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