Clin Exp Otorhinolaryngol.  2018 Mar;11(1):40-45. 10.21053/ceo.2017.00332.

Bacterial Ball as an Unusual Finding in Patients With Chronic Rhinosinusitis

• Kim DK
• Wi YC
• Shin SJ
• Jang YI
• Kim KR
• Cho SH

• KMID: 2407791
• DOI: http://doi.org/10.21053/ceo.2017.00332

Abstract

OBJECTIVES
Pathophysiology of chronic rhinosinusitis (CRS) is very complex and has not yet been clearly understood. To date, various factors have been researched to have relations with the pathogenesis of CRS, such as superantigens and biofilms. Recently, we found an unusual pathological finding in patients with CRS, and we called this new entity as bacteria ball (or bioball). In this study, we analyze the clinical characteristics of bacteria ball occurred in CRS.
METHODS
This study enrolled consecutive 247 patients with CRS who underwent functional endoscopic sinus surgery from January 2015 to August 2016. The diagnosis of bacterial ball was made when negative in Gomori-methenamine-silver stain and positive in Gram stain. Histologically, bacterial ball was defined as acellular mucous materials with bacterial colonies and inflammatory cell infiltrates. We compared clinical data and computed tomography (CT) findings between fungal and bacterial balls.
RESULTS
Six cases (2.4%) of CRS were confirmed histologically as bacterial ball. Most of them were found in the maxillary sinus of CRS without nasal polyposis (66.7%). Bacterial ball was green or brown colored materials similar to fungal ball which was harder and tightly adherent to the antral mucosa. Compared to fungal ball, patients with bacterial ball showed significantly less peripheral eosinophils (P=0.011) and calcification in CT scans (P=0.003).
CONCLUSION
Bacterial ball is unusual findings occurred in patient with CRS which is different from fungal ball and biofilm. For diagnosis of bacterial ball, Gram stain is essentially required to identify bacterial colonies. Bacterial ball might appear to be evidence of a new strategy for living in the paranasal sinuses.

Keyword

Sinusitis; Fungi; Bacteria; Endoscopic Surgery

MeSH Terms

Bacteria
Biofilms
Diagnosis
Eosinophils
Fungi
Humans
Maxillary Sinus
Mucous Membrane
Paranasal Sinuses
Sinusitis
Superantigens
Tomography, X-Ray Computed
Superantigens

Figure

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  Fig. 1. Radiological findings for sinonasal bacterial balls. Soft tissue densities were found in the maxillary (A-C) and posterior ethmoid sinuses (D). They filled the involved sinuses partially (A) or completely (B-D), and showed signs of expansile growth with bone remodeling (C, D). Each asterisk (*) indicates the location of bioball.

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  Fig. 2. Operative findings for maxillary bacterial balls. When performing maxillary antrostomy (A, B), green colored bacterial balls were found in the maxillary sinus. They were gel-like or semisolid, and tightly attached to the sinus mucosa (C, D).

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  Fig. 3. Pathology findings for sinonasal bacterial balls. Bacterial balls consisted of matrix with thick acellular mucous material (A, B; H&E stain, ×40) in which gram-positive bacteria colonies were found in central (C; box area of panel A, Gram stain, ×400) or peripheral (D; box area of panel B, Gram stain, ×400) locations.

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