Introduction: Chronic rhinosinusitis (CRS) is a common disease poorly controlled by antibiotics. Postulated etiologies of CRS include allergy, fungi, functional factors, and biofilm. Objectives: We presented a preliminary study demonstrating bacterial biofilms' presence on the sinus mucosa of patients with CRS using fluorescent in situ hybridization (FISH). The advantage of FISH in biofilm identification is that it is the only method that identifies the specific bacteria creating the biofilm matrix. We now present the results of a larger series of patients. Methods: Patients with CRS scheduled for sinus surgery were enrolled in the study. Biopsies of the sinus mucosa and cultures were taken at the time of surgery. Control samples were taken from patients undergoing septoplasty. Specimens underwent FISH testing for Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenza, and Pseudomonas aeruginosa. Results: Bacterial biofilms were present on 14 of 18 specimens. The predominant species were H. influenzae, S. pneumoniae, and S. aureus. P. aeruginosa biofilm was not identified on any specimens. The intraoperative cultures of the planktonic bacteria present in the sinuses did not correlate with the biofilms identified. Two of the five control samples were positive for biofilm. Conclusion: The presence of biofilms on the mucosa of patients with CRS offers a possible cause of antimicrobial therapy failure and could change the approach to treatment. However, the presence of biofilms on healthy control samples implies that biofilms may simply be colonizers. The precise role that biofilms play in CRS still remains to be determined. Further studies with larger sample sizes are needed.

This is a preliminary study demonstrating fungal elements within sinus mucosal biofilm and demonstrating biofilm in AFRS.

Although the techniques for surgery on the endolarynxusing suspension and the operating microscope have been fully developed,1–4 the safest, and least obtrusive anesthetic technique has yet to be manifested, as evidenced by more than 200 references to anesthesia for microlaryngoscopy in the world literature. This study reviews the physiology, physics, and problems of each anesthetic technique. In light of this review, animal and human studies are reported demonstrating the utility and safety of subglottic ventilation when provided with proper monitoring using an automatic ventilator. A modified Ben‐Jet tube is reported,5 which has a 1‐mm ID channel to monitor Pco2 and tracheal pressure. This self‐centering 3.0‐mm tube, which extends 6 to 8 cm below the glottis, is unobtrusive for the surgeon. The subglottic tube, which is much less likely to be malaligned, is much more acceptable to the anesthesiologist. Anesthesia, by intravenous sedation, utilizes neuromuscular blockade while ventilating through the jet tube powered by an automatic ventilator with an automatic shutdown feature attached to the monitor tube to prevent inadvertent barotrauma. The third phase of this study compared fluoroplastic, used in a prototype jet ventilation tube, with 6‐mm Silastic®, Red Rubber, and polyvinyl chloride (PVC) tubes when struck by maximum power of CO2, Nd‐YAG, and K‐532 lasers. The test was performed in a closed chamber in which concentrations of oxygen and nitrogen were controlled. Although damaged by the CO, laser beam, the fluoroplastic tubes did not continue burning when the laser was turned off in 100% oxygen, even when coated by blood. The other three tubes continued to burn in 23% oxygen. Neither the KTP nor Nd‐YAG laser damaged the Teflon tube, while they ignited a sustained flame in 30% oxygen. This study supports the use of fluoroplastic for a laser safe jet ventilation tube. It also demonstrates the danger of tube fires, even in low oxygen concentrations, when using Silastic, rubber, and PVC tubes in laser laryngeal surgery. There was no difference in the flammability of Silastic, rubber or PVC when struck by these lasers in this study. For these reasons, subglottic ventilation using a fluoroplastic, monitored, self‐centering, subglottic, jet ventilation tube driven by an automatic ventilator with a shutdown feature, in the event of excessive pressure buildup, is proposed for anesthetizing healthy patients undergoing suspension microlaryngoscopy, and who have no airway obstructing lesion. A large tube with inflatable cuff is indicated when a supraglottic lesion may obstruct the airway.

The understanding of the implication of chronic biofilm infections is growing rapidly but will require an enormous effort to completely control chronic rhinosinusitis.

During a 1-year period, 27 otolaryngic allergy practices recorded all systemic reactions to immunotherapy resulting from 635,600 patient visits and 1,144,000 injections. Sixty percent of injections were given at home. Major systemic reactions were observed after 0. 005% of injections. There were no hospitalizations or deaths. Eighty-seven percent of major reactions began within 20 minutes of injection. Frequently observed risk factors for major reactions were buildup phase of immunotherapy, active asthma, and first injection from a treatment vial. Home and office injections had similar rates of total systemic reactions, but home-based immunotherapy had far fewer major reactions. Home-based immunotherapy was found to be safe. The methods and precautions used to treat patients with this degree of safety are specified and discussed.