Sinusitis
The paranasal sinuses are four pairs of air filled cavities within the bones of the face, above and around the eyes and nose, named the maxillary, ethmoid, frontal and sphenoid sinuses. They are connected to the nasal cavity by small openings and are lined by the same mucous membrane that lines the nasal passages and the rest of the respiratory system.
Air passes in and out of the sinuses and mucous produced by the mucous membrane is able to drain into the back of the nasal cavity. Mucous helps to remove dust, bacteria and other air pollutants from the sinuses and nasal cavity.
What is sinusitis?
Sinusitis, also known as sinus infection, inflammatory sinus disease or rhinosinusitis, is the inflammation of the mucosal lining of one or more of the sinuses. The inflammation causes congestion which leads to the build up of pressure causing symptoms such as pain, nasal discharge, post nasal drip, headache, fever, reduced sense of smell and a feeling of fullness of the face.
What causes sinusitis?
The inflammation can be caused by infection or allergies. Usually the infection that causes sinusitis is bacterial or viral, although fungal infections can also cause the condition.
Obstructions within the sinuses or nasal cavity such as anatomic variants, deviated septum, nasal polyps or tumours, can lead to sinusitis by preventing the normal drainage of mucous and creating a breeding ground
for infection.
What is the difference between acute and chronic sinusitis?
Acute sinusitis commonly occurs as the result of a cold, a bacterial or viral infection, or allergies. Symptoms may last up to four weeks. There may be repeated occurrences but symptoms are absent in between episodes.
Chronic sinusitis is considered present if a patient has continuous symptoms for more than three months. The sinuses may become narrowed or closed completely due to chronic infection and inflammation. Ongoing allergies and environmental irritants such as cigarette smoke may also be a causative factor.
How is sinusitis diagnosed?
The diagnosis of sinusitis can be difficult as its symptoms can mimic those of a common cold. In order to make an accurate diagnosis a full medical history is taken including an assessment of the nature and duration of symptoms. A physical examination is performed including looking into the ears, throat and nose.
Imaging of the sinuses is best achieved by a CT examination of the sinuses which allows high resolution cross sectional views of the sinuses in all three planes to be analysed. CT of the sinuses has replaced plain x-rays and the CT miniseries as the investigation of choice and does not require contrast injection.
Chronic sinusitis is demonstrated on CT by mucosal thickening within the sinuses which may obstruct the drainage pathways and extend into the nasal passages as nasal polyps.
Acute sinusitis may be diagnosed on CT if there is fluid within the sinuses forming a dependent level with air above. This can often occur superimposed upon a background of chronic sinusitis.
How is sinusitis treated?
Antibiotics are used to treat acute bacterial sinusitis. Longer courses may be needed for cases of recurrent or chronic sinusitis. Steroid medications such as prednisone may be prescribed in order to treat cases of chronic sinusitis.
Surgery may be recommended for cases where medical treatment has not been effective or an obstructive lesion has been demonstrated by CT. Functional endoscopic sinus surgery (FESS) aims to improve airflow and drainage between the sinuses and the nasal cavity by correcting structural abnormalities such as a deviated septum, removing obstructions such as polyps and by removing areas of diseased tissue.
Picture 1: Sagittal view of the frontal, ethmoid and sphenoid sinuses with normal aeration
Picture 2:Coronal view of the maxillary sinuses with moderate chronic sinusitis
Picture 3: Coronal view of the maxillary and ethmoid sinuses with severe chronic sinusitis and nasal polyposis
Clinical Cases
Case 1 illustrates mpMRI that has been performed following transrectal biopsy in the evaluation for possible management of prostate cancer by active surveillance. Despite significant elevation of PSA to 16 the biopsy had yielded tumour with a low Gleason score of 3+3, present as a single focus of malignant cells within the biopsy cores.
mpMRI demonstrates a 20mm lentiform T2 dark mass that shows restricted diffusion (dark) on the ADC map. Clinically significant malignancy is very likely. The initial biopsy had probably failed to sample this significant lesion that is located within the anterior gland.
Case 2
Case 2 demonstrates mpMRI in the investigation of PSA 3.1 at 6 years following radical prostatectomy (i.e. biochemical failure). A lobulated mass of locally recurrent tumour is detected at the cystourethral anastomosis. A key diagnostic feature is early and rapid enhancement (bright) of the abnormal tissue, as has been demonstrated on the dynamic imaging following gadolinium chelate by intravenous bolus.
Case 3
Case 3 represents mpMRI for the investigation of a progressive rise in PSA from 1.4 to 5.8 in the context of a normal digital rectal examination. A T2 dark mass within the peripheral left lateral part of the gland exhibits both reduced diffusion (dark) on the ADC map and early rapid enhancement (bright). Malignant disease is very likely, and the broad interface with the capsule of the gland indicates a high probability of microscopic extracapsular extension.
REFERENCES
1. Prostate imaging and reporting and data system:
www.acr.org/~/media/ACR/Documents/.../PIRADS/PIRADS%20V2.pdf
2. NZ Ministry of Health proposal for prostate cancer management:
http://www.vision6.com.au/ch/17559/2dfsb12/2322387/1efcax017.docx
Greetings From TRG
As you will see from this newsletter, and previous editions, we are continuing to happily pursue considerable change across our company.
Firstly, bringing our entire Group under one name will allow us to simplify and improve many things. This ranges from a new single website platform and phone system helping patients to make contact with us, through to the obvious opportunity of being able to refresh the look of all our clinics.
Considerable thought has gone into this whole project with the real passion being around the patient and their experience. Understanding the differing levels of patient anxiety and their unfamiliarity with medical imaging equipment and technology was key to developing strategies to make their journey with us as pleasant and supportive as possible.
Secondly, whilst we will make our clinics, and in some cases our equipment, look great, the real key remains with people. Over the last two years it has become obvious to us that TRG is blessed with a great team of people that genuinely care about our patients and referrers and our ongoing investment in training and communication is simply enhancing this. Our patient surveys are now a key measure of our success and suffice to say these are telling us that we are on the right track.
And thirdly, we are committed to technology improvement wherever possible – our staff and patients deserve that. This year the introduction of three new 3T MRI’s, the installation of West Auckland’s first ever MRI, a new fleet of ultrasound machines and a soon to be announced technology partnership that is a NZ first in the healthcare industry, which is perhaps testimony to this commitment.
Our progress will continue through the year and we will keep you updated on our plans, but right now, many, many thanks for the patients you refer to us – we are committed to providing them with the best experience possible.
Our Changing Look!
Redevelopment of our West Auckland clinic is complete. We are installing the new Samsung digital x-ray which will be a first in NZ. It is fully automatic and getting rave reviews in the Australia market. We have also installed a Siemens MRI, which will be the first in West Auckland to service this fast expanding population there.
Where we are today is by no means the end of our journey as we continue to build and cement our position as industry leaders in excellent customer care. Over the next 16 months we will be rolling out our new name and changing the look of all our clinics in the mid and upper North Island. Our Rotorua clinic is complete as is our new clinic in West Auckland. Our next clinics to be rebranded are those located at Ormiston and Taupo. We are about to open a new clinic in South Auckland and will advise you more on that in our next issue. Meantime it is business as usual so please continue to use our current referral pads until you receive our new ones. We are just putting the finishing touches on our patient brochures and website so you will start to see changes there emerging as well.
Our commitment to minimising clinical skill shortages in NZ
We are pleased to share with you our commitment to actively promote and develop our people, not only to meet business needs, but also to help reduce the skill shortage within NZ.
We are participating with local DHBs as part of the Northern Region Sonographer Project, where both private and public radiology services are collectively working together to reduce the current shortfall in this area. We currently have seven trainee sonographers in place and are about to about to appoint a further two trainees who will commence their training this month starting with the Auckland University intensive course - Postgraduate Diploma in Health Sciences (Ultrasound). TRG Group has the largest training programme in New Zealand.
Not only do we have a formal ultrasound training programme in place, we are about to introduce a similar training scheme for MRI. We believe that very soon there will be a skill shortage in this area and we are determined to stay ahead of these growing demands so that we can continue to deliver a quality and timely service to you and your patients.
In addition to dedicated training positions (ultrasound, MRI, and mammography), we also deliver in-house learning CME workshops calling on local and international experts to provide targeted learning that not only develops the skills of our people attending, but also ensures we remain current with your requirements. Most recently we hosted in conjunction with Toshiba Medical, a very successful event with a great turnout of sonographers and radiologists. Rex de Ryke was the guest speaker (Charge Sonographer at Canterbury DHB, active in ASUM and an examiner for the DMU - Diploma of Medical Ultrasound). This workshop focused on tertiary level obstetrics and fetal medicine with specific topics being chosen for their difficulty. Rex’s presentation on scanning the fetal heart was one of the best many of those attending had ever seen. The event was a great learning experience for all, as obstetric scanning is the most difficult to do from a technical and emotional point of view.
Bowel cancer
With bowel cancer being the third most common cancer in the world, and New Zealand and Australia having the world’s highest rates of diagnosis, TRG Group continues to focus on CT Colonography (or ‘Virtual Colonoscopy’) as a key tool in the fight against the disease.
This examination is widely regarded as more comfortable than conventional colonoscopy and uses our low dose multislice CT scanners to scan the entire abdomen and pelvis. Our workstation then post-processes this data and delivers useful and interactive images.This includes 3D images where the bowel is literally "flown-through".
Colorectal cancer is predominantly a preventable disease if precursor adenomatous polyps are identified at an early stage and subsequently removed. Hence the relatively non-invasive CT Colonography examination has become highly valued byMedical Specialists, General Practitioners and their patients.
Colonic Polyps and Colon Cancer
The prevalence of colonic polyps increases with age, particularly beyond 50 years. Untreated, many colonic polyps progress to carcinoma over several years. The risk of cancer developingin sporadic 10 mm colonic polyps is approximately 8% at 10 years and 24% at 20 years. The risk forcancer development depends on the size of the polyp,villous histology, and its association with polyposis syndromes.
CT Colonography (CTC) is especially useful:
- In elderly and frail patients
- When colonoscopy may be higher risk e.g.
patients on anticoagulants - Following failed or incomplete colonoscopy:
If the incomplete colonoscopy is an obstructing lesion then a combined CTC and staging CT scan (using IV contrast) may be performed - When colonoscopy may be difficult or painful: eg: following diverticulitis (wait 6 weeks before CTC)
What’s involved?
- BowelcleansingLowresiduediet 2 days before.
- Cleansinglaxativesthe day before.
- FaecaltaggingOral stool marking. Makes residual bowel contents relatively dense
- ProcedureSmall flexible tube inserted in rectum. Bowel inflated with air or CO2.
- CT Scan Usually quick recovery after examination.
- No IV contrast or sedation. Supine and prone series to distribute the fluid and gas.
- Examinationtime - approximately 45 minutes
- Welltolerated- drive home after the examination.
Comparison of CT Colonography (CTC) to Colonoscopy
- Accuracy – both techniques have an accuracy of >95% for the detection of polyps > 10mm.
- Colonoscopy is better for detection of flat lesions and smaller polyps
- CTC is better for extra-colonic lesions (8% require additional workup and 2% are significant)
CT Colonography (CTC) is indicated for:
- Diagnosis/exclusion of colorectal cancer in symptomatic patients: especially with symptoms with a relatively low risk of colonic malignancy eg change of bowel habit, abdominal pain, weight loss, (patients who may have had a barium enema in the past).
- For screening in asymptomatic average risk people.
When CTC is not the test of choice:
- Suspected mucosal lesions such as inflammatory bowel disease and angiodysplasia.
- Known polyp syndromes (including familial) where biopsy is likely
- Young patients (<40 years) as there is a greater potential radiation risk
- Males with Fe deficiency anaemia (20% positive predictive value for significant lesion)
- Positive iFOBT. Expected to have a significant finding in up to 40%.
Why trg group ?
We have caring staff who look after your patient during and after the procedure. All our CT scanners have additional software to give a 30% radiation dose reduction compared with standard CT scanners. Our specialist radiologists are well qualified to interpret the scans.
Results from patient survey
Over the last 6 months we actively encouraged our patients to let us know what we can do better. We received over 1000 surveys from all our regions and utilised this information to improve on our service to you, our customer.
The results indicated that we are on the right track.
