Get Your Head In The Game Matthew Voorman, MD
Hutchinson Clinic March 21, 2016
About Me
Otolaryngology – Head & Neck Surgery • Geisinger Medical Center
General Surgery • University of California San Francisco Medical School • University of Southern California
Allergies
• Allergic Rhinitis (aka “hay fever”) • Food Allergies • Atopic Dermatitis • Asthma • Anaphylaxis
Allergic Rhinitis (aka “hay fever”)
• Affects 40-60 million • Not caused by hay • No fever either
Symptoms
• Runny Nose • Itchy eyes, mouth, throat • Puffy eye lids • Sneezing or cough • Stuffy nose
• Blocked ears • Trouble sleeping
Why should I care?
• Extremely common • Affects 10-30% of people each year • 31 million annually the United States
• Expensive • 22 million office visits • Direct medical cost $11 billion • 12.5 million lost work days, 60 million restricted work days
What are the Sinuses?
• Hollow spaces in the facial bones • Connected to nose through small, narrow channels
• Air enters, mucous drains
• Lined with “respiratory mucosa”
What do they do?
• Produce mucous and get infected • Decrease the weight of the head • Resonance for voice • Protection (crumple zone) in trauma • Temperature regulation / insulation
What is Sinusitis?
• Inflammation of the nose and sinuses • Swelling of sinus lining • Increased mucous production • Blockage of the drainage channels
• Often leads to bacterial or fungal infection in the sinuses • This can become a chronic problem
New Guidelines (2015)
• Based on “evidence” • Multiple specialities
• Otolaryngology – Head & Neck Surgery (ENT) • Pediatrics • Infectious Disease • Family Medicine • Dermatology • Allergy & Immunology
Official Diagnosis of Acute Rhinosinusitis
• Purulent nasal drainage PLUS • Nasal obstruction or Facial pain/pressure/fullness
Official Definitions
• Viral Rhinosinusitis • Less than 10 days, not worsening
• Acute Bacterial Rhinosinusitis • More than 10 days, or worsening symptoms
• Chronic Rhinosinusitis • More than 12 weeks
• Recurrent Acute Rhinosinusitis • Four or more acute bacterial rhinosinusitis infections in a year
What Causes Sinusitis?
• Viral infection (aka Colds) • Allergies • Structural problems • Other irritants
Can I Prevent Sinusitis?
• Break the cycle • Control Allergies / Irritants • Improve nasal function • Address structural problems
How Do I Control Allergies?
• Avoid exposure • Allergy Medication • Immunotherapy
Seasonal Allergies
• Trees • Early spring • Big blooms are better, Female trees
• Grass • Late spring, early summer
• Weeds • Late summer, early fall
• Molds • Temperature / humidity dependent
Perennial Allergies
• Dust mites • Pet hair / dander • Cockroaches • Mold
How do I avoid outdoor allergens?
• Stay indoors during peak pollen counts • Worse with wind • 5 – 10 am and dusk
• Keep windows closed • Avoid window fans
• Wear a pollen mask • Don’t dry clothing outdoors
Pollen and Mold Counts
http://pollen.aaaai.org (there is an App also) They measure the total pollen collected in previous 24 hours.
What about indoor allergens?
• Keep windows closed, run A/C • Mite-proof covers
• Wash in hot water
• Keep humidity low (30-50%) • Keep bathroom / kitchen / basement clean
What about pets?
• Wash hands / clothes after contact • Keep pet out of bedroom • Wash pets to reduce dander
Other Irritants
• Smoke • Dust • Perfumes, Hair Spray, Fumes • Laundry Detergents
Nasal Saline Rinse / Irrigation
• Helps clear the nose of mucous • Removes small particles, bacteria and viruses • Moisturizes nasal lining • Decreases inflammation
Which way works best?
• More pressure • More volume • Isotonic • Baking Soda • Other additives
Easy
How can I make my own?
• 1 Quart Water (distilled, boiled, purified) • 1 Teaspoon salt (iodine free, no preservatives) • 1 Teaspoon baking soda • Additions
• Drop of apple cider vinegar • Grapefruit seed extract • Xylitol • Other essential oils
What about medicines?
Antihistamine
• Rapid onset • Decrease body’s response to allergens/irritants
• Decrease mucous, sneeze, itchy
• Low side effects • Can be taken long term • Cheap • OTC
Nasal steroid spray
• Gradual onset (better for prevention) • Decrease inflammation
• Congestion, mucous
• Low side effects • Can be taken long term • OTC
Oral Steroids
• Rapid onset • Decrease inflammation
• Reduces congestion
• Significant side effects • Prescription
Decongestants
• Rapid onset • Decrease congestion (by decreasing blood flow) • Moderate side effects • Can become tolerant / dependent • Cheap • OTC
Nasal Cromolyn
• Gradual onset, preventative only • Stabilizes immune cells • Low side effects • Can be taken long term • Cheap • OTC
Nasal Anticholinergic
• Rapid onset • Dries nasal secretions • Low side effects
• Temporary blurry vision if you get it in your eyes
• Can be taken long term • Prescription
Mucolytics
• Rapid onset • Thins mucous
• Easier for cilia to clear • Actually increases the volume
• Moderate side effects • Cheap • OTC
Antibiotics
• Variable speed • Kill susceptible bacteria • Side effects vary • Can develop resistant bacteria • Price varies • Prescription
How do you treat an infection?
• Symptom control • Resolve the infection
Viral Rhinosinusitis (aka head cold)
• No cure for common cold • Antibiotics not recommended (0.5 – 2% chance of becoming bacterial)
• Treat symptoms • Nasal saline irrigations • Nasal steroid sprays • Pain Relievers
Acute Bacterial Rhinosinusitis
• Antibiotics vs watchful waiting • 70% will resolve on their own
• Treat symptoms • Nasal saline irrigations • Nasal steroid sprays • Pain Relievers
Reality
• Many people want (and get) antibiotics right away
Chronic Sinusitis
• Typically not responsive to medication • Surgery to address the obstruction and clear infection • Medication to reduce infections
Surgery • Approximately 350,000 sinus surgeries per year
Functional Endoscopic Sinus Surgery
• Performed through the nose • Remove bone to create wide opening into sinuses • Performed in the operating room (fully asleep) • Can address all sinuses
• Also perform septoplasty, turbinate reduction
Balloon Sinuplasty
• Performed through the nose • The natural sinus opening a dilated using a balloon
• No tissue is removed.
• Can be performed in office (sedation / local anesthesia)
Balloon Sinuplasty
Comparison
Functional Endoscopic Sinus Surgery • Remove obstructing tissue
• Raw surfaces need to heal
• General Anesthesia • 5-10 day down time • Pain meds: 5 days
Balloon Sinuplasty • Dilate natural openings
• No raw surfaces
• Can be done under local • 24-48 hour down time • Pain meds: 1 day
Other Surgeries
• Inferior Turbinate Reduction • Septoplasty
Questions?