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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 16  |  Issue : 2  |  Page : 104-108

Microbial isolates from endoscopic middle meatal swab in patients with chronic rhinosinusitis in Kaduna, Nigeria


1 Department of Otorhinolaryngology, Maitama District Hospital, Federal Capital Territory Administration, Abuja, Nigeria
2 Department of Otorhinolaryngology, College of Medical Sciences, University of Maiduguri, University of Maiduguri Teaching Hospital, Maiduguri, Nigeria
3 Department of Clinical Services, National Ear Care Centre, Kaduna, Nigeria
4 Department of Otorhinolaryngology, University College Hospital Ibadan, & College of Medicine, University of Ibadan, Ibadan, Nigeria

Date of Web Publication18-Jan-2018

Correspondence Address:
Dr. Abdullahi Musa Kirfi
Department of Clinical Services, National Ear Care Centre, Kaduna
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajmhs.ajmhs_15_17

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  Abstract 


Background: Chronic rhinosinusitis (CRS) is a common disease in otorhinolaryngologic practice. Traditionally, the standard criterion for isolation of pathogens in CRS is the nonendoscopic maxillary sinus puncture through invasive procedures with well-documented hazards. Objectives: To evaluate the pathogens associated with CRS in patients with CRS from endoscopically guided middle meatal swab. Methodology: A prospective cross-sectional study in which endoscopically guided middle meatal swab was aseptically taken from patients with diagnostic criteria of CRS and healthy volunteers. The samples were sent to the laboratory for qualitative and semi-quantitative analysis. Data collected were analyzed using the Statistical Package for the Social Sciences version 16 (SPSS Inc., 233 South Wacker Drive, Chicago, Illinois, USA). Results: A total of 110 microbial isolates were recovered from 82 (63.08%) of the 130 patients with CRS while 46 recorded among 54 (51.92%) of the 104 healthy volunteers. There were 74 (56.92%) bacterial growth out of which 55 (74.32%) were aerobic and 19 (25.68%) anaerobic isolates among the test participants with fungal growth seen in 36 (27.7%) of them while about 18% yielded a mixed growth of aerobic, anaerobic, and/or fungal isolates. Among the control group, however, the 54 people with positive isolates had 21 fungal and 25 aerobic bacteria. Conclusion: Mixed growth of aerobes, anaerobes, and fungal isolates was observed in patients with CRS. Endoscopically guided middle meatal swab is a safe and practical means for collecting samples for microbial culture.

Keywords: Culture, middle meatus, pathogens, rhinosinusitis, swab


How to cite this article:
Musa E, Kodiya AM, Kirfi AM, B. Nwaorgu OG. Microbial isolates from endoscopic middle meatal swab in patients with chronic rhinosinusitis in Kaduna, Nigeria. Afr J Med Health Sci 2017;16:104-8

How to cite this URL:
Musa E, Kodiya AM, Kirfi AM, B. Nwaorgu OG. Microbial isolates from endoscopic middle meatal swab in patients with chronic rhinosinusitis in Kaduna, Nigeria. Afr J Med Health Sci [serial online] 2017 [cited 2018 Apr 25];16:104-8. Available from: http://www.ajmhs.org/text.asp?2017/16/2/104/223578




  Introduction Top


Chronic rhinosinusitis (CRS) is a clinical disorder that encompasses a heterogeneous group of infectious and inflammatory conditions affecting the nose and paranasal sinuses.[1] It is one of the most common chronic disorders encountered by otorhinolaryngologists in Nigeria [2],[3],[4],[5],[6],[7] and could be responsible for significant physical symptoms, decreased quality of life, and impairment of daily functions resulting in millions of days of lost productivity with significant impact on the economy.[8],[9]

Many pathophysiologic mechanisms have been described to account for CRS, but in most cases, these factors apply only in susceptible hosts.[10] Today, CRS is seen as an inflammatory disease which may or may not involve pathogenic microbes.[11] Therefore, bacteria, fungi, or viruses may be involved in many cases, but there may be some cases with no identifiable pathogenic organism. In general, pathogen-positive cultures are recovered in 50% to 60% of patients with CRS.[12],[13]

In Nigeria, while a study in Ilorin [4] showed that 45% of patients with CRS had pathogenic isolates using posterior nasal swab, another study in Sokoto [6] showed that infective causes accounted for 67.1% of rhinosinusitis.

The pathogens commonly implicated in acute rhinosinusitis are more definite and include: Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus, rhinovirus, and influenza virus;[14] in CRS, the pathogens are more heterogeneous with aerobic organisms (S. aureus, Streptococcus viridans, H. influenzae, and  Neisseria More Details species), anaerobic organisms (Peptostreptococci, Corynebacteria, and Bacteroides)  Moraxella More Details catarrhalis, and a variety of fungi such as Aspergillus species encountered. The role played by bacteria in the pathogenesis of CRS may be direct or indirect.[14] Bacteria may play a role through multiple mechanisms including chronic infection, osteitis, the production of superantigens, and support through biofilms. Fungi can result in a classic chronic fungal inflammation in either allergic fungal sinusitis or immunoglobulin E-mediated inflammation.


  Methodology Top


This was a prospective cross-sectional descriptive study to evaluate the microbial isolates associated with CRS among patients with CRS in the study center from endoscopically guided middle meatal swab. The study center is a stand-alone reference Hospital for the management of and research in ear, nose, and throat diseases in Nigeria.

Middle meatal swabs from 130 patients with CRS were analyzed microbiologically to determine the common pathogens. This target population consists of male and female patients attending the study center who met the diagnostic criteria of CRS according to the Multidisciplinary Rhinosinusitis Task Force of American Academy of Otolaryngologists–Head and Neck Surgeons [8] as modified by the Sinus and Allergy Health Partnership.[10] A plain occipitomental view radiograph of the paranasal sinuses was used for supporting the diagnosis of CRS.

Healthy volunteers (staff and students) of the hospital served as control after screening for CRS using clinical diagnostic criteria.

Consecutive patients seen at the study center with diagnosis of CRS from November 2013 to May 2014 who satisfied the inclusion criteria were recruited.

A structured questionnaire based on the research questions was employed for the study. Headlight (DARAY Medical Examination Head Light 550) served as the light source for physical examination. Thudicum's nasal speculum was used for anterior rhinoscopy, rigid endoscopes size 2.7 and 4 mm, and 0° and 30° were used for nasal endoscopy and endoscopically guided middle meatal swab. Local anesthesia was achieved with 10% xylocaine spray while anesthesia, vasoconstriction, and decongestion were achieved with 2% lignocaine and adrenaline 1:200,000 dilution.

Ten milliliters syringe filled with normal saline was then used to irrigate the nasal cavities, and a sterile swab stick was then used in taking the swab from the middle meatus. The procedure was well tolerated by all the participants with only few complaints of discomfort in the nose. The collected swab was then inoculated on to the culture media: Chocolate agar and MacConkey agar for aerobic culture, cooked meat agar and blood agar for anaerobic culture while Sabouraud dextrose agar incubated with chloramphenicol was used for fungal culture.

Master Anaerobic Gaspak by Micromaster Laboratories PVT India: An oxygen absorbing and carbon-dioxide generating gaspak was used for anaerobic culture while Equitron Anaerobic Jar was used for incubation and rearing of anaerobes.


  Results Top


A total of 130 patients with CRS were studied. The age range was 18–55 years with mean age of 31.87 ± 8.60 years. This consisted of 67 (51.5%) males and 63 (48.5%) females with male-to-female ratio of 1.1:1. The control group was made up of 104 healthy participants matched for age and sex with age range 20–51 years and mean age 33 ± 7.35 years. The age distribution of the study group is presented in [Table 1]. The most common features seen at nasoendoscopy were mucopus from the middle meatus (63.1%) and hypertrophied inferior turbinate (51.3%) in patients and controls respectively as seen in [Table 2].
Table 1: Age and gender distribution of study groups

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Table 2: Findings at endoscopy***

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The microbial isolates of middle meatal swabs of participants in this study are shown in [Table 3]. A mixed growth of aerobic/anaerobic/fungal isolates was common. About 24.6% of the patients with CRS had pure aerobic growth, 3% had pure anaerobic growth, and 17.7% had pure fungal growth. About 27.7% of them had no bacterial growth and 9% had neither bacterial nor fungal growth. Pure aerobic growth among the control group was about 24% and pure fungal growth was seen in about 20% of them, but there was no anaerobic growth.
Table 3: Microbial isolates

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The distribution of various isolates cultured is presented in [Table 4]. A total of 110 aerobic/anaerobic bacteria and/or fungal isolates were recovered from 82 (63.08%) of the 130 patients with CRS while 46 aerobic bacterial and fungal isolates were isolated from 54 (51.92%) of the 104 healthy volunteers. Analysis of the 74 (56.92%) positive bacterial growth among the test participants showed that 55 (74.32%) were aerobic and 19 (25.68%) anaerobic. Fungal growth was seen in 36 (27.7%) of patients. Among the control group, however, there were 46 positive isolates made up 21 fungal and 25 aerobic bacteria. The most common bacterial isolates among the test group were S. aureus (35.14%), H. influenzae (12.16%), S. viridians (10.81%), and S. pneumoniae 5 (6.76%) while the most common fungal isolates were Aspergillus species. On the other hand, the most common bacterial isolates in the control group were coagulase-negative staphylococci (92.0%) while the most common fungal isolates were Candida species (71.43%).
Table 4: Distribution of various isolates in participants

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  Discussion Top


Nasal endoscopy has brought about a new horizon in the management of patients with CRS. An endoscopically guided middle meatal culture has overcome the limitation of antral puncture which assesses only the maxillary sinus since the anterior ethmoid frontal, and the maxillary sinuses all drain through the middle meatus.

A summary of many studies as presented by Brook [15] has shown that unlike in acute rhinosinusitis, the pathogens in CRS are usually heterogeneous with great variability in the rate of recovery of pathogens. In this study, about 25% of the patients with CRS had pure aerobic growth, 3% had pure anaerobic growth, and 18% had pure fungal growth. About 28% of them had no bacterial growth and 9% had neither bacterial nor fungal growth while about 18% yielded a mixed growth of aerobic, anaerobic, and/or fungal isolates. Hence, a total of 110 aerobic/anaerobic bacteria and/or fungal isolates were recovered from 82 (63.08%) of the 130 patients evaluated in this study. There were 74 (56.92%) bacterial growth out of which 55 (74.32%) were aerobic and 19 (25.68%) were anaerobic. This is significantly higher than findings of 24% bacterial growth among the control group (P = 0.01). It falls within the global average of 50%–60% rate of recovery of bacterial growth in CRS.[12],[13] It is, however, higher than findings of Ologe and Nwabuisi in Ilorin who reported 45% prevalence of bacterial growth in patients with CRS.[4] The difference could be because only aerobic bacteria were evaluated in that study.

The most common bacterial isolates among the test group are S. aureus (35.14%), H. influenzae (12.16%), S. viridians (10.81%), and S. pneumoniae 5 (6.76%) while the most common fungal isolates are Aspergillus species. These findings are similar to the study by Araujo et al.[14] in Brazil where S. aureus (31%) was the most common aerobes found. It is, however, lower than 48.1% reported by Ologe and Nwabuisi [4] who used swab from posterior nasal fossa instead of the middle meatal swab used in this study.

Coagulase-negative staphylococci are considered as normal flora – mainly Staphylococcus epidermidis, in the nasal mucosa. In this study, it was isolated in about 5% of the patients with CRS compared to 92% found in the control group. On the other hand, pathogenic S. aureus that is associated with numerous cell counts was isolated in 4% of the control group compared to about 35% seen among patients with CRS in this study. Hence, coagulase-negative Staphylococcus was significantly higher in the control group than in patients with CRS (P = 0.000) while pathogenic S. aureus was significantly higher in the patients with CRS than in the control group (P = 0.000).

Anaerobic organisms are generally lower in swab samples compared to aspirates. In this study, 25.68% of bacterial growth was anaerobes. This is higher than the 12% recovered in a study in Brazil by Araujo et al.[14] but similar to findings of 22.4% by Ozcan et al.[16] in middle meatal culture in Turkey. In this study as well as in Araujo et al.,[14] no anaerobes was isolated among the control group.

About 28% of the patients in this study did not have any bacterial growth showing similarity with finding of a study by Ozcan et al.[16] who reported the lack of bacterial growth in 32.3% of middle meatal cultures of patients with CRS in Turkey.

In this study, 27.70% of patients with CRS had fungal growths. This result is lower than findings by Hajiioannou et al.[17] where fungal culture was positive in 62.4% of patients with CRS with polyps. While fungal growth of about 29.8% among the control group in this study was similar to the test group, the isolates in the test group were mainly Aspergillus species while in the control group it was mostly Candida species.


  Conclusion Top


There were 74 (56.92%) bacterial growth out of which 55 (74.32%) were aerobic and 19 (25.68%) anaerobic isolates. Fungal growth was seen in 36 (27.7%) while about 18% yielded a mixed growth of aerobic, anaerobic, and/or fungal isolates. Endoscopically guided middle meatal swab is, therefore, a safe and practical means for collecting samples for the culture in CRS.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rodney JS, Bradford AW. Chronic rhinosinusitis and polyposis. In: Snow JB Jr., Wackym PA, editors. Ballenger's Otolaryngology: Head and Neck Surgery. 17th ed. Shelton: B. C. Decker; 2009. p. 573-82.  Back to cited text no. 1
    
2.
Ogunleye AO, Nwargu OG, Lasisi AO, Ijaduola GT. Trends of sinusitis in Ibadan, Nigeria. West Afr J Med 1999;18:298-302.  Back to cited text no. 2
    
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Ezeanolue BC, Aneke EC, Nwagbo DF. Correlation of plain radiological diagnostic features with antral lavage results in chronic maxillary sinusitis. West Afr J Med 2000;19:16-8.  Back to cited text no. 3
    
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Ologe FE, Nwabuisi C. Bacteriology of chronic sinusitis in Ilorin, Nigeria. Afr J Clin Exp Microbiol 2003;4:91-7.  Back to cited text no. 4
    
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da Lilly-Tariah OB. Pattern of clinical features of chronic simple rhinosinusitis in Port Harcourt. Niger J Clin Pract 2006;9:142-6.  Back to cited text no. 5
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Iseh KR, Makusidi M. Rhinosinusitis: A retrospective analysis of clinical pattern and outcome in North Western Nigeria. Ann Afr Med 2010;9:20-6.  Back to cited text no. 6
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Sogebi OA, Oyewole EA. Rhinosinusitis: Clinical features seen in Sagamu, Nigeria. Internet J Otorhinolaryngol 2007;6:1-4. [DOI: 10.5580/111].  Back to cited text no. 7
    
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Lanza DC, Kennedy DW. Adult rhinosinusitis defined. Otolaryngol Head Neck Surg 1997;117:S1-7.  Back to cited text no. 8
    
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Mainasara MG, Labaran AS, Kirfi AM, Fufore MB, Fasunla AJ, Grema US. Clinical profile and management of chronic rhinosinusitis among adults in Northwestern Nigeria. Am J Innov Res Appl Sci 2015;1:133-6.  Back to cited text no. 9
    
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Benninger MS, Ferguson BJ, Hadley JA, Hamilos DL, Jacobs M, Kennedy DW, et al. Adult chronic rhinosinusitis: Definitions, diagnosis, epidemiology, and pathophysiology. Otolaryngol Head Neck Surg 2003;129 3 Suppl:S1-32.  Back to cited text no. 10
    
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Friedman RL, Hockman M. Chronic rhinosinusitis. South Afr J Epidemiol Infect 2010;25:7-10.  Back to cited text no. 11
    
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Benninger MS, Appelbaum PC, Denneny JC, Osguthorpe DJ, Stankiewicz JA. Maxillary sinus puncture and culture in the diagnosis of acute rhinosinusitis: The case for pursuing alternative culture methods. Otolaryngol Head Neck Surg 2002;127:7-12.  Back to cited text no. 12
    
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Talbot GH, Kennedy DW, Scheld WM, Granito K, Endoscopy Study Group. Rigid nasal endoscopy versus sinus puncture and aspiration for microbiologic documentation of acute bacterial maxillary sinusitis. Clin Infect Dis 2001;33:1668-75.  Back to cited text no. 13
    
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Araujo E, Dall C, Cantarelli V, Pereira A, Mariante AR. Microbiology of middle meatus in chronic rhinosinusitis. Braz J Otorhinolaryngol 2007;73:549-55.  Back to cited text no. 14
    
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Brook I. Microbiology of sinusitis. Proc Am Thorac Soc 2011;8:90-100.  Back to cited text no. 15
    
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Ozcan M, Unal A, Aksaray S, Yalcin F, Akdeniz T. Correlation of middle meatus and ethmoid sinus microbiology in patients with chronic sinusitis. Rhinology 2002;40:24-7.  Back to cited text no. 16
    
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Hajiioannou J, Maraki S, Vlachaki E, Panagiotaki I, Lagoudianakis G, Skoulakis C, et al. Mycology of the nasal cavity of chronic rhinosinusitis patients with nasal polyps in the Island of crete. Otorhinolaryngol Head Neck Surg 2012;48:16-21.  Back to cited text no. 17
    



 
 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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