Persistent Sinusitis Despite Surgery


W. S. Tichenor, M. D.
New York, New York
212-517-6611


This section is written primarily for those patients who have had endoscopic sinus surgery and despite surgery, symptoms have continued. We will not address the immediate post-operative complications as those should be satisfactorily addressed by the Otolaryngologist and can include such things as excessive bleeding, infection, perforation into the brain or eye, etc. This time generally extends up to approximately 3-6 weeks after surgery.

Basic principals of treatment after surgery are essentially the same as the pre-surgical treatment: To ensure adequate drainage from the sinuses. It is unrealistic to expect that surgery will cure sinusitis, as the same processes which occurred prior to surgery will continue afterwards. Surgical treatment simply allows the sinuses, which previously did not drain, to drain through the ostia.

Irrigation

Once adequate drainage has been provided, it is often possible to forgo use of oral antibiotics by providing copious irrigation with an antibiotic such as Gentamycin in a saline solution to irrigate out the sinuses. It is often necessary to continue mucus thinners as well as steroid nasal sprays depending on the appropriateness of the circumstances, but during the immediate post-operative period, most patients will have stopped the mucus thinners. Irrigation with the Grossan Nasal Irrigator can also prove helpful under those circumstances.(A link to this website will appear as a pop-up window.)

Proper technique for using irrigation must include adequate amounts of saline to ensure that the sinuses are thoroughly irrigated, and make sure that you clean the irrigator regularly.

Some doctors have added antifungals ( or antibiotics ) to the Grossan irrigator. One method is to add 1 tsp of salt ( or Breathease, or salt-baking soda solution ) to 500 cc of water in the Hydropulse and irrigate. When the solution is almost gone, it is possible to add the antifungal to the irrigation fluid and continue irrigating. The antifungal solution should not be added at the beginning because it may become too diluted.

Excessive crusting is a not uncommon problem in post-surgical patients. In those cases surgical debreedment, mucous thinners, an increase in humidity level, frequent use of salt water nasal sprays,nasal gels, drinking copious amounts of water and irrigation may be helpful.

Retained Secretions

Many patients will continue to have thick secretions in their sinuses, even after surgery. Usually with fastidious irrigation, sometimes using mucus thinners or Alkalol, it is possible to adequately irrigate out the secretions. Sometimes we will have patients come in and watch them irrigate to make sure that they are irrigating correctly. Some patients with fungal sinusitis will have a more difficult time and will do better if an antifungal irrigation or oral antifungal is used.

Inflammation

Anti-inflammatory drugs will sometimes reduce inflammation in patients, but must be carefully chosen in patients who are aspirin sensitive and have the combination of nasal polyposis, asthma and aspirin sensitivity. It is important to remember that all drugs in the aspirin class such as Motrin and Aleve will cause the same problems however drugs like Celebrex may be used by some.

Occasionally, intranasal steroids can cause inflammation, in which case management may include decreasing the dosage, eliminating steroids, or using a weaker steroid and possibly adding an oral steroid. Sometimes coating the nose before spraying can be helpful.Sometimes steroid drops may be used to reduce inflammation.

Allergy management

Patients who are allergic must be carefully evaluated as even minor allergies may cause enough of an exacerbation of chronic sinusitis to cause dramatic worsening in symptoms. In addition to environmental controls, allergy immunotherapy is often used to manage these patients. It may take an extended period of time for immunotherapy to provide adequate treatment, however.

Patients who are on allergy immunotherapy must be evaluated to make sure that adequate dosages and adequate numbers of antigens are used in treatment. In patients with allergic fungal rhinosinusitis or eosinophilic fungal rhinosinusitis, it is important that good allergy management take place. Due to the effects of Managed Care, some patients may not get adequate numbers of antigens because of cost and re-imbursement issues. We commonly test for and treat for a large number of molds and fungi.

It is critically important for mold and fungal exposures be carefully controlled in patients with fungal causes for sinusitis. That can be extremely difficult, however.

Alternative techniques

Selected patients have found that a variety of unorthodox treatments may occasionally be helpful, but it is difficult to tell if this is due to a placebo effect. They must be viewed with a certain degree of skepticism, however if they work for a patient who has failed all other forms of therapy, one cannot dismiss them. Several patients have found that using a new Papaya enzyme formulation called ClearEase may be helpful. It is made by Dr. Grossan.

Reflux

It is speculated that some patients may have worsening of sinusitis due to food or stomach acid refluxing or repeating i.e. coming up from the stomach into the esophagus and subsequently into the back of the mouth. It is unclear whether it is possible for it to actually get into the sinuses. It is diagnosed by putting a tube into the esophagus to check the amount of acidity. Treatment is with proton pump inhibitors (e.g. Prilosec, Prevacid, Nexium, or Aciphex) or acid blockers (Zantac, Axid, Tagamet, Pepcid.) It is thought that some patients can have silent reflux, i.e. they don't have any symptoms. Treatment must take place for 3 months before an evaluation can be made.

Immunodeficiency

Any patients with chronic sinusitis which is poorly responsive to treatment should have an extensive immunological evaluation including immunoglobulin levels, possibly IgG subtypes, and antibody testing. Pneumococcal, diphtheria, and tetanus antibodies should be tested before and after Pneumovax and diphtheria/tetanus immunizations. Evaluation should be done by an immunologist familiar with testing as results can be difficult to interpret. Briefly, blood tests should be done testing the response to 23 different subtypes of the pneumococcal bacteria. There should be an adequate rise in the antibody titer measured by the blood test to determine that the patient has responded to the vaccine. In cases where an immunodeficiency is found, immunoglobulin (IVIG) therapy may need to be initiated. Selected patients may occasionally warrant IVIG despite normal antibody levels. Such patients must be selectively chosen by experienced clinicians, as IVIG is extremely costly, especially since insurance is often reluctant to pay for such an expensive treatment.

Children should be evaluated for cystic fibrosis. Selected patients may need to be evaluated for HIV disease. Smoke exposure can also be a problem.

Suboptimal Surgery

Some patients operated on by less experienced otolaryngologists may have less than optimal surgery performed. If the uncinate process is not removed (see the x-ray page), recurrence of symptoms is common since proper drainage may not occur. (This is called a retained uncinate.)

Sometimes a surgeon will make an opening into one of the ethmoid sinuses instead of the maxillary sinus. ( It is normal to open the ethmoid cells, but in this case, the additional opening into the maxillary sinus is not made.) This can cause continued problems with inadequate drainage from the maxillary sinus. Some patients also may not have adequate amounts of ethmoid air cells removed.

Some surgeons may have been trained at a short weekend course and as a result may not feel comfortable with doing more extensive surgery. The ethmoid sinuses, particularly the posterior ethmoids, are more difficult to operate on than the maxillary sinuses, and as a result some surgeons may be concerned about operating on them for fear of developing complications. The same is true of the sphenoid and frontal sinus. As a result, it is obviously important to make sure that you are operated on by someone with extensive experience.

Occasionally, instead of a single ostium into the maxillary sinus, there can be two openings created which can cause re-circulation of mucous, (in one ostium and out the other). This can lead to continued symptoms and may necessitate further revision surgery.

Various "new techniques" have been espoused including laser, etc., but essentially all must be used in conjunction with traditional endoscopic sinus surgery in order to provide optimal results. One must be wary of surgeons who suggest minimal procedures such as repair of a deviated septum and turbinate reduction when endoscopic sinus surgery must also be done. All too often patients may have procedures done which do not involve resection of an obstructed ostium, and they have continued symptoms. Newer techniques such as Balloon sinuplasty may be helpful. In this technique, a balloon is inserted into the small existing ostium and then expanded to enlarge the opening. This may be helpful in some patients particularly for opening the frontal and sphenoid sinuses, however there have been reports that extra openings into the maxillary sinuses have been inadvertantly made using the balloon bechniques.

The Empty Nose Syndrome

Patients who have too much tissue removed from their nose at the time of surgery will sometimes develop an empty nose syndrome. They will have a variety of symptoms including the sensation of too much air flowing through the nose, halitosis, lack of mucus, bleeding, lack of sense of smell, dryness, crusting, inflammation, dizziness, etc. Many patients are bothered severely by this and often become extremely preoccupied with it.

They may also have atrophic rhinitis which means that the the cells in the lining of the nose don't function normally and so doesn't produce enough mucus. Unfortunately as a person ages, the lining of the nose normally ages, so that many years after surgery, a patient may develop the empty nose syndrom due to development of atrophic rhinitis.

There is much debate about the cause of the empty nose syndrome. Most people think that the cause is due to having too much turbinate tissue removed at the time of surgery, but not everyone who has turbinate tissue removed will develop the empty nose syndrome.

Patients who have both the inferior turbinate and middle turbinate removed are more likely to develop the empty nose syndrome. Obviously they will have more tissue removed than someone who only had part of the middle turbinate removed.

In some cases it may be necessary to remove part of the middle turbinate in order to do surgery. Please note that the turbinate removal referred to here is not the same as the somnoplasty technique which is discussed below.

Adjunctive techniques such as irrigation, mucus thinners, and nasal sprays may be somewhat helpful. Increasing the humidity in the winter may also be helpful. Some have used glycerine solution topically to the lining of the nose. They will also use mineral oil flavored with rose geranium oil for bad breath. Some patients are helped by having cotton plugs or silicone plugs fashioned to reduce some of the nasal airflow. Unfortunately once the tissue is removed it cannot be replaced, although there are currently experimental technique to create artificial turbinates.

Somnoplasty

The somnoplasty technique was developed as a means of reducing some of the obstruction caused by the turbinates. It utilizes a radiofrequency device which gently heats the turbinate. As a result the turbinate will shrink down in size over the course of 6-8 weeks. The physician will usually give a small amount of local anesthesia and then heat the turbinate(s) for about 2 minutes. There is typically minimal crusting and bleeding. Usually no painkillers are needed afterward.

It is important to realize that whatever problems which exist in the nose such as sinusitis, allergic rhinitis, polyps, deviated septum, etc. must be addressed before the somnoplasty technique is used. If the turbinates are reduced in size, but the basic problem such as sinusitis still exists, patients won't get better.

Frontal Sinus Disease

Periodically, frontal sinus disease will persist after surgery is done on other sinuses. Usually frontal sinusitis will resolve without revision surgery, however occasionally persistent disease will require operative intervention. Sometimes it is possible to just perform revision surgery on the ethmoid sinuses and that will allow the frontal sinuses to drain properly. That decision must be made by an experienced ENT surgeon. Whenever surgery is performed on the frontal sinuses or frontal recess (the drainage area for the frontal sinuses), there is always a risk of scarring, even in the hands of the best surgeons. As a result, surgeons will often avoid performing surgery on that area if at all possible.

Patients who have had a complete resection of the middle turbinate will be much more likely to have scarring in the drainage area of the frontal sinus (frontal recess). Another reason why we're not happy when patients have a complete turbinectomy.

Previously it was difficult to perform frontal surgery due to the thickness of the bone in the area which must be resected, however with the new image guided techniques, in many cases it is possible to operate on the frontal sinuses without using the traditional procedure called a Frontal Sinus Obliteration. This is performed by performed an incision above the hairline from ear to ear, and then folding down a flap of forehead skin over the eyes to allow visualization of the bone in the forehead. ( You're right, it is pretty barbaric). The surgeon then cuts a hole in the forehead bone to allow a complete clean out of the frontal sinuses. The frontal sinus is then filled with fat so that the sinusitis won't reoccur.

Fungal disease

Patients who have recurrent disease also must be evaluated for fungal sinusitis. The discovery of eosinophilic fungal rhinosinusitis (EFRS)by the Mayo clinic has changed sinusitis treatment radically. For a more in depth discussion, please go the the page on fungal disease. Briefly, it is thought that most patients with chronic sinusitis have an unusual reaction to the normal fungi which are in everyone's sinuses. White blood cells called eosinophiles attempt to destroy the fungus and in the course of doing so injure the lining of the sinuses, which allows the bacteria to proliferate. Treatment should therefore be directed at the fungus rather than the bacteria.

Other types of fungal sinus disease include allergic fungal, invasive fungal disease, and fungus balls. Treatment of this is discussed in the section for physicians.

Once surgery has been done, it is much easier to do cultures to determine if an unusual bacteria or fungus is involved. It is possible to direct the culture into the involved sinuses at the time of endoscopy. It is often difficult for many laboratories to find fungi since they are difficult to culture for and grow out. In addition, the usual techniques for culturing fungi are often suboptimal, and must be specially modified to allow proper fungal culture. In addition, we send specimens to a special fungal lab which is better equipped to determine if there are fungi present.

Intravenous Antibiotics

Some patients who have not responded to surgery may need to get outpatient treatment with intravenous antibiotics for 6-8 weeks to clear up infection which persists after surgery. Sometimes the intravenous antibiotics will also be given before or instead of surgery as well. The exact antibiotics will be determined by the doctor. Studies are underway by a company called Sinucare.

Revision surgery

Some patients will develop new areas of sinusitis post-surgically which may or may not be able to be visualized on endoscopy and sometimes require repeat CT scans. In those cases, oral antibiotics are more likely to be necessary and in some cases surgical revision either done in office or with hospitalization may occasionally be necessary.

In some patients, scar tissue may form after surgery. Not all scarring necessarily needs to be removed, however. Fastidious post-operative care can typically reduce the incidence of scarring.

Recurrent nasal polyposis is not uncommon in patients with chronic sinusitis. The etiology of nasal polyposis is usually not clearly established, but it is felt to be related to chronic inflammation. In some cases it is thought to be due to fungal disease. In occasional cases, extensive polyposis may require further surgical revision, although often with good medical management, including oral or nasal steroids, it may be possible to avoid surgical intervention.

Rarely, it may be necessary to perform a "Lynch" procedure on the ethmoid sinuses. This involves making an incision on the side of the nose extending down from the eyebrow in a semi-circle to allow more complete resection of the ethmoid sinuses. With the advent of image-guided surgery, it is often possible to avoid this procedure which is more disfiguring than the usual endoscopic surgery

Additional medications

There have been selected reports in patients who have nasal polyps and sinusitis that they may respond to the anti-leukotriene agents (Accolate, Zyflo, and Singulair) (discussed in the asthma section). The makers of Ocean are advocating the use of Singulair dissolved in Ocean as a treatment for nasal polyps.

Exacerbating Agents

It is critical that patients be evaluated for outside agents which may exacerbate sinusitis. As stated elsewhere, tobacco smoke causes paralysis of the cilia and must be avoided if one is to hope to treat sinusitis adequately. The same applies for marijuana smoke. Alcohol can also cause dehydration, forgetfulness concerning medications, and in some cases allergy. We have found that patients on virtually all antidepressants as well as antihistamines can have an excessive amount of dryness in the sinuses and become symptomatic as a result. A report by Dr. Steinsvag from Norway suggests that a preservative called benzalkonium chloride, which is contained in almost all AQ formulations of nasal spray except for Rhinocort may cause loss of cilia from the nose. It is also in Ocean and Ayr. Whether it can cause worsening of nasal symptoms is unclear at this time. Mold exposure can be a serious exacerbating agent. We see many patients whose symptoms will abate after removal from an environment with mold exposure.

Adenoids

Some patients, especially children, may need to have their adenoids removed in order to have the sinusitis effectively treated. It is more common, however, that patients need to have their sinusitis effectively treated in order to have their adenoid disease improve.

Dental disease

We have started seeing an increasing amount of dental disease causing sinusitis. This can be as a result of the root of a molar becoming infected, the remnant of a tooth which was previously partially removed, or bony like material in the base of the sinus. This can be very difficult to treat and often requires a skilled dentist as well as a sinus specialist. Sometimes there can also be a communication between the mouth and the sinuses as a result of previous dental work.

Biofilm

Many bacteria and fungi are able to form a Saran wrap like coating over the colony of organisms which protects the colony from antibiotics. In addition, it conveys additional resistance to antibiotics. If a bacterium is part of the colony, it has a greater degree of resistance that if it were outside of the colony (called a planktonic organism). Unfortunately, when cultures are performed, the planktonic organisms are often the ones which are collected for culture, and, as a result, the sensitivity of these organisms may not represent the sensitivity of the majority of the organisms causing the infection. Although the concept of biofilm is relatively new in medicine, it is dealt with all the time in regard to dental disease. The act of brushing your teeth or removing plaque removes biofilm. Current techniques of removing biofilm involve surgical removal, irrigation with a 1% soution of Johnson's Baby Shampoo, use of tea for irrigation or the use of Sinufresh. None of these techniques have been clearly established as the best means of treatment, and the side effects are unclear.

Mycobacteria

We have recently presented a paper describing a group of patients who had mycobacteria as a cause of sinusitis. This is a class of organisms similar to tuberculosis (called non-tuberculous mycobacteria or atypical mycobacteria)(NTM). Previously all patients were reported to have cystic fibrosis or HIV disease. None of our patients had these problems. We are still early in the stage of exploration of this cause of infection, but our patients responded well to long term treatment with multiple antibiotics. The paper will be published in the near future.

Prevention

We often suggest that patients start on preventive treatment at the first sign of developing upper respiratory symptoms. These treatments include irrigation, nasal steroids, mucus thinners, decongestants, zinc gluconate lozenges, steam vaporizers, etc. As stated previously, it is often possible to avoid antibiotics.


Post surgical management in patients who have not responded to surgery can be extremely difficult for most doctors to perform, as most physicians do not have extensive experience with this kind of patient. As stated elsewhere, it is difficult for many physicians to treat patients with chronic sinusitis, but this is doubly important in patients post surgery, as you must find physicians with extensive experience in such treatment in order to provide optimal care.


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