Prof. Dr Marco Caversaccio is a leading expert in the field of ear, nose and throat medicine, specializing in particular in the treatment of tumors in the head and neck region. His expertise extends to voice preservation during laryngeal surgery and other complex procedures. Prof. Dr Caversaccio gained international recognition for his pioneering work in the field of computer-assisted surgery.
As Clinic Director and Head of the University Clinic for ENT, Head and Neck Surgery at Inselspital in Bern, he leads a highly qualified team of doctors, nurses, medical technical staff, speech therapists and psychologists. The clinic offers comprehensive care in the field of ear, nose and throat medicine in accordance with the latest scientific standards. Of particular note are endoscopic surgery of the nose and paranasal sinuses, as well as minimally invasive techniques that avoid incisions in the facial area.
Through interdisciplinary collaboration with other specialist departments such as cranio-maxillofacial surgery, neurosurgery and ophthalmology, complex cases are treated holistically. Prof. Dr Caversaccio and his team are also leaders in modern otological microsurgery, which enables improved hearing through the repair of eardrum defects and the restoration of the ossicular chain.
In the treatment of malignant tumors in the head and neck region, innovative techniques such as laser surgery and microvascular flap procedures are used alongside conventional surgical methods. Interdisciplinary collaboration within the tumor board ensures individualized and optimal treatment planning for each patient, with a constant focus on performing minimally invasive and organ-preserving surgery. At Prof. Dr Caversaccio’s clinic, the focus is on the well-being and best possible treatment of patients, with the aim of providing supportive and professional care during their illness.
The editorial team of the Leading Medicine Guide, together with Prof. Dr Caversaccio, focused on the nose and discussed treatment options for chronic rhinosinusitis – a chronic inflammation of the paranasal sinuses and nasal mucosa – which affects approximately 5–10% of the population.
Chronic rhinosinusitis (CRS) is a complex condition that affects millions of people worldwide and impacts their quality of life. This chronic inflammation of the paranasal sinuses and nasal mucosa can lead to a variety of symptoms, including persistent nasal congestion, nasal discharge, facial pain and a reduced sense of smell. CRS can be caused by various factors, including infections, allergies, anatomical abnormalities and environmental factors. The diagnosis and treatment of CRS often require a multidisciplinary approach, supported by a team of ear, nose and throat specialists, allergists and radiologists. This condition can have a significant impact on the daily lives of those affected and therefore requires a comprehensive assessment and treatment to alleviate symptoms and improve the quality of life of those affected.
“First of all, one must realize that approximately 10,000 liters of air are inhaled and exhaled through the nose every day. In the process, toxic substances or soot particles inhaled with the air are also trapped at the entrance to the nose. The tonsils also react to certain substances, and the body has to deal with them, building up its immunological memory with ‘memory cells’. As people get older, they also become more vulnerable. A cold is not serious in itself; it clears up after 10–13 days – but it must be fully recovered from, otherwise bacteria can enter the paranasal sinus system, and chronic inflammation can develop, which then covers the nasal mucosa. As a result, the sinuses become blocked, and, figuratively speaking, instead of a flowing river, you have a draining lake with a swamp. A genetic predisposition can also be a cause of CRS. For example, cystic fibrosis can affect the sinuses and lead to rhinosinusitis. Due to the thick, sticky mucus typically produced in people with cystic fibrosis, the sinuses can become blocked. This can lead to a build-up of mucus in the sinuses, which in turn can cause inflammation and infection. People with allergies or immune deficiencies generally experience nasal problems more frequently, such as those with CVID (Common Variable Immune Deficiency)”, explains Prof. Dr Caversaccio at the start of our conversation. Smoking, frequent respiratory infections, asthma and a family history of CRS increase the risk of developing CRS.
In CVID, the immune system is unable to produce sufficient antibodies to protect the body against infections. The exact cause of CVID is not fully understood, although genetic and environmental factors may play a role. People with CVID have low levels of immunoglobulin G (IgG), immunoglobulin A (IgA) and/or immunoglobulin M (IgM), which leads to an increased risk of recurrent infections, particularly of the respiratory tract, the digestive tract and the skin.
“The fact is, the nose acts as a filter. So many substances pass through it, including nanoparticles, which can then reach the brain and potentially trigger dementia. It is still unclear whether air pollution is specifically a problem or whether it is inhaled sulfur dioxide, which affects, for example, people who live near or work in lignite mining areas or nuclear power stations. The climate, and in particular humidity, also plays a major role in nasal problems, which occur more frequently in higher humidity as bacteria and viruses thrive in damp environments,” explains Prof. Dr Caversaccio.
The symptoms of CRS can vary.
The most common symptoms include persistent nasal congestion, nasal discharge, facial pain, reduced sense of smell and coughing. These symptoms can vary over time and, in some cases, become worse, particularly if the condition is not treated appropriately. “It can be said that a patient may develop CRS if a cold persists for longer than twelve weeks. The nose is blocked, it may also run, pressure builds up in the sinuses, and there may be a reduction in the sense of smell. In older patients, this is also referred to as ‘post-nasal drip’, whereby excess mucus drains from the sinuses into the throat. “Normally, the nasal mucosa produces enough mucus to keep the nose moist and to remove foreign bodies and pathogens. In CRS, this production is often increased, and the mucus can accumulate in the sinuses,” says Prof. Dr Caversaccio, adding:
“Then, with CRS, there is the type with and the type without nasal polyps. Normally, the nasal cilia beat backwards. And if there is inflammation here, it can be carried even further down, including into the lungs. In people who have developed nasal polyps, 50% also suffer from asthma. Some patients also develop hypersensitivity to acetylsalicylic acid (e.g. found in aspirin) or to white wine, where those affected react to the sulfate content in the wine, causing the nose to swell.”
The diagnosis of rhinosinusitis is usually made through a thorough medical history, physical examination and, if necessary, additional diagnostic tests.
First, the patient’s medical history is taken, during which they are asked about symptoms such as persistent nasal congestion, nasal discharge, facial pain, reduced sense of smell and coughing. “A thorough medical history is very important. I also enquire about conditions at the workplace, ask whether the patient smokes or uses cocaine (the latter gradually destroys the nasal cartilage), and whether any allergies are known. A physical examination can provide clues to inflammation of the sinuses, looking for swelling, redness or tenderness in the facial area. Additional tests may be required to confirm the diagnosis and assess the severity of the condition. These include imaging techniques such as CT scans or MRIs of the sinuses, which can help to identify structural abnormalities or signs of inflammation. In some cases, however, an endoscopic examination of the nasal cavity may also be carried out to look directly into the sinuses; unlike imaging techniques, this only reveals a fraction of the area. If an infection is suspected, a culture or swab may also be taken from the sinuses to identify the pathogen and determine the appropriate treatment. In addition, an allergy test can be carried out and desensitization administered, and a lung function test is sometimes part of the diagnostic process. The so-called ‘SNOT-22 questionnaire’ is also frequently used; this is a self-assessment tool for patients, developed by doctors to assess the severity of the symptoms and to determine the extent to which quality of life is affected,” explains Prof. Dr Caversaccio regarding the diagnosis.
Untreated rhinosinusitis can lead to complications.
Sinus infections: Blocked sinuses can provide an ideal environment for bacterial growth, which can lead to recurrent sinus infections.
Nasal polyps: Chronic inflammation can lead to the formation of polyps in the paranasal sinuses, which can obstruct breathing and lead to further symptoms such as facial pain and headaches.
Intracranial complications: In rare cases, untreated sinusitis can lead to serious complications such as meningitis, brain abscesses or other life-threatening conditions.
There are various conservative treatment options for rhinosinusitis.
“Nasal rinses or nasal douches are used regularly to cleanse the nasal cavity with an isotonic or hypertonic saline solution. This helps to remove mucus and allergenic irritants and soothe the nasal mucosa. Steam baths are also helpful, as is ensuring adequate fluid intake. Antiallergic drugs are effective for allergic CRS. Nasal sprays can be used in the short term to relieve nasal congestion and inflammation. These include decongestant cortisone nasal sprays for short-term use or steroid nasal sprays such as fluticasone for long-term treatment of inflammation. With nasal sprays, it is always important to use them in a criss-cross pattern. This means spraying into the right nostril with your left hand and into the left nostril with your right hand. This is important because it ensures the spray lands where it is intended to, rather than on the nasal septum, as this can cause it to dry out quickly or, in the long term, even lead to perforations. “In cases of bacterial infections, antibiotics may be prescribed for 2–3 months to combat the infection and reduce inflammation, particularly if the patient does not have nasal polyps,” explains Prof. Dr Caversaccio, outlining the possible conservative measures. Lifestyle changes such as giving up smoking, avoiding allergens and irritants, and regular physical activity can also help to reduce symptoms and improve well-being.
New hope for people with chronic rhinosinusitis and polyps: biologics
The introduction of biologics has revolutionised the treatment of chronic rhinosinusitis (CRS) and offers a ray of hope to many severely affected individuals. “Biologics are molecular antibodies used for immunomodulation. They have also been used extensively in rheumatology in recent years and can specifically target the causes of diseases and have an anti-inflammatory effect. The patient receives the biologics via subcutaneous injections administered every 2–3 weeks, and the patient can also administer the injection at home. As the treatment is currently still very expensive, it is used as an ‘add-on therapy’, meaning when all other conservative treatments have failed, or when surgical intervention has not achieved the desired outcome (surgery is cheaper than treatment with biologics). The therapeutic effect of biologics becomes apparent after around 7–8 months. There are few side effects. ‘In rare cases, there may be redness at the injection site; occasionally, headaches or itching around the eye may occur,’ explains Prof. Dr Caversaccio.
Biologics are medicines produced using biotechnology that are capable of blocking specific cytokines or inflammatory mediators involved in the pathogenesis of CRS. Some of the biologics commonly used for CRS include anti-interleukin-5 antibodies such as mepolizumab and reslizumab, as well as anti-interleukin-4/13 antibodies such as dupilumab. These medicines work by inhibiting the activity of inflammatory mediators that play a key role in the recruitment and activation of eosinophils, as well as by reducing mucus production and the formation of nasal polyps.
Compared to conventional therapies such as steroid nasal sprays or systemic steroids, biologics offer several advantages. Firstly, they are more specific and target the underlying inflammatory mechanisms directly, which can lead to more effective symptom control. Secondly, they can help patients for whom conventional therapies have not been sufficiently effective or who have experienced undesirable side effects, particularly with long-term steroid use. Thirdly, biologics can enable long-term remission of symptoms, thereby reducing the need for frequent repeat treatments.
Minimally invasive procedures such as endoscopic sinus surgery (FESS) are considered for patients with chronic rhinosinusitis (CRS) when conservative treatments are insufficient to alleviate their symptoms.
Firstly, the patient must have tried various conservative treatment options such as nasal rinses, nasal sprays and antibiotics without success. “It is also important to determine the patient’s immunoglobulin status to rule out the possibility that the patient has CVID (Common Variable Immune Deficiency), as in such cases a minimally invasive surgical procedure would not be successful in the long term. An assessment of the sense of smell is also necessary prior to any potential surgical intervention. “If the sense of smell is impaired, cortisone tablets (plus stomach protection) can be prescribed for ten days to improve the sense of smell,” explains Prof. Dr Caversaccio. It is important to ensure that the patient has no contraindications for the operation and is in good health.
“In an endoscopic operation, i.e. using keyhole surgery, existing polyps can be removed. The openings to the maxillary sinuses can also be widened to clear the maxillary and frontal sinuses. That is the aim. The nasal septum is the anatomical issue that often still requires surgery. If necessary, the turbinates can also be reduced in size slightly. The operation then takes 1–2 hours, depending on the extent of the procedure. And as the operation takes place close to the eyes and the brain, with the aorta on the right and left and the pituitary gland above, we rely heavily on navigation systems during the procedure to minimize risks even further. In the past, nasal packing was inserted, which is no longer done in this way today. Thanks to the techniques available today, haemostatic foam containing coagulants or haemostatic agents can be applied to the nose after the procedure. Alternatively, dissolvable packing is used. “This ensures the patient’s quality of life, as they can breathe easily again straight away. The patient usually leaves hospital after one night,” says Prof. Dr Caversaccio. Sometimes such an operation needs to be repeated. “It’s like in a garden – you mow the grass, and it grows back. It can be the same with adenoids. The aim is always for the patient to be able to breathe better again,” adds Prof. Dr Caversaccio.
Following a minimally invasive procedure such as endoscopic sinus surgery (FESS), some patients may notice an improvement in their symptoms within a few weeks, particularly regarding nasal breathing and nasal congestion. Complete healing and the optimal effect of the surgery can only be determined after a few months, as the nasal mucosa needs time to regenerate and stabilize. When using biologics to treat CRS, the time taken for symptoms to improve may also vary.
Outlook
“Anyone with nasal problems who finds breathing difficult due to congestion may well use a nasal spray for a period of 7–10 days. Anyone who then continues to use nasal spray on a regular basis risks a dry nose, which can also lead to the development of what is known as a ‘stinky nose’, where yellowish-green crusts and scabs form in the nasal cavity, giving off a putrid, sweetish odor. The problem is that the patient gets used to the nasal spray because it provides quick relief when the nose is blocked. I would definitely recommend seeing a doctor to get a proper medical diagnosis of the cause of the nasal problem. Medical technology has advanced so much today, and with the 3D endoscope, surgical procedures are much better. Biologicals are a real ‘game-changer’ – they are a real blessing for many patients because they help them regain their quality of life and sometimes even a lost sense of smell. Of course, we still need to wait for the long-term results, which will be available in about 10–20 years,” encourages Prof. Dr Caversaccio, and with that we conclude our conversation.
Thank you very much, Professor Caversaccio – that was a fascinating insight into the treatment options for chronic rhinosinusitis!
