Richard C. Haydon

Clinical practice guideline: Adult sinusitis

OBJECTIVE This guideline provides evidence-based recommendations on managing sinusitis, defined as symptomatic inflammation of the paranasal sinuses. Sinusitis affects 1 in 7 adults in the United States, resulting in about 31 million individuals diagnosed each year. Since sinusitis almost always involves the nasal cavity, the term rhinosinusitis is preferred. The guideline target patient is aged 18 years or older with uncomplicated rhinosinusitis, evaluated in any setting in which an adult with rhinosinusitis would be identified, monitored, or managed. This guideline is intended for all clinicians who are likely to diagnose and manage adults with sinusitis. PURPOSE The primary purpose of this guideline is to improve diagnostic accuracy for adult rhinosinusitis, reduce inappropriate antibiotic use, reduce inappropriate use of radiographic imaging, and promote appropriate use of ancillary tests that include nasal endoscopy, computed tomography, and testing for allergy and immune function. In creating this guideline the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of allergy, emergency medicine, family medicine, health insurance, immunology, infectious disease, internal medicine, medical informatics, nursing, otolaryngology-head and neck surgery, pulmonology, and radiology. RESULTS The panel made strong recommendations that 1) clinicians should distinguish presumed acute bacterial rhinosinusitis (ABRS) from acute rhinosinusitis caused by viral upper respiratory infections and noninfectious conditions, and a clinician should diagnose ABRS when (a) symptoms or signs of acute rhinosinusitis are present 10 days or more beyond the onset of upper respiratory symptoms, or (b) symptoms or signs of acute rhinosinusitis worsen within 10 days after an initial improvement (double worsening), and 2) the management of ABRS should include an assessment of pain, with analgesic treatment based on the severity of pain. The panel made a recommendation against radiographic imaging for patients who meet diagnostic criteria for acute rhinosinusitis, unless a complication or alternative diagnosis is suspected. The panel made recommendations that 1) if a decision is made to treat ABRS with an antibiotic agent, the clinician should prescribe amoxicillin as first-line therapy for most adults, 2) if the patient worsens or fails to improve with the initial management option by 7 days, the clinician should reassess the patient to confirm ABRS, exclude other causes of illness, and detect complications, 3) clinicians should distinguish chronic rhinosinusitis (CRS) and recurrent acute rhinosinusitis from isolated episodes of ABRS and other causes of sinonasal symptoms, 4) clinicians should assess the patient with CRS or recurrent acute rhinosinusitis for factors that modify management, such as allergic rhinitis, cystic fibrosis, immunocompromised state, ciliary dyskinesia, and anatomic variation, 5) the clinician should corroborate a diagnosis and/or investigate for underlying causes of CRS and recurrent acute rhinosinusitis, 6) the clinician should obtain computed tomography of the paranasal sinuses in diagnosing or evaluating a patient with CRS or recurrent acute rhinosinusitis, and 7) clinicians should educate/counsel patients with CRS or recurrent acute rhinosinusitis regarding control measures. The panel offered as options that 1) clinicians may prescribe symptomatic relief in managing viral rhinosinusitis, 2) clinicians may prescribe symptomatic relief in managing ABRS, 3) observation without use of antibiotics is an option for selected adults with uncomplicated ABRS who have mild illness (mild pain and temperature <38.3 degrees C or 101 degrees F) and assurance of follow-up, 4) the clinician may obtain nasal endoscopy in diagnosing or evaluating a patient with CRS or recurrent acute rhinosinusitis, and 5) the clinician may obtain testing for allergy and immune function in evaluating a patient with CRS or recurrent acute rhinosinusitis. DISCLAIMER This clinical practice guideline is not intended as a sole source of guidance for managing adults with rhinosinusitis. Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. It is not intended to replace clinical judgment or establish a protocol for all individuals with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem.

Auricular endochondral pseudocysts: diagnosis and management.

The auricle can be the site of a variety of cystic lesions, many of which involve either potential spaces between the auricular cartilage and the perichondrium or spaces within the skin and subcutaneous tissues. An auricular endochondral pseudocyst is a fluid collection located within the cartilaginous structure of the auricle. The auricular hematoma and the auricular pseudocyst may represent opposing ends of a continuum of damage and repair of traumatic insults. Whereas the hematoma represents a significant acute traumatic event resulting in cleavage between the perichondrium and the cartilage, the pseudocyst could be the outcome of chronic lower grade trauma. In this instance, the perichondrium not only separates from the cartilage but may be induced to regenerate an outer cartilaginous wall exacting the contour of the separated perichondrium, thus completing a cartilaginous auricular pseudocyst. This firm, cartilaginous outer cyst wall accounts for the increased difficulty in treating pseudocysts and clearly requires a different surgical treatment than for the hematoma. Having reviewed a substantial number of case reports, we recommend incision and drainage of the cavity followed by obliteration of the cavity by curettage, sclerosing agent, and pressure dressing. More invasive techniques should be reserved for an uncommon recurrence after adequate initial treatment.

The Relationship Between Dysphonia and Sinusitis: A Pilot Study

Though some clinicians believe chronic sinusitis is associated with dysphonia, studies confirming such a relationship are not available. This pilot study investigated vocal characteristics of chronic sinusitis patients compared to those of nonsinusitis patients. Nineteen male patients were evaluated in a single-blind, nonrandomized, prospective study at a Department of Veterans Affairs Medical Center. After candidates for the experimental and control groups were thoroughly screened [nasal and laryngology examinations, sinus computed tomography (CT) scan, history], 10 chronic sinusitis patients were assigned to the experimental group, nine patients without chronic sinusitis were assigned to the control group. Visi-Pitch analysis of their speech evaluated fundamental frequency, intensity, and perturbation. The evaluator described voice quality and vowel prolongation. Videostroboscopic examination evaluated glottic closure, supraglottic activity, vocal fold edge, amplitude, mucosal wave, and nonvibrating portion. Visi-Pitch analysis and vowel prolongation for each group was compared using an independent t-test. The average fundamental frequency mean was 113.43+/-32.75 Hz for the control group and 112.29+/-19.71 for the experimental group. This study established methods and parameters to determine if a relationship between chronic sinusitis and dysphonia actually exists. It did not establish a relationship between these entities, possibly due to the small sample size enrolled in the study, but determined that 126 subjects would be necessary to achieve significant results.

Addressing the prevalence of respiratory allergy in the home environment

Respiratory allergy prevalence has always depended both on genetic predisposition and specific environmental allergenic stimulation that leads to sensitization and eventual symptomatic disease. Changes brought about by modern technology that have afforded a higher quality of life have also accidentally increased the levels of many respirable and ingestible allergens in the environment. In many cases these higher levels of exposure have exceeded individual thresholds, resulting in the phenotypic expression of allergy in many individuals who were previously asymptomatic even though they were genotypically predisposed to developing allergies. Prevalence can be decreased only if susceptible populations are identified as early as possible through careful family history taking and appropriate testing for sensitivity and if exposure to selected allergens is controlled.

Allergic Rhinitis—Current Approaches to Skin and In Vitro Testing

This article discusses the currently available techniques used for the diagnosis of IgE-mediated upper respiratory allergy. These methods are necessary to confirm the presence and the intensity of allergy in an effort to select patients for immunotherapy and to dose immunotherapy properly. Specific techniques discussed include epicutaneous and intradermal skin tests and in vitro tests designed to measure antigen-specific IgE antibody.

Children with allergic disease as adults

Abstract In children, allergic rhinitis is considered the most common chronic disease, affecting as many as 40% of the US population, an increasing trend in prevalence seen for many allergies, and is a very common encounter in everyday practice. We believe that through proper recognition and intervention, quality-of-life for the patient can be influenced by the clinician, which will result in improved outcomes in health and function. Children with allergic disease as adults certainly deserve the time and effort necessary to improve and preserve the often overlooked impaired physical and mental function associated with IgE-mediated disease. Proper history, testing, and therapeutic intervention can go a long way in improving outcomes in these patients, and in nearly all cases patients will very much appreciate efforts made.

Gelatin sponge insertion into tympanostomy tubes: an in-vitro study to evaluate postoperative obstruction.

Objective: To analyze the efficacy of gelatin sponge insertion into lumens of tympanostomy tubes to prevent obstruction in the presence of blood. Study Design: In vitro model. Methods: Absorbable gelatin sponge wicks were placed in the lumen of Ultrasil Collar Button ventilation tubes and Shepherd Grommet ventilation tubes. One half of each group was covered with blood, the other left untreated. Each tube was treated with ofloxacin solution three times daily for seven days. After treatment, the tubes were inspected. Reinspection was performed after brief suctioning. Numerical scores were given based on degree of obstruction. Results: A statistically significant difference in degree of obstruction (P < 0.0001) was seen between all tubes with wicks alone versus those with blood added. After re-evaluation, there remained a statistically significant difference between tubes with wicks alone and tubes with wicks and blood (P < 0.0001). Conclusions: Gelatin sponge insertion does not prevent, and may in fact, enhance, obstruction of pressure equalization tube lumens in the presence of blood.

Miniseminar: Allergy Vial Mixing and Testing: New Standards in Safety

host response to this biofilm. METHODS: Prostheses made of titanium, hydroxylapatite (HA), and plastic (23 each) were cultured with PA in broth for 96 hours. Biofilm formation was assessed by electron microscopy and quantitative microbiology. RESULTS: Titanium prostheses formed less biofilm than plastic (p 0.0003) and HA (p 0.003), but there was no difference between HA and plastic. Correction for surface area did not alter these significant differences. CONCLUSION: PA forms biofilm on ossicular reconstruction prostheses, particularly those made of plastic and HA. These differences could, in part, explain the extrusion propensity of certain biomaterials. SIGNIFICANCE: The results of this study could alter which biomaterials are chosen for ossicular chain reconstruction in the setting of different middle ear pathology. SUPPORT: This project was supported by the resident research fund allocated by the Department of Otolaryngology– Head and Neck Surgery of the University of Florida. Ossicular chain reconstruction prostheses were graciously contributed by Medtronic ENT.

Miniseminar: Rhinitis: From Science to Practice

Abstract Chronic rhinitis is among the most common medical disorders in both the Western world, and is increasing in prevalence in developing nations. Otolaryngologists in practice encounter patients with rhinitis on a daily basis, and its diagnosis and management involves a major portion of their professional time. The current seminar will investigate both allergic and nonallergic rhinitis and will develop a science-based approach to the evaluation and treatment of this common problem. Using a variety of teaching modalities, including lectures, slide presentations, and interactive discussions, this seminar will provide the attendee with a thorough review of the current strategies involved in the diagnosis and treatment of rhinitis, as well as a view of future potential management methods. The seminar will focus on a discussion of the pathophysiology of rhinitis, examining both allergic and nonallergic mechanisms. Once this background is established, it will examine various methods involved in diagnosing and classifying rhinitis, including elements of the history and physical, laboratory examinations, imaging, endoscopic evaluations, and allergy testing. The program will then focus on current strategies in the management of the patient with rhinitis, including avoidance techniques, pharmacotherapy, immunotherapy, and surgical management. Finally, the seminar will examine possible future approaches in the diagnosis and treatment of rhinitis, including such areas as anti-IgE and other monoclonal antibody therapies, histamine-3 receptor blockade, and sublingual immunotherapy. With recent scientific advances and pharmacotherapeutic developments, the near-term future of rhinitis management might be somewhat different from current practice. At the conclusion of the program, the attendee will have a thorough exposure to the current state of knowledge in the pathophysiology of rhinitis, its evaluation, and its management.

Clindamycin as initial treatment of peritonsillar abscesses that fall treatment with penicillin

Objective: Penicillin has long been considered the drug of choice for the medical management of peritonsillar abscess (PTA). Several studies have reported varying degrees of penicillin resistance in organisms obtained from aspirates of such abscesses, but the evidence has not been compelling enough to recommend a change in first-line antibiotic coverage. No studies have looked at choice of antibiotic alone as it impacts treatment outcome. The purpose of this study was to examine the relationship between antibiotic choice and outcome for patients with PTA. Methods: A retrospective chart review of more than 100 consecutive patients treated for a PTA at our institution for the past 7 years was performed. Parameters measured included treatment failures, length of hospitalization, recurrence rate, need for Quinsy tonsillectomy, and antibiotic side effects. Results: There was a significant difference in outcome measures shown when primary outpatient treatment of PTA with penicillin was compared with similar treatment with clindamycin. Conclusions: The results of this study have modified our first-line antibiotic choice for these patients. The significant difference in treatment failures when penicillin is used as a first-line antibiotic, combined with differences in length of hospitalization, recurrence rates, and need for tonsillectomy, make clindamycin a prudent and cost-effective initial antibiotic for PTA.