PowerPoint Presentation

Sinusitis: Assessment, Diagnosis and Treatment

Sometimes It Is, Sometimes Its SnotMichael De Vito M.D. Capital Region Otolaryngology GroupAlbany, Troy, Clifton Park and HudsonIntroductionSinusitis:Affects 30 million individuals per year in the US90% of patients will see their primary care physician Accounts for 11.6 million visits to primary care physicians annually Accounts for 9% of pediatric and 21% of adult antibiotic prescriptions

Anatomy

Anatomy

Sinus Drainage Pathways

Pathogenesis of Sinusitis

Classification of SinusitisSinusitis is defined as an inflammation of the mucous membrane that lines the paranasal sinuses

It is classified chronologically as:Acute Recurrent Acute Subacute Chronic Acute Exacerbation of Chronic

Acute RhinosinusitisA New Infection That May Last Up To Four Weeks

Can Be Subdivided Symptomatically IntoSevereNon-severeRecurrent Acute Rhinosinusitis Four or More Separate Episodes of Acute Sinusitis That Occur Within One YearSubacute Rhinosinusitis An Infection That Lasts Between Four to Twelve Weeks

Usually Represents a Transition From Acute To Chronic InfectionChronic RhinosinusitisWhen Signs and Symptoms Last for More Than Twelve WeeksDiagnosis of Sinusitis

Viral Versus Bacterial RhinosinusitisViral Upper Respiratory Illnesses Occur:3-8 per year in children2-3 per year in adults

Gwaltney: (1996,1994)Found 90% of CT Scans Showed Evidence of Sinus Involvement With Viral RhinosinusitisViral Upper Respiratory Infection Course

Viral Versus Bacterial RhinosinusitisDifficult to DifferentiateSymptoms of Bacterial Sinusitis Worsen After Five DaysBacterial Infections Persist For At Least Ten DaysTask Force On Rhinosinusitis Of The AAO-HNSDiagnosis of Acute Sinusitis Depended On The Presence of :Two Major Diagnostic FactorsorOne Major Factor and Two Minor FactorsDiagnostic Predictive Factors of Sinusitis

Acute Sinusitis Definitions

Radiographic Imaging Radiographic Imaging Should Not Be Used In Patients That Meet The Diagnostic Criteria of Acute Rhinosinusitis

Exceptions Include:A Potential Complication of SinusitisAn Alternative Diagnosis is Suspected

Symptomatic TreatmentAnalgesics and Antipyretics for Pain and Fever

Topical or Systemic Decongestants for Symptomatic ReliefNeither have been proven to prevent a URI from becoming ABRS

Topical Better Than Systemic for Congestion Relief3 Day Maximum Longer Rebound Concern

Systemic Steroids Have Shown No Effectiveness

Antihistamines Have No Studies As To Effectiveness20Symptomatic TreatmentTopical Steroid Sprays Have Shown Some BenefitIndustry studies and included antibiotics

Nasal Saline for Quality of Life ImprovementDecrease medication use for frequent ABRS

GuaifenesinInsufficient evidence

Most Prevalent Pathogens in Adult Sinusitis Sinus and Allergy Partnership. Otolaryngol Head Neck Surg 2004.AAOHNS. Otolaryngol Head Neck Surg. 2007.

Streptococcus pneumoniae (20-43%)Haemophilus influenzae (22-35%)Streptococcus spp. (3-9%)Anaerobes (0-9%)Moraxella catarrhalis (2-10%)Staphylococcus aureus (0-8%)Other (4%)22Slide Objective: To identify the most likely organisms causing sinusitis, highlighting the 2 main causative pathogens.Speaker Notes:S pneumoniae and H influenzae are the two most common bacterial isolates recovered from the maxillary sinuses of adult patients with ABS.2As depicted in the graph above, S pneumoniae is isolated in approximately 20% to 43% and H influenzae in 22% to 35% of aspirates.1Other common pathogens include M catarrhalis, streptococcal species, S aureus, and anaerobes.1Optimal antibiotic therapy should be based on adequate coverage of anticipated bacteria.2Moxifloxacin has potent activity against S pneumoniae, H influenzae, and M catarrhalis.1References:Sinus and Allergy Partnership. Otolaryngol Head Neck Surg 2004; 130 (1 Suppl):1-45.AAOHNS. Clinical practice guideline: Adult sinusitis. Otolaryngol Head Neck Surg. 2007:137;S1-S31.Empiric Treatment in ChildrenAmoxocillin-clavulanate Rather Than AmoxocillinIncreasing prevalence of H. influenza in URIs in children

High prevalence of Beta-lactamase producing pathogens in ABRS H. influenza and Moraxella catarrhalis

IDSA 2012 Clinical Practice Guidelines for Acute Rhinosinusitis Antibiotic Regimen in Children

Starting Empiric Antibiotic TreatmentIn Adults When Clinical Diagnosis Has Been Established By The GuidelinesSymptoms of rhinosinusits lasting more than 10 daysSevere symptoms or high fever and purulent nasal discharge or facial pain lasting 3-4 consecutive days at the onset of illnessWorsening of symptoms with fever, headache or increased nasal discharge at day 5-6 of a URI that were improving.

IDSA 2012 Clinical Practice Guidelines for Acute Rhinosinusitis Antibiotic Regimen for Adults

Treatment of Penicillin Allergic PatientsSkin Testing to Confirm of Exclude Immediate HypersensitivityAdults:Respiratory Floroquinolone(Levofloxacin,Moxifloxacin)

Doxycycline

Macrolides or TMP/SMXNo Longer Recommended because of increased resistance of S. pneumonia and H. influenzaChildren with Penicillin AllergyChildren with Type 1 Hypersensitivity:LevofloxacinFDA approved for use only after Anthrax Exposure2523 Children Studied in the Pediatric Levaquin Study (Noel, 2007)Well tolerated after 12 Months ButMusculoskeletal Events1.9% vs. .79% at 2 months2.9% vs.1.6% at 12 monthsProbably Warranted with Type 1 sensitivityChildren with Non-Type 1Third Generation Oral Cephalosporin: Cefixime, Cefpodoxime

In Combination With ClindamycinDuration of Therapy 5-7 Days Seems AppropriateMost patients studied by sinus puncture had symptomatic improvement and bacteriological eradication within 72 hours of initiation of treatmentTreatment beyond 10 days for acute , uncomplicated patients seems excessive

Children Should Be Treated for 10-14 DaysStudies still lacking to recommend less Nonresponsive PatientsPatients Who Clinically Worsen After 72 Hours or Fail to Improve After 3-5 Days of Empiric Therapy:Resistant PathogensNoninfectious EtiologyStructural AbnormalitiesCT of MRINoninfectious causes of suppurative complicationsSinus or Meatal CulturesCareful Clinical Assessment Sinus Cultures Direct Sinus Aspiration :Most Accurate but Invasive , Not Well Tolerated

Middle Meatal Cultures:Benninger (2006)81% sensitivity, 91% specificity, 83% predictive value

Nasopharyngeal Swabs:Unreliable Allergy EvaluationChronic Sinusitis And Allergy:40-80% of Adults25-31% Young Adults

Should Be Considered In:Chronic RhinosinusitisRecurrent Acute Rhinosinusitis

Skin Testing As The Preferred Testing MethodImmunodeficiencyPatients with Chronic Rhinosinusits or Recurrent Acute Sinusitis

Failure of Aggressive Medical Therapy or Persistent Purulent Infection

Most Common Disorders:Selective IgA DeficiencyHypogammaglobulinemiaIgG Subclass Deficiency is UnclearHIV Patients ( 30-68%)

Fungal SinusitisMycetoma Fungal SinusitisFungus Ball Usually in the Maxillary SinusTreatment is Surgical Removal of the Lining

Allergic Fungal SinusitisAn Allergic Reaction to Environmental FungiImmunocompetent HostThick Fungi and Mucin AccumulateSurgical Removal of the Allergen(Fungi)

Fungal SinusitisChronic Indolent SinusitisGenerally outside the U.S. (Sudan, India)No Immune DeficiencyProgresses from Month to YearsCharacterized by a Granulomatous Inflammatory Infiltrate

Fulminant Fungal SinusitisImmunocompromised PatientsImmunodefeciency Disorders (Diabetes)Immunosuppressive AgentsCan Result in Progressive Destruction of the Sinuses with Resulting Invasion of the Eye or Cranial CavityMucormycosis a common fungiSinus HeadacheClinical History:Primary Complaint is Headache Without Significant Nasal Symptoms Migraine

Headache Embedded In Other Bothersome Nasal Symptoms Evaluation of Nasal and Sinus Cavities Warranted

Headache is a Minimal or Inconspicuous Complaint Rhinosinustis May Be LikelySinus HeadachePhysical Exam:Nasal Exam Findings Which May Suggest Secondary Pathology:Inflammatory Changes (Allergy)Anatomic AbnormalitiesPurulent Nasal Discharge

Testing: Imaging Can Be Useful False Positive ResultsSinus HeadachesSinus Disease As A Cause of Headache Has Been Ingrained Into The American PublicLittle Evidence to Support This

Migraine Can Present With Facial Pain, Nasal Congestion and Rhinorrhea.

In Clinical Studies Nearly 90% With Self-Diagnosed or Physician Diagnosed Sinus Headache Met The Criteria for IHS Migraine-Type Headaches.

Most Responded To Triptan InterventionsSinus Headaches

42Specialist Referral

Treatment90% of Patients Can Be Treated and Cured of Sinusitis With Medical Therapy

Surgical Treatment:For the Treatment of Anatomic Obstruction(Polyps,Septal Deviations)

Recurrent Acute Infections

CRS Non-Responsive To Medial TherapySurgical TreatmentFunctions Endoscopic Sinus Surgery (FESS):All done through the nose

Removal of Abnormal and Obstructive Tissue To Restore the Normal Drainage Pathways of the Sinuses

Results in Removal of Less Normal Tissue

Can Be Done as an OutpatientSurgical TreatmentImage Guided Surgery

Three Dimensional View of the Surgical Field

For Severe Cases or Patients Who Have Had Prior Surgery

Requires a Planning CT

BALLOON SINUPLASTY

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