Acute & Chronic Sinusitis

1. Acute & Chronic Sinusitis לימודי המשך Ephraim Eviatar Assaf Harofeh Medical Center

2. סינוסיטיס היא האבחנה החמישית אשר אנטיביוטיקה מומלצת עבורה. • סינוסיטיס מהווה 9% מכלל הילדים שקיבלו אנטיביוטיקה ו-21% במבוגרים.

3. Rhinosinusitis • Acute rhinosinusitis • Subacute rhinosinusitis • Chronic rhinosinusitis • Recurrent ARS • Acute rhinosinusitis superimposed on CRS

4. 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

5. Recurrent ARS • Episodes of bacterial infection of the paranasal sinuses, each lasting less than 30 days and separated by intervals of at least 10days during which the patient is asymptomatic.

6. Subacute sinusitis • Subacute RS:3W-3months • The same pathogens as in ARS

7. 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

8. 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.

9. 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 Major & Minor signs and symptoms in diagnosis of Chronic RS

10. 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

11. Predisposing factors • URI • Allergy • Trauma • Dental infection • Environmental Pollutants • GERD • Cystic Fibrosis

12. 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

13. The gold standard for the diagnosis of acute bacterial sinusitis is the recovery of bacteria in high density (>10colony-forming units/mL) from the cavity of a paranasal sinus 4

14. Rhinosinusitis definitions for patient care Type of rhinosinusitis CRS without polyposis Acute rhinosousitis Pattern of symptoms *Symptoms minimum 10d-28d *severe disease *worsening disease Symptoms >12w 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

15. Rhinosinusitis definitions for patient care Type of rhinosinusitis CRS with polyposis AFRS >1 of the symptoms: *ant/pos rhinitis *nasal obstruction *facial pain/pressure >2 of the symptoms: *ant/pos mucupurulent d *nasal obstruction *decrease sense of smell Symptoms for diagnosis Nasal exam.to confirm bilat polyps . CT is not essential Nasal exam. Allergic mucin, inflammation & polyps *fungal specific IgE No invasion CT is not essential Fungal culture , total IgE Objective documentation

16. Yes: Amoxicillin Or Bactrim No: Treat symptomatically Saline irrigation Oral decongestant Antihistamine (allergy) Reevaluate in 10 days Dose the patient have 2 or more major factors ...? Kinney WC : otolaryngol Head Neck Surg 2002

18. 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??

19. 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,

20. מטרת הטיפול האנטיביוטי: • לחסל את החיידקים באתר של הזיהום כדי שלהשיב את הסינוסים לבריאותם • לקצר את תקופת המחלה ולשוב לשגרת חיים נורמאלית • למנוע סיבוכים קשים, כמו מנינגיטיס. • למנוע התפתחות מחלה כרונית According to the guidelines

21. טיפול במבוגרים • האנטיביוטיקה שיעילותה הקלינית המנובאת מגיעה ל 90-92% הינם: fluoroquinolones כמו levofloxacin ו- moxifloxacin. • ceftriaxone ,augmentin • יעילות של 83-88%: cefiximehigh dose amoxicillin, cefpodoxime proxile, cefuroxime axetil, cefdinir TMP/SMX • יעילות של 77-81%:docxycyline, clindamycin, azitromycin, clarithromycin, erythromycin יעילות של 65-66%: cefaclor,loracarbef According to the guidelines

22. טיפול בילדים • 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

23. ההמלצות לטיפול התחלתי במבוגרים עם מחלה קלה • 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

24. המלצות לטיפול התחלתי במבוגרים עם מחלה קלה שטופלו קודם • Respiratory flouroquinolones, augmentin (4g/day),ceftriaxone (1-2 g/day 5 days), combination of g+ and g- • Failure after 72h: switch to alternate antimicrobial therapy, or reevaluation • CT scan, endoscopy, sinus aspiration and culture According to the guidelines

25. המלצות לטיפול התחלתי בילדים עם מחלה קלה • 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

26. המלצות לטיפול בילדים עם מחלה קלה (טופלו לאחרונה) או מחלה בינונית • 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 G- • Clindamycin or amocixillin and cefixime • Clindamycin or amoxicillin and rifampin According to the guidelines

27. New insights into the role of bacteria in CRS • Bacterial superantigens-exotoxins that are able to activate T lymphocytes • Pathogenesis of nasal polyposis- superantigens from S aureus

28. 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

29. 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 • The changes in the involved bone can explain why CRS is relatively resistant to medical therapy. Khalid et al. laryngoscope 2002

30. 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

31. CRS • 78 had criteria to CRS • 37- CT findings: positive • 41- CT findings: negative • 35: endoscopy negative & CT negative • 20: endoscopy negative & CT positive • 55: endoscopy negative 17 endoscopy: positive 6 endoscopy : positive Stankiewicz & Chow: Otolaryngol Head Neck Surg 2002

32. 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

34. 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

35. 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

36. בילדים • הסיכון שזיהום חיידקי (בעקבות URI) יופיע גדול יותר אם המחלה נמשכת מעל 10 ימים • אבחנה תעשה בילדים ומבוגרים עם סימפטומים של VIRAL URI שלא השתפרו אחרי 10 ימים או הוחמרו אחרי 5-7 ימים. • 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

37. בילדים • 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

38. בילדים • Severe symptoms include a temperature of at least 102°F (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

39. children יש קושי לפעמים להבדיל בילדים בין מחלה וירלית של דרכי נשימה עליונים ואדנואידיטיס מסינוסיטיס חריפה רק נזלת מוגלתית וסמיכה מקורה בסינוסים עצמם, והאף משמש כצינור, בעוד שנזלת מוקואדית, וירלית מערבת את האף בילבד. יש דמיון רב בין דלקת אוזן חריפה לסינוסיטיס חריפה בילדים מבחינת פטוגנסיס ומיקרוביולוגיה בגלל הקשר לנאסופארינקס

40. 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

41. 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

42. 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

44. Maximal medical management • Reflux • Macrolids • Antileukotriens • Irrigations-nasal sprays • Alternative medical approaches

45. Surgical management children • Biomaterials • Subperiosteal abscess

46. 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.

48. 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

49. 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.

50. 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