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DEFINITION RHINOSINUSITIS
ACUTE - < 4 WEEKS SUBACUTE- 4 WEEKS TO 3 MONTHS CHRONIC- > 12 WEEKS RECURRENT- > 8 WEEKS BETWEEN 2 EPISODES OF ACUTE SINUSITIS
Diagnosis and Management of Acute and Chronic Sinusitis - Dr. J.P Souaid
Inflammation of the nose and the paranasal sinuses characterised by 2 or more symptoms One symptom should be either nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip)
.
Fokkens et al. Rhinology. 2007;45(suppl 20):1.
Rhinosinusitis Symptoms
Facial Pain/ pressure
Blockage/ Obstruction/ congestion
Symptoms
10
15
Days
RISK FACTORS
EXTRINSIC
INFECTION ENVIRONMENT MEDICATIONS FOREIGN OBJECTS TRAUMA
INTRINSIC
ALLERGY ANATOMIC NASAL POLYPS TUMOURS CYSTIC FIBROSIS CILIARY DYSFUNCTION IMMUNODEFICIENCY
Diagnosis and Management of Acute and Chronic Sinusitis - Dr. J.P Souaid
PATHOPHYSIOLOGY OF RHINOSINUSITIS
Diagnosis and Management of Acute and Chronic Sinusitis - Dr. J.P Souaid
MICROBIOLOGY RHINOSINUSITIS
ACUTE
H. influenzae 30% M. catarrhalis 20% S. aureus 6% S. pneumoniae 40% S. pyogenes 3% Other 1%
Desrosiers et al. J Otolaryngol 2002;31(Suppl 2):2S2-2S14.
CHRONIC
S. AUREUS
POLYMICROBIAL!!!
P. AERUGINOSA
8
Diagnosis and Management of Acute and Chronic Sinusitis - Dr. J.P Souaid
Air-fluid levels and opacification, when present, have positive predictive value of 80% to 100%
Sensitivity is low (detects only 60% of sinusitis patients)
The Institute for Clinical Systems Integration. Postgrad Med. 1998;103:154-156, 159-160, 166-168.
Diagnosis: Cultures
Maxillary / Facial pain Symptoms >7 days Dental pain Poor response to decongestants History of coloured nasal discharge
4 or 5 signs or symptoms
2 or 3 signs or symptoms
Consider radiography
Signs
Diagnosis and Management of Acute and Chronic Sinusitis - Dr. J.P Souaid
11
Changes in Symptoms Over 21 Days with Adjunctive MFNS in Acute Recurrent Rhinosinusitis
Placebo
7
6 5 4 3 2 1
**
**
*
0.2
0.0
0
Total symptom score
*P<0.05; **P<0.01 vs placebo. Meltzer EO, et al. J Allergy Clin Immunol 2000;106:6307.
MFNS as Monotherapy?
6 5 4 3 2 1 0 0
a,b
a,b
a,b
a,b
a,b
a,b
a,b
aP0.037 bP0.012
vs placebo. vs amoxicillin 0.5 g tid. Adapted from Meltzer et al. J Allergy Clin Immunol. 2005;116:1289.
Days
*Bioavailability of intranasal triamcinolone and beclomethasone are not reported in product information Corren J: J Allergy Clin Immunol 1999; 104:S144-9.
TOPICAL STEROIDS
NASONEX AVAMYS OMNARIS
20 % 2% YES* NO NO
YES NO
6% NO NO NO NO
YES YES
Diagnosis and Management of Acute and Chronic Sinusitis - Dr. J.P Souaid
18
Up to 20% of isolates are resistant or intermediate to penicillin1 14% are resistant to macrolides2 19% of isolates are resistant to amoxicillin 14% of isolates are resistant to TMP-SMX Resistance levels of isolates are generally low 1.5% resistant to TMP-SMX
H. influenzae:3
M. catarrhalis:3
1Zhanel 3Zhanel
et al. AAC 2003;47:1867-74. 2Low et al. CBSN 2003. et al. AAC 2003;47:1875-81.
Diagnosis and Management of Acute and Chronic Sinusitis - Dr. J.P Souaid
19
nd-line 2
No clinical response to first-line therapy within 48-72 hours Patients who received antibiotics in previous 3 months (CLASS SWITCHING!) Frontal or sphenoid sinusitis Allergy to -lactams Chronic underlying conditions Immunosuppression Protracted symptoms
Diagnosis and Management of Acute and Chronic Sinusitis - Dr. J.P Souaid 20
Statements: Summary
Canadian Rhinosinusitis Guidelines 2011
Moderate Option
Strong Strong
Moderate
Strong
Option
Strong
Statements ABRS: II
Statement
5: Routine nasal culture is not recommended for the diagnosis of ABRS. When culture is required for unusual evolution, or when complication requires it, sampling must be performed either by maxillary tap or endoscopically-guided culture. 6: The 2 main causative infectious bacteria implicated in ABRS are Streptococcus pneumoniae and Haemophilus influenzae. 7: Antibiotics may be prescribed for ABRS to improve rates of resolution at 14 days and should be considered where either quality of life or productivity present as issues, or in individuals with severe sinusitis or comorbidities. In individuals with mild or moderate symptoms of ABRS, if quality of life is not an issue and neither severity criterion nor comorbidities exist, antibiotic therapy can be withheld. 8: When antibiotic therapy is selected, amoxicillin is the first-line recommendation in treatment of ABRS. In beta-lactam allergic patients, trimethoprim-sulfamethoxazole (TMP/SMX) combinations or a macrolide antibiotic may be substituted. 9: Second-line therapy using amoxicillin/clavulanic acid combinations or quinolones with enhanced gram positive activity should be used in patients where risk of bacterial resistance is high, or where consequences of failure of therapy are greatest, as well as in those not responding to first-line therapy. A careful history to assess likelihood of resistance should be obtained, and should include exposure to antibiotics in the prior 3 months, exposure to daycare, and chronic symptoms.
Strong Moderate
Strong Moderate
Option
Strong
Option
Strong
Strong
Strong
13: Treatment failure should be considered when patients fail to respond to initial therapy within 72 hours of administration. If failure occurs following use of INCS as monotherapy, antibacterial therapy should be administered. If failure occurs following antibiotic administration, it may be due to lack of sensitivity to, or bacterial resistance to, the antibiotic, and the antibiotic class should be changed.
14: Adjunct therapy should be prescribed in individuals with ABRS. 15: Topical INCS may help improve resolution rates and improve symptoms when prescribed with an antibiotic. 16: Analgesics (acetaminophen or non-steroidal anti-inflammatory agents) may provide symptom relief. 17: Oral decongestants may provide symptom relief. 18: Topical decongestants may provide symptom relief. 19: Saline irrigation may provide symptom relief.
Option
Strong
Statements ABRS: IV
Statement 20: For those not responding to a second course of therapy, chronicity should be considered and the patient referred to a specialist. If waiting time for specialty referral or CT exceeds 6 weeks, CT should be ordered and empiric therapy for CRS administered. Repeated bouts of acute uncomplicated sinusitis clearing between episodes require only investigation and referral, with a possible trial of INCS. Persistent symptoms of greater than mild-to-moderate symptom severity should prompt urgent referral. 21: By reducing transmission of respiratory viruses, hand washing can reduce the incidence of viral and bacterial sinusitis. Vaccines and prophylactic antibiotic therapy are of no benefit. 22: Allergy testing or in-depth assessment of immune function is not required for isolated episodes but may be of benefit in identifying contributing factors in individuals with recurrent episodes or chronic symptoms of rhinosinusitis. Strength of Evidence Option Strength of Recommend ation Moderate
Moderate
Strong
Moderate
Strong
Refer for expert assessment With multiple recurrent episodes, consider radiology (standard 3-vew sinus X-ray or CT scan) to confirm ABRS or to eliminate other causes Requires confirmation of 2 major symptoms* If symptoms persist, worsen or change
ABRS Diagnosis Requires the Presence of at Least 2 Major Symptoms* Major Symptoms None Mild Occasional limited episode Moderate Steady symptoms but easily tolerated Severe Hard to tolerate and may interfere with activity or sleep
P O D S
Facial Pain/pressure/fullness Nasal Obstruction Nasal purulence/discolored postnasal Discharge 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.
Minor symptoms Headache Dental pain Halitosis Cough Fatigue Ear pain/pressure Prevention Strategies Hand washing Education Environmental awareness Adjunct therapy Analgesics Decongestants Saline INCS When to refer No response to 2nd-line therapy Suspected chronicity Persistent severe symptoms Repeated bouts with clearing between episodes >3 recurrences per year Immunocompromised host Allergic rhinitis evaluation for immunotherapy Anatomic defects causing obstruction Nosocomial infection Assumed fungal infection/neoplasms Why wait >7 days? Antibiotics may not be necessary and there are side effects Diarrhea Interference with contraception Allergy Yeast infections Review previous 3-month exposure
First-line: Amoxicillin. For beta-lactam allergy: TMP/SMX combinations or a macrolide. Second-line: Fluoroquinolones or amoxicillinclavulanic acid combinations. Use with firstline failures and in patients at high risk of bacterial resistance or likely to suffer consequence of treatment failure due to underlying systemic disease.
Continue course
For symptoms lasting >4 weeks, consider chronic rhinosinusitis (CRS); refer to CRS guidelines or visit www.sinuscanada.com for additional information. Persistent severe symptoms require prompt urgent referral.
Yes
No
Emphasis on role of inflammation in the pathogenesis of CRS Distinction between CRS with nasal polyposis (CRSwNP) and CRS without NP (CRSsNP) Management strategies for the PCP Indications for referral
Statements CRS: I
Statement
23: CRS is diagnosed on clinical grounds but must be confirmed with at least 1 objective finding on endoscopy or computed tomography (CT) scan. 24: Visual rhinoscopy assessments are useful in discerning clinical signs and symptoms of CRS.
Strength of Evidence
Weak Moderate
Strength of Recommendati on
Strong Moderate
25: In the few situations when deemed necessary, bacterial cultures in CRS should be performed either via endoscopic culture of the middle meatus or maxillary tap but not by simple nasal swab.
26: The preferred means of radiological imaging of the sinuses in CRS is the CT scan, preferably in the coronal view. Imaging should always be interpreted in the context of clinical symptomatology because there is a high false-positive rate. 27: CRS is an inflammatory disease of unclear origin where bacterial colonization may contribute to pathogenesis. The relative roles of initiating events, environmental factors, and host susceptibility factors are all currently unknown.
Option
Strong
Moderate
Strong
Weak
Moderate
Moderate
Moderate
Strong
Strong
Moderate
Moderate
Statements CRS: II
Statement
31: Many adjunct therapies commonly used in CRS have limited evidence to support their use. Saline irrigation is an approach that has consistent evidence of benefiting symptoms of CRS.
Strength of Evidence
Moderate
Option
Option Option Weak Option
Moderate
Weak Weak Weak Moderate
Weak
Strong
Strength of Evidence
Option Weak Weak
CRS: Subtypes
CRSwNP
CRSsNP
Characterized by Mucopurlent drainage Nasal obstruction Hyposmia Diagnosis requires At least 2 major symptoms Bilateral polyps in the middle meatus (endoscopy) Bilateral mucosal disease (CT scan)
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 osteomeatal complex (endoscopy) or rhinosinusitis (CT)
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 allergy treatment (e.g., avoiding environmental triggers, or taking appropriate pharmacotherapy or immunotherapy) Immune function testing Not required in uncomplicated cases May be appropriate for patients with resistant CRS
CRSsNP: nasal or oral corticosteroid and oral antibiotics CRSwNP: topical intranasal steroids and short courses of oral steroids Simultaneous oral antibiotic therapy indicated only in the presence of symptoms suggesting infection (eg, pain or recurrent episodes of sinusitis, or when purulence is documented on
rhinoscopy/endoscopy)
Major Symptoms
Severe
C Facial Congestion/fullness P Facial Pain/pressure/fullness O Nasal Obstruction/blockage D Purulent anterior/posterior nasal Drainage S Hyposmia/anosmia (Smell) *A diagnosis requires at least 2 CPODS, present for 8 to 12 weeks, plus documented inflammation of the paranasal sinuses or nasal mucosa.
CRS is diagnosed on clinical grounds but must be confirmed with at least 1 objective finding on endoscopy or CT scan. Obtain CT or perform endoscopy CRSsNP: 2 major symptoms plus all of the following Endoscope Inflammation (eg, discolored mucus, edema of middle meatus /ethmoid area Absence if polyps in middle meatus Purulence originating from the ostiomeatal complex or CT image Rhinosinusitis
Immediately Refer Urgent consultation for Individuals with severe pain or swelling of the sinus areas or in immuno- compromised patients Suspected invasive fungal sinusitis Consider referral soon When failing 1 course of maximal medical therapy For 4 sinus infections per year
CRSwNP: 2 major symptoms plus all of the following Endoscope Presence of bilateral polyps in middle meatus CT image Bilateral mucosal disease
+/- specialty assessment 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
Clinical improvement after 4 weeks? Yes Continue INCS Consider saline irrigation No Refer for surgical evaluation
Persistent improvement
Refer to surgeon