Thursday, May 10, 2007

Makkiah's ENT appointment

Makkiah had his ENT appt yesterday with Dr Brewster. I thought we would be there for 30 minutes or so but it took 4 hours!

Makkiah has dealt with chronic sinus issues for years. He's maxed out on allergy meds. He takes singular, zyrtec and nasonex everyday. We went and saw the allergist a while ago and his work up was unremarkable. He had the scratch test done on his back. I was told that he has an allergy to dog and dustmites but not severe.

When we put him on antibiotics it works until we stop them. We have done anywhere from 10-30 days of antibiotics. While he's on them the drainage stops but within days of stopping the meds it's right back.

In December he started with it again. When we saw Dr W in Feb I asked him about it again. Dr W put him on antibiotics for two weeks and it stopped - again. Within days of stopping it was back so he sent him for the sinus CT.

Mak was not having any drainage when he had the CT scan done. So for the CT scan he was at his best. The guy in CT told me that his right sinus was filled with something.

The pulm (Dr W) sent a consult to the peds ENT (Dr Brewster) who we have seen many times before. He knows Makkiah well and has pretty much followed him since he was 3 months old.

I had read up on impacted sinuses and asked some people. Everything said that he would probably get his sinuses flushed out. So I thought we would be going in and getting his sinus cleaned out and then we would be on our merry way. Boy was I wrong.

First off Makkiah never developed the sinuses above his eyes probably due to them being blocked. The dr said that usually they aren't big enough to cause serious problems in kids Mak's age but Mak has none.

The left sinus below his eye is totally normal but the sinus on the right side is not. It is completely impacted and the ENT said he thinks there is an anatomical anamoly that is keeping it from draining. He thinks there is no opening between the sinus and his nasal passage.

He is having a FESS (Functional Endoscopic Sinus Surgery) with anterior ethmoidectomy and maxillary antrotomy on May 24th. Basically they will go in and chip the bone away to create holes in his sinus so they can drain.

This carries serious risk since they are so close to his eye orbit and his brain. They have millimeters of space to work with. There is a very thin bone seperating the area they are working in with the brain and another very thin bone that seperates the sinus area from the eye. They will use the CT scan as a go by during the surgery to manuever in the space.

Without the surgery they are concerned that the infection will start to eat away the bone in his face. He thinks there is still an underlying allergy issue so he needs to openings to allow his sinus to drain.

Aside from the risk of the surgery itself he has other risks. Due to his history with airway issues he is at increased risk for airway problems during surgery.

I was told that usually they use a "cuff" with positive airflow for the airway during this procedure due to it's length. They will intubate him though as they are concerned with securing his airway.

Intubating him for such a long procedure (we are looking at 1 hour minimum)carries additional risk with swelling in his airway. Because his airway is smaller than most and he still has croup episodes the tube sitting in there could cause swelling.

Because of the bronchomalacia they can't use albuterol with him as a rescue med so there is increased concern there as well. They will give him steroids during the procedure to help decrease the swelling and hopefully make it easier for them to extubate him.

The only rescue med that he really has is nebulized racemic epinephrine. He's had to have it on several occassions due to swelling in his airway during a croup episode.

No comments: