Sinusitis

Question

Hello,
I have CF and problems with the sinuses for one year. When would surgery be advisable or urgent and how does such an operation proceed, especially which risks could occur?
Regards,

Answer

Hello,

According to our opinion, ENT surgery in CF only should be performed if all conservative therapeutic measures have been exhausted, except when absolute indication for surgery is given.

Absolute indications for surgery are infections which expand from the sinuses to the neighbouring regions including the eyes and the brain, suspected malignant growth (tumor) or sepsis emerging from the sinuses. All these complications is extremely rare in CF...

Therefore, as a rule, first of all the conservative therapeutic measures should be implemented consequently, also as in CF rhinosinusitic symptoms frequently reoccur after ENT surgery.

Here are some selected conservative therapeutic options:

- decongestives (alpha-sympathomimetics as nasal-drops/sprays) are sensible at short-term obstruction, then they also can be applied prior to nasal douche or prior to application of other topic drugs. (caution: decongestans cause mucosal damage if applied for more than 5-7 days)

- topical steroids (Nasonex™, Avamys, Flutide Nasal™, Budesonid NS™ and others) have a stable evidence-based place in the therapy in case of obstruction, as well as in the therapy of nasal polyps, even if they are more effective in allergy-associated polyps (there are good safety data for application as a long-term therapy with minimal cortisone dosages, so that they do not lead to relevant levels in blood so that cortisone side-effects are prevented).

- nasal douche: gold-standard to eliminate secretions and crusts from the nose applying about 125ml saline through every nostril with a special can (e.g. Neti®-Pot, Pari Montesol Nasendusche™, Emser Nasendusche™) (caution: cleaning of the device is as important as with other inhalation devices in order to prevent intusion of pathogens with therapy)

- Pari sinus™: with this newer nebulizing system vibrating aerosols are inhaled via the nose. Drug deposition in paranasal sinuses was proven by Möller W. et al. 2010 in szintigraphic investigations with healthy individuals. We have just finished a study in which we have demonstrated a decrease of sinonasal symptoms in patients with CF who inhaled dornase alfa with the device, compared to isotonic saline (in a double blind placebo controlled trial – Pilot study in press: Mainz JG, et al. Auris Nasus Larynx) . We propose, that this is effects also could be achieved with hypertonic saline (6%) and are performing multicenter double blind placebo controlled trials on this and on sinonasal inhalation of tobramycin and colomycine. Information about this you can get via the homepage of the German CF institute (www.muko.info/studienliste).

Surgery in the ENT-region bear the same risks as all the other operations (anesthesia, ventilation, haemorrhage etc.) and additionally during and around the operation special attention has to be given to prevent import of pathogens like P. aeruginosa.

Concerning further details of surgery and your individual risks, please address your ENT-surgeon in charge.

Regards,
Jochen Mainz

21.09.2010