Chronic rhinosinusitis (CRS) is a prevalent health care problem that may be commonly encountered in patients desiring aesthetic or reconstructive rhinoplasty. The purpose of this article is to review the common bacterial pathogens associated with CRS, as well as patterns of bacterial resistance in this patient subset. Close understanding of microbial pathogens involved in CRS and their associated resistance patterns will guide facial plastic surgeons in optimally managing this important potential comorbidity, and in turn positively influence the outcome of rhinoplasty.
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Through understanding of microbiology and drug resistance patterns of chronic rhinosinusitis is a requisite if the facial plastic surgeon contemplates concurrent rhinoplasty with FESS.
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The most common organisms assayed in acute rhinosinusitis include Streptococcus pneumoniae , Moraxella catarrhalis , and Haemophilus influenzae .
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The most common organisms cultured in chronic rhinosinusitis are Staphylococcus aureus , coagulase-negative Staphylococcus , and gram-negative rods.
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S aureus is the most common organism seen on chronic sinusitis; its presence during FESS is associated with postop S aureus infection and impaired mucosal healing.
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Pseudomonas aeruginosa is the most commonly cultured gram negative rod and can be a source of recalcitrance due to biofilm formation.
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Strenotrophomonas maltophilia is a multidrug resistant gram-negative microbe seen in patients with previous FESS and prior antimicrobial treatment.
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Judicious usage of antimicrobial therapy is recommended for infectious exacerbations of chronic rhinosinusitis, ideally with endoscopically-guided cultures.
Dilemmas in concurrent management of chronic rhinosinusitis in the rhinoplasty patient
Chronic rhinosinusitis (CRS) ranks among the most common health problems in the United States. The comprehensive management algorithm for CRS entails a variety of medical therapies, such as antibiotics, oral and/or nasal steroids, leukotriene antagonists, and saline irrigations, with functional endoscopic sinus surgery (FESS) being reserved for refractory cases. Current estimates suggest that the number of sinus surgeries performed in the United States approximates 250,000 annually. In some instances, patients undergoing FESS may inquire about the possibility of concurrent reconstructive or cosmetic nasal surgery.
As our society becomes more concerned with appearance and plastic surgery procedures are more readily available and accepted, requests to combine elective aesthetic surgery with medical procedures will not be uncommon. Patients may view this as a means to decrease the number of operations performed for their overall care. Furthermore, the patient mindset may rationalize this approach with the thought that the surgeon “will be working on the nose anyway.”
Diverging opinions exist on the concept of concurrent FESS and rhinoplasty.
Arguments Against Concomitant FESS and Rhinoplasty
Some experts have advocated against these concomitant procedures for several important reasons. Intranasal inflammation and intranasal incisions as a result of rhinoplasty greatly add to the postoperative discomfort and make any attempt at effective debridement exceedingly difficult. While the exact role of debridement is controversial, most rhinologists hold that timely debridement starting 1 week after surgery is imperative to decrease the risk of synechiae formation and to achieve optimally functioning postoperative sinonasal cavities. Furthermore, nasal manipulation for debridement in the early postoperative period may alter the delicate position of the nasal osteotomies and compromise the cosmetic and functional outcome. Another argument against concurrent rhinoplasty and FESS focuses on the possibility of infection, given that FESS often takes place in an infected sinonasal space. Osteotomies performed during rhinoplasty breach the periosteum, creating a potential route for the spread of infection. The use of synthetic graft material in rhinoplasty adds another complicating factor to the possible spread of infection, though avoidance of graft materials may worsen outcomes from rhinoplasty.
Arguments for Concomitant FESS and Rhinoplasty
Conversely, others have argued that with appropriate and aggressive medical management of CRS, including preoperative, intraoperative, and postoperative antibiotic treatment, the risk of potential spread of infection to the nasal or facial tissues is greatly reduced. Moreover, the patient is spared an additional anesthetic and postoperative recuperative period, perhaps resulting in cost savings in the long term. However, within that argument rests an important caveat: to provide appropriate medical management of CRS, one must understand both its bacteriology and antibiotic resistance patterns.
Bacteriology of rhinosinusitis
Bacteria likely represent the main underlying cause of acute rhinosinusitis (ARS), with the most commonly identified bacteria being Streptococcus pneumoniae, Moraxella catarrhalis , and Haemophilus influenzae . By contrast, the central pathophysiology of CRS remains elusive to date. A variety of possible etiologic mechanisms have been proposed, including microbes (viruses, bacteria, fungi), allergy, osteitis, biofilm, staphylococcal superantigen, and derangements in innate and adaptive immunity. Although the exact role of bacteria in the disease process remains to be fully elucidated, it is likely that bacterial infection plays an important role in CRS, as either a causative or an exacerbating factor.
Differences in CRS and ARS Microbiology
The microbiology of CRS varies greatly from that of ARS. Nadel and colleagues evaluated 507 endoscopically guided cultures in 265 patients. The predominant organisms identified included Staphylococcus aureus (31.3%), coagulase-negative Staphylococcus (SCN) (44.2%), and gram-negative rods (34.3%). A multitude of gram-negative organisms were cultured, with the most common being Pseudomonas aeruginosa , Stenotrophomonas maltophilia , Escherichia coli , and Serratia marcescens . Kingdom and Swain analyzed 182 total cultures with 257 isolates in 101 patients at the time of sinus surgery. The microbiological yield was similar; the most common isolates were SCN (45%), gram-negative rods (25%), and S aureus (24%). Comparative analysis between primary and revision sinus surgery cases demonstrated no differences in the bacterial yield or types. Bhattacharyya and Gopal have demonstrated that whereas approximately half of the bacteria cultured in CRS are found in isolation, the rest exhibit polymicrobial growth, with 2 or more bacterial species.
Bacteriology of rhinosinusitis
Bacteria likely represent the main underlying cause of acute rhinosinusitis (ARS), with the most commonly identified bacteria being Streptococcus pneumoniae, Moraxella catarrhalis , and Haemophilus influenzae . By contrast, the central pathophysiology of CRS remains elusive to date. A variety of possible etiologic mechanisms have been proposed, including microbes (viruses, bacteria, fungi), allergy, osteitis, biofilm, staphylococcal superantigen, and derangements in innate and adaptive immunity. Although the exact role of bacteria in the disease process remains to be fully elucidated, it is likely that bacterial infection plays an important role in CRS, as either a causative or an exacerbating factor.
Differences in CRS and ARS Microbiology
The microbiology of CRS varies greatly from that of ARS. Nadel and colleagues evaluated 507 endoscopically guided cultures in 265 patients. The predominant organisms identified included Staphylococcus aureus (31.3%), coagulase-negative Staphylococcus (SCN) (44.2%), and gram-negative rods (34.3%). A multitude of gram-negative organisms were cultured, with the most common being Pseudomonas aeruginosa , Stenotrophomonas maltophilia , Escherichia coli , and Serratia marcescens . Kingdom and Swain analyzed 182 total cultures with 257 isolates in 101 patients at the time of sinus surgery. The microbiological yield was similar; the most common isolates were SCN (45%), gram-negative rods (25%), and S aureus (24%). Comparative analysis between primary and revision sinus surgery cases demonstrated no differences in the bacterial yield or types. Bhattacharyya and Gopal have demonstrated that whereas approximately half of the bacteria cultured in CRS are found in isolation, the rest exhibit polymicrobial growth, with 2 or more bacterial species.
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