Sinusitis Solutions
Treatment

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.


Surgical Treatment

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.



Typical schedule (from
pre-operative evaluation
to full recovery)
  1. If pre-operative evaluation (+) for: Signs &/or Symptoms c/w chronic sinusitis, should be confirmed by nasal endoscopy
    • Chronic Rhinologic Conditions:
      • Cystic Fibrosis
      • Immotile Cilia Disorder
      • Sampter's Triad
    • Patient w/high risk co-morbid factors:
      • Immune Deficiency
      • Diabetic Endarteritis
    • Culture positive for oral antibiotic resistant organisms
    • Mucopyocele
    • CT shows unequivocal hyperostosis
    • Fungal sinusitis (IV Abx wanted as adjunctive therapy)
    • Pre-operatively: To start 2 weeks prior to surgery to continue post-operatively for 4 weeks
  2. If intra-operative evaluation (+) for:
    • Culture positive for oral antibiotic resistant organism
    • Mucopyocele
    • Unequivocal hyperostosis
    • Fungal sinusitis (IV Abx wanted as adjunctive therapy)
    • Pre-operatively: To start as soons as all arrangements are made to continue for 4 - 6 weeks
  3. If post-operative evaluation (+) for:
    • Persistant signs &/or symptoms c/w chronic sinusitis
    • Recurrent signs &/or symptoms c/w chronic sinusitis
    • Culture positive for oral antibiotic resistant organism
    • CT shows unequivocal hyperostosis
    • Pre-operatively: To start as soons as all arrangements are made to continue for 4 - 6 weeks
  4. If (+) for any medical contraindications for surgery
    Medical contraindications for surgery:
    • Timing of IV Antibiotics:
      • Arrangement made for PICC line Position confirmed with CXR
      • Choice of Antibiotics: Culture specific, or if culture are negative, Polymicrobial therapy including anaerobes
      • Pre-operatively: To start as soon as all arrangements are made to continue for 4-6 weeks

Follow-up
  • Timing: To begin 2 weeks after initiation of IV Abx
  • Perform: History & Physical exam including nasal endoscopy
  • Evaluation:
    • If complete resolution (symptoms and exam), continue IV Abx for additional 2 weeks to complete therapy; then, remove PICC
    • If partial resolution (symptoms and exam), recommend additional 2 weeks of IV Abx.
    • Re-evaluation after a total of 4 weeks therapy
    • If complete resolution, remove PICC line
    • If partial resolution, see below
    • If no improvement (symptoms and exam),
    • culture or re-culture
    • consider anti-fungal therapy
    • consider changing and/or adding other Abx
    • Re-evaluation after another 2 weeks of therapy:
      • If complete resolution (symptoms and exam), continue IV Abx for additional 2 weeks to complete therapy; then, remove PICC
      • If still with partial or no improvement,
      • re-culture sinuses after discontinuing all Abx for 1 week
      • Infectious disease consultation
      • Re-evaluation by allergist
      • Re-evaluation by immunologist
  • At each follow-up visit:
  • Patient fills SF-36 (quality of life) form, and SNOT-21 (chronic sinusitis) form
    • For the first year after therapy, follow-up evaluations every 3 months and on as needed basis
    • After first year of follow-up, Follow-up yearly, and on as needed basis
  • Pre-operatively: To start as soon as all arrangements are made to continue for 4-6 weeks

What is Recurrent Sinusitis?

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:

  • Mechanical obstruction at the opening of sinuses
  • Virulent bacteria resistant to previous antibiotic treatment
  • Associated medical conditions that the patient may be experiencing
  • Congenital syndromes associated with poor ciliary function
  • Postoperative complications which have interferred with the healing process
  • Noninvasive fungal sinusitis

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.