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Chronic Sinusitis

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

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  1. Chronic Sinusitis Andre Tan, MD, FRCSC Department of Otolaryngology Queen’s University

  2. Definition: • 6-8 weeks of symptomatic infection • irreversible mucosal changes

  3. 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.

  4. you diagnosis chronic sinusitis.... • History • asthma • nasal trauma • Presenting sx • Physical exam

  5. Common presenting sx: • nasal obstruction 94% • postnasal drainage 92% • facial pain & headache 90% • rhinorrhea 61% • hyposmia / anosmia • Matthews 1991

  6. Physical examination: • purulent rhinorrhea • polyps • dental abscess • transillumination not helpful • look for complications

  7. Pathophysiology: • obstruction of osteomeatal complex region • impaired mucociliary clearance

  8. Anatomical variants: • deviated nasal septum • concha bullosa • ethmoid bulla • other middle turbinate anomalies • Agger nasi cells • Haller cells

  9. Underlying diseases: • asthma • cystic fibrosis • ciliary dysmotility • immuno-compromised: • chemotherapy • transplant • immuno-deficiency

  10. Is CT scan indicated? • support your dx • road map for your surgeon

  11. Objectives for treatment: • sterilization of sinus content • resumption of normal sinus physiology • prevention of complications

  12. Microbiology: • Anaerobes • gm+ cocci, bacteroides, corynebacteria • Frederick-52%, Brook-80% • Staphylococcus aureus • Streptococcus • H. Influenzae • M. catarrhalis

  13. Treatment options: • antibiotics • sufficient duration (at least 3-4 weeks) • selection??? • decongestants / mucoevacuants • anti-inflammatory (steroids)

  14. Antibiotics: • none approved in Canada as indication for CS • ciprofloxacin • amoxicillin-clavulanate • clarithromycin • cefuroxime • comparable -level 1 (Fombeur 1993)

  15. Antibiotics....... • Ciprofloxacin 59% (89%) • Amoxicillin-clavulanate 51% (91%) • (Legent 1993)

  16. what should we use? • beta-lactamase producers • anaerobes • amoxicillin-clavulanate • Clarithromycin • Clindamycin • metronidazole

  17. Decongestants & mucoevacuants: • maintain ostial patency • level III evidence • topical for < 3 days • naphazoline, phenylephrine & oxymetazoline • oral • ephedrine, pseudoepephedrine......... • beware of contra-indications

  18. 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)

  19. when to refer? • failure of treatment • anatomical problems • complications

  20. “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

  21. 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

  22. 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

  23. Chronic maxillary atelectasis: • Treatment • Antibiotics for 2-4 weeks • Decongestants (oral & topical) • Surgical - definitive

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