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What Causes Dizziness When Diagnosed With Chronic Resistant Sinusitis?
Question: Hello, Dr. Rynne:
I have a close friend who's been dealing with recalcitrant sinus "infections" for the last 20 years. She's currently having an episode and, the providers gave her levofloxacin. She's failed Cipro in the past. Augmentin has done nothing. At my suggestion (I am a nurse with personal experience with sinusitis/sinudynia), I encouraged her to request clindamycin due to it's effectiveness on deep tissue infections. She's been on that for 3 days now and the pressure in her head and face is getting worse. She has no fever, but has dizziness. They did a CT and told her it showed infection. This is curious to me. A CT has the capability to show inflammation, it can't diagnose infection, and it shouldn't be assumed infection is present base on imaging alone. Wouldn't it be prudent to have her get off the empiric ABX coverage and have a nasal swab performed? My personal experience also involved a nasal steroid injection, which made a huge difference. I'm encouraging her to pursue that as well. She is producing very little mucus and scant postnasal drip. Her presentation didn't include any yellow or green nasal discharge. She's had Augmentin, Biaxin, doxycycline and, as mentioned, Cipro. There was no mention if the CT showed antral defects that would lead to pooling of mucus and, therefore, cause infection. However, with the lack of impressive nasal discharge, this seems to indicate inflammation as the cause. She's miserable, is hardly able to function, is trying to launch a business (divorced and spousal support is to stop soon), and at her wit's end. She's already had sinus surgery so I would imagine scar tissue is playing a role and when inflammation sets in it exacerbates an already compromised anatomical problem. My nursing intuition is telling me: 1) she needs to get off the ABX for 48 hours and insist on a nasal swab culture or a nasal washing and the fluid cultured to isolate any bacteria for proper ABX selection. 2) she should pursue a nasal steroid injection in the hopes of getting symptomatic relief in the short term. 3) she should pursue detailed allergy testing to see if an inflammatory response in kind can be elicited if, in fact, there is no true infection. I would appreciate any feedback. Thank you
I have a close friend who's been dealing with recalcitrant sinus "infections" for the last 20 years. She's currently having an episode and, the providers gave her levofloxacin. She's failed Cipro in the past. Augmentin has done nothing. At my suggestion (I am a nurse with personal experience with sinusitis/sinudynia), I encouraged her to request clindamycin due to it's effectiveness on deep tissue infections. She's been on that for 3 days now and the pressure in her head and face is getting worse. She has no fever, but has dizziness. They did a CT and told her it showed infection. This is curious to me. A CT has the capability to show inflammation, it can't diagnose infection, and it shouldn't be assumed infection is present base on imaging alone. Wouldn't it be prudent to have her get off the empiric ABX coverage and have a nasal swab performed? My personal experience also involved a nasal steroid injection, which made a huge difference. I'm encouraging her to pursue that as well. She is producing very little mucus and scant postnasal drip. Her presentation didn't include any yellow or green nasal discharge. She's had Augmentin, Biaxin, doxycycline and, as mentioned, Cipro. There was no mention if the CT showed antral defects that would lead to pooling of mucus and, therefore, cause infection. However, with the lack of impressive nasal discharge, this seems to indicate inflammation as the cause. She's miserable, is hardly able to function, is trying to launch a business (divorced and spousal support is to stop soon), and at her wit's end. She's already had sinus surgery so I would imagine scar tissue is playing a role and when inflammation sets in it exacerbates an already compromised anatomical problem. My nursing intuition is telling me: 1) she needs to get off the ABX for 48 hours and insist on a nasal swab culture or a nasal washing and the fluid cultured to isolate any bacteria for proper ABX selection. 2) she should pursue a nasal steroid injection in the hopes of getting symptomatic relief in the short term. 3) she should pursue detailed allergy testing to see if an inflammatory response in kind can be elicited if, in fact, there is no true infection. I would appreciate any feedback. Thank you
Brief Answer:
Chronic resistant sinusitis,may require surgery.
Detailed Answer:
Hello,
Thanks for trusting Healthcaremagic!
I have gone through your query and I can understand your concerns .
As per your description your friend is having chronic sinusitis which show poor response to conventional antibiotics . She might require surgical intervention for complete cure .
CT can detect the extent of sinusitis . It shows features like mucosal thickening , opacification, which indicates infection.
Absence of post nasal drip or discharge does not rule out infection or sinusitis.
I suggest you to consult an ENT surgeon and get the following things done:-
1. As you said we can go for sinus irrigation followed by culture and sensitivity to find out exact bacteria causing this infection and also choose the appropriate antibiotic .
2.Steroid nasal sprays are quite effective in sinusitis especially in people with allergy or asthma.
3. She can go for analgesics like ibuprofen or diclofenac for pain.
4. Do frequent steam inhalation and nasal irrigation using saline nasal drops.
If conservative measures using antibiotics and nasal sprays fail, she might require surgical correction. Now a days endoscopic procedures are preferred for chronic sinusitis .
Hope I have answered your query.
Wishing you good health
Regards
Dr Shinas Hussain
Chronic resistant sinusitis,may require surgery.
Detailed Answer:
Hello,
Thanks for trusting Healthcaremagic!
I have gone through your query and I can understand your concerns .
As per your description your friend is having chronic sinusitis which show poor response to conventional antibiotics . She might require surgical intervention for complete cure .
CT can detect the extent of sinusitis . It shows features like mucosal thickening , opacification, which indicates infection.
Absence of post nasal drip or discharge does not rule out infection or sinusitis.
I suggest you to consult an ENT surgeon and get the following things done:-
1. As you said we can go for sinus irrigation followed by culture and sensitivity to find out exact bacteria causing this infection and also choose the appropriate antibiotic .
2.Steroid nasal sprays are quite effective in sinusitis especially in people with allergy or asthma.
3. She can go for analgesics like ibuprofen or diclofenac for pain.
4. Do frequent steam inhalation and nasal irrigation using saline nasal drops.
If conservative measures using antibiotics and nasal sprays fail, she might require surgical correction. Now a days endoscopic procedures are preferred for chronic sinusitis .
Hope I have answered your query.
Wishing you good health
Regards
Dr Shinas Hussain
Above answer was peer-reviewed by :
Dr. Raju A.T
Thank you for your timely response, Dr. XXXXXXX
She's tried Flonase and Nasacort inhalers to little avail. Her doctor also suggested using Flovent with a nipple adapter for her nose. I'd never heard of this but have encouraged her to try it, despite it being the same medication as Flonase, just in mist rather than liquid spray form. Doing the nasal/sinus rinses is something she's already doing; it's part of her regimen when she's hit with the symptoms.
I'm sending along the results of her most recent CT, which shows her prior partial ethmoidectomy as well as the bilateral uncinectomies. The final impression is "mild mucosal thickening" and "paradoxical curvature of the middle turbinates." Would the latter cause obstruction such that it would be the source of her headache and chronic feeling of her ears being plugged? The ear fullness/plugging is the newest component in her constellation of symptoms.
I'm inclined to suggest she get back to her ENT and focus on the turbinates. Mild mucosal thickening, in my opinion, could be scar tissue or inflammation, not necessarily infection. I'm certainly glad surgical intervention can be done endoscopically. I understand sinus surgery can be extremely painful.
Thank you, Dr. XXXXXXX
************************************
CLINICAL INDICATION: nasal infection / obstruction
PROCEDURE: CT SINUS COMPLETE WITHOUT CONTRAST
COMPARISONS: 11/23/2011
DATE: Apr 21, 2017 04:07:58 PM
TECHNIQUE: Noncontrast sinus CT was performed .
FINDINGS:
FRONTAL: The frontal sinuses are normally pneumatized and are clear.
FRONTAL RECESSES: The frontal recesses are open.
ETHMOID: Status post partial ethmoidectomy. Mild mucosal thickening
RIGHT MAXILLARY: Trace mucosal thickening
OSTIOMEATAL COMPLEX: Patent status post uncinectomy.
LEFT MAXILLARY: Mild mucosal thickening
OSTIOMEATAL COMPLEX: Patent status post uncinectomy
SPHENOID: Sphenoid sinus is normally aerated and is clear.
NASAL SEPTUM: The nasal septum is near midline.
SEPTAL PERFORATION: None
TURBINATES: Paradoxical curvature of the middle turbinates.
NASAL AIRWAY: Patent
ADENOIDS: Within normal limits for age.
BONE INTEGRITY: Normal
IMPRESSION:
Mild mucosal thickening. No air-fluid levels.
She's tried Flonase and Nasacort inhalers to little avail. Her doctor also suggested using Flovent with a nipple adapter for her nose. I'd never heard of this but have encouraged her to try it, despite it being the same medication as Flonase, just in mist rather than liquid spray form. Doing the nasal/sinus rinses is something she's already doing; it's part of her regimen when she's hit with the symptoms.
I'm sending along the results of her most recent CT, which shows her prior partial ethmoidectomy as well as the bilateral uncinectomies. The final impression is "mild mucosal thickening" and "paradoxical curvature of the middle turbinates." Would the latter cause obstruction such that it would be the source of her headache and chronic feeling of her ears being plugged? The ear fullness/plugging is the newest component in her constellation of symptoms.
I'm inclined to suggest she get back to her ENT and focus on the turbinates. Mild mucosal thickening, in my opinion, could be scar tissue or inflammation, not necessarily infection. I'm certainly glad surgical intervention can be done endoscopically. I understand sinus surgery can be extremely painful.
Thank you, Dr. XXXXXXX
************************************
CLINICAL INDICATION: nasal infection / obstruction
PROCEDURE: CT SINUS COMPLETE WITHOUT CONTRAST
COMPARISONS: 11/23/2011
DATE: Apr 21, 2017 04:07:58 PM
TECHNIQUE: Noncontrast sinus CT was performed .
FINDINGS:
FRONTAL: The frontal sinuses are normally pneumatized and are clear.
FRONTAL RECESSES: The frontal recesses are open.
ETHMOID: Status post partial ethmoidectomy. Mild mucosal thickening
RIGHT MAXILLARY: Trace mucosal thickening
OSTIOMEATAL COMPLEX: Patent status post uncinectomy.
LEFT MAXILLARY: Mild mucosal thickening
OSTIOMEATAL COMPLEX: Patent status post uncinectomy
SPHENOID: Sphenoid sinus is normally aerated and is clear.
NASAL SEPTUM: The nasal septum is near midline.
SEPTAL PERFORATION: None
TURBINATES: Paradoxical curvature of the middle turbinates.
NASAL AIRWAY: Patent
ADENOIDS: Within normal limits for age.
BONE INTEGRITY: Normal
IMPRESSION:
Mild mucosal thickening. No air-fluid levels.
Brief Answer:
CT doesn't suggest severe infection.
Detailed Answer:
Hello,
Thanks for the follow up.
I have gone through your CT scan results. Most of her sinus looks normal and there is only mild infalammation in her maxillary sinus. That means the cause of her head ache could be something else.
Paradoxial curvature of middle turbinate is an incidental finding in many individual and does not cause any harm other than recurrent nasal obstruction. If you repeatedly use steroid sprays you might trigger turbinate hypertrophy in which turbinate will over grow and further worsen the obstruction.
In some people the malformed turbinate will impinge on the lateral nasal wall and cause severe pain for long duration. It might be a reason for her headache.
We have to rule out other possible causes for headache like migraine and tension head ache which are very prevalent among middle aged women.
Consult an ENT surgeon with expertise in endoscopic surgery. Sometimes she might require a procedure called turbinectomy to remove malformed turbinate to correct the symptoms.
regards
Dr.Shinas Hussain
CT doesn't suggest severe infection.
Detailed Answer:
Hello,
Thanks for the follow up.
I have gone through your CT scan results. Most of her sinus looks normal and there is only mild infalammation in her maxillary sinus. That means the cause of her head ache could be something else.
Paradoxial curvature of middle turbinate is an incidental finding in many individual and does not cause any harm other than recurrent nasal obstruction. If you repeatedly use steroid sprays you might trigger turbinate hypertrophy in which turbinate will over grow and further worsen the obstruction.
In some people the malformed turbinate will impinge on the lateral nasal wall and cause severe pain for long duration. It might be a reason for her headache.
We have to rule out other possible causes for headache like migraine and tension head ache which are very prevalent among middle aged women.
Consult an ENT surgeon with expertise in endoscopic surgery. Sometimes she might require a procedure called turbinectomy to remove malformed turbinate to correct the symptoms.
regards
Dr.Shinas Hussain
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Above answer was peer-reviewed by :
Dr. Kampana
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