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News -> March, 2000 News
Allergic Rhinitis afflicts 17-22% of the US population and is the second most
common factor responsible for chronic or recurrent rhinosinusitis.
Otolaryngic surgeons need to be cognizant of the management of the allergic
patient as they undergo Endoscopic Sinus Surgery because good allergy care of
these patients will enhance a smoother pre and post-operative course. The
surgeon and patient will reap the rewards of improved outcomes of the proposed
sinus surgery.
In atopic patients, the nasal membranes are subject to the
release of several chemical mediators (histamine, leukotrienes, and certain
chemokines) that create the edema and increased vascular permeability
characteristic of the allergic state. Late stage inflammatory cells are more
prevalent within the mucosa such as eosinophils, neutrophils and basophils.
The eosinophils with their granules containing major basic protein, and
eosinophilic cationic protein, are the most toxic and breakdown of these cells
may potentiate post-operative edema formation. Allergic management seeks to
stabilize the early and late stage reactions and thus reduce not only the
patient's symptoms, but also improve function of the nasal and paranasal
membranes.
Preparation for Endoscopic Sinus Surgery for either functional or
hyperplastic polypoid disease requires appropriate pre-operative re-evaluation
of the patient's allergic status. Appropriate allergy management prior to
surgery enhances the surgical outcome. The analogy is the general surgeon's
bowel prep. Emergency sinus procedures preclude the luxury of proper
pre-operative allergy care, but even these patients will benefit from good
post-operative management of their allergy problems.
The history at the
initial consultation will determine the tendency for allergic rhinitis.The
reactive allergic nasal membranes are more responsive "in season" so the
history is important to the surgeon. Sinus surgery is not contraindicated in
the hay fever season, but stabilizing the reactive inflammatory process may
avoid the excessive mucus drainage and possible edema resulting from the
combined surgical and allergic attack on these membranes. Good environmental
control needs to be stressed to the patients with perennial (dust and mold)
allergy. Air-conditioned (filtered air) will reduce the total allergic load as
well. Institution of immunotherapy 6-12 weeks prior to surgery is helpful.
A review of the patient's medications is
mandatory especially in regard to their usefulness and compliance.
Allergic patients may have a closet full of
medications such as antihistamines, mucus thinners, inhaled or topical
steroids, bronchodilators and anticholinergics.
Certain first generation
antihistamines tend to have an anticholinergic drying effect on the mucosa,
and a switch to the newer generation may alleviate this effect.
Antihistamines are useful and should be continued through the entire pre and
post-operative course.
Topical nasal steroids are very efficacious in
reducing the inflammatory state, but to be effective they need to reach the
involved mucosa. Patients with large anatomic obstructions (deviated septum,
large turbinates, or polyps) may not achieve relief with these medications.
Instruction and guidance in proper topical nasal steroid use is very helpful.
If the patient is already on a topical nasal steroid prior to surgery, they
should continue up to the day of surgery. However the usual rule is to delay
re-starting the intranasal steroid in the immediate post-operative course due
to irritation of the mucosa for about 7 -10 days. Several surgeons have
advocated intraturbinal steroid injections at the end of surgery and this
technique may be desirable in the highly reactive patient.
The acute
inflammatory allergic reaction is usually immediately moderated by a loading
dose of systemic cortico-steroids. Many of these allergy patients have
received steroids in the past, and perioperative and intra-operative systemic
steroids may be required to avoid adrenal stress. Post-operative steroid taper
is not necessary except in patients in the middle of a seasonal flare, or in
patients with severe hyperplastic polypoid disease.
Sinusitis, allergic
rhinitis and asthma co-exist in many patients undergoing sinus surgery. Asthma
is now defined as an inflammatory state with chemical mediator release akin to
allergic rhinitis. Bronchospasm results from liberation of chemokines and
asthmatic flares may occur during or after surgery, leading to increased
reactive airway disease. Pre-operative management of the asthmatic patient
involves careful instruction and use of inhaled corticosteroids and
beta-agonists. These medi- cations stabilize the reactive airway. Asthmatic
reactions post-operatively should be managed with a tapering short course of
systemic steroids.
Hopefully these hints will assist all sinus surgeons to
be diligent in their regard for the patient with significant allergic rhinitis
or allergic asthmatic bronchitis preparing for sinus surgery.
James A. Hadley, MD, FACS
Chairman, By-Laws Committee, ARS
Rochester, New York
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