Sinusitis Treatments

Learn how sinusitis is treated, through both conventional medical management and surgical techniques, including the latest solutions in image-guided sinus surgery.

Doctor Examining Patient’s Sinuses

Medical Management

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 catarrhalis 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 clavulanate), aminoquinolines which includes Levaquin™. 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.

Ethmoidectomy Surgery Step 1

Step 1: Left endoscopic view of the middle meatus demonstrating the middle turbinate and the uncinate process.

Ethmoidectomy Surgery Step 2

Step 2: Left middle turbinate dispplaced medially to demonstrate the uncinate process and location of injections in the uncinate process.

Ethmoidectomy Surgery Step 3

Step 3: Left endoscopic view demonstrating the injection of the sphenopalatine ganglion.

Ethmoidectomy Surgery Step 4

Step 4: Left endoscopic view of injection of the ground lamella.

Ethmoidectomy Surgery Step 5

Step 5: Left endoscopic view of the sites of injection of the uncintae process.

Ethmoidectomy Surgery Step 6

Step 6: Left endoscopic view after completion of uncinnectomy.

Ethmoidectomy Surgery Step 7

Step 7: Left endoscopic view after removal of the ethmoidal bulla.

Ethmoidectomy Surgery Step 8

Step 8: Left endoscopic view of the penetration of the ground lamella.

Ethmoidectomy Surgery Step 9

Step 9: Left endoscopic view after completion etmoidectomy revealing posterior ethmoidal cells.

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
      • Samter'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 soon as all arrangements are made to continue for 4 - 6 weeks
  3. If post-operative evaluation (+) for:
    • Recurrent signs &/or symptoms c/w chronic sinusitis
    • Culture positive for oral antibiotic resistant organism
    • CT shows unequivocal hyperostosis
    • Pre-operatively: To start as soon as all arrangements are made to continue for 4 - 6 weeks
  4. If (+) for any 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

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:

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.

What is New In Surgery?

The excellent visualization of the surgical site has extended the surgical application of image-guided sinus surgery from the management of inflammatory disease of the paranasal sinuses to the following indications which have had successful results. They include:

Image-Guided Orbital Decompression

This image-guided application involves the surgical removal of the medial orbital wall's removal (shown at right), to accommodate the increased volume of the orbital muscles with the fat and vascular contents in the region of the anterior and posterior ethmoid sinuses. This can be further extended to the partial removal of the orbital floor through the nasal cavity. The following schematic diagrams and endoscopic views will demonstrate the surgery. This procedure is valuable in treating patients having thyroid disease with exophthalmos where significant dramatic results could be obtained by surgery. This procedure is electively performed after consultation with an ophthalmologist. The visual fields and the visual acuity should be carefully checked in evaluating patients with this disorder prior to surgery.

Image-Guided Closure of C.S.F. Leaks / Resection of Base of Skull Tumors

The image-guided closure of the cerebrospinal fluid leak from the anterior skull base can be successfully performed by direct visualization of the site of the leak. This is usually performed with computer-aided technology and tissue adhesives like the fibrin glue and tissue graft in the form of temporalis fascia and conchal cartilage. Our results have been very encouraging and the advantage is in the avoidance of a formal craniotomy and the attendant postoperative care. Because of the various techniques involved in the surgery, each patient must be evaluated on an individual basis preoperatively.

For more details on image-guided skull base surgery, please visit our website www.endoscopicskullbasesurgery.com

Image-Guided Decompression of the Optic Nerve

The technique of optic nerve decompression is based on the identification of the optic nerve in the posterior ethmoid sinus or the sphenoid sinus. This should be performed by surgeons who are familiar with anatomy in this area, and special instrumentation is necessary for successful completion of surgery. The technique is most useful in optic nerve decompression secondary to thyroid ophthalmopathy, traumatic optic nerve entrapment or optic nerve injury with compression in tumor resections at the orbital apex.

Image-Guided Resection of Tumors of the Pituitary Gland

The image-guided techniques in resection of tumors of the pituitary have been recently applied with exciting results. The technique is based on the transnasal use of the sphenoid sinus surgical approach and removal of the sella bony wall and resection of the tumor. The defect is usually closed well with fibrin glue and muscular tissue, thus decreasing the postoperative stay in the hospital and also the incidence of morbidity.

For more details on image-guided skull base surgery, please visit our website www.endoscopicskullbasesurgery.com

Eustachian Tube Balloon Dilatation Surgery

Eustachian tube dysfunction is a common complaint among patients presenting to the otolaryngologist. Typical symptoms include aural fullness or pressure, tinnitus, and a sensation of being “underwater,” and a history of recurrent or chronic otitis media may be present. Otitis media is highly prevalent in young children, partly as a result of developmental Eustachian tube anatomy. In contrast, recurrent ear infections prompt further workup, including consideration of Eustachian tube dilation. Another complaint that may raise suspicion of Eustachian tube dysfunction is the onset of symptoms during a change in atmospheric pressure, as in commercial air travel, with a subsequent inability to equilibrate the middle ear pressure. The symptoms of Eustachian tube dysfunction may produce discomfort and may have an impact on auditory function.

Management of Eustachian tube dysfunction typically includes medical therapy, which may be antihistamines, intranasal corticosteroids, and noninvasive autoinflation maneuvers. Patients with uncontrolled symptoms typically undergo myringotomy with placement of pressure equalization tubes. An alternative is direct surgical management of the Eustachian tube dysfunction. Addressing disease contributing to Eustachian tube dysfunction have included adenoidectomy, septoplasty, turbinectomy, and endoscopic sinus surgery.

Balloon dilation of the Eustachian tube is a relatively new concept aimed at addressing cases of Eustachian tube dysfunction that have not responded to medical therapy. Balloon dilation has been successfully employed as a modality in endoscopic sinus surgery.

Balloon dilation of the Eustachian tube is a relatively new surgical procedure that shows promise for the treatment of Eustachian tube dysfunction in carefully selected individuals. Advantages include ease of use, employment of existing endoscopic instrumentation, and compatibility with other endonasal procedures.

Eustachian Tube Balloon Dilatation Surgery

Eustachian Tube Balloon Dilatation Surgery

Endoscopic view of the right Eustachian tube opening prior to dilatation and postoperative follow up.

Eustachian Tube Balloon Dilatation Surgery

Arrow pointing towards the normal opening of the Eustachian tube on the left side.

Eustachian Tube Balloon Dilatation Surgery

Light cable illumination of the eustachian tube opening as viewed with an intact tympanic membrane on the right side.

Endoscopic dilation of left Eustachian tube.

How aera works.

Advances in Rhinological Procedures

Endoscopic Image Guided Balloon Sinuplasty

Endoscopic balloon sinuplasty can be carried out with accuracy using image guidance in the operating room. This can be carried out under topical /local anesthesia with or without sedation in an office setting. This minimally invasive procedure is helpful in performing enlargement of the ostia of the sinuses with minimal trauma to the mucous membrane. The Frontal sinus, Maxillary sinus and the Sphenoid sinuses can be enlarged at the ostia using this procedure. This establishes ventilation and access to the topical medications in the ongoing treatment of sinusitis in patients.

Recovery Period: Approximately Two Weeks

Balloon sinuplasty animation.

Endoscopic Cryoablation of the Spheno Palatine Ganglion (Clarifix)

This recent introduction of cryo ablation of the spheno palatine ganglion area and it postganglionic fibers have proven to be of significant value in the successful management of Chronic rhinitis and Allergic Rhinitis. This is can be carried out with topical / local anesthesia with or with or without sedation in an office setting.

Recovery Period: Approximately Two Weeks

Endoscopic Partial Inferior Turbinectomy

Hypertrophy of the inferior turbinates associated with sinusitis and allergies can be successfully managed by performing inferior turbinectomy under topical or local anesthesia. This is also helpful in treating Obstructive Sleep Apnea. This can be carried out in office setting under topical or local anesthesia with or without sedation.

Recovery Period: Approximately Two Weeks

Correction Of Nasal Valve Stenosis With Latera Implants

The introduction of the lateral implants in an office setting improves the nasal airway in patient with nasal valve issues. This can significantly improve the nasal airway with no aesthetic changes in the appearance of the nose.

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