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Acute and Chronic Rhinosinusitis,Pathophysiology, diagnosis, and management.AAAAI Rhinosinusitis CommitteeUpdated 2006,Rhinosinusitis,Group of disorders characterized by inflammation of the mucosa of the nose and paranasal sinusesSinus 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 weeksSubacute 4 to 12 weeksChronic 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 year0.5% - 2% lead to secondary bacterial infection of the sinuses.1,2Acute bacterial rhinosinusitis often present when symptoms have not resolved after 10 days or worsen after 5 to 7 days,1Gwaltney Clin Infect Dis 1996;23:12092Berg et al. Rhinology 1986;24:223-5,Viral Rhinosinusitis,Similar to bacterial rhinosinusitis clinically and radiographicallyCT scan within 48-96 hrs of a self-diagnosed “cold”(n=31)77% with infundibulum occlusion79% 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 AreaFrontalAnterior ethmoid / MaxillaryPosterior ethmoid / sphenoid,Drainage pathwayNasofrontal ductOstiomeatal unitSphenoidethmoidal recess,Pain in Acute Rhinosinusitis,MaxillaryFrontalEthmoidSphenoid,malar, posterior nasopharynx, pain in the upper teeth, zygoma,temple hyperalgesiaForehead, orbit, zygoma, templeNasal bridge, inner canthus, eye movementVertex, retro-orbit, between eyes, zygoma, temple,Other Clinical Signs of Acute Rhinosinusitis,Tenderness overlying the sinusesNasal erythemaPurulent nasal secretionsIncreased posterior pharyngeal secretionsFetid breathPeriorbital edemaEar examination may reveal eustachian tube dysfunction,Diagnosis of Acute Bacterial Rhinosinusitis,Acute clinical patternSymptoms 10 days and 28 daysObjective confirmation either / orNasal exam documenting purulent d/c beyond the nasal vestibuleRhinoscopy EndoscopyPosterior pharyngeal drainageCT scan Not recommended for routine managementMay be helpful in complex cases,Meltzer et al. JACI 2004;114:155,Diagnosis of Acute Rhinosinusitis:2 major OR 1 major & 2 minor symptoms,MajorAnterior or posterior purulent drainage Nasal obstructionFacial pain or pressure or congestionHyposmia or anosmiaFever (acute),MinorHead acheEar pain/pressureHalitosisdental painFatigueCough,JACI 2004,Radiographic Evidence of Rhinosinusitis,Air fluid levelSinus opacificationMucus membrane thickening of 4 to 6 mm or more,Advantages of CT Scan in Rhinosinusitis Diagnosis,More sensitive and specific than plain sinus radiographsAllows assessment of ostiomeatal unit patency (OMU)Useful in intubated patientsAxial cuts provide additional anatomic informationUseful in complicated cases with CNS, bony, or orbital extension,Protocol for Limited Sinus CT Scan,Patient prone in Waters position (bring table upuntil it stops automatically so you can get the full 25o tilt),Positioning:,Scout View:,Lateral skullPlace 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 rhinitisURIAnatomic abnormalitiy:Deviated septumConcha bullosaEnlarged adenoidsHaller cellsNasal polypsTumor,Foreign bodyTraumaBarotraumaDiving, swimmingSmokeTopical decongestant abuseNasal intubation,Systemic Factors Predisposing to Rhinosinusitis,Immune deficiencyIgA deficiencyPanhypogammaglobulinemiaIgG subclass deficiencyHIVCystic fibrosisCiliary disorderWegeners granulomatosisGastroesophageal reflux,Complications of Rhinosinusitis,Orbital cellulitis (ethmoid)MeningitisSubdural/epidural empyema (frontal)Brain abscess (frontal)Cavernous sinus thrombosis (sphenoid)Osteomyelitis (frontal)Asthma exacerbation,Ominous Signs in Rhinosinusitis,Facial swelling / erythema over an involved sinusVisual changesAbnormal extraocular movementsProptosisPeriorbital inflammation/edemaIntracranial or CNS involvement,Antibiotics for Acute Sinusitis,Cochrane Database Review (2004) PedsAvailable evidence suggest that antibiotics given for 10 days will reduce the probability of persistence in the short to medium-term.Cochrance Database Review (2004) AdultsCurrent evidence is limited but supports the use of antibiotics for 7 to 14 daysWeigh 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 studiesResults49 trials (n=13,660)20 were double blindCompared to controls, abx improved clinical curesRadiographic outcomes improved with abxComparison 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 resistant30 to 40% of H. influenzae and 75 to 95% of M. catarrhalis are beta-lactamase positiveWhen choosing abx consider Recent abx use (within 6 weeks)Severity of disease,Antibiotics for Acute Rhinosinusitis,FDA approved antibiotics for acute bacterial rhinosinusitisAmoxicillin, 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 ABRSRetrospective 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 LineAmoxicillinTMP-SMXErythromycin,2nd LineClarithromycinAzithromycinAugmentinCephalosporinsLevofloxaxinClindamycinmetronidazole,Results,1st LineSuccess: 90.1%1 case of periorbital cellulitisCost: $68.98,2nd LineSuccess: 90.8%1 case of periorbital cellulitisCost: $135.17 p 12 weeksTwo main subtypes:CRS without nasal polypsCRS with nasal polypsStrongly 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 CRSFactorsEosinophil 200/uL (OR=19.2, 95% CI=5.4-72.7Asthma (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 patients48 patients included in the studyAllergy testing by RAST or skin testing57.4% 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 FESS84% with allergiesPredominance 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 sinusitisBALB/c mice sensitized to ovalbumin by IP injectionNasal administration of OVA solnInfection with S. pneumoniae,Blair et al. JACI 2001;108:424-9,Allergic Inflammation and Rhinosinusitis,Results:Allergic mice had more bacteria recoveredmore 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 scansAllergic 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 helpful72% decrease in days lost from work or school25% reduction in the use of medications51% reduction in the overall symptom score,Nathan et al, Ann Allergy Asthma Immunol 2004,Allergic Fungal Rhinosinusitis,Appears to be a subset of CRsNPDefined by 5 criteria:allergy to cultured fungigross production of eosinophilic mucin that contains noninvasive fungal hyphaenasal polyposischaracteristic radiographic changesimmunocompetence,Meltzer et al, JACI 2004, 114 (suppl): 155-212.,Role of Infectious Agents in CRS,FungiEosinophilic fungal rhinosinusitis has been proposed, but is controversial.BacteriaSuperinfection 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 rhinosinusitisA well-characterized condition involving allergy to fungi and other characteristic features.Infectious fungal rhinosinusitisDirect infection of the sinuses (non-invasive vs. invasive).Eosinophilic fungal rhinosinusitisA (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 CRSwPStaph 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 examinationEndoscopy or anterior rhinoscopyPurulent drainageEdema or erythema of the middle meatus or ethmoid bullapolypsSinus CT scanMucosal thickeningAir-fluid level,Meltzer et al. JACI 2004;114:155,Medical Management of Chronic Rhinosinusitis,AntibioticsCorticosteroidsDecongestantsMuco-evacuantsAntihistaminesNon-pharmacologic treatment,Microbiology of Chronic Rhinosinusitis,Not well defined because of differences in culturing techniques, prior use of abxS. pneumoniae, H. influenzae, M. catarrhalisS. Aureus, coagulase negative staph, anaerobesFungi,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 definedAAAAI and ACAAI Joint Task Forcetreat for 3,4 or 6 weekscontinue abx for at least 1 week after the patient is symptom freeTask Force on Rhinosinusitis of the American Academy of Otolaryngology-Head and Neck Surgerytreat 4 to 6 weeks,Corticosteroids,Few controlled studies with nasal steroidsBeneficial when added to abxLonger infection free interval in CRSsystemic steroids have not been well studied,Adjunctive Therapy,DecongestantsUsed as adjuvant treatmentno controlled studies Mucolytic treatment1 double blinded study2400 mg of guaifenesin or placebo in HIV+ with chronic sinusitisimprovement in congestion and thick secretions,Wawrose et al. Laryngoscope 1992;102:1225,Adjunctive Therapy,Antihistaminesplay a role in allergic rhinitis patients with sinusitisSaline irrigationmay help mucociliary clearancemild vasoconstrictor of nasal blood flowIntravenous immune globulinindicated in patients with impaired humoral immunity,Adjunctive Therapy,Leukotriene antagonistsUseful in patients with CRS with nasal polyps,Nasal Irrigation,211 with sinonasal diseaseIrrigated with 250 mL HS using