sinusitis

Scope of Sinusitis Affects 30-35 million persons/year 25 million office visits/year Direct annual cost $2.4 billion and increasing Added surgical costs: $1 billion Third most common diagnosis for which antibiotics are prescribed Third most common diagnosis for which antibiotics are prescribed. Rhinosinusitis, like asthma is becoming more prevalent. McCraig LF, Hughes JM: Trends in antimicrobial drug prescribing among office based physicians in the US. JAMA 1995, 273:214-219

Development of Sinuses Maxillary and ethmoid sinuses present at birth Frontal sinus developed by age 5 or 6 Sphenoid sinus last to develop, 8-10 The ostia of the maxillary sinuses is situated up 2/3 of the wall of the sinus. Drainage occurs by the washing of mucus containing virus, bacteria and other material by ciliary action. Any thing that interferes with ciliary action (tobacco smoke, antihistamines) may predispose the sinus to infection. Healthy sinuses depend on ciliary action and aeration. Kaplan, second edition. Allergy. Chapter 26:448-457

Normal Sinus Sinus health depends on: Mucous secretion of normal viscosity, volume, and composition, normal mucociliary flow to prevent mucous stasis and subsequent infection; and open sinus ostia to allow adequate drainage and aeration.

Physiologic Importance of Sinuses Provide mucus to upper airways Lubrication Vehicle for trapping viruses, bacteria, foreign material for removal Give characteristics to voice Lessen skull weight Involved with olfaction Physiologic reasons for sinuses not totally understood. The above are suggestions as to their role. Kaplan, second edition. Allergy. Chapter 26:448-457

ANATOMY Septum Nasal Turbinates Concha Bullosa – Middle Turbinate Sinuses: Maxillary, Ethmoid (anterior and posterior), Frontal and Sphenoid Osteomeatal Complex Nasofrontal recess Uncinate process (hiatus semilunaris) Find out relevant background and audience interest

ANATOMY (continued) Ciliated pseudostratified columnar epithelium Two layers of mucus Thick “basement” layer Thin less viscous layer that the cilia moves to the ostia Mucosal Changes After Surgery and Long Term Disease Neuroreceptors for smell (olfactory nerve) and airflow (located in the inferior and middle turbinates

Professor Sameer Ali Bafaqeeh 11/16/2018 Professor Sameer Ali Bafaqeeh

Acute Rhinosinusitis (Viral) Common Symptoms: Nasal discharge, nasal congestion, facial pressure, cough, fever, muscle aches, joint pains, sore throat with hoarseness. Etiology,rhinovirus,influenza,parainflu,adenovirus,enterovirus,RSV,….. Symptoms resolve in 10-14 days Common in fall, winter and spring. Treatment: Symptomatic

Acute Bacterial Sinusitis Causative agents are usually the normal inhabitants of the respiratory tract. Common agents: Streptococcus pneumoniae Nontypeable Haemophilus Influenzae Moraxella Catarrhalis

SIGNS AND SYMPTOMS Pain and/or pressure Fever frontal, maxillary, upper teeth, retro-orbital, crown of the head temporal, parietal and occipital headaches are not generally associated with sinusitis children under the age of 12 who complain of headaches and, without prompting from a parent, points to the top of their head, anterior face, eye, or posterior skull most likely have sphenoid sinusitis until otherwise documented by CT or MRI scan Fever

SIGNS AND SYMPTOMS Nasal congestion and/or drainage Obstruction Rhinorrhea postnasal drainage purulent color does not determine infection Obstruction Deviated septum Hypertrophy of turbinate(s) Polyps

ACUTE SINUSITIS Less than one month duration Purulent drainage, fever, significant sinus pain and pressure Isolated acute infection without recurrent “sinus symptoms” Most commonly secondary to upper respiratory viral infection or other inflammatory condition perennial allergic rhinitis with inflammation obstruction of the ostia/drainage passages of the sinuses primarily neutrophilic inflammation with a small amount of eosinophils

Diagnosis Based on clinical signs and symptoms Physical Exam: Palpate over the sinuses, look for structural abnormalities like DNS. X-ray sinuses: not usually needed but may show cloudiness and air fluid levels Limited coronal CT are more sensitive to inflammatory changes and bone destruction

Ethmoid Sinusitis

Coronal computed tomographic scan showing ethmoidal polyps Coronal computed tomographic scan showing ethmoidal polyps. Ethmoid opacity is total as a result of nasal polyps, with a secondary fluid level in the left maxillary antrum.

Treatment About 2/3rd of patients will improve without treatment in 2 weeks. Antibiotics: Reserved for patients who have symptoms for more than 10 days or who experience worsening symptoms. OTC decongestant nasal sprays should be discouraged for use more than 5 days Supportive therapy: Humidification, analgesics, antihistaminics If the patient does not respond to antimicrobial therapy after 72 hours, he or she should be reevaluated and a change in antibiotics should be considered. Diagnostic evaluations such as computed tomography, fiberoptic endoscopy, or sinus aspiration also may be necessary for patients who experience a treatment failure.

Antibiotics a) Amoxicillin (500mg TID) OR b) TMP/SMX ( one DS for 10 days). c) Alternative antibiotics: High dose amoxi/clavunate, Flouroquinolones, macrolides,cefixime,cefuroxime,..

CHRONIC SINUSITIS Greater than three months duration multiple treatments or infections within one year multiple year history of recurrent infections or episodes of sinus pain and pressure symptoms that coincide with changes in altitude or weather chronic nasal congestion and drainage

CHRONIC RHINOSINUSITIS (CRS) WITHOUT POLYPS Neutrophilic inflammation associated with obstruction and inflammation of sinus ostia

CHRONIC RHINOSINUSITIS (CRS) WITH POLYPS Associated with eosiniphilic inflammation with some association with interleukin 4 and 5 and IgE mediated response No difference in the composition of the mucin between systemic atopic patients versus nonatopic patients Patients with genetic mucociliary transport diseases such as cystic fibrosis or, patients who have significant acquired changes of the mucosa following surgery may also have neutrophilic inflammation

ALLERGIC FUNGAL SINUSITIS (AFRS) Non-invasive local fungal hyphae in the mucin allergic response to the fungus polyps with thick grey to brownish “greasy” mucin drainage

ALLERGIC FUNGAL SINUSITIS (AFRS) Invasive Microscopic invasion of fungus in the mucosa Necrotic black tissue with nonpainful debridement is an emergent life threatening fungal infection mucomycosis

NONALLERGIC RHINITIS May be caused by drugs such as: Beta blockers Methyldopa related Reserpine Oral contraceptives Nasal sprays (OTC) Decongestants Develops and resolves during pregnancy GDM: 30-40% Increased risk for later Type II Diabetes 10-20 yrs DM I: Requires Insulin for survival

NONALLERGIC RHINITIS May also be caused by certain conditions such as: Pregnancy Hypothyroidism Temperature related Recumbency rhinitis End-stage vascular atony (Chronic allergic/inflammatory) Paradoxical nasal obstruction (Nasal cycle) Non-airflow rhinitis (Adenoid hypertrophy, choanal atresia)

TREATMENT Nasal and oral steroids Antibiotics Nasal saline irrigation Ponaris emollient Oral decongestants and antihistamines Conservative use Biofilm formation Surgery

NON-SURGICAL TREATMENT Acute sinusitis Antibiotics – ten days to three weeks Nasal steroids – six to eight weeks Nasal saline irrigations – six to eight weeks Mucocilia may take up to four to six weeks to resume normal function CT scan of sinuses if indicated Optional: Nasal spray decongestants – three days only Short course of oral steroids Surgery if indicated

NON-SURGICAL TREATMENT Chronic or recurrent sinusitis without polyps Nasal steroids – long-term treatment Nasal saline irrigation – long-term treatment Antibiotics with acute intermittent sinus infections up to six weeks CT scan sinuses Otolaryngologist evaluation Surgery

NON-SURGICAL TREATMENT Chronic rhinosinusitis with polyps Otolaryngologist evaluation Nasal steroids – long-term treatment Nasal saline irrigation – long-term treatment Antibiotics with acute intermittent sinus infections up to six weeks Allergy testing Surgery

NON-SURGICAL TREATMENT Allergic Fungal Sinusitis (AFRS) Nasal steroids – long-term treatment Nasal saline irrigation – long-term treatment Amphotericin B, mucopricin, steroid or gentamycin irrigations Most common organism – Aspergillus fumigates Antibiotics with acute intermittent sinus infections up to six weeks CT scan sinuses Surgery

SURGICAL TREATMENT Image guided endoscopic sinus surgery Balloon sinuplasty