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Chronic Sinusitis. Andre Tan, MD, FRCSC Department of Otolaryngology Queen’s University. Definition:. 6-8 weeks of symptomatic infection irreversible mucosal changes. Case Study:.

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chronic sinusitis

Chronic Sinusitis

Andre Tan, MD, FRCSC

Department of Otolaryngology

Queen’s University

definition
Definition:
  • 6-8 weeks of symptomatic infection
  • irreversible mucosal changes
case study
Case Study:
  • Your patient is a 45 y.o. female with 3 episodes of acute sinusitis since last winter. Each time you treated with antibiotics with resolution of acute sx. However, she continues to c/o pressure “sinus” headache, nasal congestion, poor smell, and intermittent rhinorrhea.
you diagnosis chronic sinusitis
you diagnosis chronic sinusitis....
  • History
    • asthma
    • nasal trauma
  • Presenting sx
  • Physical exam
common presenting sx
Common presenting sx:
  • nasal obstruction 94%
  • postnasal drainage 92%
  • facial pain & headache 90%
  • rhinorrhea 61%
  • hyposmia / anosmia
  • Matthews 1991
physical examination
Physical examination:
  • purulent rhinorrhea
  • polyps
  • dental abscess
  • transillumination not helpful
  • look for complications
pathophysiology
Pathophysiology:
  • obstruction of osteomeatal complex region
  • impaired mucociliary clearance
anatomical variants
Anatomical variants:
  • deviated nasal septum
  • concha bullosa
  • ethmoid bulla
  • other middle turbinate anomalies
  • Agger nasi cells
  • Haller cells
underlying diseases
Underlying diseases:
  • asthma
  • cystic fibrosis
  • ciliary dysmotility
  • immuno-compromised:
    • chemotherapy
    • transplant
    • immuno-deficiency
is ct scan indicated
Is CT scan indicated?
  • support your dx
  • road map for your surgeon
objectives for treatment
Objectives for treatment:
  • sterilization of sinus content
  • resumption of normal sinus physiology
  • prevention of complications
microbiology
Microbiology:
  • Anaerobes
    • gm+ cocci, bacteroides, corynebacteria
    • Frederick-52%, Brook-80%
  • Staphylococcus aureus
  • Streptococcus
  • H. Influenzae
  • M. catarrhalis
treatment options
Treatment options:
  • antibiotics
    • sufficient duration (at least 3-4 weeks)
    • selection???
  • decongestants / mucoevacuants
  • anti-inflammatory (steroids)
antibiotics
Antibiotics:
  • none approved in Canada as indication for CS
  • ciprofloxacin
  • amoxicillin-clavulanate
  • clarithromycin
  • cefuroxime
  • comparable -level 1 (Fombeur 1993)
antibiotics15
Antibiotics.......
  • Ciprofloxacin 59% (89%)
  • Amoxicillin-clavulanate 51% (91%)
  • (Legent 1993)
what should we use
what should we use?
  • beta-lactamase producers
  • anaerobes
    • amoxicillin-clavulanate
    • Clarithromycin
    • Clindamycin
    • metronidazole
decongestants mucoevacuants
Decongestants & mucoevacuants:
  • maintain ostial patency
  • level III evidence
  • topical for < 3 days
    • naphazoline, phenylephrine & oxymetazoline
  • oral
    • ephedrine, pseudoepephedrine.........
  • beware of contra-indications
anti inflammatory steroids
Anti-inflammatory (steroids):
  • generally not recommended
  • theoretical advantage (IL-5R & IL-13)
  • use ONLY in inadequate response to abc, decongesant & mucoevacuant
  • to reduce tissue inflammation, edema & hyper-reactivity (allergy)
  • topical glucocorticoids (slow vs fast)
when to refer
when to refer?
  • failure of treatment
  • anatomical problems
  • complications
sinus headache
“Sinus headache”
  • pain -- biopsychosocial model
  • sinus headache/pain does NOT mean sinusitis
    • pt relates to previous experience with sinusitis
    • abc may have analgesic effect
  • MUST have proper evaluation
chronic maxillary atelectasis
Chronic maxillary atelectasis:
  • Medial infundibular wall causes valvular occlusion of the ostium
  • Subsequent decrease of sinus volume & deformity of antral wall(s)
  • Similar sx as chronic maxillary sinusitis
  • May have cosmetic deformity
  • More common than believed
chronic maxillary atelectasis22
Chronic maxillary atelectasis:
  • Stage I
    • Retraction of the membranous fontanel & medial infundibular wall
  • Stage II
    • Inward bowing of one or more sinus wall
  • Stage III
    • Enophthalmus, hypoglobus, and/or mid-face deformity
chronic maxillary atelectasis23
Chronic maxillary atelectasis:
  • Treatment
      • Antibiotics for 2-4 weeks
      • Decongestants (oral & topical)
      • Surgical - definitive