dr hab.n.med. Mariola Popko Zagor | Otolaryngologist

Endoscopic surgery of the paranasal sinuses

Rhinoplasties

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Specialty areas

Endoscopic surgery of the paranasal sinuses

Endoscopic sinus surgery is most often performed on patients who suffer from chronic sinusitis (CRS).
CRS symptoms include headache, nasal discharge, nasal congestion, and smell disorders. CRS therapy ought to be started with pharmacological treatment, and then – if the patient’s clinical condition does not improve – surgery ought to be considered.

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Rhinoplasties

The functional and aesthetic surgery of the external nose and nasal septum (rhinoplasty) is a surgical intervention that aims to improve nasal breathing and the appearance of the external nose, i.e. the improvement of both the form and function of the nose.
This goal is achieved by correcting a deformed nasal septum as well as the external nose.

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Neck ultrasound

The neck ultrasound examination is performed in the diseases of the salivary glands, thyroid gland, oral cavity, larynx, lower pharynx, and neck lymph nodes.

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PARANASAL SINUSITIS - important information for the patient
 
Table 1. Summary of Evidence-Based Statements

Statement

Action

Strength

1A. Differential diagnosis

Clinicians should distinguish presumed ABRS from ARS caused by viral upper respiratory infections and noninfectious conditions. A clinician should diagnose ABRS when (a) symptoms or signs of ARS (purulent nasal drainage accompanied by nasal obstruction, facial pain-pressure- fullness, or both) persist without evidence of improvement for at least 10 days beyond the onset of upper respiratory symptoms, or (b) symptoms or signs of ARS worsen within 10 days after an initial improvement (double worsening).

Strong recommendation

1B. Radiographic imaging and ARS

Clinicians should not obtain radiographic imaging for patients who meet diagnostic criteria for ARS, unless a complication or alternative diagnosis is suspected.

Recommendation

2. Symptomatic relief of VRS

Clinicians may recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of VRS.

Option

3. Symptomatic relief of ABRS

 Clinicians may recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of ABRS.

Option

4. Initial management of ABRS

Clinicians should either offer watchful waiting (without antibiotics) or prescribe initial antibiotic therapy for adults with uncomplicated ABRS. Watchful waiting should be offered only when there is assurance of follow-up, such that antibiotic therapy is started if the patient’s condition fails to improve by 7 days after ABRS diagnosis or if it worsens at any time.

Recommendation

5. Choice of antibiotic for ABRS

 If a decision is made to treat ABRS with an antibiotic agent, the clinician should prescribe amoxicillin with or without clavulanate as first-line therapy for 5 to 10 days for most adults.

Recommendation

6. Treatment failure for ABRS

If the patient worsens or fails to improve with the initial management option by 7 days after diagnosis or worsens during the initial management, the clinician should reassess the patient to confirm ABRS, exclude other causes of illness, and detect complications. If ABRS is confirmed in the patient initially managed with observation, the clinician should begin antibiotic therapy. If the patient was initially managed with an antibiotic, the clinician should change the antibiotic.

Recommendation

7A. Diagnosis of CRS or recurrent ARS

Clinicians should distinguish CRS and recurrent ARS from isolated episodes of ABRS and other causes of sinonasal symptoms.

Recommendation

7B. Objective confirmation of a diagnosis of CRS

The clinician should confirm a clinical diagnosis of CRS with objective documentation of sinonasal inflammation, which may be accomplished using anterior rhinoscopy, nasal endoscopy, or computed tomography.

Strong recommendation

8. Modifying factors

Clinicians should assess the patient with CRS or recurrent ARS for multiple chronic conditions that would modify management, such as asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia.

Recommendation

9. Testing for allergy and immune function

The clinician may obtain testing for allergy and immune function in evaluating a patient with CRS or recurrent ARS.

Option

10. CRS with polyps

The clinician should confirm the presence or absence of nasal polyps in a patient with CRS.

Recommendation

11. Topical intranasal therapy for CRS

Clinicians should recommend saline nasal irrigation, topical intranasal corticosteroids, or both for symptom relief of CRS.

 Recommendation

12. Antifungal therapy for CRS

Clinicians should not prescribe topical or systemic antifungal therapy for patients with CRS.

Recommendation
Table 2. Acute Rhinosinusitis Definitions

Term

Definition

Acute rhinosinusitis (ARS)

 TUp to 4 weeks of purulent nasal drainage (anterior, posterior, or both) accompanied by nasal obstruction, facial pain-pressure-fullness, or both:a Purulent nasal discharge is cloudy or colored, in contrast to the clear secretions that typically accompany viral upper respiratory infection, and may be reported by the patient or observed on physical examination. Nasal obstruction may be reported by the patient as nasal obstruction, congestion, blockage, or stuffiness, or may be diagnosed by physical examination. Facial pain-pressure-fullness may involve the anterior face, periorbital region, or manifest with headache that is localized or diffuse.
Viral rhinosinusitis (VRS)

Acute rhinosinusitis that is caused by, or is presumed to be caused by, viral infection. A clinician should diagnose VRS when:

  1. symptoms or signs of acute rhinosinusitis are present less than 10 days and the symptoms are not worsening

Acute bacterial rhinosinusitis (ABRS)

Acute rhinosinusitis that is caused by, or is presumed to be caused by, bacterial infection. A clinician should diagnose ABRS when:

  1. symptoms or signs of acute rhinosinusitis fail to improve within 10 days or more beyond the onset of upper respiratory symptoms, or
  2. symptoms or signs of acute rhinosinusitis worsen within 10 days after an initial improvement.
a Facial pain-pressure-fullness in the absence of purulent nasal discharge is insufficient to establish a diagnosis of ARS
Table 3. Patient Information Sheet on Diagnosis of Acute Sinusitis

Question

Answer

What are the sinuses?

 Sinuses are hollow spaces in the bones around the nose that connect to the nose through small, narrow channels.The sinuses stay healthy when the channels are open, which allows air from the nose to enter the sinuses and mucus made in the sinuses to drain into the nose.

What is sinusitis?

 Sinusitis, also called rhinosinusitis, affects about 1 in 8 adults annually and generally occurs when viruses or bacteria infect the sinuses (often during a cold) and begin to multiply. Part of the body’s reaction to the infection causes the sinus lining to swell, blocking the channels that drain the sinuses.This causes mucus and pus to fill up the nose and sinus cavities.

How can I tell if I have acute sinusitis?

 You have acute sinusitis when there has been up to 4 weeks of cloudy or colored (not clear) drainage from the nose plus one or both of the following: (a) a stuffy, congested, or blocked nose or (b) pain, pressure or fullness in the face, head, or around the eyes.

How can I tell if my sinusitis is caused by viruses or bacteria?

 Acute viral sinusitis is likely if you have been sick less than 10 days and are not getting worse. Acute bacterial sinusitis is likely when you do not improve at all within 10 days of getting sick or when you get worse within 10 days after beginning to get better.

Why is it important to tell if my sinusitis is caused by bacteria?

 Because sinusitis is treated differently based on cause: acute viral sinusitis does not benefit from antibiotics, but some patients with acute bacterial sinusitis may get better faster with an antibiotic.
Table 4. Patient Information Sheet on Treating Acute Bacterial Rhinosinusitis (ABRS).

Question

Answer

How long will it take before I feel better?

 Most patients with ABRS feel better within 7 days, and by 15 days, about 90% are cured or improved

Is there anything I can do for symptomatic relief?

 There are several ways to relieve sinusitis symptoms that should be discussed with your doctor to decide which are best for you:

  1. Acetaminophen or ibuprofen can relieve pain and fever.
  2. Saline irrigations, or washing out the nose with salt water, can relieve symptoms and remove mucus that is hard to blow out.
  3. Nasal steroid sprays can reduce symptoms after 15 days of use, but the benefit is small (about 14 people must use them to get 1 person better), and side effects include headache, nasal itching, and nosebleeds.
  4. Decongestants may help you breathe easier and can be taken as a nasal spray (for no more than 3 days in a row to avoid worsening congestion) or by mouth.

Is there anything I should not do?

 Antihistamines and oral steroid medicines should not be used routinely because they have side effects and do not relieve symptoms.

If I have ABRS, do I have to take an antibiotic?

 No, both watchful waiting and antibiotic therapy are proven ways to treat ABRS. Most people get better naturally, and antibiotics only slightly increase symptom relief (about 10 to 15 people must use antibiotics to get 1 more person better after 7-15 days).

Is there any downside to using antibiotic?

 Antibiotics have side effects that include rash, upset stomach, nausea, vomiting, allergic reactions, and causing resistant germs.

What is “watchful waiting” for ABRS?

 Watchful waiting means delaying antibiotic treatment of ABRS for up to 7 days after diagnosis to see if you get better on your own.
How is watchful waiting done? Your doctor can give you an antibiotic prescription, but you should only fill the prescription and take the antibiotic if you do not get better after 7 days or if you get worse at any time. If you do use the antibiotic, contact your doctor’s office and let them know.
If I use an antibiotic, for how many days should I take it? Antibiotics are usually given for 10 days to treat ABRS, but shorter courses may be equally effective. Ask your doctor about a 5- to 7-day course of antibiotics since side effects are less common.
Table 5. Factors That Would Prompt Clinicians to Consider Prescribing Amoxicillin-Clavulanate Instead of Amoxicillin Alone for Initial Management of Acute Bacterial Rhinosinusitis (ABRS).

Factor

Comment

Situations in which bacterial resistance is likely
  1. Antibiotic use in the past month.
  2. Close contact with treated individuals, health care providers, or a health care environment.
  3. Failure of prior antibiotic therapy.
  4. Breakthrough infection despite prophylaxis.
  5. Close contact with a child in a daycare facility.
  6. Smoker or smoker in the family.
  7. High prevalence of resistant bacteria in community.

Presence of moderate to severe infection
  1. Moderate to severe symptoms of ABRS.
  2. Protracted symptoms of ABRS.
  3. PFrontal or sphenoidal sinusitis.
  4. History of recurrent ABRS.

Presence of comorbidity or extremes of life
  1. Comorbid conditions, including diabetes and chronic cardiac, hepatic, or renal disease. 
  2. Immunocompromised patient.
  3. Age older than 65 years.
Table 6. Definitions of Chronic Rhinosinusitis and Recurrent Acute Rhinosinusitis.

Term

Definition

Chronic rhinosinusitis

 Twelve weeks or longer of two or more of the following signs and symptoms:
  • mucopurulent drainage (anterior, posterior, or both),
  • nasal obstruction (congestion),
  • facial pain-pressure-fullness, or
  • decreased sense of smell.

AND inflammation is documented by one or more of the following findings:
  • purulent (not clear) mucus or edema in the middle meatus or anterior ethmoid region,
  • polyps in nasal cavity or the middle meatus, and/or
  • radiographic imaging showing inflammation of the paranasal sinuses.

Recurrent acute rhinosinusitis

Four or more episodes per year of acute bacterial rhinosinusitis (ABRS) without signs or symptoms of rhinosinusitis between episodes:
  • each episode of ABRS should meet diagnostic criteria in Table 4
Table 7. Patient Instructions for Optimal Use of Topical Nasal Steroid.*
  1. Shake the bottle well.
  1. Look down by bending your neck and looking toward the floor.
  1. Put the nozzle just inside your nose using your right hand for the left nostril and your left hand for the right nostril.
  1. Aim toward the outer wall and squirt once or twice as directed; do not aim toward the nasal septum (in the middle of the nose) to prevent irritation and bleeding.
  1. Change hands and repeat for other side.
  1. Do not sniff hard.

* Adapted from Scadding and colleagues. [272]