RHINOSINUSITIS

Stuart Henochowicz, M.D., M.B.A., F.A.C.P. Clinical Associate Professor Division of Allergy, Immunology and Rheumatology Georgetown University Medical School Washington, D.C.

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Coronal View in Relation to Facial StructureCoronal View in Relation to Facial Structure

Normal Sinus CT Scan through the OMU

Maxillary sinus

Eyeball

Ethmoid sinus

Nasal cavity

Nasal Polyp

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Rhinosinusitis

More accurate term than“sinusitis since almost always preceded by or concomitant symptoms of rhinitis

Acute – Up to 4 weeks

Subacute – 4 to 12 weeks

Chronic – > 12 weeks

Acute vs. Chronic Rhinosinusitis

Usually very different conditions.

Acute rhinosinusitis usually related to infection.

Chronic rhinosinusitis usually related to inflammation.

Acute Rhinosinusitis

1 billion viral URIs each year

0.5% - 2% lead to secondary bacterial infection of the sinuses.1,2

Acute bacterial rhinosinusitis often present when symptoms have not resolved after 10 days or worsen after 5 to 7 days

1Gwaltney Clin Infect Dis 1996;23:1209

2Berg et al. Rhinology 1986;24:223-5

Diagnosis of Acute Bacterial Rhinosinusitis

Acute clinical pattern Symptoms >10 days and < 28 days

Objective confirmation either / or Nasal exam documenting purulent d/c beyond the nasal vestibule

Rhinoscopy Endoscopy

Posterior pharyngeal drainage

CT scan Not recommended for routine management

May be helpful in complex cases

Meltzer et al. JACI 2004;114:155

Diagnosis of Acute Rhinosinusitis: 2 major OR 1 major & 2 minor symptoms

Major Anterior or posterior purulent drainage Nasal obstruction Facial pain or pressure or congestion Hyposmia or anosmia Fever (acute)

Minor Head ache

Ear pain/pressure

Halitosis

dental pain

Fatigue

Cough

JACI 2004

Obstruction of the OMU with Associated Acute Sinusitis

Sinusitis in the

ethmoid sinus.

Sinusitis in the

maxillary sinus.

Local Factors Predisposing to Rhinosinusitis

Allergic rhinitis

URI

Anatomic abnormalitiy: Deviated septum Concha bullosa Enlarged adenoids Haller cells

Nasal polyps

Tumor

Foreign body

Trauma

Barotrauma

Diving, swimming

Smoke

Topical decongestant abuse

Nasal intubation

Systemic Factors Predisposing to Rhinosinusitis

Immune deficiency IgA deficiency Panhypogammaglobulinemia IgG subclass deficiency HIV

Cystic fibrosis

Ciliary disorder

Granulomatosis with Polyangiitis (Wegener’s)

Gastroesophageal reflux

Complications of Rhinosinusitis

Meningitis

Orbital cellulitis (ethmoid)

Subdural/epidural empyema (frontal)

Brain abscess (frontal)

Cavernous sinus thrombosis (sphenoid)

Osteomyelitis (frontal)

Asthma exacerbation

Treating acute rhinosinusitis: Comparing efficacy and safety of mometasone furoate nasal spray, amoxicillin, and placebo Eli O. Meltzer, MD, Claus Bachert, MD, PhD and Heribert Staudinger, MD Volume 116, Issue 6, Pages 1289-1295

Copyright © 2005 American Academy of Allergy, Asthma and Immunology

Fig 1

Source: Journal of Allergy and Clinical Immunology 2005; 116:1289-1295 (DOI:10.1016/j.jaci.2005.08.044 )

Copyright © 2005 American Academy of Allergy, Asthma and Immunology

Antibiotics for Acute Sinusitis

Cochrane Database Review (2004) Peds Available evidence suggest that antibiotics given for 10 days will reduce the probability of persistence in the short to medium-term.

Cochrane Database Review (2004) Adults Current evidence is limited but supports the use of antibiotics for 7 to 14 days

Weigh the moderate benefits of abx treatment against the potential for adverse effects

Acute Bacterial Rhinosinusitis:

Which antibiotic to use?

No randomized, placebo-controlled trials of antibiotic treatment for ABRS using pre-and post-treatment sinus aspirate culture

Antibiotics

20 to 30% of S. pneumoniae are penicillin resistant

30 to 40% of H. influenzae and 75 to 95% of M. catarrhalis are beta-lactamase positive

When choosing abx consider Recent abx use (within 6 weeks) Severity of disease

Antibiotics for Acute Rhinosinusitis

“3. Amoxicillin-clavulanate rather than amoxicillin alone is recommended as empiric antimicrobial therapy for ABRS in children (strong, moderate).

4. Amoxicillin-clavulanate rather than amoxicillin alone is recommended as empiric antimicrobial therapy for ABRS in adults (weak, low)”.

IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults-2012

IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults

-2012

“7. Macrolides (clarithromycin and azithromycin) are not recommended for empiric therapy due to high rates of resistance among S. pneumoniae (∼30%) (strong, moderate)”.

IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults

-2012

“8. Trimethoprim-sulfamethoxazole (TMP/SMX) is not recommended for empiric therapy because of high rates of resistance among both S. pneumoniae and Haemophilus influenzae (∼30%–40%) (strong, moderate)”.

IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults

-2012

“9. Doxycycline may be used as an alternative

regimen to amoxicillin-clavulanate for initial

empiric antimicrobial therapy of ABRS in

adults…”

Acute Bacterial Rhinosinusitis: Duration of Treatment

“14. The recommended duration of therapy for uncomplicated ABRS in adults is 5–7 days (weak, low-moderate).

15. In children with ABRS, the longer treatment duration of 10–14 days is still recommended (weak, low-moderate)”.

IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults- 2012

Shortcut to acute sinusitis micro.lnk

Sinus and Allergy Health Partnership Otolaryngol Head Neck Surg 2004:130:1

Sinus & Allergy Partnership. Otolaryngol Head & N Surg 2004; 130:1

Fig 1

Journal of Allergy and Clinical Immunology 2013; 132:1230-1232

Copyright © 2013 American Academy of Allergy, Asthma & Immunology

Chronic Rhinosinusitis

Diagnosis of Chronic Rhinosinusitis

Symptoms for > 12 weeks Two main subtypes:

CRS without nasal polyps CRS with nasal polyps

Strongly associated with asthma and aspirin tolerance

Meltzer et al. JACI 2004;114:155

Common (>50%)RareAnti-Staph Toxin

LotLittle/unclearLocal IgE prod.

Very HighMildly increasedMucus MCP

HighLowVCAM and IL5

Mostly EOSMostly PMN’sInflammatory Infilt

HigherLowerASA sensitivity

HigherLowerAsthma

CRS with NPCRS without NPClinical Pathologic

Differences

RhyooRhyoo 1999, 1999, NonoyamaNonoyama 2000, 2000, DemolyDemoly 1997, 1997, BachertBachert 1998, 1998, RudackRudack 19981998

Chronic Rhinosinusitis: Risk Factors for Extensive Disease

80 patients with CRS

Factors Eosinophil > 200/uL (OR=19.2, 95% CI=5.4-72.7

Asthma (OR=6.8, 95%CI=2.2-22)

Atopy (OR=4.3,95%CI=1.5-12.8)

Age>50 (OR=6.5,95%CI=2.0-22.2)

Hoover GE et al. JACI 1997;100:185-91

Prevalence of Allergy in CRS

Chart review of 113 sinus surgery patients

48 patients included in the study

Allergy testing by RAST or skin testing

57.4% had a positive allergy test

Guman et al. Otolaryngol Head Neck Surg 2004;130:545

Type of Allergy Among Sinus Surgery Patients

None

Perennial and seasonal

Perennial

Seasonal

Emmanuel et al. Otolaryngol H&N Surg 2000; 123:687 and Ramandan et al. Am J Rhinol 1999; 13:345

Diagnosis of CRS Physical examination

Endoscopy or anterior rhinoscopy Purulent drainage Edema or erythema of the middle meatus or ethmoid bulla polyps

Sinus CT scan Mucosal thickening Air-fluid level

Meltzer et al. JACI 2004;114:155

Medical Management of Chronic Rhinosinusitis

Antibiotics

Corticosteroids

Decongestants

Muco-evacuants

Antihistamines

Non-pharmacologic treatment

v

Microbiology of Chronic Rhinosinusitis

Not well defined because of differences in culturing techniques, prior use of abx

S. pneumoniae, H. influenzae, M. catarrhalis

S. Aureus, coagulase negative staph, anaerobes

Fungi

Meltzer et al. JACI 2004;114:155

Chronic Rhinosinusitis: Which Antibiotic to Use?

-No antibiotic is approved by FDA for CRS

-We use similar abx as ABRS

Antibiotics for Chronic Rhinosinusitis

Appropriate duration is not well defined

AAAAI and ACAAI Joint Task Force treat for 3,4 or 6 weeks continue abx for at least 1 week after the patient is symptom free

Task Force on Rhinosinusitis of the American Academy of Otolaryngology-Head and Neck Surgery

treat 4 to 6 weeks

Adjunctive Therapy

Decongestants Used as adjuvant treatment

no controlled studies

Mucolytic treatment 1 double blinded study

2400 mg of guaifenesin or placebo in HIV+ with chronic sinusitis

improvement in congestion and thick secretions

Wawrose et al. Laryngoscope 1992;102:1225

Adjunctive Therapy

Antihistamines

play a role in allergic rhinitis patients with sinusitis

Saline irrigation

may help mucociliary clearance

mild vasoconstrictor of nasal blood flow

Intravenous immune globulin

indicated in patients with impaired humoral immunity

Surgery for Rhinosinusitis

FESS enlarge sinus ostia

correct anatomic deformities (septal deviation, concha bullosa)

create a common cavity for nasal drainage

ventilate sinuses

>85% improvement in selected series

Summary

Acute rhinosinusitis is usually related to infection Antibiotic management is first line

Chronic rhinosinusitis is usually related to inflammation

Further characterization of the condition is important (nasal polyps) Exploration of underlying allergy is important Management is challenging