Sinus, Sinusitis and Management of Acute sinusitis

Management of sinusitis has witnessed fundamental chagne in the last two decades. Nasal endoscopy and CT scan has revolutionized visualization of nose and sinuses.

• Basic understanding--(What is sinus?) Human skull contains four pairs of hollow air filled caivities connected to the space between npstril and nasal passages; these are called sinuses(or para nasal sinuses). Sinuses help insulate the skull, reduces its weight and add resonance to voice.

There is 4 major pair of sinuses-frontal (in the forhead), maxillary (behind the cheek bones), Ethmoid (between the eyes) and sphenoid (behind the eyes).

Sinuse are lined by respiratory epethelium with Goblet cells to secrete mucus and fine cilia to help trap and propel pollutant and bacteria outward to nose through opening of sinuses (sinus-osteum). Most of he sinuses drain into a key area (osteomeatal complex). Thus treatment of sinusitis is focused on this area.

Acute sinusitis-

Infection of sinuses is called sinusitis - acute or chronic based on time span. Sinusitis may be caused by anything that interfere with airflow into the sinuses and mucus drainage out of the sinuses, usualyy follow a viral infection, allergy, or irritants.

Signs and symptoms of sinusitis depend on which sinus is involved-usually present with nasal congestion and discharge or post nsal drip, headache, facial pain or pain under or around the eyes, fever.

Treatment of acute sinusitis:-

Aims of management are--

1. To achieve normal healthy sinuses

2. To decrease duration of symptoms

3. To prevent complications

4. To prevent development of chronic sinusitis.

Most patients of acute sinusitis can be benefitted wihout many investigations as diagnosis is mainly clinical. Proper visualization of noe and sinues by Nasal endoscopy is important for appropriate management. Endoscopic assessment of nose guides the surgery and at the same time accurate pus-swab can be obtained for bacteriological examination.

Sometimes if symptoms persist for longer duration further investigations may be required like Ct scan of sinuses, examination of mucocilliary mechanism, allergic and immune status of patient.

Medical management-

Antibiotics, analgesics, decongestant, mucolytics and/or steroids may be given to reduce swelling and thus increase clearance and drainage from the sinuses.

Antibiotics- studies confirm that sinusitis treated with antibioticshave more rapid resolution of symptoms. A effective antibiotic for a period of 10 days is usually required but in some cases especially recurrent cases up to 2 weeks course may be given.

Nasal decongestant drops- nasal decongestant drops are used to decongest sinus-osteum and thus encourage drainage. Nasal drops should not be used for for longer duration because it backfires as it has rebound effect.

Oral decongestants or mucolytics-May be used to decongest mucosa or to help thinning of secretion for easy drainage.

Analgesics-Any suitable and safe pain killer medicine may be taken.

Home care-

Steam inhalation- Plain water or medicated steam with menthol has soothing effect and helps in improving sinus drainage.

Hot fomentation-application of warm cloth, hot water bottle or gel pack to face for 5-10 minutes relieves pain and inflammation to some extent.

Saline irrigation- nose and sinuses should be washed by 1/4 tsf salt in 1 cup water using bulb syringe, alternatively commercially availabe saline nasal sprays can be used.

Adequate hydration.

Hot fluid like soups helps.

Avodance of allergen if any.

Avoidance of irriants/smoking

Use of humidifier.

Surgical management-

Usually acute sinusitis is treated by medicines. Most cases resolve with proper and effective management.

Surgical treatment is reserved for-Failure of medical management, Severe pain, or Impending complications.

Surgical management aim at cleaning the sinuses by antral lavage, endoscopic cleaning or frontal sinus wash out.

Functional endoscopic sinus surgery--

Recurent acute bacterial sinusitis or sinusitis of long duration unresponsive to medicine is major indication for endoscopic sinus surgery. Endoscopic surgery is minimal invasive surgery done by endoscope inserted through nose, it does not require skin incision.CT scanning is must before surgery.One thing is to be remembered -meticulous post oprative cleanig is equally important for success as is the expertise of operating surgeon.

Treatment plan for acute sinusitis may vary according to experience of treating physician but it is crucial to undersatnd the importance of "osteomeatal region".Effective medical mangement require good docto-patient understanding. Medical prefessional should take time for patient to educate them on importance of taking antibiotics regularly and in proper doses as advised. Often it is irregular time interval and missed doses which creates resistant bacteria and failure of medical treatment.

From my article at helium.com- http://www.helium.com/items/1269826-treatment-of-acute-sinusitis

Hearing loss in adults, Management and Hearing-aids

Hearing loss in adult should be evaluated and managed properly taking care of emotional and social impact of condition on patient & his family. Bilateral hearing loss may affect professional life of a person. Aim is to know the treatable cause and manage effectively to prevent further loss. Sensori-neural loss which can not be cured by medicines should be started with rehabilitation by hearing-aids.

Symptoms of hearing loss:

• Sound may be distorted, quieter and less clear
• Patients usually have difficulty in hearing in noisy area or while in a group
• Problem in hearing over telephone
• Turn up volume of television/Mp3 player
• Ask people frequently to repeat the sentence/words
• Patients often misunderstand what others are saying
• Patients think others are not speaking well

Evaluation of patient:

Thorough medical history(ear infection, giddiness, tinnitus, past medical illness or medication, trauma, exposure to noise-occupational or otherwise if any).

Clinical examination of Ear-Nose and Throat and patient.

Investigation-Audiometry tests to know degree and type of hearing impairment. Depending on clinical clues CT/MRI may be required.

Most common cause of hearing-impairment in adult is wax and after exclusion of wax tympanic membrane perforation is most common cause.

Management of Hearing loss

Management depends on type and cause of hearing loss; loss is of two types conductive and sensori-neural. Sometimes it may be mixed loss.

Conductive hearing loss:

When something hampering conduction of sound from your ear-canal, ear-drum and ear ossicles to reach inner ear or nerves of hearing.

Can be corrected by medicine and/or surgery, like-

• Wax or foreign body-removal
• Eustachian tube blockage or fluid in the middle ear -medicines or by procedure of putting small tube (grommet) in ear drum
• Infection(otitis media)-Medicines
• Perforation in ear drum-Surgery(Tympanoplasty)
• Otosclerosis-stapedectomy& piston placement
• Any cause in nose/throat is managed by medicine/surgery.

Sensorineural hearing loss:

When problem is in inner ear or nerves of hearing (same as one has weak eye-sight).

Causes-

• Age -hearing loss after age of 65
• noise-trauma
• Menieres disease
• Post viral infections like mumps, measles, influenza, herpes
• Ototoxic drugs like aminoglycoside antibiotics (neomycin, streptomycin, amikacin, gentamicin, netilmycin), Salycylates, certain diuretics, antimalarial ( quinine & chloroquine), erythromycin and cisplatinum.
• Hereditary
• Immune mediated
• Endocrine& metabolic disorders
• Vascular or neurogenic
• tumor

Management of sensorineural hearing loss

Mostly chronic sensori-neural loss can not be cured and person is prescribed to wear hearing-aids. In bilateral severe to profound hearing loss cochlear implant (electronic device, a part is implanted under skin by surgery) may be successful.

Some treatable causes:

If it is sudden loss, spontaneous recovery may be expected assisted by steroids. Underlying etiology present in 10-15 % should be identified & treated.

Immune mediated -steroids

Tumor-surgery

Ototoxicity-Medicine stopped.

Hearing-Aids--

Though hearing aids are not as good as normal ear but if properly met with fitting requirements it can compensate well for hearing loss.

Hearing aids should be fitted and customized to individual after thorough hearing evaluation by by E.N.T. specialist and audiologist.

Most patients are benefited but there is limitation of sound quality and back ground noise that means it works well in quiet environment but some users have trouble enjoying music and listening in a crowded room.Improving FM (frequency modulation) boosts the performance of hearing aid and hearing aids can be optimally set for music.

Quality of hearing aid is of utmost importance and it takes few days to adjust but eventually initial chaotic sound disappear and person is able to appreciate the difference. Usually patients are happy after few weeks of use often coming to tell us that it has improved their quality of life.

Sensori-neural hearing loss may be shocking news to the patient and his relatives. Good doctor-patient relationship and understanding is required to help accept the fact. Talk with your doctor, friends, family and person with same problem to support you.

Hearing loss in children:Early intervention

• Why earliest intervention?

Our ears are filled with music of our child's first talk and our heart tries to retain the memory of that sound. But imagine a situation where all you hear is "silence...". Hearing loss in children can impair normal development of speech & language, his emotional balance, and academic & intellectual skills. Profound hearing loss can lead to dumbness which can be avoided.

From birth to first three years of life are important for a child to learn speaking, so early detection and intervention is very important. Babies should be screened for hearing at birth especially high risk ones. Child with mild hearing loss is generally labelled as inattentive or slow learner. But care for your kid and try to find out if he is hearing normally. Hearing should be tested as child grows on slightest suspicion of hearing-deficit by parents, care givers, teachers and family doctors.

Simple observation at home

• Birth to 3 months: child startle to loud sound
• 3 to 6 months : turns eyes or head towards sound
• 6 to 12 months : listen attentively to familiar sound, respond to name, initiate some sound and few words like bye-bye
• 15 to 24 months : follow simple commands, repeat phrases.

When to visit a specialist: warning signs

• Delayed mile stones/speech
• Kid isolating/irritable
• Difficulty in following verbal instructions
• Ask for repetition of sentence/word
• Difficulty listening in noisy surroundings
• Turn up volume of T.V./radio
• Have academic problem
• Have repeated ear infection/blockage

On slightest doubt child should be seen by an Ear-Nose-Throat (ENT) specialist for thorough examination and evaluation of cause of hearing impairment. Audiologist may perform tests to assess degree & type of hearing-loss. Conductive hearing loss is largely preventable and can be managed by medicine or surgery. Sensorineural loss should be managed by hearing-aids.

Management of hearing-impairment

Depends on types of hearing-loss

Conductive: When sound is blocked to reach the inner ear. Causes may be wax, foreign body, allergy, fluid in the middle ear(glue ear), repeated ear infection, or perforation of ear-drum.

Usually it can be prevented and managed by medicine and/or surgery

Sensori-neural: Damage to nerve of hearing or inner ear.May be present at birth or may develop after some fever, ototoxic medication, loud noise, head/ear trauma, tumors.

Usually it is permanent and requires rehabilitation in the form of hearing-aids or cochlear implants.

Management of deaf child is team effort. Fitting of hearing aids should be considered as soon as deafness severe enough to impede natural speech development is diagnosed. Fitting should be done by experts with wide experience in the field for this age group. Auditory training, speech therapy and psychological counselling are required along with supportive handling by parents, family and teacher.

Hearing-Aids:-

Hearing-aids are instruments to amplify the sound so that you hear well.

Hearing aids should be customized and fitted as per individual children's needs.

They come in several shapes and sizes ; pocket type, behind the ear, in the ear, in the canal, ans smallest completely in the canal .

Digital hearing aids are example of advancing technology in the field and known for greater precision.They convert sound waves and modify the sound to provide clear amplified signal, so noise discomfort can be avoided. Some hearing aids have special characteristics direction setting, telephone setting, audio zoom and FM technology.

Cochlear implant :--

Child with profound hearing-loss which can not be helped by hearing-aids may be considered for cochlear-implant.