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Sinus disease. You get mucosal or anatomic obstruction so that the secretions can’t get out and the air can’t get in. The secretions stagnate. The pH drops which makes the white cells ineffective as well as some of the antibiotics. The mucosal gas metabolism changes. It becomes an anaerobic environment. Cilia and epithelium are damaged from bacteria as well as immune response. You get changes that create a culture medium that is conducive to bacterial growth. The retained secretions and all of these things going on cause tissue inflammation. The bacterial infection develops in the cavities which then pushes this thing on and on and on and until you reestablish drainage and oxygenation, you don’t have a chance. Which is not to say that that’s the only part of sinusitis. You all have seen the people that are draining well and sinusitis, sinusitus, rhinitis, runny nose
Predisposing factors. I think that the things that by far are the most common are upper respiratory tract infection and what makes some patients every time they get a URI they get a sinusitis, I don’t understand it. It’s poorly understood. It has to do, I think, with the molecular
Allergic rhinitis has never been able to be proved as a causative factor in rhinosinusitis in adults and the correlation is thin in children but it has been shown. Rhinitis medicamentosa. Hypertrophic adenoids. A big issue in children. Deviated nasal septum. If it’s bad enough can be a
Immune deficiency. By far the most common would be the common variable, but still pretty rare, is CF. You see a patient under the age of 14 that has nasal polyps, always get a sweat chloride test. Polyps are very rare in children. They occur in about 25% of the patients with cystic fibrosis but always get a sweat chloride test on that population. I think in 15 years I’ve only seen one patient that was a 13-year-old that had
Bronchiectasis and immotile cilia syndrome. Again, this is relatively rare. If you do have patients that have this, we actually end up doing a little
I put this up is because what this diagram shows is the prevalence of both allergic symptoms and sinus symptoms. What you see and what you notice in your own practice is the seasons during which allergies are the worst are the seasons during which sinusitis is the least and vice
The pathophysiology of sinusitis. Basically it has four stages. The inciting stage, whatever it was. Almost always it seems to be a viral formed body – a nasal polyp. This leads to osteal obstruction which causes, again, that stasis of secretion, that drop in pH, the drop in the oxygen content. If this sits around long enough you get the chronic stage. This is just an endoscopic picture of a turbinate with some kind of polypoid stuff in it that probably has been driven by infection. This is an endoscopic picture of an open maxillary sinus with some pus coming out of it.
Recurrent acute sinusitis. Nasal airway obstruction. Anterior and posterior discolored drainage. Facial pain or dental pain. Fevers are very
The bacteriology in acute sinusitis, H. flu, Strep pneumo, B. catarrhalis is in there also on children’s. Staph is in there also and then some anaerobes but these are less likely. Ear infections, sinus infections, acute. Pretty much the predominant organisms are these three.
What do I do for those? Patients that come in that are sinus virgins, I give them Bactrim and amoxicillin. By sinus virgins I mean they don’t have allergies, they’re not cigarette smokers, they don’t have anatomic deflections, they don’t have asthma, they don’t have reflux, they haven’t had
I tend to treat for 14 days because in sinusitis not only do you have to kill the bugs but you have to reestablish the drainage that we talked about. We have to get rid of the obstruction and clean the secretions out of there and that will increase the likelihood that you will get things
Decongestants. I don’t particularly like them. I don’t see them as being enormously helpful in the patients that I see, but I certainly don’t condemn them. They can be drying which is not good. Patients that come in with sinusitis that are on antihistamines, stop the antihistamines to clear the sinusitis because you don’t want that drying. You want to really be able to get everything washed out of there.
The chronic sinus patient. This is the patient that either didn’t come to see the doctor for their sinusitis (about 60% of the sinusitises will just clear on their own anyway) but that 40% that didn’t come to see you or came and saw you and didn’t take their medications or
The diagnosis is difficult. I think even with the best visualization it becomes vague in symptoms. It becomes like a million other things in the head. You look in the nose. It’s just kind of red. You don’t see pus, typically, because it’s kind of the battle is coming to a draw and there is obstruction so that outflow of pus is not what it once was. It’s dull aches and pains, nasal obstruction with eustachian tube obstruction. I think
What happens is the mucous membranes touch each other with the inflammation and it creates a physiologic obstruction. The cilia stop working when membrane touches membrane or it can be an absolute mechanical obstruction if it swells enough and then, again, what
The area that you will hear talked about a lot and that really is a keystone based on what we looked at with ciliary drainage is the ostiomeatal unit. This would be the orbit, frontal sinus, ethmoid sinus, middle turbinate, inferior turbinate, maxillary sinus and this is the ostiomeatal unit.
Chronic sinusitis, I treat for a minimum of three weeks. I always give them a prednisone taper. My routine is 40 for 2 days, 30 for 2 days, 20 for 2 days and 10 days for 2 days and I just have a printed script and it’s a lot cheaper than a dose pack. Then I get a CT followup. If they’ve got that history of recurrence and they’ve really been struggling with this, you’ve got to make sure that you’ve cleared them up particularly when you’ve put a couple of hundred bucks worth of antibiotics and time and three weeks of their effort into making it go away.
Complications of sinusitis. With the antibiotics we have, this is getting real rare but the most common by far is orbital cellulitis and it happens in the pediatric age group. Epidural, subdural and brain abscess, potentially in some of your immune compromised patients, either from AIDS or transplant patients or patients that are on high dose steroids. Frontal osteomyelitis is almost not heard of but in the pre-antibiotic era it was
What happens with the pediatric population is by emissary veins you get infection either under the periosteum, pre-septal or orbital. The worst case is cavernous sinus thrombosis when it grows retrograde which is, again, very rare. The thing is with these patients, they come in, if they have swelling on the top eyelid, have a very high index of suspicion for that. Frequently the whole eye will be swollen shut. You start them on high dose antibiotics. I would use something like Unasyn or clindamycin with Rocephin. I would get the ophthalmologist, get the CAT scan, get
The other thing you can get is a brain abscess. This is a picture from the archives. I have never seen one. Then this is just kind of a cool picture of a guy that actually did have infection of the anterior table of the frontal sinus post trauma and this is the posterior table and that is the end of the nose.
Nasal polyps. Again, these cause obstruction intranasally. This is just kind of good picture of them with stasis of secretions. Again, the endoscopy makes it a much easier diagnosis. These almost always have to be resected. You can hit them with steroids and get relief but my experience has been after you do that two or three times they kind of mature and become resistant and then you need to take them out
One other thing. When you have the patients that come in with acute and very painful maxillary sinusitis, if you can get an ENT doc to either show you how or to drain that sinus for you, you do a puncture under the middle turbinate, wash that stuff out of there. It sounds kind of heinous but it gives the patient rather remarkable relief right away.