Transcript Acute & chronic sinusitis

Acute & Chronic
Sinusitis
‫לימודי המשך‬
Ephraim Eviatar
Assaf Harofeh Medical Center
‫סינוסיטיס היא האבחנה החמישית אשר‬
‫אנטיביוטיקה מומלצת עבורה‪.‬‬
‫סינוסיטיס מהווה ‪ 9%‬מכלל הילדים שקיבלו‬
‫אנטיביוטיקה ו‪ 21%-‬במבוגרים‪.‬‬
Rhinosinusitis
Acute rhinosinusitis
Subacute rhinosinusitis
Chronic rhinosinusitis
Recurrent ARS
Acute rhinosinusitis superimposed on CRS
Acute rhinosinusitis
Acute sinusitis 7-21 days (7 days viral
illness)
Spontaneous resolution of ARS -40%
The most common pathogens: strep
pneumonia-30%,
non typeabale hemophilus infl.-20%,
moraxella catarrhalis.(20% in children)
Staph aureus- 30%
Anaerobes- rare
Recurrent ARS
Episodes of bacterial infection of the
paranasal sinuses, each lasting less than
30 days and separated by intervals of at
least 10 days during which the patient is
asymptomatic.
Subacute sinusitis
Subacute RS:3W-3months
The same pathogens as in ARS
Chronic rhinosinusitis
Beyond 3 months
Bacteria are as in ARS, but
More non-typeable H Influezae
More staph aureus, anaerobic bacteria,
gram- Negative, pseudomonase
aeruginosa
Polymicrobials with resistant organism
Culture recommended
Acute bacterial sinusitis
superimposed on chronic sinusitis
Patients with residual respiratory
symptoms develop new respiratory
symptoms. When treated with
antimicrobials, these new symptoms
resolve, but the underlying residual
symptoms do not.
Major & Minor signs and symptoms
in diagnosis of Chronic RS
Majors:
Facial pain/pressure
Nasal congestion/fullness
N. obstruction/blockage
N. discharge/purulence
Hyposmia/ anosmia
Purulent rhinitis
Fever (acute sinusitis only)
Minors:
Headache
Fever
Halitosis
Fatigue
Dental pain
Cough
Ear pain/
pressure/fulln
Clinical Diagnosis of rhinosinusitis
2 or more major factors
1 major & 2 minor factors
Or Purulence on examination
Duration of symptoms > 10 days or
worsen after 5-7 days
Kinney WC : otolaryngol Head Neck Surg 2002
Predisposing factors
URI
Allergy
Trauma
Dental infection
Environmental Pollutants
GERD
Cystic Fibrosis
Facial pain on percussion or palpation,
sedimentation rate and white blood count
have little diagnostic value .
Purulent secretions by history
Purulent secretions in the nasal cavity on examination
Lack of response to decongestants and antihistamines
Unilateral maxillary pain
Double-sickening": an upper respiratory infection that initially
improves then worsens
The gold standard for the diagnosis of
acute bacterial sinusitis is the recovery of
4
bacteria in high density (>10 colonyforming units/mL) from the cavity of a
paranasal sinus
Rhinosinusitis definitions for patient care
Type of rhinosinusitis
Acute rhinosousitis
Pattern of symptoms
*Symptoms minimum
10d-28d
CRS without polyposis
Symptoms >12w
*severe disease
*worsening disease
Symptoms for diagnosis
*Ant./post purulent
discharge
*nasal obstruction
*facial pain-pressure
Objective documentation
The following symtoms
*ant/post mucupurulent
*nasal obstruction
*facial pain

-
Nasal exam:purule
Radiographic
evidence
Nasal exam to exclude
polyps
CT sinus not essential
Rhinosinusitis definitions for patient care
Type of rhinosinusitis
CRS with polyposis
Symptoms for diagnosis
Objective documentation
AFRS
>2 of the symptoms:
>1 of the symptoms:
*ant/pos mucupurulent d
*ant/pos rhinitis
*nasal obstruction
*nasal obstruction
*decrease sense of smell
*facial pain/pressure
Nasal exam.to confirm
bilat polyps
.
CT is not essential
Nasal exam. Allergic
mucin, inflammation &
polyps
*fungal specific IgE
No invasion
CT is not essential
Fungal culture , total IgE
Dose the patient have 2 or more
major factors ...?
Yes:
Amoxicillin
Or Bactrim
No:
Treat symptomatically
Saline irrigation
Oral decongestant
Antihistamine (allergy)
Reevaluate in 10 days
Kinney WC : otolaryngol Head Neck Surg 2002
type
organism
drugs
comments
acute
Strep pneumoniae
h. Influenzae
m. catarrhalis
Amoxicillin 10
days
2nd generation
cephalosporin,
Macrolide, for
penicillin allergy
subacute
Increased resistant of
bacteria
2nd line drugs
chronic
Polimicrobial,
psudomonase a,
anaerobes, more
resistant
Augmentin,
2nd cephalo.
macrolide,
clinda,3-4w
Recurrent
chronic
Resistant ,
polimicrobial
consider 3-4w Culture guided
profilaxis
Suppurative
complications
G(-). Staph
aureus
Cefuroxime,
aminoglicozid
Culture
whenever
possible
Surgery if no
responce
Severe sinusitis with suspected orbital or
intracranial complications –cefuroxime or
ceftriaxone
The best in crs treat according to culture
For crs treat 3 weeks, while improvement
within 3-5 days
3-6 weeks prophylaxis once daily therapy
for patients with rapid recurrence??
Antimicrobial treatment guidelines
1. mild symptoms, not received antibiotics
within 4-6w.
2. mild disease, who received antibiotics
within 4-6w,
or with moderate disease regardless of
recent antibiotic exposure,
‫מטרת הטיפול האנטיביוטי‪:‬‬
‫לחסל את החיידקים באתר של הזיהום כדי שלהשיב את‬
‫הסינוסים לבריאותם‬
‫לקצר את תקופת המחלה ולשוב לשגרת חיים נורמאלית‬
‫למנוע סיבוכים קשים‪ ,‬כמו מנינגיטיס‪.‬‬
‫למנוע התפתחות מחלה כרונית‬
‫‪According to the guidelines‬‬
‫טיפול במבוגרים‬
‫האנטיביוטיקה שיעילותה הקלינית המנובאת מגיעה ל‬
levofloxacin ‫ כמו‬fluoroquinolones :‫ הינם‬90-92%
.moxifloxacin -‫ו‬
augmentin, ceftriaxone
high dose cefixime :83-88% ‫יעילות של‬
amoxicillin, cefpodoxime proxile, cefuroxime
axetil, cefdinir TMP/SMX
docxycyline, clindamycin, :77-81% ‫יעילות של‬
azitromycin, clarithromycin, erythromycin
cefaclor,loracarbef :65-66% ‫יעילות של‬
According to the guidelines
‫טיפול בילדים‬
91-92%: ceftriaxone, augmentin
82-87%: amoxicillin, cefpodoxime proxetil,
cefixime, cefuroxime axetil,cefdinir,TMP/SMX
78-80% :clindamycin, cefprozil, azithromycin,
clarithromycin, erythromycin
67-68%: cefaclor
According to the guidelines
‫ההמלצות לטיפול התחלתי במבוגרים עם‬
‫מחלה קלה‬
Augmentin, amoxicillin, cefpodoxime proxetil,
cefuroxime axetil, or cefdinir
For b-lactam allergies patients: TMP/SMX,
doxycilline, azithromycin,
clarithromycin,erythromycin
Failure after 72h: reevaluation or switch to
alternate antimicrobial therapy
According to the guidelines
‫המלצות לטיפול התחלתי במבוגרים עם‬
‫מחלה קלה שטופלו קודם‬
Respiratory flouroquinolones, augmentin
(4g/day),ceftriaxone (1-2 g/day 5 days),
combination of g+ and gFailure after 72h: switch to alternate
antimicrobial therapy, or reevaluation
CT scan, endoscopy, sinus aspiration and
culture
According to the guidelines
‫המלצות לטיפול התחלתי בילדים עם‬
‫מחלה קלה‬
Augmentin (90mg/k/day), amocixillin (90
mg/k/day), cefpodoxime proxetil,
cefuroxime axetil, or cefdinir
Type I hypersensitivity to b-lactams
patients: TMP/SMX, azithromycin,
clarithromycin or erythromycin.
Make differentiate an immediate
hypersensitivity from other side effects
Failure after 72 h
According to the guidelines
‫המלצות לטיפול בילדים עם מחלה קלה‬
‫(טופלו לאחרונה) או מחלה בינונית‬
Augmentin(90mg/k/day), cefpodoxime
proxetil, cefuroxime axetil or cefdinir.
Beta lactams allergic patients: TMP/SMX,
azithromycin, clarithromycin, erythromycin
Clindamycin for s pneumoniae
Ceftriaxone (5 days, parenteral), or
combination therapy for G+ and GClindamycin or amocixillin and cefixime
Clindamycin or amoxicillin and rifampin
According to the guidelines
New insights into the role of
bacteria in CRS
Bacterial superantigens-exotoxins that are
able to activate T lymphocytes
Pathogenesis of nasal polyposissuperantigens from S aureus
Biofilms-a artificial or damaged biologic
surface that formed communicating
organization of microorganisms
surrounded by a glycocalys
Biofilms is relatively impervious to
antibiotics and is never eradicated
Mechanical debridement- the only way to
resolve biofilms
Osteitis: the role of the bone
Osteomyelitis can be seen at a distance
from the primary infection
Inflammatory bone changes were noted on
contralateral side in 52% of the animals
Khalid et al. laryngoscope 2002
The changes in the involved bone can
explain why CRS is relatively resistant to
medical therapy.
Failed CRS
To sinus surgery or systemic steroid/antibiotics
Macrolid therapy (long term, low dose) effective
Cervin A et al: Otolaryngol Head Neck Surg 2002
CRS
78 had criteria to CRS
17 endoscopy: positive
37- CT findings: positive
6 endoscopy : positive
41- CT findings: negative
35: endoscopy negative & CT negative
20: endoscopy negative & CT positive
55: endoscopy negative
Stankiewicz & Chow: Otolaryngol Head Neck Surg 2002
Radiology & clinical exam
Correlated with a Sensitivity of 75%
And specificity of 84%
Endoscopy correlated poorly with sinus
disease and not predictive
Stankiewicz & Chow: Otolaryngol Head Neck Surg 2002
Endoscopy/ct findings/clinical
Easy to diagnose CRS by endoscopy
alone when nasal polyps, purulence, or
fungus is observed,
when absent, establishing the diagnosis
may be more difficult
45% of patients with clinical CRS were
both endoscopically and radiographically
negative.
Stankiewicz and Chow. Otolaryngol head neck surg 2002
Endoscopy/ct findings/clinical
Negative endoscopy alone is insufficient to
rule out sinusitis.
26% of patients who were negative on
endoscopy had positive CT – this would
suggest that if endoscopy is negative
most of the time the ct will be also
negative, even with a positive history.
Stankiewicz & Chow: Otolaryngol Head Neck Surg 2002
‫בילדים‬
‫) יופיע גדול‬URI ‫הסיכון שזיהום חיידקי (בעקבות‬
‫ ימים‬10 ‫יותר אם המחלה נמשכת מעל‬
‫אבחנה תעשה בילדים ומבוגרים עם סימפטומים‬
‫ ימים או‬10 ‫ שלא השתפרו אחרי‬VIRAL URI ‫של‬
.‫ ימים‬5-7 ‫הוחמרו אחרי‬
The diagnosis of acute bacterial sinusitis is
based on clinical criteria in children who
present with upper respiratory symptoms
that are either persistent or severe
Guidelines of American Academy of Pediatrics
‫בילדים‬
Persistent symptoms are those that last
longer than 10 to 14, but less than 30,
days. Such symptoms include nasal or
postnasal discharge (of any quality),
daytime cough (which may be worse at
night), or both.
Guidelines of American Academy of Pediatrics
‫בילדים‬
Severe symptoms include a temperature
of at least 102°F (39oC) and purulent
nasal discharge present concurrently for at
least 3 to 4 consecutive days in a child
who seems ill. The child who seems toxic
should be hospitalized and is not
considered in this algorithm.
Guidelines of American Academy of Pediatrics
‫‪children‬‬
‫יש קושי לפעמים להבדיל בילדים‬
‫בין מחלה וירלית של דרכי נשימה‬
‫עליונים ואדנואידיטיס מסינוסיטיס‬
‫חריפה‬
‫רק נזלת מוגלתית וסמיכה מקורה‬
‫בסינוסים עצמם‪ ,‬והאף משמש כצינור‪,‬‬
‫בעוד שנזלת מוקואדית‪ ,‬וירלית‬
‫מערבת את האף בילבד‪.‬‬
‫יש דמיון רב בין דלקת אוזן חריפה לסינוסיטיס חריפה‬
‫בילדים מבחינת פטוגנסיס ומיקרוביולוגיה בגלל הקשר‬
‫לנאסופארינקס‬
ARS in children
Diagnosis in children based on clinical
criteria
Radiology is only for complications,
persistent or recurrent sinusitis
For prevention there is no prophylactic
antimicrobial treatment, ancillary
therapies, complementary/alternative
medicine
Guidelines of American Academy of Pediatrics
Surgical management of crs in
children
5-8 events of colds/year
5%-13% will complicate by acute RS
Most of children with RS respond to
medical treatment
Today surgery consist of sinus lavage,
ESS, adenoidectomy
Goal of surgery
Surgery is for control of symptoms, better
quality of life and to prevent complications
Indications to surgery are not uniform
between OL and P
“cure”-the goal for surgery, but is not the
likely end point
Reversible mucosal disease may be
possible in the long run, but is unlikely to
be realized in the short term
Maximal medical management
Reflux
Macrolids
Antileukotriens
Irrigations-nasal sprays
Alternative medical approaches
Surgical management children
Biomaterials
Subperiosteal abscess
The surgical site in children
There is strong evidence to support the
fact that the OMC area is the primary site
of involvement of inflammatory sinuses
disease.
Surgical management in children
Role of adenoidectomy:
1. reservoir for pathogenic bacteria
2. interfere with nasal mucociliary
clearance
3.better drainage
Overall success of adenoidectomy-50%
Studies show reduction in the number of
bacterial pathogens in the nasopharynx
after adenoidectomy
Fear of surgery?
Surgery may cause growth retardation of
the midface
Bothwell et al. showed no difference in
facial growth of children with CRS who
operated compare with children who
refused surgery.
Surgery
Children who fail medical therapy benefit
from surgery
Adenoidectomy recommended initially for
children 6 years of age (no asthma, low
CT score)
ESS and adenoidectomy for children older
than 6 (asthma and high CT score)
Ramadan. Laryngoscope.2004
Results of surgery children
Older children do better than youngest
Old children (>6 y/o)- successes rate is
89% , but younger children (<6 y/o)successes rate is only 73%
>3 y/o who were operated have 75%
chance to be reoperate
Antibiotic therapy
Amoxicillin -1st choice
In children give high dose 60mg/kg/day
To consider 2nd generation cephalosporin, or
erythromycin with sulfonamide ,or high dose
penicillin in areas with a high incidence of
bacterial antibiotic resistance.
Based on studies showing a 20% incidence of
viable bacteria through maxillary sinus tap after
7 days of antibiotic therapy, most authors
recommend 10 days of therapy in the manage
of acute sinusitis