INTRODUCTION

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Background: In the US, there are 35 million persons with sinus problems and 15 million persons with asthma. Clinically, physicians know that a sinus infection can contribute significantly to the frequency and severity of asthma attacks. The purpose of this chapter is to outline the factors common to both conditions and to note how best to improve these conditions.

Asthma and sinusitis both have been recognized in ancient literature. In the 1940s and 1950s, considerable sinus surgery was performed to help people with asthma. Purulent diseased tissue was removed, the nasal airway was opened, and excellent results were achieved for some of these patients. Then, in the 1960s, the improvements following sinus surgery were thought to be more related to the stress reaction than from the surgical technique; therefore, sinus surgery became less popular as a principle of asthma management.

With the introduction of the CT scanning technique in the 1970s, accurately pinpointing the location and extent of the sinus pathology became possible. A return to corrective surgery for individuals with sinusitis and individuals with asthma has occurred, thanks to the studies of Rachelevsky, Spector, and many others showing the benefits of clearing sinus pathology. Then, in the 1980s, functional endoscopic sinus surgery (FESS) and the ability to physiologically improve sinus function became available.

In the 1990s, as the CT scan's ability has enhanced the view of the sinus and as endoscopic surgery, especially with the computer-assisted techniques, has improved the ability to improve sinus function, physicians are returning to sinus treatment as an aid to asthma management. Further aids to treatment have included newer antibiotics and emphasis on cilia function. Newer medications, such as the corticosteroids sprays, have given new directions for treatment. Indeed, many allergists now emphasize their role in treating sinusitis.

Pathophysiology: The physiology of mucus in individuals with asthma is similar to that of nasal mucus. Mucociliary clearance (MCC) involves cilia and the layers of mucus on the ciliated epithelium and refers to the movement of particles along a desired path for maximum health. In the upper respiratory tract, cilia propel the mucus and its trapped bacteria and particles to the nasopharynx, where it drops to the hypopharynx and is swallowed. The stomach acid then disposes of the unwanted invaders.

In the lower respiratory tract, the cilia that line the trachea and bronchial tree similarly move the mucus blanket up the trachea and into the hypopharynx for swallowing.

The science of rheology investigates the makeup of this liquid and studies its viscosity and elasticity. Two layers of mucus are present over the ciliated cell; an outer, thick, viscoelastic, semisolid mucus layer, which the cilia do not strike directly, is found over a layer of watery serous fluid. Because of the lowered viscosity of the layer of watery serous fluid, the cilia are able to beat normally and to move the watery lower layer, thereby, affecting movement of the upper thick layer. Changes of these properties affect movement of the mucus blanket and play a major role in pulmonary and sinus disease. If the movement of the blanket is slowed, bacteria are able to multiply as the mucus thickens and stagnates.

Nasal mucus is a secretory substance produced by 100,000 small seromucous glands in nasal mucosa. Nasal mucus has a lower viscosity than sputum and contains sulfate, sugars, proteins (including albumin), and protective enzymes and phagocytes.

MCC refers to the function of moving bacteria, contaminants, and carcinogens away. Ciliary beat frequency refers to the number of full whiplike movements of the cilia per second (normally 16) and involves the coordination of these movements.

Remarkably, the ciliary movement is coordinated so that an effective wave propels the mucus in a specific direction. Sinus cilia beat toward the natural sinus opening in the middle meatus, even after an antrostomy or artificial opening is created in the inferior meatus. Nasal cilia beat backward towards the nasopharynx. Thus, nasal mucus is propelled into the nasopharynx and is swallowed for disposal into the stomach. In the child, this course directs the mucus with its bacteria, debris, and foreign matter over the adenoids where lymphocytic defenses can act. The deep crypts and rugae of the adenoids create a larger surface area for greater effect. Protection from infection is achieved by the presence of lysozymes, immunoglobulins, and phagocytes in the mucus solution. Movement of the bacteria by mucus flow reduces opportunity for penetration of the cell. Dilution of bacterial products makes them less toxic. Whatever thins the nasal mucus or stimulates it (eg, proteolytic enzymes, mucolytics) helps theasthmatic chest mucus. Measuring cilia in the chest is quite difficult; measurement requires biopsy or special radioactive gasses. Measuring the nasal cilia, as by a saccharin test, is easy and is a useful reflection of the chest cilia.

Frequency:

• In the US: Asthma and sinusitis are both increasing in frequency. Fifteen million individuals with asthma and 35 million persons with sinusitis live in the US. No doubt, overlapping of the conditions occurs.

• Internationally: An increased incidence is reported in all countries. The incidence of sinusitis is higher in Japan, Indonesia, and Europe than in the US. An increased incidence of both sinusitis and asthma occurring together is reported internationally as well as in the US. Certain areas have special conditions causing an increased sinusitis incidence (eg, the fires of Kuwait and Indonesia, the chromium content of the sands of Saudi Arabia). Asthma-free areas have been noted in certain sub-Saharan areas where hookworm is endemic. The parasite system (eg, eosinophiles) is fully engaged.

Mortality/Morbidity: Despite the availability of effective antiasthmatic drugs, asthma is responsible for more than 100 million days of restricted activity and 470,000 hospitalizations annually. The most common disease of early childhood, asthma exacts a particularly high toll among persons who are economically disadvantaged.

• In poverty situations, the incidence of asthma and allergy is higher. This increased incidence is partially based on poor environmental control. Cockroaches and dust are known to be causes of asthma. In poverty situations, pets often are prevalent in close quarters, and air filtering and dust proofing often are not performed. Asthma is a disease that requires maximum cooperation of the family. Often, the parents must oversee a complicated regimen of inhalers, pills, and breathing exercises; this type of supervision and assistance may not be available in poverty situations. Poor medical service also is a major factor contributing to the high rate of poorly controlled asthma and sinusitis in these patients. Often, the only primary and follow-up care for this population of patients is in the busy emergency room.

• Sinusitis, fortunately, has a low death rate. Death can occur in young children when the condition is unrecognized. In infants, the maxillary sinuses are well developed but often are unrecognized as a source of possible lethal infection. In adults, fatalities occur primarily as a result of complications of sinus infection to the brain, meninges, and the cavernous sinus.

• Problems with sinusitis and rhinitis can make up 50% of office visits and are involved in a large percentage of medical costs.

Sex: Incidence of sinusitis appears to be equal among the sexes.

Age: Asthma and sinusitis can occur in very young children. Sinusitis in very young children is not appreciated because the presence of the maxillary and ethmoid sinuses is not always recognized. Once children start nursery school, the incidence of sinus and chest infections skyrockets.

CLINICAL

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History: Individuals with asthma often have a childhood history of allergy. Patients present with wheezing and coughing, and they complain of sleepless nights. These patients benefit by the use of an inhaler. Associated with these symptoms are complaints of frequent sinus infections, heavy pus, or thick mucus drainage into the chest. Whenever individuals with asthma get a sinus infection, the asthma worsens. When accompanied by a sinus infection, the asthma fails to clear with simple treatment. When the nose obstructs, these individuals breathe with the mouth open, which precipitates an asthma attack. Patients with asthma have a dry mouth all the time and are bothered by thick nasal phlegm dripping into the throat. The thick phlegm causes these patients to cough and try to clear the throat constantly. With a sinus infection, a much longer time period is required to clear the asthma. Obtain history regarding frequency of bouts of nasal obstruction, purulent discharge, localized sinus pain, drainage, and fever.

• Frequency

• History of frequent bouts of sinusitis is evidenced.

• Every year, 4-5 episodes of sinusitis occur and last about 4 weeks each.

• Often, the episodes do not clear until antibiotics are administered.

• Not chronic sinusitis

• A history of 4 bouts of sinusitis over the past 6 months, each of which required antibiotics and did clear, is more suggestive of the same infection hanging on.

• When the antibiotic is stopped, the infection, still present, gradually returns.

• In this case, irrigation is needed as well as possible local treatment or a longer course of antibiotic.

• Family history

• Obtaining family history is very important in cases of asthma and allergies.

• For sinusitis, a higher incidence generally does not follow a family history of sinusitis.

• The following 2 factors cause a very high incidence of sinusitis in patients with AIDS:

• Lowered immune systems allow bacterial growth.

• A thickened mucus exudate becomes stagnant and allows for bacterial growth.

• The failure of the normal mucociliary flow system accounts for an extremely high incidence of sinus disease in patients with cystic fibrosis.

Physical: In susceptible individuals, this inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. These episodes usually are associated with widespread, but variable airflow obstruction that often is reversible either spontaneously or with treatment. The inflammation also causes an associated increase in the existing bronchial hyperresponsiveness to a variety of stimuli.

• Determine if sinus infection precedes or follows asthma attack.

• Determine frequency of sinusitis and results of antibiotic therapy.

• Examine eyes, ears, nose, throat, and larynx. Look for lymphoid hyperplasia and/or hypertrophic turbinates. Determine if they are inflammatory or allergic in appearance.

• Determine if the septum is obstructive. On laryngoscopy, look for signs of irritation of the posterior larynx indicating gastroesophageal reflux disease (GERD).

• Look for history of eustachian tube dysfunction.

• Look for signs of adenoid hypertrophy or mass.

• Hypertrophic posterior turbinates may best be seen via nasopharyngeal mirror exam.

• In cases of unilateral purulent drainage from a child, especially look for a foreign body.

• Perform nasal endoscopy to reveal patent or closed sinus ostia.

• Visualize the maxillary, frontal, and sphenoid ostia.

• Physical findings of asthma

• Individuals with asthma wheeze and have impaired breathing.

• The chest sometimes is retracted or sunken, indicating inhalation difficulty. (Barrel chest indicates emphysema.)

• Nostrils flare.

• Throat is often dry.

• Physical findings of sinusitis

• Patient breathes through the mouth and shows purulent drainage.

• Patient may have a mild fever.
• Local tenderness over the affected sinus is present.

• With nasal speculum, a purulent drainage usually is observed from the middle meatus.

• Transillumination shows decreased light passage on the affected side.
• Purulent material may be observed in the pharynx and/or the nasopharynx

Causes: Asthma and sinusitis are increasing in frequency and morbidity, despite the advances made in understanding and treating these conditions. The following theories suggest what is causing these increases:

• Overuse of antibiotics

• A current theory suggests that with overuse of antibiotics, the normal disease reaction is replaced by a hypersensitivity reaction.

• This theory notes a high incidence of disease in families with upper incomes; these individuals have full access to medical care, cleanliness, and dust proofing.

• The body's immune system is designed to fight parasites and infections, and, if the antibiotic is given at the first sniffle, perhaps the normal immunity fails to develop and alternate systems are produced (eg, asthma, poor resistance to infection).

• Genetics

• When compared to sinusitis, asthma has more of a genetic etiology.

• Incidence of asthma increases when both parents have asthma.

• More individuals with asthma are having children.

• Environmental factors are becoming increasingly more important and include the following:

• The major environmental irritant, other than specific occupational substances, is tobacco smoke.

• Current theory attributes the increase of sinusitis and asthma to air pollution. When the air is polluted with smog, diesel, gasoline, and other noxious products, the sun's heat and rays may combine them into dozens of products whose long-term effects are unknown at this time.

• Additionally, smog, diesel fumes, and sulfur dioxide all combine to interfere with good cilia function. Hypersensitivity reactions seem to occur when the individual gets an overwhelming exposure and fails to recover ciliary function. Unfortunately, new solvents are marketed daily and the effect on cilia function is not provided by the manufacturers. Even more unfortunate is the fact that despite the 50 million dollars spent by the Federal Drug Administration (FDA) on clinical evaluations, no drugs are evaluated as to their effect on mucociliary clearance.

• Known industrial toxins include chlorine, sulfur dioxide, cupric compounds, and chromium dusts.

• Fires are a known factor. When countrywide fires, such as in Kuwait or Indonesia, occur, the incidence of sinusitis and asthma increases. Oil fires in Kuwait released polymelia aromatic hydrocarbons, nickel, and vanadium into the atmosphere. This contamination resulted in upper and lower respiratory infections. Similar problems have occurred with Indonesia forest fires and excess smog experience in London. Some of the respiratory problems might be prevented by simple irrigation with Locke-Ringer type solutions.

• Other environmental problems to be considered include pet allergens, house-dust mite allergen, cockroach allergen (most significant in patients who live in the inner city), indoor fungi and molds, and outdoor allergens (eg, trees, grass, weed pollens, seasonal mold spores).

• Impaired mucociliary clearance: Sinusitis and asthma are inflammatory diseases and, as such, are caused or aggravated when mucociliary clearance is impaired. Factors that slow cilia include the following:

• Cocaine
• Antihistamines
• Dehydration
• Inhalation of air or steam above 40 degrees Celsius
• Heavy load of iced drinks
• Chilling drafts
• Sulfur dioxide, ozone, smog
• Inhalation of chromium dusts
• Cupric (copper) compounds
• Nickel dusts

• Chimney dusts
• Formaldehyde
• Late stages of allergy
• Nasal polyps
• Skydrol (a solvent used in airplane maintenance)
• Pseudomonas species, Haemophilus influenzae, and many viral infections
• Hyperbaric oxygen
• Reduction of airway diameter
• AIDS

• In addition to the above factors, there is an increasing recognition of GERD as an irritant that brings on asthmatic symptoms, as well as throat and laryngeal complaints. When the larynx is visualized with mirror or endoscope, the arytenoids are inflamed, especially posteriorly. Standard GERD measures may be beneficial.

• Dye or tracers placed in the sinus appear 16 hours later in the lower trachea. Thus, there is little question that bacteria from the sinuses find their way to the lower respiratory system. Bacteria then act as an inflammatory agent.

DIFFERENTIALS

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Other Problems to be Considered:

WORKUP

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Lab Studies:

• Pulmonary function studies indicate respiratory function.
• 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 usually are 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 also may show streptococci infections

• White blood cell count and differential count

• 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

• 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.

• In cases of chronic sinusitis, some authors are testing the skin for fungus, and then they 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.
  • With postchlorine gas or other toxins, saccharin is tasted in more than 30 minutes. These patients do not recover their cilia function with treatment.

Imaging Studies:

• X-rays of sinuses are quite helpful and generally include Waters, lateral, and Caldwell views.

• To perform the Waters view, place the patient’s chin on the x-ray 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 x-ray plate, is designed to visualize the frontal and ethmoidal sinuses.

• CT scans

• CT scans have replaced regular x-rays as the preferred imaging test to look at the sinuses.

• In most communities, the radiologist performs a limited CT scan for about the price of a regular sinus x-ray.

• In cases of sinusitis, it is important to localize the condition by CT scan and correct anatomical factors.

• 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 anatomical 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 often is 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. 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

• MRI of the sinuses gives excessive false-positive results, as 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 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 prick or radioallergosorbent assay test (RAST) of intradermal testing. RAST and other lab tests are performed from blood removed from patient. These 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 best identification of a food allergy. Once the food is identified, it is best to add the food to the test to induce a reaction 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 need to be assayed for difficult cases.

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

Procedures:

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

• Nasopharyngeal mirror exam: 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.

TREATMENT

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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. But if an antibiotic is added at the same time with 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 utilizing measures to increase mucociliary clearance. Patients should drink enough fluids to lighten the urine (eg, hot tea, hot chicken soup).

• Reduce bacterial load. 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 weeks), (3) drainage, rest, and anti-inflammatories are not combined with treatment, (4) fungus is present, and (5) the mucociliary system fails. If infection fails to clear in 6 weeks, referral to ENT is recommended.
• Office suctioning or irrigation: 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 and/ or sinuses. One technique is to use a vasoconstrictor in the nose, wait 2 minutes, then irrigate with a modified Locke-Ringer solution or saline solution with a Water Pik and sinus irrigator attachment. Not only is a considerable amount of surface and sinus pus removed, but the pulsatile action at 20 pulses/second stimulates the cilia of the nose and sinuses to restore normal cilia action. This same procedure can be used at home daily for chronic sinusitis in adults or in children aged 5 years and older. Rachelevsky Water Pik type irrigation also may be of benefit 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.

• If asthma and sinusitis are considered as being inflammatory diseases, it is clear that treatment is similar for both in regards to specific infection, inflammation, drainage, attention to thinning mucus, restoring cilia, and comfort to the patient.
• Most common organisms are S 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 amoxicillin 500 mg 3 times a day, trimethoprim-sulfamethoxazole (Septra DS) twice daily, cefuroxime (Ceftin) 250 mg twice daily, or cefaclor (Ceclor) 500 mg 3 times a day. Other medications include trimethoprim-sulfa 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) 2x 250 mg tablets the first day followed by 1x 250 mg tablet every day for 4 more days, and 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 need to receive and use the drug resistant/ sensitivity data available from hospitals.
• Sinus pain is present when membranes are inflamed or swollen. Anti-inflammatory agents (eg, Naproxen) are useful.
• Treatment of Pseudomonas infections: Use piperacillin, ticarcillin, and carbenicillin, depending on the secondary organisms.

• 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 given as prednisone 5 mg number 21. It is prescribed in diminishing doses: 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. 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 taking 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 there is a need to remove heavy dust or perfume from the nose. Recently, Boek has recommended Locke-Ringer solution as being superior to regular isotonic saline solution. Hypertonic saline 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 complain of the taste. A solution of Benadryl 25 mg added to one ounce of Locke-Ringer or saline solution can be made and yields similar results. The dose of the Benadryl needs to 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, www.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 saline solution as a spray.
  • Gentamicin and tobramycin are used for irrigation. Gentamicin has the advantage of being inexpensive. Forty mg can be added to 200 cc of Locke-Ringer or saline solution for irrigation with the Water Pik device. This can be used twice daily for advanced infection or once daily for milder chronic cases. Singulair dissolved in Locke-Ringer or saline solution has been reported to be of particular value for vasomotor rhinitis.
  • Example of local irrigation: For topical irrigation with gentamicin or tobramycin, add 1 tsp of Breathe Ease or salt to 1 pt of water in Water Pik basin with sinus adaptor. Irrigate till clear. Blow nose gently till clear. Adjust solution to contain 200 cc 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: Penicillin G and V 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 (Septra, Bactrim)
  • Antifungal medications include amphotericin B, ketoconazole, and fluconazole (Diflucan).
  • Antiviral medications include acyclovir (Zovirax) and amantadine (Symmetrel).

• 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 will 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. One useful technique for treating sinusitis in children is Proetz sinus irrigation, which is performed by placing the child hyperextended over the mother'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, one eighth percent Neo-Synephrine) is placed in both nostrils. Fill both sides with modified Locke-Ringer solution (Breathe Ease) or saline solution. Take care not to get into the eyes. Gently aspirate with nasal aspirator. Keep refilling both sides with solution until the return is clear. This works better if the child cries. By removing this pus, there is less chance of developing a chronic sinus condition with an asthmatic sequel.
  • 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, especially if one places a sticker of the child's hero on the spray bottle. Or isotonic saline can be prepared without preservatives. 1/2 teaspoon of salt to 8 ounces of water makes an isotonic solution. Since there is no preservative here 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 there has been long-term use of this product, 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 preoperation. 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 visualizes the position of the magnet in the 3 views at all times, thereby reducing the complication rate (see http://www.ent-consult.com/traksurgery.html).

• Maxillary sinus: Blockage of the natural ostia can occur 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. 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. Treatment is directed to remove obstructive septum, polyps, and tissue, and it is directed to ensure sinus patency. At surgery, obstruction to drainage is removed and instruments can enter the sinus cavity to remove diseased tissue. When patients complain of pain in cheek and upper teeth, remember that the same nerve innervates the maxillary antrum as 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, it is important to remove all diseased tissue, as well as obstructive conditions. 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 exam 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, an additional factor adds to mucosal thickening, polyps, and anatomical 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 easily can 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 complain of 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). It is helpful for the clinician to palpate the cervical area and 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 complains of 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. These can be reduced safely by submucous resection of the turbinates. Make an incision inferiorly 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 usually are not 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, there is 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 had frequent failure to respond to antibiotic and other measures, ENT consult is indicated. When the patient fails good treatment, frequently, an anatomical defect with obstruction of drainage is found. A limited CT scan showing blockage of maxillary sinus requires an ENT consultation.

• If allergy management fails to improve nasal or chest breathing, consult with ENT. 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 consistently fails, 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 anatomical 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 no matter what antibiotic is used.

• Other treatment considerations: Keep in mind that recurrent sinus infection (eg, 4 infections in 5 months) 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 by the naked eye and shows characteristically as a 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 very 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.

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

• Iced drinks make the allergy worse and slow the cilia. Many allergy symptoms can be reduced by avoiding iced drinks and 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. Now, when the blankets are removed and the feet hit the cold floor, the body is already warmed and there is no need for the coughing and sneezing to warm the body. In addition, because of the tea stimulating the cilia, the dust that accumulated in the nose has been removed and no need to sneeze for their removal is present. (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 get 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.

MEDICATION

Section 6 of 9   << Previous Section | Top | Next >>

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 beta 2-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:
MDI metered dose inhaler
EIA exercise induced asthma
CDN compressor type nebulizer
DPI dry powder inhaler
HFA Hydrofluoroalkane (ozone friendly propellent)
Note: Holding chambers and spacers terms are used interchangeably.

Drug Category: Anticholinergic agent -- The parasympatholytic inhalers inhibit vagally mediated reflexes by antagonizing the action of acetylcholine released by the vagus nerve. This prevents the increase in intracellular concentration of cyclic guanosine monophosphate (GMP) caused by interaction of acetylcholine and muscarinic receptor on bronchial smooth muscle.

Help reduce mucus in the lungs. Relax the smooth muscles of the large and medium bronchi. May be used with short acting beta 2-adrenergic bronchodilators (eg, albuterol).

Drug Name	Ipratropium (Atrovent) -- Chemically related to atropine. Has anti-secretory properties, and when applied locally, inhibits secretions from serous, and seromucous glands lining the nasal mucosa. Site-specific effect, not systemic. Not utilized orally. Also available as combination product with albuterol (Combivent).
Adult Dose	MDI: 18 mcg/puff; 2-3 puffs q6h; not to exceed 12 inhalations/d CDN: 1 vial q6-8h
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity
Interactions	Drugs with anticholinergic properties (eg, dronabinol) may increase toxicity; albuterol may increase effects
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Not indicated for acute episodes of bronchospasm; caution in narrow-angle glaucoma, prostatic hypertrophy, and bladder neck obstruction; temporary blurring of vision may occur due to anticholinergic effects

Drug Category: Corticosteroids, inhaled -- From the cortex of the adrenal glands comes one of the more common classes of drugs used in cases of sinusitis and asthma. This class was discovered and named by Hans Selye while working with stressed rats. Selye described the action and named the chemical before the drug was actually identified. His work stimulated the search and identification of corticosteroids. For asthma, these drugs (1) decrease inflammation and swelling in the airways, lessening airway hyperreactivity, (2) reduce the release of body chemicals from certain inflammatory cells, and (3) increase the effect of bronchodilator medications.

Drug Name	Beclomethasone (Beclovent, Vanceril, QVAR-HFA) -- Inhibits bronchoconstriction mechanisms, produce direct smooth muscle relaxation, may decrease number and activity of inflammatory cells, in turn decreasing airway hyper-responsiveness. Various dose preparations are available and must be titrated in conjunction with other medications patient is taking; most inhaled PO medications have effect in 24 h. Other drugs in this category include: Beclomethasone (Beclovent) Budesonide (Pulmicort, Turbuhaler) Flunisolide (AeroBid, AeroBid M) Fluticasone (Flovent) Triamcinolone (Azmacort)
Adult Dose	42 mcg: 4-12 puffs/d up to 20 puffs/d
Pediatric Dose	42 mcg: 2-8 puffs/d up to 16 puffs/d
Contraindications	Documented hypersensitivity, bronchospasm, status asthmaticus, other types of acute episodes of asthma
Interactions	Coadministration with ketoconazole may increase plasma levels but do not appear to be clinically significant
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in diabetes, glaucoma, ulcerative intestinal conditions, and pregnancy; weight gain, increased bruising, cushingoid features, acneiform lesions, mental disturbances, and cataracts may occur (taper medication slowly if these changes occur)

Drug Category: Corticosteroids, systemic -- Oral steroids are administered as a short-term burst or as routine maintenance therapy. Prednisone or methylprednisolone are recommended because they are short acting and reliably well absorbed and available to the lungs.

Drug Name	Prednisone (Deltasone) -- Glucosteroids that occur naturally and synthetically. Used for both acute and chronic asthma. May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. Loading or initial dose should be taken all at once in the am; may suppress natural cortisone production; hence, requires tapering the dose upon discontinuation. As soon as the dose for relief is found, a maintenance dose may be established until the nonsteroidal drugs are effective; must always use a decreasing dose to avoid serious renal suppression. For nasal polyps the above dose should be combined with an antibiotic because the stasis of the polyp generally produces localized bacterial infection. In seasonal allergy a "booster" of prednisone may speed resolution of symptoms. Quite effective in "exhaustion" stage of seasonal allergy. Other drugs in this category include:Methylprednisolone (Medrol) Prednisolone (Delta-Cortef, Pediapred, Prelone)
Adult Dose	Allergic rhinitis: 5 mg number 21 PO; prescribed in diminishing doses: 6 tab d 1, 5 tab d 2, and so on to 1 tab the 6th d; all should be taken at once and not spaced out Other programs: Up to 60 mg qd, or every other dose to control symptoms or 40-60 mg for 3-10 d
Pediatric Dose	0.25-2 mg/kg qd or q2d
Contraindications	Documented hypersensitivity; viral infection, peptic ulcer disease, hepatic dysfunction, connective tissue infections, and fungal or tubercular skin infections; GI disease
Interactions	Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin, may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Abrupt discontinuation of glucocorticoids may cause adrenal crisis; thinning of bones (osteoporosis), which may lead to fractures or compressions, especially of the vertebral bones (backbone), loss of blood supply to bones (aseptic necrosis), which may cause severe bone pain and may require surgical correction, hypertension, glaucoma, cataracts, weight gain with increased appetite, fluid retention and stretch marks, facial fullness, increase in body hair and acne, easy bruising and thinning of the skin, along with poor wound healing, interference with growth in children, muscle weakness or cramps, joint pain, changes in menstrual cycle, diabetes, suppression of the body's adrenal gland, which makes the necessary amount of cortisol at times of stress (adrenal insufficiency), adrenal gland function usually resumes when steroids are stopped or when they are taken in a single am or pm dose qod, irritability, depression, euphoria, or hallucinations may occur with glucocorticoid use

Drug Category: Methylxanthine -- Oral theophylline is an old standby related to caffeine. Not as popular now with the availability of more specific medications with fewer adverse effects. Can be used in combination with inhaled corticosteroids. Long duration of action makes it useful for nighttime asthma.

Not recommended as a rescue medication.

Drug Name	Theophyline (Uni-Dur, Uniphyl, Theo-Dur, Theo 24, Slo-bid, Gyrocaps) -- Potentiates exogenous catecholamines, stimulates endogenous catecholamine release, and diaphragmatic muscular relaxation, which in turn stimulates bronchodilation. Generally added in order to reduce corticosteroid dosage. For bronchodilation, near toxic (>20 mg/dL) levels are usually required.
Adult Dose	10 mg/kg initial; titrate up to 800 mg/d
Pediatric Dose	10 mg/kg/d initial; titrate <1 year: Not to exceed 5 mg/kg/d >1 year: Not to exceed 16 mg/kg/d
Contraindications	Documented hypersensitivity; uncontrolled arrhythmias, peptic ulcers, hyperthyroidism, and uncontrolled seizure disorders
Interactions	Aminoglutethimide, barbiturates, carbamazepine, ketoconazole, loop diuretics, charcoal, hydantoins, phenobarbital, phenytoin, rifampin, isoniazid, and sympathomimetics may decrease effects of theophylline; theophylline effects may increase with allopurinol, beta-blockers, ciprofloxacin, corticosteroids, disulfiram, quinolones, thyroid hormones, ephedrine, carbamazepine, cimetidine, erythromycin, macrolides, propranolol, and interferon
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in peptic ulcer, hypertension, tachyarrhythmias, hyperthyroidism, and compromised cardiac function; not to inject IV solution >25 mg/min; patients diagnosed with pulmonary edema, or liver dysfunction are at greater risk of toxicity because of reduced drug clearance; may cause nausea, vomiting, cramps, diarrhea, and tremors; may affect school performance

Drug Category: Leukotriene modifiers -- Can reduce the intake of inhaled corticosteroids. May be beneficial to difficult asthma cases. Begin to work in several hours but require up to a week for full effect.

Leukotrienes are one of the products released in asthma attacks that causes bronchoconstriction and inflammatory response as well as increased mucus production. Currently available in tablet form, but being researched as a topical for the nose in spray form.

Drug Name	Montelukast (Singular), Zafirlukast (Accolate), Zileuton (Zyflo) -- Inhibit the cysteinyl leukotriene. Leukotrienes are products of arachidonic acid from mast cells and eosinophiles. They cause bronchial edema, smooth muscle contraction, and inflammation. A selective binding to the receptor occurs preventing this reaction. Zafirlukast and montelukast selectively prevent the action of leukotrienes released by mast cells and eosinophils. Zileuton inhibits leukotriene formation, which in turn decreases neutrophil and eosinophil migration, neutrophil and monocyte aggregation, leukocyte adhesion, capillary permeability, and smooth muscle contractions. Indicated for the prevention and maintenance of asthma.
Adult Dose	Montelukast: 10 mg PO hs Zafirlukast (Accolate): 20 mg PO bid Zileuton (Zyflo): 600 mg PO qid
Pediatric Dose	Montelukast: 2-5 years: 4 mg chewable PO hs 6-14 years: 5 mg chewable PO hs Zafirlukast:<12 years: Not established >12 years: Administer as in adults Zileuton:Not established
Contraindications	Documented hypersensitivity
Interactions	Montelukast: Phenobarbital and rifampin reduce effects Zafirlukast: Erythromycin and theophylline decrease serum levels of zafirlukast; aspirin increases levels of zafirlukast; zafirlukast increases toxicity of warfarin Zileuton: Increases the toxicity of propranolol, warfarin, and theophylline
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Not indicated to reverse acute asthma attacks; not for use as monotherapy in the management of exercise-induced bronchospasm; with zileuton, caution in liver disease

Drug Category: Mast cell stabilizers -- Especially effective for allergy but must be started weeks before exposure or pollen season. Minimum one wee. Inhibits sensitized mast cell degeneration when exposed to specific antigens by inhibiting the release of mediators from the mast cells. Blocks calcium ions from entering the mast cell. Inhibits immediate and nonimmediate bronchoconstriction. Has no direct action on bronchi.

Drug Name	Cromolyn sodium (Intal, Nasalcrom) -- Inhibits degranulation of sensitized mast cells following exposure to specific antigens. Recommended for prevention of cold and exercise-induced asthma. May be effective in persons exposed to fumes (eg, smog, ozone, or sulfur dioxide). Takes weeks to reach full effectiveness. Not recommended to treat an acute attack. Helps when there is unavoidable exposure to asthma triggers. Useful for pet exposure or occasional horse exposure.
Adult Dose	MDI: 2 puffs qid Nasal spray: 1 spray qid
Pediatric Dose	MDI: 1-2 puffs qid or prn
Contraindications	Documented hypersensitivity
Interactions	None reported
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	May induce bronchospasm; not for use in severe renal or hepatic impairment; symptoms may reoccur when withdrawing drug; adverse effects include throat irritation, dryness, bad taste, wheezing, and nausea

Drug Category: Antibiotics -- Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Most common organisms are S pneumoniae, H influenzae, and M catarrhalis.

Drug Name	Amoxicillin (Amoxil, Trimox) or amoxicillin with clavulanate (Augmentin) -- Interferes with synthesis of cell wall mucopeptides during active multiplication resulting in bactericidal activity against susceptible bacteria. Clavulanate increases activity of beta-lactam antibiotics in resistant bacteria.
Adult Dose	Amoxicillin: 500 mg PO tid Amoxicillin and clavulanate: 400-500 mg PO tid
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity
Interactions	Reduces efficacy of oral contraceptives; coadministration with warfarin or heparin, increases risk of bleeding
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Adjust dose in renal impairment

 

Drug Name	Trimethoprim and sulfamethoxazole (Bactrim, Septra DS) -- Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.
Adult Dose	160 mg TMP/800 mg SMZ PO q12h
Pediatric Dose	<2 months: Not recommended >2 months: Not established
Contraindications	Documented hypersensitivity; megaloblastic anemia due to folate deficiency
Interactions	May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBCs frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, give 5-15 mg/d leucovorin); caution in folate deficiency (eg, chronic alcoholics, elderly, those receiving anticonvulsant therapy, or those with malabsorption syndrome); hemolysis may occur in G-6-PD deficient individuals; AIDS patients may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation

 

Drug Name	Clarithromycin (Biaxin), azithromycin (Zithromax), Erythromycin (EES) -- Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest.
Adult Dose	Clarithromycin: 500 mg PO bid Azithromycin: Day 1: 500 mg PO Days 2-5: 250 mg PO qd Erythromycin: 250 mg erythromycin stearate/base (or 400 mg ethylsuccinate) q6h PO 1 h ac, or 500 mg q12h Alternatively, 333 mg q8h; increase to 4 g/d depending on severity of infection
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; hepatic impairment; coadministration with pimozide
Interactions	Azithromycin: May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine Clarithromycin: Toxicity increases with coadministration of fluconazole, astemizole and pimozide; clarithromycin effects decrease and GI adverse effects may increase with coadministration of rifabutin or rifampin; may increase toxicity of anticoagulants, cyclosporine, tacrolimus, digoxin, omeprazole, carbamazepine, ergot alkaloids, triazolam, HMG CoA-reductase inhibitors; cardiac arrhythmias may occur with coadministration of cisapride; plasma levels of certain benzodiazepines may increase, prolonging CNS depression; arrhythmias and increase in QTc intervals occur with disopyramide; coadministration with omeprazole may increase plasma levels of both agents Erythromycin: May increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin, increases risk of rhabdomyolysis
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	May increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients; diarrhea may be sign of pseudomembranous colitis; superinfections may occur with prolonged or repeated antibiotic therapies; coadministration of clarithromycin with ranitidine or bismuth citrate is not recommended with CrCl <25 mL/min; give half dose or increase dosing interval if CrCl <30 mL/min

 

Drug Name	Cefaclor (Ceclor), cefuroxime (Ceftin), Loracarbef (Lorabid) -- Second-generation cephalosporin maintains gram-positive activity that first-generation cephalosporins have. Adds activity against P mirabilis, H influenzae, E coli, K pneumoniae, and M catarrhalis.
Adult Dose	Cefaclor: 500 mg PO tid Cefuroxime: 250 mg PO bid Loracarbef: 400 mg PO bid
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity
Interactions	Disulfiramlike reactions may occur when alcohol is consumed within 72 h after taking cefuroxime; may increase hypoprothrombinemic effects of anticoagulants; may increase nephrotoxicity in patient receiving potent diuretics (eg, loop diuretics); coadministration with aminoglycosides increases nephrotoxic potential
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Reduce dosage by 1/2 if CrCl is 10-30 mL/min, and by 1/4 if <10 mL/min; bacterial or fungal overgrowth of non-susceptible organisms may occur with prolonged or repeated therapy

 

Drug Name	Cefixime (Suprax) -- Third-generation cephalosporin. By binding to one or more of the penicillin binding proteins it arrests bacterial cell wall synthesis and inhibits bacterial growth.
Adult Dose	400 mg/d PO qd
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity
Interactions	Coadministration of aminoglycosides increase nephrotoxicity; probenecid may increase effects of cefixime
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Adjust dose in renal impairment

 

Drug Name	Clindamycin (Cleocin) -- Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest.
Adult Dose	150-300 mg PO q6h
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; regional enteritis, ulcerative colitis, hepatic impairment, antibiotic-associated colitis
Interactions	Increases duration of neuromuscular blockade, induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis

FOLLOW-UP

Section 7 of 9   << Previous Section | Top | Next >>

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 complain of not getting enough air, burning in the nose, and dryness. These complaints 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 Empty Nose Syndrome
  The complications following mid and inferior turbinectomy include loss of airway resistance, loss of olfactory, tactile and temperature sensors.
  Dryness and crusts are prominent. CT scans shows mucosal thickening of the paranasal sinuses, loss of definition of the osteomeatal complex, enlargement of the nasal cavity with destruction of the lateral nasal wall.
  The patients may be utterly miserable and complain:
  I can’t breathe
  I can’t smell things
  I can’t get enough air
  Sleep is disturbed
  I’m plugged up
  I get frequent infections
  My ears feel plugged
  .
  This may be seen after bilateral inferior and middle turbinectomy. Symptomatic relief can be offered by Pulsatile Irrigation with a Locke-Ringer's solution such as Breathe.ease and using this as a spray TID.

• 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 patient to avoid salicylates. Begin therapy if polyps are recurring.

• Early morning sneezing: On waking up, the dust has accumulated in the nose and the body temperature is still 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 will avoid this morning cascade of sneezing and hacking.

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

• The speed of the nasal cilia often reflect the action of the chest cilia. In difficult asthma with associated coughing, see if the nasal cilia are inactive. Seek the cause: (1) Exposure to chlorine, chromium, aldehydes? If the nasal cilia are affected, so are the chest cilia.
  (2) Medication effect? Benadryl, 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 usually are tolerated well and provide relief. Continued use of a corticosteroid spray may be indicated. Nonsteroidal sprays such as Astelin may give 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 entrance channel for the common cold virus to enter the nose.

• Hypertonic solutions may benefit for short periods when the nose is boggy and edematous. Usually these solutions irritate after a while. Try 2 tsp of salt to pt 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). Boek recommends Locke Ringer solution instead of isotonic saline 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 saline 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, it is desirable to have the patient titrate the dose.

• Thick phlegm: Patients may continue to complain of thick phlegm despite good surgery, pulsatile irrigation, and nasal moisturizers. Consider inhalant usage and investigating 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.

• Vaporizers for the chest: 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.

• Patient becomes 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, like a shield against the other passengers who cough and sneeze.
  Important to avoid iced drinks and drink hot tea to improve cilia function.

• Anxiety reinforcement: 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 at the count of 4 and out at 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 saline 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 cilia. 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 normal saline solution is.

Deterrence/Prevention:

• Dust proofing is the best deterrence. Hot tea thins thick mucus. Thick mucus must be thinned by 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 http://www.ent-consult.com/) For the individual with asthma, this may constitute a disability factor. Discussion of workplace asthma by pulmonologist Larry Martin can be found at http://www.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, Naso Chrom started 6 weeks before pollen season often is effective.

• Persons who complain of 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

• 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 post sinus surgery. If there is fever 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. May arise from sphenoid sinusitis.

• Optic spread can come 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, all 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.

• Hypothyroid is associated with allergy conditions. Often, a patient may fail specific allergy desensitization and then respond 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 http://www.sinuses.com/ for details.)

• Instruct patient to keep the nose moist with moisturizer.

• Educate patient regarding importance of adequate hydration.

• Instruct patient 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.

• Educate patients regarding the availability of pollen calendars (see http://www.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 the patient 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.

MISCELLANEOUS

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Medical/Legal Pitfalls:

• Failure to diagnose pneumonia: One frequent pitfall involves the patient who is miserable with sinusitis and coughing. Whatever the medical specialty, it is essential for the physician to 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 essential thing is to 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. It is essential to have the CT scan in the operating room and to look for deep areas where the floor of the skull descends below ordinary areas. A dehiscence may already be present. The important thing is to recognize this complication. 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 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 in Chapter 7.

• 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 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, not to offer the patient the choice of allergy 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 saline solution for this patient. Drug interaction is a serious problem and one that can easily lead to litigation. Somewhere in the literature the lawyer will find a case where one drug should not be given 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 has "severe" complaints including frontal headache. When a noncomplaining patient complains of frontal pain, consider frontal sinusitis. Must obtain CT (not an MRI) to evaluate the posterior wall of the frontal sinus.

• Never refill prednisone: Good doctors do forgot to write, "do not refill" on the prescriptions and patients do keep refilling these prescriptions. Or, 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.
  Allow me to emphasize this again. Always write do not refill on a prednisone prescription. Patients often feel great on this and will think of ways to get more including altering the prescription, calling your associate or RN.

Special Concerns:

• The chart: The chart fails to adequately describe the lesion and no pictures or diagrams are in the chart. At surgery, there is a similar absence of any description of the deviated septum 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.

• Told about complications: It is fine to routinely write, "complications were discussed", 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 not necessarily long and winded but 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.

• Write the instructions: 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.

• Speak 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.

• Discuss the alternatives: The moment the doctor mentions surgery the patient's mind may close. Advise the patient of alternative care. Options include (1) continuing with medication, which, up to now, 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 already have had all options explored and tried, so surgery is the remaining option.

• Try an adequate medical course first: 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 argue that a medical expert 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, there is always an article somewhere that reports the procedure either should not be performed or should be performed differently. It is wise to be aware of the other opinions in the medical field because the opposing attorney will be aware of these options.

• Expect the worst: With diagrams, speaking clearly and using words this author thought that the mother understood, this author explained the need for adenoidectomy and myringotomy for her child and then asked if there were any questions.
  An hour later, the mother's doctor called this author to report that the patient's mother was in his office crying because this author did not tell her anything.

• A favorite legal ploy is reporting that the medical expert says never operate on 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 that he is probably misquoting. Report that important literature in the field is summarized and abstracted in the American journals and if this particular article was not, the editor did not think that it was worth printing.

BIBLIOGRAPHY

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This article is from eMedicine Journal, December 21 2001, Volume 2, Number 12, reprinted with kind permission.

Murray Grossan, MD, is a member of the following medical societies: American Headache Society, and California Medical Association

Author's Bibiliography

• Boek WM, Keles N, Graamans K: Physiologic and hypertonic saline solutions impair ciliary activity in vitro. Laryngoscope 1999 Mar; 109(3): 396-9 [Medline].
• Businco L, Fiore L, Frediani T: Clinical and therapeutic aspects of sinusitis in children with bronchial asthma. Int J Pediatr Otorhinolaryngol 1981 Dec; 3(4): 287-94 [Medline].
• Doull IJ, Lawrence S, Watson M: Allelic association of gene markers on chromosomes 5q and 11q with atopy and bronchial hyperresponsiveness. Am J Respir Crit Care Med 1996 Apr; 153(4 Pt 1): 1280-4 [Medline].
• Grossan M: Office Measurement of Nasal Mucociliary Clearance. English: Otolaryngology 1994; 2: Chapter 7.
• Hosemann W, Michelson A, Weindler J: [The effect of endonasal paranasal sinus surgery on lung function of patients with bronchial asthma]. Laryngorhinootologie 1990 Oct; 69(10): 521-6 [Medline].
• Ikeda K, Tanno N, Tamura G: Endoscopic sinus surgery improves pulmonary function in patients with asthma associated with chronic sinusitis. Ann Otol Rhinol Laryngol 1999 Apr; 108(4): 355-9 [Medline].
• Oliveria CA, Naspitz CK, Rachelefsky GS: Improvement of bronchial hyperresponsiveness in asthmatic children treated for concomitant sinusitis . Ann Allergy Asthma Immunol 1997; 79: 70-74.
• Rachelefsky GS: National guidelines needed to manage rhinitis and prevent complications. Ann Allergy Asthma Immunology March 1999; 82: 296-305.
• Rachelevsky G S, Slavin R G: Sinusitis: Acute, Chronic and Manageable. Patient Care 1998; 131.
• Slavin RG: Sinusitis and Bronchial Asthma. J Allergy and Clinical Immunol 1980; 66: 250-257.
• Spector SL: Overview of comorbid associations of allergic rhinitis. J Allergy Clin Immunology 1997; 99: S773-780.
• Subiza J: Inhibition of the Seasonal Ige Increase to Dactylis Glomerata by Daily Saline Nasal - Sinus Irrigation During the Grass Pollen Season. Journal of Allergy and Clinical ImmunologyAllergy and Clinical Immunology. 1999; 101: 387.

Edited by Lanny Garth Close, MD, Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, Columbia University College of Physicians and Surgeons; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Stephen G Batuello, MD, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado Health Sciences Center; Christopher L Slack, MD, Consulting Staff, Department of Otolaryngology-Head and Neck Surgery, David Grant Medical Center; and Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado Hospital