Presentation on theme: "Acute and Chronic Sinusitis"— Presentation transcript:
1 Acute and Chronic Sinusitis A Practical Guide for Diagnosis and TreatmentBibliographyClinical Guidelines:Management of Sinusitis, Pediatrics, Volume 108 Number 3, September 2001Kaliner, M A. Current Reviews of Rhinitis,, editor, Current Medicine 2002McCraig LF, Hughes JM: Trends in antimicrobial drug prescribing among office based physicians in the US. JAMA 1995, 273:McAlister WH, et al. Imaging of sinusitis in children. Pediatr Infect Dis J. 1999;18:Dykewicz,MS, The difficult asthmatic. Imm and All Clinics of North America, Vol21,Num3.August 2001
2 Presentation Facts File size: approximately 2013 KB Number of slides: 81Evidence-Based CME: Web site addresses for all EB recommendations are available near the end of this presentationThese slides were prepared by the AAFP and content should not be modified in any way. If content is changed, it is the user’s responsibility to remove both the AAFP and the CME logos. Instructions to remove logos: from menu, select VIEW, MASTER, SLIDE MASTER; select the logos and delete; to return to the original slide view, select VIEW, SLIDE
3 AcknowledgmentsThis is a presentation of the American Academy of Family Physicians supported by an educational grant from Aventis PharmaceuticalsThe AAFP gratefully acknowledges Harold H. Hedges, III, M.D.and Susan M. Pollart, M.D. for developing the content for the AAFPand Harold H. Hedges, III, M.D. for providing the photo images included in this slide presentation.
4 Acknowledgments and Harold H. Hedges, III, M.D. Private Practice Little Rock Family Practice ClinicLittle Rock, ArkansasandSusan P. Pollart, M.D. Associate Professor of Family Medicine University of Virginia Health System Charlottesville, Virginia
5 Upon Completion of This Presentation You Should be Able To Be knowledgeable of the causes of and risk factors associated with sinusitisDifferentiate acute from chronic sinusitisEvaluate patients by history, physical exam, appropriate laboratory and imaging studies, and when indicated screen patients for allergyPrescribe appropriate medication regimens for acute and chronic sinusitisKnow of the relationships between upper airway (rhinosinusitis) and lower airway disease (asthma)
6 Rhinosinusitis May be Better Term Because Allergic or nonallergic rhinitis nearly always precedes sinusitisSinusitis without rhinitis is rareNasal discharge and congestion are prominent symptoms of sinusitisNasal mucosa and sinus mucosa are similar and are contiguous
7 Scope of Sinusitis Affects 30-35 million persons/year 25 million office visits/yearDirect annual cost $2.4 billion and increasingAdded surgical costs: $1 billionThird most common diagnosis for which antibiotics are prescribedThird most common diagnosis for which antibiotics are prescribed. Rhinosinusitis, like asthma is becoming more prevalent.McCraig LF, Hughes JM: Trends in antimicrobial drug prescribing among office based physicians in the US. JAMA 1995, 273:
8 Normal Sinus Sinus health depends on: Mucous secretion of normal viscosity, volume, and composition,normal mucociliary flow to prevent mucous stasis and subsequent infection;and open sinus ostia to allow adequate drainage and aeration.Senior BA, Kennedy DW. Management of sinusitis in the asthmatic patient AAAI J,1996;77:6-19.
9 Development of Sinuses Maxillary and ethmoid sinuses present at birthFrontal sinus developed by age 5 or 6Sphenoid sinus last to develop, 8-10The ostia of the maxillary sinuses is situated up 2/3 of the wall of the sinus. Drainage occurs by the washing of mucus containing virus, bacteria and other material by ciliary action. Any thing that interferes with ciliary action (tobacco smoke, antihistamines) may predispose the sinus to infection. Healthy sinuses depend on ciliary action and aeration. Kaplan, second edition. Allergy. Chapter 26:
10 Physiologic Importance of Sinuses Provide mucus to upper airwaysLubricationVehicle for trapping viruses, bacteria, foreign material for removalGive characteristics to voiceLessen skull weightInvolved with olfactionPhysiologic reasons for sinuses not totally understood. The above are suggestions as to their role.Kaplan, second edition. Allergy. Chapter 26:
11 SinusitisInfectious or noninfectious inflammation of 1 or more sinuses4 paranasal sinuses, each lined with pseudostratified ciliated columnar epithelium and goblet cellsFrontalMaxillaryEthmoidSphenoid
12 Normal Water’s and Towne’ s Views of the Sinuses
14 Ostiomeatal ComplexOstiomeatal complex is that area under the middle meatus (airspace) into which the anterior ethmoid, frontal and maxillary sinuses drainPosterior ethmoids drain into the upper meatusOstiomeatal complex is the functional relationship between the space and the ostia that drain into it
15 Viral Rhinosinusitis Most upper respiratory infections are viral Short lived, last less than 10 daysSinus mucosa as well as nasal mucosa is involvedMost will clear without antibioticsTreatment: decongestants, nasal lavage, rest, fluids
16 Classification of Bacterial Sinusitis Acute bacterial sinusitis- infection lasting 4 weeks, symptoms resolve completely (children 30 days)Subacute bacterial sinusitis- infection lasting between 4 to 12 weeks, yet resolves completely (children days)Chronic sinusitis- symptoms lasting more than 12 weeks (children >90 days)Some guidelines add treatment failure + a positive imaging study
17 Recurrent Acute Bacterial Sinusitis Episodes lasting fewer than 4 weeks and separated by intervals of at least 10 days during which the patient is totally asymptomatic3 episodes in 6 months or 4/year
18 Acute Sinusitis Imposed on Chronic Sinusitis Patients with chronic, low grade symptoms experience increase in mucous flow, change in viscosity or color, or secretionsTreatedNew symptoms resolve but chronic symptoms continue
19 Differentiating Sinusitis from Rhinitis Nasal congestionPurulent rhinorrheaPostnasal dripHeadacheFacial painAnosmiaCough, feverRhinitisNasal congestionRhinorrhea clearRunny noseItching, red eyesNasal creaseSeasonal symptoms
20 Road to Bacterial Sinus Infections Obstruction of the various ostiaImpairment in ciliary functionIncreased viscosity of secretionsImpaired immunityMucus accumulatesDecrease in oxygenation in the sinusesBacterial overgrowth
21 X-Ray Image of Sinuses with Maxillary Sinusitis
25 Causes of Ciliary Dysfunction Immotile cilia syndromeProlonged exposure to cigarette smokeCommon cold viruses causing URIIncreased viscosity of mucusMedicationsFirst generation antihistamines (non sedating do not affect)AnticholinergicsAspirinAnesthetic agentsBenzodiazepinesHydration is important in treating sinusitis. Hydration will aid in decreasing the viscosity of secretions. Cilia are damaged by “cold” viruses, the effect may last several weeks.Pedersen M, et al. Nasal mucociliary transport, number of ciliated cells, and beating patters in naturally occurring colds.Euro J Resp Dis. Supplement 128:355,1983Euro J Resp Dis. Supplement 128:355,1983
26 Diseases Slowing Ciliary Function Allergic and nonallergic rhinitisRhinosinusitisAging rhinitisCystic fibrosisAny disease causing obstruction, crusting of the mucosa
27 Causes of Mechanical Obstruction Deviated nasal septumConcha bullosaForeign bodyNasal polypsCongenital atresiaLymphoid hyperplasiaNasal structural changes found in Downs syndrome
29 Other Predisposing Conditions Physical traumaScuba divingForeign bodyCleft palateDental disordersAny patient with chronic fatigue, fever, general malaise/aching or headaches should be evaluated for sinusitis
30 Acute Bacterial Sinusitis Usually begins with viral upper respiratory illnessSymptoms initially improve, but then …Symptoms become persistent or severePersistent… days but fewer than 4 weeksSevere…temperature of 102°, purulent nasal discharge for 3-4 days, child appears illDisease clears with appropriate medical treatment
31 Physical Findings Mucopurulent nasal discharge Highest positive predictive valueSwelling of nasal mucosaMild erythemaFacial pain (unusual in children)Periorbital swelling
32 Objectives of Treatment of Acute Bacterial Sinusitis Decrease time of recoveryPrevent chronic diseaseDecrease exacerbations of asthma or other secondary diseasesDo so in a cost-effective way!
33 Treatment of Acute Sinusitis Antihistamines recommended if allergy presentOral or topicalDecongestantsAntibiotic when indicated (bacteria)Nasal irrigationGuaifenesin mg q4-6 hrsHydration
34 Decongestants Topical nasal sprays (limit use to 3-7 days) PhenylephrineOxymetazolineNaphthazolineTetrahydrozolineZylometazolineTopical nasal spray (unlimited daily use)IpatropiumOralPseudoephedrine mgPhenylephrine 2-4 times/day
35 Treatment of Acute, Uncomplicated Sinusitis Antibiotic may not be indicatedMany are viralBenefit of antibiotics are only moderateWeigh factors of cost, side effects, antibiotic resistance, and antibiotic reactions
36 Antibiotics for Acute Bacterial Sinusitis Amoxicillin 500 mg tid for daysFirst line choice in most areasLocal differences in antibiotic resistance occurWhere beta-lactanase resistance is an issueAmoxicillin/clavulanateCefuroximeCefpodoximeCefprozil
37 Additional Antibiotics for Acute Bacterial Sinusitis Amoxicillin should be considered because of its efficacy, low cost, side-effect profile, and narrow spectrum ( mg/kg/d in children; 500 mg tid or qid in adults for 10 to 14 days)If penicillin-allergic clarithromycin or azithromycinErythromycin does not provide adequate coverageTrimethoprim/suflamethoxazole and erythro/sulfisoxazole have significant pneumococcal resistanceGive prescription for antibiotic for 5 days, if no response switch to another, if responding refill for full 10 day course. Where co-pays are involved give entire 10 day prescription initially.
38 Nasal Irrigation Commercial buffered sprays Bulb syringe 1/4 tsp of salt to 7 ounces waterWaterpik with lavage tip1 tsp salt to reservoirDisposable enema bucket2 tsp salt, 1 tsp soda per quart of water
39 Nasal Irrigation Washes away irritants Moistens the dry nose Waterpik with nasal irrigatorCeramic irrigatorsEnema bucket with normal saline and soda“Hose-in-the-nose”-- $2.50
40 Nasal Irrigation With enema bucket/hose…. Add 2 teaspoons of salt and 1 tsp of baking soda to a quart of warm waterOver tub, sink, or in shower lean over, head tilted slightly downward and to side place hose in upper nostril (fluid may return from either nostril or through mouth) run in 1/2 solution. Turn head to opposite side and repeat process.Use once, twice daily or as often as needed
41 When Medical Therapy for Acute Bacterial Sinusitis Fails… Assess for chronic causesIdentify allergic and nonallergic triggersAllergy testing, nasal smears for eosinophiliaConsider other medical conditions associated with sinusitisRhinolaryngoscopyImaging studiesSinus x-raysCT scanning (limited, coronal views)
42 Sinus Transillumination Helpful in older children and adultsNormal transillumination decreases chance of pus in the sinusNo light reflex suggests mucopurulent material or thickening of nasal mucosaInexpensive screening tool
43 Sinus Transillumination Have patient sit at your eye level in darkened room (the darker the better)Let eyes get accustomed to darkPlace bright light (transilluminator) over inferior orbital ridge to look at maxillary sinuses, under superior orbital rim for frontal sinusesLook at palate for presence/absence of transilluminated light
50 MRI Imaging Not used for imaging suspected acute sinusitis Suspected fungal sinusitisSuspected tumors
51 Bacteria Involved in Acute Bacterial Sinusitis Streptococcus pneumoniae 30%Haemophilus influenza 20%Moraxella catarrhalis 20%Sterile 30%Staph aureus, other streptococcal bacteria, pseudomonas, and E.coli are uncommon bacteria found in ABS.
52 Comparison of Various Approaches to the Treatment of AR Sneezing Discharge Itch Congestion Side EffectsAntihistamines traditional (A)Non-sedating (NSA) – to +Azelastine – to +Decongestants – + –NSA + decongestantsLeukotriene antag.* + to ++ + to ++ + to – to +Cromolyn –Nasal CCS (NCS)NSA + NCSImmunotherapy to ++* Presumed; no data on individual symptoms. Nayak AS, et al. Ann Allergy Asthma Immunol ;88:++++ = Strongly positive effect; += Minimal effect
53 Rational for Starting Rx with Amoxicillin In the absence of risk factors, i.e. attendance in daycare center, recent antibiotics, age younger than 2…80% of patients will respond to amoxicillinGive Rx for 5 days with a refill -- if responding treat for 10 to 14 days, if not, switch to anotherChoosing an antibiotic should be based on the prevalence of bacterial species, prevalence of resistance, and the rate of spontaneous improvement. 15% of children with strep pneumoniae, 50% with h. influenza and 50-75% M.catarrhalis recover spontaneously.
54 Reasons to Use Alternative Antibiotics No response to amoxicillin within 3-5 daysRecent treatment with amoxicillin for other causesSymptoms present for more than 30 daysRecurrent sinus infections
55 Secondary Antibiotics for Acute Sinusitis Cefdinir (Omnicef)Cefuroxime (Ceftin)Cephpodoxime (Vantin)AzithromycinClarithromycinTrimethoprim-sulfamethoxazole and erythromycin-sulfisoxazole should not be used first or second line therapy because of pneumococcal resistance.
56 Optimal Duration of Antibiotics Give antibiotic until patient free of symptoms then add 7 daysOptimal duration has not been studied thoroughly and empiric recommendations have been made of days. Using symptom free plus 7 days individualizes time for each patient and gives a minimum of 10 days therapy.
57 Chronic SinusitisSymptoms present longer than 8 weeks or 4/year in adults or 12 weeks or 6 episodes/year in childrenEosinophilic inflammation or chronic infectionAssociated with positive CT scansPoor (if any) response to antibiotics
58 Quality-of-Life Issues FatigueConcentrationNuisanceSleep disturbanceEmotional well beingSocial interactionsMissing school/workHalitosisDecreased productionImpaired studyingSniffing/snortingBlowing nose
59 Sx of Chronic Sinusitis Nasal dischargeNasal congestionHeadacheFacial pain or pressureOlfactory disturbanceFever and halitosisCough (worse when lying down)
61 Evaluation of Chronic Sinusitis CT or MRI scanningAnatomic defects, tumors, fungiAllergy testingInhalants, fungi, foodsSinus aspiration for culturesBacterialFungalImmunoglobulinsCorrection of anatomic defects, drainage of infected sinuses, immunotherapy for IgE mediated allergies, treatment of immunoglobulinemias can alter the course of chronic sinusitis. Unfortunately there are a significant number who have no demonstrable cause for this chronic disease and do not respond to medication .
62 Treatment of Chronic Sinusitis Nasal steroid sprayGuafenesinDecongestantsSteam inhalationNasal irrigationAntibiotics with exacerbations
63 Bacteria Involved in Chronic Sinusitis Role of Viruses is Unknown Streptococcus pneumoniaeHaemophilus influenzaMoraxella catarrhalisStaph aureusCoagulase negative staphylococcusAnerobic bacteriaStaph aureus, other streptococcal bacteria, pseudomonas, and E.coli are uncommon bacteria found in ABS.
64 Transition of Bacteria Rom Acute to Chronic Sinusitis In one study, while initial aspirates showed strep pneumoniae, H. influenzae, and M catarrhalis, subsequent cultures showed Porphyromonas, Peptostreptococcus, and aerobic organisms found to be increasingly resistant to antibioticsBrook I, et al. Bacteriology and beta-lactamase activity in acute and chronic maxillary sinusitis. Arch Otolaryngol Head Neck Surg 1996;122;
65 Sinus Aspiration and Culture Correlation of routine nasal culture and sinus culture are poorEndoscopically guided aspiration of cultures from medial meatus do correlate with sinus cultureGold SM, Tami TA. Role of middle meatus aspiration culture in the diagnosis of chronic sinusitis. Laryngoscope 1997;107: 1586.
66 Recommendations Made for Antibiotic Prophylaxis in ABS Has not been evaluated as has its use in otitis mediaIncreasing evidence of antibiotic resistance is an issueMay be tried in chronic or recurrent diseaseIf prophylactic antibiotics are contemplated or used need to evaluate for allergy, immunodeficiency, cystic fibrosis, ciliary dyskinesia, anatomic abnormalities.
67 Complications of Sinusitis OrbitalDiplopia, proptosisPeriorbital erythema, swellingBonePeriosteal abscessesBrainIntracranial abscesses causing neurologic symptomsCellulitis can spread around the eye and cheek indicated by swelling and erythema. Symptoms of meningitis, severe headache, focal neurologic symptoms signal spread to intracranial areas.
68 The Sinusitis-Asthma Connection Mechanism is not understoodEvidence is compellingFailure to control upper airway inflammation leads to suboptimal asthma controlCorrecting the rhinosinusitis results in better asthma controlDykewicz,MS, The difficult asthmatic. Imm and All Clinics of North America, Vol21,Num3.August 2001Several studies have demonstrated that both medical and surgical treatment of sinusitis have led to improvement in asthma. Studies have also shown that treatment with cetrizine, loratadine, and oral decongestants improved asthma with concomitant allergic rhinosinusitis..
69 Indications for Referral Allergy testing, possible immunotherapySinus aspiration for bacterial cultureSurgical interventionCorrect obstructive processDrain sinus abscessesConsideration to remove nasal polypsFamily physicians can readily learn to screen patients for allergy and complete testing for geographic relevant allergens when appropriate. The use of multiple allergen applicators is safe, very cost effective and easy to learn. It allows early diagnosis of the patient whose recurrent or chronic problems are allergic, helps to direct avoidance procedures, as well as aids in the selection of appropriate medication for rhinosinusitis.
70 Indications for Hospitalization Acutely ill child or adult with high fever, severe head painSuspected sphenoid sinusitisAnytime complications of eye, bone or intracranial structures are present
71 The RecommendationsThe recommendations cited are those proposed by a task force of the American Academy of Pediatrics in consultation with other groups regarding the evaluation, diagnosis, and treatment of patients aged 1-21 years with sinus disease…expert opinion was used when insufficient data could be found.
72 Recommendation 1The diagnosis of acute bacterial sinusitis is based on clinical criteria with patients presenting with URI symptoms that are either persistent or severe.
73 Recommendation 2aImaging studies are not necessary to confirm a diagnosis of clinical sinusitis in children younger than 6 years (older than age 6 years is controversial)Children with persistent symptoms (>10 days, < 30 days) predicted abnormal radiographs 80% of the timeChildren < 6 symptoms predicted 88% of the timeNormal x-ray suggests ABS is not present
74 Recommendation 2bCT scans of the paranasal sinuses should be reserved for:Patients in whom surgery is being considered as a management strategyPatients who do not respond to medical regimes which include adequate antibiotic useAssisting in diagnosis of anatomical changes interfering with airflow or drainageMcAlister WH, et al. Imaging of sinusitis in children. Pediatr Infect Dis J. 1999;18:
75 Recommendations for CT Scans Patients presenting with complications of sinusitisNeurologic symptoms, diplopia, periorbital or facial swelling with or without erythemaPatients with sinus symptoms accompanied by severe, boring, mid-head painRule out sphenoid sinusitisThe sphenoid sinus sits just anterior to the sella turcica. Sphenoid sinusitis usually does not occur alone but with a pan sinusitis and can be life threatening. Early diagnosis is important to decrease the chance of neurologic complications caused by extension of infection into the brain. Emergency surgery may be necessary
76 Recommendation 3Antibiotics are recommended for the management of acute bacterial sinusitis to achieve a more rapid clinical curePatients must meet requirements of persistent or severe diseaseResponse improved with doses >Minimal Inhibition ConcentrationGwaltney JM Jr. Acute community acquired sinusitis. Clin Infect Dis. 1996;
77 No EB Recommendations Found for Use of Adjunctive Therapy in ABS, May be Helpful Nasal saline irrigationOral decongestantsOral or nasal antihistaminesTopical decongestantsMucolytic agentsTopical steroidsVery little data exists to recommend any of the above on scientific basis but can be helpful. Oral/nasal decongestants aid in airflow and patient comfort. Oral Antihistamines would aid the patient with allergic rhinitis predisposing to ABS. Astelazine, an antihistamine nasal spray has a non allergic indication and can be helpful. Saline irrigation removes allergic and non allergic triggers for rhinitis and gives symptomatic relief. It also decreased crust formation and helps liquefy secretions No data on mucolytic agents in ABS..
78 SummaryAcute and chronic sinusitis is one of the most common diseases treated in family practiceIt is important to treat sinusitis aggressively to prevent chronic symptoms or development of serious complicationsThe underlying causes of chronic sinus disease should be sought out and corrected
79 Additional Bibliography Dykewicz M. Rhinitis and Sinusitis. J All Clin Immunol, 2003; 111:S520-9.Hamilos DL. J Allergy Clin Immunol 2000;106:Kaliner MA. Current Review of Rhinitis. Current Medicine, Inc., 2002.Kaliner MA. Current Review of Allergic Diseases. Current Medicine, Inc., 2000.Agency for Healthcare Research and QualityAmerican Academy of PediatricsNew England Medical Center Evidence-based Practice Center
80 Evidence-Based Recommendations Practice Recommendation: Reduce unnecessary use of antibiotics. Providers should be consistent with the recommended criteria for prescribing antibiotics in acute sinusitis endorsed by the CDC, American Academy of Family Physicians, the American College of Physicians-American Society of Internal Medicine, and the Infectious Diseases Society of America.Practice Recommendation: Use first line antibiotics, which are amoxicillin or trimethoprim-sulphamethoxazole (TMP/SMX).Practice Recommendation: Use an antibiotic that covers resistant bacteria (amoxicillin-clavulanate [Augmentin] or another second line agent) to treat patients if failed on days of amoxicillin.All recommendations available at: Accesses August 2003.
81 Thank YouThis has been a presentation of the American Academy of Family Physicians