Download AVRS Treatment

Management of Acute
and Chronic Sinusitis
Presentation Outline
1. Acute Sinusitis
2. Chronic Sinusitis
Importance
in USA, one in five antibiotic prescriptions
are for patients with sinusitis symptoms!
(acute and chronic)
Acute Sinusitis
Definition
• Acute sinusitis is defined as sinunasal
inflammatory Sx & Hx lasting less than
one month
– Acute Viral Rhinosinusitis (AVRS)
– Acute Bacterial Rhinosinusitis (ABRS)
Diagnosis
PLAIN SINUS X-RAYS AND OTHER IMAGING ARE NOT
NECESSARY IN MAKING THE DIAGNOSIS OF ACUTE
SINUSITIS
AVRS Treatment
• Maintain adequate hydration
• Steamy shower or increase humidity in
your home or personal steam vaporizer
• Apply warm facial packs
• Analgesics
(acetaminophen,
aspirin no less than 18yr)
ibuprofen,
AVRS Treatment
• Saline irrigation lavage
• Decongestants (oral)
– i.e.: Pseudoephedrine hydrochloride 60 mg
every 4 to 6 hours, not to exceed 4 doses per
24 hours.
• Decongestant nasal sprays for no longer
than 5 days
AVRS Treatment
• Adequate rest
• Sleep with head of bed elevated
• Avoid cigarette smoke and extremely cool
or dry air
When to start Abx for ABRS
– Persistence of symptoms for longer than
10 days
– Worsening of symptoms after 7 days
– Conditions Requiring Action Before Seven
Days:
• Fever >=39 and a documented history of
sinusitis
• Upper teeth pain (not of dental origin)
• Severe symptoms
• Known anatomical blockage
ABRS Germs
• Streptococcus pneumoniae
• nontypeable Haemophilus influenzae
• Moraxella catarrhalis
ABRS Treatment
• Abx:
– Amoxicillin 500 mg tab three times per day x
10-14 days… in under 18yrs try 8090mg/kg/day
– For those allergic to amoxicillin: Trimethoprimsulfamethoxazole
– For patients allergic to both amoxicillin and
TMP/SMX, macrolides can be prescribed
• Nasal steroid spray
• Pain killer
Follow up
• 3 day  children
• 7 day  adult
Partial response
• patient is symptomatically improved but
not back to normal at the end of the first
course of antibiotics
– An additional 10 to 14 days of amoxicillin
– TMP/SMX: one double strength tab BID x 14
days
Little or no improvement
• Amoxicillin/Clavulanate
• Cephalosporin 3rd generation ie. Cefuroxime,
Cefpodoxime, Cefprozil, or Cefdinir
• Clarithromycin 500mg BIDx 14 days
• Azithromycin 500 mg every day x 3 days
• Quinolones…
• In patients who have not responded to three
weeks of continuous antibiotic therapy
practitioners should consider referral to ENT
or Allergy for further workup
Invasive Fungal Sinusitis
• Uncommon
• Seen usually in immunocompromised or
diabetic patients
• Aspergillosis, mucormycosis
• Requires high index of suspscion
• Diagnosed by biopsy and culture
• Therapy for invasive forms requires wide
local debridement and IV Ampo. B
Chronic Rhinosinusitis
Definition
• Chronic
rhinosinusitis
is
a
group
of
disorders characterized by:
– inflammation of the mucosa of the nose and
paranasal sinuses for at least 12 consecutive
weeks’ duration
Diagnosis
the use of symptoms
to define CRS is not
as effective as for
ABRS
History &
Physical
examination
Endoscopy
(edema and
discolored
secretions)
CT-Scan*
Etiology
• The potential causes of CRS may be
numerous,
disparate,
and
frequently
overlapping
• A unified, accepted understanding of the
etiology of CRS is still being sought
Allergy
Bacterials
Major
debatable
CRS
etiologies
Anatomic Variations
Fungi
Allergy
• The concordance of allergy and CRS
ranges from 25% to 50%, with pediatric
studies reporting the higher association
• In the subpopulation of patients with CRS
symptomatic enough to require surgery,
allergy is present in 41% to 84% of
patients
• Perennial hypersensitivity Predominates
(especially house dust mite)
• Allergic patients with CRS responded
more poorly to medical management than
allergic patients who did not have CRS
• Impact of allergic rhinitis on surgical
results in endoscopic sinus surgery 
success rate will be diminished about 10%
(90%80%)
• The etiologic association between allergic
rhinitis, and CRS is less clear yet (despite
ABRS)
Bacterial Infection
• The role of bacteria in the pathogenesis
of CRS, remains elusive, But:
–
–
–
–
mostly of mixed
Staphylococcus aureus
infections, with a
Coagulase-negative staphylococcus median of 3 different
bacteries
Anaerobic
Gram-negative bacteria.
• Despite
the
uncertainties
surrounding
the
etiologic factors associated with CRS, antibiotic
therapy has served as a mainstay of treatment
• Why their contribution is elusive?
• Relative abundance of eosinophils and the
paucity of neutrophilic inflammation in
tissue samples of the most cases of CRS
• This
inflammatory
response
independent of infection
may
be
Probable Mechanisms
• Chronic infection
• Osteitis
• Bacterial allergy
• Superantigen (usually from SA)
• Biofilms
The exact role of bacteria
in CRS remains unclear
Fungi (mechanisms in CRS)
• Chronic Invasive Fungal Sinusitis
• Allergic Fungal Sinusitis (charactristics:
eosinophilic mucin containing noninvasive fungal
hyphae, nasal polyposis, characteristic radiographic
findings, immunocompetence, and allergy)
• Fungal balls obstruction
• Immune Complex (non-IgE inflammation)
• At the current time, it appears that multiple
conditions
may
play
a
direct
or
contributory role in the pathogenesis of
CRS
• Current literature supports the important
role that bacteria and/or fungi, appear to
play in the pathogenesis of CRS
Anatomic Variants
• May predispose to earlier obstruction of
the sinuses, allowing for the development
of CRS, although strong evidence is
lacking
CRS medical therapies
Steroids
• Topical (INCS): Four of the five clinical
trials
demonstrated
significant
improvement in symptoms
• Although systemic steroids are widely
used, no RCTs have investigated their use
in CRS without polyposis
Antibiotics
• There is a lack of RCT in the literature regarding
to this topic, however, no difference between
antibiotics was noted
• But nowadays, Macrolids are in particular
attention because in addition to
effects,
macrolides
antiinflammatory
corticosteroids
have
effects
antibacterial
some
akin
to
interesting
those
of
• Also macrolides can possibly decrease biofilm
formation and overall bacterial virulence
• Regimens (3mo duration):
– Erythromycin Ethylsuccinate: 400 q6h up
to 2wk, then 400 BD up to 10wk
– Clarithromycin: 500 q12h up to 2wk, then
500 daily up to 10wk
Nasal douching
• At least four RCTs have shown
improvement in symptoms, quality of life
and endoscopy and imaging findings
• Nasal saline irrigation has been shown to
potentially provide more benefit than nasal
saline spray in patients with CRS
• A 2007 Cochrane review concluded that
nasal saline appears to have benefits as
an adjunctive treatment for CRS
Antifungal agents
• To date no convincing evidence of their
efficacy over and above saline douching
has been provided
Decongestants
• No RCTs have been performed in
CRS
Mucolytics
• There is little evidence in the literature for
the use of mucolytics such as bromhexine
Antihistamines
• There is no evidence to support the use of
antihistamines in CRS, and they are not
recommended
Proton Pump inhibitors
• The importance of GERD as a cause of
CRS is unknown, but it may be more
important in the pediatric population than
in adults
• No RTCs have shown benefit
• GERD may be more of a comorbid state
than a cause of CRS
Conclusion
• To date, however, because of the paucity
of properly conducted trials, no absolute
recommendation for a ‘correct regimen’
can be given
CRS without nasal polyps
•
•
•
•
•
INCS for 3-6mo
Nasal Douching with N/S
Macrolide for 1.5 to 3mo
Mucolytics
On failures, perform culture guided
therapy
• If failed again  Proceed with FESS
operation
CRS with nasal polyps
• INCS for undisclosed time!
• Nasal Douching with N/S
• Macrolide administration for 1.5 - 3mo
• Oral corticosteroids for 10 days (20-40mg)
• Montelukast
Nasal Examination: Technique
Symptom Duration: 8-12 weeks
Middle turbinate
Middle meatus
Septum
Inferior turbinate
Nasal airway
Inferior meatus
Floor of nose
For examination of the left side: index finger should rest on the tip of the nose.
For examination of the right side: index finger should rest on the cheek.
Nasal Examination: Purulence
Visualizing the Middle Meatus:
Key To Sinus Disease
Complications of Acute Sinusitis
• Orbital complications
– Preseptal cellulitis
– Abscess
– Phlegmona
– Blindness
• Cerebral complications
– Meningitis
– Extadural abscess
– Intradural abscess
• Osteomyelitis
Complications
Nasal Polyposis
• Prevalence: 2 - 4%, increase > 40 years
• 26 - 30% asthma
• Asthma: 7 - 15% nasal polyposis
• Nasal obstruction, reduced sense of smell
Larsen K. Allergy Asthma Proc. 1996;17:243-9.
Johansson L et al. Ann Otol Rhinol Laryngol. 2003;112:625-9.
Demoly et al. Allergy 2003:58:233-238.
Fokkens et al. Rhinol Suppl, 2007(20): 1-136.
CT of the Sinus: Normal
Impact of INCS on CRS after ESS
• Pre-op use of INCS associated with
decreased rate of bacterial recovery at
ESS
– Effect most pronounced for revision
cases, mainly for staphylococcal species
– Corticosteroid may penetrate
sinus cavities better after ESS
• In individuals consulting for CRS persisting
after surgical therapy, 61% had a
favourable response to irrigation with
corticosteroid / saline solution
Desrosiers M, Hussain A, Frenkiel S, Kilty S, Marsan J, Witterick I, Wright E. Intranasal corticosteroid use is associated with lower rates of
bacterial recovery in chronic rhinosinusitis. Otolaryngol Head Neck Surg. 2007;136:605-9.
Nader ME, Abou-Jaoude P, Cabaluna M, Desrosiers M. Using response to a standardized treatment to identify phenotypes for genetic
studies of chronic rhinosinusitis. J Otolaryngol Head Neck Surg. 2010;39:69-75.