Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Acute Rhinosinusitis – bacterial infection or inflammation? Prof. Dr. Philippe Gevaert Dienst Neus-,

Neus-, keel- en oorheelkundeHoofd- en halschirurgie

Acute Rhinosinusitis – bacterial infection or inflammation?

Prof. Dr. Philippe Gevaert

Dienst Neus-, keel- en oorheelkundeAllergienetwerk UZ-Gent


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


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


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


Headache/facial pressure in sinusitis


Nasal Endoscopy


RX sinuses: - Waters, Caldwell an Hirtz

- poor sensitivity and specificity

- NOT RECOMMENDED!

Imaging of sinsuses


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!


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


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


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


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


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


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)


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


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


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


Acute Rhinosinusitis


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


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: ?


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


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:



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


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



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


J Allergy Clin Immunol. 2005 Dec;116(6):1289-95.


*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

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con

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tio

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ymp

tom

sco

re f

rom

bas

elin

e Days

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**

** * *

** * * * * *

Percent Change in Congestion Symptom Score (Patient-Reported)

Nasal GCS and nasal congestion


Management of Acute Rhinosinusitis


Management of Acute Rhinosinusitisfor ENT-specialist


Acute Rhinosinusitis in de praktijk

Neus-, keel- en oorheelkunde Hoofd- en halschirurgie Acute Rhinosinusitis – bacterial infection or inflammation? Prof. Dr. Philippe Gevaert Dienst Neus-,

Documents

nasal symptoms

priorities slide

bronchitis slide

physiology slide

viral rhinitis smoking

imaging of sinsuses

philippe gevaert dienst

allergic symptoms