Rhinosinusitis Jihan AL Maddah

Definition Inflammation of the mucous membrane of nose and sinuses. One of the most common conditions presenting to clinicians worldwide, and can potentially have enormous and a devastating socioeconomic impact.

Classification Rhinosinusitis can be categorized based on: Duration of infection, and then further. Subdivided by the cause.

Duration of symptoms Acute sinusitis : symptoms <4 weeks. Sub-acute sinusitis: 4-12 weeks. Chronic sinusitis: >12 weeks. Recurrent sinusitis: > 4 episodes/year.

Etiology Infective: Viral (majority). Bacterial (minority). Rhinovirus, Para-influenza, RSV, Adenovirus Bacterial (minority). Non-specific Specific (syphilis, TB) Fungal (minority). Non-infective: Allergic (Common) (ARIA) Mild, Moderate, Severe Persistent, Intermittent

Etiology Non- allergic Non-infective Non-allergic eosinophilic rhinitis Occupational Hormonal Drug induced Gustatory Vasomotor

Symptoms Three cardinal symptoms: Purulent nasal discharge (purulent-cloudy) Nasal obstruction (congestion, blockage, or stuffiness) Facial pain-pressure-fullness (involves the anterior face and peri-orbital region or manifests with headache that can be localized or diffuse).

Allergic Rhinitis and its Impact on Asthma (ARIA) 30% of patients with AR have asthma The majority of patients with asthma have AR AR is a major risk factor for poor asthma control All patients with AR should be assessed for asthma

Allergic Rhinitis and its Impact on Asthma (ARIA) Comorbidities: Up to 80% of patients with bilateral chronic sinusitis have AR Otitis media Conjunctivitis Lower respiratory tract infections Dental problems – malocclusion, discoloration Sleep disorders

ALLERGIC RHINITIS (ARIA) Moderate-severe one or more items Abnormal sleep. Impairment of daily activities, sport, leisure. Problems caused at school or work. Troublesome symptoms. Intermittent symptoms < 4 days per week Or < 4 weeks Mild Normal sleep. Normal daily activities. Normal work and school. No troublesome symptoms. Persistent symptoms > 4 days per week and > 4 weeks

Allergic Rhinitis - Causes Seasonal (Intermittent) Pollen from Grasses Weeds Trees Perennial (Persistent) House dust mites Mold and fungus spores Cockroaches Animal dander Food Chemicals

Allergic Rhinitis Predisposing Factors +ve family history Personal history of atopic disease e.g eczema, urticaria and asthma

Allergic Rhinitis - Symptoms Sensitive to specific allergens ( dust mites, pollens) Pruritus of the nose, eyes, palate, ears Sneezing > 2 at a time Watery rhinorrhoea Coexistant asthma or eczema Seasonal symptoms Family history of allergies

Diagnosis History – Present illness, past medical history, family history, environmental history and impact on quality of life. Physical Examination – Nose, Eyes, Ears, Lungs and Skin Nasal exam with endoscope – edematous Inferior turbinate, polyps

Investigations Blood test : IgE ( total & specific), eosinophilia Nasal biopsy for differential dx Skin test ( In vivo) RAST (radio-allergosorbent test) ( In vitro)

Treatment Avoidance of allergen Normal Saline douching Local and/or antihistamine Local and/or steroids Sublingual / Subcutaneous Immunotherapy (Desensitization)

Treatment-Surgical Surgical - for nasal obstruction only Septoplasty Turbinate reduction Functional endoscopic sinus surgery (FESS)

Vasomotor Rhinitis Autonomic disturbance – excessive parasympathetic activity No specific cause found Symptoms : rhinorrhoea, sneezing, nasal obstruction Treatment: Local nasal steroids, anticholinergic medication

Rhinitis Rhinitis Medicamentosa Avoid prolong use of vasoconstrictor nose drop Treatment: stop vasoconstrictors, local/systemic steroids

Sinusitis Sinusitis is characterized by inflammation of the lining of the paranasal sinuses. Because the nasal mucosa is simultaneously involved and because sinusitis rarely occurs without concurrent rhinitis, rhinosinusitis is now the preferred term for this condition. Rhinosinusitis affects an estimated 35 million people per year in the United States and accounts for close to 16 million office visits per year

The vast majority of rhinosinusitis episodes are caused by viral infection. Most viral upper respiratory tract infections are caused by rhinovirus, but coronavirus, influenza A and B, parainfluenza, respiratory syncytial virus, adenovirus, and enterovirus are also causative agents. Rhinovirus, influenza, and parainfluenza viruses are the primary pathogens in 3-15% of patients with acute sinusitis. In about 0.5-2% of cases, viral sinusitis can progress to acute bacterial sinusitis.

Rarely, sinusitis is caused by fungi. Fungal sinusitis (eg, allergic fungal sinusitis) may appear similar to lower airway disorder and allergic bronchopulmonary aspergillosis. Fungal agents associated with this condition include: Aspergillus and Alternaria species (60%). Bipolaris and Curvularia (20%).

Sinusitis Acute sinusitis Viral Bacterial Dental origin – 10% Fungal Chronic sinusitis Anatomical Allergy Polyps Immune deficiency

75% bacterial isolates, most commonly in adults: 35% coagulase-negative staphylococci (CNS) 23% Corynebacterium species 8% Staph aureus Low numbers of these species were present. In children, the most common organisms: 40% H influenzae 34% M catarrhalis 50% S pneumoniae

Pathophysiology The pathophysiology of rhinosinusitis is related to 3 factors: 1. Obstruction of sinus drainage pathways (sinus ostia) (trauma, rhinitis) 2. Ciliary impairment (Primary ciliary dyskinesia) 3. Altered mucus quantity and quality ( Cystic fibrosis).

Acute sinusitis - Symptoms Proceeding URTI or Dental infection Pain - depends on the involving sinus throbbing aggravated by coughing Nasal obstruction Purulent rhinorrhoea

Acute Sinusitis - Signs Fever Local tenderness Mucous in nose or nasopharynx Dental origin X-ray with opacity or fluid level

Acute Sinusitis Streptococcus pneumoniae Haemophilus Influenza Staphylococcus Anaerobes

Acute sinusitis is a clinical diagnosis Acute sinusitis is a clinical diagnosis. However, the evaluation might include the following laboratory tests : Nasal cytology (allergy) Nasal-sinus biopsy (mass, polyp, tumor) Tests for immunodeficiency (recurrent sinusitis associated with other infections) Sweat chloride test and electron microscopy in cystic fibrosis, or ciliary dysfunction

Treatment of acute sinusitis consists of providing adequate drainage of the involved sinus and appropriate systemic treatment of the likely bacterial pathogens. Drainage can be achieved surgically with sinus puncture and irrigation techniques. Options for medical drainage are as follows: Oral alpha-adrenergic vasoconstrictors 10-14 days Topical vasoconstrictors for a maximum of 3-5 days Antibiotic treatment is usually given for 14 days. Usual first-line therapy is Amoxicillin, Clarithromycin Azithromycin

Acute Sinusitis - Treatment Antibiotics x 2 weeks Amoxycillin Augmentin Cefuroxime + metronidazole Vasoconstrictor nose drops – aid drainage Antral washout – for resistance case both diagnostic and therapeutic Functional endoscopic sinus surgery

Chronic Sinusitis - Symptoms Usually less - no pain Nasal obstruction Nasal/Post nasal purulnt discharge Cacosmia

Chronic Sinusitis - Signs Mucopus in the meati Nasal mucosa congested X-ray show fluid level or opacity

Chronic Sinusitis - Treatment Medical Antibiotic Nasal Decongestant Topical steroid

Chronic Sinusitis - Treatment Surgical Open-depends on the site Caldwell-Luc Operation Osteoplastic flap Endoscopic-FESS

FESS Functional Endoscopic Sinus Surgery Messerklinger 1960s resume the normal function of sinus drainage ventilation Messerklinger 1960s sinus mucus drain in a genetically determined path to the natural ostium

Post FESS

Complications of Sinusitis Local Mucocele Osteomyelitis-Pott’s tumor Orbital Orbital cellulitis Orbital abscess Cavernous sinus thrombosis Intracranial Epidural abscess Subdural abscess Intracerebral abscess