of course this is a bucket. That is so vast chronic sinusitis. It is in the top five chronic conditions that affect americans. Um and depending on what uh where you read, major depression, anxiety, diabetes hypertension and chronic sinusitis. Rhinitis affect americans, daily lives more than any. And the premise of chronic sinusitis or rhinitis is control versus cure. It's really a long life treatment and with those other symptoms of depression, diabetes hypertension, those are in the same bucket for long term issues. Um so this is more of an overview uh and some of the new things that we're doing and really it's a tale of two processes. And when you look at structural issues and dr Kochar talked a little bit about that, you could really cure those patients. Those patients are the low lying fruit. When we see them in the office, we know that they're gonna do well and that has to do with septal deviation, bone growth spurs, osteo Mazz, dental origin problems. We're seeing an uptick of those now that people are getting dental implants by the thousands. Um and also after root canals and of course one sided issues. Sister mucus seals. That's really not the topic of today. Today we're looking at genetic slash um physiologic processes and those are in the bucket of the long term control. So allergy is probably the number one precursor. And when you talk about the genetic issues, there's two forms, there's the snF Ilic uh sinus reina reina logic issue and then there's the non eosinophilic and one of the things I didn't add in the talk today was those patients we I used to I call them my veteran sinus patients. They they're always in your practice or they go from one practice to the other looking for the miracle cure. Today, we have some really great options and biologicals that we could offer. These chronic veteran sinusitis patients. That is a different talk, a different uh stratosphere than what we're going to talk today, but they in the next 10 years I'll tell you a funny story. Seven years ago when I was at international meeting, they were presenting about depiction from Denmark and the lead investigator on defects and said, well you people use surgeons in the United States. You don't have to worry about your surgical practices for a decade because it'll take you that long to figure out how to pay for detection. But here in the in Denmark and europe, it's making a huge impact on chronic sinusitis. Um were but that was about seven years ago. And now finally defection is coming up to uh prime time and we have other biologics like for center etcetera. Um but that really deals with that chronic eosinophilic issue. Um Vaso motor rhinitis is another issue that is really not a sinusitis issue. We will present with those issues in in or symptoms. And just as that nice picture that dr Kochar showed with the normal new neurological pathways and then the the the mess of all the different nerves that's really the autonomic aspect of visual motor rhinitis and it not only affects the nose, it affects saliva, it affects your nation. Uh So it really is a aging neurodegenerative process. And of course the last is immuno deficiencies and that's really in patients that have uh G. G. Deficiency And now we have great treatments for those patients. Outpatient injections and that really has made a big impact. So chronic sinusitis, I think the most important takeaway today is it's not an infectious disease. It's really a baseline inflammatory immunological disease. And a lot of patients will look at it and doctors will look at it as an infectious disease. But really it's it's an inflammatory process and the infection is secondary and I look at it as the umbrella of inflammation and what are those triggers of that inflammatory process. And a lot of patients will have one aspect treated and they're still not getting symptomatic results. You really have to define all the different triggers of the inflammatory response to to help these patients and identifying is the key down in the bottom of the infections are secondary and most must treat all triggers or no improvement. And by the way the preexisting an atomic issues need to be treated as well. So allergy of course chronic infection acid reflux is a major issue and especially the silent reflux patients um environmental issues. I tell patients we all suffer from Los Angeles. We live in an environmental uh gauntlet here of low pressure uh packing down to the particular matter in this basin. And depending on the barometric pressure's patients will feel it more on one day than the other, especially here by the coast and the marine layers. Um Hormonal influences. And of course over the counter medication use Afrin and the over the counter sprays. So when you get down to the symptomatic aspect of this inflammatory process, it's just a plumbing problem. And the sinus drainage pathways are blocked by this inflammation. And then that causes the ability of your normal flora or your normal colonized. Not normal but your colony colonizing floor that's in your nasal cavity or nasal pharynx. Then to populate and invade into this pristine area. So the physiologically and this is another takeaway point. The cilia is functions is the key to normal sinus uh function. And they lined the entire sinus cavities. They are oriented towards the drainage pathways. And I'll show you that the aeration, the normal passage of gasses through in and out of the sinuses. Uh the nitrous oxide, the oxygen carbon dioxide concentrations etcetera are very important to have the normal homeostasis in the sinuses. Um And of course controlling and preventing the inflammation with which would then cause that dysfunction. And this is just a coronal view of the sinuses, the black is the air. And you notice that you have the frontal eth Boyd maxillary sinuses, the takeaway point. You know, everybody comes in and says I have post nasal drip and post nasal drip is actually physiologic. It is transparent when it is normal it is necessary the mucus production. And this is a secretary cell next to the silly it'd sell the mucus production. Not only has immunoglobulins in it, the I. G. A. But it also has musician and other proteins that allow us to lubricate our upper airways and allow us to swallow, breathe and talk and if anyone has had dry mouth you realize how disabling that is. But that mucus blanket is covering our upper airways and allows us physiologic function. The I. G. A. Has become a great topic about coronavirus because because the coronavirus is harbors in the nasopharynx. And once you have a vaccination you have um immulogic uh systemic protection hopefully but you don't have your coastal level of protection. Now some of the vaccinations do give you both print bar which is for uh New Markakis does give you both I. G. A. And I. G. G. Immuno competency. But the the current coronavirus vaccinations only give you uh antibody uh protection. So once you do get exposed then you develop your I. G. A. Immunity. And so uh I. G. A. Now has become a big topic of conversation. So the ceiling area cells, they beat the this mucus production. And one of the theories of why we have sinuses is because we needed a surface area large enough to develop enough mucus to then lubricate or upper airways along other theoretical aspects of lightning the head so we can stand up et cetera. And of course now that we're standing up in evolution, the drainage pathways are actually anti gravitational and in evolution now we've developed these auxiliary cells to push the mucus out. Um the lack of flow of mucus out of the sinuses then allows the bacteria to actually migrate into the sinuses and cause infection. And then of course the cadre of infectious sinusitis. Uh and that's you know there's a big thing in in uh infectious or in community acquired diseases the watch and wait The first three days of a viral or allergic infection. 3-5 days treat symptomatically the majority of patients will get better. Those that don't probably have then bacterial migration into their scientists and that's when they come to the office. So this is a nice little picture of the little uh function of cilia, how they move they they kind of moving a a a bidirectional fashion and they're moving that mucus that and the I. G. A. And other enzymatic uh uh materials to keep the homeostasis in the control of the bacterial overgrowth at a at a minimum. And that's called mucus illusory flow. And here is just a depiction of how the mucus mucus cilia airflow is directed towards the top of the sinus cavities. And you can see how those pathways are nicely defined and how when they do get obstructed, then you can develop that bacterial migration. And then just another nice picture of how that mucus beats out and how the prevention of the migration of bacteria into the sinuses occurs. And this is a depiction of a patient that has obstruction of that pathway and then retrograde infection. Uh the gray is infection and um uh this patient will need to be treated uh medically both in the frontal sinuses, the ETh Boyd sinuses and the maxillary sinuses. So getting back to the first aspect of curable aspect, structural is deceptive deviations. There's a lot of controversy of why we have septal deviations. I have my own anecdotal feeling, why we develop them and I believe it's related to incidental childhood trauma. When our kids learn how to walk. I witnessed it with my son taking a header into the side of the door. He got a big tomato cherry bomb on his head. Little nosebleed ensuing discussion with my wife about going to the emergency room discussion, but an argument I said, go to the emergency room, they're gonna call me, he's fine. He went back to playing with his Tonka truck and everything was fine, but he has a nice septal deviation. Now The body is just too perfectly designed. I mean we don't have, you know, 10 fingers, 10 toes or eyes are pretty symmetric to have such a prevalent anomaly. Uh There has to be some incidental trauma of childhood and development. That's my own observational aspect, nasal polyps, cysts contra below. So you'll see that in your reports constable osa is a expansion of the normal sinus cavities into the middle turbinate. Sometimes it could be in the inferior turbinate rarely. And I used the analogy of a budding rose to describe the sinuses uh every pedal, the roses of different size and shape. And when you look at a sinus cavity, the aeration, every sinus cavity is different in size and different in shape. Uh And that's how the new monetization happens. Bony growths, osteo Mazz turbulent swelling and blockage relating to either hormonal or environmental issues. We can fix those. And this is an example of a septal spur deviated septum. This is a very overlooked cause of chronic headaches and we call it rana genic headaches and they can be the precursor to to facial migraine syndrome. I can't tell you a week doesn't go by that. I see a patient for a council for chronic sinusitis, they've been on money courses Zithromax and they come in, they have perfectly pristine, normal sinuses. Uh and they actually have facial migraine rhino genetic facial migraine syndrome. Um So this is an example and this is just an endoscopic example of how that septal bone spur is in impinge ng and impacting into the turbinate tissues. And patients will tell us that when they get a little inflammation, they'll actually feel it almost like a vacuum headache and they will try to massage the side of their face. And uh they're the happiest because when you remove that bone spur, just as a bone spur of the knee or or the back they get very symptomatic relief. Um The nasal turbinate tissue uh dr Kochar talked a little bit about the nasal cycle. It's a neuro physiologic cycle. We don't know why it happens, but there's no question. Every hour to hour and half it happens. And the terminator functions. The nasal human radiators to him modify the inspired era to filter the inspirer and temperature regulate the area. So once it gets into your lungs, it's humidified for adequate guests exchange. It's clean and it's at our body temperature. So this is just example again of the the tissues. This is uh the nasal cycle one side swollen. The other side's not, patients will come in and they'll tell you that they could actually feel that this cycle going on. We all are are experiencing it right now. But without nasal obstruction, it's just a normal cycle. This is an example of a nasal polyp. Um Allergy can cause it can be related to infection. Could be a genetic polyp. Good examples when patients have colonic polyps, they have to have endoscopy is every year or two to trim back those colonic polyps, There are genetic polyps that that occur. So what is the daily things that you could tell your patients to do that will really impact their lives? And this is one thing I do it every morning washing your nose with nasal sailing. It's like brushing your teeth or washing your hands. And it really does clean the debris and the particular matter. But also most of them. The physiologic saline component actually is the hyper tonic and it actually promotes more mucus illusory flow, topical nasal sprays. And I'll talk about a new one called X hands. And these are just like fluoride for your teeth Alright for your teeth prevents and diminishes the incidence of dental carriers. You can still get one patients with inflammatory disease in their nose. It prevents science infections and improves the actual physiology, but it does not. I have to obliterate them topical medicated saltwater washes. We'll talk a little bit about that topical antibiotics and steroids, antibiotics by mouth, and a history of steroids by mouth allergy treatments and most importantly, stomach acid reflux treatment. The ah ha Moment for me about this was a publication about 20 years ago in Children with middle ear infusions that had tubes And they did all the different essays on the middle of infusions. And 82% of them had Pepsi and Pepsi in again, 1000 times more concentration than is in the serum in their middle ear fluid. So the infection was most probably secondary the acid reflux into the middle ear was primary. And uh that basically also put a you know, light bulb? Because every child reflexes until about a year and a half, why do you think mothers walk around with burp cloths on their shoulders until they're about eight months. They're basically reflux. And that's just a normal physiologic process. Some continue on and and have middle ear effusions. So stomach acid reflux especially silent. It's such an important aspect. And if you ever want to figure out what people are doing by themselves themselves treating, just go to the pharmacy and look at the the the lines of anti histamine and colds, muscular skeletal. I'll and then you have the reflex I'll. So patients are really suffering from this and and they don't they don't even realize it. But is it something to keep on your radar screen? So nasal salt water lavage cleans out the thick mucus. Who does remove the bacteria viruses the particular matter? And the nature of your salt also produces more um the mucus production nasal steroid therapy is very safe if done correctly and uh you have to teach your patients to do it correctly or else they will deposit the nasal steroids on their nasal septum, developed nosebleeds and possibly even preparations it's minimally absorbed into the body. So there's no adrenal cortical effect from them. Um And of course the main side effects is bleeding. So you really want to when you have your patients tell them the cross arm technique, right hand to the left nostril because if you do your right hand to your right nostril. Just the mechanics of the spray causes you to do it or or or point the spray onto the septum. On the contra lateral nos nostril. You're automatically going to uh propel the east prey securely and laterally. So cross arm is a very effective way. There's a new device and this is a really innovative device. Unfortunately you have to beg to get it. But in our practice we have veteran patients. Because of all the nasal sprays over the counter, we have to go through a couple hoops. But the premise of this and if you look at the diagram that was a radio nucleotides study in the middle of a natural Aquarius spray, 80% of it goes down the throat, 20% of it deposits in the nose. This device actually has a the propellant is the patient's own exhalation. And when they exhale obviously you close the posterior nasopharynx, your soft palate, creating a positive pressure back there and preventing the material. The medication from going down into the into the into the oral cavity and thus propelling it superior early into the nose. And if you look at the radio nucleotides study On the last 80% of it stays in the nose where you wanted to work. Uh and it's it's uh the patients that have been placed on this are usually very very happy with it antibiotics by mouth. Of course bacterial community. We have a bacterial flora. The community of bacteria different are different based on region from the South Bay to the valley East L. A. West L. A. Uh The the bacterial floor are are different. Um But thinking about the the inflammatory phase, there's actually two aspects of it. And this is where the Art of medicine comes in. Because patients will say you know 10 days of antibiotics that's usually what I take. But the physiologic process has not been reversed the cilia or they're still swelling. The cilia aren't beating. And although you may have calmed down that infection within 10 days the the ability of physiologically to prevent a reinfection is is not there. So in chronic sinusitis we recommend usually of course of 2-3 weeks Um sometimes even 4-6 weeks of antibiotics. The other interesting aspect of the bacterial community. It is it is a a hierarchy. So you may have one culture and you may treat that bacteria but then the bacteria floor that was suppressed by that major big strong bacteria mostly staph or strep may then start to grow. Um So it's not uncommon that patients and chronic sinusitis will have differential evolving cultures. Your culture one bacteria you knock that one out and then there's still some infection you re culture them and there's a whole new set of bacteria. They were always there but they were suppressed from growing from the dominant bacteria and there's a lot of micro biologic evidence to support that when there's irreversible changes in tissue infection. We start to think about surgery. Talking about some nuances that have happened for the 30 years of my practice we were always looking for solutions topically nebulizer uh treatments of liquid treatments um all different types of of uh therapies topically and nothing really worked in my opinion until we made got this formulation from Australia using lock support along with an unlocked supports a license home that actually attaches the medicine to the surface of the tissue. It treats biofilm and of course it's bacteria culture directed. And you can apply topical steroids. So many of my patients that have had surgery because it doesn't work as well if you don't have a cavity for the medication to get in and then to absorb. But the patients post operatively that have a cavity window that medication can get into. They just use it every whenever they get symptomatic for 3-5 days and they feel better. Stomach acid silent reflux is a major issue that we have to pay attention to. It also causes upper airway inflammatory aspects of bronchitis. And of course the treatment is behavioral modification, losing weight. Oral oral topical therapies for the enzymatic or the alkaline reflux. You know one of the worst things that happened to reflexes we call it acid reflux that should have been called reflux because there's no gatekeeper saying only the assets going up the the digestive enzymes are coming up as well. So you do. And the only therapy for those are topical therapies like Tom's gascon, gascon advanced etcetera, clean environment, no smoking HEPA filters in the bedroom. We spend the most time in in our lives in our bedroom. So you want to have the air of the cleanest there anti allergy bedding, no stuffed animals. Daily, lifelong cure, washing the nose, saltwater, daily nasal steroids. The excitement's anti acid medicines, allergic. Have you seen by your allergist? Uh daily and the history and shots and now the biologics. Um and of course treating scientists infections promptly. Uh surgery is to treat the current process that is irreversible. Um It's not a cure. Um I tell patients the surgery will take care of this infection, but you can get another infection and if you don't maintain your lifelong therapy, then that will no doubt come back. Um So, of course the behavioral modifications and lifelong therapy is important. Long term diligence to prevent recurrence. So, truly the surgery is to remove the irreversible disease also to create all right ah areas where you can deposit this topical therapy if that's necessary. So, the surgical advances of course are endoscopic outpatient. But three dimensional image guided surgery is probably the the biggest one because we can verify real time if the disease is completely removed, which is probably the biggest of the shortcomings of surgery prior to image guidance is that because of safety, we would leave disease behind and that's an inadequate surgery. So, surgery was always given a bad rap Because if you leave one infected air cell behind, they're still infected and that's going to serve as a long term seating source. So, really eradicating all the disease and ventilating the sinuses is necessary. So, this is just let's see if this is gonna work. Mhm. To attract image guidance system that's used in the operating room. All right. Three dimensions caps and what we're doing your show. Mhm Right, Sure. Yeah, they Mhm. Yeah. Mm hmm. Yeah, wow. Hi, the tractor. Mhm. Honestly. How environment? Yeah, yeah. All the So that's the tracking instruments. This was the original Uh huh platform. All right. And it changed the aspect of the safety of the sinusitis. Let's see here, balloon sinus dilation uh is another advent. It's to be able to open those obstructed inflammatory tracks. It's really limited to very unique cases, not really chronic sinusitis or with polyps, but on those incidental cases where there's an obstruction sinus and it just by aerating the sinus, they'll get better. Um This is a example of a balloon dilation with image guidance and as you see, just opening up the outflow tracts, the sinusitis did improve. Um This is just some quick examples of results and what we actually do when we do sinus surgery. This is a patient with pan sinusitis involving involving all the sinuses. And this is the postoperative. You you could see that windows have been made in the maxillary sinuses up into the ETh Boyd sinuses. And now of course the aeration has occurred by the black view. This is the view of the actual removing all those honeycomb cept ations so that you're able to take of small 10 to 20 cavities. Make one large cavity for drainage and for aeration. And this is the sagittal view of the same from the from the skull base all the way back. And I'll tell you that the big for my uh practice. The image guided is like a video was a video game for me it made me a better surgeon because I had real time immediate verification of my clinical surgical judgment at the time of surgery and dr Butler and all of us use it. It's really gives us an added margin of not only disease eradication but safety. And and this is an example of a complete skull based removal of disease without image guided. I don't think many surgeons would feel comfortable because just on the other side of that fence is the is the brain and the inter cranial cavity. And this is another example and a couple of this patient had three failed surgeries and now doing well by aerating um the sinus cavities opening the front ALs etcetera. And there's another example. So this gives you an idea of what the goals of surgery are but really it's a medical immunological disease. So the takeaway parts, it's control only in in structural aspects. Can you really get a cure? It's lifelong therapy and really addressing the inflammatory processes of these disease as a as a long term control aspect is key. And uh Dr Fuller is here today and she's absolutely ecstatic about the new biologics that we have that are chronic sinus veteran patients. All we had were steroids and now we have unbelievable biologics ah to help these patients really have healthy lives, which is fantastic. Um so that's the aspect of the chronic sinusitis talk. Um hopefully that gave you some insights of the little things that we do. But really when you talk about chronic sinusitis, as surgeons were kind of like a wide receiver really, uh the medical therapy, behavioral modifications, our allergy and immunology colleagues, they really are the front lines and um of carrying this disease or controlling this disease.