new definition and classification update on literature and treatments
DESCRIPTION
Acute Rhinosinusitis – bacterial infection or inflammation? Prof. Dr. Philippe Gevaert Dienst Neus-, keel- en oorheelkunde Allergienetwerk UZ-Gent. New definition and classification Update on literature and treatments New and practical treatment schemes acute rhinosinusitis adults - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: New definition and classification Update on literature and treatments](https://reader036.vdocuments.net/reader036/viewer/2022062301/568148f7550346895db61727/html5/thumbnails/1.jpg)
Neus-, keel- en oorheelkundeHoofd- en halschirurgie
Acute Rhinosinusitis – bacterial infection or inflammation?
Prof. Dr. Philippe Gevaert
Dienst Neus-, keel- en oorheelkundeAllergienetwerk UZ-Gent
![Page 2: New definition and classification Update on literature and treatments](https://reader036.vdocuments.net/reader036/viewer/2022062301/568148f7550346895db61727/html5/thumbnails/2.jpg)
Neus-, keel- en oorheelkundeHoofd- en halschirurgie
![Page 3: New definition and classification Update on literature and treatments](https://reader036.vdocuments.net/reader036/viewer/2022062301/568148f7550346895db61727/html5/thumbnails/3.jpg)
Neus-, keel- en oorheelkundeHoofd- en halschirurgieNeus-, keel- en oorheelkundeHoofd- en halschirurgie
Definitions and classification for General PracticeBased on symptoms:Two or more symptoms, one of which should be either
• nasal blockage/obstruction/congestion or• nasal discharge: anterior/post nasal drip;• ± facial pain/pressure,• ± reduction or loss of smell
Examination: anterior rhinoscopyX-ray/CT not recommended
* DURATIONACUTE / intermittent < 12 weeks
complete resolution of symptomsCHRONIC / persistent > 12 weeks
incomplete resolution of symptoms
Special attention to questions on allergic symptoms
![Page 4: New definition and classification Update on literature and treatments](https://reader036.vdocuments.net/reader036/viewer/2022062301/568148f7550346895db61727/html5/thumbnails/4.jpg)
Neus-, keel- en oorheelkundeHoofd- en halschirurgieNeus-, keel- en oorheelkundeHoofd- en halschirurgie
Definitions and classification
Based on symptoms:Two or more symptoms, one of which should be either
• nasal blockage/obstruction/congestion or• nasal discharge: anterior/post nasal drip;• ± facial pain/pressure,• ± reduction or loss of smell
AND EITHER
• endoscopic findings of polyps mucopurulent discharge edema or obstruction
OR
• CT scan abnormality: mucosal changes within ostiomeatal complex or sinus cavity
![Page 5: New definition and classification Update on literature and treatments](https://reader036.vdocuments.net/reader036/viewer/2022062301/568148f7550346895db61727/html5/thumbnails/5.jpg)
Neus-, keel- en oorheelkundeHoofd- en halschirurgieNeus-, keel- en oorheelkundeHoofd- en halschirurgie
Definitions and classification
* SEVERITY Visual Analogue Scale (VAS)
mild 0-3moderate 3-7severe 7-10
* DURATION
ACUTE / intermittent < 12 weekscomplete resolution of symptoms
CHRONIC / persistent > 12 weeksincomplete resolution of symptoms
CLASSIFICATION OF RHINOSINUSITIS
![Page 6: New definition and classification Update on literature and treatments](https://reader036.vdocuments.net/reader036/viewer/2022062301/568148f7550346895db61727/html5/thumbnails/6.jpg)
Neus-, keel- en oorheelkundeHoofd- en halschirurgieNeus-, keel- en oorheelkundeHoofd- en halschirurgie
Headache/facial pressure in sinusitis
![Page 7: New definition and classification Update on literature and treatments](https://reader036.vdocuments.net/reader036/viewer/2022062301/568148f7550346895db61727/html5/thumbnails/7.jpg)
Neus-, keel- en oorheelkundeHoofd- en halschirurgie
Nasal Endoscopy
![Page 8: New definition and classification Update on literature and treatments](https://reader036.vdocuments.net/reader036/viewer/2022062301/568148f7550346895db61727/html5/thumbnails/8.jpg)
Neus-, keel- en oorheelkundeHoofd- en halschirurgie
RX sinuses: - Waters, Caldwell an Hirtz
- poor sensitivity and specificity
- NOT RECOMMENDED!
Imaging of sinsuses
![Page 9: New definition and classification Update on literature and treatments](https://reader036.vdocuments.net/reader036/viewer/2022062301/568148f7550346895db61727/html5/thumbnails/9.jpg)
Neus-, keel- en oorheelkundeHoofd- en halschirurgieNeus-, keel- en oorheelkundeHoofd- en halschirurgie
Imaging of sinsuses
MRI: only recommended in tumor diagnosis
CT sinuses: current standard imaging (50mGy)
Cave! radiation damage of lens (500-2000mGy)
- Acute rhinosinusitis: only if signs for complications!!
- Chronic sinusitis: only after 4w-12w treatment!
![Page 10: New definition and classification Update on literature and treatments](https://reader036.vdocuments.net/reader036/viewer/2022062301/568148f7550346895db61727/html5/thumbnails/10.jpg)
Neus-, keel- en oorheelkundeHoofd- en halschirurgieNeus-, keel- en oorheelkundeHoofd- en halschirurgie
COMMON COLD
BACTERIAL SUPERINFECTIONStrep pneu / Haemo infl / Morax catar
increasing symptoms after 5 DAYS
no resolution after 10 DAYS
ACUTE rhinosinusitis
MULTIFACTORIAL ETIOLOGY
CHRONIC rhinosinusitisEAACI Position Paper on Rhinosinusitis and Nasal Polyps, Allergy 2005: 60: 583-601
Anatomy and physiology
![Page 11: New definition and classification Update on literature and treatments](https://reader036.vdocuments.net/reader036/viewer/2022062301/568148f7550346895db61727/html5/thumbnails/11.jpg)
Neus-, keel- en oorheelkundeHoofd- en halschirurgieNeus-, keel- en oorheelkundeHoofd- en halschirurgie
Viruses in acute rhinitis and rhinosinusitis
adenovirus
parainfl.
RSV
coronavirus
coxsakie
echovirus
influenza
rhinovirus
Adults
Least
common
Most common
adenovirus
parainfl.adenovirus
RSVparainfl.influenza
coronavirusRSVrhinovirusinfluenza
coxsackiecoronavirusRSVadenovirus
influenzaechovirusenterovirusparainfl.
echovirusinfluenzaadenovirusRSV
rhinovirusrhinovirusparainfl.rhinovirus
Young adultsAdolescents5-10 years< 4 years
Kirkpatrick, 1996
![Page 12: New definition and classification Update on literature and treatments](https://reader036.vdocuments.net/reader036/viewer/2022062301/568148f7550346895db61727/html5/thumbnails/12.jpg)
Neus-, keel- en oorheelkundeHoofd- en halschirurgie
Pathophysiology Viral Rhinitis
Impact of viral infection on the mucosa
Epithelial changes Hypersecretion and oedema
Goblet cells (hypersecretion), ciliated cells (secretion stasis)
Cell destruction with vasodilatation (cavernous sinuses!)
Release inflammatory mediators from inflammatory cells
Seromucous hypersecretion and exudation
Thickening lamina propria
![Page 13: New definition and classification Update on literature and treatments](https://reader036.vdocuments.net/reader036/viewer/2022062301/568148f7550346895db61727/html5/thumbnails/13.jpg)
Neus-, keel- en oorheelkundeHoofd- en halschirurgie
Symptoms Viral Rhinitis
1. Quickly passing sore throat: viral pharyngitis, swollen throat
2. Nasal symptoms: congestion, sneezing, rhinorrhea
gone after 7 d, mucus production peaks on d 3 and 4
3. Coughing: longest lasting symptom,
weeks in smokersand patients with reflux!
3. 1/10: short headache
4. Rarely tremors, general malaise
5. Note: more serious problems with anatomical anomalies (deviated septum) or children: otitis, rhinopharyngitis, sinusitis, tracheitis, bronchitis
![Page 14: New definition and classification Update on literature and treatments](https://reader036.vdocuments.net/reader036/viewer/2022062301/568148f7550346895db61727/html5/thumbnails/14.jpg)
Neus-, keel- en oorheelkundeHoofd- en halschirurgie
0
5
10
15
20
25
30
35
40
45
50
OBSTRUCTION RHINORRHEA HEADACHE COUGH SORE THROAT OTHERS
% o
f po
pu
latio
nSymptoms Viral Rhinitis
![Page 15: New definition and classification Update on literature and treatments](https://reader036.vdocuments.net/reader036/viewer/2022062301/568148f7550346895db61727/html5/thumbnails/15.jpg)
Neus-, keel- en oorheelkundeHoofd- en halschirurgie
0
10
20
30
40
50
60
70
NO COUGH LESS THAN 1WEEK
1-2 WEEKS 2-3 WEEKS
duration
% o
f th
e p
op
ula
tio
n
SMOKERS
NON-SMOKERS
Cough after Viral Rhinitis (smoking)
![Page 16: New definition and classification Update on literature and treatments](https://reader036.vdocuments.net/reader036/viewer/2022062301/568148f7550346895db61727/html5/thumbnails/16.jpg)
Neus-, keel- en oorheelkundeHoofd- en halschirurgie
0
2
4
6
8
10
12
14
16
18
20
22
OTITIS SINUSITIS BRONCHITIS PRESSURE IN EAR
Per
cen
tag
e (%
)
ALLERGIC
NON-ALLERGIC
Complications after Viral Rhinitis
![Page 17: New definition and classification Update on literature and treatments](https://reader036.vdocuments.net/reader036/viewer/2022062301/568148f7550346895db61727/html5/thumbnails/17.jpg)
Neus-, keel- en oorheelkundeHoofd- en halschirurgie
Therapeutical Options Common Cold
Nothing
Local vasoconstrictors: preferably only at night,
not > 7d
Physiological flushing: mainly with children or with anatomical anomalies
Note: other types of rhinitis where physiological flushing
-possibly supplemented with ointment application- may be useful:
occupational rhinitis, rhinitis due to irritants, atrophic rhinitis
Antibiotics: useless, unless complication due to surinfection
![Page 18: New definition and classification Update on literature and treatments](https://reader036.vdocuments.net/reader036/viewer/2022062301/568148f7550346895db61727/html5/thumbnails/18.jpg)
Neus-, keel- en oorheelkundeHoofd- en halschirurgieNeus-, keel- en oorheelkundeHoofd- en halschirurgie
Common cold induces changes in sinus mucosa
Virus ICAM-1
T helper 1 polarisation * CD4+ CTL* NK activity* Ig
IL-1 , IL-6, TNF-IL-8, MCP-1IFN-
CD8+ CTLsNKcellsneutrophil monocyte recruitment and activation
Elimination of rhinovirusT helper 1 polarisation * CD4+ T helper cells
* NK activity* Immunoglobulins
IL-1 , IL-6, TNF-INFgamma, IL-8
CD8+ T cytotxic cellsNatural Killer cellsNeutrophils monocyte recruitment and activation
Elimination of rhinovirus
![Page 19: New definition and classification Update on literature and treatments](https://reader036.vdocuments.net/reader036/viewer/2022062301/568148f7550346895db61727/html5/thumbnails/19.jpg)
Neus-, keel- en oorheelkundeHoofd- en halschirurgie
Acute Rhinosinusitis
![Page 20: New definition and classification Update on literature and treatments](https://reader036.vdocuments.net/reader036/viewer/2022062301/568148f7550346895db61727/html5/thumbnails/20.jpg)
Neus-, keel- en oorheelkundeHoofd- en halschirurgieNeus-, keel- en oorheelkundeHoofd- en halschirurgie
Infections induces changes in sinus mucosa
Ventilationand Drainage
Inflammationand Remodeling
B
MT
MS
I TThe ostiomeatal complex
B Bulla ethmoidalis
I T inferior turbinate
MT middle turbinate
MS maxillary sinus
![Page 21: New definition and classification Update on literature and treatments](https://reader036.vdocuments.net/reader036/viewer/2022062301/568148f7550346895db61727/html5/thumbnails/21.jpg)
Neus-, keel- en oorheelkundeHoofd- en halschirurgieNeus-, keel- en oorheelkundeHoofd- en halschirurgie
Microbiology
Normal sinuses: Free of growth
Acute rhinosinusitis:
2/3 Viral
1/3 Bacterial (St Pneumoniae,H Influenzae, M Catharralis)
Chronic rhinosinusitis:
>>Anaerobes: Propionibacterium, Bacteriodes, Peptococcus
Aerobes:Staphylococcus, Corynebacterium, Pseudomonas
Fungi (» aspergillus fumigatus)
Dentogene sinusitis: ?
![Page 22: New definition and classification Update on literature and treatments](https://reader036.vdocuments.net/reader036/viewer/2022062301/568148f7550346895db61727/html5/thumbnails/22.jpg)
Neus-, keel- en oorheelkundeHoofd- en halschirurgie
Common cold/ Acute viral rhinosinusitis
Occurence in adults: up to 4 times a year
URTI: symptoms < 10 days
Symptomatic treatment only: • Decongestants
• Pain relief
• Saline drops
Can lead to post-viral inflammation of nose and sinuses
Guidelines for Acute Rhinosinusitis
![Page 23: New definition and classification Update on literature and treatments](https://reader036.vdocuments.net/reader036/viewer/2022062301/568148f7550346895db61727/html5/thumbnails/23.jpg)
Neus-, keel- en oorheelkundeHoofd- en halschirurgie
Acute post-viral Rhinosinusitis (ARS)
• ↑ symptoms after 5 days or
• persistent symptoms after 10 days
• less than 12 weeks
Symptoms: • Nasal obstruction/congestion and/or
• Facial pain/pressure
Accompanied by:
• Nasal discharge and/or
• Reduction or loss of smell
Definition:
Guidelines for Acute Rhinosinusitis
![Page 24: New definition and classification Update on literature and treatments](https://reader036.vdocuments.net/reader036/viewer/2022062301/568148f7550346895db61727/html5/thumbnails/24.jpg)
Neus-, keel- en oorheelkundeHoofd- en halschirurgie
Acute post-viral Rhinosinusitis (ARS)
• once or more than once in defined time period (episodes per year)
• complete resolution between symptoms
Appearance: • Mild
• Severe
Occurence:
• Fever > 38,3°C
• Localized pain over the sinuses
May lead to complications !!
Streptococcus pneumoniae,Haemophilus influenzae and Moraxella catarrhalis
Guidelines for Acute Rhinosinusitis
![Page 25: New definition and classification Update on literature and treatments](https://reader036.vdocuments.net/reader036/viewer/2022062301/568148f7550346895db61727/html5/thumbnails/25.jpg)
Strength of evidence for treatment of Acute RhinosinusitisTherapy Level Recommendation Relevance
antibiotic Ia (49 studies) A yes: after 5 –10 days,or in severe cases
topical steroid 1b (1 study) A yes
addition of topical steroid to antibiotic
Ib (5 studies) A yes
oral steroid no evidence (1 study)
D no
addition of oral antihistamine in allergic patients
Ib (1 study) B no
nasal douche no evidence (3 studies)
D no
decongestion no evidence(3 studies)
D yesas symtomatic relief
mucolytics no evidence (3 studies)
D no
![Page 26: New definition and classification Update on literature and treatments](https://reader036.vdocuments.net/reader036/viewer/2022062301/568148f7550346895db61727/html5/thumbnails/26.jpg)
Neus-, keel- en oorheelkundeHoofd- en halschirurgieNeus-, keel- en oorheelkundeHoofd- en halschirurgie
![Page 27: New definition and classification Update on literature and treatments](https://reader036.vdocuments.net/reader036/viewer/2022062301/568148f7550346895db61727/html5/thumbnails/27.jpg)
Neus-, keel- en oorheelkundeHoofd- en halschirurgieNeus-, keel- en oorheelkundeHoofd- en halschirurgie
Dolor et al. JAMA Oct 2002
DBPC trial in 95 patients with acute sinusitis (with history of CRS)
All received 2x/d xylometazoline spray (3days) and
2 x 250mg/d cefuroxime (10 days)
47 patients 200µg (two puffs) Fluticasone or 48 patients placebo spray
![Page 28: New definition and classification Update on literature and treatments](https://reader036.vdocuments.net/reader036/viewer/2022062301/568148f7550346895db61727/html5/thumbnails/28.jpg)
Neus-, keel- en oorheelkundeHoofd- en halschirurgie
J Allergy Clin Immunol. 2005 Dec;116(6):1289-95.
![Page 29: New definition and classification Update on literature and treatments](https://reader036.vdocuments.net/reader036/viewer/2022062301/568148f7550346895db61727/html5/thumbnails/29.jpg)
Neus-, keel- en oorheelkundeHoofd- en halschirurgieNeus-, keel- en oorheelkundeHoofd- en halschirurgie
*P<0.001 vs placebo.Gross et al. J Allergy Clin Immunol. 2007; 119 (Suppl S):S64. P
erce
nt
chan
ge
in p
atie
nt-
rep
ort
ed
con
ges
tio
n s
ymp
tom
sco
re f
rom
bas
elin
e Days
*
**
** * *
** * * * * *
Percent Change in Congestion Symptom Score (Patient-Reported)
Nasal GCS and nasal congestion
![Page 30: New definition and classification Update on literature and treatments](https://reader036.vdocuments.net/reader036/viewer/2022062301/568148f7550346895db61727/html5/thumbnails/30.jpg)
Neus-, keel- en oorheelkundeHoofd- en halschirurgieNeus-, keel- en oorheelkundeHoofd- en halschirurgie
Management of Acute Rhinosinusitis
![Page 31: New definition and classification Update on literature and treatments](https://reader036.vdocuments.net/reader036/viewer/2022062301/568148f7550346895db61727/html5/thumbnails/31.jpg)
Neus-, keel- en oorheelkundeHoofd- en halschirurgieNeus-, keel- en oorheelkundeHoofd- en halschirurgie
Management of Acute Rhinosinusitisfor ENT-specialist
![Page 32: New definition and classification Update on literature and treatments](https://reader036.vdocuments.net/reader036/viewer/2022062301/568148f7550346895db61727/html5/thumbnails/32.jpg)
Neus-, keel- en oorheelkundeHoofd- en halschirurgie
Acute Rhinosinusitis in de praktijk