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Acute and Chronic Rhinosinusitis,Pathophysiology, diagnosis, and management. AAAAI Rhinosinusitis Committee Updated 2006,Rhinosinusitis,Group of disorders characterized by inflammation of the mucosa of the nose and paranasal sinuses Sinus and Allergy Health Partnership,Meltzer et al. JACI 2004;114:155,Rhinosinusitis,More accurate term than “sinusitis” since almost always preceded by or concomitant symptoms of rhinitis Acute Up to 4 weeks Subacute 4 to 12 weeks Chronic 12 weeks,Acute vs. Chronic Rhinosinusitis,Usually very different conditions. Acute rhinosinusitis usually related to infection. Chronic rhinosinusitis usually related to inflammation.,Acute Rhinosinusitis,Question,Is acute rhinosinusitis usually viral or bacterial?,Acute Rhinosinusitis,1 billion viral URIs each year 0.5% - 2% lead to secondary bacterial infection of the sinuses.1,2 Acute bacterial rhinosinusitis often present when symptoms have not resolved after 10 days or worsen after 5 to 7 days,1Gwaltney Clin Infect Dis 1996;23:1209 2Berg et al. Rhinology 1986;24:223-5,Viral Rhinosinusitis,Similar to bacterial rhinosinusitis clinically and radiographically CT scan within 48-96 hrs of a self-diagnosed “cold” (n=31) 77% with infundibulum occlusion 79% cleared in 2 weeks without abx,Gwaltney et al. NEJM 1994;330:25,Obstruction of the Sinus Ostium Produces Acute Rhinosinusitis,Kern EB JACI 1984:73:25,Coronal View in Relation to Facial Structure,Koepke, J.W., Dolen, W.K., Spofford, B., & Selner, J.C. (1998). Rhinolaryngoscopy (2nd ed.). Allergy Respiratory Institute of Colorado.,Saggital View in Relation to Facial Structure,Koepke, J.W., Dolen, W.K., Spofford, B., & Selner, J.C. (1998). Rhinolaryngoscopy (2nd ed.). Allergy Respiratory Institute of Colorado.,Anatomic Drainage Pathways in the Sinuses,Sinus Area Frontal Anterior ethmoid / Maxillary Posterior ethmoid / sphenoid,Drainage pathway Nasofrontal duct Ostiomeatal unit Sphenoidethmoidal recess,Pain in Acute Rhinosinusitis,Maxillary Frontal Ethmoid Sphenoid,malar, posterior nasopharynx, pain in the upper teeth, zygoma,temple hyperalgesia Forehead, orbit, zygoma, temple Nasal bridge, inner canthus, eye movement Vertex, retro-orbit, between eyes, zygoma, temple,Other Clinical Signs of Acute Rhinosinusitis,Tenderness overlying the sinuses Nasal erythema Purulent nasal secretions Increased posterior pharyngeal secretions Fetid breath Periorbital edema Ear examination may reveal eustachian tube dysfunction,Diagnosis of Acute Bacterial Rhinosinusitis,Acute clinical pattern Symptoms 10 days and 28 days Objective confirmation either / or Nasal exam documenting purulent d/c beyond the nasal vestibule Rhinoscopy Endoscopy Posterior pharyngeal drainage CT scan Not recommended for routine management May be helpful in complex cases,Meltzer et al. JACI 2004;114:155,Diagnosis of Acute Rhinosinusitis: 2 major OR 1 major & 2 minor symptoms,Major Anterior or posterior purulent drainage Nasal obstruction Facial pain or pressure or congestion Hyposmia or anosmia Fever (acute),Minor Head ache Ear pain/pressure Halitosis dental pain Fatigue Cough,JACI 2004,Radiographic Evidence of Rhinosinusitis,Air fluid level Sinus opacification Mucus membrane thickening of 4 to 6 mm or more,Advantages of CT Scan in Rhinosinusitis Diagnosis,More sensitive and specific than plain sinus radiographs Allows assessment of ostiomeatal unit patency (OMU) Useful in intubated patients Axial cuts provide additional anatomic information Useful in complicated cases with CNS, bony, or orbital extension,Protocol for Limited Sinus CT Scan,Patient prone in Waters position (bring table up until it stops automatically so you can get the full 25o tilt),Positioning:,Scout View:,Lateral skull Place lines (to get correct angle, place cursor at front of sinuses and maxilla. If this angle is 25o or less, place lines as follows: Slice #1: Place line in middle of frontal sinuses. Slice #2: Place line where Coronal suture intersects at top of orbit. Slice #3: Place line halfway between slice #1 and #2 (Note: To see OMU eventually you may need to take several slices in this area.) Slice #4: Place line mid-sphenoid.,Scout X-ray,Landmarks for performing a limited sinus CT scan in the coronal plane,Uncinate Process,Ethmoid Sinus,Middle Turbinate,Infundibulum,Inferior Turbinate,Nasal Septum,Maxillary sinus,Nasal Septum,Normal Sinus CT Scan through the OMU,Blow-up View of the Ostiomeatal Unit Area,Obstruction of the OMU with Associated Acute Sinusitis,Resolution of Acute Sinusitis after Treatment with Antibiotics,Local Factors Predisposing to Rhinosinusitis,Allergic rhinitis URI Anatomic abnormalitiy: Deviated septum Concha bullosa Enlarged adenoids Haller cells Nasal polyps Tumor,Foreign body Trauma Barotrauma Diving, swimming Smoke Topical decongestant abuse Nasal intubation,Systemic Factors Predisposing to Rhinosinusitis,Immune deficiency IgA deficiency Panhypogammaglobulinemia IgG subclass deficiency HIV Cystic fibrosis Ciliary disorder Wegeners granulomatosis Gastroesophageal reflux,Complications of Rhinosinusitis,Orbital cellulitis (ethmoid) Meningitis Subdural/epidural empyema (frontal) Brain abscess (frontal) Cavernous sinus thrombosis (sphenoid) Osteomyelitis (frontal) Asthma exacerbation,Ominous Signs in Rhinosinusitis,Facial swelling / erythema over an involved sinus Visual changes Abnormal extraocular movements Proptosis Periorbital inflammation/edema Intracranial or CNS involvement,Antibiotics for Acute Sinusitis,Cochrane Database Review (2004) Peds Available evidence suggest that antibiotics given for 10 days will reduce the probability of persistence in the short to medium-term. Cochrance Database Review (2004) Adults Current evidence is limited but supports the use of antibiotics for 7 to 14 days Weigh the moderate benefits of abx treatment against the potential for adverse effects,Antibiotics for Acute Maxillary Sinusitis in Adults,Searched from MEDLINE and EMABASE, contacts with pharmaceutical companies,and bibliographies of included studies Results 49 trials (n=13,660) 20 were double blind Compared to controls, abx improved clinical cures Radiographic outcomes improved with abx Comparison between classes of abx showed no significant differences,The Cochrane Database of Systematic Reviews 2004;1:1-69,Acute Bacterial Rhinosinusitis: Which antibiotic to use?,No randomized, placebo-controlled trials of antibiotic treatment for ABRS using pre-and post-treatment sinus aspirate culture,Antibiotics,20 to 30% of S. pneumoniae are penicillin resistant 30 to 40% of H. influenzae and 75 to 95% of M. catarrhalis are beta-lactamase positive When choosing abx consider Recent abx use (within 6 weeks) Severity of disease,Antibiotics for Acute Rhinosinusitis,FDA approved antibiotics for acute bacterial rhinosinusitis Amoxicillin, amoxicillin-clavulonate, clarithromycin, cefprozil, cefuroxime axetil, loracarbef, levofloxacin, gatifloxacin, azithromycin, trimethoprim sulfamethoxazole, moxifloxacin, telithromycin,Sinus and Allergy Health Partnership Otolaryngol Head Neck Surg 2004:130:1,Comparison of First-Line vs Second-Line Abx,Objective: compared effectiveness and cost for treatment in uncomplicated ABRS Retrospective cohort study (n=29,102) Outcome: presence or absence of additional claim for an abx, cost, complications of sinusitis,Piccirillo et al. JAMA 2001;286:1849,List of Antibiotics,1st Line Amoxicillin TMP-SMX Erythromycin,2nd Line Clarithromycin Azithromycin Augmentin Cephalosporins Levofloxaxin Clindamycin metronidazole,Results,1st Line Success: 90.1% 1 case of periorbital cellulitis Cost: $68.98,2nd Line Success: 90.8% 1 case of periorbital cellulitis Cost: $135.17 p.001,CDC recommendations for ABRS,Amoxicillin 1.5 to 3.5 g/day Doxycycline 100 mg twice daily TMP-SMX 1 DS twice daily,Sinus and Allergy Health Partnership Recommendations,Mild disease (no abx in 4-6 weeks) Amoxicillin-clavulanate, amoxicillin, cefpodoxime, cefuroxime axetil Mild disease (abx in last 4-6 weeks) or moderate disease (no abx) Amoxicillin-clavulanate, amoxicillin high dose, cephalosporins, gatifloxacin, levofloxacin, moxifloxacin Moderate disease (abx in last 4-6 weeks) Amoxicillin-clavulanate, fluoroquinolones, or combination therapy with amox or clinda plus cefpodoxime or cefixime,Acute Bacterial Rhinosinusitis: Duration of Treatment,Most clinical trials have used 10 to 14 days 95% eradication after 10 day course1 3-5 day courses of some macrolides2,3 effective2,1Gwaltney et al. JACI1992;30:457 2Klapan et al. Am J Otolaryngol 1999;20:7 3Roos et al. Chemotherapy 2002;48:100,Sinus and Allergy Health Partnership Otolaryngol Head Neck Surg 2004:130:1,Sinus 130:1,Chronic Rhinosinusitis,Diagnosis of Chronic Rhinosinusitis,Symptoms for 12 weeks Two main subtypes: CRS without nasal polyps CRS with nasal polyps Strongly associated with asthma and aspirin tolerance,Meltzer et al. JACI 2004;114:155,Mechanisms of CRS,Chronic Rhinosinusitis: Risk Factors for Extensive Disease,80 patients with CRS Factors Eosinophil 200/uL (OR=19.2, 95% CI=5.4-72.7 Asthma (OR=6.8, 95%CI=2.2-22) Atopy (OR=4.3,95%CI=1.5-12.8) Age50 (OR=6.5,95%CI=2.0-22.2),Hoover GE et al. JACI 1997;100:185-91,Prevalence of Allergy in CRS,Chart review of 113 sinus surgery patients 48 patients included in the study Allergy testing by RAST or skin testing 57.4% had a positive allergy test,Guman et al. Otolaryngol Head Neck Surg 2004;130:545,Correlation of Allergy and Rhinosinusitis,Retrospective review of 200 patients with FESS 84% with allergies Predominance of perennial (esp DM),Emanuel et al. Oto H 123:687-91,Allergic Inflammation and Rhinosinusitis,Purpose: ongoing AR enhances infection and inflammation by S. pneum in acute sinusitis BALB/c mice sensitized to ovalbumin by IP injection Nasal administration of OVA soln Infection with S. pneumoniae,Blair et al. JACI 2001;108:424-9,Allergic Inflammation and Rhinosinusitis,Results: Allergic mice had more bacteria recovered more inflammation (PMN, eos, monos),Allergic Inflammation and Rhinosinusitis,Blair et al. JACI 2001; 108:124.,Correlation of Allergy and Rhinosinusitis,42 patients with CRS underwent RAST and CT scans Allergic patients had higher CT scores (mean = 12) Nonallergic patients had lower CT scores (mean = 6) p=0.03,Type of Allergy Among Sinus Surgery Patients,None,Perennial and seasonal,Perennial,Seasonal,Emmanuel et al. Otolaryngol H 13:345,Allergy Immunotherapy for CRS,Study: 114 patients with perennial allergic rhinitis and sinusitis, surveyed using the Sinusitis Outcomes Questionnaire. 99% of patients surveyed believed immunotherapy was helpful 72% decrease in days lost from work or school 25% reduction in the use of medications 51% reduction in the overall symptom score,Nathan et al, Ann Allergy Asthma Immunol 2004,Allergic Fungal Rhinosinusitis,Appears to be a subset of CRsNP Defined by 5 criteria: allergy to cultured fungi gross production of eosinophilic mucin that contains noninvasive fungal hyphae nasal polyposis characteristic radiographic changes immunocompetence,Meltzer et al, JACI 2004, 114 (suppl): 155-212.,Role of Infectious Agents in CRS,Fungi Eosinophilic fungal rhinosinusitis has been proposed, but is controversial. Bacteria Superinfection is more common role, rather than primary cause of inflammation and obstruction. Superantigen from Staph aureus has been demonstrated to have a role in nasal polyps. Biofilm is an attractive but unproven concept. Osteitis is another unproven concept.,Meltzer et al. JACI 2004;114:155,Fungi and Chronic Rhinosinusitis,Allergic fungal rhinosinusitis A well-characterized condition involving allergy to fungi and other characteristic features. Infectious fungal rhinosinusitis Direct infection of the sinuses (non-invasive vs. invasive). Eosinophilic fungal rhinosinusitis A (proposed) non-IgE-mediated inflammatory condition characterized by fungal colonization, local chemotaxis of eosinophils, and inflammation.,Bacterial Superantigen,Local production of IgE specific to staphyloccal enterotoxins, which act as superantigens, in CRSwP Staph aureus enterotoxins induce increased severity of eosinophilic inflammation Increased colonization of Staph aureus in swabs of the middle meatus from patients with CRSwP relative to normal controls and patients with CRSsP,Smart, BA, Pediatric Asthma, Allergy and Immunology, 2005; 18:88-98,Diagnosis of CRS,Physical examination Endoscopy or anterior rhinoscopy Purulent drainage Edema or erythema of the middle meatus or ethmoid bulla polyps Sinus CT scan Mucosal thickening Air-fluid level,Meltzer et al. JACI 2004;114:155,Medical Management of Chronic Rhinosinusitis,Antibiotics Corticosteroids Decongestants Muco-evacuants Antihistamines Non-pharmacologic treatment,Microbiology of Chronic Rhinosinusitis,Not well defined because of differences in culturing techniques, prior use of abx S. pneumoniae, H. influenzae, M. catarrhalis S. Aureus, coagulase negative staph, anaerobes Fungi,Meltzer et al. JACI 2004;114:155,Chronic Rhinosinusitis: Which Antibiotic to Use?,-No antibiotic is approved by FDA for CRS -We use similar abx as ABRS,Antibiotics for Chronic Rhinosinusitis,Appropriate duration is not well defined AAAAI and ACAAI Joint Task Force treat for 3,4 or 6 weeks continue abx for at least 1 week after the patient is symptom free Task Force on Rhinosinusitis of the American Academy of Otolaryngology-Head and Neck Surgery treat 4 to 6 weeks,Corticosteroids,Few controlled studies with nasal steroids Beneficial when added to abx Longer infection free interval in CRS systemic steroids have not been well studied,Adjunctive Therapy,Decongestants Used as adjuvant treatment no controlled studies Mucolytic treatment 1 double blinded study 2400 mg of guaifenesin or placebo in HIV+ with chronic sinusitis improvement in congestion and thick secretions,Wawrose et al. Laryngoscope 1992;102:1225,Adjunctive Therapy,Antihistamines play a role in allergic rhinitis patients with sinusitis Saline irrigation may help mucociliary clearance mild vasoconstrictor of nasal blood flow Intravenous immune globulin indicated in patients with impaired humoral immunity,Adjunctive Therapy,Leukotriene antagonists Useful in patie