2. SAYED MOSTAFA HASHEMI MD FACULTI MEMBER OF ISFAHAN MEDICAL SCAIENS
Rhinosinusites
SAYED MOSTAFA HASHEMI MD
FACULTI MEMBER OF ISFAHAN MEDICAL SCAIENS

3. ANATOMY AND PHYSIOLOGY
 — Humans have four pairs of sinuses named for the bones of the skull that they pneumatize The maxillary, ethmoid (divided into anterior and posterior cells), frontal, and sphenoid sinuses are air-containing spaces that are lined by pseudostratified, columnar epithelium bearing cilia. The sinus mucosa contains goblet cells, which secrete mucus that aids in trapping inhaled particles and debris.

4. Anatomy

5. Ostiomeatal complex

6. INTRODUCTION —
Rhinosinusitis is defined as symptomatic inflammation of the nasal cavity and paranasal sinuse
The term "rhinosinusitis" is preferred to "sinusitis" since inflammation of the sinuses rarely occurs without concurrent inflammation of the nasal mucosa [1].

7. Pathophysiology
The sinuses are normally sterile under physiologic conditions. Purulent sinusitis can occur when ciliary clearance of sinus secretions decreases or when the sinus ostium becomes obstructed, which leads to retention of secretions, negative sinus pressure, and reduction of oxygen partial pressure.

8. Pathophysiology
This environment is then suitable for growth of pathogenic organisms.
Factors that predispose the sinuses to obstruction and decreased ciliary function are allergic, nonallergic, or viral insults, which produce inflammation of the nasal and sinus mucosa and result in ciliary dysmotility and sinus obstruction.

9. PATHOGENESIS of ABRS
With colds and influenza-like illnesses, viscous fluid frequently accumulates in the sinuses from exocytosis of mucus from goblet cells in the sinus mucosa [6] and possibly as the result of nose blowing.
ABRS occurs when bacteria secondarily infect the inflamed sinus cavity. Though usually occurring as a complication of viral infection

10. Conversion of AVRS to ABRS
it is generally not possible to distinguish AVRS from ABRS in the first 10 days of illness based upon history, examination, or radiologic study.
The diagnosis of ABRS is usually clinical, since sinus aspirates for culture are not readily obtainable.

11. Conversion of AVRS to ABRS
Persistent symptoms or signs of ARS lasting 10 or more days with no clinical improvement
Onset with severe symptoms (fever >39°C or 102°F and purulent nasal discharge or facial pain) lasting at least three following days at the beginning of illness
Onset with worsening symptoms following a viral upper respiratory infection that lasted five to six days and was initially Improving
immunocompromised patients

12. Only a small percentage (approximately two percent) of viral rhinosinusitis is complicated by acute bacterial sinusitis. Uncomplicated viral rhinosinusitis usually resolves in seven to ten days.

13. EPIDEMIOLOGY
 — The average adult has from two to three colds and influenza-like illnesses per year and the average child six to 10
Approximately 0.5 to 2 percent of colds and influenza-like in adults and 6-13% in children
complicated by acute bacterial sinusitis in adults

14. Classification of rhinosinusitis is based on symptom duration.

15. Recurrent acute rhinosinusitis
- four or more episodes of ARS per year, with temporary symptom resolution [2].

16. Clinical course
Acute bacterial sinusitis is also usually a self-limited disease, with 75 percent of cases resolving without treatment in one month.
untreated patients with acute bacterial sinusitis have bothersome morbidity and are at risk of developing intracranial and orbital complications
Acute bacterial sinusitis is also

17. Clinical Diagnosis Purulent rhinorrhea
Nasal congestion and/or facial pain/pressure
diagnosis is further supported by the presence of secondary symptoms, including anosmia, ear fullness, cough, and headache.
Pain localized to the sinuses when the patient is asked to bend forward may be more

18. Physical Examination
Anterior rhinoscopy with otoscope in younger children
Tenderness over sinuses
Periorbital edema and discoloration
Flexible and rigid endoscopy in older child
Most specific-- mucopurulence, periorbital swelling, facial tenderness

19. Tools for intranasal examination

20. Notable exam findings
may include diffuse mucosal edema, narrowing of the middle meatus, inferior turbinate hypertrophy, and copious rhinorrhea or purulent discharge.
Polyps or septal deviation may be noted incidentally and may indicate pre-existing anatomic risk factors for the development of ABRS.

21. plain sinus radiography
The sensitivity and specificity of plain sinus radiography is poor for detecting mucosal thickening of the paranasal sinuses (76 and 79 percent, respectively)
The high false negative rate is attributable to poor visualization of the ethmoid sinuses in plain films,
The high false positive rate to artifact and the inability to distinguish polyps and nasal masses from fluid or mucosal edema.

22. Computed tomographic (CT) scan of the sinuses showing occlusion of the infundibula (black arrow heads); viscous material adherent to the wall of the sinus cavity (white arrow); bubble in the viscous fluid which does not represent thickened sinus mucosa (white arrow head); and pneumatization of concha bullosa (asterisk). Courtesy of Jack Gwaltney, MD.

23. Sinus aspiration
cultures are rarely performed unless there has been a failure of treatment
sinus aspiration is indicated in severe toxic illness, acute illness not responsive to antibiotics within 72 hours, immunocompromised patients, supportive complications
endoscopically guided middle meatus swab correlates fairly well with sinus aspirate

24. Microbiology

25. Medical Treatment Acute Sinusitis:
Young children with mild to moderate ARS, amoxicillin at normal or high dose
Amoxil-allergic patients, treat with a cephalosporin—severe allergy, treat with macrolide
Nonresponders, more severe initial disease, those at high-risk for resistant strep, treat with high dose amoxil/clavulanate
Parenteral ceftriaxone for children not tolerating oral meds
Duration of therapy is usually days 7-10

26. Antibiotics - Other Considerations
Recent use of prior antibiotics is a risk factor for the presence of antibiotic-resistant bacteria
different antibiotic should be selected if the patient has used antibiotics in the last 4 to 6 weeks.
Guidelines from the Sinus and Allergy Health Partnership4 recommend a fluoroquinolone or high-dose amoxicillin-clavulanate (4 grams/250 milligrams per day) for patients who have received antibiotics within the past 4 to 6 weeks.
Having a child in daycare in the household is a risk factor for penicillin-resistant S. pneumoniae, for which high-dose amoxicillin is an option.

27. Treatment
Amoxicillin has been recommended as a first-line agent in the past because of its narrow spectrum and relative low cost. However, there is increasing emergence of antimicrobial resistance among respiratory pathogens, including pneumococci and H. influenzae. Resistance rates vary regionally, with the prevalence of H. influenzae resistance ranging from 27 to 43 percent in the US [9].

28. Treatment failure
 — Treatment failure is defined as progression of symptoms at any time during treatment or failure to improve after 3-5 days of therapy.
Patients who fail first-line therapy require alternative antibiotic selection. Ideally, an endoscopically-guided culture could be performed to redirect antibiotic therapy. If no material is available on endoscopy for culture, a broader antibiotic choice can be empirically started and monitored for improvement. high-dose amoxicillin-clavulanate (4 grams/250 milligrams per day) have been recommended
A CT scan of the sinuses may be performed if symptoms worsen or fail to improve, to verify that symptoms are in fact due to acute sinusitis, and not to concomitant allergy or other noninfectious etiologies.

29. Choice of Antibiotic for ABRS
Wright & Frankel

30. Treatment
trimethoprim-sulfamethoxazole, and second- or third-generation cephalosporins are not recommended for empiric therapy because of high rates of resistance of S. pneumoniae (and of H. influenzae for trimethoprim-sulfamethoxazole

31. Antibiotics - Duration
Most trials of ABRS administer antibiotic for 10 days
No significant differences in resolution rates for ABRS with a 6-10 day course of antibiotics compared with a 3-5-day course (azithromycin, telithromycin, or cefuroxime) up to 3 weeks after treatment. Refs
Another systematic review found no relation between antibiotic duration and outcome efficacy for 8 RCTs (Ip et al. 2005)
Shorter antibiotic courses associated with fewer adverse effects.
Final Recommendation on Duration?
The most common bacterial species isolated from the maxillary
sinuses of patients with initial episodes of ABRS are
Streptococcus pneumoniae, Haemophilus influenzae, and
Moraxella catarrhalis,4.34 the latter being more common in
children.
A review of sinus aspiration studies performed in
adults with ABRS suggests that S. pneumoniae is isolated in
approximately 20% to 43%, H. influenzae in 22% to 35%, and
M. catarrhalis in 2% to 10% of aspirates. 49,
Other bacterial
isolates found in patients with ABRS include Staphylococcus
aureus and anaerobes.
Local resistance patterns vary widely, but about 15% of
S. pneumoniae has intermediate penicillin resistance and
25% is highly resistant.4
When used in sufficient doses, amoxicillin is effective against susceptible and intermediate
resistant pneumococci. Amoxicillin is ineffective, however,
against beta-lactamase–producing M. catarrhalis and H.
influenzae (about 80% and 30% of isolates, respectively).
The impact of amoxicillin resistance on clinical outcomes,
however, will be reduced by the favorable natural history of
acute rhinosinusitis observed when patients receive placebo
in clinical trials (Table 9).

32. Treatment
Adjunctive therapy — Symptomatic relief measures, including analgesics, nasal saline irrigation, and topical and systemic decongestants

33. Saline irrigation
— Mechanical irrigation with buffered, physiologic, or hypertonic saline may reduce the need for pain medication and improve overall patient comfort, particularly in patients with frequent sinus infections.
It is important that irrigants be prepared from sterile or bottled water, as there have been reports of amebic encephalitis due to tap water rinses [13]. Instructions for preparing a rinse solution are shown in a table (tabl

34. Topical glucocorticoids
— The theoretic mechanism of action for intranasal glucocorticoids (corticosteroids) is a decrease in mucosal inflammation that allows improved sinus drainage
intranasal glucocorticoids are likely to be most beneficial for patients with underlying allergic rhinitis

35. Topical decongestants
— The use of topical decongestants, such as oxymetazoline, may provide a subjective sense of improved nasal patency. If used, topical decongestants should be used sparingly (no more than three consecutive days) to avoid rebound congestion
Topical decongestants are suggested for symptomatic relief in the treatment of AVRS and 2012 guidelines advise that they are not helpful in patients with ABRs
oral decongestants are not helpful in patients with ABRS

36. oral decongestants
oral decongestants are not helpful in patients with ABRS
When eustachian tube dysfunction is a significant confounding factor in AVRS, a short course (three to five days) of oral decongestants may be warranted.
Oral decongestants should be used with caution in patients with cardiovascular disease, hypertension, or benign prostate hypertrophy due to systemic adverse effects with oral alpha adrenergic preparation

37. Antihistamines
— Antihistamines are frequently prescribed for symptom relief due to their drying effects; however, there are no studies investigating their efficacy for this indication
Additionally, over-drying of the mucosa may lead to further discomfort. Antihistamines have side effects (drowsiness, xerostomia),
Their use for the treatment of acute sinusitis is not recommended

38. Indications for urgent referral
 — Patients with high fever, acute facial pain, swelling, and erythema should be treated for acute bacterial rhinosinusitis, even if symptoms have not been present for seven days.
Patients with high fevers and severe headache warrant immediate evaluation and probable imaging.

39. Stage II—Orbital Cellulitis
Proptosis, Chemosis, Edema, Pain
Dilated pupil
Visual loss
Ophthalmoplegia
Afferent pupillary defect

40. Chronic Rhinosinusitis

41. Chronic rhinosinusitis
Chronic rhinosinusitis is a group of disorders characterized by inflammation of the mucosa of the nose and paranasal sinuses of at least 12 consecutive weeks’ duration.
Patients with CRS may have intermittent acute flare-ups; in such cases, the disorder is called acute exacerbation of chronic rhinosinusitis(AECRS)

42. Ostiomeatal complex

43. EPOS Management Algorithm: Adult Chronic Rhinosinusitis
*Primary Care

44. Pathogenesis
Ostia obstruction creates increasingly hypoxic environment within sinus
Retention of secretion results in inflammation and bacterial infection
Secretion stagnate, obstruction increases, cilia and epithelial damage become more pronounced

45. Factors that may contribute to of CRS include
The recognition that CRS represents a multifactorial inflammatory disorder, rather than simply a persistent bacterial infection, has led to the reexamination of the role of antimicrobials in CRS

46. The role of bacteria in the pathogenesis of chronic sinusitis
The role of bacteria in the pathogenesis of chronic sinusitis is currently being reassessed. Repeated and persistent sinus infections can develop in persons with severe acquired or congenital immunodeficiency states or cystic fibrosis.
Current thinking supports that chronic rhinosinusitis (CRS) is predominantly a multifactorial inflammatory disease. Confounding factors that may contribute to inflammation include the following:

47. Persistent infection (including biofilms and osteitis)
Allergy and other immunologic disorders
Intrinsic factors of the upper airway
Superantigens
Colonizing fungi that induce and sustain eosinophilic inflammation
Metabolic abnormalities such as aspirin sensitivity

48. All of these factors can play a role in disruption of the intrinsic mucociliary transport system. This is because an alteration in sinus ostia patency, ciliary function, or the quality of secretions leads to stagnation of secretions, decreased pH levels, and lowered oxygen tension within the sinus. These changes create a favorable environment for bacterial growth that, in turn, further contributes to increased mucosal inflammation.

49. There are four cardinal signs of CRS:
Anterior and/or posterior mucopurulent drainage
Nasal obstruction
Facial pain, pressure, and/or fullness
Decreased sense of smell
At least TWO of these symptoms should be present to consider the diagnosis of CRS, in association with objective findings

50.  —SUBTYPES OF CRS
 CRS can be divided into three distinct clinical syndromes
CRS with nasal polyposis - 20 to 33 percent of cases
Allergic fungal rhinosinusitis - 8 to 12 percent
CRS without nasal polyposis - 60 to 65 percent

51. CRS with nasal polyposis
 — Chronic rhinosinusitis with nasal polyposis (CRS with NP) is characterized by the presence of nasal polyps. Nasal polyps are translucent, yellowish-grey to white, glistening masses filled with gelatinous inflammatory material, which may form in the nasal cavity or paranasal sinuses

52. nasal polyposis 
The grey-white color is due to the relatively avascular nature of the polyp tissue. Nasal polyps lack sensation and should be distinguished from swollen nasal turbinates, which are pink in color, similar in appearance to the rest of the nasal mucosa, and very sensitive to touch

53. Pathophysiology 
The initial trigger for their development is probably variable. Polyp tissue typically contains a predominance of eosinophils, high levels of the Th2 cytokines interleukin (IL)-5 and IL-13, and high levels of histamine [8].

54. CRS without NP
- The characteristic presentation of CRS without NP is that of persistent symptoms with periodic exacerbations characterized by increased facial pain/pressure and/or increased anterior or posterior drainage
Fatigue is a frequent accompanying symptom.
Fever is usually absent or low-grade. A subclass of patients has recurrent acute rhinosinusitis symptoms, which respond well to antibiotic treatment.
Such patients may be completely symptom free between episodes or have persistent symptoms characteristic of CRS without NP.

55. Allergic fungal rhinosinusitis
- AFRS usually presents delicately, with symptoms similar to CRS with NP. Patients may describe semi-solid nasal crusts that are similar in appearance to allergic mucin Fever is uncommon.
The patients are atopic(IgE increased)
In occasional patients, AFRS presents dramatically with complete nasal obstruction, gross facial asymmetry.

56. Physical examination 
 Anterior rhinoscopy :The nasal cavities may be examined with a penlight, use of an otoscope with a nasal speculum provides better visualization of the inferior turbinate and anterior nasal septum.
nasal endoscope is ideal for evaluating the entire nasal cavity and the region of the middle turbinate in particular Mucopurulent material seen emanating from the middle meatus, between the middle turbinate and lateral nasal wall, is strongly supportive of the diagnosis of sinusitis

57. Endoscopic view of the nose

58. Imaging studies 
— Patients with suspected chronic sinusitis that do not improve with medical therapy should be further investigated by imaging studies

59. Sinus radiographs
Sinus radiographs have traditionally been used to screen such patients; however, they often miss obstructing pathology in the OMC region of the ethmoid sinus [28]. Plain sinus x-rays have largely been replaced by the "limited" CT scan, which provides select coronal views through each of the sinuses. This relatively quick, low cost study serves as a useful tool to exclude the diagnosis of sinusitis in patients with an uncertain diagnosis.

60. Sinus computed tomographic (CT) scan

61. DIFFERENTIAL DIAGNOSIS
The chronic sinusitis patient, who has a primary complaint of facial pain or headache, in the absence of nasal symptoms, may be suffering from migraine, neuralgia, or atypical facial pain syndrome.
If the patient does not improve with treatment for sinusitis and the sinus CT is normal, an MRI scan and referral to a neurologist should be considered

62. MEDICAL MANAGEMENT —
 The goal of medical therapy for chronic sinusitis is to promote sinus drainage and eradicate the offending pathogens.
Despite the common nature of this disease, the data supporting the efficacy of these various treatment modalities are scant.
A retrospective analysis, for example, assessed the outcome of intensive medical management including one month of antibiotics, oral corticosteroids, topical steroids, and nasal irrigation the latter two therapies were continued after a period of one month [38].

63. Medical Treatment Chronic Rhinosinusitis
4 to 6 week course of beta lactam stable antibiotic
Adjuvant therapy with nasal steroids commonly employed
Antihistamines especially if underlying allergic condition suspected
Mucolytics may thin secretions

64. Recommend antibiotces
amoxicillin-clavulanate or cefuroxime, both at doses of 500 mg PO twice daily as first-line agents for chronic sinusitis. We commonly treat for 21 days; the full six-week course is usually reserved for more refractory cases. Clarithromycin (500 mg PO twice daily) or clindamycin (300 mg PO three times a day) are usually selected for patients with penicillin allergy. Quinolones, including levofloxacin or moxifloxacin, have been used to treat patients with chronic sinusitis but are best reserved for culture-demonstrated gram-negative infectio

65. Nasal irrigation
Patients who complain of nasal congestion or drainage from excessive mucus production are instructed to irrigate their nose twice a day with warm saline solution using a bulb syringe. The syringe is filled with saline prepared by adding a teaspoon of salt to a glass of warm water. The saline is gently squirted into one nostril and then the other while bending over a sink. The solution should drain out of the nostrils, carrying with it excess mucus from within the nose and sinuses. This relatively simple technique can provide great symptomatic relief in many patients with chronic sinusitis.

66. Topical steroids 
— Topical steroids in the form of nasal sprays may decrease mucosal inflammation and swelling, particularly in patients with allergic disease as a contributing factor. In one study of 95 patients with a history of chronic or recurrent sinusitis, the addition of intranasal fluticasone,]. Two puffs of fluticasone once a day for 21 days resulted in patient reports of 93.5 percent clinical success compared to 73.9 percent for placebo spray in this randomized trial.
Steroid sprays do not appear to suppress endogenous steroid secretion even after long-term use.

67. Systemic steroids
Systemic steroids may be used on a limited basis in patients with diffuse nasal polyps refractory to steroid sprays or those with exacerbations of asthma triggered by sinusitis

68. SURGICAL MANAGEMENT 
SURGICAL MANAGEMENT — The goal of functional endoscopic sinus surgery, known by the acronym FESS, is to restore physiologic sinus ventilation and drainage, which allows for the gradual resolution of mucosal disease [49].
Patients who are considered candidates for this procedure have typically required more than three courses of antibiotics for sinusitis within a 12-month period. In addition, abnormalities of the sinuses or OMC should be evident on nasal endoscopy or CT imaging.

69. Surgical Management Adenoidectomy FESS
Only after maximal medical therapy has failed and patient has been screened and treated for any underlying conditions
Concern for developing nasal and sinus anatomy in children and possibility of altering facial growth

71. Refractory Rhinosinusitis
Consider associated conditions
Allergy
Immune deficiency
Asthma
Gastroesophageal reflux disease
Cystic Fibrosis
Primary Ciliary Dyskinesia (Immotile Cilia Syndrome)
Allergic Fungal Sinusitis

72. Immune Deficiency
History of frequent otitis media, pneumonia and sinusitis may suggest a primary or secondary immunodeficiency state
Serum immunoglobulins and IgG subclasses should be checked as well as ability to respond to capsular antigens of S. pneumoniae and H. influenzae
Must have laboratory with age-appropriate norms
Chronic pediatric sinusitis associated with IgG2 deficiency
Consistent low total immunoglobulin defines common variable hypoglobulinemia
Treatment in primarily medical
Patients may benefit from IVIG therapy
Genetic counseling for patient and family may be appropriate

73. Gastroesophageal Reflux Disease
Many pediatric patients experience improvement in their chronic sinonasal symptoms after a trial of antireflux medicine
GERD theorized to have direct effect on nasal mucosa, initiating inflammatory response with edema and impaired mucociliary clearance
Phipps in 2000 reported a prospective trial in which 63% CRS patients were found to have esophageal reflux by pH probe; 32% demonstrated nasopharyngeal reflux
Bothwell in 1999 reported 89% of pediatric candidates for FESS avoided surgery with treatment for GERD

74. Cystic Fibrosis Autosomal recessive disease Mutation of CFTR protein
Patients develop chronic pulmonary disease in childhood; also affected with sinusitis and nasal polyposis, pancreatic insufficiency and biliary cirrhosis
If surgery contemplated, check coags
Recent studies suggest heterozygous mutations in the CFTR gene are associated with chronic rhinosinusitis
Raman found that 12.1% of CRS patients harbored CFTR mutations compared with the expected rate of 3-4%
Wang found a 7% incidence of CFTR mutation in 123 CRS patients compared to 2% in a control group

75. Primary Ciliary Dyskinesia
History of chronic otitis media, chronic sinusitis and chronic bronchitis or bronchiectasis
Kartagener’s syndrome: sinusitis, situs inversus, bronchiectasis and male infertility)
Diagnosis established with inferior or middle turbinate or tracheal biopsy

77. Allergic Fungal Sinusitis
Allergic reaction to aerosolized fungi, usually of the dematiceous species
Treatment is surgical with perioperative oral steroid and post-operative topical steroids
High recurrence rate, requires close follow up
Findings in children different than adult findings
Children more frequently have abnormalities of their facial skeleton
More likely to have unilateral disease

78. Complications Orbital: Intracranial:
Orbital complications more common in children than adults
Most common is medial subperiosteal abscess
Intracranial:
More common in adolescents/adults
Include meningitis (most common), epidural abscess, subdural abscess, intracerebral abscess, cavernous sinus thrombosis

79. Orbital Complications
Classified by Chandler:
I. Preseptal cellulitis
II. Orbital cellulitis
III. Periorbital abscess
IV. Orbital abscess
V. Cavernous sinus thrombosis
Spread by direct extension via osseous structures or indirectly via valveless venous plexuses
Obtain CT scan with contrast if orbital involvement suspected

80. Stage I—Preseptal Cellulitis
Eyelid edema, erythema and normal globe movement
Stage I in children more likely due to cutaneous lesions or hematogenous seeding rather than sinusitis

81. Stage III—Periorbital Abscess
Proptosis with globe displacement inferolaterally, decreased EOM, vision decreased
IVAbx with external or endoscopic drainage of abscess and involved sinus

82. Stage IV—Orbital Abscess
severe proptosis and chemosis
usually no globe displacement
opthalmoplegia present
Impaired visual acuity

83. Stage V—Cavernous Sinus Thrombosis
Progressive symptoms
Proptosis and fixation
CN II, IV, VI
Meningitis
High mortality
High fever, bilateral symptoms

84. Intracranial Complications
Meningitis, Epidural Abscess, Intracerebral Abscess, Pott’s Puffy Tumor
Neurosurgical Consultation, high-dose antimicrobial therapy, drainage of intracranial abscess planned in concert with drainage of affected sinus
Frontal sinus is most implicated sinus: venous drainage of the frontal sinus via small diploic veins extending through sinus wall; these communicate with venous plexi of dura, periorbita and cranial periostuem