sinusitis talk CAPA - capanet.org€¦ · Four recent systematic literature reviews have compared the efficacy of antibiotics to that of placebo for ABRS Antibiotics conferred a small

SinusitisSTEVEN E DAVIS, MD

Disclosures

Consultant and speaker, Novartis

Research: Intersect ENT

What are sinuses?

Stedman’s medical dictionary 25th edition 1. a channel for the passage of blood or lymph, without the coats of an

ordinary vessel; e.g., blood passages in the gravid uterus or those in the cerebral meninges

2. A hollow in bone or other tissue 3. a fistula or tract leading to a suppurating cavity

Frontals

Ethmoids

Maxillaries

Clear Sinuses (coronal)

Frontals

Source: UW radiology at http://uwmsk.org/sinusanatomy2/Frontal-Normal.html

Middle turbinatesMaxillaries

EthmoidsSeptum

Inferior turbinates

Sphenoid

Frontal

Clear Sinuses (sagittal)

Frontal

Source: UW radiology at http://uwmsk.org/sinusanatomy2/Sphenoid-Normal.html

Sphenoid

Ethmoids

Inferior turbinate

Sinusitis Defined (a work in progress)

Acute Rhinosinusitis (ARS)

Chronic Rhinosinusitis (CRS) Recurrent Acute Rhinosinusitis (RARS) Acute Exacerbation of Chronic Rhinosinusitis Subacute Rhinosinusitis

Orlandi RR, Kingdom TT, Hwang PH, et al. International Consensus Statement on Allergy and Rhinology: Rhinosinusitis. Int Forum Allergy Rhinol. 2016;6:S22-S209

Acute Rhinosinusitis

Sinonasal inflammation < four weeks

Nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior) and facial pain/pressure or reduction/loss of smell with sudden onset of symptoms

Acute viral symptoms are generally present for fewer than 10 days Inquire about symptoms suggestive of allergy

Sneezing, watery rhinorrhea, nasal and ocular pruritus, and watery eyes

Orlandi RR, Kingdom TT, Hwang PH, et al. International Consensus Statement on Allergy and Rhinology: Rhinosinusitis. Int Forum Allergy Rhinol. 2016;6:S22-S209

Chronic Rhinosinusitis

Sinonasal inflammation persisting for more than 12 weeks Nasal obstruction/congestion/blockage, nasal

drainage(mucopurulent) that may drain anteriorly or posteriorly, facial pain/pressure/fullness, and decreased or loss of sense of smell

Must be accompanied by objective findings Nasal endoscopy (purulence, polyps, or edema)

Imaging findings consisting of inflammation or mucosal changes within the sinuses

Orlandi RR, Kingdom TT, Hwang PH, et al. International Consensus Statement on Allergy and Rhinology: Rhinosinusitis. Int Forum Allergy Rhinol. 2016;6:S22-S209.

Recurrent Acute Rhinosinusitis (RARS)

Four episodes per year of ARS with distinct symptom free intervals between episodes Average adult gets between 1.4 and 2.3 viral URIs per year


Diagnosing Acute Rhinosinusitis

Diagnosing ARS (acute rhinosinusitis)

Diagnosis of ARS is clinical Nasal endoscopy and imaging are not required for diagnosis in

uncomplicated cases Based on multiple symptoms

nasal congestion or blockage drainage or PND facial pressure/pain reduction in sense of smell

Other associated symptoms include sore throat, hoarseness, and cough, as well as non-specific systemic complaints such as malaise, fatigue, and low-grade fever


Speculum Exam (anterior rhinoscopy)

PHOTO HERE

Anterior Rhinoscopy

Anterior rhinoscopy is recommended and may reveal evidence of inflammation, mucosal edema, and discharge

Anterior Rhinoscopy


Diagnostic Sinonasal Endoscopy

NORMAL VIDEO HERE

Oropharynx

Oropharynx - ARS

VS

Viral vs. Bacterial ARS

Viral vs. Bacterial ARS

Duration is a key factor in distinguishing ABRS from a common cold Persistence of symptoms beyond 10 days or worsening of symptoms

after 5 days suggest development of post-viral ABRS

Bacterial Purulent discharge

Localized unilateral pain

Period of worsening after an initial milder phase of illness

ARS Differential Diagnosis


Allergic Rhinitis History is important – does patient have known allergies?

Symptoms exacerbated by allergen exposure?

Itchy and watery eyes - common in AR but rare in ARS

Uncommon in AR: mucopurulent discharge, pain and anosmia



Primary headache syndromes Tension headache

Atypical facial pain

Migraine Cluster headache

Nasal symptoms are frequently absent



Dental disease Can present with sinus pain

Sometimes there is no toothache or fever

Ocular pain syndromes, mainly glaucoma

Orofacial pain syndromes (temporomandibular disorder) Chronic fatigue syndrome

Orlandi RR, Kingdom TT, Hwang PH, et al. International Consensus Statement on Allergy and Rhinology: Rhinosinusitis. Int Forum Allergy Rhinol. 2016;6:S22-S209.u

Sinonasal Neoplasms

Benign Osteoma Papilloma Fibrous Dysplasia Juvenille Nasopharyngeal Angiofibroma Odontogenic neoplasms

Malignant Squamous cell carcinoma - #1 Adenocarcinoma - #2 Olfactory Neuroblastoma - rare Mucosal Melanoma - rare

Papilloma

Image: Pete Batra, MD Inverted: Doug Reh, MD

Exophytic Inverted

Polyp

Juvenille Nasopharyngeal Angiofibroma (JNA)

Image by Pete Batra MD

Sinus malignancy Ocular

Neurologic Trismus Middle Ear effusion

g

ARS Management

ABRS Management: Antibiotics

Four recent systematic literature reviews have compared the efficacy of antibiotics to that of placebo for ABRS

Antibiotics conferred a small benefit, improving cure rates at 7-15 days from 86% with placebo to 91% with antibiotics

Rate of adverse events was higher with antibiotics Decision to treat ultimately comes to down to clinician’s experience

and patient expectations These prescriptions can be given at the initial visit with instructions on

when to fill them, typically if there is no improvement after 7 days or worsening at any time


The Microbiome

Rich and diverse populations of bacteria live in our nose and sinuses

Some microbes may play a beneficial role at the epithelial surface Culture remains clinical standard – sometimes helpful Newer genetic techniques show that culture only detects a small

percentage of resident bacteria Antibiotics likely create at least some shift of the microbiome from

which we hopefully recover More research needs to be done on microbiome disturbance;

however, for now the less we disturb the microbiome the better

Ramakrishnan VR, Hauser LJ, and Frank DN The sinonasal bacterial microbiome in health and disease. CurrOpin Otolaryngol Head Neck Surg. 2016 Feb; 24(1): 20–25..

ABRS Management: Antibiotics

First Line Amoxicillin, either alone or with clavulanate (when symptoms severe,

high risk of pcn resistance, comorbidities present) is the first antibiotic of choice in treating suspected ABRS

Second Line (failed 1st line or allergic) Trimethoprim-sulfamethoxazole, doxycycline, or a respiratory

fluoroquinolone

Duration = 10 days or fewer Shorter duration favors fewer adverse events and higher patient

compliance


ARS Management: Intranasal Corticosteroids (INCS)

Anti-inflammatory and potential decongestant effects with negligible systemic bioavailability

A Cochrane review meta-analysis, which included 1943 participants from four studies concluded: Symptoms in patients receiving INCS, particularly higher dose

treatments, were more likely to resolve or improve than in placebo treated patients

But the effect is modest, need 100 patients to be treated for seven to have complete symptom relief

Aggregate Grade of Evidence: A, Policy Recommendation: strong recommendation


ARS MANAGEMENT: ORAL STEROIDS

A Cochrane review meta-analysis failed to find significant evidence to support systemic corticosteroids in ARS, despite reviewing trial results from 1193 participants.

Policy recommendation Systemic corticosteroids in cases of uncomplicated ARS are not

recommended (i.e. no recommendation)

Aggregrate grade of evidence: B


ARS: Other Treatments

Sinus Irrigation (aggregrate evidence: B, Policy Recommendation: Option)

Mucolytics, anticholinergics, or herbals (no evidence either way)

Decongestants – minimal evidence to support their use Antihistamines – no evidence to support their use

Orlandi RR, Kingdom TT, Hwang PH, et al. International Consensus Statement on Allergy and Rhinology:

Rhinosinusitis. Int Forum Allergy Rhinol. 2016;6:S22-S209.

ARS Complications

Orbital Cellulitis, abscess, cavernous sinus thrombosis

ARS Complications

Intracranical Meningitis, abscess, cavernous or sagittal sinus thrombosis, CN Palsy

Osseous Osteomyelitis most commonly affecting the frontal bones (“Pott’s Puffy

Tumor”)

Chronic Rhinosinusitis (CRS)

Chronic Rhinosinusitis Differential Dx

Allergic rhinitis

Nonallergic rhinitis GERD Asthma Primary headache disorders

Chronic dental infection Foreign body Sinonasal neoplasm

CSF rhinorrhea

Chronic Rhinosinusitis Workup

CT Sinus (cone beam, low dose)

Immune workup (CBC, IgA, IgM, IgG, IgE, S pneumo abs, H flu abs) Diagnostic sinonasal endoscopy (polyps, edema, anatomic

variations) Allergy test (environmental, food)

Chronic Rhinosinusitis Workup

CRS Treatment (medical)

Intranasal corticosteroids

Saline irrigation Oral steroids

With polyps – yes

Without polyps – option

Oral antibiotics With polyps – optional

Without polyps – yes

Aggregate evidence grade - D


Macrolide Antibiotics

Anti-inflammatory properties Modulate proinflammatory cytokine production

Immunomodulatory properties

Studies suggest Reduction of nasal fibroblast proliferation, differentiation, collagen

production

Decreased eosinophilic infiltration into nasal epithelium and lamina propria


CRS treatment

Procedures Balloon Sinuplasty (in-office)

Endoscopic sinus surgery (sometimes in office, usually in OR)

Correct anatomic abnormalities (septoplasty, turbinate reduction)

Drug eluting spacers (OR for now)

Topicals (patients with a prior history of sinus surgery) Antibiotics

Surfactants

Steroids

Other (Manuka honey, xylitol, etc.)

Fungal Sinusitis

https://www.id-hub.com/2017/02/24/diagnostics-susceptibility-testing-aspergillus/

Invasive Fungal Sinusitis

Immunocompromised (uncontrolled diabetes, transplant patient, etc) Symptoms

Fever, facial or orbital swelling, pain, numbness, unilateral nervedamage, acute visual changes with altered motility or decliningvision

Emergent referral to ENT/ED

Fungus Ball

Formerly known as mycetoma, aspergilloma

Otherwise healthy patient Surigcal treatment

Allergic Fungal Rhinosinusitis

Can look ugly on ct scan or MRI

Almost always accompanied by polyps Surgical treatment (endoscopic sinus surgery) + po steroids

h

Pediatric Sinusitis

Pediatric Sinusitis

History Can often be difficult

Information from parent can be subjective

Nasal exam (oxymetazoline spray may help) Inferior turbinates, maybe middle turbinates

Mucosal character, presence of purulent drainage

Oral cavity Purulent postnasal drainage

“Cobblestoning” of the posterior pharyngeal wall

Tonsillar hypertrophy


Pediatric Sinusitis – AAP Guidelines

Only symptomatic treatment for children with uncomplicated ARS Antibiotics for severe disease or persistent/worsening course Persistent illness defined as “nasal discharge of any quality or cough or both for at

least 10 days without evidence of improvement” Monitor patients for symptom improvement/resolution within 72 hours of the initial

treatment decision Antibiotics

Amoxicillin with or without clavulanate recommended for initial empiric treatment of ABRS For amoxicillin allergy, a second or third generation cephalosporin can be used (low risk of

cross-reactivity For patients under two years of age with a documented type-1 hypersensitivity to penicillins,

a combination of clindamycin and cefixime is suggested A fluoroquinolone, such a levofloxacin, can also be used in patients with a severe penicillin

allergy but levofloxacin does not have a US FDA approved indication for ABRS in children and has potentially serious side effects, including tendonitis and tendon rupture

Pediatric ARS – complications

Orbital, intracranial, osseous

Signs and symptoms Lethargy, headache

Eye pain, pain with eye movement, periorbital edema, diplopia, photophobia, papillary edema

High fever, nausea/vomiting, seizures, cranial neuropathies, focal neurologic deficits

Workup: CT scan of the sinuses with contrast and/or an MRI with contrast

Treatment: IV antibiotics +/- surgery


When to refer to ENT?

Recurrent sinus infections (>4 per year)

Persistent sinus infection (>3 months) Abnormal exam

Deviated septum

Hypertrophic inferior turbinates

Polyps

Mass

Complication (orbital, intracranial, osseous)

Immunocompromised patient

Procedures

Future Directions

Nonsurgical Biologics

Drug eluting, self-dissolving spacers

Topicals

Surgical Fly-through, 3D Navigational Systems

More outcomes based research

Trend toward in-office treatment (Balloon, navigation, spacers)

Take home points

Acute Avoid antibiotics if possible

Sinus rinse, short course of steroids (40mg qam x 5 days), afrin x 3 days, macrolide unless serious (amox-clav)

Chronic or recurrent Allergy

CT sinus

Daily medical/spray regimen

Endoscopy

Thank you very much!!

[email protected]

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sinusitis talk CAPA - capanet.org€¦ · Four recent systematic literature reviews have compared the efficacy of antibiotics to that of placebo for ABRS Antibiotics conferred a small