Medical Management of Chronic Rhinosinusitis Michael … aspects of managing... · Medical...
Transcript of Medical Management of Chronic Rhinosinusitis Michael … aspects of managing... · Medical...
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Medical Management of Chronic Rhinosinusitis
Michael A Kaliner, MD
Medical Director, Institute for Asthma and AllergyWheaton and Chevy Chase, MD
Professor of Medicine, George Washington University School of Medicine
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1. Maxillary2. Ethmoidal bulla3. Ethmoidal cells4. Frontal sinus5. Uncinate process6. Middle turbinate7. Inferior turbinate8. Nasal septum9. Ostiomeatal
complex
Ostiomeatal complex
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The signs and symptomsof chronic sinusitis
(symptoms persisting >12 weeks):Prerequisite symptoms
� Purulent nasal and posterior pharyngeal discharge
� Plus:� Facial pain/pressure� Persistent nasal
obstruction� Cough/post-nasal
drip/throat clearing
Supporting symptoms
� Hyposmia, anosmia
� Sore throat
� Malaise
� Fever
� Headache, facial pressure, dental pain
� Halitosis
� Sleep disturbance
� Fatigue
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Infections may obstruct the OMC
B
MT
MS
IT
The ostiomeatal complex
Key
B: bulla ethmoidalis
IT: inferior turbinate
MT: middleturbinate
MS: maxillary sinus
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Underlying Causes of Chronic Rhinosinusitis� Allergy
� Seasonal AR� Perennial AR� Nonallergic rhinopathy
� Infection� Acute� Chronic: Bacterial, fungal
� Consider host defense deficency
� Structural� Ostiomeatal complex:
� Deviated nasal septum� Hypertrophic turbinates
� Others� Dental, periapical
abcess� Underlying diseases,
cystic fibrosis, ciliary immotility
� Occupational irritants and allergens
� Drug induced, rhinitis medicamentosa
� Irritant-induced rhinitis� Atrophic rhinitis
After International Consensus Report on the diagnosis and management of rhinitis. Allergy Suppl 19,49,1994
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The Signs and Symptomsof Acute Sinusitis
• Prerequisite symptoms:– Persistent URI
(>10 days)– Persistent muco-
purulent nasal or post-pharyngeal discharge
– Cough
• Supporting symptoms:– Congestion – Facial pain/pressure– Post-nasal drip– Fever– Headache, facial
pressure, tenderness– Anosmia, hyposmia– Ear pain, pressure– Halitosis– Upper dental pain– Fatigue– Sore throat
Acute sinusitis (symptoms persisting 10-28 days):
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Does this patient have sinusitis?
• Must have congestion and purulent drainage– Green, not yellow secretions
• Most patients lose their sense of smell– Rate your sense of smell between 0 and 10, 0 is zero;
10 is normal; same scale for taste• Headache and facial pressure:
– Over sinus area– Steady, not throbbing– Lasts for hours– Worsens if head is moved
• Have patient touch chin to chest or shake head “no”– Tenderness over sinus when tapped with finger
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Does patient have sinusitis?
• PE:– Congestion
– Sometimes erythematous mucosa– Purulent drainage -middle meatus
• Stranding?• History of green secretions?
– Green, yellow-green, gray
– Asymmetric transillumination
– Tenderness over sinus by percussion
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Does patient have sinusitis?
• CT Scan– Gold standard– Limited cut, coronal plane
• MRI– Very sensitive– Useful for fungal sinusitis
• Cold T2 weighted image
level.
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Does patient have sinusitis?
• Culture of middle meatus– Cotton swab is generally useless
– Use Calgiswab• Pediatric urethral culture swab• Calcium alginate on a wire• Allows direct culture from meatus
• Overall: of some use, some of the time
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Bacterial Rhinitis (local nasal infection)
• Doc: I got sinus!• Sick all the time, congestion, headache,
green drainage, gets sick a few days after last antibiotic, 5-10 antibiotics per year
• But… Normal sense of smell, normal CT• ENT evaluation and they did NOT
recommend surgery
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Bacterial Rhinitis (Local nasal infection)
• Not currently recognized as specific disease• Local Staph or Strept infections
– Crusting, green secretions– Excess drainage
• Throat clearing, cough, runny nose– Often young, constantly or recurring sick – But normal CT– No anosmia (often a keen sense of smell)
• Culture positive for Staph or Strept species• High degree of suspicion• Often with contact points (septum-
turbinate, spurs)
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Treatment of Bacterial Rhinitis
• Topical Bactroban (mupiricin) 2%– Instilled locally (finger, Q-tip) and massaged
back– Alternative: Dissolve BB in sinus rinse
• Add ½-1 inch strip of BB, add 1 Oz hot water, shake and dissolve BB, QS to 4-8 Oz, add salt, shake and then wash nose and sinuses
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Rhinologic Headaches
• Recurring headache and secretions in young, healthy patient (usually female)
• Headache is nasal/sinus in location– Steady, lasts hours to days, not affected by
head movement
• Secretions are yellow or clear; not purulent
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Rhinologic Headaches
• PE: – Septal deviation with septum-turbinate contact
• Septal spur with spur-turbinate contact
– Turbinate-turbinate contact
– Posterior valve• Turbinate-turbinate-septal contact
– Clear secretions– Adequate middle meatus/ostiomeatal complex
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Rhinologic Headaches
• Diagnosis is by high index of suspicion– Headaches and non-purulent secretions and
normal sense of smell– Normal CT scan
• Apply nasal decongestant– Spray or swab
• Apply 4% Xylocaine– Spray or swab
Evaluate headache
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Rhinologic Headaches
• Treatment:– Nasal saline washes
– Nasal corticosteroids +/-– Nasal antihistamine
• azelastine or olopatadine
– PRN topical nasal decongestant– PRN topical nasal Xylocaine
Use to prevent headaches
from occurring
Use to treatheadaches as
they occur
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Association Between Viral and Bacterial Sinusitis Infections
• Viral infections– Self-limiting– 2 to 3 acute viral respiratory
infections per year (6-8 in children)– >80% symptoms resolve in 7-10 d– Often inciting event for development
of sinusitis and other RTIs– 0.5%–2% of cases complicated by
acute bacterial infection (>20 million cases)
RTI=respiratory tract infections. RTI=respiratory tract infections.
Brook. Brook. Primary CarePrimary Care 1998;25:633; 1998;25:633; GwaltneyGwaltney . . ClinClin Infect Infect DisDis 1996;23:1209; 1996;23:1209; GwaltneyGwaltney et al. et al. N N EnglEngl J Med J Med 1994;330:25.1994;330:25.
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Common cold
Increase in symptoms after 5 days
Persistent symptoms after 10 days
0 5 10 15Days
Sym
ptom
sDefinition of Acute Nonviral
Rhinosinusitis
12Weeks
Increase in symptoms after 5 days or persistent sym ptoms after 10 days
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Healthy Rhinosinusitis
Inflammation Is Responsible for Cardinal Symptoms of Acute Rhinosinusitis
Underlying inflammation leads to …
…increased vascular permeability and mucosal oedema
…increased mucus production
…impaired mucociliaryfunction
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2010 Approach to the Treatment of Acute Rhinosinusitis
1. Hydration (6 - 8 glasses of water per day)2. Long-acting topical nasal decongestant,
BID X 3-7 days (oxymetazole)3. Nasal saline applied with nasal irrigation
device, BID4. Topical nasal CCS, 2 sprays EN BID5. If symptoms persist past 7-10 days:
Antibiotics X 7-14 days (until asymptomatic +5-7 days). Choices: amoxicillin/clavulanate, cephalosporin, clarithromycin
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Antibiotics in acute rhinosinusitis?
� Don’t treat common viral cold with antibiotics� Use symptomatic treatment in mild acute
rhinosinusitis� saline � topical decongestant� NCCS� Analgesics
� Use topical steroids in acute and chronic sinusitis (evidence A)
� Reserve antibiotics for severe, acute, presumably bacterial rhinosinusitis
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Recommended antibiotic choices -2010
First choice:Amoxicillin/clavulate or cephalosporin Good second choice: Clarithromycin(Zithromycin, 5-0-(5), may also be quite useful)
Back-ups:QuinalonesUse metronidazole plus one of the above or clindamycin when gram negative is suspectedTopical mupiricin very useful in select cases
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Unilateral Sinusitis
• Dental abscess– Foul smelling, evidence of periapical abscess
• Fungal sinusitis• Polyp• Mucocoele• Tumor of the sinus/nose
– Inverted papilloma
• Congenital aplasia/hypoplasia
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Odontogenic Sinusitis(Dental Periapical Abscess)
• Unilateral sinusitis– Nearly always in maxillary sinus above the
site of the abscess or perforation through the floor of the sinus after dental procedure
• Foul smelling– Microaerophilic Strept species
• Persistent or recurring
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Odontogenic Sinusitis(Dental Periapical Abscess)
• Diagnosis is by dental x-ray and confirmation of presence of periapicalabscess
• Treat by root canal and drainage of abscess
• Requires penicillin-type antibiotic
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Chronic Rhinosinusitis: Why?
� Chronic inflamed mucosa� Neutrophils and mononuclear cells in CRSsNP� Eosinophils in CRSwNP
� Possible chronic infection� Bacteria� Fungi
� Superantigens� Biofilms� Osteitis
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Bacteria in Biofilms
• May be antibiotic resistant• May be hard to culture• Found in surgical specimens from CRS
(44%+)– S aureus, P aeroginosa, H Influenza, S
pneumonia
• Clinical implications– Saline sinus washes– BKC?
– Zwitterionic surfactant? JBS
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Superantigens or superallergens� Bacterial Superantigens
� Staph aureus enterotoxins: SEA, SEB, SEC, SED, SEE, TSST-1
� Strep. pyogenes, � Mycoplasma arthritidis, � Yersinia pseudotuberculosis ……
� Highly potent immune stimulators� Interact with T-cell R
and MHC class II� 20% of all T-cells are activated
by SEA
SA
g
T-Cell
Vββββ Vββββ
MHC
II
TCR
APC
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S. aureus colonization and IgE antibodies to S. aureus enterotoxin mix in mucosal tissue
3327
6467
88
14
6
28
54
80
0
10
20
30
40
50
60
70
80
90
100
Controls
(n=9)
CRS
(n=22)
NP
(n=53)
NP +
asthma
(n=18)
NP +
AERD
(n=8)
Patients
(%
)
S. aureuscolonization
SAE-IgE+
*
*
*
*
*
*
T. Van Zele, P. Gevaert et al. JACI 2004
*P<0.05 vs. CRS.
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Recommended approach to the treatment of chronic rhinosinusitis 2010
� Hydration (6 - 8 glasses of water per day)� Antibiotics only if clear evidence of infection: use X 14-
21+ days (until asymptomatic +7 days). � Long-acting nasal decongestant, BID X 3-7 days
(oxymetazoline)� Nasal saline applied with nasal irrigation device, BID� Topical nasal CCS (only Mometasone has FDA
approval):� 2 sprays BID, until symptoms resolved� Reduce to lowest effective dose, to maintain
remission� Aim towards the eye and away from the nasal
septum
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Next recommended approaches
� Switch antibiotics (only if evidence of ongoing bacterial infection)
� CT scan; limited cut, coronal plane � Treat bacterial rhinitis� rarely MRI – fungal or possible tumors
� Add metronidazole or clindamycin (especially with foul smell – gram negatives)
� Consider fungal Rx (itraconazole, not amphotericin) � Oral CCS (Daily followed by QOD)� Topical antibiotics (tobramycin rarely, mupirocin nasal
ointment)
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Chronic rhinosinusitisWith and without nasal polyps
Chronic
Rhinosinusitis Nasal Polyps
Nasal Polyps
The spectrum of sinus disease
Rhinosinusitis
- Eosinophils +
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Nasal polyposisPrevalence approx. 2- 4%, 25% of CRS
Asthma in approx. 40-65%
Aspirin sensitivity in 10-15%
Mixed cellular infiltrate withprominent eosinophilia in 90%
Inflammation with � local IgE production� increased IL-5, eotaxin,
cys-LTs and ECP
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Treatment of Nasal Polyps
• Treatment of underlying condition• Continue treatment of sinusitis• Topical corticosteroids (Mometasone
only current INS approved by FDA in USA)– Flovent– Pulmicort
• Systemic corticosteroids• Polypectomy
Kaliner MA. Current Review of Allergic Diseases. Philadelphia, Pa: Current Medicine, Inc., 1999.
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Preliminary Results of Intranasal Flovent Treatment
• Retrospective chart review of 73 patients with polyps and sinusitis who failed initial therapy
• 64.4 % of patients treated with intranasal Floventwere also started on 2-3 weeks of oral CCS.
• The combination of long-term intranasal Floventand short term oral CCS resolved polyps in 77.4% of patients (p=0.0045) at 7-9 months
• There was significant reduction in polyp size within 1-2 months: 75% significantly reduced at 1 month, >80% at 2 months
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Polyp Resolution p=0.0045
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%60.00%
70.00%
80.00%
Polyp Resolution77.4%Polyps did notresolve 22.60%
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Budesonide use, 2010
� Dilute budesonide solution (Pulmicort Respules), 500-1000 ug in 2-4 Oz saline and irrigate the sinuses BID
� Have head positioned to the side so that gravity helps get washings into the sinuses; turn head as if to put the ear on knee
� Has resolved polyp resistant to nasal fluticasone sprays
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Mupiricin use
� Use mupiricin with� Recurrent crusting, particularly anterior� Congestion, headache, green secretions & normal CT
– contact points, spurs � Polyps
� Mupiricin (Bactroban 2%) anteriorly with finger or Q tip, blot nose
� Dissolved in saline, irrigate nose and sinuses with sinus rinse, along with budesonide for nasal polyps
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Polyp treatments - 2010� Anticipate 25+% improve with sinus Rx + nasal CCS� Another 25-50% improve with sinus Rx + high dose
nasal CCS (FP MDI or nasal lavages with budesonide)� The remainder improve with oral CCS + FP or nasal
lavages with budesonide solution Overall medical treatment can get close to 100% success� Mupiricin appears to help prevent polyp regrowth,
especially with crusting� Add ½-1 tsp of betadine to sinus wash� Surgery, properly done, is successful short-term but
polyps can and do recur and repeated surgery gets progressively more difficult and dangerous!
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Polyps – recommended treatment -2010
� Treat underlying sinusitis� High dose nasal CCS
� Budesonide solution (Pulmicort Respules) suspended in sinus lavage (+/- betadine)� Wash with the head positioned with ear turned to the
knee� Singulair (?)
� Prednisone 20-30 mg� Daily x 3-4 weeks, then QOD, then taper to 0
� Fluticasone (Flovent MDI) through nasal adapter (such as a baby bottle nipple)
� Mupiricin ointment topically or dissolved in sinus lavavge� Consider careful surgery if polyps are persistent, resistant or
recur� Consider oral or topical anti-fungal treatment
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Whew!!
Thank you
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