Rhinosinusitis/Allergy

Educational Objectives

The goal of this program is to improve the management of rhinosinusitis and allergy and to explore the benefits of adding an allergy treatment component to an existing otolaryngology practice. After hearing and assimilating this program, the clinician will be better able to:

1.   Recognize rhinosinusitis caused by one of several etiologies and employ a clinical algorithm in the manage­ment of acute chronic sinusitis.

2.   Select the appropriate radiographic imaging technique for sinus-related conditions.

3.   Evaluate recent advances in sinus surgery.

4.   Assess the socioeconomic and practice-management benefits of introducing allergy management into an oto­laryngology practice.

5.   Review the skills and staff requirements necessary for the establishment of allergy treatment capability within an existing otolaryngology practice.

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 faculty and the planning committee re­ported nothing to disclose. In his lecture, Dr. Greene presents information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgments

Dr. Rudman was recorded at 87th Annual Fall Clinical Conference, held November 5-7, 2009, in Overland Park, KS, and presented by the Kansas City Southwest Clinical Society. Dr. Greene was recorded at 8th Annual Otolaryngology Sympo­sium, held April 29 to May 2, 2009, in Ponte Vedra Beach, FL, presented by the New York Head and Neck Institute, and sponsored by St. Luke’s and Roosevelt Hospitals Center for Head and Neck Oncology and University Hospital of Columbia University College of Physicians and Surgeons. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Advances in Management of Rhinosinusitis

David T. Rudman, MD, Staff Physician, Menorah Medical Center and Overland Park Regional Medical Center, Overland Park, KS, and Research Medical Center and Children’s Mercy Hospital, Kansas City, KS

Background: rhinosinusitis defined as inflammation of ³1 paranasal sinuses; acute < 4 wk; subacute 4 to 12 wk; chronic >12 wk; viral etiology much more common than bacterial or fungal

Anatomy: ostiomeatal complex common final pathway for draining maxillary, anterior ethmoid, and frontal si­nuses; maxillary sinus drains through middle meatus; ostiomeatal complex most common site of obstruction

Upper respiratory infections (URIs): >1 billion viral URIs annually; only 0.5% to 2% develop into acute bacterial sinusitis; viral URIs  —  80% caused by rhinovirus; also can be caused by influenza, parainfluenza, and respiratory syncytial virus (RSV); nasal mucosa site of involvement, resulting in blockage of ostiomeatal complex; may re­sult in bacterial infection, but most viral URIs resolve without treatment in 5 to 10 days; treatment usually for symptoms (eg, mucolytics, decongestants); vitamin C or zinc may be effective; antiviral therapy for influenza can truncate course

Bacterial rhinosinusitis

Acute: usually caused by Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis; usually preceded by viral URI which causes mucosal inflammation, direct epithelial disruption, impaired mucociliary clearance, and blockage of ostiomeatal complex; nose blowing may propel nasal fluid into sinuses, resulting in progression or development of sinusitis

Chronic: commonly caused by Pseudomonas aeruginosa, coagulase negative staphylococci, Staphylococcus au­reus, and other gram-negative rods; multidrug resistance common; methicillin-resistant S aureus (MRSA) in­creasing in chronic sinusitis; may have involvement of bone of paranasal sinus (localized osteomyelitis); therapy should be culture-directed; underlying medical disorders may be predisposing factor, and should be recognized and treated

Fungal rhinosinusitis: invasive fungal rhinosinusitis may occur in immunocompromised patients; in immunocompe­tent individuals, mycetoma (fungal balls) may develop in isolated sinuses; allergic fungal rhinosinusitis is localized allergic reaction in fungus-sensitive patients; therapy  —amphotericin B irrigation, itraconazole irrigation, and sys­temic itraconazole; efficacy of antifungal agents may be due anti-inflammatory effects rather than antifungal activ­ity; steroids useful in hyperplastic eosinophilic rhinosinusitis; immunotherapy may reduce sensitivity in allergy-prone patients

Predisposing factors: environmental  —  URI, pollution, smoking, allergy, barotrauma; general host factors  —  cystic fibro­sis, ciliary dyskinesia, genetic predisposition, immuno-deficiency, stress, asthma, reflux disease; local host factors  —anatomic factors, mucosal inflammation, bone inflam-mation

Diagnosis

History: prodromal URI unimproved after »10 days; nasal congestion; purulent discharge; facial-dental pressure or pain; headache; postnasal drainage; cough; fever; past medical history of sinus problems, allergy, or reflux

Physical examination: palpation or percussion for tenderness; transillumination to look for air-fluid levels; fiber­optic endoscopy  —  to evaluate mucosa and obtain secretions for culture; to look for polyps or other obstruction of ostiomeatal complex; to look for anatomic variations, (eg, septal deviation, swollen turbinates) that can predis­pose to sinusitis

Cultures: important in establishing presence of resistant bacteria; maxillary sinus puncture and middle meatal cul­ture offer equivalent accuracy; middle meatal approach more comfortable and also representative of sinus out­flow

Radiology: plain x-rays show inflammation, but usefulness limited; ultrasonography can show air-fluid levels, but may be unavailable; computed tomography (CT)  —  best technique; shows bone and soft tissue; used during inter­ventions; best used after medical treatment; magnetic resonance imaging (MRI)  —  highly specific and overly sensitive (mucus may be mistaken for sinusitis); does not show bone, so not helpful for establishing anatomy

Medical therapy: control symptoms; open and drain sinuses; topical or systemic decongestants; saline irrigation can decrease inflammation and provide some decongestion; mucolytics (eg, guaifenesin) to thin secretions and facil­itate drainage; antihistamines helpful with allergy, but can thicken secretions, so not recommended for acute si­nusitis; leukotriene inhibitors and intranasal steroids helpful for allergic and inflammatory components of sinusitis; oral steroids for severe cases; antibiotics

Antibiotic therapy: recommendations from Sinus and Allergy Health Partnership (2004); mild disease with no re­cent antimicrobial use (in order of efficacy)  —  amoxicillin and potassium clavulanate (eg, Augmentin) at typical or high dose; amoxicillin (40 mg/kg-90 mg/kg); cephalosporins; sulfamethoxazole and trimethoprim (eg, Bac­trim); azithromycin (effective for bacterial sinusitis); if no improvement after 72 hr, prescribe fourth generation fluoroquinolone; mild disease with recent antimicrobial use  —  fourth generation fluoroquinolone (eg, levofloxa­cin [Levaquin]); high-dose amoxicillin and potassium clavulanate

Algorithm for acute sinusitis: symptomatic treatment; add antibiotics if condition lasts >7 to 10 days; signs and symptoms  —  drainage, congestion, facial pain, postnasal drip, hyposmia, anosmia, fever, cough, fatigue, maxillary-dental pain, ear fullness; severe symptoms  —  high or persistent fever, periorbital swelling, severe facial or dental pain, altered mental status, diplopia; may indicate complication

Treatment of chronic rhinosinusitis: not curative; no Food and Drug Administration (FDA)-approved therapy; anti­biotics may improve symptoms and quality of life; therapy should be culture-directed; resistant bacteria increasing; therapies should facilitate mucociliary clearance

Topical antibiotics: useful in patients with history of sinus surgery (altered anatomy allows application directly to problem area); culture-directed; considerations include concentration, dosing, distribution (vigorous irrigation most effective), side effects, and development of resistant bacteria

Surgical Treatment

Traditional approaches: Caldwell-Luc operation  —  removal of lining of sinus produces scarring; mucociliary func­tion not restored; external approaches  —  transnasal and transantral approaches; frontal osteoplastic sinusostomy; rarely used

Functional endoscopic sinus surgery (FESS): more commonly used at present; includes opening maxillary sinus outflow tract (antrostomy); merging ethmoid sinuses into one larger cavity (ethmoidectomy); enlarging openings of sphenoid and frontal sinuses (sinusostomy)

Goals of FESS: establish ventilation and facilitate drainage; reduce inflammatory load; provide better symptom control by decreasing frequency and severity; obtain material for culture, cytology, and histopathology to en­hance diagnosis

Indications: chronic rhinosinusitis; recurrent acute rhinosinusitis; anatomic abnormalities; sinonasal polyposis; complications of acute sinusitis; sinus mucoceles; fungal sinusitis

FESS outcomes: symptom improvement in 80% to 97%; revision surgery necessary in 18%; 90% of patients would repeat surgery; reasons for revision surgery  —smoking; triad of aspirin sensitivity, nasal polyps, and asthma; re­flux disease; scar band or synechiae formation

Balloon sinuplasty: combination endoscopic and fluoroscopic procedure; uses catheters with balloons to dilate max­illary, frontal, or sphenoid sinus ostia; intraoperative fluoroscopy or transillumination for guidance; no tissue re­moval; no packing; less invasive; requires anesthesia and special equipment

“FinESS”: transantral procedure under local anesthesia to open maxillary sinus outflow tract with balloon dilation; uses small (1.5 mm) endoscope; indicated for recurrent acute bacterial sinusitis of maxillary sinus only

Image guided surgery (IGS): combines advances in medical imaging, computing, software, and tracking technology to allow surgeon to interactively visualize, localize and navigate surgical field

Indications: massive disease that distorts normal anatomy; revision surgery in which usual anatomic landmarks ab­sent; patients with previous complications; sinonasal, pituitary, or skull base tumors; repair of cerebrospinal fluid leak; complex anatomy (eg, skull base lesions, optic nerve lesions, frontal and sphenoid sinuses)

Advantages: preoperative surgical planning; increased intraoperative patient safety; navigation through complex anatomy; more thorough removal of tissue, with improved outcomes; shortened operating times

Limitations: does not substitute for surgical knowledge; requires learning curve; does not reflect results of intraopera­tive manipulations; quality of preoperative imaging affects accuracy; accuracy may differ in different parts of operat­ing field

Adding Allergy to Your Otolaryngology Practice: Testing, Immunotherapy, and Asthma Manage­ment

David Greene, MD, Chief of Otolaryngology, Physicians Regional Medical Group, and Adjunct Faculty, Cleve­land Clinic Florida, Naples

Case experience

Start-up process: education phase  —  training of physicians and staff; testing phase  —  screening of and making re­ferrals for diagnosed patients; treatment phase  —  full services provided

Medical outcome: highly successful; patients bonded with nursing staff (saw them as care providers, not just ad­ministrative help); successful diagnosis of patients presenting to practice with continued disease after previous si­nus surgery elsewhere; improved health outcomes in medical and surgical treatment because otolaryngologist can address underlying inflammatory disease as well as perform sinus surgery

Practical outcome: valuable and profitable adjunct to sinus surgery practice; more rapid turnaround of sinus work-up; excellent utilization of nursing staff (eg, nurses seeing patients while physicians in operating room); bottom line  —  allergy services rapidly covered start-up and maintenance costs, and rapidly became profitable

Reasons for adding immunotherapy

Better care: ³40% of otolaryngology patient base suffers from allergic disease; numerous otolaryngologic diseases linked to allergy; growing pressure to identify underlying cause of disease; improved patient management and extend current services

Proven treatment: results in fewer symptoms; reduces need for medication; alters course of allergic disease; pro­vides long-term remission of allergic symptoms; prevents development of additional allergen sensitivities; pre­vents progression to asthma (“allergic march”)

Relationship to otolaryngology: American Board of Otolaryngology recognizes allergy as core to specialty (no lon­ger subspecialty); allergy immunotherapy now requirement in all otolaryngology residency programs; 34% of otolaryngologists currently provide immunotherapy; American Academy of Otolaryngic Allergy (AAOA) pro­vides excellent pathway to certification in otolaryngic allergy

Economics and practice management: patients already in practice; frequent requests for allergy management; first-year revenues $100,000 to $180,000; start-up costs $2000 to $6000; can outsource serum production initially

Seven steps to starting immunotherapy: 1) start with existing office staff and facilities; 2) attend AAOA basic and advanced courses; 3) know treatment of anaphylaxis and related issues; 4) add phases step by step, starting with testing; 5) work with allergen providers; ask them for help; they will educate staff; 6) use vials prepared by extract companies to minimize in-office work and complexity; know Medicare rules; 7) scale up later

Testing

Radioallergosorbent test (RAST): benefit  —  easiest to implement (send out blood samples, receive data); resources needed  —  blood-drawing capability only; multiple testing sites available (eg, local hospital, national laboratory); ancillary laboratory within practice requires Clinical Laboratory Improvement Amendments (CLIA) license; in­surance coverage variable

Skin-prick testing: inexpensive; many types of tests available; quick and easy (30 tests possible in 30 sec; tests read after 20 min); adverse reactions rare; minimal overhead and employee time

Shots vs drops: subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT); shots commonly used in United States, drops in Europe; methods declared equivalent by World Health Organization; shots given in of­fice; can be given multiple times per week, tapering to monthly over 3 to 5 yr; drops portable; shots require more office resources, eg, dedicated room, full-time nurse; procedure for drops  —  3-mo supply of drops prepared; first drop administered in office; patient observed for 20 min to ensure lack of adverse effects; patient returns in 90 days

Practice management: shots  —  industry standard; covered by insurance; may lose patients because time-consum­ing; vials easily ordered from allergen provider; mixing in office also possible; drops  —  charge for serum; not covered by insurance; may be less expensive than copayments for shots; less time commitment by patient

Asthma: reasons to establish practice  —  common condition in patients presenting to otolaryngologist; »50% patients with allergic rhinitis (AR) develop asthma; initiative within AAOA; how to implement  —  questionnaire for patients with AR, laryngopharyngeal reflux, sinusitis, and sleep disorders; techniques  —  spirometry; treatments  —  inhaled steroids, b₂-agonists, montelukast; in-office nebulization; anti-IgE monoclonal antibody given by subcutaneous in­jection; practice management  —  testing and treatment profitable; effective use of office staff

Suggested Reading

Broglie MA et al: How to diagnose sinus fungus balls in the paranasal sinus? An analysis of an institution’s cases from Janu­ary 1999 to December 2006. Rhinology 47:379, 2009; Campbell PD Jr et al: Imaging of the paranasal sinuses and in-office CT. Otolaryngol Clin North Am 42:753, 2009; Eng PA et al: Twelve-year follow-up after discontinuation of preseasonal grass pollen immunotherapy in childhood. Allergy 61:198, 2006; Ferguson BJ et al: When surgery, antibiotics, and steroids fail to resolve chronic rhinosinusitis. Immunol Allergy Clin North Am 29:719, 2009; Govindaraj S et al: Endoscopic sinus surgery: evolution and technical innovations. J Laryngol Otol Nov 23, 2009 [Epub ahead of print]; Hopkins C et al: Balloon sinuplasty in acute frontal sinusitis. Rhinology 47:375, 2009; Möller C et al: Pollen immunotherapy reduces the development of asthma in children with seasonal rhinoconjunctivitis (the PAT-study). J Allergy Clin Immunol 109:251, 2002; Leo G et al: Reapprais­ing the role of radiography in the diagnosis of chronic rhinosinusitis. Rhinology 47:271, 2009; Pillsbury HC et al: The im­pact/role of asthma in otolaryngology. Otolaryngol Head Neck Surg 136:157, 2007; Silverman JB et al: An evidence-based review of endoscopic frontal sinus surgery. Am J Rhinol Allergy 23:59, 2009; Simons FE: Anaphylaxis: Recent advances in as­sessment and treatment. J Allergy Clin Immunol 124:625, 2009; Welch KC et al: A contemporary review of endoscopic sinus surgery: techniques, tools, and outcomes. Laryngoscope 119:2258, 2009.