The Medical Management The Medical Management of Infective & of Infective & Allergic Rhinitis Allergic Rhinitis Joe Marais FRCS(ORL) Joe Marais FRCS(ORL) www.the-nose.info Hillingdon Hospital, Hillingdon Hospital, Northwick Park Hospital, Northwick Park Hospital, Bishops Wood Hospital Bishops Wood Hospital Clementine Churchill Hospital, Clementine Churchill Hospital, Harrow, London. Harrow, London.
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The Medical Management of Infective & Allergic Rhinitis Joe Marais FRCS(ORL) Hillingdon Hospital, Northwick Park Hospital, Bishops Wood.
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The Medical Management of The Medical Management of Infective & Allergic RhinitisInfective & Allergic Rhinitis
Joe Marais FRCS(ORL)Joe Marais FRCS(ORL)www.the-nose.infoHillingdon Hospital,Hillingdon Hospital,
Northwick Park Hospital,Northwick Park Hospital,Bishops Wood HospitalBishops Wood Hospital
Very common (10-15% of population)Very common (10-15% of population) Most viral (>200 species!)Most viral (>200 species!) Secondary bacterial infection (5-15%)Secondary bacterial infection (5-15%) Increasing incidenceIncreasing incidence
Definitions in SinusitisDefinitions in SinusitisInternational Rhinosinusitis Board 1997International Rhinosinusitis Board 1997
AcuteAcute Recurrent Recurrent AcuteAcute
ChronicChronic Chronic c. Chronic c. exacerbationsexacerbations
Rapid onsetRapid onset 2-4 episodes/year2-4 episodes/year Duration >12/52Duration >12/52 Worsening of existing Worsening of existing chronic symptomschronic symptoms
Duration<12/52Duration<12/52 Symptom-free for Symptom-free for >8/52 between >8/52 between attacksattacks
Microbiology of Acute Sinusitis Microbiology of Acute Sinusitis
Majority due to viruses (200 species !)Majority due to viruses (200 species !) Sinus changes on CT in >90% of URTI’sSinus changes on CT in >90% of URTI’s Many asymptomatic casesMany asymptomatic cases Changes mainly due to viscid secretions, Changes mainly due to viscid secretions,
not mucosal thickening per se.not mucosal thickening per se. Ciliary paralysisCiliary paralysis 5-15% secondary bacterial infection rate5-15% secondary bacterial infection rate
Microbiology of Microbiology of AcuteAcute Sinusitis Sinusitis
Varies with geographic region, age and Varies with geographic region, age and sampling techniquesampling technique
Therapy for acute sinusitisTherapy for acute sinusitis
Local microbiological data importantLocal microbiological data important Middle meatal swabMiddle meatal swab Empiric treatmentEmpiric treatment Co-amoxiclav ( Cefuroxime / Clarithromycin)Co-amoxiclav ( Cefuroxime / Clarithromycin) Decongestant (Xylometazoline)Decongestant (Xylometazoline) Anti-inflammatory analgesia (Voltarol)Anti-inflammatory analgesia (Voltarol) Mucolytic (?)Mucolytic (?) Consider change at 48hr.Consider change at 48hr. Failure to respond: Refer ? consider lavageFailure to respond: Refer ? consider lavage
Therapy for Chronic SinusitisTherapy for Chronic Sinusitis
Many inadequately treated at presentationMany inadequately treated at presentation Try Clarithromycin x 12/52 nb. Down-regulation of Try Clarithromycin x 12/52 nb. Down-regulation of
inflammatory mediatorsinflammatory mediators If not, try Ciprofloxacin and MetronidazoleIf not, try Ciprofloxacin and Metronidazole Combine with decongestant, nasal topical steroid, Combine with decongestant, nasal topical steroid,
NSAID and douchingNSAID and douching Prolonged treatment usually necessary.Prolonged treatment usually necessary. Refer those with recurrent or persistent Sx.Refer those with recurrent or persistent Sx. Warn patient that surgery may be requiredWarn patient that surgery may be required
What can I do to reduce referral rate?
Don’t dismiss as a recurrent common cold! Irrigation of Nose with Saline (Neilmed) Long-term (3 months) antibiotic (eg