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Sinusitis
Ephraim Eviatar
Assaf Harofeh Medical Center
.
9%
21%-.
Rhinosinusitis
Acute rhinosinusitis
Subacute rhinosinusitis
Chronic rhinosinusitis
Recurrent ARS
Acute rhinosinusitis superimposed on
CRS
Acute rhinosinusitis
Acute sinusitis 7-21 days (7 days viral
illness)
Spontaneous resolution of ARS -40%
The most common pathogens: strep
pneumonia-30%,
non typeabale hemophilus infl.-20%,
moraxella catarrhalis.(20% in children)
Staph aureus- 30%
Anaerobes- rare
Recurrent ARS
Episodes of bacterial infection of the
paranasal sinuses, each lasting less than
30 days and separated by intervals of at
least 10 days during which the patient is
asymptomatic.
Subacute sinusitis
Subacute RS:3W-3months
The same pathogens as in ARS
Chronic rhinosinusitis
Beyond 3 months
Bacteria are as in ARS, but
More non-typeable H Influezae
More staph aureus, anaerobic bacteria,
gram- Negative, pseudomonase
aeruginosa
Polymicrobials with resistant organism
Culture recommended
Minors:
Headache
Fever
Halitosis
Fatigue
Dental pain
Cough
Ear pain/
pressure/fulln
Predisposing factors
URI
Allergy
Trauma
Dental infection
Environmental Pollutants
GERD
Cystic Fibrosis
Type of rhinosinusitis
Acute rhinosousitis
Pattern of symptoms
Symptoms minimum *
10d-28d
severe disease*
worsening disease*
Symptoms for diagnosis
Ant./post purulent
*
discharge
nasal obstruction*
facial pain-pressure*
Objective documentation
Nasal exam:purule
Radiographic
evidence
Objective documentation
AFRS
ant/pos mucupurulent d*
ant/pos rhinitis*
nasal obstruction*
nasal obstruction*
facial pain/pressure*
No:
Treat symptomatically
Saline irrigation
Oral decongestant
Antihistamine (allergy)
Reevaluate in 10 days
type
organism
drugs
comments
acute
Strep pneumoniae
h. Influenzae
m. catarrhalis
Amoxicillin 10
days
2nd generation
cephalosporin,
Macrolide, for
penicillin allergy
subacute
Increased resistant of
bacteria
chronic
Polimicrobial,
psudomonase a,
anaerobes, more
resistant
Augmentin,
2nd cephalo.
macrolide,
clinda,3-4w
Recurrent
chronic
Resistant ,
polimicrobial
Suppurative
complications
G(-). Staph
aureus
Surgery if no
Cefuroxime,
responce
aminoglicozid
e
Culture
whenever
possible
:
, .
- levofloxacin fluoroquinolones : 90-92%
.moxifloxacin
ceftriaxone ,augmentin
cefixime high dose amoxicillin, :83-88%
cefpodoxime proxile, cefuroxime axetil, cefdinir
TMP/SMX
,docxycyline, clindamycin:77-81%
azitromycin, clarithromycin, erythromycin
cefaclor,loracarbef :65-66%
According to the guidelines
91-92% : ceftriaxone, augmentin
82-87%: amoxicillin, cefpodoxime proxetil,
cefixime, cefuroxime axetil,cefdinir,TMP/SMX
78-80%: clindamycin, cefprozil, azithromycin,
clarithromycin, erythromycin
67-68% : cefaclor
Augmentin, amoxicillin, cefpodoxime proxetil,
cefuroxime axetil, or cefdinir
For b-lactam allergies patients: TMP/SMX,
doxycilline, azithromycin,
clarithromycin,erythromycin
Failure after 72h: reevaluation or switch to
alternate antimicrobial therapy
According to the guidelines
Respiratory flouroquinolones, augmentin
(4g/day),ceftriaxone (1-2 g/day 5 days),
combination of g+ and gFailure after 72h: switch to alternate
antimicrobial therapy, or reevaluation
CT scan, endoscopy, sinus aspiration and
culture
According to the guidelines
Augmentin (90mg/k/day), amocixillin (90
mg/k/day), cefpodoxime proxetil,
cefuroxime axetil, or cefdinir
Type I hypersensitivity to b-lactams
patients: TMP/SMX, azithromycin,
clarithromycin or erythromycin.
Make differentiate an immediate
hypersensitivity from other side effects
Failure after 72 h
According to the guidelines
) (
Augmentin(90mg/k/day), cefpodoxime
proxetil, cefuroxime axetil or cefdinir.
Beta lactams allergic patients: TMP/SMX,
azithromycin, clarithromycin, erythromycin
Clindamycin for s pneumoniae
Ceftriaxone (5 days, parenteral), or
combination therapy for G+ and GClindamycin or amocixillin and cefixime
Clindamycin or amoxicillin and rifampin
According to the guidelines
Failed CRS
To sinus surgery or systemic steroid/antibiotics
Macrolid therapy (long term, low dose) effective
CRS
78 had criteria to CRS
endoscopy: positive 17
37- CT findings: positive
endoscopy : positive 6
41- CT findings: negative
35: endoscopy negative & CT negative
20: endoscopy negative & CT positive
55: endoscopy negative
Endoscopy/ct findings/clinical
Easy to diagnose CRS by endoscopy
alone when nasal polyps, purulence, or
fungus is observed,
when absent, establishing the diagnosis
may be more difficult
45% of patients with clinical CRS were
both endoscopically and radiographically
negative.
Stankiewicz and Chow. Otolaryngol head neck surg 2002
Endoscopy/ct findings/clinical
Negative endoscopy alone is insufficient to
rule out sinusitis.
26% of patients who were negative on
endoscopy had positive CT this would
suggest that if endoscopy is negative
most of the time the ct will be also
negative, even with a positive history.
Stankiewicz & Chow: Otolaryngol Head Neck Surg 2002
( URI )
10
10 VIRAL URI
. 5-7
The diagnosis of acute bacterial sinusitis
is based on clinical criteria in children who
present with upper respiratory symptoms
that are either persistent or severe
Guidelines of American Academy of Pediatrics
Persistent symptoms are those that last
longer than 10 to 14, but less than 30,
days. Such symptoms include nasal or
postnasal discharge (of any quality),
daytime cough (which may be worse at
night), or both.
Severe symptoms include a temperature
of at least 102F (39oC) and purulent
nasal discharge present concurrently for at
least 3 to 4 consecutive days in a child
who seems ill. The child who seems toxic
should be hospitalized and is not
considered in this algorithm.
Guidelines of American Academy of Pediatrics
children
, ,
,
.
ARS in children
Diagnosis in children based on clinical
criteria
Radiology is only for complications,
persistent or recurrent sinusitis
For prevention there is no prophylactic
antimicrobial treatment, ancillary
therapies, complementary/alternative
medicine
Guidelines of American Academy of Pediatrics
Goal of surgery
Surgery is for control of symptoms, better
quality of life and to prevent complications
Indications to surgery are not uniform
between OL and P
cure-the goal for surgery, but is not the
likely end point
Reversible mucosal disease may be
possible in the long run, but is unlikely to
be realized in the short term
?Fear of surgery
Surgery may cause growth retardation of
the midface
Bothwell et al. showed no difference in
facial growth of children with CRS who
operated compare with children who
refused surgery.
Surgery
Children who fail medical therapy benefit
from surgery
Adenoidectomy recommended initially for
children 6 years of age (no asthma, low
CT score)
ESS and adenoidectomy for children older
than 6 (asthma and high CT score)
Ramadan. Laryngoscope.2004
Antibiotic therapy
Amoxicillin -1st choice
In children give high dose 60mg/kg/day
To consider 2nd generation cephalosporin, or
erythromycin with sulfonamide ,or high dose
penicillin in areas with a high incidence of
bacterial antibiotic resistance.
Based on studies showing a 20% incidence of
viable bacteria through maxillary sinus tap after
7 days of antibiotic therapy, most authors
recommend 10 days of therapy in the manage
of acute sinusitis