Odontogenic sinusitis is a persistent infection of the sinuses that arises from a diseased upper tooth root – usually a molar. Odontogenic sinusitis comprises 5-10% of chronic sinusitis. The dental infection will cause a periapical abscess (pus collection around the root of the tooth) which is commonly located in the cheek sinus. This will cause foul-smelling, purulent unilateral drainage that usually is refractory to antibiotics. The bacteria are usually anaerobic bacteria that are common dental flora. Antibiotics do not work because there is so much pus in the sinus, they can not penetrate to the middle of the collection. Endoscopic sinus surgery is curative, by draining the sinus. Occasionally the cheek sinus infection spreads to the ethmoid and frontal sinuses. Sometimes extraction of the infected tooth can cure the infection, but usually endoscopic sinus surgery is required. Once the sinus has been opened and the diseased tooth has been removed the patient’s sinus issues resolve.
Another cause of odontogenic infections in the maxillary sinuses are dental implants. Dental implants are being used more commonly for dental restoration, and most patients do quite well. Rarely the implant can penetrate into the maxillary sinus and this results in a path for dental bacteria to travel into the sinus, resulting in a chronic sinus infection that is refractory to antibiotics. Once again, endoscopic sinus surgery will cure the infection, and the implant does not need to be removed.
Josh Meier, M.D. F.A.R.S.
Nasal complaints are common in northern Nevada. While there are many conditions that can cause nasal symptoms, high altitude, allergies and lack of humidity are some of the factors that can lead to nasal symptoms. Fortunately the majority of nasal complaints can be resolved with simple, economical solutions, many of which are available over the counter.
The bulk of patients we treat at Nevada ENT and the Reno Tahoe Sinus Center have chronic rhinosinusitis (CRS). CRS is a chronic inflammatory disease, similar to asthma. Just like asthma there is no single cure for CRS, but there are many treatments that can improve the patient’s quality of life. Symptoms can include nasal obstruction, drainage, smell loss and facial pain or pressure. Nasal steroids and rinses are the first line therapy for CRS. If they fail, a visit to an Otolaryngologist can be helpful. If a patient continues to have symptoms despite medical therapy, then a CT scan is usually ordered. Nevada ENT and the Reno Tahoe Sinus Center offer a brand new cone-beam CT scanner for this reason that allows point of care service, image quality, as well as 1/10th of the radiation as a conventional sinus CT scan. If the CT scan shows abnormalities, and if the patient has failed medical management, then endoscopic sinus surgery is an option, however the majority of patients have significant improvement with medical management and do not need surgery.
There have been significant advances in endoscopic sinus surgery (ESS) over the last 30 years. Improved techniques, optics, and instruments result in minimally invasive surgery, and significantly quicker recovery times. New techniques and advanced rhinologic training make the use of nasal splints or packing after surgery unnecessary, resulting in minimal postoperative pain for patients.
Other common nasal complaints in northern Nevada include the following:
- Nasal dryness – This is extremely common in our area. The role of the nose is to warm and humidify air as it enters the body. This job is more challenging if the baseline air humidity is 10-20% as it is here. Symptoms from too much dryness include nasal obstruction, burning, and crusting in the nose. This can be effectively treated using over the counter saline gel, Neilmed® saline rinses and a humidifier.
- Allergic rhinitis – Symptoms of allergies include nasal obstruction, clear nasal drainage, and smell loss. Watery and itchy eyes may also be seen. Topical nasal steroids such as Flonase® or Nasocort® can be purchased over the counter. Saline rinses can help as well. Oral antihistamines can be added to help eye symptoms.
- Atrophic rhinitis – This is more common in the elderly, when the nasal mucosa cannot humidify the nose properly anymore. The main symptom from this is clear nasal drainage, intensified with eating and exercise. Fortunately there is a simple prescription medication that can reduce the drainage – Atrovent® nasal spray.
Josh Meier, M.D. F.A.R.S., is the Director of the Reno Tahoe Sinus Center. He specializes in complex and revision endoscopic sinus surgery cases. He graduated from medical school from the University of Southern California and completed an Otolaryngology residency and Rhinology fellowship at Harvard Medical School. Dr. Meier is board certified by the American Board of Otolaryngology and his training also allows him to endoscopically manage disorders of the anterior skull base and orbit.
For more information or if you are having nasal issues, from simple to complex, please call and make an appointment to see physicians at Nevada ENT and the Reno Tahoe Sinus Center.
Dr. Meier authored an article on chronic sinusitis and nasal health for the October issue of Canyon Vista Living – the local magazine for Somersett Reno.
Please click below to download the PDF
Thank you to Canyon Vista Living for the great opportunity
Chronic sinusitis is, as the name implies, a chronic disease. There is no permanent cure for chronic sinusitis, but there are many treatments that can improve patients’ symptoms. The first step in treatment of chronic sinusitis is using a topical nasal steroid, like Flonase (now over the counter) and a saline rinses. If patients continue to have symptoms despite medical therapy, and they have an abnormal sinus CT (available in our office) then endoscopic sinus surgery is an option. Unfortunately patients may require more than one operation. A large part of my practice is revision sinus surgery. This can be due to polyp regrowth with symptom recurrence or due to scar tissue or incomplete prior surgery.
A unique indication for revision endoscopic sinus surgery is maxillary recirculation. This occurs when the natural ostium (hole) of the maxillary (cheek) sinus is not connected to the surgical opening that was made at the previous sinus surgery. The cilia in the sinus beats the mucus out of the natural ostium, and it falls back into the surgical opening in the maxillary. Then it goes around and around from maxillary sinus to the nasal cavity. Eventually it falls out into the nasal cavity, and patients describe usually unilateral thick post nasal drainage. It can be a source of recurrent infections as well, since bacteria frequently infect the thick mucus that resides in the maxillary. Nasal steroids and rinses can decrease symptoms, however definitive repair requires revision surgery.
By connecting the two openings in the maxillary sinus the recirculation ceases. I have had many patients that had decades of “allergies” resolve after the revision surgery. Convincing patients that had previous endoscopic sinus surgery in the 1980s or 90s is challenging, but fortunately the techniques have improved that do not require packing anymore. Without packing there is minimal pain.
If you had endoscopic sinus surgery in the past and you have symptoms similar to those list above, please make an appointment; with a few diagnostic tests I can ascertain if your would benefit from revision surgery.
I encourage you to visit https://www.doctor.com/Dr-Josh-Meier where dozens of patients have described their experiences after revision endoscopic sinus surgery for chronic sinusitis.
Josh Meier, M.D. F.A.R.S.
Director Reno Tahoe Sinus Center
Dr. Meier lectured at Renown Regional Medical Center Grand Rounds on August 10th, 2017 on “Chronic Sinusitis and Other Nasal Complaints”.
In addition to the audience present in the Mack Auditorium, there were remote attendees from Ely and Bishop.
Dr. Meier was happy to meet his referring doctors, and to answer everyone’s questions about nasal health.
Dr. Meier lectured on “Advances in Endoscopic Sinus Surgery” at Plumas District Hospital in Quincy, CA on July 31st.
He was pleased to meet many of his referring providers, and educate the staff on cutting edge treatments for chronic sinusitis.
Smell loss or anosmia can be due to many varied causes, such as acute head trauma, a severe cold, chronic sinusitis, nasal polyps, neurological conditions, and rarely tumors. An important distinguishing factor is the acuity of onset. Acute smell loss can be due to a severe upper respiratory infection or head trauma. Viruses can cause cell death of the olfactory neurons, and head trauma can shear off the olfactory nerves. Both have the potential for recovery, as olfactory nerves can regenerate, though it can take years.
A common cause of chronic smell loss is chronic sinusitis, which through inflammation can cause swelling of the sinus mucosa, and will block the path of odor molecules to the olfactory groove. Fortunately a combination of nasal topical steroids, prednisone and surgery may be able to improve smell.
Brain tumors of the olfactory groove (or anterior base of skull) can cause a gradual smell loss. These can include esthesioneuroblastoma or meningiomas – treatment would be surgical resection.
Chronic sinusitis with polyps is chronic sinusitis with more inflammation where the normal lining of the sinuses, the mucosa, becomes swollen and edematous forming small grape-like polyps. These physically block the passage of smell molecules. Surgery can help with this.
There is some data out of Stanford showing that olfactory retraining is a beneficial therapeutic option for patients with smell loss. This is a simple, cheap treatment option for patients with smell loss that Dr. Meier offers.
Josh Meier, M.D. F.A.R.S.
Fungal sinusitis is a rare variant of chronic sinusitis. There are three main type of fungal sinusitis.
- Fungal balls are also known as aspergillomas or mycetomas. These are fungal colonizations, where a fungal spore finds its way into the maxillary or sphenoid sinus and over many years will continue to divide until the sinus is filled. The most common symptoms are nasal drainage or headaches. Commonly the patient is asymptomatic, but has an imaging study for another reason that demonstrates an abnormality. Findings on CT are thickening of the bone surrounding the fungus ball and hyperdensity (i.e. brightness) of the fungus itself. Patients are usually immunocompetent. The treatment is endoscopic sinus surgery to remove the fungus ball, and no systemic antifungal treatment is required. The species of fungus is usually Aspergillus.
- Allergic fungal sinusitis is rare in Reno, but is common in the American South. Patients usually have polyps with thick allergic mucin that looks like peanut butter. Bipolaris is the usual fungal species. On a CT scan the fungal debris will be hyperdense and bony erosion can be seen. Treatment is surgery, with topical steroids after.
- Invasive fungal sinusitis fortunately is rare. This is seen in immunocompromised individuals, from chemotherapy or diabetic ketoacidosis. Mucor is the usual species, and extensive necrosis of the nose and surrounding tissues can occur due to the fungus invading blood vessels that results in tissue death. Treatment is wide surgical excision back to healthy tissue and aggressive antifungal therapy.
Fungal sinusitis is a rare cause of nasal symptoms. Treatment is usually surgical, as apposed to conventional chronic sinusitis. In the case of fungus balls, surgery is usually curative.
Josh Meier, M.D. F.A.R.S.
Chronic rhinosinusitis (CRS) is a common and prevalent disease in the United States. Symptoms include nasal congestion, drainage, facial pain or pressure and smell loss for at least twelve weeks. Previously bacterial infections were thought to be the reason for the symptoms, but now it is thought that chronic inflammation is the cause. The inflammation in sinusitis is similar to the chronic inflammation seen in asthma, and frequently people will have both disease processes. There are two main variants of chronic sinusitis – chronic sinusitis with polyps and chronic sinusitis without polyps.
Chronic sinusitis with polyps is largely an inflammatory disease and manifests with nasal obstruction, drainage and smell loss. Infections and pain are less frequent. Polyps are the end result from over-inflammation of the normal lining of the nose, in which the mucosa becomes swollen and eventually forms the grape-like polyps. They are not tumors, and are different from colon polyps. If treatment with topical nasal steroids fails, then endoscopic sinus surgery can improve quality of life for patients. Polyps do recur, however, revision sinus surgery is only required when the patient’s symptoms recur and cannot be controlled with medicine.
Chronic sinusitis without polyps has similar symptoms to CRS with polyps, but pain and infections are more common. Topical steroids and rinses are the initial treatment of choice. If the patient fails medical therapy then endoscopic sinus surgery can help through improved aeration and improved access for topical therapies to reach the sinuses.
Since both of the diseases are inflammatory, the treatments of choice to decrease inflammation are topical steroids. Flonase or any of the OTC topical steroid sprays are a good initial treatment option, in conjunction with a saline sinus rinse. If a patient continues to have symptoms then the addition of budesonide (a steroid used in treatment of asthma) to the saline rinses can have more efficacy.
Josh Meier, M.D. F.A.R.S.