Acute & Chronic

Sinusitis

Ephraim Eviatar
Assaf Harofeh Medical Center


.
9%
21%-.

Rhinosinusitis
Acute rhinosinusitis
Subacute rhinosinusitis
Chronic rhinosinusitis
Recurrent ARS
Acute rhinosinusitis superimposed on
CRS

Acute rhinosinusitis
Acute sinusitis 7-21 days (7 days viral
illness)
Spontaneous resolution of ARS -40%
The most common pathogens: strep
pneumonia-30%,
non typeabale hemophilus infl.-20%,
moraxella catarrhalis.(20% in children)
Staph aureus- 30%
Anaerobes- rare

Recurrent ARS
Episodes of bacterial infection of the
paranasal sinuses, each lasting less than
30 days and separated by intervals of at
least 10 days during which the patient is
asymptomatic.

Subacute sinusitis
Subacute RS:3W-3months
The same pathogens as in ARS

Chronic rhinosinusitis
Beyond 3 months
Bacteria are as in ARS, but
More non-typeable H Influezae
More staph aureus, anaerobic bacteria,
gram- Negative, pseudomonase
aeruginosa
Polymicrobials with resistant organism
Culture recommended

Acute bacterial sinusitis

superimposed on chronic sinusitis
Patients with residual respiratory
symptoms develop new respiratory
symptoms. When treated with
antimicrobials, these new symptoms
resolve, but the underlying residual
symptoms do not.

Major & Minor signs and symptoms

in diagnosis of Chronic RS
Majors:
Facial pain/pressure
Nasal congestion/fullness
N. obstruction/blockage
N. discharge/purulence
Hyposmia/ anosmia
Purulent rhinitis
Fever (acute sinusitis only)

Minors:
Headache
Fever
Halitosis
Fatigue
Dental pain
Cough
Ear pain/
pressure/fulln

Clinical Diagnosis of rhinosinusitis

2 or more major factors
1 major & 2 minor factors
Or Purulence on examination
Duration of symptoms > 10 days or
worsen after 5-7 days

Kinney WC : otolaryngol Head Neck Surg 2002

Predisposing factors
URI
Allergy
Trauma
Dental infection
Environmental Pollutants
GERD
Cystic Fibrosis

Facial pain on percussion or palpation,

sedimentation rate and white blood count
have little diagnostic value.
Purulent secretions by history
Purulent secretions in the nasal cavity on examination
Lack of response to decongestants and antihistamines
Unilateral maxillary pain
Double-sickening": an upper respiratory infection that initially
improves then worsens

The gold standard for the diagnosis of

acute bacterial sinusitis is the recovery of
4
bacteria in high density (>10 colonyforming units/mL) from the cavity of a
paranasal sinus

Rhinosinusitis definitions for patient care

Type of rhinosinusitis
Acute rhinosousitis
Pattern of symptoms

Symptoms minimum *
10d-28d

CRS without polyposis

Symptoms >12w

severe disease*
worsening disease*
Symptoms for diagnosis

Ant./post purulent
*
discharge
nasal obstruction*
facial pain-pressure*

Objective documentation

Nasal exam:purule
Radiographic
evidence

The following symtoms

ant/post mucupurulent*
nasal obstruction*
-facial pain*

Nasal exam to exclude

polyps
CT sinus not essential

Rhinosinusitis definitions for patient care

Type of rhinosinusitis

CRS with polyposis

Symptoms for diagnosis

Objective documentation

AFRS

of the symptoms 2>

:of the symptoms 1>

ant/pos mucupurulent d*

ant/pos rhinitis*

nasal obstruction*

nasal obstruction*

decrease sense of smell*

facial pain/pressure*

Nasal exam.to confirm

.bilat polyps
CT is not essential

Nasal exam. Allergic

mucin, inflammation &
polyps
fungal specific IgE*
No invasion
CT is not essential
Fungal culture , total IgE

Dose the patient have 2 or more

...?major factors
Yes:
Amoxicillin
Or Bactrim

No:
Treat symptomatically
Saline irrigation
Oral decongestant
Antihistamine (allergy)
Reevaluate in 10 days

Kinney WC : otolaryngol Head Neck Surg 2002

type

organism

drugs

comments

acute

Strep pneumoniae
h. Influenzae
m. catarrhalis

Amoxicillin 10
days

2nd generation
cephalosporin,
Macrolide, for
penicillin allergy

subacute

Increased resistant of
bacteria

2nd line drugs

chronic

Polimicrobial,
psudomonase a,
anaerobes, more
resistant

Augmentin,
2nd cephalo.
macrolide,
clinda,3-4w

Recurrent
chronic

Resistant ,
polimicrobial

consider 3-4w Culture guided

profilaxis

Suppurative
complications

G(-). Staph
aureus

Surgery if no
Cefuroxime,
responce
aminoglicozid
e

Culture
whenever
possible

Severe sinusitis with suspected orbital or

intracranial complications cefuroxime or
ceftriaxone
The best in crs treat according to culture
For crs treat 3 weeks, while improvement
within 3-5 days
3-6 weeks prophylaxis once daily therapy
for patients with rapid recurrence??

Antimicrobial treatment guidelines

1. mild symptoms, not received antibiotics
within 4-6w.
2. mild disease, who received antibiotics
within 4-6w,
or with moderate disease regardless of
recent antibiotic exposure,

 :



, .

According to the guidelines



- levofloxacin fluoroquinolones : 90-92%
.moxifloxacin
ceftriaxone ,augmentin
cefixime high dose amoxicillin, :83-88%
cefpodoxime proxile, cefuroxime axetil, cefdinir
TMP/SMX
,docxycyline, clindamycin:77-81%
azitromycin, clarithromycin, erythromycin
cefaclor,loracarbef :65-66%
According to the guidelines


91-92% : ceftriaxone, augmentin
82-87%: amoxicillin, cefpodoxime proxetil,
cefixime, cefuroxime axetil,cefdinir,TMP/SMX
78-80%: clindamycin, cefprozil, azithromycin,
clarithromycin, erythromycin
67-68% : cefaclor

According to the guidelines



Augmentin, amoxicillin, cefpodoxime proxetil,
cefuroxime axetil, or cefdinir
For b-lactam allergies patients: TMP/SMX,
doxycilline, azithromycin,
clarithromycin,erythromycin
Failure after 72h: reevaluation or switch to
alternate antimicrobial therapy
According to the guidelines



Respiratory flouroquinolones, augmentin
(4g/day),ceftriaxone (1-2 g/day 5 days),
combination of g+ and gFailure after 72h: switch to alternate
antimicrobial therapy, or reevaluation
CT scan, endoscopy, sinus aspiration and
culture
According to the guidelines



Augmentin (90mg/k/day), amocixillin (90
mg/k/day), cefpodoxime proxetil,
cefuroxime axetil, or cefdinir
Type I hypersensitivity to b-lactams
patients: TMP/SMX, azithromycin,
clarithromycin or erythromycin.
Make differentiate an immediate
hypersensitivity from other side effects
Failure after 72 h
According to the guidelines


) (
Augmentin(90mg/k/day), cefpodoxime
proxetil, cefuroxime axetil or cefdinir.
Beta lactams allergic patients: TMP/SMX,
azithromycin, clarithromycin, erythromycin
Clindamycin for s pneumoniae
Ceftriaxone (5 days, parenteral), or
combination therapy for G+ and GClindamycin or amocixillin and cefixime
Clindamycin or amoxicillin and rifampin
According to the guidelines

New insights into the role of

bacteria in CRS
Bacterial superantigens-exotoxins that are
able to activate T lymphocytes
Pathogenesis of nasal polyposissuperantigens from S aureus

Biofilms-a artificial or damaged biologic

surface that formed communicating
organization of microorganisms
surrounded by a glycocalys
Biofilms is relatively impervious to
antibiotics and is never eradicated
Mechanical debridement- the only way to
resolve biofilms

Osteitis: the role of the bone

Osteomyelitis can be seen at a distance
from the primary infection
Inflammatory bone changes were noted
on contralateral side in 52% of the animals
Khalid et al. laryngoscope 2002

The changes in the involved bone can

explain why CRS is relatively resistant to
medical therapy.

Failed CRS
To sinus surgery or systemic steroid/antibiotics
Macrolid therapy (long term, low dose) effective

Cervin A et al: Otolaryngol Head Neck Surg 2002

CRS
78 had criteria to CRS
endoscopy: positive 17
37- CT findings: positive
endoscopy : positive 6
41- CT findings: negative
35: endoscopy negative & CT negative
20: endoscopy negative & CT positive
55: endoscopy negative

Stankiewicz & Chow: Otolaryngol Head Neck Surg 2002

Radiology & clinical exam

Correlated with a Sensitivity of 75%
And specificity of 84%
Endoscopy correlated poorly with sinus
disease and not predictive

Stankiewicz & Chow: Otolaryngol Head Neck Surg 2002

Endoscopy/ct findings/clinical
Easy to diagnose CRS by endoscopy
alone when nasal polyps, purulence, or
fungus is observed,
when absent, establishing the diagnosis
may be more difficult
45% of patients with clinical CRS were
both endoscopically and radiographically
negative.
Stankiewicz and Chow. Otolaryngol head neck surg 2002

Endoscopy/ct findings/clinical
Negative endoscopy alone is insufficient to
rule out sinusitis.
26% of patients who were negative on
endoscopy had positive CT this would
suggest that if endoscopy is negative
most of the time the ct will be also
negative, even with a positive history.
Stankiewicz & Chow: Otolaryngol Head Neck Surg 2002


( URI )
10

10 VIRAL URI
. 5-7
The diagnosis of acute bacterial sinusitis
is based on clinical criteria in children who
present with upper respiratory symptoms
that are either persistent or severe
Guidelines of American Academy of Pediatrics


Persistent symptoms are those that last
longer than 10 to 14, but less than 30,
days. Such symptoms include nasal or
postnasal discharge (of any quality),
daytime cough (which may be worse at
night), or both.

Guidelines of American Academy of Pediatrics


Severe symptoms include a temperature
of at least 102F (39oC) and purulent
nasal discharge present concurrently for at
least 3 to 4 consecutive days in a child
who seems ill. The child who seems toxic
should be hospitalized and is not
considered in this algorithm.
Guidelines of American Academy of Pediatrics

children

, ,
,
.

ARS in children
Diagnosis in children based on clinical
criteria
Radiology is only for complications,
persistent or recurrent sinusitis
For prevention there is no prophylactic
antimicrobial treatment, ancillary
therapies, complementary/alternative
medicine
Guidelines of American Academy of Pediatrics

Surgical management of crs in

children
5-8 events of colds/year
5%-13% will complicate by acute RS
Most of children with RS respond to
medical treatment
Today surgery consist of sinus lavage,
ESS, adenoidectomy

Goal of surgery
Surgery is for control of symptoms, better
quality of life and to prevent complications
Indications to surgery are not uniform
between OL and P
cure-the goal for surgery, but is not the
likely end point
Reversible mucosal disease may be
possible in the long run, but is unlikely to
be realized in the short term

Maximal medical management

Reflux
Macrolids
Antileukotriens
Irrigations-nasal sprays
Alternative medical approaches

Surgical management children

Biomaterials
Subperiosteal abscess

The surgical site in children

There is strong evidence to support the
fact that the OMC area is the primary site
of involvement of inflammatory sinuses
disease.

Surgical management in children

Role of adenoidectomy:
1. reservoir for pathogenic bacteria
2. interfere with nasal mucociliary
clearance
3.better drainage
Overall success of adenoidectomy-50%
Studies show reduction in the number of
bacterial pathogens in the nasopharynx
after adenoidectomy

?Fear of surgery
Surgery may cause growth retardation of
the midface
Bothwell et al. showed no difference in
facial growth of children with CRS who
operated compare with children who
refused surgery.

Surgery
Children who fail medical therapy benefit
from surgery
Adenoidectomy recommended initially for
children 6 years of age (no asthma, low
CT score)
ESS and adenoidectomy for children older
than 6 (asthma and high CT score)
Ramadan. Laryngoscope.2004

Results of surgery children

Older children do better than youngest
Old children (>6 y/o)- successes rate is
89% , but younger children (<6 y/o)successes rate is only 73%
>3 y/o who were operated have 75%
chance to be reoperate

Antibiotic therapy
Amoxicillin -1st choice
In children give high dose 60mg/kg/day
To consider 2nd generation cephalosporin, or
erythromycin with sulfonamide ,or high dose
penicillin in areas with a high incidence of
bacterial antibiotic resistance.
Based on studies showing a 20% incidence of
viable bacteria through maxillary sinus tap after
7 days of antibiotic therapy, most authors
recommend 10 days of therapy in the manage
of acute sinusitis