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Sinus Surgery-Recurrent respiratory infections
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Sinus Surgery-Recurrent respiratory infections

I am a 26 year old female with a long history of asthma, allergies and chronic sinusitus since childhood.  Last July (04) I had my second sinus surgery to remove nasal polyps and open up my sinuses.  I had one nasal infection after the other after the surgery and was treated with 3 or 4 rounds of Augmentin over several months...the last culture (in Sept. or Oct.) indicated a staph infection which was treated with a gentamiacin wash.  Following these infections, I had bronchitis in November, Strep throat in January, Pneumonia in February, and then just today, diagnosed with strep again.  This is really beginning to wear me down and scare me!  My Drs' insist that I have nothing to worry about and continue to reassure me.  A follow-up chest x-ray last week came back looking great, but I am still awaiting blood test results for CBC and IgG, IgM and IgA.  Emergency room doc. ordered CT scan for next week to see if there is still some type of sinus infection.  I still continue to have sinus pain on right side, especially around jaw and can feel pain in my top teeth.  I also discharge a LOT of rubbery, thick mucous from the right side of my nose since the surgery...I never had anything close to this consistency before the surgery.  Is is possible that I have had some kind of complication from this surgery that would be causing all of these frequent infections?  Is is possible that a staph infection could still be present and be causing these infections?  Getting this step today was like the straw that broke the camels back.  I am at my witts end and searching for some answers.
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It is obvious from your note that this has been a long and frustrating problem for you.  You are correctly tackling this problem.  There could be several different problems going on. It could be a continuation of a chronic bacterial sinus infection. It could possibly be a fungal infection of the sinuses, which continues to be reinfected with bacterial infections. It could also be an immune problem etc.  It is likely that the upper airway problems are the source of your intermittent lower airway problems, as well.  It will be necessary to establish a relationship with a physician who will work through all of the possibilities to get to the cause of all of these infections.
I would suggest you consider a visit to us at National Jewish Medical and Research Center in Denver, Colorado.  We see and deal with this type of problem from individuals from all over the country on a regular basis.  Our approach uses the skills and expertise of a broad team that work together to solve complex problems.  If you would like more information about what we might be able to do, please call LUNG LINE
20 Comments
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Absolutely insist on a culture of your current rubbery discharge. Don't let them keep treating you empirically without an idea of what you have in there. There are some nasty bugs that are gentamicin resistant. I know because I send reports out on them fairly frequently, as I've been a microbiology technologist for 30 years.

It might also be wise to absolutely INSIST (tell them you want one - don't ask them) on a consult with an infectious disease specialist. These docs know their way around antibiotics. You need to get extremely proactive.

Good luck. Let us know what's happening.
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I agree with the medical technologist, but I would go even further to insist that an ENT do an actual culture of the sinuses since the discharge does not always correlate with what is actually in the sinuses.  Also it is very important to have sensitivities done so that you know which antibiotic to use.  You are too young to have to suffer from this for a lifetime.  It is very depressing; I know.  I now have a highly resistant bacterial infection and am having to be treated with IV antibiotics.  Even if the CT scan is read as normal, you can still have a low grade infection that just hangs on. In my experience most ENTs don't really want to treat sinusitis unless they see a reason to do surgery.  I have corresponded with many sinus suffers whose doctors tell them they are fine and they end up miserable.  

I am not a doctor nor in the medical field, but I have suffered with chronic sinusitis for over 20 years and my treatment up until this point has been very disappointing.  If I had it to do over again, I would be much more proactive in my care.  As it is I've had to keep searching to find a doctor to listen to my symptoms and finally get a culture done.  I also had a mold that is rare to find in the sinuses.  During the entire time, I was coughing up brown junk and had it coming out of my head and the doctors kept telling me I was fine.  

Good luck!!
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Thanks for the insight from everyone...it has been very helpful (it has also helped me to feel validated!)  I'm still on the anitbiotics for the latest strep (last week) and am starting to get severe chest congestion and a very raspy throat!  I've never been so chronically ill!  I am getting tired of hearing from the Dr.s and nurses "You are just having bad luck", "You are fine!".  
Just to touch base, my blood work all came back normal, and I just got results of the CT scan today.  I picked up the report, but haven't met with my Dr. yet.  I don't completetly understand the findings, but it does mention "extensive mucosal thickening through paranasal sinuses", "total opacification of right frontal sinus and subtotal opacification of left sphenoid sinus"....it also mentions "chronic sinusitis and acute sinusitis"...that part, of course was no surprise.  I am waiting to hear from ENT and will be sure to ask for the cultures that both of  you mentioned.   Thanks again for your help! It's nice to feel like I've got someone on my side!
AC
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Finally met back with my ENT today (same one who performed last surgery).  He confirmed lots of swelling still in sinuses including total opacification of right frontal sinus and said that my symptoms point to Allergic Fungal Sinusitis.  He said that surgery would only provide temporary relief....oral steroids would only provide temporary relief as well, he believes.  He took another culture from my nose/sinuses and said they will get back with me.  If there is a fungus he says he will proscribe anti-fugal nose spray and topical steroids.  I reminded him that we did this same thing (culture) in the fall when Allergic Fungal Sinusitis was suspected and no fungi grew from the culture.  They determined it was bacterial and put me on Augmentin or Gentamiacin (I can't remember which) I took both at different times last Fall.  Should I just go with this for now and wait for culture results or is it necessary to get a second opinion?  Every single kind of blood test I have had comes back in the normal range....I am thankful for this, yet it really makes me wonder why my body can't fight all of these infections.
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I would get a second opinion.  It sounds like you need more aggresive (aggressive) treatment than nose sprays.  From what I have read frontal sinusitis is serious.  I would obtain all of my medical history including CT scans, etc. and make an appointment somewhere else, preferably at a major center that treats sinusitis.

I think that my problems began with an isolated spenoid infection that was ignored.  If you feel like it you might want to visit http://www.deja.com, then type in alt.support.sinusitis.  This is a good site to discuss sinus problems with other sufferers, and you can get a lot of useful information.
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Thanks so much for all of your help!  You seem to be very knowledgable about the diff. cultures.  Yesterday the nurse at my ENT's office called to let me know that my culture came back as coagulase negative staph....he prescribed Augmentin XR for 20 days (4,000 mg/day).  Just curious to get your opinion on this?  I just feel like maybe that has been there all along.  One of my cultures earlier in the fall came back as staph too, and I did the 20 days of Augmentin....Dr. says he is still monitoring culture for a fungus but that it may take a few more weeks.  How common is coag. neg. staph and could it be causing all of these other infections?
Thanks!
Anne
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Avatar_f_tn
When techs run into coagulase Staphylococcus nowadays (formerly reported as Staph. epidermidis - there are many different strains, though, so the microbiologists lumped them into the catch-all phrase "coagulase negative Staphylococcus") it presents them with a big dilemma.

Back in the 70's CNS (I'll shorten it now so I don't have to type it out) was considered part of normal skin flora. It usually was only considered to be an infection when it presented in a patient with some type of indwelling catheter, typically a spinal fluid of a hydrocephalic patient who had an infected shunt, or something similar.

Over the years, CNS has been implicated more and more in infections. They are typically skin flora that has gotten displaced - mainly to places that should be sterile. They can set up housekeeping and are typically resistant to a lot of antibiotics. This is because your skin is exposed to lots of things, and the flora of the skin is exposed to many things: cleaning fluids, soap, ANTIBACTERIAL hand washes, etc. I personally try to avoid antibacterial soaps, although this is getting to be practically impossible, as all the soap companies are marketing this angle heavily.

When a micro tech sees CNS in a place where it may be either a skin contaminant or a pathogen, we debate on how to report it. I personally err on the side of safety. If it's a pure culture (i.e. with no other skin flora) and there's a lot of it, and it was taken in a surgical setting, I work it up (i.e. perform an antibiotic sensitivity) and send out the report with an ID and sensitivity. If it's just a swab taken in a non-surgical setting, with only a few colonies, or presents with other mixed flora, I tend to lump it into "normal skin flora." Unfortunately, we don't have a history on every patient and only have the plates to work with. The fact that you had it before (was it also CNS???) makes me believe more in the pathogenicity of it.

We save all plates for a week after culture sign-out. Docs can and do request workups of organisms that we sign out as "sensitivity only upon request" because they know the patient better and know what's going on.

Fungal cultures typically take at least four weeks before they're signed out as negative. Some labs hold them six weeks. With long-standing problems like yours, it's a thorough thing to order a fungal culture, and I commend your doc for doing so. If and when a fungus is isolated, it might take some time to identify. Some fungi grow quite quickly; others can take 2-3 weeks just to start growing. Obviously their identification will take longer, as each subculture will grow slowly also. Fungal cultures are typically only looked at once a week, because daily observation just doesn't pay off with these slow growing cultures. Our lab typically looks at all cultures on either Monday or Tuesday. Reports are updated, positives are worked on, and the negatives are reincubated until the following week. Preliminary reports are sent out on all positives. Docs can always call labs for preliminary reports.

Hopefully all this works for you. Keep us updated. Feel free to ask me any other micro questions if necessary. I've read out cultures for nearly 31 years now :-). Microbiology doesn't lend itself to easy answers, as it's just not a cut and dried subject.
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This information on coagulase negative staph is really interesting.  I have had it cultured several times.  The first time it started as a sore in my nose and the whole tip of my nose got sore.  I took duricef (a first generation cephalosporan) and used bactroban cream and it went away.  This was about 15 years ago when it first happened.  I also ran low grade fevers with it.  It kept reocurring over the years and eventually the duricef didn't help any more, but the bactroban did help the nose, but by then it was in my sinuses.  I have felt for years that it was my problem, but keep getting told it is normal flora.  It was also cultured out with the stenotropomonas this fall and I begged the doctor to do sensitivities, but he wouldn't.  

I'm not a doctor, but I've had enough experience with this that I know that you need to get rid of this stuff.  There are a few articles on medline that are now admitting that the CNS may be a true pathogen in sinusitis.  As a matter of a fact, if you do a search on this bacteria and sinusitis, you'll find that it is the most cultured bacterium.  Many studies just disregard it, but others are now questioning its role.

You might want to ask the doctor to give you a prescription for the bactroban cream and if the augmentin doesn't work, maybe ask for a 1st generation cephalasporin.  You will probably need to take it for longer than 2 weeks if it is in your sinuses.  I'm not trying to scare you, but if you don't get this cleared up, it can become chronic and very difficult to get rid of.  If you just keep taking short rounds of antibiotics and don't completely erradicate it, it will become more and more resistant and you might end up with an even more highly resistant "bug" like the stenotrophomonas that I now have.  It is usually recommended that you take 4-6 weeks of an antibiotic in chronic and/or stubborn cases.

There is a new theory now that chronic sinusitis is is linked to an abnormal immune response to fungi that makes the sinuses more hospitable to bacteria, so if it culures out, you should be treated for it also.  

Again, this is just my opinion based on my own personal experience.
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I really appreciate your help!  It is just nice to know that there are people out there who know what I am talking about....although I am sorry that you have gone through this as well!  I find my Dr. very intimidating and he just doesn't seem to think that there is much to be concerned about....I have done some reading online like you mentioned and there certainly is a lot of interesting info.  I am going to call Monday to make an appt. for a 2nd opinion with another ENT....I am just curious when you experienced the CNT or even with your condition now, do you have a constant dull, throbbing sensation throughout the maxillary sinuses/jaw and teeth?  That is the one symptom that has remained constant since all the post-op infections began in July.  Again, thanks so much for taking the time to listen and respond!  Good luck to you!
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http://tinyurl.com/68tyj

http://tinyurl.com/3l8gf

These two references talk about coagulase-negative Staph. as being a possibly significant isolate in surgically taken sinus cultures.

http://www.sma.org.sg/smj/4104/articles/4104cr1.pdf

This talks about Staph. lugdunensis, which many labs do not currently screen for amongst the coagulase negative Staphylococci (there are multiple strains of this bug). This straing of CNS can cause soft tissue infections. We are just starting to do this screening in certain specimen types, as it was talked about in our lab meeting last week. This is what's termed an "emerging pathogen" in the biz, I think.

Thought you guys might find these references interesting.

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Thanks for the information.  I'm going to give both of you my current email address.  I normally don't publish it over the internet, but I am getting so much spam that I am going to change it in the next few days anyway.  I've found a lot of information that I can email you.  I've done extensive research on this, but in my experience, finding an ENT to listen to a patient is next to impossible.  If you act like you have an "inkling" of what is going on, they resent it.  They think we are overstating our symptoms and I think many just write us off as hypochondriacs.  Many people on the sinus support group that I told you about have had the same experiences.   I would like to correspond with both of you. My address is ***@****.   If I ever get well enough, I plan to write a book from the patient's standpoint.
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I saw your website.  I have a story where I my Frontial Sinus was very small.
My Left Maxilarry Sinus I had Chronic Sinus Pain I had Surgury last October felt well up to this January
He did surgury on the left Maxilary Sinus the Polps and cleaned out all the sinuses. The doctor gave me some salt water nose sprays.

In about January I had the same pain now I just had surgury again just for the Left Maxilary Sinus
in April the end I still have pain now across the forehead and behind the eyes since January
Is their any possobility what can be causing it?  He enlarged also the ethnoid sinus.
Would it proabally be migranes (migraines) or behind the Spenoid Sinuses behind my eyes certain times .
Thanks,

Mike Van Der Stad
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Avatar_n_tn
I saw your website.  I have a story where I my Frontial Sinus was very small.
My Left Maxilarry Sinus I had Chronic Sinus Pain I had Surgury last October felt well up to this January
He did surgury on the left Maxilary Sinus the Polps and cleaned out all the sinuses. The doctor gave me some salt water nose sprays.

In about January I had the same pain now I just had surgury again just for the Left Maxilary Sinus
in April the end I still have pain now across the forehead and behind the eyes since January
Is their any possobility what can be causing it?  He enlarged also the ethnoid sinus.
Would it proabally be migranes (migraines) or behind the Spenoid Sinuses behind my eyes certain times .
Thanks,

Mike Van Der Stad
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Avatar_n_tn
I saw your website.  I have a story where I my Frontial Sinus was very small.
My Left Maxilarry Sinus I had Chronic Sinus Pain I had Surgury last October felt well up to this January
He did surgury on the left Maxilary Sinus the Polps and cleaned out all the sinuses. The doctor gave me some salt water nose sprays.

In about January I had the same pain now I just had surgury again just for the Left Maxilary Sinus
in April the end I still have pain now across the forehead and behind the eyes since January
Is their any possobility what can be causing it?  He enlarged also the ethnoid sinus.
Would it proabally be migranes (migraines) or behind the Spenoid Sinus.
Thanks,

Mike Van Der Stad
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Avatar_n_tn
Hi

I am new to this board,I am looking for advice on nasal polyps,I would appreciate any advice.

I have been off my work for two months feeling really ill,dizzy,tinitus,sinus pain all over my face and behind my eyes.
I have been back and forward to the doctors,had three courses of anti biotics.
I had an MRI scan last week,I am sure that I have nasal polyps as I have been on the internet looking,has anyone had the same symtoms (symptoms) as me,some nights I go to my bed crying with the pain.
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My husband just had endoscopic sinus surgery 9 days ago to clear polyps and has been in excrutiating pain ever since. His ENT said he has never had a patient respond like this before.  Since the surgery he has had to go to ER once for the pain and then 2 days later be admitted overnight to manage the pain. He now has him on steroids and is thinking that will help.  A CT scan was done prior to the admit which showed no abcess (abscess)/infection.  Painkillers such as vicodin, percocet and now oxycontin do not relieve the pain completely.  The diagnosis on the admit for pain was "intractable migraine".  My husband is suseptible to migraines and we are wondering if there is any connection there or if anyone else has had this kind of pain after sinus surgery.  I can't find any information on this type of side effect of the surgery. Also of note, he is on dilantin for a seizure disorder brought on by a skull fracture due to a motorcyle accident 30 years ago.  Can anyone help with info?  Thanks.
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hi I had something similar but simpler that went on for about 6 months. I had contract recurring nasal/sinus infections. I'd get about 3 wekks between finishing antibiotics and getting another infection. The antibiotic side affects on my gut were no fun. I found augmentin was the worst for side affects and minocycline had virtually no side affects for me. I had chronic sinus pain above my eyes for 9 days that would stike at 9 am every morning like clockwork. I'd just curl up on the floor in agony - my workmates were amused anyway. also had chrinoc excess mucous for 2 years (had it for 10 but only got bad more recently). I was given steroid nose spay and antihitamine. They sort of helped but not very well and I'm sure the steroid made me more sensitive to other allergies. After a long battle I discovered that my real problem was FOOD allergies causing the mucous in the first place. I guess have a a face full of gunk invited an infection. I narrowed the allergies down to WHEAT, GLUTEN and SOY. Since avaoiding them I've been able to breathe again normally for the first time in years and my whole respiritory system is clear as a bell. I can have a mucousy epsiode from eating one bit of a biscuit etc so I am 100% off these things for now. Soy is harder to avoid - it's used in many processed foods. Best of luck. I also developed bronitis from coughing all the time - it must have stressed the lung tissues I guess. All behind me now and life is livable again.
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Hi

I have found out that I have got nasal polyps,I am going to see a ENT consultant next week,I hope they take my polyps away,does anyone know if surgery is required will I need a CT scan.Another thing will it cure the symtoms (symptoms) that I have been having.
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Hello I'm considering having sinus surgery now after suffering for 2yrs with constant thick and excessive mucous in my mouth and throat .  I cough up tons of plemg evey few hours and in the last few months the plemg has began to make a connecting string of plimg between the sinus and the throat .  I know that sound s weird but I kept feeling this pulling sensation between my nose and throat on day and realized if I took a oral pick and gently worked it loose I could bring up the plemg that was trapped in my sinus and or throat. My ent who basically has been useless did take a look a said there was atremendous amount of plemg wrapped around my vocal cords so I'm assuming that partly what I'm coughing up.  this is so out of control now and I have been trough all the testing and antihistimines and allgery test ct scans are normal yet I cough up chunks of green intermittenly  so I believe the infection is still there.  In the past few months I have run fevers and have been on levequin and prednisone.  I guess surgery is nest the dr feels that is the only option left for me now.  Any suggestions or input appreciated.
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