MANAGING DISORDERS OF THE NOSE AND SINUS
| SINUS MEDICATIONS: BEYOND ANTIBIOTICS AND STEROIDS —Andrew H. Murr, MD, Professor of Clinical
Otolaryngology–Head and Neck Surgery, and Roger Boles Endowed Chair in Otolaryngology Education, University of
California, San Francisco, School of Medicine
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| Sinus disease: status of medical therapy—use of prescription antibiotics exceeds predicted incidence of acute and
chronic rhinosinusitis caused by bacterial infection; frequency of antibiotic class used not congruent with antimicrobial
efficacy of respective antibiotic classes; despite contradictory findings on efficacy reported in literature, inhaled corticosteroids
frequently used to treat acute rhinosinusitis; point—categorizing sinus disease helps develop targeted therapies
for important health problem
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| Practice guidelines for rhinosinusitis in adults: definitions (clinical parameters)—acute rhinosinusitis (≤4 wk of
purulent nasal discharge with associated nasal obstruction, facial pain or pressure, and fullness); acute bacterial rhinosinusitis
(symptoms and signs same as for acute rhinosinusitis, but can be present for ≥10 days beyond onset of upper respiratory
infection [URI] or worsen rather than ameliorate during 10-day period); chronic rhinosinusitis (≥2 signs or
symptoms lasting ≥12 wk, including mucopurulent discharge, nasal obstruction, facial pain, pressure, fullness, and decreased
sense of smell; inflammation documented by ≥1 finding, including purulent mucus or edema in middle meatus or
ethmoid region, polyps in nasal cavity or meatus, or radiographic imaging documenting problems); recurrent acute rhinosinusitis
(defined as ≥4 episodes of acute bacterial rhinosinusitis [ABRS] per year; signs and symptoms resolve between
episodes); bias of parameter—relying on time parameter to make diagnosis accepts notion of treatment failure;
maintaining treatment for weeks without improvement maintains dependence on bacterial/viral model of disease; lack of
emphasis placed on role of inflammation in disease process
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| Targeting causation: would lead to development of diagnostic criteria beyond history and physical examination, and
enable development of objective tests for disease; would enable development of therapies targeting causation
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| Therapeutic targets: biofilms—“blanket” of bacteria does not invade tissue directly, and functionally eludes dispersion
through mechanical organization; diagnosed by electron microscopy (light microscopy investigated as diagnostic
tool); can be broken up via pressure washes and detergents or soaps, eg, baby shampoo; fungal sinusitis—chronic inflammation
develops when fungi in mucus elicit eosinophil-mediated degranulation; diagnosed by polymerase chain reaction
(PCR) or culture; topical form of amphotericin B developed to eliminate fungi in patient with chronic
inflammatory infection; (data suggest that a bacteriostatic dose of 200-300 µg/mL administered by lavage achieves optimum
dispersion); epidermal growth factor receptor (EGFR)—component of inflammation occurring in asthma and rhinosinusitis;
activates nasal epithelial hyperplasia and subsequent polyp formation; once polyps visualized, consider
therapeutic approach targeting EGFR (aerosolized EGFR blocker under evaluation); macrolide antibiotics—exert bacteriostatic
effect; anti-inflammatory effects include inhibition of cytokine production (including interleukin [IL]-8), possible
alteration of biofilm formation, and increased apoptosis of inflammatory cells; some studies found greater anti-
inflammatory effect in patients with low IgE levels; possible management may include identifying patients with low IgE
levels and administering macrolide (instead of penicillin-based drug or quinolone) to treat both bacterial infection and
inflammation; aspirin exacerbated respiratory disease (AERD), ie, aspirin triad—with breakdown of arachidonic acid,
salicylates upregulate leukotriene end of pathway; leukotriene-receptor antagonists or 5-lipoxygenase (5-LO) antagonists
not particularly helpful in managing sinus disease, but somewhat effective in treating asthma; aspirin desensitization
for AERD—challenges sensitized patients with salicylates; eliminates leukotriene end of inflammatory pathway;
uses small daily dose of aspirin to improve control of asthma and nasal polyposis; also indicated for managing refractory
polyposis; approach not commonly accepted; NaCl channel blockade for chronic sinusitis—patients in study population
received 50 µg dose of furosemide (Lasix spray) via 2 puffs in each nostril daily according to long-term protocol;
approach did not prevent polyp formation, but helped reduce severity of relapse over 9 yr; dilutional therapy with nasal
saline—useful for managing symptoms of chronic rhinosinusitis; gastroesophageal reflux disease (GERD) therapy—
may have limited efficacy in some patients, since Helicobacter pylori occasionally isolated from opacified sinuses; pH
probe testing—eventually, may be used to evaluate patients who have persistent symptoms after functional endoscopic
sinus surgery (FESS) or continued chronic rhinosinusitis
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| Additional management options presented in literature: low-intensity pulsed ultrasound; acupuncture; strong
humming; herbal medications—pineapple enzyme (N-chlorotaurine; antioxidant); BNO-101 (Sinupret; studies show
some clinical efficacy)
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| RHINOGENIC HEADACHE: REAL OR IMAGINED? Brent A. Senior, MD, Associate Professor, Department of
Otolaryngology–Head and Neck Surgery, and Chief, Division of Rhinology, Allergy, and Sinus Surgery, University of
North Carolina at Chapel Hill School of Medicine
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| International Headache Society (IHS) criteria: acknowledge existence of headache in presence of acute rhinosinusitis,
but not chronic rhinosinusitis; acute rhinosinusitis—characterized by pathologic sinus findings on clinical evaluation,
ie, computed tomography (CT) or magnetic resonance imaging (MRI); key clinical clues include pus in nose, nasal
obstruction, hyposmia, anosmia, and fever; chronic rhinosinusitis—not validated as cause of headache or facial pain unless
patient relapses into acute disease; migraine—episodic recurrent headache lasting from 4 to 72 hr; diagnosed by
presence of 2 key clinical qualities (ie, unilateral pain; throbbing pain; pain worsened by movement) and one key symptom
(ie, nausea; vomiting; photophobia; phonophobia)
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| Migraine headache: data show most patients who present with complaints of “sinus headache” actually have migraine
or other headache syndrome; patients tend to blame sinus disease for their headaches because—migraine headaches often
have associated sinus or nasal-type symptoms that confuse clinical picture, ie, sinus pressure and pain, nasal congestion,
rhinorrhea, watery eyes, and itchy nose; over-the-counter medications marketed as being effective for treating sinus
headache; bottom line—many patients presenting with “sinus headache” actually have migraine headache without infection
and would probably benefit from trial of migraine medication
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| Midfacial-segment pain syndrome: may be responsible for majority of headaches attributed to sinus disease or migraine;
patients with syndrome—believed to have tension-type headache that affects midface; present with sensations of
pressure and blockage; have symmetric symptoms that extend over bridge of nose, into retroorbital areas, and across
cheeks; have normal endoscopic and CT findings; point—in general, these patients require different medications from
those administered to typical migraineurs
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| Sinusitis and sinonasal conditions: can contribute to development of headache; observations—both acute and
chronic rhinosinusitis causes headaches (data show headache scores significantly decrease and patients report improvement
of headaches after FESS); suspect migraine or midfacial-segment pain syndrome in people who complain of headache
and have normal endoscopic or CT findings; caveat—do not operate on any patient who presents with “sinus
headache” without associated CT findings or complaints of sinonasal disease
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| INVERTED PAPILLOMA: CURRENT SURGICAL TECHNIQUES —Andrew N. Goldberg, MD, Professor and Director,
Division of Rhinology and Sinus Surgery, Department of Otolaryngology–Head and Neck Surgery, University of California,
San Francisco, School of Medicine
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| Inverted papilloma: benign; uncommon; appears to be associated with human papillomavirus (HPV); incidence may be
reduced by increasing use of HPV vaccine; tends to invade locally; recurrence common after excision; risk of transitioning
to squamous cell carcinoma increases over time (early treatment reduces cancer risk); suspect in patient presenting
with—unilateral sinusitis; irregular tissue in area of middle meatus; staging system determines how difficult it will be to
eliminate inverted papilloma—T1 (limited to nose); T2 (located in medial area, ie, ostiomeatal complex [OMC] and medial
maxillary sinus or ethmoid); T3 (involves lateral and inferior maxillary sinus, or sphenoid and frontal sinuses); T4
(lesion extends beyond boundaries defining T3 disease)
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| Management: base of lesion—must be identified and boundaries defined; once base removed, tissue surrounding or located
near base can be preserved; currently—no medical therapy available; radiation therapy confined to managing malignant
transformation and unusual cases of unresectable disease or multiple recurrences
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| Surgery: polypectomy—removed only what surgeon saw; recurrence rate high; wider excision required; medial
maxillectomy—better approach; worked in most patients; open approach enables surgeon to—perform en bloc resection;
access areas difficult to reach endoscopically (ie, anterior and lateral anterior portions of maxillary sinus; area of nasolacrimal
duct; lateral part of frontal sinus); factors governing selection of surgical approach—results of physical
examination and imaging; access to tumor base; surgeon’s comfort level when performing particular surgical approach;
points—in ≈75% of cases, sclerotic thickened bone indicative of papilloma base; recurrence rates comparable whether
endoscopic or open surgery (involvement of sinus floor and lateral recess involve additional exposure); recurrences—
manageable; small lesions can be removed in office; postoperative endoscopic monitoring detects lesions early on; in
some cases, lesions can be removed using Blakesley forceps; occasionally, base of lesion must be cauterized; more difficult
lesions must be removed in operating room
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| Endoscopy: improves surgical precision; facilitates visualization of attachment site (usually small); targeted procedure;
essential for postoperative monitoring, whether procedure performed open or endoscopically; endoscopic surgery—can
be performed as outpatient procedure; preserves periorbita; resects entire tumor base
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| Two-stage approach: useful in difficult cases; helps define tumor and plan additional surgery; stage 1—remove bulk
of lesion; identify attachment point; lesions that can be handled immediately (ie, in middle turbinate, medial maxilla, or
attached to lamina papyracea) taken care of in one sitting; pathology data obtained during first procedure helps detect
squamous carcinoma or inverted papilloma; stage 2—lesions extending up into frontal sinus or anterior or lateral portions
of maxillary sinus require open procedure on another day
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| UPDATE ON NASAL POLYPOSIS —Dr. Murr
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| Nasal polyposis: rare in children; incidence with common diseases—adult asthma (≈7%); intrinsic asthma (≈13%);
atopic asthma (≈5%); chronic rhinosinusitis (≈2%); nonallergic rhinitis (≈5%); allergic rhinitis (≈1.5%); diseases described
by presence of polyps—aspirin intolerance; cystic fibrosis (CF); Churg-Strauss syndrome; allergic fungal sinusitis
(AFS); point—global involvement of polyposis suggests different mechanisms of development
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| Diagnosis: clues in history—nasal obstruction (unilateral or bilateral; rapid or slow onset); facial fullness or pressure;
epistaxis; exacerbation of asthma; nasal voice; rhinorrhea; anosmia; physical examination—rigid and flexible rhinoscopes
examine middle meatus, sphenoethmoidal recess, nasopharynx, and inferior meatus; radiographic imaging—plain films
have 50% false-negative rate; CT remains gold standard; MRI (helps differentiate fluid from polyp in cases in which polyps
may be suspected of causing dural or brain invasion; identifies inverted papilloma and AFS); CT (less effective than
MRI in differentiating fluid from polyp; images should be evaluated by treating physician); classification—groups patients
with chronic sinusitis according to presence or absence of nasal polyps; patients with nasal polyps may have—
eosinophilic or other inflammatory features; fungi or eosinophilic mucin with fungal hyphae (classic AFS); achieves better
treatment results by facilitating data assessment
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Factors Causing Nasal Polyposis
| Viral polyps: HPV types—6 and 11 cause inverted papillomas; 16 and 18 associated with ≈15% malignancy transformation
rate; polyps locally aggressive, do not respect anatomic boundaries, usually unilateral, and associated with high recurrence
rates; complete excision with margins—only treatment option; HPV remains in basement membrane of epithelium,
making it difficult to eliminate virus, even with adequate margins
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| Aspirin triad: associated with worse prognosis; treatment options include—aspirin avoidance (exogenous salicylates in
diet complicate approach); oral or topical steroids; leukotriene inhibitors more effective against asthma component than
against polyps; surgery associated with high recurrence rate; aspirin desensitization indicated in patients with respiratory
symptoms, ie, AERD— who have disease uncontrolled by steroids and leukotriene inhibitors or requiring repeated surgery
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| Allergic fungal sinusitis: IgE-mediated type 1 or 3 immune reaction elicits inflammatory response, ie, chronic rhinosinusitis;
characteristic peanut butter-like material causes polyposis; treatment options for fungal polyposis include—
surgery; immune desensitization; steroids (patients highly responsive; bulk of disease must be removed to maximize efficacy);
antifungal agents (dose and delivery become critical issues; recommended doses range from 100 to 300 µg/mL; lavage
best route of delivery)
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| Staphylococcus aureus: triggers nasal polyposis in patients with chronic sinusitis; management if patient has—routine sinusitis
produced by S aureus (neutrophils and interleukins cause inflammation; culture-directed antibiotic therapy might
be appropriate); polyposis caused by staphylococcal endotoxin, possibly working in combination with biofilms (eosinophils
can cause edema, chronic inflammation, and polyps; staphylococcal eradication protocol combining doxycycline or
trimethoprim-sulfamethoxazole [Septra] with steroids may be appropriate)
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| Epidermal growth factor receptor: activity relates well to development of nasal polyps; EGFR—pathway plays
role in creating chronic inflammation; found in disorganized epithelium that constitutes nasal polyps; evidence that tumor
necrosis factor α (TNF-α) induces EGFR in goblet cells that trigger chronic inflammation in which eosinophils primary
inflammatory mechanism); management—both sinusitis and nasal polyps may eventually be treated by drug that blocks
EGFR
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| Allergy and nasal polyps: macrolide antibiotics—possess anti-inflammatory mechanism; may elicit response from
polyps associated with low IgE levels; IgE level—may be useful; if IgE high, suspect AFS; if IgE low, consider trial of
macrolide antibiotic
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| Genetically related diseases associated with nasal polyposis: primary ciliary dyskinesia; Young’s syndrome;
Churg-Strauss syndrome; CF—subcohort of patients with ä508/G551D genetic mutation more heavily colonized with
Pseudomonas aeruginosa and have higher incidence of nasal polyposis
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| Environmental factors that may cause nasal polyposis: illicit substances, eg, cocaine; pesticides; water additives;
food preservatives; fungal exposure associated with carpeting, air conditioning, and heating systems; insulation material
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Suggested Reading
Bonfils P, Avan P: Evaluation of the surgical treatment of nasal polyposis. II: Influence of a non-specific bronchial hyperresponsiveness.
Acta Otolaryngol 127:847, 2007; Carney AS, Wormald PJ: Management of nasal polyps with steroids:
the current literature. Clin Otolaryngol 33:31, 2008; Cervin A, Wallwork B: Macrolide therapy of chronic
rhinosinusitis. Rhinology 45:259, 2007; Chiu AG et al: Baby shampoo nasal irrigations for the symptomatic post-functional
endoscopic sinus surgery patient. Am J Rhinol 22:34, 2008; Eross E et al: The sinus, allergy, and migraine study.
Headache 47:213, 2007; Hadley J et al: Treatment of acute and chronic rhinosinusitis in the United States, 1992-2002.
Arch Otolaryngol Head Neck Surg 133:260, 2007; Levine HL et al: An otolaryngology, neurology, allergy, and primary
care consensus on diagnosis and treatment of sinus headache. Otolaryngol Head Neck Surg 134:516, 2006; Passáli D et
al: Efficacy of inhalation furosemide to prevent postsurgical relapses of rhinosinusal polyposis. ORL J Otorhinolaryngol
Relat Spec 62:307, 2000; Pawliczak R et al: Pathogenesis of nasal polyps: an update. Curr Allergy Asthma Rep 5:463,
2005; Rosenfeld RM et al: Clinical practice guidelines: adult sinusitis. Otolaryngol Head Neck Surg 137:S1-31, 2007;
Sharp HL et al: Treatment of acute and chronic rhinosinusitis in the United States, 1999-2002. Arch Otolaryngol Head
Neck Surg 133:250, 2007; Shirazi MA et al: Activity of nasal amphotericin B irrigation against fungal organisms in
vitro. Am J Rhinol 21:145, 2007; Stevenson DD, Simon RA: Selection of patients for aspirin desensitization treatment.
J Allergy Clin Immunol 118:801, 2006.
Educational Objectives
| The goal of this program is to provide an update on current techniques for managing disorders of the nose and sinuses. After
hearing and assimilating this program, the clinician will be better able to:
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 | 1. Review current clinical practice guidelines for managing sinusitis in adults.
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| 2. Explore the role of targeted therapy in the management of sinus disease.
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| 3. Assess the role of migraine, midfacial-segment pain syndrome, and sinus disease in the development of rhinogenic
headache.
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| 4. Discuss current techniques for managing inverted papillomas.
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| 5. Describe the etiology and management of nasal polyposis.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning
committee 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. Goldberg
is affiliated with Aspire Medical and Carbylan BioSurgery; Dr. Senior is affiliated with BrainLAB and GlaxoSmithKline.
Dr. Murr and the planning committee reported nothing to disclose
Acknowledgements
The lectures of Drs. Goldberg and Senior and the first lecture by Dr. Murr were recorded at Otolaryngology Update: 2007,
presented November 8-10, 2007, in San Francisco, CA, by the University of California, San Francisco, School of Medicine.
The second lecture by Dr. Murr was recorded at Otolaryngology Update in NYC, presented October 25-26, 2007, in New
York, NY, by New York-Presbyterian Hospital and Weill Cornell Medical Center. The Audio-Digest Foundation thanks the
speakers and the sponsors for their cooperation in the production of this program.
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