Rhinosinusites

2. Rhinosinusites SAYED MOSTAFA HASHEMI MD FACULTI MEMBER OF ISFAHAN MEDICAL SCAIENS

3. ANATOMY AND PHYSIOLOGY •  — Humans have four pairs of sinuses named for the bones of the skull that they pneumatize The maxillary, ethmoid (divided into anterior and posterior cells), frontal, and sphenoid sinuses are air-containing spaces that are lined by pseudostratified, columnar epithelium bearing cilia. The sinus mucosa contains goblet cells, which secrete mucus that aids in trapping inhaled particles and debris.

4. Anatomy

5. Ostiomeatal complex

6. INTRODUCTION — • Rhinosinusitis is defined as symptomatic inflammation of the nasal cavity and paranasalsinuse • The term "rhinosinusitis" is preferred to "sinusitis" since inflammation of the sinuses rarely occurs without concurrent inflammation of the nasal mucosa [1].

7. Pathophysiology • The sinuses are normally sterile under physiologic conditions. Purulent sinusitis can occur when ciliary clearance of sinus secretions decreases or when the sinus ostium becomes obstructed, which leads to retention of secretions, negative sinus pressure, and reduction of oxygen partial pressure.

8. Pathophysiology • This environment is then suitable for growth of pathogenic organisms. • Factors that predispose the sinuses to obstruction and decreased ciliary function are allergic, nonallergic, or viral insults, which produce inflammation of the nasal and sinus mucosa and result in ciliarydysmotility and sinus obstruction.

9. PATHOGENESIS of ABRS • With colds and influenza-like illnesses, viscous fluid frequently accumulates in the sinuses from exocytosis of mucus from goblet cells in the sinus mucosa [6] and possibly as the result of nose blowing. • ABRS occurs when bacteria secondarily infect the inflamed sinus cavity. Though usually occurring as a complication of viral infection

10. Conversion of AVRS to ABRS • it is generally not possible to distinguish AVRS from ABRS in the first 10 days of illness based upon history, examination, or radiologic study. • The diagnosis of ABRS is usually clinical, since sinus aspirates for culture are not readily obtainable.

11. Conversion of AVRS to ABRS • Persistent symptoms or signs of ARS lasting 10 or more days with no clinical improvement • Onset with severe symptoms (fever >39°C or 102°F and purulent nasal discharge or facial pain) lasting at least three following days at the beginning of illness • Onset with worsening symptoms following a viral upper respiratory infection that lasted five to six days and was initially Improving • immunocompromised patients

12. Only a small percentage (approximately two percent) of viral rhinosinusitis is complicated by acute bacterial sinusitis. Uncomplicated viral rhinosinusitis usually resolves in seven to ten days.

13. EPIDEMIOLOGY •  — The average adult has from two to three colds and influenza-like illnesses per year and the average child six to 10 • Approximately 0.5 to 2 percent of colds and influenza-like in adults and 6-13% in children complicated by acute bacterial sinusitis in adults

14. Classification of rhinosinusitis is based on symptom duration.

15. Recurrent acute rhinosinusitis • - four or more episodes of ARS per year, with temporary symptom resolution [2].

16. Clinical course • Acute bacterial sinusitis is also usually a self-limited disease, with 75 percent of cases resolving without treatment in one month. • untreated patients with acute bacterial sinusitis have bothersome morbidity and are at risk of developing intracranial and orbital complications Acute bacterial sinusitis is also

17. Clinical Diagnosis • Purulent rhinorrhea • Nasal congestion and/or facial pain/pressure • diagnosis is further supported by the presence of secondary symptoms, including anosmia, ear fullness, cough, and headache. • Pain localized to the sinuses when the patient is asked to bend forward may be more

18. Physical Examination • Anterior rhinoscopy with otoscope in younger children • Tenderness over sinuses • Periorbital edema and discoloration • Flexible and rigid endoscopy in older child • Most specific-- mucopurulence, periorbital swelling, facial tenderness

19. Tools for intranasal examination

20. Notable exam findings • may include diffuse mucosal edema, narrowing of the middle meatus, inferior turbinate hypertrophy, and copious rhinorrhea or purulent discharge. • Polyps or septal deviation may be noted incidentally and may indicate pre-existing anatomic risk factors for the development of ABRS.

21. plain sinus radiography • The sensitivity and specificity of plain sinus radiography is poor for detecting mucosal thickening of the paranasal sinuses (76 and 79 percent, respectively) • The high false negative rate is attributable to poor visualization of the ethmoid sinuses in plain films, • The high false positive rate to artifact and the inability to distinguish polyps and nasal masses from fluid or mucosal edema.

22. Computed tomographic (CT) scan of the sinuses showing occlusion of the infundibula (black arrow heads); viscous material adherent to the wall of the sinus cavity (white arrow); bubble in the viscous fluid which does not represent thickened sinus mucosa (white arrow head); and pneumatization of concha bullosa (asterisk). Courtesy of Jack Gwaltney, MD.

23. Sinus aspiration • cultures are rarely performed unless there has been a failure of treatment • sinus aspiration is indicated in severe toxic illness, acute illness not responsive to antibiotics within 72 hours, immunocompromised patients, supportive complications • endoscopically guided middle meatus swab correlates fairly well with sinus aspirate

24. Microbiology

25. Medical Treatment • Acute Sinusitis: • Young children with mild to moderate ARS, amoxicillin at normal or high dose • Amoxil-allergic patients, treat with a cephalosporin—severe allergy, treat with macrolide • Nonresponders, more severe initial disease, those at high-risk for resistant strep, treat with high dose amoxil/clavulanate • Parenteralceftriaxone for children not tolerating oral meds • Duration of therapy is usually days 7-10

26. Antibiotics - Other Considerations • Recent use of prior antibiotics is a risk factor for the presence of antibiotic-resistant bacteria • different antibiotic should be selected if the patient has used antibiotics in the last 4 to 6 weeks. • Guidelines from the Sinus and Allergy Health Partnership4 recommend a fluoroquinolone or high-dose amoxicillin-clavulanate (4 grams/250 milligrams per day) for patients who have received antibiotics within the past 4 to 6 weeks. • Having a child in daycare in the household is a risk factor for penicillin-resistant S. pneumoniae, for which high-dose amoxicillin is an option.

27. Treatment • Amoxicillin has been recommended as a first-line agent in the past because of its narrow spectrum and relative low cost. However, there is increasing emergence of antimicrobial resistance among respiratory pathogens, including pneumococci and H. influenzae. Resistance rates vary regionally, with the prevalence of H. influenzae resistance ranging from 27 to 43 percent in the US [9].

28. Treatment failure •  — Treatment failure is defined as progression of symptoms at any time during treatment or failure to improve after 3-5 days of therapy. • Patients who fail first-line therapy require alternative antibiotic selection. Ideally, an endoscopically-guided culture could be performed to redirect antibiotic therapy. If no material is available on endoscopy for culture, a broader antibiotic choice can be empirically started and monitored for improvement. high-dose amoxicillin-clavulanate (4 grams/250 milligrams per day) have been recommended • A CT scan of the sinuses may be performed if symptoms worsen or fail to improve, to verify that symptoms are in fact due to acute sinusitis, and not to concomitant allergy or other noninfectious etiologies.

29. Choice of Antibiotic for ABRS Wright & Frankel

30. Treatment • trimethoprim-sulfamethoxazole, and second- or third-generation cephalosporins are not recommended for empiric therapy because of high rates of resistance of S. pneumoniae (and of H. influenzae for trimethoprim-sulfamethoxazole

31. Antibiotics - Duration • Most trials of ABRS administer antibiotic for 10 days • No significant differences in resolution rates for ABRS with a 6-10 day course of antibiotics compared with a 3-5-day course (azithromycin, telithromycin, or cefuroxime) up to 3 weeks after treatment. Refs118-120 • Another systematic review found no relation between antibiotic duration and outcome efficacy for 8 RCTs (Ip et al. 2005) • Shorter antibiotic courses associated with fewer adverse effects. • Final Recommendation on Duration?

32. Treatment • Adjunctive therapy — Symptomatic relief measures, including analgesics, nasal saline irrigation, and topical and systemic decongestants

33. Saline irrigation • — Mechanical irrigation with buffered, physiologic, or hypertonic saline may reduce the need for pain medication and improve overall patient comfort, particularly in patients with frequent sinus infections. • It is important that irrigants be prepared from sterile or bottled water, as there have been reports of amebic encephalitis due to tap water rinses [13]. Instructions for preparing a rinse solution are shown in a table (tabl

34. Topical glucocorticoids • — The theoretic mechanism of action for intranasal glucocorticoids (corticosteroids) is a decrease in mucosal inflammation that allows improved sinus drainage • intranasal glucocorticoids are likely to be most beneficial for patients with underlying allergic rhinitis

35. Topical decongestants • — The use of topical decongestants, such as oxymetazoline, may provide a subjective sense of improved nasal patency. If used, topical decongestants should be used sparingly (no more than three consecutive days) to avoid rebound congestion • Topical decongestants are suggested for symptomatic relief in the treatment of AVRS and 2012 guidelines advise that they are not helpful in patients with ABRs • oral decongestants are not helpful in patients with ABRS

36. oral decongestants • oral decongestants are not helpful in patients with ABRS • When eustachian tube dysfunction is a significant confounding factor in AVRS, a short course (three to five days) of oral decongestants may be warranted. • Oral decongestants should be used with caution in patients with cardiovascular disease, hypertension, or benign prostate hypertrophy due to systemic adverse effects with oral alpha adrenergic preparation

37. Antihistamines • — Antihistamines are frequently prescribed for symptom relief due to their drying effects; however, there are no studies investigating their efficacy for this indication • Additionally, over-drying of the mucosa may lead to further discomfort. Antihistamines have side effects (drowsiness, xerostomia), • Their use for the treatment of acute sinusitis is not recommended

38. Indications for urgent referral •  — Patients with high fever, acute facial pain, swelling, and erythema should be treated for acute bacterial rhinosinusitis, even if symptoms have not been present for seven days. • Patients with high fevers and severe headache warrant immediate evaluation and probable imaging.

39. Stage II—Orbital Cellulitis Proptosis, Chemosis, Edema, Pain Dilated pupil Visual loss Ophthalmoplegia Afferent pupillary defect

40. Chronic Rhinosinusitis

41. Chronic rhinosinusitis • Chronic rhinosinusitis is a group of disorders characterized by inflammation of the mucosa of the nose and paranasal sinuses of at least 12 consecutive weeks’ duration. • Patients with CRS may have intermittent acute flare-ups; in such cases, the disorder is called acute exacerbation of chronic rhinosinusitis(AECRS)

42. Ostiomeatal complex

43. EPOS Management Algorithm:Adult Chronic Rhinosinusitis *Primary Care

44. Pathogenesis • Ostia obstruction creates increasingly hypoxic environment within sinus • Retention of secretion results in inflammation and bacterial infection • Secretion stagnate, obstruction increases, cilia and epithelial damage become more pronounced

45. Factors that may contribute to of CRS include • The recognition that CRS represents a multifactorial inflammatory disorder, rather than simply a persistent bacterial infection, has led to the reexamination of the role of antimicrobials in CRS

46. The role of bacteria in the pathogenesis of chronic sinusitis The role of bacteria in the pathogenesis of chronic sinusitis is currently being reassessed. Repeated and persistent sinus infections can develop in persons with severe acquired or congenital immunodeficiency states or cystic fibrosis. Current thinking supports that chronic rhinosinusitis (CRS) is predominantly a multifactorial inflammatory disease. Confounding factors that may contribute to inflammation include the following:

47. Persistent infection (including biofilms and osteitis) Allergy and other immunologic disorders Intrinsic factors of the upper airway Superantigens Colonizing fungi that induce and sustain eosinophilic inflammation Metabolic abnormalities such as aspirin sensitivity

48. All of these factors can play a role in disruption of the intrinsic mucociliary transport system. This is because an alteration in sinus ostia patency, ciliary function, or the quality of secretions leads to stagnation of secretions, decreased pH levels, and lowered oxygen tension within the sinus. These changes create a favorable environment for bacterial growth that, in turn, further contributes to increased mucosal inflammation.

49.  There are four cardinal signs of CRS: At least TWO of these symptoms should be present to consider the diagnosis of CRS, in association with objective findings • Anterior and/or posterior mucopurulent drainage • Nasal obstruction • Facial pain, pressure, and/or fullness • Decreased sense of smell

50.  —SUBTYPES OF CRS CRS with nasal polyposis - 20 to 33 percent of cases Allergic fungal rhinosinusitis - 8 to 12 percent CRS without nasal polyposis - 60 to 65 percent •  CRS can be divided into three distinct clinical syndromes