mwvave respiraciuli infeqciis marTvis gaidlaini

avtorebi: i.CxaiZe, T.maRlakeliZe, q. nemsaZe, m.xerxeuliZe, n.yavlaSvili, e. kandelaki, q.barabaZe

eqspertebi: S.jafariZe, e.vaSakiZe, m.xoWava, q.HSarangia

Tbilisi2006

saqarTvelos respiraciuli asociacia

saqarTvelos Sromis, janmrTelobisa da socialuri dacvis

saministro

Sesavalirespiraciuli sistemis daavadebebi pirveladi jandacvis rgolis

dawesebulebebSi mimarTvianobis ZiriTad mizezs warmoadgenen. mwvave respiraciuli infeqciebis maRali sixSire praqtikuli medicinis seriozul problemad rCeba. gasaTvaliswinebelia sakiTxis socialuri mniSvnelobac – mwvave respiraciuli paTologiiT avadoba qveynisaTvis seriozuli ekonomikuri tvirTia, romlis Semadgenelia rogorc uSualod mkurnalobaze daxarjuli Tanxa, ise droebiTi SromisuunarobiT gamowveuli danakargebi.

mwvave respiraciuli paTologiis gaidlainSi ganxiluli iqneba zemo sasunTqi gzebis mwvave paTologia. qvemoT moyvanili diagrama asaxavs gaidlainis organizacias:

winamdebare gaidlainSi moyvanilia mwvave otitis, sinusitis, faringitis da gaciebis marTvis Tanamedrove rekomendaciebi. gaidlaini mniSvnelovania ori TvalsazrisiT. pirvel rigSi, is aRwers diagnostikisa da mkurnalobis im problemebs, romlebTanac eqimebs yoveldRiuri Sexeba aqvT. meores mxriv, am daavadebaTa marTva xSirad Seusabamo medikamentebiT xdeba, gansakuTrebiT es exeba antibiotikebs. antibiotikebis gamoyeneba maSin, rodesac is aucilebeli ar aris; meore da mesame Taobis antibiotikebis gamoiyeneba maSin, rodesac pirveli Taobisaa saWiro – yvelaferi es jandacvis

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mwvave respiraciuli paTologia

zemo sasunTqi gzebis mwvave paTologia

qvemo sasunTqi gzebis mwvave paTologia

gacieba

faringiti

otiti

sinusiti

pnevmonia bronqiti

seriozul problemas qmnis: yalibdeba baqteriebis antibiotikebis mimarT rezistentuli Stamebi. amitom am gaidlainSi gansazRvruli iqneba antibiotikis adeqvaturi gamoyenebis Cvenebebi, romelic saSualebas miscems eqims daicvas medicinis erT-erTi mTavari postulati – premium non nocere (ar avno).

gaidlainebSi moyvanili informacia Sefasebulia faqtebze damyarebuli medicinis (Evidance Based Medicine) sarwmunoebis TvalsazrisiT.

mtkicebulobis done da rekomendaciis xarisxi

done mtkicebulebis siZlieris done

xarisxi rekomendaciis xarisxi

I Zlieri mtkicebuleba, eyrdnoba minimum erT sistemur mimoxilvas, romelic efuZneba swori dizainis mqone randomizebul kontrolirebadi kvlevas

A eyrdnoba I donis mtkicebulebas da Sesabamisad mtkiced rekomendebulia

II Zlieri mtkicebuleba, eyrdnoba minimum erT swori dizainis mqone randomizebul kontrolirebadi kvlevas

B eyrdnoba II donis mtkicebulebas da Sesabamisad rekomendebulia

III klinikuri kvleva randomizaciis gareSe, kohortuli da SemTxveva-kontrolis kvlevebi

C eyrdnoba III donis mtkicebulebas da SeiZleba CaiTvalos Sesabamisad

IV araeqsperimentuli multicentruli kvlevebi

D eyrdnoba IV da V donis mtkicebulebas, saWiroebs konsesuss

Va avtoritetul profesionalTa mosazreba

Vb klinikuri gamocdileba, aRwerilobiTi kvlevebi an eqspertTa angariSi

mwvave faringiti gaidlainis aucilebloba. SemTxvevaTa umravlesobaSi mwvave faringiti

msubuqad mimdinareobs da ar saWiroebs mkurnalobas. mas mxolod erTeuli mogvianebiTi garTulebebi axasiaTebs. miuxedavad amisa, xSirad mwvave

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faringitis dros aqtiurad iyeneben antibiotikebs, romelTa aucilebloba dadasturebuli ar aris da, amave dros, maTi daniSvna mniSvnelovnad aZvirebs mkurnalobas.

pacientebis nawili xdeba yel-yur cxviris eqimTan, romelic xSirad irCevs operaciul Carevas, romlis aucilebloba emyareba pirad gamocdilebas da ara faqtebze damyarebul rekomendaciebs.

mwvave faringitis gaidlaini emyareba literaturis sistemur mimoxilvas da faqtebze damyarebuli medicinis rekomendaciebs. gaidlaini ganixilavs mwvave faringitis optimalur marTvas, ramac xeli unda Seuwyos: (a) daavadebis mZime formebis ricxvis Semcirebas; (b) mwvave revmatuli cxelebiT avadobis Semcirebas; (g) garTulebebebis prevencias; (d) Seusabamo antibiotikoTerapiis uaryofiTi zegavlenis Semcirebas.

definicia. mwvave faringiti orofaringealuri aris anTebiTi procesia. mwvave faringiti SeiZleba aRwerili iqnes rogorc “yelis tkivili” (avadmyofobaTa saerTaSoriso klasifikaciis meaTe gadaxedvis mixedviT is Seesabameba mwvave faringits - J02).

epidemiologia. epidemiologiuri monacemebi gansxvavebulia qveynebis mixedviT. weliwadSi mwvave respiraciuli infeqciiT aSS-Si erTi bavSvi saSualod 5-jer xdeba avad, maSin rodesac streptokokuli infeqciiT - mxolod erTxel yovel 4 weliwadSi. mozrdilebSi zemoaRniSnuli monacemebis sixSire saSualod 50%-iT naklebia. sxva qveynebSi mwvave faringitis sixSire SedarebiT maRalia. gansakuTrebiT maRalia antibiotikebisadmi rezistentuli Stamebis ricxvi, rac antibiotikebis araracionaluri gamoyenebiT aixsneba (sarwmunoebis done II).

aRsaniSnavia, rom avadmyofTa umravlesoba ar mimarTavs samedicino dawesebulebebs. erT-erT kvlevaSi naCvenebia, rom did britaneTSi yelis tkivilis 18 epizodidan mxolod erT SemTxvevaSi mimarTaven eqims.

mwvave faringitis sixSire SedarebiT maRalia gviani Semodgomidan adreuli gazafxulis periodamde. igi ufro xSiria 5-10 wlis da 15-25 wlis asakSi.

saqarTveloSi mwvave faringitis, iseve rogorc sinusitis an otitis monacemebi cal-calke ar registrirdeba. saqarTvelos daavadebaTa kontrolis da samedicino statistikis centris 2005 wlis monacemebiT qveyanaSi registrirebul iqna qronikuli faringitis, nazofaringitis da sinusitis 21.553 SemTxveva, rac 100.000 mosaxleze 493 SemTxvevas warmoadgens. bavSvebSi registrirebuli iqna 7.322 SemTxveva, rac 100.000 bavSvze 799

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SemTxvevas warmoadgens. amave wels saqarTveloSi registrirebul iqna nuSura jirkvlebis da danamati Rruebis qronikuli daavadebis 22.781 SemTxveva, rac 100.000 mosaxleze 521 SemTxvevas warmoadgens. bavSvebSi registrirebuli iqna 12.679 SemTxveva, rac 100.000 bavSvze 1.384 SemTxvevas warmoadgens.

etiologia. ZiriTad etiologiur faqtors warmoadgens virusi (40%) da baqteriuli (30%)

flora. yelis tkivilis gamomwvevi SeiZleba iyos agreTve qimiuri (sigaretis moweva), meqanikuri agenti (nakawri, naCxapni Zvlis fragmentiT), alergia an postnazaluri wveTi an iSviaTad kibo (adreul stadiaSi kibo xSirad vlindeba tkivilis simptomiT).

faringitis gamomwvevi ZiriTadi virusebia rinovirusi, koronavirusi, eqovirusi, koksaki, gripis da paragripis virusi. SedarebiT iSviaTia epStein-baris virusi, citomegalovirusi, adenovirusi, martivi herpesis virusi.

jgufis hemolizuri streptokoki ganapirobebs faringitis SemTxvevaTa 10-15%-s mozrdilebSi da 30%-s bavSvebSi.

sxva gamomwvevebia: Corynebacterium diphtheriae; Corynebacterium

hemolyticum, Chlamydia pneumoniae, Mycoplasma pneumoniae. bavSvebSi sxva paTogenuri flora SeiZleba iyos: Staphylococus aureus, Haemophilus catarralis,

Bacteroides fragilis, Bacteroides lannogenius, Fuzobacterium species, Peptostreptococcus

species.

paTofiziologia. infeqciuri faringitis SemTxvevaSi baqteria da virusi SeiZleba pirdapir SeiWras lorwovan garsSi da gamoiwvios anTebiTi procesi. zogi gamomwvevi, magaliTad rinovirusi, xaxis lorwovanis dazianebas ganapirobebs meoradad, rinitis ganviTarebis Semdeg. streptokokuli infeqcia xasiaTdeba lokaluri invaziiT da ujredgareT toqsinebis da proteinebis gamoTavisuflebiT. garda amisa, streptokokis zogierTi serotipis M-proteinis fragmentebi miokardiumis antigenis msgavsia da, aqedan gamomdinare, ukavSirdeba revmatul cxelebas da SemdgomSi gulis sarqvlis dazianebas. streptokokuli infeqciiT aris ganpirobebuli aseve mwvave glomerulonefriti, romelsac iwvevs antigen-antisxeulis kompleqsis depozicia glomerulebSi.

klinikuri suraTi. faringitis klasikuri simptomebi moicaven yelis tkivils, disfagias, cxelebas, saerTo sisustes, Tavis tkivils. obieqturi gamokvlevisas vlindeba xaxisa da nuSura jirkvlebis anTebiTi cvlilebebi (hiperemia, Sesiveba), Cirqovani nadebi nuSura jirkvlebze, kisris wina limfuri jirkvlebis

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Sesiveba. arc erTi es niSani ar aris paTognomuri streptokokuli etiologiis faringitisaTvis, Tumca maTi arsebobis SemTxvevaSi daaadebis baqteriuli etiologia ufro SesaZlebelia.

cxviridan gamonadeni, xvela, xmis CaxleCa, koniunqtiviti da diarea iSviaTia, da Tu es niSnebi gamoCnda, safiqrebelia daavadebis virusuli etiologia. streptokokuli etiologiisaTvis damaxasiaTebelia aseve temperaturis uecari mateba (380-ze meti) Semcivnebis gareSe.

iSviaTad mwvave faringiti SeiZleba iyos mwvave epiglotitis an zemo sasunTqi gzebis sxva seriozuli daavadebis gamovlena.

Tu am dros aRiniSneba sunTqvis gaZnelebac saswrafod gadaagzavneT avadmyofi stacionarSi da moerideT xaxis gamokvlevas.

saswrafo hospitalizacia. stacionarSi moTavseba iSviaTad aris aucilebeli. aseTia peritonzilaruli celulitis an abscesis SemTxvevebi, rodesac saWiroa otolaringologis meTvalyureoba da parenteraluri antibiotikebi. iSviaTad hospitalizaciis mizezi SeiZleba gaxdes disfagia an dehidratacia.

yelis tkivilTan erTad arsebuli stridori an sunTqvis gaZneleba hospitalizaciis saswrafo Cvenebas warmoadgens.

diagnostika.ar aris monacemebi, romlebic daadastureben, rom baqteriuli faringiti

ufro mZimed mimdinareobs, vidre virusuli an rom daavadebis xangrZlivoba gansxvavdeba etiologiis mixedviT. mwvave faringitis diagnozi SeiZleba daeyrdnos klinikur niSnebs an laboratoriul gamokvlevebs. stacionarSi uxSiresad iyeneben xaxis nacxis baqteriologiur gamokvlevas an antigenis deteqciis swraf tests (RAT).

k l i n i k u r i d i a g n o z i . daavadebis klinikuri gamovlinebani arasakmarisia baqteriuli da virusuli etiologiis sadiferenciacioT. specifiurobis da mgrZnobelobis kvlevam aCvena, rom mxolod klinikur niSnebze dayrdnobiT mwvave faringitis SemTxvevaTaA25-30% rCeba diagnostikis gareSe da SemTxvevaTa 20-40%-Si negatiuri baqteriologiuri pasuxis miuxedavad dasmuli iqneboda streptokokuli faringitis diagnozi (sarwmunoebis done II).

baqteriuli da virusuli etiologiis faringitis diferencirebas ar unda daedos safuZvlad daavadebis klinikuri niSnebi.

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b a q t e r i o l o g i u r i k v l e v a . baqteriologiuri kvlevis dadebiTi Sedegi adasturebs daavadebis streptokokul etiologias, Tumca uaryofiTi pasuxi ar gamoricxavs daavadebis baqteriul etiologias. garda amisa, aris SemTxvevebi, rodesac xaxis nacxidan izolirebulia streptokoki, Tumca infeqcia serologiurad ar dasturdeba. SemTxvevaTa 40%-Si aseve aRniSnulia streptokokis asimptomuri mtarebloba. nuSura jirkvelebis zedapiridan aRebuli flora yovelTvis ar Seesabameba tonzilebis siRrmidan miRebul masalas, arada swored es ukanaskneli aris pasuxismgebeli daavadebis ganviTarebaze. serologiurad dadasturebuli infeqciis SemTxvevaSi xaxis nacxi ar xasiaTdeba maRali specifiurobiT da mgrZnobelobiT. is aseve zrdis daavadebis Rirebulebas da SeiZleba ganapirobos araaucilebeli medikamenturi mkurnaloba (sarwmunoebis done III).

mwvave faringitis SemTxvevaSi xaxis nacxis baqteriolgiuri kvleva ar unda Catardes rutinulad.

a n t i g e n i s d e t e q c i i s s w r a fi t e s t i ( R A T ) . stacionarSi SeiZleba gamoyenebuli iqnes antigenis deteqciis swrafi testi. xaxis an nuSura jirkvlebis nacxSi streptokokis antigenis gansazRvris testis upiratesobaa misi siswrafe da maRali specifiuroba (95-100%). misi gamoyenebiT SesaZlebelia aseve SeizRudos antibiotikebis gaumarTlebeli gamoyeneba. mis ZiriTad uaryofiT mxares warmoadgens meTodis dabali mgrZnobeloba (50-95%).

s e r o l o g i u r i d i a g n o s t i k a . avadmyofis organizmis imunur pasuxze vlaparakobT maSin, rodesac antistreptolizinis, ant-dnm-is, an sxva antistreptokokuli antisxeulebis titri 4-jer matulobs. imunoserologiuri kvleva streptokokuli infeqciis erT-erTi saimedo meTodia, Tumca misi mgrZnobeloba mcirdeba antibaqteriuli Terapiis fonze. daavadebis mwvave periodSi antistreptokokuri antisxeulebis titri maqsimums aRwevs me-2-3 kviras.

yovelive zemoaRniSnulidan ganasxvaveben streptokokuli faringitis 4 tips:

1. streptokokuli faringiti: tipuri klinikuri suraTi, baqteriologiuri da serologiuri kvlevis dadebiTi Sedegebi;

2. SesaZlo streptokokuli faringiti: tipuri klinikuri suraTi, baqteriologiuri kvlevis dadebiTi Sedegi, serologiuri kvlevis SeuZlebloba;

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3. mtarebloba: tipuri klinikuri suraTi an usimptomo mimdinareoba, baqteriologiuri kvlevis dadebiTi Sedegi, uaryofiTi serologiuri pasuxi;

4. kolonizacia: usimptomo mimdinareoba, baqteriologiuri kvlevis dadebiTi Sedegi.

marTva. mwvave faringitis diagnozi ar niSnavs, rom aucileblad unda dainiSnos antibiotiki. adeqvaturi tkivilgamayuCebeli saSualebebi xSirad savsebiT sakmarisia mkurnalobisaTvis.

t k i v i l g a m a y u C e b e l i s a S u a l e b e b i . pacienTta umravlesoba arasodes ar mimarTavs eqims, vinaidan simptomuri saSualebebi aspirinis an paracetamolis saxiT savsebiT sakmarisia mkurnalobisaTvis. aqve unda aRiniSnos, rom reis sindromis ganviTarebis riskis gamo bavSvebSi aspirinis gamoyeneba ar aris daSvebuli.

a r a s t e r o i d u l i a n T e b i s s a w i n a a R m d e g o s a S u a l e b e b i . mravali kvleva aRwers arasteroiduli anTebis sawinaaRmdego saSualebebis gamoyenebas mwvave faringitis da tonzilitis dros. naCvenebia, rom mkurnalobis ori-sami dRis Semdeg ufro swrafad xdeba tkivilis, cxelebis, disfagiis, xiluli hiperemiis, limfadenopaTiis Semcireba placebosTan an paracetamolTan SedarebiT. Tumca unda aRiniSnos, rom mwvave faringitis an tonzilitis simptomebi TavisTavad mcirdeba daavadebis dawyebidan 48-72 saaTis Semdeg (sarwmunoebis done I).

amave dros, arasteroiduli anTebis sawinaaRmdego saSualebebis gamoyeneba dakavSirebulia gastrointestinaluri sisxldenis, gulisrevis, Rebinebis, muclis tkivilis da diareis ganviTarebis dadasturebul riskTan.

arasteroiduli anTebis sawinaaRmdego saSualebebis gamoyenebis riskis gamo maTi rutinuli gamoyeneba mwvave faringitis dros rekomendebuli ar aris.

d a m a t e b i T i T e r a p i a . erTeul kvlevebSi aris dadasturebuli savlebi saSualebebis (benzidaminis hidroqloridis) efeqturoba tkivilis da disfagiis Semcirebis TvalsazrisiT, magram es Sedegebi Semdgom dadasturebas moiTxoven (sarwmunoebis done I).

a n t i b i o t i k e b i s g a m o y e n e b a .antibitikebi mwvave faringitis dros. mwvave faringitis yvela

SemTxveva ar aris baqteriuli etiologiis, ase rom alogikuria mwvave faringitis yvela SemTxvevaSi gamoyenebul iqnes antibiotiki.

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Ria kvlevaSi, romelic 700 pacientSi Seiswavlida mkurnalobis sxvadasxva reJimis efeqturobas (antibiotiki, antibiotikis gareSe, antibiotikis daniSvna sami dRis dagvianebiT) naCvenebia, rom am jgufebs Soris daavadebis gamosavalis TvalsazrisiT gansxvaveba ar aris (sarwmunoebis done I).

ar arsebobs sakmarisi informacia, romelis daadasturebs antibiotikebis rutinuli gamoyenebis aucileblobas mwvave faringitis dros.

daavadebis mZime mimdinareobisas, rodesac pacientis zogadi mdgomareoba mZimea, antibiotiki unda iqnes gamoyenebuli (penicilini V 250 4-jer an 500 mg 2-jer an 4-jer dReSi 10 dRis ganmavlobaSi; bavSvebSi 250 mg 2-jer an 3 jer dReSi, 10 dRe per os)

an penicilini G (benzatin penicilini) erTjeradad kunTebSi, 1.200.000

mozrdilebSi, 27 kg-mde wonis bavSvebSi – 600.000. eqimma unda gaiTvaliswinos, rom mZime faringiti da kisris limfuri

jirkvlebis gadideba SeiZleba infeqciuri mononukleozis niSani iyos, amitom unda moeridos pirveli rigis preparatad ampicilinis gamoyenebas.

amerikis pediatriis akademiis da daavadebaTa kontrolis centris (CDC)

mier rekomendebulia amoqsicilis gamoyeneba meore rigis preparatad rezistentul floraze misi upiratesi zemoqmedebis gamo.

penicilinze alergiis SemTxvevaSi mizanSewonilia makrolidebis gamoyeneba. eriTromicinis gamoyeneba misi gverdiTi movlenebis (gulisreva, diarea) SezRudulia. rig kvlevebSi naCvenebia axali Taobis makrolidebis (spiramicini, azitromicini) efeqturoba baqteriologiuri da klinikuri monacemebis gaumjobesebis TvalsazrisiT.

(sarwmunoebis done II).antibiotikebi morecidive faringitis dros. mwvave faringitis

morecidive mimdinareoba im pacientebSi, romlebic iRebdnen antibiotikebs, miuTiTebs, rom gamoyenebul iqna Seusabamo antibiotiki, antibiotiki daniSnuli iyo araadeqvaturi doziT an xangrZlivobiT, pacienti ar daemorCila mkurnalobas, aRiniSna re-infeqcia an daavadebis gamomwvevi iyo penicilin-rezistentuli beta-laqtamazis maproducirebeli Stamebi. aseT SemTxvevebSi naCvenebia benzatin-penicilinis (penicilini G), cefuroqsimis an klindamicinis gamoyeneba (sarwmunoebis done I da III).

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ar arsebobs sakmarisi informacia, romelic daadasturebs antibiotikebis gamoyenebis aucileblobas mwvave morecidive arastreptokokuli faringitis dros.

streptokokTan asocirebuli morecidive faringitis dros mcirericxovani kvlevebia, romlebic gvidastureben 10 dRiani antibiotikoTerapiis efeqturobas gamwvavebaTa sixSiris Semcirebis TvalsazrisiT.

ar arsebobs sarwmuno informacia, romelic daadasturebs streptokokuli faringitis profilaqtikis mizniT antibiotikebis xangrZlivi gamoyenebis efeqturobas.

antibiotikebi revmatuli cxelebis da glomerulonefritis prevenciisaTvis.

streptokokuli faringitis mkurnalobis erT-erTi pirveladi klinikuri racionalizmi revmatuli cxelebis Tavidan acilebaSi mdgomareobs. analogiuri Sexedulebaa glomerulonefritTan dakavSirebiT. Tumca unda aRiniSnos, rom ar arsebobs kvlevebi, romlebic miuTiTeben antibiotikoTerapiis efeqturobas glomerulone-fritis prevenciis mizniT (sarwmunoebis done II).

tonzileqtomia morecidive faringitis drosliteraturuli monacemebi tonzileqtomiis Sesaxeb Zalian mcirea da ar

xasiaTdeba samecniero sarwmunoebiT. 80-ian wlebSi bevr qveyanaSi farTod iyo miRebuli kriteriumi, romlis Tanaxmad tonzileqtomia keTdeboda maSin, rodesac bolo wels aRiniSneboda tonzilitis 7 epizodi, an bolo 2 wels 5 epizodi yovelwliurad an bolo 3 wels 3 epizodi yovelwliurad. es kriteriumebi ar iTvaliswinebdnen avadmyofis zogadi mdgomareobis dinamikas, gansxvavebas mozrdilebsa da bavSvebs Soris da a.S.

SeiZleba vivaraudoT, rom morecidive tonzilitis epizodebis prevencia SesaZlebelia operaciuli CareviT, magram tonzileqtomia ar iZleva sxva mizezebiT ganpirobebuli morecidive faringitis prevenciis saSualebas. aqedan gamomdinare, tonzileqtomiis win morecidive tonzilitis diagnozi unda iyos dazustebuli da diferencirebuli generalizebuli faringitisagan.

tonzileqtomia saWiroebs xanmokle hospitalizacias, zogad anesTezias, da SesaZlebelia garTuldes sisxldeniT. cxovrebis Cveul ritmTan dabruneba saSualod 2 kvira saWiroebs, Sesabamisad es dro dakargulia swavlis an muSaobisaTvis.

sarwmuno kvlevebis simciris miuxedavad, mraval arakontrolirebad kvlevaSi aRniSnulia tonzileqtomiis sargeblianoba ara mxolod faringitis

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epizodebis Semcirebis, aramed zogadi janmrTelobis gaumjobesebis TvalsazrisiT (sarwmunoebis done II da III).

qvemoT moyvanilia tonzileqtomiis kriteriumebi rogorc mozrdilebis, ise bavSvebisaTvis. pacientebi unda akmayofilebdnen yvela qvemoT CamoTvlil kriteriums:

mwvave faringitis mizezi unda iyos tonziliti; erTi wlis ganmavlobaSi unda aRiniSnos mwvave faringitis 5 an

meti epizodi; simptomebi unda grZeldebodes sul mcire erTi wlis ganmavlobaSi; mwvave faringitis mimdinareoba iseTi mZime unda iyos, rom xels

uSlides avadmyofis normalur yoveldRiur saqmianobas (sarwmunoebis done II da III, rekomendacia C).

gasaTvaliswinebelia aseve, rom xSir SemTxvevaSi Zneli dasadgenia mwvave faringitebis zusti sixSire an iyo Tu ara mwvave faringitis mizezi realurad mwvave tonziliti. amitom, rekomendebulia tonzileqtomiamde 6 Tviani dakvirvebis periodi, romlis ganmavlobaSi zustdeba yelis tkivilis gamomwvevi mizezebi. mas Semdeg, rac gadawyvetileba miRebuli iqneba, operacia unda Catardes rac SeiZleba swrafad.

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gacieba (Common cold, Простудная болезнь)

gacieba avadobis farTod gavrcelebuli mizezia. miuxedavad imisa, rom is zogjer ganixileba, rogorc trivialuri daavadeba, misma simptomebma SeiZleba mniSvnelovani gavlena moaxdinos pacientis cxovrebis xarisxze saerTo sisustis, Tavis tkivilis da sxva sistemuri simptomebis ganviTarebis gamo. gaciebis adeqvaturi marTva mniSvnelovani komponentia iseTi garTulebebis efeqturi mkurnalobis TvalsazrisiT, rogoricaa asTma, sinusiti an qronikuli otiti. gaciebis mkurnalobis da mis mier gamowveuli arapirdapiri danakargebis (samuSaos gacdena da a.S.) Rirebuleba Zalian mniSvnelovania (erTi wlis ganmavlobaSi 3 miliard dolaramde aSS-Si).

warmodgenil gaidlainSi ganxiluli iqneba gaciebis diagnostikis da marTvis Tanamedrove rekomendaciebi.

definicia. gacieba ganixileba rogorc mwvave, msubuqi mimdinare kataruli sindromi, romelic, rogorc wesi, ar saWiroebs medikamentur mkurnalobas (avadmyofobaTa saerTaSoriso klasifikaciis meaTe gadaxedvis mixedviT is Seesabameba mwvave nazofaringits - J00 da zeda sasunTqi gzebis mwvave infeqciebs - J06).

epidemiologia. mozrdilebSi wlis ganmavlobaSi aRiniSneba gaciebis 2-4 epizodi. bavSvebSi misi sixSire SesaZlebelia 10-mdec ki iyos. vaJebSi daavadeba SedarebiT ufro xSiria, Tumca mozrdil asakSi gacieba ufro xSiria qalebSi. daavadeba aseve ufro xSiria im mozrdilebSi, romelTa ojaxebSic bavSvebi arian. daavadebis sezonuri mateba aRiniSneba saSualo klimatis qveynebSi weliwadis civ dros (Semodgoma-zamTarSi) da wvimis sezonze tropikul qveynebSi. daavadebis sixSiris aseTi matebis mizezia bavSvebis da mozrdilebis Tavmoyra daxurul SenobebSi wlis civ periodSi.

etiologia. gaciebas uxSiresad iwvevs virusTa 5 gvaris warmomadgenlebi: miqsovirusebi, paramiqsovirusebi (paragripi, respiraciul-sincitiuri virusi), adenovirusi, pikornavirusi (rinovirusi) da koronavirusi. maT

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Soris yvelaze xSiria rinovirusi (40%) da koronavirusi (10%). gripis virusi xSirad iwvevs gaciebis msgavsi klinikuri simptomatikis ganviTarebas.

paTofiziologia. inkubaciuri periodi grZeldeba 24-72 saaTi gamomwvevis xasiaTis gaTvaliswinebiT. infeqcia gadaecema inficirebuli adamianidan gamoyofili virusis haerSi Sewonili wveTebis SesunTqviT. infeqciis gadacemis meore gzas warmoadgens avadmyofis sekretTan pirdapiri kontaqti (xelis saSualebiT). daavadeba ar aris asocirebuli garemos dabal temperaturasTan an gadaRlilobasTan. infeqciis gadacema ufro xSirad xdeba saxlSi, skolaSi, sabavSvo baRSi. virusebis ZiriTad rezervuars bavSvebi warmoadgenen.

klinikuri niSnebi. uxSiresi simptomebia gamonadeni cxviridan, cxviriT sunTqvis gaZneleba, yelis tkivili an fxaWnis SegrZneba, Tavis tkivili da xvela. SesaZlebelia aRiniSnos xmis CaxleCa, gemovnebis an ynosvis dakargva, Tvalebis wva, yuris dagubeba an wnevis SegrZneba. xvela aRiniSneba gaciebis 30%-Si da mis erT-erT yvelaze Semawuxebel simptoms warmoadgens. is Cveulebriv iwyeba daavadebis me-4-5 dRes, maSin, rodesac nazaluri simptomebi mcirdeba. sxeulis temperatura mcired matulobs mozrdilebSi (iSviaTad scildeba 380-s), maSin rodesac adreuli asakis bavSvebSi ufro xSiria febriluri temperatura. adreuli asakis bavSvebSi aseve SesaZlebelia aRiniSnos aRgznebadoba, kvebis gaZneleba cxviridan gamonadenis gamo da diarea. diagnozis swrafi dasma Znelia, daavadebis dasawyisSi Znelia, gaTvaliswinebuli unda iqnes anamnezi da daavadebis klinikuri niSnebi.

diferencialuri diagnozi unda gatardes alergiul da araalergiul rinitTan, faringitTan, gripTan. garda amisa bavSvebSi ucxo sxeulTan cxvirSi, xolo adreuli asakis bavSvebTan unda gamoiricxos ufro seriozuli mdgomareobebi: pnevmonia, sefsisi.

garTulebebi. adreuli asakis bavSvebSi SeiZleba ganviTardes bronqioliti, virusuli pnevmonia, krupi. 3 Tvemde asakis bavSvebSi SesaZlebelia qvemo sasunTqi gzebis meoradi baqteriuli infeqciis ganviTareba. 60 wlis zemoT asakSi daaxaloebiT 65%-Si mosalodnelia qvemo sasunTqi gzebis daavadebaTa ganviTareba. am garTulebaTa ganviTarebis riski gansakuTrebiT matulobs Tambaqos mwevelebSi. SemTxvevaTa 2%-Si gacieba rTuldeba mwvave otitis ganviTarebiT, otitiT garTuleba gansakuTrebiT maRalia bavSvebSi. paranazaluri sinusebis baqteriuli infeqciiT

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garTuleba gaciebis 0,5% SemTxvevaSi gvxvdeba. filtvis qronikuli obstruqciuli daavadebiT avadmyofebSi rinovirusuli etiologiis gacieba amZimebs da axangrZlivebs fqod-s.

prognozi. gacieba saSualod grZeldeba erTi kvira. SemTxvevaTa 25%-Si daavadeba xangrZlivdeba 2 kviramde, xolo mwevelebSi xvelis simptomi ufro gamoxatuli da Semawuxebeli xdeba.

marTva. ar arsebobs medikamenti romlis efeqturoba dadgenili iqneboda gaciebis profilaqtikis an mkurnalobisaTvis. aqedan gamomdinare, medikamenturi marTva gulisxmobs simptomur Terapias. amitom ZiriTadi aqcenti keTdeba damxmare saSualebebis gamoyenebaze. upirveles yovlisa, daarwmuneT pacienti, rom gacieba msubuqi daavadebaa, romelic ar moiTxovs medikamentur mkurnalobas. aqcenti unda gakeTdes siTxis adeqvatur miwodebaze, ZuZuTi kvebaze myof bavSvebSi ufro xSir kvebaze.

simptomaturi saSualebebidan efeqturi sicxis damwevi da tkivilgamayuCebeli saSualebaa paracetamoli. alternatiul sicxis damwev saSualebebs warmoadgenen arasteroiduli anTebis sawinaaRmdego saSualebebi – aspirini (mozrdilebSi) da ibuprofeni (bavSvebSi).

sxvadasxva rekomendaciebSi mocemulia kidev ramdenime samkurnalo saSualebis gamoyeneba, Tumca ar arsebobs sarwmuno kvlevebi, romlebic daadastureben maT efeqturobas. aseTebia: bavSvebSi fiziologiuri xsnaris cxvirSi CawveTeba, orTqlis inhalaciebi, C vitaminis maRali dozebi, oraluri an nazaluri dekongestantebi (fsevdoefedrini, oqsimetazolini, qsilometazolini), amosaxvelebeli da antihistaminuri saSualebebi, antibiotikebi (garda pacientebisa fqod-iT, romelTac gaciebis fonze aReniSnebaT sul mcire ori niSani qvemoT CamoTvlilidan: sunTqvis ufro meti gaZneleba, naxvelis raodenobis mateba da Cirqovani naxvelis gaCena), eqinacea.

mwvave sinusiti

gaidlainis mizania

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baqteriuli sinusitis diagnostikisa da marTvis gaumjobeseba pirveladi jandacvis doneze;

laboratoriuli kvlevis meTodebis optimaluri da adeqvaturi gamoyenebis xelSewyoba;

sinusitis mkurnlobis erTiani unificirebuli modelis gamoyeneba pirveladi jandacvis doneze;

antibiotikebis naklebi sixSiriT gamoyenebis uzrunvelyofa, sinusitisa da mwvave respirciuli infeqciis diferenciaciis meTodikis danergvis saSualebiT.

gaidlaini moicavs mozrdilTa da bavSvTa asakSi mwvave baqteriuli sinusitis mkurnalobas

jandacvis pirveladi rgolis bazaze.gaidlaini ar moicavs:

qronikuli sinusitis mkurnalobas; sinusitis garTulebebis mkurnalobas; sinusitis hospitalur mkurnalobas.

definiciasinusiti paranazaluri sinusebis lorwovani garsis anTebaa. sinusiti

warmoadgens nazaluri ubnis lorwovani garsis momijnave aris Tanmxleb anTebiT process (avadmyofobaTa saerTaSoriso klasifikaciis meaTe gadaxedvis mixedviT is Seesabameba mwvave sinusits - J01). sinusitis ganviTareba uxSiresad iwyeba rinitis fonze, ris gamoc mas xSir SemTxvevaSi uwodeben rinosinusits.

pirveladi jandacvis rgolSi arCeven mwvave, qvemwvave da qronikul sinusits;

mwvave sinusitis xangrZlivoba naklebia 4 kviraze. mwvave baqteriuli sinusiti cxviris danamati Rruebis lorwovani garsis anTebiTi xasiaTis dazianebaa, romelic gamowveulia baqteriebis zrdiT daxSul RruSi.

qvemwvave (baqteriuli) sinusiti baqteriuli infeqciiT gamowveuli cxviris danamati Rruebis lorwovani garsis anTebiTi dazianebaa, romelic grZeldeba 30-dan 90 dRemde da romlis Semdeg simptomebi mTlianad ixsneba;

morecidive sinusitis diagnozi ismeba im SemTxvevaSi, Tu sinusitis epizodebis sixSirea 4 an metia weliwadSi, TiToeuli epizodis

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xangrZlivobaa 10 dRe da meti, da Tu gamwvavebaTa Soris periodSi pacients simptomatika ar uvlindeba;

qronikuli sinusiti grZeldeba 12 kvira da meti mkurnalobis fonze an mis gareSe.

epidemiologia Cveulebriv mozrdili adamiani wlis ganmavlobaSi 3-4 jer avadobs

mwvave respiraciuli infeqciiT, bavSvTa asakSi mri-s sixSire gacilebiTYmetia da Seadgens daaxloebiT 6-10 weliwadSi. mri-s SemTxvevaTa daaxloebiT 0,5-2%, xolo sxva avtorTa monacemebiT 7%, rTuldeba baqteriuli sinusitiT. unda aRiniSnos, rom virusuli rinosinusiti 200-jer ufro xSiria, vidre baqteriuli.

etiologia Cveulebriv paranazaluri sinusebi steriluria. baqteriuli sinusitis ZiriTadi gamomwvevebia:

Streptococus pneumonie

Haemophilus influenzae

am or gamomwvevze modis baqteriuli sinusitis daaxloebiT 50% rogorc mozrdilebSi, ise bavSvTa asakSi. rogorc mozrdilebSi, ise bavSvebSi sinusitis 5%-s iwvevs Staphylococcus aureus, Staphylococcus pyogenes.

bavSvebSi xSiria agreTve Moraxella catarrhalis (daaxloebiT 20%), mozrdilebSi misi mizeziT gamowveuli sinusitis sixSire Zalian dabalia.

mozrdilebSi sinusitis SemTxvevaTa 10% gamowveulia anaerobuli baqteriebiT (Bacteroides spp, Porphyromonas spp, Peptosostreptococus spp). mocemuli floriT gamowveuli sinusiti xSir SemTxvevaSi asocirebulia kbilis dazianebasTan.

Zalze iSviaTad (<5%) sinusitis gamomwvevi SeiZleba iyos aerobuli gram-uaryofiTi baqteriebi: Pseudomona, Klebsiella, E.coli.

paTofiziologiasinusitis ganviTareba ukavSirdeba sinusis ventilaciis da lorwos

transportirebis darRvevas. zemo sasunTqi gzebis virusuli infeqciis dros viTardeba rogorc cxviris, ise cxviris danamati Rruebis lorwovani garsis anTebiTi dazianeba, rac iwvevs sinusis Rrus obstruqcias. sinusitis ganviTarebas xels uwyobs agreTve cxviris lorwovanis mocimcime epiTelis dazianeba, rac gamowveuli xSiri virusuli infeqciiT da garemo faqtorebiT

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(mag:GTambaqos gamonabolqvi). obstruqcia TavisTavad iwvevs sekretis drenirebis darRvevas, mis stagnacias, pH-is da Jangbadis koncentraciis daqveiTebas, rac saukeTeso pirobas qmnis baqteriis cxovelmyofelobisTvis.

sinusiti viTardeba nebismier asakSi. maqsilaruli (haimoris) da ZiriTadi Zvlis wiaRi Cvil bavSvebsac aqvs ganviTarebuli, Tumca mcire zomisaa. Sublis Zvlis wiaRi viTardeba 5 wlis asakidan da sruilyofilad yalibdeba pubertatul periodSi. cxavis Zvlis wiaRi SesamCnevia 3 wlidan da srulyofilad viTardeba 12 wlis asakisaTvis.

gamoyofen sinusitis ganviTarebis 5 xelSemwyob faqtors: janmrTelobis mdgomareoba (xSiri mri, alergiuli riniti, imunodeficiti da

sxv); garemo gamRizianeblebi (Tambaqo, mtvris gamonabolqvi,

alergenebi); anatomiuri faqtori (adenoidebis hipertrofia, polipebi, Zgidis

gamrudeba da sxv); medikamentebi (topiuri dekongestantebis xangrZlivi, gadaWarbebuli

gamoyeneba); travma (kbilis eqstraqcia da sxv). klinikuri suraTi daavadebis diagnostika efuZneba daavadebis anamnezs, klinikuri

suraTs, simptomebis xangrZlivobas, obieqtur gasinjvas da, saWiroebisas, rentgenologiuri gamokvlevis Sedegebs (mtkicebulebis done A).

sinusitis damaxasiaTebeli arc erTi klinikuri niSani damoukideblad ar aris mgrZnobiare da specifiuri diagnozis dasasmelad.

baqteriuli sinusitis niSnebi bavSvebSi

baqteriuli sinusitis niSnebi mozrdilebSi

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zemo sasunTqi gzebis infeqciis klinika, romelic ar umjobesdeba 10-14 dRis ganmavlobaSi da romelsac Tan axlavs 2 niSani:

cxviridan Cirqovani gamonadeni da

gaxangrZlivebuli aradamakmayo-filebeli mdgomareoba

+/_ cxeleba xvela agzneba Zilianoba/leTargia saxis tkivili

mZime gamovlineba*mZime zogadi mdgomareoba: temperatura>390 (ar eqvemdebareba antipiretul saSualebebs)

da cxviridan Cirqovani gamonadeni, romelic asocirebulia: xvelasTan Tavis tkivilTan saxis SeSupebasTan sinusis mgrZnobelobasTan.*Zlier iSviaTia bavSvebSi, miuTiTebs SesaZlo intrakraniuli garTulebebis arsebobaze.

zemo sasunTqi gzebis infeqciis klinika romelic ar umjobesdeba 10-14 dRis ganmavlobaSi an uaresdeba 5 dRis Semdeg da romelsac Tan axlavs 2 niSani:

cxviris blokireba /cxviridan Cirqovani gamonadeni

da saxis tkivili +/_ cxeleba ybis Zvlisa da kbilis tkivili saxis SeSupeba

sxva SesaZlo NniSnebia: Tavis tkivili hiposmia/anosmia yuris tkivili/wnevis da

dagubebis SegrZneba gulisreva xvela saxis tkivili, romelic matuloba

win daxrisas.

mwvave siniusitis diagnozis saukeTeso simptomia sami ZiriTadi (ybis Zvlis da kbilis tkivili, topiuri dekongesantebis uefeqtoba da cxviridan Seferili gamonadenis arseboba) da 2 damatebiTi niSani (Cirqovani gamonadeni cxviridan da cvlilebebi transiluminaciiT) (mtkicebulebis done A).

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mwvave sinusitis diagnozi SesaZlebelia gamoiricxos, Tu saxezea mocemuli niSnebidan 2-ze naklebi. Tu saxezea 2 an 3 niSani diagnostikisaTvis SesaZlebelia saWiro iyos cxviris danamati Rruebis rentgenologiuri kvleva. Tu saxezea 4 niSani, maSin mwvave sinusitis diagnozis sarwmunoeba maRalia.

klinikuri suraTi mozrdilebSimwvave rinosinusiti ganisazRvreba damaxasiaTebeli simptomebiT,

romelTa xangrZlivoba 4 kviraze naklebia. mwvave baqteriuli sinusiti Cveulebriv warmoadgens meorad infeqcias, rac sinusis RerZis obstruqciis, lorwos gasufTavebis meqanizmis darRvevis (an orives erTad) Sedegs warmoadgens. epidemiologiuri monacemebis mixedviT, mozrdilebSi zeda sasunTqi gzebis infeqcias mxolod 0,2-dan 2%-Si rTuldeba baqteriuli rinosinusitiT. baqteriuli rinosinusitis diagnostirebis oqros standarts warmoadgens sinusis punqtanti. S. Pneumoniae da Haemopilus influenzae aris ZiriTadi baqteriebi, romlebic gamoiyofa inficirebuli maqsilaruli sinusidan. miuxedavad aRniSnulisa, sinusis punqcia warmoadgens invaziur meTods, ar aris teqnikurad ioli da igi iSviaTad sruldeba pirveladi jan.dacvis rgolSi. Aamitom diagnozi efuZneba mxolod klinikur monacemebs. Mmwvave baqteriuli sinusitis da zeda sasunTqi gzebis prolongirebuli virusuli infeqcias simptomatika Zalian msgavsia, ris gamoc xSirad xdeba virusuli paTologiis SecdomiT klasificireba.

diagnostika bavSvebSi.sinusitis diagnostika ar unda daefuZnos mxolod gamonadenis xasiaTs,

vinaidan lorwovan-Cirqovani gamonadeni SesaZlebelia aRiniSnebodes zemo sasunTqi gzebis virusuli infeqciebis drosac.

Cveulebriv zemo sasunTqi gzebis virusuli infeqcia 5-7 dRis ganmavlobaSi grZeldeba. iSviaTad igi SeiZleba gaxangrZlivdes 10 dRemdec, magram aseT dros yvela SemTxvevaSi saxezea klinikuri simptomebis gaumjobeseba. amitom mri-s simptomTa persistireba 10 dReze metad, rodesac ar aris gamoxatuli klinikuri gaumjobeseba, SesaZlebelia miuTiTebdes meoradad baqteriuli infeqciis TandarTvaze sinusitis saxiT.

ZiriTadi simptomebi, romelsac efuZneba diagnozi: zemo sasunTqi gzebis infeqciis klinika, romelic ar umjobesdeba 10-14

dRis ganmavlobaSi;

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cxviriT sunTqvis blokireba/cxviridan gamonadeni (SeiZleba mxolod lorwovani, Sesqelebuli, lorwovan Cirqovani);

persistuli xvela, romelic Zlierdeba RamiT.SedarebiT iSviaTad vlindeba gulisreva, yuris da yelis tkivili, saxis tkivili,

SeSupeba. sinusitze eWvis SemTxvevaSi obieqturi gasinjvis dros unda Sefasdes:s a x e

Sesieba an eriTema dazianebis areSi; mgrZnobeloba sinusis palpaciis an perkusiis dros.

palpaciisas mcire asakis bavSvebSi saxis tkivili da sinusis mgrZnobeloba ar vlindeba, Tumca es simptomebi kargi indikatoria saskolo asakis bavSvebsa da mozrdilebSi. zeda ybis Zvlisa da Sublis Zvlis perkusiis an zewolis dros gamoxatuli erTi mxaris tkivili miuTiTebs baqteriuli sinusitis arsebobaze.

T v a l e b i periorbitaluri Sesieba

c x v i r i lorwovan-Cirqovani sekretis arseboba; cxviris lorwovani garsis eriTema an SeSupeba; anatomiuri anomaliebi (Zgidis gamrudeba); ucxo sxeulis arseboba.

p i r i d a x a x a cxviris ukana Camonadeni; ZiriTadi kbilebis mgrZnobeloba.

y u r i Tanmxlebi Sua yuris anTeba bavSvebSi.

k i s e r i limfadenopaTia.

diagnostika mozrdilebSiaucilebelia moxdes baqteriuli da virusuli rinosinusitis Sedareba da zusti

diagnostireba. ganxilvis sagania im specifiuri niSnebis simcire, romelic gamijnavs baqteriul rinosinusits zeda respiraciuli traqtis arabaqteriuli infeqciisagan. xSirad pacientebsa da eqimebs swamT, rom zeda sasunTqi gzebis infeqcia grZeldeba sakmaod xangrZlivad, amitom antibiotikoTerapia aucilebelia. baqteriuli rinosinusiti ar aris damaxasiaTebeli im pacientebSi,

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romelTac simptomebi ugrZeldebaT 7 dReze naklebi drois manZilze. miuxedavad amisa, 7 dReze meti drois manZilze simptomebis arsebobac baqteriuli rinosinusitis arsebobis araspecifiuri mimaniSnebelia. Cirqovani gamonadeni cxviridan, maqsilaruli kbilebis gaswvriv tkivili an facialuri tkivili, unilateraluri sinusis mgrZnobeloba da sawyisi gaumjobesebis Semdeg avadobis simptomTa gauareseba miiCneva baqteriuli genezis rinosinusitis mimaniSnebel damxmare niSnebad.

diagnostikasawyis etapze sinusitze saeWvo SemTxvevebSi rutinuli rentgenologiuri

kvleva ar aris saWiro. ar aris rekomendebuli sinusebis rentgenografiis Catareba 6 wlamde asakSic. miRebulia, rom sinusitis mkurnaloba SesaZlebelia daiwyos mxolod klinikur suraTze dayrdnobiT damatebiTi rentgenologiuri kvlevebis Catarebis gareSe.

pirdapiri rentgenografia ar gamoirCeva maRali mgrZnobelobiT da mxolod 54% SemTxvevaSi gvaZlevs sinusitis diagnostikis saSualebas (mtkicebulebis done A). sinusitis diagnostikisaTvis gamoiyeneba Semdegi rentgenologiuri proeqciebi: Wate-is proeqcia - ZiriTadad fasdeba haimoris Rruebis mdgomareoba. Caldwell-is proeqcia - ZiriTadad fasdeba eTmoiduri da Sublis wiaRi. Submentovertex-is proeqcia - ZiriTadad fasdeba ZiriTadi Zvlis da cxavis Zvlis sinusi.

yvela SemTxvevaSi rentgenografia unda Catardes pacientis vertikalur poziciaSi, raTa rentgenogramaze Sefasdes sinusSi haeri-siTxis done.

rentgenologiuri kvlevis Catareba saWiroa Semdeg SemTxvevebSi: mwvave sinusitis diagnozis dros, Tu saeWvoa subperiostuli an

orbitaluri abscesi; mwvave sinusitis diagnozis dros, Tu saeWvoa intrakraniuli garTulebebi; Tu mkurnalobis miuxedavad ar aris gaumjobeseba da saWiroa

diagnozis dadastureba.sinusebis ultrasonografiuli kvleva ar gamoirCeva maRali

mgrZnobelobiTa da specifiurobiT da ar aris rekomendebuli (mtkicebulebis done D).

kompiuteruli tomografia ufro maRalmgrZnobiarea, vidre rentgenologiuri gamokvleva. misi gamoyeneba naCvenebia, Tu saeWvoa cxviris danamati Rruebis avTvisebiani paTologia (mtkicebulebis done A). misi gamoyeneba agreTve rekomendebulia im pacientebSi, romelTac esaWiroebaT sinusitis

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qirurgiuli mkurnaloba (mtkicebulebis done B). kompiuteruli tomografiis gamoyeneba agreTve mizanSewonilia:

sinusitis garTulebebis ganviTarebis SemTxvevaSi; qronikuli sinusitis dros, romelic ar eqvemdebareba mkurnalobas; daavadebis mZime mimdinareobis SemTxvevaSi, rodesac diagnozi

saeWvoa.birTvul-magnituri rezonansuli gamokvleva (MRI) ar aris rutinulad

rekomendebuli sinusitis daignostikisaTvis. laboratoriuli kvlevagaurTulebeli mwvave sinusitis dros sisxlis saerTo analizis an

nazofaringiuli kulturis rutinulad Catareba ar aris rekomendebuli. dadgenilia, rom nazofaringiuli Camonarecxis an yelis nacxiT miRebuli kultura ar Seesabameba sinusis aspiraciiT miRebul Stamebs.

miuxedavad imisa, rom sinusis aspiracia da baqteriuli kultura iTvleba baqteriuli sinusitis diagnostikis “oqros standartad” misi Catareba ar aris rekomendebuli pirveladi donis dawesebulebebSi (mtkicebulebis done D). misi gamoyeneba ar aris saWiro gaurTulebel SemTxvevebSi sinusitis sawyisi mkurnalobisaTvis. Rrus pirdapiri punqcia da aspiracia naCvenebia, Tu:

daavadeba mZimed mimdinareobs; imunodeficituri mdgomareobis dros; intrakranialuri garTulebebis SemTxvevaSi.

mkurnalobakvlevebi adastureben, rom sinusiti uxSiresad virusuli genezisaa da 60%

SemTxvevaSi spontanurad gaivlis antibiotikoTerapiiis gareSe. baqteriuli sinusitis mkurnalobis mizania sinusis Rrus SigTavsis drenireba da paTologiuri baqteriebis zrdis Seferxeba. bavSvebSi baqteriuli sinusitis samkurnalod naCvenebia antibiotikoTerapia (mtkicebulebis done A).

antibiotikoTerapiabaqteriuli sinusitis mkurnalobis mizania sinusis Rrus SigTavsis drenireba

da paTologiuri baqteriebis zrdis Seferxeba. mwvave sinusitis samkurnalod antibiotikoTerapiis dawyebis Cvenebas, rogorc mozrdilebSi, ise bavSvebSi warmoadgens Semdegi klinikuri simtomatikis arseboba:

simptomebis persistireba (magaliTad, Tu klinikuri niSnebi grZeldeba 7 - 10 dReze meti);

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mZime simptomatika (mag: profuzuli Cirqovani gamonadeni cxviridan, saxis tkivili da sistemuri dazianebis niSnebi);

pacientis mdgomareobis da simptomebis gauareseba. mozrdilebSi randomizirebuli, ormagi brma, placebo-kontrolirebadi

kvlevebiT mwvave baqteriuli rinosinusitis mkurnalobamde da mkurnalobis Semdeg miRebuli sinusis aspiratis kulturis monacemebi ar adasturebs antibiotikoTerapiis gamoyenebis saWiroebas. mwvave rinosinusitis dros xuT randomizirebul, ormag-brma klinikur kvlevebSi antibiotikebiT mkurnaloba Sedarebul iqna placebosTan. Tumca antibiotikebi ufro efeqturia, vidre placebo, simptomebis Semcirebis TvalTaxedviT efeqtis sidide (sarwmunoebis xarisxi) SedarebiT dabalia. ufro metic, pacientTa umravlesobis mdgomareoba, romlebic Rebuloben placebos, gaumjobesda antibiotikoTerapiis gareSec.

antibiotikoTerapiis daniSvnisas SeiZleba gamoyenebuli iyos “moicade da Seafase” –s principi, roca eqimi pacients ganmeorebiT vizitze ibarebs. aseT dros antibiotiki iniSneba, Tu pacientis mdgomareoba uaresdeba an vlindeba simptomebis persistireba.

ar arsebobs mkacri mtkicebulebebi romelime antibiotikis gamoyenebis sasargeblod. antibiotikis SerCevis kriteriumebi efuZneba daavadebis klinikas, uxSiresi gamomwvevi floris gansazRvras, xarjTefeqturobas, gverdiTi movlenebis Sefasebas.

pirveli rigis preparats, rogorc bavSvebSi, ise mozrdilebSi miekuTvneba amoqsicilini, romlis efeqturobac dadasturebuli placebo- kontrolirebadi kvlevebiT. misi farmakokinetikuri Tvisebebidan gamomdinare igi maRali koncentraciiT grovdeba rbil qsovilebSi da sinusitis gamomwvev yvela mikroorganizmis mimarT maRali aqtivoba gaaCnia, kargad aiTviseba mosaxleobis didi nawilis mier da ar aris ZviradRirebuli.

mozrdilebSi, Tu penicilinebis jgufis antibiotikebis mimarT arsebobs alergiuli anamnezi, SesaZlebelia dainiSnos doqsiciklini, romelic aseve kargad aiTviseba, efeqturia sinusitis samkurnalod da advilad misaRebia. bavSvTa asakSi is ar gamoiyeneba.

penicilinebze alergiis SemTxvvaSi, rogorc bavSvebSi, iseve mozrdilebSi SeiZleba dainiSnos azitromicini da klaritromicini, SesaZlebelia cefalosporinebis gamoyenebac.

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Tu pacients ar mkurnaloben antibiotikiT, igi unda daibaron 7 dRis Semdeg, raTa dadgindes, xom ar gauaresda simptomatika an moxda Tu ara gaumjobeseba.

Tu pacients mkurnaloben antibiotikebiT da misi mdomareoba ar umjobesdeba, an Tu ver xerxdeba antibiotikis miReba, magaliTad Rebinebis SemTxvevaSi, ganmeorebiTi viziti saWiroa Catardes 72 saaTSi.

Tu simptomatika grZeldeba da ar umjobesdeba Sesabamisi antibiotikoTerapiis dasasruls, saWiroa:

ganmeorebiT gadaisinjos diagnozi; Sefasdes garTulebebis arseboba; Sefasdes, Tu ramdenad asrulebs pacienti eqimis daniSnulebas.

Tu pacienti sworad ar asrulebs eqimis daniSnulebas:P SeiZleba gagrZeldes mocemuli antibiotiki; Tu antibiotikze aRiniSneba Rebineba, igi unda Seicvalos pirveli

rigis sxva preparatiT, an dainiSnos saineqcio antibiotiki, sanam ar moxdeba Rebinebis kupireba, ris Semdegac kvlav xdeba gadasvla oralur antibiotikze.

Tu pacienti sworad asrulebs eqimis daniSnulebas: saWiroa meore rigis antibiotikebis gamoyeneba

an mizanSewonilia referali

meore rigis preparatebs miekuTvneba: im pirebSi, romelTac ar aqvT alergia penicilinze amoqsicilinis da

klavulonis mJavis kombinirebuli preparati efeqturia im baqteriebis sawinaaRmdegod romelic iwvevs sinusits, maT Soris Moraxella catharalis,

Streptococus pneumonie-is penicilin-rezistentuli Stamebis mimarT. II Taobis cefalosporinebi.

Tu saeWvoa anaerobuli baqteriebiT gamowveuli sinusiti SesaZlebelia mkurnalobaSi gamoyenebuli iqnas metronidazoli.

Tu antibiotikis meore kursis Semdeg pacientis mdgomareoba ar umjobesdeba saWiroa stacionarSi gadagzavna, otorinolaringologis konsultacia sinusis punqciis da aspiratidan kulturis mgrZnobelobis gansazRvris mizniT.

orsul qalebTan da meZuZur dedebTan gamoiyeneba eriTromicini. miuxedavad imisa, rom klaritromicinTan da azitromicinTan SedarebiT is

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metad aRizianebs kuW-nawlavis traqts da Haemophilus influenzae–ze naklebad moqmedebs, dadgenilia eriTromicinis usafrTxoeba orsulebSi.

analgetiuri da antipiretuli saSualebebi mwvave sinusitis mqone pacientebSi, romelTac gamoxatuli aqvT tkivilis

sindromi, iniSneba antipiretuli preparatebi tkivilisa da temperaturuli reaqciis kupirebis mizniT. rogorc bavSvebSi ise mozrdilebSi naCvenebia paracetamolis an iboprufenis gamoyeneba.

antibiotikebi da analgetikebi Cveulebriv sakmarisia sinusitis samkurnalod. Tumca SesaZlebelia iSviaT SemTxvevaSi damatebiT gamoyenebuli iqnas is preparatebi, romelic amcirebs lorwovanis SeSupebas, aumjobesebs sinusis drenaJs.

dekongestantebiintranazaluri dekongestantebis gamoyeneba moklevadiani kursiT

SesaZlebelia sinusitis samkurnalod (mtkicebuleba C), Tumca maTi gamoyenebis sasargeblod mxolod mcire raodenobiT mtkicebulebebi arsebobs. dekongestantebi xels uwyoben lorwovani garsis SeSupebis Semcirebas da mukociliarul klirenss. intranazaluri dekongestantebis xangrZlivi droiT gamoyeneba ar aris rekomendebuli (ara umetes 7 dRisa).

intranazaluri steroidebiintranazaluri steroidebi mwvave sinusitis samkurnalod rutinulad

naCvenebi ar aris, Tumca SeiZleba misi, rogorc damxmare saSualebis, gamoyeneba (mtkicebuleba A). intranazaluri steroidebi amcirebs lorwovanis SeSupebas, Tumca maTi efeqti vlindeba mxolod 1 kviris Semdeg, ris gamoc misi gamoyeneba mwvave sinusitis samkurnalod ar aris mizanSewonili. topikuri steroidebi naCvnebia qronikuli sinusitis dros.

oraluri da intranazaluri antihistaminuri preparatebiantihistaminuri preparatebi ar aris naCvenebi (mtkicebuleba C), isini

iwveven lorwovani garsis simSrales, sekretis Sesqelebas, rac aqveiTebs sinusis drenaJis SesaZleblobas.

mukolitikebiar aris rekomendebuli, vinaidan ar aris dadasturebuli maTi efeqturoba.sxva saSualebebiar arsebobs klinikuri mtkicebulebebi fiziologiuri xsnaris nazaluri

gamoyenebis Sesaxeb. Tumca SesaZlebelia fiziologiuri xsnaris gamoyenebam xeli SeuSalos fufxebis warmoqmas da gaaTxelos sekreti, rac

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gaaiolebs mis drenaJs. damatebiT fiziologiurma xsnarma SesaZlebelia imoqmedos cxviris lorwovan garsze, rogorc sustma vazokonstriqtorma.

ar arsebobs mtkicebulebebi sinusis drenaJis gaumjobebsebis mizniT cxeli orTqlis gamoyenebis Sesaxeb. cxeli orTqlis inhalaciis gamoyeneba ar aris mizanSewonili, man SesaZlebelia gamoiwvios damwvroba, gansakuTrebiT bavSvebSi. Tu saWirod iTvleba orTqlis gamoyeneba SeiZleba gamoyenebuli iyos abazanaSi cxeli wylis moSvebisas warmoqmnili orTqli.

referalis Cvenebebia:1. sinusitis garTulebebi:

a. orbitaluri:orbitaluri celuliti.

b. lokaluri:mukocele an mukopiocele.

c. intrakranialuri baqteriuli meningiti; cerebruli abscesi; epiduraluri abscesi; osteomieliti da sxv.

2. meore rigis preparatebiT mkurnalobis araefeqturoba;3. rekurentuli daavadeba (3 epizodze meti weliwadSi);4. bavSvebSi zemo sasunTqi gzebis Tandayolili anatomiuri anomalia

Tu saeWvoa baqteriuli sinusitis garTuleba, aucilebelia pacientis referali otorinolaringologis, ofTalmologis, infeqcionistis, neiroqirurgis konsultaciiT. aseT SemTxvevaSi xSirad saWiroa agresiuli mkurnaloba.

daskvnamwvave rinosinusitebis umravlesoba ambulatoriul pirobebSi,

warmoadgens zeda sasunTqi gzebis gaurTulebel virusul infeqcias. mxolod klinikuri monacemebis safuZvelze rTulia baqteriuli da virusuli rinosinusitebis diferencireba. mwvave baqteriuli rinosinusitis klinikuri diagnozi unda iyos dasmuli im pacientebSi, romelTac rinosinusitis simptomebi ugrZeldeba 7 dRe da meti da aqvT Cirqovani nazaluri gamonadeni da maqsilaruli, facialuri da kbilebis gaswvrivi tkivili an momatebuli mgrZnobeloba. pacientebSi, romelTac rinosinusitis simptomebi aReniSnebaT 7 dReze naklebi periodis manZilze, ar ganixileba baqteriuli infeqcias arseboba. sinusis renthenografia rutinulad araa rekomendirebuli. Mmwvave baqteriuli rinosinusiti

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SemTxvevaTa umravlesobaSi ukuviTardeba antibiotikoTerapiis gareSe. Mmsubuqi simptomatikis mqone pacientebSi sawyis strategiul marTvas warmoadgens simptomuri mkurnaloba analgetikebiT, antipiretikebiT da dekongenstantebiT. antibiotiko-Terapia, miuxedavad avadobis xangrZlivobisa, gamoyenebuli unda iyos mZime baqteriuli rinosinusitis simptomatikis mqone pacientebSi. sawyisi antibiotikoTerapia unda ganxorcieldes viwro speqtris agentiT. klinikur kvlevebze dayrdnobiT pirveli rigis antibiotikebs miekuTvneba: amoqsicilini, doqsiciklini da trimetoprim-sulfamezoqsazoli.

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mwvave otitigaidlainis aucileblobamwvave otiti zemo sasunTqi gzebis dazianebis erT-erT uxSiresi mizezs

warmoadgens. is aseve erT-erT uxSiresi mizezia aSS-Si antibiotikebis daniSvnis mixedviT. aqedan gamomdinare, mwvave otitis adeqvatur diagnostikas da marTvas SeuZlia mniSvnelovani gavlena moaxdinos adamianis janmrTelobaze, mkurnalobis Rirebulebasa da antibiotikebis daniSvnis sixSireze. mwvave otiti aseve mniSvnelovani socialuri tvirTia samsaxuris da skolis gacdenis TvalsazrisiT. otitis mkurnalobis pirdapiri QRirebuleba erTi wlis ganmavlobaSi aSS-Si 1,96 mlrd dolaria, xolo arapirdapiri – 1,02 mlrd. amave qveyanaSi otitis gamo eqimTan vizitis 1000 SemTxvevaSi 809 avadmyofTan antibaqteriuli preparati iqna daniSnuli. aRniSnulidaa gamomdinare, winamdebare gaidlainis erT-erTi mizani iqneba gaurTulebeli mwvave otitis diagnostikis da marTvis Sefaseba da pirveladi jandacvis rgolisaTvis mwvave otitis mkurnalobis rekomendaciebis miwodeba.

visTvis aris gankuTvnili gaidlaini pediatri; zogadi praqtikis eqimi; gadaudebeli samedicino daxmarebis eqimi; yel-yur-cxviris eqimi.

CarTvis kriteriumebi: pacientebi, romelTac aReniSnebaT Sua yuris mwvave anTebis niSnebi

(mwvave otiti).gamoricxvis kriteriumebi

pacientebi Tanmxlebi mdgomareobiT, romlebic zrdian anTebis Camoyalibebis risks: imunodeficiti, nevrologiuri problemebi, sensoruli deficitebi.

definiciaotiti Sua yuris anTebiTi daavadebis saerTo saxelia, romelsac aqvs

mwvave an qronikuli xasiaTi, mimdinareobs simptomebiT an maT gareSe, da romelsac iwvevs virusi an baqteria. marTvis gansxvavebuli strategiebi ganapirobeben mis gansxvavebul klinikur klasifikacias: mwvave Sua yuris anTeba an Sua yuris anTeba gamonadeniT. ar arsebobs otitis SeTanxmebuli definicia. samuSao definiciad mowodebulia Sua yuris anTeba swrafi

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ganviTarebiT adgilobrivi (yuris tkivili) da zogadi simptomatikiT (cxeleba, gaRizianeba, cudi Zili). SesaZlebelia adgili hqondes zeda sasunTqi gzebis daavadebisTvis damaxasiaTebel simptomebs: xvelas da rinoreas. zogadad SeiZleba iTqvas, rom mwvave otitis diagnozi moiTxovs: daavadebis simptomebis ganviTarebis mwvave dasawyiss; gamonadenis arsebobas Sua yurSi (timpanuri membranis SeSupeba, timpanuri membranis mobilurobis SezRudva an ararseboba, otorea); Sua yuris anTebis niSnebis da simptomebis arsebobas (timpanuri membranis hiperemia, otalgia).

Sua yuris anTeba gamonadeniT ganmartebulia, rogorc Sua yuris anTeba, romelsac Tan sdevs Sua yurSi siTxis dagroveba da ar sdevs mwvave anTebis niSnebi. Sua yuris anTeba gamonadeniT xSirad asimptomuria da misTvis tkivili ar aris damaxasiaTebeli.

otitis saxeoba definicia SeniSvnasiTxe Sua yurSiMEE

siTxe Sua yurSi, miuxedavad warmoSobisa

SesaZloa nanaxi iyos otoskopiiT

miringiti (dafis apkis anTeba)

dafis apkis eriTema gamonadenis gareSe (SesaZlebelia bavSvis tirilis dros adgili hqondes cru Sedegs)

uxSiresad virusuli etiologiis. ar reagirebs antibiotikebze.adreuli etapi mwvave anTebis an procesis CaTavebisas.

Sua yuris mwvave anTeba

siTxis arseboba Sua yurSi mwvave dasawyisiT: tkiviliT, otoreiT, cxelebiT, anoreqsiiT, RebinebiT an/da sxva simptomebiT

pediatrebis uxSiresi diagnozi: 48% - 6 Tvemde asakSi, 79%- 1 wlamde asakSi da 90% 2 wlamde asakSi (Paradise 1997 [C])

sporaduli xasiaTis mwvave Sua yuris anTeba

mwvave anTeba, romelic 3 Tvis Semdeg ganviTarda gadatanili epizodis Semdeg.

SeadareT morecidive mwvave Sua yuris anTebas.

morecidive mwvave Sua yuris anTeba

6 epizodi 12 Tvis ganmavloba-Si. gaTvaliswinebuli unda iyos epizodebis simZime da

aReniSnebaT 15-30%-Si

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gamonadenis arsebobaSua yuris anTeba gamonadeniT

siTxe Sua yurSi anTebis niSnebis gareSe

gavrceleba bavSvebSi aris 15%. axlavs mwvave anTeba.

qronikuli Sua yuris anTeba gamonadeniT

mimdinareobs 3 Tveze metxans.

epidemiologiaavadobis TvalsazrisiT zogadi praqtikis eqimebi da pediatrebi pirveladi

jandacvis rgolSi xSirad xvdebian Sua yuris anTebas, romelic zeda sasunTqi gzebis dazianebis xSiri Sedegia. aTi wlis asakis bavSvebis daaxloebiT 75% zeda sasunTqi gzebis daavadebebisas avlenen Sua yuris anTebas. oTxidan erTi bavSvi pirveli aTi wlis manZilze erTxel mainc avadobs otitiT. daavadebis piki gvxvdeba 3-6 wlis asakSi. kvlevebi adastureben, rom oTx wlamde asakSi bavSvTaA 80%-s erTxel mainc hqonda otiti gamonadeniT da webvadi sacobiT yurSi. mwvave otiti SedarebiT iSviaTia mozrdilebSi, otitis SemTxvevaTa 2/3 aRiniSneba 10 wlamde asakis bavSvebSi.

etiologiamwvave otitis gamomwvevi uxSiresi baqteriuli agentebia S.pneumonie,

H.influenzae da M.cattarhalis). mwvave otitis aseve xSiri mizezia virusi (41%): rsv, paragripis virusi da gripis virusebi. isini virusuli otitebis 81%-s Seadgenen (rekomendacia C). virusul-baqteriul asociaciebs Sua yurSi procesis gaxangrZlivebasTan da dagvianebul baqteriul klirensTan mivyevarT.

risk-faqtorebi asaki < 2 welze; ojaxis wevrebis avadoba respiraciuli infeqciebiT; mSoblebis mier Tambaqos moxmareba; ZuZuTi kvebis xangrZlivoba < 3 Tvemde; memkvidruli ganwyoba.

klinikuri suraTi Sua yuris anTebis uxSiresi simptomebia: tkivili, cxeleba,

gaRizianebadoba, otorea (gamonadeni yuridan), leTargia, anoreqsia da

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Rebineba. specifiuri niSnebis nakleboba, gansakuTrebiT or wlamde asakSi, arTulebs Sua yuris mwvave anTebis dignozis dadgenas.

Sua yuris anTeba gamonadeniT SesaZloa saerTod simptomebis gareSe mimdinareobdes da gamovlenil iyos mxolod urTierTobis, qcevis, swavlis da metyvelebis problemebiT.

g a s i n j v i s t e q n i k a .Sua yuris paTologiis diagnostireba da, gansakuTrebiT misi gamijvna

klinikuri mimdinareobis mixedviT ar aris advili. kargad trenirebuli specialistis mier otoskopiiT Sua yuris areSi siTxis arsebobis dadgenis mgrZnobeloba 90%-ia, specifiuroba 80%. cxadia, am maCveneblebis miRweva SeuZlebelia, Tu specialisti, romelic sinjavs bavSvs, ar aris sakmarisad gamocdili. gansakuTrebiT maRalia pnevmo-otoskopiiT dadgenili diagnozis specifiuroba da mgrZnobeloba. CvenTan es meTodi pirveladi jandacvis rgolSi zogadi praqtikis eqimebis mier ar aris farTod gamoyenebuli.

a n a m n e z imwvave otitis dasadgenad unda aRiniSnebodes simptomebis mwvave

dasawyisi, Sua yurSi gamonadeni, Sua yuris anTebis niSnebi (sarwmunoebis done II).

mwvave otitis diagnostika

1. simtomatikis swrafi Camoyalibeba2.Sua yuridan gamonadenis arseboba, razec miiuTiTebs erTi Semdegidan:

timpanuri memebranis SeSupeba da reliefis ar arseboba; membranis daqveiTebuli mobiluroba; TeTri an/da yviTeli nadebi membranaze; otorea

3. Sua yuris anTebis simptomebi da niSnebi, razec miuTiTebs: wiTeli da SeSupebuli timpanuri membrana; tkivili anu otalgia ukanaskneli 24 saaTis manZilze.

mwvave otitis diagnostikis sizustis gazrdis mizniT rekomendebulia otoskopis an/da timpanometriis gamoyeneba (sarwmunoebis done II).

randomizebuli, kontrolirebadi kvlevebi adastureben, rom timpanometriis gamoyeneba amcirebs otitis diagnozis sixSires 14-40%-iT.

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otalgia unda iyos Sefasebuli, rogorc diskomforti, romelic normalur aqtivobas an/da Zils uSlis xels.

rekomendebulia pacientebSi morecidive mwvave otitiT gansakuTrebuli yuradReba daeTmos Civils smenis daqveiTebis, metyvelebis Seferxebis Sesaxeb.

aucileblad unda iqnes gaTvaliswinebuli, rom otitisaTvis damaxasiaTebeli simptomebi da niSnebi SeiZleba gaqres membranis perforaciis Semdeg. garda amisa, daavadebis gadatanis Semdeg Sua yurSi gamonadeni SeiZleba darCes mwvave otitis simptomebis gaqrobis Semdeg (sarwmunoebis done IV).

im SemTxvevbSi, rodesac saeWvoa smenis daqveiTeba, aucilebelia specialistis konsultacia da audiometriis Catareba;

Tu erTkviriani mkurnalobis fonze gaumjobeseba ar aRiniSneba, aucilebelia otolaringologis konsultacia;

Tu mwvave Cirqovani otitis dros aRiniSneba gareTa sasmen milSi pulsirebadi Cirqovani gamonadeni, aucilebelia otolaringologis konsultacia;

MmarTvabavSvebSi mwvave otitis msubuqi formis dros SemTxvevaTa daaxloebiT

80% mkurnalobis gareSe gamojanmrTelebiT mTavrdeba 3 dRis ganmavlobaSi. mwvave otitis recidivebi SeiZleba aRiniSnos uefeqto mkurnalobis an reinfeqciis gamo. mravali kvlevis miuxedavad dReisaTvis ar arsebobs otitis mkurnalobis saerTaSoriso konsesunsi, gansakuTrebiT es exeba antibiotikebs.

a n a l g e t i k e b imwvave otitis marTvaSi unda iyos gaTvaliswinebuli tkivilis Sefaseba.

tkivilis SemTxvevaSi aucilebelia analgetikebis gamoyeneba. es aris rekomendacia, romelic eyrdnoba randomizirebul klinikur kvlevebs. xSir SemTxvevaSi eqimebi mas saTanado yuradRebas ar aqceven. tkivilis marTva, gansakuTrebiT daavadebis pirvel 24 saaTSi aucilebelia antibiotikoTerapiis miuxedavad.

otalgiis mkurnaloba

saxeoba SeniSvnaacetaminofeni, ibuprofeni efeqturi saSualeba msubuqi da

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Sinauri saSualebebi: cxeli safenebi, zeTi, marilis safenebi (ar arsebobs efeqturobis damadasturebeli kontrolirebadi kvlevebi)

topikuri saSualebebi benzokaini naturopaTiuri saSualebebi homeopatiuri saSualebebi

narkotikuli analgetikebi (kodeini an misi analogebi)

saSualo siZlieris tkivilis dros, farTod xelmisawvdomia.

SesaZloa hqondes garkveuli efeqturoba

xanmokle efeqturoba

ar asebobs kontrolirebadi kvlevebi

efeqturia saSualo da Zlieri tkivilis dros, saWiroebs recepts, arsebobs sunTqvis daTrgunvis riski, cnobierebis Secvlis riski

mwvave otitis dros tkivilis marTvaSi paracetamols upiratesoba unda

mieniWos arasteroiduli anTebis sawinaaRmdego saSualebebTan SedarebiT am ukanasknelis gverdiTi movlenebis gamo (sarwmunoebis done I). mSoblebs unda miewodoT informacia mosalodneli safrTxis Sesaxeb dozis gadaWarbebisas.

y u r i s w v e T e b irekomendebulia, rom yvela bavSvSi mwvave otitiT unda moxdes tkivilis

Sefaseba da tkivilis arsebobis SemTxvevaSi unda dainiSnos analgetikebi. unda gaviTvaliswinoT, tkivili mwvave otitis dros, rogorc wesi, TavisiT gaivlis. amitom, aucileblobis SemTxvevaSi efeqturi da usafrTxo analgetikebis xelmisawvdomoba ufro mniSvnelovania, vidre is, Tu romeli medikamenti gamoviyenoT. es preparatebia oraluri wveTebi (paracetamoli an ibuprofeni) an yuris topikuri wveTebi (rekomendacia A).

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pacientebSi, romlebTanac saeWvoa dafis apkis perforacia da/an gamonadeni yuridan, Tavi unda avaridoT garegani saSualebebis moxmarebas, radgan maT gamoyenebas SesaZloa Tan mohyves Zlieri Tavbrusxveva da Rebineba.

a n t i b i o t i k e b i .otitis dros antibiotikebs eqimebi sxvadasxva sixSiriT iyeneben (32%

holandiaSi da 98%-iT avstraliasa da aSS-Si). kvlevebis meta-analizi gviCvenebs, rom antibiotikebi ar amcireben tkivils

mkurnalobis dawyebidan 24 saaTis ganmavlobaSi. Tumca antibiotikebis adreuli gamoyeneba amcirebs tkivilis ganviTarebis risks 40%-iT. amave dros, antibiotikebis gamoyeneba ar amcirebs otitis momdevno epizodebis sixSires an siyruis ganviTarebis risks. garda amisa, antibiotikebis gamoyenebisas TiTqmis ormagdeba Rebinebis, diareis da gamonayaris riski. antibiotikebis ar gamoyeneba ar ganapirobebs daavadebis mZime mimdinareobas (sarwmunoebis done I).

garda amisa, naCvenebia, rom im bavSvebSi, romlebSic antibiotikebi ar iyo dasawyisidanve gamoyenebuli, Zalian iSviaTia mastoiditis an sxva garTulebebis ganviTarebis riski.

antibiotikebi gamoyenebuli unda iqnes rutinulad 2 wlamde asakis bavSvebSi an orxrivi otitis dros.

mwvave otitis dros antibiotiki ar unda iyos daavadebis dasawyisSive rutinulad gamoyenebuli.

antibiotikebi gamoyenebuli unda iqnes 2 wlamde asakis bavSvebSi an orxrivi otitis dros.

a n t i b i o t i k e b i s m o g v i a n e b i T i g a m o y e n e b a .antibiotikebis mogvianebiT daniSvnasTan dakavSirebul kvlevaSi

gamoyenebuli iyo ori strategia: dauyovneblivi antibiotikoTerapia da mogvianebiTi antibiotikoTerapia (mdgomareobis ucvlelobis gamo antibiotiki daniSnuli iqna 72 saaTis Semdeg). dadginda, rom: (a) dauyovneblivi antibiotikoTerapia simptomur efeqturobas iZleva pirveli 24 saaTis Semdeg, maSin, rodesac simptomebi ukve Semcirebulia. (b) dauyovneblivi antibiotikoTerapia 10%-iT zrdis diareis sixSires; (g) mogvianebiTi antibiotikoTerapiis jgufSi antibiotikebi gamoyenebul iqna mxolod 24%-Si; (d)

34

mogvianebiTi antibiotikoTerapia amcirebs antibiotikebis gamoyenebis sixSires 76%-iT (sarwmunoebis done I).

adeqvaturi analgezia da “davelodoT da davakvirdeT’ midgoma ufro gonivrulia, dauyovnebliv antibiotikoTerapiasTan SedarebiT.

mwvave otitis dros mogvianebiTi antibiotikoTerapia (mdgomareobis ucvlelobis gamo antibiotikis daniSvna 72 saaTis Semdeg) SeiZleba gamoyenebuli iqnes pirveladi jandacvis praqtikaSi.

a n t i b i o t i k e b i s a r C e v a n i d a x a n g r Z l i v o b a .mravali kvleviT dadgenilia mwvave otitis gamomwvevi ori uxSiresi

baqteriuli gamomwvevi: Streptococcus pneumoniae da Haemophi;us influanzae.

SedarebiT iSviaTia Moraxela catarrhalis. maT sawinaaRmdegod arCevanis preparatebs warmoadgens amoqsicilini, amoqsicilini/klavulinis mJava. aseve efeqturia cefaklori da axali Taobis makrolidebi.

mkurnalobis optimaluri xangrZlivoba gansxvavebulia sxvadasxva qveyanaSi, ase magaliTad, did britaneTSi upiratesobas aniWeben 5 dRian kurss, holandiaSi 7 dRians, xolo CrdiloeT amerikaSi 10 dRian kurss.

Cochrane-is mimoxilvis mixedviT gaurTulebeli mwvave otitis dros mkurnalobis 5 dRiani kursi efeqturia. Cvili asakis bavSvebSi da garTulebuli mwvave otitis dros mkurnalobis optimaluri xangrZlivoba dadgenili ar aris (sarwmunoebis done I).

gaurTulebeli mwvave otitis dros rekomendebulia 5 dRiani antibiotikoTerapia.

d e k o n g e s t a n t e b i , a n t i h i s t a m i n u r i p r e p a r a t e b i d a m u k o l i t i k e b i .

Cochrane-is mimoxilva dekongestantebTan da antihistaminebTan dakavSirebiT 13 kvlevis analizis safuZvelze askvnis, rom maT gamoyenebas ar moaqvs damatebiTi sargebloba mkurnalobis xangrZlivobis, simptomebis Semcirebis, qirurgiuli Carevis an sxva garTulebebis Tavidan acilebis TvalsazrisiT. mxolod maTi kombinirebuli gamoyenebis SemTxvevaSi nanaxi iqna persistirebuli otitis sixSiris Semcireba. amave dros, dafiqsirda maTi gverdiTi movlenebis gamovlenis riskis mateba. amitom uefeqtobis da gverdiTi movlenebis arsebobis gamo antihistaminuri preparatebis, dekongestantebis an maTi kombinirebuli gamoyenebis, aseve mukolitikebis gamoyeneba mwvave otitebis dros rekomendebuli ar aris.

35

mwvave otitis dros antihistaminuri preparatebis da dekongestantebis gamoyeneba rekomendebuli ar aris.

Semdgomi dakvirveba Tu mdgomareoba ar umjobesdeba, aucilebelia bavSvis ganmeorebiTi

gamokvleva 48-72 saaTis Semdeg. umravles SemTxvevaSi mwvave otiti gamojanmrTelebiT mTavrdeba.

SesaZlebelia arasruli gankurneba an gamonadenis gaxangrZliveba. am dros aucilebelia ganmeorebiTi gamokvleva 2 kviris Semdeg. Tu problema grZeldeba, aucilebelia otolaringologTan referali.

perforaciis SemTxvevaSi aucilebelia mSoblebis informireba, rom es ar aris seriozuli garTuleba. aseT SemTxvevebSi aucilebelia Tavidan aviciloT yurSi wylis moxvedra an bambis tamponis gamoyeneba. ganmeorebiTi gamokvleva saWiroa 6 kviris Semdeg.

referali saswrafod gadaagzavneT otolaringologTan pacienti, Tu daewyo

gareTa sasmen milSi Cirqovani gamonadeni, gansakuTrebiT Tu igi pulsirebad xasiaTs atarebs.

saswrafod gadaagzavneT otolaringologTan pacienti, Tu gamoCnda iseTi garTulebebi, rogoricaa saxis nervis paralizi an mastoiditi.

gadaagzavneT otolaringologTan SerCeviTad, Tu eqvsi Tvis ganmavlobaSi aRiniSna mwvave otitis sami an meti epizodi, an oTxi epizodi aRiniSna 12 Tvis ganmavlobaSi.

gadaagzavneT otolaringologTan Tu mkurnalobis damTavrebis Semdeg eWvi gaqvT smenis deficitze (gamoikvlieT yvela avadmyofi. CurCuli unda ismodes daaxloebiT 6 metrze).

gaidlainis miRebis wyaro. winamdebare gaidlaini warmoadgenis sxvadasxva gaidlainebis (ix. literatura) Sejerebis da adaptaciis Sedegs.

literatura1. Diagnosis and management of childhood otitis media in primary care. Scottish Intercollegiate

Guidelines Network. 2003

2. Management of sore throat and indications for tonsilectomy. Scottish Intercollegiate

Guidelines Network. 1999

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3. S.Singh, J.Dolan, R. Centor. Optimal management of adults with pharyngitis – a multi-

criteria decision analysis. BMC Medicl informatics and Decision Making, 2006, 6:14.

4. Tonsillitis and pharingitis in children. National Guideline Clearinghouse, 2005.

5. Viral URI in adults and children. National Guideline Clearinghouse, 2005.

6. Evidance based clinical practice guideline for children with acute bacterial sinusitis in

children 1 to 18 years of age. National Guideline Clearinghouse, 2005.

7. Principles of appropriate antibioic use for acute pharyngitis in adults. Ann Intern Med 2001;

134, 509-517.

8. Diagnosis and management of Group A streptococal pharyngitis: a practice guideline. Clin

Infect Dis, 1997;25:574-83

9. Guideline for the diagnosis and treatment of acute pharingitis. Alberta medical association,

2001

10. Management of acute URTI. A clinical Guideline from Colorado Clinical Guideline

Collaborative, 2002

11. Clinical practice guideline: management of sinusitis. Pediatrics, 2001, vol.108, n 3,p.

798-808

12. Principles of appropriate antibioic use for treatment of ARTI in adults. Ann Intern Med

2001; 134, 479-486.

13. Adderson EE: Preventing otitis media: medical approaches. Pediatr Ann 1998 Feb; 27(2):

101-7

14. Aronovitz GH: Antimicrobial therapy of acute otitis media: review of treatment

recommendations. Clin Ther 2000 Jan; 22(1): 29-39.

15. Bitnun A, Allen UD: Medical therapy of otitis media: use, abuse, efficacy, and

morbidity. J Otolaryngol 1998; 27 Suppl 2: 26-36.

16. Bluestone CD: Clinical course, complications and sequelae of acute otitis media.

Pediatr Infect Dis J 2000 May; 19(5 Suppl): S37-46.

17. Bluestone CD: Role of surgery for otitis media in the era of resistant bacteria.

Pediatr Infect Dis J 1998 Nov; 17(11): 1090-8; discussion 1099-100.

18. Blumer JL: Fundamental basis for rational therapeutics in acute otitis media.

Pediatr Infect Dis J 1999 Dec; 18(12): 1130-40.

19. Bradley JS: Oral vs. intramuscular antibiotic therapy for acute otitis media: which

is best? Pediatr Infect Dis J 1999 Dec; 18(12): 1147-51.

20. Byington CL: The diagnosis and management of otitis media with effusion.

Pediatr Ann 1998 Feb; 27(2): 96-100.

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21. Carlson L, Scudder L: Controversies in the management of pediatric otitis media.

Are more definitive answers on the horizon?. Adv Nurse Pract 2004 Feb; 12(2): 73-7

22. Chartrand SA, Pong A: Acute otitis media in the 1990s: the impact of antibiotic

resistance. Pediatr Ann 1998 Feb; 27(2): 86-95.

23. Chonmaitree T, Heikkinen T: Role of viruses in middle-ear disease. Ann N Y

Acad Sci 1997 Dec 29; 830: 143-57.

24. Chonmaitree T: Viral and bacterial interaction in acute otitis media. Pediatr Infect

Dis J 2000 May; 19(5 Suppl): S24-30.

25. Conrad DA: Should acute otitis media ever be treated with antibiotics? Pediatr

Ann 1998 Feb; 27(2): 66-7, 70-4.

26. Daly KA, Giebink GS: Clinical epidemiology of otitis media. Pediatr Infect Dis J

2000 May; 19(5 Suppl): S31-6.

27. Foshee WS, Steele RW: Should prophylactic antibiotics be used for the otitis-

media–prone child? Pediatr Infect Forum 2000; 2: 2-7.

28. Glasziou PP, Hayem M, Del Mar CB: Antibiotics for acute otitis media in

children. Cochrane Database Syst Rev 2000; (2): CD000219.

29. Heikkinen T, Chonmaitree T: Increasing importance of viruses in acute otitis

media. Ann Med 2000 Apr; 32(3): 157-63.

30. Hoberman A, Paradise JL, Cohen R: Duration of therapy for acute otitis media.

Pediatr Infect Dis J 2000 May; 19(5): 471-3 [Medline] .

31. Jung TT, Hanson JB: Classification of otitis media and surgical principles.

Otolaryngol Clin North Am 1999 Jun; 32(3): 369-83.

32. Kaleida PH, Fireman P: Diagnostic assessment of otitis media. Clin Allergy

Immunol 2000; 15: 247-62.

33. Klein JO: Review of consensus reports on management of acute otitis media.

Pediatr Infect Dis J 1999 Dec; 18(12): 1152-5.

34. Kozyrskyj AL, Hildes-Ripstein GE, Longstaffe SE, et al: Short course antibiotics

for acute otitis media. Cochrane Database Syst Rev 2000; (2): CD001095.

35. Ah-See, K. (2005) Sinusitis (acute). Clinical Evidence. Volume

13http://www.clinicalevidence.com/

36. Alberta Medical Association (2000) Diagnosis and management of acute bacterial

sinusitis: children. Summary of the Alberta clinical practice guideline, December 2000.

Alberta Medical Association. http://www.albertadoctors.org/

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37. Alberta Medical Association (2005) Diagnosis and management of acute bacterial

sinusitis: adults. Summary of the Alberta clinical practice guideline, December 2000. Alberta

Medical Association. http://www.albertadoctors.org/

38. Anon, J.B., Jacobs, M.R., Poole, M.D. et al (2004) Antimicrobial treatment

guidelines for acute bacterial rhinosinusitis. Otolaryngology - Head & Neck Surgery

130(Suppl 1), 1-45. [erratum appears in Otolaryngol Head Neck Surg. 2004 Jun;130(6):794-

6].

39. Benninger, M.S., Sedory Holzer, S.E. and Lau, J. (2000) Diagnosis and treatment

of uncomplicated acute bacterial rhinosinusitis: summary of the Agency for Health Care

Policy and Research evidence-based report. Otolaryngology - Head & Neck Surgery 122(1),

1-7.

40. Blomgren, K., Alho, O.P., Ertama, L. et al (2005) Acute sinusitis: Finnish clinical

practice guidelines. Scandinavian Journal of Infectious Diseases 37(4), 245-250.

41. Brook, I., Gooch, W.M., III, Jenkins, S.G. et al (2000) Medical management of

acute bacterial sinusitis. Recommendations of a clinical advisory committee on pediatric and

adult sinusitis. Annals of Otology, Rhinology, & Laryngology - Supplement 182, 2-20.

42. Elective Services, New Zealand Ministry of Health (2003) Primary care

management guidelines: rhinosinusitis. New Zealand Ministry of Health.

http://www.electiveservices.govt.nz.

43. Elies, W. and Huber, K. (2004) Short-course therapy for acute sinusitis: how long

is enough? Treatments in Respiratory Medicine 3(5), 269-277.

mwvave sinusitis marTva protokoli

definiciamwvave sinusiti paranazaluri sinusebis lorwovani garsis anTebiTi

dazianebaa, romelic gamowveulia daxSul RruSi baqteriebis zrdiT da romlis xangrZliobac 4 kviraze naklebia. sinusitis ganviTareba uxSiresad iwyeba rinitis fonze, ris gamoc mas xSir SemTxvevaSi uwodeben rinosinusits.

damadasturebeli kriteriumebi

39

daavadebis diagnostika efuZneba daavadebis anamnezs, klinikur suraTs, simptomebis xangrZlivobas, obieqtur gasinjvas da, saWiroebisas, rentgenologiuri gamokvlevis Sedegebs.

sinusitis arc erTi klinikuri niSani damoukideblad ar aris mgrZnobiare da specifiuri diagnozis dasasmelad.

baqteriuli sinusitis klinikuri niSnebia: zemo sasunTqi gzebis infeqciis klinika, romelic ar umjobesdeba 10-14

dRis ganmavlobaSi da romelsac Tan axlavs 2 niSani: cxviridan lorwovan - Cirqovani gamonadeni

da gaxangrZlivebuli aradamakmayofilebeli mdgomareoba.

aseve SesaZlebelia: cxeleba; xvela; agzneba; saxis tkivili.

obieqturad SeiZleba gamovlindes: saxis Sesieba an eriTema dazianebis areSi; mgrZnobeloba sinusis palpaciis an perkusiis dros (palpaciisas mcire

asakis bavSvebSi saxis tkivili da sinusis mgrZnobeloba ar vlindeba, Tumca es simptomebi kargi indikatoria saskolo asakis bavSvebsa da mozardebSi); periorbitaluri Sesiveba; cxviris lorwovani garsis eriTema an SeSupeba; ZiriTadi kbilebis mgrZnobeloba; Tanmxlebi Sua yuris anTeba bavSvebSi.

ZiriTadi simptomebi, romelsac efuZneba diagnozi: zemo sasunTqi gzebis infeqciis klinika, romelic ar umjobesdeba 10-14

dRis ganmavlobaSi; cxviriT sunTqvis blokireba/cxviridan gamonadeni (SeiZleba mxolod

lorwovani, Sesqelebuli, lorwovan-Cirqovani); persistuli xvela, romelic Zlierdeba RamiT.

SedarebiT iSviaTad vlindeba gulisreva, yuris da yelis tkivili, saxis tkivili, SeSupeba.

diagnostikur-laboratoriuli testebi 40

sawyis etapze sinusitze saeWvo SemTxvevebSi rutinuli rentgenologiuri kvleva ar aris saWiro. ar aris rekomendebuli sinusebis rentgenografiis Catareba 6 wlamde asakSic. sinusitis mkurnaloba SesaZlebelia daiwyos mxolod klinikur suraTze dayrdnobiT.

rentgenologiuri kvlevis Catareba saWiroa Semdeg SemTxvevebSi: mwvave sinusitis diagnozisas, Tu saeWvoa subperiostuli an orbitaluri

abscesi; mwvave sinusitis diagnozisas, Tu saeWvoa intrakraniuli garTulebebi; Tu mkurnalobis miuxedavad ar aris gaumjobeseba da saWiroa

diagnozis dadastureba. yvela SemTxvevaSi rentgenografia unda Catardes pacientis vertikalur

poziciaSi, raTa rentgenogramaze Sefasdes sinusSi haeri-siTxis done. gaurTulebeli mwvave sinusitis dros sisxlis saerTo analizis an

nazofaringiuli kulturis rutinulad Catareba ar aris rekomendebuli. miuxedavad imisa, rom sinusis aspiracia da baqteriuli kultura iTvleba

baqteriuli sinusitis diagnostikis “oqros standartad”, misi Catareba ar aris rekomendebuli pirveladi donis dawesebulebebSi.

mwvave sinusitis arsebobas gamoricxavs simptomebis persistireba 4 kviraze metad.

mkurnalobaantibiotikoTerapiabaqteriuli sinusitis mkurnalobis mizania sinusis Rrus SigTavsis drenireba

da paTologiuri baqteriebis zrdis Seferxeba. antibiotiko-Terapiis Cvenebaa: simptomebis persistireba (magaliTad, Tu klinikuri niSnebi grZeldeba 7 -

10 dReze meti); mZime simptomatika (mag: profuzuli Cirqovani gamonadeni cxviridan,

saxis tkivili da sistemuri dazianebis niSnebi); pacientis mdgomareobis da simptomebis gauareseba.

pirveli rigis preparats miekuTvneba amoqsicilini. Tu arsebobs alergiuli anamnezi penicilinebis jgufis antibiotikebis mimarT SeiZleba dainiSnos azitromicini da klaritromicini, dadgenilia maTi maRali efeqturoba sinusitis gamomwvevebis mimarT.

meore rigis preparatebs miekuTvneba: ko-amoqsiklavi, cefuroqsimi, levofloqsacini (12 wlis zemo asakSi).

analgetiuri da antipiretuli saSualebebi 41

tkivilisa da temperaturuli reaqciis kupirebis mizniT bavSvebSi naCvenebia paracetamolis an iboprufenis gamoyeneba.

dekongestantebiintranazaluri dekongestantebis gamoyeneba moklevadiani kursiT

SesaZlebelia sinusitis samkurnalod, intranazaluri dekongestantebis xangrZlivi droiT (7 dRe da meti) gamoyeneba ar aris rekomendebuli.

sxva saSualebebiar arsebobs klinikuri mtkicebulebebi nazalurad fiziologiuri xsnaris

gamoyenebis Sesaxeb. Tumca SesaZlebelia fiziologiuri xsnaris gamoyenebam xeli SeuSalos fufxebis warmoqmas da gaaTxelos sekreti, rac gaaioloebs mis drenaJs.

stacionarSi referalis Cvenebebia:daavadebis mZime gamovlineba:

mZime zogadi mdgomareoba (Zilianoba/leTargia, Zlieri agzneba): temperatura>390 (ar eqvemdebareba antipiretul saSualebebs)

da cxviridan Cirqovani gamonadeni, romelic asocirebulia:

xvelasTan; Tavis tkivilTan; saxis SeSupebasTan; sinusis mgrZnobelobasTan.

sinusitis garTulebebi: orbitaluri, lokaluri, intrakranialuri; meore rigis preparatebiT mkurnalobis araefeqturoba; rekurentuli daavadeba (3 epizodze meti weliwadSi); bavSvebSi zemo sasunTqi gzebis Tandayolili anatomiuri anomalia.

dakvirveba Tu pacients mkurnaloben antibiotikebiT da misi mdgomareoba ar

umjobesdeba, an Tu ver xerxdeba antibiotikis miReba, magaliTad Rebinebis SemTxvevaSi, ganmeorebiTi viziti saWiroa Catardes 72 saaTSi.

Tu pacientis mdgomareoba antibiotikoTerapiis fonze ar umjobesdeba, saWiroa:^

gadaisinjos diagnozis adekvaturoba; Sefasdes garTulebebis arseboba; Sefasdes, Tu ramdenad asrulebs pacienti eqimis daniSnulebas.

Tu pacienti ar asrulebs sworad eqimis daniSnulebas: 42

SeiZleba gagrZeldes mocemuli antibiotiki Tu antibiotikze aRiniSneba Rebineba, igi unda Seicvalos sxva pirveli

rigis preparatiT an dainiSnos saineqcio antibiotiki, sanam ar moxdeba Rebinebis kupireba, ris Semdegac kvlav xdeba gadasvla oralur antibiotikze.

Tu pacienti sworad asrulebs eqimis daniSnulebas: saWiroa meore rigis antibiotikebis gamoyeneba

an referali.Tu saeWvoa baqteriuli sinusitis garTuleba, aucilebelia pacientis referali

da otorinlarigologis, ofTalmologis, neiroqirurgis konsultacia. protokolis wyaro. winamdebare protokoli efuZneba saqarTvelos

respiraciuli asociaciis “mwvave sinusitis marTvis gaidlains”.

mwvave otitis marTva (protokoli)

definiciaar arsebobs otitis SeTanxmebuli definicia. samuSao definiciad

mowodebulia Sua yuris anTeba swrafi ganviTarebiT adgilobrivi (yuris tkivili) da zogadi simptomatikiT (cxeleba, gaRizianeba, cudi Zili). SesaZlebelia adgili hqondes zeda sasunTqi gzebis daavadebisTvis damaxasiaTebel simptomebs: xvelas da rinoreas.

damadasturebeli kriteriumebi mwvave otitis diagnozi moiTxovs: daavadebis simptomebis ganviTarebis

mwvave dasawyiss; gamonadenis arsebobas Sua yurSi (timpanuri membranis SeSupeba, timpanuri membranis mobilurobis SezRudva an ararseboba, otorea); Sua yuris anTebis niSnebis da simptomebis arsebobas (timpanuri membranis hiperemia, otalgia).

klinikuri niSnebiSua yuris anTebis uxSiresi simptomebia: tkivili, cxeleba,

gaRizianebadoba, otorea (gamonadeni yuridan), leTargia, anoreqsia da Rebineba. specifiuri niSnebis nakleboba, gansakuTrebiT or wlamde asakSi, arTulebs Sua yuris mwvave anTebis dignozis dadgenas.

43

Sua yuris anTeba gamonadeniT SesaZloa saerTod simptomebis gareSe mimdinareobdes da gamovlenil iyos mxolod urTierTobis, qcevis, swavlis da metyvelebis problemebiT.

mwvave otitis diagnostikaklinikuri niSnebi da (Tu SesaZlebelia) otoskopiuri kvleva.rekomendebulia pacientebSi morecidive mwvave otitiT gansakuTrebuli

yuradReba daeTmos Civils smenis daqveiTebis, metyvelebis Seferxebis Sesaxeb.

aucileblad unda iqnes gaTvaliswinebuli, rom otitisaTvis damaxasiaTebeli simptomebi da niSnebi SeiZleba gaqres membranis perforaciis Semdeg. garda amisa, daavadebis gadatanis Semdeg Sua yurSi gamonadeni SeiZleba darCes mwvave otitis simptomebis gaqrobis Semdeg

MmarTvaa n a l g e t i k e b i . tkivilis SemTxvevaSi aucilebelia analgetikebis

(cetaminofeni, ibuprofeni) amoyeneba. tkivilis marTva, gansakuTrebiT daavadebis pirvel 24 saaTSi aucilebelia antibiotikoTerapiis miuxedavad. tkivilis marTvaSi paracetamols upiratesoba unda mieniWos arasteroiduli anTebis sawinaaRmdego saSualebebTan SedarebiT am ukanasknelis gverdiTi movlenebis gamo (sarwmunoebis done I). mSoblebs unda miewodoT informacia mosalodneli safrTxis Sesaxeb dozis gadaWarbebisas.

y u r i s w v e T e b irekomendebulia, rom yvela bavSvSi mwvave otitiT unda moxdes tkivilis

Sefaseba da tkivilis arsebobis SemTxvevaSi unda dainiSnos analgetikebi. unda gaviTvaliswinoT, tkivili mwvave otitis dros, rogorc wesi, TavisiT gaivlis. amitom, aucileblobis SemTxvevaSi efeqturi da usafrTxo analgetikebis xelmisawvdomoba ufro mniSvnelovania, vidre is, Tu romeli medikamenti gamoviyenoT. es preparatebia oraluri wveTebi (paracetamoli an ibuprofeni) an yuris topikuri wveTebi. pacientebSi, romlebTanac saeWvoa dafis apkis perforacia da/an gamonadeni yuridan, Tavi unda avaridoT garegani saSualebebis moxmarebas, radgan maT gamoyenebas SesaZloa Tan mohyves Zlieri Tavbrusxveva da Rebineba.

a n t i b i o t i k e b i .antibiotikebi gamoyenebuli unda iqnes rutinulad 2 wlamde asakis

bavSvebSi an orxrivi otitis dros.44

pirveladi jandacvis praqtikaSi. SeiZleba gamoyenebuli iqnes mogvianebiTi antibiotikoTerapia (mdgomareobis ucvlelobis gamo antibiotikis daniSvna 72 saaTis Semdeg). arCevanis preparatebs warmoadgens amoqsicilini, amoqsicilini/klavulinis mJava, cefaklori da axali Taobis makrolidebi. gaurTulebeli mwvave otitis dros rekomendebulia 5 dRiani kursi.

mwvave otitis dros antihistaminuri preparatebis da dekongestantebis rutinuli gamoyeneba rekomendebuli ar aris.

Semdgomi dakvirveba da referaliTu mdgomareoba ar umjobesdeba, aucilebelia bavSvis ganmeorebiTi

gamokvleva 48-72 saaTis Semdeg. otolaringologTan referali aucilebelia: Tu daewyo gareTa sasmen milSi

Cirqovani gamonadeni, gansakuTrebiT Tu igi pulsirebad xasiaTs atarebs; gamoCnda iseTi garTulebebi, rogoricaa saxis nervis paralizi an mastoiditi; Tu eqvsi Tvis ganmavlobaSi aRiniSna mwvave otitis sami an meti epizodi, an oTxi epizodi aRiniSna 12 Tvis ganmavlobaSi; Tu mkurnalobis damTavrebis Semdeg eWvi gaqvT smenis deficitze (gamoikvlieT yvela avadmyofi. CurCuli unda ismodes daaxloebiT 6 metrze).

protokolis wyaro. winamdebare protokoli efuZneba saqarTvelos respiraciuli asociaciis “mwvave otitis marTvis gaidlains”.

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mwvave sinusitis marTvis algoritmi

mwvave sinusitis diagnostika imonokompetentur pacientSibavSvi: cxviridan gamonadenis gaxangrZliveba; xveleba dRis saaTebSi; 10-14 dReSi ar aris gaumjobeseba.mozrdili: Cirqovani gamonadeni cxviridan; tkivili zeda ybis areSi (gans. calmxrivi); cal mxares sinusis mgrZnobeloba; sawyisi gaumjobesebis Semdeg mdgomareobis

gauareseba; gaumjobesebis ararseboba7-10 dRis Semdeg; sinusis rentgenografia sinusitis sadiagnostikod rutinulad ar gamoiyeneba

pacienti mwvave mZime sinusitiTbavSvi da mozrdili: maRali (>390C) an

mudmivi cxeleba (>3-4 dReze)

periorbituli SeSupeba 10-14 dReSi ar aris

gaumjobeseba saxis/kbilis Zlieri tkivili am simptomebis arsebobisas,

miuxedavad maTi xangrZlivobisa, saWiroa dauyovneblivi daxmareba

xangrZlivoba < 7-14 dReze (an met xans Tu

gaumjobese-ba aris) an simptomebi msubuqad aris

gamoxatuli

7-10 dRe (mozrdilebSi) an 10-14 dRe (bavSvebSi) gaum-jobesebis gareSe an ufro met xans saSualo

simZimis an mZime simptomatika, mudmivi serozul-Cirqovani gamonadeni cxviridan da/an xvela dRis

saaTebSi

simptomuri mkurnalobafiziologiuri xsnaris Ca-

wveTeba, analgetiki/anti-piretiki, adgilobrivi da/an oraluri dekongestatebi,

(antibiotikebi ara efeqtu-ria mwvave respiraciuli infeqciis dros da ar ax-dens baqteriuli

sinusitis prevencias0Tu 4-5 dReSi ar iqna

gaumjobeseba, saWiroa ganmeorebiTi konsultacia

romelime risk-faqtori saxezea? asaki 2 w-mde, aRzrda organizebul koleqtivebSi, antibiotikebis gamoyeneba bolo 3 Tvis manZilze an morecidive infeqcia.

airCieT erTi amoqsicilini:

mozrdilebi 1500 mg/dReSi 2 an 3 miRebaze; bavSvebSi: 45 mg/kg/dReSi 2 an 3 miRebaze

penicilinze WeSmariti alergia:* azitromicini an klaritromicini

mkurnaloba unda gagrZeldes myari gaumjobesebidan 7 dRe

airCieT erTi amoqsicilini:

mozrdilebi 3 g/dReSi 2 an 3 miRebaze; bavSvebSi: 90 mg/kg/dReSi 2 an 3 miRebaze

penicilinze WeSmariti alergia:* cefalosporini da/an alergologis konsultacia

gaumjobeseba ar aris 48-72 saaTSi? mxolod mudmivi gamonadeni ar aris mkurnalobis Secvlis Cveneba

SeniSvna* penicilinze WeSmariti alergia: urtikaria an anafilaqsia penicilinze miuTuTebs WeSmarit alergiaze. makulopapuluri gamonayari ar aris WeSmariti alergia Tu anamnezSi aris penicilinze WeSmariti alergia, cefalosporinis daniSvnamde miiReT alergologis konsultacia an ifiqreT respiraciul ftorqinolinze 18 welze meti asakis pacientebSi** klavulanis mJavis doza ar unda aRematebodes 10mg/kg/dReSi

47

ara

mwvave otitis marTvis algoritmi

yuris mwvave infeqciis (yuris tkivili, cxeleba) an Sua yuridan gamonadenis (dafis apkis hiperemia) niSnebi da

simptomebi

mwvave Sua yuris anTeba1. gamonadenis arseboba (SeiniSneba gasinjvis dros an

dgindeba pnevmaturi otoskopiiT)da

2. mwvave infeqciis niSnebi da simptomebi (yuris tkivili, cxeleba)

Sua yuris anTeba gamonadeniT

gamonadenis arseboba (SeiniSneba gasinjvis dros an

dgindeba pnevmaturi otoskopiiT)

mwvave infeqciis niSnebis da simptomebis gareSe. tkivilis mkurnaloba

risk faqtori: 2 wlamde asaki, bavSvi dadis baRSi an skolaSi, antibiotikis miReba bolo 3 TveSi

diaxara amoqsicilini:* 45 mg/kg/ dReSi

2-3 miRebaze (Tu 2 welze met asakSi daavadeba mZimed mimdina- reobs, saWiroa maRali doza - 90 mg/kg/ dReSi 2-3 miRebaze)

penicilinze WeSmariti alergia:** azitromicini an klaritromicini

amoqsicilini:* 90 mg/kg/ dReSi 2-3 miRebaze

penicilinze WeSmariti alergia:** cefalosporini da/an alergologis konsultacia

aris gaumjobeseba 2-3 dReSi? (mxolod gamonadeni ar aris mkurnalobis Secvlis Cveneba)

diax

mkurnaloba grZeldeba; ganmeorebiTi konsulta-cia saWiroa 4-8 kviris Semdeg da gauaresebis SemTxvevaSi

amoqsicilini: 90 mg/kg/ dReSi, ko-amoqsiklavi *** 2-3 miRebaze 10 dRe. an: ceftriaqsoni an cefuroqsimi kunTebSi (pacientebSi, romlebic ver itanen penicilinebs)

penicilinze WeSmariti alergia**

SeniSvna* 2 wlamde mkurnalobis xangrZlivoba 10 dRe, Tu 2 welis zemoT (Tu garTuleba ar aris), 5 dRe** penicilinze WeSmariti alergia: WeSmarit alergiaze miuTiTebs urtikaria da anafilaqsia penicilinis mimarT. makulo-papuluri gamonayari ar miuTiTebs WeSmarit alergiaze. Tu alergia gamoxatulia cefalosporinis daniSvnamde, saWiroa alergologis konsultacia*** klavulonis doza ar unda aRematebodes 10 mg/kg/dReSi

referalis Cveneba: otolaringologTan mastoiditis niSnebis arseboba; Tu simptomebi uaresdeba an ar umjobesdeba 2 dReSi.nevrologTan Tu gamoixata saxis nervis dazianebis simptomebi.stacionarSi Tu eWvia meningitze, mwvave labirinTitze an tvinis abscesze.audiologiuri gamokvleva saWiroa, Tu daavadeba grZeldeba 3 Tveze met xans da/an Tu SeimCneva metyvelebis, smenis

darRveva.

antibiotiki ar aris naCvenebi, saWiroa dakvirveba 3 Tve

Tu gamonadenis xangrZlivoba > 3 Tveze - saWiroa

referali otolaringologTan, smenis Sefaseba

ko-amoqsiklavi; cefuroqsimi; penicilinze WeSmariti alergia:* respiraciuli ftorqinolini 18 welze

meti asakis pacientebSimkurnaloba unda gagrZeldes myari gaumjobesebidan 7 dRe Tu gaumjobeseba ar aris saWiroa referali da/an rentgenografia