Lab Studies:
 

• Culture purulent discharge.

• Unfortunately, culture taken directly from the nose may not yield correct information. Most healthy persons harbor potentially harmful bacteria.

• The best culture is taken directly from the sinus cavity by insertion of a sterile needle and aspiration into a sterile container.

• Sensitivity studies are usually needed and are of value when the specimen has been taken by puncture aspiration.

• In individuals who are diabetic and/or immunocompromised, the culture program includes culture for fungus.

• If the patient has had many antibiotics and has chronic sinusitis, a fungus growth may show up on fungus culture. However, this may not be the cause of the sinusitis.

• Generally, bacterial exudates are in the nasal chambers. Cultures show H influenzae, Neisseria catarrhalis, and Haemophilus pneumoniae. Cultures may also show streptococci infections

• White blood cell count and differential count is as follows:

• As in any infection, WBC differential count helps differentiate between viral and bacterial infection.

• Test for infectious mononucleosis when adenopathy and tonsillitis accompany the sinus infection.

• In cases of chronic sinusitis, some authors test the skin for fungus and then desensitize it for strong positive reactors.

• Biopsy of the nasal membrane may be used to obtain tissue to be measured for cilia activity. This is often a research procedure.

• The saccharine test of nasomucociliary flow is indicated if a history of toxic exposure exists or if cystic fibrosis is suggested. This test can be used to gauge the degree of reduced cilia activity.

• In most cases of chronic sinusitis, the saccharin test of mucociliary flow shows impaired cilia action. This usually reflects the cilia of the chest.

• Place a particle of saccharin one-fourth inch behind the anterior edge of the turbinate. Instruct the patient to sit quietly to not sniff or sneeze. Ask the patient to swallow every 30 seconds and report when the sweet saccharin is tasted. The patient's report measures the speed of the nasal cilia as they propel the particle to the nasopharynx. The following measures are related to cilia activity:

   

  • In acute allergy, the saccharin is tasted in 5 minutes or less.

  • With normal nasal conditions, the saccharin is tasted in 5-8 minutes.

  • With infection and late stage allergy, the saccharin is tasted in 9-19 minutes.

  • With atrophic rhinitis and chronic sinusitis, the saccharin is tasted in 20-29 minutes.

  • After exposure to chlorine gas or other toxins, saccharin is tasted in more than 30 minutes. These patients do not recover their cilia function with treatment.

Imaging Studies:
 

• Radiography of the sinuses is quite helpful and generally includes Waters, lateral, and Caldwell views.

• To perform the Waters view, place the patient's chin on the radiograph plate and the nose 1-1.5 cm above the plate. This positioning provides the best view of the maxillary sinus with the petrous ridge being below the inferior portion of the maxillary sinus.

• The lateral view ideally shows the frontal and sphenoidal sinuses as well as the ethmoid sinuses in lateral projection. However, these views have been replaced with CT scan views that often provide exquisite detail of the sinus anatomy.

• The Caldwell view, in which the nose and forehead are on the radiograph plate, is designed to visualize the frontal and ethmoidal sinuses.

• CT scanning involves the following:

• CT scanning has replaced regular radiography as the preferred imaging test to look at the sinuses.

• In most communities, the radiologist obtains a limited CT scan for about the price of a regular sinus radiograph.

• In cases of sinusitis, localizing the condition by means of CT scanning and correcting anatomic factors is important.

• The limited CT scan shows the maxillary ostia. Look for pathology of the nasoantral opening of the maxillary sinus. If this opening is compromised, then referral to the otolaryngologist is indicated.

• With a CT scan, the bony anatomy, including the important structures of the maxillary frontal and sphenoid ostia, is detailed. The cribriform plate, whose anatomic position is a critical factor in any surgery, is visualized. The surgeon looks for depression at this area and dehiscence.

• In chronic sinusitis, a CT scan of the sinuses is often needed to pinpoint foci of infection and patency of ostia.

• Primarily look for conditions that may impair drainage, especially from the maxillary ostia. These conditions may be nasal polyps, thickened mucosa, enlarged turbinates, concha bullosa, or even a deviated septum (see Image 2). The diseased sinuses can be clearly identified. If the ostia are patent, the patient should respond to systemic management. If the sinus openings are fully closed, then systemic therapy may be insufficient, and surgical correction may be required.

• MRI involves the following:

• MRI of the sinuses produces excessive false-positive results because the MRI is too sensitive. Commonly, patients who have had an MRI for unrelated causes are referred to the ear, nose, and throat (ENT) office with a diagnosis of sinusitis from the MRI results but with a negative history of purulent drainage, nasal congestion, or fever. This is because any liquid can show up as disease on an MRI. If the patient is reported as having sinusitis based on the MRI only, this finding can be ignored.

• MRI is of use in diagnosing fungal infection. Usually a sinus filled with fungus has a characteristic appearance.

Other Tests:
 

• Allergy tests may be indicated and can be performed in the office by intradermal testing, ie, prick testing or radioallergosorbent assay test (RAST). RAST and other laboratory tests are performed from blood removed from the patient. Results are usually accurate, and a treatment serum can be made based on these results. Persons can have anaphylactic reactions to these tests, and the means of treatment must be immediately available.

• Food allergies are difficult to test for. A careful history provides the best identification of a food allergy. Once the food is identified, adding the food to the test to induce a reaction is best in order to prove the allergy. Then, prescribe an allergy-free diet with avoidance of test-identified foods.

• Lyme disease, HIV, infectious mononucleosis, leukemia, and other diseases can all mimic sinus and chest conditions and must be assayed for difficult cases.

• Cystic fibrosis must be considered in the patient with recurrent sinus and chest infection. The sweat test indicates this diagnosis, as does the saccharin test of cilia function.

• Pulmonary function studies indicate respiratory function.

• Daily expiratory flow measurements are necessary in asthma.

• Take the time to be assured that the patient/parents fully understand how these measurements are performed and how to perform the important daily log-keeping of the maximum expiratory flow rate. Demand that the patient bring the meter to the office from time to time to check on technique.

• The more expensive flow-rate meter is not necessarily the best model; however, some doctors are recommending the new computerized models that store rate values and are not dependent on the patient's record-keeping skills.

Procedures:
 

• Laryngoscopy: Look for signs of irritation of the posterior larynx indicating GERD.

• Nasopharyngeal mirror examination: Hypertrophic posterior turbinates may be observed. In cases of unilateral purulent drainage in a child, especially look for a foreign body.

• Nasal endoscopy: Patent or closed sinus ostia may be revealed. The maxillary, frontal, and sphenoid ostia are visualized. Purulent discharge is noted (see Image 3).

Medical Care: Whether sinusitis and asthma are caused by inflammation or allergies has been questioned. Today, sinusitis and asthma are attributed to inflammatory effect. An excellent example of this is the existence of nasal polyps. With administration of corticosteroids (both oral and topical), polyps may not shrink; however, if an antibiotic is added at the same time as the corticosteroids, clearing of the polyps from the nasal cavity with clearing of the blockage occurs in more than 90% of the author's patients. Patients prefer this form of treatment to surgery.

Treatment consists of using measures to increase mucociliary clearance. To help cilia movement in the chest and nose, a deep-throated "oooooommmmm" vibration is useful to help break up thick mucus. Patients should drink enough fluids (eg, hot tea, hot chicken soup) to lighten the urine. Bacterial load should also be reduced. This may be achieved by terbutaline, inhaled corticosteroids, various enzymes (eg, Bromelin or Papain taken buccally), pseudoephedrine, breathing and coughing exercises, flutter inhalation device, iodides, guaifenesin, irrigation, Locke-Ringer moisturizer spray, and exercise.

Many cases of sinusitis do not respond to treatment because (1) the wrong antibiotic is prescribed; (2) duration of the antibiotic is too short (treatment may require 6 wk); (3) drainage, rest, and anti-inflammatories are not combined with treatment; (4) fungus is present; and (5) the mucociliary system fails. If infection does not clear in 6 weeks, referral to ENT is recommended.

Because bacteria and thick phlegm play a significant role, the physician can reduce the asthmatic symptoms from sinusitis by suctioning or irrigating in the office if pus is present in the nose or sinuses. One technique is to use a vasoconstrictor in the nose, wait 2 minutes, and then irrigate with a modified Locke-Ringer solution or sodium chloride solution with pulsatile nasal/sinus irrigator, such as the Hydro Pulse. Not only is a considerable amount of surface and sinus pus removed, but also the pulsatile action at 20 pulses per second stimulates the cilia of the nose and sinuses to restore normal cilia action (see Image 4). This same procedure can be used daily at home for chronic sinusitis in adults and children aged 5 years and older (Rachelevsky, 1989).

Pulsatile irrigation may also be beneficial to the patient with allergies during the pollen season. Daily irrigation reduces the pollen load in the nose and the immunoglobulin E (IgE) levels in the nose and in the circulation (Subiza, 1999).

If asthma and sinusitis are considered as being inflammatory diseases, treatment is clearly similar for both in regards to specific infection, inflammation, drainage, attention to thinning mucus, and restoring cilia and comfort to the patient.

• Antibiotics

   

  • Most common organisms are Streptococcus pneumoniae, H influenzae, and Moraxella catarrhalis. Increasingly resistant strains of bacteria are developing. Standard treatment for acute sinusitis must include antibiotics for H influenzae and S pneumoniae. Treatment is usually one of the following:

     

    • Amoxicillin 500 mg 3 times a day

    • Trimethoprim-sulfamethoxazole (Septra DS) twice daily

    • Cefuroxime (Ceftin) 250 mg twice daily

    • Cefaclor (Ceclor) 500 mg 3 times a day

  • Other medications include the following:

     

    • Trimethoprim-sulfamethoxazole double strength (Bactrim DS) twice daily

    • Cefixime (Suprax) 400 mg once daily

    • Loracarbef 400 mg twice daily

    • Augmentin 400 mg 3 times a day

    • Clarithromycin (Biaxin) 500 mg 2 times a day

    • Azithromycin (Z-Pak) 250-mg tablets, 2 the first day followed by 1 every day for 4 more days

    • Erythromycin adult dose for chronic sinusitis

  • For chronic sinusitis, usual pathogens, anaerobes, and Staphylococcus aureus are involved. Start amoxicillin 500 mg 3 times a day, amoxicillin with clavulanate (Augmentin) 500 mg 3 times a day, or clindamycin (Cleocin) 150-300 mg every 6 hours. With all antibiotics, patients should take a full glass of water before and after each dose. Antibiotic sensitivities change almost daily and from region to region. Physicians must receive and use the drug resistance/sensitivity data available from hospitals.

  • For treatment of Pseudomonas infections, use piperacillin, ticarcillin, and carbenicillin, depending on the secondary organisms.

• Anti-inflammatory agents: Sinus pain is present when membranes are inflamed or swollen. Anti-inflammatory agents (eg, Naproxen) are useful.

• Steroids: One of the major advances in sinus and asthma treatment has been in the use of steroids. These are anti-inflammatory and serve well to reduce these factors.

   

  • Oral steroids: Prednisone is useful for allergic rhino sinusitis and may be administered as prednisone 5 mg number 21. It is prescribed in diminishing doses, as follows: 6 tablets the first day, 5 tablets the next day, and so on to 1 tablet the sixth day. These should all be taken at one time and not spaced out. Medrol Dosepak is used similarly. Systemic corticosteroids include Decadron for quick action and Celestone for delayed action. These are excellent for anti-inflammatory purposes.

  • Steroid sprays: These are very common today. Commonly used are beclomethasone dipropionate (Beconase AQ), triamcinolone acetonide (Nasacort AQ), and fluticasone propionate (Flonase). Budesonide (Rhinocort Aqua) has the advantage of being without benzalkonium. Compared with the oral antihistamines, the sprays have the advantage of effectiveness and few adverse effects. Adverse effects of steroid sprays include atrophic changes and epistaxis. After 3 months of daily use, check to see if thinning of the membranes, crusting, or bleeding is present. If these are present, stop the steroid spray use. A course of saline spray without benzalkonium, a moisturizer ointment can reverse this adverse effect. Rhinocort Aqua does not contain benzalkonium and may have fewer adverse effects.

• Mucolytic medications: Whenever stasis occurs, mucus thickens and bacteria multiply. Thinning the mucus is important in order to restore mucociliary clearance. Drinking hot tea with lemon and honey is one of the best treatments, as is ingesting chicken soup. Most cold drinks slow cilia.

   

  • Guaifenesin: This is a common mucolytic present in Robitussin and other cough preparations. Some authors dispute its value. The dose needed is 1200 mg twice daily. Preparations combined with decongestants (eg, Entex LA, Zephrex LA, Aqua Tabs) are popular and clinically appear to be beneficial.

  • Proteolytic enzymes: These enzymes (eg, papain, bromelain) reduce certain aspects of inflammation and thin mucus. Few known adverse effects are associated with these enzymes, especially if taken via the buccal route. The buccal route is the preferred route because enzymes are inactivated by stomach acid and, even when taken on an empty stomach, maximum absorption is less than 40%. One buccal tablet is Clear Ease, which contains one million enzyme units of bromelain (from pineapple) and one half million enzyme units of papain (from papaya).

  • Iodides: Potassium iodide is a useful mucolytic medication.

  • Saline sprays: These can help keep the nose moist and thin the mucus. Using preparations without benzalkonium or thimerosal is important. Some of the spray bottles can be used for mist or for stream, which is useful when removing heavy dust or perfume from the nose is necessary. In 1999, Boek recommended Locke-Ringer solution as being superior to regular isotonic sodium chloride solution. Hypertonic sodium chloride solution may be of advantage in swollen turbinates, but patients have difficulty in using this.

• Decongestants: Pseudoephedrine (Sudafed) has long been a favorite to open a stuffy nose. It is contraindicated in hypertension and in persons who are kept awake by the drug. Strangely, this drug may make children younger than 12 years drowsy. Spray decongestants include the following:

   

  • The effects of oxymetazoline last longer than the effects of neo-synephrine. Privine may cause drowsiness. For many years, Afrin was thought to cause rhinitis medicamentosum by shrinking the nose and then having rebound swelling. Today, the rebound addiction is thought to be caused by the benzalkonium; oxymetazoline is available without benzalkonium. One product is Natru Vent nasal decongestant.

  • Ipratropium bromide (Atrovent) is an acetylcholine blocker generally used as a bronchial dilator in the lungs but now used as a nasal spray.

  • Azelastine HCl (Astelin) is an antihistamine in spray form. This drug is excellent when steroid sprays are contraindicated. Many patients dislike the taste. A solution of Benadryl 25 mg added to one ounce of Locke-Ringer or sodium chloride solution can be made and yields similar results. The dose of the Benadryl must be titrated to the individual patient.

  • Cromolyn (Nasalcrom) nasal spray is highly effective for allergies if started 6 weeks before the pollen count gets high. Pollen calendars are available on the Internet (eg, AllergyBuyersClub.com)

• Topical medications

   

  • Various moisturizing ointments are available to moisturize the nose, including AYR gel.

  • Topical antibiotics are useful in the nose and sinus. Neosporin ointment may be used for mild local infection. Bactroban ointment has been used extensively as a topical antibiotic with no reported adverse effects. This ointment can be added to Locke-Ringer or sodium chloride solution as a spray.

  • Gentamicin and tobramycin are used for irrigation (Davidson, 1995). Gentamicin has the advantage of being inexpensive; 40 mg can be added to 200 mL of Locke-Ringer or sodium chloride solution for irrigation with a pulsatile irrigation device. This can be used twice daily for advanced infection or once daily for milder chronic cases. Singulair taken orally or dissolved in Locke-Ringer or sodium chloride solution has been reported to be of particular value in vasomotor rhinitis.

  • Example of local irrigation is as follows: For topical irrigation with gentamicin or tobramycin, add 1 teaspoon of Breathe Ease or salt to 1 pint of water in irrigator basin. Irrigate until clear. Blow nose gently until clear. Adjust solution to contain 200 mL of solution and add 40 mg of gentamicin or tobramycin. Irrigate with full amount. Do not blow the nose. Use twice daily in the heavy purulent stage and then once daily during the clearing stage. Average treatment duration is 3 weeks.

• Organisms and generally used antibiotics

   

  • Pneumococcus infections: Use penicillins, amoxicillin, erythromycin, and cephalosporins.

  • H influenzae: Use amoxicillin or amoxicillin with potassium clavulanate (Augmentin); macrolides such as erythromycin plus sulfasoxazole (Pediazole); cefuroxime (Ceftin); and trimethoprim and sulfamethoxazole (Septra, Bactrim).

  • Staphylococcal infections: Use amoxicillin plus potassium clavulanate (Augmentin), erythromycin, and dicloxacillin.

  • Pseudomonas infections: Use aminoglycosides, ciprofloxacin, and ofloxacin.

• General classification of antibiotics

   

  • Antimicrobials such as penicillin G and V are bacteriocidal because they inhibit cell wall synthesis.

  • Antistaphylococcic penicillins include dicloxacillin (Dynapen).

  • Amino-penicillins include ampicillin and amoxicillin.

  • Augmented penicillins include amoxicillin plus potassium clavulanate (Augmentin).

  • Antipseudomonal penicillins include ticarcillin and carbenicillin, which are for IV use.

  • Cephalosporins are bacteriocidal (they inhibit cell wall synthesis). First-generation cephalosporins include cefazolin and Ancef for IV administration and cephalexin, cefadroxil, Duricef, and Keflex. Second-generation cephalosporins include cefuroxime (Ceftin) and cefaclor (Ceclor). Second-generation equivalents include loracarbef (Lorabid). Third-generation cephalosporins include cefixime (Suprax).

  • Macrolides include erythromycins, clarithromycin, and azithromycin.

  • Clindamycins include Cleocin and Lincocin.

  • Tetracyclines inhibit protein synthesis. Bacteriostatic tetracyclines include minocycline and Vibramycin.

  • Aminoglycosides can be ototoxic, are bacteriostatic, and inhibit synthesis. They include streptomycin, neomycin, gentamicin, tobramycin, and amikacin.

  • Quinolones include ciprofloxacin (Cipro) and ofloxacin (Floxin).

  • Sulfonamides are bacteriostatic but, when used with other antibiotics, are synergistic.

  • Trimethoprim and sulfamethoxazole include Septra and Bactrim.

  • Antifungal medications include amphotericin B, ketoconazole, and fluconazole (Diflucan).

  • Antiviral medications include acyclovir (Zovirax) and amantadine (Symmetrel).

• Irrigation/aspiration: Clearing sinus infection is indicated for the individual with asthma. Irrigation/aspiration at the first office visit is a useful step in order to reduce the bacterial load. When the sinus infection does not clear with antibiotics, prescribe daily irrigation, mucolytics, and anti-inflammatory medications. Follow with a CT scan of the sinuses.

• Pediatric treatment

• Sinusitis and asthma occur in younger children (see Image 5). One useful technique for treating sinusitis in children is Proetz sinus irrigation, which is performed by placing the child hyperextended over the parent's lap so that the child's head is lowered. Ideally, the child's chin and ear are in a straight line perpendicular to the floor. The child's vasoconstrictor (eg, 1/8% Neo-Synephrine) is placed in both nostrils. Fill both sides with modified Locke-Ringer solution (Breathe Ease) or sodium chloride solution. Take care not to get into the eyes. Gently aspirate with a nasal aspirator. Keep refilling both sides with solution until the return is clear. This works better if the child cries. By removing this pus, the chance of developing a chronic sinus condition with an asthmatic sequel is diminished.

• Nasal moisturizer spray is also of benefit to young children. Breathe Ease is specially designed to be used by small hands and contains a modified Locke-Ringer solution without benzalkonium. This does not sting or burn and is used by most children as a nasal spray. (The spray can be made more attractive to children, for example, by placing a sticker of the child's hero on the spray bottle.) Or isotonic sodium chloride solution can be prepared without preservatives. One half teaspoon of salt to 8 ounces of water makes an isotonic solution. Because no preservatives are added, the solution should be changed weekly.

• Caution: When daily use of nasal spray for children occurs, pay particular attention to preservatives such as Thimerosal. The Academy of Pediatrics has recommended against its use, but it is still contained in certain nose drops. If the product is used long term, consider checking for mercury levels. Benzalkonium, another preservative, burns and stings and discourages the child from using the spray.

Surgical Care: Sinusitis may require surgical care. Primarily, the disease is a matter of obstruction of sinus drainage. If sterile cotton is placed in the healthy nose, whichever sinus is blocked becomes purulent. This is because the blockage prevents drainage along the mucociliary pathways, macrophages do not have access to the area, and bacteria are free to multiply. Surgery is directed at making sinus drainage adequate and effective.

The advances in FESS surgery make it easier and safer to clear the source of sinus disease. Insta-Trak delivers a 3-dimensional picture to the operator of the position of the instrument while the operator is performing surgery. This increases surgical success and reduces risk. A full CT scan of the sinuses is taken preoperatively. Metal markers are fixed on the patient and kept for surgery. At surgery, the same markers are placed in the designated areas. A magnet is placed on the suction. A screen shows the sinuses in 3 views. The device is used to visualize the position of the magnet in the 3 views at all times, thereby reducing the complication rate (see InstaTrak Image-Guided Surgery ).

• Maxillary sinus

   

  • Blockage of the natural ostia can be caused by a foreign body. A deviated septum may compress this area. Hypertrophy of turbinates may be sufficient to block the opening. Concha bullosa refers to a hollow enlargement of the middle turbinate so that it blocks drainage of the maxillary ostia (see Image 6). More commonly, mucosal hypertrophy blocks the ostia. Over time, the maxillary sinus shows a worsening of the disease process. An aberrant air cell of the ethmoid may obstruct the maxillary sinus opening. Nasal polyps may develop in the opening itself or grow from a distal origin and be positioned to obstruct the ostia (see Image 7).

  • Treatment is directed to ensure sinus patency and to remove obstructive septum, polyps, and tissue. At surgery, obstruction to drainage is removed and instruments can enter the sinus cavity to remove diseased tissue. When patients report pain in the cheek and upper teeth, remember that the same nerve innervates the maxillary antrum and the upper teeth and that differentiation of the source of the pain is between dental and sinus origin.

• Ethmoid sinuses

   

  • Ethmoid sinuses open into the middle meatus and the superior meatus. The same factors as above are involved (ie, polyps, turbinate hypertrophy, mucosal hypertrophy, septal deviation).

  • With the ethmoid sinuses, removing all diseased tissue, as well as obstructive conditions, is important. The ethmoid sinuses may cause infection into the globe of the eye. If the eye is swollen, consider obstruction of the ethmoid sinuses. Patients show puffy eyes, black eyes, and obstruction to breathing.

• Sphenoid sinuses: Symptoms with the sphenoid sinuses are more diffuse and may manifest only as a headache and continued fever. Endoscopic examination shows obstruction to the opening of the sphenoid sinus, which must be cleared. CT scans are vital to evaluate the mucosa and the position of the sinus itself in relation to the brain and optic system. Normally, the right and left sphenoids are highly variable, and missing the wall of the opposite sinus as it deviates far to the opposite side is an easy error to make. In a patient with vague pain, elevated white count, and no signs of sinusitis on examination, endoscopic evaluation and CT scan may be the only means of diagnosing sphenoid sinusitis.

• Frontal sinus

   

  • In addition to the usual causes of sinus obstruction, another factor adds to mucosal thickening, polyps, and anatomic obstruction. Following FESS surgery, during which the attachment to the lateral nasal wall may be compromised by removal of turbinate attachment at the sinus ostia, the middle turbinate may dislodge, swing forward, and obstruct frontal drainage.

  • Surgery consists of opening drainage channels. The frontal sinus drainage channel is somewhat long and obstruction can easily occur. Importantly, watch for severe pain or change in pain in the frontal area. An abscess may weaken or open the posterior wall into the skull cavity with serious effect. In such cases, immediate surgical correction is needed. Palpation of the floor of the frontal sinus may be diagnostic.

• Chronic frontal area pain: Often, patients report pain in the frontal sinus area without fever or purulent nasal discharge for weeks or months. This pain usually is of cervical origin, characterized by painful cervical muscle areas posteriorly that refer pain to the frontal area (course of V1). Palpating the cervical area is helpful; look for trigger points and areas of referral to the frontal area. Less commonly, the pain can refer to the maxillary area (V2).

• Removal of excess mucosa

   

  • A serious complication occurs following nasal and/or sinus surgery when excess mucosa is removed as in complete turbinectomy. Here, the nose may appear wide open yet the patient reports pain on breathing, burning, and not getting enough air.

  • Once large amounts of turbinate tissue have been removed, atrophic rhinitis with crusting takes place and requires frequent moisturizing. These patients are highly symptomatic because of the absence of normal nasal tissue that moisturizes and filters. Some of these patients have disabled nasal function because of the dryness, crusting, and discomfort. This has a serious effect on the lower respiratory system that is now breathing dry unfiltered air.

• Hypertrophied turbinates

• Hypertrophied turbinates may be the sole cause of nasal obstruction and frequent infections (see Image 9). These can be reduced safely by submucous resection of the turbinates. Make an incision inferiorly that is three fourths the length of the turbinate. Elevate the mucosa from the bone medially and laterally. Remove the bone, allowing the turbinate to move medially. Sutures are not usually placed. In healing, much of the submucosal blood vessels are reduced. Here, the mucosa is spared.

• Another technique is radiofrequency therapy. One such device is the somnoplasty turbinate instrument. Here, the instrument is inserted submucosally, and the radiofrequency spares the mucosa. This is an office procedure but may require more than one sitting.

• Removal of turbinates: Whichever technique is used in sinus and turbinate surgery, emphasis must be on preservation of nasal mucosa. Once the inferior and middle turbinates are removed, the patient has little defense to prevent chronic sinusitis. These patients have severe symptoms, and the lower respiratory system may be adversely affected as well.

Consultations: When the patient has frequently not responded to antibiotic treatment and other measures, consultation with an otolaryngologist is indicated. When good treatment is unsuccessful, frequently, an anatomic defect with obstruction of drainage is found. A limited CT scan showing blockage of the maxillary sinus requires a consultation with an otolaryngologist.

• If allergy management does not improve nasal or chest breathing, consult with an otolaryngologist. Usually, findings are a severely hypertrophied turbinate that requires surgical attention or a sinus blockage, which may be the cause of treatment failure.

• When treatment is consistently unsuccessful, consult with a hematologist or immunologist to rule out hematologic diseases and AIDS. Disorder of the globulin factors may be the cause.

• When no obvious anatomic defect is present, yet infection defies treatment, check the hospital culture resistance and sensitivities. Local bacteria may be highly resistant to the antibiotic presently administered, and change can be guided by reviewing common hospital growths and resistance. Sometimes, referral to an infectious disease specialist is needed. Irrigation to restore cilia action is important regardless of what antibiotic is used.

• Keep in mind that recurrent sinus infection (eg, 4 infections in 5 mo) is most likely the same infection that never cleared in the first place. When the sinus infection involves bone, consider intravenous treatment with appropriate medications. Some stubborn bacterial infections respond to hyperbaric treatments. Expect serous otitis when treating sinusitis with hyperbaric oxygen.

• Candidiasis and mold infection, which may occur in individuals with immune suppression, can be observed with the naked eye as a characteristically snowy white presence on MRI. Often associated with polyps, candidiasis and mold infection have very poor response to antifungal medications. Surgery and medications are needed. Another form of candidiasis is observed in cases of chronic sinusitis. Here, the fungus normally present elicits an eosinophilic response, resulting in release of eosinophilic toxic products that cause illness and poor response to sinus management. Local irrigation with antifungal medications may help. Other treatments being tried are fungal desensitization.

Diet: One of the common urban myths is that milk makes mucus. Of course, certain persons may be allergic to milk, but the popular belief that avoiding milk prevents sinusitis is a myth. On the other hand, it seems to be the kind of information that sells popular books.

• Hot tea: For singers, actors, and speakers, emphasize that hot tea with lemon and honey helps thin mucus and move the cilia; this treatment is especially recommended before a performance. Adequate hydration not only helps the sinus and chest, it can also reduce nosebleeds that many performers get when traveling or in desert climates.

• Iced drinks: Iced drinks make the allergy worse and slow the cilia. Many allergy symptoms can be reduced by avoiding iced drinks and avoiding getting chilled.

• Breakfast in bed: The individual with allergies warms the body by the actions of sneezing, hacking, and coughing. These actions do work to warm the body, but they start the cascade of symptoms of allergy. Often, 50% of these symptoms can be avoided by drinking a hot drink (eg, tea) before getting out of bed. Use a thermos or automatic percolator for the hot drink and eat a cookie or whatever else is desired. Afterwards, when the blankets are removed and the feet touch the cold floor, the body is already warmed and the coughing and sneezing are not necessary to warm the body. In addition, because of the tea stimulating the cilia, the dust that accumulated in the nose is removed and sneezing for dust removal is unnecessary. (Incidentally, each night the hotels in China provide their guests with hot tea in a thermos.)

Activity: For chest problems and postural drainage, breathing exercises are important. With shallow breathing, mucus can be trapped in distal tubules and generate bacterial infection. Stress deep breathing to remove distal air.

• For exhaustion stage of allergy, when all treatments seem to have failed, simply going to full bed rest replenishes the body's cortisone level and often cures the symptoms.

• In acute sinusitis, resting in bed and avoiding getting chilled are important parts of the therapy.

Asthmatic treatment requires combinations of smooth muscle relaxants, bronchodilators, and anti-inflammatory medications. Because asthma is considered an inflammatory condition, antibiotics may be required as well. Sinusitis requires drainage of the infection, encouragement of mucociliary flow, and usually, antibiotics. Often, both asthma and sinusitis are treated simultaneously. Remember that what affects the sinus or chest affects the entire upper respiratory system.
 

Drug Category: Short-acting beta2-adrenergic agonists -- Often for daily and acute use. Rapid action on smooth muscles in bronchi. For onset of asthma and for exercise induced asthma. Abbreviations include the following: MDI metered dose inhaler, EIA exercise induced asthma, CDN compressor type nebulizer, DPI dry powder inhaler, and HFA Hydrofluoroalkane (ozone friendly propellent). Note: Holding chambers and spacers are terms used interchangeably.

Further Inpatient Care:
 

• After 1-2 years, if sinusitis symptoms persist (eg, congestion, drainage, fever, pain), a repeat of the CT scan may be indicated.

• Following surgery, the patient may report not getting enough air, burning in the nose, and dryness. These symptoms often reflect poor cilia function. The nasal membranes appear dry and irritable, and they look thin. Even though the airway is wide open, these symptoms persist with poor cilia function. Treatment is hydration, nasal moisturizer sprays, and ointments. Pulsatile irrigation provides relief and helps restore cilia activity.

• The complications following mid and inferior turbinectomy include loss of airway resistance and loss of olfactory, tactile, and temperature sensors (the empty nose syndrome). This may be observed after bilateral inferior and middle turbinectomy. Symptomatic relief can be offered by pulsatile irrigation with a Locke-Ringer solution such as Breathe Ease tid. In this condition, dryness and crusts are prominent. CT scanning shows mucosal thickening of the paranasal sinuses, loss of definition of the osteomeatal complex, and enlargement of the nasal cavity with destruction of the lateral nasal wall. The patients may be utterly miserable and report the following:

• I can't breathe.

• I can't smell things.

• I can't get enough air.

• My sleep is disturbed.

• I'm plugged up.

• I get frequent infections.

• My ears feel plugged.

• Determine if the symptoms have returned because the patient no longer keeps environmental precautions. When asthma persists, check for GERD

• Determine if the polyps returned because the patient is taking salicylates.

• Ask if the patient acquired a new pet.

• The presence of thick phlegm breeds bacteria and keeps antigens in the system. Thick phlegm must be controlled with moisturizers and sufficient liquid and irrigation.

Further Outpatient Care:
 

• If the cilia of the nose remain normal, few sinus infections should occur; therefore, efforts should be directed to keeping the cilia of the nose normal. Use Locke-Ringer or saline (without Benzalkonium) solution to ensure moisture of the nose. Stress hydration, especially the intake of hot tea and/or chicken soup. Warm compresses to the sinus area are important.

• If sinus symptoms persist, review dust proofing of the bedroom with the patient.

• If cilia of the nose remain slow as shown by dry irritable membranes and thick phlegm, consider pulsatile irrigation with Locke-Ringer or saline solution in order to restore cilia. If cilia are permanently damaged (eg, by excess removal of mucosa, chlorine gas, other toxic substances), consider pulsatile irrigation daily to keep nose moist and remove thick phlegm and materials.

• Check for history of nasal polyps on an annual basis. Remind patients to avoid salicylates. Begin therapy if polyps are recurring.

• On waking up in the morning, the dust has accumulated in the nose and the body temperature is low. If an individual throws off the covers and touches the cold floor with the feet, a cascade of sneezing and hacking warms the body and removes the dust; however, this is an undesirable method to warm the body. Drinking hot tea before getting out of bed avoids this morning cascade of sneezing and hacking.

• Cold air and getting chilled can also trigger an asthma attack. Drinking hot tea before getting out of bed is an excellent preventative.

• The speed of the nasal cilia often reflects the action of the chest cilia. In difficult asthma with associated coughing, determine whether the nasal cilia are inactive. Seek the cause. After exposure to chlorine, chromium, or aldehydes, if the nasal cilia are affected, so are the chest cilia. Ascertain a medication effect, eg, Benadryl and chlorpheniramine may slow nasal and chest cilia.

In/Out Patient Meds:
 

• The continuous medication that is best for individual patients is variable. Pseudoephedrine with guaifenesin combinations is usually tolerated well and provides relief. Continued use of a corticosteroid spray may be indicated. Nonsteroidal sprays such as Astelin may provide nasal relief.

• Long-term use of the corticosteroids, such as Flonase and Rhinocort Aqua, may provide symptomatic relief to many patients. Adverse effects of these and similar products include thinning of membranes and epistaxis. These effects do not appear until after at least 6 months of use and may be prevented by alternating with saline without benzalkonium or Breathe Ease moisturizer spray.

• For patients who continue to catch common colds frequently with severe symptoms, daily pulsatile irrigation may be beneficial in reducing incidence of the common cold. Pulsation reduces the amount of intercellular adhesion molecule-1 (ICAM-1) on the nose. This is the channel for the common cold virus to enter the nose.

• Hypertonic solutions may provide benefit for short periods when the nose is boggy and edematous. Usually these solutions irritate after a while. Try 2 tsp of salt to a pint of water or 2 tsp of Breathe Ease. Hypertonic solutions can be administered up to 3 times the normal dose (ie, 3 tsp salt to 1 pt of water). In 1999, Boek recommended Locke-Ringer solution instead of isotonic sodium solution. When this solution is made hypertonic (ie, 3 tsp Breathe Ease to 1 pt of water), less burning occurs because of the electrolyte balance. The author recommends adding the solutions to boiled or bottled water because many persons are sensitive to the chlorine in the public water supply.

• Antihistamines in solution work for some patients. Astelin is a mixture of antihistamine for nasal use. An inexpensive mixture that patients can use is to dissolve Benadryl 50-mg capsule in an ounce of Breathe Ease or sodium chloride solution. The dose is variable, and patients do comment on the taste. Some patients do well with 100 mg of Benadryl to the 1 oz; therefore, have the patient titrate the dose.

• Patients may continue to experience thick phlegm despite good surgery, pulsatile irrigation, and nasal moisturizers. Consider inhalant usage and investigate a food allergy. Try food elimination diets. Guaifenesin and proteolytic enzymes (eg, Clear Ease) are of help. Stress adequate fluid intake. If surgery has not been performed, thick nasal phlegm in the nose reflects similar phlegm in the chest, and efforts should be directed to thinning the phlegm. Thick phlegm in the chest can easily become infected. Stress liquids, breathing exercises, postural drainage, and steam inhalation. Steam inhalation for the chest is effective if the mouth is open and the tongue is extended.

• In theory, vaporizers moisten the air and thin the mucus. In practice, they are difficult to keep clean and end up growing mold. Steam does not reach the lungs intact unless the tongue is extended. Steam in the shower is very good if the tongue is extended. For travelers, hang wet towels in the bedroom, set out pans of water (if available), and fill the bathtub with water and/or set the shower faucet to drip water.

• Some patients become ill whenever taking an airplane flight. This can be a serious problem for the patient with a sinus/asthma condition. In theory (and in practice for this author's patients), placing an antibiotic ointment, such as Bactroban, in the nose may help by killing certain bacteria, forming a shield against the other passengers who cough and sneeze. Patients should avoid iced drinks and drink hot tea to improve cilia function.

• As in any illness, anxiety can make the illness worse. Recommend some type of stress reduction technique to be part of the therapy. One method is to stand before the mirror with the chest exposed. Breathe in to the count of 4 and out to the count of 6. The exact time for each breath is not important as long as exhalation is longer than inhalation. Relax when exhaling. Visualize the face relaxing, the jaw relaxing, and the shoulders relaxing. The mirror serves as a type of biofeedback mechanism to tell patients when they are doing the stress reduction technique correctly. Instruct the patient to do this 10 minutes a day. With asthma or sinus attack, the complication of anxiety reinforcement is reduced. Stress reduction techniques are especially valuable for children.

• Not every salt can be used to make a sodium chloride solution for irrigation. Regular salt contains silica and iodine. Some patients are sensitive to this. Sea salt is evaporated and contains various products; sea salt is high in iodine. These products can be irritating to the sensitive patient. Kosher salt or pickling salt is free of iodine and silica. Breathe Ease is based on the Locke-Ringer solution formula with sodium chloride, calcium chloride, potassium chloride, and sodium bicarbonate. This balance has been shown to be more effective for cilia than isotonic sodium chloride solution is.

Deterrence/Prevention:
 

• Dust proofing is the best deterrence.

• Hot tea thins thick mucus. Thick mucus must be thinned by a moisturizer or pulsatile irrigation or proteolytic enzymes taken buccally.

• Elements of the workplace cause sinusitis and asthma. Certain chemicals are highly toxic to the cilia. These include chromium dust, sulfur dioxide, smog, ozone, and certain aldehydes (see Dr. Grossan The Ear, Nose & Throat On-line Consultant). For the individual with asthma, this may constitute a disability factor. (Discussion of workplace asthma by pulmonologist Larry Martin can be found at AllergyBuyersClub.com.)

• For persons who frequently catch the common cold, Rabizza recommends daily irrigation to remove ICAM-1, which is the entrance factor for this virus.

• For allergic nasal or chest symptoms, Naso Chrom started 6 weeks before pollen season often is effective.

• Persons who experience burning or lack of benefit from prepared nasal moisturizers may be reacting to the preservatives (eg, benzalkonium). Switch to homemade products.

Complications:
 

• Complications of sinusitis include the following:

• Generalized infection due to circulatory dissemination of bacteria

• Bronchial infection probably due to direct passage by infected mucus into the trachea: Bacteria in the sinus appear in the trachea 16 hours later.

• Meningitis via venous and lymphatic drainage into the CNS or by direct extension through the posterior wall of the frontal sinus or throughout the olfactory area: Sometimes a fistula may be present after sinus surgery. If fever develops in a patient who has had sinus surgery, rule out meningitis and look for fistula, usually in or near the cribriform plate.

• Cavernous sinus thrombosis: The cavernous sinus is a highly vascular area containing optic nerves and cranial nerves III, IV, and VI. It may arise from sphenoid sinusitis.

• Optic spread: Spread can be via the ethmoid sinuses and can cause orbital cellulitis. Optic spread is more common in children than adults.

• Asthma complications can be fatal and include the following:

• Reduced oxygenation

• Pneumonia

• Emphysema

Prognosis:
 

• Patients with sinusitis and asthma have a good prognosis. When the allergist and the ENT specialist are available for problems associated with these diseases, the prognosis is often satisfactory.

• If the patient has experienced failure after sinus surgery, the prognosis is poorer. Factors such as regrowth of obstructing tissue, poor response to infection, and poor response to antibiotics suggest nonoptimum prognosis.

• If the patient's course of sinusitis and asthma has been poor, review factors of immune response. Consider cystic fibrosis, GERD, HIV, and/or systemic infection.

• Hypothyroidism is associated with allergy conditions. Often, specific allergy desensitization may initially be unsuccessful and then succeed when thyroid supplement is added.

Patient Education:
 

• Patient education includes dust-proofing instructions. Encourage patients to keep the bedroom free of dust and mold (see Sinusitis: A Treatment Plan That Works for Asthma and Allergies Too for details).

• Instruct patients to keep the nose moist with moisturizer.

• Educate patients regarding importance of adequate hydration.

• Instruct patients to keep windows of bedroom closed at 5 am and 5 pm. This is when the plants pollinate. Allergic patients do better when they have hot tea before getting out of bed in the morning.

• Educate patients regarding the availability of pollen calendars (see AllergyBuyersClub.com). For allergy, if cromolyn nasal spray is started 6 weeks before the season, excellent results are possible.

• Dogs, cats, and birds must be kept out of the bedroom.

• Instruct patients to drive with car windows closed, especially in the late afternoon.

• Teach adults and children to blow the nose gently with both sides open. Instruct patients how to clear the ears.

• Educate patients about dust proofing the environment. Many allergy companies supply free booklets detailing the dust-proofing instructions. These should be a significant part of the armamentarium of treatment of sinusitis and asthma. Usually, during the third visit to the physician's office, the patient hears the instructions regarding dust proofing; after the fifth office visit, patients actually start the dust-proofing process. Make sure the instructions include no smoking. Repeat the instructions regarding dust proofing, daily breath exercises, and peak flow measurements with each patient visit to the office.
  
   
• For excellent patient education resources, see eMedicine's Asthma Center and Headache Center. Also, visit eMedicine's patient education articles, Asthma, Asthma FAQs, Understanding Asthma Medications, and Sinus Infection.

Medical/Legal Pitfalls:
 

• Failure to diagnose pneumonia: One frequent pitfall involves the patient who is miserable with sinusitis and coughing. Whatever the medical specialty, the physician must listen to the chest and look for asthma, pneumonia, wheezing, and/or a silent lung. Just because sinusitis is present, the physician cannot assume that this is the only cause of the cough. One problem, of course, is that some ENT specialists are not expert at listening to the chest; however, the physician must listen and document that action. When in doubt, refer to a pulmonologist or an internist. Failure to recognize asthma or pneumonia in the presence of sinusitis is an area of litigation.

• Cerebral spinal fluid fistula: The ENT surgeon works in the roof of the nose where the skull and contents are thinly separated (see Image 10). The CT scan must be in the operating room, and the surgeon must look for deep areas where the floor of the skull descends below ordinary areas. A dehiscence may already be present. Recognizing this complication is important. Look for signs of meningitis and unusual headache postoperatively. Sometimes these signs are masked by the antibiotics. A unilateral clear drainage following surgery carries a very high suspicion of a fistula. Laboratory tests are used to determine if this is cerebral spinal fluid. These fistulae can be closed via endoscopic route. The important thing is to make the proper diagnosis. Failure to make the diagnosis can lead to litigation.

• Eye complications: Surgery on the ethmoid sinuses can lead to entrance into the globe of the eye. With the increased bleeding, this complication may not be recognized. Any visual disturbance or muscle paralysis postsurgery should suggest a surgical eye complication. Often these eye complications are difficult to repair.

• Sphenoid sinus: The lateral walls of the sphenoid sinus contain the cavernous sinuses and the various ocular nerves. These areas are rarely compromised because normally the walls are thick.

• Anosmia: Anosmia is not an infrequent complication. As soon as the instrument strays to the midline, the cribriform plate, which contains the olfactory nerve endings, can be affected. A frequent cause is septoplasty in which the bone is rocked by forceps. Rocking the bone in order to break it can easily move the ethmoid bone, thereby disrupting the olfactory nerves. Always use biting forceps in this area to prevent anosmia. This complication is not reparable.

• Atrophic rhinitis: Postoperatively, the nose may look wide open; however, the patient is miserable, the nose is dry, and the normal functions of moistening the air, heating the air, and trapping bacteria in mucus are now gone because the mucosa of the turbinates have been removed. Turbinectomy, unless performed so as to preserve mucosa and function, can leave the patient highly symptomatic and ready to litigate. Prevention is to preserve turbinate mucosa. See empty nose syndrome.

• Allergy: Failure to diagnose allergy may lead to litigation. The patient may be misdiagnosed with sinusitis. An excellent surgery is performed to straighten the septum and move the turbinates. Postoperatively, the patient still has nasal obstruction and the physician recommends a second operation. The patient goes to an allergist who clearly demonstrates a 4 plus dust allergy, and the patient's condition clears on desensitization. Now, the patient is ready to legally sue the surgeon because surgery was not necessary. Performing surgery with the knowledge that an allergy condition exists and explaining that the allergy condition will either persist or improve after surgery is not a problem; however, to not offer the patient the choice of allergy therapy versus surgery is a failure of good medicine.

• Medications: The patient may be taking medicine from an orthopedist, an endocrinologist, a psychiatrist, and an internist. Because of drug interaction concerns, at times the otolaryngologist can only prescribe sodium chloride solution for the patient. Drug interaction is a serious problem and one that can easily lead to litigation. Somewhere in the literature the lawyer can find a case where one drug should not be administered with another drug. One defense is to insist that the patient only use a single pharmacist who, hopefully, looks at these interactions. Another is to speak with the internist or the hospital pharmacist.

• Frontal sinusitis: Following endoscopic surgery, the attachment of the middle turbinate may move so as to block the frontal sinus. Look for this etiology when a history of prior endoscopic procedures is present. Even in this golden age of antibiotics, frontal sinus abscesses do occur. They may rupture through the posterior wall into the brain. The difficulty with this diagnosis comes with the patient who is seen weekly who has severe symptoms, including frontal headache. When a noncomplaining patient reports frontal pain, consider frontal sinusitis. A CT scan (not an MRI) must be obtained to evaluate the posterior wall of the frontal sinus.

• Prednisone: Never refill prednisone. Good doctors do forgot to write "do not refill" on the prescriptions, and patients do keep refilling these prescriptions. Alternatively, the physician can refill a prescription by phone and not see that the patient has Cushing disease. Always write "do not refill" on prednisone and similar medications. Patients often feel great on prednisone and will think of ways to get more, including altering the prescription or calling the physician's associate or registered nurse.

• The chart: One pitfall is a chart that does not adequately describe the lesion and does not include pictures or diagrams. At surgery, any description of the deviated septum is similarly absent in the chart. Include pictures, diagrams, and descriptions with documentation in the chart so a lawyer cannot claim that surgery was not indicated. Insurance carriers look for ways to avoid payments, and a chart without adequate documentation makes this easy for them.

• Discussion of complications: Writing "complications were discussed" is acceptable, but the patient may still insist that no discussion occurred. In one such case, the office chart and hospital chart were complete and nicely written. Dictation regarding the surgery occurred right after the operation. The dictation was complete, and the important details were included. This case was easy to legally defend because any doctor with such thorough charts would obviously be just as thorough in explaining the complications.

• Written instructions: For example, one patient puts the eardrops in the mouth; another patient puts the liquid penicillin in the nose and then claims that the physician verbally instructed that the penicillin was for the nose. Always assume the worst-case scenario and write the instructions separately from verbal instructions. Keep a copy of the written instructions.

• Speaking the patient's language: Using terms and analogies that the patient really understands is necessary. Use pictures, diagrams, and other communication tools. Have the patient hold the skull while explaining the surgery.

• Discussing the alternatives: The moment the doctor mentions surgery the patient may dismiss it as a possible treatment. Advise the patient of alternative care. Options include (1) continuing with medication, which has not worked; (2) trying 2 years of allergy shots; (3) trying more cortisone and risking the adverse effects; or (4) trying surgery. In a good practice, patients usually have already explored all options, so surgery is the remaining option.

• Adequate medical course: The guidelines for ENT surgery are clear that the nonsurgical approach must be tried before surgery. Complications at sinus surgery do occur. A lawyer may argue that the CT scan showed thickened membranes. In other words, the lawyer is implying that the physician could have prescribed antibiotics and cleared the membranes without surgery. Another example is if the patient had polyps. A lawyer may quote a medical expert who says that a physician should always try medication to shrink the polyps. The lawyer then asks why this medication was not tried and implies that the physician was anxious to sell an operation. No matter what procedure is performed, some article can always be found that reports that the procedure either should not be performed or should be performed differently. Be aware of the other opinions in the medical field because the opposing attorney will be aware of these options.

• Expecting the worst: From the author's experience, using diagrams, speaking clearly, and using words that the mother seemed to understand, this author explained the need for adenoidectomy and myringotomy for her child and then asked if she had any questions. An hour later, the mother's doctor called to report that the mother was in his office crying because nothing had been explained to her regarding surgery.

• The “never operate” argument: A favorite legal ploy is reporting that the medical expert says never operate on patients with this condition. This quote may be taken out of context and may be taken from a medical journal written in a foreign language. Demand to see or read the entire article.

Caption: Picture 1. Asthma and sinusitis. Lateral sinus wall. Perform nasal endoscopy to reveal patent or closed sinus ostia. Look for purulent areas.

Picture Type: Image

Caption: Picture 2. Asthma and sinusitis. Septal deviation with concha bullosa. On the CT scan, the bony anatomy, including the important structures of the maxillary frontal and sphenoid ostia, is detailed. The cribriform plate, whose anatomic position is a critical factor in any surgery, is visualized. The surgeon looks for depression at this area and dehiscence. In the image, the septum is deviated to the left, and the concha bullosa is right of the middle turbinate.

Picture Type: Image

Caption: Picture 3. Asthma and sinusitis. Lateral wall anatomy, nasal endoscopy. Patent or closed sinus ostia may be revealed. The maxillary, frontal, and sphenoid ostia are visualized. Purulent discharge is noted.

Picture Type: Image

Caption: Picture 4. Asthma and sinusitis. Hydro Pulse Irrigator. Because bacteria and thick phlegm play a significant role, the physician can reduce the asthmatic symptoms from sinusitis by suctioning or irrigating in the office if pus is present in the nose or sinuses. One technique is to use a vasoconstrictor in the nose, wait 2 minutes, and then irrigate with a modified Locke-Ringer solution or sodium chloride solution with a pulsatile nasal irrigator. Not only is a considerable amount of surface and sinus pus removed, but the pulsatile action at 20 pulses per second stimulates the cilia of the nose and sinuses to restore normal cilia action. Flow of solution past the orifice creates a Bernoulli effect to displace the sinus contents. The additional pulsation aids this process.

Picture Type: Photo

Caption: Picture 5. Asthma and sinusitis. Radiograph of a child. Note the size of maxillary sinuses. Ethmoids are beginning to develop, but the frontal sinus is not yet present. One useful technique for treating sinusitis in children is Proetz sinus irrigation, which is performed with the child hyperextended over the parent's lap so that the child's head is lowered.

Picture Type: X-RAY

Caption: Picture 6. Asthma and sinusitis. Concha bullosa. Blockage of the natural ostia can be caused by a foreign body. A deviated septum may compress this area. Hypertrophy of turbinates may be sufficient to block the opening. Concha bullosa refers to a hollow enlargement of the middle turbinate so that it blocks drainage of the maxillary ostia.

Picture Type: Image

Caption: Picture 7. Asthma and sinusitis. Nasal polyps may develop in the opening itself or grow from a distal origin and be positioned to obstruct the ostia. Treatment is directed to ensure sinus patency and to remove obstructive septum, polyps, and tissue.

Picture Type: Photo

Caption: Picture 8. Asthma and sinusitis. The most common ENT surgery is correction of a deviated septum. Because of multiple injuries, the septum is no longer in midline. When it blocks breathing (see Image 2), the entire airflow pattern can be upset, or the septum may impact solidly against the sides (septal spur) and cause blockage of drainage from sinuses.

Picture Type: Image

Caption: Picture 9. Asthma and sinusitis. Hypertrophied turbinates may be the sole cause of nasal obstruction and frequent infections. These can be safely reduced by submucous resection of the turbinates.

Picture Type: Image

Caption: Picture 10. Asthma and sinusitis. Cerebral spinal fluid fistula. The ENT surgeon works in the roof of the nose where the skull and contents are thinly separated.

Picture Type: CT

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