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Acute & Chronic Sinusitis

Ephraim Eviatar

Assaf Harofeh Medical Center

. 9% 21%-.

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

Acute bacterial sinusitis superimposed on chronic sinusitis


Patients with residual respiratory symptoms develop new respiratory symptoms. When treated with antimicrobials, these new symptoms resolve, but the underlying residual symptoms do not.

Major & Minor signs and symptoms in diagnosis of Chronic RS


Majors: Facial pain/pressure Nasal congestion/fullness N. obstruction/blockage N. discharge/purulence Hyposmia/ anosmia Purulent rhinitis Fever (acute sinusitis only) Minors: Headache Fever Halitosis Fatigue Dental pain Cough Ear pain/ pressure/fulln

Clinical Diagnosis of rhinosinusitis


2 or more major factors 1 major & 2 minor factors Or Purulence on examination Duration of symptoms > 10 days or worsen after 5-7 days

Kinney WC : otolaryngol Head Neck Surg 2002

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

Rhinosinusitis definitions for patient care

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

Nasal exam:purule Radiographic evidence Nasal exam to exclude polyps

CT sinus not essential

Rhinosinusitis definitions for patient care Type of rhinosinusitis

CRS with polyposis

AFRS >1 of the symptoms:


*ant/pos rhinitis *nasal obstruction *facial pain/pressure Nasal exam. Allergic mucin, inflammation & polyps *fungal specific IgE No invasion

>2 of the symptoms:

Symptoms for diagnosis

*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

Dose the patient have 2 or more major factors ...?


Yes: Amoxicillin Or Bactrim No: Treat symptomatically Saline irrigation Oral decongestant Antihistamine (allergy) Reevaluate in 10 days

Kinney WC : otolaryngol Head Neck Surg 2002

type acute

organism
Strep pneumoniae h. Influenzae m. catarrhalis

drugs
Amoxicillin 10 days

comments
2nd generation cephalosporin, Macrolide, for penicillin allergy

subacute
chronic

Increased resistant of bacteria

2nd line drugs


Augmentin, 2nd cephalo. macrolide, clinda,3-4w Culture whenever possible

Polimicrobial, psudomonase a, anaerobes, more resistant Resistant , polimicrobial G(-). Staph aureus

Recurrent chronic Suppurative complications

consider 3-4w Culture guided profilaxis Cefuroxime, aminoglicozid Surgery if no responce

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??

Antimicrobial treatment guidelines


1. mild symptoms, not received antibiotics within 4-6w. 2. mild disease, who received antibiotics within 4-6w, or with moderate disease regardless of recent antibiotic exposure,

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According to the guidelines


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

According to the guidelines


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

New insights into the role of bacteria in CRS


Bacterial superantigens-exotoxins that are able to activate T lymphocytes Pathogenesis of nasal polyposissuperantigens from S aureus

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

Osteitis: the role of the bone


Osteomyelitis can be seen at a distance from the primary infection Inflammatory bone changes were noted on contralateral side in 52% of the animals
Khalid et al. laryngoscope 2002

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

Cervin A et al: Otolaryngol Head Neck Surg 2002

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

Stankiewicz & Chow: Otolaryngol Head Neck Surg 2002

Radiology & clinical exam


Correlated with a Sensitivity of 75% And specificity of 84% Endoscopy correlated poorly with sinus disease and not predictive

Stankiewicz & Chow: Otolaryngol Head Neck Surg 2002

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.

Stankiewicz & Chow: Otolaryngol Head Neck Surg 2002


) 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.

Guidelines of American Academy of Pediatrics


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.

Guidelines of American Academy of Pediatrics

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

Surgical management of crs in children


5-8 events of colds/year 5%-13% will complicate by acute RS Most of children with RS respond to medical treatment Today surgery consist of sinus lavage, ESS, adenoidectomy

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

Maximal medical management


Reflux Macrolids Antileukotriens Irrigations-nasal sprays Alternative medical approaches

Surgical management children


Biomaterials Subperiosteal abscess

The surgical site in children


There is strong evidence to support the fact that the OMC area is the primary site of involvement of inflammatory sinuses disease.

Surgical management in children


Role of adenoidectomy: 1. reservoir for pathogenic bacteria 2. interfere with nasal mucociliary clearance 3.better drainage Overall success of adenoidectomy-50% Studies show reduction in the number of bacterial pathogens in the nasopharynx after adenoidectomy

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

Results of surgery children


Older children do better than youngest Old children (>6 y/o)- successes rate is 89% , but younger children (<6 y/o)successes rate is only 73% >3 y/o who were operated have 75% chance to be reoperate

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

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