UW ENT Grand Rounds January 14th, 2009

6:30 am – Tanya Meyer, MD, Assistant Professor; Director, Voice and Swallowing Center, University of Maryland “Airway Stenosis – Breath of the Matter”

Dr. Tanya Meyer presented the pathophysiology of airway stenosis – a common problem when trauma to the airway happens. Trauma may be caused by chronic inflammatory disease, benign neoplasm (growths), malignant neoplasm (primary or metastatic cancers), and collagen vascular diseases. The most common cause of laryngotracheal stenosis continues to be trauma, which can be internal (prolonged endotracheal intubation, tracheotomy, surgery, irradiation, endotracheal burns) or external (blunt or penetrating neck trauma).

Apparently according to Dr. Meyer, “Rabbits have beautiful airways.” She previewed a film demonstrating tracheal electrocautery of the rabbit. The resulting stenosis was treated with balloon dilation. In my journal studies of the upper airways, I tend not to look at animal models since #1, such lab practices are inhumane, and #2, lab animals don’t exhibit the human variable of “volition toward wellness.” That is, humans are uniquely known to “will and command” wellness by adjusting intention, attitude, and behaviors.

Perhaps most importantly, airway stenosis is most often iatrogenically caused – that is, by physician intervention. As a preventive medicine enthusiast, it’s my mission and hope that patients “will and command” their wellness so as to reduce their chances of succumbing to prolonged intubation, from cardiovascular surgery for example.

Next, we heard from Dr. Dalley who described normal and variant radiographic anatomy of the nose and sinus passageways. Most intriguing was the observation that septal deviations are more of a variant than a pathology per se. After seeing the radiographic evidence of paradoxical curvatures, deviations, and polyps I mused to myself that the REST treatment can be put to great clinical use to reduce mucoid retention symptoms related to these common anatomic variants.

Frank Aversano, ND is an attendee of the University of Washington’s OTO-NHS Grand Rounds. He stays up to date on the latest drug and surgical procedures for the nose and sinuses.

I’d like to Schedule a Sinus Ninja treatment with Dr. Frank

University of Washington, Otolaryngology Grand Rounds, February 18th, 2009

6:30 am – Scott Manning, MD “Allergic Fungal Sinusitis & Update on Pediatric Sinusitis”

Dr. Manning began with the notion that chronic rhinosinusitis (CRS) is not a disease but “an endpoint of many interacting conditions.” Allergic rhinitis, GERD (acid reflux), eczema, migraine, and otitis (ear infection) are several conditions he mentions that add up to what the everyday patient calls “sinus trouble.” At Nova Sinus Center, we take this idea to its logical conclusion to teach patients that the rhinosinuses are often an “LED indicator” of overall inflammatory burden.

Just think of the game Operation. The playmate patient’s bright red nose lights up as the “surgeon” tries to solve other seemingly unrelated health problems. What does “water on the knee” for example have to do with CRS? Both are evidence of inflammatory processes. No one would argue that edema and effusion point to inflammation – whether in the nose or the knee. In fact, Dr. Manning observes that world is becoming “more allergic and more inflamed.” Urbanization, air pollution, high fat diet, and early introduction of food antigens are just some of the contributing variables he references.

In other words, what Dr. Manning may be saying is “where there’s smoke there’s fire.” That is, if one inflammatory process is being observed and treated, we can assume there are others. I treat the rhinosinuses as if they are the “red light” indicator of overall health. It would seem reasonable then, that treating immediately and routinely with steroids is like pulling the plug on your car’s warning indicators. Just because the light’s not on doesn’t mean your engine won’t be crashing from lack of oil.

One cause of chronic rhinosinusitis that comes up time and again during ENT rounds is primary ciliary dyskinesia (PCD) – a genetic defect causing a reduction of mucus clearance from the respiratory tract. This condition appears so often in clinical conversation that it would seem my ENT colleagues believe it’s prevalent even in the absence of biopsy-demonstrated PCD.

The REST treatment at Nova Sinus Center is designed to amplify and assist ciliatory motility resulting in improved discharge of noxious elements. Dr. Manning confirms a prevailing notion that ciliatory motility is a key factor in rhinosinus health. Clearly, anything that can be done to facilitate ciliatory motility will help reduce rhinosinus distress and inflammation. The REST treatment appears to be a missing link – a first line defense – preferable to covering up sinus trouble with steroids or moving straight away to invasive surgery.

Frank Aversano, ND is an attendee of the University of Washington’s OTO-NHS Grand Rounds. He stays up to date on the latest drug and surgical procedures for the nose and sinuses.

I’d like to Schedule a Sinus Ninja treatment with Dr. Frank

University of Washington, Otolaryngology Grand Rounds, March 4th, 2009

6:30 am – Ernest Weymuller, Jr, MD “Revision Sinus Surgery”

Dr. Weymuller emphasized two themes of interest this morning: Use surgery only when necessary, and use rational medicine strategies first. In his introduction, he invited his audience to “learn from failures and misadventures.” While his talk was on revision sinus surgery, Dr. Weymuller spoke from over 40 years experience to say that “medicine does work.” A 21-day oral prednisone taper plus broad spectrum antibiotics was his medical strategy of choice. Dr. Weymuller offers the patient the option of surgical revision when symptoms recur within a 3 month period – that is, a “try and fail” after prednisone taper and broad spectrum course.

A few things come to mind. I’m fascinated by the notion that oral or even nasal steroids are curative – that is, eliminate the cause of the illness. Besides the concern of immunosuppression with oral delivery, there is the well-known phenomenon of receptor “up-regulation” with nasal sprays. This is also referred to generally as drug “tolerance.” The flip side of tolerance is what happens when the drug is removed. As alpha-1 / alpha-2 adrenergic agonists, decongestant sprays like Afrin® and Neo-Synephrine® cause their counterpart receptors to become “hungry” for the drug when it is removed. This results in a more troublesome congestion than before use as the receptors “seek” the drug that is no longer there.

It is well known that nasal decongestant sprays cause “rebound congestion” when the spray is discontinued. Because of this, the manufacturer’s advised use is less than 3 days and physicians will often prescribe the “less addictive” nasal steroids (Flonase®, Veramyst®, Rhinocort®). This presents a curiosity. Does this mean when nasal steroid sprays are discontinued there won’t be rebound congestion? Not exactly. Nasal steroids act by a different mechanism which reduces inflammatory cells and mediators like eosinophils and leukotrienes. While the precise mechanism is unknown, it is known that removal of nasal steroids causes some rebound congestion. That is, the congestion is worse as compared to before starting the nasal steroid therapy. In fact, I have witnessed this troubling phenomenon in my own patients over the past several years with any medical intervention designed to suppress immune response or reduce inflammatory mediators. Until I encounter a better explanation, I can only conclude that something like receptor modulation is the cause.

Just recently I asked a client in the 5th treatment of her REST-6 program if her symptoms were better or worse after Flonase® taper (I had her gradually reduce the drug during her REST series). She mentioned at first, the congestion was much worse. I suspect that in the absence of REST intervention her congestion would have continued to worsen until the receptors down-regulated. Today, without Flonase® she is confident that the REST is a better choice for her. She is now better-than-baseline without receptor or immune modulation (i.e. without Flonase®). I conclude that the REST program is giving this typical client a symptom-reduced quality of life while offering a natural, “receptor-independent” (a.k.a. non-addictive) solution to her sinus trouble.

As a final note, I would agree that medicine for rhinosinusitis is effective. It is my opinion that the REST program is a rational medical strategy that avoids immune suppression and receptor-driven dependency. I propose clients use the REST program as a “try and fail” before using receptor-modulating or immunosuppressive remedies. Clearly, these drugs represent “plan B,” and surgery is agreeably “plan C.”

Editor’s note: Curiously, Flonase® also has a progesterone-like activity, the clinical effects of which to my knowledge have not been investigated.

Frank Aversano, ND is an attendee of the University of Washington’s OTO-NHS Grand Rounds. He stays up to date on the latest drug and surgical procedures for the nose and sinuses.

I’d like to Schedule a Sinus Ninja Treatment with Dr. Frank

University of Washington, Otolaryngology Grand Rounds, March 25th, 2009

6:30 am – Patricia Oakes, MD, Acting Instructor, Neurology “Chronic Headaches and Facial Pain”

In one of the UW meeting rooms where OTO-NHS Grand Rounds are held there is a fire door with a sign that reads, “Do not block.” It seems each Wednesday morning, a folded side-lying table creeps further and further in front of this emergency exit. This morning, it was completely blocking the way out. Fantasies of 20 residents and faculty tripping over each other to get out as fire licked at the main entrance flickered in my mind as I sat and gazed into the texture of the table. I began thinking this is an interesting metaphor for what happens in the nose and sinus passageways.

The emergency exit can be compared to the rhinosinus outflow system known as the ostiomeatal complex. This is the point where the frontal and maxillary sinuses normally drain into the nasal cavity. Obstruction here produces inflammation of the affected sinuses and is routinely treated with anti-inflammatory drugs and endoscopic sinus surgery. One of the great benefits of the REST treatment offered at Nova Sinus Center is that it promotes clearing of the ostiomeatal complex by supporting muco-ciliary drainage. When this emergency exit is clear, flow from the sinus ostia (openings from the sinuses into the nose passages) is enhanced. REST combines this benefit with microbicidal and biofilm reduction leading to prevention or resolution of ostiomeatal blockages. Next week, I think I’ll take some initiative and move that table out of the way.

Dr. Patricia Oakes was on hand today to present some pearls on headache of neurologic origin. She reviewed the ICHD-2 (International Headache Classification, 2ed) and placed special focus on migraine identification and differentiation of migraine from headaches of sinus origin. Dr. Oakes presented a study that concluded 86% of patients who thought they had sinus headaches actually had migraines. Despite Dr. Oakes’ admitted potential for diagnosis bias, this study was a real eye-opener for me. She went on to present differential diagnosis including the more dangerous causes of headache like stroke and artery dissection. In the end, I discovered a more refined appreciation of the causes of headache and when neurologic consult is indicated.

Frank Aversano, ND is an attendee of the University of Washington’s OTO-NHS Grand Rounds. He stays up to date on the latest drug and surgical procedures for the nose and sinuses.

I’d like to Schedule a Sinus Ninja treatment with Dr. Frank