Management of Acute and Chronic Sinusitis

1. Management of Acute and Chronic Sinusitis Bastaninejad, Shahin, MD, ORL & HNS, TUMS Amiralam Hospital

2. Presentation Outline • Acute Sinusitis • Chronic Sinusitis

3. Importance in USA, one in five antibiotic prescriptions are for patients with sinusitis symptoms! (acute and chronic)

4. Acute Sinusitis

5. Definition • Acute sinusitis is defined as sinunasal inflammatory Sx & Hx lasting less than one month • Acute Viral Rhinosinusitis (AVRS) • Acute Bacterial Rhinosinusitis (ABRS)

6. Diagnosis

7. PLAIN SINUS X-RAYS AND OTHER IMAGING ARE NOT NECESSARY IN MAKING THE DIAGNOSIS OF ACUTE SINUSITIS

8. AVRS Treatment • Maintain adequate hydration • Steamy shower or increase humidity in your home or personal steam vaporizer • Apply warm facial packs • Analgesics (acetaminophen, ibuprofen, aspirin no less than 18yr)

9. 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

10. AVRS Treatment • Adequate rest • Sleep with head of bed elevated • Avoid cigarette smoke and extremely cool or dry air

11. 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

12. ABRS Germs • Streptococcus pneumoniae • nontypeable Haemophilus influenzae • Moraxella catarrhalis

13. ABRS Treatment • Abx: • Amoxicillin 500 mg tab three times per day x 10-14 days… in under 18yrs try 80-90mg/kg/day • For those allergic to amoxicillin: Trimethoprim-sulfamethoxazole • For patients allergic to both amoxicillin and TMP/SMX, macrolides can be prescribed • Nasal steroid spray • Pain killer

14. Follow up • 3 day  children • 7 day  adult

15. 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

16. 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

17. 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

19. Chronic Rhinosinusitis

20. 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

21. Diagnosis the use of symptoms to define CRS is not as effective as for ABRS

22. CRS

23. 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

24. Allergy Bacterials Major debatable CRS etiologies Fungi Anatomic Variations

25. 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)

26. 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)

27. Bacterial Infection • The role ofbacteria in the pathogenesis of CRS,remains elusive, But: • Staphylococcus aureus • Coagulase-negative staphylococcus • Anaerobic • Gram-negative bacteria. • Despite the uncertainties surrounding the etiologic factors associated with CRS, antibiotic therapy has served as a mainstay of treatment mostly of mixed infections, with a median of 3 different bacteries

28. Why their contribution is elusive? • Relative abundance of eosinophils and the paucity of neutrophilic inflammation in tissue samplesof the most cases of CRS • This inflammatory response may be independent of infection

29. Probable Mechanisms • Chronic infection • Osteitis • Bacterial allergy • Superantigen (usually from SA) • Biofilms The exact role of bacteria in CRS remains unclear

31. Fungi (mechanisms in CRS) • Chronic Invasive Fungal Sinusitis • Allergic Fungal Sinusitis (charactristics: eosinophilicmucin containing noninvasive fungal hyphae, nasal polyposis, characteristic radiographic findings, immunocompetence, and allergy) • Fungal balls obstruction • Immune Complex (non-IgE inflammation)

33. 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

34. Anatomic Variants • May predispose to earlier obstruction of the sinuses, allowing for the development of CRS, although strong evidence is lacking

35. CRS medical therapies

36. 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

37. 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 antibacterial effects, macrolides have some interesting antiinflammatory effects akin to those of corticosteroids

38. Also macrolides can possibly decrease biofilmformation and overall bacterial virulence • Regimens (3mo duration): • ErythromycinEthylsuccinate: 400 q6h up to 2wk, then 400 BD up to 10wk • Clarithromycin: 500 q12h up to 2wk, then 500 daily up to 10wk

39. 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

40. Antifungal agents • To date no convincing evidence of their efficacy over and above saline douching has been provided

41. Decongestants • No RCTs have been performed in CRS

42. Mucolytics • There is little evidence in the literature for the use of mucolytics such as bromhexine

43. Antihistamines • There is no evidence to support the use of antihistamines in CRS, and they are not recommended

44. 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

45. Conclusion • To date, however, because of the paucity of properly conducted trials, no absolute recommendation for a ‘correct regimen’ can be given

46. 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

47. 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

48. Thank You!