1. sinusitis

2. Scope of Sinusitis Affects 30-35 million persons/year
25 million office visits/year
Direct annual cost $2.4 billion and increasing
Added surgical costs: $1 billion
Third most common diagnosis for which antibiotics are prescribed
Third 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:

3. Development of Sinuses
Maxillary and ethmoid sinuses present at birth
Frontal sinus developed by age 5 or 6
Sphenoid sinus last to develop, 8-10
The 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:

4. 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.

5. Physiologic Importance of Sinuses
Provide mucus to upper airways
Lubrication
Vehicle for trapping viruses, bacteria, foreign material for removal
Give characteristics to voice
Lessen skull weight
Involved with olfaction
Physiologic reasons for sinuses not totally understood. The above are suggestions as to their role.
Kaplan, second edition. Allergy. Chapter 26:

6. ANATOMY Septum Nasal Turbinates
Concha Bullosa – Middle Turbinate
Sinuses: Maxillary, Ethmoid (anterior and posterior), Frontal and Sphenoid
Osteomeatal Complex
Nasofrontal recess
Uncinate process (hiatus semilunaris)
Find out relevant background and audience interest

7. ANATOMY (continued) Ciliated pseudostratified columnar epithelium
Two layers of mucus
Thick “basement” layer
Thin less viscous layer that the cilia moves to the ostia
Mucosal Changes After Surgery and Long Term Disease
Neuroreceptors for smell (olfactory nerve) and airflow (located in the inferior and middle turbinates

10. Professor Sameer Ali Bafaqeeh
11/16/2018
Professor Sameer Ali Bafaqeeh

11. Acute Rhinosinusitis (Viral)
Common Symptoms: Nasal discharge, nasal congestion, facial pressure, cough, fever, muscle aches, joint pains, sore throat with hoarseness.
Etiology,rhinovirus,influenza,parainflu,adenovirus,enterovirus,RSV,…..
Symptoms resolve in days
Common in fall, winter and spring.
Treatment: Symptomatic

12. Acute Bacterial Sinusitis
Causative agents are usually the normal inhabitants of the respiratory tract.
Common agents:
Streptococcus pneumoniae
Nontypeable Haemophilus Influenzae
Moraxella Catarrhalis

13. SIGNS AND SYMPTOMS Pain and/or pressure Fever
frontal, maxillary, upper teeth, retro-orbital, crown of the head
temporal, parietal and occipital headaches are not generally associated with sinusitis
children under the age of 12 who complain of headaches and, without prompting from a parent, points to the top of their head, anterior face, eye, or posterior skull most likely have sphenoid sinusitis until otherwise documented by CT or MRI scan
Fever

14. SIGNS AND SYMPTOMS Nasal congestion and/or drainage Obstruction
Rhinorrhea
postnasal drainage
purulent
color does not determine infection
Obstruction
Deviated septum
Hypertrophy of turbinate(s)
Polyps

15. ACUTE SINUSITIS Less than one month duration
Purulent drainage, fever, significant sinus pain and pressure
Isolated acute infection without recurrent “sinus symptoms”
Most commonly secondary to upper respiratory viral infection or other inflammatory condition
perennial allergic rhinitis with inflammation
obstruction of the ostia/drainage passages of the sinuses
primarily neutrophilic inflammation with a small amount of eosinophils

16. Diagnosis Based on clinical signs and symptoms
Physical Exam: Palpate over the sinuses, look for structural abnormalities like DNS.
X-ray sinuses: not usually needed but may show cloudiness and air fluid levels
Limited coronal CT are more sensitive to inflammatory changes and bone destruction

17. Ethmoid Sinusitis

18. Coronal computed tomographic scan showing ethmoidal polyps
Coronal computed tomographic scan showing ethmoidal polyps. Ethmoid opacity is total as a result of nasal polyps, with a secondary fluid level in the left maxillary antrum.

19. Treatment
About 2/3rd of patients will improve without treatment in 2 weeks.
Antibiotics: Reserved for patients who have symptoms for more than 10 days or who experience worsening symptoms.
OTC decongestant nasal sprays should be discouraged for use more than 5 days
Supportive therapy: Humidification, analgesics, antihistaminics
If the patient does not respond to antimicrobial therapy after 72 hours, he or she should be reevaluated and a change in antibiotics should be considered. Diagnostic evaluations such as computed tomography, fiberoptic endoscopy, or sinus aspiration also may be necessary for patients who experience a treatment failure.

20. Antibiotics a) Amoxicillin (500mg TID) OR
b) TMP/SMX ( one DS for 10 days).
c) Alternative antibiotics: High dose amoxi/clavunate, Flouroquinolones, macrolides,cefixime,cefuroxime,..

21. CHRONIC SINUSITIS Greater than three months duration
multiple treatments or infections within one year
multiple year history of recurrent infections or episodes of sinus pain and pressure
symptoms that coincide with changes in altitude or weather
chronic nasal congestion and drainage

22. CHRONIC RHINOSINUSITIS (CRS) WITHOUT POLYPS
Neutrophilic inflammation associated with obstruction and inflammation of sinus ostia

23. CHRONIC RHINOSINUSITIS (CRS) WITH POLYPS
Associated with eosiniphilic inflammation with some association with interleukin 4 and 5 and IgE mediated response
No difference in the composition of the mucin between systemic atopic patients versus nonatopic patients
Patients with genetic mucociliary transport diseases such as cystic fibrosis or, patients who have significant acquired changes of the mucosa following surgery may also have neutrophilic inflammation

25. ALLERGIC FUNGAL SINUSITIS (AFRS)
Non-invasive
local fungal hyphae in the mucin
allergic response to the fungus
polyps with thick grey to brownish “greasy” mucin drainage

26. ALLERGIC FUNGAL SINUSITIS (AFRS)
Invasive
Microscopic invasion of fungus in the mucosa
Necrotic black tissue with nonpainful debridement is an emergent life threatening fungal infection
mucomycosis

29. NONALLERGIC RHINITIS May be caused by drugs such as: Beta blockers
Methyldopa related
Reserpine
Oral contraceptives
Nasal sprays (OTC)
Decongestants
Develops and resolves during pregnancy
GDM: 30-40% Increased risk for later Type II Diabetes yrs
DM I: Requires Insulin for survival

30. NONALLERGIC RHINITIS May also be caused by certain conditions such as:
Pregnancy
Hypothyroidism
Temperature related
Recumbency rhinitis
End-stage vascular atony (Chronic allergic/inflammatory)
Paradoxical nasal obstruction (Nasal cycle)
Non-airflow rhinitis (Adenoid hypertrophy, choanal atresia)

31. TREATMENT Nasal and oral steroids Antibiotics Nasal saline irrigation
Ponaris emollient
Oral decongestants and antihistamines
Conservative use
Biofilm formation
Surgery

32. NON-SURGICAL TREATMENT
Acute sinusitis
Antibiotics – ten days to three weeks
Nasal steroids – six to eight weeks
Nasal saline irrigations – six to eight weeks
Mucocilia may take up to four to six weeks to resume normal function
CT scan of sinuses if indicated
Optional:
Nasal spray decongestants – three days only
Short course of oral steroids
Surgery if indicated

33. NON-SURGICAL TREATMENT
Chronic or recurrent sinusitis without polyps
Nasal steroids – long-term treatment
Nasal saline irrigation – long-term treatment
Antibiotics with acute intermittent sinus infections up to six weeks
CT scan sinuses
Otolaryngologist evaluation
Surgery

34. NON-SURGICAL TREATMENT
Chronic rhinosinusitis with polyps
Otolaryngologist evaluation
Nasal steroids – long-term treatment
Nasal saline irrigation – long-term treatment
Antibiotics with acute intermittent sinus infections up to six weeks
Allergy testing
Surgery

35. NON-SURGICAL TREATMENT
Allergic Fungal Sinusitis (AFRS)
Nasal steroids – long-term treatment
Nasal saline irrigation – long-term treatment
Amphotericin B, mucopricin, steroid or gentamycin irrigations
Most common organism – Aspergillus fumigates
Antibiotics with acute intermittent sinus infections up to six weeks
CT scan sinuses
Surgery

36. SURGICAL TREATMENT Image guided endoscopic sinus surgery
Balloon sinuplasty