Sinus disease is a condition affecting millions of patients and costing billions of dollars to the healthcare system every year. Primary care physicians (PCPs) are on the frontline of treatment for patients with sinus disease. Advanced diagnostic tools and surgical intervention are the key tools that otolaryngologists use to assist in the care of these patients. The best outcomes occur when coordinated care and timely communication occur between PCPs and otolaryngologists.
Sinus complaints represent a significant percentage of primary care visits and account for billions of dollars to the healthcare system . While many of these patients eventually require consultative services provided by the otolaryngologists, most receive their initial care from PCPs. PCPs seek consultations from specialists for a variety of reasons: to seek a second opinion for our own presumed diagnosis; to assist with diagnosis and treatment of conditions that can only be achieved through the use of advanced procedures and techniques; and often most importantly, to educate ourselves on the standard-of-care management for conditions that can often be managed in the PCP's office.
The purpose of this article is to discuss how otoloaryngologists can help PCPs manage patients with a variety of sinus-related symptoms and conditions. This article differs from the usual ‘Current Opinion’ article in that it does not represent an up-to-date literature review of a specific topic related to sinus disease, but rather a more generalized opinion from the perspective of a provider outside the field.
‘I have sinusitis’.
Almost every day, a patient walks into my office with this complaint. The differential diagnosis for acute sinus complaints includes viral rhinitis, allergic rhinitis, acute bacterial rhinosinusitis, as well as nonsinus disease [2▪▪]. For PCPs, the history and physical exam involves trying to differentiate between these conditions, and when diagnosing acute sinusitis, determining when the use of antibiotics is appropriate.
Sinus disease is a clinical diagnosis for most physicians. We rely on the presence of key historical features including sinus pain, mucopurulent discharge, prolonged duration of symptoms, fever and worsening symptoms after initial improvement of an upper respiratory infection [3▪▪]. These symptoms are not always clear-cut. For most PCPs, a gray zone exists in which bacterial infection cannot easily be differentiated from viral or allergic disease. In these cases, physicians often feel pressure to treat with antibiotics. With our ever-growing evidence against the routine use of antibiotics to treat most respiratory infections, it is imperative that PCPs become adept at differentiating between viral or allergic rhinitis and acute bacterial rhinosinusitis.
‘Don’t just do something, stand there’. This was the mantra of my Internal Medicine residency program director. As an Infectious Disease specialist, he was out in front of the abundant literature warning of the hazards of overzealous antibiotic prescribing practices. As PCPs, we are on the frontline in the war against this practice, but as many physicians know, old practices die hard, and it remains difficult to convince patients that medications they took for the past may no longer be considered safe or necessary. This is where otolaryngologists can prove helpful.
Current practice for diagnosing acute bacterial sinusitis is mostly limited to history and physical, but findings can be nonspecific. In a specialist's office, advanced diagnostic tools improve the accuracy of diagnosis. These techniques include bedside endoscopy, sinus aspirations and endoscopically guided cultures. Radioimaging can also be helpful in diagnosing bacterial sinusitis and otolaryngologists can help PCPs in guiding them through the different radiological tests in attempts at improving diagnosis, and therefore limiting the use of antibiotics for patients who do not require them.
‘I have sinusitis. Again’
The diagnostic challenges associated with chronic sinusitis stem from the fact that there is a lack of consensus on the diagnostic criteria used to define it. The symptoms of chronic sinusitis are similar to those of acute sinusitis but last for more than 8 weeks. The differential diagnosis includes chronic infection, nasal polyposis, allergic and nonallergic rhinitis, and fungal sinusitis .
PCPs presented with a patient with chronic sinus symptoms frequently need the help of an otolaryngologist to help guide the diagnostic evaluation. Continuous treatment with broad-spectrum antibiotics is risky and may be futile when surgical intervention is the best or only option. Delaying diagnosis can result in unneeded patient suffering and an overuse of services and medication. Bedside endoscopy and diagnostic imaging can often lead to a prompt diagnosis so that the treatment can be initiated immediately.
Once the appropriate diagnosis is made, other issues such as antibiotic selection and duration, use of inhaled or systemic corticosteroids and consideration for surgery are all issues with which PCPs can use help. If surgery is not indicated, PCPs would like to be able to manage patients in the office and communication on how best to manage these patients with pharmacotherapy will help reduce the delay in the treatment that can often occur when awaiting consultation with a specialist.
‘I’m congested and can’t stop sneezing’.
Rhinitis, as defined by intermittent or chronic symptoms of nasal congestion, sneezing or rhinorrhea is a common condition, affecting up to 30% of all adults and placing a significant direct and indirect burden of dollars on the healthcare system [5▪▪]. Differentiating between allergic, nonallergic and mixed-typed rhinitis can be difficult for the PCP when symptoms and physical findings can be the same. Treatment aimed at alleviating the symptoms and improving the quality-of-life measures is the goal, often requiring the combined approach of pharmacotherapy, immunologic treatments and avoidance therapy.
Since the introduction of nonsedating antihistamines and nasally inhaled pharmacotherapy, the use of immunotherapy has seemed to be less palatable to the average patient suffering from mild-to-moderate allergic rhinitis. Certain select patients with severe symptoms and those who suffer from side-effects from medications are more likely to consider immunotherapy, and allergists and otolaryngologists can help facilitate the use of this therapy for those patients.
Another challenging symptom complex for the PCP to manage is the patient with bothersome postnasal drip and throat clearing. The treatment for these symptoms may be very different depending on the cause. Whether because of rhinitis, atypical GERD or laryngopharyngeal reflux, the otolaryngologist will always be in a better position to make the appropriate diagnosis and initiate treatment with the use of office endoscopy.
‘My surgery was a success. Now what?’
Patients recovering from functional endoscopic sinus surgery (FESS) often feel dramatic improvement of their symptoms within weeks of surgery. Improved breathing, less frequent episodes of sinusitis and reduction of sinus pain occur in the majority of patients undergoing surgery for medically refractory chronic sinusitis .
Not infrequently, recurrence of symptoms can occur by as early as 2 years, even in patients with successful anatomical outcomes. Factors related to recurrence include presence of polyps, allergic rhinitis, aspirin sensitivity and patient noncompliance . Two years after surgery, these patients will present to a PCP's office with recurrent symptoms of sinusitis. We need otolaryngologists to help ensure that these patients achieve the maximal benefit from surgery.
‘Did my ENT send you a letter?’
‘Of course’ is how I usually answer this question. In my community, most subspecialists are vigilant about the communication with PCPs. In the age of electronic health information, progress notes and consult letters can be faxed or electronically mailed at the time of consultation. Communication is not only important to improve the quality and safety of care, but also an important way for PCPs to learn about the state-of-art care.
Management of sinus disease involves comprehensive and coordinated care by both otolaryngologists and PCPs. The best outcomes occur when referrals are made early in the course of treatment for a complicated patient and when communication between providers is clear and prompt. Working as a team, patient outcomes can be maximized, and otolaryngologists play a vital role in helping PCPs care for their patients with sinus disease.
Conflicts of interest
The author has no conflicts of interest to report.
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of review, have been highlighted as:
▪ of special interest
▪▪ of outstanding interest
Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 89).
1. Summary health statistics for U.S. Adults: National Health Interview Survey, 2009. National Center for Health Statistics. Centers for Disease Control and Prevention.
2▪▪. Chow AW, Benninger MS, Brook I, et al. IDSA Clinical Practice Guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis 2012; 54:e72–e112.
This study provides the latest guidelines for use in the diagnosis and treatment of patients with acute rhinosinusitis.
3▪▪. Meltzer EO, Hamilos DL. Rhinosinusitis diagnosis and management for the clinician: a synopsis of recent consensus guidelines. Mayo Clin Proc 2011; 86:427.
A nicely written article that provides a user-friendly interpretation of guidelines for the treatment of patients with sinusitis.
4. Bhattacharyya N, Lee LN. Evaluating the diagnosis of chronic rhinosinusitis based on clinical guidelines and endoscopy. Otolaryngol Head Neck Surg 2010; 143:147.
5▪▪. Meltzer E, Bukstein D. The economic impact of allergic rhinitis and current guidelines for treatment. Ann Allergy Asthma Immunol 2011; 106:S12–S16.
A well written review of the significant financial impact of allergic rhinitis, as well as guidelines for treatment.
6. Lavigne F, Nguyen CT, Cameron L, et al.
Prognosis and prediction of response to surgery in allergic patients with chronic sinusitis. J Allergy Clin Immunol 2000; 105:746–751.
7. Richtsmeier WJ. Top 10 reasons for endoscopic maxillary sinus surgery failure. Laryngoscope 2001; 111(11 Pt 1):1952–1956.