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