The scoring per sinus is as follows:
Grade 1: Less than 50% of the sinus walls involved and osteitis less than 3 mm wide.
Grade 2: Less than 50% of the sinus was involved and 3–5 mm width.
Grade 3: Less than 50% of the sinus involved and wider than 5 mm or greater than 50% of the sinus wall involved and less than 3 mm wide osteitic changes.
Grade 4: Greater than 50% of the sinus wall involved and 3–5 mm.
Grade 5: Greater than 50% of the sinus wall and thicker than 5 mm.
In this way, each sinus was given a grading ranging from 0 to 5. The scores of all 10 sinuses (right and left frontal, anterior ethmoid, posterior ethmoid, maxillary, and sphenoid) are added, producing a composite score (range 0–50). We have shown that the grading using this scale is easy to perform (usually 2–3 min per patient) and gives reproducible results. We found that inter-rater variability was low, and the agreement between different assessors, using intraclass correlation coefficient, was excellent (0.947). The best agreement was found for the maxillary sinuses and the lowest for the ethmoids. Using this grading scale, a direct correlation between L-M score and GOSS was found [13▪] (Fig. 3).
Radiological features in single-photon emission computed tomography
Bone scintigraphy is considered the method of reference for the diagnosis of bone inflammation, although it is used rarely in everyday clinical practice. Two studies have assessed CRS patients with single-photon emission computed tomography (SPECT) scans. In the first study, 36 patients awaiting surgery for CRS underwent SPECT with technetium 99m-methylene diphosphonate. Thirty-two out of 36 were positive (increased uptake in the ethmoid sinus), and this result was confirmed with pathological findings in 31 (bone changes from lamellar to woven in the face of the bulla) .
Another study showed that 19 out of 24 patients with CRS had positive bone scintigraphy, with more positive results in patients with radiologically more extensive sinusitis .
Studies using CT, using various criteria to define osteitis, showed that the incidence of radiological changes associated with bony inflammation in patients with CRS ranged between 4 , 36 , and 40% [13▪]. Both the study by Lee as well as the study by Richtsmeier found an increased incidence of osteitis in patients with higher L-M score, while another study found a greater incidence in patients undergoing revision surgery. Using the GOSS, we found that the incidence of osteitis was 33% in the nonoperated group compared to 75% in the operated group (P < 0.001) [13▪]. Interestingly, there was an almost linear relation between the mean Global Osteitis Score and the number of previous surgeries, rising from 1.6 in patients with no previous surgeries, to 3.6 in those who had undergone one sinus procedure, to 15.5 in those with two previous operations, and to 31.5 in patients with more than 6 previous sinus surgeries (P < 0.001) (Fig. 4).
Although one would expect osteitis to be associated with more severe symptoms, this has not been shown: In our study [13▪], there was no correlation between nasal rhinosinusitis outcome measure scores and the presence of osteitis. Specifically, using VAS to assess headache, there was no correlation between osteitis severity and headache [13▪].
Similar results were found in a subsequent study from the USA, which used the Rhinosinusitis Disability Index (RSDI) and chronic sinusitis survey (CSS) patients-reported outcome measures to assess patients with CRS and osteitis and failed to show any worse baseline quality-of-life (QOL) scores in patients with osteitis [17▪].
Unlike subjective symptoms, radiological measures of disease extent seem to be worse in patients with osteitis. Both L-M scores as well as endoscopic scores have been shown to be correlated with osteitis in a number of studies [13▪]. Many studies [9,13▪,18] have confirmed the link between revision surgery and duration of symptoms with osteitis, although it remains unclear whether this is a primary or secondary association (underlying disease severity being the common factor).
It appears that osteitis is an independent negative prognostic factor after ESS for CRS, both in terms of endoscopic grading of the outcome as well as in terms of QOL improvement after ESS [17▪].
The management of osteitic bone in patients with CRS remains controversial.
The idea of removing all involved bone, through drilling and the performance of radical procedures (Denker , endoscopic modified Lothrop or Draf 3 ), is an attractive one. There is some evidence that an endonasal medical maxillectomy (Denker) may improve the outcome in patients with recalcitrant CRS . However, its role – if any – in patients with osteitis is less well defined. Indeed, a recent study showed worse surgical outcomes in patients with osteitis [17▪], while we should not forget that there is a direct correlation between the number of surgeries and osteitis [13▪]. Although this could be a secondary association, both osteitis and number of surgeries being surrogate markers of severe disease, the possibility that surgery may trigger or exacerbate osteitis must also be kept in mind.
Antibiotics (p.o. and i.v.)
The use of long-term antibiotics, especially macrolides, has been advocated in CRS, not only (or even primarily) for their antibacterial properties, but also in view of their direct anti-inflammatory action [21,22]. However, a recent large randomized multicenter trial has put doubts on it [23▪], which is also reflected in the recent European position paper on rhinosinusitis guidelines [1▪]. Unfortunately, the evidence of long-term antibiotics in osteitis is even more scarce: its advocates use the example of long bone osteomyelitis, to suggest that intravenous administration of antibiotics can produce high enough levels in the bone to clear an infection [24,25]. However, both studies suffer from methodological problems, number of participants, and lack of control group, while even more importantly, it is difficult to support such an intervention conceptually, when no group has yet demonstrated the presence of active, alive bacteria within areas of sinus osteitis.
Osteitis is increasingly recognized as a common factor in cases of recalcitrant or difficult-to-treat rhinosinusitis. We do know that the number and extent of previous surgeries is associated with osteitis and that it is predictive of worse postoperative outcomes; however, the role if any of antibiotics or radical surgery in its management remains undefined.
Conflicts of interest
There are no conflicts of interest.
There has been no funding received by the National Institutes of Health (NIH), Wellcome Trust, and Howard Hughes Medical Institute (HHMI).
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of review, have been highlighted as:
▪ of special interest
▪▪ of outstanding interest
Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 89).
1▪. Fokkens WJ, Lund VJ, Mullol J, et al.
European position paper on rhinosinusitis and nasal polyps 2012. Rhinol Suppl 2012; 3 pages preceding table of contents, 1–298.
The recent European evidence-based guidelines for CRS.
2. Westrin KM, Norlander T, Stierna P, et al. Experimental maxillary sinusitis induced by Bacteroides fragilis
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8. Giacchi RJ, Lebowitz RA, Yee HT, et al. Histopathologic evaluation of the ethmoid bone in chronic sinusitis. Am J Rhinol 2001; 15:193–197.
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13▪. Georgalas C, Videler W, Freling N, Fokkens W. Global Osteitis Scoring Scale and chronic rhinosinusitis: a marker of revision surgery. Clin Otolaryngol 2010; 35:455–461.
A study introducing a fully validated grading scale for osteitis and also assessing the QOL impact of it.
14. Catalano PJ, Dolan R, Romanow J, et al. Correlation of bone SPECT scintigraphy with histopathology of the ethmoid bulla: preliminary investigation. Ann Otol Rhinol Laryngol 2007; 116:647–652.
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16. Richtsmeier WJ. Top 10 reasons for endoscopic maxillary sinus surgery failure. Laryngoscope 2001; 111 (11 Pt 1):1952–1956.
17▪. Bhandarkar ND, Mace JC, Smith TL. The impact of osteitis on disease severity measures and quality of life outcomes in chronic rhinosinusitis. Int Forum Allergy Rhinol 2011; 1:372–378.
An interesting prospective study in the effect of surgery in patients with CRS and osteitis.
18. Telmesani LM, Al-Shawarby M. Osteitis in chronic rhinosinusitis with nasal polyps: a comparative study between primary and recurrent cases. Eur Arch Otorhinolaryngol 2010; 267:721–724.
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20. Georgalas C, Hansen F, Videler WJM, Fokkens WJ. Long terms results of Draf 3 procedure. Rhinology 2011; 49:195–201.
21. Ragab SM, Lund VJ, Scadding G. Evaluation of the medical and surgical treatment of chronic rhinosinusitis: a prospective, randomised, controlled trial. Laryngoscope 2004; 114:923–930.
22. Fokkens W, Lund V, Mullol J, et al
. European position paper on rhinosinusitis and nasal polyps 2007. Rhinol Suppl 2007; 1–136.
23▪. Videler WJ, Badia L, Harvey RJ, et al. Lack of efficacy of long-term, low-dose azithromycin in chronic rhinosinusitis: a randomized controlled trial. Allergy 2011; 66:1457–1468.
The most recent and largest randomized trial of macrolide in CRS.
24. Tovi F, Benharroch D, Gatot A, Hertzanu Y. Osteoblastic osteitis of the maxillary sinus. Laryngoscope 1992; 102:426–430.
25. Schaberg MR, Anand VK, Singh A. Hyperostotic chronic sinusitis as an indication for outpatient intravenous antibiotics. Laryngoscope 2010; 120 (Suppl. 4):S245.
Keywords:© 2013 Lippincott Williams & Wilkins, Inc.
osteitis; rhinosinusitis; surgery