Учебники / The Sinus Sourcebook Rosin 1998

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The nasal septum, which is the cartilage and bony wall separating the two sides of the nose, can be deviated (or twisted), leading to sinusitis by blocking the sinus ostia (drainage areas). Correction of this problem is called septoplasty or submucous resection, an outpatient procedure requiring packing in the nose for at least one day. Since surgery on the septum may affect facial growth, it is rarely advised in children before age sixteen (roughly following the child's growth spurt). In those infrequent situations in which marked deviation of the septum causes nasal or sinus disease in children, surgery is performed in a conservative fashion, removing as little cartilage and bone as possible.

"Draining the Sinuses"

In certain situations, a procedure called antral lavage is performed. This involves lavaging or "washing out" the antrum, which is another name for the maxillary or cheek sinus. A needle is placed through the nose into the maxillary sinus to wash it out of infections. This does not provide long-term benefit but may clear out a collection of pus that is not responding to antibiotics. Sinus lavage does provide a way to obtain material from the sinus for culture in the very sick patient (often a patient with a deficient immune system). Sometimes your doctor may recommend antral lavage to clean out the sinuses at the same time that a child is under anesthesia for adenoidectomy.

Nasal Antral Window

Another procedure utilized in children with sinus disease that is unresponsive to medications is called a "nasal antral

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window." This is performed through the nose, where an opening is made between the nose and the antrum (the maxillary sinus). This results in permanent ventilation of the sinus through this "window" between the nose and the maxillary sinus (refer to Figure 1.3 on page 5). This window prevents filling of the sinus with mucus and pus during subsequent upper respiratory infections.

While this procedure is relatively easy to perform through the nose, it typically must be done under general anesthesia. These windows have a tendency to close, and may not offer a permanent solution to chronic sinus problems. There is also the potential for injury to developing teeth, since upper tooth roots may lie in the floor of the maxillary sinus.

Caldwell-Luc Operation

Sinus problems in children may warrant procedures directed at specific sinuses. An example of this is the Caldwell-Luc procedure, where an incision is made under the gum to get into the maxillary sinus. This is utilized in situations of chronic maxillary sinus infection, allowing for direct visualization of the sinus. However, because the sinus may not yet be fully developed in the child, there is the possible risk of interrupting normal sinus growth or normal dentition (secondary teeth that are developing are at risk).

External Ethmoid Sinus Drainage

External surgery to drain the ethmoid sinuses (sinuses between the eyes) is termed an external ethmoidectomy. Currently, ethmoid sinus disease can be approached through the nose, and so this external surgery, which

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leaves a scar on the face, is usually used only in those cases where there has been a serious orbital (eye) complication of sinus disease.

Endoscopic Sinus Surgery

In the past decade, the philosophy of sinus surgery has shifted from external surgeries on diseased sinuses to "functional" procedures, aimed at restoring normal sinus function and drainage. These procedures are termed functional endoscopic sinus surgery, as they are performed with an endoscope or telescope through the nose. There are fewer complications in these intranasal procedures when performed by an experienced sinus surgeon. Recuperation is typically easier than with external procedures. Endoscopic surgery involves removing diseased tissue of the ethmoid sinus and creating an opening (called a window or antrostomy) between the maxillary sinus and its natural drainage opening into the nose beneath the middle turbinate bone (see Figure 1.3 on page 5).

The philosophy and technique of endoscopic sinus surgery, which is currently the standard procedure in the United States, is described in detail in Chapter 10. There are a few variations to remember in children. First, intranasal surgery in children whose nasal passages and paranasal sinuses are still developing can be difficult and should not be taken lightly. Additionally, postoperative cleaning and suctioning of the sinus cavities is important, especially to prevent the formation of scar bands. While it can be performed in the office setting in teenagers and adults, this post-op cleaning may require a second anesthetic agent in a child, who will typically not sit still for a telescopic exam in the office. Therefore, you should feel

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comfortable that you have exhausted all other options (including medications and allergy treatment) before allowing your child to undergo surgery on his sinuses.

Sinus Surgery in Children adenoidectomy +/- tonsillectomy septoplasty (to correct deviated septum) antral lavage (sinus "wash")

nasal antral window Caldwell-Luc

external ethmoidectomy

endoscopic sinus surgery (endoscopic ethmoidectomy and middle meatus nasal antral window)

Conclusion

Sinus disease in children, while in some ways similar to that in adults, has a number of factors specific to the pediatric population. Symptoms can be subtle, making diagnosis difficult. The role of allergy and frequent upper respiratory infections in children should be considered. Surgical options should be used only if long-term medical therapy fails to provide relief.

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Chapter 8

Medications for the Nose and Sinuses

There are probably more nonprescription medications for the nose and sinuses than any other part of the body. In 1994 more than four billion dollars was spent on cold, sinus, allergy, and cough products. However, all this money is not necessarily well-spent. In a poll of pharmacists regarding which product categories cause confusion among consumers, allergy relief, cough, and cold preparations top the list, with sinus remedies close behind.

In a survey on self-medication comparing fourteen countries, the United States led the list in percent of consumers using nonprescription medication. Lower cost is the reason most often given for using these products, followed by convinience and eliminating the need for a doctor's visit. If you are familiar with these products, you will be

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able to select appropriate ones for relief of your nasal and sinus symptoms. You also need to be aware of potential misuse and side effects of the readily available medications.

The term over-the-counter, designated as OTC, will be used synonymously with nonprescription. In recent years, many drugs that formerly required a prescription have been changed to OTC status. This makes it even more important for you to understand the benefits and limitations of these medicines. Since many sinus problems, especially infection, require prescription drugs, we'll present an overview of categories of medications that your doctor may prescribe. The lists of medications in this chapter are not all-inclusive but are offered to provide a general sense of some of the more popular medicines available in the United States. Their order is purely alphabetical.

Nasal Decongestants

More than three thousand years ago the Chinese inhaled vapors from a plant called horsetail to relieve congestion. Today we know that this plant contains the drug ephedrine, a decongestant which has the ability to shrink the lining of the nose and facilitate easier breathing. Nasal congestion, with swelling of the lining of the nose, is common to upper respiratory infections such as colds, nasal allergies, and sinusitis. This swelling is largely due to dilated blood vessels within the nasal lining. Nasal decongestants shrink the swollen lining by stimulating receptors in the blood-vessel wall to contract. Decongestants come in oral and topical forms (sprays, drops) that work directly on the nasal lining.

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Oral Decongestants

The two most common oral forms of decongestants are pseudoephedrine and phenylpropanolamine. The latter, in addition to its decongestant properties, is also used as an appetite suppressant. Both drugs are found in many nonprescription product combinations. The most readily available decongestant, with no additional ingredients, is SudafedTM, a trade name of pseudoephedrine. This can be purchased in 30 or 60 mg tablets, or in a 30 mg per teaspoon liquid form for children. Table 8.1 outlines dosages that can be given every four to six hours.

Sudafed twelve-hour caplets are available for adult use only. The primary side effects of pseudoephedrine and other decongestant-containing tablets is an increase in heart rate and blood pressure, and stimulation of the central nervous system. This stimulation may take the form of nervousness, dizziness, or sleeplessness. These drugs should

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be avoided by patients with high blood pressure, heart disease, diabetes, or thyroid disorders, since they can worsen these conditions. They should also be avoided by patients taking any of the group of drugs known as monoamine oxidase inhibitors. In people who are kept awake by decongestants, take the last dose by six p.m. Since decongestants have an adverse effect on men with prostate enlargement, they should be taken in smaller doses in men older than sixty, and the sustained twelve-hour form should be avoided.

Topical Decongestants

For those who cannot take oral decongestants for any of the above reasons, topical decongestants in the form of nose sprays or nose drops can provide relief. Sprays are somewhat easier to use and offer a better spread of medication across the lining of the nose. Drops may be easier to use in infants and young children, since they can be dripped into the nose. Topical decongestants tend to have fewer side effects than their oral counterparts, but there is some absorption of sprays and drops. This is especially true in infants and children, where there may be excessive absorption of the drug. The side effect of blood-pressure elevation and rapid pulse can occur with their use, so the same cautions as listed for decongestant tablets apply.

The major caution regarding use of nose sprays or drops is that use longer than three to five days may result in rebound. As the effect of a given dose wears off, the nasal lining swells again. The patient finds that the subsequent doses provide less relief, and a vicious cycle is set up. This is typified by my patient Gwen, who had been

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over.)

Spray: 0.1% for adults

using a nasal decongestant spray every few hours for the past five years yet still felt unable to breathe through her nose. The lining was swollen and inflamed from chronic nose-spray use. I made her throw out her spray while in my office, and had her begin using saline (pure saltwater) sprays. When I saw her a month later, she was feeling great and off all nasal medications.

A minor annoyance of these topical medications may be burning, stinging, or sneezing. These can be minimized by spraying the nose with a saltwater (saline) solution before applying the decongestant. The decongestant drops and sprays listed in Table 8.2 are available without a prescription (list is not all-inclusive). Phenylephrine can be used every four hours if needed. The other products listed have up to twelve hours of action, and should be used twice a day (but only for three to five days). They are intended only for use by children older than twelve and adults.

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