Diseño y variables de análisis

A case example will help accentuate several points.

An

18-year-old secretary came to my office with a history of a cold one week previously. Just as the

Clinical Manual of Otolaryngology

Streptococcus pneumoniae Haemophilus influenzae Viruses Moraxelfa catarrhalis Group A Streptococcus Staphylococcus aureus Gram-negative bacilli

Proteus

Klebsiella

Escherichia coli

Pseudomonas aeruginosa Anaerobes

Peptostreptococcus Bacteroides

*The organisms at the top of the list are the most common in acute paranasal sinus disease, those at the bottom are more common in chronic paranasal sinus disease.

cold seemed to be abating, she developed pain on the left side of her face. She saw her dentist, who referred her to the author. Examination of the nose was normal, the oropharynx revealed a mucopurulent postnasal discharge. Her temperature was

101 op

orally. Finger percussion over the left maxilla elicited pain.

A

clinical diagnosis of acute maxillary sinusitis was made. The patient was given a prescription for amoxicillin

500

mg po three times a day for

10

days and advised to use sudafed for nasal stuffiness. The patient was also told to mix

1

teaspoon of salt in a glass of water and to put two drops of this solution into each nostril four times a day. She was to sniff this in and then blow it out. She was instructed not to return if the symptoms abated. However, if the symptoms persisted, recurred, or increased she should return immediately.

The patient returned

2

weeks later stating that the symptoms had disappeared on the antibiotic therapy but as soon as she stopped taking the amoxicillin the symptoms returned. The examination showed the same results. This is an older case, and at this time plain sinus X-rays were used to evaluate and diagnose inflammatory sinus illness.

Figures 3.2A to D

shows skull positioning for the four standard sinus X-rays.

Figures 3.3A to D

shows a normal sinus series. While the author virtually never orders these today, there is useful anatomy to be learned.

The patient's Waters' view

(Figures 3.4A to

C) showed the air-fluid level on the left side and an opacified sinus on the right side. To document this as an air-fluid level, the patient's head was tilted slightly to the right and the repeat Waters' view showed a shift in the air-fluid level. The patient

Figures 3.2A to D: Views of the skull showing position of the head for each of the four standard sinus X-rays, assuming that the X-ray beam is horizontal. (A) Posteroanterior view; (B) Waters' view; (C) Lateral view; (D) Submental vertical view

was placed on amoxicillin with clavulanic acid 875 mg po bid. The symptoms did not recur.

If the second line antibiotics had failed to clear the infection, a nasal work-up would have been initiated and based on the findings of that work­ up, appropriate therapy recommended.

As has been stated, plain sinus radiographs are no longer used to evaluate acute sinus disease, and when, in fact, a radiograph is indicated, sinus CTs are ordered. Figure 3.4C is a coronal CT that demonstrates the kind of

Clinical Manual of Otolaryngology

Figures 3.3A to 0: Normal results of sinuses series of X-rays. Sinus films are taken with

the patient upright, in a coned-down focus, and with soft-tissue penetration. (A) Posteroanterior view; (B) Waters' view;

(C)

Lateral view; (D) Submental vertical view Key: F-frontal sinus; E-ethmoid sinus; M-maxillary sinus; S-sphenoid sinus

Figures 3.4A to C: X-rays of acute maxillary sinusitis.

(A)

Waters' view showing an air­ fluid level in the left maxillary sinus and opacification of the right maxillary sinus. Note the small air bubble in the superior medial corner of this sinus; (B) Waters' view with the head tilted to the right. Note how the air-fluid level orientation changes in the left maxillary sinus; (C) Coronal CT on an individual with symptoms of acute maxillary sinusitis. Note the extensive anterior ethmoidal disease obstructing the ostial meatal complex and the accumulation of fluid in both maxillary sinuses

Clinical Manual of Otolaryngology

findings that might commonly be observed in an individual with acute maxillary sinusitis. Note that the primary disease is in the anterior ethmoids in the area called the ostiomeatal complex. It is because of the disease in this region that the natural sinus ostia for the maxillary sinuses are obstructed and therefore, fluid and infection accumulate in the maxillary sinus. Because the patient is positioned upside down, air-fluid levels are now seen at the top of the sinuses.

An algorithm for the evaluation and treatment of sinus infection is shown in

Figure 3.5.

Sometimes the disease is not cleared; it becomes indolent and presents as chronic sinusitis. Chronic sinusitis includes that disease that has been refractory to prior treatments and disease that has been indolent and has become a bothersome problem.

These individuals require a more complex and thorough work-up. The nature and degree of this work-up differs among both physicians and

institutions.

Table 3.2

lists those tests that can be performed at the UCSD

Recurrent or

Allergic chronic sinusitis Bacterial

Itchy nose Nasal obstruction

Itchy Eyes post nasal drip

Sneezing cough

Enviromental control

Bacterial Sx

Nasal steroids Antibiotics (2)

Nasal saline irrigations Amoxicillin 250mg

immunotherapy Allergic Sx p.o. tid

Doxycycline 50-100 mg

p.o. bid

Persistence/

Complications

(3)

Sinus CT scan (4)

Evaluate and ENT referral

(5) Treat for for endoscopic

other illness, sinus surgery

e.g. Chronic (ESS) (6)

pain,

Headache etc.

Nasal Dysfunction Clinic and not all are required for each patient. A history is appropriate. The physical examination should include endoscopic rhinoscopy. The oropharynx should be examined. Important findings in the nose are patency of the airway and presence or absence of a septal deviation, particularly if obstructive to breathing. The mucosa of the inferior turbinate is reflective of the mucosa of the reminder of the nasal cavity. If this is inflamed, it implies a bacterial infection; if it is edematous and either pale or bluish in color, this is most consistent with an allergic problem. The presence of blood or of a tumor is a significant finding, as is presence of polyps. The presence of secretions is also a pertinent finding. Clear or white secretions are found in allergic rhinitis. Purulent secretions are found m bacterial rhinitis. Dry, shrunken mucosa suggests an atrophic rhinitis.

Table 3.2: Evaluation lor nasal dysfunction

History Anterior rhinoscopy Oropharyngeal examination Nasal endoscopy Olfactory testing Rhinomanometry Nasal cytology Serum lgE level

Serum immunoglobulin G, M & A Radio allergo sorbent test (RAST)

panel screen Sinus CT

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