AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

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.

With the introduction of CT scanning in the 1970s, accurately pinpointing the location and extent of the sinus pathology became possible. A return to corrective surgery for individuals with sinusitis and for individuals with asthma has occurred, thanks to the studies of Rachelefsky,¹ Spector,² and many others showing the benefits of clearing sinus pathology. In the 1980s, functional endoscopic sinus surgery (FESS) and the ability to physiologically improve sinus function became available.

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.

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

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

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}

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

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

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Lab 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

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

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

Section 7 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

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.

Drug Category: 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.

Drug Category: 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).

Drug Category: 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.

Drug Category: 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.

Drug Category: 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.

Drug Category: 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 bronchocons