Management of Acute and Chronic Sinusitis Bastaninejad, Shahin, MD, ORL & HNS, TUMS Amiralam...

Management of Acute Management of Acute and Chronic Sinusitisand Chronic Sinusitis

Bastaninejad, Shahin, MD, ORL & Bastaninejad, Shahin, MD, ORL & HNS, TUMSHNS, TUMS

Amiralam HospitalAmiralam Hospital

Presentation OutlinePresentation Outline

1.1. Acute SinusitisAcute Sinusitis

2.2. Chronic SinusitisChronic Sinusitis

ImportanceImportance

in USA, one in five antibiotic prescriptions

are for patients with sinusitis symptoms!

(acute and chronic)

Acute SinusitisAcute Sinusitis

Definition

• Acute sinusitis Acute sinusitis is defined as sinunasal

inflammatory Sx & Hx lasting less than one

month

– Acute Viral Rhinosinusitis (AVRS)

– Acute Bacterial Rhinosinusitis (ABRS)

DiagnosisDiagnosis

PLAIN SINUS X-RAYS AND OTHER IMAGING ARE NOT PLAIN SINUS X-RAYS AND OTHER IMAGING ARE NOT NECESSARY IN MAKING THE DIAGNOSIS OF ACUTE NECESSARY IN MAKING THE DIAGNOSIS OF ACUTE

SINUSITISSINUSITIS

AVRS TreatmentAVRS Treatment

• Maintain adequate hydration

• Steamy shower or increase humidity in your

home or personal steam vaporizer

• Apply warm facial packs

• Analgesics (acetaminophen, ibuprofen,

aspirin no less than 18yr)

AVRS Treatment• Saline irrigation lavage

• Decongestants (oral)

– i.e.: Pseudoephedrine hydrochloride 60 mg every

4 to 6 hours, not to exceed 4 doses per 24 hours.

• Decongestant nasal sprays for no longer

than 5 days

AVRS Treatment

• Adequate rest

• Sleep with head of bed elevated

• Avoid cigarette smoke and extremely cool

or dry air

When to start Abx for ABRSWhen to start Abx for ABRS

– Persistence of symptoms for longer than Persistence of symptoms for longer than 10 days 10 days

– Worsening of symptoms after 7 daysWorsening of symptoms after 7 days– Conditions Requiring Action Before Seven Conditions Requiring Action Before Seven

Days:Days:• Fever >=39 and a documented history of Fever >=39 and a documented history of

sinusitis sinusitis • Upper teeth pain (not of dental origin) Upper teeth pain (not of dental origin) • Severe symptoms Severe symptoms • Known anatomical blockage Known anatomical blockage

ABRS GermsABRS Germs

• Streptococcus pneumoniae

• nontypeable Haemophilus influenzae

• Moraxella catarrhalis

ABRS Treatment• Abx:

– Amoxicillin 500 mg tab three times per day x 10-14 days… in under 18yrs try 80-90mg/kg/day

– For those allergic to amoxicillin: Trimethoprim-sulfamethoxazole

– For patients allergic to both amoxicillin and TMP/SMX, macrolides can be prescribed

• Nasal steroid spray• Pain killer

Follow up

• 3 day children

• 7 day adult

Partial responsePartial response

• patient is symptomatically improved but

not back to normal at the end of the first

course of antibiotics

– An additional 10 to 14 days of amoxicillin

– TMP/SMX: one double strength tab BID x 14

days

Little or no improvementLittle or no improvement• Amoxicillin/Clavulanate • Cephalosporin 3rd generation ie. Cefuroxime,

Cefpodoxime, Cefprozil, or Cefdinir• Clarithromycin 500mg BIDx 14 days• Azithromycin 500 mg every day x 3 days• Quinolones…

• In patients who have not responded to In patients who have not responded to three weeksthree weeks of continuous antibiotic therapy practitioners of continuous antibiotic therapy practitioners should consider referral to ENT or Allergy for should consider referral to ENT or Allergy for further workupfurther workup

Invasive Fungal Sinusitis

• Uncommon

• Seen usually in immunocompromised or diabetic patients

• Aspergillosis, mucormycosis

• Requires high index of suspscion

• Diagnosed by biopsy and culture

• Therapy for invasive forms requires wide local debridement and IV Ampo. B

Chronic RhinosinusitisChronic Rhinosinusitis

DefinitionDefinition

• Chronic rhinosinusitis is a group of disorders characterized Chronic rhinosinusitis is a group of disorders characterized

by:by:

– inflammation of the mucosa of the nose and paranasal sinuses

for at least 12 consecutive weeks’ duration

DiagnosisDiagnosis

the use of symptoms the use of symptoms to define CRS is not to define CRS is not as effective as for as effective as for ABRSABRS

EtiologyEtiology

• The potential causes of CRS may be

numerous, disparate, and frequently

overlapping

• A unified, accepted understanding of the A unified, accepted understanding of the

etiology of CRS is still being soughtetiology of CRS is still being sought

Major Major debatable debatable

CRS CRS etiologiesetiologies

AllergyAllergy BacterialsBacterials

Anatomic VariationsAnatomic Variations FungiFungi

AllergyAllergy• The concordance of allergy and CRS

ranges from 25% to 50%, 25% to 50%, with pediatric pediatric studies reporting the higher associationstudies reporting the higher association

• In the subpopulation of patients with CRS symptomatic enough to require surgery, allergy is present in 41% to 84% 41% to 84% of patients

• Perennial hypersensitivity Predominates Perennial hypersensitivity Predominates (especially house dust mite)(especially house dust mite)

• Allergic patients with CRS responded more poorly to medical management medical management than allergic patients who did not have CRS

• Impact of allergic rhinitis on surgical results in endoscopic sinus surgery success rate success rate will be diminished about 10% (90%80%)

• The etiologic association between allergic The etiologic association between allergic rhinitis, and CRS is less clear yet (despite rhinitis, and CRS is less clear yet (despite ABRS)ABRS)

Bacterial InfectionBacterial Infection• The role of bacteria in the pathogenesis of CRS, remains

elusiveelusive, But: – Staphylococcus aureus

– Coagulase-negative staphylococcus– Anaerobic

– Gram-negative bacteria.

• Despite the uncertainties surrounding the etiologic factors associated

with CRS, antibiotic therapy has served as a mainstay of treatment

mostly of mixed mostly of mixed infections, with a infections, with a

median of 3 different median of 3 different bacteriesbacteries

• Why their contribution is elusive?Why their contribution is elusive?

• Relative abundance of eosinophils and the

paucity of neutrophilic inflammation in

tissue samplestissue samples of the most cases of CRS

• This inflammatory response may be

independent of infection

Probable MechanismsProbable Mechanisms

• Chronic infectionChronic infection

• OsteitisOsteitis

• Bacterial allergy Bacterial allergy

• Superantigen (usually from SA) Superantigen (usually from SA)

• BiofilmsBiofilmsThe exact role of bacteria The exact role of bacteria in CRS remains unclearin CRS remains unclear

Fungi Fungi (mechanisms in CRS)(mechanisms in CRS)• Chronic Invasive Fungal Sinusitis

• Allergic Fungal Sinusitis (charactristicscharactristics:

eosinophilic mucin containing noninvasive fungal

hyphae, nasal polyposis, characteristic radiographic

findings, immunocompetence, and allergy)

• Fungal balls obstruction

• Immune Complex (non-IgE inflammation)

• At the current time, it appears that multiple multiple

conditions may play a direct or conditions may play a direct or

contributory rolecontributory role in the pathogenesis of

CRS

• Current literature supports the important

role that bacteria and/or fungirole that bacteria and/or fungi, appear to

play in the pathogenesis of CRS

Anatomic VariantsAnatomic Variants

• May predispose to earlier obstruction of

the sinuses, allowing for the development

of CRS, although strong evidence is although strong evidence is

lackinglacking

CRS medical therapies

SteroidsSteroids

• Topical (INCS): Four of the five clinical

trials demonstrated significant significant

improvement improvement in symptoms

• Although systemic steroids are widely

used, no RCTs have investigated their use

in CRS without polyposis

AntibioticsAntibiotics• There is a lack of RCT in the literature regarding to

this topic, however, no difference between

antibiotics was noted

• But nowadays, MacrolidsMacrolids are in particular attention

because in addition to antibacterialantibacterial effects,

macrolides have some interesting antiinflammatoryantiinflammatory

effects akin to those of corticosteroids

• Also macrolides can possibly decrease biofilm decrease biofilm

formation and overall bacterial virulence

• Regimens (3mo duration):

– ErythromycinErythromycin Ethylsuccinate: Ethylsuccinate: 400 q6h up to

2wk, then 400 BD up to 10wk

– Clarithromycin:Clarithromycin: 500 q12h up to 2wk, then 500

daily up to 10wk

Nasal douchingNasal douching

• At least four RCTs have shown improvement in symptomssymptoms, quality of life quality of life and endoscopyendoscopy and imagingimaging findings

• Nasal saline irrigation has been shown to potentially provide more benefit than nasal saline spray in patients with CRS

• A 2007 Cochrane review concluded that nasal saline appears to have benefits as an adjunctive treatment for CRS

Antifungal agentsAntifungal agents

• To date no convincing evidence no convincing evidence of their

efficacy over and above saline douching

has been provided

DecongestantsDecongestants

• No RCTs have been performed in CRS

MucolyticsMucolytics

• There is little evidence in the literature for

the use of mucolytics such as bromhexine

AntihistaminesAntihistamines

• There is no evidence to support the use of antihistamines

in CRS, and they are not recommended

Proton Pump inhibitorsProton Pump inhibitors

• The importance of GERD as a cause of CRS The importance of GERD as a cause of CRS

is unknownis unknown, but it may be more important in

the pediatric population than in adults

• No RTCs have shown benefitNo RTCs have shown benefit

• GERD may be more of a comorbid state than

a cause of CRS

ConclusionConclusion

• To date, however, because of the paucity

of properly conducted trials, no absolute no absolute

recommendation for a ‘correct regimen’ recommendation for a ‘correct regimen’

can be given can be given

CRS without nasal polypsCRS without nasal polyps• INCS for 3-6mo

• Nasal Douching with N/S

• Macrolide for 1.5 to 3mo

• Mucolytics

• On failures, perform culture guided On failures, perform culture guided therapytherapy

• If failed again If failed again Proceed with FESS Proceed with FESS operationoperation

CRS with nasal polypsCRS with nasal polyps

• INCS for undisclosed time!

• Nasal Douching with N/S

• Macrolide administration for 1.5 - 3mo

• Oral corticosteroids for 10 days (20-40mg)

• Montelukast