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eRounds - Summer 2013


Help for Chronic Sinusitis

You don’t want to see your patients suffer the pain of chronic sinusitis. Not only is it the most common chronic condition seen in primary care practices in the U.S., but it also is linked to quality-of-life scores worse than those of other chronic diseases such as heart failure, asthma and COPD. At Cleveland Clinic, we can help make what is sometimes a tricky diagnosis, and help pinpoint what medical or surgical solution is best and get the patient back to you. Relieved.

Patients fall into the chronic sinusitis category once they’ve had multiple, recurrent infections or are not getting better despite treatment for 12 weeks. An ENT can help confirm the diagnosis, based on a clinical history, nasal endoscopy and CT scan performed after maximal medical therapy.

However, says Raj Sindwani, MD, Head of Cleveland Clinic’s Section of Rhinology, Sinus and Skull Base Surgery, it’s important to watch out for several red flags that indicate additional help is needed sooner.

“Unusual symptoms like numbness, visual problems, severe pain or unilateral symptoms can warrant an earlier referral to a specialist, as they could represent something more serious such as a neoplasm,” Dr. Sindwani explains.

Getting the Right Diagnosis

Diagnosing chronic sinusitis can be challenging, Dr. Sindwani says, because many patients who have chronic sinusitis also suffer from allergies and the coexisting conditions both require careful management.

Once a diagnosis is confirmed, the patient may be a good candidate for endoscopic sinus surgery, which recent studies show can significantly improve the quality of life in patients with chronic sinusitis.

At Cleveland Clinic, fellowship-trained rhinologists with extensive experience perform the well-tolerated procedure using a very minimally invasive approach, which leaves no cuts or bruises — and often is done without using nasal packing. Patients go home the same day with only a few days of recovery. Our experts also use the most state-of-the-art surgical navigation systems to further reduce the very low risk of eye injury, or brain fluid leaks.

Is surgery the end of problems? Since there is no cure for chronic sinusitis, unfortunately not. But, Dr. Sindwani says, surgery followed by ongoing medical management can make a world of difference to patients. “Once we perform surgery, open and ventilate the sinuses, their symptoms improve, their quality of life improves, and they have fewer issues down the road.”

Knowledge is Power

Another advantage that rhinologists at Cleveland Clinic can offer your patients (especially after surgery) is accessing the sinuses to perform endoscopically guided cultures during “persistent or difficult infections.

“We can painlessly take a sample from within the sinus drainage pathways or even from within the sinus cavities themselves after they are opened surgically, and send it to the lab and find out a lot of information about what is going on,” Dr. Sindwani says. “It tells us the bacterium that’s causing the infection and even what the best antibiotics are to kill that particular organism.

“It takes us from a shot-in-the-dark kind of scenario to a very sophisticated, culture-guided therapy. It can be very helpful down the road when patients get an infection after surgery that they cannot shake.”

A wide range of targeted topical therapies also is being used for patients with chronic sinusitis who have undergone surgery and the interior of their sinuses is accessible for topical drug delivery.

“Since the blocked passageways are open after surgery, we can access the sinuses for a culture and then deliver a topical drug right to the site of inflammation or infection,” Dr. Sindwani says. So, commonly, topical antibiotics, steroids or even antifungals are used for several weeks or months to improve any issues that arise.

“The advantage of this type of treatment modality is that you don’t expose the patient to all of the systemic side effects of the drug — say, oral steroids, for example — and we can get a higher concentration of the medicine right to the site where we want it in the sinuses.” Topical delivery of steroids using irrigations allows a much higher concentration of the drug to actually reach inflamed mucosa or nasal polyps, and can be more effective than just using conventional nasal steroid sprays, for example.

Cleveland Clinic rhinologists regularly partner with primary care physicians to consult with them on their patients to help them when they hit a rough patch. “If they get an infection, we’re happy to culture them and send a note back to the primary care doctor letting them know the results and together we can decide on the most effective treatment, whether that’s determined to be oral or increasing topical drug therapy,” Dr. Sindwani says.

If you have patients with chronic sinusitis and would like to consult or refer to one of our rhinologists, please call 855.733.3712.


Doc, Do I Need to Worry?

“What are we ruling out if it’s not cancer?...When they say nodules or spots on your lungs, it’s just the first thing you think of. What other options are there?”

When is follow-up needed for nodules?

For incidentally discovered lung nodules in patients at high risk, the Fleischner Society recommendations are as follows:

  • For nodules 4 mm or smaller, follow-up in 12 months; if no growth, then no further follow-up
  • For nodules 4 to 6 mm, follow-up at 6 to 12 months, then 18 to 24 months if no growth
  • For nodules 6 to 8 mm, follow-up at 3 to 6 months, then 9 to 12 months, then 24 months if no growth
  • For nodules 8 mm or larger, follow-up at 3, 9 and 24 months, or perform a positron emission tomography, or biopsy, or both

At Cleveland Clinic, if the nodule is large enough or is deemed to be of high-enough risk, adjuvant testing with diagnostic imaging, guided bronchoscopy, transthoracic needle aspiration, or minimally invasive resection is offered.

This patient had low-risk lung nodules. Yet these are the types of thoughts, documented in a recent study appearing in the journal Chest, that actually run through patients’ minds when they are told they have a nodule. This is why it is so important for patients with lung nodules to receive appropriate care, such as through the Lung Nodule Clinic in Cleveland Clinic’s Respiratory Institute.

“It is absolutely critical for clinicians to be aware of how much fear patients may experience upon learning they have a lung nodule,” says Peter Mazzone, MD, MPH, who oversees the Lung Nodule Clinic and also serves as Lung Cancer Program Director in the Respiratory Institute. “Proper communication and education is key to helping them deal with it properly.”

The Lung Nodule Clinic is a resource for primary care physicians who have patients with a lung nodule incidentally discovered on a lung scan or during a lung cancer screening. It brings together all of the experts needed, including pulmonologists, thoracic surgeons and other healthcare professionals, all with extensive knowledge of lung nodule management.

“Our lung nodule clinic is trying to provide the most appropriate care to these patients to put both the patient and his or her primary care physician at ease, and to make certain patients receive the best treatment, when necessary,” he says.

How much concern should there be?

Lung nodules are fairly common. They’re typically asymptomatic and can be found on up to half of all CT scans. Thankfully, more than 90 percent of lung nodules smaller than 1 cm in diameter are benign.

Most of the time, spots found on the lungs are scars from old infections. Within the Ohio River Valley, a fungal infection called histoplasmosis is the cause of many lung nodules, both calcified and non-calcified.

“Though most lung nodules are not malignant, it is very important that those representing cancer are identified early in their course, when they are curable,” Dr. Mazzone stresses. The larger the nodule is, and more irregularly shaped it is, the more likely it is to be cancerous.

Regardless of the small percentage of lung nodules that end up being malignant, the Lung Nodule Clinic follows every single nodule with the utmost care.

Advanced diagnostics and treatment, when needed

“We use the most advanced CT, PET and volumetric analysis to calculate patients’ risk,” Dr. Mazzone explains. “If necessary, we also offer advanced diagnostic procedures, including guided bronchoscopy. Our team will develop a personalized treatment plan for your patients and answer any questions either you or they have.”

Distinguishing between a nodule that is an early malignancy and one that is benign remains challenging.

“Our team has the experience to not only manage these different types of lung nodules, but also do so in a way that minimizes radiation exposure for patients and improves cost-effectiveness,” Dr. Mazzone says.

If the nodule is small enough or if its features suggest a very low likelihood that it represents a cancer, the nodule should be followed over time with repeated chest imaging. If the nodule does not grow over time, it will be confirmed to be benign. If a concerning pace of growth is noted, then additional evaluation would be suggested.

The interval between scans and the length of follow-up depends on the size of the nodule and the risk of malignancy.

If an active infection is found or an inflammatory disease is diagnosed, the treatment would be based on the condition identified and the symptoms that are present.

If the nodule is malignant, there does not appear to be any spread of the cancer and the patient is fit, then the cancer should be surgically removed. If a nonsurgical biopsy of a nodule with high concern for malignancy is done and the results are inconclusive, it is recommended that the nodule be taken out. At Cleveland Clinic, both thoracotomy and video-assisted thoracoscopy are used when pulmonary nodules must be removed.

When necessary, our team can draw on the expertise of the entire Chest Cancer Center at Cleveland Clinic to help patients find the most effective treatments, allowing them to enjoy the best quality of life possible.

If you have a patient with lung nodules whom you would like followed by our Lung Nodule Clinic, call 216.445.4632.

Who Should Receive Lung Cancer Screening?

Goal: The goal of lung cancer screening with a low-dose chest CT is to detect the disease early in its course, when it is easier to treat.

Eligibility: To qualify for lung cancer screening, a person must:

  • Be referred by their physician
  • Be 55 to 74 years old
  • Be a smoker, or a smoker who quit smoking less than 15 years ago
  • Have a smoking history of ≥ 30 pack-years
  • Have not had a chest CT in the last 12 months

What to Consider: The low-dose CT can find nodules in at least 25 percent of those who get the scan. At this time, most insurers do not cover the cost of a lung cancer screening low-dose chest CT. The out-of-pocket cost is $125.

Refer a patient to our Lung Cancer Screening Program by calling 216.445.3800.


Innovative, Minimally Invasive Treatment for Lumbar Spinal Stenosis Improves Pain, QOL

Cleveland Clinic’s Department of Pain Management now offers an innovative, minimally invasive outpatient treatment to help your patients with lumbar spinal stenosis, called mild® (minimally invasive lumbar decompression, from Vertos Medical).

The state-of-the-art technique decreases pain and increases mobility while maintaining the structural stability of the spine, says Nagy Mekhail, MD, PhD, Director of Evidence-based Pain Medicine in the Department of Pain Management.

Quality of life issues

Lumbar spinal stenosis (LSS), a painful condition that occurs due to degenerative changes, can greatly affect patients’ quality of life, according to Dr. Mekhail. The average age of patients seeking treatment for the condition is 73 years.

LSS causes low back or leg pain with the cardinal signs of:

  • Limitation of standing
  • Limitation of walking

In patients with LSS, ligaments in the spinal canal, ligamentum flavum, become hypertrophic. When the patient stands or walks, the spinal canal narrows even more, causing low back and leg pain known as neurogenic claudication. LSS is diagnosed by MRI when hypertrophic ligamentum flavum is identified.

Patients who present with moderate-to-severe LSS often cannot stand longer than five minutes or walk farther than 300 feet. Many patients who undergo the mild treatment are able to get back to activities such as grocery shopping or golf, Dr. Mekhail says — and it’s not uncommon for them to progress to walking a mile without stopping.

Treatment options

Nonsurgical treatment for LSS includes NSAIDs, physical therapy, and/or epidural injections to relieve inflammation and swelling. However, these treatments are effective only in a small percentage of patients, and if they do work, the effect may not be sustained.

These therapies tend to have limited effectiveness because LSS is an ischemic rather than a mechanical problem and the spinal nerves feed the pain, Dr. Mekhail says.

Some patients who have LSS can benefit from open spine surgery in which part of the spine is removed to relieve some of the pressure in the spinal canal. However, not all patients are candidates for open spine surgery, especially given that within this older demographic, surgery and anesthesia may be higher-risk.

Patients who have failed conservative treatment and who aren’t candidates for open spine surgery could potentially benefit from mild if their diagnostic MRIs do not show bone calcification, Dr. Mekhail says.

Minimally invasive procedure

The mild procedure is performed under deep sedation through a 1-cm incision. The clinician uses a special, 5-mm diameter sculpting tool to go between the bones, scrape out the ligaments and widen the spinal canal to decrease nerve compression. X-ray fluoroscopy is used to assess positioning and assist with visualization throughout the procedure.

Routine pathology is always done to confirm that only ligament tissue was removed. Because the spine remains intact, spinal mechanics are not disrupted. Patients typically recover quickly and are able to begin walking the next day. Dr. Mekhail encourages them to walk regularly and/or participate in PT.

Dr. Mekhail and colleagues have published study findings on the mild procedure:

  • No major device or procedure-related complications
  • Significant reduction in pain at one year
  • Improvement in physical functionality and mobility
  • Decreased disability secondary to neurogenic claudication

Medicare began covering mild in July 2012. With more than 10,000 baby boomers turning 65 years old every day, Dr. Mekhail says that more and more patients are seeking innovative treatments such as mild that will allow them to stay active and maintain their quality of life.

To learn more or refer a patient for mild, call 216.444.9114.


Improving Outcomes for Lupus Patients

Fighting lupus is still an uphill battle. But the good news is that significant advances in diagnosis and treatment are improving outcomes. Among them? The implementation of multidisciplinary lupus clinics, such as Cleveland Clinic’s new Lupus Clinic, has been a game changer that can help patients with systemic lupus erythematosus (SLE) when they are part of your practice.

“In a condition such as lupus, with multi-organ/systemic involvement, a multidisciplinary team approach is essential for both timely diagnosis as well as proper treatment,” explains Cleveland Clinic rheumatologist Howard R. Smith, MD.

The Lupus Clinic was recently established by Cleveland Clinic’s Department of Rheumatic and Immunologic Diseases, where Dr. Smith, Mehrnaz Hojjati, MD, and other specialists work together with the department’s entire team of rheumatologists to provide streamlined access to the highest quality of care for these complex patients.

The clinic unites specialists, including those in rheumatology, nephrology and dermatology, to care for patients with lupus and overlap syndromes.

The new clinic is designed for both newly diagnosed patients as well as those with established disease, Dr. Hojjati says. “The clinic’s triage system allows specialists to coordinate care in multiple disciplines and expedites appointments with multiple specialty clinics, including nephrology and dermatology.”

Progress has been made in recent years both in diagnoses and treatments for patients with SLE that have resulted in improved outcomes. Multidisciplinary clinics make a positive difference because advanced diagnostic and therapeutic modalities from each specialty are applied to individualized, patient-centered care. Even patients with mild features of the disease require close monitoring, and patients with serious organ system involvement (such as renal complications) may require the use of potent immunosuppressive medications.

“SLE disease activity can be difficult to monitor and flares are unpredictable,” says Dr. Smith. Our team can closely work with patients to customize their care, which typically includes therapy, consisting of glucocorticoids combined with immunotherapy.

Despite improvements in therapy, lupus remains a serious condition that could be associated with morbidity and mortality, mainly due to infections, renal failure and cardiovascular disease. However, progress continues to be made in research and the new Lupus Clinic also is involved in clinical trials for lupus and other autoimmune diseases.

To refer a patient to the Lupus Clinic, call 855.REFER.123 (855.733.3712).