4/7/13 SINUSITIS WHO ARE WE TREATING? AMANDA SAM CONLEY RN, MSN, CFN, LNC, FNP- BC

Transcription

1 SINUSITIS WHO ARE WE TREATING? AMANDA SAM CONLEY RN, MSN, CFN, LNC, FNP- BC 1

2 DefiniGons Anatomy Review Signs and Symptoms OBJECTIVES Acute Viral vrs. Acute Bacterial Treatment Guidelines ANATOMY REVIEW Sinuses: air filled spaces within the head, lined with Gssue (mucosa). Maxillary: paired group below eyes and lateral to nasal cavity. Ethmoid: honeycomb between eyes. Frontal: large cavity above eyebrows. Sphenoid: large space behind the nose. 2

3 SINUSES WHY DO WE HAVE THEM? 3

4 KEY CONCEPT OSTEOMEATAL COMPLEXES: Small passages connecgng sinuses with the inside of nose. Osteomeatal blockage 4

5 HOW THE SINUSES WORK Lining (mucosa). Glands produce mucus. (moisten; smell) Cilia sweep mucus to osteomeatus. Nasal cavity to back of throat, swallow. Blockage between sinus and nasal cavity causes mucus to collect in sinuses: Sinus pressure, pain, infec6on. AMERICAN ACADEMY OF OTOLARYNGOLOGY HEAD & NECK SURGERY Clinical Prac6ce Guidelines: Adult sinusigs TERMS: rhinosinusitis since it always involves nasal cavity. RhinosinusiGs: symptomagc inflammagon of paranasal sinuses and nasal cavity. Chronic or Acute. Viral or Bacterial. 5

6 Cardinal Symptoms of Acute RhinosinusiGs Up to 4 weeks of 1) purulent (not clear) nasal drainage 2) nasal obstrucgon 3) facial pain/pressure/fullness. All 3 criteria. IMPACT Each year in the U.S.: 31 million adults will be DX with sinus infecgon. 1 in 7 adults will be DX with sinusigs. 5.8 billion dollars spent on DX and treatment. More than 1 in 5 angbiogcs are ordered for sinusigs; 5 th most common reason to write for angbiogcs. 76 million days of inacgvity, lost work. Common Primary care presentagon. 6

7 Viral rhinosinusigs Caused by a viral infecgon, ohen follows URI. Symptoms present less than 10 days and ARE NOT WORSENING. Self limigng: cough, sneezing, rhinorrhea, sore throat, nasal congesgon. **Sputum color misleading Bacterial RhinosinusiGs (ABRS) Caused by bacterial infecgon. Symptoms present 10 days or more beyond onset of URI or Symptoms worsen within 10 days aher inigal improvement (worsening). 7

8 ABRS AddiGonal signs and symptoms: Fever Cough FaGgue (malaise) Maxillary dental pain Ear fullness or pressure Hyposomia/anosmia IniGal DiagnosGc EvaluaGon Vital signs Physical exam of head and neck: Swelling, erythema or edema over involved cheekbone or periorbital area. Palpable cheek tenderness. Pain upper teeth. Purulent drainage in nose or throat. **key words: Fullness of my sinuses 8

9 If suspect complicagons DiabeGc RADIOGRAPHS Past history of facial trauma Malignancy suspected CT of sinuses w/o contrast most common test Normal Sinus CT 9

10 Axial View Ethmoid cancer 10

11 TREATMENT GOAL: Open osteomeatal complexes to facilitate drainage. Topical decongestant (Afrin). 3 days. AnGhistamine therapy (dries secre)ons). worsen Pain relief (NSAIDS). Nasal irrigagon (Alkalol or saline). OBSERVATION Non- severe illness, ARS or ABRS may be observed for 7 days aher diagnosis IF FOLLOW- UP CAN BE ASSURED If condigon fails to improve aher 7 days, or worsens, angbiogcs are started. High percentage of spontaneous improvement. 11

12 ANTIBIOTICS FOR ACUTE BACTERIAL RHINOSINUSITIS (ABRS) Amoxicillin is first- line angbiogc for most adults. JusGficaGon relates to safety, efficacy, low cost, and narrow microbiologic spectrum. No significant difference in rate of clinical resolugon in pagents treated with Amoxicillin, AugmenGn, cephalosporins or macrolides. Penicillin- allergic pagents Folate inhibitors (Azithromycin) Macrolides (Biaxin) 12

13 What organisms are we treagng? Streptococcus pneumoniae (20%- 43%) Haemophilus influenzae (22%- 35%) Moraxella catarrhalis (children). (2%- 10%) Factors which could modify choice of inigal angbiogc therapy Penicillin allergy may receive macrolide or trimethoprim- sulfamethoxazole. Recent angbiogc 4-6 weeks. Fluoroquinolone or high- dose amoxicillin- clavulanate. Child in day care is risk factor for adult for penicillin- resistant S. pneumoniae. High dose amoxicillin. 13

14 DuraGon of treatment Most trials administer angbiogcs for 10 days, however, no significant differences in resolugon rates with a 6-10 day course, or a 3-5 day course (azithromycin). TREATMENT FAILURE First examine for complicagons such as orbital or intracranial spread of infecgon. Symptoms: Proptosis, visual changes, severe headache, abnormal EOMs, changes in mental status, periorbital inflammagon, edema. 14

15 TREATMENT FAILURE AFTER 7 DAYS Consider non- bacterial cause. Consider infecgon with drug- resistant bacteria. Prompt change to alternate angbiogc. CHRONIC OR RECURRENT RHINOSINUSITIS Evaluate for nasal obstrucgons. Masses (malignancy) Anatomical deviagons Evaluate for allergic and immunodeficient states. ENT Consult. 15

16 QUESTIONS 16