Rhinosinusites SAYED MOSTAFA HASHEMI MD FACULTI MEMBER OF
ISFAHAN MEDICAL SCAIENS
Slide 3
ANATOMY AND PHYSIOLOGY Humans have four pairs of sinuses named
for the bones of the skull that they pneumatize The maxillary,
ethmoid (divided into anterior and posterior cells), frontal, and
sphenoid sinuses are air-containing spaces that are lined by
pseudostratified, columnar epithelium bearing cilia. The sinus
mucosa contains goblet cells, which secrete mucus that aids in
trapping inhaled particles and debris. Humans have four pairs of
sinuses named for the bones of the skull that they pneumatize The
maxillary, ethmoid (divided into anterior and posterior cells),
frontal, and sphenoid sinuses are air-containing spaces that are
lined by pseudostratified, columnar epithelium bearing cilia. The
sinus mucosa contains goblet cells, which secrete mucus that aids
in trapping inhaled particles and debris. 3
Slide 4
Anatomy
Slide 5
Ostiomeatal complex 5
Slide 6
INTRODUCTION Rhinosinusitis is defined as symptomatic
inflammation of the nasal cavity and paranasal sinuse
Rhinosinusitis is defined as symptomatic inflammation of the nasal
cavity and paranasal sinuse The term "rhinosinusitis" is preferred
to "sinusitis" since inflammation of the sinuses rarely occurs
without concurrent inflammation of the nasal mucosa [1]. The term
"rhinosinusitis" is preferred to "sinusitis" since inflammation of
the sinuses rarely occurs without concurrent inflammation of the
nasal mucosa [1].1 6
Slide 7
Pathophysiology The sinuses are normally sterile under
physiologic conditions. Purulent sinusitis can occur when ciliary
clearance of sinus secretions decreases or when the sinus ostium
becomes obstructed, which leads to retention of secretions,
negative sinus pressure, and reduction of oxygen partial pressure.
The sinuses are normally sterile under physiologic conditions.
Purulent sinusitis can occur when ciliary clearance of sinus
secretions decreases or when the sinus ostium becomes obstructed,
which leads to retention of secretions, negative sinus pressure,
and reduction of oxygen partial pressure. 7
Slide 8
Pathophysiology This environment is then suitable for growth of
pathogenic organisms. This environment is then suitable for growth
of pathogenic organisms. Factors that predispose the sinuses to
obstruction and decreased ciliary function are allergic,
nonallergic, or viral insults, which produce inflammation of the
nasal and sinus mucosa and result in ciliary dysmotility and sinus
obstruction. Factors that predispose the sinuses to obstruction and
decreased ciliary function are allergic, nonallergic, or viral
insults, which produce inflammation of the nasal and sinus mucosa
and result in ciliary dysmotility and sinus obstruction. 8
Slide 9
PATHOGENESIS of ABRS With colds and influenza-like illnesses,
viscous fluid frequently accumulates in the sinuses from exocytosis
of mucus from goblet cells in the sinus mucosa [6] and possibly as
the result of nose blowing. With colds and influenza-like
illnesses, viscous fluid frequently accumulates in the sinuses from
exocytosis of mucus from goblet cells in the sinus mucosa [6] and
possibly as the result of nose blowing.6 ABRS occurs when bacteria
secondarily infect the inflamed sinus cavity. Though usually
occurring as a complication of viral infection ABRS occurs when
bacteria secondarily infect the inflamed sinus cavity. Though
usually occurring as a complication of viral infection With colds
and influenza-like illnesses, viscous fluid frequently accumulates
in the sinuses from exocytosis of mucus from goblet cells in the
sinus mucosa [6] and possibly as the result of nose blowing. With
colds and influenza-like illnesses, viscous fluid frequently
accumulates in the sinuses from exocytosis of mucus from goblet
cells in the sinus mucosa [6] and possibly as the result of nose
blowing.6 ABRS occurs when bacteria secondarily infect the inflamed
sinus cavity. Though usually occurring as a complication of viral
infection ABRS occurs when bacteria secondarily infect the inflamed
sinus cavity. Though usually occurring as a complication of viral
infection 9
Slide 10
Conversion of AVRS to ABRS it is generally not possible to
distinguish AVRS from ABRS in the first 10 days of illness based
upon history, examination, or radiologic study. it is generally not
possible to distinguish AVRS from ABRS in the first 10 days of
illness based upon history, examination, or radiologic study. The
diagnosis of ABRS is usually clinical, since sinus aspirates for
culture are not readily obtainable. The diagnosis of ABRS is
usually clinical, since sinus aspirates for culture are not readily
obtainable. 10
Slide 11
Conversion of AVRS to ABRS Persistent symptoms or signs of ARS
lasting 10 or more days with no clinical improvement Onset with
severe symptoms (fever >39C or 102F and purulent nasal discharge
or facial pain) lasting at least three following days at the
beginning of illness Onset with worsening symptoms following a
viral upper respiratory infection that lasted five to six days and
was initially Improving immunocompromised patients
Slide 12
Only a small percentage (approximately two percent) of viral
rhinosinusitis is complicated by acute bacterial sinusitis.
Uncomplicated viral rhinosinusitis usually resolves in seven to ten
days. Only a small percentage (approximately two percent) of viral
rhinosinusitis is complicated by acute bacterial sinusitis.
Uncomplicated viral rhinosinusitis usually resolves in seven to ten
days. 12
Slide 13
EPIDEMIOLOGY The average adult has from two to three colds and
influenza-like illnesses per year and the average child six to 10
The average adult has from two to three colds and influenza-like
illnesses per year and the average child six to 10 Approximately
0.5 to 2 percent of colds and influenza-like in adults and 6-13% in
children Approximately 0.5 to 2 percent of colds and influenza-like
in adults and 6-13% in children complicated by acute bacterial
sinusitis in adults complicated by acute bacterial sinusitis in
adults 13
Slide 14
Classification of rhinosinusitis is based on symptom duration.
14
Slide 15
Recurrent acute rhinosinusitis - four or more episodes of ARS
per year, with temporary symptom resolution [2]. - four or more
episodes of ARS per year, with temporary symptom resolution [2].2
15
Slide 16
Clinical course Acute bacterial sinusitis is also usually a
self-limited disease, with 75 percent of cases resolving without
treatment in one month. Acute bacterial sinusitis is also usually a
self-limited disease, with 75 percent of cases resolving without
treatment in one month. untreated patients with acute bacterial
sinusitis have bothersome morbidity and are at risk of developing
intracranial and orbital complications untreated patients with
acute bacterial sinusitis have bothersome morbidity and are at risk
of developing intracranial and orbital complications Acute
bacterial sinusitis is also usually a self-limited disease, with 75
percent of cases resolving without treatment in one month. Acute
bacterial sinusitis is also usually a self-limited disease, with 75
percent of cases resolving without treatment in one month.
untreated patients with acute bacterial sinusitis have bothersome
morbidity and are at risk of developing intracranial and orbital
complications untreated patients with acute bacterial sinusitis
have bothersome morbidity and are at risk of developing
intracranial and orbital complications 16 Acute bacterial sinusitis
is also
Slide 17
Clinical Diagnosis Clinical Diagnosis Purulent rhinorrhea
Purulent rhinorrhea Nasal congestion and/or facial pain/pressure
Nasal congestion and/or facial pain/pressure diagnosis is further
supported by the presence of secondary symptoms, including anosmia,
ear fullness, cough, and headache. Pain localized to the sinuses
when the patient is asked to bend forward may be more Pain
localized to the sinuses when the patient is asked to bend forward
may be more 17
Slide 18
Physical Examination Anterior rhinoscopy with otoscope in
younger children Tenderness over sinuses Periorbital edema and
discoloration Flexible and rigid endoscopy in older child Most
specific-- mucopurulence, periorbital swelling, facial tenderness
18
Slide 19
Tools for intranasal examination 19
Slide 20
Notable exam findings may include diffuse mucosal edema,
narrowing of the middle meatus, inferior turbinate hypertrophy, and
copious rhinorrhea or purulent discharge. may include diffuse
mucosal edema, narrowing of the middle meatus, inferior turbinate
hypertrophy, and copious rhinorrhea or purulent discharge. Polyps
or septal deviation may be noted incidentally and may indicate
pre-existing anatomic risk factors for the development of ABRS.
Polyps or septal deviation may be noted incidentally and may
indicate pre-existing anatomic risk factors for the development of
ABRS. 20
Slide 21
plain sinus radiography The sensitivity and specificity of
plain sinus radiography is poor for detecting mucosal thickening of
the paranasal sinuses (76 and 79 percent, respectively) The
sensitivity and specificity of plain sinus radiography is poor for
detecting mucosal thickening of the paranasal sinuses (76 and 79
percent, respectively) The high false negative rate is attributable
to poor visualization of the ethmoid sinuses in plain films, The
high false negative rate is attributable to poor visualization of
the ethmoid sinuses in plain films, The high false positive rate to
artifact and the inability to distinguish polyps and nasal masses
from fluid or mucosal edema. The high false positive rate to
artifact and the inability to distinguish polyps and nasal masses
from fluid or mucosal edema. 21
Slide 22
Computed tomographic (CT) scan of the sinuses showing occlusion
of the infundibula (black arrow heads); viscous material adherent
to the wall of the sinus cavity (white arrow); bubble in the
viscous fluid which does not represent thickened sinus mucosa
(white arrow head); and pneumatization of concha bullosa
(asterisk). Courtesy of Jack Gwaltney, MD. Computed tomographic
(CT) scan of the sinuses showing occlusion of the infundibula
(black arrow heads); viscous material adherent to the wall of the
sinus cavity (white arrow); bubble in the viscous fluid which does
not represent thickened sinus mucosa (white arrow head); and
pneumatization of concha bullosa (asterisk). Courtesy of Jack
Gwaltney, MD. 22
Slide 23
Sinus aspiration cultures are rarely performed unless there has
been a failure of treatment cultures are rarely performed unless
there has been a failure of treatment sinus aspiration is indicated
in severe toxic illness, acute illness not responsive to
antibiotics within 72 hours, immunocompromised patients, supportive
complications sinus aspiration is indicated in severe toxic
illness, acute illness not responsive to antibiotics within 72
hours, immunocompromised patients, supportive complications
endoscopically guided middle meatus swab correlates fairly well
with sinus aspirate endoscopically guided middle meatus swab
correlates fairly well with sinus aspirate 23
Slide 24
Microbiology 24
Slide 25
Medical Treatment Medical Treatment Acute Sinusitis: Acute
Sinusitis: Young children with mild to moderate ARS, amoxicillin at
normal or high dose Amoxil-allergic patients, treat with a
cephalosporin severe allergy, treat with macrolide Nonresponders,
more severe initial disease, those at high-risk for resistant
strep, treat with high dose amoxil/clavulanate Parenteral
ceftriaxone for children not tolerating oral meds Duration of
therapy is usually days 7-10 25
Slide 26
Antibiotics - Other Considerations Recent use of prior
antibiotics is a risk factor for the presence of
antibiotic-resistant bacteria different antibiotic should be
selected if the patient has used antibiotics in the last 4 to 6
weeks. Guidelines from the Sinus and Allergy Health Partnership 4
recommend a fluoroquinolone or high-dose amoxicillin- clavulanate
(4 grams/250 milligrams per day) for patients who have received
antibiotics within the past 4 to 6 weeks. Having a child in daycare
in the household is a risk factor for penicillin-resistant S.
pneumoniae, for which high-dose amoxicillin is an option.
Slide 27
Treatment Amoxicillin has been recommended as a first-line
agent in the past because of its narrow spectrum and relative low
cost. However, there is increasing emergence of antimicrobial
resistance among respiratory pathogens, including pneumococci and
H. influenzae. Resistance rates vary regionally, with the
prevalence of H. influenzae resistance ranging from 27 to 43
percent in the US [9]. Amoxicillin has been recommended as a
first-line agent in the past because of its narrow spectrum and
relative low cost. However, there is increasing emergence of
antimicrobial resistance among respiratory pathogens, including
pneumococci and H. influenzae. Resistance rates vary regionally,
with the prevalence of H. influenzae resistance ranging from 27 to
43 percent in the US [9]. 27
Slide 28
Treatment failure Treatment failure is defined as progression
of symptoms at any time during treatment or failure to improve
after 3-5 days of therapy. Treatment failure is defined as
progression of symptoms at any time during treatment or failure to
improve after 3-5 days of therapy. Patients who fail first-line
therapy require alternative antibiotic selection. Ideally, an
endoscopically-guided culture could be performed to redirect
antibiotic therapy. If no material is available on endoscopy for
culture, a broader antibiotic choice can be empirically started and
monitored for improvement. high-dose amoxicillin-clavulanate (4
grams/250 milligrams per day) have been recommended Patients who
fail first-line therapy require alternative antibiotic selection.
Ideally, an endoscopically-guided culture could be performed to
redirect antibiotic therapy. If no material is available on
endoscopy for culture, a broader antibiotic choice can be
empirically started and monitored for improvement. high-dose
amoxicillin-clavulanate (4 grams/250 milligrams per day) have been
recommended amoxicillin-clavulanate A CT scan of the sinuses may be
performed if symptoms worsen or fail to improve, to verify that
symptoms are in fact due to acute sinusitis, and not to concomitant
allergy or other noninfectious etiologies. A CT scan of the sinuses
may be performed if symptoms worsen or fail to improve, to verify
that symptoms are in fact due to acute sinusitis, and not to
concomitant allergy or other noninfectious etiologies. Treatment
failure is defined as progression of symptoms at any time during
treatment or failure to improve after 3-5 days of therapy.
Treatment failure is defined as progression of symptoms at any time
during treatment or failure to improve after 3-5 days of therapy.
Patients who fail first-line therapy require alternative antibiotic
selection. Ideally, an endoscopically-guided culture could be
performed to redirect antibiotic therapy. If no material is
available on endoscopy for culture, a broader antibiotic choice can
be empirically started and monitored for improvement. high-dose
amoxicillin-clavulanate (4 grams/250 milligrams per day) have been
recommended Patients who fail first-line therapy require
alternative antibiotic selection. Ideally, an endoscopically-guided
culture could be performed to redirect antibiotic therapy. If no
material is available on endoscopy for culture, a broader
antibiotic choice can be empirically started and monitored for
improvement. high-dose amoxicillin-clavulanate (4 grams/250
milligrams per day) have been recommended amoxicillin-clavulanate A
CT scan of the sinuses may be performed if symptoms worsen or fail
to improve, to verify that symptoms are in fact due to acute
sinusitis, and not to concomitant allergy or other noninfectious
etiologies. A CT scan of the sinuses may be performed if symptoms
worsen or fail to improve, to verify that symptoms are in fact due
to acute sinusitis, and not to concomitant allergy or other
noninfectious etiologies. 28
Slide 29
Choice of Antibiotic for ABRS Wright & Frankel
Slide 30
Treatment trimethoprim-sulfamethoxazole, and second- or
third-generation cephalosporins are not recommended for empiric
therapy because of high rates of resistance of S. pneumoniae (and
of H. influenzae for trimethoprim-sulfamethoxazole
trimethoprim-sulfamethoxazole, and second- or third-generation
cephalosporins are not recommended for empiric therapy because of
high rates of resistance of S. pneumoniae (and of H. influenzae for
trimethoprim-sulfamethoxazole 30
Slide 31
Antibiotics - Duration Most trials of ABRS administer
antibiotic for 10 days No significant differences in resolution
rates for ABRS with a 6-10 day course of antibiotics compared with
a 3-5-day course (azithromycin, telithromycin, or cefuroxime) up to
3 weeks after treatment. Refs 118-120 Another systematic review
found no relation between antibiotic duration and outcome efficacy
for 8 RCTs (Ip et al. 2005) Shorter antibiotic courses associated
with fewer adverse effects. Final Recommendation on Duration?
Slide 32
Treatment Adjunctive therapy Symptomatic relief measures,
including analgesics, nasal saline irrigation, and topical and
systemic decongestants Adjunctive therapy Symptomatic relief
measures, including analgesics, nasal saline irrigation, and
topical and systemic decongestants 32
Slide 33
Saline irrigation Mechanical irrigation with buffered,
physiologic, or hypertonic saline may reduce the need for pain
medication and improve overall patient comfort, particularly in
patients with frequent sinus infections. Mechanical irrigation with
buffered, physiologic, or hypertonic saline may reduce the need for
pain medication and improve overall patient comfort, particularly
in patients with frequent sinus infections. It is important that
irrigants be prepared from sterile or bottled water, as there have
been reports of amebic encephalitis due to tap water rinses [13].
Instructions for preparing a rinse solution are shown in a table
(tabl It is important that irrigants be prepared from sterile or
bottled water, as there have been reports of amebic encephalitis
due to tap water rinses [13]. Instructions for preparing a rinse
solution are shown in a table (tabl 33
Slide 34
Topical glucocorticoids The theoretic mechanism of action for
intranasal glucocorticoids (corticosteroids) is a decrease in
mucosal inflammation that allows improved sinus drainage The
theoretic mechanism of action for intranasal glucocorticoids
(corticosteroids) is a decrease in mucosal inflammation that allows
improved sinus drainage intranasal glucocorticoids are likely to be
most beneficial for patients with underlying allergic rhinitis
intranasal glucocorticoids are likely to be most beneficial for
patients with underlying allergic rhinitis 34
Slide 35
Topical decongestants The use of topical decongestants, such as
oxymetazoline, may provide a subjective sense of improved nasal
patency. If used, topical decongestants should be used sparingly
(no more than three consecutive days) to avoid rebound congestion
The use of topical decongestants, such as oxymetazoline, may
provide a subjective sense of improved nasal patency. If used,
topical decongestants should be used sparingly (no more than three
consecutive days) to avoid rebound congestion Topical decongestants
are suggested for symptomatic relief in the treatment of AVRS and
2012 guidelines advise that they are not helpful in patients with
ABRs Topical decongestants are suggested for symptomatic relief in
the treatment of AVRS and 2012 guidelines advise that they are not
helpful in patients with ABRs oral decongestants are not helpful in
patients with ABRS oral decongestants are not helpful in patients
with ABRS 35
Slide 36
oral decongestants oral decongestants are not helpful in
patients with ABRS oral decongestants are not helpful in patients
with ABRS When eustachian tube dysfunction is a significant
confounding factor in AVRS, a short course (three to five days) of
oral decongestants may be warranted. When eustachian tube
dysfunction is a significant confounding factor in AVRS, a short
course (three to five days) of oral decongestants may be warranted.
Oral decongestants should be used with caution in patients with
cardiovascular disease, hypertension, or benign prostate
hypertrophy due to systemic adverse effects with oral alpha
adrenergic preparation Oral decongestants should be used with
caution in patients with cardiovascular disease, hypertension, or
benign prostate hypertrophy due to systemic adverse effects with
oral alpha adrenergic preparation 36
Slide 37
Antihistamines Antihistamines are frequently prescribed for
symptom relief due to their drying effects; however, there are no
studies investigating their efficacy for this indication
Antihistamines are frequently prescribed for symptom relief due to
their drying effects; however, there are no studies investigating
their efficacy for this indication Additionally, over-drying of the
mucosa may lead to further discomfort. Antihistamines have side
effects (drowsiness, xerostomia), Additionally, over-drying of the
mucosa may lead to further discomfort. Antihistamines have side
effects (drowsiness, xerostomia), Their use for the treatment of
acute sinusitis is not recommended Their use for the treatment of
acute sinusitis is not recommended 37
Slide 38
Indications for urgent referral Patients with high fever, acute
facial pain, swelling, and erythema should be treated for acute
bacterial rhinosinusitis, even if symptoms have not been present
for seven days. Patients with high fever, acute facial pain,
swelling, and erythema should be treated for acute bacterial
rhinosinusitis, even if symptoms have not been present for seven
days. Patients with high fevers and severe headache warrant
immediate evaluation and probable imaging. Patients with high
fevers and severe headache warrant immediate evaluation and
probable imaging. 38
Chronic rhinosinusitis Chronic rhinosinusitis is a group of
disorders characterized by inflammation of the mucosa of the nose
and paranasal sinuses of at least 12 consecutive weeks duration.
Chronic rhinosinusitis is a group of disorders characterized by
inflammation of the mucosa of the nose and paranasal sinuses of at
least 12 consecutive weeks duration. Patients with CRS may have
intermittent acute flare-ups; in such cases, the disorder is called
acute exacerbation of chronic rhinosinusitis(AECRS) Patients with
CRS may have intermittent acute flare-ups; in such cases, the
disorder is called acute exacerbation of chronic
rhinosinusitis(AECRS) 41
Slide 42
Ostiomeatal complex 42
Slide 43
EPOS Management Algorithm: Adult Chronic Rhinosinusitis
*Primary Care
Slide 44
Pathogenesis Ostia obstruction creates increasingly hypoxic
environment within sinus Ostia obstruction creates increasingly
hypoxic environment within sinus Retention of secretion results in
inflammation and bacterial infection Retention of secretion results
in inflammation and bacterial infection Secretion stagnate,
obstruction increases, cilia and epithelial damage become more
pronounced Secretion stagnate, obstruction increases, cilia and
epithelial damage become more pronounced 44
Slide 45
Factors that may contribute to of CRS include 45 The
recognition that CRS represents a multifactorial inflammatory
disorder, rather than simply a persistent bacterial infection, has
led to the reexamination of the role of antimicrobials in CRS
Slide 46
The role of bacteria in the pathogenesis of chronic sinusitis
46 The role of bacteria in the pathogenesis of chronic sinusitis is
currently being reassessed. Repeated and persistent sinus
infections can develop in persons with severe acquired or
congenital immunodeficiency states or cystic fibrosis. Current
thinking supports that chronic rhinosinusitis (CRS) is
predominantly a multifactorial inflammatory disease. Confounding
factors that may contribute to inflammation include the
following:
Slide 47
47 Persistent infection (including biofilms and osteitis)
Allergy and other immunologic disorders Intrinsic factors of the
upper airway Superantigens Colonizing fungi that induce and sustain
eosinophilic inflammation Metabolic abnormalities such as aspirin
sensitivity
Slide 48
48 All of these factors can play a role in disruption of the
intrinsic mucociliary transport system. This is because an
alteration in sinus ostia patency, ciliary function, or the quality
of secretions leads to stagnation of secretions, decreased pH
levels, and lowered oxygen tension within the sinus. These changes
create a favorable environment for bacterial growth that, in turn,
further contributes to increased mucosal inflammation.
Slide 49
There are four cardinal signs of CRS: There are four cardinal
signs of CRS: Anterior and/or posterior mucopurulent drainage
Anterior and/or posterior mucopurulent drainage Nasal obstruction
Nasal obstruction Facial pain, pressure, and/or fullness Facial
pain, pressure, and/or fullness Decreased sense of smell Decreased
sense of smell At least TWO of these symptoms should be present to
consider the diagnosis of CRS, in association with objective
findings At least TWO of these symptoms should be present to
consider the diagnosis of CRS, in association with objective
findings 49
Slide 50
SUBTYPES OF CRS SUBTYPES OF CRS CRS can be divided into three
distinct clinical syndromes CRS can be divided into three distinct
clinical syndromes CRS with nasal polyposis - 20 to 33 percent of
cases CRS with nasal polyposis - 20 to 33 percent of cases Allergic
fungal rhinosinusitis - 8 to 12 percent Allergic fungal
rhinosinusitis - 8 to 12 percent CRS without nasal polyposis - 60
to 65 percent CRS without nasal polyposis - 60 to 65 percent
50
Slide 51
CRS with nasal polyposis Chronic rhinosinusitis with nasal
polyposis (CRS with NP) is characterized by the presence of nasal
polyps. Nasal polyps are translucent, yellowish-grey to white,
glistening masses filled with gelatinous inflammatory material,
which may form in the nasal cavity or paranasal sinuses Chronic
rhinosinusitis with nasal polyposis (CRS with NP) is characterized
by the presence of nasal polyps. Nasal polyps are translucent,
yellowish-grey to white, glistening masses filled with gelatinous
inflammatory material, which may form in the nasal cavity or
paranasal sinuses 51
Slide 52
nasal polyposis nasal polyposis The grey-white color is due to
the relatively avascular nature of the polyp tissue. Nasal polyps
lack sensation and should be distinguished from swollen nasal
turbinates, which are pink in color, similar in appearance to the
rest of the nasal mucosa, and very sensitive to touch The
grey-white color is due to the relatively avascular nature of the
polyp tissue. Nasal polyps lack sensation and should be
distinguished from swollen nasal turbinates, which are pink in
color, similar in appearance to the rest of the nasal mucosa, and
very sensitive to touch 52
Slide 53
Pathophysiology Pathophysiology 53 The initial trigger for
their development is probably variable. Polyp tissue typically
contains a predominance of eosinophils, high levels of the Th2
cytokines interleukin (IL)-5 and IL-13, and high levels of
histamine [8]. The initial trigger for their development is
probably variable. Polyp tissue typically contains a predominance
of eosinophils, high levels of the Th2 cytokines interleukin (IL)-5
and IL-13, and high levels of histamine [8].8
Slide 54
CRS without NP - The characteristic presentation of CRS without
NP is that of persistent symptoms with periodic exacerbations
characterized by increased facial pain/pressure and/or increased
anterior or posterior drainage - The characteristic presentation of
CRS without NP is that of persistent symptoms with periodic
exacerbations characterized by increased facial pain/pressure
and/or increased anterior or posterior drainage Fatigue is a
frequent accompanying symptom. Fatigue is a frequent accompanying
symptom. Fever is usually absent or low-grade. A subclass of
patients has recurrent acute rhinosinusitis symptoms, which respond
well to antibiotic treatment. Fever is usually absent or low-grade.
A subclass of patients has recurrent acute rhinosinusitis symptoms,
which respond well to antibiotic treatment. Such patients may be
completely symptom free between episodes or have persistent
symptoms characteristic of CRS without NP. Such patients may be
completely symptom free between episodes or have persistent
symptoms characteristic of CRS without NP. 54
Slide 55
Allergic fungal rhinosinusitis - AFRS usually presents
delicately, with symptoms similar to CRS with NP. Patients may
describe semi-solid nasal crusts that are similar in appearance to
allergic mucin Fever is uncommon. - AFRS usually presents
delicately, with symptoms similar to CRS with NP. Patients may
describe semi-solid nasal crusts that are similar in appearance to
allergic mucin Fever is uncommon. The patients are atopic(IgE
increased) The patients are atopic(IgE increased) In occasional
patients, AFRS presents dramatically with complete nasal
obstruction, gross facial asymmetry. In occasional patients, AFRS
presents dramatically with complete nasal obstruction, gross facial
asymmetry. 55
Slide 56
Physical examination Physical examination Anterior rhinoscopy
:The nasal cavities may be examined with a penlight, use of an
otoscope with a nasal speculum provides better visualization of the
inferior turbinate and anterior nasal septum. Anterior rhinoscopy
:The nasal cavities may be examined with a penlight, use of an
otoscope with a nasal speculum provides better visualization of the
inferior turbinate and anterior nasal septum. nasal endoscope is
ideal for evaluating the entire nasal cavity and the region of the
middle turbinate in particular Mucopurulent material seen emanating
from the middle meatus, between the middle turbinate and lateral
nasal wall, is strongly supportive of the diagnosis of sinusitis
nasal endoscope is ideal for evaluating the entire nasal cavity and
the region of the middle turbinate in particular Mucopurulent
material seen emanating from the middle meatus, between the middle
turbinate and lateral nasal wall, is strongly supportive of the
diagnosis of sinusitis 56
Slide 57
Endoscopic view of the nose 57
Slide 58
Imaging studies Imaging studies Patients with suspected chronic
sinusitis that do not improve with medical therapy should be
further investigated by imaging studies Patients with suspected
chronic sinusitis that do not improve with medical therapy should
be further investigated by imaging studies 58
Slide 59
Sinus radiographs Sinus radiographs have traditionally been
used to screen such patients; however, they often miss obstructing
pathology in the OMC region of the ethmoid sinus [28]. Plain sinus
x-rays have largely been replaced by the "limited" CT scan, which
provides select coronal views through each of the sinuses. This
relatively quick, low cost study serves as a useful tool to exclude
the diagnosis of sinusitis in patients with an uncertain diagnosis.
Sinus radiographs have traditionally been used to screen such
patients; however, they often miss obstructing pathology in the OMC
region of the ethmoid sinus [28]. Plain sinus x-rays have largely
been replaced by the "limited" CT scan, which provides select
coronal views through each of the sinuses. This relatively quick,
low cost study serves as a useful tool to exclude the diagnosis of
sinusitis in patients with an uncertain diagnosis.28 59
DIFFERENTIAL DIAGNOSIS The chronic sinusitis patient, who has a
primary complaint of facial pain or headache, in the absence of
nasal symptoms, may be suffering from migraine, neuralgia, or
atypical facial pain syndrome. The chronic sinusitis patient, who
has a primary complaint of facial pain or headache, in the absence
of nasal symptoms, may be suffering from migraine, neuralgia, or
atypical facial pain syndrome. If the patient does not improve with
treatment for sinusitis and the sinus CT is normal, an MRI scan and
referral to a neurologist should be considered If the patient does
not improve with treatment for sinusitis and the sinus CT is
normal, an MRI scan and referral to a neurologist should be
considered 61
Slide 62
MEDICAL MANAGEMENT The goal of medical therapy for chronic
sinusitis is to promote sinus drainage and eradicate the offending
pathogens. The goal of medical therapy for chronic sinusitis is to
promote sinus drainage and eradicate the offending pathogens.
Despite the common nature of this disease, the data supporting the
efficacy of these various treatment modalities are scant. Despite
the common nature of this disease, the data supporting the efficacy
of these various treatment modalities are scant. A retrospective
analysis, for example, assessed the outcome of intensive medical
management including one month of antibiotics, oral
corticosteroids, topical steroids, and nasal irrigation the latter
two therapies were continued after a period of one month [38]. A
retrospective analysis, for example, assessed the outcome of
intensive medical management including one month of antibiotics,
oral corticosteroids, topical steroids, and nasal irrigation the
latter two therapies were continued after a period of one month
[38].corticosteroids38corticosteroids38 62
Slide 63
Medical Treatment Chronic Rhinosinusitis Chronic Rhinosinusitis
4 to 6 week course of beta lactam stable antibiotic Adjuvant
therapy with nasal steroids commonly employed Antihistamines
especially if underlying allergic condition suspected Mucolytics
may thin secretions 63
Slide 64
Recommend antibiotces amoxicillin-clavulanate or cefuroxime,
both at doses of 500 mg PO twice daily as first-line agents for
chronic sinusitis. We commonly treat for 21 days; the full six-
week course is usually reserved for more refractory cases.
Clarithromycin (500 mg PO twice daily) or clindamycin (300 mg PO
three times a day) are usually selected for patients with
penicillin allergy. Quinolones, including levofloxacin or
moxifloxacin, have been used to treat patients with chronic
sinusitis but are best reserved for culture-demonstrated
gram-negative infectio amoxicillin-clavulanate or cefuroxime, both
at doses of 500 mg PO twice daily as first-line agents for chronic
sinusitis. We commonly treat for 21 days; the full six- week course
is usually reserved for more refractory cases. Clarithromycin (500
mg PO twice daily) or clindamycin (300 mg PO three times a day) are
usually selected for patients with penicillin allergy. Quinolones,
including levofloxacin or moxifloxacin, have been used to treat
patients with chronic sinusitis but are best reserved for
culture-demonstrated gram-negative infectio
amoxicillin-clavulanatecefuroximeClarithromycin
clindamycinlevofloxacinmoxifloxacin
amoxicillin-clavulanatecefuroximeClarithromycin
clindamycinlevofloxacinmoxifloxacin 64
Slide 65
Nasal irrigation Patients who complain of nasal congestion or
drainage from excessive mucus production are instructed to irrigate
their nose twice a day with warm saline solution using a bulb
syringe. The syringe is filled with saline prepared by adding a
teaspoon of salt to a glass of warm water. The saline is gently
squirted into one nostril and then the other while bending over a
sink. The solution should drain out of the nostrils, carrying with
it excess mucus from within the nose and sinuses. This relatively
simple technique can provide great symptomatic relief in many
patients with chronic sinusitis. Patients who complain of nasal
congestion or drainage from excessive mucus production are
instructed to irrigate their nose twice a day with warm saline
solution using a bulb syringe. The syringe is filled with saline
prepared by adding a teaspoon of salt to a glass of warm water. The
saline is gently squirted into one nostril and then the other while
bending over a sink. The solution should drain out of the nostrils,
carrying with it excess mucus from within the nose and sinuses.
This relatively simple technique can provide great symptomatic
relief in many patients with chronic sinusitis. 65
Slide 66
Topical steroids Topical steroids Topical steroids in the form
of nasal sprays may decrease mucosal inflammation and swelling,
particularly in patients with allergic disease as a contributing
factor. In one study of 95 patients with a history of chronic or
recurrent sinusitis, the addition of intranasal fluticasone,]. Two
puffs of fluticasone once a day for 21 days resulted in patient
reports of 93.5 percent clinical success compared to 73.9 percent
for placebo spray in this randomized trial. Topical steroids in the
form of nasal sprays may decrease mucosal inflammation and
swelling, particularly in patients with allergic disease as a
contributing factor. In one study of 95 patients with a history of
chronic or recurrent sinusitis, the addition of intranasal
fluticasone,]. Two puffs of fluticasone once a day for 21 days
resulted in patient reports of 93.5 percent clinical success
compared to 73.9 percent for placebo spray in this randomized
trial. fluticasone Steroid sprays do not appear to suppress
endogenous steroid secretion even after long-term use. Steroid
sprays do not appear to suppress endogenous steroid secretion even
after long-term use. 66
Slide 67
Systemic steroids Systemic steroids may be used on a limited
basis in patients with diffuse nasal polyps refractory to steroid
sprays or those with exacerbations of asthma triggered by sinusitis
Systemic steroids may be used on a limited basis in patients with
diffuse nasal polyps refractory to steroid sprays or those with
exacerbations of asthma triggered by sinusitis 67
Slide 68
SURGICAL MANAGEMENT SURGICAL MANAGEMENT SURGICAL MANAGEMENT The
goal of functional endoscopic sinus surgery, known by the acronym
FESS, is to restore physiologic sinus ventilation and drainage,
which allows for the gradual resolution of mucosal disease [49].
SURGICAL MANAGEMENT The goal of functional endoscopic sinus
surgery, known by the acronym FESS, is to restore physiologic sinus
ventilation and drainage, which allows for the gradual resolution
of mucosal disease [49].49 Patients who are considered candidates
for this procedure have typically required more than three courses
of antibiotics for sinusitis within a 12-month period. In addition,
abnormalities of the sinuses or OMC should be evident on nasal
endoscopy or CT imaging. Patients who are considered candidates for
this procedure have typically required more than three courses of
antibiotics for sinusitis within a 12-month period. In addition,
abnormalities of the sinuses or OMC should be evident on nasal
endoscopy or CT imaging. 68
Slide 69
Surgical Management Adenoidectomy Adenoidectomy FESS FESS Only
after maximal medical therapy has failed and patient has been
screened and treated for any underlying conditions Concern for
developing nasal and sinus anatomy in children and possibility of
altering facial growth 69
Immune Deficiency History of frequent otitis media, pneumonia
and sinusitis may suggest a primary or secondary immunodeficiency
state History of frequent otitis media, pneumonia and sinusitis may
suggest a primary or secondary immunodeficiency state Serum
immunoglobulins and IgG subclasses should be checked as well as
ability to respond to capsular antigens of S. pneumoniae and H.
influenzae Serum immunoglobulins and IgG subclasses should be
checked as well as ability to respond to capsular antigens of S.
pneumoniae and H. influenzae Must have laboratory with
age-appropriate norms Chronic pediatric sinusitis associated with
IgG2 deficiency Consistent low total immunoglobulin defines common
variable hypoglobulinemia Treatment in primarily medical Treatment
in primarily medical Patients may benefit from IVIG therapy
Patients may benefit from IVIG therapy Genetic counseling for
patient and family may be appropriate Genetic counseling for
patient and family may be appropriate 72
Slide 73
Gastroesophageal Reflux Disease Many pediatric patients
experience improvement in their chronic sinonasal symptoms after a
trial of antireflux medicine Many pediatric patients experience
improvement in their chronic sinonasal symptoms after a trial of
antireflux medicine GERD theorized to have direct effect on nasal
mucosa, initiating inflammatory response with edema and impaired
mucociliary clearance GERD theorized to have direct effect on nasal
mucosa, initiating inflammatory response with edema and impaired
mucociliary clearance Phipps in 2000 reported a prospective trial
in which 63% CRS patients were found to have esophageal reflux by
pH probe; 32% demonstrated nasopharyngeal reflux Phipps in 2000
reported a prospective trial in which 63% CRS patients were found
to have esophageal reflux by pH probe; 32% demonstrated
nasopharyngeal reflux Bothwell in 1999 reported 89% of pediatric
candidates for FESS avoided surgery with treatment for GERD
Bothwell in 1999 reported 89% of pediatric candidates for FESS
avoided surgery with treatment for GERD 73
Slide 74
Cystic Fibrosis Autosomal recessive disease Autosomal recessive
disease Mutation of CFTR protein Mutation of CFTR protein Patients
develop chronic pulmonary disease in childhood; also affected with
sinusitis and nasal polyposis, pancreatic insufficiency and biliary
cirrhosis Patients develop chronic pulmonary disease in childhood;
also affected with sinusitis and nasal polyposis, pancreatic
insufficiency and biliary cirrhosis If surgery contemplated, check
coags If surgery contemplated, check coags Recent studies suggest
heterozygous mutations in the CFTR gene are associated with chronic
rhinosinusitis Recent studies suggest heterozygous mutations in the
CFTR gene are associated with chronic rhinosinusitis Raman found
that 12.1% of CRS patients harbored CFTR mutations compared with
the expected rate of 3-4% Wang found a 7% incidence of CFTR
mutation in 123 CRS patients compared to 2% in a control group
74
Slide 75
Primary Ciliary Dyskinesia History of chronic otitis media,
chronic sinusitis and chronic bronchitis or bronchiectasis History
of chronic otitis media, chronic sinusitis and chronic bronchitis
or bronchiectasis Kartageners syndrome: sinusitis, situs inversus,
bronchiectasis and male infertility) Kartageners syndrome:
sinusitis, situs inversus, bronchiectasis and male infertility)
Diagnosis established with inferior or middle turbinate or tracheal
biopsy Diagnosis established with inferior or middle turbinate or
tracheal biopsy 75
Slide 76
76
Slide 77
Allergic Fungal Sinusitis Allergic reaction to aerosolized
fungi, usually of the dematiceous species Allergic reaction to
aerosolized fungi, usually of the dematiceous species Treatment is
surgical with perioperative oral steroid and post-operative topical
steroids Treatment is surgical with perioperative oral steroid and
post-operative topical steroids High recurrence rate, requires
close follow up High recurrence rate, requires close follow up
Findings in children different than adult findings Findings in
children different than adult findings Children more frequently
have abnormalities of their facial skeleton More likely to have
unilateral disease 77
Slide 78
Complications Orbital: Orbital: Orbital complications more
common in children than adults Most common is medial subperiosteal
abscess Intracranial: Intracranial: More common in
adolescents/adults Include meningitis (most common), epidural
abscess, subdural abscess, intracerebral abscess, cavernous sinus
thrombosis 78
Slide 79
Orbital Complications Classified by Chandler: Classified by
Chandler: I. Preseptal cellulitis II. Orbital cellulitis III.
Periorbital abscess IV. Orbital abscess V. Cavernous sinus
thrombosis Spread by direct extension via osseous structures or
indirectly via valveless venous plexuses Spread by direct extension
via osseous structures or indirectly via valveless venous plexuses
Obtain CT scan with contrast if orbital involvement suspected
Obtain CT scan with contrast if orbital involvement suspected
79
Slide 80
Stage IPreseptal Cellulitis Eyelid edema, erythema and normal
globe movement Eyelid edema, erythema and normal globe movement
Stage I in children more likely due to cutaneous lesions or
hematogenous seeding rather than sinusitis Stage I in children more
likely due to cutaneous lesions or hematogenous seeding rather than
sinusitis 80
Slide 81
Stage IIIPeriorbital Abscess Proptosis with globe displacement
inferolaterally, decreased EOM, vision decreased Proptosis with
globe displacement inferolaterally, decreased EOM, vision decreased
IVAbx with external or endoscopic drainage of abscess and involved
sinus IVAbx with external or endoscopic drainage of abscess and
involved sinus 81
Slide 82
Stage IVOrbital Abscess orbital abscess severe proptosis and
chemosis usually no globe displacement opthalmoplegia present
Impaired visual acuity 82
Slide 83
83 Stage VCavernous Sinus Thrombosis Progressive symptoms
Proptosis and fixation CN II, IV, VI Meningitis High mortality High
fever, bilateral symptoms
Slide 84
84 Intracranial Complications Meningitis, Epidural Abscess,
Intracerebral Abscess, Potts Puffy Tumor Meningitis, Epidural
Abscess, Intracerebral Abscess, Potts Puffy Tumor Neurosurgical
Consultation, high-dose antimicrobial therapy, drainage of
intracranial abscess planned in concert with drainage of affected
sinus Neurosurgical Consultation, high-dose antimicrobial therapy,
drainage of intracranial abscess planned in concert with drainage
of affected sinus Frontal sinus is most implicated sinus: venous
drainage of the frontal sinus via small diploic veins extending
through sinus wall; these communicate with venous plexi of dura,
periorbita and cranial periostuem Frontal sinus is most implicated
sinus: venous drainage of the frontal sinus via small diploic veins
extending through sinus wall; these communicate with venous plexi
of dura, periorbita and cranial periostuem