Medical knowledge | Otorhinolaryngology, ear, nose, throat » Pathogenesis and Clinical Aspects of Rhinosinusitis

Source: http://www.doksinet Pathogenesis and Clinical Aspects of Rhinosinusitis Source: http://www.doksinet Background: Incidence and Significance • URTI: most common acute illness evaluated in the outpatient setting • Self-limited, catarrhal disease • Colds: 2-5/year in adults, 7-10/year in children Cold URTI: Upper Respiratory Tract Infection Source: http://www.doksinet Background: Incidence and Significance • • • • Bacterial infection: 0.5-2% of viral URTI Acute Bacterial Rhinosinusitis in children: 10% of cold cases CRS: 15-16%. Partly speculative: incoherent symptoms, uncertain definition Sinusitis is the fifth most common diagnosis for which an antibiotic is prescribed (National Ambulatory Medical Care Survey) CRS: Chronic Rhinosinusitis URTI: Upper Resp. Tract Infection Source: http://www.doksinet Pathological Definition • Inflammatory disease, inflammation and thickening of the paranasal sinus linings with production of secretion in the cavities

• Terminology: rhinosinusitis Source: http://www.doksinet Epidemiological Definition • Based on characteristic history and symptoms, without clinical examination Eur Position Paper on RS and NP (EP3OS), Rhinology 2007; Suppl20; Clinical Practice Guideline. Otolaryngol HNS 2007; 137:Suppl3 Source: http://www.doksinet Epidemiological Definition Acute viral (non-bacterial) rhinosinusitis (AVRS) – Paranasal mucosa inflammation due to simple viral URT infection. Moderate symptoms not longer than 7-10 days Acute bacterial (non-viral) rhinosinusitis (ABRS) – Symptoms more severe after 5-7 days and/or do not resolve within 10 days. Complete recovery within 12 weeks Acute recurrent (intermittent) rhinosinusitis (ARRS) – 2-4 acute episodes in a year, no symptoms between the episodes Chronic rhinosinusitis: persistent symptoms > 12 weeks Eur Position Paper on RS and NP (EP3OS), Rhinology 2007; Suppl20; Clinical Practice Guideline. Otolaryngol HNS 2007; 137:Suppl3

Acute Severeness of symptoms Source: http://www.doksinet 7th day 12 4th week time Acute recurrent 1 year time Chronic time 7th day 12th week Source: http://www.doksinet Clinical Definition ƒ Based on symptoms and otolaryngological exam ƒ Symptoms (at least two) à Nasal obstruction and/or nasal discharge (anterior/posterior) à Facial pain, -tenderness à Smelling disorder • and ƒ Endoscopic findings ‚ Middle meatal polyp and/or mucopurulent discharge ‚ Middle meatal edema and/or obstruction • and/or ƒ Relevant CT-pathology Eur Position Paper on RS and NP (EP3OS), Rhinology 2007; Suppl20; Clinical Practice Guideline. Otolaryngol HNS 2007; 137:Suppl3 Source: http://www.doksinet Symptoms Major Tenderness/facial pain Facial fullness Nasal obstruction Nasal discharge Smelling disorders Fever Minor Headache Fever Foetor ex ore Fatigue/tiredness Pain in the teeth Coughing Otalgia, pain or tenderness of the ears Source: http://www.doksinet Acute Viral

Rhinosinusitis • Viral URTI/Cold • Sudden onset of mild/moderate symptoms < 7-10 days • No antibiotics • Symptomatic treatment Source: http://www.doksinet Major symptoms in Acute Bacterial Rhinosinusitis (ABRS) • Thick, mucopurulent anterior/posterior nasal discharge • Nasal obstruction • Facial pain/tenderness, tension – unilateral • Smelling disorder • Fever, headache • Coughing, sino-bronchial syndrome (children) Source: http://www.doksinet ABRS Antral sinus Right middle meatus Source: http://www.doksinet Frequency of isolated sinusitis 1. 2. 3. 4. 5. Sinusitis maxillaris Sinusitis ethmoidalis Sinusitis frontalis Sinusitis sphenoidalis Pansinusitis 4 3 2 . Source: http://www.doksinet Etiology of ABRS à Streptococcus pneumoniae 20-41 % à Haemophilus influenzae 6-50 % à Moraxella catarrhalis 2-15 % à Streptococcus pyogenes 1-8 % à Staphylococcus aureus 1-8 % à Gram-negative bacteria 0-24 % à Anaerobs (Fusobacterium,

Peptostreptococcus, Bacteroides) 0-10 % Regional differences Source: http://www.doksinet Diagnosis of ABRS • • • • History, special signs and symptoms Laboratory tests – routine blood test, CRP, AST Otolaryngological examination Endoscopy – mucosa, discharge, edema • Bacteriological culture – sinus wash • X-ray, sinuscopy, sonography, nasal cytology Not routine Source: http://www.doksinet Endoscopy is relevant in the diagnostic procedure Localization of discharge, mucosal inflammation and edema Source: http://www.doksinet Imaging (X-Ray, Ultrasound) • Misleading and contradictory – Not specific and sensitive enough – Numerous false positive and negative cases – Depends on image quality – Moderate ability to diagnose rhinosinusitis • Not indicated as a routine • Indications: severe and recurrent cases, prior to sinus wash-out, frontal or sphenoid involvement Source: http://www.doksinet Maxillary Sinus Tap seems to be the most accurate

tool to diagnose ABRS • Clinically ABRS-patients: 49-83% was proved by sinus taps; < 50% with positive x-rays • Endoscopically guided middle meatal culture: accuracy of 87% compared to antral wash-out • Clinical signs, significant x-ray pathology, positive culture: most reliable Source: http://www.doksinet Treatment of ABRS Source: http://www.doksinet Evidence Based Therapy of ABRS • Antibiotics (10-14 days), if the symptoms undoubtedly presume bacterial infection (Ia-A): empirical and/or targeted • Nasal steroid – NS (Ib-A) • antibiotics with additional NS treatment decrease significantly faster and better the mucosal-swelling associated symptoms (nasal obstruction, facial pain, headache), than antibiotics alone • Vasoconstrictors (IV-D) • Oral II. generation antihistamines (AR, IIb-B) • Removal of secretion • mechanical (blowing, suction) • medical – mucolytics (acetylcystein, ambroxol) – D-level – mucoregulants (carbocystein) • local

warming (IV-D) • nasal douche (Ib) I-IV: evidence based recommendations Source: http://www.doksinet Goal of the Antibiotic Therapy • Mild/moderate cases: self-limited diseases in many instances • Eradication of the pathogens • Shortening the duration of the disease • Prevention of complications, recovery is faster and more complete (evidence: Ia, A) Source: http://www.doksinet Antibiotic Treatment of Airway Pathogens Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Atypical bacteria Legionella pneum. Chlamydia pneum. Mycoplasma pneum. Amoxicillin Source: http://www.doksinet Antibiotic Treatment of Airway Pathogens Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Atypical bacteria Legionella pneum. Chlamydia pneum. Mycoplasma pneum. Amox+clav.acid Source: http://www.doksinet Antibiotic Treatment of Airway Pathogens Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Atypical bacteria Legionella

pneum. Chlamydia pneum. Mycoplasma pneum. Macrolids Source: http://www.doksinet Antibiotic Treatment of Airway Pathogens Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Atypical bacteria Legionella pneum. Chlamydia pneum. Mycoplasma pneum. Airway kinolons Source: http://www.doksinet Acute bacterial rhinosinusitis – antibiotic therapy (10-14 days) Patient group First choice Second choice Penicillin-allergy Non complicated, community acquired, Immune competent Amoxicillin Amoxicillin+ clav.acid Cefuroxim, Cefprozil Levo-, moxifloxacin Cefuroxim, Cefprozil Levo-, moxifloxacin Severe Persistent moderate Antibioticpretreatment Recurrent Amoxicillin+ clav.acid Cefuroxim, Cefprozil Levo-, moxifloxacin Ab. not yet prescribed for long time (14-21 days) Cefotaxim, Ceftriaxon Levo-, moxifloxacin Cefuroxim, Cefprozil Pediatric-moderate Pediatric community Amoxicillin+ clav.acid 80-100 mg/bw Cefuroxim, Cefprozil Cefdinir Cefuroxim, Cefprozil Cefdinir

Azithro-, Clarithromycin Clindamycin Dental origin Amoxicillin+ clav.acid Clindamycin Moxifloxacin Moxifloxacin Cefuroxim, Cefprozil Moxifloxacin Source: http://www.doksinet Evidence Based Therapy of ABRS • Antibiotics (10-14 days), if the symptoms undoubtedly presume bacterial infection (Ia-A): empirical and/or targeted • Nasal steroid – NS (Ib-A) • antibiotics with additional NS treatment decrease significantly faster and better the mucosal-swelling associated symptoms (nasal obstruction, facial pain, headache), than antibiotics alone • Vasoconstrictors (IV-D) • Oral II. generation antihistamines (AR, IIb-B) • Removal of secretion • mechanical (blowing, suction) • medical – mucolytics (acetylcystein, ambroxol) – D-level – mucoregulants (carbocystein) • local warming (IV-D) • nasal douche (Ib) I-IV: evidence based recommendations Source: http://www.doksinet Wash-out of the Maxillary Sinus • Puncture is not indicated on a daily basis –

Invasive, unnecessary • Indications • Severe case with infundibular obstruction • Insufficient drainage • Dental origin Source: http://www.doksinet Chronic Rhinosinusitis without Nasal Polyposis CRSNP- Chronic Rhinosinusitis with Nasal Polyposis CRSNP+ 29 Source: http://www.doksinet CRSNP- and CRSNP+ seem to be different airway diseases with distinct inflammatory markers, cells and cytokines Subgroup CRSNP CRSNP+ 20% 30 Source: http://www.doksinet Definition (Nasal Polyposis) • Benign edematic mucosal protrusion from the nasal meatus to the common nasal passages Source: http://www.doksinet Prevalence of Nasal Polyposis Rinia et al., EP3OS 2007 Source: http://www.doksinet CRSNP±: multifactorial disease ƒ ƒ ƒ ƒ Genetic predisposition Allergyatopy Asthma Mucociliary transport disturbances à cystic fibrosis, ciliary dyskinesis à Kartagener’s, Young’s syndrome ƒ ASA(Samter)-triad: aspirin (NSAID)-intolerance ƒ Triggering pathogens: bacteria,

moulds ƒ Anatomical variations ƒ Not all CRS cases are related to ostio-meatal obstruction ƒ Not all CRS cases are related to chronic bacterial infection ƒ Alterations of immune-associated genes and environmental factors Rhinosinusitis: Establishing Definitions for Clinical Research and Patient CareOtolaryngol HNS 2004; 131(Suppl)6 33 Source: http://www.doksinet Role of Allergy ƒ Prevalence of AR is incresed in CRSNP ƒ Direct relationship between AR and CRSNP is not proved ƒ Clinically manifest airway allergy should be treated in CRSNP 34 Source: http://www.doksinet Role of Infection and Microorganisms Bacteria Fungi ƒ Aerob, anaerob, mixed and intracellular colonization is frequent ƒ Staphylococcus aureus enterotoxins react as superantigens ƒ None of them was etiologically related to CRSNP ƒ Targeted antibiotic therapy has no clinical efficacy ƒ Antral cavity of healthy and CRSNP patients are colonized with fungi (96100%) ƒ Abnormal immune reactions to fungi ƒ

Presence of fungi has not been associated with etiologic significance ƒ Antifungal agents have no therapeutic value so far 35 Source: http://www.doksinet Tissue Eosinophilia Eosinophil cells IL-5, IL-3, GM-CSF T-lymphocytes CRSNP- 2% tissue eosinophilia (mean) CRSNP+ 50-80% tissue eosinophilia (mean) Tissue eosinophilia: marker of severity of inflammation; Correlates with IgE, ECP, IL-5 concentration in the tissue; Prognostic factor (recurrence, remission, efficacy of steroids) independent from atopy and allergy. GM-CSF: granulocyta/macrophag kolónia-stimuláló faktor, CysLT: cysteinyl-leukotrién 36 Source: http://www.doksinet Tissue Eosinophilia Allergic mucin Mucosal edema with a number of eosinophil cells 37 Source: http://www.doksinet Diagnosis • • • • History ENT examination Nasal endoscopy - obligatory CT (MRI) – obligatory (optimal timing) • Screening of risk factors • Histology • Bacteriological culture CRSNP – CT, MRI Source:

http://www.doksinet 39 Source: http://www.doksinet Treatment guidelines in CRSNP- Eur Position Paper on RS and NP (EP3OS), 2007 40 Source: http://www.doksinet Treatment guidelines in CRSNP+ Eur Position Paper on RS and NP (EP3OS), 2007 41 Source: http://www.doksinet Surgery •Indicated primarily if conservative treatment failed •Endoscopic Sinus Surgery (ESS) improves symptoms in 80-90% of the cases and is more effective, than • classical endonasal operations • radical paranasal sinus interventions •Surgery has beneficial effect on symptoms and functions of the lower airways Hungarian Otolaryngological and Infectological Collegium Source: http://www.doksinet Differential Diagnosis Persistent allergic and non-allergic rhinitis Adenoidal inflammation/hypertrophy Tumors Granulomas Foreign bodies Specific infections Source: http://www.doksinet Complications Intraorbital • Orbital Cellulitis • Orbital Phlegmone • Neuritis retrobulbaris • Orbital

Abscess • Protrusion • Dislocation of the bulb • Chemosis • Double vision Intracranial • Frontal Osteomyelitis • Epi-, subdural Abscess • Brain Abscess • Meningitis • Cavernous Sinus Thrombosis