Intubation Tips

Adverse respiratory events (AREs) are leading causes of post-operative morbidity and mortality. Anesthesia is the use of medicine to prevent or reduce the feeling of pain or sensation during surgery or other painful procedures (such as getting stitches). Giving as an injection or through inhaled gases or vapours, different types of anesthesia affect the nervous system in various ways by blocking nerve impulses and, therefore, pain.

Anesthesia can help control your breathing, blood pressure, blood flow, and heart rate. It may be used to:

1. Relax you,
2. Block pain,
3. Make you sleepy or forgetful,
4. Make you unconscious for your surgery.

Adverse Respiratory Events (ARE)
Adverse outcomes of such events are fatal and lead to Death & Brain Damage. Three mechanisms of injury are reported to account for highest adverse respiratory events:
Inadequate Ventilation: Insufficient Gas Exchange can produce the adverse outcome. Esophageal Intubation: Incubation between the two sides of the esophagus inadvertently.
Difficult tracheal intubation: Tracheal Intubation is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway. It is performed facilitate ventilation of lungs in severely ill, anesthetized patients.

Other’s are as listed below:

• Airway Obstruction
• Inadequate inspired oxygen delivery
• Aspiration
• Endobronchial Intubation
• Premature Extubation

Residual neuromuscular blockade is an important postoperative complication associated to the use of neuromuscular blocking drugs and is commonly observed in the post-anesthesia care unit (PACU) after non-depolarizing neuromuscular blocking agents (NMBAs) are administered intra-operatively. Incomplete neuromuscular recovery can be minimized with acceleromyography monitoring. The risk of adverse respiratory events during early recovery from anesthesia can be reduced by intra-operative acceleromyography use.

Reintubation is a serious adverse respiratory event and the consequences include increased cardiac and respiratory complications, prolonged length of stay at the PACU, intensive care unit (ICU) and hospital, prolonged mechanical ventilator support, higher costs, and increased mortality. Overweight and obesity have also been identified as risk factors for postoperative respiratory complications. Most adverse respiratory events are considered preventable with improved monitoring such as:

• Pulse Oximetry
• Capnometry
• Combination of Both

Closed observation of the clinical factors and appropriate monitoring by well trained people are factors necessary to prevent adverse outcome.

In case you have a concern or query you can always consult an expert & get answers to your questions!

Adverse respiratory events (AREs) are leading causes of post-operative morbidity and mortality. Anesthesia is the use of medicine to prevent or reduce the feeling of pain or sensation during surgery or other painful procedures (such as getting stitches). Giving as an injection or through inhaled gases or vapours, different types of anesthesia affect the nervous system in various ways by blocking nerve impulses and, therefore, pain.

Anesthesia can help control your breathing, blood pressure, blood flow, and heart rate. It may be used to:

1. Relax you
2. Block pain
3. Make you sleepy or forgetful
4. Make you unconscious for your surgery

Adverse Respiratory Events (ARE)
Adverse outcomes of such events are fatal and lead to death & brain damage. Three mechanisms of injury are reported to account for highest adverse respiratory events:

1. Inadequate Ventilation: Insufficient Gas Exchange can produce the adverse outcome.
2. Esophageal Intubation: Incubation between the two sides of the esophagus inadvertently.
3. Difficult tracheal intubation: Tracheal Intubation is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway. It is performed facilitate ventilation of lungs in severely ill, anesthetized patients.

Other’s are as listed below:

• Airway Obstruction
• Inadequate inspired oxygen delivery
• Aspiration
• Endobronchial Intubation
• Premature Extubation

Residual neuromuscular blockade is an important postoperative complication associated to the use of neuromuscular blocking drugs and is commonly observed in the post-anesthesia care unit (PACU) after non-depolarizing neuromuscular blocking agents (NMBAs) are administered intra-operatively. Incomplete neuromuscular recovery can be minimized with acceleromyography monitoring. The risk of adverse respiratory events during early recovery from anesthesia can be reduced by intra-operative acceleromyography use.

Reintubation is a serious adverse respiratory event and the consequences include increased cardiac and respiratory complications, prolonged length of stay at the PACU, intensive care unit (ICU) and hospital, prolonged mechanical ventilator support, higher costs, and increased mortality. Overweight and obesity have also been identified as risk factors for postoperative respiratory complications. Most adverse respiratory events are considered preventable with improved monitoring such as:

• Pulse Oximetry
• Capnometry
• Combination of Both

Closed observation of the clinical factors and appropriate monitoring by well trained people are factors necessary to prevent adverse outcome.

In case you have a concern or query you can always consult an expert & get answers to your questions!

Adverse respiratory events (AREs) are leading causes of post-operative morbidity and mortality. Anesthesia is the use of medicine to prevent or reduce the feeling of pain or sensation during surgery or other painful procedures (such as getting stitches). Giving as an injection or through inhaled gases or vapours, different types of anesthesia affect the nervous system in various ways by blocking nerve impulses and, therefore, pain.

Anesthesia can help control your breathing, blood pressure, blood flow, and heart rate. It may be used to:

1. Relax you,
2. Block pain,
3. Make you sleepy or forgetful,
4. Make you unconscious for your surgery.

Adverse Respiratory Events (ARE)
Adverse outcomes of such events are fatal and lead to Death & Brain Damage. Three mechanisms of injury are reported to account for highest adverse respiratory events:
Inadequate Ventilation: Insufficient Gas Exchange can produce the adverse outcome. Esophageal Intubation: Incubation between the two sides of the esophagus inadvertently.
Difficult tracheal intubation: Tracheal Intubation is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway. It is performed facilitate ventilation of lungs in severely ill, anesthetized patients.

Other’s are as listed below:

• Airway Obstruction
• Inadequate inspired oxygen delivery
• Aspiration
• Endobronchial Intubation
• Premature Extubation

Residual neuromuscular blockade is an important postoperative complication associated to the use of neuromuscular blocking drugs and is commonly observed in the post-anesthesia care unit (PACU) after non-depolarizing neuromuscular blocking agents (NMBAs) are administered intra-operatively. Incomplete neuromuscular recovery can be minimized with acceleromyography monitoring. The risk of adverse respiratory events during early recovery from anesthesia can be reduced by intra-operative acceleromyography use.

Reintubation is a serious adverse respiratory event and the consequences include increased cardiac and respiratory complications, prolonged length of stay at the PACU, intensive care unit (ICU) and hospital, prolonged mechanical ventilator support, higher costs, and increased mortality. Overweight and obesity have also been identified as risk factors for postoperative respiratory complications. Most adverse respiratory events are considered preventable with improved monitoring such as:

• Pulse Oximetry
• Capnometry
• Combination of Both

Closed observation of the clinical factors and appropriate monitoring by well trained people are factors necessary to prevent adverse outcome. If you wish to discuss about any specific problem, you can consult a general surgeon.

Adverse respiratory events (AREs) are leading causes of post-operative morbidity and mortality. Anesthesia is the use of medicine to prevent or reduce the feeling of pain or sensation during surgery or other painful procedures (such as getting stitches). Giving as an injection or through inhaled gases or vapours, different types of anesthesia affect the nervous system in various ways by blocking nerve impulses and, therefore, pain.

Anesthesia can help control your breathing, blood pressure, blood flow, and heart rate. It may be used to:

1. Relax you,
2. Block pain,
3. Make you sleepy or forgetful,
4. Make you unconscious for your surgery.

Adverse Respiratory Events (ARE)
Adverse outcomes of such events are fatal and lead to Death & Brain Damage. Three mechanisms of injury are reported to account for highest adverse respiratory events:
Inadequate Ventilation: Insufficient Gas Exchange can produce the adverse outcome. Esophageal Intubation: Incubation between the two sides of the esophagus inadvertently.
Difficult tracheal intubation: Tracheal Intubation is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway. It is performed facilitate ventilation of lungs in severely ill, anesthetized patients.

Other’s are as listed below:

• Airway Obstruction
• Inadequate inspired oxygen delivery
• Aspiration
• Endobronchial Intubation
• Premature Extubation

Residual neuromuscular blockade is an important postoperative complication associated to the use of neuromuscular blocking drugs and is commonly observed in the post-anesthesia care unit (PACU) after non-depolarizing neuromuscular blocking agents (NMBAs) are administered intra-operatively. Incomplete neuromuscular recovery can be minimized with acceleromyography monitoring. The risk of adverse respiratory events during early recovery from anesthesia can be reduced by intra-operative acceleromyography use.

Reintubation is a serious adverse respiratory event and the consequences include increased cardiac and respiratory complications, prolonged length of stay at the PACU, intensive care unit (ICU) and hospital, prolonged mechanical ventilator support, higher costs, and increased mortality. Overweight and obesity have also been identified as risk factors for postoperative respiratory complications. Most adverse respiratory events are considered preventable with improved monitoring such as:

• Pulse Oximetry
• Capnometry
• Combination of Both

Closed observation of the clinical factors and appropriate monitoring by well trained people are factors necessary to prevent adverse outcome. If you wish to discuss about any specific problem, you can consult a General Surgeon.

Adverse respiratory events (AREs) are leading causes of post-operative morbidity and mortality. Anesthesia is the use of medicine to prevent or reduce the feeling of pain or sensation during surgery or other painful procedures (such as getting stitches). Giving as an injection or through inhaled gases or vapours, different types of anesthesia affect the nervous system in various ways by blocking nerve impulses and, therefore, pain.

Anesthesia can help control your breathing, blood pressure, blood flow, and heart rate. It may be used to:

1. Relax you,
2. Block pain,
3. Make you sleepy or forgetful,
4. Make you unconscious for your surgery.

Adverse Respiratory Events (ARE)
Adverse outcomes of such events are fatal and lead to Death & Brain Damage. Three mechanisms of injury are reported to account for highest adverse respiratory events:
Inadequate Ventilation: Insufficient Gas Exchange can produce the adverse outcome. Esophageal Intubation: Incubation between the two sides of the esophagus inadvertently.
Difficult tracheal intubation: Tracheal Intubation is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway. It is performed facilitate ventilation of lungs in severely ill, anesthetized patients.

Other’s are as listed below:

• Airway Obstruction
• Inadequate inspired oxygen delivery
• Aspiration
• Endobronchial Intubation
• Premature Extubation

Residual neuromuscular blockade is an important postoperative complication associated to the use of neuromuscular blocking drugs and is commonly observed in the post-anesthesia care unit (PACU) after non-depolarizing neuromuscular blocking agents (NMBAs) are administered intra-operatively. Incomplete neuromuscular recovery can be minimized with acceleromyography monitoring. The risk of adverse respiratory events during early recovery from anesthesia can be reduced by intra-operative acceleromyography use.

Reintubation is a serious adverse respiratory event and the consequences include increased cardiac and respiratory complications, prolonged length of stay at the PACU, intensive care unit (ICU) and hospital, prolonged mechanical ventilator support, higher costs, and increased mortality. Overweight and obesity have also been identified as risk factors for postoperative respiratory complications. Most adverse respiratory events are considered preventable with improved monitoring such as:

• Pulse Oximetry
• Capnometry
• Combination of Both

Closed observation of the clinical factors and appropriate monitoring by well trained people are factors necessary to prevent adverse outcome.

Adverse respiratory events (AREs) are leading causes of post-operative morbidity and mortality. Anesthesia is the use of medicine to prevent or reduce the feeling of pain or sensation during surgery or other painful procedures (such as getting stitches). Giving as an injection or through inhaled gases or vapours, different types of anesthesia affect the nervous system in various ways by blocking nerve impulses and, therefore, pain.

Anesthesia can help control your breathing, blood pressure, blood flow, and heart rate. It may be used to:

1. Relax you
2. Block pain
3. Make you sleepy or forgetful
4. Make you unconscious for your surgery

Adverse Respiratory Events (ARE)
Adverse outcomes of such events are fatal and lead to Death & Brain Damage. Three mechanisms of injury are reported to account for highest adverse respiratory events:

1. Inadequate Ventilation: Insufficient Gas Exchange can produce the adverse outcome. Esophageal Intubation: Incubation between the two sides of the esophagus inadvertently.
2. Difficult tracheal intubation: Tracheal Intubation is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway. It is performed facilitate ventilation of lungs in severely ill, anesthetized patients.

Other’s are as listed below:

1. Airway Obstruction
2. Inadequate inspired oxygen delivery
3. Aspiration
4. Endobronchial Intubation
5. Premature Extubation

Residual neuromuscular blockade is an important postoperative complication associated to the use of neuromuscular blocking drugs and is commonly observed in the post-anesthesia care unit (PACU) after non-depolarizing neuromuscular blocking agents (NMBAs) are administered intra-operatively. Incomplete neuromuscular recovery can be minimized with acceleromyography monitoring. The risk of adverse respiratory events during early recovery from anesthesia can be reduced by intra-operative acceleromyography use.

Reintubation is a serious adverse respiratory event and the consequences include increased cardiac and respiratory complications, prolonged length of stay at the PACU, intensive care unit (ICU) and hospital, prolonged mechanical ventilator support, higher costs, and increased mortality. Overweight and obesity have also been identified as risk factors for postoperative respiratory complications. Most adverse respiratory events are considered preventable with improved monitoring such as:

1. Pulse Oximetry
2. Capnometry
3. Combination of Both

Closed observation of the clinical factors and appropriate monitoring by well trained people are factors necessary to prevent adverse outcome.

What is ECMO?
Like dialysis for unfunctional kidney, Ecmo for unfunctional lung.

Ecmo stands for extracorporeal membrane oxygenation. It is a method of giving oxygen for the body when icu pateint lungs and/or heart are not able to supply oxygen on their own. 

Why ICU pateint put on ECMO?

Doctors place ICU patients on ECMO when patients are not able to supply oxygen to the body.

ICU patients’ lungs fail for a number of reasons including pneumonia, lung cancer, pulmonary edema, pulmonary embolism and COPD.

 When a patient’s lungs fail, he/she first is intubated (breathing tube) and hooked up to a ventilator (breathing machine).
 However, sometimes lungs are so damaged that providing oxygen through intubation is not enough.

This is when doctors turn to v-v ecmo.
A heart can fail for many reasons including heart attack, pulmonary embolism, bad valve disease, or worsening heart failure. When a heart fails, doctors try to fix the underlying problem. They may also start medications (called ionotropes) to help improve the pump function of the heart. If medications are not enough, doctors will turn to v-a ecmo.

How long can someone stay on ecmo?

That is a complicated question. Due to the risks of ecmo discussed above, doctors try to keep patients on ecmo for as short a time as possible. Often patient will be on ecmo for several days up to 1-2 weeks. Every day, several blood and imaging tests are done to determine if a patient is ready to come off ecmo. As the technology of ecmo improves, hopefully side effects will decrease and patients can remain on ecmo for longer periods of time.

What is the difference between ecmo and a ventilator (breathing machine)?

Both ecmo and a ventilator aim to provide oxygen to the body when the patient’s own lungs and breathing are failing. The ventilator assists the patient’s own lungs by pushing oxygen with pressure into the lungs. Ecmo instead provides oxygen directly via a catheter placed in a patient’s vein or artery. We almost always try oxygenating a patient with a ventilator first. However, when a patient’s lungs are too sick for this, we turn to ecmo to assist in providing oxygen to the body. V-v ecmo provides oxygen through a vein. This blood then has to travel to the heart and be pumped around the rest of the body through arteries. Therefore, with v-v ecmo or with a ventilator, a patient must have a well-functioning heart to get the oxygen pumped throughout the body. V-a ecmo has the additional advantage of pumping blood directly to arteries. This “by-passes” the heart and is therefore the method of ecmo we use when a patient’s heart is failing.

Implications of cough before and after surgery: it's prevention and treatment are key to judicious management

Patients with cough frequently present to clinicians working in both primary and secondary care. Acute cough, which often follows an upper respiratory tract infection, may be initially disruptive but is usually self limiting and rarely needs significant medical intervention. Chronic cough often points towards some underlying lung pathology but many a times it presents as the sole manifestation of some throat pathology as well. Even with a clear diagnosis, cough can be difficult to control and, for the patient, can be associated with impaired quality of life. Any surgery may have some implications on the course of cough for any cause, whatsoever. On the other hand, surgery, per say, may create some situations which lead to distressing cough.

Acute cough before surgery:

May occur as an exacerbation of chronic underlying lung disease eg. Asthma, copd or lung fibrosis or an acute viral illness, commonly. The chronic disease should be evaluated in terms of lung function to predict post-operative risk for prolonged ventilation. Any acute viral illness causing distressing cough may entail delaying the surgery for 6 weeks, depending on the assessment of concerned anaesthesiologist. This is due to the fact that an acute viral infection may make the person more susceptible to the ill effects of anaesthetic agents. Another issue regarding the effect of violent cough in some specific form of surgery like cataract extraction is the adverse operative outcome due to raised pressure in eyes with every bout. So, the cough needs to get controlled by applying vigorous measures, depending on the cause and extent of cough, in such special cases.

Post- operative cough:

There could be several causes occurring not very rarely in many post-operative cases. The causes may be:
I) effect of anaesthetic gases
Ii) laryngeal swelling due to placement of plastic tube in airways during any prolonged surgery
Iii) segmental lung collapse due to lack of chest wall movement
Iv) infection in lower airways due to any compromised immune status or pre-existing illness
V) partial damage of a nerve named phrenic nerve in any upper abdominal surgery, causing partial immobility to the diaphragm
Most of the conditions deserve separate attention, but common post-operative measures taken to mitigate cough, are:
a) post-operative deep breathing exercises
b) incentive spirometry
c) chest physiotherapy
d) steam inhalation, mostly for tracheal problems regarding intubation
e) inhaled bronchodilators as and when necessary
f) suitable antibiotics, as needed

Good effect of cough, post-operatively

Mainly after thoracic and upper abdominal surgeries, cough-reflex is very important. The natural defence mechanism to clear the airways, is utterly needed in these cases to prevent post-operative pneumonia. The only precaution to be taught is, the patient has to immobilise the operative site with a clinching pillow, while coughing, to prevent wound dehiscence and other complications.
To summarise, cough as a reflex to clear the airways, is welcome proposition to prevent stasis of secretions and subsequent infection. But, distressing and uncontrolled cough is a real worrisome phenomenon, needing meticulous prevention and control before and after surgery, to avoid untoward complications.

Sinusitis: Management and Prevention

Sinusitis is infl ammation of the mucous membranes lining one or more of the paranasal sinuses. The various presentations are as folllows:
● acute sinusitis: infection lasting less than 30 days, with complete resolution of symptoms
● subacute infection: lasts from 30 to 90 days, with complete resolution of symptoms
● recurrent acute infection: episodes of acute infection lasting less than 30 days, with resolution of symptoms, which

Recur at intervals of at least 10 days apart
● chronic sinusitis: infl ammation lasting more than 90 days, with persistent upper respiratory symptoms
● acute bacterial sinusitis superimposed on chronic sinusitis:

New symptoms that occur in patients with residual symptoms from prior infection (s). With treatment, the new symptoms resolve but the residual ones do not.
Physical findings and clinical presentation
● patients often give a history of a recent upper respiratory illness with some improvement, then a relapse.
● mucopurulent secretions in the nasal passage
● purulent nasal and postnasal discharge lasting more than 7 to 10 days
● facial tightness, pressure, or pain
● nasal obstruction
● headache
● decreased sense of smell
● purulent pharyngeal secretions, brought up with cough, often worse at night
● erythema, swelling, and tenderness over the infected sinus in a small proportion of patients
● diagnosis cannot be excluded by the absence of such findings.
● these fi ndings are not common, and do not correlate with number of positive sinus aspirates.
● intermittent low-grade fever in about one half of adults with acute bacterial sinusitis
● toothache is a common complaint when the maxillary sinus is involved.
● periorbital cellulitis and excessive tearing with ethmoid sinusitis
● orbital extension of infection: chemosis, proptosis, impaired extraocular movements.

Characteristics of acute sinusitis in children with upper respiratory tract infections:
● persistence of symptoms
● cough
● bad breath
● symptoms of chronic sinusitis (may or may not be present)
● nasal or postnasal discharge
● fever
● facial pain or pressure
● headache
● nosocomial sinusitis is typically seen in patients with nasogastric tubes or nasotracheal intubation.

Cause
● each of the four paranasal sinuses is connected to the nasal cavity by narrow tubes (ostia), 1 to 3 mm in diameter; these drain directly into the nose through the turbinates. The sinuses are lined with a ciliated mucous membrane (mucoperiosteum).
● acute viral infection
● infection with the common cold or infl uenza
● mucosal edema and sinus infl ammation
● decreased drainage of thick secretions, obstruction of the sinus ostia
● subsequent entrapment of bacteria

A. Multiplication of bacteria
B. Secondary bacterial infection

Other predisposing factors
● tumors
● polyps
● foreign bodies
● congenital choanal atresia
● other entities that cause obstruction of sinus drainage
● allergies
● asthma
● dental infections lead to maxillary sinusitis.
● viruses recovered alone or in combination with bacteria (in 16% of cases):
● rhinovirus
● coronavirus
● adenovirus
● parainfluenza virus
● respiratory syncytial virus
● the principal bacterial pathogens in sinusitis are streptococcus pneumoniae, nontypeable haemophilus influenzae, and moraxella catarrhalis.
● in the remainder of cases, fi ndings include streptococcus pyogenes, staphylococcus aureus, alpha-hemolytic streptococci, and mixed anaerobic infections (peptostreptococcus, fusobacterium, bacteroides, prevotella).

Infection is polymicrobial in about one third of cases.
● anaerobic infections seen more often in cases of chronic sinusitis and in cases associated with dental infection; anaerobes are unlikely pathogens in sinusitis in children.
● fungal pathogens are isolated with increasing frequency in immunocompromised patients but remain uncommon
Pathogens in the paranasal sinuses. Fungal pathogens include aspergillus, pseudallescheria, sporothrix, phaeohyphomycoses, zygomycetes.
● nosocomial infections occur in patients with nasogastric tubes, nasotracheal intubation, cystic fi brosis, or those who are immunocompromised.
● s. Aureus
● pseudomonas aeruginosa
● klebsiella pneumoniae
● enterobacter spp.
● proteus mirabilis

Organisms typically isolated in chronic sinusitis:
● s. Aureus
● s. Pneumoniae
● h. Infl uenzae
● p. Aeruginosa
● anaerobes

Differential diagnosis
● migraine headache
● cluster headache
● dental infection
● trigeminal neuralgia

Workup
● water’s projection: sinus radiograph
● ct scan
● much more sensitive than plain radiographs in detecting acute changes and disease in the sinuses
● recommended for patients requiring surgical intervention, including sinus aspiration; it is a useful adjunct to
 

Guide therapy:
● transillumination
● used for diagnosis of frontal and maxillary sinusitis
● place transilluminator in the mouth or against cheek to assess maxillary sinuses, and under the medial aspect of the supraorbital ridge to assess frontal sinuses.
● absence of light transmission indicates that sinus is filled with fluid.
● dullness (decreased light transmission) is less helpful in diagnosing infection.
● endoscopy
● used to visualize secretions coming from the ostia of infected sinuses
● culture collection via endoscopy often contaminated by nasal flora; not nearly as good as sinus puncture
● sinus puncture
● gold standard for collecting sinus cultures
● generally reserved for treatment failures, suspected intracranial extension, nosocomial sinusitis.

Treatment Nonpharmacologic therapy
● sinus drainage
● nasal vasoconstrictors, such as phenylephrine nose drops, 0.25% or 0.5%

● topical decongestants should not be used for more than a few days because of the risk of rebound congestion.
● systemic decongestants
● nasal or systemic corticosteroids, such as nasal beclomethasone, short-course oral prednisone
● nasal irrigation, with hypertonic or normal saline (saline may act as a mild vasoconstrictor of nasal blood fl ow)
● use of antihistamines has no proved benefi t, and the drying effect on the mucous membranes may cause crusting,

Which blocks the ostia, thus interfering with sinus drainage.
● analgesics, antipyretics.

Antimicrobial therapy
● most cases of acute sinusitis have a viral cause and will resolve within 2 weeks without antibiotics.
● current treatment recommendations favor symptomatic treatment for those with mild symptoms.
● antibiotics should be reserved for those with moderate to severe symptoms who meet the criteria for diagnosis of

Bacterial sinusitis.

● antibiotic therapy is usually empirical, targeting the common pathogens.
● first-line antibiotics include amoxicillin, tmp-smz.
● second-line antibiotics include clarithromycin, azithromycin, amoxicillin-clavulanate, cefuroxime axetil, loracarbef, ciprofloxacin, levofloxacin.
● for patients with uncomplicated acute sinusitis, the less expensive first-line agents appear to be as effective as the

Costlier second-line agents.

Surgery
● surgical drainage indicated
● if intracranial or orbital complications suspected
● for many cases of frontal and sphenoid sinusitis
● for chronic sinusitis recalcitrant to medical therapy
● surgical débridement imperative for treatment of fungal sinusitis