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Vol. 66, No. 1 2015
Northeast Florida Medicine
Otolaryngology
cancer risks associated with ionizing radiation has increased
in recent years due to the rising incidence of children’s cancer.
CT scans should be adjusted for the weight and size of the
patient to allow the lowest radiation dose possible. Although
today’s CT scanners allow high-resolution images at smaller
radiation doses, the use of these studies should be weighed
against their potential benefit. It is axiomatic that imaging
studies, particularly CT scans, should be done only when
they may influence the physician’s clinical decision.
6
Biocompatible Dressings
Athirdmajordevelopment insinonasal operative technology
is the appearance of biocompatible dressings.These have been
developed in the form of powders, sprays, gels and sponges,
but they share the common characteristic of being largely
resorbable. For many surgeons, this has eliminated the need
to place traditional packing materials in the nose postopera-
tively. Becausemost of thesematerials are also hemostatic, this
change in technique has occurred without an increased risk in
bleeding. In fact, these authors have observed less bleeding,
since it is no longer necessary to disturb the nasal passages
24 to 48 hours after surgery with solid packing removal. This
also increases patient comfort after surgery, and considerably
reduces patient anxiety about packing removal.
7,8
Resorbable packingmaterial follows the trend of splintless
nasal septum surgery. Although some surgeons continue to
use internal nasal splints after septoplasty with good results,
the community trend for some years has moved away from
these. Instead, resorbable intranasal sutures are usedwhich fall
out on their own after one or two weeks. This, too, reduces
patient anxiety and improves patient comfort after surgery.
9
ENT Challenges
Not all the recent changeswithinOtolaryngology have been
positive. Economic recession and the changing realities of the
third-party payor system have challenged medical progress
across all specialties. Within ENT, the wide selection of pre-
scriptionmedications available in the 1990s–including nasal
steroids, antihistamines, and antibiotics–has been narrowed
by the imposition of formulary restrictions. Although the
change to generic prescribing has resulted in cost savings
for many patients, choice and efficacy have suffered. When
considered alongside the paucity of new antibiotics on the
market, conventional pharmacotherapy is inarguably more
limited than it was 10 to 15 years ago.
This change has required adaptation in the way sinona-
sal disease is treated medically. With respect to antibiotic
treatment, bacterial identification and determination of
antibiotic susceptibilities can improve the effectiveness of
therapy. Endoscopically-acquired sinus cultures have been
proven as a highly sensitive and accuratemethod of acquiring
this information. Beyond conventional sinus cultures, poly-
merase chain reaction (PCR) assay has become increasingly
available as a send-out test for qualitative determination of
specific bacterial infection.
Another treatment modality to adapt despite these re-
strictions is compounded topical therapy.Topical antibiotic
therapy has evolved from a fringe treatment to a mainstay
of sinonasal care, particularly for postsurgical patients.
Compounded topical therapy allows the administration
of stronger antibiotics, such as vancomycin or amikacin,
directly to the nasal mucosa without the need for IV therapy.
Newer, portable nebulizing devices have been developed
such as Sinus Dynamics’ NasaTouch device, a lightweight
and handheld device which holds 15 mL of solution and
atomizes 2 mL (1 treatment) in just 30 seconds.
10
Such
devices allow for quick administration of powerful antibiot-
ics previously available only for parenteral administration.
When combined with the results from endoscopic sinus
culture or PCR assay, select patients with chronic sinus
infection can be treated more easily and effectively.
11
Updated Guidelines
As in other specialties, economic realities of medical care
coupled with desire for better outcomes have prompted
Otolaryngologists to develop evidence-based treatment
guidelines. In 2007, the American Academy of Otolaryn-
gology-Head andNeck Surgery publishedmultidisciplinary
clinic practice guidelines for adult sinusitis.
12
These guidelines
were composed based on input from a broad range medical
specialties including allergy and immunology, infectious
disease, emergency medicine, family medicine, internal
medicine and radiology.
The AAO-HNS Adult Sinusitis guidelines emphasize
appropriate diagnosis and provide management options
that include observation, antibiotic therapy and additional
testing. A strong recommendation was made to distinguish
acute bacterial sinusitis from that caused by colds, viruses
and non-infectious conditions. The guidelines defined
acute sinusitis as purulent nasal drainage accompanied by
nasal congestion and facial pain/ pressure/ fullness lasting
up to four weeks. For viral and mild bacterial sinusitis,
observation and symptomatic treatment was recommended.
Amoxicillin for seven days is indicated as first-line therapy
in non-penicillin-allergic individuals. A distinction was
made between chronic sinusitis (lasting 12 weeks or longer)
and recurrent acute sinusitis (four episodes per year with
no symptoms in between). (Short-course amoxicillin was
not recommended, nor is it necessarily appropriate, for
chronic or recurrent acute sinusitis). Routine sinus x-rays
were discouraged for the diagnosis of sinusitis. Instead, for
