Endoscopic surgery of the paranasal sinuses
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.
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.
The neck ultrasound examination is performed in the diseases of the salivary glands, thyroid gland, oral cavity, larynx, lower pharynx, and neck lymph nodes.
PARANASAL SINUSITIS - important information for the patient
Table 1. Summary of Evidence-Based Statements
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).
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.
2. Symptomatic relief of VRS
Clinicians may recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of VRS.
3. Symptomatic relief of ABRS
|Clinicians may recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of ABRS.|
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.
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.|
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.
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.
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.
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.
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.
10. CRS with polyps
The clinician should confirm the presence or absence of nasal polyps in a patient with CRS.
11. Topical intranasal therapy for CRS
Clinicians should recommend saline nasal irrigation, topical intranasal corticosteroids, or both for symptom relief of CRS.
12. Antifungal therapy for CRS
Clinicians should not prescribe topical or systemic antifungal therapy for patients with CRS.
Table 2. Acute Rhinosinusitis Definitions
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:
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:
|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
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).
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:|
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).
Situations in which bacterial resistance is likely
Presence of moderate to severe infection
Presence of comorbidity or extremes of life
Table 6. Definitions of Chronic Rhinosinusitis and Recurrent Acute Rhinosinusitis.
|Twelve weeks or longer of two or more of the following signs and symptoms:|
AND inflammation is documented by one or more of the following findings:
Recurrent acute rhinosinusitis
Four or more episodes per year of acute bacterial rhinosinusitis (ABRS) without signs or symptoms of rhinosinusitis between episodes:
Table 7. Patient Instructions for Optimal Use of Topical Nasal Steroid.*
* Adapted from Scadding and colleagues.