INFECTIOUS RHINOSINUSITIS References- •Cummings Otolaryngology Head & Neck Surgery 6 th edition •Scott-brown’s Otolaryngology, Head & Neck Surgery 7 th edition •Infectious Diseases Society of America (IDSA) Guideline for ABRS: CID. March 20, 2012 •European Position Paper on Rhinosinusitis and Nasal Polyps(EPOS) March 2012 Dr Vikas
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INFECTIOUS RHINOSINUSITIS
References-•Cummings Otolaryngology Head & Neck Surgery 6th edition•Scott-brown’s Otolaryngology, Head & Neck Surgery 7th edition•Infectious Diseases Society of America (IDSA) Guideline for ABRS: CID. March 20, 2012•European Position Paper on Rhinosinusitis and Nasal Polyps(EPOS) March 2012
Dr Vikas
Rhinosinusitis is a group of disorders characterized by inflammation of the lining of the nose and paranasal sinuses.
The ciliated respiratory mucosal lining of the nose and paranasal sinuses are contiguous and it would be rare for one to be affected without the other.
Scott-brown
Pathophysiology Acute rhinosinusitis develops in conjunction with an acute viral upper
respiratory tract infection. Occur more commonly in predisposed individuals The infection results in mucosal swelling with occlusion or obstruction
of the sinus ostia. A reduction in oxygen tension occurs which can reduce mucociliary
transport and transudation of fluid into the sinuses. The inflammation also results in changes in the mucous that become
more viscous and alterations in cilia beat frequency often occurs. These changes in the nasal-sinus environment lead to mucostasis
and bacterial colonization. If the sinuses remain obstructed or the mucociliary. transport system
does not return to normal, a bacterial infection can ensue.
Scott-brown
Classification of infectious rhinosinusitis
Report of the Rhinosinusitis Task Force Committee Meeting. Otolaryngology and Head and Neck Surgery. 1997; 117: 51-68.
Conventional Criteria for Diagnosis of SinusitisBased on Presence of at Least 2 Major or 1 Major and 2 Minor
Symptoms
IDSA Guideline for ABRS: CID.March 20, 2012
Acute rhinosinusitis-◦ Acute onset of symptoms ◦ Duration of symptoms < 4
weeks ◦ Symptoms resolve
completely◦ Streptococcus pneumoniae
(20%-45%) and Haemophilus influenzae (22%-35%) are the predominant organisms in adults, whereas
◦ S. pneumoniae (30%-43%), H. influenzae (20%-28%), and Moraxella catarrhalis (20%-28%) are the predominant organisms in children
Subacute rhinosinusitis◦ Duration of symptoms >4 weeks to < 12 weeks◦ Pathogens are same as ARS
Recurrent acute rhinosinusitis◦ 4 or more episodes of acute rhinosinusitis per year, with each
lasting longer than 7 to 10 days,◦ Complete recovery between attacks◦ Symptom-free period of > 8 weeks between acute attacks in
absence of medical treatment◦ Bacteriology and pathophysiology would be similar to those of
individual episodes of ABRS
Chronic rhinosinusitis Duration of symptoms> 12 weeks Persistent inflammatory changes on imaging > 4 weeks after
starting appropriate medical therapy no intervening acute episodes Unlike for ABRS, the role of bacteria in CRS is not well supported CRS is an inflammatory disease, and it may or may not involve
pathogenic microbes. Therefore, bacteria, fungi or viruses may be involved in some cases In those patients with CRS who do have potential pathogenic
bacteria, the most common organisms are Staphylococcus species (55 percent) and Staphylococcus aureus (20 percent).
Some studies have shown a high prevalence of Enterobacteriaceae organisms, anaerobes, Gram-negative bacteria and fungi.
Acute exacerbations chronic rhinosinusitis AECRS is a sudden worsening of the baseline CRS symptoms or
appearance of new symptoms Complete resolution of acute (but not chronic) symptoms between
episodes There may be a change in the bacteriology of the disease
Acute Rhinosinusitis
Acute rhinosinusitis in adults Inflammation of nose and paranasal sinuses
≥ 2 symptoms, one of nasal blockage/obstruction/congestion or nasal discharge (ant/post nasal drip):
± facial pain/pressure
± reduction or loss of smellEPOS March 2012
And eitherendoscopic signs of:◦ nasal polyps, and/or◦ mucopurulent discharge from middle meatus and/or◦ edema/mucosal obstruction in middle meatus
and/or◦ CT changes:◦ mucosal changes within ostiomeatal complex and/or sinuses
For <12 weeks
4/26/12
Acute rhinosinusitis in children Inflammation of nose and paranasal
sinuses ≥ 2 symptoms one of nasal
blockage/obstruction/congestion or nasal discharge (ant/post nasal drip):
± facial pain/pressure ± cough
EPOS March 2012
Acute rhinosinusitis in children And either endoscopic signs of:
nasal polyps, and/or mucopurulent discharge from middle meatus and/or edema/mucosal obstruction in middle meatus
And/or CT changes:
mucosal changes within the ostiomeatal complex and/or sinuses
For < 12 weeks
EPOS March 2012
Severity of disease in adult and children
Define disease severity: Mild: VAS 0-3
Moderate: VAS 4-7
Severe: VAS 8-10
EPOS March 2012
Acute rhinosinusitis can be divided into Common Coldand post- viral rhinosinusitis. A small subgroup of post-
viral rhinosinusitis is caused by bacteria (ABRS).EPOS March 2012
Classification of ARS in adult/children Common cold/ acute viral rhinosinusits :
◦ duration of symptoms for< 10 d
Acute post-viral rhinosinusitis: ◦ increase of symptoms after 5 d or persistent symptoms after 10 d with < 12
wk duration.
ABS: ≥ 3 symptoms/signs◦ Discoloured discharge (unilat predominance) and purulent secretion in nasi◦ Severe local pain (unilat predominance)◦ Fever (>38 °C)◦ Elevated ESR/CRP◦ ‘Double sickening’ (deterioration after initial milder of illness)
EPOS March 2012
Signs of ABSAt least 3 of:-Discoloured d/c-Severe local pain-Fever-Elevated ESR/CRP-Double sickening
Postviral acute rhinosinusitis
Increase in symptoms after 5 d
Persistent symptom after 10 d
EPOS March 2012
Any of following clinical presentations are recommended for identifying patients with acute bacterial vs viral rhinosinusitis Onset with persistent S/S compatible with ARS ≥ 10 d without
any evidence of clinical improvement.
Onset with severe S/S of high fever ≥ 39 °C and purulent nasal discharge or facial pain at least 3–4 consecutive d at beginning of illness.
Onset with worsening S/S characterized by new onset of fever, headache, increase in nasal discharge following typical viral URI that lasted 5–6 d and were initially improving (‘‘doublesickening’’).
IDSA Guideline for ABRS: CID.March 20, 2012
Associated Factors◦Environmental Exposures( dampness in
home ,air pollution, irritants)◦Anatomical factors
septal deviation, paradoxical turbinate; nasal polyps, and choanal obstruction by benign adenoid tissue, or odontogenic sources of infection
◦Allergy individuals with allergies have a higher incidence of
developing both acute and chronic rhinosinusitisEPOS March 2012
◦Ciliary impairment Ciliary function diminished during viral and bacterial rhinosinusitis. Exposure to cigarette smoke and allergic inflammation has been shown
to impair ciliary function. Impaired mucociliary clearance in Allergic Rhinitis patients predisposes
patients to ARS◦Primary Ciliary Dyskinesia◦Smoking◦Laryngopharyngeal reflux
Pacheco-Galvan et al. 1997-2006 have shown significant associations between GERD and sinusitis.
Recent systematic review, Flook and Kumar showed only poor association between acid reflux, nasal symptoms, and ARS
EPOS March 2012
◦Anxiety and depression Poor mental health, anxiety, or depression is associated with susceptibility
to ARS Mechanisms are unclear.
◦Drug resistance◦Concomitant Chronic Disease
Concomitant chronic disease (bronchitis, asthma, CVS disease, DM,) in children has been associated with increased risk of developing ARS secondary to influenza.
◦ Iatrogenic factors Including surgery, medications, nasal packing or nasogastric tube
placement.EPOS March 2012
Pathophysiology Acute rhinosinusitis develops in conjunction with an acute viral upper
respiratory tract infection. Occur more commonly in predisposed individuals The infection results in mucosal swelling with occlusion or obstruction
of the sinus ostia. A reduction in oxygen tension occurs which can reduce mucociliary
transport and transudation of fluid into the sinuses. The inflammation also results in changes in the mucous that become
more viscous and alterations in cilia beat frequency often occurs. These changes in the nasal-sinus environment lead to mucostasis
and bacterial colonization. If the sinuses remain obstructed or the mucociliary. transport system
does not return to normal, a bacterial infection can ensue.
Scott-brown
Investigations
Bacterial Culture Microbiological investigations are not required for diagnosis
of ARS in routine practice. ( EPOS March 2012) May be required in research settings, or in atypical or
recurrent disease Maxillary sinus tap with culture is the gold standard for the
diagnosis of ABRS, There is increasing interest in the role of endoscopic-guided
middle meatal cultures, but their reliability in children has not been established
Nasopharyngeal cultures are unreliable and are not recommended for microbiologic diagnosis of ABRS
Current accepted reference standard for culture is more than 10,000 colony forming units (CFU)/mL in sinus aspirate.
IDSA Guideline for ABRS: CID.March 20, 2012
Nasal endoscopyNasal endoscopy may be used to
visualize nasal and sinus anatomy provide biopsy and microbiological
◦ Modality of choice to confirm extent of pathology and anatomy.◦ Very severe disease, immuno-compromised pt, suspicion of
complications. ◦ Routine CT scan in ARS little useful information
Plain sinus X Rays ◦ Insensitive & limited usefulness
Ultrasound◦ Insensitive & limited usefulness
EPOS March 2012
XVII. Which Imaging Is Most Useful for Severe ABRS who suspected to have Suppurative complication?
CT rather than MRI is recommended to localize infection and to guide further treatment.
IDSA Guideline for ABRS: CID.March 20, 2012
Algorithm for the management of acute bacterial rhinosinusitis
IDSA Guideline for ABRS: CID.March 20, 2012
Algorithm for the management of acute bacterial rhinosinusitis
IDSA Guideline for ABRS: CID.March 20, 2012
Algorithm for the management of acute bacterial rhinosinusitis
IDSA Guideline for ABRS: CID.March 20, 2012
CHRONIC RHINOSINUSITIS
Definition Chronic Rhinosinusitis (with or without NP) in
adults ≥ 2 symptoms one of which should be either nasal
blockage/obstruction/congestion or nasal discharge(ant/post drip) or
± Facial pain/pressure ± reduction or loss of smell
for ≥12 weeksEPOS 2012
CRSwNP: bilateral, endoscopically visualised polyps in middle meatus.
CRSsNP: no visible polyps in middle meatus
Definition
EPOS 2012
CRS in children ≥ 2 symptoms
◦one of which should be either nasal blockage/obstruction/congestion or nasal discharge(ant/postnasal drip) or
◦± Facial pain/pressure ◦± Cough
for ≥12 weeksEPOS 2012
Factor associated with CRS Ciliary impairment Allergy Asthma Aspirin sensitivity Immunocompromised state Genetic factor Pregnancy and endocrine state Local host factor Biofilm Environmental factor Iatrogenic factor H.pylori and laryngopharyngeal reflux Osteitis
Pathophysiology
Scott-brown
The role of allergies has been strongly suggested but not proven
Antigen-antibody reactions result in the release of histamine and other mediators of inflammation.
These mediators cause changes in vascular permeability, destabilization of lysosomal membranes and other reactions that produce inflammation, mucosal swelling and ostia obstruction
Pathophysiology
Scott-brown
Many cells and proteins that are involved with inflammatory response have been implicated and are being investigated to their roles in rhinosinusitis, particularly CRS.
These include, but are not limited to, eosinophils, neutrophils, mast cells, T and B celis, immunoglobulins, interleukins, tumour necrosis factor, major basic protein and a number of other mediators of inflammation.
Other factors have also been identified that may play a role in the development or perpetuation of CRS, including, superantigens, biofilms and osteitis.
•Superantigens are exotoxins that are able to activate T lymphocytes
Immune barrier hypothesis of CRS
EPOS 2012
Biofilms◦ Artificial or damaged biologic surface that formed
communicating organization of microorganisms surrounded by a glycocalys
◦ Biofilms is relatively impervious to antibiotics and is never eradicated
◦ Mechanical debridement- the only way to resolve biofilms Osteitis
◦ Inflammatory bone changes were noted on contralateral side in 52% of the animals (Khalid et al. laryngoscope 2002)
Eosinophilic and noneosinophilic form of sinusitis
Spencer C et al. J Allergy Clin Immunol 2011;128:710-20
Mucosa in CRS characterized by basement membrane thickening, goblet cell hyperplasia, subepithelial edema, and mononuclear cell infiltration with few eosinophils