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Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Acute Rhinosinusitis – bacterial infection or inflammation? Prof. Dr. Philippe Gevaert Dienst Neus-,

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Presentation on theme: "Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Acute Rhinosinusitis – bacterial infection or inflammation? Prof. Dr. Philippe Gevaert Dienst Neus-,"— Presentation transcript:

1 Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Acute Rhinosinusitis – bacterial infection or inflammation? Prof. Dr. Philippe Gevaert Dienst Neus-, keel- en oorheelkunde Allergienetwerk UZ-Gent

2 Neus-, keel- en oorheelkunde Hoofd- en halschirurgie New definition and classification Update on literature and treatments New and practical treatment schemes acute rhinosinusitis adults children chronic rhinosinusitis adults children nasal polyposis Research needs and priorities

3 Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Definitions and classification for General Practice Based on symptoms: Two or more symptoms, one of which should be either nasal blockage/obstruction/congestion or nasal discharge: anterior/post nasal drip; ± facial pain/pressure, ± reduction or loss of smell Examination: anterior rhinoscopy X-ray/CT not recommended * DURATION ACUTE / intermittent< 12 weeks complete resolution of symptoms CHRONIC / persistent> 12 weeks incomplete resolution of symptoms Special attention to questions on allergic symptoms

4 Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Definitions and classification Based on symptoms: Two or more symptoms, one of which should be either nasal blockage/obstruction/congestion or nasal discharge: anterior/post nasal drip; ± facial pain/pressure, ± reduction or loss of smell AND EITHER endoscopic findings of polyps mucopurulent discharge edema or obstruction OR CT scan abnormality: mucosal changes within ostiomeatal complex or sinus cavity

5 Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Definitions and classification * SEVERITY Visual Analogue Scale (VAS) mild0-3 moderate3-7 severe7-10 * DURATION ACUTE / intermittent< 12 weeks complete resolution of symptoms CHRONIC / persistent> 12 weeks incomplete resolution of symptoms CLASSIFICATION OF RHINOSINUSITIS

6 Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Headache/facial pressure in sinusitis

7 Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Nasal Endoscopy

8 Neus-, keel- en oorheelkunde Hoofd- en halschirurgie RX sinuses: - Waters, Caldwell an Hirtz - poor sensitivity and specificity - NOT RECOMMENDED! Imaging of sinsuses

9 Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Imaging of sinsuses MRI: only recommended in tumor diagnosis CT sinuses: current standard imaging (50mGy) Cave! radiation damage of lens ( mGy) - Acute rhinosinusitis: only if signs for complications!! - Chronic sinusitis: only after 4w-12w treatment!

10 Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Neus-, keel- en oorheelkunde Hoofd- en halschirurgie COMMON COLD BACTERIAL SUPERINFECTION Strep pneu / Haemo infl / Morax catar increasing symptoms after 5 DAYS no resolution after 10 DAYS ACUTE rhinosinusitis MULTIFACTORIAL ETIOLOGY CHRONIC rhinosinusitis EAACI Position Paper on Rhinosinusitis and Nasal Polyps, Allergy 2005: 60: Anatomy and physiology

11 Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Viruses in acute rhinitis and rhinosinusitis adenovirus parainfl. RSV coronavirus coxsakie echovirus influenza rhinovirus Adults Least common Most common adenovirus parainfl.adenovirus RSVparainfl.influenza coronavirusRSVrhinovirusinfluenza coxsackiecoronavirusRSVadenovirus influenzaechovirusenterovirusparainfl. echovirusinfluenzaadenovirusRSV rhinovirus parainfl.rhinovirus Young adultsAdolescents5-10 years< 4 years Kirkpatrick, 1996

12 Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Pathophysiology Viral Rhinitis Impact of viral infection on the mucosa Epithelial changes  Hypersecretion and oedema  Goblet cells (hypersecretion),  ciliated cells (secretion stasis)  Cell destruction with vasodilatation (cavernous sinuses!)  Release inflammatory mediators from inflammatory cells  Seromucous hypersecretion and exudation  Thickening lamina propria

13 Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Symptoms Viral Rhinitis 1. Quickly passing sore throat: viral pharyngitis, swollen throat 2. Nasal symptoms: congestion, sneezing, rhinorrhea  gone after 7 d, mucus production peaks on d 3 and 4 3. Coughing: longest lasting symptom,  weeks in smokersand patients with reflux! 3. 1/10: short headache 4. Rarely tremors, general malaise 5. Note: more serious problems with anatomical anomalies (deviated septum) or children: otitis, rhinopharyngitis, sinusitis, tracheitis, bronchitis

14 Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Symptoms Viral Rhinitis

15 Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Cough after Viral Rhinitis (smoking)

16 Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Complications after Viral Rhinitis

17 Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Therapeutical Options Common Cold Nothing Local vasoconstrictors: preferably only at night, not > 7d Physiological flushing: mainly with children or with anatomical anomalies Note: other types of rhinitis where physiological flushing -possibly supplemented with ointment application- may be useful: occupational rhinitis, rhinitis due to irritants, atrophic rhinitis Antibiotics: useless, unless complication due to surinfection

18 Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Common cold induces changes in sinus mucosa Virus ICAM-1 T helper 1 polarisation* CD4+ CTL * NK activity * Ig IL-1 , -6,TNF-  IL-8, MCP-1 IFN-  CD8+ CTLs NKcells neutrophil monocyte recruitment and activation Elimination of rhinovirus T helper 1 polarisation* CD4+ T helper cells * NK activity * Immunoglobulins IL-1 , -6,TNF-  INFgamma, IL-8 CD8+ T cytotxic cells Natural Killer cells Neutrophils monocyte recruitment and activation Elimination of rhinovirus

19 Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Acute Rhinosinusitis

20 Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Infections induces changes in sinus mucosa Ventilation and Drainage Inflammation and Remodeling B MT MS I TI T The ostiomeatal complex B Bulla ethmoidalis I T inferior turbinate MT middle turbinate MS maxillary sinus

21 Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Microbiology Normal sinuses: Free of growth Acute rhinosinusitis: 2/3 Viral 1/3 Bacterial (St Pneumoniae,H Influenzae, M Catharralis) Chronic rhinosinusitis: >>Anaerobes: Propionibacterium, Bacteriodes, Peptococcus Aerobes:Staphylococcus, Corynebacterium, Pseudomonas Fungi (» aspergillus fumigatus) Dentogene sinusitis: ?

22 Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Common cold/ Acute viral rhinosinusitis Occurence in adults: up to 4 times a year URTI: symptoms < 10 days Symptomatic treatment only: Decongestants Pain relief Saline drops Can lead to post-viral inflammation of nose and sinuses Guidelines for Acute Rhinosinusitis

23 Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Acute post-viral Rhinosinusitis (ARS) ↑ symptoms after 5 days or persistent symptoms after 10 days less than 12 weeks Symptoms: Nasal obstruction/congestion and/or Facial pain/pressure Accompanied by: Nasal discharge and/or Reduction or loss of smell Definition: Guidelines for Acute Rhinosinusitis

24 Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Acute post-viral Rhinosinusitis (ARS) once or more than once in defined time period (episodes per year) complete resolution between symptoms Appearance: Mild Severe Occurence: Fever > 38,3°C Localized pain over the sinuses May lead to complications !! Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis Guidelines for Acute Rhinosinusitis

25 Strength of evidence for treatment of Acute Rhinosinusitis TherapyLevelRecommendationRelevance antibioticIa (49 studies)Ayes: after 5 –10 days, or in severe cases topical steroid1b (1 study)Ayes addition of topical steroid to antibiotic Ib (5 studies)Ayes oral steroidno evidence (1 study) Dno addition of oral antihistamine in allergic patients Ib (1 study)Bno nasal doucheno evidence (3 studies) Dno decongestionno evidence (3 studies) Dyes as symtomatic relief mucolyticsno evidence (3 studies) Dno

26 Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Neus-, keel- en oorheelkunde Hoofd- en halschirurgie

27 Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Dolor et al. JAMA Oct 2002 DBPC trial in 95 patients with acute sinusitis (with history of CRS) All received 2x/d xylometazoline spray (3days) and 2 x 250mg/d cefuroxime (10 days) 47 patients 200µg (two puffs) Fluticasone or 48 patients placebo spray

28 Neus-, keel- en oorheelkunde Hoofd- en halschirurgie J Allergy Clin Immunol Dec;116(6):

29 Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Neus-, keel- en oorheelkunde Hoofd- en halschirurgie *P<0.001 vs placebo. Gross et al. J Allergy Clin Immunol. 2007; 119 (Suppl S):S64. Percent change in patient-reported congestion symptom score from baseline Days * * * * * * * * * * * * * * Percent Change in Congestion Symptom Score (Patient-Reported) Nasal GCS and nasal congestion

30 Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Management of Acute Rhinosinusitis

31 Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Management of Acute Rhinosinusitis for ENT-specialist

32 Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Acute Rhinosinusitis in de praktijk 90 %patiënten: 1. bij neusverstopping: volwassene: xylo- of oxymethazoline (max 7 d), pseudo-efedrine(+desloratadine) nasaal corticoid 2x/dag 2. bij pijn: paracetamol: 500 mg 4 à 6 x per dag 3. warme damp en/of neusspoeling met fysiologisch water <10% patiënten: AMOXICILLINE 3 x 1 gr/dag gedurende 7-14 d Indien geen verbetering binnen de 3 dagen: Amoxi vervangen door 3X875 Amoxicilline-Clav alternatief bij allergie: chinolones (ciproxine, avelox, proflox, tavanic, tarivid à 0,5-1g/d)


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