1

Diagnosis 2

Is based upon clinical signs and symptoms Is based upon clinical signs and symptoms

Is Not Indicated in the initial evaluation Is Not Indicated in the initial evaluation  In the absence of signs suggesting complicated disease

5

6

Any patient with one major symptom and two minor symptoms Or Two major symptoms is diagnosed to have rhinosinusitis 7

Distinguishing bacterial from viral infection 8

No clear Data 9

10 Symptom duration and progression

1.Persistent symptoms or signs of ARS lasting 10 or more days without evidence of clinical improvement (Nasal discharge) 11

Symptoms often persistent for more than 10 days with a viral infection Symptoms often persistent for more than 10 days with a viral infection Typically there is some improvement in the clinical course by day 10 Typically there is some improvement in the clinical course by day 10 12

2.Onset of severe symptoms or signs of high fever (>39°C or 102°F) + Purulent nasal discharge Or Facial pain for at least three to four consecutive days at the beginning of illness. Facial pain for at least three to four consecutive days at the beginning of illness.13

Fever associated with a viral infection generally subsides in hours Fever associated with a viral infection generally subsides in 24 to 48 hours Purulent nasal discharge usually occurs after four or five days Purulent nasal discharge usually occurs after four or five days

3.Onset with worsening symptoms or signs (new onset fever, headache, nasal discharge) o following a typical viral upper respiratory infection that lasted five to six days and were initially improving. 15

Persistent symptoms or signs of ARS ≥ 10 days Onset of severe symptoms or signs Worsening symptoms or signs after initial improvement Distinguishing bacterial from viral infection

Physical Examination 17

The usual evaluation for respiratory infection: The usual evaluation for respiratory infection:  Vital signs  Eyes, ears, pharynx, teeth, sinus tenderness, lymph nodes, and chest

Facial pain : more reliable in the diagnosis of rhinosinusitis Pain localized to the sinuses (bending forward) > provoked pain by percussion Pain localized to the sinuses (bending forward) > provoked pain by percussion Wilson JF. In the clinic. Acute sinusitis. Ann Intern Med 2010; 153:ITC31.

20 Handheld Otoscope Nasal Speculum

Diffuse mucosal edema Diffuse mucosal edema Narrowing of the middle meatus Narrowing of the middle meatus Inferior turbinate hypertrophy Inferior turbinate hypertrophy Copious rhinorrhea or purulent discharge Copious rhinorrhea or purulent discharge

Diagnostic Tests 22

Microbiologic culture Viral culture of nasal secretions is: Viral culture of nasal secretions is:  Impractical and unnecessary 23

Bacterial culture Blind swabs of the nasal cavity Blind swabs of the nasal cavity Purulent nasal secretions Purulent nasal secretions  Is not recommended  As results are not reliable 24

Cultures (obtained by endoscopy) are indicated in patients with documented sinusitis: Cultures (obtained by endoscopy) are indicated in patients with documented sinusitis:  who are not responding to empiric antibiotic therapy  A suspicion of intracranial extension of the infection or other serious complications 25 Endoscopic image of purulent drainage from the middle meatus in a patient with acute bacterial rhinosinusitis

Radiologic studies Radiologic studies

Radiography of any modality is not indicated in the initial evaluation of uncomplicated acute rhinosinusitis (ARS) Radiography of any modality is not indicated in the initial evaluation of uncomplicated acute rhinosinusitis (ARS)

Indication the Radiologic studies Complicated ABRS Complicated ABRS

Indication the Radiologic studies Recurrent or treatment- resistant sinusitis Recurrent or treatment- resistant sinusitis

Indication the Radiologic studies Helping delineate anatomic blockage of the ostio-meatal complex Helping delineate anatomic blockage of the ostio-meatal complex

Water’s position for sinus

The high false-negative rate of Water’s position for sinus Poor visualization of the ethmoid sinuses Poor visualization of the ethmoid sinuses

The high false-positive rate of Water’s position for sinus Artifact Artifact  The inability to distinguish polyps and nasal masses from fluid or mucosal edema

Coronal CT scan of sinuses

Coronal CT scan of sinuses revealing sinusitis bilaterally with fluid level in the left maxilla

MRI and CT are considered complementary studies for the evaluation of possible orbital or intracranial complications of ABRS MRI scan of brain Extensive destruction of roof of left ethmoidal sinus with brain contents extending into the nose

Treatment

Supportive care AVRS treatment  Mild analgesics  Saline nasal irrigation and fluid 38

Supportive care AVRS treatment  Intranasal glucocorticoids 39

Decongestants - AVRS treatment Decongestants may be useful when Eustachian tube dysfunction is a factor for patients with AVRS Decongestants may be useful when Eustachian tube dysfunction is a factor for patients with AVRS Are not likely to be helpful for patients with ABRS and have adverse side effects Are not likely to be helpful for patients with ABRS and have adverse side effects40

Antihistamines - AVRS treatment We suggest not treating symptoms with antihistamines (Grade 2C ) We suggest not treating symptoms with antihistamines (Grade 2C )41

ABRS treatment We recommend treatment with an antibiotic for patients whose clinical symptoms meet criteria for ABRS We recommend treatment with an antibiotic for patients whose clinical symptoms meet criteria for ABRS42

ABRS treatment Initial empiric treatment with Amoxicillin-clavulanate rather than Macrolides Initial empiric treatment with Amoxicillin-clavulanate rather than Macrolides43

ABRS treatment Doxycycline is a reasonable alternative for first-line therapy Doxycycline is a reasonable alternative for first-line therapy Can be used in patients with penicillin allergy Can be used in patients with penicillin allergy44

ABRS treatment A respiratory fluoroquinolone: A respiratory fluoroquinolone:  ( Levofloxacin or Moxifloxacin ) is another option for penicillin-allergic patients. 45

Local and regional histograms of bacterial resistance - ABRS treatment To understand resistance trends in the local community To understand resistance trends in the local community46

No indication for surgery in patients with uncomplicated ABRS 47

Surgery may be emergently indicated in patients experiencing Surgery may be emergently indicated in patients experiencing  Extra-sinus complications of ABRS: Orbital abscess Orbital abscess Epidural abscess Epidural abscess Meningitis Meningitis Brain abscess Brain abscess 48

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50 Allergic Rhinitis

51 Rhinitis: Symptomatic disorder of the nose characterized by itching, nasal discharge, sneezing and nasal airway obstruction Allergic rhinitis: Induction of rhinitis symptoms after allergen exposure by an IgE-mediated immune reaction; accompanied by inflammation of the nasal mucosa and nasal airway hyperreactivity.

52 Allergic Rhinitis Co-Morbidities Conjunctivitis Sinusitis Otitis Media Cough Asthma

53 ALLERGIC RHINITIS AND ITS IMPACT ON ASTHMA ARIA JACI 2001:56:

54 Intermittent Symptoms < 4 days / week or < 4 weeks Persistent Symptoms > 4 days / week or > 4 weeks Mild Sleep: normal Daily activities (incl. sports): normal Work-school activities: normal Severe symptoms: no Moderate- severe Sleep: disturbed Daily activities: Restricted Work and school activities: disrupted Severe symptoms: yes Allergic Rhinitis Classification

55 Globally Important Sources of Allergens House dust mites Grass, tree and weed pollen Pets Cockroaches Molds

56 Diagnosis of Allergic Rhinitis Detailed personal and family allergic history Intranasal examination – anterior rhinoscopy Symptoms of other allergic diseases Allergy skin tests and/or In vitro specific IgE tests

57 Allergy Skin Prick Testing Skin prick test / positive result

58 Primary Ab Secondary Ab Enzyme Sample to be measured Substrate Concept of In Vitro IgE Assays

59 MANAGEMENT OF ALLERGIC RHINITIS

60 Environmental Control House dust mites Pets Cockroaches Molds Pollen 1. Allergens 2. Pollutants and Irritants

61 Allergen Avoidance Pets Remove pets from bedrooms and, even better, from the entire home Vacuum carpets, mattresses and upholstery regularly Wash pets regularly (±) Molds Ensure dry indoor conditions Use ammonia to remove mold from bathrooms and other wet spaces Cockroaches Eradicate cockroaches with appropriate gel-type, non-volatile, insecticides Eliminate dampness, cracks in floors, ceilings, cover food; wash surfaces, fabrics to remove allergen Pollen Remain indoors with windows closed at peak pollen times Wear sunglasses Use air-conditioning, where possible Install car pollen filter

62 House dust mite allergen avoidance  Provide adequate ventilation to decrease humidity  Wash bedding regularly at 60°C  Encase pillow, mattress and quilt in allergen impermeable covers  Use vacuum cleaner with HEPA filter  Dispose of feather bedding  Remove carpets  Remove curtains, pets and stuffed toys from bedroom

63 PHARMACOTHERAPY OF ALLERGIC RHINITIS

64 Oral Antihistamines First generation agents Chlorpheniramine Brompheniramine Diphenydramine Promethazine Tripolidine Hydroxyzine Azatadine Newer agents Acrivastine Azelastine Cetirizine Desloratadine Fexofenadine Levocetirizine Loratadine Mizolastine

65 Nasal Antihistamines Azelastine Levocabastine Olopatadine

66 Decongestants: Alpha-2 Adrenergic Agonists Oral Pseudoephedrine Nasal Phenylephrine Oxymetazoline Xylometazoline

67 Anti-Leukotriene Agents * Approved for allergic rhinitis

68 Nasal Corticosteroids Most potent anti-inflammatory agents Effective in treatment of all nasal symptoms including obstruction Superior to anti-histamines and anti-leukotienes First line pharmacotherapy for persistent allergic rhinitis

69 Allergen Immunotherapy (Vaccines) Subcutaneous Sublingual Nasal

70