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Sinusitis. Westly Bailey, MD Emory Family Medicine April 8, 2010. Physiologic Importance of Sinuses. Provide mucus to upper airways Lubrication. Vehicle for trapping viruses, bacteria, foreign material for removal. Give characteristics to voice Lessen skull weight Involved with olfaction.

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sinusitis

Sinusitis

Westly Bailey, MD

Emory Family Medicine

April 8, 2010

physiologic importance of sinuses
Physiologic Importance of Sinuses
  • Provide mucus to upper airways
    • Lubrication.
    • Vehicle for trapping viruses, bacteria, foreign material for removal.
  • Give characteristics to voice
  • Lessen skull weight
  • Involved with olfaction

1. Acute and Chronic Sinusitis: A Practice Guide for Diagnosis and Management. AAFP CME Presentation.

development of sinuses
Development of Sinuses
  • Maxillary and ethmoid sinuses present at birth.
  • Frontal sinus developed by age 5 or 6 yrs.
  • Sphenoid sinus last to develop, 8-10 yrs.

1. Acute and Chronic Sinusitis: A Practice Guide for Diagnosis and Management. AAFP CME Presentation.

normal sinus
Normal Sinus
  • Sinus health depends on:
    • Mucous secretion of normal viscosity, volume, and composition.
    • Normal muco-ciliary flow to prevent mucous stasis and subsequent infection.
    • Open sinus ostia to allow adequate drainage and aeration.

1. Acute and Chronic Sinusitis: A Practice Guide for Diagnosis and Management. AAFP CME Presentation.

2. Senior BA, Kennedy DW. Management of sinusitis in the asthmatic patient AAAI J,1996;77:6-19.

sinusitis5
Sinusitis
  • 4 paranasal sinuses, each lined with pseudostratified ciliated columnar epithelium and goblet cells
    • Frontal
    • Maxillary
    • Ethmoid
    • Sphenoid

Infectious or noninfectious inflammation of 1 or more sinuses

1. Acute and Chronic Sinusitis: A Practice Guide for Diagnosis and Management. AAFP CME Presentation.

sinusitis6
Sinusitis
  • Affects 30-35 million persons/year.
  • 25 million office visits/year.
  • Direct annual cost $2.4 billion and increasing.
  • Added surgical costs: $1 billion.
  • Third most common diagnosis for which antibiotics are prescribed.

1. Acute and Chronic Sinusitis: A Practice Guide for Diagnosis and Management. AAFP CME Presentation.

2. JAMA 1995, 273:214-219

the sinusitis asthma connection
The Sinusitis-Asthma Connection
    • Failure to control upper airway inflammation leads to suboptimal asthma control.
    • Mechanism is not understood
  • Evidence Implications
    • Correcting the rhinosinusitis results in better asthma control.
diagnosis
Diagnosis
  • Primarily based on HPI & PE.
  • Imaging based on demographics and exam findings.
ostiomeatal complex
Ostiomeatal Complex
  • Ostiomeatal complex is that area under the middle meatus (airspace) into which the anterior ethmoid, frontal and maxillary sinuses drain.
  • Posterior ethmoids drain into the upper meatus.

1. Acute and Chronic Sinusitis: A Practice Guide for Diagnosis and Management. AAFP CME Presentation.

differentiating sinusitis from rhinitis
Rhinitis

Nasal congestion

Rhinorrhea clear

Itching, red eyes

Seasonal symptoms

Nasal crease

Sinusitis

Nasal congestion

Purulent rhinorrhea

Postnasal drip

Headache

Facial pain

Cough, fever

Anosmia

Differentiating Sinusitis from Rhinitis

1. Acute and Chronic Sinusitis: A Practice Guide for Diagnosis and Management. AAFP CME Presentation.

acute sinusitis
Acute Sinusitis
  • Acute
    • Symptoms <4 wks
    • Typically viral; preceded by “cold”; resolves within 10 days
      • Viral damages sinus cells, causing inflammation and obstruction.
    • Bacterial complications in 0.5-2% cases
      • Usually a complication of obstruction- S. pneumoniae, H. influenzae, M. catarrhalis, S. aureus, anaerobes.
      • 75% self resolution within 1 mth.
      • Complications: pre-orbital & orbital cellulitis
    • 85 - 98% patients in the U.S. given abx regardless.
  • Subacute
    • Symptoms 4 – 12 wks
  • Recurrent
    • Either 3 episodes in 6 months or 4+ yearly episodes with ≥10 days interim symptom resolution.

1. Hwang, P and Getz, A. "Acute Sinusitis and Rhinosinusitis in Adults." UpToDateOnline. 2009.

pathogenesis of nasal obstruction
Pathogenesis of Nasal Obstruction
  • Viral upper respiratory infections
    • Daycare centers
  • Allergic Stimuli
    • Pollens, House dust mite, animal dander, mold, foods, beverages.
  • Immunodeficiency disorders
    • Immunoglobulin deficiency (IgA, IgG)
  • Anatomic Abnormalities
    • Deviated septum, concha bullosa, polyps, foreign body, atresia, lymphoid hyperplasia, Down’s Syndrome

1. Acute and Chronic Sinusitis: A Practice Guide for Diagnosis and Management. AAFP CME Presentation.

pathogenesis of nasal obstruction ciliary dysfunction nonallergic causes
Common Cold Viruses

Tobacco smoke

Perfumes

Cleaning solutions

Potpourri

Burning candles

Cosmetics

Hair spray

Auto exhaust

Gas, diesel fuel

Cold/Dry air

Changes in barometric pressure

Nonallergic foods & drinks

Pathogenesis of Nasal Obstruction & Ciliary Dysfunction – Nonallergic Causes

1. Acute and Chronic Sinusitis: A Practice Guide for Diagnosis and Management. AAFP CME Presentation.

other causes of ciliary dysfunction
Other Causes of Ciliary Dysfunction
  • Rhinitis, Sinusitis, CF, Churg-Strauss, SLE, Sarcoid, Sjogren’s, Wegener’s, Immotile cilia syndrome, Cleft Palate, Dental Disorders.
  • Increased viscosity of mucus
  • Medications
    • First generation anti-histamines (DNA to non-sedating anti-histamines)
    • Anti-cholinergics
    • Aspirin
    • Anesthetic agents
    • Benzodiazepines

1. Acute and Chronic Sinusitis: A Practice Guide for Diagnosis and Management. AAFP CME Presentation.

other predisposing conditions for sinusitis
Other Predisposing Conditions for Sinusitis
  • Physical trauma
  • Scuba diving
  • Foreign body

1. Acute and Chronic Sinusitis: A Practice Guide for Diagnosis and Management. AAFP CME Presentation.

physical findings
Physical Findings
  • Brain
    • Intracranial abscesses causing neurologic symptoms
  • Orbital
    • Diplopia, proptosis
    • Periorbitalerythema, swelling
  • Nares
    • Mucopurulent Nasal Discharge
      • Highest positive predictive value.
    • Swelling of Nasal Mucosa
    • Mild Erythema
  • Facial Pain (unusual in children)

1. Acute and Chronic Sinusitis: A Practice Guide for Diagnosis and Management. AAFP CME Presentation.

physical findings17
Physical Findings

www.entkent.com/rhino-sinusitis.html

http://www.clevelandnasalsinus.com/images/turbinates-nasal-turbinates-levine.jpg

www.entkent.com/rhino-sinusitis.html

http://www.ent.com.hk/images/our_services0224.jpg

physical findings18
Physical Findings
  • Sinus Trans-illumination
    • Helpful in older children and adults.
      • Have patient sit at your eye level in darkened room (the darker the better).
      • Let eyes get accustomed to dark.
      • Place bright light (trans-illuminator) over inferior orbital ridge to look at maxillary sinuses, under superior orbital rim for frontal sinuses.
      • Look at palate for presence/absence of trans-illuminated light.
    • Normal trans-illumination decreases chance of pus in the sinus.
    • No light reflex suggests mucopurulent material or thickening of nasal mucosa.

1. Acute and Chronic Sinusitis: A Practice Guide for Diagnosis and Management. AAFP CME Presentation.

sinus trans illumination
Sinus Trans-illumination
  • Have patient sit at your eye level in darkened room (the darker the better)
  • Let eyes get accustomed to dark
  • Place bright light (trans-illuminator) over inferior orbital ridge to look at maxillary sinuses, under superior orbital rim for frontal sinuses
  • Look at palate for presence/absence of trans-illuminated light.

1. Acute and Chronic Sinusitis: A Practice Guide for Diagnosis and Management. AAFP CME Presentation.

photo image of sinus trans illuminator
Photo Image of Sinus Trans-illuminator

1. Acute and Chronic Sinusitis: A Practice Guide for Diagnosis and Management. AAFP CME Presentation.

trans illumination of frontal maxillary sinuses
Trans-illumination of Frontal & Maxillary Sinuses

1. Acute and Chronic Sinusitis: A Practice Guide for Diagnosis and Management. AAFP CME Presentation.

rhinoscopy aids in diagnosing
Rhinoscopy Aids in Diagnosing
  • Causes of Obstruction
    • Nasal polyps
    • Septal deviation
    • Conchabullosa
    • Adenoid hyperplasiaT
    • Tumors
  • Causes of hoarseness
  • Eustachian tube dysfunction

http://www.entcentrecclau.com/images/services_p04.jpg

http://voicecare.in/endostroboscopy/flexible%20nasopharyngoscopes.gif

1. Acute and Chronic Sinusitis: A Practice Guide for Diagnosis and Management. AAFP CME Presentation.

rhinoscope
Rhinoscope

1. Acute and Chronic Sinusitis: A Practice Guide for Diagnosis and Management. AAFP CME Presentation.

radiographic imaging
Radiographic Imaging?
  • Adults
    • Ordered to evaluate orbital or brain extension.
radiographic imaging25
Radiographic Imaging?
  • Pediatric Recommendations from AAP
    • Imaging studies are not necessary to confirm a diagnosis of clinical sinusitis in children younger than 6 years (older than age 6 years is controversial).
      • Radiographs:
        • Children with persistent symptoms (>10 days, < 30 days) predicted abnormal radiographs 80% of the time.
        • Children < 6 symptoms predicted 88% of the time.
        • Normal x-ray suggests ABS is not present.
      • CT scans of the paranasal sinuses should be reserved for:
        • Assisting in diagnosis of anatomical changes interfering with airflow or drainage.
        • Patients who do not respond to medical regimes which include adequate antibiotic use.
        • Patients in whom surgery is being considered as a management strategy.

1. Acute and Chronic Sinusitis: A Practice Guide for Diagnosis and Management. AAFP CME Presentation.

radiographic imaging26
Radiographic Imaging?
  • Pediatric Recommendations (continued)
    • CT Scans:
      • Patients presenting with complications of sinusitis
        • Neurologic symptoms, diplopia, periorbital or facial swelling with or without erythema
      • Patients with sinus symptoms accompanied by severe, boring, mid-head pain
        • Rule out sphenoid sinusitis.

1. Acute and Chronic Sinusitis: A Practice Guide for Diagnosis and Management. AAFP CME Presentation.

x ray image of sinuses with maxillary sinusitis
X-Ray Image of Sinuses with Maxillary Sinusitis

1. Acute and Chronic Sinusitis: A Practice Guide for Diagnosis and Management. AAFP CME Presentation.

sinus ct
Sinus CT

www.entkent.com/rhino-sinusitis.html

normal water s and towne s views of the sinuses
Normal Water’s and Towne’ s Views of the Sinuses

1. Acute and Chronic Sinusitis: A Practice Guide for Diagnosis and Management. AAFP CME Presentation.

lateral view showing normal sphenoid sinus
Lateral View Showing Normal Sphenoid Sinus

1. Acute and Chronic Sinusitis: A Practice Guide for Diagnosis and Management. AAFP CME Presentation.

management
Management
  • Lifestyle Changes
    • Smoking Cessation, Allergen avoidance, etc.
  • Treat Underlying Conditions
  • *Nasal Irrigation
  • Humidifier
  • Decongestants
  • Antibiotics
  • Steroids
  • Surgery
nasal irrigation
Nasal Irrigation
  • Irritant removal and mucosal moistening.
nasal irrigation33
Nasal Irrigation
  • Commercial buffered sprays
  • Bulb syringe
    • 1/4 tsp of salt to 7 ounces water
  • Waterpik with lavage tip
    • 1 tsp salt to reservoir
  • Ceramic Irrigators
    • “Neti-Pot”
  • Disposable enema bucket
    • 2 tsp salt, 1 tsp soda per quart of water
    • “Hose-in-the-nose”-- $2.50
    • Over tub, sink, or in shower lean over, head tilted slightly downward and to side place hose in upper nostril (fluid may return from either nostril or through mouth) run in 1/2 solution. Turn head to opposite side and repeat process.

1. Acute and Chronic Sinusitis: A Practice Guide for Diagnosis and Management. AAFP CME Presentation.

nasal irrigation34
Nasal Irrigation

http://chinafromjapan.files.wordpress.com/2009/06/netipot-jpg.jpeg

http://worldofliz.files.wordpress.com/2008/02/neti-pot.jpg

nasal irrigation35
Nasal Irrigation

http://www.getridofthings.com/images/diaper-rash-3.jpg

http://www.getprice.com.au/images/uploadimg/192/350_fess-little-noses.jpg

http://www.drug3k.com/img2/ayr_12906_6_(big)_.jpg

http://www.expresschemist.co.uk/pics/products/23019/2/neilmed-sinus-rinse.jpg

http://www.dentist.net/images/ayr-no-drip.jpg

http://media.photobucket.com/image/waterpik%20nasal/daniel_toh/being%20lazy/nasalwash.jpg

humidified air
Humidified Air

http://www.ubergizmo.com/photos/2007/2/water-bottle-humidifier.jpg

http://www.healthgoods.com/shopping/images/Air_O_Swiss_AOS_7135_Humidifier_lg.jpg

decongestants
Decongestants
  • May be helpful  No Evidence-Based Recommendations.
    • Topical nasal sprays (limit use to 3-7 days; avoid in children)
      • Phenylephrine
      • Oxymetazoline
      • Naphthazoline
      • Tetrahydrozoline
      • Zylometazoline
    • Topical nasal spray (unlimited daily use; avoid in children)
      • Ipatropium
    • Oral (3-5 days)
      • Pseudoephedrine 30-60 mg.
      • Phenylephrine 2-4 times/day.

1. Acute and Chronic Sinusitis: A Practice Guide for Diagnosis and Management. AAFP CME Presentation.

antibiotics for acute bacterial sinusitis
Antibiotics for Acute Bacterial Sinusitis
  • Shorten Duration of Symptoms
    • Give antibiotic until patient free of symptoms then add 7 days.
  • Amoxicillin
    • First line choice in most areas  Cheap, Efficacious, and well-tolerated.
    • 45-90 mg/kg/d in children; 500 mg tid or qid in adults for 10 to 14 days.
  • Where Beta-Lactamase Resistance is an Issue:
    • Amoxicillin/Clavulanate
    • Cefuroxime (Ceftin)
    • Cefpodoxime (Vantin)
    • Cefprozil
    • Cefdinir (Omnicef)

1. Acute and Chronic Sinusitis: A Practice Guide for Diagnosis and Management. AAFP CME Presentation.

antibiotics for acute bacterial sinusitis39
Antibiotics for Acute Bacterial Sinusitis
  • Penicillin Allergy:
    • Azithromycin or clarithromycin.
    • Erythromycin is inadequate.
  • Reasons to Use Alternative Antibiotics
    • No response to amoxicillin in 3-5 days.
    • Recent treatment with amoxicillin for other causes.
    • Recurrent sinus infections.
    • Subacute cases.
  • Trimethoprim/suflamethoxazole and erythro/sulfisoxazole have significant pneumococcal resistance.

1. Acute and Chronic Sinusitis: A Practice Guide for Diagnosis and Management. AAFP CME Presentation.

when antibiotics fail
When Antibiotics Fail…
  • Failure
    • No response in 3-5 days or resolution in 3-5 days on amoxicillin.
    • No response to alternative abx.
  • Assess for Chronic Causes
    • Identify allergic and non-allergic triggers
      • Allergy testing, nasal smears for eosinophilia.
  • Consider other medical conditions associated with sinusitis.
  • Rhinolaryngoscopy
  • Imaging studies

Sinus x-rays

CT scanning (limited, coronal views)

  • ENT Referral

1. Acute and Chronic Sinusitis: A Practice Guide for Diagnosis and Management. AAFP CME Presentation.

do steroids help
Do Steroids Help?
  • Chronic Sinusitis
    • Yes
  • Acute Viral Sinusitis
    • Possibly - Mometasone furoate proven to significantly reduce major symptom scores vs. amoxicillin and vs. placebo. Difference noted within 2-3 days.
  • Acute Bacterial Sinusitis
    • “Published reports investigating topical glucocorticoids should be interpreted with caution, as they often contain both heterogeneous patient populations (acute, chronic and/or viral rhinosinusitis) and treatment regimens (concomitant decongestant, saline irrigation, antibiotic).”

* No controlled studies for systemic steroids.

Parikh, A, Scadding, GK, Darby, Y, Baker, RC. Topical corticosteroids in chronic rhinosinusitis: a randomized, double-blind, placebo-controlled trial using fluticasone propionate aqueous nasal spray. Rhinology 2001; 39:75.

Lavigne, F, Cameron, L, Renzi, PM, et al. Intrasinus administration of topical budesonide to allergic patients with chronic rhinosinusitis following surgery. Laryngoscope 2002; 112:858.

Meltzer et al. Treating acute rhinosinusitis: comparing efficacy and safety of mometasonefuroate nasal spray, amoxicillin, and placebo. J Allergy ClinImmunol. 2005 Dec;116(6):1289-95. Epub 2005 Oct 24.

Zalmanovici, A, Yaphe, J. Steroids for acute sinusitis. Cochrane Database Syst Rev 2007; :CD005149.

Williamson, IG, Rumsby, K, Benge, S, et al. Antibiotics and topical nasal steroid for treatment of acute maxillary sinusitis: a randomized controlled trial. JAMA 2007; 298:2487.

comparison of various approaches to the treatment of acute sinusitis
Comparison of Various Approaches to the Treatment of Acute Sinusitis

Sneezing Discharge Itch Congestion Side Effects

Antihistaminestraditional (A) +++ +++ +++ + +++

Non-sedating(NSA) +++ ++ +++ + – to +

Azelastine +++ ++ +++ + – to +

Decongestants – + – +++ ++

NSA + decongestants +++ +++ +++ +++ ++

Leukotriene antag.* + to ++ + to ++ + to ++ ++ – to +

Cromolyn ++ + + + –

Nasal CCS (NCS) +++ +++ +++ +++ +

NSA + NCS ++++ ++++ ++++ ++++ +

Immunotherapy +++ +++ +++ +++ + to ++

* Presumed; no data on individual symptoms. Nayak AS, et al. Ann Allergy Asthma Immunol. 2002;88:592-600.

++++ = Strongly positive effect; += Minimal effect

1. Acute and Chronic Sinusitis: A Practice Guide for Diagnosis and Management. AAFP CME Presentation.

management of chronic sinusitis
Management of Chronic Sinusitis
  • Evaluation
    • CT or MRI scanning
      • Anatomic defects, tumors, fungi.
    • Allergy testing
      • Inhalants, fungi, foods.
    • Sinus aspiration for cultures
      • Correlation of routine nasal culture and sinus culture are poor
      • Endoscopically guided aspiration of cultures from medial meatus do correlate with sinus culture
        • Gold SM, Tami TA. Role of middle meatus aspiration culture in the diagnosis of chronic sinusitis. Laryngoscope 1997;107: 1586.
    • Immunoglobulins

1. Acute and Chronic Sinusitis: A Practice Guide for Diagnosis and Management. AAFP CME Presentation.

management of chronic sinusitis44
Management of Chronic Sinusitis
  • Treatment
    • Nasal irrigation
    • Nasal steroid spray
    • Steam inhalation
    • Guaifenesin
    • Decongestants
    • Antibiotics with exacerbations
    • Surgery

1. Acute and Chronic Sinusitis: A Practice Guide for Diagnosis and Management. AAFP CME Presentation.

indications for hospitalization
Indications for Hospitalization
  • Acutely ill child or adult with high fever, severe head pain.
  • Suspected sphenoid sinusitis.
  • Suspected or evident eye, bone or intracranial processes.
slide46

Additional References

  • 1. http://www.rollforinitiative.com/wp-content/uploads/2007/01/sinus.jpg
  • 2. Hamilos, D. “Management of Chronic Rhinosinusitis.” UpToDateOnline. 2009.