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BackTable / ENT / Podcast / Transcript #142
Podcast Transcript: Evaluation and Management of Chronic Frontal Sinusitis in Sweden
with Dr. Jens Andersson
In this episode of BackTable ENT, Dr. Gopi Shah and Dr. Jens Andersson, practicing ENT at Sweden’s Skåne University Hospital, tackle chronic frontal sinusitis. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Swedish Healthcare System 101
(2) Clinical Presentations of Chronic Frontal Sinusitis
(3) Risk Factors for Chronic Frontal Sinusitis
(4) Physical Examination of a Patient with Frontal Sinusitis
(5) Initial Management of Sinusitis
(6) Other Pathologies Associated with Sinusitis
(7) Antibiotic Management of Sinusitis
(8) Surgical Approaches to Frontal Frontal Sinusitis
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[Dr. Gopi Shah]
Hello, everyone, and welcome to the BackTable ENT Podcast where we discuss all things ENT. We bring you the best and brightest in our field with the hope that you can take something from our show to your practice. My name is Gopi Shah, and I'm a pediatric ENT, and I have a really awesome guest today. I have Dr. Jens Andersson. He's an otolaryngologist practicing in Skåne University Hospital in Sweden. Dr. Andersson is here to talk to us about the evaluation and management of patients with chronic frontal sinusitis in his practice in Sweden. Welcome to the show, Jens. How are you?
[Dr. Jens Andersson]
Thank you very much. I'm fine. How are you?
[Dr. Gopi Shah]
I'm good. Thank you for coming on. For our listeners, I got to meet Jens at the European Society of Pediatric Otolaryngology. It was a great conference in Liverpool in March. You were kind enough, there was two seats next to you and Anita Jayakumar and I came in a little late to this beautiful banquet and got to sit down and-
[Dr. Jens Andersson]
Yes, and it was our pleasure to have you there.
[Dr. Gopi Shah]
We got to talking and I was like we got to get Jens's perspective on BackTable. Thank you for coming on.
[Dr. Jens Andersson]
Thank you for having me.
[Dr. Gopi Shah]
Before we get into our clinical topic, can you tell us a little bit about yourself and your practice?
[Dr. Jens Andersson]
I work at the ENT clinic at the Skåne University Hospital which is a hospital that is spread over two sites, which are the towns of Lund and Malmö. I don't know if you've heard about Lund University Hospital? It's the more famous one of the two, but we spend an equal amount of time on both sites with all non-emergency visits located in Lund and emergency consultations in both towns. Outpatient surgery is done primarily in Malmö. I'm responsible for seeing to that things run as smoothly as possible at the Malmö site including the cooperation with other departments at the hospital such as the ER, and the ICU, and pediatrics, et cetera.
[Dr. Gopi Shah]
Your practice, when we were in the ESPO you mentioned that is it mostly rhinology or do you pretty much see everything and you have a special interest in rhinology?
[Dr. Jens Andersson]
I have a special interest in rhinology, so I mainly see rhinology patients but when you are the consulting doctor for the junior doctors that are on call, then you obviously get to see all kinds of patients.
[Dr. Gopi Shah]
Can you tell our audience a little bit about you guys have an ENT newsletter that you put out and put cases. Tell us a little bit about that.
[Dr. Jens Andersson]
Yes, we have a magazine that comes out with four issues every year. Yes, I'm surprised you remember that. We are three editors. I'm actually one of the editors. I think most of the ENT specialists in Sweden read it. Sometimes it's just stuff for fun, sometimes it's clinical research, sometimes it's what the residents have done, they need to do a special small paper before they get their exam, and sometimes we publish that as well. We're supposed to publish everyone's but they don't send it in so we can't.
(1) Swedish Healthcare System 101
[Dr. Gopi Shah]
That's awesome. Before we get again into our clinical topic, let's set the stage a little bit in terms of can you tell us a little bit about the Swedish healthcare system.
[Dr. Jens Andersson]
Sure. Basically, the Swedish healthcare system is free, if you can call it that because obviously we pay it through our taxes. I'm not going into politics but it is a basic human right to have access to equal healthcare. It's even in the UN Charter from 1948, Article 25, if you're interested but basically it's free. As children, they don't pay anything. You don't pay anything for child healthcare at all including medication. Sometimes when I see American movies, for instance, I'm surprised. I think it was Four Weddings and a Funeral. Have you seen that movie?
[Dr. Gopi Shah]
Yes, it's been a while.
[Dr. Jens Andersson]
Yes, and she can't pay for her kid's asthma medicine and I had such a hard time understanding that when I was younger. Now I know how it works, but yes, kids don't pay for healthcare at all. The adults, they pay a nominal fee of about 300 Swedish crowns which is in the vicinity of $27 per visit, but only until they've reached the limit of what we call the high cost protection which is currently at 1,300 Swedish crowns. It's $118 for a year. After that, it's free for the rest of the year. Some things are excluded like certain types of vaccinations. Many are given for free during school years or when you're younger but some other things you have to pay for. We do have private care as well but most private actors are also affiliated with ordinary healthcare system and have contracts providing the same type of care and costs that go with it.
Then for medication, you pay the full price for medication unless you're a child at the beginning of a period that is one year long but also there there's a high cost protection. The more you've paid, the larger your reduction. There's an upper limit at 2,600 Swedish crowns, so it's $235 and then after that medication is free for adults as well.
[Dr. Gopi Shah]
Wow. The patients that have government insurance but also then have supplemental like maybe another private insurance carrier, why do people do that?
[Dr. Jens Andersson]
You don't really have a government insurance. You can have a private insurance because public basic healthcare is free so you don't have to have a government insurance. You pay taxes and that's enough but you can have a private insurance. You can get an appointment faster sometimes not necessarily better because sometimes they have to refer you anyway to a government-run hospital. That's it.
(2) Clinical Presentations of Chronic Frontal Sinusitis
[Dr. Gopi Shah]
That's interesting. In terms of, now getting into our clinical topic, we're going to talk about chronic frontal sinusitis. How did these patients present to you? What symptoms do they usually have?
[Dr. Jens Andersson]
I knew this question was going to come and still I have a hard time answering it because they can actually come in any number of ways. They can obviously have had problems for a long time with headaches and stuffiness and nasal congestion and sometimes low-grade fever. Actually, this week I had a man who came I think originally from Bangladesh but he'd been in the healthcare system. He'd been seeing his GP for a while and then they referred him to the ophthalmology clinic and always it's easy when you are the last one seeing the patients. Sometimes I say that the most useful tool we have is the retrospectoscope. When we see something and we can tell, "Oh, okay, you should have seen this coming," and they didn't. He presented with a swollen right eye, and then when we did the CT scan, he had a severe frontal sinusitis with bony wall destruction to his right eye. Then also almost surprised that it wasn't a Potts puffy tumor because he had a destruction in his frontal table of the sinus and also actually a bit in the back and towards the intracranial space. He had been going with this for a long time. Actually, I think it was dental from the beginning because one of the biggest mucous seals in the maxillary sinus that I've seen. His teeth were not that good.
[Dr. Gopi Shah]
Wow. You're right. Sometimes the presentations can be a little indolent and it can take a long time in the frontal sinus because of where it's located the patients can present. You're right, they don't always look as sick as they should.
[Dr. Jens Andersson]
No, no. I always see them when they've been to other doctors so I can only read about how it started because I always see them later when they're ill. When they're worse. Yes.
[Dr. Gopi Shah]
You're right. They might have in addition to the nasal congestion and then drainage, they might have that low-grade fever, headache, sometimes the eye presentation where acute maxillary sinusitis isn't going to always have as many, maybe, but sometimes it can be hard to tease out.
[Dr. Jens Andersson]
Yes. Often, they have the frontal headache right between the eyes and a bit down towards the nasion.
[Dr. Gopi Shah]
Do you have a group of patients where it's isolated frontal sinusitis or do you find that in your practice they'll still have associated max ethmoid as well?
[Dr. Jens Andersson]
The feeling I have is that it's more often other sinuses involved as well. I would say if someone has an isolated frontal sinus problem, obviously, they can have, but maybe more if they had a trauma before, sometimes it's-- what do you call it in English? Barotrauma in Swedish. Sorry. That can absolutely present as an isolated frontal sinus problem but more often than not, I would say that more sinuses are involved in my experience.
(3) Risk Factors for Chronic Frontal Sinusitis
[Dr. Gopi Shah]
Yes that brings up the next question I'm going to ask you is, some of the risk factors for chronic frontal sinusitis in terms of risk factors, trauma, or history of a frontal sinus fracture or head trauma potentially, what other kinds of risk factors? You mentioned barotrauma, is that usually somebody that dives, scuba dives or flight even?
[Dr. Jens Andersson]
Yes, sometimes divers come and complain about this, but sometimes also just ordinary people who fly a lot. We had flight attendants, which is obviously very stressful because they can't really work because it hurts like crazy. I actually know what it feels like. I used to have those problems. I was scuba diving when I was younger and I had those. I often pressurized my frontal sinuses with blood and it's not a pleasant feeling. Other risk factors are polyps, for instance. As this patient I just described, other types of infections like dental infections or if you're immunocompromised. There are a lot of things that actually can predispose for having frontal sinusitis. You're forgetting one.
[Dr. Gopi Shah]
Yes, we can stick with that as our case example for this podcast. The dental infections is definitely-- I feel like I don't look at the teeth enough or pay attention to that, but you're right. It leads to deep neck infections, sinus infection.
[Dr. Jens Andersson]
More before, I think it was overlooked. Nowadays, I look at the radiography pictures myself, and I always look at the teeth. If I'm uncertain, I actually call the radiologists and discuss with them because we have some very good radiologists and those I know they look at the teeth. If they have answered, I really don't need to call them because I know they've looked at it. If it's someone I don't recognize or sometimes you can outsource the radiology departments, when someone else looks at the picture and then sometimes I have to call my friends at my own radiology department and ask them.
(4) Physical Examination of a Patient with Frontal Sinusitis
[Dr. Gopi Shah]
In terms of a physical exam, what's usually part of your physical exam when these patients come to you?
[Dr. Jens Andersson]
Well, obviously, I look in the nose and I can come back to that. Also, obviously, an oral exam, and I don't mean I ask them questions, but I look them in the mouth and see how their teeth are. If they had dental procedures or if they're swollen or if they have pain, I actually sump them with my spatula over the teeth and see if they feel any pain. Then when I look them inside the nose, actually, I start with the anterior rhinoscopy also because I'm getting older, but I've also started with always looking with the microscope because we have the microscope in all our rooms because we switch between people who do the autosurgery and stuff like that. It's really useful to look with a microscope with the anterior rhinoscopy. I would highly recommend it, actually.
[Dr. Gopi Shah]
You have your nasal speculum in the nose and then you are visualizing with the microscope. That's how I take out foreign bodies from babies and children.
[Dr. Jens Andersson]
Yes.
[Dr. Gopi Shah]
Tell me, what do you see more? What information do you get?
[Dr. Jens Andersson]
Obviously, if you want to examine the whole nose, you have to use endoscopy. You can't really lose that but you can see further in the nose with the microscope. Often, you can see up into the middle meatus. You can see almost all the way back to the epipharynx. I also use it in nosebleeds. It's so much easier to see dilated vessels or other weird areas.
[Dr. Gopi Shah]
Yes. It's funny how much even like the anterior part of the nose, we might miss just putting a scope straight in. You know what I mean? When you're with a scope and you're going to that turbinate and you're not even always even seeing at the head of the inferior turbinate, you just go right in.
[Dr. Jens Andersson]
I always try to do the anterior rhinoscopy first with the microscope.
[Dr. Gopi Shah]
With a microscope. That's interesting. Does that change or help you adjust what you're looking for or how you might then perform your nasal endoscopy?
[Dr. Jens Andersson]
Not really. I normally start with actually the flexible endoscope. If I sometimes feel I have to move on with a rigid endoscope, then I'll do that. Mainly, I do rigid endoscopy in people I've already done surgery on and when I want to see because if you haven't had surgery in your nose, you can basically reach everything. You can visualize all parts of the nose with a flexible endoscope.
[Dr. Gopi Shah]
Do you usually decongest the nose? Do you first take a look without decongestion and then look after? What do you like to do?
[Dr. Jens Andersson]
Yes, I do the anterior rhinoscopy first. Then it suits me very fine to spray them right after because then I talk a lot, and so I can just let the time pass and they will decongest. If I need to, then I'll put in cotton swabs or small cut triangles of gauze with decongestant as well where I need them to be in the middle meatus or in the inferior meatus. Most often the middle.
[Dr. Gopi Shah]
Do you usually just use oxymetazoline or what do you use in your clinic?
[Dr. Jens Andersson]
I should have looked up what the generic name is because it's-- let me see. I think it's oxymetazoline. It's called Nafasolin in Swedish. The brand name, which is funny because 'Nafas' in Arabic means breathe through your nose as far as I know. No, actually, I just checked it. It's Nafasolin is the generic name as well.
[Dr. Gopi Shah]
What do you usually find with your scoping? I think a swelling, I think a pus, what else?
[Dr. Jens Andersson]
I don't know what the translation would be. We call it valgata in Swedish. It means the street of pus. If you see a line of pus coming from one of the sinuses, that's a strong indication that something is wrong. You obviously look for polyps. You look for tumors. You look for blood.
[Dr. Gopi Shah]
The gentleman who had the dental issues that came in, the one that we referenced at the beginning, what did his scope look like?
[Dr. Jens Andersson]
It didn't look that great because he had such a large mucocele from his maxillary sinus. First of all, his nose was filled with pus. Then, because I didn't meet him before, I just saw the pictures, I heard him reference and I said I can do the surgery. I actually didn't meet him until just before the surgery. I didn't feel I had the need to. I had to actually take down the wall. It was very easy because it was very thin from the expansion. I could just actually use, what do you call it? An elevator just to push it because his eye was very swollen and he couldn't open it really and he had double vision. Then when you start going up to the front nasal recess, then the pus started to drain and his eye sank back in. That's when you're happy and you feel good. You feel you're doing something.
(5) Initial Management of Sinusitis
[Dr. Gopi Shah]
In terms of the patients that come to you in clinic, for the ones that say don't have imaging, at that visit, do you get imaging? Do you send them home with antibiotics? Do you culture the pus? What are your next steps?
[Dr. Jens Andersson]
I also knew this question was going to come and it's highly dependent on how they present themselves. It's hard to give a generic answer to that. If there's something and they had it for a long time, they haven't had any imaging, which is actually rare when I see them because normally they pass a few institutions on the way and there are some pictures, radiography taken. Obviously, I think about doing it, but I do take cultures. If there's pus, I always culture. Sometimes I do it when there's not because I want to see if there's something else wrong. If they have a history of other infections, I try to do an immunology assessment. I don't know if you do the MBL, Mannose-Binding Lectin, also Swedish. It's a molecule. You can have a deficiency of this MBL and that can predispose you. If you ask the infectionists, they say that it doesn't really matter if you don't have an IgG deficiency as well.
In my experience, I've had some patients with severe runny noses with pus and all kinds of weird bacteria. The only thing I can find is the MBL deficiency that we can't do anything about, but it's-
[Dr. Gopi Shah]
It's at least information.
[Dr. Jens Andersson]
Yes. I've had a few of those actually, but how important it is, I can't really tell you. Also, the question was, when do I do imaging? If they have had longstanding problems, pain, and I can't resolve it because sometimes they haven't rinsed enough and they haven't used the cortisone spray. I start by telling them that you have to do this. You have to do the rinses. You have to do the cortisone spray. Otherwise, I won't see you basically, or I won't go the next step.
[Dr. Gopi Shah]
In terms of longstanding, I usually think of the 12 weeks, the three months of symptoms.
[Dr. Jens Andersson]
Yes. That's the definition of chronic sinusitis. It depends on how troubled they are, how much pain they are in or how little they can breathe through the noses. You always have to weigh in all the symptoms.
[Dr. Gopi Shah]
Yes. The patients that you've cultured, do you start them on empiric antibiotics in that clinic visit, or do you wait for the culture to come back?
[Dr. Jens Andersson]
Also depends on your symptoms because if you have low-grade symptoms and you've had them for a long time, then I absolutely wait for the culture to come back. If the culture is what we call blank, if it doesn't show anything. Also I've had this discussion with our microbiology department because sometimes we ask, "Is there anything growing here?" They answer, "Nothing that is clinically relevant." Sometimes I want to decide what is clinically relevant because-
[Dr. Gopi Shah]
You're looking at the nose and the patient.
[Dr. Jens Andersson]
Yes. One of these girls who had this MBL deficiency, and I've had to culture her for several, I don't know how many times. One time I asked them, just answer everything that grows and I'll be the judge of what's clinically relevant. They still said it was blank. Then one of my colleagues asked a direct question, is it Klebisella ozaenae? It was. I just had wished they told me that before.
[Dr. Gopi Shah]
In terms of the sinus rinses, have any ever used antibiotic in the rinses, like Bactroban or Mupirocin?
[Dr. Jens Andersson]
It's not the tradition in Sweden. I'm not opposed to it at all, but I don't have any experience with it. I do sometimes use budesonide in the rinses, but I've never done the antibiotics. Are you familiar with that?
[Dr. Gopi Shah]
I've used it for my cystic fibrosis patients, depending on what their cultures are. Sometimes the pharmacies can do tobramycin irrigations prep for them, occasionally maybe in my PCD, my Primary Ciliary Dyskinesia kids, but not routinely. I've done Mupirocin or Bactroban rinses, meaning I'll have the family, because my practice is it's all children, so a little bit of Mupirocin or Bactroban ointment in the rinse bottle. If they're growing staph or if there's a lot of inflammation. Sometimes I'll have them do that just for a week, something like that, but nothing nebulized or anything, and not anything routinely. Other than those three categories, I have not. Budesonide rinses, yes, most of the time insurance will be okay, but every once in a while, I've had to do the phone call and discuss, and sometimes they approve it, sometimes they don't. In terms of CTs, do you have in-office imaging? How does the CT work in Sweden?
[Dr. Jens Andersson]
I'm unsure about the nomenclature, so in-office means that I have it right where I'm at?
[Dr. Gopi Shah]
Yes, in your clinic.
Imaging of the Sinuses
[Dr. Jens Andersson]
No, not in my clinic, but the radiology department is not that far. For the sinuses, we have access to three types of scans. We have the old one, we never do just plain X-rays, it's very old, but I hope people don't do that because there's a low dose.
[Dr. Gopi Shah]
If you say that every once in a while, I would have patients refer to me having had X-rays that was ordered by their primary care, and I think that for some people maybe, I'm like, "Why did they order this? We don't use it, I don't know what to do with this information, we have a report on it, and it talks about there's something there that shows something consistent with a chronic sinusitis." Then the family, really think there's something going on, and then I'm like, "Well, maybe they just do it because they need something." The symptoms are there, and this is what they have access to.
[Dr. Jens Andersson]
Who does those? It should be a radiologist who says, "I can't use them for anything."
[Dr. Gopi Shah]
This isn't helpful. This is not helpful, yes.
[Dr. Jens Andersson]
We have the low-dose CT, which I'm not a fan of. We have the other better, higher dose CT that we can use for navigation. Then I'm very fond of using the cone beam CT, the CBCT, which is also low-dose, but much better pictures than the ordinary low-dose CT. That's not at all exclusively, but I use the CBCT far more than I use any other type of CT because you can actually do navigation with CBCT as well.
[Dr. Gopi Shah]
Do you have a system? How do you normally look at your CT sinus scans, and what do you find are some of the characteristics that you see with patients with chronic frontal sinusitis?
[Dr. Jens Andersson]
How I look at them? Nowadays, I think a more get off, a general impression of how they are, but obviously, you can use the Lund-Mackay score. You can grade them. If I am doing surgery, I always look at them with the acronym CLOSE. The cribriform plate, the Lamina papyracea, the O is for Onodi cells, which is actually not called anymore, but also the optic nerve, and S is for the skull base, and also sphenoid sinus, and E is for ethmoidal arteries. It's what I always do when I'm doing surgery. Then I also, and I forget the acronym for that now, but this, the newer classification of how the tilt of the olfactory, it starts with a G, and I wish I remembered because sometimes I have lectures about it, but now because I'm on a podcast, I forget it, but the tilt of the fovea ethmoidalis, it says if it's too horizontal, it's a much higher risk to penetrate up into the skull than if it just goes down more vertically, and so over 45 degrees, if you have time later, I can look it up.
[Dr. Gopi Shah]
I know. I'm trying to look that up but-
[Dr. Jens Andersson]
You can try to inject it here when I'm actually-
[Dr. Gopi Shah]
That's okay.
[Dr. Jens Andersson]
-looking for it, yes. Also, when I try to see how much air is there? Are they totally filled? Are there bony destructions? Is there any process that I need to be aware of? Is there another explanation for it? Is it on both sides? Is it one-sided, which is more, it doesn't have to be malignant, but it makes me think about Schneiderian papilloma, so like inverted papilloma and stuff like that. That's some things I look for.
[Dr. Gopi Shah]
Yes. When do you ever consider getting an MRI on these patients?
[Dr. Jens Andersson]
If I'm in doubt, if there's invasion, if there's bony erosion, especially along the skull base or in the sphenoid sinus or in the back of the posterior table of the frontal sinus, or if I'm thinking of it as a tumor, then I will also do an MRI, yes. Not necessarily for an inverted papilloma if it's small, but if it's something else, yes. We do a lot of biopsies, of course, in-office biopsies as well.
(6) Other Pathologies Associated with Sinusitis
[Dr. Gopi Shah]
In terms of pathology, I think of, history of sinus surgery in kids, we would see the occasional fibrous dysplasia or ossifying fibroma. What other pathologies do in your practice that can lead to the chronic frontal? I had cystic fibrosis, occasionally, not common, but occasionally in some of my kids, I had two or three that I can think of in the last 10 years that was their main issue, but a lot of them had surgery before, so.
[Dr. Jens Andersson]
I don't know if I can give you a clear answer on that one. We see all kinds of stuff. Fibrous dysplasia is not that common where-- I've seen a few patients, but it's not that many.
[Dr. Gopi Shah]
Yes. We saw, it was ossifying fibroma that was a little bit more common in our adolescent males more. No, we saw some in some of our girls too, but it'd be like a once a year new patient, but you're right. Fibrous dysplasia wasn't as common. It was a rare finding.
[Dr. Jens Andersson]
Yes, and ossifying fibroma, it's not seen that much, but we're not that big because we're the third biggest hospital in Sweden, but still the whole southern region is 1.4 million people, and many don't come to us primarily. We are the university hospital for the region, but we don't have a ton of patients.
[Dr. Gopi Shah]
Yes. Those are rare.
[Dr. Jens Andersson]
Everything that's uncommon, we see them probably less than you do.
(7) Antibiotic Management of Sinusitis
[Dr. Gopi Shah]
Yes. Let's say you did do antibiotics for the patient in clinic. How many days do you usually give?
[Dr. Jens Andersson]
Depends also, 7 to 10 days, depending. Sometimes if they're getting partial resolution of their symptoms, I can prolong it. Then there are the other cases where we do the long-term antibiotic treatments. Sometimes there are three, but more often there are six months with macrolide, you call that in English as well?
[Dr. Gopi Shah]
Yes.
[Dr. Jens Andersson]
Normally, first I try, with the rinses and spray and then about 7 to 10 days treatment or sometimes 14, but not much more than that.
[Dr. Gopi Shah]
Are oral steroids part of your treatment plan ever?
[Dr. Jens Andersson]
Sometimes, yes. This patient that we referenced before, he got some oral steroids as well when he was admitted.
[Dr. Gopi Shah]
Did it help with his eye and his swelling?
[Dr. Jens Andersson]
Actually, what helped was when we drained the pus. I'd like to think that it helped because you don't get the swelling afterwards because it's always hard. That's the hardest part with frontal sinus surgery. The hardest part is to get it to stay open. Often it's not that difficult to open it up, but it's hard to get it to remain open. That's an ongoing discussion all the time. How do we do it the best?
(8) Surgical Approaches to Frontal Frontal Sinusitis
[Dr. Gopi Shah]
Let's talk about some of the surgical approaches. For frontal work, do you always use navigation? Is that always part of your setup?
[Dr. Jens Andersson]
I actually use navigation as often as I can and always try to tell the residents to do it as well because, yes, it costs money. Also if you use it on the simpler cases, then when you get to the difficult cases, you already know what you're doing and you're not practicing two things at the same time because you already know how to work the navigation. For simple surgery, I don't do it and especially if I don't have anyone with me. Normally there should be a resident and then often I try to hook up the navigation system.
[Dr. Gopi Shah]
Yes. If I have a scan that's fine cut, which most of them are nowadays, thankfully, and I have access to a navigation system, I use it. I totally agree with your point of if how to work your machine and those reps are going to come in with as many setups as you can get in when it's 10:00 PM at night or something and you have a case that's got to go, then I'm not sitting here like, "Well, is the tech here that knows how to set it up? Can I get a rep here?" No, it's me.
[Dr. Jens Andersson]
Yes. You also have to know how to work the machine.
[Dr. Gopi Shah]
Yes, and that's the last thing I want to have to think about is being limited by that because that's somewhat a little bit out of my control.
[Dr. Jens Andersson]
You have to know how to get the pictures in. You have to know how to adjust the settings, the contrast, the lighting.
[Dr. Gopi Shah]
Yes. Navigate the instruments. Right? How many times have we had everything set up and we can't get the straight section to navigate? What are the little tips and tricks for that? Is it the cord? Maybe. There could be about three other things we have to do.
[Dr. Jens Andersson]
Yes. Sometimes you just need to move the screen further away because that's actually happened because it-
[Dr. Gopi Shah]
It was too close.
[Dr. Jens Andersson]
Yes.
[Dr. Gopi Shah]
Then, so tell me about your approach to the funnels. What scopes do you like? What instruments do you like? If you're teaching your residents, what are some of the pros that you tell them about frontal sinus work?
[Dr. Jens Andersson]
You have to ask them if I say something good, but I try to use the 0-degree scope as long as I can. More often than not, you can actually do almost the whole of the surgery with the 0-degree scope, but then you have to have vision. Normally I switch to a 45 or 70 degree actually scope when I try to see what I've done and also try to see if there's something more I need to take down, if there's another wall or some piece of mucosal debris that I need to remove. I tend to use the 0-degree scope mostly when I'm doing the surgery. Then I can switch and I can sometimes I do the final parts with an angle scope.
[Dr. Gopi Shah]
Yes. I don't like switching back and forth a lot either. I like to do as much surgery as I can with the zero and then I graduate up depending on why I'm there and what I'm doing. I find a good shoulder roll. If I know I'm going to be in the front rolls, I find a good shoulder roll really helps me get the view as well. Then, in terms of instruments, they have nice angled sections these days, which is great. The Hosemann and the Kerrison, do you use that or are they called anything different? The Hosemann which is like a-
[Dr. Jens Andersson]
Yes, the Hosemann we use. We call it the baby Hosemann. Maybe it's not the correct term because sometimes I've discovered that what we call our instruments is not really what they're called in the catalog. We have one of those. It looks almost like a mushroom punch, with a point at the end. Yes. We also have actually angled mushrooms as well. We have what we call the giraffe forceps. I use the curettes. I really like that because you can feel what you're doing. You can feel in your fingers with actually how much pressure you're applying. Also because you're using it back to front, so it feels safe to use it. I try not to, if I can, it's obvious to you, but maybe not some of the listeners, but I try not to tear the mucosa all the way around in a circular fashion, because I'm always, I don't really like when it scars over.
[Dr. Gopi Shah]
What tips do you have for mucosal sparing, especially in the recess? Do you have any tips or tricks or things that you found work well or, hey, be careful of this?
[Dr. Jens Andersson]
Be careful not to try tear stuff. Try to bite and try to have instruments that are actually sharp. Sometimes you use the sickle knife sometimes for, not for the frontal recess, but you have what we call a sickle knife. Yes. I once got the sickle knife and I said, "This is not working. It's very slow." Yes, it says it's sickle knife slow here and I was like, "No, that doesn't exist." Someone must have said that this is a slow knife and they just put it back. They marked it up for sharpening and then they just put it back and wrote "Sickle knife slow." Yes, no, you have to have sharp instruments and try not to tear. Also if you cut mucosa and you get it stuck in your forceps, don't try to pull it towards you. Try to push it away. In that way it might go off easier and not tear away the whole part of mucosa closest to you.
[Dr. Gopi Shah]
Do you ever use angled microdebriders?
[Dr. Jens Andersson]
Yes, I do.
[Dr. Gopi Shah]
It can cut well, but I have to make sure I can see. Sometimes just being able to see where the blade is can be really hard because there's not any room. It's helpful, but-
[Dr. Jens Andersson]
I don't often use, so I have to correct myself there. When I almost always use the 12 angle, so it's not really angled, the 12 degree angle. When I do the frontal sinus, I almost never use an angled debrider. It's not wrong to do it, but I normally don't do it. I use angled burrs when I have to get the frontal beak down. That's about it. I think about how much power tools I want to put up there.
[Dr. Gopi Shah]
Yes. I think I use more for that anterior ethmoid tools because I find that that's probably one of the hardest parts of the surgery, in sinus surgery, posterior ethmoids are probably the easiest, and then, max and sphenoid, I feel like can be tied. That anterior ethmoid is something that I feel I didn't really appreciate the difficulty until I was out in practice. I don't think I appreciated that as a trainee.
[Dr. Jens Andersson]
That you don't get high enough up?
[Dr. Gopi Shah]
Yes, high enough, and then it's like, "Okay, this is why I'm working in a hole." In terms of any tricks for when you drill, and actually, before we get to that question, I wanted to ask you, how do you decide how much frontal sinus work to do? Is it ever enough just to do a good uncinectomy and then maxillary antrostomy, or how do you know how far to go?
[Dr. Jens Andersson]
It's also a very good question. It also depends on how it has presented itself. What I think the underlying problem is, sometimes it can be enough. If I think the problem is actually coming from down below, that is the maxillary sinus problem or, ethmoids, but if not, then I don't think it's enough, obviously. Sometimes it's enough and you can just get more space there for the drainage pathways to work as intended, or hopefully as intended. Then sometimes I just try to put a suction up and see, is there passage, and I try to not affect the mucosa too much because I'm afraid of scarring. I'm not afraid, afraid, but I don't like it and I don't want to give them problems that they didn't have before because sometimes if it scars enough, then you have to do much larger frontal sinus surgery. You have to do a draft three or something. If I can avoid it, I'll try.
[Dr. Gopi Shah]
Do you use stents, or how do you keep it from scarring? Do you put anything up there? Are you using propels? Are you using silicone?
[Dr. Jens Andersson]
I only have my thumbs and I cross them very hard. No, actually, the propel stents, we don't have access to them yet. They're coming, but we don't have them. For this patient that we refer to a number of times now, I wish I had them, but I didn't. I went the old school way and I put up a one centimeter gauze strip with antibacterial ointment. You can use this ointment just-- sometimes I've just actually took a syringe and put it on a 70 degree angle suction catheter and deposited the ointment up there. It's a combination of oxytetracycline and hydrocortisone. Normally I put them on the strips of gauze and I put them up. For this patient, it seems to have worked. I removed them. It's also an ongoing discussion, how long should you keep them? I held my finger up in the air and decided two days. I removed it and I had him at the outpatient clinic and looked at him and it looked fine. It was open. His eye was better and better. I'm seeing him again next week and, hopefully, it's-
[Dr. Gopi Shah]
It stays. I was going to ask how soon after surgery, if the frontal recess is going to scar, how far out have you seen that happen? Early on we're like, "Okay, if it's not here at a week, it's probably okay." I find that the longer you are in practice or the more patients in follow-up, you're like, "Oh, dang, it's been two months. It looked good three weeks ago." Then it's like, well, do I do anything? Do we do steroids? Is it soft? Is it just swelling? Do we just need to get back on rinses? Then we're kicking the can, especially in a patient that's not symptomatic.
[Dr. Jens Andersson]
Yes. It's a very hard thing to answer as well. Yes. I've seen one and I did everything I could and he had a large opening. There's an expression in Sweden, "I could throw my hat in it." When I saw him a week later, everything was swollen and he had gotten some swollen mucosa. It was almost like, "You know polyps there," and he wasn't a polyp patient, it was a mucocele. I've seen a range from one week to several months.
[Dr. Gopi Shah]
Yes. That's why they're chronic, I guess, right?
[Dr. Jens Andersson]
Yes.
[Dr. Gopi Shah]
In terms of other techniques or procedures, do you ever use balloons in the frontal sinus in your practice? Is that ever part of your practice?
[Dr. Jens Andersson]
I used to use more balloons than I do now. Now I basically don't. It's also because we're a small country and the best balloons we had went out of market and I couldn't find a substitute. I looked for a while. I was some courses and in contact with a few companies and I couldn't really find anything I liked because if you're doing balloons, I don't know what your opinion is, but I like to have the guidewire. If I need to put a hard tip of an object up the frontonasal recess anyway, then I might as well do surgery. That's my opinion.
[Dr. Gopi Shah]
Yes. I don't have as much experience either. My practice is pediatrics. I did a lot of pediatric chronic sinus stuff and I just didn't-- one of my partners, actually, she had a lot more experience. For me, it was like you said, if the light tip or the guidewire, all that stuff, if I'm not doing it all the time, I just didn't want to end up in the eyes. I don't want to end up in the wrong place. I just didn't use them as much. I used a handful of times that I can think of.
[Dr. Jens Andersson]
I just don't find them all that useful in the setting that we have in Sweden. I think you do more in office stuff, but in my setting, I don't see any use for them in sphenoids, which is a fairly easy sinus to reach. I don't see a reason for it to do it in the maxillary sinus, but in, frontal sinus in barotrauma patients, I would say that this is something I would use if I had a good balloon because you don't scar as much, and it's an easy identifiable problem that you can probably solve quite easily with a balloon. If it's other stuff like polyps or other underlying conditions, I can't really see the use. In my view, it's better to open up.
[Dr. Gopi Shah]
Yes. When we were at ESPO, there was a lot more talk about balloons for acute complications of sinusitis, like POTS and intracranial. There were some talks on that. Even, again, it's access, and having all that stuff.
[Dr. Jens Andersson]
I would still, and I do open up what I consider to be the proper way. People can feel free to disagree, but it's my point of view.
[Dr. Gopi Shah]
As we start to round things out, any final tips or pearls on chronic frontal sinusitis?
[Dr. Jens Andersson]
No, I don't know. I had a pearl for nosebleeds, but that's not my-
[Dr. Gopi Shah]
Oh, well, tell us your pearl for nosebleeds.
[Dr. Jens Andersson]
My pearl for nosebleeds, one that I got from a senior colleague of mine one night when I was younger, and I had had three patients bleed on me the same night, and I couldn't find any hospital garments that would suit me. It was all dresses, and it would be okay, but it's-- he told me that if you have someone because also, people are unique, and I can say that. I can generalize, but in Sweden, often it's the older men that keep talking even though the blood is running from the nose, and they still have to say something funny or something, and then they spray the blood all over you. You take a piece of gauze, you fold it only two times, you ask them to bite down on it, and you put it under the nostril that's bleeding. It prevents you from getting soaked in blood. They can't spray it on you. You tell them it's because I don't want you to get a lot of blood in your mouth, but really, it's for you.
[Dr. Gopi Shah]
Then they're not talking.
[Dr. Jens Andersson]
Yes.
[Dr. Gopi Shah]
That's a good tip.
[Dr. Jens Andersson]
Yes, thanks.
[Dr. Gopi Shah]
Oh, goodness. Thank you so much for taking the time to come on to the show, Jens.
[Dr. Jens Andersson]
Thank you for having me.
[Dr. Gopi Shah]
It was wonderful to catch up.
[Dr. Jens Andersson]
Yes, you too.
[Dr. Gopi Shah]
For any of our listeners that want to know more about you, your hospital, or your practice, are you on any social media or any websites? Obviously, they can email BackTable, and I can always forward information to you.
[Dr. Jens Andersson]
No, I'm not. I only have a private Facebook account. Since I work in public healthcare and I'm not planning to move, I don't need to promote myself in any way. I am happy with anonymity that I enjoy here.
[Dr. Gopi Shah]
That sounds good. That sounds good. All right. Well, I think it's a wrap. Thank you.
[Dr. Jens Andersson]
Yes, thank you very much.
Podcast Contributors
Dr. Jens Andersson
Dr. Jens Andersson is a practicing ENT at Skåne University Hospital in Sweden.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Cite This Podcast
BackTable, LLC (Producer). (2023, November 14). Ep. 142 – Evaluation and Management of Chronic Frontal Sinusitis in Sweden [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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