m.mohammadi ardehali,md. associate professor of tums amiralam hospital

RHINOSINUSITIS

M.Mohammadi Ardehali,MD.Associate Professor of TUMS

AMIRALAM HOSPITAL

Anatomy

Development

MAXILLARY AND ETHMOID SINUSES DEVELOPS DURING 3RD & 4TH GESTATIONAL MONTH AND GROW IN SIZE UNTIL LATE ADOLESCENCE

SPHENOID SINUS PRESENTS BY 2 YEARS OF AGE

FRONTAL SINUS DEVELOPS DURING 5 AND 6 YRS.

Factors Predisposing To Obstruction Of Sinus Drainage.

A. MUCOSAL SWELLING

Systemic disorderViral URIAllergic inflammationCystic fibrosisImmune disorderImmotile cilia

Local insultFacial traumaSwimming, divingRhinitis medicamentosa

B. MECHANICAL OBSTRUCTION

Choanal atresiaDeviated septumNasal polypForeign bodyTumorEthmoid bullae

C. MUCUS ABNORMALITIESViral URIAllergic inflammationCystic fibrosis

Pathophysiology Key Factors:

The patency of the ostiaNormal ciliary functionThe quality and quantity

of secretion

The patency of the ostia

Obstruction of the sinus ostium

Negative pressure

Intruduction of bacteria

sinusitis

Normal ciliary function

ciliary Dysfunction

Impaired secretion clearance

Sinusitis

The quality and quantity of secretion

Antioxidan activiyHumidification of URTEntrapping microorganismsImmunologic antimicrobial functions

Loss of:

Sinusitis

Epidemiology

Incidence Lifetime Incidence: 25%United States clinic office visits: 1% Attendance at Day Care CenterOccurs during viral respiratory seasonSchool-age siblings in the household

Definitions: Acute Rhinosinusitis

Transition from Viral to Bacterial InfectionTransition from Viral to Bacterial Infection

Up to 2% of VRS complicated by bacterial infection

Day 1-10: Can be difficult to distinguish VRS from ABRS.

“Double Sickening” PatternPt initially gets better then gets worse

Consistent with ABRS

Symptoms And Signs

PERSISTENT>10 DAYS

No appreciable improvement

Nasal discharge of any quality

Cough(must be present during day)

Malodorous breath

Facial Pain and headache are rare

If fever then low grade

May not appear very ill

SEVEREHigh fever > 39 C

Purulent nasal discharge

And Present for at least 3-4 days

Headaches may be present

Periorbital swelling occasionally

Subacute Sinusitis

30 days to 4 months

Mild to moderate and often intermittent symptoms

Nasal discharge of any quality

Cough often worse at night

Low-grade fever may be periodic usually not prominent

Chronic Sinusitis

Extremely protracted nasal symptoms

Discharge

or Congestion

or Cough or both

Some cases rhinorhhea minimal or absent

Nasal congestion-mouth breathing-sore throat

Chronic Sinusitis

Chronic headache usually on awakeningIntermittent feverMalodorous breathSecondary affects–fatigue, impaired sleep–decreased appetite–irritability

Physical Findings

Mucopurulent discharge in nose or posterior pharynxNasal mucosa- erythematousThroat- moderate injectionEars- acute otitis or otitis with effusionParanasal sinus tenderness- occasionally Periorbital edema-occasionallyMalodorous breath

Differential Diagnosis-Purulent Nasal Discharge

Uncomplicated viral URIGroup A Strep infectionAdenoiditisNasal foreign body

Differential Diagnosis- Nasal Symptoms

Persistent clear nasal discharge or nasal congestion– Allergic rhinitis: nasal discharge, congestion,

sneezing, itchiness of eyes, nose, other mucous membranes, pale boggy mucosa, Dennies lines, allergic shiners, transverse crease on bridge of nose, headaches

Differential Diagnosis-Nasal Symptoms

No allergic rhinitis-resemble allergic rhinitis

children -specific allergens cannot be demonstrated, IgE levels normal, radioallergosorbent test negative

Rhinitis Medicamentosa

Vasomotor Rhinitis

Differential Diagnosis-Cough

Reactive airway disease

GER

CF

pertussis

Mycoplasma bronchitis

TB

Diagnosis

Diagnosis-Imaging Standard views

– Anterioposterior– Lateral – Occipitomental

Sinus XRay (Rarely indicated) Complicated Acute Sinusitis Suspected Chronic Sinusitis

Significantly abnormal in 88% of children younger than 6

Imaging

Imaging

Imaging

Diagnosis- CT Scans

Frequent abnormalities are found in patients with a “fresh common cold”

Indicationscomplicated sinus disease(either orbital or CNS complications)

numerous recurrences

protracted or nonresponsive symptoms(surgery is being contemplated)

Axial CTScan

Limitations of CT:– Radiation may be 10x that of plain

films– lack of specificity for bacterial

infection

Diagnosis- CT Scans

DIAGNOSIS

The diagnosis is based largely on symptoms with confirmation by nasendoscopy

Are endoscopically-directed cultures

of the middle meatus an acceptable means of

documenting microbiological diagnosis of acute sinusitis?

Talbot et al. (1995)– 47 evaluable patients with acute maxillary

sinusitis– overall sensitivity = 65%, specificity =40%– better performance with Streptococcus

pneumoniae, Haemophilus influenzae, Moraxella catarrhalis

– increased isolation of staphylococcal species with endoscopic cultures

ABRS Microbiology

Streptococcus pneumoniae 30-40%

Haemophilus influenzae 20%

Moraxella catarrhalis 20%

Strep pyogenes 4%

Respiratory viral isolates 10% – adenovirus– parainfluenzae– influenzae– rhinovirus

Other rarer isolates- group A strep, group C strep, viridians strep, peptostrep, Moraxella species, Eikenella corrodens

CRS Microbiology:

Anaerobes gm+ cocci, bacteroides, corynebacteria

Staphylococcus aureus

Streptococcus

H. Influenzae

M. catarrhalis

Complications

Complications of Acute Bacterial Sinusitis Preseptal cellulitis Orbital cellulitis Osteomyelitis Subperiosteal orbital abscess Subdural or Epidural Empyema Meningitis Brain abscess Cortical thrombophlebitis Cavernous or sagittal sinus thrombophlebitis

6 weeks post op.

Treatment

Choice of Antibiotic for ABRS

Wright & Frankel

Symptomatic Relief of Acute Bacterial Rhinosinusitis

Adjunctive treatments for rhinosinusitis that may aid in symptomatic relief include – decongestants (-adrenergic) – corticosteroids (topical?)– saline irrigation– Mucolytics– **None of these products have been specifically approved by the

FDA for use in acute rhinosinusitis (as of February 2007), and few have data from controlled clinical studies supporting this use.

In patients with acute sinusitis 40-50% have spontaneous clinical cure rate

Hospitalization- systemic toxicity or unable to take oral antimicrobials– cefuroxime– ampicillin/sulbactam– cefotaxime and vanco. if suspecting penicillin-

resistant strep pneumoniae

Treatment: cont,

Treatment: cont,

Clinical improvement is prompt If no reduction of nasal discharge or cough

in 48 hours reevaluate Patients with brisk response- 10 days of

treatment If respond more slowly- treat until patient is

symptom free plus 7 more days

Recurrent Sinusitis

Most common cause is recurrent viral URIs– day care attendance– presence of other school age siblings in house

Other predisposing conditions– allergic and nonallergic rhinitis– CF– immunodeficiency disorder– ciliary dyskinesia– anatomical problem

Absolute Indications for Surgery

Failure of maximal medical therapy

Causing brain abscess or meningitis, subperiosteal/orbital abscess, cavernous sinus thrombosis, another contiguous infection, or an impending complication (Pott’s tumor)

Sinus mucocele or pyocele

Fungal sinusitis (all types(

Nasal polyps (massive )

Neoplasm or suspected neoplasm

Surgery

Functional endoscopic sinus surgery (FESS)

Rarely required in children Consider if anatomical variations causing

local obstruction,

Thank you