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

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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.