RHINOSINUSITIS: DIAGNOSIS AND TREATMENT Edoardo Cervoni, M.D. GP Trainees 27/11/13, Education Centre RPH 1
May 07, 2015
RHINOSINUSITIS:DIAGNOSIS AND TREATMENT
RHINOSINUSITIS:DIAGNOSIS AND TREATMENT
Edoardo Cervoni, M.D.Edoardo Cervoni, M.D.
GP Trainees 27/11/13, Education Centre RPHGP Trainees 27/11/13, Education Centre RPH 11
DiscolosuresDiscolosures
• Grant/Research Support: no disclosure
• Consultant: no disclosure • Major Shareholder: Locumdoctor4u
Ltd. (Locum and Concierge Medical Services)
• I will not be discussing “off-label” uses of medications or investigations
• Grant/Research Support: no disclosure
• Consultant: no disclosure • Major Shareholder: Locumdoctor4u
Ltd. (Locum and Concierge Medical Services)
• I will not be discussing “off-label” uses of medications or investigations
ENT ReferralsENT Referralsi. Most ENT referrals are linked to Audiological and
Otological problems.
ii. Out of 271 consecutive referrals to the RHP ENT Department triaged in 2011, 58% could be potentially managed in Primary Care.
CLPCT NHS Survey 2011 – E Cervoni
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ENT ReferralsENT Referralsi. Snoring and sleep apnoea were relatively common reasons of
referrals.ii. In a rather significant proportion of cases, relevant information,
with specific reference to the physical examination, were missing.
iii. Among the referrals redirected to the GPwSI in ENT, deafness with wax, epistaxis and blocked nose were the most common complaints.
CLPCT NHS Survey 2011 – E Cervoni
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Conditions referredConditions referred
Cervoni E - 2011 GP Trainees 27/11/13, Education Centre RPHGP Trainees 27/11/13, Education Centre RPH
EPOS 2012EPOS 2012
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Inflammation of the nose and paranasal sinuses characeterized by the presence of 2 or more symptoms of which one MUST be nasal obsteruction or rhinorrhoea with:
Inflammation of the nose and paranasal sinuses characeterized by the presence of 2 or more symptoms of which one MUST be nasal obsteruction or rhinorrhoea with:
Endoscopic signs:
- polyps and/or- purulent secretion from the middle meatus and/or- oedema/mucosal obstruction prevalent in the middle meatus
- polyps and/or- purulent secretion from the middle meatus and/or- oedema/mucosal obstruction prevalent in the middle meatus
Associated with and/or CT abnormal
changes:
- mucosal changes at the level of the osteo-meatal complex or of the paranasal sinuses
- mucosal changes at the level of the osteo-meatal complex or of the paranasal sinuses
±facial pain/pressure±hypo/anosmia±facial pain/pressure±hypo/anosmia
RhinosinusitisRhinosinusitis
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Rhinosinusitis may be classified into mild, moderate or severe on the basis of VAS score.
Mild = VAS 0 - 3 Moderate = >3 - 7 Severe = VAS >7 - 10
Mild = VAS 0 - 3 Moderate = >3 - 7 Severe = VAS >7 - 10
To assess the severity of the symptoms the patient is asked to answer the following question:
How painful are the symptoms of your sinusitis?How painful are the symptoms of your sinusitis?
10 cmNo pain Worst possible pain
CLASSIFICATION on severity of the symptoms
CLASSIFICATION on severity of the symptoms
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12 weeks
ACUTE/RECURRENT(complete resolution of the symptoms)
ACUTE/RECURRENT(complete resolution of the symptoms)
CHRONIC(incomplete resolution of the symptoms)
CHRONIC(incomplete resolution of the symptoms)
CLASSIFICATION on duration
CLASSIFICATION on duration
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Sudden onset of its symptoms of which one must be nasal obstruction or rhinorrhoea
±facial pain/pressure±hypo/anosmia±facial pain/pressure±hypo/anosmia
And duration <12 weeks
Presence of endoscopic signs of:
•Purulent secretion from the middle meatus•Oedema and/or obstruction of the middle meatus
Presence of abnormal changes to CT imaging
Presence of endoscopic signs of:
•Purulent secretion from the middle meatus•Oedema and/or obstruction of the middle meatus
Presence of abnormal changes to CT imaging
Acute Rhinosinusitis: clinical features
Acute Rhinosinusitis: clinical features
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Duration of the symptoms < 10 daysDuration of the symptoms < 10 days
Acute viral (common cold)
- Symptoms oncrease after 5 days
- Persistence of the symptoms after 10 days, but for less than 12 weeks
- Symptoms oncrease after 5 days
- Persistence of the symptoms after 10 days, but for less than 12 weeks
Acute post-viral
Presence of at the least 3 symptoms and/or signs:
-Purulent secretion
-Pain with unilateral preponderance
-Fever (>38 C)
-Raised ESR and CPR
-Worsening of the symptoms after a phase of remission
Presence of at the least 3 symptoms and/or signs:
-Purulent secretion
-Pain with unilateral preponderance
-Fever (>38 C)
-Raised ESR and CPR
-Worsening of the symptoms after a phase of remission
Bacterial post-viral
Acute rhinosinusitis: typesAcute rhinosinusitis: types
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Viral infection of the upper airways
Allergic rhinitis
It is characterized by rhinorrhoea (which is not purulent), senstion of nasal obstruction, itchy nose, sneezing (spontaneus regression of the symptoms or following treatment)
Associated to ophtalmological symptoms/signs
It is characterized by rhinorrhoea (which is not purulent), senstion of nasal obstruction, itchy nose, sneezing (spontaneus regression of the symptoms or following treatment)
Associated to ophtalmological symptoms/signs
Confirmed positivity to a common allergenConfirmed positivity to a common allergen
Odontogenic
Absence of nasal signs and symptomsAbsence of nasal signs and symptoms
Acute rhinosinusitis: differential diagnosisAcute rhinosinusitis: differential diagnosis
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Sudden appearance of two or more symptoms of which ine should be nasal obstruction or rhinorrhoea
±facial pain/pressure±hypo/anosmia±facial pain/pressure±hypo/anosmia
Duration >12 weeks
Presence of endoscopic signs of:
•Nasal polyps•Muco-purulent secretion from the middle meatus•Oedema and/or obstruction of the middle meatus
Presence of CT abnormalities
Presence of endoscopic signs of:
•Nasal polyps•Muco-purulent secretion from the middle meatus•Oedema and/or obstruction of the middle meatus
Presence of CT abnormalities
CHRONIC RHINOSINUSITISCHRONIC RHINOSINUSITIS
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Without nasal polyps
With nasal polyps
Types of chronic rhinosinusitis
Types of chronic rhinosinusitis
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This disequilibrium determines an activation of TH2 immune response.The response is characterized by the production of cytokines which may differ depending of the specific nature of the chronic inflammatory response.
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Usually unilateral, with occasional purulent secretion
Characterized by high levels of IL-4, IL-5 and IL-13.
The high levels of IL-5 observed on those patients affected by allergic fungal rhinosinusitis highlights who this condition may be considered independently from oesinophils dysfunction disease.
Allergic fungal rhinosinusitisAllergic fungal rhinosinusitis
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Allergic fungal rhinosinusitis
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Invasive form• Acute fulminant• Chronic: - granulomatous - invasive
Non-invasive form• Allergic fungal rhinosinusitis• Fungal ball
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NOTE: surgery must be associated to antibiotic therapy and corticosteroids aiming to reduce the inflammatory component and/or infective. There is scientific evidence to support the use of topical steroids, antibiotics and antifungal drugs.
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Diagnosis is based on CT, MRI and pathology results
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Chronic rhinosinusitis:- Without asthma or allergy- Whitout asthma, but with allergy- With asthma and allergy- With asthma, but without allergy- With allergy to aspirin- Allergic fungal- Cystic fibrosis
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DIAGNOSIS
- Anamnesis- Anterior rhinoscopy- Nasal endoscopy- Nasal swab- CT- MRI- Biofilm Research
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Little role of plain x-rays(Skinner et al., 1991)
Maxillary sinus
Ethimoid
Sphenoid
Nasal cavity
F.N.*
3%
55%
43%
3%
20%
-
1%
4%
77%
36%
52%
93%
F.P.** A.D.***
False negatives: Rx normal/pathological mucosaFalse positives: Rx pathological/ normal mucosa Diagnostic accuracy: Rx findings/Intra-operative findings in keeping with Rx
***
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DIAGNOSIS
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ESTENSIONE DELLA PATOLOGIA
PRESENZA DI INTERRUZIONE DELLE LIMITANTI OSSEE
PRESENZA DI ANOMALIE ANATOMICHE
• Extension of the disease
• Presence of bone eroisions
• Presence of anatomical variances with possible operative challenges
• Extension of the disease
• Presence of bone eroisions
• Presence of anatomical variances with possible operative challenges
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OsteitisOsteitis
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Does not offer details of bone structures
Overestimes presence of mucosal abnormalities
Does not offer details of bone structures
Overestimes presence of mucosal abnormalities
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Excellent visualization of soft tissues.
Helpful to assess neoplastic pathology
Helpful to assess the extension of inflammatory processes.
Excellent visualization of soft tissues.
Helpful to assess neoplastic pathology
Helpful to assess the extension of inflammatory processes.
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DIAGNOSIS
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European guidelines for the treatment of rhinosinusitis and
nasal polyps
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“EVIDENCE BASED MEDICINE”
Shekelle et al., BMJ 1999
Evidence from meta-analysis of randomised controlled
trials
Evidence from at least one randomised controlled trials
Evidence from at least one controlled study without
randomisation
Evidence from at least one other type of quasi-
experimental study
Evidence from non-experimental descriptive studies, such
as comparative studies, correlation studies, and case-
control studies
Evidence from expert committee reports or opinions or
clinical experience of respected authorities, or both
Evidence from meta-analysis of randomised controlled
trials
Evidence from at least one randomised controlled trials
Evidence from at least one controlled study without
randomisation
Evidence from at least one other type of quasi-
experimental study
Evidence from non-experimental descriptive studies, such
as comparative studies, correlation studies, and case-
control studies
Evidence from expert committee reports or opinions or
clinical experience of respected authorities, or both
Ia
Ib
IIa
IIb
III
IV
Ia
Ib
IIa
IIb
III
IV
Categories
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Acute rhinosinusitis: therapy
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Acute rhinosinusitis: therapy
Antibiotic thereapy is indicated only when strictly required(confirmed bacterial infection, fever and severe pain)
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Acute rhinosinusitis: length of antibiotic therapy
Short treatments appear to have the same effectiveness of longer antibiotic courses
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Acute rhinosinusitis: type of antibiotic treatment
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Acute rhinosinusitis: topical steroid therapy
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Acute rhinosinusitis: combined therapy (steroid and oral antibiotic)
Corticosteroids when combined with oral antibiotics appear to be particularly effective in producing a prompt improvement of the symptoms – evidenca IA
Duration of treatment 3-5 days
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Acute rhinosinusitis: complications
Between 3,7% and 20%Can be:
• Orbital (60-75%) , • Intracranial (15-20%)• Bones (5-10%).
Sinusites account for 10% of the intra-cranial complications, and up to 90% of the orbital complications.
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Acute rhinosinusitis: treatment summaryAcute rhinosinusitis: treatment summary
Chronic rhinosinusitis without nasal polyposis
topical steroids
Only 2 recent papers have reported a significant benefit of topical steroids versus placebo.Anatomical factors and type of device to affect effectiveness of the treatment.
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Chronic rhinosinusitis without nasal polyposis
topical steroids
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Chronic rhinosinusitis without nasal polyposis
topical steroids
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Chronic rhinosinusitis without nasal polyposis
topical steroids
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Chronic rhinosinusitis without nasal polyposis
topical antibioticsThere is no evidence of benefits resulting from topical antibiotic therapy.
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Chronic rhinosinusitis without nasal polyposis
oral antibioticsThere is no evidence of benefits from antibiotic therapy < 4 weeks(short term), if there is no evidence of infection on the basis of microbiology results.
Macrolids are the only class of antibiotics to have shown some benefits (Ib)
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Chronic rhinosinusitis with nasal polyposis
topical steroids
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Rinosinusite cronica con poliposi nasaleterapia corticosteroidea sistemica
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Chronic rhinosinusitis with nasal polyposis
topical steroids
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Rinosinusite cronica con poliposi nasaleterapia antibiotica sistemica
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When surgery?
ExperienceExperience
Common senseCommon sense Knowledge of the pathologyKnowledge of the pathology
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WHY SURGERY?
Remove paranasal obstructionImprove ventilation and drainage of sinusesReduce number of exacerbationsReduce complicationsImprove quality of life
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PROBABILITY OF SUCCESS OF ENDOSCOPIC SURGERY
Poor paranasal sinuses ventilationRecurring sinusitisSinusitis affwecting only one sinus“Fungus ball”MucoceleAntral polypOrbital/intra-cranial complications
Maximal
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Cystic Fibrosis
Kartagener’s S.Congenital disorders
Rhinosinusitis with macropolyposis
Rhinosinusitis with asthma
ASA-SyndromeIntermediate
Minimal
PROBABILITY OF SUCCESS OF ENDOSCOPIC SURGERY
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