How To Cure Your Sinus Infection

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What Is Chronic Pediatric Sinusitis

Whereas most clinicians would easily accept that a chronic sinus condition exists when a single process persists for more than several months, there is little evidence to suggest that this occurs in young children at a rate beyond rarely. By contrast, the pediatric sinus is frequently, and sometimes continually, assailed by the multitude of respiratory pathogens typical of the day-care flora. It appears that a number of clinicians have extrapolated certain diagnostic and therapeutic approaches from otitis media to the assessment and management of pediatric sinusitis. At first glance, the rationale appears sound the same organisms, similar respiratory epithelium, closed-space infections, and the like. The two major inconsistencies relate to the

Heterogeneity Of Sinusitis

The onset of acute sinusitis typically involves an antecedent mucosal insult, such as one of a wide variety of viral infections or atopic inflammation, followed by infection caused by one of several different bacterial species. Because a large number of host factors add to the variance related to multiple viral and bacterial causes of sinusitis, clinicians dealing with this entity are actually faced with a wide and very heterogeneous group of processes with significant differences in severity of illness, natural history, and response to a given intervention. In all probability, if we were to try to lump such a huge array of processes together at any other anatomic site and attempt to develop logical and consistent diagnostic or therapeutic algorithms, we would be laughed out of academic medicine. In short, sinusitis is a vague description of inflammatory processes involving the sinuses. It is now clear that viruses can cause rhinosinusitis, as well as bacteria, as can, in all...

When Is Sinusitis Present

Many lecturers try to convince their audiences that unless the signs and symptoms of pediatric sinusitis have been present and unabated for 7 to 10 days, the chance of having sinusitis is remote. This notion is false. More accurately, the likelihood of having significant bacterial infection in the maxillary sinus is small. However, most patients with a cold or respiratory virus actually do have rhinosinusitis, at least according to histopathologic and radi-ologic criteria. We have traditionally ignored viral rhinosinusitis because we had no effective therapy, and because the disease was usually uncomplicated and spontaneously resolving although the degree of morbidity and length of symptoms varies widely. Consider now that we are on the threshold of possessing prescription drugs active against influenza or the common cold that will shorten the period of symptomatology and viral shedding. Suddenly, we are in the business of diagnosing diseases that have, for several generations, been...

Antibiotics for Use in Pediatric Rhinosinusitis

Pediatric sinusitis a literature review with emphasis 1997 116 4-15. qd, once a day bid, twice a day tid, three times a day qid, four times late-phase reaction after exposure to antigen.71 Accordingly, steroid nasal sprays are especially useful in children with allergic rhinitis or nasal polyps or both. Nasal sprays containing ipatropium bromide have a different mechanism of action, and no studies have been done to validate the efficacy of this drug in rhinosinusitis. Humidification may also be a simple means by which to moisturize sinonasal mucosa, thin nasal secretions, and facilitate mucociliary transport. Care must be taken, however, to minimize potential fungal overgrowth in the humidifier, as this may actually worsen or precipitate rhinosinusitis. Mucolytic agents such as guaifenesin serve to thin mucus, potentially reducing stasis and promoting clearing of secretions. Their efficacy in children has not been established in rhinosinusitis....

Stepwise Summary of Assessment Management and Management of Uncomplicated Chronic Pediatric Rhinosinusitis

Step 1 Thorough history and physical examination suggesting chronic rhinosinusitis Step 3 Medical management of rhinosinusitis 2. Lusk R, Stankiewicz, J. Pediatric rhinosinusitis. Otolaryngol Head Neck Surg 1997 117 S53-S57 3. Wald E. Rhinitis and acute and chronic sinusitis. In Bluestone C, Stool S, Kenna M, eds. Pediatric Otolaryngology. 3rd Ed. WB Saunders Philadelphia 1996 843-858 5. Otten F, Van Aarem A, Grote J. Long-term follow-up of chronic maxillary sinusitis in children. Int J Pediatr Otorhino-laryngol 1991 22 81-84 6. April M, Zinreich S, Baroody F, Naclerio R. Coronal CT scan abnormalities in children with chronic sinusitis. Laryngoscope 1993 103 985-990 7. Parsons D, Wald E. Otitis media and sinusitis. Otolaryngol Clin North Am 1996 29 11-25 9. Ohashi Y, Nakai Y. Functional and morphological pathology of chronic sinusitis mucous membrane. Acta Otolaryngol (Stockh) 1983 397 11 11. Giebink G. Criteria for evaluation of antimicrobial agents and current therapies for acute...

Brief History of Pediatric Sinusitis

Before the 1980s, pediatric sinusitis, especially in the young child or infant, was rarely entertained as a distinct clinical entity. Most cases were apparently dismissed as an unimportant allergy or a cold and were rarely treated with anything beyond decon-gestants or antihistamines, or both, perhaps not an altogether bad approach. Through a series of well-designed and executed studies, Dr. Ellen Wald and her associates in Pittsburgh established a logical framework for diagnosing and treating children with sinus infections.1'2 These and other studies, many with pharmaceuticals industry support, demonstrated the efficacy of antimicrobial therapy.3,4 During the late 1980s the recognition of the value of coronal computed tomography (CT) and sinus telescopes led to the rise of osteomeatal fundamentalism as a predominant sinus doctrine, especially among rhinologic surgeons. Obstruction of the osteomeatal complex (OMC), recognized as being involved in selected cases of persistent or...

Evaluation and Diagnosis

The most frequent presenting symptoms of IP are nasal obstruction (64 to 78 ), followed by headache, epistaxis, facial pain, periorbital swelling, purulent rhinorrhea, chronic sinusitis, allergy, hyposmia, visual changes, and meningitis. Some patients are even asymptomatic. These signs and symptoms make IP difficult to distinguish from inflammatory dis- tomographic (CT) imaging of the nose and paranasal sinuses are the gold standards of evaluation.8 In contrast to the more translucent bilateral inflammatory polyps, IP is usually unilateral (although in rare cases it is bilateral), vascular, and bulky. However, IP often arises along with nasal polyps, making the diagnosis difficult. The surgeon should always submit operative specimens according to their site of origin, rather than as a combined specimen. IP can display bone invasion on a CT scan, even to the extent that skull base erosion occurs this finding requires craniofacial resection despite no evidence of cancer.7,15,35 As a...

Evaluation Scales and Staging Systems

Several evaluation scales currently exist for patients with chronic rhinosinusitis.3 For subjective evaluation there are general health status instruments, such as the Medical Outcomes Study Short Form-36 (SF-36), as well as disease-specific instruments such as the Chronic Sinusitis Survey (CSS), the Rhinosinusitis Outcome Measure (RSOM-31) Sinonasal Outcome Test (SNOT-20), and the Rhinosinusitis Disability Index (RSDI). Arecently released comprehensive tool for the subjective evaluation of chronic rhinosinusitis is the Chronic Sinusitis TyPE Specific Questionnaire, published by the Health Outcomes Institute. Objective staging systems for rhinosinusitis also exist. Although an ideal and widely accepted staging scale remains elusive, two staging systems have achieved reasonable accep tance and utility. Kennedy's1 detailed analysis of a patient cohort permitted the proposal of a rational staging system that incorporated surgical findings and radiological appearance and this system has...

Subjective Outcomes Measures

Disease-specific health measurement tools are available as well. The CSS, developed at the Massachusetts Eye and Ear Infirmary, is duration-based and monitors both symptoms and need for medical therapy over an 8-week period.8 Studies have demonstrated that the CSS is statistically reliable and is sensitive to clinical change over time. The CSS has been used as a research tool to evaluate the outcomes of sinus surgery on quality of life and seems like a reasonable candidate to use in the evaluation and management of patients with chronic rhinosinusitis.9 This clinical use remains to be formally evaluated and the potential shortcomings for the CSS include a limited range of symptoms and psychometric data. The RSDI is a unique disease-specific outcome measure in that it evaluates the self-perceived impact of chronic rhinosinusitis in a first-person descriptive format.11 It is unclear Another recently released tool for outcomes assessment is the Chronic Sinusitis TyPE (Technology of...

Current Management Strategies

The results of the recent outcome studies discussed are providing increasingly compelling evidence that subjective improvement, particularly in the short to medium term (18 months), does not equate with disease resolution in chronic rhinosinusitis, hence is not predictive of a long-term successful outcome. The extension of this concept is that the most significant parameter for management of patients after sinus surgery is the objective endoscopic appearance during the healing period. Subjective assessment of outcomes after treatment of chronic rhinosinusitis, however, has significant initial relevance. These assessments are of paramount importance to the patient. They are also important to the analysis of cost-benefit evaluations and quality-of-life issues, which are being increasingly scrutinized in modern health care. In the future, with refinements of measurement tools and with establishment of staging systems such as those seen in the CSS and the third portion of TyPE...

When To Consider Revision Surgery

Based on the management scheme outlined, patients receive intensive follow-up after endoscopic sinus surgery for chronic rhinosinusitis. Such meticulous surveillance generally avoids significant recurrence. Patients who receive suboptimal follow-up, whether for logistical reasons or poor compliance, are more likely to develop bulky recurrence of their disease with neo-osteogenesis. This forms one group of patients who are more likely to require revision surgery. However, a significant number of such patients will be able to be managed nonsurgically with aggressive medical and debridement therapy as outlined. Chronic rhinosinusitis is a complex multifactorial illness that is managed in a comprehensive fashion with the incorporation of surgical and medical therapy. Objective assessments are currently the primary factors in formulating management decisions. Instruments for subjective evaluation are available and are important with respect to outcomes research and quality-of-life issues....

Classification Antibiotic penicillin

Uses For beta-lactamase-producing strains of the following organisms Hemophilus influenzae and Moraxella catarrhalis causing lower respiratory tract infections, otitis media, and sinusitis Staphylococcus aureus, Escherichia coli, and Klebsiella, causing skin and skin structure infections E. coli, Klebsiella, and Enterobacter, causing UTI. Note Mixed infections caused by organisms susceptible to ampicillin and organisms susceptible to amoxicillin potassium clavulanate should not require an additional antibiotic. Contraindications Hypersensitivity to pencillins. Clavulanate K-asso-ciated cholestatic and or liver dysfunction.

Oral Suspension Chewable Tablets Tablets

Adults One 875-mg tablet q 12 hr or one 500-mg tablet q 8 hr. Children over 3 months old 45 mg kg day of amoxicillin in divided doses q 12 hr or 40 mg kg day in divided doses q 8 hr (these doses are used in children for otitis media, lower respiratory tract infections, or sinusitis). Treatment duration for otitis media is 10 days.

Nasotracheal Intubation

Nasotracheal intubation is the preferred method of intubation if prolonged intubation is anticipated (increased patient comfort). Intubation will be facilitated if the patient is awake and spontaneously breathing. There is an increased incidence of sinusitis with nasotracheal intubation.

Inner Ear Visible In

Tympanic Membrane Type

The causes are generally eustachian tube obstruction secondary to mucosal edema due to infection (sinusitis, nasopharyngitis) or allergy extrinsic pressure on the cartilaginous portion of the eustachian tube due to hyperplasia of glandular or lymphoid tissue or, rarely, due to tumors malfunction of the tubal muscles as in children with cleft palate, or malformation of the tube itself as in Down's syndrome. Other factors that may contribute include bacteriologic, immunologic, genetic, socioeconomic status, seasonal variation, as well as lack of transmission of specific immunoglobulins in non-breast-fed infants. All these factors cause tubal dysfunction or occlusion leading to negative middle ear pressure due to oxygen absorption by the mucosa of the middle ear cleft. Normally, the tendency of the tubal walls to collapse at the level of the isthmus can be overcome by an increase in the nasopharyngeal pressure. A negative middle ear pressure up to -25 mm Hg can be thus corrected. On the...

Classification Antihistamine

Special Concerns Use with care during lactation. Safety and efficacy have not been determined in children less than 12 years of age. Side Effects CNS Drowsiness, fatigue. GI Nausea, dyspepsia. Miscellaneous Viral infection (flu, colds), dysmenorrhea, sinusitis, throat irritation.

Cribriform Plate Infection

Subdural Empyema Pathogenesis

Pathogens usually reach the CNS by local extension from a nearby infectious focus (e. g. sinusitis, mastoiditis) or by hematogenous spread from a distant focus. The ability of pathogens to spread by way of the bloodstream depends on their virulence and on the immune status of the host. They use special mechanisms to cross or circumvent the blood-brain barrier (p. 8). Some pathogens enter the CNS by centripetal travel along peripheral nerves (herpes simplexvirus type I, variE cella-zoster virus, rabies virus), others by en- S docytosis (Neisseria meningitidis), intracellular transport (Plasmodium falciparum via erythro-1 cytes, Toxoplasma gondii via macrophages), or in-O tracellular invasion (Haemophilus influenzae). u Those that enter the subarachnoid space probably g do so by way of the choroid plexus, venous 3 sinuses, or cribriform plate (p. 76). Having fa entered the CSF spaces, pathogens trigger an in-(< u flammatory response characterized by the release of complement factors...

Osteomyelitis in Flat and Irregular Bones

Osteomyelitis Skull

Fig. 6.24A, B Focal infection in a craniotomy defect. A Anterior pinhole scan of the left frontal skull shows intense tracer uptake localized in the immediate supraorbital region, indicating focal infection of a craniotomy defect (arrow). Uninfected craniotomy defects do not concentrate tracer. Incidentally, some tracer uptake is seen in the periphery of the left frontal sinus due to unrelated sinusitis (arrowheads). B Water's view radiograph reveals the craniotomy defect in the left frontal bone with scalp sutures (arrows) and clouding of the left frontal sinus (arrowheads). The infection in the left supraorbital bone is hardly recognizable (curved arrow)

Discharge And Home Healthcare Guidelines

M eningitis is an acute or subacute inflammation of the meninges (lining of the brain and spinal cord). The bacterial or viral pathogens responsible for meningitis usually come from another site, such as those that lead to an upper respiratory infection, sinusitis, or mumps. The organisms can also enter the meninges through open wounds. Bacterial meningitis is considered a medical emergency because the outcome depends on the interval between the onset of disease and the initiation of antimicrobial therapy. In contrast, the viral form of meningitis is sometimes called aseptic or serous meningitis. It is usually self-limiting and, in contrast to the bacterial form, is often described as benign.

Examples of Computed Tomography Staging Systems

SOURCE Adapted from Lund VJ, Mackay IS. Staging in rhinosinusitis. Rhinology 1993 107 183-184 pared with other chronic illnesses. Such comparisons show that patients with chronic sinusitis have SF-36 scores in domains such as general health and vitality similar to scores of patients with other chronic illnesses, such as chronic obstructive pulmonary disease. Using generic health measures in this way gives us a better understanding of the relative public health impact of one illness versus another.

Classification Cephalosporin secondgeneration

Action Kinetics Sixty percent is recovered in the urine unchanged. Uses Pharyngitis and tonsillitis due to Streptococcus pyogenes. Acute bacterial sinusitis due to Streptococcus pneumoniae, Staphylococcus aure-us, Haemophilus influenzae, and Moraxella catarrhalis. Otitis media

When Should Radiologic Evaluations Be Ordered

Because of the very high incidence of abnormal CT scans in young children,14 a scan cannot rationally be used to determine the need for sinus surgery. Most abnormal CT findings are related to routine (self-limiting) viral and bacterial infections or to postinfectious inflammatory changes that are not related to any particular symptomatology. CT scans, or perhaps other imaging studies, are reasonably ordered with a clinical suspicion of complications (periorbital, intracranial) or in the face of significant symptoms that may be related to sinusitis (e.g., marked worsening of bron-chospasm) without findings specific for sinusitis. Children with abnormal nasal symptoms (e.g, rhinorrhea, congestion) will, in the vast majority of cases, have a scan with abnormal findings. Does one type of CT finding make the patient a better surgical candidate than another set of findings Some surgeons prefer to consider patients with mucosal disease limited to the OMC, whereas others prefer their surgical...

What About Allergy Immunodeficiency And Reflux

By the time a child arrives in the otolaryngologist's office for evaluation of chronic sinusitis, someone in the family will have raised the issue that this is all due to allergy. In many situations, the nature of the rhinorrhea and congestion does resemble that seen in atopic patients. However, microscopic and immunologic analyses of the secretions are not consistent with what is seen in IgE-mediated rhinitis. Rather, the findings are those of acute infectious inflammation. Whereas some reports report a higher incidence of sinusitis in atopic children, concerns about reporting biases and biases in the allergy practices reporting such findings raise concerns about the validity of the reports. The primary risk factors for such disease are primarily related to exposure to other children, as in day care. The prompt response to effective antimicrobials also weighs against allergy being of primary importance. As a child grows beyond 3-5 years of age, the incidence of IgE-mediated disease...

Pediatric Sinus Surgerya Stinging Assessment

The advocates of a surgical approach actively excluded their detractors from self-organized consensus panels, papers, and discussions, while the pediatric and sinus leadership turned a blind and ineffectual eye. In the case of PESS, surgeons are advocating a procedure that has no proven efficacy over nonsurgical management and that may have no proven rationale. The procedure is associated with significant costs, possible complications, and a likelihood of at least occasionally adversely affecting facial growth. Sinusitis, as a vague and poorly defined clinical entity, is a dream come true for the unscrupulous or less-than-thoughtful clinician. 2. Wald ER, Milmoe GJ, Bowen A, et al. Acute maxillary sinusitis in children. N Engl J Med 1981 304 749-754 3. Wald ER. Antimicrobial therapy of pediatric patients with sinusitis. J Allergy Clin Immunol 1992 90(3 pt 2) 469-473 4. Wald ER, Chiponis D, Ledesma-Medina. Comparative effectiveness of amoxicillin and amoxicillin-clavulanate potassium...

Surgical Management

There is little doubt that sinus-like symptoms occur in children with large obstructive adenoid pads. If the obstructive adenoid pad is not removed, the nasal cavity cannot become healthy. Several studies indicate that adenoidectomy improves the signs and symptoms of sinusitis.36,37 Good prospective studies designed to assess the efficacy of adenoidectomy in well-documented cases of sinusitis are needed. The use of maxillary sinus irrigation and nasal antral windows is not a routine approach primarily because these techniques address only the maxillary sinus and do not show good results.38 Endoscopic sinus surgery is currently the primary method of treatment for chronic sinusitis. The indications for endoscopic sinus surgery remain controversial. The Consensus Panel1 preferred to divide their indications into absolute and possible indications. Absolute indications include (1) complete nasal airway obstruction in cystic fibrosis due to massive polyposis or closure of the nose by...

Biofilm and Medical Devices

Biofilm, as a matter of fact, is involved in acute and chronic infectious diseases and has been described in human and experimental pathology such as native valve endocarditis, otitis media, bacterial chronic rhinosinusitis, COPD, chronic urinary infections, bacterial prostatitis, osteomyelitis, dental caries, biliary tract infections, Legionnaire's disease and amyloidosis.

Embryology and Anatomy

Development of the typically paired frontal sinus is quite variable. After 4 years of age, the frontal sinus is in a supraorbital position however, it is radiologically indistinguishable from the ethmoid sinus until 6 to 8 years of age. Growth then continues for another 8 to 10 years before reaching full adult development.3 The sphenoid sinus is present at 3 years of age and is generally fully developed by 12 years of age. Its slow growth and relative isolation in the skull base may preserve it from frequent infection, as isolated sphenoid sinusitis is uncommon in children.3

Physiology and Pathophysiology

Ostial obstruction thus initiates a vicious circle, with self-mediated mucosal edema and hyperplasia, obstruction of sinus drainage, retention of secretions, and ciliary dysfunction, cumulatively creating an environment ideal for long-standing infection. In children, OMC obstruction is recognized as a critical factor in chronic rhinosinusitis, however, it is unclear whether this is the primary cause of the disease. Perhaps critical to our further understanding of this unique pathophysiologic model is the concept that there is rarely a single isolated cause. A number of conditions have been identified as predisposing to chronic rhinosinusitis in children, although an acute viral illness the common cold appears to be the most frequently recognized association.11,12 Data suggest children average 6 to 8 upper respiratory infections (URIs) per year, and acute sinusitis complicates 5 to 10 of cases.13,14 The precise mechanism whereby viruses predispose to rhinosinusitis is unknown, but it...

Factors Involved in Treatment Algorithm for Chronic Otitis Media

After initial evaluation, including ancillary studies and assignment to a subcategory of disease (Table 38-1), possible contributory disease processes such as allergic rhinosinusitis, smoking, obesity and or diabetes mellitus, immunocompro-mise, should be assessed and controlled if possible (Fig. 38-1). Assignment to Subcategory and Management of Contributory Disease -Allergic rhinosinusitis

Gastroesophageal Reflux

Gastroesophageal reflux (GER) has been suggested as another important factor contributing to rhinosinusitis in some children.45-47 This concept is based on the theory that there is reflux into the nasopharynx, and that when low pH gastric contents contact upper respiratory mucosa, edema and irritation result, potentially leading first to obstruction of the eustachian tubes or sinus ostia, and eventually to rhinosinusitis. Most children do not exhibit typical GER symptoms such as heartburn or regurgitation, however in these cases, the history is often not suggestive of the condition. In a child with chronic rhinosinusitis, the potential for GER as an underlying condition may be addressed by empirically optimizing positional and dietary factors. Reflux precautions are advised to all patients and include head-of-bed elevation, and avoidance of caffeine spicy foods pre-bedtime meals. An antacid trial may be initiated as well if the diagnosis of GER is under consideration. If a child does...

Supplemental Medical Therapy

Additional medical therapies are often used in conjunction with antimicrobial agents to decrease sinonasal edema and reestablish a more normal functioning nasal environment. No controlled studies have been performed to document their efficacy in chronic pediatric rhinosinusitis. Investigators report that buffered hypertonic nasal irrigation provides rapid and effective cleansing of nasal debris, decreases mucosal edema, and may improve mucociliary flow patterns by decreasing ciliary transit times.7,48 Although frequent nasal irrigation with this solution may allow for a healthier sinonasal tract, the improvement lasts only hours. For longer-lasting nasal decongestion in children with chronic rhinosinusitis, several Consensus Panel members support intranasal steroid sprays,17 which may be even more effective when used after hypertonic saline irrigation.48 These agents reduce cholinergic receptor sensitivity, reduce the number of basophils and eosinophils in nasal mucosa, and inhibit the

Classification Antihistamine ophthalmic

Contraindications Not to be injected. Not to be instilled while the client is wearing contact lenses. Special Concerns Use with caution during lactation. Safety and efficacy have not been determined for children less than 3 years of age. Side Effects Ophthalmic Burning or stinging, dry eye, foreign body sensation, hyperemia, keratitis, lid edema, pruritus. Nose throat Pharyngitis, rhinitis, sinusitis. Oral Taste perversion. Miscellaneous Headache, asthenia, cold syndrome. Drug Interactions None reported. How Supplied Solution 0.1 Solution in a 5-mL drop dispenser

Hivaids Introduction

Infants with perinatal acquired AIDS are normal at birth but may develop symptoms within the first 18 months of life. Clinical manifestations in children include fever decreased CD4 count anemia decreased WBC count (less than 3,000 cells mm3) neutropenia (absolute neutrophil count of less than 1,500 cells mm3) thrombocytopenia myelosuppression vitamin K deficiency hepatitis pancreatitis stomatitis and esophagitis meningitis retinitis (common with low CD4 counts) otitis media and sinusitis (chronic or recurrent) lymphadenopathy hepatosplenomegaly recurrent bacterial infections (especially, Streptococcus pneumoniae and Haemophilus influenzae) Mycobacterium infections (MAC) or tuberculosis cytomegalovirus (CMV) failure to thrive (in infants) chronic diarrhea neurologic involvement, (developmental delays and microcephaly in infants, or loss of motor skills in the older child) and pulmonary infections (Pneumocystis carinii PCP , lymphocytic interstitial pneumonitis LIP , and pulmonary...

Phenylephrine hydrochloride

Uses Systemic Vascular failure in shock, shock-like states, drug-induced hypotension or hypersensitiv-ity. To maintain BP during spinal and inhalation anesthesia to prolong spinal anesthesia. As a vasoconstrictor in regional analgesia. Paroxysmal SVT. Nasal Nasal congestion due to allergies, sinusitis, common cold, or hay fever. Ophthal-mologic 0.12 Temporary relief of redness of the eye associated with colds, hay fever, wind, dust, sun, smog, smoke, contact lens. 2.5 and 10 Decongestant and vasoconstrictor, treatment of uveitis with posterior synechiae, open-angle glaucoma, refraction without cyclople-gia, ophthalmoscopic examination, funduscopy, prior to surgery. Contraindications Severe hypertension, ventricular tachycardia. Special Concerns Use with extreme caution in geriatric clients, severe arteriosclerosis, bradycardia, partial heart block, myocardial disease, hyperthyroidism and during pregnancy and lactation. Nasal and ophthalmic use of phenylephrine may be systemically...

Type of Headache Symptoms and Signs Syndromes

Posttraumatic, drug-induced, vascular (p. 182), intracranial mass, hydrocephalus, sinusitis, parkinsonism, cervical dystonia, myoarthropathy of the masticatory apparatus,1 mental illness (depression, schizophrenia, hypochondria), cervical spine lesions (degenerative lesions, fractures, Klippel Feil syndrome), Down syndrome, basilar impression, osteoporosis, skull metastasis, spondylitis, rheumatoid arthritis, lesions of cervical spinal cord meningismus (tumor, hemorrhage, syringomyelia, cervical myelopathy, von Hippel-Lindau syndrome, meningitis, carcinomatous meningitis, intracranial hypotension)

Problems And Complications Of Pess

The true incidence of nasal synechiae or other abnormal intranasal scars is unknown but is undoubtedly underreported. Most of the pediatric intranasal synechiae that we have seen have not been reported to the family by the operating surgeon. An occasional case of PESS becomes markedly dysfunctional. This patient, who initially may have had relatively limited OMC mucosal disease during an episodic case of rhinosinusitis develops chronic staphylococcal, pseudomonal, or fungal sinusitis and osteitis after PESS, with years of symptomatology, intravenous antibiotics (usually unsuccessful), and multiple operations. There may be important functional and protective reasons that sinus ostia developed in such anatomically protected locations. Most of us caring for a significant number of sinus surgery cases note the creation of a small number of sinus cripples. They exist in two varieties. The first type is the patient with the unrelenting opportunistic infection in a sinus that has been...

Classification Oral antidiabetic

Diabetic ketoacidosis, with or without coma. Type 1 diabetes. Special Concerns Use with caution in impaired hepatic function. Safety and efficacy have not been determined in children. Side Effects CV Chest pain, angina, ischemia. GI Nausea, diarrhea, constipation, vomiting, dyspepsia. Respiratory URI, sinusitis, rhinitis, bronchitis. Musculoskeletal Arthralgia, back pain. Miscellaneous Hypoglyce-mia, headache, paresthesia, chest pain, urinary tract infection, tooth disorder, allergy.

Endoscopic Sinus Surgery

When prolonged maximal medical therapy and adenoidectomy both fail to provide adequate relief in a child with at least 6 months of severe symptoms of chronic rhinosinusitis, the child may be a potential candidate for functional endoscopic sinus surgery (FESS).78,85 The Caldwell-Luc procedure is essentially contraindicated in young children due to the potential for damage to unerupted teeth.29,44 Indications for FESS in pediatric rhinosinusitis remain poorly defined and shrouded in controversies. The Consensus Meeting in Brussels defined their indications in the context of absolute and possible and are as follows.17 Traumatic injury in the optic canal (decompression) Dacryocystorhinitis due to sinusitis resistant to appropriate medical management Fungal sinusitis Some meningoencephaloceles Some neoplasms Chronic rhinosinusitis that persists despite optimal medical management, and after exclusion of systemic disease (optimal medical management includes 2 to 5 weeks of appropriate...

Objective Outcome Measures and Staging Systems

In an effort to objectify the severity of chronic rhinosinusitis and the response to medical therapy, numerous staging systems have been proposed. Theoretically, a uniform reporting scheme and a uniformly accepted staging system would improve scientific and accurate communication between otolaryngologists. Such a staging system might also permit the subsequent re-staging of patients after therapeutic intervention and thus become a management tool. To date, however, such a staging system has remained elusive. Early attempts to devise such objective staging systems incorporated measures of disease severity (e.g., localized vs diffuse disease) combined with the presence or absence of related factors (e.g., asthma, allergy, polyposis).13'14 Extensions and refinements of these techniques have been proposed more recently. The first significant step forward was made by Kennedy1 in 1992 and, more recently, the Lund-MacKay staging system was endorsed by the Rhinosinusitis Task Force for future...

Staging and Stratification

The challenge of developing outcomes management systems rests in adequately defining and stratifying starting points and in accurately quantifying endpoints. In sinusitis, for example, a great deal of attention has been focused on the appropriate method to stage a preoperative computed tomography (CT) scan of the paranasal sinuses. Yet, the factors that comprise a good staging system (i.e., validity, reliability, statistical distribution, comprehensiveness, and the ability to predict outcome) are rarely considered or objectively evaluated. In two studies of clinician-based staging systems,1'2 we have found wide variations in reliability (both intra-rater and inter-rater) and the lack of substantial correlations to postoperative outcome. Nevertheless, for consistency in reporting results, it is necessary to choose a staging system. Table 18-1 describes several proposed staging systems that have been evaluated. In the comprehensive evaluation by Metson et al.,2 which included staging...

Why The Maxillary Sinus

Although the frontal and sphenoid sinuses have long been recognized as occasional sites of clinically important disease, the maxillary sinus has traditionally been the focus for defining bacterial sinusitis. Emphasis on the OMC has only recently shifted new attention to the importance of the eth-moidal cells. In retrospect, it was our ability to image the maxillary sinuses satisfactorily with standard radiographic equipment, that led to that site as the gold standard for assessing the microbiology and efficacy issues surrounding sinusitis. The insistence by established sinus investigators and regulatory agencies, such as Food and Drug Administration (FDA), that sinusitis primarily be considered by maxillary investigations is not consistent with our current understanding. In all likelihood, for most cases of symptomatic acute sinusitis, mucosal disease in the ethmoids and nasal cavity accounts for more symptoms than what transpires in the maxillary sinus, especially in children....

Background

The use of advanced radiographic studies such as computed tomography (CT) scanning with contrast and magnetic resonance imaging (MRI) with contrast can help identify tumor extent, allowing for better surgical planning.3,12,13 This is especially helpful in finding tumor extending into the frontal, sphenoid, or maxillary sinus as opposed to fluid or sinusitis secondary to ostia blockage.1

Outcomes Measures

Assessing endpoints or outcomes is the next step in developing outcomes management systems. Although traditional endpoints such as complications and mortality rates are important, they are imprecise for nonmorbid disease processes such as sinusitis. Therefore, these measures must be supplemented by more precise and useful measurements. Unlike hearing or vision loss, patients with sinusitis suffer in ways that are less easily measured but that certainly affect their functioning and well-being. Therefore, it is clear that patient-based quality-of-life measures should be a vital element of any studies in patients with sinusitis. The recommended elements of a quality-of-life outcomes monitor for sinusitis include a general health assessment, which is a global view of the patient's well-being as well as a disease-specific assessment that focuses more narrowly on the disease entity and that is usually more sensitive to clinical change with treatment.6,9,10 Probably the most widely tested...

Available Measures

Table 18-2 presents several available instruments and the number of published studies identified in a Medline search through 1998. I do not recommend any one particular instrument. For different purposes, different instruments will be most suitable. For example, the rhinosinusitis outcome measure (RSOM-31,)13 and its derivative, the Sinonasal Outcomes Test (SNOT-20), was developed in primary care practices in order to better ascertain which symptoms are best correlated with the diagnosis of sinusitis. As such, it has potential to be used as a discriminative test to help differentiate patients who have sinusitis from those who do not. The Chronic Sinusitis Survey (CSS), (also known as the Nasal Outcome Survey),6 was developed as a brief, highly sensitive evaluative instrument designed to measure change with therapy. This makes it particularly useful for clinical trials or for following patients who are undergoing surgery. Of all the reliable sinusitis instruments, it is the least...

Specific History

Chronic focus of infection Dental abscess (usually the patient has poorly maintained dentition on physical exam, with one or more sensitive teeth however, occult abscess formation without signs or symptoms has also been reported), chronic sinusitis, chronic dermatophytosis, candidiasis, intestinal parasitosis, diverticulitis.

Cefuroxime axetil

Action Kinetics Cefuroxime axetil is used PO, whereas cefuroxime sodium is used either IM or IV. Uses PO (axetil). Pharyngitis, tonsillitis, otitis media, sinusitis, acute bacterial exacerbations of chronic bronchitis and secondary bacterial infections of acute bronchitis, uncomplicated UTIs, uncomplicated skin and skin structure infections, uncomplicated gonorrhea (urethral and endocervical) caused by non-penicillinase-producing strains of Neisseria gonorrhoeae. Early Lyme disease due to Borrelia burgdorferi. The suspension is indicated for children from 3 months to 12 years to treat pharyngitis, tonsillitis, acute bacterial otitis media, and impetigo. Contraindications Hypersensitivity to cephalosporins. Use in infants < 1 month.

Churg Strauss Disease

A biopsy of affected organs, including small arteries, arterioles or venules shows extravas-cular eosinophils,which confirms the diagnosis. Neurological involvement occurs in 62 of cases, including stroke and intracerebral hemorrhage (Fig. 7.6) 21,22 . Steroids usually stabilize this condition, but treatment with cyclophosphamide may be required. A normal angiogram does not exclude this form of

Mucocele Extraction

Caldwell Luc Operation Definition

A similar appearance is seen in nasal allergy, either seasonal hay fever or perennial allergy, but the edematous turbinate mucous membrane appears gray (c) rather than red (b). A persistent purulent nasal discharge usually means that there is a sinusitis. Corticosteroid nasal sprays for nasal allergy reduce the obstruction, rhinorrhea, and sneezing that characterize both seasonal and perennial nasal allergy. Skin tests to detect specific allergens are of use with grass pollen and house dust allergy related to the house dust mite. A similar appearance is seen in nasal allergy, either seasonal hay fever or perennial allergy, but the edematous turbinate mucous membrane appears gray (c) rather than red (b). A persistent purulent nasal discharge usually means that there is a sinusitis. Corticosteroid nasal sprays for nasal allergy reduce the obstruction, rhinorrhea, and sneezing that characterize both seasonal and perennial nasal allergy. Skin tests to detect specific allergens are of use...

Immunology

X-linked agammaglobulinemia (Bruton's agammaglobulinemia) X- inked recessive disorder that affects males. B-cells are low or absent infections begin after 6 months when maternal antibodies disappear. Look for recurrent lung and sinus infections with Streptococcus and Haemophilus spp.

Cellulitis

Lagophthalmos Ectropion

INTRODUCTION Preseptal cellulitis is defined as inflammation and infection confined to the eyelids and periorbital structures anterior to the orbital septum. The orbital structures posterior to the septum are not involved, but may be secondarily inflamed. In children, the most common cause of preseptal cellulitis is underlying sinusitis. Preseptal cellulitis in children under TREATMENT Initial antibiotic selection is based on the history, clinical findings, and initial laboratory studies. With positive culture, prompt sensitivity studies are indicated so that the antibiotic selection can be revised, if necessary. Staphylococcus aureus is the most common pathogen in patients with preseptal cellulitis from trauma. The infection usually responds quickly to penicllinase-resistant penicillin. Imaging studies should be performed to rule out underlying sinusitis if no direct inoculation site is identified. If the patient does not respond quickly to oral antibiotics or if orbital involvement...

Richard N Hubbell

Pediatric Chronic Rhinosinusitis Assessment and Management This chapter is intended to guide the sophisticated consumer of otolaryngology literature through many of the challenging clinical problems for which there are no straightforward answers, no definite proofs of efficacy, and no consensus. Pediatric sinusitis, particularly those aspects that pertain to surgical therapy, is an ideal topic for such a work, especially because so few published pertinent works are intellectually sound, scientifically rigorous, and unbiased in their conclusions. Nonetheless, pediatric sinusitis is a common and important entity, and clinicians can better manage patients, families, and other clinicians through improved understanding of the diagnostic and therapeutic dilemmas we face. This review includes a brief historic overview and then considers controversies and problem areas in the definition, diagnosis, and treatment of disease. It is my intent to pull no punches, but rather to expose the reader...

Antimicrobial Issues

There have been no recent clinical trials pitting one antibiotic versus another for pediatric sinusitis. The major reason has to do with the perceived need to obtain bacteriologic data by means of maxillary antral taps. Still, the lack of direct comparative evidence does not diminish the compelling evidence from other sources about the relative efficacy of available antimicrobials against the pathogens of interest. Young children with persistent bacterial rhinosinusitis often harbor multiple relatively resistant pathogens, making empirical therapy with a single agent problematic. Even the more potent agents (e.g., amoxicillin-clavulanate, cefuroxime axetil, cefpodoxime proxetil) will fail against some of strains of S. pneumoniae and H. influenzae. Resistance to sulfa drugs and the macrolides (including azithromycin and clarithromycin) is relatively common among those same organisms. Even pneumococcal resistance to clindamycin is increasing. However, if a given strain is isolated and...

Surgical Options

Adenoidectomy is the most commonly recommended procedure for young children with problematic sinusitis. That procedure may alleviate posterior nasal obstruction or reduce the reservoir of pathogenic bacteria. A number of clinicians still routinely perform therapeutic lavages of the maxillary sinuses of affected children,18 whereas a number never perform this procedure. We have found it neither useful nor necessary. We know from the otitis media literature that almost two-thirds of infants and children identified as prone to otitis on historic grounds no longer continue that pattern, with placebo providing dramatic improvement. Pediatric rhinosinusitis should be no different. In a study of chronic pediatric maxillary opacification, almost all resolved spontaneously.19 In cases of sinusitis complicating asthma, PESS has been reported to significantly improve the course of the asthma.20 A number of clinicians have used that information to lower the threshold for PESS in the presence...

Loratidine

Special Concerns Use with caution, if at all, during lactation. Give a lower initial dose in liver impairment. Safety and efficacy have not been determined in children less than 2 years of age. Side Effects Most commonly, headache, somnolence, fatigue, and dry mouth. GI Altered salivation, gastritis, dyspepsia, stomatitis, tooth ache, thirst, altered taste, flatulence. CNS Hypoesthesia, hyperkinesia, migraine, anxiety, depression, agitation, paroniria, amnesia, impaired concentration. Ophthalmologic Altered lacrimation, conjunctivitis, blurred vision, eye pain, blepharo-spasm. Respiratory Upper respiratory infection, epistaxis, pharyngitis, dyspnea, coughing, rhinitis, sinusitis, sneezing, bronchitis, bronchospasm, hemoptysis, laryngitis. Body as a whole Asthenia, increased sweating, flushing, malaise, rigors, fever, dry skin, aggravated allergy, pruritus, purpura. Musculoskeletal Back chest pain, leg cramps, arthralgia, myalgia. GU Breast pain, menorrha-gia, dysmenorrhea, vaginitis....

Culture

In general, cultures of the nasal cavity have not been readily used in the pediatric population. The primary reasons are poor patient compliance and the inability to obtain an uncontami-nated specimen. Recently cultures of the middle meatus have shown a high correlation with antral punctures.9 In the cooperative patient, endoscopically directed cultures of the middle meatus may be very useful, particularly in communities with increased resistance. Cultures of the maxillary sinus in patients who have complicated acute sinusitis or in those who fail to respond appropriately are indications that a culture should be obtained by antral puncture.1

Pathophysiology

The multifactorial cause of sinusitis continues to fuel the controversy regarding the underlying pathophysiologies of chronic sinusitis. Age is clearly one of the most significant factors in pediatric sinusitis. The younger the child, the higher the incidence of sinusitis and the more likely the maxillary sinus will be diseased.6,10 Children also have an immature immune system, making them more likely to develop upper respiratory tract viral infections and associated acute sinusitis. There is a strong association between sinusitis and respiratory viral infections.11 The viral infections cause mucosal edema that obstructs the ostium and increases the risk of bacterial infection in the sinuses. As the infundibulum is one of the narrowest drainage sites, the adjacent anterior ethmoid sinuses and maxillary sinuses would be the most likely to be involved with sinusitis. Van der Veken and Clement and colleagues,6 and Lusk et al.5 found that this indeed is the case and that the maxillary...

Variations

The importance of anatomic abnormalities as a cause of sinusitis remains an area of significant controversy, especially in the pediatric population. It is best to think of these anatomic structures as variants of normal, and not as abnormalities. This issue is of some importance because if anatomic variations are not associated with increased sinusitis, the cause of sinusitis is more likely to be systemic, and possibly more amenable to medical management. If the problem is more systemic, conservative surgical procedures may be adequate. The anatomy is most effectively assessed by computed tomography (CT) scans. Most anatomic variations are found equally in control and sinusitis patients.22'23 There is convincing evidence that the incidence of anatomic variations increases with age.20 In general, anatomic variations are not associated with increased sinusitis24 and the incidence of anomalies is similar in diseased and control patients.22 The variations thought to be most likely...

Mucormycosis

CLINICAL PRESENTATION Orbital involvement is seen in 80 of patients with mucormycosis, and 11 will progress to cavernous sinus thrombosis. Patients usually present with impaired ocular movement, loss of vision, proptosis, chemosis, and periorbital cellulitis. An orbital apex syndrome with blindness and total ophthalmoplegia may be seen. Serous retinal detachment may result from inflammation of the sclera. Rare cases of fungal enophthalmitis result from angioinvasion by fungal hyphae. With eyelid involvement cutaneous lesions may appear as large necrotic and ulcerating lesions with erythematous borders, and oozing black pus. Sinusitis and nasal discharge occur and nasal exam reveals a thick, dark blood-tinged discharge and reddish black necrotic eschar on the turbinates and septum. Cerebral involvement and hemiparesis can be seen in 15 to 20 of cases. Major systemic signs and symptoms include lethargy and headache.

Medical Management

Much is unknown about antibiotic therapy and chronic sinusitis. Prospective studies are lacking in the use of antihistamines and decongestants. Theoretically, decongestants would decrease the amount of edema and open the ostia. This has not been proved, however. Topical steroids have been shown to decrease edema within 2 weeks and may be of modest benefit. If reflux is present, it should be aggressively treated before surgical intervention is attempted. Increasing resistance of S. pneumoniae is of increasing concern. It is the most common organism to cause acute sinusitis, but it has become dramatically more resistant. The current recommendations for treatment of cultured resistant bacteria are high-dose amoxicillin (80 to 90 mg kg day), azithromycin, clindamycin, and rifampin.35 In patients with resistant bacteria, surgery may be necessary to improve drainage.

Definitions

According to the most recent consensus meeting in Brussels,17 chronic rhinosinusitis in children is defined as a sinus infection with low-grade symptoms and signs that persists for longer than 12 weeks. This definition allows for a diagnosis without the previously mandatory computed tomography (CT) scan, based on the consensus panel's belief that imaging all children with suspected chronic rhinosinusitis is not feasible.17 Patients with acute exacerbations of chronic rhinosinusitis may have multiple acute episodes in addition to persistent low-grade symptoms and signs that do not resolve completely between acute episodes.

Predisposing Factors

Chronic pediatric rhinosinusitis is recognized as a multifactorial disease with various predisposing factors that change over time. Once the diagnosis of rhinosinusitis is suspected in a child, underlying modifiable contributors to sinonasal inflammation must be identified and managed appropriately. Once this is accomplished, the infectious disease aspect which actually may be secondary, can then be more effectively treated.7 Although their roles are still being defined, conditions that are currently recognized as potential predisposing factors for rhinosinusitis

Allergy

Allergy is one of the most common causes of problematic nasal mucosa edema48 and is implicated as a contributing factor in rhi-nosinusitis.49 Some investigators consider allergy in children the most important predisposing element in pediatric chronic rhi-nosinusitis,50'51 although its true role in this disease process is still under debate. Controlled studies comparing the incidence of sinusitis in allergic groups with nonallergic groups are very scarce, especially in pediatric populations. One study found no difference in the involvement of the sinuses of atopic children in comparison to nonallergic children with chronic nasal complaints.52 The same investigators showed the prevalence of rhinosinusitis to decrease after 8 years of age, and the prevalence of atopy to increase with age.52 Together, these findings suggest that allergy may not be a primary cause of chronic pediatric rhinosinusitis.44 Interestingly, however, the prevalence of rhinosinusitis in allergic children is higher...

Immunodeficiency

Young children all have a relative physiologic immunodeficiency because of a slow continual rise in plasma immunoglobulins (IgG, IgM, IgA) until 6 to 10 years of age, when adult levels are finally reached.29 Thus, children are theoretically more susceptible to infection during this period. Immunologic assessment is typically not warranted in all children with chronic rhinosinusi-tis however, the clinician must have a low threshold of suspicion for primary or secondary immune deficiency in patients with recalcitrant disease. Chronic rhinosinusitis is reportedly the most common clinical presentation of common variable immune deficiency (CVID),56 a disorder characterized by reduced levels of at least two serum immunoglobulin classes, usually IgG and IgA. IgG subclass deficiency also may manifest as chronic rhinosinusitis.56 Less common childhood immunodeficiencies are X-linked agammaglobulinemia, C4 deficiency, ataxia-telangiectasia, and hyper-IgM immunodeficiency.56 Evaluation for...

Genetic Disorders

An association between cystic fibrosis, nasal polyposis, and chronic rhinosinusitis is recognized.58 Studies indicate that nasal polyposis generally occurs after 5 years of age, although mucopy-osinusitis of the maxillary sinus can occur as early as 3 months of age.59 The maxillary sinus seems to be the first sinus affected by cystic fibrosis,59 although eventual pansinusitis is the norm. A positive family history and nasal polyposis in a child are indications for sweat testing to rule out cystic fibrosis nasal polyps are otherwise uncommon in the pediatric population. Characteristic CT findings of this disease are pansinusitis with uncinate process demineralization and bilateral medial displacement of the lateral nasal wall.60 Despite management of the underlying disorder, cystic fibrosis is a progressive disease. Cystic fibrosis may be associated with massive polyposis and complete nasal obstruction, and is frequently an indication for endoscopic sinus surgery unfortunately,...

Antibiotics

The goals of therapy in chronic pediatric rhinosinusitis are to eradicate the infection, provide reversal of sinus obstruction, and return effective mucociliary clearance.62 After all factors predisposing to this disease have been appropriately pursued, and the positive findings addressed, antibiotic therapy remains the cornerstone of treatment in children with rhinosinusitis. The choice of antibiotic is most often empirical, as representative cultures are difficult to routinely obtain in children. Selective cultures, however, are indicated for complicated cases (see Diagnosis). Ideally, antimicrobial therapy is aimed at eradicating the most commonly found pathogens associated with a particular disease process. However, the microbiology of chronic sinusitis in children has received very limited study, and discrepancies exist in the bacterial results of several investigations.3 Some studies implicate respiratory anaerobic organisms as the predominant pathogens of chronic...

Adenoidectomy

After the multifactorial causes of rhinosinusitis have been addressed and adequate medical management has continually failed to yield effective responses, the clinician may then consider a more interventional approach to therapy. Adenoidectomy offers promise as a simple, effective, and relatively safe procedure that may affect the sinuses indirectly.75 Clinical trials have shown adenoidectomy to be effective in alleviating symptoms in some patients,76'77 although definite conclusions cannot be drawn, owing to the limited size of these studies. Different theories have been described to explain the relationship between adenoids and the symptoms of chronic rhinosinusitis. One theory is that adenoid hypertrophy with chronic nasal obstruction and stasis may merely mimic signs and symptoms of rhinosinusitis with adenoidectomy, the effective relief of symptoms may be so great that further aggressive intervention is unneccessary.7,78 Another theory asserts that an adenoidal bed of any size...

Nasal Antral Window

The nasal antral window, or inferior meatal antrostomy, no longer plays a role in the management of uncomplicated pediatric chronic rhinosinusitis.2,80-82 This technique is unsuccessful in part because the cilia continue to beat toward the obstructed natural ostium, and because it does not address ethmoid disease. The current indication for the inferior antrostomy is in primary ciliary dyskinesia, as normal ciliary patterns do not exist, and the goal is gravitational drainage.

Antral Lavage

Antral lavage is another procedure that is not a viable therapy for chronic rhinosinusitis in children.17,83,84 This technique requires multiple irrigations, each under general anesthesia, and does not address the ethmoid disease common in pediatric rhinosinusitis. It does, however, remain a useful diagnostic tool in severe complicated disease that is based primarily in the maxillary sinus. The indications for antral lavage are identical to those for sinus puncture as described earlier (see Diagnosis).17

Summary

Chronic pediatric rhinosinusitis is a multifactorial disease process that continues to be a topic of considerable controversy. Although many predisposing factors have been identified, the complete natural history of this disease is still unknown. It is recognized, however, that there is a spontaneous tendency toward recovery in children after the age of 6 to 8 years.24,73, 74 Thus, with maturation of a child's immune system and developing anatomy, chronic rhinosinusitis may indeed resolve, warranting a conservative approach to treatment. As our understanding of this disease process advances, it is becoming increasingly apparent that chronic pediatric rhinosinusitis is medically treatable in most cases and that surgery is very rarely indicated in infants and children (Table 69-2).

Fungal Infections

Aspergillosis involving the CNS has findings similar to those of mucormycosis. CNS aspergillosis may result either from direct extension of nasal cavity and paranasal sinus infection, or more commonly from hematogenous dissemination. By direct extension, Aspergillus invades the cavernous sinus and circle of Willis, resulting in angitis, thrombosis, and infarction. In hematogenous spread, septic infarction occurs, with associated cerebritis and abscess formation

Future Directions

Meticulous postoperative debridement and medical therapy are the best manner in which to achieve a successful objective and subjective outcome in the long-term. However, the cost-effectiveness of such a management strategy has never been demonstrated. Intuitively, avoidance of revision surgery with its associated costs and risks would seem advantageous. However, aggressive postoperative follow-up and the use of prolonged systemic steroid therapy and antibiotics are not without risk and cost. It is our strong clinical impression that maintaining a patent cavity and minimizing inflammation and persistent recurrent disease permit the inflammation and mucosal hyperreactivity to slowly resolve during the years after surgical intervention. Thus, these patients slowly continue to improve clinically and require fewer medications. However, this observation requires further longitudinal documentation. If not validated, it is possible that periodic revision surgery could be more cost-effective...

Discussion

Endoscopic Medial Maxillectomy

The differential diagnosis of any unilateral nasal lesion should consider tumor first. The most common benign nasal tumor is inverting papilloma. Once endoscopic examination and or CT scanning indicates that the tumor is limited to the nose or sinuses, or both, an endoscopic examination can often pinpoint the precise origin of the tumor, permitting more precise surgical planning. This possiblity was unavailable before endoscopy and is one of the reasons intranasal removal under direct vision failed. Tumors were usually detected only when large and bulky, requiring extensive surgery for removal. Also, the advent of endoscopic diagnosis with CT scanning for sinusitis has resulted in earlier diagnosis of sinusitis and sinus tumors again, less surgery. Once the diagnosis is made, further radiologic evaluation to determine the extent of tumor may be necessary. Small localized tumors require only a CT scan. Large tumors affecting the nose and ethmoid sinus with evidence of sinusitis or...

Chronic Drainage

Probably 80 of acutely draining PE tubes clear with initial treatment, and another 80 of chronically draining tubes clear with anti-Pseudomonas treatment with or without tube removal. The remaining few patients, probably less than 5 of all patients with chronic draining PE tubes, have underlying localized mucosal or temporal bone disease, or upper respiratory immunologic, allergic, or bacterial disease that perpetuates tube drainage. A careful history and examination at the first office visit usually identifies these patients. Does the patient have allergy or sinus disease, especially inhalant allergy with rhinitis and sinusitis Does the patient have frequent bronchitis or pneumonia, perhaps associated with sinusitis and recurrent otitis Consider immunoglobulin G (IgG) subclass deficiency, immotile cilia syndrome, iatrogenic immuno-suppression, human immunodeficiency virus (HIV) infection, tuberculosis, and Wegener's granulomatosis. Does chronic ear pain suggest neoplasm, particularly...

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