"Doc, I think I have a sinus infection and need an antibiotic," is a common patient complaint that I hear at this time of year. 

With the ups and downs of the weather around Spring time and with the allergy season in full force it is common for me to see patients who have significant sinus and allergy problems. Many patients associate sinus symptoms with sinus infection. 

Sinus pressure or inflammation of the sinuses (Sinusitis) can actually be caused by many things. These include viruses, allergies, and bacteria. The most common cause is a viral infection associated with the common cold. Bacterial sinusitis, which is treated with antibiotics, complicates viral sinusitis in only about 0.5 to 2 percent of cases. (1) In theory, this means that the vast majority of patients that present with a "sinus infection" should not be treated with antibiotics. 

However, it is not always so clear when someone has a bacterial sinus infection. So what are some criteria that are more suggestive of bacterial sinusitis. The Infectious Disease Society of America suggests the following three criteria (2):

• Persistent signs or symptoms that don't show clinical improvement in 10 days
• Onset of severe symptoms or signs of high fever (>39°C or 102°F) and purulent nasal discharge or facial pain for 3-4 consecutive days
• Worsening symptoms after initial improvement after 5-6 days 

Fortunately, if you do have a sinus infection or sinus symptoms there are some traditional treatments that may help. These include anti-inflammatories, saline irrigation, intranasal steroids like Flonase, antihistamines, mucolytics (guaifenesin), and decongestants. If these treatments are not helping or symptoms are worsening than antibiotics are often necessary. Antibiotics that are commonly used in adults include Augmentin, Doxycycline, Clindamycin, or a Levofloxacin. 

Steroids may also help and have been shown to shorten the time to resolution. 

Some natural treatments that may help include colloidal silver, essential oils, and natural antihistamines. 

If you are experiencing significant sinus or allergy symptoms please feel free to give me a call or see your doctor. 

References:

1. Fokkens W, Lund V, Mullol J, European Position Paper on Rhinosinusitis and Nasal Polyps Group. EP3OS 2007: European position paper on rhinosinusitis and nasal polyps 2007. A summary for otorhinolaryngologists. Rhinology 2007; 45:97.

​2. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis 2012; 54:e72.

At my family practice I frequently see lacerations and put in stitches. I also take out cysts and other lesions. One of the questions I frequently get asked is when it is appropriate to get stitches. 

Before I get to more details on when a cut should be stitched I think it is important to review a few basics. 

To start off, the basics of laceration repair have not really changed significantly over the past one hundred years. The goals of laceration repair is to help prevent wound infection, assist in stopping bleeding, and to produce an aesthetically pleasing scar. 

The skin is composed of the epidermis, dermis and subcutaneous layers. The two outer layers of the skin are the epidermis and dermis. These two layers are clinically nearly indistinguishable from each other. 

The subcutaneous tissues are mainly composed of fat tissue, muscle, blood vessels, and nerves.

Interesting, the top layer of skin or the epidermis closes over a wound within 48 hours after suture closure. Collagen (scar) formation starts after 48 hours and wounds continue to heal for up to 12 months. 

Things that impair wound healing include diabetes, poor nutrition, poor vascular supply, and medicines such as steroids.

So when are stitches appropriate? 

Wound repair with sutures is appropriate when the depth of wound extends through both the epidermis and dermis layers into the subcutaneous layers. Basically if you see fat (yellow) or muscle a wound should be closed.

How should a wound be closed?

Some wounds such as those on the scalp or when longer than 5 cm may be closed faster with staples. Some wounds that are not under tension and less than 5 cm may be closed adequately with skin adhesive. All other wounds should be closed with stitches. 

How long do you have to get stitches? 

I often have patients come into the clinic several days after a wound has happened and they are surprised to learn that I cannot put stitches in. 

In general, clean, uninfected wounds can be closed up to 18 hours following the injury without increasing the risk of infection. Facial and neck wounds may be closed up to 24 hours later or longer if there are no signs of infection.

Wounds that are grossly contaminated, infected, or don't come to medical attention early enough should not be closed. Other wounds that are not generally closed include animal bites, deep puncture wounds, wounds with too much tension, or superficial wounds. 

Also, for any wound and especially ones that will be closed with sutures it is key to irrigate the wound thoroughly and remove any debris and dead tissue. Irrigation can be performed with normal saline. Many people use Hydrogen Peroxide (H202) or Iodine but it is important to remember that H202 and Iodine are toxic to healthy issues and may impair wound healing. 

For those with any questions about proper wound care or when a laceration should be sutured feel free to reach out to me or come into the clinic. I typically charge about half of what you would pay at other clinics.