Alabama Nasal & Sinus Center

Alabama Nasal & Sinus Center

Help me, doc! I can't smell!

Help me Doc, I can’t smell!

Loss of your sense of smell is a really troubling problem.  Because of the connection between smell and taste, when one loses their sense of smell they also lose taste sensation, thus severely reducing your enjoyment of food.   There are many reasons someone can lose their sense of smell. 

The most common cause of anosmia, or complete loss of sense of smell, in young adults is head trauma, such as that suffered in car accidents or some high velocity sports injuries.  Another common cause of anosmia/hyposmia is viral upper respiratory infections, like the common cold.  In elderly patients, anosmia, or hyposmia (partial loss of sense of smell) can be an early sign of Alzheimer’s disease. 

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Hearing Aids - When and How. All about access to hearing aids.

Hearing loss and access to care.

margaretThe current healthcare environment is very sensitive to issues of access.  One of the problems we face is understanding what various parties mean when they speak of access.  This problem has recently come to my attention regarding questions of access for patients to hearing aids. 

There are many reasons why those with significant hearing loss are not participants in the current system, including, but not limited to: failure to realize the problem, denial of the problem, perceptions regarding a potentially complex system, and cost. While the AAO-HNS (American Academy of Otolaryngology –Head and Neck Surgery) agrees that efforts must be made to overcome these barriers, we must move forward with careful consideration and analysis relating to what can be done to significantly increase utilization (by easing entry and reducing costs) while retaining necessary protection for patients.

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Balloon sinuplasty

Balloon sinuplasty

I revisit balloon sinuplasty today because we are still getting a lot of questions about this technology and the role it plays in treatment of sino-nasal disease. 

Studies show safety and efficacy of the balloon in opening sinuses.  However, does a tool that is safe and effective mean it is necessary.  More to the point, does this tool change the indications for surgery on the sinuses?  Furthermore, is it the right tool for your case?   The role of balloon catheter dilation for treatment of chronic rhinosinusitis was recently reviewed in an article in Otolaryngology – Head and Neck Surgery.  The conclusion of the authors was that current evidence supporting the role of balloon sinuplasty for treatment of chronic rhinosinusitis is incomplete.  Interestingly, the review of several studies found that sinus surgery cases done in the operating room have better quality of life outcomes and longer duration of effect than in-office sinus procedures.  This seems to make some sense in that the surgeon can be more aggressive in the operating room, with the patient under general anesthesia, than she/he can in the office setting with only topical anesthetic.   In addition, the in-office cases are likely patients with lower disease burden than those taken to the operating room and thus the magnitude of improvement is less.   There are certainly many reasons for these findings, but at least it should be a word of caution for the patient and/or surgeon hoping to cure chronic sinus disease with a simple catheter passed into the sinus while the patient is awake in the office, ready to go back to work that afternoon.

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Thanksgiving

Thoughts on Thanksgiving.

Thanksgiving, man! Not a good day to be my pants.

--Kevin James

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Sinus Headache

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Sinusitis and Headaches

What is the most common symptom of a "sinus infection"?  If you are like most people, you most likely think of sinus headache as a primary problem with sinus infection.  Both sinusitis and headaches are very common problems.  Because the sinuses are located in the front of the head, where most headaches occur, there is bound to be a lot of overlap between these two diagnoses.

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Two are better than One - A discussion of hearing aids

Two Ears Are Better Than One....

Have you ever had a family member tell you that you need a hearing aid? Or that you need to get your hearing checked. Or, have you noticed that you can sleep through a thunderstorm while others around you are awakened. Well, our tendency is to blow off these signs as yet another reason not to attend the next family reunion – all those crazy folks, you know. However, it might be prudent to consider for a moment that you might have hearing loss (gasp!). One of the things I do here at Alabama Nasal and Sinus Center is take care of people with hearing loss. Husbands who cannot hear wives and play the TV way too loud and wives who have to constantly ask others to repeat themselves are the types of people I see commonly in my office. We are very fortunate to have two outstanding audiologists on our staff that we work with to rehabilitate patients with hearing loss. Together, the physician and audiologist can diagnose and treat the underlying cause of your hearing loss, if possible. The audiologist has further expertise in fitting, programming, and servicing hearing aids for those who need them. If you or a family member are experiencing hearing loss, you might be considering the use of hearing aid amplification

As hearing care professionals, we are often asked, "Do I need two hearing aids, or can I wear just one?" Wearing hearing instruments on both ears is often recommended and will provide advantages that only one hearing aid will not.

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Rest

Rest

I just came back from a short trip to Sandestin, Florida for The Deep South Otolaryngology Meeting, where the ENT societies of Alabama, Mississippi, and Louisiana get together to discuss boogers and stuff related to ear, nose, and throat care. We had a great meeting, with lots of excellent speakers and lively discussion of relevant topics to those who practice otolaryngology.

The time away gave me a chance to contemplate life a little. I was able to bring my family along on the trip, so all of my time not spent in the meeting was spent with my wife and children either eating something tasty or playing in the Gulf of Mexico. The juxtaposition of professional development alongside really great family time serves as a window into one of life's greatest challenges – the work time –family time balance. There is a tendency (for me) to feel guilty about attending meetings when my kids are waiting for me to take them to the beach or the arcade. Then, when I'm at the arcade, there is a temptation (for me, at least) to worry that maybe I should be networking more with colleagues or writing a paper or whatever. In both cases, I have learned that the secret to happiness and success in both arenas is presence. Don't be in one place thinking of what you should be doing in another. Don't be distracted by what happened at work or what you left hanging at work when your teenage daughter is talking to you about her day. Be present. Or, as Dr. Kevin Elko says, "Be where your feet are planted." Be fully engaged wherever you are. People, especially your family, want your presence. They want your undivided attention. But, you have a lot of other responsibilities. True. Don't we all. So, manage your life (notice, I did not say manage your time – we all have the same amount of time in the day and each of our days are numbered) in such a way that you have allotted time for work, family, faith, recreation, etc. Contrary to what the culture tells us, this type of positive, proactive life management begins with rest. The principle of Sabbath – deep abiding rest in the knowledge that God is in control and will provide all you need – is in view here. We work from our rest. We rest to clear our minds, let our souls catch up to our bodies, and prepare both for the next season. I encourage you to make Sabbath a regular part of your week and year. Make a plan and stick to it, but don't be ruled by it – be flexible. Set goals and execute the plans to reach those goals. Prioritize those five fundamental areas of your life: faith, family, faculty (work and hobbies), fitness, and fun. I hope that challenges you and helps you a little.

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Sinusitis Guidelines 4

Hey guys, did you miss me?  Well, ready or not, here we go with the final installment of Sinusitis Guidelines.  Also known as ansers to hot boiling questions (regarding sinusitis).  

1.  If I have acute bacterial rhinosinusitis (ABRS), do I have to take an antibiotic?

No, both watchful waiting and antibiotic therapy are proven ways to treat ABRS. Most people get better naturally, and antibiotics only slightly increase symptom relief (about 10 to 15 people must use antibiotics to get 1 more person better after 7 to 15 days).

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Sinusitis Guidelines 3

I'm back, gang!  Today, I  present here, for your education and enlightenment, our summary of the clinical practice guidelines for adult sinusitis as it applies to the patient.  The following will be in question/answer format.  

1.  What are the sinuses?
Sinuses are hollow spaces in the bones around the nose that connect to the nose through small, narrow channels. The sinuses stay healthy when the channels are open, which allows (a) air from the nose to enter the sinuses and (b) mucus made in the sinuses to drain into the nose.
2.  What is sinusitis?
Sinusitis, also called rhinosinusitis, affects about 1 in 8 adults annually and generally occurs when viruses or bacteria infect the sinuses (often during a cold) and begin to multiply. Part of the body's reaction to the infection causes the sinus lining to swell, blocking the channels that drain the sinuses. This causes mucus and pus to fill up the nose and sinus cavities.
3.  How can I tell if I have acute sinusitis?
You have acute sinusitis when there has been up to 4 wk of cloudy or colored (not clear) drainage from the nose, plus one or both of the following: (a) a stuffy, congested, or blocked nose; (b) pain/ pressure/fullness in the face, head, or around the eyes.
4.  How can I tell if my sinusitis is caused by viruses or bacteria?
Acute viral sinusitis is likely if you have been sick less than 10 days and are not getting worse. Acute bacterial sinusitis is likely when you do not improve at all within 10 days of getting sick or when you get worse within 10 days after beginning to get better.

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5.  Why is it important to tell if my sinusitis is caused by bacteria?
Because sinusitis is treated differently according to cause, acute viral sinusitis does not benefit from antibiotics, but some patients with acute bacterial sinusitis may get better faster with an antibiotic.
6.  How long will it take before I feel better?
Most patients with ABRS feel better within 7 days, and by 15 days about 90% are cured or improved.
7.  Is there anything I can do for symptomatic relief?
There are several ways to relieve sinusitis symptoms that should be discussed with your doctor to decide which are best for you:
     a.  Acetaminophen or ibuprofen can relieve pain and fever.
     b. Saline irrigations, or washing out the nose with salt water, can relieve symptoms and remove mucus that is hard to blow out.
     c. Nasal steroid sprays can reduce symptoms after 15 days of use, but the benefit is small (about 14 people must use them to get 1 person better), and side effects include headache, nasal itching, and nose bleeds.
     d. Decongestants may help you breathe easier and can be taken as a nasal spray (for no more than 3 days in a row, to avoid worsening congestion) or dry mouth.

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Sinusitis Guidelines 2

Hello, world!  Did you miss me?  Ready to talk Sinusitis again?  Remember our last post was about definitions.  Well, let's continue that theme.  

Viral rhinosinusitis: Acute rhinosinusitis that is caused by, or is presumed to be caused by, viral infection. A clinician should diagnose viral rhinosinusitis when;
• symptoms or signs of acute rhinosinusitis are present <10 days and the symptoms are not worsening.


Chronic rhinosinusitis: Twelve weeks or longer of two (2) or more of the following signs and symptoms:   

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Sinusitis Guidelines

Sinusitis Guidelines

Though not topping the headlines of your local newspaper or headlining the prime time shows on Fox News or CNN, the American Academy of Otolaryngology – Head and Neck Surgery just made news in the world of ear, nose, and throat specialists.  The Academy released its long awaited update to the clinical practice guideline for adult rhinosinusitis.  (Gasp!! Ooo! Ahhh!)  The 14 developed recommendations address diagnostic accuracy for adult rhinosinusitis, the appropriate use of ancillary tests to confirm diagnosis and guide management (including radiography, nasal endoscopy, computed tomography, and testing for allergy and immune function), and the judicious use of systemic and topical therapy. Emphasis was also placed on identifying multiple chronic conditions that would modify management of rhinosinusitis, including asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia.  An updated guideline is needed as a result of new clinical trials, new systematic reviews, and the lack of consumer participation in the initial guideline development group.

We ENT doctors get all geeked out on this stuff.  It’s what we do!  The full text of the guideline document is a hearty thirty-nine pages with essentially no pictures.  I read the whole thing.  Again, it’s what I do.  I would not suggest you, the non-professional try that at home, unless you are suffering from insomnia.  But, there are some things in there that will affect how we practice and thus will become important to you if you are or have been a patient who suffers acute sinusitis.  To begin, we should define some terms for everyone. 

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Point-of-Care CT Imaging

In-office CT (point of care imaging)

Over the past several years, point-of-care imaging (radiographic imaging done in the office) has grown in response to such factors as improved patient access, the availability of prompt clinical diagnosis and treatment, and low radiation CT imaging equipment suitable for an office setting. Point-of-care imaging represents a modality of service that is in line with the Institute of Medicine’s six dimensions of high quality care; care that is safe, timely, effective, efficient, equitable, and patient-centered [1].  The Alabama Nasal and Sinus Center is proud to be able to provide patients with timely, effective, efficient, and patient-centered diagnostic imaging studies and interpretation by Drs. Sillers and Lay.

All otolaryngologists receive training in head and neck imaging as part of their medical specialty training, and it is a component of the Scope of Knowledge for Board Certification.  We believe that patients should receive the most appropriate imaging modality to help diagnose their condition.  For patients undergoing Computed Tomography (CT) imaging of the paranasal sinuses, skull base and temporal bones, both conventional CT and cone beam CT (CBCT) imaging are appropriate methods for imaging these anatomical structures.  Physicians should have the discretion to determine the most appropriate imaging modality for the care of the patient.  CBCT provides greater spatial resolution at a significantly lower level of radiation than a conventional CT scanner [2].  We have recently upgraded our in-office cone beam scanner, investing in new hardware and the latest software available.  This new technology allows us the opportunity to provide patients imaging of the paranasal sinuses, skull base, and temporal bone in the comfort and convenience of our office.  Other radiographic imaging that we commonly order, including MRI of the head, thyroid ultrasound, and neck CT, are all still done outside the office.   

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We're CT Accredited

Alabama Nasal and Sinus Center Receives CT Accreditation by the IAC:

Computed Tomography (CT) is a highly regarded diagnostic imaging tool due to its ability to detect minute differences in tissue as well as its multiplanar reformatted imaging capabilities. An estimated 69 million CT scans are performed annually in the United States to diagnose conditions of the neck, chest, abdomen, pelvis, extremities, cardiac system and sinus and temporal bones.

Early detection of life threatening conditions and other diseases is possible through the use of CT procedures performed within hospitals, outpatient centers and physicians’ offices. While these tests are helpful, there are many facets that contribute to an accurate diagnosis based on CT testing. The skill of the CT technologist performing the examination, the type of equipment used, the background and knowledge of the interpreting physician and quality assurance measures are each critical to quality patient testing.

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Featured

New Options in Immunotherapy

Sublingual immunotherapy

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It’s that time of year again!  No, not Christmas in March, it’s allergy season.  Spring Allergy Season

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Balloon Sinuplasty Revisited.

What’s Up with the Balloon?

imgres 2Undoubtedly you have heard much of the discussion about balloon sinuplasty (BSP).   Numerous advertisements on radio and in print have raised awareness in the public about this relatively new surgical device. What is it and where does it fit in the spectrum of treating patients with sinusitis?

Simply stated, since its introduction in 2005, the balloon is one tool among many that can be used to open a blocked sinus. By using balloon catheter dilation technology to perform BSP, the outflow tracts of the maxillary, frontal and sphenoid sinuses can be dilated. No tissue is removed during BSP.  Importantly, however, is the fact that the ethmoid sinus is not directly treated. 

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Is balloon sinuplasty for me?

Is balloon sinuplasty for me?

“What’s up with the balloon, doc?”  That is a question that Dr. Sillers and I hear several times a week.  I have written blog posts about balloon sinuplasty previously, which can be found on the website.  So, for the two people who read that blog (thanks mom and dad!) some of this material will be redundant.  Today’s post is meant to further explain our position on balloon sinuplasty and answer the question whether or not balloon sinuplasty is right for you.

Balloon sinuplasty is not really a new sinus procedure.  However, there is much more public awareness of late, in large part because of advertisements on radio and in print publications.  Balloon sinuplasty technology, based on similar balloon technology used to dilate occluded blood vessels, was developed at various centers around the country over a decade ago.  Today, there is a significant body of experience and evidence supporting the use of balloon sinus dilation as safe and effective therapy for chronic sinusitis.  The touted advantages are that, because there is no removal of tissue, the pain level is less and recovery is faster.  Additionally, because of this less invasive technique, the procedure can be performed in the office setting without general anesthetic.  Let’s examine some of these claims and see how they may apply to you, the consumer.

Balloon sinuplasty is best understood as a tool that sinus surgeons can use to perform sinus surgery.  The invention of the balloon sinus dilator did not change the indications for sinus surgery.  If a patient suffers chronic sinus infections and has failed maximal medical therapy, then he or she may be a candidate for sinus surgery and the balloon may be one tool the surgeon chooses to use for that operation.   The companies that make these surgical devices like to emphasize the ease of the operation and the speed of recovery and they also emphasize the increase in ability to breathe after the procedure.  While it may be true that use of a balloon causes a little less pain than standard ESS techniques, focus only on pain fails to take into consideration the fact that the more significant impact upon pain level is extent of disease, rather than technique used.  In other words, use of a balloon or standard techniques on limited disease is likely to result in very little pain.  Conversely, operations on patients with extensive disease require more aggressive dissection of tissues, resulting in more pain, whether you use a balloon or not.  In fact, if disease is extensive, you are less likely to be able to use a balloon.  A study recently published by Dr. Sillers and myself in the Laryngoscope demonstrated that use of a balloon for sinus surgery on a patient with chronic rhinosinusitis with polyps (i.e. more severe inflammatory disease) provides no significant advantage over standard approaches to endoscopic sinus surgery.   

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Featured

Questions About My Bill.

st-vincentHealth care is changing. Thats not news, but these changes are affecting physicians and patients on a daily basis. It has become increasingly important for patients to understand how their insurance works for them and what their responsibilities are related to deductibles. Many patient’s deductibles have increased so that their payment responsibilities at the point of service may be higher than the usual copays to which they are accustomed.

As ear, nose, and throat specialists at the Alabama Nasal and Sinus Center we often employ certain procedures such as nasal endoscopy and flexible endoscopy of the throat and voice box. These procedures are separately reported and billed so that your explanation of benefits will show a “surgical procedure”charge. Depending on your deductible, part or all of the allowable fee for these services may be your responsibility. This may be in addition to your copay. Admittedly, this is confusing. We are always happy to discuss this issue with you if you have questions.

Another confusing issue is how charges are billed for post-operative care. For most surgical procedures we perform, post-operative care is included in the global fee. Typically there is no charge for after surgery visits for up to 90 days after tonsillectomy, ear tubes, and septoplasty, for example. Sinus surgery is an exception. The global period for endoscopic sinus surgery is zero days. In other words, post-operative care after sinus surgery is billed as a separate encounter, beginning the day after surgery. When you come for an office visit after sinus surgery, you will be responsible for the copay as well as any portion of the nasal endoscopy with debridement for which your deductible has not been met. The rules governing global periods are decided by the Centers for Medicare and Medicaid (CMS) and/or by your insurance company, not the Alabama Nasal and Sinus Center! Once again, this is confusing, but we are happy to answer any question you have related to billing.

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Balloon Sinuplasty - Part II

ImageToday, I will continue discussion of one of the newest technologies introduced to the armamentarium of the sinus surgeon, balloon sinuplasty.

A reminder, the balloon sinus dilator is a tool that utilizes a small wire catheter that can be placed into a sinus opening and then the balloon attached to the catheter inflated to widen the sinus opening.  

Dr. Sillers and I were involved in the initial testing of this new technology in 2002.  Dr. Sillers was much more instrumental than I, as he was the Chair of the Rhinology Division of the Department of Otolaryngology – Head and Neck Surgery at the University of Alabama - Birmingham at the time and I was but a lowly resident.  

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Alabama Nasal and Sinus Center Receives CT Accreditation by the IAC

Alabama Nasal and Sinus Center Receives CT Accreditation by the IAC

Computed Tomography (CT) is a highly regarded diagnostic imaging tool due to its ability to detect minute differences in tissue as well as its multiplanar reformatted imaging capabilities. An estimated 69 million CT scans are performed annually in the United States to diagnose conditions of the neck, chest, abdomen, pelvis, extremities, cardiac system and sinus and temporal bones.

Early detection of life threatening conditions and other diseases is possible through the use of CT procedures performed within hospitals, outpatient centers and physicians’ offices. While these tests are helpful, there are many facets that contribute to an accurate diagnosis based on CT testing. The skill of the CT technologist performing the examination, the type of equipment used, the background and knowledge of the interpreting physician and quality assurance measures are each critical to quality patient testing.

Alabama Nasal and Sinus Center located in Birmingham, AL has been granted a three-year term of accreditation in CT in the areas of Sinus and Temporal Bone CT by the Intersocietal Accreditation Commission (IAC).

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Balloon Sinuplasty

If you listen to talk radio or read the advertisements in newspaper and other circular publications, you have likely heard about balloon sinuplasty.  "That first breath of air through my nose.., etc.”  Balloon sinusplasty is a relatively new tool, which can be used for surgical treatment of patients with chronic sinusitis.   

Long ago, (in a galaxy far, far, away) sinus surgery was done through open techniques, where incisions were made on the face or under the lip to expose the facial bones and then the sinus cavities.  A great advance in sinus surgery came with the development of endoscopic surgical techniques.  Commonly termed functional endoscopic sinus surgery (or FESS), the endoscopic approach relies upon in-depth knowledge of the nasal cavity and paranasal sinuses and illumination and visualization of these structures with small diameter endoscopes.

The surgical technique is to remove a limited amount of tissue and bone to re-establish the natural outflow of the native sinuses.  Standard FESS techniques were first developed in Europe and later took hold in the United States in the 1980’s.  In addition to the endoscope, the sinus surgeon has a plethora of tools available to precisely and conservatively remove tissue that is diseased to allow the sinuses to drain as they should.  In standard FESS, grasping and cutting instruments and even a microdebrider will be used to achieve the desired results.  Over the years, as technique advanced, new instruments were developed to aid the surgeons in safely and effectively performing these types of surgeries.  One such tool to arrive on the scene was the sinus balloon dilator. 

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