A CLINICAL COURSE IN RHINOLOGY
From the Medical College of Georgia’s Southern States Rhinology Course
| The Medical Management of Rhinosinusitis—Brent Senior, MD, Associate Professor, Department of Otolaryngology–
Head and Neck Surgery, and Chief, Rhinology, Allergy, and Sinus Surgery, University of North Carolina, School of Medicine,
Chapel Hill
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| Diagnosis: differential—includes noninfectious, infectious, and allergic causes; infectious causes include viral upper
respiratory infection (URI), acute bacterial illness, or chronic bacterial or fungal illness; rhinosinusitis task force criteria
(1997)—designated major symptoms as nasal obstruction, decreased sense of smell, pus in nasal cavity, fever in children,
and facial pain and pressure in conjunction with other factors; minor symptoms listed as headache, fever, halitosis,
fatigue, dental pain, cough, and ear pain; however, criteria ineffective for accurately diagnosing rhinosinusitis; study—of
78 patients who met criteria for sinusitis, only ≈50% showed evidence of significant mucosal thickening on computed tomography
(CT); CT findings did not correlate with symptom severity; new paradigm in diagnosis—rhinosinusitis disease
of mucosal inflammation, not purely infectious; chronic rhinosinusitis defined as disease of ≥12 wk duration, with
physical findings on endoscopy or anterior rhinoscopy; CT helpful in making diagnosis, but not necessary, especially if
endoscopy available
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| Etiology of chronic rhinosinusitis: mucosal infectious disease—acute bacterial rhinosinusitis infectious disease
associated with Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis; however, chronic sinusitis
involves different pathogens (eg, coagulase-negative staphylococcal species, Staphyloccocus aureus, Streptococcus
viridans, oral organisms); in addition, some studies show fairly high incidence of anaerobic bacteria; speaker’s study
of patients with chronic sinusitis found high incidence of Pseudomonas, coagulase-negative Staphylococcus species, and
S aureus during postoperative period; bone involvement—patients with chronic sinusitis show osteitis or osteomyelitis;
study used histomorphometry (ie, tetracycline bone labeling) to look at bone activity; chronic sinusitis associated with
marked bone activity; patients with chronic sinusitis show same pattern of bone activity as patients with chronic osteomyelitis
of long bones (organisms cannot be cultured); fungal involvement—study found positive fungal cultures in 202
of 210 patients with chronic rhinosinusitis; allergic mucin found in 97 of 101 consecutive surgical cases; however, 14
control subjects had positive fungal cultures; another study found 40% of 5-day-old neonates had positive fungal cultures
from nasal mucosa, as did 94% of 4-mo-old infants
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| Other etiologies: staphylococcal superantigen—enterotoxin and toxic shock syndrome (TSS) associated with superantigen
activity; 20% of T cells activated, compared to 1 in 10000 T cells activated with normal antigen; consistent with observation
of immune system overactivation in chronic sinusitis; biofilms—bacteria form colonies that “take on life form of
their own”; bacteria that would normally succumb to specific antibiotic, less susceptible when part of colony or biofilm
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| Antibiotic therapy for sinusitis: Food and Drug Administration (FDA) list of approved antibiotics for acute maxillary
sinusitis includes β-lactams (amoxicillin–clavulanate, cefdinir, cefpodoxime, cefprozil, cefuroxime, and loracarbef),
macrolides (clarithromycin, telithromycin, and azithromycin), and quinolones (ciprofloxacin, gatifloxacin,
levofloxacin, and moxifloxacin); no FDA-approved antibiotics for ethmoid sinusitis or for chronic sinusitis; list does not
include drugs approved by other agencies for treatment of sinusitis, eg, amoxicillin, erythromycin, or sulfonamides; antibiotic
resistance—altered penicillin-binding proteins found in S pneumoniae; efflux mechanism of antibiotic resistance;
topoisomerases can neutralize quinolones; target protein alteration occurs within bacterium; S pneumoniae resistance to
macrolides, clindamycin, and doxycycline issue in community-acquired infections
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| Guidelines for treatment of acute bacterial rhinosinusitis: mild to moderate—if patient not treated with
antibiotics in previous 6 wk, consider amoxicillin–clavulanate (≈90% effective), amoxicillin (87%-88% effective), cefpodoxime,
cefdinir, and cefuroxime (83%-87% effective); patients allergic to penicillin without previous treatment—
consider trimethoprim–sulfamethoxazole (TMP–SMX; 83% effective), doxycycline (81% effective), or macrolides (77%
effective); moderate sinusitis (patient exposed to antibiotics)—quinolones (92% effective), amoxicillin-clavulanate (91%
effective), and ceftriaxone (91% effective); patients allergic to penicillin with previous treatment—quinolones, clindamycin,
and rifampin
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| Adjunctive treatments: consider in patients with chronic and acute sinusitis; none approved by FDA; oral steroids—
beneficial in chronic rhinosinusitis, especially in patients with polyps; questionable role in acute rhinosinusitis; drug
course >14 days requires tapering; dose packs fall to subtherapeutic levels after 2 days; direct dose-risk relationship with
long-term systemic steroid use; low-dose short courses can cause adverse effects, including aseptic necrosis of hip; long-
term use associated with suppression of hypothalamic-pituitary-adrenal axis (HPA) function, ocular hypertension, osteoporosis,
and posterior capsular cataracts; consider separate consent; intranasal steroids—first-generation, eg, beclomethasone,
have breakdown product with active metabolite, thus not as safe as second-generation; second-generation
steroids (eg, budesonide, fluticasone, mometasone) associated with greater in vitro potency, no HPA suppression at standard
doses (except possibly fluticasone), almost completely metabolized by liver on first pass, and have similar clinical
efficacy; intranasal steroids in children—data suggest reduction in growth velocity can occur; more common with first
than with second generation; consider getting consent; decongestants—little experimental support for efficacy and resolution
of symptoms, but subjective accounts indicate benefits; mucolytics (eg, guaifenesin)—no data to support use, but
probably beneficial; may encourage mucociliary action; nasal saline irrigation/steam inhalation—may encourage mucocilary
activity; leukotriene inhibitors—5-lipoxygenase inhibitors and receptor antagonists may have benefit; subjective
improvement in symptoms suggested; nebulized antibiotics, topical antibiotics, and rinses—some studies suggest
benefit; macrolide anti-inflammatory properties—macrolides associated with improvement in 20-Item Sino-Nasal Outcome
Test (SNOT-20), endoscopic appearance, and interleukin (IL)-8 level in patients with chronic rhinosinusitis; antifungal
agents—2 uncontrolled reports showed improvement in polyps in patients with chronic rhinosinusitis; another
study found 75% of patients had subjective improvement from intranasal antifungal agents, and 25% of patients had objective
improvement; controlled report (2004) found 2 of 28 subjects on topical amphotericin B had improvement; double-blind
study in 30 patients found no difference in groups based on symptoms, but significant improvement seen on CT
and endoscopy
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| Managing Epistaxis—Rodney J. Schlosser, MD, Associate Professor, Department of Otolaryngology–Head and Neck Surgery,
Medical University of South Carolina, and Director of Rhinology and Sinus Surgery, The Nose and Sinus Center,
Charleston, SC
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| Vascular supply to nose: sphenopalatine artery (SPA) branches into posterior lateral nasal artery (goes to back of
inferior turbinate and basal lamella) and nasal septal artery (supplies posterior septum), which frequently branch before
exiting sphenopalatine foramen; anterior and posterior ethmoid arteries receive blood supply from internal carotid artery;
anterior septal and alar branches of facial artery; anterior ethmoid neurovascular bundle—can be on mesentery up to 5
mm below skull base; on CT, anterior ethmoid artery located by finding most posterior cut of globe, starting transition
into optic nerve (artery 1 or 2 cuts on either side of this cut); if on mesentery, greater chance for injuring it intraoperatively;
anterior ethmoid artery can be surrounded by dura mater, so if transected, cerebrospinal fluid (CSF) leak can occur
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| Refractory epistaxis: defined as bleeding that continues after 15 min of applied pressure, multiple episodes in which
packing placed, blood loss requiring transfusions, or true posterior nasal bleeding; risk factors—hypertension; medications;
herbal supplements; bleeding disorders; vascular abnormalities (eg, arteriovenous malformations, vascular tumors,
hereditary hemorrhagic telengiectasia [HHT])
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| Treatment: options include control of etiologic factors, cauterization, packing, and surgery; simple cauterization—
consider using scissors to flake pieces of silver nitrate off stick and applying these with otologic alligator forceps to
precisely cauterize septum or area of inferior turbinate; traditional nasal packing—consider if cautery fails; options
include pneumatic balloons, Foley catheter, or vasoline gauze; newer materials associated with improved healing may
not improve hemostasis; higher percentage of postpacking adhesions found with pneumatic balloons, compared to traditional
packing methods; higher incidence of granulation tissue and ingrowth associated with large-pore-size packing
material (eg, gauze); consider newer absorbable materials for packing, because removal creates trauma; some products
contain hyaluronic acid (HA; eg, MeroGel, SepraPak); some products specifically designed for hemostasis (eg, FloSeal,
Surgiflo); some studies suggest some products produce increased granulation tissue and synechiae; study using
animal model found HA products can produce inflammatory response, resulting in ingrowth of material as mucosa regenerates;
speaker recommends sewing expandable sponge onto glove finger (avoids ingrowth of granulation tissue,
easily placed and removed, and well tolerated by patient); controversies—no evidence that oral antibiotics or antibiotic-impregnated
packing materials improve effectiveness or prevent infections; prophylactic antibiotics not effective
in preventing toxic shock syndrome (TSS); myospherulosis associated with lipid-containing packing materials; avoid
use of ointments during packing; embolization—requires good interventional radiologist; facial and internal maxillary
arteries embolized, depending on site of bleeding and results of angiography; success rates 88% to 90%; serious adverse
effects include facial nerve palsy, permanent blindness, stroke, and lip numbness
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 | Surgical intervention: transnasal SPA ligation—studies show success rate equal to that of embolization, and more successful
than other techniques, eg, nasal packing; perform in bloodless field if inexperienced with procedure; consider
maxillary antrostomy; technique—take down posterior fontanelle to hard palatine bone; elevate on broad front; identify
crista ethmoidalis of perpendicular plate of palatine bone; remove crista and curette back wall of maxillary sinus;
trace SPA proximally to internal maxillary artery (IMA) as far as needed; clip or use bipolar cautery on main trunk; use
piece of Surgicel and standard vascular clip if bleeding occurs
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| Anterior ethmoid artery ligation: consider if SPA embolization or ligation fails; can perform simultaneously
with transnasal SPA ligation; performed externally or endoscopically; endoscopic approach—get CT of sinuses to locate
SPA; perform ethmoidectomy and take down lamina; dissect all way up with bipolar cautery; external ligation—
use standard Lynch incision; know measurements of anterior and posterior arteries and optic nerve; avoid posterior ethmoid
artery (3-6 mm from optic nerve)
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| Inherited disorders: eg, HHT or Osler-Weber-Rendu disease; potassium titanyl phosphate (KTP) laser—can work
on only one side of septum at time; speaker uses suction irrigator to evacuate smoke; to decrease bleeding, speaker lasers
circumferentially around normal tissue before approaching lesion; >1 treatment may be required; do not touch mucosa
with laser (may cause more bleeding); septodermoplasty—indicated in patients who fail laser cautery; study found decrease
in transfusions and improvement in quality of life, but many patients required multiple secondary procedures
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| Gastroesophageal Reflux Disease (GERD), Refractory Sinusitis, and Postnasal Drip—John M. DelGaudio, MD, Chief of
Rhinology and Sinus Surgery, Emory University School of Medicine, Atlanta, GA
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| Gastroesophageal reflux disease (GERD): common symptoms include hoarseness, globus sensation, throat
clearing, phlegm, postnasal drip, cough, and sore throat; less common symptoms include reactive airway disease, laryngospasm,
burning mouth syndrome, burning tongue, bad taste in mouth, and halitosis; associated disease processes—
chronic laryngitis, vocal process granulomas, idiopathic subglottic stenosis, adenoid hypertrophy, chronic sinusitis, and
middle ear disease in children
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| Nasopharyngeal reflux and refractory sinusitis: direct exposure of nasal mucosa to reflux of gastric acid;
no mechanism that protects nasopharynx from gastric acid; study data—studies looking at Helicobacter pylori and
chronic sinusitis found no correlation; mucociliary clearance affected when nasal mucosa drops to pH 5.5; study found
greater incidence and frequency of pharyngeal acid reflux events in patients with medically refractory chronic sinusitis;
retrospective study found history of gastroesophageal reflux correlated strongly with failure of endoscopic sinus surgery;
study in children who failed traditional medical therapy for chronic sinusitis found that therapy for reflux resulted in dramatic
improvement of symptoms in 89% of children; another study looked at 65 middle ear effusions in children; 59 of
65 middle ear effusions had pepsin or pepsinogen levels 1000 times higher than serum; cannot have that much pepsin
without direct reflux into nasopharynx, through eustachian tube, and into middle ear; pepsin active up to pH 7
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| Diagnosis: pH study only diagnostic test for GERD (pH <4 for ≥4% of study indicates abnormal reflux in esophagus);
for laryngopharyngeal reflux (LPR), no uniformly accepted criteria for abnormal reflux in pharynx; nasopharyngeal
reflux—study looking at direct nasopharyngeal reflux of gastric acid in surgically refractory chronic sinusitis patients
who had ≥1 sinus surgeries and continued to have mucosal inflammation; ≈40% of patients in experimental group had
nasopharyngeal reflux events at pH <4.0, compared to 1 in 10 of patients with successful sinus surgery and 1 in 19 of normal
controls; 76% of experimental group had nasopharyngeal reflux at pH <5.0, compared to 50% of patients with successful
sinus surgery and 2 in 19 normal controls
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| Treatment issues: chronic sinusitis multifactorial disease; consider treatment with proton pump inhibitors (PPIs) in
patients still symptomatic after sinus surgery who have mucosal inflammation, and especially if postnasal drip main
symptom; study found patients with positive pH study in nasopharynx at pH <5 had significantly more complaints of
postnasal drip, compared to patients with negative pH study; start patients on once-daily PPI therapy; consider bid therapy
if still symptomatic after 3 mo; treat patients empirically; standard pH probe study uncomfortable; new probe coming
out that measures pH of aerosolized refluxate at upper esophageal sphincter; accuracy equivalent to standard probe
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Questions and Answers
| Is PPI therapy linked to increased risk for gastric cancer? no reported cases
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| When do you use H2 blockers? at night in patients with refractory disease
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| Which patients do you scope? those with refractory disease because of correlation with Barrett’s esophagus
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| Are you performing transnasal esophagoscopy? speaker does not because of possible complications; if scoping deemed
necessary, patient sent to gastroenterologist
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| Are patients on once-daily PPI therapy treated before breakfast or before dinner? breakfast
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Suggested Reading
Coffey CS et al: Endoscopically guided aerobic cultures in postsurgical patients with chronic rhinosinusitis. Am J
Rhinol 20:72, 2006; DelGaudio JM: Direct nasopharyngeal reflux of gastric acid is a contributing factor in refractory
chronic rhinosinusitis. Laryngoscope 115:946, 2005; Dibaise JK et al: Does gastroesophageal reflux contribute
to the development of chronic sinusitis? A review of the evidence. Dis Esophagus 19:419, 2006; Douglas R et
al: Update on epistaxis. Curr Opin Otolaryngol Head Neck Surg 15:180, 2007; Geisthoff UW et al: Health-related
quality of life in hereditary hemorrhagic telangiectasia. Otolaryngol Head Neck Surg 136:726, 2007; Kennedy
DW et al: Histology and histomorphometry of ethmoid bone in chronic rhinosinusitis. Laryngoscope 108:502,
1998; Pincus RL et al: A study of the link between gastric reflux and chronic sinusitis in adults. Ear Nose Throat
J 85:174, 2006; Pletcher SD et al: Endoscopic ligation of the anterior ethmoid artery. Laryngoscope 117:378,
2007; Weldon D: Laryngopharyngeal reflux and chronic sinusitis. Curr Allergy Asthma Rep 7:197, 2007; Wise
SK et al: Association of nasopharyngeal and laryngopharyngeal reflux with postnasal drip symptomatology in patients
with and without rhinosinusitis. Am J Rhinol 20:283, 2006.
Educational Objectives
| The goal of this program is to improve the management of rhinosinusitis, epistaxis, and refractory sinusitis related to
nasopharyngeal reflux. After hearing and assimilating this program, the clinician will be better able to:
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| 1. Discuss the inadequacies of the diagnostic criteria for rhinosinusitis.
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| 2. List the etiologies for chronic rhinosinusitis.
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| 3. List the risk factors for refractory epistaxis.
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| 4. Evaluate the treatment options for refractory epistaxis.
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| 5. Describe the relationship between chronic sinusitis and nasopharyngeal reflux.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose
relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any
identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary
business or commercial interest. For this program, the following has been disclosed: Dr. Senior is a consultant
for Brainlab, and Dr. Schlosser is a consultant for Brainlab, Xomed, Gyrus, and Johnson & Johnson. Dr.
DelGaudio received research funding from AstraZeneca.
Acknowledgements
Drs. Senior, Schlosser, and DelGaudio were recorded October 19-21, 2006, in Augusta, GA, at The Southern States
Rhinology Course, sponsored by the Medical College of Georgia. The Audio-Digest Foundation thanks the speakers
and the Medical College of Georgia for their cooperation in the production of this program.
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