Tuesday, January 31, 2012

When is a turbinectomy indicated?

When is a turbinectomy indicated?

Nasal obstruction is the most common complaint treated by otolaryngologists.

Turbinectomy or conchotomy is the surgical removal of an abnormally enlarged turbinate, which opens up the nasal passages by removing bone and soft tissue from inside the nose to improve breathing.

The turbinate or conchae is a bone in the nose; it is an extension of the ethmoid bone and is situated along the sidewall of the nose, covered by mucous membrane.

 It may be warranted in cases in which the upper airway is obstructed due to:
  • deviated nasal septum
  • swelling of the turbinate due to allergy, chronic inflammation, or chronic sinusitis
  • nasal polyps or other tumour obstructing the nose
  • swelling of the adenoids




When a 'turbinate bone' or 'conchae' is abnormally enlarged, it produces an ‘empty nose syndrome’, with symptoms like chronic nasal dryness, inflammation, 'paradoxical obstruction' (loss of airflow sensation) leading to breathing difficulties, grogginess and dizziness, and often pain and repeated nasal infections. These symptoms have a significant impact on the patient’s quality of life and sense of well-being. It can produce difficulty concentrating (appears in the medical literature as 'aprosexia nasalis'), pre-occupation with symptoms, anxieties and often clinical depression.[1]
The goals of nasal airway surgery include the following: to improve airflow through the nose, to control nosebleeds, to enhance visualization of the inside of the nose, to relieve nasal headaches associated with swelling of the inside of the nose, and to promote drainage of the sinus cavities. Nasal airway surgery is done through the nostrils without the need for external incisions.
Over resection of the inferior turbinates in the nose may lead to chronic nasal dryness, chronic mucosal inflammation, squamous metaplasia, mucosal atrophy and in rare cases even to full blown atrophic rhinitis. The remaining mucosal structures (the septum and the remaining turbinates) often hypertrophy and complicate diagnosis.[2][3][4][5][6]
  Bibliography
  • Rice DH, Kern EB, Marple BF, Mabry RL, Friedman WH. The turbinates in nasal and sinus surgery: a consensus statement. Ear Nose Throat J. 2003;82(2):82-84.
  • Cottle MH. Nasal Atrophy, Atrophic Rhinitis, Ozena: Medical and Surgical Treatment. Journal Of The International College Of Surgeons. Volume 29(4), pages 472-484, 1958.
  • Passàli D, Lauriello M, Anselmi M, et al. Treatment of the inferior turbinate: long-term results of 382 patients randomly assigned to therapy. Ann Otol Rhinol Laryngol. 1999;108:569-75.
  • Moore GF, Freeman TJ, Yonkers AJ, Ogren FP. Extended follow-up of total inferior turbinate resection for relief of chronic nasal obstruction. Laryngoscope,  1985 Sept., volume 95 (9 Pt. 1): 1095-9.
  • Berenholz L, et al'. Chronic Sinusitis: A sequela of Inferior Turbinectomy. American Journal of Rhinology, July-August 1998, volume 12, number 4.
  • Wang Y, Liu T, Qu Y, Dong Z, Yang Z. Empty nose syndrome. Zhonghua Er Bi Yan Hou Ke Za Zhi. 2001 Jun;36(3):203-5.

Monday, January 30, 2012

Symptoms and treatment of cavernous sinus thrombosis

Symptoms and treatment of cavernous sinus thrombosis

Symptoms
  1. Patients suffering from cavernous sinus thrombosis (CST), one of dangerous side effects of sinus infection may feel very ill and complain about the following:
    • sudden headache,
    • nausea and vomiting,
    • lethargy,
    • pain in eye and
    • neck stiffness (nuchal rigidity).




  1. Cranial nerve testing may reveal sensory deficit of the trigeminal nerve’s ophthalmic branch and muscle paralysis (palsies) of the some nerves.
  1. Doctors may observe sluggish or dilated pupils, bulging eyeballs (proptosis), swelling of optic nerve (papilledema), retinal hemorrhages, tenderness and orbital edema during eye examination.
  1. Inflammation and blood clot (thrombosis) in the cavernous sinuses and / or nearby area occur.
  1. Cornea swelling (chemosis) may drooping eyelids (ptosis) may also indicate CST.
  1. Other CST symptoms include
    • Quick development of proptosis
    • The motor cranial nerves paralysis
    • Symptoms of acute orbital cellulites
    • Meningitis signs
    • Picket fence fever in which temperature reaches to high level
    • Stupor, unconsciousness and unclear thoughts

  1. If CST is spreading from the sphenoid sinuses, papillitis and proptosis may occur with thrombosis in cavernous sinuses.
  1. Headaches may lead to periorbital edema and fever after some days.
  1. The orbital veins may get blocked, causing periorbital edema. So, never ignore side effects of sinus infection.
Treatment
During initial stage, aggressive treatment is required to prevent the infection from spreading further. Patients shall be monitored during treatment to observe any further complications and / or improvements. However, even after treatment, cranial nerve paralysis (palsies) does not disappear. Half of the patients who recover from CST suffer from complete or partial palsies of the cranial nerve.
An assortment of antibiotics is administered to treat these side effects of sinus infection. However, the type of antibiotics depends on the result of the sinus exudate and blood cultures. Besides systemic antibiotic therapy, emergency surgery may be required to drain the infection.  If CST patients do not respond to antibiotics, corticosteroids may be administered to reduce chances of adrenal insufficiency and orbital congestion. However, use of systemic corticosteroids is controversial.
Intravenously given anticoagulants may check growth of the thrombosis. Anticoagulants may facilitate recanalization of thrombous (clot), enabling easy and quick penetration of antibiotics. However, anticoagulation therapy may cause septic emboli, thereby causing risk of intracranial bleeding. In addition, very few studies have been conducted on effectiveness of anticoagulation. The use of anticoagulation, thus, is controversial. Some times steroid therapy is used for the treatment, but it is also controversial. So, consult your physician.

Friday, January 27, 2012

Symptoms and treatment of cavernous sinus thrombosis

Symptoms and treatment of cavernous sinus thrombosis

Symptoms
  1. Patients suffering from cavernous sinus thrombosis (CST), one of dangerous side effects of sinus infection may feel very ill and complain about the following:
    • sudden headache,
    • nausea and vomiting,
    • lethargy,
    • pain in eye and
    • neck stiffness (nuchal rigidity).
  1. Cranial nerve testing may reveal sensory deficit of the trigeminal nerve’s ophthalmic branch and muscle paralysis (palsies) of the some nerves.

  1. Doctors may observe sluggish or dilated pupils, bulging eyeballs (proptosis), swelling of optic nerve (papilledema), retinal hemorrhages, tenderness and orbital edema during eye examination.
  1. Inflammation and blood clot (thrombosis) in the cavernous sinuses and / or nearby area occur.

  1. Cornea swelling (chemosis) may drooping eyelids (ptosis) may also indicate CST.
  1. Other CST symptoms include

    • Quick development of proptosis
    • The motor cranial nerves paralysis

    • Symptoms of acute orbital cellulites
    • Meningitis signs

    • Picket fence fever in which temperature reaches to high level
    • Stupor, unconsciousness and unclear thoughts

  1. If CST is spreading from the sphenoid sinuses, papillitis and proptosis may occur with thrombosis in cavernous sinuses.
  1. Headaches may lead to periorbital edema and fever after some days.

  1. The orbital veins may get blocked, causing periorbital edema. So, never ignore side effects of sinus infection.
Treatment
During initial stage, aggressive treatment is required to prevent the infection from spreading further. Patients shall be monitored during treatment to observe any further complications and / or improvements. However, even after treatment, cranial nerve paralysis (palsies) does not disappear. Half of the patients who recover from CST suffer from complete or partial palsies of the cranial nerve.
An assortment of antibiotics is administered to treat these side effects of sinus infection. However, the type of antibiotics depends on the result of the sinus exudate and blood cultures. Besides systemic antibiotic therapy, emergency surgery may be required to drain the infection.  If CST patients do not respond to antibiotics, corticosteroids may be administered to reduce chances of adrenal insufficiency and orbital congestion. However, use of systemic corticosteroids is controversial.
Intravenously given anticoagulants may check growth of the thrombosis. Anticoagulants may facilitate recanalization of thrombous (clot), enabling easy and quick penetration of antibiotics. However, anticoagulation therapy may cause septic emboli, thereby causing risk of intracranial bleeding. In addition, very few studies have been conducted on effectiveness of anticoagulation. The use of anticoagulation, thus, is controversial. Some times steroid therapy is used for the treatment, but it is also controversial. So, consult your physician.

Thursday, January 26, 2012

Nasodren®: How much time to symptom relief and clinical recovery?

Nasodren®: How much time to symptom relief and clinical recovery?

Nasodren® has demonstrated its efficacy and safety in rhinosinusitis treatment in 15 comparative studies and in 7 cohort follow-up studies. In all of these studies, Nasodren® was administered at a dose of 2.6 mg /day (1.3 mg per nostril/ day) between 7 and 14 days in monotherapy or in combination.




In 5 of these studies (3 performed in adults and 2 in children) the time to symptom relief and clinical recovery with Nasodren® was compared with a combination of standard therapy.

Symptom relief: Nasodren® relieves symptoms after 3-4 days of treatment. In comparison with the conventional combination treatment, alone or in combination it shows a quicker recovery (3-4 versus 6-7 days) (1,2,3). Nasodren® administered in monotherapy shows similar efficacy than the standard combination treatment, but with a quicker recovery. In patients with purulent RS, Nasodren® also showed a quicker recovery, with a 4-day difference vs. conventional treatment group (7.3 versus 11.4 days)  (1).
Clinical recovery (Cure): Nasodren® recovery from RS symptoms in 7-10 days of treatment, starting on days 6-7. Nasodren presents a faster cure

than the standard combined therapy (7-10 versus 10- 12 days) (1, 3). In children, Nasodrenâ recovery from clinical symptoms after 2-3 days of treatment. Nasodrenâ also normalized the rhinoscopic pattern quicker than in the control group (4-5 versus 8-10 days) (4,5).

In a cohort study, Nasodren® improved the overall state and reduced the relevant symptom in patients with ARS and CRS exacerbation in 5 days (6).

From this review it can be concluded that in all clinical studies Nasodren® shows that it is one of the treatment options for the beginning of an ARS episode, as monotherapy, even in non-purulent cases, as well as in combination. Compared with other treatments, Nasodren halved the time to relieve symptoms in adults and children, with a fast improvement in the general well-being and QoL of patients. Nasodren also reduces time to cure by 55% to 75% in comparison to the standard treatments, with an important contribution to the reduction of disease progression time, as well as to the number of complications and chronification (4).
BIBLIOGRAPHY

1) Mashkova TA, Matveeva VN. Objective evaluation of the effectiveness of secretolytic, secretostimulant therapy in complex treatment of acute rhinosinusitis. Russian Otorhinolaryngology 2007;5(30):109-112.

2) Ianov IuK, Riazantsev SV, Timchuk LE. [Efficacy of Sinuforte monotheraphy in patients with acute and chronic rhinosinusitis at an exacerbation stage]. Vestn Otorinolaringol 2007;(4):49-51.

3) Bogatov PP. Treatment of acute purulent sinusitis with Sinuforte. Rhinology, Journal of the Society of scientists and otorhinolaryngologists of Ukraine 2003:1.

4) Printz OM, Bashek V. Study of the use of Sinuforte® in the treatment of children with inflammatory conditions of the paranasal sinuses. Central Children’s Hospital in the city of ZHITOMIR (Ukraine). 2004.

5) Chernisheva LI, Siniachenko VV. Clinical and immunological investigation of the efficacy of Sinuforte use in children with acute sinusitis. J Otorynolaryngol Dis (Kiev) Special Edition 2004;3.

6) Timoshenko NA, Guriev TA. Experience on Sinuforte administration for the treatment of acute and chronic rhinosinusitis. 2nd International Conference of the Belarusian-Polish Otorhinolaryngologists. Grodno (Belarus), 2003.

7) Petrova LG. Treatment of exudative otitis media with Sinuforte. Journal of otorhinolaryngological diseases 2004;2.

Wednesday, January 25, 2012

Symptoms-sinus infections causing osteomyelitis

Symptoms-sinus infections causing osteomyelitis

Although osteomyelitis is rare now-a-days, the past medical records confirm that the physicians were aware of the disease even in the first century A.D. For instance, Celsus, the Roman physician, mentioned about osteomyelitis in 1st century A.D and suggested surgical removal of the affected bone.  In 17th century, Fabricius Hildanus described the osteomyelitis of the frontal bone.



The frontal sinuses’ mucous membranes have veins. These veins communicate with the sinus’s diploic veins draining the frontal bone and the marrow cavity. Since the intracranial venous sinus system and the veins have a direct contact, the veins deposit bacteria in the frontal bone’s marrow space and cause thrombophlebitis, and thereby spread the frontal sinus infection.
Spread of sinus infection into the cranial bone marrow via diploic veins causes local osteitis, the bone inflammation. The diploic veins, draining the frontal sinus via bone marrow, do not have valves, so spreading of the infection is easier. The frontal bone erosion may further the process and true osteomyelitis signs may develop.  The infection may even cross the suture lines, spreading the infection in vast area. The infection removes the dura matter from the bone’s inner surface. The loss of dura matter results in bone devascularization because the dura supplies blood to the bone.  As a result, signs of vascular necrosis (i.e. changes in morphology indicating death of the cells) appear and thereby the infection reaches the devascularized tissues easily.
To treat osteomyelitis, the affected bone is removed completely and the frontal sinus is obliterated. Post surgery, antibiotics are administered up to six weeks. The advent of antibiotics has checked the number of incidences, especially of the frontal osteomyelitis. The related mortality rate has declined from 60% before the invention of antibiotics to just about 4% in the post antibiotic era. Sooner the disease is diagnosed, lesser the chances of complications.
Symptoms-sinus infections, trauma, including surgical trauma, and the frontal sinus fracture can cause frontal osteomyelitis. The disease may appear after the first instance of the frontal sinusitis even if there is no trauma. Alternatively, it may occur when chronic symptoms-sinus infections are accompanied by acute infection. A number of osteomyelitis patients might have suffered from allergic rhino sinusitis in the past. Vascular insufficiency and immunodeficiency may aggravate the problem and reduce the effect of treatment therapy. Thus, these deficiencies should also be treated simultaneously. Generally, young adults and adolescents suffer from osteomyelitis. Divers and swimmers having acute bacterial sinusitis are prone to osteomyelitis.

Tuesday, January 24, 2012

Macrolide antibiotics for sinus symptoms

Macrolide antibiotics for sinus symptoms

There are over 2,000 macrolides extracted from natural sources besides their several synthetic and semi-synthetic derivations. Macrolide antibiotics, popular antimicrobial agents, have been associated with infectious disease treatment since ages. The agents boast a broad antimicrobial activity spectrum, high safety level on the therapeutic index and effective oral administration. However, macrolides have some limitations too: drug action starts slowly and lower efficacy against Gram +ve bacteria as compared to that of penicillin.  Since gastric acid destroys macrolides, they are sold as enteric-coated tablets. And, the absorption of macrolides depends on type of food consumed.




If patients suffering from H. influenzal sinusitis or streptococcal sinusitis are allergic to penicillin, macrolide antibiotics may be prescribed. Japan pioneered the use of macrolides to treat chronic sinus symptoms. In Japan, macrolide therapy is commonly used to treat chronic sinusitis and the sinusitis related to diffuse panbronchiolitis. Anti-inflammatory activity of macrolide antibiotics helps in treating chronic sinusitis. The macrolides used for treating the sinusitis include erythromycin (EM) and newly developed three macrolides- azithromycin (AZM), clarithromycin (CAM) and roxithromycin (RXM).  McGuire and his colleagues discovered EM derived from Streptomyces erthreus strain in mid of twentieth century. AZM, CAM and RXM are derived from EM.

EM, mainly Gram positive, is a common macrolide resembling penicillin G. Gram positive organisms include streptococci penumonea and pyogenes, B. anthracis and C. diptheriea, clostridia. However, there are also some Gram-negative organisms, such as H. influenzea, M. catarrhalis and N. meningitides.  

Newer AZM, CAM and RXM have long action duration. Administration frequency of these macrolides is low and thereby compliance is good. The macrolides have less impact on gastrointestinal tract (GIT), so these antibiotics are more tolerable. The three new macrolides have wider microorganism range consisting of Myco. Tuberculosis (atypical), Mycoplasma penumonea and H. influenza.

The semi-synthetic macrolide RXM is resistant to acid. Its oral tolerability is good. The drug is more active against G. vaginalis and Br. Catarrhalis. The antibiotic administration is also quite convenient. RXM is preferred for sinusitis, otitis media and pneumonia.

The antimicrobial spectrum of CAM resembles to that of EM. CAM is active against H. pylori, Mycoplasma pneumonia and Myco. avium complex (MAC). GIT irritation associated to CAM is less. Acid stable AZM is effective against N. gonorrhoea, mycoplasma and H. influenzea. The AZM drug is not metabolized.

Controlled clinical studies have shown that AZM and CAM are effective for acute bacterial sinusitis like amoxicillin-clavulanate and amoxicillin. Recent research studies also suggested that calrithromycin and azithromycin are comparable to amoxicillin in terms of efficacy to treat acute maxillary sinusitis. However, erythromycin (EM) is not prescribed for acute sinus symptoms.

Monday, January 23, 2012

What is Capsaicin in intranasal application?

What is Capsaicin in intranasal application?

Capsaicin is a phenolic chemical contained within the oil of the Capsicum pepper.

Capsaicin has been used clinically with moderate success as a topical treatment for pain from rheumatoid and osteoarthritis, psoriasis, diabetic neuropathy, and postherpetic neuralgia.



When used intranasally, capsaicin irritates the nasonasal area. However, the area becomes desensitized to the irritation after repeated use. Nerve endings responsible for rhinorrhea, sneezing, and congestion become desensitized when capsaicin is applied to the nasal mucosa. Capsaicin use has been targeted at patients presenting congestion, rhinorrhea, sneezing, or a combination of these symptoms.

Clinical studies revealed a 60% reduction in nasal airway resistance. In most patients, effectiveness continued for more than 4 months after study completion. In addition, most patients showed significantly improved scores on visual analog scales. However, no significant difference was documented for nasal blockage, rhinorrhea, sneezing, coughing, mucus production, or eye irritation before, during, or after study completion. Documented adverse reactions were limited to initial nasal irritation and increased nasal airway resistance.

The majority of studies on capsaicin intranasal application have been addressed to nasal mucosa pathologies (idiopathic rhinitis, allergic rhinitis, chronic rhinopathy, etc.).

A double-blind, randomized, placebo-controlled pilot study on capsaicin nasal spray was recently completed (pending publication). The study was designed to evaluate the effectiveness and safety of capsaicin for the treatment of sinus and nasal congestion in patients suffering from non-allergic rhinitis. It measured the improvement in nasal congestion, sinus pressure, and pain. It also evaluated speed of action and safety parameters. Key findings include:
  • Capsaicin started to provide relief from sinus/nasal congestion, pressure, and headache pain in less than one minute.
  • Capsaicin subjects continued to show a statistically significant improvement in nasal congestion and sinus pain at each of the established intervals and follow-up visits over the two-week duration of the study.
  • Capsaicin is a powerful solution for sinus congestion, pressure and headaches that not only provides immediate relief, but also sustains this relief throughout the course of the two-week treatment period.
  • Additional clinical trials are needed to confirm these findings in a larger patient population.

Capsaicin versus Nasodren /Sinuforte

Articles comparing the efficacy of Nasodren/Sinuforte versus capsaicin have not been published. According to available data, we have compiled the following table comparing both products:

 

Nasodren/Sinuforte

Capsaicin

Clinical trials in rhinosinusitis

15

1

Reduction of mucosal obstruction and mucopurulent secretion evaluated by endoscopy

Shown

Not Shown

Reduction of sinus occlusion evaluated by CT-Scan.

Shown

Not Shown

Provides significant therapeutic benefit in adults and children (aged ≥5 years) with acute and chronic rhinosinusitis as a first line, administered in monotherapy or in combination

Shown

Not Shown

 

 

Administered with other drugs efficacy is improved, especially with antibiotics, antibiotics + corticoids and decongestants

Shown

Not Shown

 

 

Is associated with lower costs per successfully treated patient, in terms of the health system and from a socio-economic perspective*

Shown

Not shown

* Pending publication

 

 

Thursday, January 19, 2012

Can divers be affected by a sinus barotrauma?

Can divers be affected by a sinus barotrauma?



Sinus barotrauma is the result of disparate pressure between the nose and sinuses as a result of ostial insufficiency. Even if the sinus ostium is sufficiently large to permit a gradual equalization of pressure, a person cannot be accommodated to the rapidly changing pressure that occurs during scuba diving. For this reason, sinus barotrauma is more commonly observed in divers.




Barotrauma of the sinuses in diving was reported more than 50 years ago. 7,8 The most common symptom is pain referred to the frontal area, although radiological examination showed that the maxillary sinus was most affected. X-rays showed a mucosal thickening and air/fluid levels. Half of the patients present a recent upper respiratory infection or symptoms referable to nasal disease.

The sinonasal symptoms and radiographic findings 10 were observed in a more recent study of 50 scuba divers affected by sinus barotrauma. 28% of patients developed an acute sinusitis 10, and another 14% of patients presented a preexisting chronic sinusitis (condition that predisposed the sinuses to recurrent barotrauma). The maxillary nerve involvement is the only neurological complication of sinus barotrauma. Possibly, repeated diving may foster permanent sinus mucosal changes or progressive ostial insufficiency. 10

It is important to differentiate between recurrent sinus barotrauma and chronic sinusitis. Patients with recurrent sinus barotrauma may have no clinical or radiological evidence of sinusitis between barotraumatic episodes. Upper respiratory infection, rhinitis, sinusitis, and intranasal pathology (e.g., nasal polyps or septal deviation) are a few factors that can compromise the capacity of the sinus ostia to accommodate the large, rapid pressure changes that occur during scuba dives. Ostial insufficiency always puts patients at risk of developing barotrauma when scuba diving. There are also some important barriers that separate the central nervous system and ocular globe from the nose and sinuses like, in all probability, the nasal mucosa, periosteum and dura. They are important in preventing the spread of infections from the nose to the eye or central nervous system, avoiding the complications reported here that would otherwise be much more common.

The air locked in patients who had a history of chronic sinusitis, may have formed within the sinuses or nasal cavity, the hyperplastic polypoid mucosa functioning like a ball valve, and both circumstances preventing highly pressurized air inspired at depth from escaping as the patients ascended. Complicating factors included the repeated, forceful Valsalva manoeuvre by both divers at depth; this manoeuvre can produce more than 250 mm Hg of pressure and could have forced pus through a small defect in the cribriform plate into the intracranial cavity (in the first diver) and air into the orbit and middle ear (in the second diver). As diver 2 ascended, the air in the orbit and middle ear expanded and compromised blood flow through the retinal artery. Pressurized air in the middle ear thus probably caused the inner ear barotrauma in each diver, as well as repeated episodes of facial palsy. 14

When examining patients with recurrent sinus barotrauma, clinicians should first rule out causative pathology by examining the nasal cavities endoscopically and possibly by obtaining a CT-scan of the sinuses. Divers with recurrent sinus barotrauma should be advised not to dive with a congested nasal cavity (e.g., during an upper respiratory infection or during an episode of either allergic or nonallergic rhinitis). In addition, intranasal disease (e.g., nasal polyps or septal deviation) in these divers may require correction to avoid compromising the ostiomeatal complex. Divers with persistent difficulty equalizing pressure in the ear and sinuses should be taught methods of equalizing this pressure. These divers should be advised to begin this equalization while at the surface of the water, then to descend slowly (with feet descending first) and to equalize continuously until a depth of 20 feet or more is reached. Those who have persistent difficulty clearing their ears and sinuses should be advised not to dive at all.

Patients who show evidence of chronic sinusitis should be treated with appropriate medical management. If radiological evidence of disease persists, functional endoscopic sinus surgery should be considered. If no clinical or radiological evidence of ostial insufficiency persists, then a pressure test should be conducted either in a hyperbaric chamber or (more practically) in a 14-foot or deeper swimming pool. If no pain develops at this depth, diving may be resumed. However, these patients must be warned that clearing may still be difficult and that this problem could result in disabling or life-threatening injuries.

Divers who present chronic rhinosinusitis should be instructed on the optimal control of their sinus disease and on non-forceful methods of clearing. Only when medical management fails, endoscopic sinus surgery is beneficial for preventing recurrent episodes of barotrauma in divers 11,13 who have recurrent or chronic sinusitis.

BIBLIOGRAPHY

1.
Roydhouse N. 1001 disorders of the ear, nose and sinuses in SCUBA divers. Can J Appl Sport Sci 1985; 10:99–103.

2.
Becker GD, Parell CJ. Otolaryngologic aspects of scuba diving. Otolaryngol Head Neck Surg 1979; 87:569–572.

3.
Buisson P, Darsonval V, Dubin J. Sinus infection and diving [in French]. Rev Laryngol Otol Rhinol (Bord) 1990; 111:141–143.

4.
Goldmann RW. Pneumocephalus as a consequence of barotrauma. JAMA 1986; 255:3154–156.

5.
Bellini MJ. Blindness in a diver following sinus barotrauma. J Laryngol Otol 1987; 101:386–389.

6.
Murrison AW, Smith DJ, Francis TJR, Counter RT. Maxillary sinus barotrauma with fifth cranial nerve involvement. J Laryngol Otol 1991; 105:217–219.

7.
Campbell PA. Aerosinusitis: its causes, course and treatment. Ann Otol 1944; 53:291–301. 


8.
Flottes L. Barotrauma of the ear and sinuses caused by underwater immersion [in Spanish]. Acta Otorinolaryngol Iber Am 1965; 16:453–483.

9.
Fagan P, McKenzie B, Edmonds C. Sinus barotrauma in divers. Ann Otol Rhinol Laryngol 1976; 85(1 Pt 1)61–64.

10.
Edmonds C. Sinus barotrauma: a bigger picture. SPUMS J 1994; 24(2):13–19. 


11.
Taniewski M, Graczyk M, Laba L. Mucous membrane of the nose and paranasal sinuses in professional divers. Bull Inst Marit Trop Med Gdynia 1979; 30:237–244.

12.
Parsons DS, Chambers DW, Boyd EM, Long-term follow-up of aviators after functional endoscopic sinus surgery for sinus barotrauma. Aviat Space Environ Med 1997; 68:1029–1034.

13.
Bartley J. Functional endoscopic sinus surgery in divers with recurrent sinus barotrauma. SPUMS J 1995; 25(2):64–66. 


14.
Becker GD. Recurrent alternobaric facial paralysis resulting from scuba diving. Laryngoscope 1983; 93:596–598.

Wednesday, January 18, 2012

Symptoms-sinus infections causing osteomyelitis

Symptoms-sinus infections causing osteomyelitis

Although osteomyelitis is rare now-a-days, the past medical records confirm that the physicians were aware of the disease even in the first century A.D. For instance, Celsus, the Roman physician, mentioned about osteomyelitis in 1st century A.D and suggested surgical removal of the affected bone.  In 17th century, Fabricius Hildanus described the osteomyelitis of the frontal bone.

The frontal sinuses’ mucous membranes have veins. These veins communicate with the sinus’s diploic veins draining the frontal bone and the marrow cavity. Since the intracranial venous sinus system and the veins have a direct contact, the veins deposit bacteria in the frontal bone’s marrow space and cause thrombophlebitis, and thereby spread the frontal sinus infection.




Spread of sinus infection into the cranial bone marrow via diploic veins causes local osteitis, the bone inflammation. The diploic veins, draining the frontal sinus via bone marrow, do not have valves, so spreading of the infection is easier. The frontal bone erosion may further the process and true osteomyelitis signs may develop.  The infection may even cross the suture lines, spreading the infection in vast area. The infection removes the dura matter from the bone’s inner surface. The loss of dura matter results in bone devascularization because the dura supplies blood to the bone.  As a result, signs of vascular necrosis (i.e. changes in morphology indicating death of the cells) appear and thereby the infection reaches the devascularized tissues easily.

To treat osteomyelitis, the affected bone is removed completely and the frontal sinus is obliterated. Post surgery, antibiotics are administered up to six weeks. The advent of antibiotics has checked the number of incidences, especially of the frontal osteomyelitis. The related mortality rate has declined from 60% before the invention of antibiotics to just about 4% in the post antibiotic era. Sooner the disease is diagnosed, lesser the chances of complications.

Symptoms-sinus infections, trauma, including surgical trauma, and the frontal sinus fracture can cause frontal osteomyelitis. The disease may appear after the first instance of the frontal sinusitis even if there is no trauma. Alternatively, it may occur when chronic symptoms-sinus infections are accompanied by acute infection. A number of osteomyelitis patients might have suffered from allergic rhino sinusitis in the past. Vascular insufficiency and immunodeficiency may aggravate the problem and reduce the effect of treatment therapy. Thus, these deficiencies should also be treated simultaneously. Generally, young adults and adolescents suffer from osteomyelitis. Divers and swimmers having acute bacterial sinusitis are prone to osteomyelitis.

Tuesday, January 17, 2012

Cephalosporin antibiotics

Cephalosporin antibiotics

Cephalosporins, commonly used antibiotics, are made from a fungus. Cephalosporins work against both Gram-negative and Gram-positive bacteria. When compared to penicillin, cephalosporins are more effective against Gram-negative bacteria and less effective against Gram-positive bacteria. However, both penicillin and cephalosporins have similar chemical compositions. Cephalosporins are broadly divided into the following four classes:

First-generation cephalosporins

Cefazolin sodium, the first generation cephalosporin, is active against staphylococci, streptococci, H. influenzae, P. mirabilis, C. diptheriae and Listeria.

Second-generation cephalosporins

These drugs are more effective for anaerobic and some Gram-negative organisms than the first generation cephalosporins. The antibiotics may therefore be used for infections that cannot be treated with other antibiotics, such as infections due to E. coli, Klebsiella species and Haemophilus influenzae. Cefprozil, cefurxime axetil, cefaclor and cefdinir, the 2nd generation cephalosporins, are used for treating symptoms-sinus.





Studies concluded that 250 mg of cefuroxime axetil is better than cefaclor in case of patients suffering from acute maxillary symptoms-sinus. Efficacy of amoxicillin and cefuroxime are same.

Cefoxitin sodium, the second-generation cephalosporin, works against B. fragilis, which is resistant to many common antimicrobial drugs.

Cefuroxime sodium, the second-generation cephalosporin, is similar to other cephalosporins of the second generation. It is administered to children suffering from bacterial meningitis.

Third-generation cephalosporins

The third-generation cephalosporin antibiotics are active against a wider range of Gram-negative bacteria. The drugs work against scores of strains resistant to 1st and 2nd generation cephalosporins and other antibiotics. Therefore, the drugs may be useful to treat infections caused by Providencia, Serratia and Citrobacter species. These drugs can also reach inflamed meninges, thus used for meningeal infections caused by Streptococcus penumoniae and H. influnenzae. As cephalosporins move from first to thrid generation, their activity against Gram-negative bacteria increases and activity against Gram-positive bacteria decreases. Since 2nd and 3rd generation drugs are highly resistant to cephalosporinases, the beta-lactamase enzymes released by inactive cephalosporins or some organisms, these are more effective for Gram-negative bacteria. The third generation cephalosporins are used for intracranial abscess caused by streptococci, and dural sinus thrombophlebitis, a complication of symptoms-sinus.

Cefotaxime sodium (claforan), the third generation cephalosporin, is known for ant-bacterial activity against numerous strains that are resistant to many other antibiotics, and Gram-negative and Gram-positive bacteria. The drug is prescribed to patients suffering from serious infections caused by microorganisms.

Ceftazidime (fortaz), the third generation cephalosporin, is active against bacterial strains resistant to amino glycosides and P. aeruginosa and other Gram-negative bacteria. It also works against Gram-positive organisms.

Ceftriazone sodium (rocephin), the third generation cephalosporin, is effective for most of the Gram-negative and Gram-positive bacteria.

Fourth-generation cephalosporins

The fourth generation drugs cover a wide range of anti-microbial activities. The drugs are more stable against beta-lactamase enzyme action when compared to the 3rd generation cephalosporins.

Cefepime, the first cephalosporin of the 4th generation cephalosporins, works against Gram-negative (P. aeruginosa) and Gram-positive (staphylococci and streptococci) bacteria. The drug is more effective against Enterobacteriaceae than the 3rd-generation cephalosporins.

Cefepime hydrochloride (maxipime), the fourth generation cephalosporin, is prescribed for infections caused by K. penumoniae or E. coli, and soft and skin tissue infection due to staphylococci and streptococci.

Monday, January 16, 2012

Brain abscess

Brain abscess

Brain abscesses are rare. The abscesses can occur from contiguous structures like sinuses or from distant sources. Thus, the brain abscesses can broadly be divided into two categories: contiguous abscesses and hematogenous abscesses (i.e. distant sources). The cases of contiguous foci-based abscesses are more common than that of from the distant sources.




The contiguous abscesses include abscess that originate within nose, throat and ear. These abscesses affect the cortical area. Infection spreads directly or indirectly. If infection source is known, organisms causing the abscess can generally be predicted.  For instance, frontal abscess due to sinusitis usually occurs because of streptococcus milleri.  A wide range of antibiotics is administered up to six months for treating the abscess. Complete removal of the affected body part is also necessary.

A brain abscess affecting the fontal lobe (cortical area) is generally secondary to the frontal sinuses’ symptoms(sinusitis). About 15% of brain abscesses are due to sinusitis. However, in developed nations, incidences of sinusitis related brain abscess have declined. Since the frontal lobe is generally neurologically silent, there may not be any signs indicating the abscess. Frontoethmoidal disorder is the main cause of the sinugenic brain abscesses, i.e. sinuses’ symptoms-induced abscess.

A brain abscess may grow slowly or rapidly. If the abscess forms gradually, minimal constitutional signs appear. Especially in case of frontal abscesses, only subtle changes in the behavior or mood are seen. However, if surrounding part of the brain has notable edema, intracranial pressure may increase. And if the abscess breaks within the ventricular system, patient dies quickly.  The abscess may also grow rapidly and the edema may lead to herniation of the uncus.

A sinuses symptoms-induced brain abscess usually occurs in boys and men who are in their 20s and 30s. The infection may spread directly or indirectly. In case of direct source, the infection may spread via meninges, intervening bone and tissues. The indirect source of the infection is diploic veins’ retrograde thrombophlebitis. The brain abscess location depends on predisposing causes. For instance, sinusitis related abscesses occur in the brain’s cortical area.

Common brain abscess symptoms

Patients having brain abscess may have the following symptoms:

Fever

Drowsiness

Lack of attention (inattention)

Generalized hemicranial headache

Minor changes in behavior or mood

Changes in mental status and reduced mental function

Seizures may occur before abscess’ surgical draining.

Increase in the intracranial pressure may cause vomiting and nausea.

Friday, January 13, 2012

Intracranial complications related to symptoms of sinus infections

Intracranial complications related to symptoms of sinus infections

In some cases, partially treated or untreated symptoms of sinus infections may cause various intracranial complications, such as meningitis, superior sagittal sinus thrombosis (SSST), intracerebral abscess, subdural empyema, epidural abscess and osteomyelitis. The frontal sinus infections are the main cause of intracranial disorders, followed by infections originating in the ethmoid, maxillary and sphenoid sinuses. Both acute stage of chronic sinusitis and acute sinusitis may result in intracranial problems, especially in adolescent male patients. If fever of an adolescent patient suffering from frontal sinusitis is not reducing and pain is not relieved within two days of starting the therapy, it implies that the intracranial problems have developed.





During intracranial complications, retrograde thrombophlebitis spreads the infection through Breschet’s veins, the diploic veins without valves. The diploic veins enable free flow between the sinuses and cranial periosteum, orbital and dural veins. The cortical and dural veins travel to the sagittal sinus, offering a direct channel for the movement of septic thrombi between the sinuses and brain parenchyma.

Although the complications related to symptoms of sinus infections are lethal, but with the invention of antibiotics, incidences of intracranial problems have reduced substantially. A successful treatment requires a multi-disciplinary approach. Services of neurosurgeons are needed. A surgical process done at right time will resolve both sinus infection and related intracranial problems. If ocular symptoms, particularly those reducing vision of the patient, increase, a quick surgery is necessary.

Antibiotics are administered intravenously to ensure that medicine reaches the affected area.  Initially, a combination of penicillin that is resistant to penicillinase and other antimicrobial agents is given to the patients. In fact, results of the culture of the affected area determine the most suitable antibiotic. Although steroids are a controversial treatment, these are used if the brain edema is severe. Seizures occur in about 80% of intracranial complications, thus anticonvulsant drugs are required.

For diagnosis, a high-resolution computed tomography (CT) scan of the sinuses, orbit and brain is required, but initial level pathology may not be clear in the scan and the sinus scan documents may not be accurate. Thus, the CT scan report should be studied with the report of a clinical examination while selecting the suitable therapy. Alternatively, a MRI scan can be used as it identifies the problem earlier than a CT scan and accurately. In some cases, additional image analysis is also required to assess the amount of infection and decide the time for surgery.

Thursday, January 12, 2012

What causes cavernous sinus thrombosis?

What causes cavernous sinus thrombosis?

Cavernous sinus thrombosis (CST), one of the infections-sinus-induced complications, affects cranial nerves passing through the cavernous sinus. This thrombophlebitis results in thrombosis and inflammation. Bilateral ocular findings are characteristic of CST, but unilateral ocular symptoms occurring simultaneously with meningitis symptoms may also indicate presence of the thrombosis. Bilateral CST is rare and fatal. The unilateral CST may affect the opposite eye within 48 hours of the onset of the thrombosis.

Generally, blood-borne infection travels from the paranasal sinuses, nasal cavity, ear or face to the cavernous sinus or the surrounding area via inferior and superior ophthalmic veins. The thrombosis, therefore, interrupts the venous flow, especially flow in the superior ophthalmic vein that is the main drainage channel of the orbit. Even untreated or poorly managed orbital infections may also cause CST. Staphylococcus aureus is the main cause of CST (up to 70% cases).

CST, a serious condition, can be of aseptic (non-infectious) or septic (infectious) origin. However, infections-sinus-induced CST, an ocular emergency, is septic. Although infections-sinus and orbital cellulites are principally responsible for CST, dental abscess, gingivitis and other odontogenic infections may lead to CST. If only one eye is affected, diagnosing CST is quite difficult. CST may also follow upper respiratory tract symptoms. CST may occur in immunity deficient host.  For instance, in diabetic patients, fungal sinusitis may cause CST.

The cavernous sinuses, located on the sides of the sphenoid, intercommunicate and feature a network of venous passages. The cerebral veins and superior ophthalmic vein supply blood to the cavernous sinuses. The cranial nerves passing through the cavernous sinus enters the orbit and performs many basic eye functions. For instance, cranial nerves III, IV and VI control eye movements. Except cranial nerve VI, all these nerves occupy cavernous sinus’s lateral wall. The cranial nerve VI is located near carotid artery and is affected by the cavernous sinus diseases fast due to its location.

CST could be dangerous. For instance, if phlebitis, inflammation of the veins, reaches the cortical veins and dural sinuses, abscesses, multiple cerebral thrombosis and meningitis may develop. If inflammation also affects the pituitary gland, pituitary insufficiency may occur. If contralateral ocular symptoms develop, loss of vision, paralysis of the eye muscles (ophthalmoplegia) and bulging of the eyeball (proptosis) may happen. However, blindness, ophthalmoplegia and pituitary insufficiency are non-fatal. The CST mortality rate is up to 30%, but untreated CST is fatal.

Wednesday, January 11, 2012

What is the value of Sinus punctures in Rhinosinusitis?

What is the value of Sinus punctures in Rhinosinusitis?

Sinus puncture is a technique used in the diagnosis of bacterial sinusitis and in the treatment of rhinosinusitis as a drainage procedure, when patients do not respond to medical treatment.
Sinus puncture as a diagnosis method for rhinosinusitis

Sinus puncture is used to identify acute rhinosinusitis and acute bacterial rhinosinusitis. It is the most accurate way to determine the causative organism in sinusitis. After anesthetization of the puncture site, usually in the canine fossa or inferior meatus, the contents of the maxillary sinus are aspirated under sterile technique, and bacterial cultures are performed to identify the organism. Culture specimens obtained from nasal swabs correlate poorly with sinus pathogens found by puncture because of contamination of the swab with normal nasal flora (1).
Sinus puncture provides culture material to guide antibiotic selection when empiric therapy has failed or when antibiotic choice is limited. This is particularly important in patients who are immunocompromised or under intensive care, in whom sinusitis can be a prominent source of sepsis (2). However, because sinus puncture is an invasive procedure, it is not routinely performed. Sinus puncture with culture is the diagnostic reference standard in some countries like Eastern European countries or Nordic countries, but in other countries it is rarely used because it is invasive and costly; it is not a practical routine procedure. Alternative less invasive reference standard methods for diagnosing acute rhinosinusitis are needed (3).
A meta-analysis of six studies shows that sinus radiography has moderate sensitivity (76 percent) and specificity (79 percent) compared with sinus puncture in the diagnosis of acute bacterial rhinosinusitis. Studies comparing sinus ultrasonography with puncture or sinus radiography were inconclusive in determining how well ultrasonography identifies patients with acute bacterial rhinosinusitis. The results of ultrasonography varied substantially, possibly because of differences in patient populations, ultrasonography techniques, or medical personnel involved in diagnostic testing (3). More recently, studies have shown a close correlation between organisms found by sinus puncture and by endoscopically guided aspiration of the sinus cavities through the middle meatus (1). No studies comparing magnetic resonance imaging with radiography or sinus puncture were found. The one randomized trial comparing computed tomography with sinus radiography was inadequately reported (3).
Future studies of clinical criteria (including risk scores), ultrasonography, and endoscopy with middle meatal sampling, ideally comparing them with sinus puncture in a variety of research and clinical settings, are needed to establish their diagnostic utility (3).

Sinus puncture as a treatment for Rhinosinusitis
Several techniques have been described for drainage of the maxillary sinus. Sinus puncture is used to drain sinus when appropriate medical therapy has failed to control the infection, resulting in prolonged or slowly resolving symptoms, or for the prevention of, or treatment for rhinosinusitis complications (2).
Sinus puncture and irrigation techniques allow for surgical therapy, a means of removing thick purulent sinus secretions. The purpose of surgical drainage is to enhance mucociliary flow and provide material for culture and sensitivity. A surgical means of sinus drainage should be used when appropriate medical therapy has failed to control the infection and prolonged or slowly resolving symptoms result, or when complications of sinusitis occur (2).
There are no statistics for the use of sinus puncture in diagnosis or treatment. In spite of the lack of a standard method of diagnosis or treatment for rhinosinusitis, the use of sinus puncture is controversial and changes from country to country.
Bibliography
1. Christine Radojicic. Sinusitis. Disease Management Project Main. August 1, 2010. (http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/allergy/rhino-sinusitis/)
2. S.E. Sobol, M D Schloss, T L Tewfik, Sinusitis, Maxillary, Acute, Surgical Treatment. E-Medicine: Medscape continually updated Clinical reference. Jul 14, 2009. (http://emedicine.medscape.com/article/862030-overview)
3. AHRQ Evidence Report Summaries. 9 Diagnoses and Treatment of Acute Bacterial Rhinosinusitis: Summary. Bookshelf ID: NBK11860. Rockville (MD): Agency for Healthcare Research and Quality (US); 1998-2005. (http://www.ncbi.nlm.nih.gov/books/NBK11860/)

Tuesday, January 10, 2012

Sinuses infection-induced eye complications

Sinuses infection-induced eye complications

The orbit (eye socket) is structurally located near the sinuses. Thus, sinuses’ infection may cause orbital complications if surgery is delayed, stubborn and virulent organisms are present, host immunity is impaired and medication is inadequate. The sphenoid and ethmoid sinuses bound the orbit medially. The frontal sinus is located superiorly, whereas the maxillary sinus is placed inferiorly. Ethmoid sinuses infection is the main reason of the complications followed by maxillary sinusitis and frontal sinusitis. The problems ascribed to the sphenoid sinusitis are rare. The complications may occur any time in life but generally are common in young children.

How does infection spread?

The infection may reach the orbit due to retrograde thrombophlebitis and direct extension. Retrograde thrombophlebitis means that infection spreads through the valve-less vein network enabling smooth movement between the orbit and the sinuses, nasal cavity and face. The eroded bony wall of the lamina papyracea, congenital body splitting or unstitched suture line may spread the infection.

Types of orbital complications

The orbital complications are divided into five groups: cavernous sinus thrombosis, inflammatory edema, orbital abscess, orbital cellulite and subperiosteal abscess.  Periorbital cellulite is the most common complication.
 
Cavernous sinus thrombosis (CST) is mainly ascribed to infection of the sphenoid and ethmoid sinuses. The infection may spread due to retrograde thrombophlebitis involving the ophthalmic vein or direct extension. Initially, the patient may suffer from periorbital edema, diplopia, photophobia, headache and fever.

Inflammatory edema is also called preseptal or periorbital cellulite. Eyelids swell near the orbital septum, but the orbit’s soft tissues are not affected. The septum prevents infection from spreading into the orbit. If extra ocular movement stops, soft tissues are also affected.

Orbital abscess means pus accumulation within the tissue of the orbit. This complication may lead to proptosis, which means forward displacement or projection of the eyeball, and loss of vision. The abscess may also limit the extra ocular movement.

Orbital cellulite implies inflammation and edema of the orbit area, but there is no abscess. Partial or complete paralysis of eye muscles (ophthalmoplegia), conjunctival edema (chemosis) and proptosis may occur. If the cellulite is not treated, an abscess may develop and the patient may become blind.

Subperiosteal abscess is pus accumulation between the orbital wall bone and the orbital periosteum. During initial stage, displacement may occur in the orbit area. If the infection continues to spread, ocular movement is affected, thereby conjunctival edema develops. The abscess may reach the eyelids.

Monday, January 9, 2012

21 interesting facts about nasal treatments

21 interesting facts about nasal treatments

  1. The 1500 BCE records reveal that Egyptians mastered the art and skill of removing the cranial material through the nose to avoid any disfiguration of the face while mummifying the bodies.

 

  1. Records of various rhinologic procedures practiced during 700 BCE are found in the Egyptian and Indian medical books.
  1. In 5th century, Susruta, the famous Indian surgeon, invented nasal reconstructive flaps and rhinoplasty that are still used.

 

  1. Do you know that physicians examined the anterior of the nose in candlelight until 16th century?
  1. In 1744, Boerhaave introduced a ground-breaking idea: nasal polyps are elongated sinus membranes.

 

  1. The German doctor Hirshberg reported aspirin sensitivity in 1899.
  1. In 1933, Shenck and Kern suggested that nasal polyps were related to allergy. The polyps were commonly found in the ethmoid air cell system.

 

  1. In 1940s, advancements in immuno-biology and  immuno-histochemistry techniques enabled description of lymphocyte and eosinophil present in the polyps.
  1. In 1959, Lurie discovered relationship between the polyps and cystic fibrosis for the first time.

 

  1. In 1969, Beer and Samter threw light on the triad of asthma, nasal polyps and aspirin sensitivity.
  1. In the end of the twentieth century, the first rigid and flexible fiber-optic endoscope was discovered. The invention changed the way upper aero-digestive tract was examined.

 

  1. Since Hippocrates influence was strong during golden age of the Greek civilization, he is remembered as the father of medicine and rhinology. However, Susruta used highly advanced surgical techniques to treat nasal disorders. Hippocrates recorded disorders related to nasal polyps and fractures. He named the nasal growth as polypus, as it resembled to the polyps found in the sea.  He defined polyps as “the sacs of phlegm that cause nasal obstruction and derange the sense of smell.”
  1. Hippocrates knew that nasal polyps are recurrent in nature.

 

  1. The world-famous physicians like Fabricius Hildanus, Paulus Aegineta and Claudius Galen also treated the polyps dexterously.
  1. Egyptian physicians believed that a bad smelling nose confirmed presence of polyps.

 

  1. Celsus said, “Large polyps dangled into the pharynx and on cold and damp days strangulate a man.”
  1. A crude nasal speculum was used by Hippocrates, Haly Abbas- an eminent Islamic medicine expert, and the Indian Ayurvedic physicians in bygone eras. In fact, these speculums were an improvisation of the instruments employed for rectal and gynecological examinations.

 

  1. Fabricius Hildanus invented an aural speculum, which resembles the modern speculum.
  1. Alfred Kirstein pioneered use of artificial light for nasal examination. He invented first headlight that inspired the modern headlights.

 

  1. In Greece, tampons and nasal packs soaked in copper salts and honey were used to prevent reoccurrence of polyps.
  1. The Roman physicians used turpentine and other irritating substances, calf tallow, goose fat and oily products to treat the polyps.