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Rhinosinusitis
Acute rhinosinusitis Subacute rhinosinusitis Chronic rhinosinusitis Recurrent ARS Acute rhinosinusitis superimposed on CRS
Acute rhinosinusitis
Acute sinusitis 7-21 days (7 days viral illness) Spontaneous resolution of ARS -40% The most common pathogens: strep pneumonia-30%, non typeabale hemophilus infl.-20%, moraxella catarrhalis.(20% in children) Staph aureus- 30% Anaerobes- rare
Recurrent ARS
Episodes of bacterial infection of the paranasal sinuses, each lasting less than 30 days and separated by intervals of at least 10 days during which the patient is asymptomatic.
Subacute sinusitis
Subacute RS:3W-3months The same pathogens as in ARS
Chronic rhinosinusitis
Beyond 3 months Bacteria are as in ARS, but More non-typeable H Influezae More staph aureus, anaerobic bacteria, gram- Negative, pseudomonase aeruginosa Polymicrobials with resistant organism Culture recommended
Predisposing factors
URI Allergy Trauma Dental infection Environmental Pollutants GERD Cystic Fibrosis
Facial pain on percussion or palpation, sedimentation rate and white blood count have little diagnostic value .
Purulent secretions by history Purulent secretions in the nasal cavity on examination Lack of response to decongestants and antihistamines Unilateral maxillary pain
Double-sickening": an upper respiratory infection that initially improves then worsens
The gold standard for the diagnosis of acute bacterial sinusitis is the recovery of 4 bacteria in high density (>10 colonyforming units/mL) from the cavity of a paranasal sinus
Type of rhinosinusitis
Acute rhinosousitis Pattern of symptoms *Symptoms minimum 10d-28d *severe disease CRS without polyposis Symptoms >12w
*worsening disease
Symptoms for diagnosis *Ant./post purulent discharge *nasal obstruction *facial pain-pressure The following symtoms *ant/post mucupurulent
*nasal obstruction
*facial pain
Objective documentation
*ant/pos mucupurulent d
*nasal obstruction
*decrease sense of smell Objective documentation Nasal exam.to confirm bilat polyps . CT is not essential
CT is not essential
Fungal culture , total IgE
type acute
organism
Strep pneumoniae h. Influenzae m. catarrhalis
drugs
Amoxicillin 10 days
comments
2nd generation cephalosporin, Macrolide, for penicillin allergy
subacute
chronic
Polimicrobial, psudomonase a, anaerobes, more resistant Resistant , polimicrobial G(-). Staph aureus
Severe sinusitis with suspected orbital or intracranial complications cefuroxime or ceftriaxone The best in crs treat according to culture For crs treat 3 weeks, while improvement within 3-5 days 3-6 weeks prophylaxis once daily therapy for patients with rapid recurrence??
: , .
levofloxacin fluoroquinolones : 90-92% .moxifloxacin - augmentin, ceftriaxone high dose amoxicillin, cefixime :83-88% cefpodoxime proxile, cefuroxime axetil, cefdinir TMP/SMX docxycyline, clindamycin, :77-81% azitromycin, clarithromycin, erythromycin cefaclor,loracarbef :65-66%
According to the guidelines
91-92%: ceftriaxone, augmentin 82-87%: amoxicillin, cefpodoxime proxetil, cefixime, cefuroxime axetil,cefdinir,TMP/SMX 78-80% :clindamycin, cefprozil, azithromycin, clarithromycin, erythromycin 67-68%: cefaclor
Augmentin, amoxicillin, cefpodoxime proxetil, cefuroxime axetil, or cefdinir For b-lactam allergies patients: TMP/SMX, doxycilline, azithromycin, clarithromycin,erythromycin Failure after 72h: reevaluation or switch to alternate antimicrobial therapy
According to the guidelines
Respiratory flouroquinolones, augmentin (4g/day),ceftriaxone (1-2 g/day 5 days), combination of g+ and gFailure after 72h: switch to alternate antimicrobial therapy, or reevaluation CT scan, endoscopy, sinus aspiration and culture
According to the guidelines
Augmentin (90mg/k/day), amocixillin (90 mg/k/day), cefpodoxime proxetil, cefuroxime axetil, or cefdinir Type I hypersensitivity to b-lactams patients: TMP/SMX, azithromycin, clarithromycin or erythromycin. Make differentiate an immediate hypersensitivity from other side effects Failure after 72 h
According to the guidelines
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Augmentin(90mg/k/day), cefpodoxime proxetil, cefuroxime axetil or cefdinir. Beta lactams allergic patients: TMP/SMX, azithromycin, clarithromycin, erythromycin Clindamycin for s pneumoniae Ceftriaxone (5 days, parenteral), or combination therapy for G+ and GClindamycin or amocixillin and cefixime Clindamycin or amoxicillin and rifampin
According to the guidelines
Biofilms-a artificial or damaged biologic surface that formed communicating organization of microorganisms surrounded by a glycocalys Biofilms is relatively impervious to antibiotics and is never eradicated Mechanical debridement- the only way to resolve biofilms
The changes in the involved bone can explain why CRS is relatively resistant to medical therapy.
Failed CRS
To sinus surgery or systemic steroid/antibiotics Macrolid therapy (long term, low dose) effective
CRS
78 had criteria to CRS 17 endoscopy: positive 37- CT findings: positive 6 endoscopy : positive 41- CT findings: negative 35: endoscopy negative & CT negative 20: endoscopy negative & CT positive 55: endoscopy negative
Endoscopy/ct findings/clinical
Easy to diagnose CRS by endoscopy alone when nasal polyps, purulence, or fungus is observed, when absent, establishing the diagnosis may be more difficult 45% of patients with clinical CRS were both endoscopically and radiographically negative.
Stankiewicz and Chow. Otolaryngol head neck surg 2002
Endoscopy/ct findings/clinical
Negative endoscopy alone is insufficient to rule out sinusitis. 26% of patients who were negative on endoscopy had positive CT this would suggest that if endoscopy is negative most of the time the ct will be also negative, even with a positive history.
) URI ( 10 10 VIRAL URI . 5-7 The diagnosis of acute bacterial sinusitis is based on clinical criteria in children who present with upper respiratory symptoms that are either persistent or severe
Guidelines of American Academy of Pediatrics
Persistent symptoms are those that last longer than 10 to 14, but less than 30, days. Such symptoms include nasal or postnasal discharge (of any quality), daytime cough (which may be worse at night), or both.
Severe symptoms include a temperature of at least 102F (39oC) and purulent nasal discharge present concurrently for at least 3 to 4 consecutive days in a child who seems ill. The child who seems toxic should be hospitalized and is not considered in this algorithm.
children
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ARS in children
Diagnosis in children based on clinical criteria Radiology is only for complications, persistent or recurrent sinusitis For prevention there is no prophylactic antimicrobial treatment, ancillary therapies, complementary/alternative medicine
Guidelines of American Academy of Pediatrics
Goal of surgery
Surgery is for control of symptoms, better quality of life and to prevent complications Indications to surgery are not uniform between OL and P cure-the goal for surgery, but is not the likely end point Reversible mucosal disease may be possible in the long run, but is unlikely to be realized in the short term
Fear of surgery?
Surgery may cause growth retardation of the midface Bothwell et al. showed no difference in facial growth of children with CRS who operated compare with children who refused surgery.
Surgery
Children who fail medical therapy benefit from surgery Adenoidectomy recommended initially for children 6 years of age (no asthma, low CT score) ESS and adenoidectomy for children older than 6 (asthma and high CT score)
Ramadan. Laryngoscope.2004
Antibiotic therapy
Amoxicillin -1st choice In children give high dose 60mg/kg/day To consider 2nd generation cephalosporin, or erythromycin with sulfonamide ,or high dose penicillin in areas with a high incidence of bacterial antibiotic resistance. Based on studies showing a 20% incidence of viable bacteria through maxillary sinus tap after 7 days of antibiotic therapy, most authors recommend 10 days of therapy in the manage of acute sinusitis