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Acute Rhinosinusitis – bacterial infection or inflammation. Prof. Dr

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

2 New definition and classification
Update on literature and treatments New and practical treatment schemes acute rhinosinusitis adults children chronic rhinosinusitis adults nasal polyposis Research needs and priorities

3 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 Slide 12: Definition of rhinosinusitis for general practice For general practice, the definition is based on symptomatology without any need for ENT examination or radiology. It is important to realize that the presence of sinonasal symptoms determines whether a patient requires therapy or not. In general, there is no place for a X ray of the skull in the diagnostic work-up of sinus disease.

4 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 Slide 10: Clinical definition of rhinosinusitis/nasal polyps Spreekt voor zich

5 Definitions and classification
CLASSIFICATION OF RHINOSINUSITIS * SEVERITY Visual Analogue Scale (VAS) mild moderate 3-7 severe * DURATION ACUTE / intermittent < 12 weeks complete resolution of symptoms CHRONIC / persistent > 12 weeks incomplete resolution of symptoms Slide 11: Classification of rhinosinusitis SEVERITY The disease can be divided into MILD and MODERATE/SEVERE based on total severity visual analogue scale (VAS) score (10 cm). To evaluate the total severity the patient is asked to indicate on a VAS the question: « How troublesome are your symptoms of rhinosinusitis ?» DURATION Spreekt voor zich

6 Headache/facial pressure in sinusitis

7 Nasal Endoscopy

8 Imaging of sinsuses RX sinuses: - Waters, Caldwell an Hirtz
- poor sensitivity and specificity - NOT RECOMMENDED!

9 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 Anatomy and physiology
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 Slide 9:Definitions A common cold is a virally induced disease with acute onset and nasal symptoms resolving within 10 days or with atenuation of symptoms after 5 days of symptoms. In case of a bacterial superinfection, nasal symptoms get worse in the following days and symptoms last for more then 10 days. An acute rhinosinusitis is defined as nasal obstruction in combination with discharge or headache. A multifactorial etiology is believed to be responsible for the development of chronic rhinosinusitis, in which not only microbial but also many other local and systemic factors are involved. EAACI Position Paper on Rhinosinusitis and Nasal Polyps, Allergy 2005: 60:

11 Viruses in acute rhinitis and rhinosinusitis
adenovirus parainfl. RSV influenza coronavirus rhinovirus coxsackie echovirus enterovirus Young adults Adolescents 5-10 years < 4 years Kirkpatrick, 1996 Adults Most common rhinovirus influenza echovirus coxsakie coronavirus RSV parainfl. Least common adenovirus

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

14 Symptoms Viral Rhinitis

15 Cough after Viral Rhinitis (smoking)

16 Complications after Viral Rhinitis

17 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 Common cold induces changes in sinus mucosa
Virus ICAM-1 CD8+ T cytotxic cells CD8+ CTLs IL IL - - 1 1 b b , , IL IL - - 6 6 , , TNF TNF - - a a Natural Killer cells NKcells I INFgamma, IL-8 L - 8 , MCP - 1 Neutrophils neutrophil IFN - g monocyte monocyte recruitment and activation recruitment and activation T helper 1 polarisation T helper 1 polarisation * CD4+ CTL * CD4+ T helper cells * NK activity * NK activity Elimination of rhinovirus Elimination of rhinovirus * Ig * Immunoglobulins

19 Acute Rhinosinusitis

20 Infections induces changes in sinus mucosa
B MT MS I T Ventilation and Drainage Inflammation and Remodeling The ostiomeatal complex B Bulla ethmoidalis I T inferior turbinate MT middle turbinate MS maxillary sinus

21 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 Guidelines for Acute Rhinosinusitis
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

23 Guidelines for Acute Rhinosinusitis
Acute post-viral Rhinosinusitis (ARS) Definition: ↑ 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

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

25 Strength of evidence for treatment of Acute Rhinosinusitis
Therapy Level Recommendation Relevance antibiotic Ia (49 studies) A yes: after 5 –10 days, or in severe cases topical steroid 1b (1 study) yes addition of topical steroid to antibiotic Ib (5 studies) oral steroid no evidence (1 study) D no addition of oral antihistamine in allergic patients Ib (1 study) B nasal douche no evidence (3 studies) decongestion no evidence (3 studies) as symtomatic relief mucolytics

26

27 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 Dolor et al. JAMA Oct 2002

28 J Allergy Clin Immunol. 2005 Dec;116(6):1289-95.

29 Nasal GCS and nasal congestion
Percent Change in Congestion Symptom Score (Patient-Reported) Days * Percent change in patient-reported congestion symptom score from baseline * * * * * * * In the pooled analysis of 4 independent phase III trials in SAR, patients receiving MFNS 200 µg OD experienced significantly greater percent reductions from baseline in congestion score (patient-reported) than patients receiving placebo after the first dose (on day 1; P<0.001) and at all subsequent daily time points during the study (P<0.001, days 2-15). This data demonstrate rapid, powerful, and durable relief of congestion with MFNS 200 µg OD in patients with SAR. Data on file, Schering Corporation, Kenilworth, NJ. Protocol No. C93-103, C93-184, C94-145, I * * * * * * *P<0.001 vs placebo. Gross et al. J Allergy Clin Immunol. 2007; 119 (Suppl S):S64.

30 Management of Acute Rhinosinusitis

31 Management of Acute Rhinosinusitis for ENT-specialist

32 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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