Presentation on theme: "Acute Rhinosinusitis – bacterial infection or inflammation. Prof. Dr"— Presentation transcript:
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 treatmentsNew and practical treatment schemesacute rhinosinusitis adultschildrenchronic rhinosinusitis adultsnasal polyposisResearch needs and priorities
3 Definitions and classification for General Practice Based on symptoms:Two or more symptoms, one of which should be eithernasal blockage/obstruction/congestion ornasal discharge: anterior/post nasal drip;± facial pain/pressure,± reduction or loss of smellExamination: anterior rhinoscopyX-ray/CT not recommended* DURATIONACUTE / intermittent < 12 weekscomplete resolution of symptomsCHRONIC / persistent > 12 weeksincomplete resolution of symptomsSpecial attention to questions on allergic symptomsSlide 12: Definition of rhinosinusitis for general practiceFor 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 eithernasal blockage/obstruction/congestion ornasal discharge: anterior/post nasal drip;± facial pain/pressure,± reduction or loss of smellAND EITHERendoscopic findings of polypsmucopurulent dischargeedema or obstructionORCT scan abnormality: mucosal changeswithin ostiomeatal complex or sinus cavitySlide 10: Clinical definition of rhinosinusitis/nasal polypsSpreekt voor zich
5 Definitions and classification CLASSIFICATION OF RHINOSINUSITIS* SEVERITY Visual Analogue Scale (VAS)mildmoderate 3-7severe* DURATIONACUTE / intermittent < 12 weekscomplete resolution of symptomsCHRONIC / persistent > 12 weeksincomplete resolution of symptomsSlide 11: Classification of rhinosinusitisSEVERITYThe 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 ?»DURATIONSpreekt voor zich
8 Imaging of sinsuses RX sinuses: - Waters, Caldwell an Hirtz - poor sensitivity and specificity- NOT RECOMMENDED!
9 Imaging of sinsusesMRI: only recommended in tumor diagnosisCT 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 COLDBACTERIAL SUPERINFECTION Strep pneu / Haemo infl / Morax catarincreasing symptoms after 5 DAYSno resolution after 10 DAYSACUTE rhinosinusitisMULTIFACTORIAL ETIOLOGYCHRONIC rhinosinusitisSlide 9:DefinitionsA 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 adenovirusparainfl.RSVinfluenzacoronavirusrhinoviruscoxsackieechovirusenterovirusYoung adultsAdolescents5-10 years< 4 yearsKirkpatrick, 1996AdultsMost commonrhinovirusinfluenzaechoviruscoxsakiecoronavirusRSVparainfl.Leastcommonadenovirus
12 Pathophysiology Viral Rhinitis Impact of viral infection on the mucosaEpithelial changesHypersecretion and oedema Goblet cells (hypersecretion), ciliated cells (secretion stasis)Cell destruction with vasodilatation (cavernous sinuses!)Release inflammatory mediators from inflammatory cellsSeromucous hypersecretion and exudation Thickening lamina propria
13 Symptoms Viral Rhinitis Quickly passing sore throat: viral pharyngitis, swollen throatNasal symptoms: congestion, sneezing, rhinorrhea gone after 7 d, mucus production peaks on d 3 and 4Coughing: longest lasting symptom, weeks in smokersand patients with reflux!1/10: short headacheRarely tremors, general malaiseNote: more serious problems with anatomical anomalies (deviated septum) or children: otitis, rhinopharyngitis, sinusitis, tracheitis, bronchitis
17 Therapeutical Options Common Cold NothingLocal vasoconstrictors: preferably only at night,not > 7dPhysiological flushing: mainly with children or with anatomical anomaliesNote: other types of rhinitis where physiological flushing-possibly supplemented with ointment application- may be useful:occupational rhinitis, rhinitis due to irritants, atrophic rhinitisAntibiotics: useless, unless complication due to surinfection
18 Common cold induces changes in sinus mucosa VirusICAM-1CD8+ T cytotxic cellsCD8+ CTLsILIL--11bb,,ILIL--66,,TNFTNF--aaNatural Killer cellsNKcellsIINFgamma, IL-8L-8, MCP-1NeutrophilsneutrophilIFN-gmonocytemonocyterecruitment and activationrecruitment and activationT helper 1 polarisationT helper 1 polarisation* CD4+ CTL* CD4+ T helper cells* NK activity* NK activityElimination of rhinovirusElimination of rhinovirus* Ig* Immunoglobulins
20 Infections induces changes in sinus mucosa BMTMSI TVentilationandDrainageInflammationandRemodelingThe ostiomeatal complexB Bulla ethmoidalisI T inferior turbinateMT middle turbinateMS maxillary sinus
21 Microbiology Normal sinuses: Free of growth Acute rhinosinusitis: 2/3 Viral1/3 Bacterial (St Pneumoniae,H Influenzae, M Catharralis)Chronic rhinosinusitis:>>Anaerobes: Propionibacterium, Bacteriodes, PeptococcusAerobes:Staphylococcus, Corynebacterium, PseudomonasFungi (» aspergillus fumigatus)Dentogene sinusitis: ?
22 Guidelines for Acute Rhinosinusitis Common cold/ Acute viral rhinosinusitisOccurence in adults: up to 4 times a yearURTI: symptoms < 10 daysSymptomatic treatment only:DecongestantsPain reliefSaline dropsCan lead to post-viral inflammation of nose and sinuses
23 Guidelines for Acute Rhinosinusitis Acute post-viral Rhinosinusitis (ARS)Definition:↑ symptoms after 5 days orpersistent symptoms after 10 daysless than 12 weeksSymptoms:Nasal obstruction/congestion and/orFacial pain/pressureAccompanied by:Nasal discharge and/orReduction 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 symptomsAppearance:MildSevereFever > 38,3°CLocalized pain over the sinusesStreptococcus pneumoniae,Haemophilus influenzaeand Moraxella catarrhalisMay lead to complications !!
25 Strength of evidence for treatment of Acute Rhinosinusitis TherapyLevelRecommendationRelevanceantibioticIa (49 studies)Ayes: after 5 –10 days, or in severe casestopical steroid1b (1 study)yesaddition of topical steroidto antibioticIb (5 studies)oral steroidno evidence (1 study)Dnoaddition of oral antihistaminein allergic patientsIb (1 study)Bnasal doucheno evidence (3 studies)decongestionno evidence (3 studies)as symtomatic reliefmucolytics
27 DBPC trial in 95 patients with acute sinusitis (with history of CRS) All received 2x/d xylometazoline spray (3days) and2 x 250mg/d cefuroxime (10 days)47 patients 200µg (two puffs) Fluticasone or 48 patients placebo sprayDolor et al. JAMA Oct 2002
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.
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/dag2. bij pijn: paracetamol: 500 mg 4 à 6 x per dag3. warme damp en/of neusspoeling met fysiologisch water<10% patiënten:AMOXICILLINE 3 x 1 gr/dag gedurende 7-14 dIndien geen verbetering binnen de 3 dagen:Amoxi vervangen door 3X875 Amoxicilline-Clavalternatief bij allergie: chinolones (ciproxine, avelox, proflox, tavanic, tarivid à 0,5-1g/d)
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