Sinusitis from an ENT’s Perspective – Part 2

 

Q: Is sinusitis really that big of a deal? Can’t your body’s immune system fight it off?

A: Many doctors, inspired by medical literature, scientific investigation, patient’s preference, and the desires of parents of patients, seek to use as few antibiotics as possible.  This is laudable, and the right thing to do in most instances.  After all, our bodies have the capability to fight off infection, and the better our body is at doing that, the better our natural immunities become, creating a resistance so that we don’t often get the same infection again.

The problems start, however, when an infection creates inflammation that leads to sinus obstruction, with a bacterial infection arising from the trapped mucous.  It is often difficult to know when a threshold has been reached where your body and its immune system need the help of pharmaceuticals.

Typical viral illnesses, which we try to treat supportively and without antibiotics, begin with headache, sore throat, joint pain, and fever.  Profuse nasal discharge, sometimes off-colored, is a hallmark of upper respiratory viral illness as well. But viral illness can set up the unfortunate secondary bacterial complication of sinusitis by causing so much inflammation that the sinuses block. Viral illness can take a turn for the worse and become something suspicious for a bacterial infection.  A patient might feel that they were “turning the corner” when the coughing worsens, sinus pressure intensifies, and quality of the mucous expectorant becomes more tenacious, thick, and foul.

At this point it is difficult to predict how supportive care alone, with saline rinses, decongestants, expectorants, and hydration will be successful in overcoming the illness.  ENT providers, of course, tend to see those who lose the battle with their illness.  We also tend to see patients whose past struggles with sinusitis have left them with a lessened ability to tolerate recurrent illness without antibiotic assistance.

The unfortunate reality is that once a sinus is blocked and infected, there can be permanent alteration in the mucous membrane lining that leaves a patient much more susceptible to illness and much more in need of our care.

The desire to avoid antibiotic treatment for sinusitis isn’t usually as problematic as trying to avoid antibiotics for otitis media.  The incidence of complication in allowing otitis to advance unimpeded is much more likely to have a grave outcome.  This is why the third leading cause of death in major cities in the pre-antibiotic era was as a complication of ear infections.  Sinusitis rarely has intracranial complication, although it does occur.  But before that happens, there is usually high fever and severe headache.

One of the more discouraging problems that we encounter is the combination of nasal polyps, asthma, and aspirin sensitivity.  This problem is well known as one of the reasons for early recurrence of polyps shortly after surgery meant to remove them.

Over the years, we have attempted to stay ahead of the polyps of Samter’s triad by using oral and topical steroids, montelukast sodium (an anti-leukotriene, one of the inflammatory mediators), and repeated surgery.  Often, this has proven very frustrating.  Not only do the polyps recur, but the asthma seems to worsen in some patients as well.

Over the last decade, aspirin desensitization has proven a useful adjunctive therapy.  While it is initially fairly risky, and tremendously inconvenient, it appears that overwhelming the body’s response to aspirin may the inflammatory mediators), and repeated surgery.  Often, this has proven very frustrating.  Not only do the polyps recur, but the asthma seems to worsen in some patients as well.

Over the last decade, aspirin desensitization has proven a useful adjunctive therapy.  While it is initially fairly risky, and tremendously inconvenient, it appears that overwhelming the body’s response to aspirin may significantly slow the rate of progress of the disease.

While ENT doctors are the surgeons that manage blocked sinuses and obstructing polyps, we rely on the services of our allergy colleagues to manage the aspirin desensitization process.

A team approach is the most effective way to treat this refractory, obstinately difficult problem.

Q: What are my options when it comes to fixing sinusitis?

A: After exhausting our other options, surgery is considered. Surgery of the sinuses is not as uncomfortable and dangerous as you might think. Significant changes in the way that surgery is performed have increased the effectiveness and decreased the morbidity of surgery.

As recently as the 1980s, the technique used only benefitted roughly 20% of people.  This gave sinus surgery a really bad name.  Additionally, most people had to be packed with yards of gauze packing, which was removed with them awake. An unsettling event as you may imagine.

Now the surgery is much less aggressive, bleeds much less, usually requires no packing, and is much more “targeted” in its approach.  Success rates are vastly higher, as is patient satisfaction.