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?