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Acute and Chronic Sinusitis

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Slide 1 :

1 Acute and Chronic Sinusitis A Practical Guide for Diagnosis and Treatment

Slide 2 :

2 Presentation Facts File size: approximately 2013 KB Number of slides: 81 Evidence-Based CME: Web site addresses for all EB recommendations are available near the end of this presentation These slides were prepared by the AAFP and content should not be modified in any way. If content is changed, it is the user’s responsibility to remove both the AAFP and the CME logos. Instructions to remove logos: from menu, select VIEW, MASTER, SLIDE MASTER; select the logos and delete; to return to the original slide view, select VIEW, SLIDE

Slide 3 :

3 Acknowledgments This is a presentation of the American Academy of Family Physicians supported by an educational grant from Aventis Pharmaceuticals The AAFP gratefully acknowledges Harold H. Hedges, III, M.D. and Susan M. Pollart, M.D. for developing the content for the AAFP and Harold H. Hedges, III, M.D. for providing the photo images included in this slide presentation.

Slide 4 :

4 Acknowledgments Harold H. Hedges, III, M.D. Private Practice Little Rock Family Practice Clinic Little Rock, Arkansas and Susan P. Pollart, M.D. Associate Professor of Family Medicine University of Virginia Health System Charlottesville, Virginia

Slide 5 :

5 Upon Completion of This Presentation You Should be Able To Be knowledgeable of the causes of and risk factors associated with sinusitis Differentiate acute from chronic sinusitis Evaluate patients by history, physical exam, appropriate laboratory and imaging studies, and when indicated screen patients for allergy Prescribe appropriate medication regimens for acute and chronic sinusitis Know of the relationships between upper airway (rhinosinusitis) and lower airway disease (asthma)

Slide 6 :

6 Rhinosinusitis May be Better Term Because Allergic or nonallergic rhinitis nearly always precedes sinusitis Sinusitis without rhinitis is rare Nasal discharge and congestion are prominent symptoms of sinusitis Nasal mucosa and sinus mucosa are similar and are contiguous

Slide 7 :

7 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

Slide 8 :

8 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. Senior BA, Kennedy DW. Management of sinusitis in the asthmatic patient AAAI J,1996;77:6-19.

Slide 9 :

9 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

Slide 10 :

10 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

Slide 11 :

11 Sinusitis 4 paranasal sinuses, each lined with pseudostratified ciliated columnar epithelium and goblet cells Frontal Maxillary Ethmoid Sphenoid Infectious or noninfectious inflammation of 1 or more sinuses

Slide 12 :

12 Normal Water’s and Towne’ s Views of the Sinuses

Slide 13 :

13 Lateral View Showing Normal Sphenoid Sinus

Slide 14 :

14 Ostiomeatal Complex Ostiomeatal complex is that area under the middle meatus (airspace) into which the anterior ethmoid, frontal and maxillary sinuses drain Posterior ethmoids drain into the upper meatus Ostiomeatal complex is the functional relationship between the space and the ostia that drain into it

Slide 15 :

15 Viral Rhinosinusitis Most upper respiratory infections are viral Short lived, last less than 10 days Sinus mucosa as well as nasal mucosa is involved Most will clear without antibiotics Treatment: decongestants, nasal lavage, rest, fluids

Slide 16 :

16 Classification of Bacterial Sinusitis Acute bacterial sinusitis- infection lasting 4 weeks, symptoms resolve completely (children 30 days) Subacute bacterial sinusitis- infection lasting between 4 to 12 weeks, yet resolves completely (children 30-90 days) Chronic sinusitis- symptoms lasting more than 12 weeks (children >90 days) Some guidelines add treatment failure + a positive imaging study

Slide 17 :

17 Recurrent Acute Bacterial Sinusitis Episodes lasting fewer than 4 weeks and separated by intervals of at least 10 days during which the patient is totally asymptomatic 3 episodes in 6 months or 4/year

Slide 18 :

18 Acute Sinusitis Imposed on Chronic Sinusitis Patients with chronic, low grade symptoms experience increase in mucous flow, change in viscosity or color, or secretions Treated New symptoms resolve but chronic symptoms continue

Slide 19 :

19 Differentiating Sinusitis from Rhinitis Sinusitis Nasal congestion Purulent rhinorrhea Postnasal drip Headache Facial pain Anosmia Cough, fever Rhinitis Nasal congestion Rhinorrhea clear Runny nose Itching, red eyes Nasal crease Seasonal symptoms

Slide 20 :

20 Road to Bacterial Sinus Infections Obstruction of the various ostia Impairment in ciliary function Increased viscosity of secretions Impaired immunity Mucus accumulates Decrease in oxygenation in the sinuses Bacterial overgrowth

Slide 21 :

21 X-Ray Image of Sinuses with Maxillary Sinusitis

Slide 22 :

22 Pathogenesis of Nasal Obstruction Viral upper respiratory infections Daycare centers Allergic and nonallergic stimuli Immunodeficiency disorders Immunoglobulin deficiency (IgA, IgG) Anatomic changes Deviated septum, concha bullosa, polyps

Slide 23 :

23 Allergic Stimuli Causing Rhinosinusitis Pollens Tree, grass, weeds House dust mite Animal danders Cat, dog, mice, gerbil, other animals with fur Molds Allergic foods and beverages

Slide 24 :

24 Nonallergic Stimuli Causing Rhinosinusitis Tobacco smoke Perfumes Cleaning solutions Potpourri Burning candles Cosmetics Car exhaust, diesel fumes Hair spray Cold air Dry air Changes in barometric pressure Auto exhaust Gas, diesel fuel Nonallergic foods Nonallergic beverages

Slide 25 :

25 Causes of Ciliary Dysfunction Immotile cilia syndrome Prolonged exposure to cigarette smoke Common cold viruses causing URI Increased viscosity of mucus Medications First generation antihistamines (non sedating do not affect) Anticholinergics Aspirin Anesthetic agents Benzodiazepines

Slide 26 :

26 Diseases Slowing Ciliary Function Allergic and nonallergic rhinitis Rhinosinusitis Aging rhinitis Cystic fibrosis Any disease causing obstruction, crusting of the mucosa

Slide 27 :

27 Causes of Mechanical Obstruction Deviated nasal septum Concha bullosa Foreign body Nasal polyps Congenital atresia Lymphoid hyperplasia Nasal structural changes found in Downs syndrome

Slide 28 :

28 Vasculitides, Autoimmune and Granulomatous Diseases Churg-Strauss vasculitis Systemic lupus erythematosis Sjogren’s syndrome Sarcoidosis Wegener granulomatosis

Slide 29 :

29 Other Predisposing Conditions Physical trauma Scuba diving Foreign body Cleft palate Dental disorders Any patient with chronic fatigue, fever, general malaise/aching or headaches should be evaluated for sinusitis

Slide 30 :

30 Acute Bacterial Sinusitis Usually begins with viral upper respiratory illness Symptoms initially improve, but then … Symptoms become persistent or severe Persistent… 10-14 days but fewer than 4 weeks Severe…temperature of 102°, purulent nasal discharge for 3-4 days, child appears ill Disease clears with appropriate medical treatment

Slide 31 :

31 Physical Findings Mucopurulent nasal discharge Highest positive predictive value Swelling of nasal mucosa Mild erythema Facial pain (unusual in children) Periorbital swelling

Slide 32 :

32 Objectives of Treatment of Acute Bacterial Sinusitis Decrease time of recovery Prevent chronic disease Decrease exacerbations of asthma or other secondary diseases Do so in a cost-effective way!

Slide 33 :

33 Treatment of Acute Sinusitis Antihistamines recommended if allergy present Oral or topical Decongestants Oral or topical Antibiotic when indicated (bacteria) Nasal irrigation Guaifenesin 200-400 mg q4-6 hrs Hydration

Slide 34 :

34 Decongestants Topical nasal sprays (limit use to 3-7 days) Phenylephrine Oxymetazoline Naphthazoline Tetrahydrozoline Zylometazoline Topical nasal spray (unlimited daily use) Ipatropium Oral Pseudoephedrine 30-60 mg Phenylephrine 2-4 times/day

Slide 35 :

35 Treatment of Acute, Uncomplicated Sinusitis Antibiotic may not be indicated Many are viral Benefit of antibiotics are only moderate Weigh factors of cost, side effects, antibiotic resistance, and antibiotic reactions

Slide 36 :

36 Antibiotics for Acute Bacterial Sinusitis Amoxicillin 500 mg tid for 10-14 days First line choice in most areas Local differences in antibiotic resistance occur Where beta-lactanase resistance is an issue Amoxicillin/clavulanate Cefuroxime Cefpodoxime Cefprozil

Slide 37 :

37 Additional Antibiotics for Acute Bacterial Sinusitis Amoxicillin should be considered because of its efficacy, low cost, side-effect profile, and narrow spectrum (45-90 mg/kg/d in children; 500 mg tid or qid in adults for 10 to 14 days) If penicillin-allergic clarithromycin or azithromycin Erythromycin does not provide adequate coverage Trimethoprim/suflamethoxazole and erythro/sulfisoxazole have significant pneumococcal resistance

Slide 38 :

38 Nasal Irrigation Commercial buffered sprays Bulb syringe 1/4 tsp of salt to 7 ounces water Waterpik with lavage tip 1 tsp salt to reservoir Disposable enema bucket 2 tsp salt, 1 tsp soda per quart of water

Slide 39 :

39 Nasal Irrigation Washes away irritants Moistens the dry nose Waterpik with nasal irrigator Ceramic irrigators Enema bucket with normal saline and soda “Hose-in-the-nose”-- $2.50

Slide 40 :

40 Nasal Irrigation With enema bucket/hose…. Add 2 teaspoons of salt and 1 tsp of baking soda to a quart of warm water Over tub, sink, or in shower lean over, head tilted slightly downward and to side place hose in upper nostril (fluid may return from either nostril or through mouth) run in 1/2 solution. Turn head to opposite side and repeat process. Use once, twice daily or as often as needed

Slide 41 :

41 When Medical Therapy for Acute Bacterial Sinusitis Fails… Assess for chronic causes Identify allergic and nonallergic triggers Allergy testing, nasal smears for eosinophilia Consider other medical conditions associated with sinusitis Rhinolaryngoscopy Imaging studies Sinus x-rays CT scanning (limited, coronal views)

Slide 42 :

42 Sinus Transillumination Helpful in older children and adults Normal transillumination decreases chance of pus in the sinus No light reflex suggests mucopurulent material or thickening of nasal mucosa Inexpensive screening tool

Slide 43 :

43 Sinus Transillumination Have patient sit at your eye level in darkened room (the darker the better) Let eyes get accustomed to dark Place bright light (transilluminator) over inferior orbital ridge to look at maxillary sinuses, under superior orbital rim for frontal sinuses Look at palate for presence/absence of transilluminated light

Slide 44 :

44 Photo Image of Sinus Transilluminator

Slide 45 :

45 Transillumination of Frontal Sinus

Slide 46 :

46 Transillumination of Maxillary Sinus

Slide 47 :

47 Rhinoscopy Aids in Diagnosing Nasal polyps Septal deviation Concha bullosa Eustachian tube dysfunction Causes of hoarseness Adenoid hyperplasia Tumors

Slide 48 :

48 Rhinoscope

Slide 49 :

49 CT Scan Maxillary and Ethmoid Sinuses

Slide 50 :

50 MRI Imaging Not used for imaging suspected acute sinusitis Suspected fungal sinusitis Suspected tumors

Slide 51 :

51 Bacteria Involved in Acute Bacterial Sinusitis Streptococcus pneumoniae 30% Haemophilus influenza 20% Moraxella catarrhalis 20% Sterile 30%

Slide 52 :

52 Comparison of Various Approaches to the Treatment of AR Sneezing Discharge Itch Congestion Side Effects Antihistamines traditional (A) +++ +++ +++ + +++ Non-sedating (NSA) +++ ++ +++ + – to + Azelastine +++ ++ +++ + – to + Decongestants – + – +++ ++ NSA + decongestants +++ +++ +++ +++ ++ Leukotriene antag.* + to ++ + to ++ + to ++ ++ – to + Cromolyn ++ + + + – Nasal CCS (NCS) +++ +++ +++ +++ + NSA + NCS ++++ ++++ ++++ ++++ + Immunotherapy +++ +++ +++ +++ + to ++ * Presumed; no data on individual symptoms. Nayak AS, et al. Ann Allergy Asthma Immunol. 2002;88:592-600. ++++ = Strongly positive effect; += Minimal effect

Slide 53 :

53 Rational for Starting Rx with Amoxicillin In the absence of risk factors, i.e. attendance in daycare center, recent antibiotics, age younger than 2… 80% of patients will respond to amoxicillin Give Rx for 5 days with a refill -- if responding treat for 10 to 14 days, if not, switch to another

Slide 54 :

54 Reasons to Use Alternative Antibiotics No response to amoxicillin within 3-5 days Recent treatment with amoxicillin for other causes Symptoms present for more than 30 days Recurrent sinus infections

Slide 55 :

55 Secondary Antibiotics for Acute Sinusitis Cefdinir (Omnicef) Cefuroxime (Ceftin) Cephpodoxime (Vantin) Azithromycin Clarithromycin

Slide 56 :

56 Optimal Duration of Antibiotics Give antibiotic until patient free of symptoms then add 7 days

Slide 57 :

57 Chronic Sinusitis Symptoms present longer than 8 weeks or 4/year in adults or 12 weeks or 6 episodes/year in children Eosinophilic inflammation or chronic infection Associated with positive CT scans Poor (if any) response to antibiotics

Slide 58 :

58 Quality-of-Life Issues Fatigue Concentration Nuisance Sleep disturbance Emotional well being Social interactions Missing school/work Halitosis Decreased production Impaired studying Sniffing/snorting Blowing nose

Slide 59 :

59 Sx of Chronic Sinusitis Nasal discharge Nasal congestion Headache Facial pain or pressure Olfactory disturbance Fever and halitosis Cough (worse when lying down)

Slide 60 :

60 Conditions Causing Chronic Sinusitis Allergic and nonallergic rhinitis Uncorrected anatomic conditions Ciliary dyskinesia Cystic fibrosis Tumors Immunodeficiency disorders IgA, IgM Granulomatous diseases

Slide 61 :

61 Evaluation of Chronic Sinusitis CT or MRI scanning Anatomic defects, tumors, fungi Allergy testing Inhalants, fungi, foods Sinus aspiration for cultures Bacterial Fungal Immunoglobulins

Slide 62 :

62 Treatment of Chronic Sinusitis Nasal steroid spray Guafenesin Decongestants Steam inhalation Nasal irrigation Antibiotics with exacerbations

Slide 63 :

63 Bacteria Involved in Chronic Sinusitis Role of Viruses is Unknown Streptococcus pneumoniae Haemophilus influenza Moraxella catarrhalis Staph aureus Coagulase negative staphylococcus Anerobic bacteria

Slide 64 :

64 Transition of Bacteria Rom Acute to Chronic Sinusitis In one study, while initial aspirates showed strep pneumoniae, H. influenzae, and M catarrhalis, subsequent cultures showed Porphyromonas, Peptostreptococcus, and aerobic organisms found to be increasingly resistant to antibiotics Brook I, et al. Bacteriology and beta-lactamase activity in acute and chronic maxillary sinusitis. Arch Otolaryngol Head Neck Surg 1996;122;418-23.

Slide 65 :

65 Sinus Aspiration and Culture Correlation of routine nasal culture and sinus culture are poor Endoscopically guided aspiration of cultures from medial meatus do correlate with sinus culture Gold SM, Tami TA. Role of middle meatus aspiration culture in the diagnosis of chronic sinusitis. Laryngoscope 1997;107: 1586.

Slide 66 :

66 Recommendations Made for Antibiotic Prophylaxis in ABS Has not been evaluated as has its use in otitis media Increasing evidence of antibiotic resistance is an issue May be tried in chronic or recurrent disease

Slide 67 :

67 Complications of Sinusitis Orbital Diplopia, proptosis Periorbital erythema, swelling Bone Periosteal abscesses Brain Intracranial abscesses causing neurologic symptoms

Slide 68 :

68 The Sinusitis-Asthma Connection Mechanism is not understood Evidence is compelling Failure to control upper airway inflammation leads to suboptimal asthma control Correcting the rhinosinusitis results in better asthma control

Slide 69 :

69 Indications for Referral Allergy testing, possible immunotherapy Sinus aspiration for bacterial culture Surgical intervention Correct obstructive process Drain sinus abscesses Consideration to remove nasal polyps

Slide 70 :

70 Indications for Hospitalization Acutely ill child or adult with high fever, severe head pain Suspected sphenoid sinusitis Anytime complications of eye, bone or intracranial structures are present

Slide 71 :

71 The Recommendations The recommendations cited are those proposed by a task force of the American Academy of Pediatrics in consultation with other groups regarding the evaluation, diagnosis, and treatment of patients aged 1-21 years with sinus disease…expert opinion was used when insufficient data could be found.

Slide 72 :

72 Recommendation 1 The diagnosis of acute bacterial sinusitis is based on clinical criteria with patients presenting with URI symptoms that are either persistent or severe.

Slide 73 :

73 Recommendation 2a Imaging studies are not necessary to confirm a diagnosis of clinical sinusitis in children younger than 6 years (older than age 6 years is controversial) Children with persistent symptoms (>10 days, < 30 days) predicted abnormal radiographs 80% of the time Children < 6 symptoms predicted 88% of the time Normal x-ray suggests ABS is not present

Slide 74 :

74 Recommendation 2b CT scans of the paranasal sinuses should be reserved for: Patients in whom surgery is being considered as a management strategy Patients who do not respond to medical regimes which include adequate antibiotic use Assisting in diagnosis of anatomical changes interfering with airflow or drainage

Slide 75 :

75 Recommendations for CT Scans Patients presenting with complications of sinusitis Neurologic symptoms, diplopia, periorbital or facial swelling with or without erythema Patients with sinus symptoms accompanied by severe, boring, mid-head pain Rule out sphenoid sinusitis

Slide 76 :

76 Recommendation 3 Antibiotics are recommended for the management of acute bacterial sinusitis to achieve a more rapid clinical cure Patients must meet requirements of persistent or severe disease Response improved with doses >Minimal Inhibition Concentration

Slide 77 :

77 No EB Recommendations Found for Use of Adjunctive Therapy in ABS, May be Helpful Nasal saline irrigation Oral decongestants Oral or nasal antihistamines Topical decongestants Mucolytic agents Topical steroids

Slide 78 :

78 Summary Acute and chronic sinusitis is one of the most common diseases treated in family practice It is important to treat sinusitis aggressively to prevent chronic symptoms or development of serious complications The underlying causes of chronic sinus disease should be sought out and corrected

Slide 79 :

79 Additional Bibliography Dykewicz M. Rhinitis and Sinusitis. J All Clin Immunol, 2003; 111:S520-9. Hamilos DL. J Allergy Clin Immunol 2000;106:213-27. Kaliner MA. Current Review of Rhinitis. Current Medicine, Inc., 2002. Kaliner MA. Current Review of Allergic Diseases. Current Medicine, Inc., 2000. Agency for Healthcare Research and Quality American Academy of Pediatrics New England Medical Center Evidence-based Practice Center

Slide 80 :

80 Evidence-Based Recommendations Practice Recommendation: Reduce unnecessary use of antibiotics. Providers should be consistent with the recommended criteria for prescribing antibiotics in acute sinusitis endorsed by the CDC, American Academy of Family Physicians, the American College of Physicians-American Society of Internal Medicine, and the Infectious Diseases Society of America. Practice Recommendation: Use first line antibiotics, which are amoxicillin or trimethoprim-sulphamethoxazole (TMP/SMX). Practice Recommendation: Use an antibiotic that covers resistant bacteria (amoxicillin-clavulanate [Augmentin] or another second line agent) to treat patients if failed on 10-14 days of amoxicillin. All recommendations available at: http://www.icsi.org/knowledge/detail.asp?catID=29&itemID=148. Accesses August 2003.

Slide 81 :

81 Thank You This has been a presentation of the American Academy of Family Physicians

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