1、Acute and Chronic RhinosinusitisPathophysiology,diagnosis,and management.AAAAI Rhinosinusitis CommitteeUpdated 2006 RhinosinusitisGroup of disorders characterized by inflammation of the mucosa of the nose and paranasal sinuses Sinus and Allergy Health Partnership Meltzer et al.JACI 2004;114:155Rhino
2、sinusitis 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 weeksAcute vs.Chronic Rhinosinusitis Usually very different conditions.Acute rhinosinusitis usually related to infection.Chronic rhino
3、sinusitis usually related to inflammation.Acute RhinosinusitisQuestionIs 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
4、 not resolved after 10 days or worsen after 5 to 7 days1Gwaltney Clin Infect Dis 1996;23:12092Berg et al.Rhinology 1986;24:223-5Viral Rhinosinusitis Similar to bacterial rhinosinusitis clinically and radiographically CT scan within 48-96 hrs of a self-diagnosed“cold”(n=31)77%with infundibulum occlus
5、ion 79%cleared in 2 weeks without abxGwaltney et al.NEJM 1994;330:25Obstruction of the Sinus Ostium Produces Acute RhinosinusitisKern EB JACI 1984:73:25Coronal View in Relation to Facial StructureKoepke,J.W.,Dolen,W.K.,Spofford,B.,&Selner,J.C.(1998).Rhinolaryngoscopy(2nd ed.).Allergy Respiratory Ins
6、titute of Colorado.Saggital View in Relation to Facial StructureKoepke,J.W.,Dolen,W.K.,Spofford,B.,&Selner,J.C.(1998).Rhinolaryngoscopy(2nd ed.).Allergy Respiratory Institute of Colorado.Anatomic Drainage Pathways in the SinusesSinus AreaFrontalAnterior ethmoid/MaxillaryPosterior ethmoid/sphenoidDra
7、inage pathwayNasofrontal ductOstiomeatal unitSphenoidethmoidal recessPain 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,
8、between eyes,zygoma,templeOther 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 dysfunctionDiagnosis of Acute Bacterial
9、 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 casesMeltzer
10、 et al.JACI 2004;114:155Diagnosis 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 CoughJAC
11、I 2004Radiographic Evidence of Rhinosinusitis Air fluid level Sinus opacification Mucus membrane thickening of 4 to 6 mm or moreAdvantages of CT Scan in Rhinosinusitis Diagnosis More sensitive and specific than plain sinus radiographs Allows assessment of ostiomeatal unit patency(OMU)Useful in intub
12、ated patients Axial cuts provide additional anatomic information Useful in complicated cases with CNS,bony,or orbital extensionProtocol for Limited Sinus CT ScanScout X-rayLandmarks for performing a limited sinus CT scan in the coronal planeUncinate ProcessEthmoid SinusMiddle TurbinateInfundibulumIn
13、ferior TurbinateNasal SeptumMaxillary sinusNasal SeptumNormal Sinus CT Scan through the OMUBlow-up View of the Ostiomeatal Unit AreaObstruction of the OMU with Associated Acute SinusitisResolution of Acute Sinusitis after Treatment with AntibioticsLocal Factors Predisposing to Rhinosinusitis Allergi
14、c 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 intubationSystemic Factors Predisposing to Rhinosinusitis Immune deficiency IgA deficiency Panhy
15、pogammaglobulinemia IgG subclass deficiency HIV Cystic fibrosis Ciliary disorder Wegeners granulomatosis Gastroesophageal refluxComplications of Rhinosinusitis Orbital cellulitis(ethmoid)Meningitis Subdural/epidural empyema(frontal)Brain abscess(frontal)Cavernous sinus thrombosis(sphenoid)Osteomyeli
16、tis(frontal)Asthma exacerbationOminous Signs in Rhinosinusitis Facial swelling/erythema over an involved sinus Visual changes Abnormal extraocular movements Proptosis Periorbital inflammation/edema Intracranial or CNS involvementAntibiotics for Acute Sinusitis Cochrane Database Review(2004)Peds Avai
17、lable 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
18、 the potential for adverse effectsAntibiotics 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 Radio
19、graphic outcomes improved with abx Comparison between classes of abx showed no significant differences The Cochrane Database of Systematic Reviews 2004;1:1-69Acute Bacterial Rhinosinusitis:Which antibiotic to use?No randomized,placebo-controlled trials of antibiotic treatment for ABRS using pre-and
20、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 diseaseAntibiotics for Acute Rhinosinusitis FDA
21、approved antibiotics for acute bacterial rhinosinusitis Amoxicillin,amoxicillin-clavulonate,clarithromycin,cefprozil,cefuroxime axetil,loracarbef,levofloxacin,gatifloxacin,azithromycin,trimethoprim sulfamethoxazole,moxifloxacin,telithromycinSinus and Allergy Health Partnership Otolaryngol Head Neck
22、Surg 2004:130:1Comparison 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 sinusitisPiccirillo et al.JAMA 2001;286:1849Li
23、st of Antibiotics1st Line Amoxicillin TMP-SMX Erythromycin2nd Line Clarithromycin Azithromycin Augmentin Cephalosporins Levofloxaxin Clindamycin metronidazoleResults1st Line Success:90.1%1 case of periorbital cellulitis Cost:$68.982nd Line Success:90.8%1 case of periorbital cellulitis Cost:$135.17 p
24、 12 weeksTwo main subtypes:CRS without nasal polyps CRS with nasal polypsStrongly associated with asthma and aspirin toleranceMeltzer et al.JACI 2004;114:155Mechanisms of CRSChronic Rhinosinusitis:Risk Factors for Extensive Disease 80 patients with CRS Factors Eosinophil 200/uL(OR=19.2,95%CI=5.4-72.
25、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;100:185-91Prevalence 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 testG
26、uman et al.Otolaryngol Head Neck Surg 2004;130:545Correlation of Allergy and Rhinosinusitis Retrospective review of 200 patients with FESS 84%with allergies Predominance of perennial(esp DM)Emanuel et al.Oto H&S.2000;123:687-91Allergic Inflammation and Rhinosinusitis Purpose:ongoing AR enhances infe
27、ction 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.pneumoniaeBlair et al.JACI 2001;108:424-9Allergic Inflammation and Rhinosinusitis Results:Allergic mice had more bacteria recoveredmore inflammat
28、ion(PMN,eos,monos)Allergic Inflammation and RhinosinusitisBlair 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=0.03Type of Allergy Amon
29、g Sinus Surgery PatientsNonePerennial and seasonalPerennialSeasonalEmmanuel et al.Otolaryngol H&N Surg 2000;123:687 and Ramandan et al.Am J Rhinol 1999;13:345Allergy Immunotherapy for CRS Study:114 patients with perennial allergic rhinitis and sinusitis,surveyed using the Sinusitis Outcomes Question
30、naire.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 scoreNathan et al,Ann Allergy Asthma Immunol 2004Allergic Fungal Rhinosinusitis Appears to be a subset of CRsNP Def
31、ined 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 rhino
32、sinusitis 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
33、 unproven concept.Meltzer et al.JACI 2004;114:155Fungi 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).Eosi
34、nophilic 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 aureu
35、s 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 CRSsPSmart,BA,Pediatric Asthma,Allergy and Immunology,2005;18:88-98Diagnosis of CRS Physic
36、al 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 levelMeltzer et al.JACI 2004;114:155Medical Management of Chronic Rhinosinusitis Antibiotics Corticosteroids Decongestants Muco-
37、evacuants Antihistamines Non-pharmacologic treatmentMicrobiology 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 FungiMeltzer et al.JACI 2004;114:155Chronic
38、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
39、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 studiedAdjun
40、ctive 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 secretionsWawrose et al.Laryngoscope 1992;102:1225Adjunctive Therapy Antihistami
41、nes 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 immunityAdjunctive Therapy Leukotriene antagonists Useful in patients with CR
42、S with nasal polypsNasal Irrigation 211 with sinonasal disease Irrigated with 250 mL HS using a Water Pik BID for 3 to 6 weeks Rated nasal symptoms and QOLTamooka et al.Laryngoscope 2000:1189-93Nasal Irrigation Results 23/30 symptoms improved QOL improved 92%compliance 83/109(76%)improved 26(24%)rep
43、orted adverse effects or no benefitNasal Irrigation Improves mucociliary function Decreases mucosal edema Decreasing inflammatory mediators Clearing mucusOutcomes of Medical Management of CRS 200 pediatric and adult patients treated with 4 weeks of oral abx,nasal corticosteroids,lavage and topical d
44、econgestants patients followed 1 to 27 months(mean 6 months)all improved 6%required surgeryMcNally PA,et al.Allergy and Asthma Proc1997;18:169Outcomes of Medical Management Retrospective series of 40 patients treated with abx for 4 to 6 weeks and 10 days of prednisone most patients also used nasal s
45、teroid spray and saline irrigation 36 had improvement in both symptom and CT scoresSubramanian H,Hamilos DL.Am J Rhinol 2002;16:303Surgery for Rhinosinusitis FESS enlarge sinus ostia correct anatomic deformities(septal deviation,concha bullosa)create a common cavity for nasal drainage ventilate sinu
46、ses 85%improvement in selected seriesSummary Acute rhinosinusitis is usually related to infection Antibiotic management is first line Chronic rhinosinusitis is usually related to inflammation Further characterization of the condition is important(nasal polyps)Exploration of underlying allergy is important Management is challenging
