Nonallergic Rhinitis (Ch.46) Acute and Chronic Sinusitis (Ch. 47)

1. Nonallergic Rhinitis (Ch.46)Acute and Chronic Sinusitis (Ch. 47) Marilene B. Wang, MD, FACS Professor UCLA Department of Head Neck Surgery Chief of Otolaryngology VA Greater Los Angeles Healthcare System

2. 1. Nonallergic rhinitis • Is more common in males • Incidence increases with age • May occur in conjunction with allergic rhinitis • B and c • All of the above

3. 2. Innervation of the nasal mucosa • Parasympathetic nerves are the primary component of the efferent nasal reflex arc. • Parasympathetic nerves release vasoactive intestinal peptide • Parasympathetic nerves cause nasal decongestion • C fibers are efferent nerves that react to pain, changes in temperature, osmolarity and irritants. • All of the above

4. 3. Nasal provocation testing • Can differentiate between allergic and non-allergic rhinitis • Done with histamine is specifically for allergic rhinitis • Done with capsaicin is specifically for nonallergic rhinitis • Done with histamine causes decreased vascular permeability, sneezing, and nasal obstruction • Done with methacholine leads to increased rhinorhea

5. 4. Nonallergic rhinitis with eosinophilia • Occurs in response to common allergens such as dust, pollen, mold • Symptoms are exacerbated by weather changes • Occurs in over half of patients with nonallergic rhinitis • Involves mast cells and Ig-A positive cells in the nasal mucosa • Does not occur with nasal polyps

6. 5. Rhinitis of pregnancy • Occurs more frequently in pregnant women who smoke • Affects the majority of pregnant women • Occurs in response to estrogen-induced vascular smooth muscle relaxation • Severity of symptoms parallels blood progesterone levels • All of the above

7. 6. Medication-induced rhinitis can be found from use of the following medications: • Aspirin • Oral contraceptives • Amitryptiline • Hydralazine • All of the above

8. 7. Atrophic rhinitis • Is most commonly associated with infection from Klebsiella pneumoniae • Can occur after aggressive nasal surgery • Is most common in young adults • Results in changes in nasal mucosa from squamous epithelium to ciliated respiratory epithelium • Can be treated effectively with antibiotics

9. 8. Idiopathic rhinitis • Is also known as vasomotor rhinitis • Occurs rarely • Involves autonomic nervous system dysfunction • A and c • All of the above

10. 9. Diagnosing nonallergic rhinitis • Requires a thorough history • Requires acoustic rhinomatry • Requires a sinus CT scan • All of the above • None of the above

11. 10. Treatment of nonallergic rhinitis a. May include nasal steroids, antihistamines, and anticholinergics b. Septoplasty and/or turbinate reduction may be of benefit c. Vidianneurectomy can provide relief of rhinorrhea d. A and c e. All of the above

12. Acute and Chronic Sinusitis

13. Major Healthcare Problem Problem • One of most common healthcare problems in U.S. • Over 31 million Americans affected annually • 18-22 million physician office visits annually

14. Definition of rhinosinusitis • Group of disorders characterized by inflammation of the mucosa of the nose and paranasal sinuses • Acute, subacute, chronic

16. Paranasal Sinus Function • Lining – pseudostratified ciliated columnar epithelium • Mucous and serosanguinous glands • Parasympathetic and sympathetic innervation

17. Paranasal Sinus Function • Mucous blanket renewed every 10-15 minutes • Warm and humidify air • Secrete immunoglobulins, interferons, inflammatory cells

18. Paranasal Sinus Function • Cilia beat 10-15 times/second • Cilia function varies with environment, allergies, etc. • Mucociliary system—cleanse sinus, immunoprotective • Move mucous to natural ostia of sinuses

20. Rhinosinusitis-Major factors • Facial pain/pressure • Nasal obstruction/blockage • Nasal discharge/purulence/discolored postnasal drip

21. Rhinosinusitis-Major factors • Hyposmia/anosmia • Purulence in nasal cavity on examination • Fever (acute rhinosinusitis only)

22. Rhinosinusitis-Minor factors • Headache • Fever • Halitosis • Fatigue

23. Rhinosinusitis-Minor factors • Dental pain • Cough • Ear pain/pressure/fullness

24. Categories of Rhinosinusitis • Acute • Subacute • Chronic • Recurrent, acute • Acute exacerbations of chronic

25. Acute Rhinosinusitis • Duration up to 4 weeks • > 2 major factors • 1 major factor + 2 minor factors • Nasal purulence on exam

26. Subacute Rhinosinusitis • Duration 4-12 weeks • >2 major factors • 1 major factor + 2 minor factors, or nasal purulence on exam • Complete resolution after effective medical therapy

27. Chronic Rhinosinusitis • Duration > 12 weeks • History same as for subacute • Facial pain does not constitute suggestive history in absence of other nasal symptoms or signs

28. Recurrent acute • >4 episodes/year + each episode last >7-10 days. • Absence of intervening signs of chronic rhinosinusitis

29. Acute exacerbations of chronic • Sudden worsening of chronic rhinosinusitis • Return to baseline after treatment

30. Factors Associated with Chronic Rhinosinusitis • Allergies • Immunodeficiency • Genetic/congenital

31. Factors Associated with Chronic Rhinosinusitis • Endocrine • Neural

32. Factors Associated with Chronic Rhinosinusitis • Anatomic • Neoplastic • Acquired mucociliary dysfunction

33. Associated Factors • Microorganisms—viral, bacterial, fungal • Noxious chemicals, pollutants, smoke • Medications • Trauma • Surgery

34. Microbiology of acute sinusitis (adults) • S. pneum (20-43%) • H. influenzae (22-35%) • Strep spp. (3-9%) • Anaerobes (0-9%) • M. catarrhalis (2-10%) • S. aureus (0-8%) • Other (4%)

35. Microbiology of acute sinusitis (children) • S. pneum (25-30%) • H. influenzae (15-20%) • M. catarrhalis (15-20%) • S. pyogenes (2-5%) • Anaerobes (2-5%) • Sterile (20-35%)

36. Recommended abx for adults with acute bacterial rhinosinusitis • Mild disease with no recent antimicrobial use • Augmentin, Amoxicillin • Vantin • Ceclor • Omnicef

37. Switch if no improvement after 72 hours • Tequin, Levaquin, Avelox • Augmentin • Combination (Amox or clinda + Suprax)

38. Abx for acute sinusitis if PCN-allergic • Bactrim • Doxycycline • Zithromax, Biaxin, Erythromycin • Switch to quinolone if no improvement in 72 hours

39. If recent abx use • Quinolone • Augmentin • Clindamcin + rifampin • Consider IV abx

40. Abx for acute sinusitis in children • Augmentin, Amoxicillin • Vantin • Ceclor • Omnicef • Switch if no improvement after 72 hours

41. If PCN-allergic • Bactrim • Macrolide

42. If recent abx use (children) • Augmentin • Rocephin • Bactrim, macrolide • Consider IV abx if no improvement

43. Other symptomatic therapies • Afrin for 3 days • Normal saline sprays • Decongestants • Antihistamines • ?Steroids

44. Complications of sinusitis • Periorbital cellulitis • Preseptal cellulitis/abscess • Orbital cellulitis • Orbital abscess • Cavernous sinus thrombosis

45. Chronic rhinosinusitis • Antibiotics • Antihistamines • Nasal steroids • Normal saline irrigations • Allergy evaluation +/- immunotherapy

46. Chronic rhinosinusitis • Sinus CT scan • Consider anatomic factors—septal deviation, nasal polyps, concha bullosa, ostio-meatal blockage

47. Indications for sinus surgery • Nasal polyposis • Anatomic blockage—deviated septum, enlarged turbinate, concha bullosa • Mucocele • Orbital abscess

48. Indications for sinus surgery • Fungal sinusitis—allergic vs. invasive (mucor) • Tumor of nasal cavity or sinus

49. Indications for sinus surgery • Chronic, recurrent sinusitis • Failure to respond to maximal medical therapy • Obtain cultures