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Management of Acute and Chronic Sinusitis Bastaninejad, Shahin, MD, ORL & HNS, TUMS Amiralam Hospital.

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Presentation on theme: "Management of Acute and Chronic Sinusitis Bastaninejad, Shahin, MD, ORL & HNS, TUMS Amiralam Hospital."— Presentation transcript:

1 Management of Acute and Chronic Sinusitis Bastaninejad, Shahin, MD, ORL & HNS, TUMS Amiralam Hospital

2 Presentation Outline 1.Acute Sinusitis 2.Chronic Sinusitis

3 Importance in USA, one in five antibiotic prescriptions are for patients with sinusitis symptoms! (acute and chronic)

4 Acute Sinusitis

5 Definition Acute sinusitisAcute sinusitis is defined as sinunasal inflammatory Sx & Hx lasting less than one month –Acute Viral Rhinosinusitis (AVRS) –Acute Bacterial Rhinosinusitis (ABRS)

6 Diagnosis

7 PLAIN SINUS X-RAYS AND OTHER IMAGING ARE NOT NECESSARY IN MAKING THE DIAGNOSIS OF ACUTE SINUSITIS

8 AVRS Treatment Maintain adequate hydration Steamy shower or increase humidity in your home or personal steam vaporizer Apply warm facial packs Analgesics (acetaminophen, ibuprofen, aspirin  no less than 18yr)

9 AVRS Treatment Saline irrigation lavage Decongestants (oral) –i.e.: Pseudoephedrine hydrochloride 60 mg every 4 to 6 hours, not to exceed 4 doses per 24 hours. Decongestant nasal sprays for no longer than 5 days

10 AVRS Treatment Adequate rest Sleep with head of bed elevated Avoid cigarette smoke and extremely cool or dry air

11 When to start Abx for ABRS –Persistence of symptoms for longer than 10 days –Worsening of symptoms after 7 days –Conditions Requiring Action Before Seven Days: Fever >=39 and a documented history of sinusitisFever >=39 and a documented history of sinusitis Upper teeth pain (not of dental origin)Upper teeth pain (not of dental origin) Severe symptomsSevere symptoms Known anatomical blockageKnown anatomical blockage

12 ABRS Germs Streptococcus pneumoniae nontypeable Haemophilus influenzae Moraxella catarrhalis

13 ABRS Treatment Abx: –Amoxicillin 500 mg tab three times per day x days… in under 18yrs try mg/kg/day –For those allergic to amoxicillin: Trimethoprim- sulfamethoxazole –For patients allergic to both amoxicillin and TMP/SMX, macrolides can be prescribed Nasal steroid spray Pain killer

14 Follow up 3 day  children 7 day  adult

15 Partial response patient is symptomatically improved but not back to normal at the end of the first course of antibiotics –An additional 10 to 14 days of amoxicillin –TMP/SMX: one double strength tab BID x 14 days

16 Little or no improvement Amoxicillin/Clavulanate Cephalosporin 3rd generation ie. Cefuroxime, Cefpodoxime, Cefprozil, or Cefdinir Clarithromycin 500mg BIDx 14 days Azithromycin 500 mg every day x 3 days Quinolones… In patients who have not responded to three weeks of continuous antibiotic therapy practitioners should consider referral to ENT or Allergy for further workupIn patients who have not responded to three weeks of continuous antibiotic therapy practitioners should consider referral to ENT or Allergy for further workup

17 Invasive Fungal Sinusitis Uncommon Seen usually in immunocompromised or diabetic patients Aspergillosis, mucormycosis Requires high index of suspscion Diagnosed by biopsy and culture Therapy for invasive forms requires wide local debridement and IV Ampo. B

18

19 Chronic Rhinosinusitis

20 Definition Chronic rhinosinusitis is a group of disorders characterized by:Chronic rhinosinusitis is a group of disorders characterized by: –inflammation of the mucosa of the nose and paranasal sinuses for at least 12 consecutive weeks’ duration

21 Diagnosis the use of symptoms to define CRS is not as effective as for ABRS

22 History & Physical examination Endoscopy (edema and discolored secretions) CT-Scan*

23 Etiology The potential causes of CRS may be numerous, disparate, and frequently overlapping A unified, accepted understanding of the etiology of CRS is still being soughtA unified, accepted understanding of the etiology of CRS is still being sought

24 MajordebatableCRSetiologies AllergyBacterials Anatomic Variations Fungi

25 Allergy 25% to 50%, pediatric studies reporting the higher associationThe concordance of allergy and CRS ranges from 25% to 50%, with pediatric studies reporting the higher association 41% to 84%In the subpopulation of patients with CRS symptomatic enough to require surgery, allergy is present in 41% to 84% of patients Perennial hypersensitivity Predominates (especially house dust mite)Perennial hypersensitivity Predominates (especially house dust mite)

26 medical managementAllergic patients with CRS responded more poorly to medical management than allergic patients who did not have CRS success rateImpact of allergic rhinitis on surgical results in endoscopic sinus surgery  success rate will be diminished about 10% (90%  80%) The etiologic association between allergic rhinitis, and CRS is less clear yet (despite ABRS)The etiologic association between allergic rhinitis, and CRS is less clear yet (despite ABRS)

27 Bacterial Infection elusiveThe role of bacteria in the pathogenesis of CRS, remains elusive, But: –Staphylococcus aureus –Coagulase-negative staphylococcus –Anaerobic –Gram-negative bacteria. Despite the uncertainties surrounding the etiologic factors associated with CRS, antibiotic therapy has served as a mainstay of treatment mostly of mixed infections, with a median of 3 different bacteries

28 Why their contribution is elusive?Why their contribution is elusive? tissue samplesRelative abundance of eosinophils and the paucity of neutrophilic inflammation in tissue samples of the most cases of CRS This inflammatory response may be independent of infection

29 Probable Mechanisms Chronic infectionChronic infection OsteitisOsteitis Bacterial allergyBacterial allergy Superantigen (usually from SA)Superantigen (usually from SA) BiofilmsBiofilms The exact role of bacteria in CRS remains unclear

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31 Fungi (mechanisms in CRS) Chronic Invasive Fungal Sinusitis charactristicsAllergic Fungal Sinusitis (charactristics: eosinophilic mucin containing noninvasive fungal hyphae, nasal polyposis, characteristic radiographic findings, immunocompetence, and allergy ) Fungal balls  obstruction Immune Complex (non-IgE inflammation)

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33 multiple conditions may play a direct or contributory roleAt the current time, it appears that multiple conditions may play a direct or contributory role in the pathogenesis of CRS role that bacteria and/or fungiCurrent literature supports the important role that bacteria and/or fungi, appear to play in the pathogenesis of CRS

34 Anatomic Variants although strong evidence is lackingMay predispose to earlier obstruction of the sinuses, allowing for the development of CRS, although strong evidence is lacking

35 CRS medical therapies

36 Steroids significant improvementTopical (INCS): Four of the five clinical trials demonstrated significant improvement in symptoms Although systemic steroids are widely used, no RCTs have investigated their use in CRS without polyposis

37 Antibiotics There is a lack of RCT in the literature regarding to this topic, however, no difference between antibiotics was noted Macrolids antibacterial antiinflammatoryBut nowadays, Macrolids are in particular attention because in addition to antibacterial effects, macrolides have some interesting antiinflammatory effects akin to those of corticosteroids

38 decrease biofilmAlso macrolides can possibly decrease biofilm formation and overall bacterial virulence Regimens (3 mo duration): –ErythromycinEthylsuccinate: –Erythromycin Ethylsuccinate: 400 q6h up to 2wk, then 400 BD up to 10wk –Clarithromycin: –Clarithromycin: 500 q12h up to 2wk, then 500 daily up to 10wk

39 Nasal douching symptomsquality of life endoscopyimagingAt least four RCTs have shown improvement in symptoms, quality of life and endoscopy and imaging findings Nasal saline irrigation has been shown to potentially provide more benefit than nasal saline spray in patients with CRS A 2007 Cochrane review concluded that nasal saline appears to have benefits as an adjunctive treatment for CRS

40 Antifungal agents no convincing evidenceTo date no convincing evidence of their efficacy over and above saline douching has been provided

41 Decongestants No RCTs have been performed in CRS

42 Mucolytics There is little evidence in the literature for the use of mucolytics such as bromhexine

43 Antihistamines There is no evidence to support the use of antihistamines in CRS, and they are not recommended

44 Proton Pump inhibitors The importance of GERD as a cause of CRS is unknownThe importance of GERD as a cause of CRS is unknown, but it may be more important in the pediatric population than in adults No RTCs have shown benefitNo RTCs have shown benefit GERD may be more of a comorbid state than a cause of CRS

45 Conclusion no absolute recommendation for a ‘correct regimen’ can be givenTo date, however, because of the paucity of properly conducted trials, no absolute recommendation for a ‘correct regimen’ can be given

46 CRS without nasal polyps INCS for 3-6mo Nasal Douching with N/S Macrolide for 1.5 to 3mo Mucolytics On failures, perform culture guided therapyOn failures, perform culture guided therapy If failed again  Proceed with FESS operationIf failed again  Proceed with FESS operation

47 CRS with nasal polyps INCS for undisclosed time! Nasal Douching with N/S Macrolide administration for mo Oral corticosteroids for 10 days (20-40mg) Montelukast

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