Education

Sinuses are boney rooms of air which are lined with a special type of mucosa that contains cilia, or hair like structures, that transport mucous from the sinus to its natural drainage point, the nasal cavity.  The sinuses are a different organ from your nose; they ventilate with the nasal cavity but are not physiologically the same as your nose.  Therefore, patients with nasal problems such as nasal allergies do not necessarily have, and in fact, usually do not have, sinus inflammation.  However, sometimes the two conditions exist at the same time.

How do Sinuses Work?

Sinuses are thought to exist to decrease the weight of our facial skeleton by replacing bone with air.  A healthy sinus has very thin mucosa and must be able to ventilate freely to the outside world.  Sinuses produce nitric oxide, which is hypothesized to help with our body’s immune system and to assist the ciliary function within its mucosa.

What is Sinusitis and What are its Symptoms?

The term sinusitis is a general term given to diseases and conditions that cause inflammation of the lining of the sinus cavities.  There are two common types of sinusitis, Acute and Chronic Sinusitis.  These are very different problems.  Acute sinusitis is inflammation caused by a virus or bacterial.  These pathogens cause the sinus to become inflamed, and often produce pus (yellow or greenish drainage).  When someone has acute sinusitis, that person will usually have facial pressure, pain, potentially a low grade fever, and will cough up or blow colored drainage from his nose.  If a bacterial cause is suspected, acute sinusitis is treated with antibiotics.  On the other hand, Chronic Sinusitis is an inflammatory condition, which may be caused by chronic infection, but often it is not.  Similar to eczema of the skin, we often are not able to determine the underlying cause of the inflammation;  rather, we focus on known treatments that help improve and/or resolve the inflammation.  Patients with chronic sinusitis will complain of chronic nasal congestion, intermittent facial pressure, sometimes post-nasal drip or headaches, and sometimes loss or diminished sense of smell.  A more severe form of chronic sinusitis is one that causes the formation of nasal polyps.  This is a chronic condition that requires long-term management.

Sinusitis Treatments

Acute sinusitis treatment usually includes antibiotics, but often also includes nasal saline lavage, topical nasal steroids, decongestants, fever and pain reducers, and oral steroids.  The goal is to treat the infection and inflammation such that the sinus tissue can heal and return to normal.  Temporarily, decongestants can be used to help improve facial pressure/pain symptoms. In severe cases, sinus surgery can be necessary.  If the sinus infection is related to dental disease, the diseased tooth must also be addressed by a dentist or oral surgeon.

Chronic Sinusitis, on the hand, requires long-term medical management with topical nasal steroids and nasal saline irrigations.  Short term treatments with decongestants can temporarily relieve some of the symptoms but they are not safe to use long term.  Sometimes, sinus procedures are needed to augment the medical regimen.  The sinus procedures may utilize balloon sinuplasty technology or more traditional endoscopic sinus surgery techniques.  These are often performed in the office setting but sometimes general anesthesia in a facility.

Is Asthma related to Sinusitis?

Patients who have asthma and who knowingly, or unknowingly, have poorly controlled chronic sinusitis will often have a more difficult time controlling their asthma symptoms.  Asthma is also an inflammatory condition.  Improving sinus inflammation will assist in improving bronchial inflammation, the cause of asthma symptoms.

When to see an Ear, Nose, and Throat (ENT)

Anyone who suspects he or she is suffering from sinusitis should seek an evaluation with an Ear, Nose, and Throat physician.  Only an ENT physician has the appropriate training and skills to accurately diagnose, treat, and manage sinusitis.  While other health care providers may diagnose sinusitis, ENT physicians are the health care experts with the medical and surgical skills required to effectively manage these conditions.

Sinus terminology/glossary

Sinusitis – Inflammation of the lining of the sinus cavities

Acute Sinusitis – Sinus inflammation due to viral or bacterial infection

Chronic Sinusitis – Sinus inflammation that is present for more than 12 consecutive weeks, often not secondary to an underlying infection, but rather due to an undetermined inflammatory condition which causes persistent inflammation of the sinus mucosa.

Balloon Sinuplasty – A simple sinus procedure that utilizes a balloon to create a permanent improvement in sinus ventilation.

Endoscopic Sinus Surgery – Procedures, which can include balloon sinuplasty, performed to improve sinus ventilation, decrease the burden of disease, improve the delivery of topical medications and cleaning of the sinuses.

Topical Therapy – Application of medications and/or saline irrigations directly into the nasal cavity such that a portion of those therapies reach inside the sinuses to medicate and/or clean the sinus.

Inflamed nasal mucosa caused by exposure to allergens is referred to as Allergic Rhinitis.  Allergens are molecules that provoke inflammation in individuals sensitized to those molecules.  Common allergens include dust mite, grass, weed, or tree pollen, and animal dander such as from dogs or cats.  In unsensitized persons, these molecules do not cause any inflammatory reaction;  however, patients who suffer from Allergic Rhinitis can develop a robust inflammatory reaction inside their nose which causes numerous symptoms.

Nasal Allergy symptoms

Symptoms of nasal allergies include sneezing, itchy nose and/or throat, and clear nasal drainage, either down the back of the nose called post-nasal drip, or out the front of the nose.  Patients will also complain of feeling congested.  Because congestion is also a symptom of sinusitis, it requires an evaluation with an ENT to determine what is causing the patient’s symptom of congestion.

Nasal Allergy treatments

Nasal allergy treatments include cleaning the nasal cavity with saline irrigations to wash away the allergens, applying topical steroids to inhibit nasal mucosal inflammation, and taking oral antihistamines, as needed, to block the effects of histamine, one of the major chemicals produced in the allergy inflammatory cascade, that causes some of the symptoms of nasal allergies.  Other treatments, including short courses of oral or intramuscular steroids, can be used during severe exacerbations.  Long-term control can often be achieved with immunotherapy.

What is immunotherapy?

Immunotherapy is a homeopathic treatment whereby patients are exposed to high doses of their allergens, either through subcutaneous or under the tongue administration, which diminishes the immune system’s response to the allergens.  In effect, immunotherapy “re-programs’ the your body’s immune system to not react to the allergens that it is currently reacting to.  Immunotherapy can only be offered after an allergy test is performed to confirm the allergens to which you are reactive.  If the allergy testing is negative, that person is not a candidate for immunotherapy.

Who should get allergy testing?

Patients who develop severe reactions to allergens, those who experience year around allergy symptoms, patients who suffer from moderate to severe asthma, and patients who experience severe seasonal allergy symptoms should undergo allergy testing.

When to see an allergy doctor?

Patients should be evaluated for nasal allergies if they have year around symptoms, or suffer from severe seasonal symptoms.  Any patient who suffers from asthma-like symptoms such as wheezing, shortness of breath, chest tightness or chronic cough should also be evaluated by an allergist/immunologist or an ENT who treats allergy.  ENT and allergists often work together to treat patients suffering from Allergic Rhinitis, asthma, and/or sinusitis.

Allergy terminology/glossary

Allergic Rhinitis – Nasal mucosal inflammatory reaction to allergens.

Allergens – Molecules in our environment that are otherwise inert, except for sensitized individuals who developed marked nasal mucosal inflammatory reactions with exposure.

Immunotherapy – homeopathic treatment of Nasal allergies that reprograms one’s immune system to no longer react to allergens.

Histamine – one of the major chemicals produced during an allergic inflammatory cascade that produces many of the symptoms of nasal allergy such as sneezing and itching

Topical Steroids – nasal sprays containing gentle steroids which act to inhibit nasal mucosal inflammation

Obstructive Sleep Apnea (“OSA”) event is a phenomenon that occurs during sleep where the upper airway becomes so narrow during sleep that adequate airflow is no longer possible.  In order to open the airway to allow adequate airflow, the person must have a short arousal of the brain which temporarily restores body muscle tone, thereby allowing the throat to dilate and re-establish proper air flow.  Once airflow is re-established, the brain falls back into a sleep state, thus potentially leading to another obstruction.

What is Obstructive Sleep Apnea Syndrome (“OSAS”)?

OSAS is a constellation of signs and symptoms caused when a person suffers from repeated obstructive sleep apnea events during his sleep.  In essence, a person who suffers from OSAS will have the same symptoms as someone who suffers from chronic sleep deprivation.  These symptoms include fatigue, daytime sleepiness, irritability, mental fog, memory problems and sometimes even erectile dysfunction.  Patients who have repeated obstructive events will feel their sleep is restless and usually will have a dry mouth upon awakening.  The person may sweat at night and wake several times per night to urinate.  Patients who suffer from OSAS snore, and often snore loudly.  However, one does not need to wake up feeling like they are gasping or choking for air to suffer from OSAS.

Who’s at risk for OSAS?

The most well-known risk factor for OSA is being overweight.  However, that does not mean people who are “fit” or not overweight cannot suffer from obstructive events during sleep.  There is no single sign or symptom that accurately diagnoses a person with OSAS.  However, without exception, any patient who has had a stroke or heart attack or suffers from coronary artery disease should be screened for OSA.  Patients who require treatment for high blood pressure, especially patients requiring two (2) or more medications to control their blood pressure, should be screened. In addition, having a neck circumference of 17” for a man or 16” for a woman have shown a fairly high correlation to testing positive for OSA.  Finally, patients who experience the symptoms listed above should be screened for sleep apnea.

Why Should I Care if I have Obstructive Sleep Apnea?

Living with OSAS means a person is living with chronic sleep deprivation because untreated OSA caused sleep fragmentation, which leads to poor sleep quality, and chronic sleep deprivation.  Chronic sleep deprivation is the main cause of OSAS symptoms.  However, not only does untreated OSAS not let you feel your best, it also significantly raises your risk for a heart attack or stroke, just like untreated high blood pressure or poorly controlled diabetes.  Treating OSAS helps you feel better during the day and reduces your risk of a premature heart attack or stroke.

Obstructive sleep apnea treatments

Treatments for OSAS are usually divided into non-invasive and invasive categories.  The most well-accepted non-invasive treatments are continuous positive air pressure therapy (“CPAP”) and oral appliance therapy (“OAT”).  Invasive treatments refer to surgical procedures, such as tonsillectomy, palate procedures, hyoid or tongue procedures.  Another type of surgical treatment is neuromodulation;  implanting a neurostimulator to provide muscle tone to the throat during inspiration.

The gold standard non-invasive treatment is CPAP.  CPAP is the gold standard because it generally alleviates obstructive events almost completely while being used.  The short-coming of CPAP therapy for some, is intolerance;  some patients are not able to use it most of the night, or not at all.  Therefore, for some patients it is a hero, and others a zero when it comes effective treatment for their OSAS.

Another non-invasive treatment option are oral appliances, called Oral Appliance Therapy (“OAT”).  Oral appliances work by improving the space in the upper airway by holding the lower jaw slightly forward while you sleep.  Patient selection is very important when choosing this therapy as OAT can be very effective or essentially ineffective.  We use office and sometimes sleep endoscopy examinations of the upper airway to identify candidates who have a high chance of achieving effective therapy with OAT.

For patients who cannot tolerate or are unwilling to use CPAP therapy, there are numerous surgical procedures that can improve the upper airway patency during sleep.  Surgical procedures include procedures focused on the soft tissues of the throat, procedures and address craniofacial skeletal anomalies, and neurostimulation.  Determining which procedures are right for any given patient requires a comprehensive evaluation.  The same procedure is not performed on every patient and the techniques are individualized based on each patient’s anatomy and findings during Drug Induced Sleep Endoscopy (“DISE”).

What is Drug Induced Sleep Endoscopy (“DISE”)?

DISE is an anatomic examination of the upper airway that is performed using endoscopy equipment while the patient is in a drug-induced sleep state.  This is the best way to determine why and how the airway is obstructing during sleep so that proper surgical planning can be accomplished.  Patients interested in being evaluated for the INSPIRE implantable neuromodulator must have a DISE performed to determine if they are a candidate for the procedure.

Do all Sleep Medicine physicians who treat Obstructive Sleep Apnea have the same experience and training?

Typically, obtaining treatment for OSAS requires multiple providers;  The primary care physician to order the testing, a sleep laboratory to administer the test, and if positive, a Durable Medical Equipment (“DME”) company to provide air pressure equipment, and often a pulmonologist to manage the air pressure therapy.  If a person wishes to try oral appliance therapy, then the patient is referred to a sleep dentist for evaluation for an oral appliance.  And finally, patients are recommended to have an upper airway examination by an Ear, Nose, and Throat (“ENT” or “Otolaryngologist”) to rule out anatomic abnormalities that may contribute to the patient’s OSA events.  Thus, it takes 3 to 5 providers to diagnose, treat, and manage OSAS for most patients.

Dr. Ludwick is board certified in both Sleep Medicine and Otolaryngology.  This means that patients who come to Sugar Land ENT & Sleep Center, PA only require ONE physician to evaluate and treat them for OSAS.

Dr. Ludwick has treated OSAS for over 20 years.  This includes performing necessary medical and surgical treatments to improve the nose, sinus, and upper airway, as well as fitting, dispensing, and managing continuous positive airway pressure (“CPAP”) therapy.  In addition, Sugar Land ENT & Sleep Center, PA also fits and dispenses oral appliances for the treatment of OSAS.  Dr. Ludwick has dispensed and managed CPAP therapy since 2006.  However, unlike his sleep trained pulmonary colleagues, Dr. Ludwick is also a Board Certified Ear, Nose, and Throat surgeon who performs surgeries to treat OSAS.  Dr. Ludwick’s diverse and extensive background in the non-invasive and invasive forms of OSAS treatment ensures his patients receive the best treatment options for their unique situation and preferences.

While Dr. Ludwick sub-specializes in Allergy, Sinus, and Obstructive Sleep Apnea, he is still a general Otolaryngologist with over 20 years of experience treating patients with a wide variety of conditions affecting the head and neck region, including children and adults.  Out of our five senses (hearing, smell, sight, taste, touch), Otolaryngologists are the medical experts of FOUR of them! It is truly incredible the number of conditions that affect the head and neck region;  which is why it is important to seek care from a well-trained and experienced Otolaryngologist when you have a problem affecting your head or neck region.

Ear

The “E” in ENT stands for “Ear” and Otolaryngologists are the medical experts when it comes to diseases affecting the entire ear, from the pinna to the inner ear.  In fact, Otolaryngologists are the only surgical sub-specialists that surgically treat ear conditions such as tympanic membrane perforations or middle ear fluid.  Common ear conditions evaluated and treated by Dr. Ludwick include ear pain, ear infections, ear drainage, plugged ears, hearing loss, dizziness or vertigo, Meniere’s Disease, Positional Vertigo, tympanic membrane perforations and foreign bodies of the ear canal.  The range of conditions varies widely, from removing a retained earring to excision of skin cancer of the pinna with local reconstruction.  Regardless of the problem, if it involves the ear, Dr. Ludwick has the training and experience to diagnose and treat it!

Nose

The “N” in ENT stands for “Nose” and there is much more to a nose than nasal allergies and sinusitis.  The “Nose” includes all problems affecting the external nose, the nasal cavity, then sinuses and the back of the nose called the nasopharynx.  From enlarged adenoids that obstruct the back of the nose to bleeds (epistaxis), intra-nasal tumors, nasal cavity foreign bodies, changes or loss of smell or taste, and even excessive tearing (epiphora) caused by obstructed lacrimal ducts, as a Board-Certified Otolaryngologist, Dr. Ludwick can diagnose and treat these issues.

Throat

While the “T” in ENT stands for “Throat”, the term really refers to the remainder of the areas treated by Otolaryngologists and includes the mouth, throat, and face and neck.  There is a broad array of diseases and conditions that can affect these areas, from enlarged tonsils and/or tonsillitis, lump sensation in throat, throat pain, reflux, thyroid nodules or an enlarged thyroid gland (goiter), to neck masses, head and neck cancers, hoarseness and difficulty swallowing.  As an Otolaryngologist, Dr. Ludwick has training and extensive experience evaluating, diagnosing and treating diseases in these areas.