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

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

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.

Acute Sinusitis Acute Sinusitis

Recurrent Acute Sinusitis

Chronic Sinusitis

Acute-on-Chronic Sinusitis

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

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.

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

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

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

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

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

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

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

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

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

Post-op ESS