Why Do My Sinuses Still Get Infected After Sinus Surgery
||Martin Desrosiers, MD, FRCSC.
Program director, ORL-HNS
Université de Montréal
Patients who have undergone endoscopic sinus surgery (ESS) for management of chronic sinusitis (CRS) with or without nasal polyposis may nevertheless continue to have symptoms of chronic sinusitis and/or episodes of infection despite initially apparently successful sinus surgery. Several studies have shown that even well-performed sinus surgery can have recurrence of nasal polyps after surgery. In a study from Sweden, 50% of patients showed signs of recurrence of nasal polyps as early as five months after surgery.
Despite patient concerns, only rarely this a consequence of technical with performance of surgery. Chronic sinusitis, with or without nasal polyposis, is a chronic disease which reflects changes at the level of the sinus mucosa. While we don’t yet know everything about nasal polyposis, we do know that chronic sinusitis represents an ongoing form of inflammation, and that medication should be used to prevent recurrence of the inflammation. The reasons for this are multiple, and reflect the chronic nature of CRS and the factors underlying its development.
1. Medical treatment needs to be continued medication after surgery. Medication is usually required after sinus surgery to avoid recurrence of disease. If patients are not taking medication In the same study referred to earlier, patients who continued using an intranasal topical corticosteroid spray after ESS delayed return of the nasal polyps by an additional period of several months. Frequently, physicians will attempt to increase the effectiveness of this therapy by using sinus irrigations composed of salt water and corticosteroids mixed together. This underlines the importance of continuing therapy after ESS. and ensuring that you’re following physician recommendations faithfully.
2. The type of underlying inflammation may require treatment with an alternate type of anti-inflammatory therapy. It’s possible that the type of inflammation that drives your chronic sinusitis may be of a type that does not respond well to corticosteroids. Some patients have a form of inflammation which is neutrophilic, as opposed to eosinophilic in origin. Unfortunately this type of inflammation frequently does not respond as well to corticosteroids. While there is no magic bullet currently available for treatment of this condition, physicians will often try and use a alternate anti-inflammatory treatment, such as the macrolide antibiotic azithromycin taken at low doses for a several month period to help regain control.
3. Persistent low level bacterial infection. Another reason that may be at play is a persistent bacterial infection. The bacteria present in chronic sinusitis have a tendency to form a thick, tenacious film called a biofilm, which protects them by ‘hiding’ them from natural defence mechanisms and destruction by white blood cells and making them resistant to antibiotics. This may make these infections more difficult to clear and lead to persistent symptoms and recurrent infections. Occasionally, physicians will use a type of surfactant, or “soap” to try and get rid of these. One homemade recipe for this that is often used is a small quantity of baby shampoo in the sinus irrigation solution. However, this therapy is not for everyone and may carry some minor risks so it should only be used on the position of vice of course.
4. Recurrent viral infections triggering bouts of sinusitis. Exacerbations of your sinus condition may occur following exposure to viruses producing viral upper respiratory tract infections. Patients frequently exposed to viruses, such as daycare workers, elementary school teachers, and certain healthcare workers, as well as parents with children in day care, may have frequent “colds” which may unbalance the delicate balance of their sinus situation, leading to development of acute infection.
5. An underlying immune deficiency. Lastly, if you find your getting sick too often after surgery, there is a possibility that you may have a problem with your immune system which defends itself well against infection. While these conditions are rare, you should discuss this with your physician as specialised consultation and/or specific testing may be required to explore this possibility.
Cough, your Baby and You—What’s a Parent to Do?
||Gustavo Ferrer, MD.
About the author: Dr. Ferrer is one of the top pulmonologists in the country, an expert who is often able to cure coughs in patients who have seen a dozen other pulmonologists. He is the founder of Cleveland Clinic’s Cough Clinic in Florida and the author of the Amazon bestseller Cough Cures: The Complete Guide to the Best Natural Remedies and Over-the-Counter Drugs for Acute and Chronic Coughs.
The FDA requires cough medications to be labeled “not for children two and under” because of the potential of overdosing and side effects. In fact – as I explain in my book Cough Cures – most cough medications are ineffective at best and unsafe at worst, even for adults.
In doing the research for my book, I found that people tend to assume that medications in a drugstore have been thoroughly checked by the FDA and that their effectiveness have been documented by research studies. Nothing could be further from the truth. The FDA cannot possibly check the tens of thousands of over-the-counter medications. What’s worse, companies can make all kinds of advertising claims on the front part of the label without having to submit a single research study. Some of the most common cough medicines like guaifenesin have no research supporting their use.
You must be especially wary of combination medications, ones that combine several different ingredients for different purposes. Perhaps one is meant to suppress the cough, another to thin the mucus, and a third to help you sleep. Many combination medicines contain acetaminophen (Tylenol), and it’s very easy to unintentionally take too much in 24-hour period. You have to read the back part of the label and add up how much Tylenol you’re getting in all your different medications combined. The FDA considers 3000 mg a day as a safe level, but I recommend only 1500 mg, because too much Tylenol can cause liver failure and its attributed to hundreds of deaths per year. I still see many patients at the Intensive Care Unit where I work with liver failure from Tylenol, even after the FDA lowered the safe dosage to 3000 mg a day.
Robitussin and other cough syrups contain codeine. It’s a small amount and not enough to cause dependency for short term use. It could be a problem with long-term use however, and the real problem is that teenagers can easily buy enough of it over the counter to get a dependency-forming amount of codeine. If you have teenagers in your house, please go to www.StopMedicineAbuse.org for a long list of all the cough syrups that can be abused by teens.
What about prescription medications? As you probably know by now, the antibiotics prescribed by doctors for coughs, colds and flu are ineffective because these are viral illnesses, and antibiotics only work against bacteria. It’s a common myth that the antibiotics will protect against a secondary bacterial infection. But there is no research evidence that they do, and in fact the World Health Organization has said that antibiotics should not be used to prevent a cough from turning into bronchitis or pneumonia.
So what can we do instead? For adults, who prefer drugstore medicines, the only type I recommend is antihistamines, because they dry up the post nasal drip that causes many coughs. Even then, I teach readers to distinguish between the “first generation” or older antihistamines like Benadryl, which have stronger side effects, and the “second generation” or newer ones like Claritin, Zyrtec and Allegra. If you research the side effects online they are about the same for both types of antihistamines, but they occur less often and are milder with the second generation. The trade-off is that the second generation antihistamines are not as effective, but I recommend starting with them. Only go to a stronger one like Benadryl if the newer ones fails to help. Be wary of “PM” cough medications in which include Benadryl to make you drowsy: sleep doctors advise NOT to use Benadryl as a sleeping aid, because it can increase sleep apnea.
The reason antihistamines work for coughs is their ability to dry up postnasal drip, but there is a better and safer way for everyone in the family. Before you turn to a drugstore medication or natural remedy, the safest way to stop coughs caused by postnasal drip is to use a saline rinse, specifically one administered with a prefilled NeilMed plastic squeeze bottle. As I explain in Cough Cures, the NeilMed system solves two common problems with saline rinses: it has a bulb tip that regulates the flow, preventing the water from coming into the nose under too much pressure; and it slightly alkalinizes the saline solution, so that it does not irritate the sensitive nasal tissues. Fortunately for the harried parent of a coughing infant, NeilMed provides Nasabulb, a special version just for babies.
For more information, visit:
Amazon: Cough Cures
Green mucus anxiety and managing childhood respiratory events. Part 1: Expectations
||Professor Richard Harvey MD PhD.
Rhinologist, surgeon and educator.
About the author: Professor Harvey leads innovative research into the causes of chronic sinus disease and novel therapies to manage the condition. As program head, Rhinology and Skull Base Surgery, at UNSW and Macquarie University, he is asked to speak nationally and internationally on changing the traditional paradigms in upper airway and sinus care. His research has provided fundamental shifts in the way sinus disease is managed.
As nose and sinus specialist, I’m often asked for advice, by parents, on managing recurrent respiratory symptoms during childhood. The symptoms of nasal discharge, congestion and cough, are common during childhood and may even appear persistent as the break between events is short. While there are some significant medical problems that can produce true ‘persistent’ nasal symptoms, with no return to normal function in between, most respiratory events during childhood are ‘episodic’ and represent part of the normal exposure and immune development that occurs during these years.
Unfortunately, the medical marvel of antibiotic development, which changed the mortality associated with severe bacterial infections such as pneumonia, sepsis and meningitis, is now over applied in our community. There is a growing concern that modern health therapies applied inappropriately and unnecessarily to our population, and especially children, is not only wasteful but harmful to health. A great example of this is the overuse of antibiotics to manage recurrent respiratory exacerbation in childhood. These events are viral and don’t represent bacterial infections. I intentionally avoid the use of the term ‘majority of events’ as this is misleading and an unnecessary ‘disclaimer’ as the number of viral respiratory events that become bacterial and need treatment is much less than 1%. Unfortunately, 50% of children still leave an consultation from a local family doctor with a course of antibiotics1 and while this is an improvement from the 1990’s, when sadly, up to 75% of all antibiotic prescriptions were used on children2, it still remains unacceptably too high.
Mucus production observed by parents drives much of this anxiety3. And, in particular, green or discoloured mucus. As a parent myself, its normal behaviour to want to help our children when they are ill, however, understanding the nature, duration and frequency for these mucus producing events is critical to ensuring that care or interventions we offer our children are both safe, effective and appropriate.
The green color of mucus is produced from myeloperoxidase or MPO. This enzyme arises from white blood cells (neutrophils) and presents 5% of the dry weight neutrophils4. The green pigment iron-containing heme groups within MPO. Neutrophils and MPO are normally expressed (100 fold) during viral respiratory events. Green mucus is not a sign of ‘bacterial’ infection but simply an immune response from our children.
Viral events are common in childhood. Communal day-care, centralised schooling and urban living all provide much closer human contact at an earlier stage in life compared to our ancestors. One of the resulting effects is frequent viral respiratory events, as multiple serotypes are quickly transmitted. The frequency of these events is 4 episodes a year5(Table) and duration of viral events commonly 10 days6. Thus the average ‘healthy’ child should expect to have 40 days or more with respiratory symptoms (and green mucus) as part of their normal immune growth and development.
Over a series of postings we will discuss the expectations, symptom management and prevention strategies for childhood respiratory events.
1. Jansen AG, Sanders EA, Schilder AG, et al. Primary care management of respiratory tract infections in Dutch preschool children. Scand J Prim Health Care 2006;24:231-236.
2. Acute respiratory infections: the forgotten pandemic. Communique from the International Conference on Acute Respiratory Infections, held in Canberra, Australia, 7-10 July 1997. Int J Tuberc Lung Dis 1998;2:2-4.
3. Taylor JA, Kwan-Gett TS, McMahon EM, Jr. Effectiveness of a parental educational intervention in reducing antibiotic use in children: a randomized controlled trial. Pediatric Infectious Disease Journal 2005;24:489-493.
4. Schultz J, Kaminker K. Myeloperoxidase of the leucocyte of normal human blood. I. Content and localization. Archives of Biochemistry & Biophysics 1962;96:465-467.
5. Leder K, Sinclair MI, Mitakakis TZ, et al. A community-based study of respiratory episodes in Melbourne, Australia. Aust N Z J Public Health 2003;27:399-404.
6. Lambert SB, O’Grady KF, Gabriel SH, et al. Respiratory illness during winter: a cohort study of urban children from temperate Australia. J Paediatr Child Health 2005;41:125-129.
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Benefits of Having Parents use Nasal Aspirator on Infants in a Pediatric Practice
||Ronda Miller-Ernest, DNP, APRN-BC
About the author: Ronda is a Board Certified Pediatric Nurse practitioner who has been practicing in a private pediatric office for 27 years.
Some of the most common concerns I hear from parents in their infants first six months of life are; “My baby always sounds stuffy.” My baby won’t nurse because “they can’t breathe and suck with this stuffy nose.” “If I could only clear their nose they would feel better!”
In the first few months of life infants are obligatory nose breathers. Their narrow nasal passages are very sensitive to dry air, especially in the winter months when the forced warm air heating systems used in most homes, are turned on. Where I practice the low humidity climate also tends to aggravate the nasal mucosa dryness. Infants are too young to sniff or take deep nasal breaths in to clear their nose. They are totally dependent on an outside resources to help clear their nasal passages or external moisture to relieve the symptoms of dryness.
In my practice I have a large refugee population who commonly don’t understand the concept of a humidifier and/or cannot afford one, however the nasal oral aspirator is something I can demonstrate in the office with a saline solution sample. With the demonstration this is easily understood even with a language barrier and very portable to take home with them. Due to NeilMeds’ generous sample availability I can stock them in my office.
I have found that instructing parents on the use of the NeilMed Naspira and frequently in combination with the saline nose drops that the infant eats better; feels better, parents feel they can finally do something to help their infant and by clearing the airways it can decrease additional unnecessary sick appointments. This device is simple to use, affordable, easy to clean and requires very little extra office time for instruction.
Soothe your child’s cold the natural way
||Monika Pis, PhD, CPNP
About the author: Monika Pis, PhD, CPNP is a primary care pediatric nurse practitioner with a specialty in health promotion and risk reduction. Her interests are nutrition and functional medicine.
During the flu season, viruses circulate in our communities cause upper respiratory symptoms such as runny nose or nasal congestion making our children cranky and uncomfortable. Antibiotics do not work for viral illness and over-the-counter medications are either not effective or unsafe for children younger than 6 years of age. However, there are safe and effective evidence-based natural remedies that will stimulate your child’s immune system and improve comfort while her body fights off the viral infection and tries to heal.
• Saline nasal rinses
Saline nasal rinses are very effective in managing nasal symptoms related to an upper respiratory infection, such as a cold or even sinus infection. The exact mechanism of action is not known, but the saline rinses may improve the function of the nasal mucosa by removing inflammation and cleansing the nasal cavity.
You can perform a saline nasal rinse on an older child by instilling saline solution into one nostril and allowing it to drain out of the other one. These rinses can be performed by using a neti pot, low positive pressure squeeze bottle, or gravity-based pressure bottle with a nasal spout.
For a younger child, you can use a saline nasal mist or spray. Since saline solution is not medicated, it can be safely used several times a day as needed even in infants.
• Chicken soup
Eating chicken soup while sick is no longer an old wife’s tale. A study published in the CHEST Journal, the official publication of The American College of Chest Physicians, provided evidence that chicken soup has anti-inflammatory properties and helps relieve symptoms of an upper respiratory infection (1).
Another study published in The American Journal of Therapeutics suggested that chicken soup contains an anti-inflammatory substance called carnosine that could help in warding off viral infections such colds (2).
Since it is the broth that has medicinal properties, it is not a big deal if your child does not want to finish the noodles or even the veggies. An option for picky eaters would be sipping on the broth from a mug.
Pineapple contains a powerful anti-inflammatory enzyme bromelain that provides relief for sore throats and upper respiratory infections. It also thins out mucus in the respiratory system and reduces coughing.
In a double-blind trial of patients with acute sinusitis, 87% of patients who took bromelain reported good to excellent results compared with 68% of those who took placebo (3).
To get the befit of pineapple, when your child is sick with an upper respiratory infection, offer her the fresh fruit, or make a slushy of coconut milk, pineapple chunks, and ice.
1. Rennard, B., et al. Chicken soup inhibits neutrophil chemotaxis in vitro (2000). CHEST, 118(4):1150-7.
2. Babizhayev, M., et al. Management of virulent influenza virus infection by oral formulation of nonhydrolized carnosine and isopeptide of carnosine attenuating proinflammtory cytokine-induced nitric oxide (2012). Am J Ther., 19(1):e25-47.
3. A double blind clinical evaluation of bromelain in the treatment of acute sinusitis (1967). Headache, 7: 13-7.