Acute and Chronic Rhinosinusitis

1. Acute and Chronic Rhinosinusitis Pathophysiology, diagnosis, and management. AAAAI Rhinosinusitis Committee Updated 2006

2. Rhinosinusitis Group of disorders characterized by inflammation of the mucosa of the nose and paranasal sinuses Sinus and Allergy Health Partnership Definition developed by Sinus and Allergy Health Partnership Task Force for Rhinosinusitis: Consensus of 5 National Societies AAAAI ACAAI ARS (American Rhinologic Society) AAO-HNS (American Academy of Otolaryngology – Head & Neck Surgery) AAOA (American Academy of Otolaryngic Allergy) Definition developed by Sinus and Allergy Health Partnership Task Force for Rhinosinusitis: Consensus of 5 National Societies AAAAI ACAAI ARS (American Rhinologic Society) AAO-HNS (American Academy of Otolaryngology – Head & Neck Surgery) AAOA (American Academy of Otolaryngic Allergy)

4. Rhinosinusitis More accurate term than “sinusitis” since almost always preceded by or concomitant symptoms of rhinitis Acute – Up to 4 weeks Subacute – 4 to 12 weeks Chronic – > 12 weeks

5. Acute vs. Chronic Rhinosinusitis Usually very different conditions. Acute rhinosinusitis usually related to infection. Chronic rhinosinusitis usually related to inflammation.

6. Acute Rhinosinusitis

7. Question Is acute rhinosinusitis usually viral or bacterial???

8. Acute Rhinosinusitis 1 billion viral URIs each year 0.5% - 2% lead to secondary bacterial infection of the sinuses.1,2 Acute bacterial rhinosinusitis often present when symptoms have not resolved after 10 days or worsen after 5 to 7 days Majority of the cases of rhinosinusitis are viral Sig bacterial growth in 60% of patients with URI for >10Majority of the cases of rhinosinusitis are viral Sig bacterial growth in 60% of patients with URI for >10

9. Viral Rhinosinusitis Similar to bacterial rhinosinusitis clinically and radiographically CT scan within 48-96 hrs of a self-diagnosed “cold” (n=31) 77% with infundibulum occlusion 79% cleared in 2 weeks without abx Majority of individuals with viral URI will have CT scan evidence of paranasal sinus involvementMajority of individuals with viral URI will have CT scan evidence of paranasal sinus involvement

10. Obstruction of the Sinus Ostium Produces Acute Rhinosinusitis This diagram summarizes Dr. Kern’s concept of how bacterial sinusitis develops3. The initiating event is obstruction of the sinus ostium. As a consequence, hypoxia develops with vascular dilation, a reduction in ciliary function, and mucous gland dysfunction. With these changes, sinus secretions accumulate, bacteria are introduced and an infection develops.This diagram summarizes Dr. Kern’s concept of how bacterial sinusitis develops3. The initiating event is obstruction of the sinus ostium. As a consequence, hypoxia develops with vascular dilation, a reduction in ciliary function, and mucous gland dysfunction. With these changes, sinus secretions accumulate, bacteria are introduced and an infection develops.

11. Coronal View in Relation to Facial Structure Coronal and horizontal sections of the head at the level of the orbits. The coronal section indicates that the floor of the nasal passage is composed of the hard palate of the maxilla. The floor of the maxillary sinuses extends into the alveolar processes of the upper dentition. The maxillary sinus ostia are posterior and superior, requiring that they not only be patent but that ciliary action sweeps secretions and bacteria against the force of gravity up to the small ostium, which drains into the middle meatus. The concha of the inferior turbinate is a separate bone sitting in an opening in the maxilla and resting in the lateral wall of the nasal passage. The middle and superior turbinates are suspended from the roof of the nose rather than from the lateral wall. The fovea ethmoidalis (roof of the ethmoid sinuses) extends above the level of the cribriform plate. These two sections emphasize the relationship of the multiple ethmoid sinuses, which comprise the ethmoid labyrinth, to the orbits. The delicate, bony lattice that defines the ethmoid labyrinth is separated from the orbit by the lamina papyracea. The anterior ethmoid air cells make a prominent bulge in the middle meatus, creating the ethmoid bulla. Coronal and horizontal sections of the head at the level of the orbits. The coronal section indicates that the floor of the nasal passage is composed of the hard palate of the maxilla. The floor of the maxillary sinuses extends into the alveolar processes of the upper dentition. The maxillary sinus ostia are posterior and superior, requiring that they not only be patent but that ciliary action sweeps secretions and bacteria against the force of gravity up to the small ostium, which drains into the middle meatus. The concha of the inferior turbinate is a separate bone sitting in an opening in the maxilla and resting in the lateral wall of the nasal passage. The middle and superior turbinates are suspended from the roof of the nose rather than from the lateral wall. The fovea ethmoidalis (roof of the ethmoid sinuses) extends above the level of the cribriform plate. These two sections emphasize the relationship of the multiple ethmoid sinuses, which comprise the ethmoid labyrinth, to the orbits. The delicate, bony lattice that defines the ethmoid labyrinth is separated from the orbit by the lamina papyracea. The anterior ethmoid air cells make a prominent bulge in the middle meatus, creating the ethmoid bulla.

12. Saggital View in Relation to Facial Structure Lateral view of the ethmoid labyrinth with the middle and superior turbinates removed. Ethmoid cells emptying into the middle meatus are defined as anterior ethmoid cells, and those with ostia emptying into the superior or supreme meatus are defined as posterior ethmoid cells. Lateral view of the ethmoid labyrinth with the middle and superior turbinates removed. Ethmoid cells emptying into the middle meatus are defined as anterior ethmoid cells, and those with ostia emptying into the superior or supreme meatus are defined as posterior ethmoid cells.

13. Anatomic Drainage Pathways in the Sinuses Sinus Area Frontal Anterior ethmoid / Maxillary Posterior ethmoid / sphenoid Drainage pathway Nasofrontal duct Ostiomeatal unit Sphenoidethmoidal recess There are six anatomic drainage pathways from the sinuses -- three for each side. The frontal sinus drains via the nasofrontal duct into the anterior superior nasal cavity. The anterior ethmoid and maxillary sinuses drain via a common area, the ostiomeatal unit. The posterior ethmoid and sphenoid sinuses drain via the sphenoethmoidal recess. Obstruction of any one pathway leads to sinusitis in the respective sinus areas. There are six anatomic drainage pathways from the sinuses -- three for each side. The frontal sinus drains via the nasofrontal duct into the anterior superior nasal cavity. The anterior ethmoid and maxillary sinuses drain via a common area, the ostiomeatal unit. The posterior ethmoid and sphenoid sinuses drain via the sphenoethmoidal recess. Obstruction of any one pathway leads to sinusitis in the respective sinus areas.

14. Pain in Acute Rhinosinusitis Maxillary Frontal Ethmoid Sphenoid malar, posterior nasopharynx, pain in the upper teeth, zygoma,temple hyperalgesia Forehead, orbit, zygoma, temple Nasal bridge, inner canthus, eye movement Vertex, retro-orbit, between eyes, zygoma, temple In acute sinusitis, the clinical presentation of pain or discomfort may provide the clinician with clues as to which sinus is infected. Sphenoid sinusitis may be difficult to localize but is often associated with a vertex or retro-orbital headache. Ethmoid sinusitis is associated with discomfort in the nasal bridge, the inner canthus or with eye movement. In chronic sinusitis, the correlation of sinus pain or pressure with radiographic findings is less precise. In acute sinusitis, the clinical presentation of pain or discomfort may provide the clinician with clues as to which sinus is infected. Sphenoid sinusitis may be difficult to localize but is often associated with a vertex or retro-orbital headache. Ethmoid sinusitis is associated with discomfort in the nasal bridge, the inner canthus or with eye movement. In chronic sinusitis, the correlation of sinus pain or pressure with radiographic findings is less precise.

15. Other Clinical Signs of Acute Rhinosinusitis Tenderness overlying the sinuses Nasal erythema Purulent nasal secretions Increased posterior pharyngeal secretions Fetid breath Periorbital edema Ear examination may reveal eustachian tube dysfunction

16. Diagnosis of Acute Bacterial Rhinosinusitis Acute clinical pattern Symptoms >10 days and < 28 days Objective confirmation either / or Nasal exam documenting purulent d/c beyond the nasal vestibule Rhinoscopy Endoscopy Posterior pharyngeal drainage CT scan Not recommended for routine management May be helpful in complex cases

17. Diagnosis of Acute Rhinosinusitis:2 major OR 1 major & 2 minor symptoms Major Anterior or posterior purulent drainage Nasal obstruction Facial pain or pressure or congestion Hyposmia or anosmia Fever (acute) Minor Head ache Ear pain/pressure Halitosis dental pain Fatigue Cough

18. Radiographic Evidence of Rhinosinusitis Air fluid level Sinus opacification Mucus membrane thickening of 4 to 6 mm or more Three radiographic findings indicate sinusitis: air-fluid level, opacification (partial or complete), and mucus membrane thickening of 4 to 6 mm or more. Three radiographic findings indicate sinusitis: air-fluid level, opacification (partial or complete), and mucus membrane thickening of 4 to 6 mm or more.

19. Advantages of CT Scan in Rhinosinusitis Diagnosis More sensitive and specific than plain sinus radiographs Allows assessment of ostiomeatal unit patency (OMU) Useful in intubated patients Axial cuts provide additional anatomic information Useful in complicated cases with CNS, bony, or orbital extension Frequently, plain radiographic studies are not sufficiently sensitive or specific to detect sinusitis or follow treatment. The CT scan is a more sensitive and specific method of detection of sinusitis. The limited sinus CT scan allows assessment of OMU patency. In the intubated patient, individuals with complications of the central nervous system or patients with bony or orbital extension, the CT scan provides a major advantage over the standard radiographic evaluation. Axial sinus CT cuts are usually reserved for patients with complicated sinusitis or for preoperative assessment. Frequently, plain radiographic studies are not sufficiently sensitive or specific to detect sinusitis or follow treatment. The CT scan is a more sensitive and specific method of detection of sinusitis. The limited sinus CT scan allows assessment of OMU patency. In the intubated patient, individuals with complications of the central nervous system or patients with bony or orbital extension, the CT scan provides a major advantage over the standard radiographic evaluation. Axial sinus CT cuts are usually reserved for patients with complicated sinusitis or for preoperative assessment.

20. Protocol for Limited Sinus CT Scan The “limited” sinus CT scan has become the most widely used radiographic study for diagnosis of sinusitis. It is obtained in the coronal projection with cuts through the frontal sinus, anterior ethmoid/maxillary sinuses, posterior ethmoid and spenoid sinuses. Typically, 3-4 cuts spaced 1 mm apart are taken through the anterior ethmoid/maxillary sinsuses to visualize the ostiomeatal unit (OMU). A recommended protocol for performing a limited sinus CT scan is presented on this slide (Courtesy of Barnes-Jewish West County Hospital – Radiology Department, St. Louis, MO).The “limited” sinus CT scan has become the most widely used radiographic study for diagnosis of sinusitis. It is obtained in the coronal projection with cuts through the frontal sinus, anterior ethmoid/maxillary sinuses, posterior ethmoid and spenoid sinuses. Typically, 3-4 cuts spaced 1 mm apart are taken through the anterior ethmoid/maxillary sinsuses to visualize the ostiomeatal unit (OMU). A recommended protocol for performing a limited sinus CT scan is presented on this slide (Courtesy of Barnes-Jewish West County Hospital – Radiology Department, St. Louis, MO).

24. Normal Sinus CT Scan through the OMU This slide shows normal sinus anatomy on a coronal sinus CT scan. This is a cut through the ostiomeatal unit (OMU) showing the drainage pathways from the anterior ethmoid and maxillary sinuses on both sides.This slide shows normal sinus anatomy on a coronal sinus CT scan. This is a cut through the ostiomeatal unit (OMU) showing the drainage pathways from the anterior ethmoid and maxillary sinuses on both sides.

25. Blow-up View of the Ostiomeatal Unit Area This is a blow-up view through the OMU. The OMU is well visualized on this normal sinus CT scan. The major structures illustrated include the maxillary infundibulum, the ethmoid infundibulum, the uncinate process, and the middle turbinate. The OMU is a three-dimensional structure made up of these individual components.This is a blow-up view through the OMU. The OMU is well visualized on this normal sinus CT scan. The major structures illustrated include the maxillary infundibulum, the ethmoid infundibulum, the uncinate process, and the middle turbinate. The OMU is a three-dimensional structure made up of these individual components.

26. Obstruction of the OMU with Associated Acute Sinusitis This sinus CT scan shows acute sinusitis with mucus membrane thickening in both maxillary and ethmoid sinuses and thick “bubbly” mucus in the maxillary sinuses. The acute sinusitis is associated with bilateral obstruction of the OMU. This sinus CT scan shows acute sinusitis with mucus membrane thickening in both maxillary and ethmoid sinuses and thick “bubbly” mucus in the maxillary sinuses. The acute sinusitis is associated with bilateral obstruction of the OMU.

27. Resolution of Acute Sinusitis after Treatment with Antibiotics This sinus CT scan was taken one month after treatment of the patient in the previous slide with antibiotics for four weeks. The sinuses are now clear, and the OMU are now patent bilaterally.This sinus CT scan was taken one month after treatment of the patient in the previous slide with antibiotics for four weeks. The sinuses are now clear, and the OMU are now patent bilaterally.

28. Local Factors Predisposing to Rhinosinusitis Allergic rhinitis URI Anatomic abnormalitiy: Deviated septum Concha bullosa Enlarged adenoids Haller cells Nasal polyps Tumor Foreign body Trauma Barotrauma Diving, swimming Smoke Topical decongestant abuse Nasal intubation A number of local and systemic factors predispose to the development of sinusitis6. The factors are summarized in this slide. Basically, any local condition that interferes with normal sinus drainage predisposes to the development of infection.A number of local and systemic factors predispose to the development of sinusitis6. The factors are summarized in this slide. Basically, any local condition that interferes with normal sinus drainage predisposes to the development of infection.

29. Systemic Factors Predisposing to Rhinosinusitis Immune deficiency IgA deficiency Panhypogammaglobulinemia IgG subclass deficiency HIV Cystic fibrosis Ciliary disorder Wegener’s granulomatosis Gastroesophageal reflux The physician must also be aware that certain systemic disorders may present with recurrent sinusitis. The most common form of hypogammaglobulinemia is IgA deficiency.The physician must also be aware that certain systemic disorders may present with recurrent sinusitis. The most common form of hypogammaglobulinemia is IgA deficiency.

30. Complications of Rhinosinusitis Orbital cellulitis (ethmoid) Meningitis Subdural/epidural empyema (frontal) Brain abscess (frontal) Cavernous sinus thrombosis (sphenoid) Osteomyelitis (frontal) Asthma exacerbation The important complications of sinusitis are listed on this slide. The specific complication is often linked to infection of a particular sinus. In particular, S. aureus sphenoiditis is associated with cavernous sinus thrombosis. 1/10,000 casesThe important complications of sinusitis are listed on this slide. The specific complication is often linked to infection of a particular sinus. In particular, S. aureus sphenoiditis is associated with cavernous sinus thrombosis. 1/10,000 cases

31. Ominous Signs in Rhinosinusitis Facial swelling / erythema over an involved sinus Visual changes Abnormal extraocular movements Proptosis Periorbital inflammation/edema Intracranial or CNS involvement

32. Antibiotics for Acute Sinusitis Cochrane Database Review (2004) Peds Available evidence suggest that antibiotics given for 10 days will reduce the probability of persistence in the short to medium-term. Cochrance Database Review (2004) Adults Current evidence is limited but supports the use of antibiotics for 7 to 14 days Weigh the moderate benefits of abx treatment against the potential for adverse effects Literature is unsatisfactory No db randomized study using aspirates pre and postLiterature is unsatisfactory No db randomized study using aspirates pre and post

33. Antibiotics for Acute Maxillary Sinusitis in Adults Searched from MEDLINE and EMABASE, contacts with pharmaceutical companies,and bibliographies of included studies Results 49 trials (n=13,660) 20 were double blind Compared to controls, abx improved clinical cures Radiographic outcomes improved with abx Comparison between classes of abx showed no significant differences Of 2058 articles ( 1861 were rejected definitely not meeting inclusion criteria simply on the basis of title or abstract) Abx versus controls, abx comparison Outcome: global change in clinical status Secondary outcome measures: bacteriological cure, radiographic improvement, relapse rate (7.7%), drop out due to adverse effectsOf 2058 articles ( 1861 were rejected definitely not meeting inclusion criteria simply on the basis of title or abstract) Abx versus controls, abx comparison Outcome: global change in clinical status Secondary outcome measures: bacteriological cure, radiographic improvement, relapse rate (7.7%), drop out due to adverse effects

34. Acute Bacterial Rhinosinusitis:Which antibiotic to use? No randomized, placebo-controlled trials of antibiotic treatment for ABRS using pre-and post-treatment sinus aspirate culture

35. Antibiotics 20 to 30% of S. pneumoniae are penicillin resistant 30 to 40% of H. influenzae and 75 to 95% of M. catarrhalis are beta-lactamase positive When choosing abx consider Recent abx use (within 6 weeks) Severity of disease Jacobs et. al. Susceptibiities of Streptococcus pneumoniae and Haemophilus influenzae to 10 oral antimicrobial agents based on pharmacodynamic parameters: 1997 U.S. Surveillance study. Antimicrob Agents Chemother 1999;43:190-8. Jacobs et al. The Alexander Project 1998-2000: susceptibility of pathogens isolated from community-acquired respiratory tract infection to commonly used antimicrobial agents. J. Antimicrob Chemother 2003;52:229-46. Jones R. SENTRY Surveilllance Program-US isolates; 2003 Jacobs et. al. Susceptibiities of Streptococcus pneumoniae and Haemophilus influenzae to 10 oral antimicrobial agents based on pharmacodynamic parameters: 1997 U.S. Surveillance study. Antimicrob Agents Chemother 1999;43:190-8. Jacobs et al. The Alexander Project 1998-2000: susceptibility of pathogens isolated from community-acquired respiratory tract infection to commonly used antimicrobial agents. J. Antimicrob Chemother 2003;52:229-46. Jones R. SENTRY Surveilllance Program-US isolates; 2003

36. Antibiotics for Acute Rhinosinusitis FDA approved antibiotics for acute bacterial rhinosinusitis Amoxicillin, amoxicillin-clavulonate, clarithromycin, cefprozil, cefuroxime axetil, loracarbef, levofloxacin, gatifloxacin, azithromycin, trimethoprim sulfamethoxazole, moxifloxacin, telithromycin

37. Comparison of First-Line vs Second-Line Abx Objective: compared effectiveness and cost for treatment in uncomplicated ABRS Retrospective cohort study (n=29,102) Outcome: presence or absence of additional claim for an abx, cost, complications of sinusitis Acute uncomplicated sinusitisAcute uncomplicated sinusitis

38. List of Antibiotics 1st Line Amoxicillin TMP-SMX Erythromycin 2nd Line Clarithromycin Azithromycin Augmentin Cephalosporins Levofloxaxin Clindamycin metronidazole

39. Results 1st Line Success: 90.1% 1 case of periorbital cellulitis Cost: $68.98 2nd Line Success: 90.8% 1 case of periorbital cellulitis Cost: $135.17 p<.001 No difference in outcome Difference in cost not due to other chargesNo difference in outcome Difference in cost not due to other charges

40. CDC recommendations for ABRS Amoxicillin 1.5 to 3.5 g/day Doxycycline 100 mg twice daily TMP-SMX 1 DS twice daily

41. Sinus and Allergy Health Partnership Recommendations Mild disease (no abx in 4-6 weeks) Amoxicillin-clavulanate, amoxicillin, cefpodoxime, cefuroxime axetil Mild disease (abx in last 4-6 weeks) or moderate disease (no abx) Amoxicillin-clavulanate, amoxicillin high dose, cephalosporins, gatifloxacin, levofloxacin, moxifloxacin Moderate disease (abx in last 4-6 weeks) Amoxicillin-clavulanate, fluoroquinolones, or combination therapy with amox or clinda plus cefpodoxime or cefixime

42. Acute Bacterial Rhinosinusitis:Duration of Treatment Most clinical trials have used 10 to 14 days 95% eradication after 10 day course1 3-5 day courses of some macrolides2,3 effective2

44. Sinus & Allergy Health Partnership. Otolaryngol Head&N Surg 2004;130:1Sinus & Allergy Health Partnership. Otolaryngol Head&N Surg 2004;130:1

45. Chronic Rhinosinusitis

46. Diagnosis of Chronic Rhinosinusitis Symptoms for > 12 weeks Two main subtypes: CRS without nasal polyps CRS with nasal polyps Strongly associated with asthma and aspirin tolerance Dx based on symptoms is common but unreliable Dx based on symptoms is common but unreliable

49. Mechanisms of CRS

50. Chronic Rhinosinusitis: Risk Factors for Extensive Disease 80 patients with CRS Factors Eosinophil > 200/uL (OR=19.2, 95% CI=5.4-72.7 Asthma (OR=6.8, 95%CI=2.2-22) Atopy (OR=4.3,95%CI=1.5-12.8) Age>50 (OR=6.5,95%CI=2.0-22.2)

51. Prevalence of Allergy in CRS Chart review of 113 sinus surgery patients 48 patients included in the study Allergy testing by RAST or skin testing 57.4% had a positive allergy test This study provides evidence that allergic rhinitis is an important factor in chronic and recurrent acute rhinosinusitis needing surgeryThis study provides evidence that allergic rhinitis is an important factor in chronic and recurrent acute rhinosinusitis needing surgery

52. Correlation of Allergy and Rhinosinusitis Retrospective review of 200 patients with FESS 84% with allergies Predominance of perennial (esp DM) Comorbid conditionComorbid condition

53. Allergic Inflammation and Rhinosinusitis Purpose: ongoing AR enhances infection and inflammation by S. pneum in acute sinusitis BALB/c mice sensitized to ovalbumin by IP injection Nasal administration of OVA soln Infection with S. pneumoniae To ensure proper sensitization , skin testing and total IgE was measuredTo ensure proper sensitization , skin testing and total IgE was measured

54. Allergic Inflammation and Rhinosinusitis Results: Allergic mice had more bacteria recovered more inflammation (PMN, eos, monos)

55. Allergic Inflammation and Rhinosinusitis Blair, et al, JACI 2001; 108:124Blair, et al, JACI 2001; 108:124

56. Correlation of Allergy and Rhinosinusitis 42 patients with CRS underwent RAST and CT scans Allergic patients had higher CT scores (mean = 12) Nonallergic patients had lower CT scores (mean = 6) p=0.03

57. Type of Allergy Among Sinus Surgery Patients 7 + 4.0% reacted only to seasonal allergens 27.1 + 6.4% reacted only to perennial allergens 27.1 + 6.4% reacted to at least 1 seasonal allergen and at least one perennial allergen Emmanuel et al. Otolaryngol H&N Surg 2000;123:687 and Ramandan et al. Am J Rhinol 1999;13:3457 + 4.0% reacted only to seasonal allergens 27.1 + 6.4% reacted only to perennial allergens 27.1 + 6.4% reacted to at least 1 seasonal allergen and at least one perennial allergen Emmanuel et al. Otolaryngol H&N Surg 2000;123:687 and Ramandan et al. Am J Rhinol 1999;13:345

58. Allergy Immunotherapy for CRS Study: 114 patients with perennial allergic rhinitis and sinusitis, surveyed using the Sinusitis Outcomes Questionnaire. 99% of patients surveyed believed immunotherapy was helpful 72% decrease in days lost from work or school 25% reduction in the use of medications 51% reduction in the overall symptom score

59. Allergic Fungal Rhinosinusitis Appears to be a subset of CRsNP Defined by 5 criteria: allergy to cultured fungi gross production of eosinophilic mucin that contains noninvasive fungal hyphae nasal polyposis characteristic radiographic changes immunocompetence

60. Role of Infectious Agents in CRS Fungi Eosinophilic fungal rhinosinusitis has been proposed, but is controversial. Bacteria Superinfection is more common role, rather than primary cause of inflammation and obstruction. Superantigen from Staph aureus has been demonstrated to have a role in nasal polyps. Biofilm is an attractive but unproven concept. Osteitis is another unproven concept.

61. Fungi and Chronic Rhinosinusitis Allergic fungal rhinosinusitis A well-characterized condition involving allergy to fungi and other characteristic features. Infectious fungal rhinosinusitis Direct infection of the sinuses (non-invasive vs. invasive). Eosinophilic fungal rhinosinusitis A (proposed) non-IgE-mediated inflammatory condition characterized by fungal colonization, local chemotaxis of eosinophils, and inflammation.

62. Bacterial Superantigen Local production of IgE specific to staphyloccal enterotoxins, which act as superantigens, in CRSwP Staph aureus enterotoxins induce increased severity of eosinophilic inflammation Increased colonization of Staph aureus in swabs of the middle meatus from patients with CRSwP relative to normal controls and patients with CRSsP

63. Diagnosis of CRS Physical examination Endoscopy or anterior rhinoscopy Purulent drainage Edema or erythema of the middle meatus or ethmoid bulla polyps Sinus CT scan Mucosal thickening Air-fluid level Confirmed by physical evidenceConfirmed by physical evidence

65. Medical Management of Chronic Rhinosinusitis Antibiotics Corticosteroids Decongestants Muco-evacuants Antihistamines Non-pharmacologic treatment Limited data exists on the efficacy of medical tx for CS. Based on clinical experience rather than formal trialsLimited data exists on the efficacy of medical tx for CS. Based on clinical experience rather than formal trials

66. Microbiology of Chronic Rhinosinusitis Not well defined because of differences in culturing techniques, prior use of abx S. pneumoniae, H. influenzae, M. catarrhalis S. Aureus, coagulase negative staph, anaerobes Fungi In adults ,anaerobes varys from 5-67%In adults ,anaerobes varys from 5-67%

67. Chronic Rhinosinusitis:Which Antibiotic to Use? -No antibiotic is approved by FDA for CRS -We use similar abx as ABRS

68. Antibiotics for Chronic Rhinosinusitis Appropriate duration is not well defined AAAAI and ACAAI Joint Task Force treat for 3,4 or 6 weeks continue abx for at least 1 week after the patient is symptom free Task Force on Rhinosinusitis of the American Academy of Otolaryngology-Head and Neck Surgery treat 4 to 6 weeks

69. Corticosteroids Few controlled studies with nasal steroids Beneficial when added to abx Longer infection free interval in CRS systemic steroids have not been well studied Studies suggest may be beneficial when added to abx, Longer infection free interval after treatment in acute CRS In mucosal bx, after 10 day course of steroids– decrease in tnf alfa, IL-16 Benefit in allergic rhinitis, polyps by decreasing edema, and release of inflammatory mediatorsStudies suggest may be beneficial when added to abx, Longer infection free interval after treatment in acute CRS In mucosal bx, after 10 day course of steroids– decrease in tnf alfa, IL-16 Benefit in allergic rhinitis, polyps by decreasing edema, and release of inflammatory mediators

70. Adjunctive Therapy Decongestants Used as adjuvant treatment no controlled studies Mucolytic treatment 1 double blinded study 2400 mg of guaifenesin or placebo in HIV+ with chronic sinusitis improvement in congestion and thick secretions

71. Adjunctive Therapy Antihistamines play a role in allergic rhinitis patients with sinusitis Saline irrigation may help mucociliary clearance mild vasoconstrictor of nasal blood flow Intravenous immune globulin indicated in patients with impaired humoral immunity

72. Adjunctive Therapy Leukotriene antagonists Useful in patients with CRS with nasal polyps

73. Nasal Irrigation 211 with sinonasal disease Irrigated with 250 mL HS using a Water Pik BID for 3 to 6 weeks Rated nasal symptoms and QOL Sinonasal disease = AR CS Symptoms: congestion, sleep disturbance, discharge, PND, allergies, anosmia stress, cough, hoarseness, sneezing, head and facial painSinonasal disease = AR CS Symptoms: congestion, sleep disturbance, discharge, PND, allergies, anosmia stress, cough, hoarseness, sneezing, head and facial pain

74. Nasal Irrigation Results 23/30 symptoms improved QOL improved 92% compliance 83/109 (76%) improved 26 (24%) reported adverse effects or no benefit Pts with nasal irrigation alone compared with nasal irrigation +meds trend towards improvement but not sig Adverse effects: nasal irritation, discomfort, otalgia, or pooling of saline in sinuses with subsequent drainage.Pts with nasal irrigation alone compared with nasal irrigation +meds trend towards improvement but not sig Adverse effects: nasal irritation, discomfort, otalgia, or pooling of saline in sinuses with subsequent drainage.

75. Nasal Irrigation Improves mucociliary function Decreases mucosal edema Decreasing inflammatory mediators Clearing mucus

76. Outcomes of Medical Management of CRS 200 pediatric and adult patients treated with 4 weeks of oral abx, nasal corticosteroids, lavage and topical decongestants patients followed 1 to 27 months (mean 6 months) all improved 6% required surgery

77. Outcomes of Medical Management Retrospective series of 40 patients treated with abx for 4 to 6 weeks and 10 days of prednisone most patients also used nasal steroid spray and saline irrigation 36 had improvement in both symptom and CT scores Lack of correlation between subjective and objective measures abnormalities in the osteomeatal unit persisted in 8/17 patientsLack of correlation between subjective and objective measures abnormalities in the osteomeatal unit persisted in 8/17 patients

78. Surgery for Rhinosinusitis FESS enlarge sinus ostia correct anatomic deformities (septal deviation, concha bullosa) create a common cavity for nasal drainage ventilate sinuses >85% improvement in selected series If blockage not responsive to medical therapy, tumor, If blockage not responsive to medical therapy, tumor,

79. Summary Acute rhinosinusitis is usually related to infection Antibiotic management is first line Chronic rhinosinusitis is usually related to inflammation Further characterization of the condition is important (nasal polyps) Exploration of underlying allergy is important Management is challenging