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Department of Otolaryngology
Nose and Sinus Diseases
Sinusitis
Sinusitis is one of the most common health care complaints in the United States accounting for more than 35 million physician visits. The diagnosis of acute sinusitis is usually not difficult but the diagnosis of chronic sinusitis may be more challenging because nomenclature is not clear and the symptoms may be vague. Symptoms of chronic sinusitis can vary from mild headaches around the eyes and yellow to green phlegm in the throat to severe facial pain, headaches, chronic yellow-green nasal discharge, nasal congestion, chronic throat drainage, sore throats, and cough. The diagnosis of chronic sinusitis is made on the basis of the history and the physical exam, and may be confirmed by x-rays and cultures of the pus. Standard sinus x-rays are sufficient for the diagnosis of acute sinusitis in adults but are of limited value in the diagnosis of chronic sinusitis in adults and in most types of sinusitis in children. Computed tomography (CT) scans are reserved for the evaluation of patients with chronic sinusitis.
Antibiotics are the mainstay of treatment for both acute and chronic sinusitis. In acute, uncomplicated sinusitis, antibiotics combined with decongestants are effective in most cases. In recurrent sinusitis and in chronic sinusitis (persistence of the infection for longer than 3 months) the patient should be evaluated for predisposing anatomical factors using CT scans and nasal endoscopy.
Recent studies of the underlying cause of chronic sinusitis has shown that the clearance of mucus from the maxillary, frontal, and anterior ethmoid sinuses is directed toward a structure called the ostiomeatal complex, which is an anatomical region about the size of a dime that is located about an inch inside the nose on the lateral wall. Inflammation of the nasal lining secondary to a viral upper respiratory infection, congestion of this lining due to allergic rhinitis, and/or anatomical abnormalities such as a markedly deviated septum or an enlarged air cell in the middle turbinate (that part of the nose that hangs in the nasal passage like a curtain) may cause obstruction in the region of the ostiomeatal complex.
Recent technological advances have provided us with the tools to diagnose chronic sinusitis more accurately and to treat it more effectively. CT scans of the sinuses provide a much more detailed view of sinus anatomy and sinus disease than do the standard sinus x-rays. One of the most significant advances in the management of patients with sinusitis is the use of endoscopes to supplement the physical examination of the nose. Sinus endoscopes are rigid fiberoptic instruments the size of a straw that are inserted into the nose to provide the physician with a magnified view of the anatomy. The tips of these endoscopes can be angled to provide a "look around the corner." These endoscopes can be used both for diagnosis and for surgical treatment.
When medical treatment fails or when complications of sinusitis develop, surgical treatment should be considered. Although standard sinus operations are still indicated for certain conditions, functional endoscopic sinus surgery (FESS) has superseded most other sinus operations over the past few years. FESS was developed in Europe and brought to this country in the mid 1980's. Advances in instrumentation, specifically the development of the rigid fiberoptic nasal endoscope, combined with improved imaging using high resolution CT scans lead to the development of the FESS procedure. The other important development was the recognition of the importance of the ostiomeatal complex in the development of chronic sinusitis. In functional endoscopic sinus surgery the drainage of the sinuses is enhanced by enlarging the natural openings of the sinuses and the lining of the sinuses is preserved. In contrast, the older sinus operations are more destructive and usually involve removal of sinus lining and creating nonphysiological drainage patterns. The purpose of endoscopic sinus surgery is to remove disease in the target areas, such as the ostiomeatal complex, allowing normal mucociliary flow to be restored. The advantages of the endoscopic approach over more traditional approaches are the following: restores the natural drainage patterns in the nose and sinuses, no external incisions, and usually is performed as outpatient surgery.
WVU Sinus Center
The West Virginia University Sinus Center has been established to deal with complicated cases of sinus disease in a multidisciplinary manner. The expertise of many specialists, such as otolaryngologists, allergists, immunologists, infectious disease specialists, and radiologists is used for the assessment and evaluation of patients with sinus disease. The purpose of the center is to have the input and recommendations of these specialists available for the treatment of difficult or complicated sinusitis in both adults and children. For example, the Sinus Center team handles sinusitis in cases of immunoglobulin deficiencies, cystic fibrosis, or anatomical anomalies. The physicians who are involved in the Sinus Center are working together in an attempt to find new treatments, both medical and surgical, for some of these patients. The easiest point of access to the Sinus Center physicians is through Dr. Hassan Ramadan's clinic at the Physician's Office Center if he feels that the expertise of the other members of the team is warranted, he will make the appropriate referrals. The WVU Sinus Center physicians hold a monthly conference to discuss these complicated or unusual cases.
Endoscopic Sinus Surgery
Computer assisted endoscopic sinus surgery is available at a few centers in the United States. Just as endoscopic techniques revolutionized sinus surgery, the addition of computerized images has revolutionized endoscopic sinus surgery itself. In the last year, balloon sinuplasty was introduced as a new tool for sinus surgery for use to open sinuses instead of cutting and removing bone. A balloon is used to open and wash sinus without scarring.
Historically, sinus surgery has been difficult and prone to complications. Using computers, the surgeon can correlate the surgical anatomy with continual real time 3-dimensional images and CT scans of the sinuses. This technology makes sinus procedures much safer and is very helpful in instances where the anatomy is not normal, such as in cases of severe polyposis. It is also invaluable in revisions where previous surgery has destroyed anatomic landmarks. Computer imaging allows the surgeon to perform a safer and more thorough procedure and will allow the use of endoscopic techniques in certain cases that currently require an external approach.
This very expensive equipment has recently been purchased by Ruby Memorial Hospital. Dr. Hassan Ramadan has received advanced training in this new technique. The ability to perform computer assisted sinus surgery and balloon sinuplasty will make the WVU Sinus Center one of the most advanced centers in the country for performing surgery on the paranasal sinuses.
Allergy Program
The West Virginia University Department of Otolaryngology-Head and Neck Surgery offers a full range of allergy services at our outpatient clinic in the Physicians Office Center (POC) in Morgantown. Dr. Michael Hurst has expertly guided the allergy program. Our department utilizes either skin testing using the skin endpoint titration test or a blood test using the radioallergosorbent test (RAST) as indicated by clinical circumstances. Our allergy nurses manage skin testing, allergy immunotherapy injections, and ordering and keeping track of our RAST test results.
In addition to Dr. Hurst's long standing interest in allergies, Dr. Hassan Ramadan also engages in allergy evaluation and treatment in the POC. We have a very good working relationship with the general allergists and immunologists in the departments of Internal Medicine and Pediatrics and we do not hesitate to enlist their assistance when we feel it is appropriate.
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