1. The Medical Management of Infective & Allergic Rhinitis Joe Marais FRCS(ORL) www.the-nose.info Hillingdon Hospital, Northwick Park Hospital, Bishops Wood Hospital Clementine Churchill Hospital, Harrow, London.

2. I. Infective Rhinosinusitis  Very common (10-15% of population)  Most viral (>200 species!)  Secondary bacterial infection (5-15%)  Increasing incidence

3. Definitions in Sinusitis International Rhinosinusitis Board 1997 Acute Recurrent Acute Chronic Chronic c. exacerbations Rapid onset 2-4 episodes/year Duration >12/52 Worsening of existing chronic symptoms Duration<12/52 Symptom-free for >8/52 between attacks Persistent radiological changes despite adequate Rx Resolution of acute flare-ups, but not chronic symptoms Resolution of acute flare-ups, but not chronic symptoms Complete Resolution between attacks No Resolution. Constant symptoms Symptoms variable, but always present.

4. Acute Sinusitis Acute Sinusitis

5. Recurrent Acute Sinusitis

6. Chronic Sinusitis

7. Acute-on-Chronic Sinusitis

8. Microbiology of Acute Sinusitis  Majority due to viruses (200 species !)  Sinus changes on CT in >90% of URTI’s  Many asymptomatic cases  Changes mainly due to viscid secretions, not mucosal thickening per se.  Ciliary paralysis  5-15% secondary bacterial infection rate

9. Microbiology of Acute Sinusitis  Varies with geographic region, age and sampling technique  Strep.pneumoniae & Haemophilus influenzae 50%  Gram Negatives 10%  Staphlococcus 6%  Rest incl. Moraxella, Branhamalis, S.pyogenes.

10. Microbiology of Chronic Sinusitis  Multi-organism infection more common  Gram –’ves more common (Pseudomonas,Klebsiella,Proteus) up to 30%  Controversy re anaerobes: 12-90%

12. Mechanisms of Inflammation  Abnormal mucociliary function  Pathogen adherence  Inflammatory mediators: Histamine, PAF, Bradykinin, Il-4, Il-5, Il-13 etc  Cellular infiltrates  Oedema  Ostium obstruction

13. Why have I got “Sinus”, Doctor? Mucosal and ciliary damage Mucus stasis Ciliary paresis 2°bacterial infection   VIRAL URTI

14. Goals in Management  Eradicate infection  Decrease duration  Prevent Complications

15. Complications in Sinusitis  Chronicity  Acute orbit  Intra-cranial sepsis

16. Therapy for acute sinusitis  Local microbiological data important  Middle meatal swab  Empiric treatment  Co-amoxiclav ( Cefuroxime / Clarithromycin)  Decongestant (Xylometazoline)  Anti-inflammatory analgesia (Voltarol)  Mucolytic (?)  Consider change at 48hr.  Failure to respond: Refer ? consider lavage

17. Therapy for Chronic Sinusitis  Many inadequately treated at presentation  Try Clarithromycin x 12/52 nb. Down-regulation of inflammatory mediators  If not, try Ciprofloxacin and Metronidazole  Combine with decongestant, nasal topical steroid, NSAID and douching  Prolonged treatment usually necessary.  Refer those with recurrent or persistent Sx.  Warn patient that surgery may be required

18. What can I do to reduce referral rate?   Don’t dismiss as a recurrent common cold!   Irrigation of Nose with Saline (Neilmed)   Long-term (3 months) antibiotic (eg clarithromycin).nb non-compliance.   Nasal steroid sprays   Failure mandates referral

19. Surgical Treatment of Chronic Sinusitis   Open middle meatal drainage pathway   Allow mucociliary regeneration   Managed endoscopically   Offwork +/- 10days   Prognosis good

20. Post-op ESS