Nonstandard Thinking Required to Meet the Challenge of Complex Sinus Conditions

“I think the issue is not how many debridements you do, but how often you see them. It depends on what I see whether I debride them or not,” said Dr. Palmer. He suggested post-surgery follow-ups for one and two weeks, then a one month follow-up. If something such as a papilloma had been removed along with significant mucosa tissue he would add xylometazoline into the equation, along with a rinse containing antibiotics. As for saline, he suggested isotonic be used since hypertonic solution has been shown to destroy cilia.

However, there is little evidence showing either debridement or saline to be superior. “I had not seen any significant difference in outcome between the two different modalities of care,” said Dr. Parikh.

Cerebrospinal Fluid Leaks

Another case was of a 49-year-old woman who presented with left nasal congestion and drainage that was attributed to allergic rhinitis and treated with nasal steroids. However, three years later she continued to have clear fluid discharge. There was a diagnosis of a spontaneous cerebrospinal fluid (CSF) rhinorrhea.

Panelists agreed this was a complicated case, and suggested a variety of investigations. “I routinely use lumbar drainage post-operatively in CSF leaks, that would also give me the ability to use fluorescein localization of the leak,” said Douglas Ross, MD, Associate Professor of Otolaryngology at Yale University School of Medicine in New Haven, Conn.

Dr. Fried stated that the defect was localized at the roof of the ethmoid, repaired, and a lumbar drain was done. However there was a releak two months later and there was suspected benign intracranial hypertension.

Work is being done by researchers at Pennsylvania to develop protocols for treating CSF leaks, said Dr. Ross. He advised that in CSF leak patients, one should get a pressure when putting the lumbar drain in, then leave the drain for two days.

“At 48 hours we’ll clamp it, hook it up to a pressure transducer then get a pressure there.” he said. Then a test in which the neck is compressed can provide more information. With compression “CSF pressure will go up because of the lack of venous outflow. If that goes up… then you know you have a closed system and you know you can get a real pressure,” Dr. Ross said.

Pressure under 20 cm H20 means there will not be releak, between 20 and 30 means possible risk of releaks, and over 30 means there will be releak and it should be shunted. He advised getting a neurosurgeon involved in the case.

Aggressive Approach to Fungal Sinusitis

The final case was of a 43-year-old diabetic man who had chronic sinusitis, intermittent epistaxis, elevated liver function test (LTF), bilateral obstructive polyps, and allergic fungal sinusitis. After three CT-guided procedures for extensive disease, polyposis returned after a year. “He continues to have disease now. He’s on prednisone, oral itraconazole. His LFT started going up. He’s on [montelukast sodium],” said Dr. Fried.