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Nasal and sinus endoscopy for medical management of resistant rhinosinusitis, including postsurgical patients

2007; Elsevier BV; Volume: 121; Issue: 4 Linguagem: Inglês

10.1016/j.jaci.2007.08.065

1097-6825

Wellington S. Tichenor, Allen Adinoff, Brian A. Smart, Daniel L. Hamilos,

Head and Neck Surgical Oncology

Nasal endoscopy has been practiced by allergists since the early 1980s; however, allergists in general have not embraced endoscopic evaluation of patients with sinus disease, either before or after surgery. Allergists are in a unique position to render medical (as opposed to surgical) care of patients with sinusitis. There has been a growing realization that endoscopy is a valuable procedure for the evaluation and medical treatment of patients with difficult sinusitis. This has resulted in the need for a resource to allow allergists to understand the nature of endoscopic findings in patients with sinusitis, either preoperatively or postoperatively. This article introduces the findings at endoscopy that are common in patients with sinusitis, including those that may be seen after surgery. The findings include perforation of the septum, retained secretions, small surgical ostium caused by postoperative ostial stenosis, previous Caldwell Luc procedure, recirculation of mucus, hyperplastic nasal disease, synechiae, recurrent disease in previously unaffected sinuses, empty nose syndrome, frontal sinus disease, dental disease, and other, more complicated entities. Nasal endoscopy has been practiced by allergists since the early 1980s; however, allergists in general have not embraced endoscopic evaluation of patients with sinus disease, either before or after surgery. Allergists are in a unique position to render medical (as opposed to surgical) care of patients with sinusitis. There has been a growing realization that endoscopy is a valuable procedure for the evaluation and medical treatment of patients with difficult sinusitis. This has resulted in the need for a resource to allow allergists to understand the nature of endoscopic findings in patients with sinusitis, either preoperatively or postoperatively. This article introduces the findings at endoscopy that are common in patients with sinusitis, including those that may be seen after surgery. The findings include perforation of the septum, retained secretions, small surgical ostium caused by postoperative ostial stenosis, previous Caldwell Luc procedure, recirculation of mucus, hyperplastic nasal disease, synechiae, recurrent disease in previously unaffected sinuses, empty nose syndrome, frontal sinus disease, dental disease, and other, more complicated entities. Practice parameters and practical descriptions for performance of nasal endoscopy have been written previously but have not been recently updated.1Selner J. Koepke J. Rhinolaryngoscopy in the allergy office.Ann Allergy. 1985; 54: 479-482PubMed Google Scholar, 2Georgitis J. Druce H.M. Goldstein S. Meltzer E.O. Okuda M. Selner J.C. et al.Rhinopharyngolaryngoscopy.J Allergy Clin Immunol. 1993; 91: 961-962Abstract Full Text PDF PubMed Scopus (7) Google Scholar This article focuses on the use of nasal and sinus endoscopy for chronic rhinosinusitis in both presurgical and postsurgical patients. The article does not focus on normal anatomy and diagnostic aspects of normal endoscopy, because these subjects have been reviewed previously.3Selner J. Visualization techniques in the nasal airway: their role in the diagnosis of upper airway disease and measurement of therapeutic response.J Allergy Clin Immunol. 1988; 82: 909-916Abstract Full Text PDF PubMed Scopus (9) Google Scholar Allergists began performing flexible nasal and sinus endoscopy (hereafter referred to simply as "endoscopy") in the early 1980s.4Rohr A. Hassner A. Saxon A. Rhinopharyngoscopy for the evaluation of allergic-immunologic disorders.Ann Allergy. 1983; 50: 380-384PubMed Google Scholar Around the same time, functional endoscopic sinus surgery (FESS) began gaining popularity and has since become the primary surgical technique for treatment of patients with chronic rhinosinusitis that has proven refractory to medical treatment.5Aukema A.A. Fokkens W.J. Chronic rhinosinusitis: management for optimal outcomes.Treat Respir Med. 2004; 3: 97-105Crossref PubMed Scopus (27) Google Scholar, 6Bolger W. Kennedy D. Surgery of the paranasal sinuses in adults.in: Druce H. Sinusitis: pathophysiology and treatment. Marcel Dekker, New York1994: 107-128Google Scholar, 7Kennedy D. Senior B. Endoscopic sinus surgery: a review.Otolaryngol Clin North Am. 1997; 30: 313-330PubMed Google Scholar Endoscopy is a useful technique that affords the allergist the ability to assess and localize sinus pathology with far greater precision than a routine nasal examination. Use of endoscopy can also improve diagnostic accuracy and thereby reduce costly and unnecessary medication use (eg, antibiotics). It is highly desirable that all specialists treating nasal and sinus disease be able to perform a complete endoscopic evaluation of the nose and sinuses, especially for evaluation of inflammatory disease.8Druce H. Diagnosis of sinusitis in adults: History, physical examination, nasal cytology, echo, and rhinoscope.J Allergy Clin Immunol. 1992; 90: 436-441Abstract Full Text PDF PubMed Scopus (42) Google Scholar Endoscopy should be viewed as part of a complete examination of the nose and sinuses. Allergists are in a unique position to treat the entire "unified airway."9Lipworth B. White P. Allergic inflammation in the unified airway: start with the nose.Thorax. 2000; 55: 878-881Crossref PubMed Scopus (47) Google Scholar For these reasons, it is highly desirable for allergists to be skilled in nasal endoscopy and in the preoperative and postoperative treatment of patients with rhinosinusitis.6Bolger W. Kennedy D. Surgery of the paranasal sinuses in adults.in: Druce H. Sinusitis: pathophysiology and treatment. Marcel Dekker, New York1994: 107-128Google Scholar, 10Levine H.L. Functional endoscopic sinus surgery: evaluation, surgery, and follow-up of 250 patients.Laryngoscope. 1990; 100: 79-84PubMed Google Scholar, 11Kennedy D. Prognostic factors, outcomes and staging in ethmoid sinus surgery.Laryngoscope. 1992; 102: 1-18PubMed Google Scholar, 12Senior B.A. Kennedy D.W. Tanabodee J. Kroger H. Hassab M. Lanza D. Long-term results of functional endoscopic sinus surgery.Laryngoscope. 1998; 108: 151-157Crossref PubMed Scopus (378) Google Scholar A strong argument can be made for incorporating endoscopy in the routine care of any patient with chronic rhinosinusitis. According to the otolaryngology (ENT) literature, sinus surgery affords benefit in the vast majority of cases selected for surgery.6Bolger W. Kennedy D. Surgery of the paranasal sinuses in adults.in: Druce H. Sinusitis: pathophysiology and treatment. Marcel Dekker, New York1994: 107-128Google Scholar, 10Levine H.L. Functional endoscopic sinus surgery: evaluation, surgery, and follow-up of 250 patients.Laryngoscope. 1990; 100: 79-84PubMed Google Scholar, 11Kennedy D. Prognostic factors, outcomes and staging in ethmoid sinus surgery.Laryngoscope. 1992; 102: 1-18PubMed Google Scholar, 12Senior B.A. Kennedy D.W. Tanabodee J. Kroger H. Hassab M. Lanza D. Long-term results of functional endoscopic sinus surgery.Laryngoscope. 1998; 108: 151-157Crossref PubMed Scopus (378) Google Scholar Still, relapses after surgery are not infrequent and are usually best managed medically provided that the initial sinus surgery was technically adequate and resulted in an acceptable outcome. The list of conditions amenable to medical management in postsurgical patients is long and includes (1) allergic or nonallergic chronic inflammation, (2) chronic infection, (3) fungal colonization, (4) hyperplastic mucosa, (5) nasal or sinus polyposis, and (6) aspirin hypersensitivity. With experience, it is also possible to recognize anatomic abnormalities that may contribute to persistent disease after surgery.13Desrosiers M. Refractory chronic rhinosinusitis: pathophysiology and management of chronic rhinosinusitis persisting after endoscopic sinus surgery.Curr Allergy Asthma Rep. 2004; 4: 200-207Crossref PubMed Scopus (36) Google Scholar Competence in endoscopy merely enhances the already important role of the allergist in recognizing and treating all diseases of the nose and sinuses and in recognizing other important contributing conditions, such as gastroesophageal reflux disease (GERD), aspirin sensitivity, immunodeficiencies, and less common diseases such as cystic fibrosis, sarcoidosis, Wegener granulomatosis, and ciliary dyskinesia or tumors. Wegener typically may have constitutional symptoms associated with nasal blockage, crusting, epistaxis with facial pain, septal perforation, and nasal collapse. Tumors most commonly arise in the maxillary sinus. They tend to be unilateral, with nasal obstruction, hyposmia, and epistaxis. Orbital symptoms are common. If any suspicion of malignancy occurs, the patient should be referred for biopsy. It has been shown that patients with chronic rhinosinusitis and allergic rhinitis fare better after endoscopic sinus surgery if their allergies are managed optimally.14Lavigne F. Nguyen C.T. Cameron L. Hamid Q. Renzi P.M. Prognosis and prediction of response to surgery in allergic patients with chronic sinusitis.J Allergy Clin Immunol. 2000; 105: 746-751Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar Although some allergists have expressed concern about performing nasal endoscopy, nasal endoscopy is generally considered part of normal procedures for allergists by both malpractice and health insurance companies and is usually included in malpractice insurance. In addition, many allergists receive training in endoscopy during their fellowship or at subsequent courses.3Selner J. Visualization techniques in the nasal airway: their role in the diagnosis of upper airway disease and measurement of therapeutic response.J Allergy Clin Immunol. 1988; 82: 909-916Abstract Full Text PDF PubMed Scopus (9) Google Scholar In our experience, it is easier to examine certain areas such as the sphenoethmoidal recess, the anterior wall of the maxillary sinus (in patients who have had previous surgery), and the sphenoid sinus with a flexible endoscope. This is also true with respect to large patent accessory maxillary sinus ostia. Often, the entire maxillary sinus can be examined with the flexible endoscope in patients who have had previous surgery. Although concerns about safety have been expressed by some allergists, there are minimal concerns in reality other than vasovagal reactions.15Pfleiderer A. Antroscopy via the inferior meatal route under local anaesthetic: a practical guide to technique.J Laryngol Otol. 1987; 101: 1035-1039Crossref PubMed Scopus (11) Google Scholar Most allergists do not perform biopsies (other than perhaps mucosal brushings); as a result, there is little, if any, risk of bleeding. Assuming that one does not attempt to enter forcibly a small sinus ostium or pass through an area where there are sharp bony fragments such as the frontal recess, there is minimal, if any, risk of problems removing the endoscope. Although rigid endoscopes are the most popular among otolaryngologists, flexible endoscopes are preferred by allergists for the reasons mentioned.3Selner J. Visualization techniques in the nasal airway: their role in the diagnosis of upper airway disease and measurement of therapeutic response.J Allergy Clin Immunol. 1988; 82: 909-916Abstract Full Text PDF PubMed Scopus (9) Google Scholar Partly this relates to the fact that allergists, unlike ENT surgeons, do not perform procedures requiring rigid endoscopes (eg, FESS), but the main reason is the ease of use and the ability to manipulate the flexible endoscope easily into narrow recesses. On the contrary, many otolaryngologists prefer the superior optics and visualization afforded by the rigid endoscopes. In addition, it is easier to use another instrument alongside the rigid scope. Rigid endoscopes are made in varying angles: 0°, 30°, 45°, and 70°. The less experienced examiner will typically start with a 0° endoscope. Flexible endoscopes are made by numerous manufacturers (Pentax, Montvale, NJ; Olympus, Center Valley, Pa; and others) in varying diameters. Endoscopes with and without procedure or biopsy channels are available. The narrowest useful diameter without a channel is approximately 2.2 mm; however, with the narrower pediatric fiberoptic endoscopes, some sacrifice must be made in image quality to use a smaller diameter endoscope. One must therefore choose whether to use a narrower scope and compromise some image quality. The 2.2-mm or 2.4-mm endoscopes are most commonly used. The narrowest endoscope with an internal biopsy channel is 3.4 mm. Care must be taken in handling the endoscopes, because they are delicate and easily damaged. Repairs may cost several thousand dollars. Although more expensive xenon light sources can be used, halogen light sources are usually adequate. Cleaning of the endoscope is accomplished easily. Initially a leakage test should be performed to ensure that the integrity of the instrument has not been compromised and it will not be damaged in the cleaning process. The instrument is then rinsed to remove any gross debris and very gently wiped down to prevent damaging the instrument. The instrument is then placed in an enzymatic cleaner (eg, Endozime, Ruhoff, Mineola, NY; or Enzol, Johnson & Johnson, Irvine, Calif) for the recommended time (usually 10 minutes). The instrument is once again rinsed and gently wiped down. It is then placed in glutaraldehyde (eg, Cidex, Advanced Sterilization Products, Ethicon, Irvine, Calif; Metricide, Metrex, Orange, Calif) or a related product, ortho-phthalaldehyde (eg, Cidex-OPA) following the manufacturer's suggestions for duration of sterilization. For Cidex-OPA, the time required is 12 minutes. Thereafter, the endoscope must be thoroughly rinsed to remove all traces of the microbicide and then dried. A wall-mounted cleaning stand can be used to simplify the process (EndoCaddy; Aztec Medical Products, Williamsburg, Va). If an endoscope with a channel is used, more extensive cleaning is required. A suggested protocol for the use of Cidex-OPA is included in this article's Appendix E1 and E2 in the Online Repository at www.jacionline.org. The endoscopic procedure can either be viewed through the eyepiece or through a video monitor. With the smaller diameter endoscopes, there is a significant reduction in image quality that may compromise the evaluation when used with a video monitor. Various video camera attachments are available for recording purposes. Although cameras (Fig 1) are now small (eg, 5 cm × 3 cm × 3 cm), the bulk at the head of the endoscope may make subtle maneuvers more difficult to perform. Alternatively, a video camera cable can be attached to the endoscope and connected to a table-mounted camera. It is also possible to mount the endoscope from a ceiling support. During endoscopy, it is possible to perform a number of therapeutic procedures. First, in patients who are having acute pain during the procedure, it is possible to irrigate tissues with small amounts of lidocaine using a Sinus Irrigation Catheter (Medtronic Xomed, Minneapolis, Minn; Fig 2). (Otolaryngologists may use lidocaine or cocaine soaked pledgets or injections of local anesthetics, but these may not be available to allergists.) For patients with inflammatory disease or signs of infection, it is possible to directly instill corticosteroids, saline, or antibiotics into a sinus cavity if the sinus ostium is patent. There are several options for patients who need procedures performed during the endoscopy. First, as described previously, fiberoptic endoscopes are available that have a separate channel contained within the endoscope through which procedures can be performed. The advantage of this is that the channel is self-contained within the endoscope. However, this type of endoscope is impractical for everyday use. Although the same endoscope can be used both for routine endoscopy and for cultures or other therapeutic endeavors, the greater diameter of the dual channel endoscope makes it more difficult to maneuver and more uncomfortable for the patient. Also, the dual channel endoscope requires more extensive cleaning or use of a protective sheath each time the endoscope is used, whether or not the channel is used. Hence, the dual channel scope is usually reserved for special procedures or research activities. There is a sheath available with an external channel (Vision Sciences/Medtronic Xomed, Jacksonville, Fla; Fig 3). This has been a valuable addition to the endoscopist's armamentarium. Originally, sheaths were developed as a means for using endoscopes (particularly gastrointestinal endoscopes with internal channels) without having to sterilize them after each use. The sheath is applied over the endoscope and disposed of after 1 use. This significantly shortens the time between procedures. The sheath protects the channel as well, and the cleaning process is therefore much easier. It was later discovered that it was possible to create a sheath with a channel external to the endoscope but self-contained within the sheath. Using this device, brushings or procedures such as foreign body or fungus ball removal can be performed by using a brush (Fig 4), snare (Fig 5), or basket (Fig 6) with an endoscope that was not originally designed for surgical procedures.Fig 4Brush. Courtesy of US Endoscopy.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 5Snare. Courtesy of US Endoscopy.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 6Basket. Courtesy of US Endoscopy.View Large Image Figure ViewerDownload Hi-res image Download (PPT) A sinus puncture device (Sinoject; Atos Medical, Milwaukee, Wis) was recently developed that has dramatically reduced the complexity of sinus puncture; however, this procedure remains infrequently used because of trauma, patient dislike for the procedure, and the risk of iatrogenically introducing organisms into the sinus.16Vogan J. Bolger W. Keyes A. Endoscopically guided sinonasal cultures: a direct comparison with maxillary sinus aspirate cultures.Otolaryngol Head Neck Surg. 2000; 122: 370-373PubMed Google Scholar The Sinoject is not currently distributed in the United States. Unlike rigid endoscopes, with which the examiner can perform endoscopy and other procedures without assistance, use of the flexible scope requires an assistant to perform other procedures or cultures. The examiner must use 1 hand to hold the tip of the endoscope and the second hand for obtaining the cultures. With practice, the assistant can be taught to hold the endoscope during this procedure. All too frequently in routine practice, patients treated for sinus infections do not respond to treatment. In part, this is because of empiric use of antibiotics without knowledge of the bacteria, fungi, mycobacteria,17Spring P. Miller R. Initial report of primary sinusitis caused by an atypical pathogen (Mycobacterium chelonae) in an immunocompetent adult.Ear Nose Throat J. 1999; 78 (362-4): 358-359PubMed Google Scholar or other organisms involved. There is also a real risk of creating more severe infections, such as those caused by Gram-negative or methicillin-resistant Staphylococcus aureus by repeatedly using antibiotics empirically. Fungal overgrowth is another possible side-effect. Obtaining meaningful cultures during endoscopy can help alleviate these problems and afford medical management a much greater likelihood of success.16Vogan J. Bolger W. Keyes A. Endoscopically guided sinonasal cultures: a direct comparison with maxillary sinus aspirate cultures.Otolaryngol Head Neck Surg. 2000; 122: 370-373PubMed Google Scholar, 18Gold S. Tami T. Role of middle meatus aspiration culture in the diagnosis of chronic sinusitis.Laryngoscope. 1997; 107: 1586-1589Crossref PubMed Scopus (98) Google Scholar That said, meaningful cultures are not simple to obtain and must be performed with proper techniques, appropriate collection vessels and transport media, and timely delivery to the laboratory. Therefore, the endoscopist must be aware of these factors before embarking on culturing sinus mucus. The techniques for specimen collection require some practice, and equipment must be obtained specifically for this purpose.19Gill V. Fedorko D. Witebsky F. The clinician and the microbiology laboratory.in: Mandell G. Bennett J. Dolin R. Principles and practice of infectious diseases. Churchill Livingstone, Philadelphia2000: 184-222Google Scholar Samples must be placed in proper transport media to avoid desiccation and to support the growth of pathogens. Specimens must be transported to the laboratory within time constraints set for the transport media selected; otherwise, the culture results cannot be trusted. Fungal cultures must be sent in appropriate transport medium to a laboratory with expertise in mycology, including speciation of fungi and determination of antifungal sensitivities. Adequate amounts of material must be sent for both bacterial and mycological cultures. The larger the volume of material, the more likely a pathogen will be recovered.19Gill V. Fedorko D. Witebsky F. The clinician and the microbiology laboratory.in: Mandell G. Bennett J. Dolin R. Principles and practice of infectious diseases. Churchill Livingstone, Philadelphia2000: 184-222Google Scholar We recommend not obtaining cultures unless these points are taken into consideration. Culturing for anaerobic bacteria is more difficult than culturing for aerobic bacteria and requires special techniques and specimen handling. The role of culturing for anaerobic bacteria has been emphasized by Brook et al20Brook I. Yocum P. Frazier E. Bacteriology and beta-lactamase activity in acute and chronic maxillary sinusitis.Arch Otolaryngol Head Neck Surg. 1996; 122: 418-422Crossref PubMed Scopus (79) Google Scholar and Brook21Brook I. Microbiology and antimicrobial management of sinusitis.Otolaryngol Clin North Am. 2004; 37: 253-266Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar but is of uncertain value in the outpatient management of chronic rhinosinusitis. Although strict criteria for timing of cultures do not exist, generally cultures should not be performed during antibiotic treatment. If they need to be performed, the presumption is that the antibiotic being used is not effective. Although some authors have suggested otherwise, to avoid misleading culture results, the antibiotic should be stopped for at least 48 hours before obtaining cultures. Cultures should be taken from appropriate areas, especially from the middle meatus16Vogan J. Bolger W. Keyes A. Endoscopically guided sinonasal cultures: a direct comparison with maxillary sinus aspirate cultures.Otolaryngol Head Neck Surg. 2000; 122: 370-373PubMed Google Scholar or directly from the sinuses in patients who have patent ostia. Care must be taken not to contaminate the specimen. Unlike cultures taken from the nose, endoscopically guided cultures from the ostiomeatal unit using Dacron urethral swabs have been found to reproduce accurately cultures taken from within the sinuses, either at the time of surgery or via sinus puncture; however, larger studies still need to be performed.16Vogan J. Bolger W. Keyes A. Endoscopically guided sinonasal cultures: a direct comparison with maxillary sinus aspirate cultures.Otolaryngol Head Neck Surg. 2000; 122: 370-373PubMed Google Scholar, 18Gold S. Tami T. Role of middle meatus aspiration culture in the diagnosis of chronic sinusitis.Laryngoscope. 1997; 107: 1586-1589Crossref PubMed Scopus (98) Google Scholar, 22Benninger M.S. Appelbaum P.C. Denneny J.C. Osguthorpe D.J. Stankiewicz J.A. Maxillary sinus puncture and culture in the diagnosis of acute rhinosinusitis: the case for pursuing alternative culture methods.Otolaryngol Head Neck Surg. 2002; 127: 7-12Crossref PubMed Scopus (52) Google Scholar Generally, the most reliable cultures can be expected when the mucus collected is visibly purulent,16Vogan J. Bolger W. Keyes A. Endoscopically guided sinonasal cultures: a direct comparison with maxillary sinus aspirate cultures.Otolaryngol Head Neck Surg. 2000; 122: 370-373PubMed Google Scholar, 23Poole M. Endoscopically guided vs. blind nasal cultures in sinusitis.Otolaryngol Head Neck Surg. 1992; 107: 272Google Scholar but there may be exceptions to this rule. For instance, Orobello and Park24Orobello P. Park R. Microbiology of chronic sinusitis in children.Arch Otolaryngol Head Neck Surg. 1991; 117: 980-983Crossref PubMed Scopus (119) Google Scholar reported a strong correlation between middle meatal cultures and both maxillary and ethmoid sinus cultures in children, even though gross purulence was not present in the former location. Devices such as the Xomed Sinus Secretion Collector (a catheter with long thin tubing for collection of sinus mucus and debris; Medtronic Xomed; Fig 7) can be directed into the middle meatus (ostiomeatal unit) or, occasionally, into a sinus ostia.25Kuhn F. Javer A. Current concepts in the surgical management of frontal sinus disease: primary endoscopic management of the frontal sinus.Otolaryngol Clin North Am. 2001; 34: 59-75Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar The sinus secretion collector consists of a 2-mm plastic malleable catheter inside a protective sheath. This is attached to a suction device. The protective sheath minimizes but does not completely eliminate contamination from the anterior nares. After introduction into the middle meatus or sinuses, the outer sheath is retracted, suction applied, and a sample taken. The cultured material is retained within a Lukens collection trap. This device allows collection of larger volumes of mucus for more accurate and less contaminated cultures. Once collected, the sample can be divided, transferred to special bacterial or fungal transport media, and then sent to the laboratory. In addition, a sample may be sent for cytology in an appropriate medium. Because of the low recovery rate for fungal stains and cultures, consideration should be made to sending specimens to more than 1 laboratory. Cultures should be relied on for species identification, because identification of species is often difficult on the basis of stain, cytology, or surgical specimen. Equally important are discussions with the laboratory supervisor. These discussions should occur before the endoscopist begins performing cultures so the requirements for these cultures can be established. Depending on the clinical circumstances, bacterial and fungal cultures and sensitivities can be obtained by using the appropriate culture media suggested by the supervisor. If the patient has persistent infection despite adequate therapy, other unusual types of infections, such as those caused by atypical mycobacteria or other organisms, should also be considered. It may be necessary to consult the microbiologist and mycologist regarding what sensitivities may be done. Generally, if swabs are used for culture, it is preferable not to use cotton tipped swabs because they may reduce the yield of cultures. Purulent drainage from the middle meatus or sinus ostium can be collected on a calcium alginate swab on an aluminum shaft (eg, Calgiswab; Puritan Hardwood Products Co, Guilford, Me) or a Dacron-tipped swab or with a sinus aspirator (eg, Xomed aspiration system with a Lukens collection trap; Medtronic Xomed Tami Sinus Secretion Collector). In some cases, a Gram stain or cytologic examination for eosinophils and Charcot-Leyden crystals may also be useful. Fungal stains such as Gomori methenamine silver or periodic acid-Schiff are most commonly used to stain mucus for fungal hyphae; however, staining may be unreliable. As a result, a more sensitive fluorescein-labeled chitinase stain that stains the chitin layer of the fungal organism (eg, Fungalase; Anomerics, Baton Rouge, La) has been described.26Taylor M.J. Ponikau J.U. Sherris D.A. Kern E.B. Gaffey T.A. Kephart G. et al.Detection of fungal organisms in eosinophilic mucin using a fluorescein-labeled chitin-specific binding protein.Otolaryngol Head Neck Surg. 2002; 127: 377-383Crossref PubMed Scopus (99) Google Scholar However, this stain is not yet in general use. Molecular diagnosis of the presence of fungi in mucus or tissue specimens is a promising and emerging technology using either panfungal or species-specific nucleotide primers.27Hendolin P.H. Paulin L. Koukila-Kähkölä P. Anttila V.J. Malmberg H. Richardson M. et al.Panfungal PCR and multiplex liquid hybridization for detection of fungi in tissue specimens.J Clin Microbiol. 2000; 38: 4186-4192PubMed Google Scholar, 28Polzehl D. Weschta M. Podbielski A. Riechelmann H. Rimek D. Fungus culture and PCR in nasal lavage samples of patients with chronic rhinosinusitis.J Med Microbiol. 2005; 54: 31-37Crossref PubMed Scopus (45) Google Scholar However, only limited studies have been performed, and the mere presence of fungal DNA or mRNA in mucus may not differentiate normal from abnormal levels of fungal colonization or disease. Elevated levels of major basic protein may allow such differentiation,29Ponikau J.U. Sherris D.A. Kephart G.M. Kern E.B. Congdon D.J. Adolphson C.R. et al.Striking deposition of toxic eosinophil major basic protein in mucus: implications for chronic rhinosinusitis.J Allergy Clin Immunol. 2005; 116: 362-369Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar but further work needs to