Acute Rhinosinusitis – bacterial infection or inflammation? 
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Acute Rhinosinusitis – bacterial infection or inflammation?  Prof. Dr. Philippe Gevaert Dienst Neus-, keel- en oorheelkunde Allergienetwerk UZ-Gent. New definition and classification Update on literature and treatments New and practical treatment schemes acute rhinosinusitis adults

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New definition and classification update on literature and treatments

Acute Rhinosinusitis – bacterial infection or inflammation?  Prof. Dr. Philippe GevaertDienst Neus-, keel- en oorheelkundeAllergienetwerk UZ-Gent


New definition and classification update on literature and treatments

  • New definition and classification

  • Update on literature and treatments

  • New and practical treatment schemes

  • acute rhinosinusitis adults

    • children

  • chronic rhinosinusitis adults

    • children

  • nasal polyposis

  • Research needs and priorities


  • Definitions and classification for general practice

    Definitions and classification for General Practice

    • Based on symptoms:

    • Two or more symptoms, one of which should be either

      • nasal blockage/obstruction/congestion or

      • nasal discharge: anterior/post nasal drip;

      • ± facial pain/pressure,

      • ± reduction or loss of smell

    • Examination: anterior rhinoscopy

    • X-ray/CT not recommended

    • * DURATION

    • ACUTE / intermittent< 12 weeks

    • complete resolution of symptoms

    • CHRONIC / persistent> 12 weeks

    • incomplete resolution of symptoms

    • Special attention to questions on allergic symptoms


    Definitions and classification

    Definitions and classification

    • Based on symptoms:

    • Two or more symptoms, one of which should be either

      • nasal blockage/obstruction/congestion or

      • nasal discharge: anterior/post nasal drip;

      • ± facial pain/pressure,

      • ± reduction or loss of smell

    • AND EITHER

      • endoscopic findingsof polyps

  • mucopurulent discharge

  • edema or obstruction

  • OR

    • CT scan abnormality: mucosal changes

    • within ostiomeatal complex or sinus cavity


  • Definitions and classification1

    Definitions and classification

    CLASSIFICATION OF RHINOSINUSITIS

    * SEVERITYVisual Analogue Scale (VAS)

    mild0-3

    moderate3-7

    severe7-10

    * DURATION

    ACUTE / intermittent< 12 weeks

    complete resolution of symptoms

    CHRONIC / persistent> 12 weeks

    incomplete resolution of symptoms


    Headache facial pressure in sinusitis

    Headache/facial pressure in sinusitis


    New definition and classification update on literature and treatments

    Nasal Endoscopy


    New definition and classification update on literature and treatments

    Imaging of sinsuses

    • RX sinuses: - Waters, Caldwell an Hirtz

    • - poor sensitivity and specificity

      • - NOT RECOMMENDED!


    Imaging of sinsuses

    Imaging of sinsuses

    • MRI: only recommended in tumor diagnosis

    • CT sinuses: current standard imaging (50mGy)

      • Cave! radiation damage of lens (500-2000mGy)

  • - Acute rhinosinusitis: only if signs for complications!!

  • Chronic sinusitis: only after 4w-12w treatment!


  • Anatomy and physiology

    Anatomy and physiology

    COMMON COLD

    BACTERIAL SUPERINFECTIONStrep pneu / Haemo infl / Morax catar

    increasing symptoms after 5 DAYS

    no resolution after 10 DAYS

    ACUTE rhinosinusitis

    MULTIFACTORIAL ETIOLOGY

    CHRONIC rhinosinusitis

    EAACI Position Paper on Rhinosinusitis and Nasal Polyps, Allergy 2005: 60: 583-601


    Viruses in acute rhinitis and rhinosinusitis

    < 4 years

    5-10 years

    Adolescents

    Young adults

    rhinovirus

    parainfl.

    rhinovirus

    rhinovirus

    RSV

    adenovirus

    influenza

    echovirus

    parainfl.

    enterovirus

    echovirus

    influenza

    adenovirus

    RSV

    coronavirus

    coxsackie

    influenza

    rhinovirus

    RSV

    coronavirus

    influenza

    parainfl.

    RSV

    adenovirus

    parainfl.

    adenovirus

    Kirkpatrick, 1996

    Viruses in acute rhinitis and rhinosinusitis

    Adults

    Most common

    rhinovirus

    influenza

    echovirus

    coxsakie

    coronavirus

    RSV

    parainfl.

    Least

    common

    adenovirus


    Pathophysiology viral rhinitis

    Pathophysiology Viral Rhinitis

    Impact of viral infection on the mucosa

    • Epithelial changes

      • Hypersecretion and oedema

      •  Goblet cells (hypersecretion),  ciliated cells (secretion stasis)

  • Cell destruction with vasodilatation (cavernous sinuses!)

    • Release inflammatory mediators from inflammatory cells

  • Seromucous hypersecretion and exudation

     Thickening lamina propria


  • Symptoms viral rhinitis

    Symptoms Viral Rhinitis

    • Quickly passing sore throat: viral pharyngitis, swollen throat

    • Nasal symptoms: congestion, sneezing, rhinorrhea

       gone after 7 d, mucus production peaks on d 3 and 4

    • Coughing: longest lasting symptom,

       weeks in smokersand patients with reflux!

    • 1/10: short headache

    • Rarely tremors, general malaise

    • Note: more serious problems with anatomical anomalies (deviated septum) or children: otitis, rhinopharyngitis, sinusitis, tracheitis, bronchitis


    New definition and classification update on literature and treatments

    Symptoms Viral Rhinitis


    New definition and classification update on literature and treatments

    Cough after Viral Rhinitis (smoking)


    New definition and classification update on literature and treatments

    Complications after Viral Rhinitis


    Therapeutical options common cold

    Therapeutical Options Common Cold

    • Nothing

    • Local vasoconstrictors: preferably only at night,

      not > 7d

    • Physiological flushing: mainly with children or with anatomical anomalies

      • Note: other types of rhinitis where physiological flushing

        -possibly supplemented with ointment application- may be useful:

        occupational rhinitis, rhinitis due to irritants, atrophic rhinitis

    • Antibiotics: useless, unless complication due to surinfection


    Common cold induces changes in sinus mucosa

    Common cold induces changes in sinus mucosa

    Virus

    ICAM-1

    CD8+ T cytotxic cells

    CD8+ CTLs

    b

    b

    a

    a

    IL

    IL

    -

    -

    1

    1

    ,

    ,

    IL

    IL

    -

    -

    6

    6

    ,

    ,

    TNF

    TNF

    -

    -

    Natural Killer cells

    NKcells

    I

    INFgamma, IL-8

    L

    -

    8

    , MCP

    -

    1

    Neutrophils

    neutrophil

    g

    IFN

    -

    recruitment and activation

    recruitment and activation

    monocyte

    monocyte

    T helper 1 polarisation

    T helper 1 polarisation

    * CD4+ CTL

    * CD4+ T helper cells

    Elimination of rhinovirus

    Elimination of rhinovirus

    * NK activity

    * NK activity

    * Ig

    * Immunoglobulins


    Acute rhinosinusitis

    Acute Rhinosinusitis


    Infections induces changes in sinus mucosa

    B

    MT

    MS

    IT

    Infections induces changes in sinus mucosa

    Ventilation

    and

    Drainage

    Inflammation

    and

    Remodeling

    The ostiomeatal complex

    B Bulla ethmoidalis

    IT inferior turbinate

    MT middle turbinate

    MS maxillary sinus


    Microbiology

    Microbiology

    Normal sinuses: Free of growth

    Acute rhinosinusitis:

    2/3 Viral

    1/3 Bacterial (St Pneumoniae,H Influenzae, M Catharralis)

    Chronic rhinosinusitis:

    >>Anaerobes: Propionibacterium, Bacteriodes, Peptococcus

    Aerobes:Staphylococcus, Corynebacterium, Pseudomonas

    Fungi (» aspergillus fumigatus)

    Dentogene sinusitis: ?


    Guidelines for acute rhinosinusitis

    Guidelines for Acute Rhinosinusitis

    • Commoncold/ Acute viralrhinosinusitis

    Occurence in adults: up to 4 times a year

    URTI: symptoms < 10 days

    Symptomatictreatmentonly:

    • Decongestants

    • Pain relief

    • Saline drops

    Can lead to post-viral inflammation of nose and sinuses


    Guidelines for acute rhinosinusitis1

    Guidelines for Acute Rhinosinusitis

    • Acute post-viral Rhinosinusitis (ARS)

    Definition:

    • ↑symptomsafter 5 daysor

    • persistent symptomsafter 10 days

    • lessthan 12 weeks

    Symptoms:

    • Nasalobstruction/congestion and/or

    • Facial pain/pressure

    • Accompaniedby:

      • Nasal discharge and/or

      • Reductionor loss of smell


    Guidelines for acute rhinosinusitis2

    Guidelines for Acute Rhinosinusitis

    • Acute post-viral Rhinosinusitis (ARS)

    Occurence:

    • onceor more thanonce in defined time period (episodes per year)

    • complete resolutionbetweensymptoms

    Appearance:

    • Mild

    • Severe

    • Fever > 38,3°C

    • Localized pain over the sinuses

    Streptococcus pneumoniae,

    Haemophilusinfluenzae

    and Moraxellacatarrhalis

    May lead to complications !!


    Strength of evidence for treatment of acute rhinosinusitis

    Strength of evidence for treatment of Acute Rhinosinusitis


    New definition and classification update on literature and treatments

    DBPC trial in 95 patients with acute sinusitis (with history of CRS)

    All received 2x/d xylometazoline spray (3days) and

    2 x 250mg/d cefuroxime (10 days)

    47 patients 200µg (two puffs) Fluticasone or 48 patients placebo spray

    Dolor et al. JAMA Oct 2002


    New definition and classification update on literature and treatments

    J Allergy Clin Immunol. 2005 Dec;116(6):1289-95.


    Nasal gcs and nasal congestion

    Nasal GCS and nasal congestion

    Percent Change in Congestion Symptom Score (Patient-Reported)

    Days

    *

    Percent change in patient-reported congestion symptom score from baseline

    *

    *

    *

    *

    *

    *

    *

    *

    *

    *

    *

    *

    *

    *P<0.001 vs placebo.

    Gross et al. J Allergy Clin Immunol. 2007; 119 (Suppl S):S64.


    Management of acute rhinosinusitis

    Management of Acute Rhinosinusitis


    Management of acute rhinosinusitis for ent specialist

    Management of Acute Rhinosinusitisfor ENT-specialist


    Acute rhinosinusitis in de praktijk

    Acute Rhinosinusitis in de praktijk

    • 90 %patiënten:

      1. bijneusverstopping:

      volwassene: xylo- of oxymethazoline (max 7 d),

      pseudo-efedrine(+desloratadine)

      nasaal corticoid 2x/dag

      2. bijpijn: paracetamol: 500 mg 4 à 6 x per dag

      3. warme damp en/of neusspoeling met fysiologisch water

    • <10% patiënten:

      AMOXICILLINE3 x 1 gr/dag gedurende 7-14 d

      Indiengeenverbeteringbinnen de 3 dagen:

      Amoxivervangen door 3X875 Amoxicilline-Clav

      alternatiefbijallergie: chinolones (ciproxine, avelox, proflox, tavanic, tarivid à 0,5-1g/d)


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