Wednesday, January 11, 2012

What is the value of Sinus punctures in Rhinosinusitis?

What is the value of Sinus punctures in Rhinosinusitis?

Sinus puncture is a technique used in the diagnosis of bacterial sinusitis and in the treatment of rhinosinusitis as a drainage procedure, when patients do not respond to medical treatment.
Sinus puncture as a diagnosis method for rhinosinusitis

Sinus puncture is used to identify acute rhinosinusitis and acute bacterial rhinosinusitis. It is the most accurate way to determine the causative organism in sinusitis. After anesthetization of the puncture site, usually in the canine fossa or inferior meatus, the contents of the maxillary sinus are aspirated under sterile technique, and bacterial cultures are performed to identify the organism. Culture specimens obtained from nasal swabs correlate poorly with sinus pathogens found by puncture because of contamination of the swab with normal nasal flora (1).
Sinus puncture provides culture material to guide antibiotic selection when empiric therapy has failed or when antibiotic choice is limited. This is particularly important in patients who are immunocompromised or under intensive care, in whom sinusitis can be a prominent source of sepsis (2). However, because sinus puncture is an invasive procedure, it is not routinely performed. Sinus puncture with culture is the diagnostic reference standard in some countries like Eastern European countries or Nordic countries, but in other countries it is rarely used because it is invasive and costly; it is not a practical routine procedure. Alternative less invasive reference standard methods for diagnosing acute rhinosinusitis are needed (3).
A meta-analysis of six studies shows that sinus radiography has moderate sensitivity (76 percent) and specificity (79 percent) compared with sinus puncture in the diagnosis of acute bacterial rhinosinusitis. Studies comparing sinus ultrasonography with puncture or sinus radiography were inconclusive in determining how well ultrasonography identifies patients with acute bacterial rhinosinusitis. The results of ultrasonography varied substantially, possibly because of differences in patient populations, ultrasonography techniques, or medical personnel involved in diagnostic testing (3). More recently, studies have shown a close correlation between organisms found by sinus puncture and by endoscopically guided aspiration of the sinus cavities through the middle meatus (1). No studies comparing magnetic resonance imaging with radiography or sinus puncture were found. The one randomized trial comparing computed tomography with sinus radiography was inadequately reported (3).
Future studies of clinical criteria (including risk scores), ultrasonography, and endoscopy with middle meatal sampling, ideally comparing them with sinus puncture in a variety of research and clinical settings, are needed to establish their diagnostic utility (3).

Sinus puncture as a treatment for Rhinosinusitis
Several techniques have been described for drainage of the maxillary sinus. Sinus puncture is used to drain sinus when appropriate medical therapy has failed to control the infection, resulting in prolonged or slowly resolving symptoms, or for the prevention of, or treatment for rhinosinusitis complications (2).
Sinus puncture and irrigation techniques allow for surgical therapy, a means of removing thick purulent sinus secretions. The purpose of surgical drainage is to enhance mucociliary flow and provide material for culture and sensitivity. A surgical means of sinus drainage should be used when appropriate medical therapy has failed to control the infection and prolonged or slowly resolving symptoms result, or when complications of sinusitis occur (2).
There are no statistics for the use of sinus puncture in diagnosis or treatment. In spite of the lack of a standard method of diagnosis or treatment for rhinosinusitis, the use of sinus puncture is controversial and changes from country to country.
Bibliography
1. Christine Radojicic. Sinusitis. Disease Management Project Main. August 1, 2010. (http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/allergy/rhino-sinusitis/)
2. S.E. Sobol, M D Schloss, T L Tewfik, Sinusitis, Maxillary, Acute, Surgical Treatment. E-Medicine: Medscape continually updated Clinical reference. Jul 14, 2009. (http://emedicine.medscape.com/article/862030-overview)
3. AHRQ Evidence Report Summaries. 9 Diagnoses and Treatment of Acute Bacterial Rhinosinusitis: Summary. Bookshelf ID: NBK11860. Rockville (MD): Agency for Healthcare Research and Quality (US); 1998-2005. (http://www.ncbi.nlm.nih.gov/books/NBK11860/)

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