Ambulatory Healthcare Pathways for Nasal Disorders

Sinusitis

[1] Definition: Chronic sinusitis is a mucociliary transport abnormality in which the paranasal sinuses are neither aerated nor drained. As a consequence low-grade bacterial infection ensues. While pain is common it is difficult to distinguish the pain of chronic sinusitis from that of headache. Hence, the most reliable symptoms are nasal obstruction, nasal congestion, postnasal drip, cough, not feeling well and finally facial pain. Chronic sinusitis is a sinus infection that persists for periods of 6 or more weeks.

Recurrent sinusitis is a similar illness in which the disease responds to antibiotics, but then after normal health, once again recurs. Typically the infections are recalcitrant to treatment and often require 3 or more weeks of antibiotics.

[2] Antibiotics: The key to antibiotic therapy of chronic sinusitis is to provide the antibiotic for an extended period of time to allow the mucociliary transport system time to recover. This is typically 6-12-18 weeks. The antibiotics suppress bacterial infection while the mucociliary transport system recovers. Because there is significant morbidity to potent high dose antibiotics taken over these extended periods, the typical prescriptions are for penicillins, tetracyclines and erythromycins. These are prescribed in low-doses and are taken for a long period of time. Amoxicillin 250mgs 3 x a day is the preferred medication. Doxycycline is an alternate medication. Cephalexin, 250mgs orally 3x days is an alternative for those who claim cutaneous penicillin allergy. The key to the antibiotic therapy is the 6-12 weeks duration.

[3] Complications: These include extension of disease into the orbit or CNS.

[4] Sinus CT Scan: The CT scan is the hallmark of the failure of medical therapy. The CT scan should be taken at a time that the patient is ill. If it is abnormal, then the patient indeed has chronic sinusitis and it is presumed that endoscopic sinus surgery will be indicated and will provide benefit. If the CT scan, taken at a time when the patient is ill, is absolutely normal, then it is presumed that the illness is not a chronic sinusitis. The illness will not respond favorably to surgical intervention. The presumed diagnosis is some other illness, such as, midfacial pain syndrome, which is a chronic pain syndrome -- or one of the trigeminal headaches. Further medical evaluation and therapy is indicated.

[5] Evaluate and Treat: The trigeminal nerve modulates many illnesses of which chronic sinusitis is only one. The differential list of frontal headaches is all modulated by the trigeminal nerve. If the pain is localized over the sinuses, some describe this as a midfacial pain syndrome. Surgical therapy has provided no benefit for these individuals. Further medical evaluation is indicated. If no other specific diagnosis is reached, a midfacial pain syndrome diagnosis is made and the patient is treated with chronic pain medication.

[6]Endoscopic Sinus Surgery (ESS): ESS is an operation which opens the individual sinus ostia and restores normal mucociliary transportation. For those individuals with chronic or recurrent sinusitis the operation has a 90% success rate with low morbidity in the hands of the experienced, rhinologic surgeon.

Overview of Sinusitis

Acute sinusitis is extremely common. Most upper respiratory tract viral infections develop a mucopurulent rhinorrhea. Virtually, all of these involve the sinuses. The average American suffers acute viral rhinosinusitis twice annually.

Fortunately, most of these resolve and as the underlying mucosa regains its integrity, the bacterial infection resolves.

Acute bacterial sinusitis is caused by mucociliary transport obstruction at the sinus ostia. This may be inflammation in the anterior ethmoids with secondary obstruction of the maxillary and/or frontal sinus drainage systems or it can be swelling and obstruction of the ostia directly, all of the above are compounded by anatomic narrowing and by previous inflammation with resultant cicatricial scarring.

The two most common causes of acute ostial obstruction are the common cold and allergic rhinitis. In these situations the ostia are narrowed and the mucociliary transport systems of the sinuses are impaired. Secretions stagnate and are infected by the ever present upper respiratory tract bacteria including: Streptococcus, H. influenza, M. catarrhalis and occasionally Staphylococcus and Pseudomonas. Bacteriology according to Dr. Fairbanks is listed in Table 1.

*Pocket Guide to Antimicrobial Therapy in Otolaryngology-Head and Neck Surgery, 12th edition, 2005
The American Academy of Otolaryngology-Head and Neck Surgery Foundation, Inc.

The treatment for acute bacterial sinusitis is antibiotics. The ancillary nasal medicaments are the art of medicine, and while they may improve patient comfort, have no proven benefit for outcome. Antibiotic therapy is driven by susceptibilities. Those relative to sinusitis are listed in Table 2. according to Dr. Fairbanks.

Most patients respond to antibiotics within 36– 48 hours. If within this period they fail to respond or continue to worsen, one assumes the bacteria are resistant to the antibiotic and second line antibiotic therapy is recommended.

*Pocket Guide to Antimicrobial Therapy in Otolaryngology-HNS, 12th Ed., 2005, AAO-HNS

Acute isolated frontal and sphenoid sinusitis is uncommon, but when it occurs, is concerning because of its immediate proximity to the brain and potential to cause meningitis and brain abscess. If frontal or sphenoid sinusitis fails to respond within 24 hours, it requires aggressive treatment, including IV antibiotics. If it does not respond to intravenous antibiotics, surgical drainage is indicated. Emergent frontal sinusitis presents with isolated frontal sinus pain of acute onset. The patient is sick and has fever. The white count is elevated with a left shift. The sinus is tender to percussion. Emergent sinus CT scan is indicated. If abnormal, the patient is admitted for IV antibiotic therapy. Failure to improve within 24 hours is an indication for emergency surgery.

The same paradigm is true for sphenoid sinusitis and ethmoid sinusitis with periorbital cellulitis or abscess.

Recurrent sinusitis is the diagnosis for those who clear the sinus infection, but very shortly after discontinuing antibiotic therapy, develop a new infection. This can be from a narrowed, scarred, or otherwise damaged sinus drainage, or it can result from ongoing allergic or other inflammatory rhinitis. Low dose prophylactic antibiotics are indicated, but if, after 6–12 weeks of antibiotics the sinusitis again recurs, the prognosis without surgical drainage is poor.

Chronic sinusitis is an entirely different illness. Chronic rhinosinusitis (CRS) is one of the most common medical conditions affecting Americans. In health surveys, CRS affects more than 10% of individuals in western countries, with an overall direct cost of CRS in the United States annually estimated at $4.3 billion. ^1,2

To understand chronic sinusitis one must understand the mucociliary transport system. The nose and paranasal sinuses are lined with upper respiratory tract epithelium. This is an epithelium with cilia covered by a mucus blanket floating on a layer of saline. Bacteria, irritants and other particulate matter are trapped in the mucus layer and then carried along by the ciliary motion out of the sinuses, to the back of the nose, and into the pharynx. If the mucociliary transport system is impaired, the sinuses will be chronically infected. Aerobes and anaerobes are easily grown. Culture and sensitivity and stronger and stronger antibiotics provide little benefit. Attention must be directed towards the cause of the mucociliary transport system impairment. This may be anatomic or it may be scarring from repeated infections. Very often it is caused by or worsened by allergy and very often it is worsened by the irritants present in today’s polluted air. If the cause cannot be identified and corrected, the patient is chronically infected, congested, obstructed, and ill with sinus symptoms such as pain, postnasal drip and cough.

If a patient with sinusitis continues to have symptoms after 6-12 weeks of appropriate antibiotic and nasal steroid therapy, ENT referral is indicated.

With the advent of nasal endoscopy and sinus CT, we have come to learn that plain sinus radiographs are misleading so much of the time, that they are of no benefit. Even the presence or absence of maxillary and frontal sinusitis is often misinterpreted on plain radiographs. Plain sinus radiographs are virtually never requested.

The diagnosis of sinusitis is made on the basis of history and physical examination. Sinus CT is ordered primarily as a “road map” for the operating surgeon. It can be ordered, however, to document presence and extent of disease.

If a patient is being referred for an ENT consultation, one should request a sinus CT prior to the visit.

MRI is a poor imaging examination for sinus disease and would never be ordered in lieu of sinus CT. If diffuse sinusitis is present on MR, a sinus CT will be indicated.

Lastly, sinus CT is not the end all for evaluating sinus disease. Some individuals with sinus symptoms and normal sinus CT will be found to have chronically inflamed sinus mucosa at surgery. This group does benefit from sinus surgery despite negative imaging studies.

Endoscopic sinus surgery has become the surgery of choice for sinus disease. Conversely, the old surgical procedures including Caldwell-Luc, nasal antral windows, external ethmoidectomy, etc. are rarely recommended.

Endoscopic sinus surgery evolved from the understanding of the mucociliary transport system and a realization that the best way to obtain normal healthy sinuses is to enlarge the natural sinus ostia.

Once an improved drainage system is established, the diseased sinus mucosa reverts to normal. The surgery is relatively safe and is performed as an outpatient. Discomfort is minimal, convalescence is short, and complications are few. Overall success rates are around 90%.

There are certain conditions in which the prognosis is less than 90%. Individuals with the ASA sensitivity or sampters triad (asthma, aspirin sensitivity, and nasal polyps) do poorly with all treatments. They can be improved with sinus surgery. We do not speak of cure, we speak of control, and for many, surgery has improved control significantly.

Nasal polyps are felt to be a result of inflammation, present in those with infection, allergy, and other sources of irritation. Patients with nasal polyps do benefit from endoscopic sinus surgery, but the cure is only as good as the subsequent control of the underlying inflammatory rhinitis. Post polypectomy treatment is twice daily pulsatile nasal irrigation and topical nasal steroids. This treatment continues for life.

Many patients with asthma have allergic rhinitis and chronic sinusitis. Endoscopic sinus surgery will improve the sinus disease. Those individuals, whose asthma worsens during flare ups of their nasal and sinus illness, will have marked benefit in their nose and their lungs following sinus surgery. Carefully selected groups will have very high cure rates; poorly selected groups will have limited benefit.

Many HIV infected patients will develop sinonasal disease as their HIV illness progresses. These patients will benefit greatly from endoscopic sinus surgery followed by twice daily nasal irrigations. Many children and young adults with cystic fibrosis will have sinonasal disease; many will have nasal polyps. These people also benefit from early endoscopic sinus surgery followed by aggressive nasal irrigations.

Footnotes

1. Pynnonen M, Fowler K, Terrell J: Clinical predictors of chronic rhinosinusitis. American Journal of Rhinology, 21:2;159-163, 2007

2. Reh D, Mace J, Robinson J: Impact of age on presentation of chronic rhinosinusitis and outcomes of endoscopic sinus surgery. American Journal of Rhinology, 21:2;207-213, 2007

Allergic Rhinitis

Overview of Allergic Rhinitis

Allergic rhinitis affects 30–40 percent of Americans. It is a very common illness. Inhalant allergens typically include dust mites, molds, animal dander, (cats more than dogs), and botanical pollens, typically trees and grasses.

The symptoms of allergic rhinitis are itchy nose, itchy eyes, and sneezing. Symptoms of obstruction and rhinorrhea are caused by allergic rhinitis, but are also caused by bacterial sinusitis and are not normally helpful in the differential. The occasional “attack” of allergy is well treated with an antihistamine. H1 specific antihistamines are less sedating and for those who take them on a regular basis, seem superior to the over-the-counter antihistamines or antihistamine/decongestant combinations.

For the patient with allergic rhinitis who does not obtain adequate relief with antihistamines, treatment with nasal steroids is recommended. Leukotriene inhibitors may provide additional benefit.

The key to the treatment of allergic rhinitis is environmental control.

Most allergy product companies have educational materials with appropriate product information. These can be obtained easily by the primary care physician. In fact, many of the companies who provide the products for environmental control have very nice brochures with excellent information available at no charge. They are more than willing to send 50 or 100 at a time.

Environmental control combined with nasal steroids will successfully manage a large percentage of individuals with allergic rhinitis. Those with other underlying illness such as anatomic nasal obstruction or chronic sinusitis may benefit from ENT consultation and surgery. The individual with unrelenting allergic rhinitis may benefit from desensitization.

While we are a proponent of desensitization, it is a tremendous undertaking. The underlying allergies are identified and then a special desensitization serum is custom made and administered to the patient 3 times a week for the first six to twelve months and once a week for a long time thereafter. This is expensive and a major time commitment.

Nasal irrigation is an ancillary procedure, which we at the UCSD Nasal Dysfunction Clinic have found to provide substantial benefit to those with allergic rhinitis. Irrigating the nasal cavity once or twice a day either washes away enough of the allergen laden mucus or by some other mechanism provides sufficient benefit that many patients report tremendous relief.

Anosmia

Smell impairment affects 1–2% of Americans and while it is true that some do not complain, for many it is a significant sensory loss. The majority of food appreciation comes from olfaction. Those who are smell impaired have lost their ability to taste and appreciate the flavors of food. In addition, it represents a health hazard, for they cannot smell smoke, the early warning sign of fire. They cannot smell the odorants placed in propane and natural gas to warn of gas leaks. They cannot detect the odors of spoiled and rotten foods and are therefore at risk for recurrent food poisoning.

Smell testing is not generally available. The alcohol sniff test described above is a very good screening test. The average ENT physician and neurologist is neither skilled nor interested in smell impairment; therefore, individuals often need to be treated by their primary care physician or referred to a center with interest and expertise in olfaction.

In non-demented individuals, one third of smell impairments are caused by inflammatory nasal disease. Other common causes are upper respiratory tract infection and head trauma. Olfactory loss is common in many dementias, most notably in Alzheimer’s and in Parkinson’s disease. Olfactory loss is also seen with aging.

The differential diagnosis for smell impairment is lengthy, but for most diseases it is only one of a myriad of signs and symptoms. For the interested physician, there are numerous articles and even textbooks on the subject.

The suggested ambulatory pathway is reasonable. The prednisone challenge, combined with a history looking for viral, traumatic and inflammatory nasal causes, will lead to a correct diagnosis or reason for referral in the majority of cases.

For those who are smell impaired, the following are the standard recommendations we offer at the UCSD Nasal Dysfunction Clinic.

Special Instructions to Anosmics

Persons who are anosmic should observe some simple precautions.

A smoke detector in the home is important. At a minimum there should be a smoke detector in the kitchen, in every room that might have a fire, such as a room with a fireplace, and in every room in which the patient might sleep, i.e. bedroom, den, etc. Smoke detectors can be battery operated or connected directly into a 110 volt AC current system. They can be obtained at most hardware, lighting or other building stores.

An electric stove is preferable to a gas stove, but a gas stove equipped with an automatic pilot improves the safety. Commercial gas detectors are available. If the house uses propane or natural gas, there should be an appropriate gas detector at each location where a gas leak might occur. Propane gas and regular gasoline are heavier than air, and so detectors for these substances should be placed near the floor. Natural gas is lighter than air and rises as does smoke. Detectors for these substances should be placed at high points such as the ceiling, top of the stairwell, etc. Propane detectors are available through propane dealers, recreational vehicle dealers, and marine stores. Natural gas detectors, propane detectors, and gasoline detectors are all available through marine facilities.

Care should be taken in preparing food, particularly leftovers, since undetected, spoiled food can be hazardous. When in doubt, discard leftovers or have a family member with a normal sense of smell confirm that the food is not spoiled.

Epistaxis

Nose bleeds are very common. The majority are controlled by time and direct pressure. Anterior rhinoscopy will often show a dilated septal mucosal vessel with an overlying sore or scab.

Treatment consists of placing the mucosa at rest with a small cotton plug and vasolinated ointment for 3–5 days. Thereafter, the individual can apply the vasolinated ointment to their nose 2, 3, or 4 times daily. For those on anticoagulants coagulation labs should be carefully checked and monitored. For patients taking aspirin for arteriosclerosis prophylaxis, 80 mg of aspirin is sufficient. Most use 325 mg daily, as the adult aspirin tablets are easier to find and cheaper.

Most people over clean their nose most commonly with Kleenex nasal tissues. The septum is not to be rubbed. Teach patients to blow their nose without rubbing or touching the nasal septum.

If the vessel continues to bleed, it may benefit from cautery. Silver nitrate cautery will stop some. Others will require electric cautery.

Never cauterize both sides of the septum at the same time for this puts the patient at risk for septal perforation. A few patients develop profuse epistaxis and these invariably come from medium sized arteries in the superior and posterior nasal cavities. These are only controlled via tamponade of the bleeding vessel, accomplished by occluding the posterior choana and the anterior naris––commonly called an anterior-posterior pack.

Assuming ENT referral is available, this is recommended. The otolaryngologist will typically vasoconstrict and anesthetize the nose and then endoscopically examine the nasal cavity. If the bleeding artery can be identified, it can be cauterized. If the bleeding is profuse and endoscopy is impossible, if the septum is tortuous, or the anatomy is such that the bleeding site cannot be seen, the otolaryngologist can place a more secure anterior-posterior pack. Treatment alternatives are then threefold. The most conservative conventional approach is to hospitalize the patient and leave the packing in place for 3–5 days. The packing is then removed and most patients are successfully discharged.

Three to five days of hospitalization is expensive. The anterior-posterior pack is uncomfortable. A surgical alternative is to anesthetize the patient, examine the nose endoscopically, and cauterize the bleeding vessel. If the septum prevents this, a septoplasty is performed. If this is not successful then the internal maxillary artery and its contributing branches can be ligated in the sphenopalatine fossa behind the maxillary sinus. These are accessed through a standard Caldwell-Luc procedure.

Fifteen percent of nose bleeds arise from the ethmoid vessels, and in these cases an additional incision will be made between the nose and the eye and the anterior and posterior ethmoid arteries clipped.

The third alternative is to perform an arteriogram. Bleeding coming from the internal maxillary artery can be embolized. The anterior ethmoid arteries arise from the ophthalmic artery which in turn arises from the internal carotid. These are not amenable to embolization.

The disadvantages of arteriography and embolization are the expense and the small risk of a stroke. The skilled interventional radiologist experienced in embolization can do this reasonably well with reasonable safely. For the most part, angiography and embolization are ideal very sick individuals who are significantly anticoagulated and for whom surgery is not a safe option.

Nose picking is a contributing factor in epistaxis. Adults can usually be instructed to be more careful. Children pick their nose at night and this is best controlled by placing a glove or sock over their hand so that their fingers no longer fit inside their nose.

Dry climates predispose to recurrent nose bleeds. Daily or twice daily application of Vaseline® provides substantial benefit. The petroleum based antibiotics are not recommended as these predispose to topical sensitivity. Bacitracin® ointment contains the necessary petroleum properties and is bacteriostatic. Other petroleum products work equally well.

There is a caveat for nose bleeds. While most are simple, straight forward problems, they are often the heralding sign of underlying coagulopathy. Hemophilia, von Willibrand’s disease, thrombocytopenia, all may have epistaxis as their initial symptom.

Hereditary hemorrhagic telangiectasia (HHT) also called Von Willebrandt’s disease produces terrible nosebleeds UCSD is currently an HHT center. Information regarding HHT epistaxis is listed in medical information on Dr. Davidson’s website.