sinusitis management

8/3/2019 Sinusitis Management.

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DIAGNOSIS AND

MANAGEMENTOF

ACUTE/CHRONICRHINOSINUSITIS

JEAN-PIERRE SOUAID MD, FRCSC

QUEENSWAY-CARLETON HOSPITAL

OTTAWA, ONTARIO


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Rhinosinusitis: Clinical Definition

Rhinosinusitis is defined as:

Inflammation of the nose and the paranasalsinuses characterised by 2 or more symptoms

One symptom should be either nasal

blockage/obstruction/congestion or nasaldischarge (anterior/posterior nasal drip)

.Fokkens et al. Rhinology. 2007;45(suppl 20):1.


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Rhinosinusitis Symptoms

Reduction/loss ofSmell

Facial Pain/pressure

NasalDischarge(anterior/posteriornasal drip)

Blockage/Obstruction/congestion


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Common Cold/Acute Rhinosinusitis

0 5 10 15

Days

Symptom

s

Viral rhinosinusitis/common cold

Acute rhinosinusitis/increase after 5 days

Acute rhinosinusitis/persist after 10 days

No need for antibiotictherapy Consider treatment with antibiotics

and/or steroids

Fokkens et al. EP3OS Guidelines. Rhinol Suppl. 2005;18:1.


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Diagnosis and Management of Acute andChronic Sinusitis - Dr. J.P Souaid 6

RISK FACTORS

EXTRINSIC

INFECTION

ENVIRONMENTMEDICATIONS

FOREIGN OBJECTS

TRAUMA

INTRINSIC

ALLERGY

ANATOMICNASAL POLYPS

TUMOURS

CYSTIC FIBROSIS

CILIARY DYSFUNCTIONIMMUNODEFICIENCY


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PATHOPHYSIOLOGY OF

RHINOSINUSITIS


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MICROBIOLOGY RHINOSINUSITIS

POLYMICROBIAL!!!

S. pneumoniae

40%

M. catarrhalis

20%

S. aureus

6%

S. pyogenes

3%

Other

1%

H. influenzae

30%

ACUTE

CHRONIC ANAEROBES

GRAM NEG.

S. AUREUS

P. AERUGINOSA

Desrosiers et al. J Otolaryngol 2002;31(Suppl 2):2S2-2S14.


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Diagnosis: ABS Imaging

X-ray

Air-fluid levels and opacification, when

present, have positive predictive value of

80% to 100%

Sensitivity is low (detects only 60% of sinusitis

patients)

Sensitivity of mucosal thickening is high

(>90% of ABS patients), but nonspecific

The Institute for Clinical Systems Integration. Postgrad Med. 1998;103:154-156, 159-160, 166-168.
http://e/My%20Documents/AI%20References/ICSI%20Acute%20Sinusitis.pdfhttp://e/My%20Documents/AI%20References/ICSI%20Acute%20Sinusitis.pdfhttp://e/My%20Documents/AI%20References/ICSI%20Acute%20Sinusitis.pdfhttp://e/My%20Documents/AI%20References/ICSI%20Acute%20Sinusitis.pdfhttp://e/My%20Documents/AI%20References/ICSI%20Acute%20Sinusitis.pdfhttp://e/My%20Documents/AI%20References/ICSI%20Acute%20Sinusitis.pdfhttp://e/My%20Documents/AI%20References/ICSI%20Acute%20Sinusitis.pdfhttp://e/My%20Documents/AI%20References/ICSI%20Acute%20Sinusitis.pdfhttp://e/My%20Documents/AI%20References/ICSI%20Acute%20Sinusitis.pdfhttp://e/My%20Documents/AI%20References/ICSI%20Acute%20Sinusitis.pdfhttp://e/My%20Documents/AI%20References/ICSI%20Acute%20Sinusitis.pdfhttp://e/My%20Documents/AI%20References/ICSI%20Acute%20Sinusitis.pdfhttp://e/My%20Documents/AI%20References/ICSI%20Acute%20Sinusitis.pdf


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Diagnosis: Cultures

Maxillary sinus puncture and aspiration

Not warranted/recommended

Painful Requires expertise to minimize

complications (eg, infection)

Reserved for research setting or patients

with a complicated infection

Brook I et al.Ann Otol Rhinol Laryngol. 2000;109:2-20.
http://e/My%20Documents/AI%20References/BrookAORL2000.pdfhttp://e/My%20Documents/AI%20References/BrookAORL2000.pdfhttp://e/My%20Documents/AI%20References/BrookAORL2000.pdfhttp://e/My%20Documents/AI%20References/BrookAORL2000.pdfhttp://e/My%20Documents/AI%20References/BrookAORL2000.pdfhttp://e/My%20Documents/AI%20References/BrookAORL2000.pdfhttp://e/My%20Documents/AI%20References/BrookAORL2000.pdfhttp://e/My%20Documents/AI%20References/BrookAORL2000.pdfhttp://e/My%20Documents/AI%20References/BrookAORL2000.pdfhttp://e/My%20Documents/AI%20References/BrookAORL2000.pdfhttp://e/My%20Documents/AI%20References/BrookAORL2000.pdfhttp://e/My%20Documents/AI%20References/BrookAORL2000.pdfhttp://e/My%20Documents/AI%20References/BrookAORL2000.pdfhttp://e/My%20Documents/AI%20References/BrookAORL2000.pdf


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Diagnosis of Acute Sinusitis

Symptoms Maxillary / Facial pain

Symptoms >7 days

Dental pain

Poor response todecongestants

History of coloured nasaldischarge

Signs Purulent nasal secretion Abnormal transillumination

Fever

4 or 5 signs orsymptoms

2 or 3 signs orsymptoms

Less than 2

signs orsymptoms

high probability of

sinusitis

Consider radiography

Can rule out sinusitis


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Objectives of Medical Treatment of

Rhinosinusitis

Eliminate infection

Reduce inflammation

Improve symptoms

Multifaceted treatment

regimen


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MFNS as Adjunctive Therapy to Antibiotics?


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Changes in Symptoms Over 21 Days with

Adjunctive MFNS in Acute Recurrent

Rhinosinusitis

*P


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MFNS as Monotherapy?


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0

1

2

3

4

5

6

7

8

9

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

MFNS Monotherapy in Acute

Rhinosinusitis: Effect on Major Symptom

Score

M

ajorsymptomsc

ore

Days

Major Symptom Scores (Days 1-15)

aP0.037 vs placebo.b

P0.012 vs amoxicillin 0.5 g tid.

Adapted from Meltzer et al. J Allergy Clin Immunol. 2005;116:1289.

Data on file, Schering-Plough

MFNS 200 g bid (n=234)

Amoxicillin 0.5 g tid (n=249)

Placebo (n=247)

Baseline

a,ba

a,b

a,ba,b

a,ba,b a,b

a,b a,b a,b a,b a,b

a,b


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Diagnosis and Management of Acute andChronic Sinusitis - Dr. J.P Souaid

17

Intranasal Corticosteroids:

Low Systemic Bioavailability

There are differences among the various

agents bioavailabilities*

Budesonide (Rhinocort): 20% Triamcinolone (Nasacort): 22%

Fluticasone (Flonase): 2%

Mometasone (Nasonex): < 0.1%

Low bioavailability minimizes risk of

systemic effects*Bioavailability of intranasal triamcinolone and beclomethasone are not reported in product information

Corren J: J Allergy Clin Immunol 1999; 104:S144-9.


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18

TOPICAL STEROIDS

NASONEX AVAMYS OMNARIS

EPISTAXIS 8 % 20 % 6 %

GLAUCOMA NO 2 % NO

KIDS (3 Y.O.) YES YES* NO

POLYPS YES NO NO

ACUTE SINUSITIS YES (bid) NO NO(monotherapy and /or adjuvant)

SEASONAL A.R. YES YES YES

PERENNIAL A.R. YES NO YES

*ONLY FOR PEDIATRIC SEASONAL A.R.


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Antibiotic Resistance in ABS

Resistance of ABS pathogens against antibiotics is increasing inCanada

S. pneumoniae:

Up to 20% of isolates are resistant or intermediate to penicillin1

14% are resistant to macrolides2

H. influenzae:3 19% of isolates are resistant to amoxicillin

14% of isolates are resistant to TMP-SMX

M. catarrhalis:3

Resistance levels of isolates are generally low

1.5% resistant to TMP-SMX Fluoroquinolone resistance of respiratory pathogens is low (~1%)

across Canada1,3

1Zhanel et al. AAC 2003;47:1867-74. 2Low et al. CBSN 2003.3Zhanel et al. AAC 2003;47:1875-81.


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Indications for 2nd-line Antibiotic

Therapy

No clinical response to first-line therapy within48-72 hours

Patients who received antibiotics in previous 3

months (CLASS SWITCHING!) Frontal or sphenoid sinusitis

Allergy to -lactams

Chronic underlying conditions

Immunosuppression

Protracted symptoms

Desrosiers et al. J Otolaryngol 2002;31(Suppl 2):2S2-2S14.
http://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdf


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Statements: SummaryCanadian Rhinosinusitis Guidelines

2011
http://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdf


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StatementStrength

ofEvidence

Strength ofRecommendati

on

1: ABRS may be diagnosed on clinical grounds using symptoms and signsof more than 7 days duration.

Moderate Strong

2:Determination of symptom severity is useful for the management ofacute sinusitis, and can be based upon the intensity and duration andimpact on patient's quality of life

Option Strong

3:Radiological imaging is not required for the diagnosis of uncomplicated

ABRS. When performed, radiological imaging must always be interpretedin the light of clinical findings as radiographic images cannot differentiateother infections from bacterial infection and changes in radiographicimages can occur in viral URTIs.

Criteria for diagnosis of ABRS are presence of an air/fluid level orcomplete opacification. Mucosal thickening alone is not considereddiagnostic. Three-view plain sinus X-rays remain the standard. Computedtomography (CT) scanning is mainly used to assess potential

complications or where regular sinus X-rays are no longer available.

Radiology should be considered to confirm a diagnosis of ARBS in patientswith multiple recurrent episodes, or to eliminate other causes

Moderate Strong

4: Urgent consultation should be obtained for acute sinusitis withunusually severe symptoms orsystemic toxicity orwhere orbital orintracranial involvement is suspected.

Option Strong

Summary of Guideline Statements: ABRS I
http://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdf


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StatementStrength

ofEvidence

Strength ofRecommend

ation

5: Routine nasal culture is not recommended for the diagnosis of ABRS.When culture is required for unusual evolution, or when complicationrequires it, sampling must be performed either by maxillary tap orendoscopically-guided culture.

Moderate Strong

6:The 2 main causative infectious bacteria implicated in ABRS areStreptococcus pneumoniae and Haemophilus influenzae.

Strong Strong

7:Antibiotics may be prescribed for ABRS to improve rates of resolution

at 14 days and should be considered where either quality of life orproductivity present as issues, or in individuals with severe sinusitis orcomorbidities. In individuals with mild or moderate symptoms of ABRS, ifquality of life is not an issue and neither severity criterion norcomorbidities exist, antibiotic therapy can be withheld.

Moderate Moderate

8: When antibiotic therapy is selected, amoxicillin is the first-linerecommendation in treatment of ABRS. In beta-lactam allergic patients,trimethoprim-sulfamethoxazole (TMP/SMX) combinations or a macrolideantibiotic may be substituted.

Option Strong

9: Second-line therapy using amoxicillin/clavulanic acid combinations orquinolones with enhanced gram positive activity should be used inpatients where risk of bacterial resistance is high, or where consequencesof failure of therapy are greatest, as well as in those not responding tofirst-line therapy. A careful history to assess likelihood of resistance shouldbe obtained, and should include exposure to antibiotics in the prior 3months, exposure to daycare, and chronic symptoms.

Option Strong

10:Bacterial resistance should be considered when selecting therapy. Strong Strong

Statements ABRS: II
http://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdf


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StatementStrength

ofEvidence


ation

11: When antibiotics are prescribed, duration of treatment should be 5 to10 days as recommended by product monographs. Ultra-short treatmentdurations are not currently recommended by this group.

Strong Moderate

12:Topical intranasal corticosteroids (INCS) can be useful as sole therapyof mild-to-moderate ABRS.

Moderate Strong

13:Treatment failure should be considered when patients fail to respond

to initial therapy within 72 hours of administration. If failure occursfollowing use of INCS as monotherapy, antibacterial therapy should beadministered. If failure occurs following antibiotic administration, it maybe due to lack of sensitivity to, or bacterial resistance to, the antibiotic,and the antibiotic class should be changed.

Option Strong

14:Adjunct therapy should be prescribed in individuals with ABRS. Option Strong

15:Topical INCS may help improve resolution rates and improve

symptoms when prescribed with an antibiotic.

Moderate Strong

16: Analgesics (acetaminophen or non-steroidal anti-inflammatoryagents) may provide symptom relief.

Moderate Strong

17:Oral decongestants may provide symptom relief. Option Moderate

18:Topical decongestants may provide symptom relief. Option Moderate

19:Saline irrigationmay provide symptom relief. Option Strong

Statements ABRS: III
http://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdf


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StatementStrength

ofEvidence


ation

20: For those not responding to a second course of therapy,chronicity should be considered and the patient referred to aspecialist. If waiting time for specialty referral or CT exceeds 6weeks, CT should be ordered and empiric therapy for CRSadministered. Repeated bouts of acute uncomplicated sinusitisclearing between episodes require only investigation and

referral, with a possible trial of INCS. Persistent symptoms ofgreater than mild-to-moderate symptom severity shouldprompt urgent referral.

Option Moderate

21: By reducing transmission of respiratory viruses, handwashing can reduce the incidence of viral and bacterial sinusitis.Vaccines and prophylactic antibiotic therapy are of no benefit.

Moderate Strong

22: Allergy testing or in-depth assessment of immune functionis not required for isolated episodes but may be of benefit inidentifying contributing factors in individuals with recurrentepisodes or chronic symptoms of rhinosinusitis.

Moderate Strong

Statements ABRS: IV
http://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdfhttp://d/Desrosiers%20et%20al.pdf


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Management of ABRS (I)

Recurrent ABRSRepeated symptomatic episodes of acute sinusitis( 4 infections per year), with clear, symptom-freeperiods in between corresponding to completeresolution between infections.Episodes of sinusitis will increase as exposure toviruses increases.

With multiple recurrent episodes, considerradiology (standard 3-vew sinus X-ray or CT scan)

to confirm ABRS or to eliminate other causes

Symptoms of Sinusitis

More than 7 days Less than 7 days

Higher likelihood ofbacterial infection

Requires confirmationof 2 major symptoms*

ABRS Diagnosis Requires the Presence of at Least 2 Major Symptoms*

Major SymptomsNone Mild

Occasionallimited episode

ModerateSteady symptoms

but easily tolerated

SevereHard to tolerate and mayinterfere with activity or

sleep

P Facial Pain/pressure/fullness

O Nasal Obstruction

D Nasal purulence/discolored postnasal Discharge

S Hyposmia/anosmia (Smell)

*Patient must have: 1) Nasal obstruction OR nasal purulence/discolored postnasal discharge, AND 2) At least 1 other PODS symptom.

Consider ABRS under any one of the following conditions: 1) Worsening after 5 to 7 days (biphasic illness) with similar symptoms; 2)Symptoms persist more than 7 days without improvement; or 3) Presence of purulence for 3 to 4 days with high fever.

Viral URTITreat symptomatically

If symptoms persist,worsen or change

RED FLAGS for Urgent ReferralAltered mental status, headache,systemic toxicity, swelling of the orbitor change in visual acuity, hardneurological findings, or signs ofmeningeal irritationSuspected intracranial complications

Meningitis Intracranial abscess Cavernous sinus thrombosis

Involvement of associated structures Periorbital cellulitis Potts puffy tumor

Refer for expert assessment
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Management of ABRS (II)

Identify level of severity

Mild to moderate Severe

Intranasal corticosteroids (INCS)

Clinical response in 72 hrs?

INCS + antibiotics

If symptoms persist,

worsen or changeYes No

Continue course Consider antibiotics if symptomduration is >7 days

First-line: Amoxicillin. For beta-lactam allergy:TMP/SMX combinations or a macrolide.Second-line: Fluoroquinolones or amoxicillin-clavulanic acid combinations. Use with first-

line failures and in patients at high risk ofbacterial resistance or likely to sufferconsequence of treatment failure due tounderlying systemic disease.


Yes No

Continue therapy for full courseduration per product monograph

Use second-line agentor change antibiotic class


Yes NoFor symptoms lasting >4 weeks, considerchronic rhinosinusitis (CRS); refer to CRSguidelines or visit www.sinuscanada.com foradditional information.Persistent severe symptoms require prompt

urgent referral.

Minor symptomsHeadache Dental painHalitosis CoughFatigue Ear pain/pressure

Prevention Strategies

Hand washingEducationEnvironmental awareness

Adjunct therapyAnalgesics

DecongestantsSalineINCS

When to referNo response to 2nd-line therapy

Suspected chronicityPersistent severe symptomsRepeated bouts with clearingbetween episodes>3 recurrences per yearImmunocompromised host

Allergic rhinitis evaluation forimmunotherapyAnatomic defects causing obstructionNosocomial infectionAssumed fungal infection/neoplasms

Why wait >7 days?Antibiotics may not be necessary andthere are side effects

Diarrhea Interference with contraception Allergy Yeast infections

Review previous 3-month exposure
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Chronic Rhinosinusitis: New for 2011

Emphasis on role of inflammation in thepathogenesis of CRS

Distinction between CRS with nasal

polyposis (CRSwNP) and CRS without NP(CRSsNP)

Management strategies for the PCP

Indications for referral

Management of the post-surgical patient
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StatementStrength

of

Evidence

Strength ofRecommendati

on23:CRS is diagnosed on clinical grounds but must be confirmed with atleast 1 objective finding on endoscopy or computed tomography (CT) scan.

Weak Strong

24: Visual rhinoscopy assessments are useful in discerning clinical signsand symptoms of CRS.

Moderate Moderate

25:In the few situations when deemed necessary, bacterial cultures inCRS should be performed either via endoscopic culture of the middlemeatus or maxillary tap but not by simple nasal swab.

Option Strong

26:The preferred means of radiological imaging of the sinuses in CRS isthe CT scan, preferably in the coronal view. Imaging should always beinterpreted in the context of clinical symptomatology because there is ahigh false-positive rate.

Moderate Strong

27:CRS is an inflammatory disease of unclear origin where bacterialcolonization may contribute to pathogenesis. The relative roles of initiatingevents, environmental factors, and host susceptibility factors are all

currently unknown.

Weak Moderate

28:Bacteriology of CRS is different from that of ABRS. Moderate Strong

29: Environmental and physiologic factors can predispose to developmentor recurrence of chronic sinus disease. Gastroesophageal reflux disease(GERD) has not been shown to play a role in adults.

Moderate Strong

30:When diagnosis of CRS is suggested by history and objective findings,oral or topical steroids with or without antibiotics should be used formanagement.

Moderate Moderate

Statements CRS: I

Statements CRS: II
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StatementStrength

ofEvidence

Strength ofRecommenda

tion

31:Many adjunct therapies commonly used in CRS have limited evidence to

support their use. Saline irrigation is an approach that has consistentevidence of benefiting symptoms of CRS.

Moderate Moderate

32: Use of mucolytics is an approach that may benefit symptoms of CRS. Option Moderate

33: Use of antihistamines is an approach that may benefit symptoms of CRS. Option Weak

34: Use of decongestants is an approach that may benefit symptoms of CRS. Option Weak

35: Use of leukotriene modifiers is an approach that may benefit symptoms

of CRS.

Weak Weak

36: Failure of response should lead to consideration of other possiblecontributing diagnoses such as migraine or temporomandibular jointdysfunction (TMD).

Option Moderate

37:Surgery is beneficial and indicated for individuals failing medicaltreatment.

Weak Moderate

38: Continued use of medical therapy post-surgery is key to success and is

required for all patients. Evidence remains limited.

Moderate Moderate

39 Part A: Patients should be referred by their primary care physician whenfailing 1 or more courses of maximal medical therapy or for more than 3sinus infections per year.

Weak Moderate

39 Part B: Urgent consultation with the otolaryngologist should be obtainedfor individuals with severe symptoms of pain or swelling of the sinus areas orin immunosuppressed patients.

Weak Strong

Statements CRS: II
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StatementStrength

ofEvidence


ation

40:Allergy testing is recommended for individuals with CRS aspotential allergens may be in their environment.

Option Moderate

41: Assessment of immune function is not required inuncomplicated cases.

Weak Strong

42:Prevention measures should be discussed with patients. Weak Strong

Statements CRS: III
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CRS: Subtypes

CRSwNP Characterized by

Mucopurlent drainage

Nasal obstruction

Hyposmia Diagnosis requires

At least 2 major symptoms

Bilateral polyps in themiddle meatus (endoscopy)

Bilateral mucosal disease(CT scan)

CRSsNP Characterized by

Mucopurlent drainage

Nasal obstruction

Facial pain / pressure /fullness

Diagnosis requires

At least 2 major symptoms

Inflammation (endoscopy)

Absence of polyps(endoscopy)

Purulence from osteomeatalcomplex (endoscopy) orrhinosinusitis (CT)
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CRS: Specialist Referral

Referral to a specialist is warranted when a patient

Fails 1 course of maximal medical therapy, or

Has > 3 sinus infections/year

URGENT consultation w/otolaryngologist required if patient

Has severe symptoms of pain/swelling of the sinus areas, or

Is immunosuppressed

Allergy testing

Identify allergic components that might respond to allergytreatment (e.g., avoiding environmental triggers, or takingappropriate pharmacotherapy or immunotherapy)

Immune function testing

Not required in uncomplicated cases

May be appropriate for patients with resistant CRS
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CRS: Initial Management Is Medical

In the absence of complication or severe illness CRSsNP: nasal or oral corticosteroid and oral

antibiotics

CRSwNP: topical intranasal steroids and shortcourses of oral steroids

Simultaneous oral antibiotic therapy indicatedonly in the presence of symptoms suggestinginfection (eg, pain or recurrent episodes of

sinusitis, or when purulence is documented onrhinoscopy/endoscopy)

M f CRS (I)
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Management of CRS (I)

Obtain CT or perform endoscopy

CRSsNP: 2 major symptoms plus all of the followingEndoscopeInflammation (eg, discolored mucus, edema of middle meatus /ethmoid areaAbsence if polyps in middle meatusPurulence originating from the ostiomeatal complexorCT image

Rhinosinusitis

CRS Diagnosis Requires the Presence of at Least 2 MajorSymptoms*

Major SymptomsNone Mild

Occasional limitedepisode

ModerateSteady

symptomsbut easilytolerated

SevereHard to tolerate

and mayinterfere with

activity or sleep

CFacial Congestion/fullness

PFacial Pain/pressure/fullness

ONasal Obstruction/blockageDPurulent anterior/posterior nasal

Drainage

SHyposmia/anosmia (Smell)

*A diagnosis requires at least 2 CPODS, present for 8 to 12 weeks, plusdocumented inflammation of the paranasal sinuses or nasal mucosa.

CRS is diagnosed on clinical grounds but must be confirmed with at least 1 objective finding onendoscopy or CT scan.

CRSwNP: 2 major symptoms plus all of the followingEndoscopePresence of bilateral polyps in middle meatusCT image

Bilateral mucosal disease

Immediately ReferUrgent consultation forIndividuals with severe painor swelling of the sinus areasor in immuno- compromisedpatientsSuspected invasive fungalsinusitisConsider referral soon

When failing 1 course ofmaximal medical therapyFor 4 sinus infections peryear
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36/36

Management of CRS (II)

Reassess after 2 to 4 months

CRSsNP

Persistence or

Recurrence of symptoms

Possible alternative diagnoses Allergic fungal rhinosinusitis Allergic rhinitis Atypical facial pain Invasive fungal rhinosinusitis Migraine or other headache

diagnosis Nasal septal deformation

Nonallergic rhinitis Temporomandibular joint

dysfunction (TMD) Trigeminal neuralgia Vasomotor rhinitis

CRSwNP

If positive exam, treat with INCS Antibiotics (2nd line) Consider short course of oral

steroids Consider saline irrigation

+/- specialty assessment

Clinical improvement after 4 weeks?

Yes No

Continue INCSConsider saline

irrigation

Refer for surgicalevaluation

If negative exam, assumerecurrent sinusitis and treatwith INCS or consideralternative diagnoses

INCS Short course oral steroids Antibiotic if suspicion of infection (purulence or pain)

Broad spectrum such as fluoroquinolones oramoxicillin-clavulanic acid combinations

Consider leukotriene receptor antatgonists in

appropriate patients Specialty referral Allergy testing if suspected allergen present in

environment

Persistent improvement

Refer to surgeonContinue INCS

Consider saline irrigation
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