eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Allergy

Asthma and Sinusitis

Murray Grossan, MD, Consulting Staff, Department of Otolaryngology, Cedars Sinai Hospital of Los Angeles

Updated: Jun 15, 2009

Introduction

Background

In the United States, 35 million people have sinus problems, and 20 million people have asthma. Physicians know that a sinus infection can substantially contribute to the frequency and severity of asthma attacks. This article outlines  the factors common to both conditions and discusses how best to improve these conditions.

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

Septal deviation with concha bullosa. CT scan shows the bony anatomy, including the important structures of the maxillary frontal and sphenoid ostia. The cribriform plate, the anatomic position of which is a critical factor in any surgery, is depicted. The surgeon looks for depression at this area and dehiscence. On the image, the septum is deviated to the left, and the concha bullosa is right of the middle turbinate.

In the 1990s, as CT scanning enhanced the visualization of the sinus and as endoscopic surgery, especially with the computer-assisted techniques, advanced the ability to improve sinus function, physicians returned to sinus treatment as an aid to asthma management. Further aids to treatment have included newer antibiotics and an emphasis on cilia function. Newer medications, such as the corticosteroids sprays, have given new directions for treatment. Many allergists now emphasize the role of these drugs in treating sinusitis.

Asthma and sinusitis are increasing in frequency and morbidity, despite the advances made in understanding and treating these conditions. The overuse of antibiotics in childhood may alter the normal inflammatory response to change to an allergic-type response. A current theory suggests that a hypersensitivity reaction replaces the normal disease reaction when antibiotics are overused. This theory notes a high incidence of disease in families in the upper income brackets. These individuals have full access to medical care, cleanliness, and dust proofing. The body's immune system is designed to fight parasites and infections; if antibiotics are administered at the first sign of illness, the normal immunity may not develop, and alternate systems are produced (eg, asthma, poor resistance to infection). One suggestion is that the early antibiotics kill the good flora of the intestinal tract, which may lead to the aberrant/allergic reaction to inflammation.

For further reading, please see the following asthma resources from Medscape and eMedicine:

• Asthma News and Articles
• Asthma Clinical Reference
• Asthma CME

Pathophysiology

The physiology of mucus in individuals with asthma is similar to that of nasal mucus in healthy individuals. Mucociliary clearance (MCC) involves the cilia and the layers of mucus on the ciliated epithelium and refers to their ability to promote maximum health by moving particles along a desired path. In the upper respiratory tract, cilia propel mucus, bacteria, and the particles trapped in mucus to the nasopharynx, where the mucus drops to the hypopharynx and is swallowed. 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.

Rheologists investigate the makeup of this liquid and study 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 directly strike, is found over a layer of watery serous fluid. Because of the low viscosity of the layer of watery serous fluid, the cilia can beat normally and move the watery lower layer, affecting movement of the upper thick layer. Changes in 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 can multiply as the mucus thickens and stagnates.

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

MCC is 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.

Ciliary movement is remarkably 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 toward the nasopharynx. Therefore, 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 large surface area for enhanced effect.

Lysozymes, immunoglobulins, and phagocytes in the mucus solution provide protection from infection. Movement of the bacteria by mucus flow reduces the opportunity for penetration of the cell. Dilution of bacterial products decreases their toxicity. Anything that thins the nasal mucus or stimulates it (eg, proteolytic enzymes, mucolytics) helps the asthmatic chest mucus. Measuring cilia in the chest is difficult; measurement requires biopsy or use of special radioactive gasses. Measuring the nasal cilia (eg, with a saccharin test) is easy, and the findings are a useful reflection of the chest cilia.

Frequency

United States

Asthma and sinusitis are both increasing in frequency. About 20 million individuals have asthma, and 35 million have sinusitis. The conditions undoubtedly overlap. The number of children with asthma is increasing at an alarming rate and not only in developed countries.

The incidence of asthma and allergy increases with poverty. This increased incidence is partially based on poor environmental control. Cockroaches and dust are known causes of asthma. In areas with lower socioeconomic status, pets are often prevalent in close quarters, and air filtering and dust proofing are often not performed. Asthma is a disease that requires maximum cooperation of the patient and family. 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 is another major contributor to the high rate of poorly controlled asthma and sinusitis in impoverished patients. The source of primary and follow-up care for this population is often provided by the busy emergency department.

International

An increased incidence of sinus disease has been reported in all countries. The incidence of sinusitis is higher in Japan, Indonesia, and Europe than in the United States. An increasing incidence of both sinusitis and asthma that occur together has been reported internationally, as well as in the United States. Special conditions (eg, fires in Kuwait and Indonesia, chromium content of the sands of Saudi Arabia) increase the incidence of sinusitis. Asthma-free areas are present in certain sub-Saharan areas, where hookworm disease is endemic. The parasitic system (eg, eosinophiles) is fully engaged. In Somalia, which has a high incidence of hookworm disease, the reported incidence of asthma is low.

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.

• Sinusitis 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 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 account for 50% of office visits and are involved in a large percentage of medical costs.

Race

In Alaska, the incidence of sinusitis is high partly because of the decreased robustness of the ciliary system among Native Americans. This high rate is also associated with a high incidence of ear disease and the many hours that the population spends indoors with open fires, dry air, damp walls, and stale dust.

Sex

The incidence of sinusitis appears to be equal between the sexes.

Age

Asthma and sinusitis can occur in young children. Sinusitis in young children is not appreciated because the maxillary and ethmoid sinuses are not always recognized. After children start nursery school, the incidence of sinus and chest infections dramatically increases.

The asthma rate is increasing among children. In a recent survey in Massachusetts, 9.5% of pre–high school students had asthma. In 2004, the Centers for Disease Control and Prevention reported that 7.6% of children aged 14 years or younger had asthma.

Clinical

History

Individuals with asthma often have a childhood history of allergy. Patients present with wheezing and coughing, and they report sleepless nights. These patients benefit from the use of an inhaler. Associated findings are symptoms of frequent sinus infections, heavy pus, or drainage of the thick mucus into the chest. Whenever individuals with asthma have a sinus infection, the asthma worsens. When accompanied by a sinus infection, the asthma does not clear with simple treatment. If the nose is obstructed, these individuals breathe with their mouth open, a practice that precipitates an asthma attack.

Patients with asthma have a dry mouth all the time and are bothered by thick nasal phlegm dripping into their throat. The thick phlegm causes patients to cough and constantly try to clear the throat. With a sinus infection, additional time is required to clear the asthma.

• Obtain a history about the frequency of nasal obstruction, purulent discharge, localized sinus pain, drainage, and fever.
• Acute sinusitis refers to a single episode, which may be severe and even last 6 weeks despite treatment.
  • Nonchronic sinusitis is characterized by about 1-2 attacks per year that clear with treatment. One or 2 such attacks per year are not chronic sinusitis.  
  • Chronic sinusitis is defined as 4-5 episodes of sinusitis per year, in which the episodes last about 4 weeks each. Often, the episodes do not clear until antibiotics are administered.
  • A history of 4 episodes of sinusitis over the last 6 months, which each cleared with the required antibiotics, suggests a persistent single infection.
  • If an antibiotic is stopped, a still-present infection might gradually return. In this case, irrigation is needed; local treatment or a course of antibiotics longer than the previous course are also possibly needed. The usual physiologic process is that the antibiotic killed the bacteria, but the cilia did not return to function. Several of the following scenarios are possible:
    • The antibiotic did not kill the pathogen.
    • The antibiotic killed the pathogen, but the cilia did not return to function and because the mucus was not moved out, a new infection occurred. This is common in the patient whose infection responded to treatment and was clear 2 weeks ago but who now returns with yellow discharge, sneezing, blockage, and feeling sick.
    • The eosinophilic attack deposited major basic protein (MBP) in the mucus, and the MBP is inhibiting the return of cilia function.
• Obtaining a family history is important in cases of asthma and allergies. A family history of sinusitis does not generally increase the incidence of sinusitis.
• An essential aid to preventing sinus or lung infection in patients with AIDS is moisturizing the respiratory tract and encouraging cilia function. The following 2 factors cause a high incidence of sinusitis in patients with AIDS:
  • A lowered immune system that allows bacterial growth
  • Thickened mucus exudate that becomes stagnant and allows bacterial growth
• Failure of the normal mucociliary flow system accounts for an extremely high incidence of sinus disease in patients with cystic fibrosis.
  • The pathology here is that the mucus, because of high salt content, is too thick for proper mucociliary flow; therefore, bacteria can multiply and enter the body.
  • Dr Terrance Davidson of the University of California at San Diego has pioneered sinus treatment in cystic fibrosis by using pulsatile irrigation to remove and thin thick mucus.

Physical

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

• Physical examination
  • Determine whether sinus infection precedes or follows an asthma attack.
  • Determine the frequency of sinusitis and the results of antibiotic therapy.
  • Examine the patient's eyes, ears, nose, throat, and larynx. Look for lymphoid hyperplasia, hypertrophic turbinates, or both. Determine if they are inflammatory or allergic in appearance. In patients with allergy, hyperplasia of the postpharyngeal wall is pale, and the mucus is clear. In those with chronic sinusitis, the hyperplasia is red, and the mucus is colored.
  • Determine if the septum is obstructive. On laryngoscopy, look for signs of irritation of the posterior larynx that indicate gastroesophageal reflux disease (GERD).
  • Look for a history of eustachian-tube dysfunction. Are the ears affected when the patient gets a sinus infection? Heavy nose blowing often causes this effect. Do their ears become blocked when they fly?
  • Look for signs of adenoid hypertrophy or mass. Enlarged adenoids are common in children with sinusitis but uncommon in adults. A suspected adenoid mass in the adult must be examined to rule out malignancy. A unilateral mass is highly suspect. A unilateral adenoid mass with bleeding is presumptively diagnosed as a malignancy until proven otherwise. A unilateral blocked ear may be a sign of an adenoid mass.
  • Hypertrophic posterior turbinates may best be observed by means of nasopharyngeal examination with a mirror. These turbinates can impair breathing and block the eustachian tube. Although this pathology was common in the past, it is now uncommon, perhaps because of improvement in antihistamine therapy.
  • In children with unilateral purulent drainage, look for a foreign body.
  • Perform nasal endoscopy to examine for patent or closed sinus ostia (see Image 1).
  • Visualize the maxillary, frontal, and sphenoid ostia.
• Physical findings of asthma
  • Individuals with asthma wheeze and have impaired breathing.
  • The chest is sometimes retracted or sunken, indicating inhalation difficulty. (A barrel chest indicates emphysema.)
  • The nostrils flare.
  • The throat is often dry.
• Physical findings of sinusitis
  • The patient breathes through the mouth and has purulent drainage.
  • The patient may have a mild fever.
  • Local tenderness is present over the affected sinus.
  • On examination with a nasal speculum, a purulent drainage is usually observed from the middle meatus.
  • Transillumination shows decreased passage of light on the affected side.
  • Purulent material may be observed in the pharynx, nasopharynx, or both.

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
• The overuse of antibiotics in childhood may alter the normal inflammatory response to change to an allergic-type response.
• A current theory suggests that a hypersensitivity reaction replaces the normal disease reaction when antibiotics are overused.
• This theory notes a high incidence of disease in families in the upper income brackets. These individuals have full access to medical care, cleanliness, and dust proofing.
• The body's immune system is designed to fight parasites and infections; if antibiotics are administered at the first sign of illness, the normal immunity may not develop, and alternate systems are produced (eg, asthma, poor resistance to infection).
• Genetic factors
• Asthma has more of a genetic etiology than does sinusitis.
• The incidence of asthma increases when both of the patient's parents have asthma.
• More individuals with asthma are having children now than before.
• Biofilm: This occurs when bacteria develop a colony-type integration with sticky attachment to surfaces, an enveloping shield that blocks antibiotic action, and a departmentalization of certain bacteria that causes some to go dormant and others to multiply. In addition, real channels are developed. At a certain size, these break off and seed to other surfaces. This is a major problem for catheters and certain stents but is also an increasing problem for the sinus and chest. Gentle stream irrigation may not be sufficient to remove these; pulsatile irrigation tests in orthopedic research projects have been successful.³
• Major basic protein (MBP) produced by eosinophiles against fungus: In the common "Mayo-type" fungal condition, a common fungus may cause eosinophiles to overreact and overproduce a toxic product to kill the fungus. This toxic product, called MBP, irritates and inflames the respiratory system, causing nasal congestion and secondary infection.
• Environmental factors
• These factors are becoming increasingly important.
• 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.
• In addition, smog, diesel fumes, and sulfur dioxide all combine to interfere with good cilia function. Hypersensitivity reactions seem to occur when the individual has an overwhelming exposure and does not recover ciliary function. Unfortunately, manufacturers are marketing new solvents daily without disclosing their effect on ciliary function. Despite the $50 million spent on clinical studies for evaluation required by the US Food and Drug Administration (FDA), no drugs have been evaluated for their effect on MCC.
• Known industrial toxins include chlorine, sulfur dioxide, cupric compounds, and chromium dusts, all of which can be toxic to respiratory functions.
• Fires are a known risk factor. When fires occur countrywide, such as in Kuwait or Indonesia, the incidence of sinusitis and asthma increases. The 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 the Indonesian forest fires and with excessive smog in London. Some of the respiratory problems might have been prevented with simple irrigation by using Locke-Ringer–type solutions. Lung and sinus pathology affected teenagers in these regions a decade after these severe fires.
• Closed environments: An increase in the number of pets in closed quarters may be causing an increase in asthma and sinusitis. Closed environments may also have mold and no fresh air.
• Other environmental problems to be considered are pet allergens, house dust-mite allergen, cockroach allergen (most important for inner-city residents), indoor fungi and molds, and outdoor allergens (eg, trees, grass, weed pollens, seasonal mold spores).
• Impaired MCC
• Sinusitis and asthma are inflammatory diseases and, as such, are caused or aggravated when MCC is impaired.⁴
• Factors that slow cilia include the following:
• Cocaine
• Antihistamines
• Dehydration
• Inhalation of air or steam hotter than 40°C
• Frequently drinking iced drinks
• Chilling drafts
• Sulfur dioxide, ozone, smog, and diesel fumes
• 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)
• Benzalkonium (a common preservative in saline sprays)
• Infections with Pseudomonas species, Haemophilus influenzae, and many viral pathogens
• Hyperbaric oxygen
• Reduction of airway diameter
• AIDS
• Gastroesophageal reflux disease
• In addition to the above factors, recognition of GERD as an irritant that brings on asthmatic symptoms, as well as throat and laryngeal symptoms, is increasing.
• When the larynx is visualized with mirror or endoscope, the arytenoids are inflamed, especially posteriorly.
• Standard GERD measures may be beneficial. Often, keeping the head of the bed elevated, avoiding spices, and not eating after 8 pm can be highly therapeutic. Trials of acid inhibitors must be started with twice-daily dosing in order to determine effectiveness.
• Bacteria
• Dye or tracers placed in the sinus appear 16 hours later in the lower trachea. Therefore, bacteria from the sinuses find their way to the lower respiratory system.
• Bacteria then act as inflammatory agents.
• Development of drug-resistant bacteria
• Fungi
• Researcher Jens Ponikau and others have discussed fungal infection as a cause of chronic sinusitis.⁵   They have cultured fungi from the sinuses of chronically ill patients; however, other researchers have shown that the same organisms can be cultured from healthy individuals.
• In reading the literature and especially in obtaining the patient's history, consider the term "fungal sinus infection " with caution. This term is loosely defined and used to refer to 1 of 4 of the following distinct entities:
• Overwhelming total infection that fills all the sinuses, as observed in immunocompromised patients 
• Presence of fungus that is cultured in a patient with a chronic sinus condition
• Presence of fungus that is opportunistic and that results after the use of antibiotics, especially topical ones 
• Presence of fungus normally observed when sinus symptoms are of other etiologies, such as migraine head pain
• Sleep apnea is commonly found in patients with asthma, especially in patients who are obese.
• A diagnosis of sleep apnea is essential.⁶ The following factors are used in the diagnosis of sleep apnea: 
• Loud snoring that bothers the patient's partner
• Tiredness in the morning after sleeping
• Falling asleep during the day or after lunch
• Not feeling rested in the morning no matter how long one sleeps
• A reduction of forced expiratory volume in one second (FEV₁), forced vital capacity (FVC), total lung capacity, functional residual capacity, and expiratory reserve volume are associated with obesity/asthma. Obesity causes fat on the diaphragm and weakness of chest muscles and leads to obstructive sleep apnea (OSA). 
• In OSA, the fall in O₂ may lead to a reflex bronchoconstriction, an increase in GERD, or both. Treatment with continuous positive airway pressure (CPAP) can dramatically improve respiratory function.
• Children with asthma may also have OSA and obesity.
• People with asthma reproducing with other people with asthma
• An increase in stress levels: This could possibly lower natural immunity.
• Studies today show that many failures in asthma are due to the patient not being properly educated and/or simply not understanding or following instructions. Rechecking, at each visit, the proper use of medications, inhalers, adequate hydration, cleaning the environment, and breathing and relaxation exercises is important.^7,8,9

Differential Diagnoses

Foreign Bodies of the Airway

Other Problems to Be Considered

Differential diagnoses of asthma

Chronic obstructive pulmonary disease (chronic bronchitis or emphysema)
Congestive heart failure
Cough secondary to drugs (eg, angiotensin-converting enzyme inhibitors)
Laryngeal dysfunction (eg, ventricular dysphonia)
Mechanical obstruction of the airways (eg, tumors, anatomic changes)
Retrosternal thyroid
Pulmonary embolism
Pulmonary infiltration with eosinophilia
Bronchostenosis
Enlarged lymph nodes
Foreign body in trachea or bronchus
Laryngeal webs
Laryngotracheomalacia (primarily in infants)
Tracheal stenosis in infants
Tumor
Vascular rings
Vocal cord dysfunction
Bronchopulmonary dysplasia
Cystic fibrosis
Heart disease
Obliterative bronchiolitis
Viral bronchiolitis
Aspiration from swallowing mechanism dysfunction
GERD
Recurrent cough not due to asthma
Environmental irritants

Differential diagnoses of sinusitis

Cervical or temporomandibular joint (TMJ) referred pain
Allergic rhinitis
Nasal polyps
Foreign body (common in children; characterized by unilateral purulent odorous drainage)
Acute common cold
Deviated nasal septum
Rhinitis medicamentosum

Workup

Laboratory Studies

• Cultures of purulent discharge
• Samples taken directly from the nose may not yield correct information because most healthy people harbor potentially harmful bacteria.
• The best sample is taken directly from the sinus cavity by inserting a sterile needle and aspirating the material into a sterile container.
• Another method is to prepare 500 mL of isotonic saline in a pulsatile irrigation container (eg, Hydro Pulse unit). Irrigate about 150-300 mL into each side, then stop and gently clear the nose. Next, irrigate by using the remaining 200 mL but catch the returning material in a sterile urine container. This method may provide a proper sinus culture because this last 200 mL comes from the sinuses and because the nasal bacteria were removed with the first irrigation. However, the sinus from which the second irrigation drains is unknown.
• Sensitivity studies are usually needed and are of value when the specimen is obtained by means of puncture aspiration.
• In individuals with diabetes and/or individuals who are immunocompromised, cultures should include one for fungus.
• If the patient has taken many antibiotics and has chronic sinusitis, fungus culture may show fungal growth. However, this may not be the cause of the sinusitis.
• In general, bacterial exudates are in the nasal chambers. Cultures show H influenzae, Neisseria catarrhalis, and Haemophilus pneumoniae. Cultures may also show streptococcal infections. Sinus staphylococcal infections are not regularly seen.
• Regional (eg, Seattle vs Miami) and even seasonal differences can be extreme. The author recommends obtaining regular reports of bacterial prevalence and sensitivity from the local hospital to best select drugs to treat the bacteria.
• WBC count and differential count
• As in any infection, WBC and differential counts help to differentiate viral and bacterial infections.
• Test for infectious mononucleosis when adenopathy and tonsillitis accompany the sinus infection.
• Test for skin fungus
• In cases of chronic sinusitis, some physicians test the skin for fungus and then desensitize it for strong positive reactors.
• This method is currently highly debated.
• Biopsy of the nasal membrane
• Biopsy may be used to obtain tissue to measure ciliary activity.
• This is often a research procedure.
• Saccharine test of nasomucociliary flow
• The saccharine test of nasomucociliary flow is indicated if the patient has a history of toxic exposure or if cystic fibrosis is suspected. This test can be used to gauge the reduction in ciliary activity.
• In most cases of chronic sinusitis, the saccharin test shows impaired ciliary action. This finding usually reflects the cilia of the chest.
• To perform the test, place a particle of saccharin 0.25 in behind the anterior edge of the turbinate. Instruct the patient to sit quietly and not to sniff or sneeze. Ask the patient to swallow every 30 seconds and report when he or she tastes the sweet saccharin. The patient's report is used to measure 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, saccharin is tasted in 5 minutes or less.
• With normal nasal conditions, saccharin is tasted in 5-8 minutes.
• With infection and late-stage allergy, saccharin is tasted in 9-19 minutes.
• With atrophic rhinitis and chronic sinusitis, saccharin is tasted in 20-29 minutes.
• After exposure to chlorine gas or other toxins, saccharin is tasted in more than 30 minutes. In patients with this exposure, ciliary function does not recover with treatment.

Imaging Studies

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

• To obtain the Waters view, place the patient's chin on the radiographic plate, with his or her nose 1-1.5 cm above the plate. This positioning provides the best view of the maxillary sinus with the petrous ridge 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, CT scans, which often provide exquisite detail of the sinus anatomy, have replaced these views.
• The Caldwell view, on which the nose and forehead are on the radiographic plate, is designed to depict the frontal and ethmoidal sinuses.

CT scanning has replaced regular radiography as the preferred imaging test to visualize the sinuses.

• In most communities, the radiologist performs limited CT scanning for about the same price as regular sinus radiography.
• In patients with sinusitis, localizing the condition by means of CT scanning and correcting anatomic factors is important.
• Limited CT scans show the maxillary ostia. Look for pathology of the nasoantral opening of the maxillary sinus. If this opening is compromised, referral to an otolaryngologist is indicated.
• CT scans show details of the bony anatomy, including the important structures of the maxillary frontal and sphenoid ostia. The cribriform plate, whose anatomic position is a critical factor in any surgery, is visualized. The surgeon looks for depression at this area and dehiscence.
• In chronic sinusitis, a CT scan of the sinuses is often needed to pinpoint the foci of infection and to assess the patency of the ostia.
• Primarily look for conditions that may impair drainage, especially from the maxillary ostia. These conditions may be nasal polyps, thickened mucosa, enlarged turbinates, concha bullosa, or even a deviated septum (see Image 2). The diseased sinuses can be clearly identified. If the ostia are patent, the patient's condition should respond to systemic management. If the sinus openings are fully closed, systemic therapy may be insufficient, and surgical correction may be required.
• MRI is useful in diagnosing fungal infection. Usually a sinus filled with fungus has a characteristic appearance.
• MRI of the sinuses produces excessive false-positive results because the MRI is too sensitive.
• Patients who have undergone MRI for causes unrelated to asthma and sinusitis but are diagnosed with sinusitis based on the MRI results (but have a negative history of purulent drainage, nasal congestion, or fever) are referred to an otolaryngologist. This diagnosis occurs because any liquid can appear as disease on MRI. If the patient is diagnosed as having sinusitis on the basis of MRI results alone, this finding can be ignored.
• Acoustic rhinometry is useful in determining the dimension of the nasal airway and in deciding if surgical intervention is indicated (eg, to treat a deviated nasal septum or hypertrophied turbinates).
• When the nasal septum severely blocks breathing, correcting a septal deviation is valuable.
• Acoustic rhinometry helps when the deviated septum is only partially blocked and when the surgeon must decide if the patient with asthma or other nasal and/or sinus problems may benefit from surgery.

Other Tests

• Allergy tests may be indicated and can be performed in the office by means of intradermal testing, eg, prick testing or radioallergosorbent assay test (RAST).
  • RAST and other laboratory tests are performed by using blood samples.
  • The results are usually accurate, and a treatment serum can be made on the basis of the results.
  • Patients can have anaphylactic reactions to materials used in these tests, and means of treating these reactions must be immediately available.
• Testing for food allergies is difficult.
  • A careful history provides the best opportunity to identify a food allergy.
  • After the food is identified, adding the food to the test to induce a reaction is the best way to prove the allergy.
  • Prescribe an allergy-free diet without the test-identified foods.
• Lyme disease, HIV infection, infectious mononucleosis, leukemia, and other diseases can mimic sinus and chest conditions. These conditions must be investigated in patients with difficult cases of asthma and sinusitis.
• Cystic fibrosis must be considered in the patient with recurrent sinus and chest infection. The sweat test (and the saccharin test of ciliary function) helps in this diagnosis.
• Pulmonary function studies indicate respiratory function.
• Daily expiratory-flow measurements are necessary in patients with asthma.
  • Take the time to ensure that the patient and his or her parents fully understand how these measurements are performed and how to record the maximum expiratory flow rates on a daily basis.
  • Ask the patient or his or her parents to periodically bring the meter to the office to check their technique.
  • A more expensive flow-rate meter is not necessarily the best model. However, some physicians recommend the new computerized models that store rate values and therefore do not depend on the patient's or family's record-keeping skills.
• A sleep apnea test is indicated if the patient has a history of morning sleepiness, excess fatigue, or periods of apnea during sleep. A history of automobile accidents may indicate the need for sleep apnea studies.

GERD may be diagnosed by laryngoscopy evaluation of the posterior interarytenoid fold or by 24-hour pH studies.

Procedures

• Laryngoscopy: Look for signs of irritation of the posterior larynx that indicate GERD.
• Nasopharyngeal mirror examination: Hypertrophic posterior turbinates may be observed. In children with unilateral purulent drainage, look for a foreign body.
• Nasal endoscopy: Patent or closed sinus ostia may be revealed. The maxillary, frontal, and sphenoid ostia are visualized. Purulent discharge is noted (see Image 3).
• For asthma, a full range of pulmonary function tests should be done at the onset.
• Of note, asthma is not always the correct diagnosis for a patient with wheezing.
• Careful history taking and pulmonary testing are essential.

 

Histologic Findings

Biopsy may show squamous changes of the nasal cilia or an absence of cilia. The best diagnosis of ciliary dysfunction is achieved when the biopsy tissue is placed in solution and the ciliary frequency is measured by using a strobe or similar means. The strobe frequency is adjusted to match the ciliary frequency.

Treatment

Medical Care

Whether inflammation or allergies cause sinusitis and asthma has been questioned. Today, sinusitis and asthma are attributed to an inflammatory effect. An excellent example of this is the existence of nasal polyps. These polyps may not shrink with the administration of both oral and topical corticosteroids; however, in the author's experience, when an antibiotic is added to the corticosteroids, the polyps and blockage are cleared from the nasal cavity in more than 90% of  patients. Patients prefer this treatment to surgery.

If asthma and sinusitis are considered to be inflammatory diseases, treatment is clearly similar for both with regard to the specific infection, inflammation, drainage, thinning mucus, and restoring cilia and comfort to the patient.

Treatment consists of using measures to increase MCC. To help ciliary movement in the chest and nose, a deep-throated "ooommm" vibration is useful to help break up thick mucus. Patients should drink enough fluids (eg, hot tea, hot chicken soup) to lighten the urine. The bacterial load should also be reduced by means of terbutaline, inhaled corticosteroids, various enzymes (eg, Bromelin or Papain taken buccally), pseudoephedrine, breathing and coughing exercises, flutter inhalation devices, 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) the duration of the antibiotic is too short (treatment may require 6 wk); (3) drainage, rest, and anti-inflammatories are not combined with treatment; (4) a fungus is present; and (5) the mucociliary system fails. If infection does not clear in 6 weeks, referral to an otolaryngologist is recommended.

Irrigation and aspiration

Clearing the sinus infection is indicated in individuals with asthma. Irrigation and/or aspiration on the first office visit are useful steps to reduce the bacterial load. When the sinus infection does not clear with antibiotics, prescribe daily irrigation, mucolytics, and anti-inflammatory medications. Follow with CT scanning of the sinuses.

Because bacteria and thick phlegm play an important role, if pus is present in the nose or sinuses, the physician can reduce the asthmatic symptoms from sinusitis by performing in-office suctioning or irrigation. One technique is to use a vasoconstrictor in the nose, wait 2 minutes, and then irrigate with a modified Locke-Ringer or sodium chloride solution with pulsatile nasal or sinus irrigator (eg, Hydro Pulse). This method can remove a considerable amount of surface and sinus pus, and the pulsation at 20 pulses per second stimulates the nasal cilia and sinuses to restore normal ciliary action (see Image 4). This same procedure can be used daily at home to treat chronic sinusitis in adults and in children aged 5 years or older.¹

Pulsatile irrigation may also be beneficial to the patient with allergies during pollen season. Daily irrigation reduces the pollen load in the nose and the levels of immunoglobulin E (IgE) in the nose circulation.¹⁰

Pediatric treatment

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

Nasal moisturizer spray is also of benefit to young children. Breathe Ease is specially designed for children's small hands and contains a modified Locke-Ringer solution without benzalkonium. This solution does not sting or burn, and most children use it as a nasal spray. The spray can be made more attractive to children by placing a sticker of the child's hero on the spray bottle, for example. As an alternative, an isotonic sodium chloride solution can be prepared without preservatives by adding 0.5 tsp of salt to 8 oz. of water. Because no preservatives are added, the solution should be changed weekly.

Caution: When children are using a nasal spray on a daily basis, pay particular attention to preservatives such as thimerosal. The Academy of Pediatrics has recommended against its use, but some nose drops still contain this preservative. If the product is used long term, consider checking the patient's mercury levels. Benzalkonium, another preservative, burns and stings and discourages the child from using the spray containing it.

Medications used to treat sinusitis and asthma

• Antibiotics: The most common organisms are Streptococcus pneumoniae, H influenzae, and Moraxella catarrhalis. Therefore, standard treatment for acute sinusitis must include antibiotics for H influenzae and S pneumoniae. However, increasingly resistant strains of bacteria are developing. 
• Treatment is usually 1 of the following regimens:
• Amoxicillin 500 mg 3 times a day
• Trimethoprim-sulfamethoxazole (Septra DS) twice a day
• Cefuroxime (Ceftin) 250 mg twice a day
• Cefaclor (Ceclor) 500 mg 3 times a day
• Other medications include the following:
• Trimethoprim-sulfamethoxazole double strength (Bactrim DS) twice a day
• Cefixime (Suprax) 400 mg once a day
• Loracarbef 400 mg twice a day
• Augmentin 400 mg 3 times a day
• Clarithromycin (Biaxin) 500 mg 2 times a day
• Azithromycin (Z-Pak) 250-mg tablets, 2 on the first day followed by 1 every day for 4 days
• Erythromycin adult dose for chronic sinusitis
• For chronic sinusitis, the 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 drink a full glass of water before and after each dose. Antibiotic sensitivities change almost daily and from region to region. Physicians must obtain and use the drug resistance and sensitivity data available from hospitals.
• For the treatment of Pseudomonas infections, use piperacillin, ticarcillin, and carbenicillin, depending on the secondary organisms.
• Anti-inflammatory agents: Sinus pain is present when membranes are inflamed or swollen. Anti-inflammatory agents (eg, Naproxen) are useful.
• Steroids: One of the major advances in sinus and asthma treatment has been in the use of steroids. These are anti-inflammatory and serve well to reduce these factors.
• Oral steroids: Prednisone is useful for allergic rhinosinusitis and may be administered at a dose of 5 mg (21 tablets). It is prescribed in diminishing doses, as follows: 6 tablets the first day, 5 tablets the next day, and so on, to 1 tablet on the sixth day. The tablets should be taken together and not spaced out. The Medrol Dosepak is used similarly. Systemic corticosteroids include Decadron for quick action and Celestone for delayed action. These are excellent for anti-inflammatory purposes.
• Steroid sprays: These are commonly used today and include beclomethasone dipropionate (Beconase AQ), triamcinolone acetonide (Nasacort AQ), and fluticasone propionate (Flonase). Budesonide (Rhinocort Aqua) has the advantage of not containing 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 so, stop use of the steroid spray. A course of saline spray without benzalkonium and/or a moisturizer ointment can reverse this adverse effect. Rhinocort Aqua does not contain benzalkonium and may have fewer adverse effects than other sprays.
• Mucolytic medications: Whenever stasis occurs, mucus thickens and bacteria multiply. Thinning the mucus is important to restore MCC. Drinking hot tea with lemon and honey is one of the best treatments, as is eating 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 appear to be clinically 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 they are taken buccally. The buccal route is preferred because stomach acid inactivates the enzymes. Even when they are taken on an empty stomach, maximum absorption is less than 40%. One buccal tablet is Clear Ease, which contains 1 million enzyme units of bromelain (from pineapple) and 0.5 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. Use of preparations without benzalkonium or thimerosal is important. Some spray bottles can be used to provide mist or stream, which is useful when removal of heavy dust or perfume from the nose is necessary. In 1999, Boek described the Locke-Ringer solution as being superior to regular isotonic sodium chloride solution. Hypertonic sodium chloride solution may be of advantage in swollen turbinates, but patients have difficulty using it.
• Decongestants: Pseudoephedrine (Sudafed) has long been a favorite for opening a stuffy nose. It is contraindicated in patients with hypertension and in those kept awake by the drug. A strange effect is that this drug may cause drowsiness in children younger than 12 years.
• 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 causing rebound swelling. Today, benzalkonium is thought to cause rebound addiction; oxymetazoline is available without benzalkonium. Another product is Natru-Vent nasal decongestant.
• Ipratropium bromide (Atrovent) is an acetylcholine blocker generally used as a bronchial dilator in the lungs, but now it is also used as a nasal spray.
• Azelastine HCl (Astelin) is an antihistamine in spray form. This drug is excellent when steroid sprays are contraindicated. Many patients dislike the taste. A solution of Benadryl 25 mg added to 1 oz. of Locke-Ringer or sodium chloride solution yields results similar to those of azelastine. The dose of the Benadryl must be titrated to the individual patient.
• Cromolyn (NasalCrom) nasal spray is highly effective for allergies if it is started 6 weeks before the pollen count becomes high. Pollen calendars are available on the Internet (eg, from AllergyBuyersClub.com) to assist with the timing of therapy.
• Topical medications
• Various moisturizing ointments are available for the nose, including AYR gel.
• Topical antibiotics are useful in the nose and sinus. Neosporin ointment may be used for mild local infection. Bactroban ointment has been used extensively as a topical antibiotic with no reported adverse effects. This ointment can be added to Locke-Ringer or sodium chloride solution as a spray.
• Gentamicin and tobramycin are used for irrigation (Davidson, 1995). Gentamicin has the advantage of being inexpensive; 40 mg can be added to 200 mL of Locke-Ringer or sodium chloride solution for irrigation with a pulsatile irrigation device. This treatment can be used twice daily for advanced infection or once daily for milder chronic cases. Singulair taken orally or dissolved in Locke-Ringer or sodium chloride solution has been reported to be of particular value in vasomotor rhinitis.
• An example of local irrigation is as follows: For topical irrigation with gentamicin or tobramycin, add 1 tsp of Breathe Ease or salt to 1 pint of water in irrigator basin. Irrigate until clear. Gently blow the nose until it is clear. Adjust the solution to make 200 mL of solution and add 40 mg of gentamicin or tobramycin. Irrigate by using full amount. Do not blow the nose. Use these treatments 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 infections: Use amoxicillin or amoxicillin with potassium clavulanate (Augmentin), macrolides such as erythromycin plus sulfasoxazole (Pediazole), cefuroxime (Ceftin), and trimethoprim and sulfamethoxazole (Septra, Bactrim).
• Staphylococcal infections: Use amoxicillin plus potassium clavulanate (Augmentin), erythromycin, and dicloxacillin.
• Pseudomonas infections: Use aminoglycosides, ciprofloxacin, and ofloxacin.
• General classification of antibiotics
• Antimicrobials, such as penicillin G and V, are bacteriocidal because they inhibit cell-wall synthesis.
• Antistaphylococcal penicillins include dicloxacillin (Dynapen).
• Amino-penicillins include ampicillin and amoxicillin.
• Augmented penicillins include amoxicillin plus potassium clavulanate (Augmentin).
• Antipseudomonal penicillins include ticarcillin and carbenicillin, which are for IV use.
• Cephalosporins are bacteriocidal (they inhibit cell wall synthesis). First-generation cephalosporins include cefazolin and Ancef for IV administration and cephalexin, cefadroxil, Duricef, and Keflex. Second-generation cephalosporins include cefuroxime (Ceftin) and cefaclor (Ceclor). Second-generation equivalents include loracarbef (Lorabid). Third-generation cephalosporins include cefixime (Suprax).
• Macrolides include erythromycins, clarithromycin, and azithromycin.
• Clindamycins include Cleocin and Lincocin.
• Tetracyclines inhibit protein synthesis. Bacteriostatic tetracyclines include minocycline and Vibramycin.
• Aminoglycosides can be ototoxic, are bacteriostatic, and inhibit synthesis. They include streptomycin, neomycin, gentamicin, tobramycin, and amikacin.
• Quinolones include ciprofloxacin (Cipro) and ofloxacin (Floxin).
• Sulfonamides are bacteriostatic but, when used with other antibiotics, are synergistic.
• Trimethoprim and sulfamethoxazole include Septra and Bactrim.
• Antifungal medications include amphotericin B, ketoconazole, and fluconazole (Diflucan).
• Antiviral medications include acyclovir (Zovirax) and amantadine (Symmetrel).

Surgical Care

Sinusitis may require surgical care. The disease is primarily a matter of obstructed sinus drainage. If sterile cotton is placed in the healthy nose, whichever sinus is blocked becomes purulent 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.

Advances in functional endoscopic sinus surgery (FESS) have made clearing the source of sinus disease easier and safer than before. The Insta-Trak unit delivers a 3-dimensional picture of the position of the instrument while the operator is performing surgery. This imaging increases surgical success and reduces the risk. Full CT scanning of the sinuses is preoperatively performed. Metal markers are fixed on the patient and kept in place for surgery. At surgery, the same markers are placed in the designated areas. A magnet is placed on the suction device. A screen shows the sinuses in 3 views. The device is used to visualize the position of the magnet in the 3 views at all times, thereby reducing the complication rate (see InstaTrak Image-Guided Surgery).


• Maxillary sinus
  • A foreign body can clock the natural ostia. A deviated septum may compress this area. Hypertrophy of the turbinates may be sufficient to block the opening. Concha bullosa refers to a hollow enlargement of the middle turbinate so that it blocks drainage of the maxillary ostia (see Image 6). Mucosal hypertrophy commonly blocks the ostia. Over time, the maxillary sinus shows worsening of the disease process. An aberrant air cell of the ethmoid may obstruct the opening of the maxillary sinus. Nasal polyps may develop in the opening itself or grow from a distal origin and be positioned to obstruct the ostia (see Image 7).
  • Treatment is directed at ensuring sinus patency and removing obstructive septum, polyps, and tissue. At surgery, the obstruction to drainage is removed, and instruments are used to enter the sinus cavity to remove diseased tissue. When patients report pain in the cheek and upper teeth, remember that the same nerve innervates the maxillary antrum and the upper teeth and that differentiation of the source of the pain is between dental and sinus origin.
• Ethmoid sinuses
  • Ethmoid sinuses open into the middle meatus and the superior meatus. The same factors as above are involved (ie, polyps, turbinate hypertrophy, mucosal hypertrophy, septal deviation).
  • With the ethmoid sinuses, removing all diseased tissue, as well as obstructive conditions, is important. The ethmoid sinuses may cause infection into the globe of the eye. If the eye is swollen, consider obstruction of the ethmoid sinuses. Patients show puffy eyes, black eyes, and obstruction to breathing.
• Sphenoid sinuses
  • Symptoms with the sphenoid sinuses are diffuse and may manifest only as a headache and continued fever.
  • Endoscopic examination shows obstruction to the opening of the sphenoid sinus, which must be cleared.
  • CT scans are vital to evaluate the mucosa and the position of the sinus itself in relation to the brain and optic system. The right and left sphenoids are normally 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, an elevated WBC count, and no signs of sinusitis on examination, endoscopic evaluation and CT scanning may be the only means of diagnosing sphenoid sinusitis.
• Frontal sinus
  • In addition to the usual causes of sinus obstruction, another factor adds to mucosal thickening, polyps, and anatomic obstruction. After FESS surgery, during which the attachment to the lateral nasal wall may be compromised by removal of turbinate attachment at the sinus ostia, the middle turbinate may dislodge, swing forward, and obstruct frontal drainage.
  • Surgery consists of opening drainage channels. The frontal sinus drainage channel is somewhat long and obstruction can easily occur. Importantly, watch for severe pain or change in pain in the frontal area. An abscess may weaken or open the posterior wall into the skull cavity with serious effect. In such cases, immediate surgical correction is needed. Palpation of the floor of the frontal sinus may be diagnostic.
• Frontal area
  • Patients often report chronic pain in the frontal sinus area without fever or purulent nasal discharge for weeks or months. This pain is usually of cervical origin and characterized by painful areas in the posterior aspects of the cervical muscle that refer pain to the frontal area (course of V1).
  • Palpating the cervical area is helpful; look for trigger points and areas of referral to the frontal area. The pain can also be referred to the maxillary area (V2).
• Mucosa
  • A serious complication occurs after nasal surgery, sinus surgery, or both when excess mucosa is removed, as in a complete turbinectomy. The nose may appear to be wide open, yet the patient reports pain on breathing, burning, and not getting enough air.
  • After large amounts of turbinate tissue are removed, atrophic rhinitis with crusting takes place, and frequent moisturizing is required. These patients are highly symptomatic because of the absence of normal nasal tissue that moisturizes and filters. Some 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 receiving dry, unfiltered air.
  • Dr Eugene Kern of the Mayo Clinic coined the term “empty-nose syndrome .” He noticed that sinus radiographs revealed an empty nose in patients with crusting and nasal pain who reported difficulty breathing, anxiety, and depression.
  • The concept “make more room to breathe,” which some doctors are taught, is incorrect. Save the nasal mucosa first.
• Turbinates
  • Hypertrophied turbinates may be the sole cause of nasal obstruction and frequent infections (see Image 9). These can be safely reduced by means of submucous resection of the turbinates. Make an incision inferiorly that is three fourths of the length of the turbinate. Elevate the mucosa from the bone medially and laterally. Remove the bone, allowing the turbinate to move medially. Sutures are not usually placed. In healing, much of the submucosal blood vessels are reduced. Here, the mucosa is spared.
  • Another technique is radiofrequency therapy. One such device is the somnoplasty turbinate instrument. The instrument is inserted submucosally, and the radiofrequency spares the mucosa. This is an office procedure but may require more than one sitting.
  • Regarding the removal of turbinates, whichever technique is used in sinus and turbinate surgery, emphasize preservation of the nasal mucosa. After the inferior and middle turbinates are removed, the patient has little defense to prevent chronic sinusitis. These patients have severe symptoms, and the lower respiratory system may be adversely affected as well.

The introduction of balloon sinuplasty has been a significant advancement in surgical care. The principle is similar to angioplasty: once a balloon is dilated and the sinus opening expanded, healing takes place. First, a guide is introduced under fluoroscopic vision, and then the balloon is passed over the guide. After the balloon is properly positioned, it is expanded. This permits blocked purulent materials to exit, and the formerly blocked sinus, now open, can heal. The chief advantage is that it is the least traumatic procedure. This procedure is particularly advantageous when used in frontal and sphenoid blockages.

Consultations

When the patient's condition infrequently responds to antibiotic treatment and other measures, consultation with an otolaryngologist is indicated. When good treatment is unsuccessful, an anatomic defect with obstruction of drainage is often found. A patient with a limited CT scan that shows blockage of the maxillary sinus requires consultation with an otolaryngologist.

• If allergy management does not improve nasal or chest breathing, consult an otolaryngologist. The findings usually include a severely hypertrophied turbinate that requires surgical attention, GERD, or a sinus blockage, which may be the cause of treatment failure. Another common cause of a failure of allergy desensitization is hypothyroid levels and Lyme disease.
• When treatment is consistently unsuccessful, consult a hematologist or immunologist to rule out hematologic diseases and AIDS. Disorder of the globulin factors may be the cause.
• When no obvious anatomic defect is present yet infection defies treatment, check the hospital culture resistance and sensitivity report. Local bacteria may be highly resistant to the antibiotic presently administered, and a review of common hospital growths and resistance can guide a change in treatment. Sometimes, referral to an infectious disease specialist is needed. Irrigation to restore cilia action and remove major basic protein (MBP) in the mucus is important regardless of what antibiotic is used.
• Recurrent sinus infection (eg, 4 infections in 5 mo) is most likely the same infection that never cleared. When the sinus infection involves bone, consider intravenous (IV) treatment with appropriate medications. Some stubborn bacterial infections respond to hyperbaric treatments. Expect serous otitis when sinusitis is treated with hyperbaric oxygen. Remember, this hyperbaric oxygenation worsens a viral infection.
• Candidiasis and mold infection, which may occur in individuals with immune suppression, can be observed with the naked eye and as a characteristically snowy white presence on MRI. Often associated with polyps, candidiasis and mold infection respond poorly to antifungal medications. Surgery and medications are needed. Another form of candidiasis is observed in cases of chronic sinusitis. 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. Another treatment being tried is fungal desensitization.

Diet

One of the common urban myths is that milk makes mucus. Of course, certain people may be allergic to milk, but the popular belief that avoiding milk prevents sinusitis is a myth.

• Hot tea
• For singers, actors, and speakers, emphasize that drinking hot tea with lemon and honey helps to thin the mucus and move the cilia.
• This treatment is especially recommended before a performance.
• Adequate hydration not only helps the sinus and chest but also reduces nosebleeds that many performers get when traveling or when in desert climates.
• Iced drinks
• Iced drinks make the allergy worse and slow the cilia.
• Many allergy symptoms can be reduced by avoiding iced drinks and avoiding getting chilled.
• Breakfast in bed
• The individual with allergies warms the body by the actions of sneezing, hacking, and coughing. These actions do work to warm the body, but they also start the cascade of symptoms of allergy.
• In many cases, 50% of these symptoms can be avoided by drinking a hot drink (eg, tea) before getting out of bed.
• The patient can use a bedside thermos or automatic percolator to make the hot drink and eat a cookie or whatever else is desired. Later, when the blankets are removed and the individual's feet touch the cold floor, his or her body is already warmed, and coughing and sneezing are not necessary to warm the body.
• In addition, because the tea stimulates the cilia, the dust that had accumulated in the nose is removed, and sneezing for dust removal is unnecessary.
• An incidental note: Each night, the hotels in China provide their guests with hot tea in a thermos.

Activity

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

• For the exhaustion stage of allergy, that is, when all treatments seem to have failed, simple 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 therapy.

Medication

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

Short-acting beta2-adrenergic agonists

These drugs are often prescribed for daily and acute use. They rapidly act on smooth muscles in the bronchi. These drugs are used to treat an onset of asthma and exercise-induced asthma (EIA). Note: the terms “holding chambers” and “spacers” are used interchangeably. Hydrofluoroalkane (HFA) preparations contain an ozone-friendly propellent.




Albuterol (Proventil, Ventolin)

Beta-agonist for bronchospasm. Relaxes bronchial smooth muscle by action on beta2-receptors with little effect on cardiac muscle contractility.
Available as inhaler or tab. Inhaler used for acute episodes of bronchospasm or to prevent bronchospasm. For EIA. Other drugs in class are bitolterol (Tornalate), levalbuterol (Xopenex), metaproterenol (Alupent), pirbuterol (Maxair), and terbutaline (Brethaire, Brethine, Bricanyl).

Dosing

Adult

Metered-dose inhaler (MDI): 2 puffs q4-6h; not to exceed 12 inhalations/d
Dry-powered inhaler (DPI): 1 cap q4-6h
Compressor-type nebulizer (CDN): 2.5 mg tid/qid
Syrup (Syr): 5-10 mL PO q6h

Pediatric

<4 years: Not established
>4 years:
MDI: 2 puffs qid
DPI: 1 cap q4-6h
Syr: 5 mL PO q6h

Interactions

Beta-adrenergic blockers antagonize effects; inhaled ipratropium may increase duration of bronchodilatation by albuterol; MAOIs, inhaled anesthetics, TCAs, and sympathomimetic agents may increase cardiovascular effects

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hyperthyroidism, diabetes mellitus, convulsive disorders, and cardiovascular disorders; tachycardia, smooth muscle tremor, hypokalemia, and increased lactic acid may occur; beta-receptor blockers inhibit albuterol action; large IV albuterol doses may aggravate preexisting diabetes mellitus




Metaproterenol (Alupent)

Inhaled bronchodilator. Rapid onset of action. Activates adenyl cyclase. Potent beta-adrenergic stimulator. Preferential effect on beta2-adrenergic receptors compared with isoproterenol. For asthma and bronchial spasm of bronchitis and emphysema. Aerosol contains 150 mg of metaproterenol for inhalation. Available as inhaler, solution for inhalation, syr, and 10- or 20-mg tab.

Dosing

Adult

MDI: 1-3 puffs initially; repeat in 3 h; total dose is 12 times q24h; delivers 0.65 mg of metaproterenol sulphate; can be used with positive-pressure device
Tab: 20 mg PO tid

Pediatric

<6 years: Not established
6-9 years: 5 mL syr PO tid/qid
>9 years: 10 mL syr PO tid/qid
Tab: 10 mg PO tid
Nebulizer (6-12 y): 0.1 mL single dose of 5% sol

Interactions

Beta-adrenergic blockers antagonize effects; cardiovascular effects may increase with MAOIs, inhaled anesthetics, tricyclic antidepressants, and sympathomimetic agents

Contraindications

Documented hypersensitivity; cardiac arrhythmias or tachycardias

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Titrate dose; caution in hyperthyroidism, diabetes mellitus, and cardiovascular disorders; decreased serum potassium may occur

Anticholinergic agents

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. Anticholinergics also help reduce mucus in the lungs and relax the smooth muscles of the large and medium bronchi. They may be used with short-acting beta2-adrenergic bronchodilators (eg, albuterol).




Ipratropium (Atrovent)

Chemically related to atropine. Has antisecretory properties, and when applied locally, inhibits secretions from serous and seromucous glands lining the nasal mucosa. Site-specific effect, not systemic. Not used PO. Also available as combination product with albuterol (Combivent).

Dosing

Adult

MDI: 18 mcg/puff; 2-3 puffs q6h; not to exceed 12 inhalations/d
CDN: 1 vial q6-8h

Pediatric

Not established

Interactions

Drugs with anticholinergic properties (eg, dronabinol) may increase toxicity; albuterol may increase effects

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

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 because of anticholinergic effects

Corticosteroids, inhaled

One of the most common classes of drugs used in sinusitis and asthma comes from the cortex of the adrenal glands. Hans Selye discovered and named this class of drugs while working with stressed rats. Selye described the action and named the chemical before the drug was actually identified. His work stimulated the search for 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.




Beclomethasone (Beclovent, Vanceril, QVAR-HFA)

Inhibits bronchoconstriction mechanisms and directly relaxes smooth muscle. May decrease number and activity of inflammatory cells, decreasing airway hyperresponsiveness. Various preparations available and must be titrated with patient's other medications. Most inhaled PO medications have effect in 24 h. Other drugs in this class are beclomethasone (Beclovent), budesonide (Pulmicort, Turbuhaler), flunisolide (AeroBid, AeroBid M), fluticasone (Flovent), and triamcinolone (Azmacort).

Dosing

Adult

42 mcg: 4-12 puffs/d up to 20 puffs/d

Pediatric

42 mcg: 2-8 puffs/d up to 16 puffs/d

Interactions

Coadministration with ketoconazole may increase plasma levels but does not appear to be clinically significant

Contraindications

Documented hypersensitivity; bronchospasm; status asthmaticus; other types of acute episodes of asthma

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in diabetes mellitus, glaucoma, ulcerative intestinal conditions, and pregnancy; weight gain, increased bruising, cushingoid features, acneiform lesions, mental disturbances, and cataracts may occur (taper slowly if these changes occur)

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.




Prednisone (Deltasone, Sterapred, Orasone)

Glucosteroid that occurs naturally and synthetically. Used for acute and chronic asthma. May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. Other drugs in class are methylprednisolone (Medrol) and prednisolone (Delta-Cortef, Pediapred, Prelone).
Loading or initial dose should be taken all at once in am; may suppress natural cortisone production; hence, requires tapering on discontinuation. As soon as dose for relief found, maintenance dose may be established until nonsteroidal drugs effective; must always use decreasing dose to avoid serious renal suppression.
For nasal polyps, should be combined with an antibiotic because stasis of polyp generally produces localized bacterial infection. In seasonal allergy, booster of prednisone may speed resolution of symptoms. Effective in exhaustion stage of seasonal allergy.

Dosing

Adult

Allergic rhinitis: 5 mg 21 tabs PO; prescribed in diminishing doses, as follows: 6 tab on day 1, 5 tab on day 2, and so on, to 1 tab on day 6; all tabs 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

0.25-2 mg/kg PO qd or q2d

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

Contraindications

Documented hypersensitivity; viral infection; peptic ulcer disease; hepatic dysfunction; connective tissue infections; fungal or tubercular skin infections; GI disease

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Abrupt discontinuation of glucocorticoids may cause adrenal crisis; thinning of bones (ie, osteoporosis, which may lead to fractures or compressions, especially of vertebrae), loss of blood supply to bones (ie, 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 mellitus, suppression of the body's adrenal gland (which makes necessary the amount of cortisol at times of stress, ie, 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

Methylxanthines

Oral theophylline is an old standby drug related to caffeine. It is not as popular now as before because of the availability of more specific medications with fewer adverse effects. These drugs can be used in combination with inhaled corticosteroids. Their long duration of action makes them useful for nighttime asthma. They are not recommended as rescue medications.




Theophylline (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 to reduce corticosteroid dosage. For bronchodilation, near-toxic (>20-mg/dL) levels usually required.

Dosing

Adult

10 mg/kg PO initially; titrate up to 800 mg/d

Pediatric

10 mg/kg/d PO initially; titrate
<1 year: Not to exceed 5 mg/kg/d
>1 year: Not to exceed 16 mg/kg/d

Interactions

Aminoglutethimide, barbiturates, carbamazepine, ketoconazole, loop diuretics, charcoal, hydantoins, phenobarbital, phenytoin, rifampin, isoniazid, and sympathomimetics may decrease; allopurinol, beta-blockers, ciprofloxacin, corticosteroids, disulfiram, quinolones, thyroid hormones, ephedrine, carbamazepine, cimetidine, erythromycin, macrolides, propranolol, and interferon may increase effects

Contraindications

Documented hypersensitivity; uncontrolled arrhythmias; peptic ulcers; hyperthyroidism; uncontrolled seizure disorders

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in peptic ulcer, hypertension, tachyarrhythmias, hyperthyroidism, and compromised cardiac function; do not inject IV solution >25 mg/min; patients with pulmonary edema or liver dysfunction at increased risk of toxicity because of reduced drug clearance; may cause nausea, vomiting, cramps, diarrhea, and tremors; may affect school performance

Leukotriene modifiers

These agents can reduce the intake of inhaled corticosteroids and may be beneficial in difficult cases of asthma. These drugs 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 cause bronchoconstriction and an inflammatory response, as well as increased mucus production. Leukotriene modifiers are currently available in tablet form, but a topical nasal spray is being researched.




Montelukast (Singular)

Inhibits cysteinyl leukotriene. Leukotrienes are products of arachidonic acid from mast cells and eosinophils and cause bronchial edema, smooth muscle contraction, and inflammation. Selective receptor binding prevents reaction.

Dosing

Adult

Montelukast: 10 mg PO hs


Pediatric

<2 years: Not established
2-5 years: 4 mg chewable PO hs
6-14 years: 5 mg chewable PO hs
>14 years: Administer as in adults

Interactions

Phenobarbital and rifampin reduce effects


Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Not indicated to reverse acute asthma attacks; not for monotherapy of exercise-induced bronchospasm

Neuropsychiatric events have been reported; following further FDA evaluation, the prescribing information has been updated to include case reports during postmarketing surveillance that include agitation, aggression, anxiousness, dream abnormalities, hallucinations, depression, insomnia, irritability, restlessness, suicidal thinking and behavior (including suicide), and tremor




Zafirlukast (Accolate)

Inhibits cysteinyl leukotriene. Leukotrienes are products of arachidonic acid from mast cells and eosinophils and cause bronchial edema, smooth muscle contraction, and inflammation. Selectively prevents action of leukotrienes.

Dosing

Adult

20 mg PO bid

Pediatric

<12 years: Not established
>12 years: Administer as in adults

Interactions

Erythromycin and theophylline decrease serum levels; aspirin increases levels of zafirlukast; zafirlukast increases toxicity of warfarin



Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Not indicated to reverse acute asthma attacks; not for use as monotherapy in the management of exercise-induced bronchospasm

Neuropsychiatric events have been reported; following further FDA evaluation, the prescribing information has been updated to include case reports during postmarketing surveillance that include agitation, aggression, anxiousness, dream abnormalities, hallucinations, depression, insomnia, irritability, restlessness, suicidal thinking and behavior (including suicide), and tremor




Zileuton (Zyflo)

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.


Dosing

Adult

600 mg PO qid


Pediatric

Not established

Interactions

Increases the toxicity of propranolol, warfarin, and theophylline

Contraindications

Documented hypersensitivity; active liver disease or transaminase elevation greater than or equal to three times the upper limit the normal value

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in liver disease; elevation of liver function tests may occur; not indicated in the reversal of acute asthma attacks

Neuropsychiatric events have been reported; following further FDA evaluation, the prescribing information has been updated to include case reports during postmarketing surveillance that include agitation, aggression, anxiousness, dream abnormalities, hallucinations, depression, insomnia, irritability, restlessness, suicidal thinking and behavior (including suicide), and tremor

Mast-cell stabilizers

These agents are especially effective for allergy but must be started weeks (a minimum of 1 week) before exposure or pollen season. They inhibit sensitized mast-cell degeneration when the patient is exposed to specific antigens by inhibiting the release of mediators from the mast cells. These drugs block calcium ions from entering the mast cell and inhibit immediate and nonimmediate bronchoconstriction. They have no direct action on the bronchi.




Cromolyn sodium (Intal, NasalCrom)

Inhibits degranulation of sensitized mast cells after exposure to specific antigens. Recommended for prevention of cold- and exercise-induced asthma. May be effective in persons exposed to fumes (eg, smog, ozone, sulfur dioxide). Takes weeks to reach full effectiveness. Not recommended to treat acute attack. Helps when exposure to asthma triggers unavoidable. Useful for pet or occasional horse exposure.

Dosing

Adult

MDI: 2 puffs qid
Nasal spray: 1 spray qid

Pediatric

MDI: 1-2 puffs qid or prn

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May induce bronchospasm; not for use in severe renal or hepatic impairment; symptoms may reoccur during withdrawal; adverse effects include throat irritation, dryness, bad taste, wheezing, and nausea

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.






Amoxicillin (Amoxil, Trimox)

Interferes with synthesis of cell-wall mucopeptides during active multiplication, resulting in bactericidal activity against susceptible bacteria.

Dosing

Adult

500 mg PO tid


Pediatric

20-50 mg/kg/d PO divided q8h; not to exceed 2 g/dose

Interactions

Reduces efficacy of PO contraceptives; coadministration with warfarin or heparin increases risk of bleeding

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment




Trimethoprim (TMP) and sulfamethoxazole (SMZ) (Bactrim, Septra DS)

Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.

Dosing

Adult

160 mg TMP/800 mg SMZ PO q12h

Pediatric

<2 months: Not recommended
>2 months: Not established

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 people; 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

Contraindications

Documented hypersensitivity; megaloblastic anemia due to folate deficiency

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Discontinue at first appearance of skin rash or adverse reaction; obtain CBC counts 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, administer leucovorin 5-15 mg/d); caution in folate deficiency (eg, chronic alcoholism, old age, anticonvulsant therapy, malabsorption syndrome); hemolysis may occur in individuals deficient in G-6-PD; patients with AIDS may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); administer fluids to prevent crystalluria and stone formation




Clarithromycin (Biaxin)

Inhibit bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, arresting RNA-dependent protein synthesis.

Dosing

Adult

500 mg PO bid


Pediatric

Not established

Interactions

Toxicity increases with coadministration of fluconazole, astemizole, and pimozide; 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, and 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



Contraindications

Documented hypersensitivity; hepatic impairment; coadministration with pimozide

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May increase hepatic enzymes and cholestatic jaundice; caution in impaired hepatic function, prolonged QT interval, or pneumonia; caution in hospitalized, geriatric, or debilitated patients; diarrhea may indicate pseudomembranous colitis; superinfections may occur with prolonged or repeated antibiotic therapies; coadministration with ranitidine or bismuth citrate not recommended if CrCl <25 mL/min; administer half dose or increase dosing interval if CrCl <30 mL/min




Cefaclor (Ceclor)

Second-generation cephalosporin maintains gram-positive activity of first-generation cephalosporins and adds activity against Proteus mirabilis, H influenzae, Escherichia coli, Klebsiella pneumoniae, and M catarrhalis.

Dosing

Adult

500 mg PO tid


Pediatric

Not established

Interactions

Disulfiram-like reactions may occur when alcohol is consumed within 72 h; may increase hypoprothrombinemic effects of anticoagulants; may increase nephrotoxicity in patients who receive potent diuretics (eg, loop diuretics); coadministration with aminoglycosides increases nephrotoxic potential

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Reduce dosage by one half if CrCl is 10-30 mL/min and by one fourth if <10 mL/min; bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy




Cefixime (Suprax)

Third-generation cephalosporin. Arrests bacterial cell wall synthesis and inhibits bacterial growth by binding to 1 or more penicillin-binding proteins.

Dosing

Adult

400 mg/d PO qd

Pediatric

Not established

Interactions

Coadministration of aminoglycosides increases nephrotoxicity; probenecid may increase effects of cefixime

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment




Clindamycin (Cleocin)

Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, arresting RNA-dependent protein synthesis.

Dosing

Adult

150-300 mg PO q6h

Pediatric

Not established

Interactions

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption

Contraindications

Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis




Amoxicillin and clavulanate (Augmentin)

Amoxicillin inhibits bacterial cell wall synthesis by binding to penicillin-binding proteins. Addition of clavulanate inhibits beta-lactamase producing bacteria.
Good alternative antibiotic for patients allergic or intolerant to the macrolide class. Usually is well tolerated and provides good coverage to most infectious agents. Not effective against Mycoplasma and Legionella species. The half-life of oral dosage form is 1-1.3 h. Has good tissue penetration but does not enter cerebrospinal fluid.
For children >3 months, base dosing protocol on amoxicillin content. Due to different amoxicillin/clavulanic acid ratios in 250-mg tab (250/125) vs 250 mg chewable-tab (250/62.5), do not use 250-mg tab until child weighs >40 kg.


Dosing

Adult

400-500 mg PO tid for 7-10 d


Pediatric

<3 months: 125 mg/5 mL PO susp based on amoxicillin; 30 mg/kg/d divided bid for 7-10 d
>3 months: If using 200 mg/5 mL or 400 mg/5 mL susp, 45 mg/kg/d PO q12h; if using 125 mg/5 mL or 250 mg/5 mL suspension, 40 mg/kg/d PO q8h for 7-10 d
>40 kg: Administer as in adults


Interactions

Coadministration with warfarin or heparin, increases risk of bleeding; may act synergistically against selected microorganisms when coadministered with aminoglycosides; coadministration with allopurinol may increase incidence of amoxicillin rash; may decrease efficacy of oral contraceptives when administered concomitantly

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatic impairment may occur with prolonged treatment in the elderly; diarrhea may occur; adjust dose in renal impairment; cross allergy may occur with other beta-lactams and cephalosporins




Azithromycin (Zithromax)

Acts by binding to 50S ribosomal subunit of susceptible microorganisms and blocks dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Nucleic acid synthesis is not affected.
Concentrates in phagocytes and fibroblasts as demonstrated by in vitro incubation techniques. In vivo studies suggest that concentration in phagocytes may contribute to drug distribution to inflamed tissues.
Treats mild-to-moderate microbial infections.


Dosing

Adult

Day 1: 500 mg PO
Days 2-5: 250 mg PO qd



Pediatric

<6 months: Not established
>6 months:
Day 1: 10 mg/kg PO once; not to exceed 500 mg/d
Days 2-5: 5 mg/kg PO qd; not to exceed 250 mg/d


Interactions

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

Contraindications

Documented hypersensitivity; hepatic impairment; do not administer with pimozide

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Site reactions can occur with IV route; bacterial or fungal overgrowth may result from prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function or prolonged QT intervals




Erythromycin (Erythrocin, E.E.S.)

Recommended dosing schedule of erythromycin may result in GI upset, causing one to prescribe an alternative macrolide or change to tid dosing. Covers most potential etiologic agents, including Mycoplasma species.
Erythromycin is less active against H influenzae. Although 10 d seems to be a standard course of treatment, treating until the patient has been afebrile for 3-5 d seems a more rational approach. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal and streptococcal infections.
In children, age, weight, and severity of infection determine proper dosage. When bid dosing is desired, half-total daily dose may be taken q12h. For more severe infections, double the dose.
Has the added advantage of being a good anti-inflammatory agent by inhibiting migration of polymorphonuclear leukocytes.


Dosing

Adult

250 mg erythromycin stearate/base (or 400 mg ethylsuccinate) PO q6h, or 500 mg q12h (1 h ac or 2 h pc)
Alternatively, 333 mg PO q8h; increase to 4 g/d depending on severity of infection


Pediatric

30-50 mg/kg/d (15-25 mg/lb/d) PO divided q6-8h; double dose for severe infection

Interactions

Inhibits CYP450 1A2, 3A3/4 isoenzymes; coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin, increases risk of rhabdomyolysis; decreases metabolism of repaglinide, thus increasing serum levels and effects

Contraindications

Documented hypersensitivity; hepatic impairment

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI side effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur






Cefuroxime (Ceftin)

Second-generation cephalosporin maintains gram-positive activity of first-generation cephalosporins; adds activity against P mirabilis, H influenzae, E coli, K pneumoniae, and M catarrhalis.
Binds to penicillin-binding proteins and inhibits final transpeptidation step of peptidoglycan synthesis, resulting in cell wall death. Condition of patient, severity of infection, and susceptibility of microorganism determine proper dose and route of administration. Resists degradation by beta-lactamase.


Dosing

Adult

250-500 mg PO bid


Pediatric

125-250 mg PO bid; alternatively, oral susp 20-30 mg/kg/d PO divided bid

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 patients who receive potent diuretics such as loop diuretics; coadministration with aminoglycosides increase nephrotoxic potential

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Reduce dosage by 1/2 if creatinine clearance is 10-30 mL/min, and by 3/4 if <10 mL/min (high doses may cause CNS toxicity); bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy




Loracarbef (Lorabid)

Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins. Inhibits final transcription step of peptidoglycan synthesis in bacterial cell wall.

Dosing

Adult

400 mg PO bid

Pediatric

7.5-15 mg/kg PO bid

Interactions

Probenecid may increase serum levels of loracarbef

Contraindications

Documented hypersensitivity to drug or related products

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy

Follow-up

Further Inpatient Care

• After 1-2 years, if symptoms of sinusitis (eg, congestion, drainage, fever, pain) persist, repeat CT scanning may be indicated.
• After surgery, the patient may report not getting enough air, burning in the nose, and dryness.
  • Although the airway is wide open, these symptoms persist and often reflect poor ciliary function.
  • The nasal membranes appear dry and irritable, and they look thin.
  • Treatment is hydration, use of nasal moisturizer sprays, and ointments. Pulsatile irrigation provides relief and helps restore ciliary activity.
• Complications after bilateral mid and inferior turbinectomy include loss of airway resistance and loss of olfactory, tactile, and temperature sensors (empty-nose syndrome).
  • Pulsatile irrigation with a Locke-Ringer solution, such as Breathe Ease 3 times per day, can offer symptomatic relief.
  • In this condition, dryness and crusts are prominent.
  • CT scanning shows mucosal thickening of the paranasal sinuses, loss of definition of the ostiomeatal complex, and enlargement of the nasal cavity with destruction of the lateral nasal wall.
  • Patients may be utterly miserable and report the following:
    • "I can't breathe."
    • "I can't smell things."
    • "I can't get enough air."
    • "My sleep is disturbed."
    • "I'm plugged up."
    • "I get frequent infections."
    • "My ears feel plugged."
• Determine if the symptoms have returned because the patient is no longer taking 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.
  • When the patient with asthma or allergies refuses to part with his or her dog or cat, every allergist tells the humorous story of Mrs Jones, who was treated without success for 5 years. However, in the sixth year, treatment was successful—because that's when her cat ran away.  
  • If patients insist on keeping their pets, the pets must be kept out of the bedroom. Insist on dust proofing the bedroom, and perform desensitization. Patients should set up a decontamination room, where they can change to pet hair–robes or clothing before they enter the bedroom. They should use a high-efficiency particulate arresting (HEPA) filter in the bedroom.
• 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.
• Other factors, such as fatigue, vigorous sneezing, consuming iced drinks, becoming chilled, and eating spices, must be considered when medication does not work.

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, chicken soup, or both. Warm compresses applied 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 to restore the cilia. If the cilia are permanently damaged (eg, by excessive removal of mucosa or exposure to chlorine gas or other toxic substances), consider daily pulsatile irrigation to keep nose moist and to remove thick phlegm and materials.
• Check for a history of nasal polyps on an annual basis. Remind patients to avoid salicylates. Begin therapy if polyps are recurring.
• When patients awaken in the morning, dust has accumulated in their nose, and their body temperature is low. If an individual throws off the covers and touches the cold floor with his or her feet, a cascade of sneezing and hacking ensues to warm the body and remove the dust. However, this is an undesirable method for warming the body. Drinking hot tea before getting out of bed helps prevent this morning cascade of sneezing and hacking.
• Cold air and getting chilled can also trigger an asthma attack. Drinking hot tea before getting out of bed is an excellent preventive measure.
• The speed of the nasal cilia often reflects the action of the chest cilia. In difficult cases of asthma associated with coughing, determine whether the nasal cilia are inactive. Seek the cause. If the nasal cilia are affected after exposure to chlorine, chromium, or aldehydes, so are the chest cilia. Ascertain if a medication (eg, Benadryl and chlorpheniramine) is slowing the nasal and chest cilia.
• Be cognizant of what products are being advertised. For example, an ionizer that the patient installed may be the cause of his or her symptoms, as ionized air can worsen respiratory symptoms. In theory, ionization causes the dust to precipitate; however, in practice, the dust falls to the couch and is in the air when the patient sits down. In addition, the ozone that is produced irritates the respiratory system.
• Refer patients to the Web sites of the American Academy of Allergy Asthma & Immunology or America's College of Allergy for dust-proofing information.
  • In addition, tear sheets from companies that make allergy products, such as National Allergy Supply, are helpful.
  • If patients have specific questions about allergic materials or products, the Allergies Buyers Club has a consumer's review of products, and patients are invited to call them for specific questions about dust proofing.
• With the increasing rate of asthma in children (see Age above), preventative measures must be rethought.
  • Should the child have a dog or cat? Statistics indicate that either might be justifiable.
  • Chronic sinus problems should be cleared. Pulsatile irrigating to clear a chronic sinus infection may benefit the sinuses as well as the chest. In severe asthma, the chest cilia are impaired.
  • The patient should try to avoid exposure to diesel-polluted air. Consider the use of filters if a child has to walk far along a highway.
  • Dust proofing the bedroom is best.

Inpatient & Outpatient Medications

• The continuous medication that is best for individual patients varies. Pseudoephedrine with guaifenesin combinations are usually tolerated well and provide relief. Continued use of a corticosteroid spray may be indicated. Nonsteroidal sprays, such as Astelin, may provide nasal relief.
• Long-term use of the corticosteroids, such as Flonase and Rhinocort Aqua, may provide symptomatic relief to many patients. Adverse effects of these and similar products include thinning of membranes and epistaxis. These effects do not appear until after at least 6 months of use and may be prevented by alternating them with saline without benzalkonium or Breathe Ease moisturizer spray.
• For patients who continue to frequently catch common colds with severe symptoms, daily pulsatile irrigation may be beneficial in reducing the incidence. Pulsation reduces the amount of intercellular adhesion molecule-1 (ICAM-1) on the nose. This is the channel for the common cold virus to enter the nose. Evidence suggests that vitamin B-12 500 mcg taken sublingually twice daily might raise the immune response, but final proof is not available. For most forms of vitamin B-12, absorption is poor; therefore only the sublingual form may be of value.
• Hypertonic solutions may provide benefit for short periods when the nose is boggy and edematous. These solutions usually cause irritation after a while. Try 2 tsp of salt to a pint of water or 2 tsp of Breathe Ease to the pint. Hypertonic solutions can be administered at up to 3 times the normal dose (ie, 3 tsp salt to 1 pt of water). In 1999, Boek recommended Locke-Ringer solution instead of isotonic sodium solution. When this solution is made hypertonic (ie, 3 tsp Breathe Ease to 1 pt of water), burning is reduced because of the electrolytic balance.¹¹ 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 a 50-mg capsule of Benadryl in an ounce of Breathe Ease or sodium chloride solution. The dose is variable, and patients comment on the taste. Some patients do well with 100 mg of Benadryl to 1 oz; therefore, have the patient titrate the dose. In acute allergy, combining Astelin twice daily with a cortisone nasal spray (eg, Nasarel or similar) twice daily is useful. When symptoms are controlled, the dose of Nasarel is decreased to see if the patient remains symptom free, and then, the dose of Astelin can be reduced.
• Patients may continue to experience thick phlegm despite good surgical results, pulsatile irrigation, and nasal moisturizers. Consider the use of an inhalant and investigate for a food allergy. Try food-elimination diets. Guaifenesin and proteolytic enzymes (eg, Clear Ease) are of help. Emphasize 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 at thinning the phlegm. Thick phlegm in the chest can easily become infected. Emphasize drinking liquids, breathing exercises, aiding postural drainage, and using steam inhalation. Steam inhalation for the chest is effective if the mouth is open and the tongue is extended.
• In theory, vaporizers moisten the air and thin the mucus. In practice, they are difficult to keep clean and end up growing mold. Steam does not reach the lungs intact unless the tongue is extended. Steam in the shower is 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 turn on the shower faucet to drip water.
• Some patients become ill whenever they take an airplane flight. This can be a serious problem for the patient with a sinus or asthmatic condition. In theory (and in the author's experience), placing an antibiotic ointment (eg, Bactroban) in the nose may help by killing certain bacteria, by forming a shield against other passengers who cough and sneeze. Breathe Ease Nasal Gel (available over the counter) may work in a similar manner. Patients should avoid consuming iced drinks and instead drink hot tea to improve ciliary function.
• As with any illness, anxiety can make the illness worse. Recommend stress reduction as part of therapy. One method is to have patients stand before the mirror, watching their chest. They should breathe in to the count of 4 and out to the count of 6. The exact timing for each breath is not important as long as exhalation is longer than inhalation. They should relax when exhaling and visualize the face, jaw, and shoulders relaxing. The mirror serves as a biofeedback mechanism to tell patients when they are doing the technique correctly. Instruct the patient to do this exercise 10 minutes a day. With an asthma or sinus attack, the complication of anxiety reinforcement is reduced. Stress reduction techniques are especially valuable for children.
• Not every salt can be used to make a sodium chloride solution for irrigation. Regular salt contains silica and iodine. Some patients are sensitive to these elements. Sea salt is evaporated and contains various products; sea salt is high in iodine. These products can be irritating to the sensitive patient. Kosher salt or pickling salt is free of iodine and silica. Breathe Ease is based on the Locke-Ringer solution formula, along with sodium chloride, calcium chloride, potassium chloride, and sodium bicarbonate. This balance is more effective than isotonic sodium chloride solution on cilia.

Deterrence/Prevention

• Dust proofing is the best deterrence.
• Hot tea thins thick mucus. Thick mucus must be thinned by using a moisturizer, performing pulsatile irrigation, or buccally administering proteolytic enzymes.
• Elements in the workplace cause sinusitis and asthma.
  • Certain chemicals are highly toxic to the cilia; these include chromium dust, sulfur dioxide, smog, ozone, and certain aldehydes (see Dr. Grossan The Ear, Nose & Throat On-line Consultant).
  • For the individual with asthma, these elements may constitute a disability factor.
  • A discussion of workplace asthma by pulmonologist Larry Martin can be found at AllergyBuyersClub.com.
• For people who frequently catch common colds, Rabizza recommends daily irrigation to remove ICAM-1, which is the entrance factor for this virus.
• For allergic nasal or chest symptoms, NasalCrom started 6 weeks before pollen season is often effective.
• Persons who experience burning or lack of benefit from prepared nasal moisturizers may be reacting to the preservatives (eg, benzalkonium). Switch to homemade products.

Complications

• Complications of sinusitis include the following:  
  • Generalized infection due to circulatory dissemination of bacteria
  • Bronchial infection probably due to direct passage by infected mucus into the trachea.: Bacteria in the sinus appear in the trachea 16 hours later.
  • Meningitis by means of venous and lymphatic drainage into the CNS or by direct extension through the posterior wall of the frontal sinus or throughout the olfactory area: Sometimes, a fistula may be present after sinus surgery. If fever develops in a patient who has had sinus surgery, rule out meningitis and look for fistula, which is usually in or near the cribriform plate.
  • Cavernous sinus thrombosis: The cavernous sinus is a highly vascular area containing optic nerves and cranial nerves III, IV, and VI. It may arise from sphenoid sinusitis.
  • Optic spread: Spread can occur by means of 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 an allergist and an otolaryngologist are available to manage problems associated with these diseases, the prognosis is often satisfactory.
• If sinus surgery fails, the prognosis worsens. Factors such as regrowth of obstructing tissue, a poor response to infection, and a poor response to antibiotics suggest a suboptimal prognosis.
• If the patient's course of sinusitis and asthma has been poor, review factors of his or her immune response. Consider the possibility of cystic fibrosis, GERD, HIV infection, and/or systemic infection.
• Hypothyroidism is associated with allergic conditions. Specific allergic desensitization may initially be unsuccessful and later succeed when thyroid supplement is added.

Patient Education

• Patient education includes dust-proofing instructions. Encourage patients to keep the bedroom free of dust and mold (see Sinusitis: A Treatment Plan That Works for Asthma and Allergies Too for details).
• Instruct patients to keep the nose moist with a moisturizer.
• Educate patients regarding the importance of adequate hydration.
• Instruct patients to keep the bedroom windows closed at 5 AM and at 5 PM, when plants pollinate. Patients with allergies improve when they have hot tea before getting out of bed in the morning.
• Educate patients regarding the availability of pollen calendars (see AllergyBuyersClub.com). For patients with 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 their car windows closed, especially in the late afternoon.
• Teach adults and children to blow their nose gently with both sides open. Instruct patients how to clear their ears.
• Educate patients about dust proofing their environment.
  • Many allergy companies supply free booklets with detailed instructions for dust proofing, which is an important component of the treatment of sinusitis and asthma.
  • During the third visit to the physician's office, the patient usually hears instructions for dust proofing; after the fifth office visit, patients actually start the dust-proofing process.
  • Ensure that the instructions include advice for no smoking.
  • Repeat the instructions regarding dust proofing, daily breath exercises, and peak flow measurements with each of the patient's visits to the office.
• For excellent patient education resources, see eMedicine's Asthma Center and Headache Center. Also, visit eMedicine's patient education articles, Asthma, Asthma FAQs, Understanding Asthma Medications, and Sinus Infection.

Miscellaneous

Medicolegal Pitfalls

• Failure to diagnose pneumonia: One common pitfall involves the patient who is miserable with sinusitis and coughing. Whatever his or her medical specialty, the physician must listen to the chest and look for asthma, pneumonia, wheezing, and/or a silent lung. The physician cannot assume that this is the only cause of the cough just because sinusitis is present. One problem, of course, is that some otolaryngologists are not expert at listening to the chest; however, he or she must listen and document that action. When in doubt, refer the patient to a pulmonologist or an internist. Failure to recognize asthma or pneumonia in the presence of sinusitis is a potential cause of litigation.
• CSF fistula: The ENT surgeon works in the roof of the nose where the skull and contents are thinly separated (see Image 10). The CT scan must be in the operating room, and the surgeon must look for deep areas where the floor of the skull descends below ordinary areas. A dehiscence may already be present. Recognizing this complication is important. Look for signs of meningitis and unusual headache postoperatively. Sometimes these signs are masked by the antibiotics. Unilateral clear drainage after surgery highly suggests a fistula. Laboratory tests are used to determine if the fluid is CSF. The fistulae can be closed via endoscopic route. Proper diagnosis is important. 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 increased bleeding, this complication may not be recognized. Any visual disturbance or muscle paralysis after surgery should suggest a surgical eye complication. These eye complications are often 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 the walls are normally 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 to break can easily move the ethmoid bone, disrupting the olfactory nerves. Always use biting forceps in this area to prevent anosmia. This complication is not reparable.
• Atrophic rhinitis: After surgery the nose may look wide open; however, the patient might still be 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 were removed. Turbinectomy, unless performed to preserve mucosa and function, can leave the patient highly symptomatic and ready to litigate. Prevention is aimed at preserving turbinate mucosa. (See also the comment on empty-nose syndrome above.)
• Allergy: Failure to diagnose allergy may lead to litigation. For example, the patient may receive a misdiagnosis of sinusitis. An excellent surgery is performed in which the septum is straightened and the turbinates moved. However, after surgery, the patient still has nasal obstruction, and the physician recommends a second operation. The patient is referred to an allergist, who clearly demonstrates 4+ dust allergy, and the patient's condition clears with desensitization. Now, the patient is ready to sue the surgeon because surgery was not necessary. Performing surgery with the knowledge that an allergic condition is present and explaining that the condition will either persist or improve after surgery is not a problem; however, neglecting to offer the patient a choice of allergy therapy versus surgery is poor medicine.
• Medications: The patient may be taking medicine from an orthopedist, an endocrinologist, a psychiatrist, and an internist. Because of concerns about drug interactions, the otolaryngologist might prescribe only a sodium chloride solution. Drug interaction is a serious problem and one that can easily lead to litigation. Somewhere in the literature, a lawyer can find a case in which a drug should not have been administered with another. One defense is to insist that the patient use only a single pharmacist who, hopefully, looks at these interactions. Another is to speak with the internist or the hospital's pharmacist.
• Frontal sinusitis: After endoscopic surgery, the attachment of the middle turbinate may move to block the frontal sinus. Look for this etiology when the patient has a history of previous endoscopic procedures. Even in this age of antibiotics, abscesses of the frontal sinus do occur. They may rupture through the posterior wall into the brain. The difficulty with this diagnosis occurs in the patient who is seen weekly and who has severe symptoms, including frontal headache. When a noncomplaining patient reports frontal pain, consider frontal sinusitis. A CT scan (not an MRI) must be obtained to evaluate the posterior wall of the frontal sinus.
• Prednisone: Never refill prednisone. Good physicians do forget to write "do not refill" on the prescriptions, and patients keep refilling the prescriptions. Another pitfall is the physician can refill a prescription by phone without examining the patient and not see that the patient has Cushing disease. Note: Always write "do not refill" on prednisone and similar medications. Patients often feel great while taking prednisone and think of ways to get more, including altering the prescription or calling the physician's associate or registered nurse.
• Patient's chart: One pitfall is inadequately describing the lesion and a lack of pictures or diagrams in the patient's chart. Likewise, description of the deviated septum during surgery might similarly be absent on the chart. Include pictures, diagrams, and descriptions with documentation in the chart so a lawyer cannot claim that surgery was not indicated. In addition, insurance carriers look for ways to avoid payments, and a chart without adequate documentation makes denial of payments easy for them.
• Discussion of complications: Writing "complications were discussed" is acceptable, but the patient may still insist that no discussion occurred. In one example, the office and hospital charts were complete and nicely written. Complete and detailed dictation regarding the surgery occurred right after the operation. This case was easy to defend legally because any physician with such thorough charts is likely to be just as thorough in explaining the complications.
• Written instructions: Patients may put eardrops in the mouth or liquid penicillin in the nose and then claim that the physician verbally instructed him or her to do so. Therefore, always assume the worst-case scenario, and write the instructions in addition to providing verbal instructions. Keep a copy of the written instructions.
• Speaking the patient's language: Use terms and analogies that the patient understands. Use pictures, diagrams, and other communication tools. Have the patient hold the skull while explaining the surgery.
• Discussing the alternatives: The moment the physician mentions surgery, the patient may dismiss it as a possible treatment. Advise the patient of alternative care. Options include (1) continuing with medication that has not worked, (2) trying allergy shots for 2 years, (3) trying more cortisone and risking the adverse effects, or (4) trying surgery. In a good practice, patients usually have already explored all options; therefore, surgery is the remaining option.
• Adequate medical course: The guidelines for ENT surgery are clear in that the nonsurgical approach must be tried before surgery. Complications of sinus surgery do occur. A lawyer may argue that the CT scan showed thickened membranes, implying that the physician could have prescribed antibiotics and cleared the membranes without surgery. Another example is the patient with polyps. A lawyer may quote a medical expert who says that a physician should always try medication to shrink the polyps. The lawyer then asks why this medication was not tried and implies that the physician was anxious to perform an operation. No matter what procedure is performed, some article can always be found to contradict the need for surgery or choice of procedure. Be aware of the other opinions in the medical field because the opposing attorney will be aware of these options.
• Expecting the worst: In one case from the author's experience, the need for adenoidectomy and myringotomy was explained to a pediatric patient's mother by using diagrams, speaking clearly, and using words that the mother seems to understand. She was asked if she had any questions. An hour later, the mother's physician called to report that the mother was in his office crying because nothing had been explained to her regarding the surgery.
• "Never operate" argument: A favorite legal ploy is reporting that the medical expert says to never operate on patients with this condition. This quote may be taken out of context and may be taken from a medical journal written in a foreign language. Demand to see or read the entire article.

Multimedia



Media file 1: Lateral sinus wall. Perform nasal endoscopy to reveal patent or closed sinus ostia. Look for purulent areas.



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



Media file 3: Anatomy of the lateral wall on nasal endoscopy. Patent or closed sinus ostia may be revealed. The maxillary, frontal, and sphenoid ostia are shown. Purulent discharge is noted.



Media file 4: Hydro Pulse irrigator. Because bacteria and thick phlegm play a clinically significant role, if pus is present in the nose or sinuses, the physician can reduce asthmatic symptoms due to sinusitis by performing in-office suctioning or irrigation. One technique is to use a vasoconstrictor in the nose, wait 2 minutes, and then irrigate the area with a modified Locke-Ringer or sodium chloride solution with a pulsatile nasal irrigator. A considerable amount of surface and sinus pus is removed, and the pulsatile action at 20 pulses per second stimulates the nasal cilia and sinuses to restore normal ciliary action. The flow of solution past the orifice creates a Bernoulli effect to displace the sinus contents; pulsation also aids this process.



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



Media file 6: Concha bullosa. A foreign body can block the natural ostia. 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.



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



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



Media file 9: Hypertrophied turbinates may be the sole cause of nasal obstruction and frequent infections. These can be safely reduced by means of submucous resection of the turbinates.



Media file 10: CSF fistula. The ear, nose, and throat (ENT) surgeon works in the roof of the nose, where the skull and contents are thinly separated.

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Keywords

asthma, sinusitis, respiratory distress, bronchitis, allergic bronchitis, sinus problems, sinus infection, postnasal drip, rhinitis, allergic rhinitis, mucociliary clearance, asthmatic, reactive airway disease, wheeze, bronchiolitis, bronchial asthma, acute asthma, allergies, bronchial airways, bronchial airway narrowing, inflammation of the bronchi, bronchial smooth muscle contraction, wheezing, dyspnea, airway narrowing, noisy breathing, difficult breathing, difficulty breathing, respiratory disease

Contributor Information and Disclosures

Author

Murray Grossan, MD, Consulting Staff, Department of Otolaryngology, Cedars Sinai Hospital of Los Angeles
Murray Grossan, MD is a member of the following medical societies: American Medical Association, American Tinnitus Association, California Medical Association, and Los Angeles County Medical Association
Disclosure: Hydro Med Inc  Ownership interest Management position

Medical Editor

Lanny Garth Close, MD, Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, Columbia University College of Physicians and Surgeons
Lanny Garth Close, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Physicians, American Laryngological Association, American Society for Head and Neck Surgery, and New York Academy of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Stephen G Batuello, MD, Consulting Staff, Colorado ENT Specialists
Stephen G Batuello, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Physician Executives, American Medical Association, and Colorado Medical Society
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

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