Get Your Head In The Game Matthew Voorman, MD Hutchinson Clinic March 21, 2016
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?