bigger sample size is needed to establish the causality.

Chronic Rhinosinusitis (CRS) is an upper airway inflammatory disorder lasting more than 12 weeks. It is a significant health burden affecting 5 to 12 % of general population and is one of most common cause for loss of workforce in the society [1]. 

Etiopathogenesis of this condition is multifactorial and poorly understood. Numerous studies have suggested immunological dysfunction [2], microbial infection and impaired mucociliary function as important causative factors.

Most of the cases of CRS are associated with Streptococcus pneumoniae, Hemophilus influenza, Staphylococcus aureus as well as members of Enterobacteriaceae.  Anaerobes are also found to be associated with long standing cases. Both aerobes and anaerobes are implicated to altered natural flora, mucociliary dysfunction, inflammation and oedema of sinus mucosa leading to various symptoms of CRS [3].
Symptomatological association of microbiota is needed so as to target the treatment and prevent undue use of antibiotics.

• To identify type of predominant bacterial flora in maxillary sinusitis.

• To associate the symptomatology of chronic maxillary rhinosinusitis with causative bacteria

Study design, duration and center of study: A prospective observational study was conducted in Department of ENT in association with Department of Microbiology, BRD Medical College Gorakhpur between January1st 2019 to December 31st 2019.

Inclusion Criteria: All patient between 15 to 70 year of age irrespective of gender with symptoms of chronic maxillary sinusitis more than 12 weeks with 2 or more symptoms one of which is fever, nasal discharge, nasal blockage, facial pain, anosmia or hyposmia and either positive endoscopic findings (oedema /discharge /obstruction of middle meatus) and /or positive CT findings (mucosal changes in osteomeatal complex and/ or sinuses)

Exclusion Criteria: Patients with predominant allergic symptoms , patients who had previous sinus surgery, persons having no nasal symptoms for the last 4 weeks and exhibiting normal finding the nasal cavity by anterior rhinoscopy and Diagnostic nasal endoscopy (DNE), patients with confirmed nasal polyposis on DNE and those with immunological disorders

Data Collection: All patients visiting ENT OPD of Nehru Hospital associated with BRD medical College Gorakhpur between January 1st 2019 to December 31st 2019 who had symptom of chronic maxillary sinusitis and confirmed with mucosal thickening in NCCT PNS were enrolled in the study after carefully explaining them about the procedure and obtaining written consent from the patient/ attendant. Ethical clearance certificate was obtained from Institutional ethics committee before starting the study.

Sample Collection: The degree of mucosal thickening was evaluated by noting the nearest distance between the air mucosal interface and the lateral part of the sinus wall (mucosal thickening was defined as a mucosal width of 5.5 mm or more). The sample was collected during diagnostic nasal endoscopy and taking nasal swab. Under direct vision swab was taken from middle meatus using 5 circular motions and was sent to department of microbiology in same setting for microbiological analysis [4]. In the laboratory each specimen was inoculated on Blood agar and McConkey agar for aerobic culture and Robertson cooked meat broth for anaerobic culture. After incubation at 37°C for 24 hours the plates were observed for growth and the organisms were identification up to species level was performed by a battery of biochemical tests.

Outcome Measures: Patients were interviewed and assessed for headache, nasal blockage, nasal discharge, foul smelling nasal discharge, crust formation, anosmia/hyposmia and epistaxis. These were reported as present or absent. Visual Analogue Scale was used for headache assessment which was graded as mild moderate and severe [5].

                             Figure1: Outcome Measures of patients.

Sample size: The study of SM. Finegold [6] et al observed that bacterial isolates were recovered from 114(76%) of 150 patients. Taking this value as reference, the minimum required sample size with 10% margin of error and 5% level of significance is 70 patients. So total sample size taken is 70. Formula used is:- 

                                                                            n ≥ (p(1 -p))/(ME/zα)2

                                                      Where Zα is value of Z at two sided alpha error of 5%

                                                                      ME is margin of error

                                                  P is proportion of patients with bacterial isolates Calculations                                

                 n>= ((.76*(1-.76))/(.1/1.96)2=70.07=70(approx.)

The presentation of the Categorical variables was done in the form of number and percentage (%). The comparison of the variables which were qualitative in nature was analyzed using Chi-Square test. If any cell had an expected value of less than 5 then Fisher’s exact test was used.

The data entry was done in the Microsoft EXCEL spreadsheet and the final analysis was done with the use of Statistical Package for Social Sciences (SPSS) software, IBM manufacturer, Chicago, USA, version 25.0.

For statistical significance, p value of less than 0.05 was considered statistically significant.

Graph1: Distribution of Symptomatic Presentation of Study Subjects.

                                                                                                                    Table 1: Frequency of  Isolated Microorganism.

Graph 2: Distribution of Cases According to Nature of Discharge.

Graph 3: Distribution of Symptoms Observed with Associated Bacteria.

Table 2: Distribution of Case in Relation to Nature of Headache and Predominant Bacteria.

The maxillary sinuses are clinically most significant of the entire paranasal air sinus as they frequently get infected in all age group. The infection is mostly chronic and with each exacerbation there is an extension of infection to the ethmoid air cells and to some extent frontal sinus.

In our study, out of 70 patients, majority had presented with headache (74.3%) other symptoms like nasal blockage was in (47%) cases, nasal discharge (45.7%) foul smell (30%) anosmia/hyposmia (14.3%) crust formation (11.4%) and epistaxis (7%).

52/70 (74.3%) Patients presented with headache. We observed most common organism associated with severe headache to be Staphylococcus aureus, Streptococcus pyogenes and Streptococcus pneumonia but association was non-significant. In the study conducted by Levine et al [7] 36.40% cases presented with headache, Rice et al [8] reported headache in 88% cases in their series, none of them have graded headache severity and no bacteriological causal association was mentioned.

In our study E coli is found to be significantly associated with nasal blockage. Whereas nearly 32% of samples associated with nasal blockage was culture negative. Streptococcus aureus, Pseudomonas aeruginosa and E .coli were predominantly found in purulent discharge. Proteus mirabilis, Streptococcus pneumonia and Klebsiella pneumoniae were observed in mucopurulent discharges whereas Streptococcus pyogenes was seen in mucoid discharge. E coli have shown interesting association with crust formation, epistaxis, anosmia or hyposmia.

Pseudomonas aeruginosa is responsible for all the cases associated with foul smell. Staphylococcus aureus which is mainly responsible for formation of thick viscid pus. Vickery et al. [9] mentioned in their study that hypofunction of cilia due to

Staphylococcus aureus leads to obstruction of ostea and ultimately present in the form of headache and purulent nasal discharge.

Streptococcus pyogenes is associated with mucoid discharge. It causes more inflammation and oedema in surrounding tissues by releasing streptokinase and hyaluronidase enzymes. This leads to blockage of maxillary ostia and presents in the form of headache and mucoid discharge [10].

E. coli mainly present with nasal blockage, foul smell, hyposmia and crust formation well as headache. It produces various types of exotoxins and hemolysin which may be responsible for damaged cilia and leads to stagnation of discharge (pus) along with formation of crust causing blockage of ostia and headache. Krawczyk et al [11]. In their case series reported E Coli to be associated with mucosal irregularity, nasal obstruction and snoring. They also found toxin like uropathogenic specific protein, alpha hemolysin and cytotoxin necrotizing factor-1 responsible for mucosal inflammation.

Colonization of sinuses with Pseudomonas aeruginosa is rare; they are mostly associated with immunodeficient state [12,13]. The bacteria are not responsible for greater amount of mucosal inflammation and edema therefore ostea remain patent hence not associated with headache. Pyocyanin, fluorescein hydroxyphenazine toxin released by Pseudomonas aeruginosa leads to minimal stasis and foul smell discharge.

Chronic maxillary sinusitis is a multifactorial entity. Knowledge of microbiota and their association with specific symptoms paves a path to targeted antimicrobial treatment. In our study Streptococcus aureus was found to be the most common associated bacteria followed by Pseudomonas aeruginosa. Staphylococcus aureus, Streptococcus pneumoniae and Streptococcus pyogenes were associated to severe headache. Interestingly E. coli was found to have significant association with symptoms like nasal obstruction, anosmia/hyposmia and crust formation. Pseudomonas aeruginosa was found to be associated with foul smell in all the cases. This causal association is useful in predicting the course the treatment but a study with bigger sample size is needed to establish the causality.

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Corresponding Author: Vertika Tewari, Department of ENT, BRD Medical College India. E-mail: vrtsmbe26@gmail.com

Copyright: ©2022 All copyrights are reserved by Vertika T, published by Coalesce Research Group. This work is licensed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.