title: Staphylococcus aureus biofilms: Nemesis of endoscopic sinus surgery.
abstract: OBJECTIVE
  Chronic rhinosinusitis (CRS) patients with biofilms have persistent postoperative symptoms, ongoing mucosal inflammation, and recurrent infections. Recent evidence suggests that biofilms of differing species confer varying disease profiles in CRS patients. We aimed to prospectively investigate the effects of Staphylococcus aureus, Pseudomonas aeruginosa, Haemophilus influenzae, and fungal biofilms on outcomes following endoscopic sinus surgery (ESS).
  
  
  METHODS
  Prospective blinded study.
  
  
  METHODS
  In this prospective blinded study, 39 patients undergoing ESS for CRS assessed their symptoms preoperatively using internationally accepted standardized symptom scoring systems and quality-of-life measures (10-point visual analog scale, Sino-Nasal Outcome Test-20, global severity of CRS). Their sinonasal mucosa was graded (Lund-Kennedy scale) and extent of radiologic disease on computed tomography scans scored (Lund-McKay scale). Random sinonasal tissue samples were assessed for different bacterial species forming biofilms by using fluorescent in-situ hybridization and confocal laser microscopy. For 12 months after surgery, CRS symptoms, quality of life, and objective evidence of persisting disease were assessed by using the preoperative tools.
  
  
  RESULTS
  Different bacterial species combinations were found in 30 of 39 patients; 60% of these 30 biofilms were polymicrobial biofilms and 70% had S aureus biofilms. Preoperative nasendoscopy and radiologic disease severity were significantly worse in patients with multiple biofilms (P = .02 and P = .01, respectively), and they had worse postsurgery mucosal outcomes on endoscopy (P = .01) requiring significantly more postoperative visits (P = .04). Those with S aureus biofilms progressed poorly with their symptom scores and quality-of-life outcomes, with significant differences in nasendoscopy scores (P = .007).
  
  
  CONCLUSIONS
  S. aureus biofilms play a dominant role in negatively affecting outcomes of ESS with persisting postoperative symptoms, ongoing mucosal inflammation, and infections.
authors.affiliation: Department of Surgery-Otorhinolaryngology Head and Neck Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.
authors.forename: Deepti
authors.initials: D
authors.lastname: Singhal
authors.forename: Andrew
authors.initials: A
authors.lastname: Foreman
authors.forename: Joshua
authors.initials: J
authors.lastname: Jervis-Bardy
authors.forename: Josh-Jervis
authors.initials: JJ
authors.lastname: Bardy
authors.forename: Peter-John
authors.initials: PJ
authors.lastname: Wormald
mesh_terms: D000328:Adult; D000704:Analysis of Variance; D018441:Biofilms / Q000254:growth & development*; D002908:Chronic Disease; D004724:Endoscopy / Q000009:adverse effects* / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D013517:Otorhinolaryngologic Surgical Procedures / Q000009:adverse effects / Q000379:methods; D010256:Paranasal Sinuses / Q000382:microbiology / Q000601:surgery; D011183:Postoperative Complications / Q000453:epidemiology / Q000382:microbiology; D011237:Predictive Value of Tests; D011300:Preoperative Care / Q000379:methods; D011446:Prospective Studies; D012220:Rhinitis / Q000382:microbiology* / Q000601:surgery; D018570:Risk Assessment; D016037:Single-Blind Method; D012852:Sinusitis / Q000382:microbiology* / Q000601:surgery; D013203:Staphylococcal Infections / Q000175:diagnosis / Q000601:surgery*; D013211:Staphylococcus aureus / Q000502:physiology*; D018709:Statistics, Nonparametric; D013997:Time Factors