The Medical Management of Chronic Sinusitis & Polyps
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Transcript The Medical Management of Chronic Sinusitis & Polyps
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.
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
Complete Resolution
Complete Resolution
between attacks
No Resolution.
Constant symptoms
Symptoms variable,
but always present.
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%
Relative Frequency of Infecting Organisms
50
45
40
35
30
% 25
Acute
Chronic
20
15
10
5
Chronic
0
Gr +
Acute
Gr Staph
Other
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?
VIRAL URTI
Mucosal and ciliary
damage
2°bacterial infection
Mucus stasis
Ciliary paresis
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