1. rhinosinusites sayed mostafa hashemi md faculti member of isfahan medical scaiens

Rhinosinusites SAYED MOSTAFA HASHEMI MD FACULTI MEMBER OF ISFAHAN MEDICAL SCAIENS

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

Anatomy

Ostiomeatal complex 5

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

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

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

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

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

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

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

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

Classification of rhinosinusitis is based on symptom duration. 14

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

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

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

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

Tools for intranasal examination 19

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

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

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

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

Microbiology 24

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

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.

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

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

Choice of Antibiotic for ABRS Wright & Frankel

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

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?

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

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

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

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

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

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

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

39 Stage IIOrbital Cellulitis Proptosis, Chemosis, Edema, Pain Proptosis, Chemosis, Edema, Pain Dilated pupil Visual loss Ophthalmoplegia Afferent pupillary defect

40 Chronic Rhinosinusitis

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

Ostiomeatal complex 42

EPOS Management Algorithm: Adult Chronic Rhinosinusitis *Primary Care

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

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

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:

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

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.

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

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

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

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

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

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

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

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

Endoscopic view of the nose 57

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

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

Sinus computed tomographic (CT) scan Sinus computed tomographic (CT) scan 60

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

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

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

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

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

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

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

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

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

Refractory Rhinosinusitis Consider associated conditions Consider associated conditions Allergy Immune deficiency Asthma Gastroesophageal reflux disease Cystic Fibrosis Primary Ciliary Dyskinesia (Immotile Cilia Syndrome) Allergic Fungal Sinusitis 71

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

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

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

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

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

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

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

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

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

Stage IVOrbital Abscess orbital abscess severe proptosis and chemosis usually no globe displacement opthalmoplegia present Impaired visual acuity 82

83 Stage VCavernous Sinus Thrombosis Progressive symptoms Proptosis and fixation CN II, IV, VI Meningitis High mortality High fever, bilateral symptoms

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

1. rhinosinusites sayed mostafa hashemi md faculti member of isfahan medical scaiens

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