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Treatment of Sinusitis
Otolaryngology Head and Neck Surgery Volume t'12 Number 4
Letters to the Editor
Author's Reply: While I think I understand what Dr. Lempert is asking, his letter illustrates many of the problems with our thinking of vestibular problems. My study 1was a randomized study in which I found that there was no difference in improvement rates for patients with benign positional vertigo assessed 1 month after treatment, whether or not the "canalith repositioning maneuver" as described by Epley 2 was used. As discussed in my article, I used Epley's method, except for the inclusion of a vibrator, not a "modification" as Lempert has presumed. I believe that the high spontaneous improvement rate for this disease must be considered when any therapeutic maneuver is recommended. Contrary to Dr. Lempert's assertion, the study by Herdman et al. 3 did not find Epley's maneuver superior to anything. The authors reported no difference between two different methods. This is an honest result and would be expected if these maneuvers have no physiologic effect. Dr. Lempert points to the best reference that we have in the literature that attempts to precisely identify the geometry of the semicircular canals? This reference indicates that the posterior canal makes an angle of 55.84 +- 3.95 degrees with the sagittal plane, which is the measurement relevant to the present discussion. Using these data, Lempert then states that "...a further 90degree head rotation is to be added..." I don't understand to what this 90 degrees is to be added or why. Does Dr. Lempert mean that the patient should be prone? Why is 90 degrees added to whatever rather than 55 degrees? Finally, Lempert's statement that relief occurs "...in 77% after one treatment..." provides no evidence that the maneuver had any impact. Many patients who undergo only an aggressive Hallpike test report no dizziness afterwards. In my study, I arbitrarily chose 1 month as an end point, but I have no reason to presume that these patients required 1 full month. The time course of this illness is likely to vary from practice to practice, so I do not hold out my data as the final truth on spontaneous improvement rates in all cases. Assessment of efficacy can only be made when the natural course of the disease is simultaneously considered. Randomization to treatment and nontreatment groups is one way to do this.
Brian W. Blakley, MD, PhD Gordon H. Scott Hall of Basic Medical Science 540 E. Canfield Ave. Detroit, MI 48201 23/8/62219 REFERENCES
1. Blakley BW. A randomized, controlled assessment of the canalith repositioning maneuver. OTOLAR~OOLHEAD NECK SURO 1994;I10:391-6. 2. Epley JM. The canalith repositioning procedure for treatment of benign paroxysmal positional vertigo. OTOLARYNGOLHEA~ NECKSURG1992;107:399-404.
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3. Herdman SJ, Tusa RJ, Zee DS, Proctor LR, Mattox DE. Single treatment approaches to benign paroxysmal positional vertigo. Arch Otola~ngol Head Neck Surg 1993;119:450-4. 4. Blanks RHI, Curthoys IS, Markham CH. Planar relationships of the semicircular canals in man. Acta Otolaryngol 1975;80: 185-96. Treatment of Sinusitis
To the Editor: Your editorial of April 1994 by Stankiewicz and Osguthorpe on "Medical Treatment of Sinusitis" (OTOLARVNGOL HEAD NECK SURG 1994;110:361-2.) exhibits a glaringly deficient omission in medical treatment of sinusitis. In doing so, the editorial emphasizes an unfounded, overrated faith in antibiotics. Omitted in the discussion regarding subacute and chronic sinusitis are the office procedures of nasal packing with argyrol or cocaine, displacement irrigation, natural ostium irrigation, and puncture irrigation. Are these formerly belabored teachings of the specialty abandoned in this report because "medical" means drug treatment? Is the advocated use of more expensive antibiotics for a longer duration serving the best interests of patients or drug industry profits? How motivated should the otolaryngologists be in pursuing alternatives to surgery when their highest financial interests are achieved by operation on "medical" failures? Is this supposed expert consensus or opinion of the belief that allergy management has no role or relation to sinusitis either recurrent or chronic? It is idealistic to expect all practitioners to ask themselves these questions. It is essential that the elite of the specialty and the government regulators ask these questions, otherwise where is the patient to look for an advocate?
Robert R. Somerville, MD 712 N. 77 Sunshine Strip Suite 21 Harlingen, TX 78550 23]8/59213
Authors' Reply: We appreciated Dr. Robert Sommerville's letter commenting on what he believes are omissions in the "Medical Treatment of Sinusitis" guest editorial of the April issue of the Jot;rcN~. The editorial represented a consensus of the Academy's Rhinology and Paranasal Sinus and Infectious Diseases Committees. While we disagree with Dr. Sommervilte's assertion regarding :'an unfounded, overrated faith in antibiotics," we do agree that judicious use of ancillary office procedures can be beneficial for localized sinusitis. Cocaine decongestion is excellent for the recalcitrant acute sinusitis, but it can provoke untoward side effects and is not necessary for the average case. Proetz displacement, ostia irrigation, and puncture irrigation are not necessary for routine cases of acute sinusitis and have most benefit for fiuid-filled sinus disease or localized maxillary, sphenoid, and (questionably) frontal sinusitis. These procedures are not as beneficial for mucosal thickened pansinusitis. While we understand Dr.
Letters to the Editor
Author's Reply: While I think I understand what Dr. Lempert is asking, his letter illustrates many of the problems with our thinking of vestibular problems. My study 1was a randomized study in which I found that there was no difference in improvement rates for patients with benign positional vertigo assessed 1 month after treatment, whether or not the "canalith repositioning maneuver" as described by Epley 2 was used. As discussed in my article, I used Epley's method, except for the inclusion of a vibrator, not a "modification" as Lempert has presumed. I believe that the high spontaneous improvement rate for this disease must be considered when any therapeutic maneuver is recommended. Contrary to Dr. Lempert's assertion, the study by Herdman et al. 3 did not find Epley's maneuver superior to anything. The authors reported no difference between two different methods. This is an honest result and would be expected if these maneuvers have no physiologic effect. Dr. Lempert points to the best reference that we have in the literature that attempts to precisely identify the geometry of the semicircular canals? This reference indicates that the posterior canal makes an angle of 55.84 +- 3.95 degrees with the sagittal plane, which is the measurement relevant to the present discussion. Using these data, Lempert then states that "...a further 90degree head rotation is to be added..." I don't understand to what this 90 degrees is to be added or why. Does Dr. Lempert mean that the patient should be prone? Why is 90 degrees added to whatever rather than 55 degrees? Finally, Lempert's statement that relief occurs "...in 77% after one treatment..." provides no evidence that the maneuver had any impact. Many patients who undergo only an aggressive Hallpike test report no dizziness afterwards. In my study, I arbitrarily chose 1 month as an end point, but I have no reason to presume that these patients required 1 full month. The time course of this illness is likely to vary from practice to practice, so I do not hold out my data as the final truth on spontaneous improvement rates in all cases. Assessment of efficacy can only be made when the natural course of the disease is simultaneously considered. Randomization to treatment and nontreatment groups is one way to do this.
Brian W. Blakley, MD, PhD Gordon H. Scott Hall of Basic Medical Science 540 E. Canfield Ave. Detroit, MI 48201 23/8/62219 REFERENCES
1. Blakley BW. A randomized, controlled assessment of the canalith repositioning maneuver. OTOLAR~OOLHEAD NECK SURO 1994;I10:391-6. 2. Epley JM. The canalith repositioning procedure for treatment of benign paroxysmal positional vertigo. OTOLARYNGOLHEA~ NECKSURG1992;107:399-404.
629
3. Herdman SJ, Tusa RJ, Zee DS, Proctor LR, Mattox DE. Single treatment approaches to benign paroxysmal positional vertigo. Arch Otola~ngol Head Neck Surg 1993;119:450-4. 4. Blanks RHI, Curthoys IS, Markham CH. Planar relationships of the semicircular canals in man. Acta Otolaryngol 1975;80: 185-96. Treatment of Sinusitis
To the Editor: Your editorial of April 1994 by Stankiewicz and Osguthorpe on "Medical Treatment of Sinusitis" (OTOLARVNGOL HEAD NECK SURG 1994;110:361-2.) exhibits a glaringly deficient omission in medical treatment of sinusitis. In doing so, the editorial emphasizes an unfounded, overrated faith in antibiotics. Omitted in the discussion regarding subacute and chronic sinusitis are the office procedures of nasal packing with argyrol or cocaine, displacement irrigation, natural ostium irrigation, and puncture irrigation. Are these formerly belabored teachings of the specialty abandoned in this report because "medical" means drug treatment? Is the advocated use of more expensive antibiotics for a longer duration serving the best interests of patients or drug industry profits? How motivated should the otolaryngologists be in pursuing alternatives to surgery when their highest financial interests are achieved by operation on "medical" failures? Is this supposed expert consensus or opinion of the belief that allergy management has no role or relation to sinusitis either recurrent or chronic? It is idealistic to expect all practitioners to ask themselves these questions. It is essential that the elite of the specialty and the government regulators ask these questions, otherwise where is the patient to look for an advocate?
Robert R. Somerville, MD 712 N. 77 Sunshine Strip Suite 21 Harlingen, TX 78550 23]8/59213
Authors' Reply: We appreciated Dr. Robert Sommerville's letter commenting on what he believes are omissions in the "Medical Treatment of Sinusitis" guest editorial of the April issue of the Jot;rcN~. The editorial represented a consensus of the Academy's Rhinology and Paranasal Sinus and Infectious Diseases Committees. While we disagree with Dr. Sommervilte's assertion regarding :'an unfounded, overrated faith in antibiotics," we do agree that judicious use of ancillary office procedures can be beneficial for localized sinusitis. Cocaine decongestion is excellent for the recalcitrant acute sinusitis, but it can provoke untoward side effects and is not necessary for the average case. Proetz displacement, ostia irrigation, and puncture irrigation are not necessary for routine cases of acute sinusitis and have most benefit for fiuid-filled sinus disease or localized maxillary, sphenoid, and (questionably) frontal sinusitis. These procedures are not as beneficial for mucosal thickened pansinusitis. While we understand Dr.