The conventional medical treatment involves the use of broad spectrum antibiotics, antihistamines with or without decongestants, and mucolytic agents in patients with uncomplicated sinusitis. The choice of medications is based on the patient's medical condition and there are times when the choice may be severely restricted, due to another medical condition that patient may be experiencing.
In treating adult Sinusitis, the antibiotics are usually chosen based on culture results or prudent medical judgement. The choice would also vary with the immunological status of the patient. In patients with cystic fibrosis, immotile cilia syndrome, severe allergic diathesis, antibiotic resistance from previous medical or surgical treatments, or the severely immunosuppressed, patients may require careful evaluation in the choice of antibiotics. This may vary depending on the extent of the disease and the general medical condition of the patient. Streptococcus Pneumonia, Homophiles Influenza and Moraxella Catarhalis are the most commonly encountered organisms at the present time and the antibiotics are chosen accordingly. Community acquired Sinusitis with Beta Lactamase producing organisms require a careful selection of antibiotics. This includes the use of Augmentin™ (containing Potassium Clavulunate), Aminoquinolones which include Levaquin™, Tequin™ and Avelox™. In patients where the response to oral antibiotics are poor, intravenous antibiotics are recommended, based on culture results. A practical introduction to the usage of intravenous antibiotics is suggested by the author.
The surgical treatment of sinusitis has seen a radical change in the recent past, and this is due to a better understanding of the physiology of sinuses and their functions. Image-Guided sinus surgery, as introduced in the USA in 1984, is based on the extensive clinical work performed by Professor Messerklinger and his associates from Graz, Austria. The technique is based on the endoscopic viewing of the surgical site at the time of surgery and can be carried out effectively under local anesthesia with sedation. General anesthesia is also used in performing this technique, a choice made by the surgeon in consultation with the patient. The procedure can be effectively performed with minimal bleeding and nasal packing is usually avoided. The type of endoscopic sinus surgery performed may vary significantly in patients, necessitating different forms of radiologic studies prior to the surgery. Computer-aided surgery has been in the forefront of endoscopic sinus surgery in the recent past and the triplanar viewing of the surgical site radiologically has provided the surgeon an opportunity to be clear about the usage of techniques at the surgical site. Patients who undergo endoscopic sinus surgery should be closely watched for wound healing in the post-operative period to obtain the desired results.
The surgical results and the improvement of symptoms are based on the disease condition, the wound healing process, and the diligent post-operative follow-up. The average duration for improvement of symptoms following surgery is usually three to four weeks, when the reepithelialisation is seen. The following images will describe the different steps of surgery in an uncomplicated image-guided ethmoidectomy.
Recurrent sinusitis is a condition that is best described as repeated incidents of sinusitis, despite well thought out medical treatment, or surgical procedures performed to improve the patient's well being. Recurrent sinusitis may be due to:
Any patient who has recurrent sinusitis should be evaluated carefully and if necessary, perform a CT scan. There is usually a good cause for the recurrence; if it is identified and treated adequately, the patient's general condition improves significantly.
In the image-guided evaluation, these patients should be examined under topical anesthesia and, if necessary, an endoscopic guided culture should be performed. These culture reports should be reviewed and an appropriate antibiotic chosen for coverage of the infection.
The most common cause of postoperative sinusitis is usually secondary scar tissue formation at the surgical site which had produced an obstruction to drainage which leads to repeated infections.
Patients suffering from recurrent sinusitis will require a careful evaluation and the diagnosis is made after a completion of an adequate nasal endoscopy. Once the diagnosis is established the treatment should commence with a proper plan in place. The use of appropriate antibiotics or antifungal agents may be sufficient in some patients. Occasionally the patients will require intravenous antibiotics and this may be delivered through a central intravenous line for a period of four to six weeks. Patients in this category who do not show improvement in spite of maximum medical therapy should be evaluated for hypogammaglobulinemia or immune deficiency. These are the patient's who require an immunological evaluation and treatment. In some patients the use of steroids is necessary in order to facilitate the wound healing and in the avoidance of asthma like symptoms either before surgery or in the immediate postoperative period. The use of the steroids is usually in the form of an oral intake in divided doses.
In patients where recurrent disease involving the sinuses requires surgical attention the use of the computer-aided surgery is strongly recommended. Patients will require a triplanar CT Scans preoperatively and surgery is planned after a careful review of the CT Scans. In these patients the use of intravenous antibiotics preoperatively and in the postoperative period has significantly improved the wound healing process and has enabled patients to return to their work earlier than planned. The postoperative follow-up in patients undergoing revision sinus surgery will require frequent nasal endoscopy for debridement purposes and in the prevention of scar tissue formation at the surgical site.