Acute Rhinosinusitis – Treatment Options Michael Kaliner, MD ...
RHINOSINUSITIS - Internal Medicine · IDSA Clinical Practice Guideline for Acute Bacterial...
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RHINOSINUSITIS
Stuart Henochowicz, M.D., M.B.A., F.A.C.P. Clinical Associate Professor Division of Allergy, Immunology and Rheumatology Georgetown University Medical School Washington, D.C.
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Coronal View in Relation to Facial StructureCoronal View in Relation to Facial Structure
Normal Sinus CT Scan through the OMU
Maxillary sinus
Eyeball
Ethmoid sinus
Nasal cavity
Nasal Polyp
www.entusa.com
Rhinosinusitis
More accurate term than“sinusitis since almost always preceded by or concomitant symptoms of rhinitis
Acute – Up to 4 weeks
Subacute – 4 to 12 weeks
Chronic – > 12 weeks
Acute vs. Chronic Rhinosinusitis
Usually very different conditions.
Acute rhinosinusitis usually related to infection.
Chronic rhinosinusitis usually related to inflammation.
Acute Rhinosinusitis
1 billion viral URIs each year
0.5% - 2% lead to secondary bacterial infection of the sinuses.1,2
Acute bacterial rhinosinusitis often present when symptoms have not resolved after 10 days or worsen after 5 to 7 days
1Gwaltney Clin Infect Dis 1996;23:1209
2Berg et al. Rhinology 1986;24:223-5
Diagnosis of Acute Bacterial Rhinosinusitis
Acute clinical pattern Symptoms >10 days and < 28 days
Objective confirmation either / or Nasal exam documenting purulent d/c beyond the nasal vestibule
Rhinoscopy Endoscopy
Posterior pharyngeal drainage
CT scan Not recommended for routine management
May be helpful in complex cases
Meltzer et al. JACI 2004;114:155
Diagnosis of Acute Rhinosinusitis: 2 major OR 1 major & 2 minor symptoms
Major Anterior or posterior purulent drainage Nasal obstruction Facial pain or pressure or congestion Hyposmia or anosmia Fever (acute)
Minor Head ache
Ear pain/pressure
Halitosis
dental pain
Fatigue
Cough
JACI 2004
Obstruction of the OMU with Associated Acute Sinusitis
Sinusitis in the
ethmoid sinus.
Sinusitis in the
maxillary sinus.
Local Factors Predisposing to Rhinosinusitis
Allergic rhinitis
URI
Anatomic abnormalitiy: Deviated septum Concha bullosa Enlarged adenoids Haller cells
Nasal polyps
Tumor
Foreign body
Trauma
Barotrauma
Diving, swimming
Smoke
Topical decongestant abuse
Nasal intubation
Systemic Factors Predisposing to Rhinosinusitis
Immune deficiency IgA deficiency Panhypogammaglobulinemia IgG subclass deficiency HIV
Cystic fibrosis
Ciliary disorder
Granulomatosis with Polyangiitis (Wegener’s)
Gastroesophageal reflux
Complications of Rhinosinusitis
Meningitis
Orbital cellulitis (ethmoid)
Subdural/epidural empyema (frontal)
Brain abscess (frontal)
Cavernous sinus thrombosis (sphenoid)
Osteomyelitis (frontal)
Asthma exacerbation
Treating acute rhinosinusitis: Comparing efficacy and safety of mometasone furoate nasal spray, amoxicillin, and placebo Eli O. Meltzer, MD, Claus Bachert, MD, PhD and Heribert Staudinger, MD Volume 116, Issue 6, Pages 1289-1295
Copyright © 2005 American Academy of Allergy, Asthma and Immunology
Fig 1
Source: Journal of Allergy and Clinical Immunology 2005; 116:1289-1295 (DOI:10.1016/j.jaci.2005.08.044 )
Copyright © 2005 American Academy of Allergy, Asthma and Immunology
Antibiotics for Acute Sinusitis
Cochrane Database Review (2004) Peds Available evidence suggest that antibiotics given for 10 days will reduce the probability of persistence in the short to medium-term.
Cochrane Database Review (2004) Adults Current evidence is limited but supports the use of antibiotics for 7 to 14 days
Weigh the moderate benefits of abx treatment against the potential for adverse effects
Acute Bacterial Rhinosinusitis:
Which antibiotic to use?
No randomized, placebo-controlled trials of antibiotic treatment for ABRS using pre-and post-treatment sinus aspirate culture
Antibiotics
20 to 30% of S. pneumoniae are penicillin resistant
30 to 40% of H. influenzae and 75 to 95% of M. catarrhalis are beta-lactamase positive
When choosing abx consider Recent abx use (within 6 weeks) Severity of disease
Antibiotics for Acute Rhinosinusitis
“3. Amoxicillin-clavulanate rather than amoxicillin alone is recommended as empiric antimicrobial therapy for ABRS in children (strong, moderate).
4. Amoxicillin-clavulanate rather than amoxicillin alone is recommended as empiric antimicrobial therapy for ABRS in adults (weak, low)”.
IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults-2012
IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults
-2012
“7. Macrolides (clarithromycin and azithromycin) are not recommended for empiric therapy due to high rates of resistance among S. pneumoniae (∼30%) (strong, moderate)”.
IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults
-2012
“8. Trimethoprim-sulfamethoxazole (TMP/SMX) is not recommended for empiric therapy because of high rates of resistance among both S. pneumoniae and Haemophilus influenzae (∼30%–40%) (strong, moderate)”.
IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults
-2012
“9. Doxycycline may be used as an alternative
regimen to amoxicillin-clavulanate for initial
empiric antimicrobial therapy of ABRS in
adults…”
Acute Bacterial Rhinosinusitis: Duration of Treatment
“14. The recommended duration of therapy for uncomplicated ABRS in adults is 5–7 days (weak, low-moderate).
15. In children with ABRS, the longer treatment duration of 10–14 days is still recommended (weak, low-moderate)”.
IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults- 2012
Shortcut to acute sinusitis micro.lnk
Sinus and Allergy Health Partnership Otolaryngol Head Neck Surg 2004:130:1
Sinus & Allergy Partnership. Otolaryngol Head & N Surg 2004; 130:1
Fig 1
Journal of Allergy and Clinical Immunology 2013; 132:1230-1232
Copyright © 2013 American Academy of Allergy, Asthma & Immunology
Chronic Rhinosinusitis
Diagnosis of Chronic Rhinosinusitis
Symptoms for > 12 weeks Two main subtypes:
CRS without nasal polyps CRS with nasal polyps
Strongly associated with asthma and aspirin tolerance
Meltzer et al. JACI 2004;114:155
Common (>50%)RareAnti-Staph Toxin
LotLittle/unclearLocal IgE prod.
Very HighMildly increasedMucus MCP
HighLowVCAM and IL5
Mostly EOSMostly PMN’sInflammatory Infilt
HigherLowerASA sensitivity
HigherLowerAsthma
CRS with NPCRS without NPClinical Pathologic
Differences
RhyooRhyoo 1999, 1999, NonoyamaNonoyama 2000, 2000, DemolyDemoly 1997, 1997, BachertBachert 1998, 1998, RudackRudack 19981998
Chronic Rhinosinusitis: Risk Factors for Extensive Disease
80 patients with CRS
Factors Eosinophil > 200/uL (OR=19.2, 95% CI=5.4-72.7
Asthma (OR=6.8, 95%CI=2.2-22)
Atopy (OR=4.3,95%CI=1.5-12.8)
Age>50 (OR=6.5,95%CI=2.0-22.2)
Hoover GE et al. JACI 1997;100:185-91
Prevalence of Allergy in CRS
Chart review of 113 sinus surgery patients
48 patients included in the study
Allergy testing by RAST or skin testing
57.4% had a positive allergy test
Guman et al. Otolaryngol Head Neck Surg 2004;130:545
Type of Allergy Among Sinus Surgery Patients
None
Perennial and seasonal
Perennial
Seasonal
Emmanuel et al. Otolaryngol H&N Surg 2000; 123:687 and Ramandan et al. Am J Rhinol 1999; 13:345
Diagnosis of CRS Physical examination
Endoscopy or anterior rhinoscopy Purulent drainage Edema or erythema of the middle meatus or ethmoid bulla polyps
Sinus CT scan Mucosal thickening Air-fluid level
Meltzer et al. JACI 2004;114:155
Medical Management of Chronic Rhinosinusitis
Antibiotics
Corticosteroids
Decongestants
Muco-evacuants
Antihistamines
Non-pharmacologic treatment
v
Microbiology of Chronic Rhinosinusitis
Not well defined because of differences in culturing techniques, prior use of abx
S. pneumoniae, H. influenzae, M. catarrhalis
S. Aureus, coagulase negative staph, anaerobes
Fungi
Meltzer et al. JACI 2004;114:155
Chronic Rhinosinusitis: Which Antibiotic to Use?
-No antibiotic is approved by FDA for CRS
-We use similar abx as ABRS
Antibiotics for Chronic Rhinosinusitis
Appropriate duration is not well defined
AAAAI and ACAAI Joint Task Force treat for 3,4 or 6 weeks continue abx for at least 1 week after the patient is symptom free
Task Force on Rhinosinusitis of the American Academy of Otolaryngology-Head and Neck Surgery
treat 4 to 6 weeks
Adjunctive Therapy
Decongestants Used as adjuvant treatment
no controlled studies
Mucolytic treatment 1 double blinded study
2400 mg of guaifenesin or placebo in HIV+ with chronic sinusitis
improvement in congestion and thick secretions
Wawrose et al. Laryngoscope 1992;102:1225
Adjunctive Therapy
Antihistamines
play a role in allergic rhinitis patients with sinusitis
Saline irrigation
may help mucociliary clearance
mild vasoconstrictor of nasal blood flow
Intravenous immune globulin
indicated in patients with impaired humoral immunity
Surgery for Rhinosinusitis
FESS enlarge sinus ostia
correct anatomic deformities (septal deviation, concha bullosa)
create a common cavity for nasal drainage
ventilate sinuses
>85% improvement in selected series
Summary
Acute rhinosinusitis is usually related to infection Antibiotic management is first line
Chronic rhinosinusitis is usually related to inflammation
Further characterization of the condition is important (nasal polyps) Exploration of underlying allergy is important Management is challenging